Pass X< ;\\ cv\, Book,_AV^ GopightW ___Q^ COPYRIGHT DEPOSIT; ^ i HI m BOOKS BY THE SAME AUTHOR. A TEXT-BOOK OF THE PRACTICE OF MEDICINE. Cloth, $5.00, net; Leather, $6.00, net; Half Morocco, $6.50, net. A TEXT-BOOK OF PRACTICAL DIAGNOSIS. FIFTH EDITION. Cloth, $5.00, net; Leather, $6.00, net; Half Morocco, $6.50, net. A SYSTEM OF PRACTICAL THERAPEUTICS. Cloth, $5.00; Leather, $6.00; Half Morocco, $7.00. MEDICAL SEQUELAE OF TYPHOID FEVER. Cloth, $2.40, net. When called to guide a patient through an illness the physician should be constantly a watchman, and a therapeutist only when necessity arises. A good physician is one who, having pure drugs, knows when to use them, how to use them, and, equally important, when not to use them. When a physician gives a drug and the patient improves, care should be taken not to ascribe all the good results to the remedy employed. Nature must be given credit for a large part of the improvement. A TEXTBOOK PRACTICAL THERAPEUTICS, WITH ESPECIAL REFERENCE TO THE APPLICATION OF REMEDIAL MEASURES TO DISEASE AND THEIR EMPLOYMENT UPON A RATIONAL BASIS. BY HOBART AMORY HARE, M.D., B.Sc, PROFESSOR OF THERAPEUTICS AND MