' . ; STAFF BLOOMINCTON, 1ND. MATEEIA MEDICA AND THERAPEUTICS^ INORGANIC SUBSTANCES BY CHARLES D. F. PHILLIPS, M.D. MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, ETC. ; LATE LECTURER ON MATEBIA MEDICA AND THERAPEUTICS AT THE WESTMINSTER HOSPITAL MEDICAL SCHOOL (gftiteb anfo QUmpteft to tljc U. Q. }3ljarmac0pccia BY LAUEENCE JOHNSON, A.M., M.D. LECTURER ON MEDICAL BOTANY, MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE CITY OF NEW YORK ; FELLOW OF THE NEW YORE ACADEMY OF MEDICINE, ETC. VOLUME I. NEW YORK WILLIAM WOOD & COMPANY 1882 ^ J J COPTBIQHT WILLIAM WOOD & COMPANY 1882 TROW'S PRINTING AND BOOKBINDING COMPANY 201-213 East Twelfth Street NEW YORK $0 JOHN EEIC EKICHSEN, F.R.S. EX-PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, SURGEON EXTRAORDINARY TO HER MAJESTY THE QUEEN iG Book is Dcbicatcb EXPRESSION OF ESTEEM FOR HIS PROFESSIONAL ABILITY GRATITUDE FOR MUCH PERSONAL KINDNESS ,9 a I/. PUBLISHERS' PREFACE. THE first part of Dr. Phillips's " Materia Medica and Therapeu- tics " the " Vegetable Kingdom "edited by Dr. Piffard, was pub- lished in "Wood's Library of Standard Medical Authors in 1879. T~ This, the concluding part, has but just been completed by the i author, and is adapted to the United States Pharmacopeia, for this ^ series, by Dr. Laurence Johnson. The author's text is presented en- /} tire ; all additions are included in brackets. *> PREFACE. THIS volume is published in succession to one upon the Vegetable Kingdom, and is arranged upon a similar plan. Several of our best modern treatises upon the same subjects completely separate pharma- cology from therapeutics, but it has seemed to me better to recom- mend their simultaneous study, and I have devoted more space than is now usual to pharmaceutical chemistry ; this will be to the advan- tage, I am sure, of the student, and I trust, of the practitioner. That ample space should be given to discussing the physiological action of medicines is a necessary condition of any modern work, and if the conclusions reached, and the bearings of facts gathered under this head, are still rather vague and undefined, they at least engage and deserve earnest attention, and point to the direction in which further advance may be made. My former volume was published in 1874, and as some explana- tion of the long interval between it and the present one, I may say that in 1877 I had commenced arrangements with the printer when a serious railway accident interrupted my work, and incapacitated me for any exertion for upward of two years ; the conditions under which I have now completed the book may perhaps be accepted as some apology for its defects. During the interval, several excellent treatises on the same sub- jects have been published, and I have to acknowledge many obliga- tions to those of Dr. H. C. Wood, Jr., Dr. Bartholow, Dr. Garrod, Dr. Ringer, as well as to the works of Trousseau, Stille, Husemann, Nothnagel, Kohler, Gubler, and Kabuteau. I am also indebted to the " Poisons " of Dr. Taylor, the " Therapeutics " of Dr. Waring, Vlll PREFACE. the " Commentary " of Dr. W. G. Smith, the " Handbook; " of Dr. Fothergill, the " Companion " of Squire, and the " Chemistry " of Miller: the latter I have mainly followed as to mercury, iron, and other important drugs, but it is possible that some discrepancies may still be found between older and more modern chemical formulae. The "Medical Digest" of Dr. !Neale I have found exceedingly useful. Various important monographs, e.g., those of Preyer, Binz, liebreich, Frazer, Brunton, and others, and valuable papers in various journals will be found quoted in their proper place. The abbreviations and references will, I believe, be found suffi- ciently full for easy recognition. The British and Foreign Medico- Chwurgical Review is quoted either as Brit, and For. Rev. or as Med.-Chir. Rev. j the Edinburgh Journal of Medicine as Edin. Journ. ; the American Journal of. the Medical Sciences as Amer. Journ. or Amw. Rev. ; Practitioner refers to the London journal of that name, unless otherwise specified ; Dub. Quart, or Dub. Journ. to the Dublin Journal of Medical Science. Finally, I have to thank Dr. Mackey, Dr. Menzies of Cannes, Dr. Port, and Mr. A. Pearce Gould, for their valuable assistance in look- ing up references and aiding me with many suggestions and correc- tions while the work was passing through the press. 2 GBOSVENOR SQUARE, LONDON, W., December 1, 1881. CONTENTS OF VOL. I. OXYGEN OZONE COMPRESSED AIR 1-14 Physiological Action, External, 2 ; Internal, 2-8 ; Therapeutical Action, 8 ; Mode of Administration, 14. NITROGEN 15 HYDROGEN 16 Peroxide of, 16. CARBO CHARCOAL 18-20 Therapeutical Action, External, 19 ; Internal, 19, 20 ; Preparations and Dose, 20. SULPHUR 21 SULPHIDES OR SULPHURETS 22-34 Absorption and Elimination, 22 ; Physiological Action, External, 23 ; In- ternal, 23, 24 ; Therapeutical Action, External, 24 ; Internal, 28 ; Prep- arations and Doses, 33 ; Adulterations, 34. PHOSPHORUS 35-57 Absorption and Elimination, 36 ; Physiological Action, External, 36 ; In- ternal, 37 ; Toxic Action, 40 ; Tolerance, 41 ; Theory of Action, 42 ; Antidotes, 44 ; Therapeutical Action, Internal, 45 ; Preparations and Dose, 57. IODUM IODINE. . . 58-59 X CONTENTS. PAGE COMPOUNDS OF IODINE IODOFORM 59-94 Absorption and Elimination, 60 ; Physiological Action, External, 62 ; In- ternal, 62 ; Idiosyncrasy Toleration. 68 ; Incompatibles, 69 ; Therapeu- tical Action, External, 70 ; Internal, 82 ; Preparations and Dose, 93. BROMUM BROMINE 94-97 Physiological Action, 95 ; Therapeutical Action, External, 98 ; Internal, 97. COMPOUNDS OP BROMINE 97-120 Absorption and Elimination, 98 ; Physiological Action, Internal, 99 ; " Bromism," 100 ; Therapeutical Action, External, 104 ; Internal, 105 ; Preparations and Dose, 119. CHLORUM CHLORINE 120-124 Absorption and Elimination, 121 ; Physiological Action, External, 121 ; Internal, 122 ; Therapeutical Action, External, 123; Internal, 124 ; Prep- . arations and Dose, 124. AQUA WATER 125-150 Absorption and Elimination, 125 ; Physiological Action, External (Forms of Bath), 125 ; Internal, 135 ; Therapeutical Action, External, 136 ; In- ternal, 119. SEA-BATHING 150-153 Physiological Action, 151 ; Therapeutical Action, 152 ; Errors in, 152, 153. MINERAL WATERS AND BATHS 153-180 Physiological and Therapeutical Action, 153, 154; Classification, 154, ACIDUM ACETICUM ACETIC ACID GLACIAL ACETIC ACID 180 ACIDUM ACETICUM DILUTUM VINEGAR 180-184 Absorption and Elimination, 181 ; Physiological Action, 181 ; Prepara- tions and Do'se, 183. ACIDUM CARBONICUM CARBONIC ACID 184-189 Absorption and Elimination, 184 ; Physiological Action, 185 ; Therapeu- tical Action, 187. CONTENTS. XI PAGE ACIDUM ClTRICUM ClTRIC ACID 189-191 Absorption and Elimination, 190 ; Physiological Action, 190 ; Therapeu- tical Action, 190 ; Preparations and Dose, 191. ACIDUM HTDBOCHLORICUM HYDROCHLORIC ACID 191-199 Absorption and Elimination, 192 ; Physiological Action, 192 ; Toxic Ac- tion, 195 ; Therapeutical Action, External, 196 ; Internal, 196 ; Prepara- tions and Dose, 199. ACIDUM NITRO-HYDROCHLORICUM DILUTUM DILUTE NITRO-HYDRO- CHLORIC ACID 199-201 Physiological and Therapeutical Action, 200 ; Preparations and Dose, 201 ; Bath, 201. A.CIDUM HYDROCYANICUM DILUTUM DILUTED HYDROCYANIC ACID 202-215 Absorption and Elimination, 203 ; Physiological Action Toxic Action, 204 ; Theory of Action, 209 ; Antidotes, 210 ; Therapeutical Action, Ex- ternal, 211 ; Internal, 212 ; Preparations and Dose, 214. ACIDUM NITRICUM NITRIC ACID 215-221 Absorption and Elimination, 216 ; Physiological Action, 216 ; Therapeu- tical Action, External, 217 ; Internal, 219 ; Preparations and Dose, 221. ACIDUM PHOSPHORICUM DILUTUM DILUTE PHOSPHORIC ACID 221-227 Absorption and Elimination, 222 ; Physiological Action, 222 ; Therapeu- tical Action, 224 ; Preparation and Dose, 227. ACIDUM SULPHURICUM SULPHURIC ACID 227-233 Absorption and Elimination, 227 ; Physiological Action, 228 ; Therapeu- tical Action, External, 230 ; Internal, 231 ; Preparations and Dose, 233. ACIDUM SULPHUROSUM SULPHUROUS ACID 233-247 ALKALINE SULPHITES AND HYPOSULPHITES 234-247 Absorption and Elimination, 235 ; Physiological Action, External (Disin- fection), 235 ; Internal, 236 ; Therapeutical Action, External, 237 ; In- ternal, 243 ; Preparations and Dose, 247. Xll CONTENTS. PAGE ACIDUM TARTABICUM TARTARIC ACID 247-249 Absorption and Elimination, 248 ; Physiological Action, 248 ; Therapeu- tical Action, 249 ; Preparation and Dose, 249. AMMONIUM AMMONIA GAS 249-250 COMPOUNDS OF AMMONIA 250-264 Absorption and Elimination, 252; Physiological Action, 253; Therapeu- tical Action, External, 257 ; Internal, 259 ; Preparations and Dose, 263. ALUMINUM ALUM. 265-266 COMPOUNDS OF ALUMINA 266-275 Absorption and Elimination, 266 ; Physiological Action, 266 ; Theory of Action, 268 ; Therapeutical Action, External, 268 ; Internal, 271 ; Prep- arations and Dose, 275. ANTIMONIUM ANTIMONY AND COMPOUNDS 275-298 Absorption and Elimination, 278 ; Physiological Action, External, 279 ; Internal, 279 ; Theory of Action, 285 ; Tolerance, 286 ; Antidotes, 286 ; Therapeutical Action, External, 287 ; Internal, 287 ; Preparations and Dose, 297. MATERIA MEDICA AND THERAPEUTICS. SUBSTANCES. OXYGEN, 0,= 16 OZONE, O s . OXYGEN is the most universally diffused element, forming part of the air, the water, the earth, and of the tissues of plants and animals. Of the air it constitutes 23.01 per cent, by weight, 20.81 per cent, by meas- ure, being about one-fifth part. By Priestley, who discovered it (in 1774), it was named " dephlogisticated or vital air." Ozone is an allotropic form of oxygen. Its discoverer, Schonbein, did not arrive at a knowledge of its real nature, but Odling (in 1860), by a " splendid hypothesis," concluded it to be a condensed condition of oxygen, and this was afterward verified, among other observers, by Bro- die, who adopted the symbol O 3 , implying that three atoms of oxygen are condensed in each one of ozone. A minute proportion of it is found in the atmosphere more in that of the open country and of the sea than in that of towns, but its precise distribution and variation are not yet ascer- tained. Richardson calculated its amount as 1 in 10,000 of air ("Brit- ish Association Report," 3865). PBEPARATIOTST. Oxygen may be obtained pure from most of its com- binations, but is conveniently and usually prepared by heating the per- oxide of manganese, or the chlorate of potash, or both together. The former yields about one-ninth of its weight of oxygen. 3MnO,=MnO, Mn,O 3 + 2O; or 2KC1O 3 =2KC1+3O 2 . Ozone is produced in small quantities during the slow oxidation of phosphorus and some other substances. Lender recommends for its evo- VOL. I. 1 2 MATERIA MEDICA AND THERAPEUTICS. lution in sick chambers a mixture of peroxide of manganese, permanga- nate of potash, and oxalic acid, to be dissolved in water. In the labora- tory it is prepared by passing a succession of electric sparks through a closed chamber filled with air. CHARACTERS AND TESTS. The principal characteristic of oxygen is its energetic power of combination with organic principles, and with min- erals, to form acids and salts (oxidation), and with hydrogen to form water. It is a gas devoid of color, odor, or taste, of sp. gr. 1.1057 (at- mospheric air being taken as 1). Under a pressure of 320 atmospheres, and at a temperature of 220 F., it has been -liquefied by Pictet (1877). Ozone is much denser than oxygen, and in most chemical and physical, though not in all vital effects, it is more active; it is further distin- guished by a peculiar odor; also it is a powerful oxidizing agent, and changes many protosalts into persalts; it displaces iodine from some of its combinations, hence iodized starch paper is used as a test for the gas the paper turns bluish as iodine is set free, and combines with the starch, but the test is not very dependable. Ozone is absorbed by tur- pentine. According to Paul Bert, it possesses marked antiseptic properties, and animal substances keep long unputrefied in an atmosphere to which a minute proportion of ozone has been added (Medical Record, 1876; Comptes Jtendus, t. 80). PHYSIOLOGICAL ACTION (EXTERNAL). Th,e external and local action of oxygen in contact with mucous membrane or denuded skin is moder- ately stimulating. PHYSIOLOGICAL ACTION (INTERNAL). To describe fully the physiolo- gical action of oxygen would involve a description of the processes of respiration, sanguification, nutrition, and tissue-change, for to all these, and to life itself, it is essential. If it be deficient in the respired air, or if it be insufficiently absorbed, all the functions become disordered, assim- ilation is impeded, circulation diminished, and temperature lowered, and if its access to the lungs be prevented for a few minutes, life altogether ceases. But we are concerned, at present, only with the results of certain experiments in which animals or men have been made to respire either pure oxygen, or an atmosphere artificially charged with a definite pro- portion of the gas, and the first question that arises is whether more than a normal amount of oxygen can be taken into the blood under such cir- cumstances. It was early proved that animals kept under a bell-jar filled with oxy- gen lived longer than in ordinary air; and also that animals made to breathe oxygen could resist asphyxia longer than similar animals that had breathed only air (Priestley, Beddoes), but Regnault and Reiset, while corroborating the former observation, concluded, from a series of experiments, that breathing an atmosphere rich in oxygen, or even one of OXYGEN. 3 the pure gas, did not make the blood take up more oxygen than it would from ordinary air, nor was more carbonic acid excreted in consequence (Annales de Chimie, 1844). But these conclusions, which had much in- fluence on professional opinion at the time, have been disproved. Preyer showed that a greater saturation from oxygen-inhalation is, & priori, prob- able, and that ordinary arterial blood is not fully saturated with oxygen that it can take up more by being shaken with the gas. Demarquay proved it by showing that suppurating, indolent, or unhealthy wounds on the extremities of animals became quickly florid and hyperasmic when pure oxygen was inhaled; .an extra amount of the stimulating gas must clearly have been carried by the circulation to the wound. Allen and Pepys, and later, Limousin, showed, by inhaling an equal quantity of at- mospheric air at one time, and of oxygen at another, that, after the lat- ter, double the amount of carbonic acid was expired, and this increase continued fifteen minutes after the inhalation had finished. Other ob- servers have reported that the elimination of uric acid during a course of oxygen-inhalation is markedly lessened, i.e., that more complete combus- tion occurs within the system (Schmidt's Jahrb., 1865, t. 1, s. 28); thus, Kollmann found that while 300 grammes of the ordinary secretion of urine contained 236 milligrammes of acid, the same quantity contained only 122 milligrammes after inhalation of 12 litres of oxygen. On an- other occasion the amount of acid came down from 134 milligrammes to 25 milligrammes. A clinical illustration, pointing in the same direction, is given by Gubler. After several copious draughts of the pure gas in an active nas- cent condition, the respiratory movements and the pulse became slower, a general sense of comfort was felt, and, without any dyspnoea, the pause between expiration and inspiration could be much prolonged. Thus, tak- ing thirty seconds as a maximum time during which the breath may be " held " after breathing atmospheric air, it rises to ninety to one hundred seconds after breathing oxygen. From other observations, Gubler con- cludes that the blood receives the gas in proportion to its physical capa- city for it, rather than in proportion merely to the vital necessity of hae- matosis: the globules absorb what they need, while any excess circulates free, and enters into combination only as the haemoglobulin loses oxygen in passing through the capillaries. Hence, the amount of oxygen absorbed by an individual is proportionate to the number of his corpuscles (we should now say of his haemoglobin), and a plethoric man quickly using up his reserve air breathes faster than a healthy one. On the other hand, an anaemic patient also breathes more rapidly than normal, since his cor- puscles are either too few in number or otherwise altered, so that they cannot take up enough oxygen. 1 Buchheim states an opposite view, viz., 1 " Quinquaud, availing himself of the reducing properties of sodic hydrosulphite, was enabled to calculate the maximum, quantity of oxygen capable of being absorbed 4 MATERIA MEDICA AND THERAPEUTICS. that oxygen is not absorbed proportionally to the amount of it brought to the lungs, but to its requirement for tissue-change; yet even he admits that the amount taken in can be increased to some extent by continued deep inspirations, and by breathing air rich in oxygen or under high pres- sure; he only denies that such adventitious oxygen affects the tissue- change (Archiv fur Exper. Pathologic: Klebs, Bd. iv., 1875); he admits also that improvement in symptoms may result from breathing compressed air or pure oxygen, but thinks we cannot hope to influence the course of illness by increasing the amount of oxygen contained in the blood. Granting, then, the possibility of taking into the blood more than the normal amount of the gas, it yet remains true that in many healthy persons no marked effect is to be noted from inhalations of fifteen to thirty litres of oxygen, unless it be a sense of warmth in the mouth and at the epigastrium (Husemann). Naoumoff and Beliaieff, breathing it for seven to seventeen minutes, found no appreciable change in pulse or temperature, whilst in dogs made to breathe alternately air and oxygen, the temperature rose sometimes with the latter a few tenths of a degree, and there seemed some dilatation of capillaries (Abstract, Lancet, i., 1875). Mr. Savory, partly following Regnault and Reiset, and partly relying upon observations with animals which showed no increase of temperature under oxygen-inhalations, has also argued that these can exert no effect on the system; but Dr. Edward Smith has pointed out that such ex- periments, to be conclusive, should extend over long periods, and take account of changes in diet, etc.; he himself found evidence of increased chemical change under oxygen. In some persons, inhalation of the gas causes temporary nerve-symp- toms, such as exhilaration, sense of vigor, heat of skin, tingling of fingers, and even pain referred to the fifth nerve (Husemann). I have myself observed all these symptoms, except the last, immediately after the in- halation; also some giddiness, and some rise of pulse, probably from extra effort in breathing; in the delicate, improved appetite, improved motor power, and sleep have followed. I can corroborate this observation, which has been made by Birch, Demarquay, and others. Oxygen, then, is not without effects, though these vary with different individuals, and we cannot yet reduce them to precise scientific expression. Dr. Richardson, judging partly from a case in which the blood passed from the lungs back to the right heart, and so circulated "surcharged with oxygen," states that such excess leads to great exhaustion of mus- by a given amount of blood. The mean capacity in health, he found, was 240 cubic centimetres of oxygen to every 1,000 grammes of blood=:128 grammes haemoglobin." He assumes that this absorption capacity is invariable, but in reality it varies accor*d- ing to illness, especially in forms of anaemia. (Coupland : Gulstonian Lectures, March, 1881). OXYGEN. 5 cular and nerve-power and constant perspiration (Lancet, ii., 1878), but the conditions are not simple enough for asserting that these symptoms are solely due to the gas. If an animal be kept in a closed vessel full of oxygen, it dies we cannot exactly say why. Broughton discovered that rabbits, guinea-pigs, sparrows, etc., thus kept, were at first lively and ex- cited with quickened circulation and respiration, but passed in an hour's time into a weakly, depressed condition, and finally died, although the air in the bell-jar was still pure enough to rekindle a flame. Dr. Richardson obtained similar results with oxygen that had been breathed and then purified, and he inferred that some principle essential to life yvas removed from the gas in the process of respiration (British Medical Journal, ii., 1860). He found in the animals after death a condition of " hyperinosis," and Demarquay, who met with analogous results, describes the volume of the blood as apparently much increased, the muscular and other tissues brightly red, the venous blood distinctly to be recognized, but less dark than usual, and more quickly reddened on exposure, the lungs congested being " intensely red," and all the viscera unduly vascular. The same observer states that a small amount of gas may be passed directly into the blood by careful intravenous injection, and in such cases, after death, the spleen is markedly redder than usual. Theory of Action. Rosenthal concluded from certain experiments that an increased amount of oxygen in the blood caused " apncea," for if, after blowing in air for twenty to sixty minutes through the trachea of an animal, the artificial respiration be suddenly interrupted, the animal remains motionless and without breathing for twenty to forty seconds, then respiratory action, at first weak, ultimately normal, returns. Now, this being an opposite condition to one of dyspnoea, and the latter being dependent upon want of oxygen and consequent extra stimulus of the respiratory centre, he argued that apncea must depend on overmuch oxygen. Ewald also, by experiment, determined some slight increase of oxygen in the blood in apnoea; Hering not so. In any case there is really no causal relation between the two facts (Buchheim: loc. cit.), nor is apnosa complained of after oxygen-inhalation or condensed air treatment. Experiments of this nature, though very interesting, cannot be taken as practical guides in the clinical use of the gas, and, under ordinary con- ditions of inhalation, oxygen never causes the lung-inflammation and exaggerated vital processes predicted by Beddoes and others. Direct Influence of Oxygen on the Heart. Some observations by Cyon on this subject deserve notice. Separating the heart of a frog, he connected it with a system of glass tubes and a manometer, and then passed through its cavities, first, serum saturated with carbonic acid gas, and afterward serum saturated with oxygen. The former caused sudden arrest in diastole, while the latter restored the movements of the heart Mr. Erichsen found, in experiments on asphyxiated animals, that ventri- 6 MATERIA MEDICA AND THERAPEUTICS. cular contraction could be re-excited by oxygen when ordinary air had no effect. According to Hermann, oxygen is not indispensable for the cardiac contractions they may occur without it, but irregularly; and if the gas be absent, or supplied in insufficient quantity, regular and synchronous contractions are impossible (Robin's Journal d' Anatomic et de Physio- logic, 1868-70). Musculo- Nervous System. Many observers have localized in the mus- cular system the special action of oxygen, and Spallanzani, finding that a chrysalis absorbed much less of the gas than a butterfly, argued that the difference was determined by the less movement of the former. Brovvn-Sequard has shown, by interesting experiments, that when the muscular and the nerve tissues have lost their vital properties, they may recover them under the influence of freshly oxygenated blood (" Journal," 1858). Thus, having injected some of his own blood (defibrinated and charged with oxygen) into the radial artery of a man executed thirteen hours previously, and whose limbs were quite rigid, muscular irritability returned to the hand. In another case he removed the arm, and three hours later, when rigor mortis was complete, he injected dog's blood through the brachial artery, and the rigidity disappeared, first in the fingers, then in other parts; the skin resumed its color, became elastic and supple, and the hair-bulbs projected (goose-flesh). In animals the vital qualities could not be restored so long after death; but, in one curious experiment, the head of a dog being cut off, was injected through the carotid and vertebral arteries, and movements of the eyes and the face- muscles continued for a quarter of an hour. Other observations have proved that oxygen augments the vital functions of the spinal cord and motor and sensory nerves, and that, by the continued injection of blood charged with it, a dead body resists decomposition for upwards of fifty hours. Richardson, injecting oxygen into the arteries of recently killed animals, tested the muscular irritability by Faradic currents, and found that the gas (warmed to 75 F.) increased irritability very much, but only for a short time. The onset of permanent rigidity was rather hastened. COMPRESSED AIR. PHYSIOLOGICAL ACTION. This varies somewhat according as to whether the patient is wholly immersed in an atmosphere of air compressed to one-half to one atmosphere in a closed chamber for one or two hours, or whether he simply breathes it from a reservoir through a tube with closely fitting mouthpiece for twenty to sixty inspirations. The former and older method, as carried out by Reichenhall, often caused oppression of head, tinnitus, and other disagreeable sensations, but had a sedative and equalizing effect on the circulation, slowing heart- action, raising arterial tension and altering the distribution of blood, lessening its amount in the veins and increasing it in the arteries. It increased also expectoration and excretion (Burdon Sanderson: Practi- tioner, vol. i.). OXYGEN. 7 In the more recent method employed by Waldenburg and Biedert, the extra compression amounts to only T ^ to -j atmosphere, and the good results obtained are more clearly traceable to the extra amount of oxygen. Nutrition and blood-formation are improved, the " lesser circulation " is rendered freer and less congested, and at the same time the vital capacity of the lungs is increased. The alternate use of rarefied air, which induces rather opposite conditions, is employed in this method (Medical Times, ii., 1877). Certainly theory favors further trials of "pneumatic med- icine," but we require more extensive experience before judging of its merits. Ducrocq, indeed, reports almost opposite conclusions to those of Burdon Sanderson (Archives Generale, September, 1876). Mosso describes various anomalous results in the distribution of blood in the extremities under a pressure of two atmospheres, and explains them by changes in the innervation of the heart, or, with Paul Bert, by chemical, rather than by mechanical changes (Medical Record, 1879). Workmen employed in making bridges, etc., under a pressure of two to three atmospheres, suffer from pains in the ears and joints, apparently due to " dilatation of superficial vessels," after leaving work. Among a large number of men no hemorrhage, heart disease, or serious disorder occurred (Medical Times, ii., 1877; of. Moxon: British Medical Journal, i., 1881, p. 496). OZONE. PHYSIOLOGICAL ACTION. Dewar and McKendrick pointed out the remarkable fact that, instead of the blood becoming more highly oxygenated under ozone-inhalations, it assumes venous characters in all the vessels, a fact which is explained by the greater density of this gas interfering with the due excretion of carbonic acid from the blood ; it causes also some local irritation of the lining of the air-passages, and it induces slowing of the heart-action and respiration (" Proceedings of the Royal Society," 1873-74). This was not in accord with previous observations, for Dr. Ireland had stated that ozone quickened respiration and circulation, excited the ner- vous system, and promoted coagulation of blood (Edinburgh Medical Journal, 1862-63, p. 729), but it is probable that his animals respired mainly oxygen. Day also had found that oxygen, " ozonized in propor- tion of one-twelfth, caused rapid respiration and heart-action, and much local irritation ; " but quite recently Dr. John Barlow has confirmed and added to the observations of Dewar and McKendrick. He reports that ozonized air depresses the nervous system, probably through leading to accumulation of carbonic acid in the blood; it lessens the frequency of respiration, and hence also of heart-action, together with the excretion of carbonic acid and the absorption of oxygen. It irritates the pulmonary mucous membrane, and may cause bronchitis or lung-congestion (Red- fern), or even asphyxia. It decolorizes the red corpuscles, and causes a granular appearance, probably from uniting with haemoglobin; it stops 8 MATERIA MEDICA AND THERAPEUTICS. the amoeboid movements of the white corpuscles, and renders the nucleus apparent ; there is no evidence of its entering the circulation in a free state. As illustrating its irritant effect, Dr. Barlow records its producing an obstinate inflammation of the nasal membrane (Journal of Anatomy, October, 1879). THERAPEUTICAL ACTION (EXTERNAL). Ulceration Gangrene. The gas has been applied in jet to atonic scrofulous ulcers by M. Demarquay, with much advantage. Gangrene has been attributed by M. Raynaud to deficient oxygenation of tissue, and Langier and other French surgeons have recorded good re- sults from its local treatment by oxygen (Bulletin de Therapeutique, 1863- 66). The destruction of tissue has been checked and limited, the swelling subdued, and the neighboring threatened livid tissue restored to its natural color. Dr. Goolden has recorded severe cases of phagedenic ulceration, especially one affecting the throat, which yielded to local application of oxygen, and he has recently written to renew his advocacy of this remedy (Lancet, i., 1866; ii., 1879). THERAPEUTICAL ACTION (INTERNAL). Inhalation. Remedially, oxy- gen may be considered as it exists diluted in the atmosphere, or as pre- pared artificially for inhalation with a definite proportion of air. Pure fresh air of the elevated country or the coast is of well-known efficacy in all conditions of debility, of chronic catarrh and chronic dys- pepsia; sea-air especially contains more ozone than the air of land, and is of value to those who have lived in towns and followed sedentary oc- cupations. On the other hand, patients with weak chests and readily congested lungs are better in a less rare and less ozonized atmosphere, since a large proportion of ozone may excite in them irritation of mucous membrane (Cornelius Fox). During epidemics of influenza an unusual amount of ozone has been verified in the air, while in cholera epidemics it has been almost absent. The choice of a climate for any given case is, however, generally influenced by other considerations than the mere amount of oxygen to be obtained; the subject need not, therefore, be fully considered in this place. The chief cases in which theory indicates, and experience justifies, the use of oxygen-inhalation, are those of as- phyxia and of venous congestion occurring in the course of phthisis, asth- ma, or emphysema. ASPHYXIA. When this condition is induced by breathing noxious gases, the best results are obtained from oxygen. Sometimes a free cur- rent of fresh air is sufficient to restore persons rendered unconscious by an escape of gas or by the products of combustion retained within a room.; but, in extreme cases, pure oxygen would seem the only means of saving life. Limousin has reported a case of asphyxia from carbonic acid inhalation, with intense cyanosis, which recovered under the use of oxy- OXYGEN. gen, and in which he was able to verify a steadily increased elimination of carbonic acid by the lung, in proportion to the oxygen taken ( Comptes Rendus, Societe de Therapeutique, 1868). M. Constantin Paul has re- corded many cases, including cyanosis from obstructed respiration, coma from opium-poisoning (when the respirations were only seven per minute), and asphyxia from carbonic oxide, all quickly and markedly relieved by oxygen (Bulletin de Therapeutique, August, 1868). Rabuteau refers to an instance of its good effect in asphyxia from sewer-gas, when ordinary means, employed by M. Griscolle, had failed to relieve (" Elements," p. 48) ; and finally I may quote a striking case recently reported by Dr. Charles B. Ball. A man, wife, and daughter, were found unconscious in a small room where there had been, through the night, a large fire, though the chimney was blocked. The two adults recovered with fresh air and ordinary means, but the daughter, aged sixteen (phthisical), re- mained unconscious and convulsed. After many hours of stimulating treatment she seemed to be dying ; respiration was feeble and slow, the pulse imperceptible; then she was made to inhale pure oxygen, afterward oxygen and air. " The effects were rapid and marked: " respiration, color, and pulse improved, and though at -first convulsed, she ultimately re- covered. Dr. Ball, impressed by this case, and remembering Reynault's proof that man can live in an atmosphere strong in carbonic acid, pro- vided that the proportion of oxygen is also increased, has contrived an apparatus with a reservoir of oxygen and a mask for safe use in dangerous mines. He has himself safely respired an atmosphere containing 18 per cent, carbonic acid with 30 per cent, oxygen added (British Medical Jour- nal, i., 1878). If we compare the result in Dr. Ball's case with the fatal course of such cases of gas-asphyxia as, e.g., may be found in the Edin- burgh Journal, 1874, we shall better realize the importance of using oxygen in preference to other measures. In various forms of poisoning, whenever death threatens from asphyxia, as under prussic acid, chloro- form, etc., artificial respiration, i.e., supplying more oxygen, offers the best means of saving life. Rosenthal and Leube found that the symptoms of strychnia-poison- ing might be deferred or prevented by artificial respiration (Reichert's Archiv, 1867). H. Ebner thought the same result could be obtained by rhythmical movements of the limbs without supplying more air to the lungs, but Ananoff has since proved that pure oxygen is distinctly an- tagonistic to strychnia-action, and that when supplied to animals poisoned by this alkaloid it relieves them more than free access of ordinary air, or any movements ( Gentralblatt fur Medicin, No. 27, 1874). Asthma Emphysema, etc. The main suffering, the " besoin de res- pirer," common to these maladies, is clearly traceable to deficient access of oxygen to the blood in the lung-capillaries, and I arn satisfied that in the majority of instances relief to this suffering may be given by sup- 10 MATEBIA MEDIOA AND THERAPEUTICS. plying a larger proportion of the gas. If it be objected that permanent good results are not obtained from it, the same objection may be made to many other remedies ; it is still something to have a means at hand for temporary relief. Dr. John Hooper thus describes its effects in a man of fifty-five, " for many years a martyr to asthma." During a very severe paroxysm he was thought to be dying it seemed impossible that he could rally. As a dernier ressort, oxygen was tried, the end of a glass retort containing it being applied to his mouth, though he had not power to enclose it with his lips. " The effect was wonderful and quickly mani- fest in increased mobility of the ribs,, fuller inspiration, disappearance of lividity, and lastly in his seizing the end of the retort, and in the avidity with which he inhaled when possessing the voluntary power" (British Medical Journal, i., 1862). Details of diagnosis are not given in this instance, but paroxysms of true nervous asthma and of bronchitic asthma may both be shortened by similar inhalation. Beddoes related twenty- two cases, of which he claimed to have cured ten and relieved nine ; and it seems worth while to refer to his case of " Mr. Hare, of Conduit Street, who, in 1796, after having been subject for eleven years to asthmatic at- tacks accompanied by indescribable suffeatog, and only relieved after many hours by blisters and expectorants," recovered average health un- der the use of the gas continued for some months (op. cit., 4th part, p. 49). M. Demarquay also witnessed excellent results, e.g., in a man aged nineteen, subject from childhood to asthmatic attacks: "they ceased, as if by magic, as soon as he began to inhale oxygen (" Essai de Pneumato- logie," p. 725). Dr. Mackey has reported a good illustration of the value of the gas in ad- vanced emphysema pulmonum (Practitioner, vol. ii., May, 18G9). A lady, aged fifty-five, was subject to constant dyspnoea, increased by every move- ment, and amounting at times to partial asphyxia. She had the physical signs of the malady, together with dilated weak heart and embarrassed cir- culation, as evidenced by osdema of the face and extremities; was subject to attacks of bronchitis, but at the time of treatment the main complaint was the difficulty of breathing. She inhaled a mixture of from three to twelve pints of oxygen, with sixty of air, at intervals of three or four days, for a period of six weeks. After each dose " marked relief was ex- perienced, which she expressed as being able to take a deep breath and get sufficient air (a feeling not known for years), as being able to move with comparative ease, feeling more buoyant and more like healthy per- sons should feel than she ever remembered." Expectoration was rendered more copious and facile for a day or two after the inhalation ; there was no other definite effect on secretion, nor any on circulation, unless it were some palpitation during the night after a large dose. The nervous irri- table states to which such patients are liable were also soothed under the treatment, which certainly effected more than ordinary medicinal agents. OXYGEN. 11 It could not, however, alter the organic conditions, and cardiac death occurred suddenly, after an attack of bronchitis, in the following win- ter. These illustrations seem to me sufficient to prove that oxygen might he used more often than it commonly is in such cases. According to Biedert's method, emphysema is treated by a few short sittings of res- piration in compressed air, and then by expirations into an atmosphere of rarefied air, " in order to counteract anaemia by attracting blood to- ward the lung-tissue." In Bronchitis, bronchial catarrh, and bronchial asthma, compressed air is used to stimulate the lung, improve its circulation, and facilitate ex- pectoration ; it seems to be useless during actual asthmatic attacks. In mitral disease it is said to be valuable, and in dyspnoaa dependent on dilatation of the right heart. Pleuritic Effusion Empyema. I have used oxygen in several of these cases with good results. During inhalation relief to breathing was experienced, which lasted for some time afterward; compressed air has also been employed for these disorders. Biedert reports two cases of pleuritic adhesion in which vital capacity was much increased by it, and Kelemen one of empyema in which the effusion disappeared as diuresis set in (Medical Record, August, 1879). Whooping- Cough. Moutard-Martin says that compressed air baths are efficient in this complaint (Union Medical, March 11, 1879). Phthisis. The true value of oxygen-inhalations in this disease has been the subject of much discussion. So early as 1783 it was tried with apparent good result, and Fourcroy was appointed by the French Govern- ment to report on the subject. After examining into twenty cases he concluded that almost all patients, benefited, for a time at least, by the treatment, but relapsed and got worse more rapidly and with more in- flammatory complication than if oxygen had not been used (" Sur les Proprietes Medicinales de PAir Vital," 1789). It is evident that to establish such a conclusion very careful observa- tion is required, and more precision than the then art of diagnosis could attain; but the opinion exercised considerable influence at the time, was adopted by Dr. Beddoes and some other observers, and was one reason why this method of treatment fell into a disuse which was not altogether deserved. Among modern writers, Dr. Birch, Constantin Paul, and Demarquay have reported relief in cases of phthisis, and the following occur among others related by Dr. Mackey. Mrs. W., aged thirty-one, of phthisical family, when first seen had had, for six months, cough, emaciation, and latterly diarrhoea, night-sweating, hectic, haemoptysis, and purulent expec- toration ; much chest-pain ; there were dulness and crepitation at left apex. After some months of treatment of the usual recognized kind, she 12 MATERIA MEDICA AND THERAPEUTICS. improved, and complained mostly of debility, cough, pain, expectoration, and dyspnoea. She commenced oxygen-inhalations (six to twelve pints in sixty). After eight inhalations, at intervals of two days, all these symptoms were markedly better, and treatment was omitted. The mal- ady was arrested for a time, but, after exposure to poverty and misfor- tune, this patient died one or two years later. R., aged nineteen, with family history of phthisis, after partial recov- ery from acute softening of the right apex, commenced inhalation as a remedy for dyspnoea and pain in the chest, and at the end of two months was sufficiently recovered to resume the sedentary work of a clerk. It should be stated that iron and cod-liver oil were given throughout, but the patient distinguished definite relief to his breathing from the use of the gas. He was in fair health six months afterward, when the case was reported, but he died within eighteen months, of acute phthisis following imprudent exposure. A third patient, a man aged thirty-four, commenced inhalation while still suffering from acute symptoms dependent on softening tubercle, and continued it for nearly three months, with marked improvement as to breathing-power, cough, expectoration, and appetite. In this case the end came by pneumonia and pleuritic effusion, but after a prolonged ex- posure to bad weather, and independently of the treatment. Such cases in themselves do not show more than a temporary relief of symptoms, and at least no harm from the gas, and they are really too few for any conclusions. A larger number are given by Dr. A. H. Smith ("New York Prize Essay"), and his general results are so far favorable as to warrant still further trials with this agent. I would except from its use cases of very acute character, and of haemoptysis, in which, indeed, the mere exertion of inhaling would contra-indicate it. In other cases benefit may be hoped for, not so much through any local action on the lung-tissue as through improvement of the blood-condition, the appetite, and the power of assimilation; nor, speaking from experience, do I believe that oxygen, used with ordinary care and in such dilution as has been mentioned, can at all irritate or inflame the lung-tissue. Dr. Read (Long Island) has reported a series of twenty cases treated by inhalations of oxygen in conjunction with cod-liver oil. The majority did well, and he reports it "an admirable adjuvant to the usual routine treatment of phthisis, especially when the patients were unable to go out of doors." He gave the gas also in acute pneumonia, and apparently with advantage. The use of compressed and rarefied air seems rather to alleviate symptoms than to cure phthisis. In pretubercular stages it may serve to strengthen the respiratory muscles and open out the chest, but it is not suitable for acute or hemorrhagic cases, or those with a krgo area of congestion. Hepatic Congestion. Dr. Birch has advocated the use of the gas in OXYGEN. 13 this condition, and states that it will relieve the constipation and other symptoms connected with it. The remedy has no doubt been of service, especially in cases with much headache, depression, loss of appetite, and sense of pain and constriction about the shoulder and chest, with palpi- tation and dyspncea. In some chronic cases in which it was tried I have not seen benefit, and, as a general rule, medicinal and dietetic treatment, with such oxygen as is obtained by increased exercise, will give at least more rapid results. Chlorosis Anaemia. Beddoes relates many instances of chlorosis benefited by inhalations, but other observers have not met with equal success from its use in this malady. I have, however, known it to relieve chlorotic headache. In extreme cases of anaemia the gas is not always well borne; it has seemed sometimes to increase depression for the time, and cause faintness and palpitation. Diabetes. Pettenkofer and Vogt determined that diabetics absorbed less oxygen than healthy persons, and that hence we might hope, by in- troducing more into their system, to obviate some conditions of their malady. Bouchardat, and also Demarquay, have recorded cases relieved by this treatment, but no extensive trial of it has been made. Peroxide of hy- drogen has been given internally with the same object of oxygenation and with some partial success. I have tried oxygen-inhalation in several cases of diabetes in which prostration, dyspncea, and tendency to cyanosis were prominent symptoms one case was at the very unusual age of seventeen months, another at thirteen years, and three others at adult age. The gas certainly relieved for a time the symptoms mentioned, although it did not in any instance reduce the sugar in the urine. Albuminuria. In a few cases of Bright's disease, narrated by Dr. C. Paul, albumen disappeared from the urine during treatment by oxygen. This occurred also in the often-quoted case observed by Kollman and Eckart (Schmidt's Jahrb., 1865). More recently, Dujardin Beaumetz re- ports a case "in the last stage," and in which every diuretic had proved useless, and yet, twenty-four hours after inhaling oxygen, the albumen disappeared, and was still absent twelve days afterward when the case was reported (Medical Itecord, March, 1879). Other physicians, while recording similar cases in their own experience, stated that the good re- sult was not of long duration. Nerve Disorders. A few cases of severe neuralgia relieved by oxygen are on record (Birch, J. Hooper: loc. cit.), and it has been praised in spi- nal palsy, nerve debility, and hysteria, but I think without sufficient rea- son. What little trial I have made of it in such cases has not given me any good result. Dr. Ramskill has reported a case of epilepsy apparently relieved by 14 MATERIA MEDICA AND THERAPEUTICS. the gas, which he gave by inhalation from peroxide of hydrogen (Medical Times, i., 1863). Hydrophobia. Drs. Paul and Josias used oxygen in this malady, and, although the patients died, some relief was given to the symptoms of as- phyxia. Recently Dr. Schmidt has recorded the case of a girl, aged twelve, who, when recovering from diphtheria, was bitten by a mad dog; seventeen days afterward she had difficulty of breathing and of swallow- ing, and oxygen-inhalation relieved her; she relapsed next day with con- vulsions, spasms of respiratory muscles, and unconsciousness; oxygen again relieved her, and, after some complications traceable to the diph- theria, she ultimately recovered (Medical Record, 1878). Tetanus Strychnia- Poisoning. Richardson refers to some cases of tetanus, under Sir J. Paget, much relieved by oxygen-inhalation; the pa- tients became bathed in perspiration, and the muscles relaxed. He insists also on its importance in strychnia-poisoning in conjunction with amyl nitrite, as unless elimination be promoted by oxygen, the spasm, even if relieved, soon returns. " Oxygen is a remedy for all excess of nerve-ac- tion leading to spasm " (cf. p. 12). MODE OF ADMINISTRATION. M. Demarquay obtained his oxygen from chlorate of potash, and made use of caoutchouc bags, which were filled with the washed gas and could be carried to the patient's bedside. M. Limousin has introduced a small portable apparatus with brass retort, wash-bottle, and caoutchouc bag, so that the gas can be prepared and used on the spot; but in this country the most available method is that of Mr. Barth, of Bloomsbury: he supplies a small gasometer, with the gas condensed under high pressure into iron bottles, from which a measured quantity can be introduced and mixed in definite proportion with air, and then inhaled in the usual way. This method leaves nothing to be desired. The patient should be quiet for a time before and after inhala- tions, and not be over-fatigued; the stomach should be neither full nor quite empty; the feet should be warm, and the circulation equable. Other modes have been devised for introducing oxygen into the system, as by oxygenated water and oxygenated bread, but I have no confidence in these preparations. A method still open to investigation is the adminis- tration of peroxides, especially those of hydrogen and of iron, and of chlorate or permanganate of potash (v. Potash); and some experiments of C. Bernard warrant the conclusion that these compounds give up to the blood a proportion of their oxygen, and are eliminated in a less oxi- dized condition. CoNTRA-IxDiCATioxs. I have not met with any case wherein oxygen, more or less diluted, was indicated, and could not be safely used. If or- ganic heart disease be present, care should be taken to regulate the force and the effort of inhaling, which sometimes gives rise to giddiness or pal- pitation independent of the remedy. Some soreness of the throat, and NITROGEN. 15 temporary discomfort about the mouth, may occur if the apparatus be not quite free from dust; but from the gas I have seen no bad results what- ever. The contra-indications to the use of compressed air are degenera- tion of vessels and an apoplectic tendency; to that of rarefied air, pul- monary hemorrhage. NITROGEN, N,=14, This gas is very widely diffused, constituting 76.99 per cent, by weight of the atmosphere, 79.19 percent, by measure. In combination, it occurs in the mineral kingdom as the basis of nitrates, nitrites, etc., it enters into the composition of almost all animal tissues, and in the vegetable kingdom it is found as a constituent of the alkaloids and the most active medicines, as well as of the most nourishing foods. PREPARATION. Nitrogen may be obtained by burning either phos- phorus or a mixture of iron filings and sulphur, or certain other sub- stances, in a limited quantity of air, as under a bell- jar: the oxygen will be taken up and only nitrogen left. The process is not an easy one, and hence, possibly, the little trial so far made of the gas in medicine. CHARACTERS. A colorless, odorless gas, sp. gr. .975, soluble in water to some extent. PHYSIOLOGICAL ACTION. This is negative in character; the gas will not support respiration (" azote ") nor combustion, and it seems to act in the atmosphere as a diluting agent for the too stimulating oxygen. M. Demarquay injected nitrogen into the peritoneum and cellular tissue of animals, and came to the conclusion that more or less exhalation from the lungs, etc., of the normal gases of the blood was caused by it (Archives Generates, 1859). THERAPEUTICAL ACTION (EXTERNAL). On the hypothesis that the stimulation of ordinary air caused irritation and suppuration in wounds, stumps, etc., M. Demarquay was led to try the effect of enclosing them in caoutchouc bags full of nitrogen; but the practice was not successful. THERAPEUTICAL ACTION. INHALATION. It has been proposed to utilize nitrogen by adding a larger than normal proportion of it to ordi- nary air for inhalation in irritable and inflammatory lung-condition, but no definite results have been obtained in this country. Steinbrtick (Vienna) has, however, lately recommended nitrogen-inhalations in the first and second stages of phthisis in young persons, stating that " they lower the circulation and allay nerve-irritability, give great relief, and sometimes cure; " in the third stage they are injurious (DobelVs Iteports, 1876). T have not seen any confirmation of these results. The power of nitrous oxide as an anaesthetic has been largely developed in recent times (v. Anaesthetics). 16 MATERIA MEDICA AND THERAPEUTICS. HYDROGEN, H,=l. Hydrogen, being the lightest of known elements, is commonly taken as a standard of specific gravity and combining proportion. It has been found free in small proportions in certain volcanic gases, and occurs extensively in combination, e.g., in water, in many acids and gases, in hydrocarbons, and all substances used for artificial light tallow, oils, coal-gas, etc. and throughout the vegetable kingdom. It was formerly known as " in- flammable air," and when lighted burns with a bluish flame. PREPARATION. By acting on granulated zinc with dilute sulphuric or hydrochloric acid Zn + H a SO 4 =:ZnSO 4 + H 2 CHARACTERS. A colorless, inodorous gas, of sp. gr. 0.0692. PHYSIOLOGICAL ACTION. This is negative in character. Hydrogen does not support respiration or combustion, and Priestley ascertained that animals immersed in it died as soon as in carbonic acid. Beddoes found that attempts to inhale it caused cyanosis of lips and face, quick- ness and smallness of pulse, vertigo, impaired vision, and in some persons, drowsiness, slight insensibility, and when pushed, asphyxia in greater or less degree. A mixture with oxygen, when inhaled, causes the voice to become shrill. THERAPEUTICAL ACTION. Dr. Beddoes used hydrogen gas as an in- halation in phthisis, both by itself and in mixture with oxygen. He reported some cases as relieved and others cured, but his results have not been corroborated. The most constant effect seems to have been the production of sleep. HYDROGEN II PEROXIDUM PEROXIDE OF HYDROGEN, H.0^34. PREPARATION. By acting on barium peroxide with hydrochloric acid. CHARACTERS. This compound of hydrogen is a liquid of the con- sistence of syrup, of strong, disagreeable, metallic taste, very unstable, and readily parting with its oxygen; hence, it is a powerful oxidizer. It blanches a solution of litmus. A solution, of sp. gr. 1,006, is in common use abroad for bleaching purposes, and is said to be permanent. PHYSIOLOGICAL ACTION (EXTERNAL). This liquid, applied locally, whitens the skin and mucous membranes, and acts as a moderate caustic. It has also marked antiseptic power, though not equal to carbolic acid in that respect. Urine mixed with one-tenth of peroxide remained nine months without putrefying (Guttmann). The patent disinfectant termed " Sanitas " is said to depend for its efficacy mainly upon this peroxide. PHYSIOLOGICAL ACTION (INTERNAL). It produces, when given inter- nally, some oxidizing, stimulating, and, in full doses, irritant effects. The bleaching solution, of sp. gr. 1,006, has been used by Assmuth, Schmidt, HYDROGEN. 1 7 and Gutttnann for hypodermic injection in animals, and found to cause dyspnoea, clonic convulsions, and death in a few minutes from asphyxia. The last-named observer traces this to the development of bubbles of gas in the right cavities of the heart, the blood frothing up as if air entered by the veins. The result is partially antagonized by injection of ferrous sulphate, implying the combination of this with part of the oxygen liber- ated (Abstract, Medical Times, ii., 1878). THERAPEUTICAL ACTION (EXTERNAL). Ulcerations. Lotions con- taining peroxide have been used with advantage in soft chancre and in cases of fetid ulcerations of the mouth. THERAPEUTICAL ACTION (INTERNAL). Chronic Dyspepsia. Richard- son, Guttmann, and others have reported improvement of the digestion under this remedy, but it is not much used. Diabetes. Cases of this disorder treated successfully by peroxide of hydrogen have been recorded (British Medical Journal and Lancet, 1868), and much good was at one time expected from it as an oxidizing agent; but Dr. B. W. Richardson, who introduced the remedy and used it in more than two hundred cases, came to the conclusion that, although it could reduce the specific gravity of the urine, it at the same time in- creased its quantity, and had no really good effect (Medical Times, ii., 1868). Dr. Pavy tried it in a few cases without any result (" On Dia- betes," p. 268). Cyanosis Pulmonary Congestion (Passive). In these conditions, where oxygenation of the blood is defective, and which are generally connected with heart disease, I have sometimes seen advantage from the internal use of peroxide of hydrogen it is worth trial, but further ob- servations are needed for estimating its true powers. Dr. B. W. Foster has reported two cases of congenital cyanosis relieved by it (" Clinical Medicine," 1874). Phthisis Strutna. I have no personal experience of its use in these diseases, but benefit has been reported from it. In early stages it is said to improve digestion, in later stages to relieve dyspnoaa, and in struma to cause absorption of glandular swellings (Ranking, 1868). Pertussis. Much power has been claimed for peroxide of hydrogen in the relief of paroxysms of whooping-cough, but I have no experience of it. In a severe case, complicated with cj'anosis, in a child with patent foramen ovale, Dr. Mackey used the remedy with apparently good result for the time; the degree of cyanosis was less while the remedy was taken, and the attack of pertussis ran a mild course. PREPARATIONS AND DOSE. rA solution containing ten volumes of oxygen is the one recommended by Dr. Richardson; an ethereal solution is preferred by others. Dose: of the former, 1 to 4 dr. freely diluted j of the ethereal solution, ^ to 2 dr. VOL. I. 2 18 MATERIA MEDIC A AND THERAPEUTICS. CAKBO, CHAECOAL, C, = 12. Carbon is very widely distributed throughout all the kingdoms of nature ; the diamond represents its purest condition, crystallized in the form of a regular octahedron. Plumbago, or graphite, the " black lead" of our pencils, is another form which is nearly pure, and is sometimes crystalline. This element, combined with oxygen and various earths and minerals, forms carbonates, as chalk and limestone, and combined with oxygen it occurs as carbonic acid in the air and in many mineral waters. Two varieties of carbon are now officinal, in the form of charcoal prepared from wood and from bones. CARBO L1GNIWOOD CHARCOAL. PREPARATION. By burning wood in covered heaps or in closed ves- sels, in such a manner as to almost entirely prevent the access of air. The oxygen, hydrogen, and nitrogen of the vegetable substance are driven off, and about 20 per cent, of carbon remains, with a small pro- portion of earthy salts carbonates of potash and lime, etc. A pure charcoal may be obtained from the combustion of oils or resins with in- sufficient oxygen, and is known as lamp-black. For medicinal use, either kind may be further purified by ignition in a closed vessel to a red heat. CHARACTERS. Wood charcoal occurs as a black powder, or in black, brittle pieces, very light, and retaining the shape and texture of the original wood. It is distinguished from purified animal charcoal by leaving a bulky,_white mineral ash, which is the 1 or 2 per cent, of mineral salt. CARBO AN1MAL1S-AN1MAL CHARCOAL BONE-BLACK. PREPARATION. By exposing the bones of animals to a red heat-with- out access of air. Thus prepared, it contains 10 to 20 per cent, of char- coal, the remainder being mostly phosphate and carbonate of lime, with some iron sulphuret. It may be obtained from any animal substance, a good quality being procured from dried blood. CARBO ANIMALIS PURIFICATU8-PURIF1ED ANIMAL CHARCOAL. PREPARATION. By digesting the commercial charcoal with dilute hydrochloric acid for two days in a warm place; filtering, washing, drying the residue, and igniting in a closed crucible. By these processes the salts are rendered soluble, and removed as superphosphates and soluble chlorides, while carbonic acid and sulphuretted hydrogen gases are driven off. CHARCOAL. 1 9 CHARACTERS. It occurs as a smooth, black powder, which has no odor and scarcely any taste; when burned it leaves very little ash. Char- coal has certain chemical and mechanical properties which are very useful in pharmacy. That prepared from wood is used as a deoxidizing agent, as in the preparation of sulphurous from sulphuric acid (by distilling the latter with it), and the reduction of iodate to iodide of potassium. Ani- mal charcoal is used as a decolorizer in the preparation of alkaloids, etc. Its power in this respect is such that diluted tincture of litmus will filter through it colorless. Warrington ascertained that it would remove the bitterness of hops and other vegetable infusions, and Dr. Garrod soon afterward pointed out that it would destroy the activity of many organic poisons, as opium, aconite, and nux vomica (Lancet, ii., 1845). Animal charcoal is much more powerful as an antidote than that prepared from wood. ' Both varieties possess great absorptive power, taking up more than twice their weight of gases, and may be used for purifying water by fil- tration, and for the disinfection of sewer-emanations, and the deodorizing of sick-rooms, dissecting-rooms, etc. (Letheby). A respirator containing a layer of charcoal has been recommended (Stenhouse, Marcet). THERAPEUTICAL ACTION" (EXTERNAL). Fetid Discharges. Charcoal is used in surgery to cleanse and alter the condition of old and sloughing ulcers, suppurating sores and wounds, and is sometimes applied directly to them in the form of powder, or poultice with bread; to relieve offen- sive odors it is better enclosed dry in muslin bags and placed near the wounds. In open cancer a paste of soot with glycerin is said to be a use- ful application (Debreyne: Medical Times, i., I860, p. 402). For offen- sive perspiration of the feet or axillae, charcoal may be mixed with alum or zinc oxide, and used as a dusting powder; with chalk it forms a cleans- ing dentifrice. CAUTERY. Charcoal "pegs" have been used as a cautery; they are mixed with nitrate of potash (Lancet, ii., 1866, 309). THERAPEUTICAL ACTION (INTERNAL). For ordinary medicinal use, wood charcoal is commonly preferred. Dyspepsia, Flatulence, etc. It is very useful for patients suffering from pain, weight, and sense of fulness at the epigastrium with flatulent distention, acidity, sour or bitter eructations, nausea or vomiting, furred tongue, foul breath, and with a tendency to loose, ill-formed motions. These stomach symptoms are usually accompanied with palpitation. The charcoal powder, which acts by absorbing intestinal gases and neutralizing offensive products of decomposition, should be perfectly fresh and taken dry, and preferably at the commencement of a meal. The dose need not be so large as a teaspoonful, which is commonly given; in many cases I have found 2 to 5 gr. sufficient. Bismuth and magnesia are sometimes advisable at the same time. 20 MATERIA MEDIC A AND THERAPEUTICS. Diarrhea. Charcoal acts well in the diarrhoea of scrofulous children when the stools are small, slimy, and light-colored, with intermediate troublesome discharge of flatus and itching of the anus; also when the attacks have depended upon irritation of the mucous membrane from un- digested food, etc. It may be well given with milk (of. Medical Record, March, 1881). Rhubarb is often usefully combined with it in the cases described. Charcoal is also serviceable in the atonic irritative diarrhoea of old people, but I have more than once known intestinal hemorrhage occur after its use. If large quantities be given, some may be retained and act as a mechanical irritant, so that the remedy is not so innocent as com- monly thought. Dysentery. Charcoal has been recommended in dysentery, and its antiseptic powers may be serviceable in chronic cases. The pu-trid smell of the discharges may certainly be relieved by a few doses of 30 to 60 gr., but it returns on discontinuance of the remedy; the effect is a tem- porary chemical one. Dr. Farre has reported cases in which it has acted equally well when given in enema (Ranking, ii., 1862). In Enteric Fever charcoal lessens the distention of stomach and intes- tines, and when mixed with magnesia sometimes proves still more bene- ficial. Cancer of Stomach Gastric Ulcer. In these organic diseases many of the distressing symptoms may be relieved by charcoal. Ascarides. A daily dose of charcoal mixed with salt, and given in the early morning, has been found useful in destroying and preventing the development of these parasites. PREPARATIONS AND DOSE. Of icood charcoal, many varieties are in use, some practitioners giving the preference to that made from heavy woods (box, acacia, etc.), others to the light woods (poplar or willow). Dr. A. Leared recommended that made from " vegetable ivory." Char- coal from the haematoxylon campechianum is good, but has been over- praised. Belloc's is also a good preparation; it is made from poplar. Biscuits and lozenges of charcoal are also used, but in my experience are not so effective as the powder, and they sometimes irritate the stomach. Carbo ligni: dose, as antacid, antiseptic, or absorbent, 10 to 60 gr., or more. Cataplasma carbonis (*' charcoal poultice ") contains oz. of wood charcoal. Carbo animalis is to be preferred as an antidote to poisons : dose, from -fa oz. to 2 oz. or more, according to the amount of poison swallowed ; it is best taken suspended in water. Carbo animalis purificatus : dose, 20 to 60 gr. or more. [PREPARATIONS, U. S. P. Carbo animalis, Carbo animalis purificat us, and Carbo ligni.] SULPHUR. 21 SULPHITE, S,=32. This element occurs in the animal kingdom as a constituent of the albuminous (protein) tissues, of bile, of cystin, etc., and in the vegetable kingdom in many essential oils and resins, such as those of mustard, horse- radish, garlic, and asafcetida. In volcanic districts it is found native, and in many places it is met with combined with metals, as sulphide, or " py- rites "; the bisulphide of iron contains more than half its weight of sul- phur. United with hydrogen or with alkalies, it is found in many organic substances and mineral waters, and with oxygen it forms sulphuric acid and the various sulphates. CHARACTERS AND TESTS. Sulphur occurs in commerce either as a gritty powder, or in round sticks (roll sulphur brimstone), or in crystals; it is opaque and brittle, pale yellow in color, of insipid taste, and emitting a peculiar odor if it be rubbed; it is inflammable, burning with a bluish flame and evolution of sulphurous acid gas. Sulphur melts at 115 F. ; at greater heats it becomes amber-colored, then brown, and gradually thickens until the containing vessel may be inverted without spilling it; it is insoluble in water, slightly soluble in alcohol (absolute alcohol dis- solves nearly 1 per cent.), partially soluble in fixed and volatile oils and bisulphide of carbon. Hydrochloric acid added to sulphur or its com- pounds causes evolution of sulphuretted hydrogen, which will be known by its characteristic odor. OFFICINAL FORMS. Two varieties of sulphur are placed in the Phar- macopoeia the sublimed and the precipitated. SULPHUR SUBLIMATUM SUBLIMATED SULPHUR- FLOWERS OF SULPHUR. PREPARATION. By melting or burning the native sulphur-earth, or any metallic sulphide, and condensing the vaporized sulphur in large chambers. CHARACTERS. Sublimed sulphur is a gritty powder, canary-yellow in color, and possessing the characters of the element as already described. It may be acid in reaction from the presence of a little sulphuric acid,* formed by slow oxidation, and should be freed from this by washing with distilled water, after which it becomes "sulphur lotum." SULPHUR PR^GIPITATUM PRECIPITATED SULPHUR. Called also lac sulphuris (milk of sulphur), though this name was ori- ginally given to an old preparation made with lime sulphate. 22 MATERIA MEDICA AND THERAPEUTICS. PREPARATION. From the sublimed sulphur, by first boiling it with slaked lime until the substances combine, and then adding hydrochloric acid, which unites with the lime while the sulphur is precipitated. The reactions are somewhat complex, but may be thus represented: SCaH^+eS^SCaS^CaSJH^+SI^O and then, on adding the acid, 2CaS 5 + CaS a H,O 4 + 6HC1 =3CaCl 2 + 4H a O + 6S,. The precipitated sulphur should be dried at a heat of 120 F. CHARACTERS. A pure specimen is of pale dead-yellow color, without odor or taste, very smooth to the touch, not readily diffused in water. Under the microscope it presents opaque rounded granules, separate or in clusters. [SULPHUR LOTUM, U. S. P. Washed Sulphur. Sublimed sulphur, thoroughly washed with water. It is wholly volatilized by heat, and, when moistened with water, does not change the color of litmus.] SULPHIDES OR SULPHUEETS. Sulphurated potash (hepar sulphuris, or "liver of sulphur") (v. Pot- ash) and sulphide of calcium (hepar calcis, or " liver of lime ") are in com- mon medical use, and the sulphides of sodium and of ammonium are found in many of the sulphurous mineral waters. Their action is some- what similar to that of sulphur, perhaps more powerful. The sulphide of calcium (not officinal) is found native, or may be prepared artificially by calcining, in a closed vessel, equal parts of sublimed sulphur and pul- verized oyster-shell (a pure form of lime carbonate). It is a yellowish white powder of sulphurous taste and odor. Jfypochloride of sulphur consists of " flowers of sulphur " impregnated with a small quantity of chloride of sulphur (S a Cl a ) obtained by passing chlorine over sulphur. It is apt to explode if kept in full glass bottles closely corked. ABSORPTION AND ELIMINATION. It has been stated, though not satis- factorily proved, that finely divided sulphur may pass as such into the blood. Eberhard states further that he has seen it in the lymphatics, and Griffith that he has found it excreted in the urine, but these statements lack confirmation, and are not easy of credence. It is more probable that, before absorption, under the influence of alkaline saliva and mucus, and the secretion of intestinal glands, an alka- line sulphide is formed, part of which is decomposed in the intestine (the resulting sulphuretted hydrogen being passed as flatus), and part oxidized, since its administration increases the urinary sulphates (Regensburger: Centralblatt f. Med., 1877). Of any ordinary dose of sulphur, a certain proportion passes out unchanged and unabsorbed in the fasces. Fatty substances are said to promote absorption of sulphur, though the experi- ments of A. Krause (1853) scarcely support this view. He found that SULPHUR. 23 when equal doses of sulphur were given, either with or without fat, the amount of sulphates excreted by the urine was the same. The sulphuretted hydrogen which is absorbed is eliminated by the skin, the bronchial membrane, and by the various glands, and gives indi- cation of its presence, both by its odor and by staining silver articles worn about the person. Orfila detected it in the urine. In exceptional cases the gas may be formed in, and absorbed from, the intestine with production of marked but temporary nerve-depression. I have not myself seen this as an effect of taking sulphur medicinally, and in cases where sulphuretted hydrogen has been injected into veins it has been so quickly eliminated by the lungs that the arterial current remained unaffected by it (C. Bernard). Dr. B. W. Richardson conclud- ed, from observations with " sulphur alcohol," that its compounds were not absorbed from the alimentary canal, but I believe that occasionally they may be so. In aged persons, and in some cases of hepatic and in- testinal disorder, I have noticed attacks of depression coincident with flatulence and foul breath, and relieved by a stimulating purge; and Dr. Senator has recorded the case of an adult suffering from gastric catarrh, in whose breath and urine sulphuretted hydrogen had been detected, and who had more than one attack of collapse lasting for a few minutes and accompanied with pallor, giddiness, and small, quick pulse; he recovered after purgation (Berlin, klin. Woch., 1868, No. 24). PHYSIOLOGICAL ACTION (EXTERNAL). Applied with friction to the sound skin, sulphur causes a moderate degree of irritation; much more if the surface be excoriated. The alkaline sulphurets, such as those of potash and of lime, irritate severely, if used in strong and warm solution, to a delicate skin. Sulphur and some of its compounds have the power of destroying the lower forms of vegetable and even animal life; whence their practical value as " anti-zymotic and anti-parasitic " remedies. Binz attributes this power to the formation of sulphurous acid under the influ- ence of exposure to the air, and to heat, and to contact with protoplas- mic organisms (e.g., the oi'dium Tuckeri of the grape). The subject of disinfection is more fully considered under the heading of Sulphurous Acid. PHYSIOLOGICAL ACTION (INTERNAL). Given to animals it produces at first, at least, some stimulant effect. Benk states that its after-effect is of reverse character, and that this is accompanied by, and is probably due to, intestinal irritation. Hertwig found also that animals were read- ily brought under the influence of the drug with production of diarrhoea. Circulatory System. Sulphur and the sulphides, in moderate doses, stimulate the circulation, especially that of the capillaries, the skin and mucous membrane, and the venous circulation within the pelvis. Con- gestive headache, vertigo, and sometimes hemorrhage have been traced to the use of the drug and of mineral waters containing it. Gubler, Mit- 24 MATERIA 1IEDICA AND THERAPEUTICS. scherlich, and many older authorities are agreed upon these points, and assert further that a rise in temperature and distinct pyrexia may be caused by sulphur, especially in plethoric persons. Secretion and Accretion. Buchheim and some modern writers express doubts as to whether sulphur really increases secretion from the bronchial mucous membrane and the skin; but I cannot agree with them, for I have frequently seen an augmentation of these secretions under the use of this remedy. According to Boecker the urinary water and solids are increased in amount under the action of sulphur, but this requires confirmation (Husemann). Cutaneous System. Some dark coloration and much irritation of the skin may occur from the internal use of sulphur. I have seen a red pap- ular eruption from it, and also occasionally boils and carbuncles. The waters of Harrogate, Bareges, Aix-la-Chapelle, etc., have been known to produce such effects. Digestive System. The sulphides, in small doses, excite a sensation of warmth at the epigastrium; in excessive doses, they may cause gastro- enteritis, and even, it is said, " insensibility and speedy death " (Ringer). Sulphur itself in small doses excites a similar sense of warmth, sometimes gaseous eructations; sulphurous waters in the quantity of several ounces often cause pain and oppression in delicate subjects. Doses of 20 to 40 gr. and upwards of sulphur in powder cause moderate stools, semi-solid in character, and passed with perceptibly increased peristaltic action; hence, it has been presumed that the muscular coat is mainly acted upon. Sundeliri maintained that sulphur had a " specific" action on the mucous coat, but we cannot speak positively about this (Biriz). The prolonged use of sulphur as an aperient induces intestinal catarrh. Husemann supports the view that unabsorbed sulphur mechanically protects the intestinal mucous membrane like bismuth, and this would explain the fact that large doses relax without colic, while moderate doses relax equally, but with some colic, and small doses cause pain without the relaxation. SYNERGISTS. As a stimulant, sulphur is aided in effect by the volatile oils; as an alterative, it has analogies with arsenic, phosphorus, and pos- sibly iodine (Gubler); as an aperient, magnesia and the acid tartrate of potash assist its action. Chemically, sulphur belongs to the same group as oxygen, selenium, and tellurium, and between oxides and sulphides there is much analogy. ANTAGONISTS. Sedatives, refrigerants, astringents, and cold oppose the ordinary action of sulphur; quinine and bromides have a specially antagonistic effect. THERAPEUTICAL ACTION (EXTERNAL). Parasitic Skin Diseases Sca- bies. Sulphur is one of the substances which are fatal to acari, and it still remains one of the best, as it is the commonest, remedy for sea- SULPHUR. 25 bies, though Dr. McCall Anderson and others have objected to it as too irritant. It is nearly certain that sulphur, when used by itself or mixed with lard, has simply a mechanical effect on the epidermis; but when carbonate of potash is added to the ointment, sulphurated potash is formed, and this compound quickly destroys the acari. We know, from clinical ob- servation, that these insects often live in the plain sulphur ointment for several days without much apparent detriment, while, as Kuchenmeister says, " the acari, kept in a solution of sulphurated potash, die in a quarter of an hour." The strength and the frequency of the application should be varied according to the delicacy of the patient's skin and the amount of the eruption; the more active the preparation, and the more thorough its use, the quicker will be the cure. Thus, painting the body with a solution of chloride of sulphur in sulphuret of carbon is said to cure in five minutes (Medical Times, i., 1856, pp. 247, 368); while Bourguignon's formula with lime and sulphur (boiled together) is allowed half an hour, and M. Hardy's method with soft-soap frictions, warm bath, and anointing with 2 parts of sulphur to 8 of lard and 1 of potash carbonate, effects its purpose in four hours (British and Foreign Review, ii., 1852, Leons); but such results are liable to be accompanied with unnecessary irritation and pain to the patient. Dr. Tilbury Fox, having seen eczematous eruptions and chronic irritation often induced by the excessive use of too strong an ointment, and founding his advice on observation of the parts usually affected, advocates the use of a mild ointment (1 part in 16, i.e., % dr. to the ounce of lard) to the wrists and between the jingers only, in acute cases accompanied with general irritation (Lancet, ii., 1871); but, as Hebra and R. Liveing observe, the restriction of the application to a, few portions needs very exact diagnosis, and, as a rule, the ointment of the selected strength should be applied to every part. A prolonged warm bath (half-hour), and thorough cleansing with soap and friction, should precede the inunction; then, after drying, either the mild ointment of Fox, or the simple ointment of the Pharmacopoeia (1 part in 5), or one of intermediate strength (1 part in 8, with % a part of potash carbonate) should be plentifully rubbed over the trunk and the limbs, especially the flexor side of the limbs and between the fingers and toes; and then socks, gloves, drawers, and jersey should be used to keep the ointment in con- tact with the skin (Liveing). An ointment I commonly prescribe is made with sublimed sulphur, 2 dr.; sulphide of calcium, ^ dr.; and simple ointment, 2 oz. After a night's application, a warm bath in the morning may be used to remove the odor of sulphur, but then a second or third inunction may be required; if the first one can be left undisturbed for twenty-four hours, it will often suffice to cure. In some cases, a lotion of sulphuret of calcium (liquor calcis c. sulplmre) acts better, because it is 26 MATERIA MEDICA AND TIIERAPEDTICS. more thoroughly applied than an ointment; its use should also be pre- ceded by a warm bath, and it need only be gently applied with a sponge or brush; if used with friction it may cause very severe irritation. A sulphur-ic^A is not so effacious as these remedies, but may some- times be required, and may be made with half a pound of sulphurated potash to thirty gallons of water or with sulphur, hyposulphite of soda, and acid (v. Preparations). Wooden or porcelain vessels should be used for the baths, of which several will be required. Sulphur in vapor may also be employed. It is important to remember that irritation of skin may remain even after the scabies itself is cured, and this irritation is to be treated by soothing remedies; sulphur is not to be continued longer than absolutely necessary for the destruction of the parasite. Sometimes it may be alto- gether contraindicated, or may be inconvenient, and then recourse may be had to styrax, tolu, petroleum, or iodide of potassium; but in most cases the preceding method will give satisfactory results. Tinea Tonsurans Chloasma. The parasites in these maladies are curable by sulphur applications, but a compound ointment containing ammoniated mercury acts better than simple sulphur ointment (Ung. hydrarg. ammon., with an equal part of Ung. sulphuris, is a good for- mula). Sycosis Mentagra (" JBarber's Itch"). In this disease Hebra advises that the affected hairs should be pulled out, and then a paste containing sulphur, glycerin, and alcohol, in equal parts, should be rubbed over the diseased skin every night and morning; by this means a cure is rapidly effected, but it is rather severe treatment. It is especially adapted for the parasitic form, but is useful also in the more common one, because sulphur, as well as sulphides, lessens pus-formations. Prurigo. In chronic prurigo especially when connected with phthei- riasis, but also in independent forms an ointment containing sulphur with a preparation of tar is often of much service. Anderson recommends 6 dr. of pix liquida in 4 oz. of ordinary sulphur ointment (Lancet, ii., 1869). Sulphur vapor baths are useful. In ordinary pruritus 1 find a lotion of sulphurated potash very effective (v. p. 34). Eczema Psoriasis. When eczema occurs as a complication of sca- bies, Hebra joins with the sulphur an equal quantity of tar and half the quantity of chalk; and there are some stages of idiopathic eczema when sulphur acts as a useful stimulant, viz., when the eruption is on the decline, but remains in obstinate chronic patches, especially about the legs. It acts best in lymphatic constitutions; but, as a rule, I prefer potash or tar applications to sulphur. I may say the same as to my own experience in chronic psoriasis, but compound sulphur ointments have been found useful in this malady; and part of the benefit following the use of caoutchouc bandages has been traced to the sulphur they contain SULPHUR. 27 (Hebra). Dr. Wetzler states that ordinary psoriasis, when not much de- veloped, can be cured by the Aix-la-Chapelle waters alone, if prolonged baths can be borne. In very extensive and obstinate cases, however, he adds iodide of potassium to the water, and prescribes in addition sul- phurous vapor baths, tar-frictions, etc., and, it is stated, with the best results (" Practical Treatise," 1862, p. 66). Acne. With the exception of scabies, acne is the skin disease in which sulphur is most frequently used and gives the best results; the degree of stimulus or irritation supplied by it seems more appropriate than that of any other application, unless it be sometimes mercury. In the simple acne of young people, occurring in the sebaceous glands about the face and shoulders, accompanied by comedo and without much general congestion, a fairly strong preparation may be used, such as the sulphur ointment of the Pharmacopoeia; or potash may be added to it (Lancet, ii., 1878), or a lotion containing 6 dr. of precipitated sulphur and 1 dr. of glycerin, with 6 oz. of rectified spirit (Anderson). When a moderate degree of irritation is present the proportions may be altered; thus, 1 dr. of sublimed sulphur may be rubbed up with a little alcohol, and then 2 dr. of the smoother variety may be added, with water to dilute sufficiently (Morris: Lancet, i., 1855); or a lotion that I commonly use with advan- tage is made with 2 to 4 dr. of precipitated sulphur, with the same quan- tity of spirit and glycerin, in 6 oz. of rose-water. Spirits of camphor or ether may be added, to relieve itching or heat, and special indications for internal treatment must be considered. Sometimes dusting with the pure, dry precipitated sulphur answers better than anything (Par- sons: British Medical Journal, i., 1879). The local remedies should be lightly or firmly applied, according as they can be borne, left in contact all night, and washed off with mucilaginous decoctions or water in the morning. For acne rosacea, one of the best applications is an ointment contain- ing 2 dr. of the hypochloride of sulphur in the ounce of rumex ointment (Wilson), or a lotion of oz. of sublimed sulphur in 4 oz. of elderflower water. The ointment of iodide of sulphur, which is still stronger, may be carefully used to chronic cases of any form of acne. A certain amount of temporary irritation must be expected from these remedies, and may require their occasional intermission and the use of sedatives; but some compound of sulphur, judiciously employed, will be found the most effec- tive cure. The internal use of calcium sulphide should be conjoined with this treatment. Burns Scalds. Dr. Myrtle, of Harrogate, has recommended sulphur ointment as a good application for burns and scalds (Edinburgh Medical Journal, 1862). Granular Ophthalmia. Wharton Jones has found advantage from the use of sulphur ointment as a stimulant, a small quantity being applied 28 MATE1UA MEDICA AND THERAPEUTICS. between the lids at bedtime (Medical Times, i., 1859). There are, how- ever, better applications than this. Rheumatism. The friction of rheumatic limbs with sulphur is as an- cient at least as Pliny (lib. xxxv.), and attention was specially directed to it again some years ago by Dr. Fuller, Dr. O'Connor, and others (Med- ical Times, i., 1858). They found it useful also in sciatica and lumbago, adding to the frictions close and constant covering with flannel. Renard found it very serviceable in rheumatism affecting tendinous parts, in his own person, after an acute attack; it produced some degree of heat and increase of perspiration when it acted well. It should certainly be tried in all obstinate forms of rheumatism, and especially that form which at- tacks the soles of the feet in those who are exposed to damp and cold. It is in the different forms of chronic rheumatism and chronic skin disease that baths of sulphurous waters, as at Bareges arid Aix-la-Cha- pelle, are found most valuable. THERAPEUTICAL ACTION (INTERNAL). The therapeutical action of sul- phur and the sulphides is somewat similar, but the former is commonly used in small doses to produce an "alterative," and in large doses a laxa- tive effect, and the latter to modify some acute conditions, especially when they are connected with suppuration in various stages. Skin Disease. The internal use of sulphur for many skin diseases rests on an old tradition, but is not much adopted in modern practice. I have tried it extensively, and although the alkaline sulphurous waters are useful sometimes, and in acne rosacea the calcium sulphide, in ^ to ^ gr. doses thrice daily, seems to help absorption of the tubercles and abate venous hypersemia, yet, with these exceptions, I have not seen much ad- vantage. Dr. Cane refers to sixteen cases of acne in which the last-named remedy was useful (Lancet, ii., 1878). Scrofula Swollen Lips, Glands, etc. Scrofulous children are often disfigured by a chronic swelling of the upper lip and alee nasi, which may be connected with a crack or fissure on the inner surface of the mucous membrane. Accompanying this condition, there often exists a tendency to dyspepsia and indolent swelling of the mesenteric, cervical, and other glands. Although we cannot wholly cure the constitutional tendency in such cases by sulphide of calcium, yet I have seen their general condition greatly improved by small doses ( gr.) given night and morning for a few weeks; the fissure has healed and the lip-swelling subsided, and the glands have grown less. In cases where pus has actually formed in some of the glands, the effects of this remedy may readily be traced in the subsidence and disap- pearance of some of the swellings, while others progress quickly, matu- rate and discharge, and others that have been open and discharging un- healthily for some time take on healthy action, and ultimately contract SULPHUR. 29 and heal. For permanent good results this treatment should be followed up by cod-liver oil and generous diet, and, if possible, change to the sea- side. As a rule, frequent doses of the sulphide are not desirable, as they are apt to derange the stomach and cause troublesome eructation of sul- phuretted hydrogen. Scrofulous Ophthalmia, etc. In this affection I can recommend sul- phide of calcium, and especially when ulceration of the cornea is pres- ent; it also acts well in scrofulous otorrhcea, and indeed in almost all purulent discharges occurring in children, especially when becoming fetid and obstinate in character. Suppuration. Calcium sulphide exerts a marked influence on the formation of pus. If given early, it controls the inflammatory process, either aborting it so that it does not go on to suppuration, or, if this take place, controlling and limiting its extent, promoting a more healthy for- mation, quicker evacuation, and more rapid subsequent healing. In the treatment of simple abscess I have frequently used it with much advantage; in tonsillar abscess (quinsy) it is particularly valuable, and may save recourse to incision; and in mammary abscess, if the time for belladonna or antimony is past, the sulphide is quite the best remedy. It has seemed to me to check the spread of the inflammation, and to help quickly to evacuate matter, and so shorten the tedious course common in this malady. Should hardness and pain continue after an opening has formed, and should the discharge come away incompletely, the remedy must still be continued, and is likely to exert a favorable influence. In bubo, especially if indolent, and with scanty, unhealthy pus-forma- tion, the sulphide will often determine a more healthy action; ^ to ^ gr. iu pill every three or four hours is a suitable dose. In ordinary boils, and in carbuncles also, a compress moistened with sulphide of calcium lotion (4 gr. to the pint of water) should be ap- plied. When eruptions of boils recur at intervals, I commonly advise a course of the precipitated sulphur 5 to 10 gr. night and morning for several weeks during the intervals, but, at the time of actual maturation, recommend the sulphide as acting more quickly. Even in pneumonia, in those exceptional cases when the exudation in later stages degenerates into pus, I have seen benefit from the same remedy; it has equally seemed to assist evacuation of matter already formed, and to check the tendency to its fresh formation. Syphilis. In most of the later manifestations of this disorder, sul- phurous waters have a good reputation, but, in my opinion, without suffi- cient reason. At Aix-la-Chapelle, for instance, the treatment is conduct- ed mainly by mercurial inunction, and the sulphur-waters used locally and internally, can only b^considered adjuvants to this more powerful remedy. I think they serve mainly to cleanse and stimulate the skin, to regulate the action of the bowels and viscera, and to counteract any injurious ef- 30 MATERIA MEDICA AND THERAPEUTICS. fects that might arise from the mercury (v. p. 170). They have, perhaps, a further use for diagnostic purposes, since it is said that obscure symp- toms really due to old or latent syphilis manifest themselves more fully under a course of the waters, and thus give the necessary indications for treatment by iodides or mercury. Dr. Wetzler gives several instances of this (op. cit.), and I have no doubt of its possibility. I must say also that I have seen advantage from the use of sulphide of calcium in sypMKtic laryngitis, notably when mercury had been pre- viously taken to saturation. Diphtheria. During certain stages of this malady, preparations of aconite, iron, iodine, bromine, etc., are indicated, as described under those medicines; but at the time when pus is commencing to form, and the false membrane is becoming somewhat loosened from the mucous surface, the sulphide of calcium is often useful, for it exerts the action already referred to, of assisting to healthy completion and at the same time limit- ing the extent of the suppurative process. We know that this formation of pus-cells occurs as part of the diphtheritic inflammation before the re- turn of healthy conditions, and, as remarked by Mackenzie (who does not, however, mention this remedy), "when it is found impossible to check the formation of lymph, it is rational treatment to convert, as far as we can, the inflammatory into a suppurative process "("On Diphtheria," 1879). If commenced early in this stage, in doses of -fa to gr. every one or two hours, it produces the best effects; but it is useful also even if begun after pus-formation is fully developed, and I believe it has some influence in lessening blood-poisoning. The value of steam-inhalation in helping on the natural changes of diphtheria and the formation of muco- pus and loosening of the membranes has been often proved (P. James, Oertel), and is now well known. I find it still more efficacious if the sul- phide of calcium be added to the boiling water in the proportion of about 4 gr. to the pint, so that a certain amount of sulphurous vapor is locally applied. The local insufflation of finely powdered sulphur has been credited with arresting the development of diphtheritic exudation (Practitioner, Novem- ber, 1868, vi.), but has disappointed expectation. Oertel concludes, after much experience, that it acts only as a " scouring powder," wearing off the membranes by friction; it has no influence at the onset of the malady, but has seemed to answer only when purulent infiltration and fibrinous exudation have already ceased. It has an antizymotic, but no other speci- fic power, and is liable to cause irritation (British Medical Journal, January 11, 1879). Mr. Erskine Stuart has, however, written still more recently in favor of local applications of precipitated sulphur. According to his latest ex- perience, " it is best applied, after being rubbed up with a little water, on a swab to the affected part; it is free from grittiness, it sticks better, and SULPHUR. 31 hence exerts its action for a longer time, and is applied more safely in this manner than by insufflation." He states " that every case treated with sulphur made a rapid recovery " (Practitioner, October, 1879), but the number apparently is not more than six, and he unduly depreciates other remedies. In Laryngo-tracheal Diphtheria ( Croup), when we cannot always see the false membrane, I find the sulphide of calcium treatment indicated if wheezing, rattling sounds accompany the breathing, i.e., when the mem- brane begins to be loosened, rather than in the first stage, when the breath-sounds are of dry and sawing character. Chronic Sore Throat. Dr. Gueneau de Mussy has specially pointed out the value of sulphur waters in " glandulous angina," which, under or- dinary treatment, is an obstinate malady. The waters of Eaux Bonnes are of remarkable efficacy in such cases (v. Mineral Waters); the sulphu- rous acid spray is also useful if not too irritating. Scarlet Fever. Mr. Pigeon believes that in sulphur he has found the true remedy for this fever, and he certainly applies it very thoroughly, and appears to have had good success. He anoints the patient twice daily with sulphur ointment, gives 5 gr. of sulphur by the mouth twice daily, and fumigates frequently with sulphur vapor (Lancet, ii., 1876). Variola. Sulphide of calcium, I believe, often moderates excessive suppuration in this malady. Asthma Chronic Bronchitis. In cases with much cough and profuse secretion, sulphur will often relieve, lessening and modifying the expec- toration. I have seen this accomplished in many instances. The old physicians described it as " balsamum pectoris," and it still forms part of some quack "nostrums." Dr. Graves records his experience in its favor. Binz suggests that sulphuretted hydrogen, being excreted by the bronchial mucous membrane, may partially narcotize the terminals of irritated bron- chial nerves, and advocates for the continued use of small doses of sul- phur in asthma are not wanting (Duclos: Bulletin, 1SG1). I have seen cases marked by loud wheezing, profuse but difficult expectoration, troublesome palpitation, and nocturnal spasms of severe dyspnoea, improve quickly with 5 to 10 gr. of sulphur taken thrice daily. The sulphur springs of Weilbach are celebrated for relieving cases of chronic bronchi- tis, especially when complicated with haemorrhoids. Phthisis. Sulphur was well known to the ancients as a remedy in consumption, and Galen ordered to phthisical patients inhalation of the vapor from the crater of Etna. It is not much used internally in modern practice, but for chronic phthisis the springs at Weilbach have a favor- able reputation. Sutro finds sulphur of good service in some cases of phthisis, and the presence of haemorrhoids is one indication for it; he suggests that it com- bines with the iron of effete blood-corpuscles, quickens the elimination of 32 MATERIA MEDICA AND THERAPEUTICS. this and other residua, and thus relieves the portal system and indirectly the lungs (Medical Times, i., 1862, p. 362), and I quite agree with those observers who have noted, in this disease, much advantage from the use of sulphur both internally and by inhalation. Dr. Devvar relates instances where sulphurous acid and steam acted .unexpectedly well on phthisical subjects exposed to them (Medical Times, i., 1867). A spray containing sulphurous acid facilitates expectoration, and also disinfects and lessens purulent secretion, and so far relieves certain symptoms, but has no speci- fic power over the disease. Chrome Rheumatism. Sulphur frictions for rheumatism have been already mentioned, and the drug was formerly considered a good internal remedy for chronic muscular and articular pain, and no doubt it is often of real value when given in doses of from 5 to 20 gr. twice daily for some time I think the smaller doses give the better results. Remedies calcu- lated to produce diaphoresis, such as vapor-baths, should be generally combined with its use. In acute articular rheumatism it has little or no power. Paralysis. In chronic and asthenic cases of impaired motor power, the use of sulphur internally and externally deserves a fair trial. Dr. Graves was accustomed to depend upon it after a course of strychnia. Wetzler has recorded four cases of progressive muscular palsy benefited by warm sulphur-baths and the administration of the water at Aix-la- Chapelle (British and Foreign Review, ii., 1856, p. 457), and in his treatise (1862) has added several other cases. Althaus found these reme- dies useful in locomotor ataxy (Lancet, ii., 1865). I have also seen some advantage from them in the latter condition. Mercurial Tremor Mercurialism. In cases of palsy and tremor con- nected with the action of mercury, sulphur is useful (Lettsom) and de- serves trial; it is said also to neutralize acute mercurialism accompanied with salivation, etc., and may be given in 5 to 10 gr. doses at the same time as chlorate of potash. On the other hand, in patients who have taken mercury at some previous period, sulphur, like iodides and other powerful alterants, has sometimes determined a fresh salivation. Lead- Colic Lead-Palsy. In these conditions sulphur has been found available, though iodide of potassium is now proved to be better. In an epidemic of lead-poisoning at Havre, M. Marguerette found sulphur give much relief; it required to be exhibited at first in very large doses (50 grammes in the first day), being afterward gradually diminished as the symptoms improved (Bulletin, October, 1867). Hepatic Disease. Chronic enlargement of the liver, with obstruction to the portal circulation, accompanied as it usually is by haemorrhoids^ is often much benefited by a course of sulphur, or of calcium sulphide, or potassium sulphide. Constipation hemorrhoids. The mild action of sulphur on the mu- SULPHUR. 33 cous membrane, or muscular coat of the intestine, renders it a useful ape- rient for children and delicate persons, especially if there be congestion about the rectum or pelvic viscera. In cases of haemorrhoids it is one of the best laxatives, and if not powerful enough may be combined with tartarated potash, or with confection of senna. A " compound liquorice powder," in which sulphur is the main ingredient, has recently been intro- duced into the British Pharmacopoeia, but the Prussian formula, which in- cludes also finely powdered senna, is superior. In the treatment of piles, sulphur need not be given in quantity sufficient to produce a laxative effect, unless this is otherwise required, for it can relieve by virtue of a stimulant and tonic action on the venous and capillary circulation, es- pecially of the rectum and pelvic viscera, without any direct aperient action. The ordinary dose should be 5 to 10 gr. morning and night. Weak sulphur ointments locally applied increase the good result. The remedy may also be used in the form of vapor, and if the fumes from burning sulphur can, by means of apparatus, be applied directly, they often relieve congested, painful, bleeding piles; this is a popular domestic " cure " in some parts of the country (Pairman). Dr. Thorowgood attri- butes to sulphur a special value in torpor of the colon, which often causes or complicates dyspepsia; he recommends 10 to 20 gr. to be taken in the early morning with nux vomica; the lozenges of Holsverck contain the same ingredients (Lancet, i., 1869; Medical Times, i., 1858, p. 457). Diarrhoea Dysentery Cholera. Dr. Blacklock, of the Madras army, and Dr. Graves quote an extensive experience in favor of the effi- cacy of sulphur in these maladies; the latter observer combines it with soda and spirits of lavender, and in severe cases with opium (" On Chol- era," 18G5). Mr. Prosser also finds drachm doses given with mucilage to be "one of the best remedies in epidemic diarrhoea and cholera," (Lan- cet, ii., 1866, p. 483). This is not a general experience, nor is it mine, although I have found sulphur in 2 or 3 gr. doses useful in the fetid, watery diarrhoea of scrofulous children, and in some cases of chronic dys- enteric diarrhoea with tenesmus. Disorders of Menstruation. When the menses are delayed in weakly and phlegmatic persons, sulphur used as an habitual laxative has some influence in bringing on the flow; on the other hand, it has been recom- mended for relieving uterine congestion and its consequences at the cli- macteric period (Tilt). Ascaris Vermicular is. Precipitated sulphur is often a simple and efficient remedy for these parasites; 5 to 10 or 15 gr. should be given daily, morning and night, for some weeks. PREPARATIONS AND DOSES. Pure precipitated sulphur is more fia-ely divided, and is thought to be more active, than the sublimed form; the dose of either is, however, the same, 5 to 10 gr. as a stimulant, 20 to 60 gr. as a laxative; it is well given in milk, honey, or treacle. Conffictio VOL. I. 3 34 MATEKIA MEDICA AND THERAPEUTICS. (made with sublimed sulphur): dose, 60 to 120 gr. Unguentwn contains 1 part to 4 of benzoated lard. A milder and often more useful form of ointment is made with half the amount of sulphur and ^ dr. of carbonate of potash to the ounce ; essence of lemon conceals the odor (Squire). iSolutio colds c. sulphure may be prepared by boiling together 1 oz. of quick-lime and 5 of sublimed sulphur in 1 pint of water for half an hour* tilter, and make up, if necessary, to half a pint; a similar solution is now commonly sold by wholesale chemists. > Lotto potassce sulphurates rnav be prepared with 1 dr. to half a pint of water for use in irritable skin eruptions. Balneum potassce sulphurates : % Ib. to 30 gallons of water, in porcelain or wooden vessel. Balneum sulphuris comj)ositum (Star- tin): precipitated sulphur, 2 oz. ; hyposulphite of soda, 1 oz. ; dilute sul- phuric acid, % fl. oz.; water, 1 pint: to be added to 30 gallons of water. A sulphur vapor bath may be prepared by evaporating % oz. to 2 oz. of the solution of lime and sulphur by means of a spirit-lamp placed under a suitable arrangement of chair, coverings, etc. ; the face should be pro- tected from the vapor (Medical Times, i., 1870, p. 308). [PREPARATION, U. S. P. Unguentum Sulphuris: sublimed sulphur, 1 troyounce; lard, 2 troyounces.] ADULTERATIONS. The precipitated sulphur commonly sold, especially before the passing of the Adulteration Act, contained a large proportion of sulphate of lime; this was due to the employment of sulphuric acid instead of the hydrochloric acid ordered in the Pharmacopoaia; but, as some excuse, it may be mentioned that a former London Pharmaco- posia contained a preparation made with sulphuric acid, and known as "milk of sulphur." This name has now been transferred as a synonym to the modern "precipitated sulphur," and hence has arisen much confu- sion and even litigation. Druggists have been prosecuted for supplying the lime compound when asked for " milk of sulphur," and although con- victed by some magistrates of offences against the Act, the convictions have mostly been quashed on appeal to a higher court, on the ground that "milk of sulphur" is known by trade custom to be a distinct thing from the pure precipitated form. It is desirable that this should be par- ticularly understood (British Medical Journal, i., 1877; Lancet, i., 1876, p. 936). As a rule, a pure preparation may be obtained by asking for that of the British Pharmacopoeia. An adulterated specimen is whiter, with only slight yellowish tinge, and when pressed looks silky and glis- tening; under the microscope, crystals may be seen in thin tables or elongated prisms, and on exposure to a red heat, lime is left as a white ash (Medical Times, i., 1853). Washed Sicilian sulpnur is nearly always pure, but that prepared from pyrites often contains arsenic. PHOSPHORUS. 35 PHOSPHOKUS, P,=31. This non-metallic element was obtained in the seventeenth century from the urinary phosphates, by German chemists, and by Dr. Boyle in this country. London was, for some time, the principal place of its manufacture, so that it became known as "phosphorus anglicanus." It occurs, variously combined, in certain especially fertile soils, in the seeds of vegetables, and in the nerve-tissue and bone of animals (particularly when young), as well as in the blood and the urine. PREPARATION. It is now procured from bone-ash (os ustum) by di- gesting it in sulphuric acid, and then distilling with charcoal. The contained phosphate of lime is partially changed into superphos- phate and metaphosphate: phosphorus distils over, and, by a further pro- cess of purifying, is obtained as a colorless, oily liquid, which solidifies in cakes, or in rounded hollow pencils, according to the shape of the glass moulds employed. The last part of the process may be represented thus: CHARACTERS. The cakes or pencils are colorless, waxy, and translu- cent when fresh, but on exposure become coated with an opaque layer of crystals, which may be white, yellowish, or sometimes red from the forma- tion of an allotropic variety of phosphorus. Phosphorus inflames so easily that it needs to be kept under cold water, in which it is practically insoluble; in ether, turpentine, and oils it is soluble to a great extent; in rectified spirit it is but slightly so (1 part in 320); in chloroform, 1 per cent.; but in bisulphide of carbon it is wholly soluble. ("Fenian fire" is the term given to a very inflammable solution in this liquid, containing 70 per cent.) Naunyn states that phosphorus is very slightly soluble in water at 96 to 104 F. ; it is more soluble in organic fluids. The ele- ment is soft and flexible at ordinary temperatures, melts at 110, and takes fire at a little over that point; it is luminous in the dark, and, when exposed to air, gives off white vapors of phosphorous acid, exhaling an odor sui generis, which has been compared to that of garlic. On exposure to sunlight or to heat in closed vessels, it is converted into red or " amorphous " phosphorus a brittle powder which is not acted on by the air, and is insoluble; when volatilized, this reverts to the ordinary form. Amorphous phosphorus has been, by some observers, credited with physiological activity. Thus, Bednar used it for a long period in small doses, and observed symptoms of excitation, trembling, and clonic con- vulsions; but as much as 1 oz. has been given to dogs without percepti- ble effect. Thompson, in twelve carefully observed cases, found its ac- tion nil, and plausibly attributes its supposed powers to a slight amount of contained ordinary phosphorus (Pharmaceutical Journal, July, 1875). 36 MATERIA MEDICA AND THERAPEUTICS. I believe it to be practically inert, and the following 1 observations will refer only to the ordinary form. Zinci Phosphidum Phosphide of Zinc, PZn s (not officinal). A grayish, friable substance, having a lustrous, crystalline fracture, stable at ordinary temperatures, readily decomposed by weak acids, almost taste- less, but possessing active properties like those of phosphorus. ABSORPTION AND ELIMINATION. Phosphorus taken by the mouth, and especially when finely divided or dissolved, is absorbed into the blood under the influence of alkaline, albuminoid, or oleaginous materials with which it meets in the stomach and intestine; the amount and the rapidity of its absorption are proportionate to the amount of such mate- rials, and especially of fats, which are its best solvents. The exact con- dition in which it circulates is still a subject for discussion ; according to varying circumstances some portion may pass into the blood unaltered (Orfila, etc.), another oxidized, as hypophosphorous, phosphorous, or phos- phoric acid (Frerichs, Munk and Leyden, etc.), and a third portion as phosphuretted hydrogen (Lecorche : Archives de Physiologie, 1-2). It has been found in each of these forms in certain cases of poisoning, though in other cases none at all has been detected. Portions of unabsorbed phosphorus pass sometimes with the faeces, rendering them phosphorescent, and the urine has presented a similar appearance: the element has also been found in a free state in the liver, ten hours after death (Dybkowsky); it is eliminated by it, and by the other glandular organs, by the skin, and by the lungs. PHYSIOLOGICAL ACTION (EXTERNAL). When applied in substance, phosphorus v has been known to inflame on the skin, and, indeed, has been used as a rnoxa; it is liable to cause very troublesome sores and even gangrene, and the same results may follow its use in ointment. In certain experiments on dogs, however, when pieces of the element were placed in the cellular tissue they remained unaltered as to size and trans- lucency, and no inflammation was excited, yet the animals are said to have died in a few weeks from phosphorus-poisoning; while, on the other hand, rabbits and some other animals treated in the same way did not show either local or general symptoms. Trasbot records a curious circumstance : a dog swallowed a stick of phosphorus, and no symptoms of local irritation appeared, and afterward it was found in an abscess as an ordinary foreign body might have been. It is not easy to draw definite conclusions from such experiments, other than that pure phosphorus does not necessarily act as a local irritant (Ranvier: Gazette Medicale, 1867; Archives Generates, 1868). Phosphorus vapor causes irritation, catarrh, and even inflammation of mucous membranes with which it comes in con- tact, especially the conjunctival and respiratory membranes; it has also a special effect in causing inflammation of the periosteum and bone, with necrosis of exposed parts, such as the maxilla and teeth. It is only when PHOSPHORUS. 37 * the phosphorus vapor directly reaches the periosteum or some raw vascu- lar surface in immediate connection with the nutrition of bone, and when its application is prolonged under particular circumstances of tempera- ture, and probably of oxidation, that its injurious effects are witnessed. Thus it is, when there are carious teeth in the jaw, and the fumes can act directly on the exposed dental pulp, that necrosis occurs, and it is noteworthy that not until eleven years after the opening of the match factory in Vienna was the first case of this kind seen, and only those en- gaged in " dipping and drying " the matches were affected. The disease is more common in the lower jaw, but not rare in the upper, and it has also attacked the palate and frontal bones. The general health of the workers previous to the necrosis or buccal inflammation is, with the ex- ception of pulmonary catarrh, remarkably good. PHYSIOLOGICAL ACTION (INTEKTSTAL). D-igestive System. After tak- ing, in ethereal tincture, -$ gr. each morning for ten days, and then T ^g- gr. for nearly four weeks, I experienced increased thirst and dryness of mouth, with coated tongue, flatulent distention and eructation, and un- easy feeling in the region of the gall-bladder, without nausea or vomit- ing; the motions were dark, but healthy, the urine natural. There was slight headache and sense of fulness along the vertex and over the left temple, with increased restlessness and sleeplessness. On discontinuing the medicine, these symptoms disappeared in about three days, and on resuming it at the end of a month I felt them return in about ten days' time. Other persons may take the quantity just mentioned without so much inconvenience, but larger doses (^ to -fa gr. and upwards) are very liable to disorder the stomach, causing nausea and a sense of warmth or irritation. The appetite may be at first increased, but in many patients dyspepsia quickly occurs, and nausea, flatulence, colic, or diarrhoea hinders the employment of at least the ordinary preparations of phosphorus. A silvery white condition of the tongue may be caused, and the gums may become inflamed. Zinc phosphide in any quantity above gr. readily induces vomiting. Professor Gubler, examining the effects of this phosphide upon arti- ficial digestion, found that the phosphuretted hydrogen which was de- veloped arrested the process, and he concluded that the same thing oc- curred with other preparations of phosphorus taken by the stomach;, while Dr. A. Thompson attributes gastric irritation to the formation of hypophosphorous acid, and states that he has only seen these symptoms occur after the use of mixtures prepared with a vegetable oil. Whatever the precise explanation may be, the limit of medicinal and the commencement of toxic doses is marked by more evident irritation of the digestive organs the mouth becomes tender and sore, the nausea is accompanied with retching, vomiting, and diarrhoea; tenderness and en- largement of the liver may be detected, and there is an icteric tint of 38 MATERIA MEDICA AND THERAPEUTICS. skin and conjunctivas. In the irritant form of phosphorus-poisoning (to be described separately), these symptoms become very severe. Cutaneous System Mucous Membrane. A good deal of irritation with hyperaesthesia may be determined in the skin and the conjunctivas, as well as in the buccal membrane, by the use of phosphorus. It is not easy to say whether this is caused by the elimination of the drug, or by the presence of biliary compounds from altered liver-function, or from impaired blood-condition; the icteric tint has been already mentioned. In cases of poisoning, erythematous and hemorrhagic patches occur in the skin, and increased perspiration has been traced to the medicinal use of the drug. Genito-urinary System. There is but little evidence of any stimulus to the generative function or organs exerted by phosphorus given to healthy subjects, whatever may be its power in certain forms of disease. The stimulation that has been noted in some cases, both of men and ani- mals, was not special, but merely a part of the general stimulus to the whole nervous system. Leroy, indeed, and some other French authors, have reported some temporary genital stimulation from large doses, and, in a few cases of poisoning, irritation and excitement of the genitalia have been recorded, but they are to be explained as above. Thompson gave to two healthy adults 1 to 1 gr. of zinc phosphide daily for eight or nine days, and to another to -J- gr. of free phosphorus until symptoms of incipient poisoning arose, but without any trace of aphrodisiac effect. Dr. Eames has reported similar negative results from observations with phosphuretted oil, and Mr. Bradley's experience is to the same effect. With special reference to this point, I have myself carefully experi- mented upon twenty healthy men. Ten of them took ^V g' r - daily for a fortnight; five took -J gr. each day for a similar period; and the other five took gr. every third day for five successive doses. Toxic symp- toms occurred in some of the subjects, but, except possibly in one of the last set, no sign or feeling of increased sexual excitement was observed. I have, however, seen men from forty to sixty years of age, apparently in good health, but suffering from complete loss of generative power (in consequence either of previous sexual abuse, or of overtaxed brain and nervous system), in whom very small doses -jj-g gr. thrice daily caused weak erections and involuntary emissions, but mental depression was de- veloped to such an extent as to compel the suspension of the drug: this implies a state of irritation, but certainly not one of increased tone or strength. With regard to its influence upon the uterus, we have evidence that long-suppressed menstruation may reappear under its continued use in small doses, but this may reasonably be connected with improvement in the blood-condition rather than with specific stimulation; in cases of poi- soning, however, uterine hemorrhage and abortion occur (v. p. 41). PHOSPHORUS. 39 The urine under the influence of phosphorus becomes high-colored and loaded, sometimes phosphorescent, and with a smell of violets, or of sulphur. Husemann reports the nitrogenous constituents increased in amount, and more recently, in dogs poisoned by phosphorus, Bauer found the excretion of urea notably increased 20 to 90 per cent, above normal (Zeitschrift far Biologie, Bd. xiv., Hft. 4, 1878); the phosphates are un- altered in quantity (Derlon). Leucin, tyrosin, and paralactic acid have been found in cases of poisoning. Osseous System. Wegner has furnished definite proof that phospho- rus stimulates the growth of true bone, for, after giving minute doses continuously to animals, he found the epiphyseal cartilages ossify more quickly and more completely than usual, and the cancellous and compact bone become more dense, even to the extent of obliterating the medul- lary canal (Virchow's Archiv, June 22, 1872). Exostoses commonly form in cattle feeding near the bone-works at Swansea, and have been plausi- bly traced to phosphorus fumes in the surrounding atmosphere (Stanley on Bones: JHedical Times, 1854), and although we find clinically that in- flammation and necrosis follow the direct local irritation of strong phos- phorus vapor, yet even in such cases exostoses commonly form in another part of the same bone. Nervous System. The fact just recorded of phosphorus stimulating the growth of bone a tissue of which it forms a component part has led to the inference that it can stimulate the nutrition of nerve-tissue, of which also it forms a normal constituent; but the evidence on this sub- ject is rather clinical than experimental. Gubler describes the effect of "sV * iV r ' * ke a " general sense of stimulation more complete than that caused by coffee, more active than that produced by opium." A. Thompson speaks of it as producing " exhilaration and increased capacity for exertion, both mental and physical, and an effect like that of alcohol without the subsequent depression." He states also that if ^ to 1 gr. be taken in the course of twenty-four hours, the feelings described are more sustained, and transient giddiness or quasi-intoxication occurs. There seems to me some exaggeration in these accounts, but it is within my own experience that a general tonic effect may be obtained from these and smaller quantities of the drug. In cases where poisonous symptoms are developed, marked excitement, tremor, and spasmodic muscular twitching occur, and, in severe cases, cramp or partial paralysis, delirium, convulsion, collapse, or coma. Circulatory System. In accordance with the slight general excita- tion already described, the pulse and temperature are slightly raised about an hour after taking doses of ^ ff gr. ; and after such doses, given daily for some weeks, the circulation has been found more equable and more steady than before (Dr. Ford on fifteen patients: American Journal 40 MATERIA MEDICA AND THERAPEUTICS. of Insanity, January, 1874). Thompson has noted dilatation of the skin- capillaries. In toxic cases the pulse rises to 120 or more per minute, and the temperature to 102 to 103 F., though this condition is only tem- porary. Dr. Gowers has proved that, under the influence of small, continued doses, the proportion of red blood-corpuscles is increased (British Medi- cal Journal, i., 1878), at least in lymphoma, and this interesting observa- tion may throw light on the tonic power of the drug. Toxic ACTION. The poisonous symptoms produced are essentially of irritant and destructive character, but vary in degree, and are often obscure and insidious probably in proportion to the varying amount absorbed, or the chemical changes the drug undergoes under different circumstances. Lecorche makes three forms of " acute phosphorismus ": 1, that produced by phosphuretted hydrogen; 2, that by phosphoric acid; 3, a mixed form; but the clinical varieties described by Trousseau, or better by Dr. Guy, are of more practical importance he names them as 1, the irritant; 2, the nervous; and 3, the hemorrhagic form and a brief notice of them comes within the scope of our subject, because it will help to fix in the mind of the reader the characters of the full physiological action of the drug. 1. The irritant form is the most common: it is induced (on the Con- tinent, not infrequently) by swallowing match-heads, or a certain rat- poison paste. A foul taste and smell, like garlic or sulphur, are first perceived, then heat and swelling of the tongue and fauces, pain and dis- tension of the stomach, bilious and mucous vomiting and purging, with colic and abdominal tenderness. The ejecta occasionally contain blood, and may be phosphorescent, and the faeces contain small masses of crys- tals of the fatty acids, and later in the attack become clay-colored. The pulse rises to 120 or higher, and the temperature to 102 or 103 F. ; but this pyrexia passes away as the gastro-intestinal symptoms become very severe, and is succeeded by an opposite condition (Gubler). In the early stages there is pronounced nerve-excitement, with hyper- sesthesia, agitation, talkative delirium, and delusion, which is sometimes of erotic character, though priapism is rare. Muscular twitchings and cramps, and even general convulsions occur, but later on follow prostra- tion, fainting, and collapse, loss of muscular sense, and of sensation, re- tention of urine, and partial paralysis, affecting mostly the extensor mus- cles. 2. In the nervous form these latter symptoms become much more marked, but there is little pyrexia; erythematous spots occur in the skin, which is dry and yellow, and later becomes cold; dilatation of pupil and strabismus are described, and the fatal termination comes on with som- nolence and coma. 3. The hemorrhagic form is less quickly fatal than the others. In it PHOSPHORUS. 41 the ejecta are almost wholly sanguineous; bleeding occurs in and from the skin and mucous membranes, and many parts of the body. It is due partly to the altered blood-state, and partly to general softening of the tissues, including fatty degeneration of vessels (Lebert). In women there is uterine hemorrhage, miscarriage, or abortion but these may be due to the irritant effects on the intestinal canal. In all cases of phosphorus-poisoning, about the third or fourth day pain is felt over the liver, and is followed shortly afterward by jaundice, headache, and sleeplessness; the urine is found to contain bile, and gen- erally albumen, leucin, tyrosin, and paralactic acid. The presence of bile is an argument that the jaundice depends not on suppression, but on occlusion of the biliary passages, which is probably catarrhal in character. In exceptional cases (in which, probably, only a small amount of the poison has been absorbed) there has been neither gastro-enteritis, nerve- excitement, nor quick pulse, but the prominent symptoms have been jaundice and hepatic congestion (British and Foreign Review, April, 1863). The time that elapses from the taking of the phosphorus to the appearance of symptoms varies from a few minutes to two days. Death, when it occurs, is usually from asthenia, but the course of the illness is not always steadily progressive: sometimes the severe symptoms subside for a few hours or days, and death takes place suddenly, from failure of the cardiac muscle (Habershon: Medico- Chinirgical Transactions, v., 50). A fatal dose may be stated as about 1 to 2 gr. for adults, but much less for children, in whom vomiting and convulsions are usually the prom- inent symptoms. TOLERANCE. The system may become habituated to the use of phos- phorus to some extent, and a gradual increase of dose may be borne up to an amount which would not at first be tolerated. In using it for neuralgia, Thompson has found that cases not relieved by a gradually in- creased dose have yielded to a similar dose, given at once after allowing an interval to elapse. Any " cumulative action," so called, may be ex- plained by the mechanical accumulation of the drug in the stomach or intestines. PATHOLOGICAL CHANGES INDUCED BY PHOSPHORUS. Ecchymoses and gangrenous spots have been found in the intestinal tract, together with swelling and softening of the mucous membrane and mesenteric glands; rarely perforation. The viscera are hypersemic, and oedema and hemor- rhagic infiltration affect the skin, serous membranes, and other tissues, especially the mediastinum; hemorrhage has also occurred between the spinal membranes, thus accounting for a paralysis. The blood itself is black and viscid, and in many cases, even during life, the corpuscles are destroyed and the haemoglobin altered, so that it will not show the usual spectrum (Lecorche, Voit, etc.) ; in others the corpuscles have been found normal after death, and the blood-crystals (of haemoglobin and haemato- 42 MATEKIA MEDIC A AND THERAPEUTICS. crystalline) found unchanged (Lebert, Gubler); but in all cases the blood and the solid organs contain an increased proportion of waste products, such as urea, creatin, leucin, tyrosin, etc., and fatty degeneration affects every tissue. The muscles, including the cardiac muscle, are discolored, soft, and fatty, the capillary walls are degenerated in a similar manner, the gastric glands and renal tubules are choked with fatty epithelium, and the liver especially is enlarged, yellow in color, and its cells filled with fat-globules; in protracted cases, cell-atrophy occurs. The condition described resembles closely that found in an idiopathic malady, "acute yellow atrophy" of the liver, and the question of diag- nosis has been raised in medico-legal cases (Annales cTIIygi&ne, Januarv, 1869). An illustration is recorded by Surgeon-Major Martin, in a man ad- mitted to Netley Hospital without any history of poison, and whose case was diagnosed as acute yellow atrophy; it was only after death that the real fact of phosphorus-poisoning was disclosed by examination (British Medical Journal, i., 1878). THEORY OF ACTION. The direct irritant effects on the intestinal canal depend rather upon the oxygen or hydrogen compounds formed, than upon phosphorus itself, and the pain, vomiting, prostration, etc., fol- low from the local irritation produced, just as with other corrosive poisons. To explain the other constitutional symptoms, and the subsequent arrest of nutrition and fatty degeneration, several modern writers have argued that the strong affinity of phosphorus for oxygen leads it to ab- stract that vital gas from the blood, and so induce a condition of asphyxia (Eulenburg Lecorche); but, as oxygen would be continually renewed by inspiration, and the amount that can be absorbed by the metalloid is only limited, I cannot see that such serious consequences would result; neither would asphyxia produce preliminary excitement nor subsequent waste, nor is the blood of poisoned animals always found black; it is sometimes red, a condition incompatible with asphyxia (Vigier: Bulletin, 1868). Others have argued that phosphorus indeed removes oxygen from the blood and the tissues, but with the main result of forming phosphorous and phosphoric acids, which act as local corrosive agents, and which, after absorption, destroy blood-corpuscles. The stomach contains some free oxygen, especially after food (Chevreul), and it has been suggested that, when the drug is taken under circumstances which favor its retention in the stomach and its oxidation there, then gastro-intestinal troubles are the most marked (irritant form of poisoning). That phosphoric acid is formed in the system seems proved by its excretion from the lungs; and further, it is pointed out that this acid, when injected into the veins, will destroy the corpuscles, and will lead to fattj' degeneration (Personne); and although it will not act thus when given by the mouth, yet it may do so when directly generated within the system by the oxidation of free phosphorus. While allowing this to some extent, I cannot believe it PHOSPHORUS. 43 possible that a sufficient amount to account for such results could be formed in this manner. Again, oxygen has proved an antidote to phos- phorus-poisoning (Crocq), and turpentine acts as an antidote by a process of oxidation, while free ventilation is the best means of preventing necrosis of the maxilla, etc., in phosphorus factories (Savory, Sieveking), so that it seems at least unlikely that oxidation of phosphorus is the cause of its ill-effects. In explaining the action of the drug I incline to accept the theory of Gubler, who suggests that it acts chiefly by the strong ozonizing power which we know burning phosphorus to possess. Although through this combustion a minimum quantity of oxygen gets lost for the respiration, the remainder would shortly acquire, from its admixture with the ozonized portion, so great an increase in combustion power as to be very likely to induce general stimulation of the system. But increased activity is ac- companied by an increased waste, particularly of the blood-cells; anaemia follows this irregular activity, and fatty degeneration of the tissues and impairment in the function of the different organs take place. On the other hand, amorphous phosphorus, which has no ozonizing power, would fail to produce any such symptoms, as is really the case; but more accu- rate analyses of the secretions are required in order to support this hypo- thesis. The excretion of carbonic acid is said to be lessened (Rabuteau) we should not expect this unless in advanced stages; as already stated, nitrogenous excretions are increased in amount, while the urinary phos- phates remain about normal. I have still to refer to the effects of Phosphuretted Hydrogen, which would readily be formed from water and phosphorus, or from any phos- phides, or from the very unstable hypophosphorous acid. We have seen that this gas interferes with the digestive process, and we know that, if it be passed into defibrinated blood, it turns it black and destroys its haemo- globin (Dybkowsky) ; also that it possesses, equally with phosphoric acid, and other acids and substances which act destructively on the blood, the power of inducing fatty degeneration from impaired nutrition (Bence Jones and others: Medical Times, ii., 18G5, p. 593). The formation of phosphuretted hydrogen in the system would equally well explain the production of the principal toxic effects of free phosphorus, and I incline to attribute them largely to it. Lecorche states that this compound has been found in the tissues in fatal cases, and he connects its presence specially with the second or neurotic form of poisoning, in which the course is rapid and nerve-symptoms are prominent. Fatty degeneration was found by Munk and Leyden in the tissues of frogs and rabbits within two or three days after giving phosphorus (Medical Times, ii., 1865, p. 593), and since these researches its occur- rence in phosphorus-poisoning has been amply demonstrated, especially by German observers (v. Naunyn in Ziemssen's " Cyclopaedia "). 44 MATEBIA MEDICA AND THERAPEUTICS. In Tamassia's experiments it was very rapidly produced. He in- jected 3, 4, 5, 6 gr. respectively into the rectum of four animals (dogs and rabbits); toxic symptoms occurred in about fifteen minutes, death in eight hours (the temperature falling 8 F.). In all four of the animals the kidneys, and in two of them the liver also, were in a state of fatty degeneration ( Medical Record, January, 1878). SYNERGISTS. Arsenic is allied to phosphorus in its power of acting upon the blood (with advantage in small doses, in large doses with de- structive effect), also in its action upon nutrition. Cantharides, oxygen, and stimulants have somewhat analogous stimulating powers. It is a curious speculation that ergot of rye owes its properties to the phosphoric acid it contains (Levi: British and Foreign Review, April, 1876). Adjuvants are found in phosphoric acid, and in fatty and fleshy foods. Phosphoric acid has especially been shown to develop or augment the powers of phosphorus, probably from aiding in its solution and circulation (Personne). The brains of animals and the flesh of hogs are said to be rich in phosphorus, and roast food to retain more than boiled. ANTAGONISTS ANTIDOTES. Hydrate of magnesia, or of lime, will neutralize the acid compounds of phosphorus, and carbon will absorb phosphorus vapor. Sulphide of carbon antagonizes the excitant action of the drug, as also do sulphuretted hydrogen, aneesthetics generally, and cyanides (Gubler). Nitrate of silver was recommended as antidotal by Bellini (Medico- Chirurgical Review, ii., 1875). In an important experiment by Crocq, oxygen was used as an anti- dote, defibrinated blood charged with the gas being injected into the veins, with the effect of restoring to its normal condition the dark, pitch- like blood of poisoned animals (British and Foreign Review, ii., 1875). But the two antidotes which claim special attention are sulphate of copper and oil of turpentine. With any soluble salt of copper, phos- phorus forms a black phosphide, non-poisonous; and as copper sulphate is also a good emetic, it is specially available for cases when the poison has been taken by the stomach, and when the remedy can be given soon afterward. Five grains should be given every two or three minutes until free vomiting is induced, and then, either continued in smaller doses and with opium, or turpentine may be substituted. If oil of turpentine be brought into contact with phosphorus at a suit- able temperature, a crystalline white solid is formed terebinthino-phos- phorous acid which is not poisonous. Kohler and Schimpf obtained it by adding gradually 2 Ibs. of the oil to f oz. of the element at 40 C., and the same substance has been obtained in the distillate from urine in cases of poisoning (Pharmaceutical Journal, March, 1873). To produce the desired result, the oil must come into direct contact with phosphorus in the stomach, and in the proportion of about 100 parts to each one of the PHOSPHORUS. 45 latter. Eleven hours is the longest time that has elapsed before the ad- ministration of the remedy in successful cases. Moreover, it is not every kind that will act well; the pure rectified oil, and much of that imported as German and American, do not form the crystalline acid, and hence a difference in the results of some observers. It is the crude, acid, French oil, or that which has been ozonized by long exposure, which gives reliable results. It is said also that milk lessens its good effect. A case illustrating the value of both the antidotes recommended oc- curred in my practice some years ago. A young man (insane from over- study for examination) swallowed some pieces of solid phosphorus, and, while his friends were gone for assistance, gashed his throat and body with a razor. When I saw him the most pressing need was to stay hemorrhage, and while doing this I sent for some copper sulphate and turpentine, giving him at once mustard and water. This and the copper produced good emesis, with rejection of a piece of phosphorus two inches long. I then began giving turpentine in milk (also in water), but still encouraged vomiting, because from the small pieces left in the patient's bottle of phosphorus more was thought to have been taken. Eventually two other pieces, 1 in. and in. long, were rejected, after having been in the stomach at least three hours. Several more doses of turpentine were given, and the patient made a good recovery, with the exception of some dyspepsia: he was seen afterward by Dr. Fuller, the family physi- cian, and passed from under my care, but is, I believe, still living in an asylum. The case may be considered another illustration of the fact that large pieces of phosphorus are less dangerous than the finely divided sub- stance; but I think real benefit resulted from the antidotes used. A case is reported of a man who swallowed 120 match-heads, and then took turpentine to increase the effect. He did not vomit, but recovered (Medico- Chirurgical JReview, ii., 1869, p. 555). Other cases, cured by the same antidotes, are given in Braithwaite, i., 1872, p. 131, and in Sydenham Society's " Year Books," and British Medical Journal, i., 1878. THERAPEUTICAL ACTION (INTERNAL). From what has preceded, it will be recognized that the value of phosphorus lies in its power of strengthening and giving tone to the nervous centres when their activity is impaired; also, since nerve-debility is a cause of many other besides what are called nervous diseases, a nerve-tonic of this kind has a wide field of usefulness, and is applicable not only in nerve-exhaustion and pain, but in many conditions of adynamia. Rabuteau, however, states an opposite view when he says: "I do not hesitate to assert that this poison has never cured anything up to the present time, and I would never prescribe it; it has always been useless" ("Elements," p. 211); while Beaumetz, A. Thompson, and others have recorded wonderful re- sults from it. The truth probably lies between the two extremes, and 46 MATEBIA MEDICA AND THERAPEUTICS. we must not forget that some failures may be accounted for by inactive preparations of a drug always difficult to dispense. Neuralgia. Eighty years ago von Lobel, a physician, related his cure from an inveterate cranial neuralgia (which was accompanied with debil- ity and failure of mental and sensory power) by an ethereal solution of the drug. He took gr. every two hours, and (with one relapse) was re- stored to health in a short time, and after only a few doses. This experi- ence was corroborated to some extent, and the remedy came into great repute, but was soon found to be a dangerous one and difficult to man- age, and it gradually fell into disuse, no doubt owing to the largeness of the doses. A few years ago Mr. M. Bradley published a case of neuralgia of the chest-walls, rapidly cured by "tincture of phosphorus," after fail- ure of all recognized remedies, and later he recorded other successful re- sults {British Medical Journal, October, 1872). In the following year Dr. Slade King added testimony to its value in doses of ^ to -fa gr. (Medical Times), and Dr. Ashburton Thompson recorded forty consecutive cases either cured or relieved (Practitioner, 1873); Mr. Sanger, of Alfris- ton, referred to an equal number (British Medical Journal), and Dr. Hammond praised it in America (Practitioner, i., 1877). Drs. Radcliffe and Broadbent may be cited also among those who early employed it with good results, the latter especially in "anginoid pain" a cardiac neuralgia (Practitioner, 1875). It was found useful in cases connected with extreme general debility whether from over-lactation, hemorrhage, or simple asthenia in cases due to pregnancy, to cold, and to local irritation, such as carious teeth, and even to rectal cancer (Thomp- son). Anstie's experience was not so favorable. I have myself seen much benefit from it in many of the above cases, also in uterine neuralgia occurring in sensitive patients, and induced either by protracted lactation, excessive sexual passion, or by mental or local causes. The severe pain is apt to com'e on just before or during the monthly period, and then -j-J-j to -^ gr. should be given three or four times daily; during the interval the smaller dose should be given, and less frequently. Intercostal Neuralgia. For upwards of twenty years I have been ac- customed to use phosphorus in this affection, and can speak favorably of its power. I have notes of fifty-six cases wherein the pain quickly sub- sided under this treatment, and did not, so far as I know, subsequently return. In some instances phosphorus succeeded where arsenic had quite failed. The dose was yj^j- to $ gr. three times daily. With regard to the dose of phosphorus in neuralgia and nerve-disor- ders generally, I may say that in my experience the comparatively large doses recommended by Dr. A. Thompson cannot be tolerated for any length of time by the system. They may seem at first to stimulate, or rather over-stimulate, the nerve-centres, but after a short time they de- PHOSPHORUS. 47 press in a disastrous manner; while the small doses of ?*-$ to -fa gr., con- tinued for due time, nourish and strengthen nerve-tissue, without any evidence of undue excitement. A therapeutical, and not a physiological action, is to be always desired. Herpes Zoster. In this affection, which is distinctly neurotic, I have found good from phosphorus, for it has in some instances quickly relieved the severe pain. Facial Spasm. Twitching of the facial muscles, especially about the orbit, often occurs in cases of neuralgia and of impaired nerve-power. I have known it markedly improved by phosphorus. Nerve- Exhaustion. Gubler found phosphide of zinc remove the sen- sation of fatigue after hard work, improve appetite and digestion, and conduce to sleep. He gave a -gr. dose with an ordinary digestive pill at dinner-time; but such a dose is too large, and is very liable to nau- seate. When the nervous system is jaded and below par, so that slight impressions are too deeply felt, and the nerve-controlling power is im- paired, phosphorus has been found to supply what is wanting for a time; also, it has been said to improve intellectual tone in those subjected to either monotonous brain-work or to an unusual mental effort (Thompson). Dr. Broadbent early recorded some striking cases of this kind: one of " nervous break-down " in a city merchant, with insomnia, and extreme depression and incapacity for work, and another in which " epileptiform vertigo " was present in addition. Both got well " quickly and com- pletely" under phosphorus (Practitioner, 1873). In cases of Chronic Exhaustion of Brain-Power, or of general nerve- exhaustion consequent on chronic disease, small doses continued for a long time are advisable, and have been plausibly held to supply to the nerve-tissue a vital element in which it is deficient, and to improve its nutrition, just as Wegner showed that the drug improved the nutrition of bone; and certainly its supply, in some form, to nerve-tissue, is as neces- sary as that of iron to blood-corpuscles. I have reason to believe that benefit may be obtained from phosphorus even when there exists evidence of atrophic change in the brain, of the nature of white softening or chronic fatty degeneration, with such symp- toms as failure of memory and of self-control, loss of proper sensation and cerebral power generally. These are commonly associated with fee- ble heart-action, and with arterial degeneration, and may occur not only in advanced life, but as a consequence of wasting disease, chronic alco- holism, etc. I remember well a case of this kind in which epistaxis was a frequent symptom, and had proved rebellious to iron, acids, and other ordinary treatment in the hands of experienced men: small doses of phos- phorus (ethereal tincture) improved the patient very much both as to brain and muscular power, but the symptoms always tended to recur on omis- sion of the remedy, and he continued it for a long time with good results. 48 MATEKIA J1EDICA AND THERAPEUTICS. A suitable dose is -fa gr. thrice daily for about a fortnight, and then it should be reduced to -j-J-g. gr. or less, and should be taken for twelve to eighteen months, omission being made for about ten days in each month. Although I do not find this experience to be general, yet it is not wholly singular, for Dr. Hammond also speaks of the value of the remedy in conditions of softening; he recommends similar doses given with cod- liver oil, or zinc phosphide in -fa gr. doses. Fatty Degeneration. That a different action may be obtained from a different dose of the same medicine is an elementary therapeutical axiom in constant application, and it is, I believe, a clinical fact that phosphorus can relieve the symptoms which are usually associated with fatty degeneration, not only of the brain, but of other organs. I have notes of more than thirty cases in which fatty degeneration of the heart might fairly be diagnosed: the cardiac sounds were feeble, the impulse weak, the pulse slow, sometimes excited, irregular, soft, and compressi- ble; with dyspnoea on exertion, arid a sense of anxiety and tendency to syncope to a greater or less degree; arcus senilis sometimes present. After taking phosphorus for a few months, most of the patients were much relieved, and were able to move about without fear, and with com- parative comfort. No doubt somewhat similar cardiac symptoms may be caused by nerve-exhaustion or gout; the absolute diagnosis of fatty de- generation cannot always be insisted on, and I do not wish to maintain that phosphorus reconstructs degenerate cells, but its acknowledged power over nutrition makes it reasonable to suppose that it can hinder or stop commencing degeneration, and especially improve the condition of the nervous system. It is highly important to carefully proportion the dose to the necessi- ties of each individual case, as some will take with advantage more than others. Where the heart-action has been very irregular, or the dyspnoea and syncopal feelings more than ordinarily troublesome, I have given -fa to fa gr. occasionally; but these doses should not be given frequently, for fear of aggravating the symptoms. I prefer to give -gfa to y^^ or fa gr. twice or thrice daily. Not only in heart disease of the kind described, but in fatty degeneration of other organs, and in the form which threat- ens during typhus and some other acute diseases, phosphorus is worthy of attention. For many years I have been accustomed to use it in such cases, and the improvement traceable to it is often remarkable. The smaller doses mentioned are to be preferred, in order to avoid irritant effects, and to get the system slowly, but more fully under the influence of the remedy; when this is done, the effect is more thorough and lasting. Exhaustion of Fevers, etc. The value of phosphorus in conditions of extreme exhaustion in advanced disease is one of the earliest recorded experiences of Kramer, Mentz, Leroy, etc. (1733-1798). They used it PHOSPHORUS. 49 in the muttering delirium and incipient coma of typhus, the collapse of malignant "bilious fever," and the profound depression of extensive pneu- monia. Bayle says, " in every disease where death is imminent from failure of vital force without much structural alteration, phosphorus is indicated. We see this in severe continuous fevers during their last stage, whether they be caused by some miasm, typhus, plague, etc., or by ' spontaneous alteration of the blood,' as in adynamia or putrid fevers (so called) ; in such cases phosphorus reanimates vitality, furnishes nature the means of effectually resisting the disease, and eliminating its material causes by natural excretory outlets. It is indicated, secondly, in all acute exanthemata when eruption has disappeared suddenly, with aggravation of symptoms (measles, variola, erysipelas, low fever with exanthem); thirdly, in malignant pustule, where the disease has reached its acme and the vital power is almost extinct." Bayle adds that it is useful in chronic gout and rheumatism (which are relieved through profuse excre- tion of sweat or urine), and " all morbid conditions wherein it is proper to excite these secretions, and at the same time to stimulate vitality in a speedy and energetic manner" (" Bibliotheque de Therapeutique," vol. ii.). Powers so extensive as these have not been accorded to phosphorus by more modern writers, but Mr. Clay has illustrated its value in the collapse of variola (Lancet, ii., 1858, p. 315), and Dr. John Brunton in the adyna- mia of typhus and typhoid fevers, rapid improvement taking place under drachm-doses of the following solution: Tinct. phosph. aeth. (gr. ^ ad 3 j) 3 iij., Spt. vini rectif. 3 ss., Glycerini ad iss. About two grains were taken in the course of two days. I have frequently prescribed phosphorus in the exhaustion of typhus and typhoid, and have sometimes seen remarkably good results from it; but, on the other hand, have been often disappointed, and cannot but consider it an uncertain remedy in such cases. I would place more de- pendence upon ammonia, camphor, and other stimulants of that class, but, if they failed, should then have recourse to phosphorus. Another use of the drug in fevers is to assist development of the specific eruption, e.g., in enteric, scarlet fever, and measles, and within my own experience it has proved of service when the eruption has disappeared suddenly with the onset of serious symptoms. Exhaustion of Generative System-^Impotence. In such conditions phosphorus has long had a reputation, and was much valued by early authorities, but modern experience has limited its powers. If the special exhaustion referred to be only part of a generally enfeebled state, it will doubtless improve as general tone and vigor improve, but this system is not to be stimulated apart from the others; indeed, if it were- so, this might be a serious drawback to the ordinary use of the remedy. I may say, however, that in some of my own cases an irritable, weakly condition VOL. L 4 50 of the sexual organs, traceable to previous early abuses or subsequent ex- cesses, has been much benefited by steadily continued doses of ^-J T to y^ gr. thrice daily. Spinal Irritation. I consider phosphorus of greater value when this condition is connected with onanism than when arising from over-fatigue el O or other causes. The irritation is marked by local discomfort, a burning pain in the lumbar region, sense of fatigue and impaired walking power, mental distress, etc. In such cases it is essential that the patient exert moral control over himself, and that treatment be continued judiciously for some months. The remedy relieves the spinal pain and the mental depression, and thus indirectly tends to lessen abnormal sexual desire. disorders of Menstruation. Patients with scanty, watery, and ir- regular catamenia sometimes suffer, about the time of the periods, from sick headache, and when this is the case a continued course of phos- phorus increases the quantity and improves the quality and regularity of the menses, and the headaches frequently disappear. Phosphorus, like aconite, restores the discharge when suddenly interrupted by cold or fright. When the discharge is not only too profuse, but watery in character, and rather delayed beyond the natural time, phosphorus is of consider- able use, as it checks the overflow, relieves the backache, improves the mental depression, removes the nausea and vomiting so frequently at- tendant, and strengthens the general condition. It is also useful in pro- fuse menstruation attended with excessive sexual excitement. The dose should rarely exceed y-J^ gr. every two to four hours during the menses, and morning and night during the menopause. Paralysis. Cases of hemiplegia relieved by phosphorus are on rec- ord, but not from very reliable sources. It is contraindicated in acute irritative conditions, but in chronic stages should be tried, particularly if exhaustion be a prominent symptom. I agree, generally, with Le- maire, who has summarized the modern use of it for paralysis, and finds that, in local palsies after severe illness, or from anaemia or hemorrhage, it has a general tonic, stimulant power, but not a specific curative effect, and is always uncertain. In paralysis dependent on severe organic dis- ease, tumor, or hemorrhage in the nerve-centres, it cannot, of course, be relied upon, nor in hysterical palsy, although, in the last-named, I have sometimes seen advantage from it, and Dr. Hammond speaks well of a combination of zinc phosphide with strychnia. It is commonly useless in old paraplegia, in sclerosis, and in lead-palsy; and Mr. Sanger is almost alone in reporting paraplegia and paralysis agitans cured by the drug. I have, however, known it relieve formication in paralyzed parts. It has been found of service in recent ataxy and in mercurial palsy (tre- mor), arid its advantage has been distinct in functional derangement with adynamia, and in some slight structural lesions when inflammation, PHOSPHORUS. 51 fever, and cerebral excitement were absent (Bulletin General de TJiera- peutique, September, 1875). The dose recommended is about one milli- gramme (^5- gr.). For intra-ocular paralysis it was used by Tavignot, externally and internally. Tremor. In alcoholic tremor, as well as in the mercurial form, and in partial paralysis of the same kind caused by arsenic, Dr. G. De Mussy has found advantage from four-milligramme doses (-^ gr.) (Lancet, i., 1876). Locomotor Ataxy. Dujardin Beaumetz has advocated the use of phosphorus in ataxia, upon the strength of four partially successful cases, of which, however, the after-history is not given. His favorable observations have not been generally confirmed, though a patient said to be suffering from "progressive locomotor ataxy," unrelieved by bro- mides, strychnia, quinine, and iron, was able to stand and to walk after two months' treatment by phosphuretted oil (Hartley: Lancet, i., 1877), and some other scattered observations may be found. The malady ex- hibits, in its natural course, remission and improvements, partial, and lasting for a variable time, but sufficient to throw uncertainty on the ac- tion of any medicine, unless very carefully and frequently verified. This was instanced in one of eighteen cases of ataxy reported by Mr. Bradley (British Medical Journal, ii., 1878); the improvement observed might have been credited to the remedy, had not the patient relapsed after- ward while under the same treatment. The others remained in statu quo. It is possible that, in these and similar instances, the dose was too large, or not continued long enough, and further observations should be made. Certainly, in some few cases I have seen much improvement during a prolonged use of phosphorus (ifa gr.) or zinc phosphide, though I am not satisfied that it was really due to the drug. Hysteria. Nerve-power is impaired in this affection, the emotions not being under normal control; more or less neuralgia is often concomi- tant, and altogether it is a condition in which we should expect phos- phorus to be useful, and instances of its value are on record. The cases benefited by it have been acute or chronic, dependent on sudden shock, or gradually coming on with increasing weakness and despondency; in either form a period of debility is liable to be followed by convulsive at- tacks. I do not undervalue moral and hygienic treatment; but, among medicines, phosphorus in doses of -j-J-^ to -fa gr. has proved efficient in my hands. When hysterical attacks are connected with delayed or sup- pressed menses, pain in iliac and lumbar regions, vomiting, palpitation, and general excitement alternating with depression, I have found this remedy regulate the menstrual periods and cure the hysterical symptoms. Epilepsy. In true epilepsy it has, like most other nerve-tonics, been used and commended, but evidence of its really preventing the attacks is contradictory. Broadbent found it useful in epileptiform vertigo (Prac- 52 MATERIA MEDIC A AND THERAPEUTICS. titioner, viii.-x.), and Anstie observed it relieve the depression of epi- leptics and improve their temper and power of control (Medical Times, i., 1862). In the early period of the disease, when dependent upon sexual abuse, I have known phosphorus prove very beneficial. I remember es- pecially the cases of two men, aged nineteen and twenty-three, whose attacks began soon after puberty, and who had taken large doses of po- tassium bromide without evident relief, and who became quite freed from their attacks during a course of phosphorus, and have continued free from them during the four and six years that have since elapsed. The dose was only -j-J-g- gr. three times daily, which was continued (irregu- larly) for twelve or fifteen months. Melancholia Dementia. Dr. S. W. Williams in this country, and Dr. Ford in America, have recorded their experience of phosphorus in these conditions. The six cases of the former physician were treated by -g^-gr. doses (Kirby's pills) twice or thrice daily, but only two could be considered relieved (Journal of Mental Science, 1874). Dr. Ford recog- nized improvement in fifteen cases of dementia (American Journal of Insanity, January, 1874). Dr. Judson Andrews had previously written in favor of. phosphoric acid in different forms of insanity, but especially those tending to melancholia (American Journal of Insanity, October, 1869). I have notes of thirteen cases of recovery from this distressing affec- tion in patients between the ages of thirty-two and forty-five years, most of whom showed well-marked symptoms, such as despondency and de- pression, suicidal impulse, fear of solitude, loss of sleep, etc. : they looked haggard, with flushed face, and complained of cold, clammy skin, vertigo, and various disturbances of the digestive system. In addition to general treatment by exercise and different forms of bath, and the occasional use of nux vomica or aperients, I gave phosphorus, at first -fa gr., afterward rhr g r -> thrice daily, with the result that all recovered in the course of two to three months. My experience of fourteen other cases between the ages of thirty-five and fifty shows, however, that it is an uncertain remedy, and although quickly beneficial in some cases, in others it is dis- appointing. Pneumonia. A simple pneumonia usually terminates favorably, in- dependently of medicine, and requires at least no active interference; but, under certain conditions and complications, phosphorus has proved, in my experience, a valuable adjuvant. Thus, if at the commencement of an attack adynamia is very pronounced, this medicine is indicated. It is curious that the most amenable to its action seem to be adult subjects previously robust, and old persons. It is a matter of common observa- tion that the nerve-power fails more rapidly in severe illness attacking such subjects, than it does in the young or the simply delicate. Some degree of biliary disturbance usually accompanies the early stages of PHOSPHORUS. 53 pneumonia, and so long as this does not assume a very aggravated form, I have found it a good indication for phosphorus treatment, and espe- cially if prostration be extreme. Again, it is good in ordinary cases with difficult muco-sanguineous expectoration and very marked lowering of strength and evening exacerbations; also in later stages, when either pyrexia has subsided and the patient is left very feeble, and does not progress toward convalescence; or again, when red hepatization is com- plete, fever and prostration increase, and suppuration is imminent although, when pus has actually formed, phosphorus is contra-indicated. Dr. A. Thompson, speaking highly of the value of phosphorus in pneumonia, remarks that success depends much on the dose given, and in his opinion the better results of older practitioners were traceable to their use of full doses, toxic effects being less known and consequently less feared by them. He says that " no caution need limit the quantity of such a preparation as the tincture, the only limit to be recognized being improvement in the patient." He commonly orders -j^-gr. dose in the cases referred to, but I cannot agree either with this theory or practice; my best results have been obtained with ^^ to T ^ 7 or -$ gr. given every two to four hours. I have also had good results from phosphorus in chronic pneumonia; but when it occurs in tuberculous subjects with tendency to hemorrhage, this drug should be avoided. In acute or chronic cases, complicated with bronchitis, phosphorus is less appropriate than other remedies. Chronic Bronchitis. In simple cases of this affection, when patients complain of a feeling of tension throughout the respiratory tract, and a hacking, dry, and exhausting cough, phosphorus is, however, often valu- able. Pleurisy. In pleuritis with extensive recurrent effusion of dark, bloody-looking serum (as proved by aspiration), in patients whose blood has been impoverished by excessive and long-continued use of stimulants, I have found phosphorus as well as arsenic of much use in hastening absorp- tion of the fluid, and giving tone to the nervous system. Tuberculous Phthisis. The action of phosphorus in this affection can only be considered palliative; but it can, at least, moderate some trouble- gome and irritating symptoms. I have used it in various doses in upwards of eight hundred cases of which I have record, and am satisfied that it does not cure advanced tuberculosis, but appears in many cases to arrest its progress, at least for a time; also to improve the condition of the throat and the voice, and to relieve the dry, harassing cough, the pain after food, and even the colliquative diarrhosa and night-sweats. It has also removed pleuritic stitches, and seemed to strengthen the general condition; on the other hand, its use is not free from danger, and requires caution, since it may induce obstinate haemoptysis where there is a ten- dency to hemorrhage. 54 MATEKIA MEDICA AND THEEAPEUTICS. Chronic Diarrhoea, in children, with frequent watery evacuations, abdominal pains, depression, and emaciation, or the colliquative form, occurring, e.g., in phthisical adults, has often in my hands yielded quickly to phosphorus. Sometimes it is well to give a few doses of Fowler's solution of arsenic in conjunction with phosphorus. Intestinal Ulceration. Phosphorus is useful in ulceration of the in- testinal mucous membrane, the result of muco-enteritis, dysentery, or other causes, and especially when considerable prostration, restlessness, and emaciation are present. It is well, sometimes, to combine it with a course of arsenic. Chronic Otorrhoea. In some obstinate cases, common in strumous children, phosphorus is very valuable in stopping the discharge and giving nerve-tone and strength to the system generally. When glycerin of tannin and other astringents fail to permanently stop the discharge, a course of phosphorus, conjoined with the daily application of the tannin, will accomplish a cure. Cutaneous Diseases. The value of phosphorus in these maladies was mentioned by Cazenave, and in 1850 Burgess recommended it in psoriasis and in lupus. More recently Dr. Broadbent, inquiring how far the chemical analogies of drugs would guide to their therapeutical effect, was led to use phosphorus in the same class of cases as arsenic, and he recorded six cases of eczema and six of psoriasis treated by the former drug. The majority of these were relieved or cured (" Clinical Society's Transac- tions," vol. iv.). Dr. Eames also reported successful cases under the same treatment (Dublin Journal, January, 1872), and Mr. Squire, recording in detail the course of psoriasis in a young girl, to whom full doses (fa to \ gr. per diem) were given for several weeks, concludes that the remedy was of much advantage, though not wholly curative by itself (British Medical Journal, ii., 1877); and it seems to me that in this case more allowance should be made for the change of air and diet, the girl having come from Wales to London. In a case of Dr. Whipham's, whatever good was obtained in the first month of treatment was lost in the second, and in several cases within my own knowledge severe and chronic cases, it is true phosphorus was given without benefit. It would seem, then, that it is uncertain as a remedy, and, without denying its occasional power of relieving, I think, with Erasmus Wilson, that it is indicated rather for the impaired nerve- condition accompanying many skin disorders than for any direct influence upon the nutrition of the skin. Lupus Scrofuloderma. In these forms of depraved nutrition theory would suggest that phosphorus might be useful, and Dr. Eames states that some cases have recovered under its use in from five to nine months. Dr. Mackey has given it a fair trial in three or four instances of various PHOSPHOKUS. 55 forms of lupus, and has found it improve the general condition, but with- out exerting any special influence over the local affection. In rodent and cancerous ulceration, however, I have known it relieve the burning and other pains, and also check discharge and lessen exhaus- tion. V Pemphigus Acne Soils. Cases of cure from each of these disor- ders, under the use of phosphorus, have been recorded (British Medical Journal, ii., 1876). In pemphigus, arsenic, as a rule, is to be preferred, and during an eruption of boils, phosphorus is only indicated if the pus becomes thin and sanious, and the nerve-power unusually depressed. A severe case of acne indurata under Dr. Eames seems to have im- proved remarkably, but the few cases in which I have used it did not derive benefit from it. Abscess (Fetid). In simple cases of abscess, antiseptic surgery, care- fully carried out, generally proves successful; but, should it not do so, and should the pus become fetid and watery, and hectic fever appear, with rapid failure of strength, then T ^g- to ^ gr. phosphorus should be given every two to four hours, and 1 have seen this produce most favorable results. JBone Disease Rachitis Fracture. In cases of fracture, resection, and transplanting of periosteum, Wegner found that small, continued doses of phosphorus stimulated the growth of new bone, especially in young animals; also that ossification in the fcetus was promoted by giv- ing phosphorus to the mother. It is noteworthy that he obtained similar results, though less in degree, from phosphoric acid and oxy -compounds of phosphorus, but not from the amorphous element, nor from lime phos- phate. I have myself seen good results from phosphorus in ordinary caries of bone, and again, in cases of abscess connected with necrosed bone, it les- sens suppuration and hastens the separation of the sequestrum; given during pregnancy, it relieves the dental caries and neuralgia often inci- dental to that state, and I have given the hypophosphites successfully in such cases. It may be presumed that phosphorus, and such preparations of it, would also improve the nutrition of the fcetus in weakly subjects, and I think they might often be used with advantage in chronic rachitis. Leucocythcemia Pernicious Anaemia Lymphadenoma. It is in such blood and gland disorders, which are essentially of serious, if not fatal import, that phosphorus has been recently employed, and Dr. Broad- bent, one of the first to recommend it, offered some evidence in its favor. A boy with " essential anaemia," prostration, diarrhoea, yellow, waxy face, etc., recovered very quickly under phosphorus capsules, and remained well for some time. Another case of " leucocythasmia," treated in the same manner, got inflamed spleen, " apparently from very rapid blood- formation " (Practitioner, i., 1875). In a woman with lymphadenoma, 56 MATERIA MEDIC A AND THERAPEUTICS. having symmetrical enlargement of cervical glands, anaemia, dyspnoea, etc., steadily getting worse for some time, " complete recovery took place" after taking phosphorus (British Medical Journal, ii., 187G, p. 792). In two other cases one very far advanced, the other chronic the same remedy was successful. Some support w.as given to Dr. Broadbent's conclusions by a case, under Dr. Wilson Fox, of "leukaemia splenica" occurring in a man, aged thirty-seven, in University College Hospital, for, when extremely enfeebled, he began to take -fa to -^ gr. doses, and after three months' treatment was greatly improved; he died, however, in the following year (Lancet, ii., 1875). If we add to these cases one of leukaemia (Dr. Gowers), in which the use of phosphorus was followed by diminution in size of glands, and les- sened anaemia (though albuminuria and death afterward occurred), it will be seen that the evidence in favor of phosphorus is not strong, while many cases of its failure are on record. Dr. Moxon objects even to re- ceive Dr. Fox's successful case as one of leukaemia, because the white cor- puscles in the field were " only twenty to thirty," and refers to about thirty cases of his own (" pernicious anaemia," apparently), all unsuccess- fully treated by phosphorus (British Medical Journal, ii., 1876, p. 792). At the meetings of the Clinical Society at which this subject was dis- cussed (November, 1876), Dr. Greenfield and Dr. Goodhart related unsuc- cessful cases, and Sir William Jenner referred to three of " splenic leuco- cythaemia," in which the remedy seems to have had a really fair trial with- out any good result. The question was even raised whether it might not be responsible for some fatty degeneration found post-mortem; but, without laying stress upon that point, the general conclusion of compe- tent authorities, both at that time and since, has been adverse to the value of phosphorus in such cases. It would seem, perhaps, to offer a better prospect in. cases of tympha- denoma than of leukaemia, and especially in early cases, and more evidence must be collected before -we can rightly estimate the true power of the drug. I have already referred to the increase of red blood-corpuscles, re- ported by Dr. Gowers, under the use of phosphorus; this was in a case of " lymphoma," and the increase in one month was from 52 to 66 per cent., and in another month to 74 per cent. ; ^ gr. was taken three times and then six times daily no other drug was given, nor were the circum- stances of the patient altered. The pathology of these maladies is, how- ever, still very obscure, and they are not well defined one from the other. Greater clearness in their diagnosis and prognosis must be expected to precede therapeutic advance; but we may say this, that much more bene- fit has been already recorded from arsenic, both in pernicious anaemia and in lymphadenoma, than from phosphorus. The two remedies are doubt- less allied, but the former claims much more reliance than the latter. Bronchocele. In nine cases of bronchocele (fibrous) I have made trial PHOSPHORUS. 57 of phosphorus in varied doses, but without good result. Dr. Leech (Man- chester) has sometimes seen the growth subside under the use of this drug, after iodine had failed (British Medical Journal, i., 1874), and it may occasionally prove a resource. Dr. Moxon has pointed out that glandular tumors vary in size, not only under various remedies, but some- times without apparent cause. PREPARATIONS AND DOSE. Phosphorus : dose, T ^ to -fa gr., less or more. Oleum phosphor atum (made with oil of almonds previously heated to 300 F., to destroy organic impurities); 5 min. contain -% gr. : dose, 3 to 10 min. Pilula phosphori (made with tolu and yellow wax); 5 gr. of the pill contain -fa gr. An exception has been taken to these officinal preparations: to the oil as disagreeing with the stomach, to the pill as being too concentrated, or not soluble enough; and many other formulae for the medicine have been published (British Medical Journal, i., 1879, etc.). It is commonly agreed that the free unoxidized element will produce effects which none of its chemical compounds can do, and it is desirable, therefore, to give it in its pure, unaltered state. It cannot be finely divided without risk of oxidation, and the vehicles of fluid preparations, especially oils, are apt to disagree with the stomach. Devergie, Solon, and others state that a solution in any vegetable oil, exposed to light and air, is apt to decompose, with partial conversion of the element into hypophosphorous acid, which has toxic properties, and hence some untoward accidents that have occurred with the phosphorated oil. A solution in cod-liver oil is not liable to this, but Dr. Broadbent finds it soon becomes oxidized, and loses its effect. An alcoholic tincture may be prepared by adding phosphorus in excess to boiling alcohol quite free from water; this will take up 1 gr. in 6 dr. 20 min. (Thompson), and, if carefully kept from light and air, will remain unchanged for some weeks. As the result of many observations, Dr. A. Thompson recommends 3 dr. 10 min. of this tincture (=gr. phosphorus) to be added to 1 oz. 40 min. of anhydrous glycerin, with 5 min. of spt. peppermint, and he finds this more stable and less disagreeable than any other form. I myself prefer an ethereal tincture, in which 1 gr. phosphorus is first dissolved in 1 dr. of pure ether; and this solution, after standing some days, is mixed with pure alcohol, so that a proportion of 1 gr. in 500 min. is preserved. From 2 to 5 or 10 min. of this (^ be a frequent adulteration. VOL. I. 7 98 MATERIA MEDIC A AND THERAPEUTICS. AMMONII DROMIDUM BROMIDE OF AMMONIUM, NHf acid-poisoning, so that they can take much larger doses than the herbivora without ill results. (This has been accounted for by the increased formation of ammonia compounds in the latter class of animals under the influence of the acid, causing its neutralization, to some extent). The experiments of Walter prove, how- ever, that it is possible, by means of the internal administration of acids, to withdraw alkalies from the vital fluids, and this to such an extent as even to cause death from their deprivation. With regard to the influence of hydrochloric acid on the general cir- culation, it was noticed by early observers Boerhaave and others that even moderate doses accelerate the pulse and cause flushing of the face; and full doses produce some excitement of brain-function, so that the symptoms have been compared to those caused by alcohol (Deutsch). Bobrick took 18 min. diluted with 5 oz. of water, and within half an hour noted an increase of pulse by six beats. This continued for an hour, but HYDROCHLORIC ACID. 195 was succeeded by a fall of four beats below the normal frequency. He noticed excitement of similar character after internal and external ap- plications of the acid to frogs, and concluded that it was produced through the nervous system, for it did not appear after destruction of th< nerve-centres. Respiratory System Toxic Action. F. Walter found that in differ- ent animals of the same species, the action of the acid was different; from 7 to 8 grammes of hydrochloric acid per kilogramme of body- weight might be given to a rabbit in one day without necessarily serious result, but if the proportion of 9 grammes in the same period were exceeded, death certainly followed within a few hours. The first symptom of poisoning was an increase of frequency in respiration; then the separate breath- movements became deeper and more laborious, with violent heaving of the thorax; the heart beat so quickly that the pulse could not be counted; the animal lost power of moving, and lay quiet on the side for a quarter of an hour before death. The respiration then lost its dyspnceal character, and grew superficial and weaker as collapse set in, and the heart-action ceased a few moments after the breathing (loc. cit. p. 157). Post-mortem inspection revealed no sufficient change in the organism to account for these symptoms; sometimes, it is true, erosion of the gastric membrane occurred, but the course of the poisoning was not altered in such cases, and there- fore it could not be dependent on such erosion: a different concentration of solution, whether 4 or 8 per cent., made no difference in the symptoms; the blood was only so far altered that it coagulated more slowly than us 4 ual. It was not found acid in reaction. Hence apparently neutraliza- tion of alkali, or withdrawal of some portion of alkali from the blood and tissues, was the cause of death; and this hypothesis was remarkably con- firmed by the results of injection of an alkali into the blood-current after full and toxic doses of acid had been given by the stomach. A rabbit that had received more than 6 grammes of hydrochloric acid in three days three times as much as would kill it together with 0'2 gramme carbonate of soda injected under the skin with each dose, recovered without loss of appetite or any symptom of poisoning. Another animal received more than 2 grammes of acid, and just when the symptoms indicated the near approach of death 0'5 gramme of soda carbonate was injected into the jugular vein; within ten minutes the strong thoracic movements subsided, the heart-action grew slower and stronger, the animal sat up and began to eat, and in an hour's time seemed quite restored. This direct antidotal action of injected alkali is very striking. It would seem that the result of diminished alkali in the blood is first a stimulation and then a palsy of the respiratory centre, through which death may be induced. The dyspnoea is not connected with altered heart- action, and the paralysis of respiration must be distinguished from that of asphyxia, for the oxygen contained in the blood remains unchanged. 196 MATERIA MEDIC A AND THERAPEUTICS. SYNERGISTS. As refrigerant, tonic, and astringent, the other acids; as tonic and digestive, bitters, and also pepsine and possibly pancreatine. INCOMPATIBLES. Alkalies and bases, salts of silver especially. To neutralize irritant poisonous doses of acid, the alkali should be given in mucilaginous or albuminous liquids. THERAPEUTICAL ACTION (EXTERNAL). Stomatitis, etc. In inflam- mation, with patches of ulceratiori about the mucous membrane of the mouth and gums, hydrochloric acid, diluted with an equal part of glycer- in, and applied to the sloughing spots will induce healthy action. In mercurial stomatitis, and in the aphthous conditions that occur in chil- dren, or during advanced disease, lotions containing 1 part of acid in 10 of rose-water, either alone or with chlorate of potash and glycerin, are very serviceable. The acid is also valuable given internally in such cases. To avoid possible injury to the teeth, plain or alkalized water should be used immediately afterward. Cynanche Maligna Ulcerosa. In all forms of ulcerative sore throat, whether scarlatinal or otherwise, but especially when sloughing is pres- ent, and when there is marked general asthenia, hydrochloric acid is indi- cated as well locally as internally. It may be applied with a brush (1 part in 15 of liquid) or in gargle (2 dr. to 8 oz.). In gangrenous or "pu- trid " sore throat, the nearly pure acid may be carefully and lightly pen- cilled over the affected part. Diphtheria. Bretonneau recommended the application of the strong acid mixed only with a little honey to the false membranes and adjacent tissues, and this has sometimes arrested the local progress of the malady; but, on the other hand, it has sometimes done harm by exciting irrita- tion, which has favored the development of membrane. A weaker solu- tion, such as the dilute acid of the Pharmacopoeia (1 in 3), is to be pre- ferred, and much advantage has been traced to it (Dr. Heslop: Medical Times, i., 1858, p. 612). A weaker gargle (1 or 2 dr. in 8 oz.), as above mentioned, may be used if the conditions admit. THERAPEUTICAL ACTION (INTERNAL). Dyspepsia. There are two varieties of indigestion in which hydrochloric acid is especially indicated the so-called " atonic " form, and the " acid " form but the mode of its use is somewhat different for each. Atonic dyspepsia occurs either in connection with general weakness or impaired hygienic conditions for instance, in over-worked factory girls, seamstresses, etc., or in well-fed person who tax their stomach with too much nitrogenous food while leading a sedentary life. The secretion of gastric juice is but scanty, and the patient suffers from weight and heavi- ness after food, from general oppression, and other signs of unfinished digestion. One indication for the treatment of such a condition is to supply additional acid to the gastric secretion; but, as we have reason to believe that adding such acid before a meal will check the formation of HYDROCHLORIC ACID. 197 the naturally acid though scanty gastric juice, it is better to allow this to do what it can, and to prescribe our medicinal acid shortly after food has been taken, with the object of assisting nature, and not interfering un- duly. 1 In cases of " acid " dyspepsia, the patient suffers rather from heart- burn and regurgitation of sour fluid, connected either with hyper-secre- tion from the gastric glands, or abnormal fermentation of starchy, sac- charine, or fatty food. It is true that the symptoms may often be relieved by soda, but in many cases, more permanent relief will be given bv dilute hydrochloric acid administered about half an hour before a meal. This will lessen the amount of the natural secretion, and will check fermenta- tion. It is only recently that this important distinction as to the time of taking an acid with reference to food has been recognized; many writers, Nothnagel for instance, are satisfied with recommending its use always before meals, and certainly if it be given after food, in cases of pyrosis or water-brash, it will aggravate the mischief; these are the true cases in which its use is indicated before meals, when it exerts an astringent ac- tion. It is contra-indicated in acute inflammatory, and also in organic disease; and in any case its use should not be continued too long, or the digestive property of the gastric juice will be impaired. Headache, especially felt in the temple and brow, and marked giddi- ness are often connected with the dyspepsia above described, and are re- lieved by hydrochloric acid. Diarrhoea. In this complaint, hydrochloric is often preferred to other acids, not because it has a more energetic effect than, e.g., sulphuric acid, but because it is better borne by the stomach. It is most reliable in cases that are due to abnormal fermentation in the bowels, with formation of lactic acid, as in what is called summer diarrhoea and gastric catarrh of infants; there are, however, many other remedies for this condition which must be considered better than the acid. Fevers. In typhoid or " low " fever, hydrochloric acid had, at one time, a high reputation; it was said to moderate the pyrexia, to limit the alteration of the blood, and to directly influence the morbid process. We scarcely expect so much now, but still there is reason to think that a ju- dicious use of this acid may favor the assimilation of food, if it do not ex- ert antiseptic influence. According to the investigation of Manassein, with the gastric juice of fever patients, it is not pepsine that is deficient but acid, and this deficiency may be supplied for a time by the artificial acid, which then much aids the impaired digestion. It matters little 1 Manassein showed that in dogs made anaemic by blood-letting, the normal propor- tion of acid and pepsine was altered, and in such animals an addition of artificial acid to the gastric juice is, ceteris partinu, more effective than in the healthy (Virchow'a Archiv, lv., p. 451). 198 MATERIA 3IEDICA AND THERAPEUTICS. whether we say with this observer, and with Chambers, that we supply deficient acid, or, with Richardson, that we neutralize by it super-abun- dant alkali formed during fever. Chambers records an emphatic opinion as to its value, after a fairly extensive use of it at St. Mary's Hospital, in * low " fever, apparently typhus and typhoid. The treatment by hydro- chloric acid was more successful than by any other method, but we must add that he conjoined with the former, strict attention to nourishment, giving milk and beef-tea regularly every two hours, day and night (Med- ical Times, 1858; Medico Chirurgical Review, ii., 1863). Henderson has reported on its value during an epidemic at Shanghai (Medical Times, i., 1863). On the other hand, Dr. G. Johnson is satisfied with the far better progress made by his typhoid patients in King's College Hospital since he omitted wholly mineral acid from their treatment. He finds, es- pecially, that diarrhoea is less troublesome, and considers that acids irri- tate the bowels, just as bread or meat would do (British Medical Journal, i., 1875). I cannot think Dr. Johnson's reasoning very conclusive, though his facts are of course to be accepted. I think the acid sometimes useful, and if well diluted the doses required will not irritate the bowels. It may be given as a refrigerant drink in lemonade, or mixed with essence of meat so as to aid assimilation. Scarlet Fever. There is also evidence as to the value of hydrochloric acid in scarlatina. Osborne records a prolonged experience in its favor (Lancet, ii., 1862), and more recently Egbert (Pennsylvania) has quoted nearly three hundred cases, all treated by a mixture containing this acid with chlorate of potash (Ranking, i., 1873). He gave about 8 min. of acid with 20 gr. of chlorate every two hours to a child of six, and more or less than this according to age. Occasionally Tinct. camph. co. was added to relieve restlessness; no applications were made to the throat, unless sometimes ice externally; only one death occurred. Of course it may be said that fevers tend to get well, and will do so under any treat- ment, but yet these results deserve careful attention. I myself constantly use hydrochloric acid internally and locally in cases of scarlet fever where there is marked general asthenia with dark ill-developed rash, and ten- dency to sloughing in the fauces (v. Chlorate of Potash). Variola. Dr. McDonald advocates the treatment of small-pox, both internally and externally, by this acid. He uses a lotion containing 3 ss. ad x. liq., and finds it considerably relieve the cutaneous itching and irritation. Urinary Deposits. In oxaluria, Dr. Prout long ago recommended hydrochloric acid, and its use is especially indicated for the impaired digestive power, and the anxious and depressed mental condition usually connected with the malady (v. p. 197). It may be given before meals with a bitter, such as nux vomica or chirata, and continued till urates begin to appear in excess in the renal secretion. In cystic oxide and phos- DILUTE NITRO-IIYDROCHLORIC ACID. 199 phatic deposits with alkaline urine, it is also useful, and has sometimes been injected into the bladder for its local effect (TTtij. ad f iv. Aq.) Gout. Dr. Duncan recommended this acid as a preventive of the un- due formation of lithic acid (Dublin Quarterly Journal, May, 1865) by its aiding assimilation; hence it should be serviceable in chronic gout, but such a view has not been supported by the experience of others, and, as a rule, gouty subjects are very intolerant of any acid treatment. There are several other disorders in which hydrochloric acid is some- times, though not generally used, but in which its good influence on the digestive tract may fairly be expected to relieve. Pneumonia. Traube states that he has found it useful in that form of pneumonia which sets in with much biliary disturbance nausea, coated tongue, gastric catarrh, and diarrhoea. Eczema. Mr. Erichsen has published cases illustrating its value in chronic eczema (London Medical Gazette, 1846, p. 198), but in this, and in hepatic disorder, its value is better shown when in combination with nitric acid, Syphilis. The former reputation of this acid as a cure for syphilis (Medical Quarterly Review, 1835) in Vienna, need be mentioned only as an historical fact (Nothnagel). The aqua regia may, however, prove of service in chronic cachetic conditions. PREPARATIONS AND DOSE. Acidum hydrochloricum dilutum : dose, 10 to 30 min. freely diluted. The strong acid, given internally in an un- diluted form, is an irritant poison. [PREPARATIONS, U. S. P. Acidum muriaticum, sp. gr. 1.160; Acidum muriaticum dilutum : muriatic acid 4 troyounces, distilled water, sufficient to make 1 pint.] ADULTERATIONS. Sulphurous and sulphuric acids, chlorine, and iron. The commercial acid is often colored from the presence of iron impurities. ACIDUM OTTRO-HYDROCHLORICUM DILUTUM DILUTE NITRO-HYDROCHLORIC ACID AQUA REGIA. PREPARATION. By mixing 3 parts of nitric, with 4 of hydrochloric acid, and afterward 25 of distilled water: the strong acids, undiluted, are left to act upon each other for twenty-four hours to insure complete de- composition and the full development of free chlorine. 2HNO 3 + 6HC1 = 4H,O + 2NO 4- 3C1, At the same time two other compounds are formed chloro-nitrous and chloro-nitric gas. If the acids be diluted before being mixed, the same reaction occurs, but requires several days for completion. 200 MATEBIA MEDICA AND THERAPEUTICS. CHARACTERS AND TEST. A colorless or yellowish liquid, with the odor of chlorine, volatile, and easily decomposed by light; sp. gr. 1.074. It has the power of dissolving gold, the king of metals hence its old name, "aqua regia." PHYSIOLOGICAL ACTION. In its full strength this acid is irritant and corrosive; in moderate doses it has an alterative tonic action; it stimu- lates the glandular system, and is apt to cause salivation and also an in- creased flow of bile. Its actual chemical composition is not thoroughly known, and its difference in action from the other and simpler mineral acids has not yet been verified. THERAPEUTICAL ACTION. It is useful in many of the diseases men- tioned under nitric acid, but seems to possess exceptional power to influ- ence the liver and glandular structures of the alimentary canal. Hepatic Disorder. In hepatitis, not so much in the acute as in the chronic form of the malady, which usually ends in enlargement and indu- ration, it has been praised by good authorities. Sir R. Martin strongly recommends its application by means of a bath, putting about 1|- oz. of acid to each gallon of water (v. Preparations). Two gallons represent an average quantity for a foot-bath, which should be used warm, and while the feet are immersed, the inner side of the limbs and the regions of liver and spleen should be sponged alternately for ten to fifteen min- utes altogether. Martin recommended this bath morning and evening, but I have usually found an evening bath sufficient, and have seen excel- lent results from it; generally it has regulated the action of the bowels, and even produced laxative effects. Some patients are nauseated and weakened by its use, though they receive benefit: it requires watching, and smaller quantities of the acid should be tried first in delicate sub- jects. If it does not relax the bowels, an aperient should be taken occa- sionally during the course of the baths. In hepatic torpor, or chronic catarrhal jaundice, if no inflammation be present, and in chronic dysentery with hepatic congestion, this form of bath is also valuable, and may be conjoined with the internal exhibi- tion of the acid: even in cirrhosis and the consequent dropsy, benefit has been derived from this treatment. Syphilis. In the later stages of syphilitic cachexia, when the blood- condition is impaired, and elimination by the liver and skin is often in- efficient, the acid used internally and in the form of bath has been recom- mended: a spare but nutritious diet should be enjoined in these cases. Rachitis. Attention has been drawn by Mr. Brodhurst to the value of nitro-hydrochloric acid baths in rickets (Lancet, ii., 1868); they should be conjoined with hygienic, treatment, iron, and cod-liver oil. Chronic Bronchitis. When the expectoration is profuse and semi- purulent, sponging of chest and trunk with the acid solution already mentioned is said to give much relief (Dr. Waring, op. cit. p. 443). DILUTE NITRO-I1YDROCHLORIC ACID. 201 Acne Hosacea. A lotion containing the dilute acid, 1 or 2 dr. to 8 oz. of rose-water, is sometimes a useful stimulant to the affected part, and an acid foot-bath tends to relieve the internal congestions with which the disorder is generally associated. Oxaluria. This is, in most cases, dependent on some fault in pri- mary digestion (I have known it produced apparently by continued use of a drinking water containing much lirne), besides the renal symptoms, malaise, depression, and hypochondriacal feelings accompany the malady. Relief may be given by the mineral acids conjoined with attention to diet and drinking water; and of the different acids the nitro-hydrochloric seems to be the best, as originally stated by Dr. Prout (" Stomach Dis- ease," p. 73); he advised its continuance for a few weeks at a time, or until lithates appeared in the urine. Deposits of cystine are relieved by the same treatment. Sciatica Rheumatism. In the great majority of these cases, an al- kaline rather than an acid treatment is indicated, but when they occur in connection with oxaluria the acid should be given (Fuller). In rheumatic gout in cachectic subjects it is also serviceable. Dyspepsia. In dyspepsia or " apepsia," connected with deficient ac- tion of the intestinal glands, and accompanied with a chronic looseness of the bowels, the acid has given very good results, used in the manner directed under hydrochloric acid. PREPARATIONS AND DOSE. Acidum nitro-hydrochloricum dilutum : dose, 5 to 20 min., freely diluted (it is liable to injure the teeth; they should therefore be cleansed with an alkaline wash or plain water). Bath. As a matter of convenience the bath may be prepared with six fluid ounces of the dilute nitro-hydrochloric acid added to each gallon of water in a wooden or porcelain vessel, but the more active formula of Sir R. Martin is the following: Acid. nit. fort. 3 ij., Acid, hydrochloric, fort. 3 iij. ; mix and allow to remain together for at least twelve hours; afterward add 5 oz. of water. Of this mixture 3 oz. should be used for each gallon of water: two gallons are an average quantity for a foot-bath. The bath may be kept in use for several days by adding \ oz. of acid sol- ution and 1 pint of water each time to compensate for evaporation, warm- ing only as much as is necessary (96 to 98 F.). The towels and sponges used should be kept in cold water during the interval. [PREPARATIONS, U. S. P. Acidum nitro-muriaticum : nitric acid, 3 troyounces; muriatic acid 5 troyounces. Acidum nitro-muriaticum dilu- tum: nitric acid 1 troyounce, muriatic acid 2 troyounces; distilled water, sufficient to make 1 pint.] ADULTERATIONS. Chiefly sulphuric and hydrochloric acids. 202 MATERIA MEDIOA AND THERAPEUTICS. ACIDUM HYDROCYANICUM DILUTUM DILUTED HY- DROCYANIC ACID, HCN or HCy,=27. A solution in water containing 2 per cent, by weight of the anhydrous acid (Scheele's acid contains 4 to 5 per cent., Vauquelin's 3.3 per cent.). Amygdalin and emulsin, from which the acid is developed, exist to- gether in many plants; in the leaves of the cherry-laurel, the kernels of the peach, almond, cherry, etc. In the mineral kingdom the acid is found in combination as cyanate and cyanide; it occurs also in various animal secretions, and may be obtained by heating nitrogenized organic matter in contact with a base. Scheele discovered the acid in 1782, and is said to have been accidentally poisoned by it. PREPARATION. By distilling, with gentle heat, a mixture of ferrocy- anide of potassium (yellow prussiate of potash) and dilute sulphuric acid. Half the cyanogen passes over into the water of a cooled receiver as hy- drocyanic acid, and part remains in combination with potassium and iron as a yellowish-white insoluble double salt (Everitt's salt). Some acid sul- phate of potassium is also formed: thus 2K 4 FeCy 6 4-GH a SO 4 =FeK 2 Fe Cy, + 6KHSO 4 + 6HCy. CHARACTERS AND TESTS. The pharmacopceial solution is a colorless volatile liquid of characteristic bitter-almond odor. Its taste has been variously described as " hot and bitter " (Taylor), or " cooling, afterward irritating" (R. W. Smith); sp. gr. 0.997 (nearly that of pure water). If free from other acid it reddens litmus but transiently. It loses strength on exposure to air and light, but that which is prepared by the pharma- copceial process and kept in dark-colored bottles may be retained for years without perceptible change. Stronger solutions alter more readily, and of the anhydrous acid (which has sp. gr. of 0.697) a part evaporates on paper so quickly as to freeze the rest. Cyanides prevent fermentation, and are fatal to vegetable life (Dumas). 1. The White or Silver Test. Nitrate of silver gives, with prussic acid solutions, a dense flocculent white precipitate of cyanide of silver, insoluble in cold, soluble in boilirig nitric acid HCy+AgNO,=AgCy -t-HNO s . This test may be conveniently applied to the detection of prussic acid vapor by means of two watch glasses, the lower one contain- ing a little of the suspected solution, and the upper one, inverted over it, a few minims of nitrate solution (1 gr. to the oz.): the latter soon be- comes opalescent, and when dry, leaves a white stain, showing under the microscope prisms or long plates interlaced. Cyanide of silver, like other insoluble cyanides, may be further tested by placing it in a narrow glass tube drawn out at one end and heating: cyanogen will escape and may be lighted at the pointed end; it burns with a rose-colored flame, having a bluish halo. DILUTED HYDROCYANIC ACID. 203 2. The Blue or Iron Test. Tills is applied by adding to the solution a little liquor potassae and a few drops of a mixed solution of a proto- and per-salt of iron (protosulphate and perchloride are commonly used); a greenish-brown precipitate falls, which, on addition of a little dilute hydrochloric acid, becomes dark or Prussian blue in color. The potassic cyanide, first formed, gives rise to ferrocyanide and afterward to ferric cyanide with the iron salts, thus: HCy+KHO = 4KCy + FeCy a =K 4 FeCy. The acid dissolves any excess of precipitated iron oxides that might ob- scure the color. 3. The Red or Sulphur Test. Add to the solution a few drops of am- monia and of yellow sulphide of ammonium; warm gently till colorless, and evaporate slowly; o the residue add a drop of acid solution of per- chloride of iron; a blood-red color (sulphocyanide of iron, Fe a 6CyS) is developed; it is discharged by corrosive sublimate, and thus distin- guished from meconic acid. In this test some free sulphur in the ammo- nium sulphide unites with the alkaline cyanide to form sulphocyanate of ammonia. 2AmCy+S 3 =2AmCyS. The ammonia combines with excess of free sulphur, and forms, among other compounds, sulphydrate of ammonium, which should be removed by boiling and evaporation, and if this be not carried far enough, some of the latter compound remains and gives rise to black sulphide of iron instead of sulphocyanide on addition of the perchloride solution. These two tests are also applicable to the vapor by means of watch glasses. 4. The Copper Test. To the liquid, rendered slightly alkaline by liquor potassae, add solution of sulphate of copper; a greenish-white pre- cipitate falls, containing cyanate of potash and of copper with some blue oxide. When this is dissolved by a little hydrochloric acid, the precipi- tate becomes nearly white. ABSOKPTION AND ELIMINATION. Hydrocyanic acid is absorbed to some extent, even through the unbroken skin, especially if a strong solu- tion be applied with friction; from a wound, or from mucous membrane, it is, however, absorbed much more readily. When placed on the tongue or swallowed in the ordinary way, it passes sooner into the circulation than when injected into the stomach, rectum, or vagina (Coullon, Kn- mer). In less than thirty-six seconds after a little of the strong acid is placed on an animal's tongue, it may be detected in the circulating blood (Krimer: Horn's Archiv, 1826): after intravenous injection, also, it quickly produces its effects, but most quickly after inhalation. Guinea- 204 MATERIA MEDICA AND THERAPEUTICS. pigs made to inhale the anhydrous acid for one second, die within fifteen seconds, and strong rabbits exposed to the vapor for three seconds, are destroyed within thirty (Preyer: "Die Blausaure," zw. Theil, 1870, s. 133). The weakly, the young, and the aged among warm-blooded ani- mals are much more easily affected. by the acid; while frogs, and all cold- blooded creatures, are much less sensitive to its action, and survive toxic doses for several hours. Horses are said to be insusceptible to quanti- ties of one or two ounces (Amory: Boston Journal, 1866). Although so rapidly poisonous to most animals as it is also to men, there is yet no difficulty in concluding that absorption must precede any general action, and Stille has shown that if a tight ligature be placed round a limb exposed to the acid, constitutional effects do not occur, so long as the local is cut off from the general circulation (vol. ii., p. 222, 3d ed.). Ordinary blood is not essential to its action, for the bloodless " salt frog " exhibits the same symptoms under prussic acid as the normal creature (Lewisson: Reichert's Archiv, 1870.) ^ Elimination is rapid, and for ordinary medicinal doses is probably complete within an hour; even after a full or poisonous amount, if life can be prolonged for that time, recovery may be hoped for. The acid passes out partly by the saliva, to a slight extent by the kidneys, but mainly by the lungs, as evidenced by the characteristic odor of the breath. PHYSIOLOGICAL ACTION (INTERNAL). Digestive System. Small medi- cinal doses 2 to 5 min. of the officinal acid seldom exert more than a transient effect of sedative character on the gastric mucous membrane; 10 to 20 min. induce local irritation of the fauces and stomach, with in- creased flow of saliva and nausea; breathing the vapor, or taking by the mouth 20 to 30 min. or more of the diluted acid, causes such symptoms in a marked degree, though not always immediately (Taylor). Toxic Action. If, with animals, such doses be used as allow time for a somewhat gradual poisoning, vertigo is noted as an early symptom, with loss of power over the muscles, so that the animal quickly falls; the breathing, at first perhaps hurried and panting, soon becomes slow and difficult, while the heart-beats are rapid and weak. Convulsions mark (according to Preyer) the second stage of cyanic poisoning; they may be tonic or clonic, and affect not only the limbs, but the respiratory muscles and the heart: livid features, protruding shining eyeballs, and congested veins evidence the obstructed circulation, and either death soon comes from asphyxia, or after a period of paralysis and torpor, recovery gradu- ally ensues. Evacuations from the bladder and bowel commonly occur during the unconscious stage, and a peculiar shriek often, though not always, precedes death. Post-mortem, intense congestion of the larger venous trunks and the cerebral membranes is the most marked appear- ance. DILUTED HYDROCYANIC ACID. 205 In man, more than 60 min. of the dilute, or 1 gr. of the anhydrous acid, will be usually a fatal dose, though symptoms may not be devel- oped for some minutes; after as much as ^ fl. oz., however, they will come on in a few seconds, or even during the act of swallowing Volition and power may be retained just long enough to walk a few paces, to ar- range the bed-clothes, or to cork a phial; but suddenly the subject, if standing, will fall prostrate, often with a scream or in convulsions. Within two minutes he will be insensible, paralyzed, with fixed and glis- tening eyes, dilated insensible pupils, cold clammy skin, and swollen cyanotic face: the jaw is set, saliva exudes from the mouth, and evacua- tions occur from the bladder and bowel: the breathing, at first perhaps hurried, soon becomes convulsive and gasping, with long pauses and pro- longed expiration: the pulse, after a brief quickening, is soon impercep- tible, and death occurs by asphyxia within three to five minutes from the fatal dose. 1 Respiratory System. In man, ordinary medicinal doses do not affect respiration, but 10 to 20 min. may render it irregular and labored. Under small doses, the breathing-rate of animals either remains unaltered at first, or is markedly lowered; it is never increased. With larger doses and concentrated solutions, the course of poisoning is so rapid that respirations can scarcely be counted; convulsive movements also interfere with observation, but we can say that in this stage the rate is lowered, and continues so. As the animal passes into a comatose condition, a slight rise may occur, which increases if recovery is proceeding, but which soon gives place to a marked slowing and then complete cessation of breathing. The heart may continue to beat for some little time after this, and if so, even if in other respects the animal seems dead, artificial respiration will restore it to life. The general character of the respiratory changes resembles (according to Preyer), not that occurring in apncea, but that which occurs when the vagi are divided and the cut end of the central branch is stimulated, or irritated, by electricity. At the beginning of the poisoning the inspira- tions are deeper than normal, then follows a pause, and then short shal- low expirations. In many instances during the convulsive stage there occurs on inspiration a tetanic spasm of the diaphragm, such as Traube found after direct vagus irritation. Nervous System. Doses which disturb the digestive and circulatory systems 10 to 20 min. may cause not only giddiness, but also a sense of constriction and heaviness of the head, prominence of the eyes, some confusion of intellect, and muscular weakness. Upon which part of the 1 The glistening condition of the eye usually described, and the evacuation of the bladder and bowel, are not, I think, so constant as commonly supposed : in four cases within my experience, the former symptom was not present, and in only one did the evacuations occur. 206 MATERIA MEDICA AND THERAPEUTICS. nervous system the special effects of larger doses are exerted whether upon the vagus, the nerve-centres, or the peripheral nerves has been disputed. Vagus Nerve. Arguing from the conditions already described, and from the fact that poisoning by prussic acid is most rapid if the vapor bti inhaled, Preyer concluded that its chief action was exerted on the vagus terminals in the lungs, stimulation, or rather irritation of them being propagated to the respiratory centre, and causing the phenomena of as- phyxia. That the stimulation was not, in normal conditions, exerted di- rectly on the respiratory centre he held to be evident from the fact, already noted, that section of the vagi i.e., interruption of communication be- tween the ends and the centre delayed the course of the poisoning and the time of death: the occasional occurrence of tetanic spasm of diaphragm he explained by a secondary transfer of irritation from the medulla to the phrenic nerve. In animals with divided vagi, the respiratory changes were somewhat different, and death in such cases was explained either by an action on the terminals of other (unknown) nerves of the lungs, or by direct action on the centre in the medulla, or when occurring under large doses, by direct paralysis of the heart. Nerve- Centres. On the other hand, Boehm and Knie, conclude that the main change is always exerted on the central nervous system the medulla the functions of which are for a brief period stimulated and then destroyed (Archiv fur Exper. Path. Jflebs., Bd. ii., p. 137). In cats prepared for experiment according to their method, there occur under prussic acid at first two to four deep labored inspirations, then quick and convulsive expiration, " resembling that caused by irritation of the superior laryngeal nerve " (Rosenthal); they observe no inspiratory cramp or teta- nus, and no influence of the vagi, whether it be left entire or divided, upon the course of the poisoning, nor upon the heart (v. p. 268). (The practical result is that these observers attach no value to atropia as an antidote, though equally with Preyer they recognize the excellent results to be obtained by artificial respiration.) I am not prepared to reconcile the differences between these and other observations, but in a more recent essay Preyer attributes the differences to undue manipulation of the animals, maintains his conclusions unaltered, and offers additional facts in support of some of them (Archiv fur Exper. Path. JEflebs., April, 1875). We must add, however, that Lecorche and Meuriot, while agreeing with him that cyanic death is connected with intense excitation of the vagus nerve, and that section of the vagi delays it, yet attribute such excitation to a central, not peripheral, action of the poison. A striking experiment made by Prof. Jones bears in the same direction: having found, with alligators, that the internal giving of the poison did not easily or quickly take effect, he applied it directly to the medulla oblongata, and within sixty seconds there followed complete ex- DILUTED HYDKOCYAN10 ACID. 207 piration of the air contained in the lungs, with collapse of those organs, and tetanic contraction of the respiratory muscles (New York Medical Record, vol. ii.). The convulsions which often occur in cyanic poisoning are cerebral in origin, for they do not occur in parts situated below a transverse section of the spinal cord i.e., in parts with which cerebral communication has been interrupted (H. C. Wood). We may further conclude that they are con- nected with disturbed cerebral circulation, for they have been noticed to commence directly after cardiac arrest (Laschkewitsch, Coze). Peripheral Nerves and Muscles. We are unable to conclude positively with Preyer that the peripheral ends of the vagus receive the first and main influence of the poison, for the mere extent of absorbing surface and ready contact with blood in the lungs would go far to account for the greater rapidity of the effects of inhalation, and there is other evidence that the respiratory centres are affected. This question, however, apart, we may accept the careful observations of Kolliker, that peripheral sensory nerves are paralyzed by local contact with sufficiently strong solutions, and the early disappearance of reflex function in cyanic poisoning is con- nected with such paralysis rather than with paralysis of the cord (Kied- rowski). Nerve-tissue placed in a solution of prussic acid loses its con- ducting power, and muscular tissue loses its irritability still more quickly, although the nerve-trunks are probably acted upon at the same time as the muscles after internal administration of the acid (Virchow's Archiv, Bd. x., p. 272). When the whole blood is rendered venous, as in later stages of poisoning, there is increased action of the contractile fibres of organic life (involuntary muscular tissue), and hence, often increased peristalsis of the intestine, contraction of the bladder, and evacuations from those viscera. The same result occurs sometimes in asphyxia from hanging, carbonic acid poisoning, etc., and is commonly attributed to the same cause (venosity of blood), though indeed it may result from paral- ysis of sphincters, as it does under chloroform, or during an epileptic attack. Circulatory System. Continued small doses 1 to 5 min. given at moderate intervals of two to four hours, lessen the force and rapidity of the heart-action: 10 to 20 min. taken by the mouth, or inhaled, may cause giddiness and faintness, with slowing, or sometimes quickening, of the pulse, and suffusion of the face. With animals, full or large doses cause a sudden arrest in diastole; this continues for a variable time, and is fol- lowed by quickened action, and afterward by diminution, and then by either gradual return to the normal number of beats, or total cessation according to the dose, and to the age, strength, etc., of the animals (La- schkewitsch, Preyer). A point of much interest is the statement that section of the vagi in the neck prevents this primary diastolic arrest, and Preyer, who has MATERIA MEDICA AND THERAPEUTICS. studied the subject with the greatest care, and has made very numerous experiments, affirms that after such section, no slowing of the heart-action occurs under doses that would with uncut vagi stop the heart (Op. cit., erst. Theil, 1868, p. 35); also that death, under toxic doses, is much slower when these nerves are divided than when they are not. We know from Pfliiger's researches that weak stimulation of the vagus causes slowing of the heart, and a very strong stimulus of it causes stoppage in diastole, and Preyer argues that the action of prussic acid on the heart is exerted through the vagi in accordance with these results, and the secondary and temporary quickening which occurs with certain doses is due to a second- ary paralysis of the control-influence of the same nerves. On the other hand, we have directly contradictory observations upon cats by Boehm and Knie, who found no primary diastolic arrest, and no influence exerted either way by section of the pneumogastrics; but their animals, though more accurately dosed, were in still less natural condition than those of Preyer, for they were chloralized, tracheotomized, and in- jected through an exposed jugular vein: we cannot think their observa- tions conclusive (v. p. 265). With very large toxic doses death is instantaneous, and the heart is arrested in diastole without any recurrence of ventricular contraction, though some movement of the auricles may be perceived on opening the chest (Lecorche and Meuriot, Archives Gen., t. xi., 6e serie): with such doses the result is not influenced by section of the vagi, and death is pre- sumed to follow direct cardiac paralysis (Preyer). Applied directly to the heart, the acid arrests its movement and destroys its muscular irrita- bility. Arterial Pressure in the vessels is said to be increased under the ac- tion of prussic acid (Wahl), but according to Boehm and Knie, such in- crease is temporary only; the pressure soons falls below normal, and after large doses remains so for some time. The startling rapidity of action of prussic acid suggests an immediate toxic effect on the blood, and there is indeed a remarkable color-change induced, which has been thought to give a clue to the intimate working of the poison. Thus, if the jugular vein of a rabbit be exposed, and seen to contain dark blood, and a toxic dose of acid be then given by the mouth, so soon as convulsive movements indicate its taking effect, will the stream of venous blood take on a clear red color, and the vessel greatly enlarge in size. Tf the blood be let flow from an incision, a similar change is ob- served, and if the right heart be examined in sitfl, the dark blood contained in it is equally seen to become red ; it is so also in the nose and ears (Gaeth- gens: Med.-Chem. Untersuch., drit. Heft., Berlin, 1868, Hoppe-Seyler). This had been noticed, though with less detail, by earlier observers, by Vietz and others, by Claude Bernard (who got a similar result with car- bonic oxide), and by Preyer, who found the same appearance caused not DILUTED HYDROCYANIC ACID. 209 only by diluted sulphuretted hydrogen, but also by the mere removal of any obstructions placed in the air-passages (Op. cit., p. 88). It is not therefore, due to a specific action of prussic acid, but is secondary to altered respiration, and although very interesting, has rrot the importance attached to it by Gaeth'gens. The apparently contradictory observations of Bischoff and others, to the effect that all the blood found in the body after cyanic poisoning is unusually dark and venous, are explained by a difference mainly in the rapidity of the poisonous action: if life be pro- longed for a few minutes, the red color is gradually replaced by dark, while if death be very sudden, red blood only is found in the heart sometimes even on the following day (C. Bernard). In cold-blooded ani- mals, the red color persists much longer than in the warm-blooded (Preyer). Theory of Action. It is easier to ascertain, than it is at present to explain these facts. Hoppe-Seyler suggests that the red corpuscles lose for a time their power of giving up oxygen in the capillaries that oxida- tion of tissue is suspended ( Uhtersuchungen, 1866, erst. Heft, s. 140). Geinitz argued that a change in the physical form of the corpuscles would explain change of color, and found that the acid mixed with blood outside the body caused various alterations of their form (Pfliiger's Archiv, Bd. iii., 1870): but according to Preyer the blood of a poisoned animal taken from the vessels directly after death, and examined by the microscope, exhibits no change in the character of the corpuscles (Chemismus, Leip- sic, 1840). He inquires whether the deepened breathing could for a time induce a hyper-oxygenated condition, as in animals dying from apnoaa and found by PflQger to have light-red blood (Archiv, i., p. 106), or whether the increased blood-pressure could drive the blood so quickly through the capillaries as to prevent its giving up oxygen as usual. I cannot satisfy myself as to a clear explanation, but believe that dur- ing the first stage of cyanic poisoning oxidation is arrested, and that the venous condition of blood found in later stages of poisoning is connected with spasm of the pulmonary arterioles, and paralysis of the respiratory and cardiac muscles. It would seem that no permanent toxic combination is found with the corpuscles; they are not at once fatally spoiled, nor is oxygen wholly driven out, but for the moment (and it may be finally) its interchange with tissues is prevented. The results of many careful spectroscopic ex- aminations by Preyer and others, and of many laborious gas analyses by Gaethgens, confirm this view: the red blood shows still the absorption bands of oxyhsemoglobin, and the dark blood those of haemoglobin, with little or no combined oxygen: outside the body, indeed, prussic acid de- stroys haemoglobin (forming a new compound, cyanohaemoglobin, which is destitute of ozonizing power), but apparently does not do so during life. Laschkewitsch could not detect such compound, but on the contrary found oxyhsemoglobin (Reichert's Archiv, 1868), and more recently, Hil- VOL. I. 14 210 MATERIA MEDICA AND THERAPEUTICS. ler and Wagner, examining blood while still within the mesenteric ves- sels, obtained characteristic though feeble lines of oxyhsemoglobin (Lan- cet, ii., 1877). If withdrawn from the body, the dark blood, shaken up with oxygen, resumes its normal red tint, and a most important practical point the condition just described may be remedied during life by se- curing access of additional oxygen by artificial respiration. Gaethgens proved (1) that the property of de-oxygenated blood to ab- stract oxygen from surrounding media is not destroyed by prussic acid; (2) that blood saturated with oxygen exposed to the action of prussic acid gives off no oxygen, and that substances which would usually with- draw oxygen from fresh blood do so with much difficulty under the influence of the acid. Both oxygen and carbonic acid are excreted in less than normal total quantity during the poisoning (on account of the slow rate of the breathing), but not only is the actual percentage of carbonic acid in the expired air less than normal, but the percentage of oxygen in the same expired air is greater than normal i.e., it has not been used up in the system. SYNERGISTS. Cyanides owe their activity to prussic acid, and exert a similar action. Cherry-laurel water, and essence of bitter almonds, owe their chief properties to the same acid. All substances which hinder haematosis, or the union of oxygen with the blood-corpuscles such as arsenic, antimony, and most sedatives favor the action of hydrocyanic acid. ANTAGONISTS INCOMPATIBLES. The effect of medicinal doses is les- sened by diffusible stimulants, by strong acids or alkalies, and by opium (Gubler). Warmth quickly volatilizes the acid, otherwise it favors its action. The most dependable antidote to poisonous doses is oxygen, which is best introduced into the system by artificial respiration. Preyer strongly recommends atropia as a " dynamic antidote," since it acts upon the vagus nerve in a manner contrary to that of hydrocyanic acid (v. Vegetable Kingdom). I must agree with Boehm and others that his observations are somewhat wanting in .scientific accuracy, as when he speaks of injecting "a little atropia," or says simply, "Injected sulphate of atropia, and afterward a rather large dose of prussic acid, which would assuredly have caused death " (" Versuche," p. 74, 36-37), and although Bartholow, Lecorche, and others have failed to obtain confirmative evi- dence, still they hold true to a certain extent. A practical difficulty in their useful application must always be the extremely rapid course of cyanic poisoning, and the (comparatively) slow diffusion of atropia; to be of any service, the alkaloid would have to be used almost on the instant of poisoning. Sal-ammoniac was strongly recommended by J. Murray (Edinburgh Philosophical Journal, 1822), and although Orfilaand Elwert showed that it could not be depended upon as an antidote, I think this and other DILUTED HYDROCYANIC ACID. 211 compounds of ammonia well deserve further trial. Modern observation credits the drug with a power of directly stimulating the respiratory centres (v. p. 255), and this, in addition to its general stimulating power, eeems specially to indicate its use in cyanic poisoning. Chlorine and chlorine water have been used with advantage by A. Chevallier and Orfila, but they are not manageable. Turpentine, though recommended as a specific antidote, has only value as a stimulant. I can- not see that phosphorus offers a resource of value, nor can much be ex- pected from coffee. Some indefinite evidence exists as to an antidotal power possessed by strychnia. Thus, a puppy that had taken gr. of prussic acid quickly recovered after swallowing a dose of the alkaloid (Medical Times, ii., 1859), and some other instances are reported (Lancet, i., 1868). Stannius also found that strychnia-convulsions were modified by the acid, but Dr. Lauder Brunton concluded " that although the acid may somewhat lessen the convulsion, it cannot be employed as an antidote to strychnia with any hope of success," and G. Harley thought " that it rather hastened death from strychnia " (Medical Times, ii., 1861). Silver and metallic oxides generally, form insoluble compounds with prussic acid, and fresh proto-carbonate of iron has been recommended as antidotal by Messrs. Smith (" Medico-Chirurgical Transactions," ii., 1865); practically, however, their influence can scarcely be exerted quickly enough. It remains that artificial respiration is the main resource in all forms and stages of cyanic poisoning it may be carried out in the ordinary methods, or excited by the sudden affusion of water, first cold and then hot, thrown over head and chest. This does not exclude the use of an emetic, the application of ammonia to the nostrils, or even its injection into the veins, while stimulating frictions and warmth should be applied to the limbs; by the steady use of these means, patients have revived from apparently hopeless insensibility, and if life can be prolonged for an hour, the chances of recovery become greatly increased. THERAPEUTICAL ACTION (EXTERNAL). Urticaria Prurigo. I have seen great relief given, even in obstinate forms of these maladies, by lo- tions containing hydrocyanic acid in sufficient strength. Pereira states that he did not observe relief in such cases, but he seems to have used only 2 dr. of acidHn % pint of water. I have recommended oz. or more in 10 oz. of liquid (rose water), and have never seen ill effects, but such a remedy should not be placed in careless hands, nor ordered if the skin be excoriated; sometimes a much smaller proportion will answer well, and especially when mixed with lead or soda lotion. The cyanide of potas- sium has also been used for lotion and ointment in the strength of dr. to 8 oz. of liquid, or 1 02. of cerate; a greater strength has caused severe irritation. 212 MATERIA MEDIC A AND THERAPEUTICS. Headache Neuralgia, Trousseau used a lotion of cyanide locally in cases of sick headache, and Fuller recommended the painting of neuralgic parts with a strong preparation of the acid ( oz. with 2 dr. each of gly- cerin and water), but such applications have rightly fallen into disuse. Eye Diseases. The same may be said of cyanic lotions and vapors in the treatment of eye disease, for which at one time they were in vogue. J. V. Solomon recorded numerous cases of conjunctivitis (sub-acute), ophthalmia, iritis, photophobia, etc., which were relieved by applications of dilute Scheele's acid, 1 part in 3 (Medical Times, i., 1852). Turnbull invented an instrument for applying the strong vapor to the eye, but this sometimes produced serious symptoms; in one case of its use, Sir W. Wilde describes faintness, giddiness, and unconsciousness (Medical Times, i., 1861). Nunnely records that he found strong applications to the conjunctiva poison as quickly as by the stomach (" Transactions Prov. Med. Surg. Association," N. S., iii., p. 58). Ringworm. Dr. Gee has found advantage from a lotion containing oz. of sulphocyanide of potassium in 7 oz. of water with 1 oz. of gly- cerin, kept applied to the scalp. The effect must be watched, and a daily washing with soap and water practised. THERAPEUTICAL ACTION (INTERNAL). Hydrocyanic acid has a certain value in relieving spasmodic pain and irritation, but its use is limited by the extreme care required in dosage, and the risk of causing unpleasant symptoms; yet to say with Trousseau that "it is often dangerous, almost always useless, and very rarely curative," greatly overstates the facts. Gastrodynia Enterodynia. Cases described under these names, and which seem to be frequently of neuralgic type, are often quickly relieved by suitable doses of prussic acid. Pereira gives instances of very severe spasmodic pain, where there was no complaint of pyrexia, of faintness, nor of any ordinary symptoms of dyspepsia; the pain was such as to lead to suspicion of organic disease, but it disappeared under the use of the acid. In one case it was seated in the intestine, came on about 2 P.M., and lasted until night, unrelieved by many remedies until this one was used, and Pereira made the further observation that its action is exerted quickly, and either produces complete relief or none at all. Sir T. Wat- son " has seen more rapid and decided relief from it in gastrodynia than from anything else!" Dyspepsia. Dr. Elliotson, in a special treatise on the subject, makes several groups of cases in which he found prussic acid extremely useful; some were marked by pain and tenderness only, others by flatulence, nausea, anorexia, liver-troubles, and vertigo, others again by pyrosis, heartburn, and palpitation ( Medico- Chirurgical Review, i., 1821). A. T. Thompson made somewhat similar observations, especially noting benefit when the tongue was hot, red, and sore (Dispensatory). Bailey DILUTED HYDROCYANIC ACID. 213 also published illustrative cases (London Medical Repository, 1828), and alluded to its value when there was sympathetic heart-disturbance, pal- pitation, etc. In such cases, it is still in frequent use, although other remedies may be required if there be marked symptoms of unhealthy se- cretion. Disappointment as to its effects may be sometimes traced to the inertness from age of the preparation, or to admixture with other drugs. Vomiting. The acid is useful in the vomiting of fever, and in sym- pathetic vomiting, and is sometimes indicated in that of ordinary gastric derangement: it may be added to effervescent mixtures, or to bismuth, but as a rule is better given alone in distilled water. In some patients, or in some conditions, and more especially when the dose is too large, nausea and vomiting seem to be increased or caused by the drug, and then it is better omitted: on the other hand, I have seen severe cases recover with 6 to 8 min. doses, when smaller doses and all ordinary means had failed. In simple intestinal obstruction, even when faecal vomiting had occurred, I have used 10 min. doses with the effect of staying the vomiting, but care is necessary in watching the results. Dr. Brinton found the acid useful in the vomiting of gastric ulcer; Dr. Harley com- bined it with bismuth, opium, etc., in that of enteric fever; Pereira recommended it in the vomiting and purging of phthisis, and even of cholera, and it may well be tried in the " nervous " form of vomiting, that connected with pregnancy, or with cerebral concussion or disorder. Phthisis. In the early part of this century Dr. Granville published a small treatise " to establish the claims of a new and powerful remedy," and in his second edition (1820) congratulates himself on the conclusive and numerous facts which have proved he was " not indulging in the chim- eras of a revery " when he recommended the prussic acid for treating, if not curing, consumption. Being before the days of physical diagnosis, his cases scarcely bear examination, and his peculiar egotistic style jars upon the professional reader; but he may be credited with pointing out the relief often given to the general nervous irritability, the dyspepsia and harrassing cough of phthisical subjects. The exaggerated views en- tertained both by the eminent Majendie and by Granville as to its powers of checking the disorder and curing asthma, chronic cough, etc., have not been verified by later experience. We can only say that it is a use- ful palliative for the irritative dry cough, especially in cases when morphia is not suitable, and that with alkalies and calumba it is often serviceable in phthisical dyspepsia. Whooping- Cough "Nervous Cough." Dr. Granville states, " with- out presumption," that in almost every case of whooping-cough this medicine, given early, removes the disease (p. 64), and Dr. Hamilton Roe, in a special treatise (1838), records equally excellent results. He was rather in advance of his time in concluding pertussis to be not always 214 MATERIA MEDICA AND THERAPEUTICS. inflammatory, but "a nervous affection, having its seat in the mucous membrane of the bronchi and the pneumogastric nerve," and for the " nervous element," i.e., the peculiar whooping or spasmodic cough, he valued prussic acid more than opium, belladonna, or any other remedies then in use: he gave very full doses, such as f min. of Scheele's acid to infants, and 1 drop every quarter-hour for twelve hours to a child of ten years. I think this another illustration of the benefit to be obtained from the medicine when it may be justifiably and yet cautiously pressed, but for average practice it would be dangerous, and I agree with Sir T. Watson, who thinks the remedy in such doses "too gigantic for such young subjects; " also with Dr. C. West, who finds it " sometimes magi- cal " for diminishing the frequency and severity of the paroxysm, but sometimes inert, sometimes poisonous. Dr. Atlee, judging from two hundred cases, gives a most favorable report of it (American Journal, vol. x.), and my own experience is decidedly in the same direction the more purely nervous the paroxysms, the better will the remedy act, though some difficulty in graduating its dose will always remain: also, as is well known, the results obtained from remedies unaccountably vary in different epidemics and different individuals. In other forms of irrita- tive cough, connected with spinal or vagus irritation, I have seen more benefit from this acid than from any ordinary sedatives; and the long- recognized clinical value of the drug in such conditions is of marked in- terest taken in connection with the special effect on the medulla and vagus, mentioned under physiological action. Asthma. Much relief may be given to patients suffering from simple spasmodic asthma, by small and repeated doses of prussic acid. Palpitation. Whether palpitation arises from cardiac hypertrophy or from ordinary functional derangement of the heart, dependent upon nervous exhaustion or dyspepsia, hydrocyanic acid will often prove use- ful. Vertigo Cerebral Irritation Mania. The acid certainly exerts some control over exalted cerebral function, whether by acting through the circulation or otherwise. Vertigo, especially, if dependent on gastric derangement, may be relieved by it. Dr. McLeod has furnished evidence of its calmative power in acute mania and, acute melancholia, recording forty cases, in most of which the relief given to violent excitement was marked and rapid; about 5 min. of Scheele's acid was the usual dose, or 3 min. injected under the skin (Medical Times, i., 1862). In Delirium Tremens, Dr. Dow has seen it serviceable (British Medi- cal Journal, i., 1873), and Dr. Maudsley recommends its combination with digitalis (Practitioner, January, 1869, vol. ix.). PREPARATIONS AND DOSE. Acidum hydrocyanicum dilutum (con- tains 2 per cent, of anhydrous acid): dose, 2 to 8 min. Vapor acidi hydrocyanici (inhalation) is prepared with 10 to 15 min. in 1 fl. dr. of NITRIC ACID. 215 cold water. " Mix in a suitable apparatus, and let the vapor that arises be inhaled." Lotio: 2 dr. to oz. in pint of rose water; it should not be applied to an abraded skin. Anhydrous prussic acid being one of the most active and rapid poisons known, should never be prescribed; neither should Scheele's prussic acid, which contains 4 per cent, of anhydrous acid. [PREPARATION, U.S. P. Acidum hydrocyanicum dilutum, contains 2 per cent, of anhydrous acid.] ACIDUM NITRICUM NITRIC ACID AQUA FORTIS, HNO S ,=63. Nitric acid, the highest known oxide of nitrogen, may be detected in the atmosphere after thunder-storms, for electricity determines the neces- sary combination of the gases. United with potash, soda, lime, or am- monia, it forms a nitrate which is found native in efflorescence on the soil of some countries; it occurs, also, in some minerals and in certain plants, e.g., as potash nitrate in pareira root. PREPARATION. Being a volatile acid, it may be prepared from any nitrate (usually a nitrate* of potash or soda), by distilling it with the more stable sulphuric acid, when sulphate of potash is formed, and nitric acid being set free, rises with the vapor of water and condenses in the receiver. KNO. + I^SO^HNC^ + KHSO,. Of anhydrous acid, it con- tains 60 per cent. The dilute nitric acid contains 6 oz. of the strong acid in 31 oz. of distilled water, or about 1 min. in every 5 min. Heat is developed dur- ing its preparation, and condensation of volume occurs. CHARACTERS AND TESTS. The pure acid, protected from light, re- mains colorless, but if exposed becomes yellowish in color, from develop- ment of orange-colored oxides, mainly N a 4 (nitric peroxide); at a sp. gr. of 1.42 it is a stable compound, boils at 250, and distils over un- changed; it has a very sour, corrosive taste, and an acrid, suffocating odor; its affinity for water is great, and the white fumes which it emits on exposure are caused by the combination of its invisible vapor with atmospheric moisture forming a cloud of minute drops. A good test for nitric acid is its action on metallic copper or iron; when undiluted and poured on them, it gives dense red vapors of per- oxide of nitrogen and other oxides, but if first diluted, a colorless gas, nitric oxide, NO, is given off, which changes into peroxide, N 9 4 , and becomes orange-red in color on contact with the air. If the colorless gas, NO, be passed into a solution of protosulphate of iron, it will com- 216 MATERIA MEDICA AND THERAPEUTICS. bine with a portion of it, causing a dark brown color. Morphia and brucia are colored bright red by the acid. There is no precipitation test for nitric acid, because all neutral nitrates are soluble, but its adulteration with sulphuric or hydrochloric acid is detected by chloride of barium and nitrate of silver respectively. Nitric acid is a powerful oxidizing agent, and is used in pharmacy to prepare the nitrates of different metals; also for the making of certain organic compounds, as gun-cotton, nitrite of amyl, etc. ABSORPTION AND ELIMINATION. Dilute nitric acid in medicinal doses is diffusible and readily absorbed. In the blood it either combines with alkaline bases forming nitrates, or it circulates in a free state, or loosely joined (invisque) with albumen (Gubler) : it cannot be detected free in the blood by analysis. It is eliminated mainly by the urine as nitrate of potash or soda, not as free acid; yet it highly increases the acidity of the secretion by liberating acids weaker than itself (such as uric and lactic acids) from their combinations. From its effects upon the intestinal glandular structure, and from the comparatively small amount passed in the urine, it is probable that some is excreted by the lower bowel. PHYSIOLOGICAL ACTION (EXTERNAL). Strong nitric acid applied but for a moment, stains organic tissue yellow, and leads to desquamation of the epidermis; if applied firmly and for longer time, it exerts a potent caustic effect, due to abstraction of the water from the tissues and com- bination of the acid with alkaline bases; xantlfo-proteic or -picric acid is also formed, and the part becomes yellow. Dilute solutions exert a stimulant, moderately astringent effect; by continued contact they change most animal and vegetable substances into oxalic, malic, or carbonic acids (H. C. Wood: "Elements," 2d ed., p. 96). Nitric peroxide is an efficient but irritating disinfectant. PHYSIOLOGICAL ACTION (INTERNAL). For a general statement as to the action of acids on the organism, reference may be made to hydro- chloric acid. Digestive System. Given internally, in medicinal doses, dilute nitric acid exerts a stimulant effect on the glandular system of the alimentary canal, and some tonic bracing effect on the mucous membrane, so that appetite is improved by it, and undue secretion lessened; this is probably owing to a direct local action. Salivation sometimes occurs under the use of nitric acid, either in consequence of the gastric irritation, or of direct stimulation of the salivary glands by the medicine. It is commonly cred- ited with some power of stimulating the secretion and excretion of bile. Large doses act like other violently corrosive irritant poisons. In a case that proved fatal on the eighth day after swallowing 1 dr. of the strong acid, the oesophagus and stomach were found inflamed and ulcer- ated, the colon was in the same state, but the small intestine was sound; suppression of urine had occurred. NITRIC ACID. 217 SYNEKGISTS ANTAGONISTS. The same as those of sulphuric acid. THERAPEUTICAL ACTION (EXTERNAL). Disinfectant. Nitrous fumes may be generated by the action of sulphuric acid on nitrate of potash. They efficiently disinfect unhealthy wards, prisons, etc., but the use of less irritating substances has practically replaced this method. Phagedcenic Ulceration. In cases of sloughing chancre, of phage- daena, of hospital gangrene, etc., when it is necessary to destroy por- tions of diseased tissue, and to stimulate to healthy action, strong nitric acid is one of the best caustics in use. The affected part should be cleansed and dried, so that the acid be not too diluted by secretion, the neighboring parts should be protected by oil or ointment, and the caustic then thoroughly applied with a glass brush, splinter of wood, or pledget of lint, until a firm dry yellowish mass is formed; the pain is at first se- vere, but soon subsides under cold water dressings, the eschar formed is not very deep, and usually separates in one or two days; the application may sometimes require to be repeated. Bubo. The strong acid may, with advantage, be lightly pencilled over torpid suppurating buboes, to destroy the integument and stimulate to healthy discharge; should a sinus be formed, the upper wall should be touched in the same manner (Lancet, ii., 1867, p. 796). Lupus. The same application is indicated for the indolent edges of an ulcerating lupus, though acid nitrate of mercury is perhaps better. Uterine Disease. Dr. Lornbe Atthill has had the best results from applications of strong nitric acid to the interior of the uterus, in cases of fungoid granulation and excessive hemorrhage: lint bound on a uterine probe conveys the caustic through a small speculum placed in the cervix (Obstetrical Journal, June, 1873, and Treatise). It is a good application also in chronic inflammatory disease of the same part and in granular erosion of cervix if there be not excessive tenderness (British Medical Journal, i., 1876). H. Lee has found the acid good in uterine disease, if the mucous membrane be not too much thickened; it is important that it be not diluted by secretion, and that an alkaline injection be used after it (Lancet, i., 1874). As injurious effects have sometimes followed the use of nitrate of mercury and of strong iron solutions, I myself prefer the nitric acid for vaginal and uterine disease of the kinds named, but in cases of hemorrhage from the vagina or uterine neck, connected, e.g., with carcinoma, I think the perchloride or persulphate of iron mixed with glycerin, are better haemostatics. Internal Haemorrhoids. It has been thought that strong nitric acid would supersede all operative interference in this disorder, but its cura- tive power is really somewhat limited. Its local application is only useful in small granular piles, and in " vel- vety " conditions of the mucous membrane; it checks the bleeding, but severe hemorrhage may occur when the slough separates. One or two 218 MATERIA MEDIC A AND THERAPEUTICS. applications ought to suffice for the cure of such a condition, but for large masses, or for haemorrhoids with narrow vascular attachments, other treat- ment is better. Billroth, however, reports much success with nitric acid in most forms of internal hasmorrhoids, but especially in the flat form: after protrusion, he applies the remedy till the part is " stiff and yellow- ish-gray in color," and then oils it well he notes the importance of not touching sound parts with the acid, for it causes great pain (Ranking, i., 1872). Dr. Houston first proposed this treatment (Dublin Medical Jour- nal, vols. xxiii.-xxvi.); and Mr. Henry Smith has used it extensively, and written in its favor. In less severe cases where the parts bleed and are somewhat swollen, Dr. Ringer recommends a lotion containing 1 to 1 dr. dilute acid to pint water. Prolapsus Hecti. If the strong acid be applied in one or two hori- zontal bands to the prolapsed mucous membrane of the rectum, in such a degree as to cause moderate but not too deep sloughing, these bands, on healing, will leave cicatrices which by their contraction are often suffi- cient to cure the complaint. In children, in whom prolapsus ani is rather common, benefit is often obtained from bathing the part with a weak ni- tric acid lotion, and giving the same acid internally. Condylomata on the limbs or genitals, especially when of a syphilitic origin, disappear under the external use of nitric acid. Warts and Corns. Erasmus Wilson recommends nitric acid for the treatment of callosities, the cauterized portion being removed occasion- ally by the knife. I have used nitric acid extensively for the removal of moles on the face; the cicatrices are hardly visible. Ncevi. Superficial nsevi may be safely destroyed by painting with strong nitric acid; Mr. T. Holmes speaks highly of this method. Due precaution should be taken to protect the sound skin, and an alkaline lo- tion should be used afterward. If the affected part be extensive, a por- tion only should be treated at one time, the caustic being applied about every second day, until its full effect be produced (Lancet, ii., 1866, and 1867). For small naevi on the face, I can recommend puncture with a needle dipped in the acid: it is safe, effective, and leaves comparatively little scar. Indolent Ulcers. For ordinary indolent or moderately sloughing ul- ceration, a lotion containing nitric acid diluted, about 1 dr. in pint of water, is a good dressing. Pruritus. A similar lotion will often relieve itching in papular and neurotic diseases, such as lichen and prurigo; it may be conjoined with prussic acid, or with the liquor carbonis detergens. Alopecia. The acid, diluted with so much olive oil as will prevent the caustic though not the stimulant effects, makes a good liniment in some cases of falling off of the hair from debility. NITRIC ACID. 219 THEBAPEUTICAL ACTION (INTERNAL). Dyspepsia Debility. Dilute nitric acid is a serviceable tonic in cases of nerve-debility and of conva- lescence from acute disease, when appetite and digestive power are im- paired. It acts well in combination with a few minims of tincture of nux vomica, stimulating the gastric glands and the biliary secretions, and may be given between meals, or shortly before or after, according to the conditions already mentioned under hydrochloric acid (v. p. 197). Hepatic Disorder. Nitric acid has long been held in repute for the treatment of chronic hepatic congestion, or chronic hepatitis, especially when occurring in Anglo-Indians, and after mercurials have been used. Dr. Murchison met with marked improvement, even in cases of waxy liver, from the continued use of nitric acid with vegetable bitters (" Dis- eases of Liver," 1868, p. 33), but in later writings he remarks that there is no evidence of its assisting bile-flow, and that its action is less direct than that of alkalies; that in congestion (of acute character), or when lithiasis is present, it either does no good, or aggravates the malady, though it may relieve the dyspepsia of debility: he sometimes gives alka- lies before a meal, and acid after (British Medical Journal, i., 1874). R. Martin, Thudichum, and indeed the majority of writers twenty years ago, allowed to nitric acid a larger sphere of usefulness in hepatic disor- der, jaundice, etc.; it was presumed to "lixiviate biliary deposits, tone digestion, and act antiseptically " (British Medical Journal, ii., 1860). Annesley noted that it acted better, the more freely it was diluted he used it in chronic splenic disorder. I have found nitric acid useful in chronic hepatitis, when watery diarrhoea and constipation occur alter- nately. Phosphatic Urine Chronic Cystitis. Sir B. Brodie constantly em- ployed strong nitric acid, in full doses 30 min. or more largely diluted, and given in divided doses during the day, for phosphatic and alkaline urine. In cases of chronic cystitis, and even of phosphatic calculus, he also employed local injections containing 1 to 2 "min. of the strong acid in the ounce of warm water. The best mode of administering nitric acid under these conditions is to give 5 to 10 min. of the dilute acid in 1 or 2 oz. of decoction of pareira brava every three or four hours. Diarrhoea. When the dejections are frequent, serous or " watery " in character, especially if markedly alkaline, and if there be no evidence of acute inflammation and not much pain, then nitric acid acts well, and in cases of profuse purging from summer heat, and in the diarrhoaa of phthisis, it has a deserved repute: if necessary, it may be combined with a small quantity of opium. In dysenteric diarrhoea with tenesmus, blood, and profuse discharge of mucus, nitric acid acts well. Dr. Hope had reason to prefer the dilute nitrous to the nitric acid; he gave 15-min. doses, with laudanum and camphor water, in most forms of diarrhoea and chronic dysentery, with much success. Dr. H. C. Wood found it succeed 220 MATEEIA MEDIC A AND THERAPEUTICS. in some cases where nitric acid had failed: it is, however, unstable, and requires to be recently prepared. Constipation. Dr. Graves says, " In constipated habits I have occa- sionally derived very remarkable benefit from the use of nitric acid given in sufficient doses. It seems, like the carbonate of iron, to possess the advantage of combining tonic with aperient qualities " (" Clinical Medi- cine," ii., p. 215). I think that this different action of the medicine de- pends upon dose, and perhaps combination, and is not contradictory to that mentioned in the last section. Nitric acid in small or moderate doses is astringent, especially if prescribed with opium; but nitric acid in futt doses has an aperient effect, especially in combination with bitter in- fusion, such as gentian; this may be traced either to direct intestinal irritation or to hepatic- stimulation. Otorrhcea occurring in scrofulous children or in syphilitic patients, is often quickly controlled by a course of this acid. Purulent Ophthalmia, with extensive ulceration of the cornea, whether of a gonorrhoeal or scrofulous form, is much benefited by a course of 5 to 10 min. of the dilute acid three or four times a day, together with local treatment. Fevers. Dr. Osborne has recorded a good experience of nitric acid in typhoid fever (Lancet, ii., 1862), and Dr. Bailey (U. S.) inintermittents he prescribed it to relieve profuse sweating, and unexpectedly found a curative effect on the ague: of ninety cases, eighty made a rapid recov- ery. Dr. Hammond has corroborated his results (Ranking, 1862). Secondary Syphilis. A course of dilute nitric acid will often be of service in later syphilitic cachexia, especially after mercurials have been used, and in debilitated subjects. It benefits ulcerations of the mouth, throat, and nose, and also periosteal swellings, and may be applied at the same time in the form of bath 1 to 2 oz. for each bath. Mercurial sali- vation is relieved by the acid. Skin Diseases. In chronic syphilitic cutaneous eruption, such as rupia or psoriasis, this acid has been rightly commended. In ordinary, non-specific disorder, it is indicated whenever general debility is a marked symptom, and especially when nerve-power is impaired. Dr. Tilbury Fox frequently gave it, in conjunction with a bitter tonic, for psoriasis in weakly subjects. Chronic Laryngeal Congestion. In this malady, when brought on by excessive vocal exertion, as in singers and readers, 5 to 6-min. doses of dilute nitric acid in sugared water have been found very useful, bracing up the relaxed membrane and throat follicles, and relieving hoarseness; also in chronic laryngitis, dependent upon a syphilitic taint, it is of much use. Chronic Bronchitis. I agree with some good observations made by Dr. Glover, drawing attention to the benefit obtained sometimes from DILUTE PHOSPHORIC ACID. 221 nitric acid in cases of chronic catarrh and bronchitis when secretion is fairly free, when nerve-exhaustion is a prominent symptom, and when ammonia and expectorants fail to relieve (Lancet, i., 1865); this fact de- serves more attention than it has yet received. Dr. Glover combines nitrous ether with the acid, and sometimes tinct. camph. co. is also indi- cated, the precipitated camphor, etc., being readily suspended in cetraria or mucilage. Pertussis. Nitijc acid has been found by some observers valuable in relieving the spasmodic recurrent attacks of cough, and lessening profuse expectoration; and it may certainly be credited with tonic bracing action on the faucial and laryngeal membranes. Arnoldi, who introduced this mode of treatment, ordered as much acid as would render a tumblerful of sugared water " like lemon juice," to be taken every three or four hours. Dr. Gibb, who reported the best results, gave as much as 10 min. to infants, and 40 min. to children of ten years; and some other practi- tioners have used this medicine with success, as Ussher (Medical Times, i., 1862), and Berry in an epidemic at Lancaster who found it effective, safe, and cheap (Medical Times, i., 1873). I have been reluctant to press it for fear of injuring teeth, and when I have used it as freely as could be borne, I have not seen definite benefit. PREPARATIONS AND DOSE. Acidum nitricum Aqua fortis : dose 1 to 3 min. freely diluted. Acidum nitricum dilutum : dose, 10 to 30 min. freely diluted. [PREPARATIONS, U.S. P. Acidum nitricum, sp. gr. 1.420, Acidum nitricum dilutum : nitric acid 3 troyounces, water sufficient to make 1 pint.] ADULTERATIONS. Chiefly sulphuric and hydrochloric acids. ACIDUM PHOSPHORICUM DILUTUM DILUTE PHOS- PHOEIC ACID, H 3 PO 4 ,=98. This acid is rather widely diffused, being found free or combined with alkaline and earthy bases in soils, and in many vegetables and fruits, such as wheat, potatoes, rice, lemons, etc., also in fish, and in the bones, nerves, and flesh of animals, and according to Marcet, more 'in the lungs than in other parts; also in the urine and other secretions. PREPARATION. The officinal (tribasic) acid is prepared by distilling phosphorus with dilute nitric acid by the aid of gentle heat; some of the latter acid passes over in vapor, and therefore the distillate is returned to the retort occasionally in order to prevent loss: it is finally concentrated to a syrupy consistence (heat being used to get rid of nitrous fumes), and the resulting strong phosphoric acid is diluted with water to a sp. gr. of 1.08, which represents about 14 per cent, of acid. 222 MATERIA MEDICA AND THERAPEUTICS. CHARACTERS AND TESTS. Tribasic or orthophosphorous acid is a color- less, inodorous liquid, of acid, not unpleasant taste, and even when con- centrated, not corrosive, nor coagulating albumen. It gives with ammo- nio-nitrate of silver, a canary-yellow precipitate of phosphate. There are two other forms of phosphoric acid, not officinal, but of much interest to the chemist. If heat be applied to the common acid it loses water, and its first anhydride (pyrophosphoric or bibasic acid, H 4 P 4 O 7 ) is produced: by a higher heat, more water is driven off, and its second anhydride, glacial or metaphosphoric or monobasic acid HPO 3 , is formed. This is in the U. S. Pharmacopoeia, and is a colorless, ice-like, deliques- cent solid: it is the only form which coagulates albumen. All soluble phosphates give a white crystalline precipitate with sul- phate of magnesia, after the addition of sal-ammoniac and liquor ammonias (ammonio-magnesian phosphate, or "triple phosphate" MgNH 4 PO 4 ). ABSORPTION" AND ELIMINATION. Phosphoric acid is readily absorbed by the stomach. Ordinary doses combine with alkalies potash or soda salts probably displacing them from combination with weaker acids, lactic or carbonic, and forming phosphates; after larger or poisonous doses, Hoffmann states that he has found it free in the blood or loosely combined with albumen (Journal de Chemie, June, 1868). As phosphate it is mainly eliminated in the urine, and Booker found the excretion of potash phosphate especially increased under its use: some acid may possibly be eliminated in a free state. PHYSIOLOGICAL ACTION. The action of phosphoric acid bears a gen- eral resemblance to that of sulphuric acid, but in medicinal doses it is less liable to irritate the stomach or interfere with digestion, and it exerts a more stimulating effect on the general system : it has a more pleasant taste than the other inorganic acids. The pharmacopreial solution does not coagulate albuminous tissues, and like oxalic and tartaric acid only coagulates egg-albumen after addition of chloride of sodium or other neu- tral salt. Circulatory System. The effect of moderate doses of phosphoric acid is stimulant, but of large doses, especially when injected into the blood- current, depressant. Two cub. centim. of a four per cent, solution given to a frog, increased the pulse-frequency, and the direct application of acid to the frog's heart at first strengthened though it afterward weakened the contractions; after death, the heart-muscle was non-excitable (Munk and Leyden). In warm-blooded animals, after the subcutaneous injection of about 8 grammes, slowness, weakness, and irregularity of heart-beat occurred, with retarded respiration, lowered temperature, prostration, and death (Meyer). After injections of phosphoric acid into the jugular vein, the blood- pressure and the pulse-frequency are lowered, although after small quan- "titiesthey quickly rise again. Pavy found that he could inject 8 or 10 DILUTE PHOSPHORIC ACID. 223 dr. of the pharmacopoeia! solution into the jugular of a dog without causing death, and if, in any animal, the maximum amount compatible With life was injected, the urine and the arterial blood became highly charged with sugar ("Guy's Hospital Reports," vol. vii., 1861). We may connect this result with the fact that phosphoric acid acts even more powerfully than hydrochloric in diminishing the alkalinity of blood (Wal- ter), while, on the other hand, injections of soda prevent the production of artificial diabetes; but the full bearing of such facts is not yet known. Injections of acid into the carotid caused primary slowing of pulse with secondary quickening before death, strong inspiratory cramp, convulsions and coma (quoted by Husemann). After death from excessive quanti- ties, ecchymoses were almost always found in the lungs, and the blood was altered, being dark but fluid, and not easily coagulable, sometimes gelatinous. The effect on the blood is not always the same: thus, Pavy in one experiment found the " large venous trunks in the liver plugged with coagulated blood" after an injection of 30 dr. of acid into the du- odenum; and Gubler says, "introduced into the veins of animals, phos- phoric acid coagulates the blood and causes death in a few minutes: " this depends on the dose and concentration. Neumann states that the cor- puscles are not destroyed by the acid, but may be much altered in form and vital properties. The action upon man is of more practical interest, but very few in- vestigations have been made with phosphoric acid. Bobrick records a rise of the pulse from 70 to 90 beats per minute, but in the course of an hour it fell to 66; this was after a dose of $ oz. A rigor also occurred, the cause of which is not easy to trace, but it was followed by a pleasant sensation of warmth. Dr. J. B. Andrews (N. Y.) administered doses of from 1 to 3 dr., and investigated the effect by means of sphygmograms taken at intervals of from fifteen minutes to one hour. He says, " With- in the first interval there is an increase in the force of the pulsations, though there is little change in the number during the whole time of ex- perimentation. The increase is most marked after the lapse of from one to two hours, and it is not till after several hours that the pulse returns to its normal condition. The first experiment I made upon myself, be- ginning with 20 drops, and continuing the use of the remedy in increased doses till the amount of 4 dr. was reached. The sensations experienced from 40 min. to 3 dr. were those of moderate alcoholic stimulation, slight pain through the frontal region, and a buoyancy and lightness of feeling rather agreeable. ... In the pulse-traces, additional force is manifest in the heart's action in all cases, and in the general appearance of weakly persons placed on acid treatment the same fact is apparent the conges- tion of the extremities and lips has soon given place to a more natural color" (American Journal of Insanity, October, 1869). Nervous System. Dr. J. B. Andrews and many others find phosphoric 224 MATEKIA MEDIC A AND THEEAPEUTICS. acid to be a powerful nerve-tonic, hut the conclusions are founded more upon clinical observations on depressed persons than on the healthy. " Moderate doses produced on the latter the feeling of buoyancy and ex- hilaration already mentioned, but larger quantities caused a feeling of drowsiness, an inclination to lie down, and unwillingness for mental la- bor." The acid exerts also a marked control over the vaso-motor nerves, and through them improves the tone of the circulation. Hecker and Burdach concluded that phosphoric acid acts more than any other on the nervous system, heightening excitability in a great degree. Sundelin asserted that this action is directed especially to the genital organs, and although neither Neligan nor Andrews could verify this, I have myself noted it in sixteen patients, who had no knowledge of the supposed aphrodisiac quality of the drug; they all complained to me of such effects in greater or less degree. Digestive System. Moderate doses tend to improve the tone and functional power of the stomach, and, as already remarked, this acid ir- ritates much less, even after continued use, than the other inorganic acids; large or concentrated doses, however, taken by the mouth, may cause gas- tro-enteritis, and after death, redness, erosion, and ecchymoses have been found in the stomach and duodenum (Monk and Leyden). When Pavy injected 1 to 2 oz. into the stomach of dogs it was quickly rejected, but on passing it into the duodenum, a saccharine condition of the urine and the blood was produced, just as after intravenous injections. After toxic doses, fatty degeneration has been found in the liver, kidneys, and mus- cular tissue. SYNERGISTS AND ANTAGONISTS. The same as for other mineral acids (v. p. 196). THERAPEUTICAL ACTION (INTERNAL). Nerve- Debility. The thera- peutical influence of phosphoric acid is mainly exerted on the nervous system, and in the treatment of nerve-debility acts much like iron in anae- mia, as a chemical food supplying something actually deficient in nerve-nu- trition. When mental effort has been protracted till a sense of weariness renders its continuance difficult, a dose of the acid, from its stimulant effect, relieves fatigue, and seems to invigorate the mental powers, and prepare the mind for renewed exertion. Dr. J. Andrews, describing a case of impaired mental power from ex- cessive brain-activity, observes, " The patient is languid, unable to do mental work with the usual facility, nervous, and at times fearful, timid, and agitated, the memory weakened, and permanent impairment threat- ened. Such cases have been termed ' cerebral paresis,' but for their re- covery, relaxation from business, and phosphoric acid, with some suitable tonic, generally suffices." Of more serious conditions, such as dementia following acute mania, Dr. Andrews remarks, " This is a period of nervous exhaustion, of reac- DILUTE PHOSPHORIC ACID. 225 tion from the increased mental and physical activity -which marked the previous state of the disease; tone and vigor must be supplied to the prostrated system, and for this phosphoric acid is of material service." It relieves peripheral congestions connected with impaired tone of vaso- motor nerves, and in weakened relaxed conditions akin to impotence, and resulting from sexual excess, it has proved a special help. Fever. In any fever where the nervous system is specially depressed, phosphoric acid is indicated; it assuages thirst, and helps to remove ex- haustion; its pleasant taste is one advantage over the other mineral acids. Stromeyer, and others, recommend it in "eruptive fevers." The fol- lowing is a convenient form: 1. Acidi phosphorici diluti, fl. 3 iij.; gly- cerini, fl. 3 j.; decocti hordei, Oij. : mix, and use when cold as a common drink. Diabetes. Phosphoric acid often relieves the thirst of this malady, and has been recommended by Latham, Paris, Watson, and other practi- cal physicians; on the other hand, the experiments of Pavy (already quoted) indicate that much of it would be injurious, and Griesinger not only states that it does not lessen the excretion of sugar, but in one case supposes it actually to have caused the malady. Against this, we might set a case recorded by Thornley, in which the thirst was relieved and the patient apparently cured (Medical Press, May 20, 1868); but, without being in a position to dogmatize on the matter, I may say that I have known the acid on several occasions to relieve symp- toms and diminish the amount of sugar in the urine. Urinary Disorder. In phosphatic deposits connected with waste of nervous tissue, and in alkalinity of urine with nerve-depression, phos- phoric acid is very useful, and it has relieved the symptoms of phosphatic calculus and urethro-vesical catarrh, when nitric and hydrochloric acids had failed. Benefit has also been derived from it in oxaluria. In Rachitis, the milky phosphatic condition of urine is cleared by the acid, though Dr. H. Wood considers that the phosphates act better. Phthisis Struma. In these conditions generally, phosphoric acid fulfils many indications as a grateful moderately astringent tonic; it re- lieves hoarseness and dry irritating cough accompanied by pain and laryngeal soreness. Dr. Cotton gave it to twenty-five patients with chronic uncomplicated phthisis at Brompton Hospital, and observed benefit in a few advanced cases: it improved appetite and controlled se- cretion, although sometimes nausea and pain were excited: he could not trace a specific effect from it, but rather the action of a general nerve- tonic; it acted specially well combined with iron (Medical Times, i., 1863). Dr. C. J. B. Williams recommends it with cod-liver oil (Lancet, ii., 1868, p. 213). In the dyspepsia so common in phthisis, it is also useful^ relieving the VOL. I. 15 226 MATERIA MEDICA AND THERAPEUTICS. pain, sickness, and diarrhoea which occur after meals. Profuse night- sweats and other exhausting discharges are controlled by it, and it exerts a sedative effect upon the excessive sexual desire which often developes in some stages of phthisis. Dr. Todd used it in cardialgia. Haemoptysis Hemorrhage. M. Hoffman has written to specially re- commend this acid in haemoptysis; and the main reasons for his prefer- ence of it would seem to be its " less corrosive action," and better toleration by the stomach, otherwise its stimulant powers would make it less generally suitable than sulphuric acid; he gives 10 to 30 drops in mucilage (Journal de Chim. Medic., June, 1868). I have myself seen good results from the acid in purpura and passive hemorrhage, also in metrorrhagia. Strumous Conjunctivitis. This malady is often troublesome, not so much from its severity, as from its persistence and great tendency to re- lapse, and Mr. Balman, has written to praise phosphoric acid, not only in struma, but especially " in the intermittent ophthalmia of a scrofulous constitution": he says that, given in doses of from 5 to 20 min. in cal- umba, the acid both cures and prevents recurrence of the affection (Lon- don Medical Gazette, August 22, 1858). Scorbutus. Liebig and others have held that the scurvy of sailors is mainly owing to the exclusion of phosphoric acid from their diet, since in the ordinary preparation of meat for sea-stores the greater portion of the acid is extracted from it, and the complaint has been cured by giving food containing the acid, although the sailors continued to use the salted beef to which scurvy was attributed (" Letters on Chemistry," p. 425). Professor Galloway has verified the presence of phosphoric acid in lemon- juice, and hence, according to Morgan and Neligan, its superiority to citric or tartaric acids, but I am not aware that the theory has been largely tested in practice. Bone Diseases Caries. In caries, M. Leutin applied dilute phos- phoric acid to the affected bone with the idea of supplying a deficient element, and practically this sometimes relieves and improves the bone- condition. Its good effect is, however, better seen from internal adminis- tration, especially if much hectic be present. It is said to be also bene- ficial in cases of unusual depositions of phosphate of lime, as in exostosis, and bony tumors generally (Neligan, Garrod). Wormald states that the detection of phosphoric acid in pus is diagnostic of necrosis (Lancet, ii., 1862, p. 440). In Rachitis I have found it a useful medicine, and it relieves the diar- rhoea and sweating of that disorder. Diarrhoea. Phosphoric acid is suitable for cases of diarrhoea when an acid is indicated. Sedgwick strongly recommends it for choleraic cases, and argues for its use in true cholera (Lancet, ii., 1871, p. 280). SULPHURIC ACID. 227 PREPARATION AND DOSE. Acidum phosphoricum dilutum : dose, 10 to 30 min. freely diluted. [PREPARATIONS, U. S. P. Acidum phosphoricum dilutum, sp. gr. 1.056. Acidum phosphoricum glaciale used in preparations.] ACIDUM SULPHURICUM- SULPHURIC ACID OIL OF VITRIOL, H,S0 4 ,=98. This occurs native in the water near volcanoes, as in Java, and in the " Sour Springs," in the town of Byron, Genesee County, N. Y. It is found in combination in twenty-two natural sulphates, also with am- monium in rain-water, near towns. It contains 79 per cent, of anhyd- rous sulphuric acid, SO,. There are two other forms of the same acid, the acidum sulphuricum dilutum, and the acidum sulphuricum aromaticum, which are weaker by one-seventh than the first-mentioned. PREPARATION. By passing sulphurous acid gas (sulphurous anhyd- ride) into leaden chambers, and bringing it there into contact with steam and nitrous fumes (nitrous anhydride);, from the latter it absorbs an atom of oxygen, becoming sulphuric acid (anhydrous), and this combines with water to form a dilute sulphuric acid, which is afterward concentrated up to a sp. gr. of 1.843; a small quantity of nitric oxide gas will act as a carrier of oxygen from the atmosphere to a large quantity of sulphurous acid. In chemical formulae the main reaction may be represented as follows: SO, 4- H,0 + N,0 3 = H S S0 4 + 2NO. CHARACTERS AND TESTS. The pure acid is an oily-looking, colorless liquid, but the commercial acid is often dark-colored from contained frag- ments of organic matter, which are charred by the acid. It has an ener- getic affinity for water, which it absorbs readily, so that a partially-filled bottle of acid, if exposed to the air, will, after a time, overflow; if quickly mixed with water it undergoes condensation, and much heat is evolved. A very small quantity of sulphuric acid, or of any soluble sulphate, can be detected by adding to the diluted solution a little chloride of barium, which gives a dense white precipitate, insoluble in acids. ABSORPTION AND ELIMINATION. Moderate doses of the dilute acid are readily absorbed, either as sulph-albuminates (Orfila), or, after com- bining with bases in the gastric secretion, as sulphate of potash or soda (Miguel): very small doses only in the latter form (Husemann). The dilute acid forms with albumen both a soluble, and an insoluble compound according to the degree of dilution the former resulting from quite weak acid (Berzelius). That dilute sulphuric acid may be absorbed through the skin, follows from the experiments of Lebkuchner, who in- 228 MATERIA MEDIC A AND THERAPEUTICS. duced acid reaction of urine and faeces by applications to the abdomen of rabbits. Gubler teaches that this, like the other mineral acids, circulates in the blood, but loosely combined with albumen, and that on reaching the emunctories the combination breaks up, albumen remaining in the vessels, while the acid passes out with the excretions, combining with the bases therein found. It has been a question whether after poisonous doses, the acid may be absorbed and remain free in the blood, leading to its coagulation. Geoghegan states that after 1 oz., when a woman survived thirty-one hours, he found traces of acid in the pericardium and in the kidney, not in the blood, but in that fluid he found much phosphoric acid, derived, he suggested, from phosphate of soda from which sulphuric acid had dis- placed it (Medical Gazette, xl.). In another case Dr. Walker found a trace in the cerebral fluid and in the cardiac blood (Edinburgh Journal, 1850). Casper found the blood and serous fluids acid, and Carus states that he found sulphuric acid in all the organs of a foetus, after a fatal dose taken by the mother ("Beck's Jurisprudence," ii., p. 429). More recent researches state that mineral acids cannot be detected free in the blood, and that its reaction cannot be rendered acid consistently with life (F. Walter; v. Hydrochloric Acid). It is not likely that the coagula de- scribed by Bouchardat in the great vessels were really due to direct ac- tion of free acid, Taylor could find no trace of it in similar coagula (" On Poisons," p. 31). The acid is eliminated by the urine, and according to Dr. Letheby, very quickly after full doses (Medical Gazette, xxxix., p. 116). Most ob- servers agree that it cannot be found free in that secretion, but as sul- phate (Bence Jones), and the heightened acidity is really due to uric and lactic acids displaced by the stronger sulphuric acid from their ordinary combinations. Seeing the comparatively small amount of sulphuric acid accounted for in the renal secretion, Headland suggested that some passed by the lower bowel and the skin, and this is probable. PHYSIOLOGICAL ACTION (EXTERNAL). The dilute acid, applied to the skin, causes some burning pain and pallor, followed by redness; more concentrated, it destroys the epithelium, changing it into a firm brown mass. It coagulates albumen, and disintegrates horny tissues with for- mation of leucin and tyrosin. In its full strength, it causes destruction and sloughing of any tissue by virtue of its strong affinity for organic bases, as well as for the water with which they are combined. The acid has disinfectant and antiseptic powers, and destroys infusorial life. PHYSIOLOGICAL ACTION (INTERNAL). Digestive System. Very small doses give a characteristic markedly acid taste, and lessen the sensation of thirst; 10 to 15 min. of the dilute acid, administered several times at intervals, stimulate the appetite and exert some astringent effect on the SULPHURIC ACID. 229 gastric and other secretions. If continued, however, the medicine induces dyspepsia with acid eructation; colic, and even diarrhoea, which may be due to the large amount of alkaline sulphates formed, as well as to direct irritation. The local symptoms induced by toxic doses of the strong acid are very severe; intensely acid pungent taste is followed by acute burning pain in the mouth, pharynx, and stomach, and violent retching and vomiting the ejecta usually containing dark blood; there is extreme thirst and great sense of distress sometimes purging with tenesmus. The faucial inflammation may induce suffocation, angina, or laryngeal oedema, and thus prove fatal early in the case, or peritonitis may be set up, and if death do not occur from collapse, it may follow on perforation of the oesophagus, stomach, or bowel in twelve to forty-eight hours after the poisonous dose; should life be saved for the time, the inflammation of the alimentary-tract is likely to be followed by serious contraction, etc. swellings, and suppuration of the parotid glands may occur. Any slough produced by this acid is black in color. Circulatory /System. Bobrick found, with frogs, that this acid, given by the stomach, or applied to the skin, caused the heart to act more slowly, and finally stopped it in diastole. Hertwig, experimenting on mammalia, found that moderate doses of the dilute acid lowered the pulse-rate and the temperature, while arterial tension was increased. I am not aware that similar results have been verified on the healthy hu- man subject, nor has proof been given of the acid's power to lower tem- perature in febrile conditions. It has been said by some that the blood becomes less, by others more, coagulable, but its exact state is not ascer- tained; nor do we rightly know whether the smaller vessels are con- tracted or not by the acid (Nothnagel; v. p. 228). When injected into the veins it causes instant death from coagulation of blood and thrombo- sis, and the corpuscles are altered or destroyed by toxic doses taken in- ternally. In cases of poisoning by the acid, the disturbance of circulation is mainly secondary to the gastric irritation: there may be faintings, pass- ing on to actual syncope or collapse, the pulse becoming later rapid and small, the extremities icy cold, and respiration labored and superficial. Nervous System. Ordinary doses do not produce other than tonic effects upon this system. In fatal cases of poisoning, the mind is gener- erally clear or but slightly clouded; exceptionally, coma has developed. Glandular System. Most of the secretions become more acid under the free use of this drug, and some of them, especially those of the skin and the bowel, are lessened in amount. Bobrick, however, found the quantity of urine and the amount of urinary sulphates increased by it. After large doses, Leyden and Munk distinguished different conditions corresponding to different alterations in the kidney; finding albumen MATERIA MEDICA AND THERAPEUTICS. alone, or with epithelial casts, or with fatty globules and epithelium, or in addition, hyaline casts, and blood- and pus-corpuscles. PATHOLOGICAL CHANGES. The anatomical lesions found in the stom- ach after death vary according to the concentration of the acid, and the duration of its effects. In milder cases, the epithelial and the upper layer of the rete mucosum are shrunk, parchment-like and greyish: in the severest, the whole tissue is mortified, blackened, and changed into a soft gangrenous mass. Fatty degeneration of different organs has also been lately described as a constant result of poisoning by sulphuric acid, and particularly in the liver, the striped muscular tissue, the heart, and the renal epithelium. This change is to some extent explained by the destructive action on the red corpuscles, which are in part destroyed, and in part altered, becoming smaller, darker, and of granular appearance, and certainly unequal to their proper function; hence the tissues are im- perfectly nourished, and readily degenerate. The same alteration in the oxygen-carriers explains the lowered temperature, the feeble pulse, and the general debility, as well as the functional albuminuria from excretion of constituents of the altered blood-cells. SYNERGISTS. The other acids and cooling remedies are allied in ac- tion, and, as regards styptic effects, ergot and astringents generally are auxiliaries. ANTAGONISTS INCOMPATIBLES. Warm stimulating remedies and " fluidifying " medicines, such as mercury and iodides, antagonize some of the effects of sulphuric acid. Alkalies and bases are chemically incom- patible. The best antidotes in a case of poisoning are magnesia, chalk or white-wash, and soap, which should be given in albuminous solutions, such as milk and water. Alkaline carbonates are considered not advis- able because they form irritant compounds (Christison); also they evolve much carbonic acid, but may be used in cases of emergency. Oil to pro- tect the mucous membrane of the stomach is also very useful. THERAPEUTICAL ACTION (EXTERNAL). The highly caustic property of strong sulphuric acid is utilized comparatively seldom on account of the difficulty of restraining it within due limits. Chancre Gangrene Cancer. In chancre, with phagedaenic ulcer- ation, Ricord recommends a caustic paste made with sulphuric acid and charcoal to be applied on linen for several hours until a slough forms. In hospital gangrene the pure acid has been successfully employed (Medical Times, i., 1859). For such purposes and for cancer, Sir J. Simpson mixed it with zinc sulphate. The reason for using powders, es- pecially charcoal, to mix with the acid, is to secure a full strength in con- venient form without dilution with water: Syme employed sawdust; Vel- peau, saffron. Caries Necrosis. It is evident that a lotion containing mineral acid will dissolve out the earthy bases of bone-tissue and quicken disintegra- SULPHURIC ACID. 231 tion, and for this purpose it has been applied to some extent in surgery. Chassaignac recommended dilute hydrochloric acid, but more recently Mr. Pollock has brought forward much evidence in favor of the applica- tion of sulphuric acid mixed with an equal part of water, " for the more speedy removal of dying bone, or more rapid separation of dead portions, or destruction of the surface of carious cavities; " he finds it simple and safe, and comparatively painless nor has he ever seen bad consequences from it. His first case, one of necrosis of cranial bone, was touched daily with the dilute acid, the diseased part quickly separated, and healthy granulations formed. Cavities may be filled with lint soaked in acid, and, when this is removed, in two or three days an opaque white layer may be seen and taken away; this is a slough, soft owing to removal of earthy particles, which may be found lying loose in the wound: any pain caused by the caustic ceases in a short time because the acid is soon neutral- ized. In some flat bones, such as those of the trunk or pelvis, the undi- luted acid may be cautiously used. Recovery may be secured " in weeks instead of months " under such treatment, though it will not always suc- ceed without operative interference (Lancet, i., 1870). W. Hayward, H. Marsh, and others, have also recorded good results from the practice recommended by Mr. Pollock. Ectropion Entropion. In these deformities of the eyelids, sulphuric acid has been used by Laurence to cause a linear cicatrix, which, by its contraction, shall restore the natural position of parts, but other methods of cure are preferable. Poisoned Wounds. This, like the other mineral acids, when em- ployed to cauterize poisoned wounds, bites, etc., has the advantage over solid caustic of more penetrating power. W. Frazer considered strong sulphuric acid better than any other (" Materia Medica," p. 12). Parasitic Skin Diseases. In ringworm and in scabies, an ointment containing 1 dr. of acid to the oz. of lard has sometimes proved useful, though irritating; for the latter malady it is said to be largely used in the Prussian army (Neligan). Pruritus. In prurigo, lichen, and chronic urticaria, disorders attended with violent itching, a lotion containing 1 to 3 dr. of dilute acid in 8 oz. of water often relieves. Pereira says that its internal administration is also efficacious. Angina. For relaxed surfaces coated with tenacious mucus dilute sulphuric acid is an excellent cleansing astringent: hence it is inconstant use as a gargle (1 to 2 dr. in 8 oz. of infusion of roses) for relaxed uvula, etc.; in weaker proportion it is also suitable for scarlatinal throat. The addition of 2 dr. of alum to the gargle often greatly increases its value. THERAPEUTICAL ACTION (INTERNAL). It is commonly said that for digestive disorders requiring an acid, hydrochloric is the best: to stimu- late hepatic and intestinal secretion nitric acid is indicated, while the as- 232 MATERIA MEDIC A AND THERAPEUTICS. tringent effect of sulphuric is of special value in controlling sanguineous and other discharges. Hemorrhage. Sulphuric acid was formerly in very frequent use as an internal remedy for hemorrhage, especially of passive character, whether from the stomach, lungs, or uterus. That there is difficulty in explain- ing how it can exercise astringent effect after dilution and possibly com- bination in the blood, would be no argument against its use if this were proved efficacious; but my experience is the same as that of many modern observers (among whom I may mention Nothnagel and H. C. Wood), who give to sulphuric acid a secondary place among haemostatics, although I have known it succeed sometimes when other remedies have failed. Diarrhoea. Dilute sulphuric acid has a well-deserved reputation in various forms of intestinal flux, and especially in summer diarrhoea of choleraic character: it often answers well, but when given alone I have sometimes found it aggravate the disorder, whether by irritation or by increasing the acidity of secretions: the aromatic sulphuric acid should then be preferred in combination with some preparation of opium. In diarrhoea, with coated tongue and evidence of biliary disorder, the acid has acted admirably with small doses of magnes. sulph., tinct. rhei., and aqua chloroformi: it is a good remedy for children. Cholera. Dr. Curtin has recorded that a severe epidemic in an insti- tution under his direction ceased within twelve hours after the inmates were treated freely with "sulphuric acid lemonade" the only fresh case occurring in a man who refused to take the medicine. Two days after it was discontinued two new cases appeared, and an epidemic threatened, but was again stayed by the acid, and in the surgical wards, where the acid was used from the first, no case appeared, while every other part of the institution suffered more or less (Philadelphia Medical Times, iii., p. 649). This experience makes it desirable under similar circumstances to adopt the same method as prophylactic. Fever. In the diarrhoea of enteric fever, H. Kennedy, Murchison, and other authorities advocate the use of sulphuric acid (v. p. 197). We do not expect from it, as formerly, a power of shortening the morbid pro- cess; but it will allay thirst, and, to some extent, moderate the pyrexia and the undue secretion. In any enteric cases, the dose used should be small and well diluted: the aromatic, I find preferable to the simple form. Pyrexia Phthisis. Whether sulphuric acid does or does not lower pulse and temperature in the usually employed doses, it certainly is of more service in secondary pyrexial states than in specific fever. In sub- acute inflammatory conditions of protracted character occurring, e.g., dur- ing caseous pneumonia or chronic phthisis, it alleviates the general symp- toms, and sometimes the local conditions. It is well suited for phthisical cases with a tendency to undue discharges, for it acts as a grateful tonic and astringent, lessening the night-perspirations, the intestinal flux, the SULPHUROUS ACID. 233 expectoration, and passive haemoptysis; by combination with opium, or belladonna, aromatics, etc., so much relief may be sometimes given as to merit for the remedy its old title of " Elixir Vitriol." The presence of cough does not contra-indicate its use, but irritation 'of the fauces must be obviated by mucilage or syrup: acids should, how- ever, be omitted if gastric irritation be excited bv them. Palpitation. Nothnagel recommends ,this acid, combined with laxa- tives, in the palpitation of plethoric subjects; it is not indicated for the anaemic or chlorotic, nor specially useful in the palpitation of valve dis- ease. Lead Poisoning. Since the publication of the cases of M. Gendrin and Dr. H. Bennett in 1846, the acid has had more or less reputation as an antidote and prophylactic in poisoning by lead; but modern observation does not quite corroborate their estimate of it. Tanquerel especially failed to obtain any good results ("Maladies de Plomb," ii., p. 497); on the contrary, the use of an acid lemonade seemed to make the workmen rather more liable to colic. PREPARATIONS AND DOSE. Acidum sulphuricum Oil of vitriol: is not used internally except in the following: Acidum sulphuricum aro- maticum : dose, 5 to 30 min. freely diluted. Acidum sulphuricum dilu- tum : dose, 5 to 30 min. freely diluted. An alkaline mouth-wash should be used after taking the acid, or a little butter placed on the teeth before. ADULTERATIONS. The usual impurities of this acid are salts, nitrous oxides, arsenic, and lead. ACIDUM SULPHUEOSUM SULPHTJKOUS ACID, SO 2 , = 64. The pharmacopoaial sulphurous acid is a solution of the gas in water, containing 9.2 per cent, by weight =: twenty times its volume. PREPARATION. By deoxidizing sulphuric acid by distilling it with coarsely-powdered wood charcoal. The carbon combines with part of the oxygen of .the acid to form carbonic acid and probably carbonic oxide, while sulphurous acid gas (anhydrous) passes over into a receiver con- taining distilled water, being previously washed from sulphuric acid and other impurities. 2C+H a SO 4 =CO a +2H 3 O+2SO, CHARACTERS AND TESTS. A nearly saturated solution of sulphurous anhydride, SO,, colorless, of strong suffocating odor and pungent acid taste, which, however, is not unpleasant in moderate dilution. It bleaches vegetable colors, and is an energetic oxidizing agent: it is said to ab- sorb radiant heat in a high degree (R. Bird). The hydrated acid can be obtained in crystals but is very unstable. A solution of the officinal 234 MATEEIA MEDIC A AND THERAPEUTICS. strength and upward oxidizes on exposure to light and air (e.g., when kept in partially-filled transparent bottles), with formation of sulphuric acid an important change, since the special properties of the drug are thereby impaired or lost; contact with chlorine at once induces this change. It should therefore be carefully kept; or better still, be freshly prepared when wanted. Water would absorb forty or fifty times its bulk, alcohol still more; but Professor Redwood recommends a 5 per cent, so- lution, as more easily made and more stable than that of the British Pharmacopoeia. Tests. 1. When evaporated, it should leave no residue. 2. Barium chloride gives a copious white precipitate (of barium sulphate) if sul- phuric acid be present. 3. Sulphurous acid decolorises a solution of iodine with formation of hydriodic and sulphuric acids, thus SO,+2H,O+I,=H,SO 4 +mL 3.2 gr. sulphurous acid neutralize 12.7 iodine. Of the gas, 1 part in 100,000 of air is perceptible to the nose; 9 parts are disagreeable and provoke cough ; 20 parts are irritating, and 43 parts (=4 parts in 10,000) are irrespirable: much less than this will kill plants (Letheby, loc. cit.). In generating it by burning sulphur in air, 32 parts by weight combine with an equal quantity of oxygen to produce 64 parts of sulphurous anhydride, which occupy precisely the same bulk as the oxygen consumed. Its density is high, the sp. gr. being 2.247; a cubic foot weighs about 1,206 gr., and to produce it 603 gr. of sulphur and a cubic foot of oxygen (=5 cubic feet of atmospheric air) are requisite (Letheby: Medical Times, ii., 1873). Alkaline sulphites and hyposulphites owe their properties to the sul- phurous acid liberated from them, and although not officinal are often prescribed. Sodce Sulphis Sulphite of Soda. Prepared by saturating a solution of carbonate of soda with sulphurous acid gas, and crystallizing. It oc- curs in white efflorescent prisms which have a slight alkaline reaction, and the odor and taste of sulphurous acid ; soluble in cold water (1 part in 4), and in less than 1 part boiling water. Sodce Hyposulphis Hyposulphite of Soda (Appendix B. P.). Pre- pared by gently warming a solution of sulphite of sodium with finely- powdered sulphur, or by passing sulphurous acid gas through it. Occurs in colorless crystals (oblique rhombic prisms); bitter, slightly alkaline, and sulphurous in taste, less unpleasant than the sulphite. Very soluble in water, not in alcohol; decolorises iodine solutions, and dissolves salts of silver which are commonly insoluble, e.g., the chloride. A solution of hyposulphite is distinguished from one of sulphite by the precipitation of sulphur on adding sulphuric acid. Hyposulphites do not act on iodide of potassium. Potasses, Sulphis Sulphite of Potash. Prepared by saturating a so- SULPHUROUS ACID. 235 lution of potash carbonate with sulphurous acid gas, and crystallizing 1 . It occurs in white opaque fragments or powder, with slight odor of the gas very soluble in water (1 in 3). Taste saline and sulphurous. Magnesioe Sulphis Sulphite of Magnesia. Contains proportionately more of the acid (gas) than any other; it is also the most soluble, and the least unpleasant (Polli). Golds Sulphis Sulphite of Lime. Is soluble only in 800 parts wa- ter, but the bisulphite and hyposulphite are freely soluble. ABSORPTION AND ELIMINATION. Sulphurous acid is readily absorbed, and its characteristic odor has been observed in the breath and secretions after its administration (Dr. George Wilks: British Medical Journal, ii., 1870). It passes out also with the urine and fseces as sulphate or sul- phuric acid, for it is readily oxidized in the system. The sulphites are decomposed in the stomach by the gastric acid, sul- phurous acid is given off, and they are mostly changed into sulphates (Kletzinsky), and are eliminated as such, partly by the intestinal canal, but chiefly by the kidneys (Bartholow); they pass within twelve to twen- ty-four hours after administration (Polli). The hyposulphites undergo similar changes, but more slowly, for they are more stable. After very large doses, these salts may be found unchanged in the urine (Rabuteau), and, after their application to wounds, free sulphuric acid may be traced in the same secretion (De Ricci). PHYSIOLOGICAL ACTION (EXTKBNAL). Externally applied, sulphurous acid is refrigerant, somewhat astringent, and in full strength irritant. The most important property of the gas and its compounds is that of ar- resting fermentation, and of destroying the lower forms of vegetable and animal life, and certain infective organic poisons. Its power of controll- ing ferments and destroying visible parasites is readily proved, but its action on infectious organic particles a true " disinfectant " action, by which they are rendered inert is not so capable of demonstration, because the poison itself, the essence of infection, has not yet been verified and isolated; still, as Dr. Sansom observes, "we know that such poison is ponderable, that it obeys physical laws, and is active for long periods, though so minutely divided as to be undemonstrable by ordinary direct physical means " (British Medical Journal, ii., 1872). The diffusion-ex- periments of Chauveau and Sanderson have proved, at least for vaccinia, variola, and sheep-pock, that the poison is solid, insoluble, -and indiffusi- ble; and, to judge from its effects, its extraordinary power of multiplica- tion, etc., either it must have some properties of living matter, or act by a process of catalysis or fermentation : the former seems more likely, but however it be, if we make evident that sulphurous acid can prevent or arrest the development of the bacteria, monads, and germs of fungi, etc., which accompany decomposition, it is by analogy probable that it can 236 MATERIA MED1CA AND THERAPEUTICS. exert a similar effect on the minuter particles which constitute infective poison. In proof of the former fact, among other experiments, Dr. San- som placed cubes of egg-albumen under glass covers with solutions of permanganate, of aluminium chloride, of carbolic and sulphurous acids; and, with the two latter agents, notably with the last, secured almost complete preservation, even after the admission of air (British Medical Journal, loc. cit.). For aerial disinfection, Hoppe-Seyler, after careful trial, found sulphurous acid gas the best agent, 1 or 2 per cent, of it in the air of a room destroying all the lower organisms: this could be secured by burning to 1 dr. of sulphur for each 100 cubic feet of space (Lancet, ii., 1871, p. 304). Letheby arrived at similar conclusions, but recommended, for greater security, a larger proportion of sulphur 1 oz. to each 100 cubic feet of air (Medical Times, ii., 1873). Dr. Baxter, taking up the same question from another point of view, concluded not only that sulphurous acid was the best of aerial disinfect- ants, but that its action on vaccine virus was more potent than that of chlorine or carbolic acid. Thus he vaccinated one arm of a child with points of virgin lymph, and the other arm with points previously exposed to the action of the three agents, and while small vesicles often resulted after the use of chlorine or carbolic acid, none could be obtained after sulphurous acid, "even under conditions which seemed to render the vir- ulent particles least susceptible to destructive influences " (" Sixth Report of Medical Officer Privy Council," N. S., and Lancet, i., 1876). It is true that Dr. Dougall had found sulphurous not so effective as other mineral acids (notably chromic acid) in preventing the decomposition of organic solutions, but Grace Calvert showed this was not correct, and 1 part of the former in 1,000 of albuminous solution was enough to preserve it for forty days, while other acids only preserved it for nine or ten days. Dr. Fergus also compared glasses of beef extract heated with sulphurous acid, carbolic acid, and terebene, and found several weeks afterward that the one heated with sulphurous acid remained quite sweet while the others were decomposed (Practitioner, i., 1877). PHYSIOLOGICAL ACTION (INTERNAL). From the preceding and many other observations, there can be no doubt of the disinfectant power pos- sessed by sulphurous acid in a very high degree when brought into direct contact with infective or putrescent material, whether in the air, or in wounds, etc., but the further question whether it can be so introduced in- to the circulating blood of living animals as to neutralize a septic poison therein also circulating, or so as to prevent the admission of such poison, is more difficult to resolve. Dr. Polli (Milan) held the affirmative to be proved by his experiments upon dogs with sulphites and hyposulphites; f after treating an animal with these medicines, he injected septic poison, and found it did not succumb to the effects, while a healthy but untreated SULPHUROUS ACID. 237 animal quickly did so. In other cases, examining the bodies of animals killed after sulphite treatment, they were found to decompose much less quickly and less readily than others not so treated. He offered, also, some clinical evidence of the value of these remedies in septicaemia, and much practical benefit was expected from his observations; they have not, however, yet passed the region of controversy. Semmola, O. Weber, and others, deny them, or characterize them as " negative." Clinical re- sults differ, and although I hold that much may be done by introducing "disinfectant" medicines, especially sulphurous acid, into the organism, I acknowledge that definite proofs of their power and mode of action within it are still to be desired (v. p. 243, also Carbolic. and Salicylic Acids). Digestive System. Sulphurous acid solution may be taken internally in moderate doses and well diluted without definite effects on the healthy body, unless it be the quenching of thirst and some refrigerant action. Insufficiently diluted, the solution excites local irritation of the digestive tract, some persons being more sensitive to this than others. The sul- phites and hyposulphites in large doses increase peristalsis, and cause purging, though not so readily as sulphates. Temperature. Given during the pyrexial state, e.g., of remittent fever, sulphurous acid is said to lower the body-temperature. SYNEKGISTS. Disinfectants and antiseptics generally, aid the action of sulphurous acid, but it is so readily oxidized that it is better used alone. Steam favors the aseptic action of the gas, and nitre added to the burning sulphur makes it more effective (Dewar). ANTAGONISTS. All oxidizing substances alter the chemical constitu- tion of sulphurous acid, and impair the peculiar properties of sulphites, especially when in solution. The mineral acids, including sulphuric, de- compose sulphites and hyposulphites. THERAPEUTICAL ACTION (EXTERNAL) . Parasitic Skin Disease Favus Ringworm. Sulphurous acid solution is a cleanly and efficient mode of treating these maladies, as first pointed out by Sir William Jen- ner (Medical Times, ii., 1853, p. 181). It may be painted on occasionally in full strength, or used in lotion or compress, 1 part to 2 or 4 of water and glycerin the great point is to secure its thorough contact with the diseased surface. Pityriasis Versicolor ( Chloasma). A weaker lotion than the last- mentioned, 1 part in 8, or one containing sulphite or hyposulphite of soda ( 1 j- i n v "j-) w ^ cure ^is disorder. Pruritus Vulvce, etc. When pruritus is dependent on discharge, or other source of irritation, possibly parasitic, injections and lotions con- taining " bisulphite of soda " (gr. xv. ad j.) have been found serviceable (Lancet, ii., 1871, p. 454). The itching of lichen and of true prurigo senilis may also be relieved by lotions containing sulphites. 238 MATERIA MEDICA AND THERAPEUTICS. Erysipelas. A sulphurous lotion will often give great relief to the burning pain of erysipelas, and its constant application is said to cut short the malady. Dr. Hewson records twenty-seven cases of various degrees of severity seven of them idiopathic, and all treated by the local ase of a sulphite lotion (sodse sulphitis gr. x. ad 3 j.) applied on lint covered with oiled silk; it bleaches the skin and " destroys the inflamma- tion " (Philadelphia Medical Times, i., 1868). Mr. Pairman describes great and immediate relief to pain in a severe case of facial erysipelas from a lotion of equal parts of glycerin and sulphurous acid: the patient recovered at the end of a week, but tincture of steel and other remedies were given internally; relief, however, was clearly traceable to the lotion, and it deserves to be more generally used than it is at present. Chilblains Corns Fissured Nipples, etc. For these minor, but an- noying ailments, sulphurous acid is a good remedy. Mr. Pairman applies the strong solution of the acid on lint covered with oiled silk: if the skin be broken, the acid should be diluted. Sore nipples are to be "soaked well with strong acid for a few times" (Pamphlet: "The Great Sulphur Cure," 13th ed., 1868). Mr. Fergus applies the acid in spray to chilblains, or uses as a wash 3 parts of the solution to 1 of glycerin and 1 of water (Lancet, ii., 1870, p. 769). Bruises Sprains. The same surgeon, who speaks from good expe- rience at Marlborough College, has found a lotion containing sulphurous acid very useful in " every kind of bruise and sprain." He recommends a spray of pure acid for six or seven minutes till the part feels cold, then lotion (1 in 8) to be applied and frequently changed; in forty-eight hours inflammation and pain have subsided, and on the third or fourth day the limb can be strapped or bandaged. Wounds Fractures. Mr. Fergus records also excellent results from the acid used in lotion to a compound fracture and to a severe contused wound of the face (where it is always important to avoid scarring): under a lotion of 1 part in 7 constantly applied, the wounds healed quickly and without suppuration. Dr. John Balfour has had marked success with a lotion (1 in 12) applied on thin rag kept constantly wet for the first day or two after injury, afterward wetted every twelve hours with tepid lotion kept covered by oiled silk, zinc ointment being substituted about the third or fourth day. Severe compound fractures of the hand with laceration of tendon, and gunpowder burns, fractures of the shoulder and other joints by machinery all did well under this treatment, which seemed to give almost instant relief from pain, to control and greatly re- strain suppurative action, and secure primary union whenever possible. (Edinburgh Medical Journal, June, 1869, November, 1871). Mr. Pair- man notes its value in quickly curing a " hack " in horses. Ulceration Gangrene. In cases of unhealthy open wounds, and even hospital gangrene, sulphurous acid has sometimes proved more SULPHUROUS ACID. 239 efficacious than carbolic; this was especially seen in hospitals at Metz during the Franco-Prussian war (Medical Times, ii., 1871, p. 358). Angina. In various forms of sore throat, sulphurous acid in gargle, or preferably in fine spray, is exceedingly useful, relieving pain, lessening inflammation, destroying parasitic growth, and cleansing unhealthy sup- purating surfaces. It is, in my experience, of great value in aphthous conditions such as occur during phthisis or other exhausting diseases, as well as in the ordinary form common during infancy; it often relieves the pain, tension, and ulceration of scarlatinal and variolous throats, and I have seen it of the greatest service in chronic syphilitic ulceration of the fauces. In the acute inflammatory stage of catarrhal angina, it is not always well borne, but will be found to answer better in such cases when used of full strength, if only for a very short time, than if diluted; in the latter case, it has seemed to irritate the mucous membrane without controlling in- flammation, but there is no one rule, a short trial will be the best guide; young children do not usually bear it well. Fergus, on the other hand, says it is good "in all forms of inflammation of the throat and tonsil;" it should change the turgid redness to a light pink during the applica- tion. Dysphonia Clericorum Follicular Pharyngitis. Dr. Dewar has pub- lished cures of this condition, so rapid and after so many years' duration of the malady, as to border on the marvellous. One clergyman, a sufferer for twenty years, found immediate relief from the spray " something loose, feeling braced up;" and others suffering also from general weak- ness, night-sweats, nervousness, partial aphonia, etc., are said to have been restored by sulphur fumes and spray. The cases are described in popular language rather than with scientific accuracy, but we may accept the fact of much relief being afforded in the class of maladies referred to (Medical Times, i., 1867, p. 545). Catarrh Hay Fever. A sulphurous acid spray applied to the nos- trils often relieves the annoying symptoms of both these maladies. Sul- phur-fumigation is also said to 'have cured them quickly (Dewar, Pair- man), but this cannot always be depended upon (McGregor: Edinburgh Medical Journal, October, 1869). Chronic Bronchitis. The spray is sometimes a useful adjunct in the treatment of this condition; it acts as a stimulating expectorant, thin- ning the tough viscid phlegm; sulphur-fumigation is also good (Fergus). It will not, however, accomplish the wonders at one time expected from it, and should be commenced cautiously. Asthma. In this capricious malady, sulphurous sprays and fumiga- tions have been tried, and apparently with advantage, but more often with marked increase of irritation; as a rule, other remedies relieve more. Phthisis. Dr. Dewar has recorded a remarkable case in the person of 240 MATERIA MEDICA AKD THERAPEUTICS. a groom advanced in phthisis, with emaciation, cough, sweatings, haemop- tysis, etc., and apparently in a hopeless condition, who conducted sul- phur-fumigations for cattle (y. p. 242), remaining with them in the sheds "with the most wonderful benefit to his own health: within one week the night-sweats had ceased, his cough abated, and expectoration dimin- ished; he gained weight nearly two stone in four months: is now de- pendent for his life on one lung only, or nearly so, but with the exception of being somewhat short-winded, looks nearly as strong and as able for ordinary work as before his illness" (Pamphlet: " On the Application of Sulphurous Acid Gas," 1866). He reports four other cases of " chronic phthisis" equally benefited; and Mr. Pairman corroborates his observa- tions; they deserve careful consideration, but up to the present there has been little further trial of the method. It was thought that the sulphurous spray would be of great service in the relief of phthisical symptoms, but I have not seen lasting or im- portant results from it, though it facilitates expectoration and lessens laryngeal irritation. Fumigation in Infectious Disease, etc. The burning of sulphur for the prevention or cure of infectious disorder long preceded any modern scientific inquiry. The Chinese esteemed it highly in prehistoric times. Ulysses, according to Homer, employed it to disinfect his palace after slaughtering the suitors, calling it " the remedy of all evils, and cure of all sores " (" Odyssey," Book xxii., line 481, etc.). Ovid praises it in the " Fasti," and Pliny in his " Natural History; " but it is within quite recent years, and since the recognition of a " germ theory " in disease, that the systematic use of sulphurous acid, within, as well as without, has been placed upon a logical basis or fairly pressed upon the profession as a method of treatment. When cattle plague was epidemic, Dr. Dewar found the best results from fumigating cattle sheds with sulphurous acid. His own cattle never suffered, and " a large dairy, notorious for thirty years for mortality among its cows (from pleuro-pneumonia), and which for eight years of the then tenant's occupancy had never been free from disease for a month, in which sixteen cows had lately died, the last, three days before fumigation began; this dairy from that time till the date of writing had been perfectly healthy." He states also that "an epidemic of diphtheria was cut short by it; two cases having occurred in one house within twenty-four hours, and no others after sulphur-fumigations." Mr. Pair- man reports similar experience, but it must be said that neither author, however earnest and truthful in reality, writes in such a manner as to convince the profession, and hence, perhaps, they have not yet widely in- fluenced ordinary practice. The variola epidemic, arrested on the coast of Iceland by Dr. Hjalte- lin, seems to me admissible evidence of the value of the gas, though even SULPHUROUS ACID. 241 "s, this arrest has by some been attributed to the quarantine and isolation enforced. Twenty-two cases were brought on shore from the fishino- vessels; seven were confluent; only one died (moribund on admission); in no instance did the disease spread. A workman emploved in the hos- pital did not catch small-pox, although shortly after he proved suscepti- ble to vaccination; in every case the attack was quickly and favorably modified: results which may fairly be connected with the treatment constant use of sulphur fumes in the air, and the giving of sulphurous so- lution internally (British Medical Journal, ii., 1871). (An epidemic of small-pox in the last century 1707 destroyed one-fourth of the popula- tion of the same country). Dr. A. W. Foote, during the last epidemic of variola in Dublin, en- deavored to carry out a thorough disinfectant treatment in his wards at the Meath Hospital, giving sulpho-carbolates as well as sulphurous acid, applying the latter locally, and burning sulphur three or four times a day; he treated 59 cases, of which 24 were confluent, 6 semi-confluent, and 11 died, and he concluded that the treatment was of value, and that sul- phur vapor acted " as a prophylactic," but was irritating to bronchitic subjects. This fact is important, for in confluent small-pox, laryngitis is a frequent and serious complication (Dublin Journal and Medical Times, April, 1872). On the other hand, we have to note unsatisfactory results from the use of similar treatment during an epidemic at Trinidad. Dr. Bakewell, though riot furnishing many details, states that he treated twenty-five patients with sulphur-fumigations and sulphurous acid, apparently " with- out any effect " ( Medical Times, L, 1872). The experience of Mr. Fergus as to disinfection after an epidemic of scarlatina is very favorable: upwards of 4,000 blankets and other articles of infected bedding and clothing were exposed thoroughly for four hours to the fumes of burning sulphur, "with complete success" (Practitioner, i., 1877). He is accustomed to depend on a short personal exposure to sulphur fumes after visiting an infectious case, and has never conveyed infection in his own person. He lays stress upon an important point, in- attention to which might possibly account for some failure: the vapor should be used at intervals for half to one hour at a time, and at its full strength, rather than by being constantly given off at low tension the latter method is apt to be ineffective, as well as more likely to give rise to unpleasant sulphur combinations. The acid bleaches vegetable colors, and corrodes metals, etc., but not so markedly as to cause inconvenience in practice. The pernicious effect on human air-passages, formerly attributed by high authorities to effect- ive sulphur vapor has been quite disproved. Dr. Angus Smith says, "This acid gas is an irritant, and causes coughing, which becomes painful and dangerous according to the amount used, and as it is destructive to VOL. I. 16 242 MATEKIA MEDICA AND THEKAPEUTICS. animal structures it does not seem advisable to use it more than can be avoided" (On Disinfectants): such an opinion lias doubtless told against its use, but after the observations of Dewar, Pairman, Fergus, and others, must now be modified. Cholera. The burning of sulphur fires round infected villages has been strongly urged (Tuson: Lancet, ii., 1876, p. 313). Mode of fumigating with Sulphurous Acid Gas. Dr. Dewar, refer- ring more particularly to the process as applied for cattle plague, recom- mends as the safest and most convenient apparatus, " a chaffer two-thirds full of red cinders, a crucible inserted therein, and a piece of sulphur stick " "a piece " the length of a man's thumb will burn for twenty min- utes and be sufficient for a shed containing six cattle, and if ventilation be free at the same time, a man can remain without the least risk of de- triment this is repeated three or four times daily. Its efficacy is in- creased by simltaneous steam-fumigation, and if only " inanimate ob- jects " are to be disinfected, nitre may be added to the sulphur, and thus some sulphuric acid generated (Pamphlet, pp. 7-21). For phthisical and other patients, the room is simply filled with fumes three times a day. Mr. Pairman places half a teaspoonful of sulphur on paper on a shovel and ignites, repeating this process every twenty min- utes till the patient has had one or two hours of fumigation; the head should not be held too near, nor the furnes made so strong as to excite much coughing. He is in favor of keeping " mild sulphur fumes almost constantly in the sick room," but the occasional and temporary use of a full dose is to be preferred. Dr. A. W. Foote " used " flowers of sulphur dropped on a heated shovel, and carried about the room, and this is quite under control and readily borne by patients unless bronchitis or asthma renders them unusually sensitive. From 1 to 2 dr. will be an average quantity: it is scarcely necessary to make an exact calculation. If a room is to be thoroughly disinfected in the absence of inmates, the doors, windows, and other apertures should be closed pasting paper over chinks is sufficient colored clothes removed, and metal protected by grease or otherwise; then sulphur should be burnt in quantity propor- tioned to the space, taking Letheby's estimate of 1 oz. for each hundred cubic feet, or more roughly the proportion of |- Ib. for a large room (Fergus). If dried and finely powdered, it will burn when lighted, and may be conveniently placed in a small earthern jar standing in water: mixed with -fa part of its weight of powdered charcoal it burns, perhaps, more readily, and will not melt and run over the charcoal will be uncon- sumed (Fergus). If this mixture be placed on an iron plate two feet square it will be safe, though for precaution some would put the plate or vessel over water. After an hour's fuming, a free current of air should be ad- mitted for several hours before occupying the room. Mr. Keates, the chemist, has suggested the burning of bisulphide of carbon as a conve- SULPHUROUS ACID. 243 nient means of obtaining gaseous sulphurous acid, for much more of this gas is given off than of carbonic acid especially is this the case if petro- leum be mixed with it. In a room of 1,300 cubic feet} 280 gr. bisulphide charged the air so efficiently with SO 3 that one could not remain in it, and a lamp has been contrived to burn a graduated amount (Lancet, ii., 1876, p. 712). It is said too that the offensive smell of bisulphide is got rid of in the purer preparations (Price & Co.), but still it remains highly inflammable, and the method seems more dangerous and more complex than simple sulphur burning. THERAPEUTICAL ACTION (!NTEBXAL). Following up the observations already mentioned as to the effect of sulphites upon dogs, Prof. Polli de- vised a special method of treating " zymotic " diseases the " anti-fer- mentative, or anti-zymotic method," which aimed at prophylaxis by sat- urating the blood with these remedies. The method made progr^s in Italy, Spain, and France, not much in Germany, and lately it has lost ground even in the former countries (Nothnagel); still I think that with modifications it has a future before it, and will mark a distinct advance in rational therapeutics. It is applied not only to the specific fevers, cholera, intermittents, and the like, but also to pyaemia and septicsemia generally. Septicaemia. Dr. Polli, Dr. De Ricci, and others, have recorded cases of pyaemia, phthisis with suppuration, chronic empyema, etc., benefited by sulphites. Mr. Spencer Wells traced improvement in septicaemia uterine cases to the use of hyposulphites (Medical Times, ii., 1864). McCall Anderson cured eruptions of furunculi with -dr. doses of sul- phite of soda (Lancet, i., 1870, p. 897), and Dr. Ricci, chronic pemphigus with sulphite of magnesia (Dublin Journal, vol. xxxvi.). Dr. C. B. Rad- cliffe, when suggesting the use of the same salt in cattle plague, states that he has seen good results from it in fevers (Lancet, i., 1870, p. 897). Snow Beck used frequent vaginal injections of sulphite of soda in puerperal fever, and gave internally the sulphites of lime or magnesia, and advocated this treatment as better than any other (Lancet, i., 1865, p. 340). Sulphite of soda in 2-dr. doses daily (readily taken in beef-tea) proved valuable in pyaamia in the Liverpool Infirmary (Medical Times, ii., 1868, p. 336), and Dr. Miller, while reporting the hyposulphite inef- fectual in typhus, found it distinctly of service when given early in sep- ticsemic cases connected with parturition (Edinburgh Journal, September, 1869). This is not a large amount of evidence, and, though more might be collected from foreign sources, it would not be enough to place this medication yet on an assured basis, but considering how serious a condi- tion is in question, it well deserves further inquiry. Of course, if blood- poisoning have reached beyond a certain point, recovery is not possible under any treatment, and if the salts employed be not fresh and pure, 244 MATERIA MEDICA AND THERAPEUTICS. failure also will result; irritation of stomach and intestinal tract may also hinder their employment, and I think that sulphurous acid is really a bet- ter form to employ than its alkaline compounds; but whichever be chosen should be early and thoroughly given. There is no objection to combin- ing this medication with the internal use of aconite, and with all recog- nized remedies to promote elimination. Variola. We have already stated that in the hands of. Dr. Hjaltelin and Dr. A. W. Foote, the internal use of sulphurous acid solution in small- pox was combined with the external application of the gaseous form, and, so far as could be judged, with good effect. The secondary fever of this malady is due to absorption from the pustular eruption, and this ought to be influenced by the early employment of such remedies, and I believe is so influenced. In one exceedingly severe case of confluent small-pox, considered hopeless by a good practitioner, the patient was enabled to take -dr. doses of sulphurous acid every hour or two, and within a short time showed signs of improvement, which went on to complete recovery, not in accord with the normal rate of progress in such cases. To vario- lous pustules maturating the acid with glycerin is a good application. Erysipelas. The relief given by the acid spray in erysipelas by Dr. Hewson and Mr. Pairman has been already noted, but the internal use of the remedy may be well conjoined with the external. In the case of an infant living under unhealthy conditions, and in whom a severe attack of the idiopathic malady affected one arm and leg, the pudenda and head, and when iron had no control over it, the internal use of sulphurous acid seemed the cause of improvement which very quickly followed. Diphtheria. Under sulphur it has been stated that the local applica- tion of that 'remedy is not desirable (v. p. 30), but sulphurous acid acts very much better, and is, as a rule, well borne, and even liked by the patient. Dr. Dewar and Mr. Pairman used it rather in fumes and spray or gar- gle, and conjoined with it iron or chlorate of potash. Dr. Joyce (quoted by Dr. Geo. Johnson, Lancet, i., 1875, p. 82) had the best results from the same practice (with iron). Fergus depends on the acid with ice only, and other observers have had satisfactory results from the salts: thus Dr. Hayden from the hyposulphite (Dublin Quarterly, August, 1866). I think the local application of the acid in spray highly desirable. Enteric Fever. While recognizing the difficulty of a true judgment about the effect of medicines in this fever on account of some uncertainty in its natural course and duration, and of the usual recoveries indepen- dently of any specific treatment, yet I must state my conviction that its course may be favorably influenced by the internal use of sulphurous acid, if commenced early enough. I know that many of the highest authorities have taught that the fever-poison having once been received must pass through certain changes before elimination, and that the best SULPHUROUS ACID. 245 practice is mainly, intelligent nursing; but careful observation of many enteric cases has led me to the conclusion that in some instances, under the influence of the administration of sulphurous acid or the sulphites the attack has been shortened, and in others, high temperature and pro- fuse diarrhoea have been relieved, coincidently with improvement in the general symptoms. In some advanced cases, with muttering delirium, sorcles, and signs almost of dissolution, a favorable change has occurred shortly after commencing the acid treatment. Of thirty-six consecutive cases thus treated by Dr. Mackey, several illustrated these points, and none died. Special advantage from the acid is not claimed on the score only of the number recovered, for equal results have been recorded from other methods: the number is still too small to justify positive conclu- sions, but the impression made on^ my own mind as to the value of the acid is highly favorable. It is true that sometimes unusual or persistent vomiting interferes with its administration, and the drachm or two-drachm doses recom- mended cannot always be given: 10 to 30 drops has been an average dose for an adult, when repeated every two to four hours, and when urgent bronchitis contra-indicates this remedy, for a time expectorants and diaphoretics must be substituted. Several years ago, Dr. Hamilton (Liverpool), treating his last eight cases of an epidemic of typhoid with sulphurous acid, " was struck by the mild form assumed, and apparent cut- ting short of the fever." They were typical cases at the commencement five children, three adults and the dose was from 1 to 3 dr.; they were generally better on the second day, and by the fifth day improvement had set in (Lancet, i., 1869, p. 45). Dr. George Wilks, of Ashford, refers to 171 cases of enteric fever treated by him with sulphurous acid, and all end- ing in recovery, some under very unpromising conditions; thus he instances a poverty-stricken child of four years, with violent vomiting, purging, tym- panitis, and delirium, who could not have ordinary care and attention; a woman of seventy -three equally neglected; and a man of fifty-four ap- parently dying under ordinary treatment of astringents, etc., and yet rapidly recovering after commencement of the acid treatment (British Medical Journal, ii., 1870). The patients took from 2 to 20 drops with syrup and water every four hours for many days, until they showed am- ple evidence of the absorption and elimination of sulphur. Dr. Skinner reports twenty cases of enteric fever treated by sulpho-carbolate of soda (with one death). Dysenteric Diarrhoea Cholera. Dr. Scoffern writes recommending the sulphite of lime in choleraic diarrhoaa (Lancet, ii., 1866, p. 279), but it has not been much used. On the hypothesis of cholera being dependent upon the absorption of organic poison, sulphurous acid ought to prove of some service in its treatment, more so than the sulphites and hyposul- phites, which are slower in action and liable to irritate. Professor Gra- 246 MATEBIA MEDICA AND THERAPEUTICS. ham, indeed, first introduced the solution of sulphurous acid to Sir Wm. Jenner as a possible remedy for cholera, but it has never received full trial. A main difficulty, as regards any remedy in cholera, is to secure its absorption, all vital function being annihilated with such fearful rapidity: hence we can never hope for the same results as in enteric fever, but sulphur fumes should certainly be used as disinfectant and prophylactic. It has been pointed out that workers in copper, and in powder fac- tories (at Madras especially), have shown special immunity in cholera epidemics, and although Dr. Burq claims specific virtues for copper in this respect (v. Cuprum), the presence of sulphurous acid is a more likely explanation (Lancet, ii., 1873). Ague. The hypothesis of ague being dependent upon the absorp- tion of minute fungi or spores given off by the soil of malarious districts has been forcibly maintained by H. Schmidt, Salisbury, and others, who have even reported the finding of such microscopic organisms in the blood and secretions of patients, and in the neighboring marshes (Lancet, ii., 1867, p. 588). Evidence in favor of this theory seems furnished by such instances as that of the ship Argo, which took on board for (water sup- ply to) a band of soldiers, water from a malarious district, and almost all who drank of it got intermittent fever, while the sailors of the same ves- sel, who had a different water supply, did not suffer (Lancet, loc. cit). Still, the hypothesis is not proved, and clinical evidence as to the value of sulphite treatment is contradictory thus, while Sanger refers to four cases of intractable ague, soon relieved and ultimately cured by scruple doses of hyposulphite of soda (Lancet, i., 1869), McClean criticises the result, and notes that quinine and other remedies had been previously used, and that it it is well-known quinine often does not cure, unless a blood depurant, such as potash or soda first be given, and moreover many cases in the Mauritius were treated by the sulphites without effect, and were afterward cured by quinine (Lancet, i., 1869, p. 511). Several American writers have reported the cure of intermittents by hyposul- phites after failure of quinine (Ranking, Abstract, ii., 1868, ii., 1870), but Farelli, from an exhaustive analysis of the recorded evidence, con- cludes that their good effect is neither so quick nor so constant as that of the latter; they are not prophylactic, and their continued use leads to anaemia: he holds that their action, such as it is, " is reductive, not disin- fectant " (Abstract, Lancet, i., 1873, p. 634). Syphilis. Several writers, chiefly American, have strongly recom- mended the internal and external use of the sulphites in the later stages of syphilis (Ranking, ii., 1868). I have had no occasion to prescribe them, but have found the acid locally applied most useful in throat and other ulcerations. Dr. Purdon has recorded an illustrative case (British Medical Journal, i., 1868). TARTARIC ACID. 247 Pyrosis Sarcinous Vomiting. In these conditions, which are clearly dependent more or less upon fermentations or the presence of low or- ganisms, the influence of sulphurous acid and its compounds ought, d priori, to be clearly shown, and so practically \ve find it, for sulphurous acid in -dr. doses is one of the best remedies that can be given. Sir William Jenner was one of the first to point this out (Medical Times, ii., 1853), and Dr. Henry Lawson, one of the first to secure for it the atten- tion of the profession (Practitioner, vol. i.). C. Drysdale also early recorded a case rapidly relieved by this treatment after failure of bismuth, prussic acid, etc. (Lancet, ii., 1869). Other physicians have succeeded with the hyposulphites (Medical Times, i., 1853), and even with sulphites, and if Dr. Lawson found no benefit from these, as compared with the acid itself, it was probably because his dose was but small: the hyposul- phites, however, must deposit sulphur, and as a rule, the acid will be found best. PREPARATIONS AND DOSE. Acidum sulphurosum : dose, to 1 fl. dr., diluted. For external application the solution may be used in full strength, or diluted with equal parts of glycerin and water, or as a lotion 1 part in 8. Sodce sulphis : dose, 20 to 60 gr., freely diluted: as a lotion (anti- parasitic), 1 part in 8: as an injection, etc., 2dr. to -J oz. in 8 oz. of fluid. Sodcv hyposulphis : dose, 20 to 60 gr. Calcis sulphis : dose, 10 to 20 gr. Magnesias sulphis: dose, 10 to 30 gr. Potasses sulphis : dose, 10 to 30 gr. [All the foregoing, except Calcis sulphis and Magnesias sulphis, are officinal in the U. 8. Pharmacopoeia.} ACIDUM TARTARICUM-TAKTARIC ACID, H 8 C 4 H 4 O. (or . H,T),=150. An organic acid very widely diffused: it occurs in fruits partly in the free state, and partly combined with potash or lime. PREPARATION. From "cream of tartar" acid tartrate of potash which is derived from grape-juice. The process of preparation involves three distinct reactions: (it is a favorite test-question at examinations). 1. The salt having been boiled with sufficient water, prepared chalk is gradually added, and an insoluble tartrate of lime is formed and pre- cipitates: but tartaric acid is dibasic, and the other equivalent of basic potash remains in the solution as a neutral tartrate (K a T). 2(KHC 4 H 4 6 ) 4- CaC0 3 = Ca0 4 H 4 6 + K S C 4 H 4 O,,+ CO, + H,O. 2. To precipitate this element of tartaric acid also as tartrate of lime, solution of chloride of calcium is added, giving rise to formation of chlor- ide of potassium, and precipitating the tartrate of lime. K,C 4 H 4. + CaCl, = CaC 4 H 4 6 + 2KC1. 3. The tartrate of lime, having been washed, is decomposed by sul- 248 MATERIA MEDICA AND THERAPEUTICS. phuric acid, which precipitates an insoluble sulphate, tartaric acid being left in solution. CaC 4 HA+H,S0 4 =H,C 4 H 4 0.+CaS0 4 . CHARACTERS AND TESTS. Tartaric acid occurs in fine white powder, of strongly acid taste, or in large colorless oblique rhombic prisms, which become luminous in the dark on friction. While dry, these are perman- ent in air, but an aqueous solution becomes mouldy on keeping, with for- mation of acetic acid (a change which may be prevented by the addition of some rectified spirit). A usual test for tartaric acid in solution (not too dilute) is the formation of a crystalline white precipitate of tartrate of potash on the addition of acetate of potash. Solutions neutralized by an alkali also give with chloride of calcium a white precipitate of tartrate of lime soluble in cold liquor potassse, but falling again when heated. Tartaric acid may be added to bicarbonate of potash to saturation with- out any precipitate, but if the bicarbonate be added to the acid, bitartrate is at once formed and precipitates (Squire). ABSORPTION AND ELIMINATION. Tartaric acid, in moderate doses, is readily absorbed, but we do not exactly know what changes it undergoes in the system. That it combines with earthy bases is probable, for Woh- ler found it in the urine (by which secretion it is eliminated) in the form of tartrate of calcium (Medical Times, ii., 1845). Dragendorff, Buchheim, and Pietrowski found only a small amount in the urine, and conclude that the greater part is oxidized in the body. PHYSIOLOGICAL ACTION (EXTERNAL). On the skin, concentrated sol- utions of tartaric acid produce temporary irritation and burning. PHYSIOLOGICAL ACTION (INTERNAL). Digestive System. Small doses have a cooling taste and quench thirst, but, if continued, may irritate the stomach, and large doses cause purging. Very large quantities have toxic effects, though not of so severe a kind as those of oxalic, or even of citric acid (Husemann). A fatal re- sult is very rare, but Taylor records one in which death followed nine days after taking 1 oz. of tartaric acid in solution: the symptoms and ap- pearances were those of gastro-enteritis. In other cases the mucous membrane of the stomach and the intestines has been found either white (not inflamed) or ecchymosed, with partial softening. Circulatory System, etc. Bobrick reported weakening and slowing of the heart-action in frogs, rabbits, and men, after large but non-toxic doses; the vagus nerve was not concerned in this effect (Husemann: Arzneimittellehre, ii., 894). According to Mitscherlich, rabbits die from doses of 3 to 4 dr. with symptoms of adynamia, weakened heart-action, and difficult respiration; the blood is found fluid, in some cases light, in others dark-red. Bence Jones found tartaric acid increase acidity of urine, and lead to excretion of uric acid in a free state (Lectures, 1867). AMMONIA GAS. 249 SYNERGISTS. Citric and other vegetable acids. INCOMPATIBLES. Alkalies, salts of mercury and lead, and vegetable astringents are incompatible. Lime and magnesia are the best antidotes. THERAPEUTICAL ACTION (EXTERNAL). Fetid Perspiration. Schottin states that tartaric acid relieves this unpleasant condition, and I can cor- roborate the observation. For the feet it may be used sprinkled in the stockings, or these may be washed in a strong solution. The powder may also be rubbed into the axillae, with the caution that if irritation be pro- duced it must be replaced by some soothing powder. THERAPEUTICAL ACTION (INTERNAL). This acid, dissolved and sweet- ened, is sometimes used as a refrigerant drink; and it exerts a slightly sedative effect on the circulatory system. It is sometimes used in place of citric acid, but is not so pleasant to the taste, nor so well borne by the stomach. Of seidlitz powders, the " white paper " contains about 35 to 40 gr. of this acid, which, when dissolved and mixed with the same quantity of soda bicarbonate and 120 gr. of tartarated soda (the contents of the " blue paper"), forms a sedative, refrigerant, and slightly aperient draught. Annesley considered tartaric acid of service in excessive secretion of mucus by the stomach or intestine. In cases of ammoniacal urine with cystitis from calculi, prostatic disease, etc., I have often found it relieve the symp- toms, and render the secretion duly acid and clear: full doses of 20 to 40 gr. well diluted should be given three or four times daily for a short time. PREPARATION AND DOSE. Acidum tartaricum: dose, 10 to 30 gr. or more dissolved in water, and sweetened. For effervescent draughts, 20 gr. neutralize 26 gr. of potash bicarbonate, 22 gr. of the soda salt. ADULTERATIONS. Oxalic acid and lime, sulphuric acid, cream of tartar, and alum are sometimes found in samples of tartaric acid; also lead, which may be derived from the vessels in which it is crystallized. AMMOKIUM, NH 4 ,= 18. AMMONIA GAS, NH,,=1T. Ammonia exists in the air in minute quantity (probably as carbonate), in sea-water and many mineral waters, and rain-water; in the soil and in animal excretions, especially the urine. It is a usual product of decom- posing nitrogenous matter, and is said to occur free in certain plants, as in the leaves of aconite and the root of hellebore. The chloride is found native near volcanoes, and in many coal mines. Its salts are commonly obtained from " gas-liquor," a product of the distillation of coal in gas-manufacture: when this is neutralized by hydro- chloric acid, it yields a chloride, NH 4 C1 (sal-ammoniac), and from this salt, when purified, are derived all the other ammonium compounds used in medicine. 250 MATERIA MEDICA AND THERAPEUTICS. CHARACTERS. Ammonia itself is a colorless gas, which may be lique- fied. It has a pungent odor and alkaline reaction; it forms salts with acids, and, as these are very analogous in chemical relations to salts of potash and soda, it is believed that they have a metallic base, which is named ammonium, and is the fundamental radical of the series. But while potassium and sodium are simple, ammonia is a compound body or radical (NH 4 ), acting like a simple one, and until its recent isolation as a blue liquid, its existence was inferred rather than demonstrated (Smith's Commentary). LIQUOR AMMONIA FORTIOR LIQUOR AMMONIA. Solutions of ammonia gas in water, the former containing 32.5 per cent, and being about one-third stronger than the simple liquor; they are commonly called " spirits of hartshorn," because formerly prepared by heating scrapings of horns and hides. PREPARATION. By heating sal-ammoniac with slaked lime, and dis- tilling, the gas being passed through wash bottles into a receiver con- taining water. CaH 3 O a + 2NH 4 C1 = CaCl s + 2H,O + 2NH 3 CHARACTERS AND TESTS. The stronger solution is colorless, of sp. gr. .891 to .900, of characteristic pungent odor and alkaline reaction. A piece of moist red litmus paper held in the neck of the bottle is at once turned blue. The tests for its purity are When diluted with four times its volume of water, it gives no color or precipitate (a) with lime water, showing the absence of carbonic acid ; or (b) with oxalate of ammonia, showing the absence of lime; or (c) with sulphide of ammonium, proving its freedom from lead, copper, and other metals; or (d) with ammonio- sulphate of copper, showing its freedom from sulphuretted hydrogen. (e) When rendered acid by excess of nitric acid it gives no precipitate with nitrate of silver or chloride of barium, showing its freedom from chlorides, bromides, iodides, cyanides, phosphates, and sulphates. The properties of liquor ammonise are similar, but weaker in degree. COMPOUNDS OP AMMONIA. AMMONITE CARBON 'AS- CARBONATE OF AMMONIA, N 4 H 18 C 3 8 =236. The real constitution of this complex formula is probably, two mole- cules of acid carbonate, and one of carbonate of ammonium. PREPARATION. By heating a mixture of chalk (carbonate of lime) and sal-ammoniac (chloride ammon.), when chloride of calcium and a AMMONIA. 251 complex carbonate of ammonia are formed; the latter distils over, and is condensed. CHARACTERS. When recent it is seen in colorless, translucent, crys- talline masses, of strong characteristic odor and acrid taste, markedly alkaline in reaction, volatile, soluble in water, less so in spirit, and effer- vescent with acids. When exposed to the air it gives off ammonia and carbonic acid, loses its odor, and crumbles into an opaque mass of bicar- bonate of ammonium. In consequence of ready decomposition, the aqueous solution of the ordinary salt will contain both neutral and acid carbonates. The neutral salt has not been isolated in the solid state. AMMON1I CHLORIDUM CHLORIDE AMMONIUM SAL-AMMONIAC, NH 4 C1,=53.5. PREPARATION. Generally from gas-liquor, by adding hydrochloric acid to neutralization, evaporating the liquid, and purifying the crystals by sublimation. CHARACTERS AND TESTS. Occurs in pieces of the hemispherical cakes in which it is sublimed, of translucent fibrous appearance and pungent saline taste inodorous. Its ordinary form is hard to powder. It is soluble in one part of boiling water and three of cold, its solution being attended by reduction of temperature; also soluble in rectified spirit. Heated with potash, soda, or lime, it evolves ammonia. AMMONII BROMWUM (y>. Bromine, p. 98). LIQUOR AMMONIA ACETAT1S SOLUTION OF ACETATE OF AM- MONIA. Acetate of ammonia, NH 4 C a H t O,,=77, dissolved in water, commonly called spirit of Mindererus. PREPARATION. By gradual neutralization of carbonate of ammonia with acetic acid. CHARACTERS AND TESTS. When pure and fresh this is a limpid, color- less liquid, without odor and with strong saline taste; but unless carefully kept it soon spoils. With caustic alkalies it evolves ammonia, and with sulphuric acid, acetic vapors. AMMONITE C1TRATIS LIQUOR SOLUTION OF CITRATE OF AM- MONIA. Citrate of ammonia, 3NH 4 C 6 H 6 O,,=243, dissolved in water. PREPARATION. By neutralizing a solution of citric acid with strong solution of ammonia. It is a colorless liquid of saline taste. 252 MATERIA MEDIOA AND THERAPEUTICS. AMMONITE PHOSPHAS PHOSPHATE OF AMMONIA, (NH 4 ),HP0 4 ,=132. PREPARATION. By neutralizing phosphoric acid with ammonia, the latter being in excess. CHARACTERS AND TESTS. The crystals, which are transparent when recent, become opaque on exposure, and part with ammonia and water. Soluble in water, insoluble in spirit, gives a characteristic yellow precipi- tate with nitrate of silver. AMMONITE BENZOA8BENZOATE OF AMMONIA, NH 4 C T H.O, PREPARATION,. By dissolving benzoic acid in water, with solution of ammonia, and crystallizing. CHARACTERS AND TESTS. Occurs in colorless laminar crystals, which are soluble in water and alcohol: they are sublimed by heat. Hydro- chloric acid precipitates benzoic acid from solution, and caustic potash heated with it causes evolution of ammonia. Per-salts of iron give a yellow precipitate. Ammonii Sulphidum (Appendix II.), (NH 4 ) a S, = 68. By passing sulphuretted hydrogen into liq. ammoniae to saturation, then adding more liq. ammoniae. NH 3 + H 2 S=NH 4 HS and NH 4 HS+NH s =(NH 4 ) a S A colorless liquid, becoming yellow when kept, of disagreeable taste and fetid odor. It is incompatible with almost all metallic and acid so- lutions. Ammonias JWitras Nitrate of Ammonia, NH 4 NO 3 ,=80. (Placed in the appendix only for the preparation of nitrous oxide gas.) ABSORPTION AND ELIMINATION. Ammonia and its carbonate are not wholly absorbed as such a part becomes changed into chloride in the stomach (Rabuteau). Most of the free ammonia combines with carbonic acid in the organism (Bellini: ^British Medical Journal, i., 1874). Salts of ammonia with organic acids (citrate, etc.) are decomposed in the cap- illaries, when the acids are oxidized and ammonia is set free. Compounds of ammonia with mineral acids form alkaline salts at the expense of car- bonates in the blood (Bellini). Though Lange did not find ammonia in the air expired by animals taking it (Archiv fur Exper. Path., Bd. ii.), other observers have often done so, and Bellini concluded that caustic ammonia and the carbonate, when taken in small doses, were entirely and very quickly eliminated by the lungs / of large doses, some passed also by other channels. Whatever salt was taken, carbonate was eliminated by the lungs. AMMONIA. 253 There is sufficient evidence that the carbonate, when taken in moder- ate or even large doses, is not excreted, as such by the kidneys. Rabu- teau, took 60 gr. daily for five days without finding any in the urine, which continued acid, whereas a mere trace of ammonia added directly to the urine suffices to give an alkaline reaction. Dr. Bence Jones had pre- viously pointed out this continued acidity of urine under ammonia, and suggested that the drug becomes so far oxidized in the system as to give rise to nitrous or nitric acid, which appears in that secretion (" Philosophi- cal Transactions," 1851, and Medical Times, ii., 1854). Only after very large doses (160 gr. daily) some carbonate of ammonia is eliminated in the urine, which then becomes alkaline, and deposits ammonio-magnesian phosphate. Ammonium chloride does not readily decompose in the system; it is excreted by the urine and partly by the saliva (Rabuteau); a small quan- tity passes out by the skin. Frerichs taught that in uraemia an unusual amount of ammonia car- bonate (arising from decomposition of urea) circulated in the blood and was excreted by the lungs, and, although some doubt has been thrown upon this by Dr. George Johnson and others (Medical Times, i., 1858), it certainly occurs in some cases (cf. p. 256). Richardson has pointed out that during an actual attack of uraemic convulsion, the amount of ammo- nia excreted is less than at other times on account of the retention of urea in the system (Lancet, ii., 1860). Gull found ammonia, when the albumen in the urine was not large in amount (Medical Times, i., 1861, p. 616). Unemic coma is, however, connected with the circulation of urea, etc., rather than of ammonia (Medical Times, i., 1862). PHYSIOLOGICAL ACTION (EXTERNAL). The vapor of carbonate of am- rnonia (smelling salts) is stimulant and slightly irritant, that of the strong ammonia is intensely irritant to the whole of the air-passages and con- junctivse, and has even caused fatal bronchitis. Liquid ammonia is also a strong local irritant; diluted with oil it is " rubefacient," but applied in strength, and evaporation prevented, it vesicates, and if injected under the skin causes severe sloughing. Oertel reported that the direct appli- cation of liquor ammonise to the air-passages caused a membranous effu- sion similar to that of croup; but very careful observations by Meyer on the same point verified only a local catarrhal inflammation and hemor- rhage (British Medical Journal, ii., 1874). Ammoniacal urine commonly irritates the bladder. Ammonia has marked antiseptic powers: 1 dr. of liq. ammon. fort, on lint under a bell-jar preserves morbid specimens, and the same quantity with water preserves them better than spirit. PHYSIOLOGICAL ACTION (INTERNAL). Circulatory System. Medici- nal doses of ammonia and its compounds quicken the heart's action and capillary circulation, but only for a comparatively short time: such stimu- 254 MATERIA MEDICA AND THERAPEUTICS. lation is not always marked in healthy persons it is more evident in the weak and in invalids: there is increased sense of warmth, the face be- comes flushed, the eyes more brilliant, and the mental condition stimu- lated. Ten drops of the liquor, diluted with 1 or 2 oz. of warm water and injected into a, vein, excite the heart so powerfully as to rouse a patient from a state of collapse (Tibbitts: Medical Times, ii., 1872). Larger quantities 30 drops given in the same manner, after a momentary arrest, stimulate intensely, and may induce convulsion: still larger quan- tities cause momentary fall of arterial pressure, then sudden and enor- mous rise, with corresponding increase of pulse-rate: this result occurs equally after division of the cord, hence it is not due to stimulation of the vaso-motor centre, but of the accelerator nerves of the heart (Lange). On the other hand, according to Rabuteau, 40 grs. of carbonate, dis- solved and injected into a vein, weaken the cardiac contractions and ren- der them irregular, while GO gr. cause a sudden arrest of the circulation, the heart-muscle being paralyzed. The corpuscles are altered by toxic doses; they cease to contain the normal quantity of oxygen, and do not absorb it even when shaken up with the gas (Feltz and Ritter). The continued use of ammonia salts causes similar toxic effects; the pulse becomes very feeble, and the corpuscles pale and wasted, as after typhoid fever; this is but the recognized effect of all alkalies. These results are reported by Cazenave (Bulletin de Therapeutique, t. xxxi.), yet Pereira has given 15 gr. thrice daily for two months without apparent injury, and often a scruple thrice daily for two or three weeks. Ammonia or its carbonate added^ to blood outside the body renders it or keeps it fluid, and, when given internally, exerts an influence in the same direction; Dr. Richardson even thinks they have sometimes caused disintegration of clot already formed in the vessels (v. p. 259). Coagu- lation of blood is not, however, due to escape of ammonia, as thought probable at one time, nor will ammonia always or wholly prevent it. A difference in time of coagulation was the only difference observed by Rabuteau in experiments on dogs, for while coagulation of their blood usually occurs in two minutes after withdrawal, it occurred only in ten minutes when 60 gr. of ammonia carbonate had been injected: the clot, however, was firm and resistant. Chloride of ammonium delays coagulation of blood, and when added to it with access of air renders or keeps it red, as do other chlorides. Nervous /System. Ammonia salts, in medicinal doses, stimulate the general nervous system, probably by quickening circulation, but the spe- cial effect of large doses is exerted on the motor tract of the spinal cord, which is stimulated much in the same manner as by strychnia. Convul- sions are produced, especially by strong intravenous injection, and as AMMONIA. 255 these occur equally when communication with the brain is severed, they are not cerebral in origin (Lange): neither do they start in the periphe- ral nerves, for they take place if the blood be cut off from these nerves by ligature (Funke) : we conclude them, therefore, to be of spinal origin (Pfiilger'sArchiv., Bd. ix.), and section of the nerve-trunk of a limb stops their occurrence. Prostration follows the convulsive seizure, and a par- tial paralysis of the hinder limbs of animals (Rabuteau and Behier: Comptes Jtendus, Soc. Biol., 1873). Spiegelberg made "certain experi- ments in order to test the opinion of Frerichs that the convulsions of albuminuria were due to the circulation of ammonia carbonate, and when he had injected as much as 6 gr. of that salt into the veins of a dog, gen- eral convulsions occurred with clonic spasm and trismus, the pupil was dilated, general sensibility was reduced, and coma set in; after an hour and a half, free salivation and urination took place, and the animal recov- ered, remaining stupid for some time: larger doses caused vomiting, afterward, tetanus and coma; the vessels were found full of dark fluid blood (Lancet, ii., 1870). It is probable that ammonia is a direct and in- tense stimulant of respiratory centres in the medulla. The full effects of chloride of ammonium are not often exemplified, but in the case of a lunatic who swallowed a large (unknown) quantity, there were vomiting, giddiness, shivering, depression, delirium, convul- sion, and, later, collapse so complete as to simulate death: recovery was effected with galvanic and other powerful stimuli, and then tetanic spasms came on (C. Browne: Lancet, i., 1S68). Temperature is raised under the physiological action of the chloride; lowered under the other salts. Digestive System. Ammonia and its carbonate have a direct antacid effect on the gastric secretions, and moderate doses induce a sense of warmth and stimulation at the epigastrium. More than 5 gr. is likely to irritate; 10 gr. will commonly nauseate, and 20 gr. will produce vomit- ing. Diarrhoea is sometimes observed from continued medicinal doses (Cazenave). Liquid ammonia, when swallowed, acts as an irritant poi- son, and in fatal cases has caused inflammation and erosion of the upper part of the alimentary tract: occasionally it has acted upon the larynx, and induced rapidly fatal oadema glottidis. Death has been caused by 2 dr. of the strong solution; in other cases by 1 oz. (British MedicalJour- nal, i., 1878), and % pint (British Medical Journal, ii., 1878). /Secretion and Excretion. Medicinal doses of ammonia, under favor- able conditions of warmth, etc., increase most of the secretions, such as those of the skin, the kidneys, and the bronchial mucous membranes. The liq. ammoniae acetatis has a special action on the skin and kidneys, the carbonate on the lungs, the chloride on the liver and kidneys (Stew- art, Rutherford). The pulmonary secretions and the bile are also ren- dered more fluid ammonium chloride especially stimulates the latter se- 256 MATERIA MEDICA AND THERAPEUTICS. cretions. The alkaline salts of ammonia are not " remote antacids," i.e., they do not render the urine alkaline. Influence on Nutrition Urea. Although ammonia is seldom taken long 1 enough in medical practice to directly affect nutrition, there is evi- dence that its continued use will produce debilitating effects like other alkalies as indeed might be expected from its influence on the blood. Cazenave has reported pallor, anorexia, debility, and emaciation; and Huxham, a case in which hectic, hemorrhage^ and general marasmus fol- lowed upon the habitual eating of ammonia carbonate (Essay on Fe- vers). Prout noted a great increase in the amount of urea excreted under citrate of ammonia, taken for dyspepsia, and the same thing has been recorded in cases of debility with irritable bladder, and pale urine of low sp. gr. (Medical Times, ii., 1863). Rabuteau, however, as the re- sult of experiments on himself in health with 75 gr. of citrate daily, found that urea was slightly diminished, and also sulphates, but that phosphates were much increased in amount. Richardson maintains that ammonia suspends oxidation, and checks formation of all downward products of albumen, and retards nutrition (Medical Times, i., 1862, ii., 1866). There are not many observations on this point, but according to Lange, ammonia carbonate may itself furnish, by decomposition, an additional quantity of urea. Under the chloride, however, urea is distinctly increased, and oxida- tion of tissue rendered more active. The iodide and bromide of ammonium exert the absorbent and seda- tive effects of alkaline bromides generally; if anything, they are more active and less depressing than the corresponding salts of soda and pot- ash. SYNERGISTS. Diffusible stimulants, heat, and, according to Gubler, opium and iodine. Both Gull and Paget have pointed out that ammo- nia aids the action of iodide of potassium, and it has been asserted that 5 gr. of the latter, with 3 gr. of ammon. carb., is equivalent to 8 gr. of the iodide alone (British Medical Journal, i., 1874). Volatile ammonia assists also the action of anti-spasmodics, such as valerian, castor, etc. Other alkalies and bases assist its antacid power. ANTAGONISTS IXCOMPATIBLES. Cold, emollient drinks, quinine, tan- nin, interfere with the action of ammonia, and are " dynamic antidotes " (Gubler). Incompatibles are acids and fixed alkalies, salts of iron (except the tartarated iron), calomel, lead salts, etc. Freely diluted, ammonia and its carbonate may be used as antidotes to mineral acids. Christison, Pereira, and others, consider them also antidotal to prussic acid: they certainly have dynamic effects, opposite in character to those of the acid, though they do not chemically neutralize it: they antagonize also the toxic effects of alcohol, and in some degree those of animal poisons. AMMONIA. 257 THERAPEUTICAL ACTION (EXTERNAL). Neuralgia Rheumatism, etc. The strong liquor ammonias has been used as a counter-irritant, or a rapid vesicant, in cases of muscular, neuralgic, and rheumatic pain, and to relieve deeper-seated inflammation, for instance, of the tonsil and fau- ces, by derivation to the skin. For such purposes the ammonia liniment may be rubbed in, or, if vesication be necessary, it may be secured in the course of five minutes by the strong liquor applied on lint. Dr. Waring recommends, as a simple method, to fill the lid of a wooden pill-box with circular pieces of lint to above the rim, saturate with the liquid, and in- vert over the part. M. Gondret introduced a vesicating ointment made with ammonia and one-fourth part lard and olive oil, and it is commonly used in France. M. Ducros advised painting the liquor over the palate and gums for relief of tic. Falling off of the Hair. The stimulating properties of ammonia are highly useful in promoting growth of hair when it has been thinned by debility or illness. Half an ounce of the strong liquor, with almond oil, rosemary spirit, and honey-water to about 6 oz. is a good proportion (E. Wilson). Amenorrhoea Pruritus. In cases of chlorotic amenorrhcea, a stimu- lating vaginal injection of about 1 dr. of liq. ammoniae to a pint of warm milk has been found useful by Dr. Ashwell, and I have fre- quently ordered it with advantage, the breasts being stimulated at the same time by friction with weak ammonia liniment. Dr. Dewees has recorded the cure of an obstinate case of pruritus pudendi by a similar injection. Local Inflammations. Lotions containing ammonium chloride are very useful in inflammatory swellings of muscles, joints, lymphatic and other glands, and sometimes in the hydroceles of children 2 dr. may be used to 4 or 6 oz. of spirit and water. In orchids and in milk engorgements with heat and tension of the breasts, the same application is cooling and absorbent. Gueneau de Mussy recommends for the latter cases an ointment containing 5 parts of the chloride mixed with 1 of camphor and 30 of lard, to be used fre- quently. It is said that threatening abscess may be aborted by the con- tinued application of compresses wet with spirit of rosemary containing about 1 dr. of the salt to the pint, and if an abscess has formed of indo- lent character, such as bubo often is, it may be stimulated to heal by the injection of sal-ammoniac solution after withdrawal of some pus (Rank- ing, i., 1871). Acne. In chronic cases of acne simplex with comedones, a lotion containing the chloride with alum and sulphuret of potash is sometimes an effective resource. Stings Snake-Site. Dilute liquor ammonias relieves the pain that follows the stings of venomous insects, wasps, etc. ; it should be freely VOL. I. 17 258 MATEBIA MEDICA AND THERAPEUTICS. rubbed into the part, and given internally if there be tendency to col- lapse. Professor Halford (Melbourne) has strongly advocated intravenous injection of ammonia in snake-bite, using 15 to 30 min. of the liquor, dilu- ted with 3 or 4 parts of water, both as antidotal to the poison, and as a general stimulant. Many cases have recovered under this treatment, but there is yet much doubt as to how far it may be depended upon: in some of them it is probable that the bites were not of fatal character, and, when experiments were repeated with more accuracy, ammonia, even injected by Professor Halford, did not avert a fatal result (Medical Times, ii., 1876). It has also been found powerless against the bite of Indian snakes, which are more poisonous than those of Australia (Fayrer, Short, Brun- ton, Ewart): in some cases death followed even more quickly than usual after the injection (Report of Commission). The intravenous injection of liq. ammonise is a subject of much import- ance, and one that deserves more general attention than has yet been given to it: it is not free from risk and danger, especially if the large dose of 30 min. be used, but in suitable quantity it has powerfully stimu- lated the heart, and revived cases apparently in articulo mortis. Shock and Collapse from Injury, etc. Cases of fracture and lacera- tion accompanied with collapse and treated by ammonia-injections have been recorded by Mr. Tibbitts. In one man, 40 drSps with 2 oz. of %varm water were passed into one of the veins of the arm, and, after temporary arrest of breathing, a violent convulsion occurred; but, on subsidence of this, general stimulation was evident, and he rallied for several hours. In a second case, 30 drops were injected, with a somewhat similar result; in the third patient, when only 10 drops were given, pulse and respiration were at once restored, vomiting occurred, and recovery followed (Medi- cal Times, ii., 1872). Recovery, though only temporary in character, followed a similar in- jection given during collapse in severe scarlet fever (British Medical Journal, i., 1877), and in the same condition, occurring during puerperal fever, Tyler Smith injected 30 min. with 3 parts of water, and ultimate recovery followed; but two cases thus treated by Mr. Spencer Wells proved unsuccessful (British Medical Journal, ii., 1869). JVarcosis. Neild injected 30 drops of ammonia on four separate occa- sions in a patient fatally narcotized by chloroform ; temporary recovery occurred each time (Medical Times, i., 1871). In a case of opium-poison- ing, when 40 gr. had been taken, and death was imminent, revival, though only for a time, also followed directly on ammonia-injection (British Medical Journal, ii., 1872). Mr. Richards has specially drawn attention to the value of ammonia-injections in alcoholic coma, and has shown that some of Dr. Halford's patients who had much brandy (one got a bottle and a half in three hours) were really more comatose from the alcohol AMMONIA. 259 than from the bite, and hence their recovery. He remarks on the im- portance of a slow injection, and recommends 10-min. doses (Lancet, i., 1880, p. 115). Exhaustion. In a case where extreme exhaustion was consequent on prolonged suppuration, 15 min. were injected into a vein, and again eight hours afterward with permanent good result (British Medical Journal, i., 1877); some of the caustic entered the cellular tissue, and caused local sloughing, and in other cases, where injection has been made purposely into this tissue, serious ulceration and abscess have followed (Medical Times and Lancet, i., 1870). THERAPEUTICAL ACTION (INTERNAL). Exhaustion Alcoholism, etc. One of the most frequent uses of ammonia, and one which it commonly serves very well given by the mouth in the ordinary manner, is to quicken the general circulation and to revive failing heart-action in cases of ex- haustion and threatened syncope from almost any cause: being volatile, it diffuses and acts rapidly. The vapor of the carbonate, as disengaged from "smelling salts," is sometimes usefully given by inhalation in the same class of cases, and the vapor of liquor ammonias has been utilized in partial asphyxia, and in the semi-coma of drunkenness. In several extreme cases of alcoholism, wherein relapses were frequent, I have known the aromatic spirit of ammonia in drachm-doses every hour or two "steady " the patient very markedly; it has acted better than, e.g. , vinegar, which seemed to increase liver congestion and give only temporary relief to symptoms. The depression and dyspepsia which commonly follow exces- sive use of alcohol are also well treated by ammonia compounds, especially if combined with valerian: in the prostration of delirium tremens, the same remedies are very useful. Tlwombosis Embolism. Rapid separation of fibrine in the heart- cavities seems to occur previous to death in many acute exhausting dis- eases, such as pneumonia, croup, peritonitis, etc., and after prolonged or difficult parturition. Dr. B. W. Richardson states that advantage may be derived in such apparently hopeless condition from the use of liquor ammonise TTlx. every hour, alternately with iodide of potassium (Ranking, ii., 1872). Dr. Shepherd Fletcher (Manchester) has reported a well- marked case of embolism occurring in a puerperal woman and recovering under 5-gr. doses of ammonia carbonate given every hour (British Medi- cal Journal, i., 1864), and Dr. Philipson has recorded another illustration of the same character (British Medical Journal, 1865). More recently, Dr. Richardson has written to point out distinctive signs of the separation of fibrinous coagula in the large thoracic vessels e.g., dyspnoea with open air-passages, fulness of the neck-veins, feeble pulse with tumultuous heart-action, and weakened first sound: for such conditions he strongly advises the persistent administration of ammonia, not so much as a stimu- lant, but as a solvent of blood-clot, and preventive of putrefaction (Lancet, 260 MATERIA MEDICA AND THERAPEUTICS. i., 1875). I cannot, however, yet adopt so sanguine a view of this medi- cation (v. p. 254). Pyrexia. In acute pyrexial and inflammatory conditions, solutions of acetate and citrate of ammonia relieve many of the symptoms by promo- ting secretion from the skin and kidneys. Typhus and Typhoid Fever. In adynamic stages of these fevers, ammonia has often been used but not always with advantage; thus Stille reports its failure, though largely given during an epidemic of typhus at Philadelphia. There is reason to believe that the amount of ammonia circulating in the blood is unduly increased in these maladies, and this would be a reason against using it: certainly its administration is very distasteful to the patients. Scarlatina. On the other hand, there is much clinical evidence of the value of ammonia in this fever. De Witt, Peart (1802), Wilkinson, and Strahl have written specially in its praise, and many illustrations of its value have been given by Hillier, Camden, Graham, Sisson, Langdon Down, and others (Lancet, 1860, 1864, 1870; Medical Times, 1858, 1862, 1873, and "London Hospital Reports/' vol. i.). From 3 to 6 gr. of .car- bonate, freely diluted, are to be given every one or two hours, until im- provement occurs: it determines to the skin, and perhaps thus hastens elimination of the poison. I have found it especially useful in cases ac- companied by malignant sore throat. Dr. Down refers to 192 cases oc- curring in one epidemic at Earlswood Asylum; 78 had severe angina, and 49 were malignant cases: all received 5 gr. of the carbonate every four hours, and were otherwise treated alike: alcoholic stimulants were used in moderation. Ten only died, and of these seven were tuberculous, and considering the low resisting power of imbeciles this result is good. He considered the remedy diminished febrile excitement and calmed the ner- vous system: it was taken readily without pain to the throat. Chest Diseases. In acute stages of pneumonia, bronchitis, or pleurisy, the acetate or citrate of .ammonia is often serviceable. In asthenia cases, the later chronic conditions of bronchitis, and in senile catarrh, the car- bonate and liquor are good stimulant expectorants, being eliminated in part by the pulmonary membrane, they modify its condition and thin the secretion. Ammonium chloride is also valuable in such conditions, and in asthenic lung-congestions: it may at first increase pyrexia, but generally facilitates the expectoration, " softens the cough," and improves appetite. Dr. Patton has written to commend the carbonate in acute pneumonia, and the chloride in later stages (Practitioner, vol. vi.). In the bronchitis of measles, and of rachitis, ammonia is commonly and advantageously used, Sir W. Jenner, indeed, speaks of it as the remedy in the lung-affections of the latter malady, which are generally asthenic and tend to collapse (Medical Times, i., 1860). On the other hand, Dr. Eustace Smith maintains that if too early given to children with AMMONIA. 261 bronchitis it may determine even a fatal issue (Medical Times i 1873). Group. In the later stages, when the membrane is more or less loosened, and perhaps capillary bronchitis is present, carbonate of am- monia may prove a useful stimulant expectorant or emetic. Pertussis. I have seen relief given to the cough in later stages by inhalation of ammonia vapor, and Mr. Grantham has devised a simple method of effecting this by adding 1 oz. of the liquor to 1 gallon of boil- ing water in a bucket or bath, and then putting in a red-hot brick (Brit- ish Medical Journal, ii., 1871). The atmosphere of gas-works has often relieved chronic cases, a good effect which has been traced to the volatile sulphide of ammonium. Bronchial Catarrh Hoarseness. The chloride of ammonium in va- por deserves trial in obstinate cases of this kind, and Dr. H. Beimel in- 3 O troduced an arrangement of three bottles, one containing liquor ammo- nia, another hydrochloric acid, and a third " wash-bottle " with water, through which air impregnated with the vapor was drawn for inhalation (Lancet, ii., 1867): it has not come into general use. Liebermann has suggested another form of apparatus for inhaling it (Bulletin de Thera- peutique, 1873). The bromide is of service in capillary bronchitis (Bartholow), in per- tussis, and other spasmodic coughs. The chloride in lozenge and vapor has also been advised for hoarse- ness and granular sore throat, but the stimulus at first sometimes aggra- vates the symptoms. Nerve Diseases Migraine. The acetate of ammonia in 1 to 2 -dr. doses will often relieve sick-headache. The chloride, in 10 to 20-gr. doses, is indicated in bilious and nervous forms occurring in the young, and in delicate over-worked women, " it stimulates the sensory nerves, and regulates the vaso-rnotors " (Anstie: Practitioner, vol. i.). In headache connected with menorrhagia it is said to be more useful than in that connected with irregular or suppressed menstruation (Baral- lier : Bulletin de Therapeutique, 1859). Neuralgia. In true neuralgia, the chloride is often of great value, as Dr. Clifford Allbutt states after observation of fifty cases (Medico- Chi- rurgical Review, January, 1872): it is, however, very nauseous to some patients. In tic-douloureux, or facial neuralgia, especially if there be a marked rheumatic element and the lower jaw be affected, -dr. doses of chloride should be given at short intervals, for four doses: relief will probably have then set in if this remedy is going to benefit (Watson : " Lectures," vol. i.). In cases accompanied with heat and swelling, Brenchley recorded marked relief to pain and lowering of temperature under this treatment (Ranking, ii., 1858). 262 MATERIA MEDICA AND THERAPEUTICS. In hemicrania from nerve-prostration it is often curative (Medical Times, i., 1875), and in sciatica I have found either carbonate or chloride valuable, more or less permanently when the pain is worst when the pa- tient is in the standing or sitting posture. In intercostal neuralgia, in anaemic or suckling women, in hepatalgia, and in ovarian neuralgia, Dr. Anstie also reported much benefit from the chloride; and of the latter mal- ady Dr. W. Curran has reported six severe cases marked by acute pain, py- rexia, vomiting, etc., occurring mostly at a period, and accompanied with fulness over the region of the ovary, all much relieved by the chloride in 15-gr. doses, which were given, however, with 5 min. of aconite (Ranking, ii., 1868). Dysmenorrhcea. The acetate of ammonia will often relieve the pain of congestive dysmenorrhcea. I have frequently prescribed it with suc- cess, especially if there be a sub-inflammatory or turgescent state of mu- cous membrane, or when suppression has occurred from cold, shock, or fatigue (British Medical Journal, i., 1878, etc.). Uterine Disorder, etc. The chloride has often produced good results in amenorrhoea (Cholmeley : Practitioner, vol. ii.), and Dr. Anstie ad- vised it in cases marked by general feebleness rather than by anaemia. Dr. Atlee states that the salt has in his practice caused the diminution of fibroid tumors (British Medical Journal, i., 1868). This observation may be compared with that of Dr. Rae, who asserts that the same salt is val- uable in goitre and glandular enlargements (Ranking, ii., 1858), but there is not much evidence on these points. Myalgia. For this variety of pain, Dr. Anstie affirms " nothing in the whole list of remedies comes near the chloride in efficiency," and H. Jones speaks of its power in muscular rheumatism " as remarkable and positive " (Lancet, ii., 1859). Hysteria. Ammonia relieves several of the symptoms of this disorder, such as the lassitude and tendency to fainting, and the flatulent disten- sion of the stomach. The aromatic spirit is a good preparation in com- mon use. The liquor with asafoatida or valerian is still more effective, t)ut nauseous; it has some power in staying convulsive attacks of hyster- ical character. Dyspepsia Acidity, etc. In cases where flatulence with acidity are marked symptoms, ammonia will relieve by its alkalinity and by stimulat- ing the stomach to contract and expel flatus; it is usefully combined with other remedies the carbonate or aromatic spirit with soda or bitters. The chloride with hydrochloric acid relieves in some cases when the tongue is furred and the biliary secretion deficient (British Medical Journal, i., 1875). For gastric and intestinal catarrh also, it is commonly given in Germany not so in England. Hepatic Disorders. In various forms of hepatic disorder accompanied with congestion, ammonium chloride is a valuable remedy, perhaps not AMMONIA. 263 yet sufficiently known in this country. Dr. Murchison recommended it in "functional liver-disorder" accompanied with lithaemia, and Dr. Anstie in suppression of biliary secretion consequent on nerve-shock. It is much used abroad in catarrh of the bile-ducts, and in the jaundice dependent on this condition; also in hepatic dropsy; but perhaps its best effects are seen in passive hepatic congestion when there is deficient intestinal secretion with loaded urine, constipation, coated tongue, and general "bilious" condition. As already stated, the chloride stimulates a due secretion of bile and increases the excretion of urea. Dr. Stewart, of the Indian service, has especially drawn attention to the value of this remedy in hepatitis, and even hepatic abscess, and has found it act better in acute than in chronic stages of these maladies. If the skin be dry, he orders first the acetate of ammonia and afterward 20 gr. of chloride every four or six hours: a feeling of warmth and exhilaration is produced, hepatic pain is quickly and markedly relieved, perspiration and urine are freely secreted, and sleep commonly follows (Lancet, 1870; British Medical Journal, ii., 1878). Hemorrhage. In hemorrhage of different kinds, usually passive in character, the chloride is praised by Copland, who gave it with hydro- chloric acid. It is not much used, but Warburton Begbie has seen good results from doses of 20 gr. in hsematuria: in the illustrative case recorded by him, there was no definite cause for the malady (Lancet, ii., 1875). Urinary Disorder. In acute albuminuria, the liquor ammoniseacetatis is often useful, as first noticed by Addison (Lancet, ii., 1855), and in diabetes, Barlow, Golding-Bird, and Bouchardat specially valued the car- bonate as being a stimulant and a nitrogenous substance ( Guy's Reports, vol. v., etc.). Basham recommended the phosphate to be given with the carbonate and lemon-juice (British Medical Journal, i., 1869). Prout also thought the citrate serviceable, but rather as a diaphoretic than as possessing specific powers. The sulphide has been recommended to les- sen morbid appetite in diabetes, but it does not diminish the excretion of sugar (Garrod), and ammoniacal salts have not retained their reputation in this serious malady. In Vesical Catarrh and Prostatitis, the chloride has proved useful, and in a case of irritable bladder, with pale urine of low sp. gr., and deficient in urea, much relief was apparently given by the citrate; the excretion of urea was at once increased under its use (Medical Times, ii., 1863). The benzoate of ammonia is valuable in chronic catarrhal cystitis, with phosphatic deposit; also in scarlatinal dropsy (Lancet, ii., 1861, Garrod: Medical Times, 1864). PREPARATIONS AND DOSE. Liquor ammonia? fortior: dose, 3 to 10 min. well diluted, but seldom used internally. Liquor ammonite: dose, 10 to 30 min. well diluted. Spiritus ammonias futidus (with asafoatida): dose, 30 to 60 min. Ammonias carbonas: dose, 3 to 10 gr. or more as a 264 MATERIA MEDICA AND THERAPEUTICS. stimulant; 30 gr. as an emetic. Spiritus ammonias aromaticus (sal- volatile); dose, 15 to 60 min. Ammonii chloridum (sal-ammoniac): dose, 5 to 20 gr. or more. Ammonii bromidum : dose, 2 to 20 gr. Am- monii iodidum (riot officinal): dose, 1 gr. and upwards. Liquor ammonioB acetatis (spirit of Mindererus): dose, 2 to 6 dr. diluted freely. Liquor ammonias citratis : dose, 2 to 6 dr. Ammonias benzoas : dose, 10 to 20 gr. AmmonicB sulphidum (in solution) : dose, 3 min. and upwards (sel- dom used: dangerous if incautiously given). Ammonics nitras : used only for making nitrous oxide. Ammonias phosphas: dose, 5 to 20 gr. freely diluted. Linimentum ammonias (with olive oil), for external use. Compound camphor liniment also contains ammonia solution. [PREPARATIONS, U. S. P. Aqua ammonias, sp. gr. 0.960; Aqua am- monias fortior, sp. gr. 0.900; Linimentum ammonias: water of ammonia 1 fluidounce, olive oil 2 troyounces; Spiritus ammonias, ; Spiritus am- monias aromaticus; Liquor ammonii acetatis; Ammonii benzoas; Am- monii bromidum; Ammonii carbonas; Ammonii chloridum; Ammonii chloridum purijicatum; Ammonii iodidum; Ammonii nitras; Ammonii sulphas used in preparations; Ammonii valerianas, dose, 2 to 8 grains.] METALLIC PREPARATIONS. ALUMIMUM Al,=27-5. This metal has not been found native, but alumina, its oxide, A1 2 O, (known also as argillaceous earth), is widely diffused as a silicate in clay, slate, granite, etc., and occurs nearly pure in the sapphire and ruby. The metal itself is of steel-gray color and is not readily oxidized: sp. gr. 2*67. Alumen, the officinal alum, NH 4 ,A1,(SO 4 ) 8 12H,O, is a double sulphate of alumina and ammonia with a large amount of water of crystallization: it occurs native sometimes in mineral waters, and in efflorescence on stone. (There are many similar "alums, " or double sulphates of an alkaline base, and a metal: thus there is a potash-alum^ formerly officinal, but more ex- pensive than ammonia-alum a soda-alum, etc. The same name is applied even when no alumina is present, as to the double sulphate of iron and ammonia iron-alum and to similar compounds of manganese and chro- mium.) PREPARATION. The officinal alum is prepared by oxidation of alumin- ous schist, sulphates of alumina and iron being formed then dissolved in water, and treated by sulphate of ammonia: on concentrating the solution, alum crystallizes out. CHARACTERS AND TESTS. Alum crystallizes in octahedral, sometimes in cubic, forms, but is generally met with in irregular lumps, translucent and colorless when fresh, efflorescent and covered with small crystals after exposure. It has an acid reaction and a strongly astringent, subacid taste; is insoluble in alcohol, soluble in eighteen parts of cold, and half its weight of boiling water. Heated, it dissolves in its water of crystallization, and when this has been driven off, alum remains as a dry, white, spongy mass (alumen exsiccatum vel ttstum dried, or burnt alum). This has very astringent, somewhat caustic properties; it readily absorbs moisture, but is sparingly soluble: heated beyond 400 F. it is decomposed, and alumina, the oxide, A1 S O S , remains. This oxide is insoluble in water, and when alum solutions are decomposed, separates as precipitate; hence the use of alum for clearing turbid water, for when it is added, the alkaline and earthy salts present in the water combine with the sulphuric acid of the 26C MATERIA MEDIC A AND THERAPEUTICS. alum, and the alumina which precipitates, carries with it most of the im- purities present: it has also special disinfecting powers. The acetate of alumina (argilla acetica), the chloride (aluminium chlo- ratum), and the single sulphate (argilla sulphurica), though not officinal, are in occasional use; they are all soluble salts, of characteristic styptic taste. The sulphate has been found native, though not quite pure; it is more acid than the ordinary double sulphate, so that it blunts steel instru- ments and corrodes linen. 1. The bisulphide of ammonium (NH 4 HS), when added to solution of the salts of aluminium hydrate, gives a white gelatinous precipitate of ammonium hydrate. 2. The caustic alkalies and their carbonates give a \vhiteprecipitate with aluminous solutions, soluble in excess of the former. 3. Solutions of the aluminous salts should not give a blue color on the addition of ferrocyanide and ferricyanide of potassium, showing freedom from iron. 4. Alum, when heated with caustic soda or potash, evolves ammonia. ABSORPTION AND ELIMINATION. Taken into the mouth alum exerts the local action presently to be described, and its first sweetish taste is followed by a peculiar feeling of constriction, and abundant flow of saliva: after reaching the stomach, combined, more or less, with albumen, some of it becomes absorbed though slowly. Orfila detected it in the urine and viscera of dogs after large doses (Annales d' Hygiene pub., i., 235 9,v.), and Krauss found the urine become very acid under itp use. The greater part of the alum taken combines to form insoluble compounds with the bile and other organic products, and is eliminated with the fasces. It is remarkable, that although alumina is so common a constituent of vegeta- ble food, it is not found in the human organism, showing how completely it passes out. PHYSIOLOGICAL ACTION (EXTERNAL). Alum acts as a typical simple astringent, contracting the arterioles and muscular fibres of the part touched by it, and rendering the surface pale and dry. It combines with albuminous secretions forming whitish flakes, or membranous films, in- soluble in water, but soluble in acetic and hydrochloric acids (Mitscher- lich). If there be not enough fluid present to saturate the alum, it affects the deeper tissues in a somewhat caustic manner: this is especially the case with the dried salt. Strong or long-continued applications ex- cite irritation with some degree of inflammation, and, under such circum- stances, discharge from an affected part e.g., the conjunctiva, or the vaginal mucous membrane may be increased rather than diminished. The acetate of alumina and chlor-aluminium have marked disinfec- tant powers, preserving organic tissue, and hindering putrefaction. Burow (185?) found that the acetate, mixed with fresh blood, formed a brown syrupy mass, in which the shape of the corpuscles was not retained, but which remained, without decomposing, for many months. Albumen, ALUMINIUM. 2G7 treated with the same salt, continued clear, and did not coagulate much on boiling: 0.5 per cent, prevented putrefaction of urine an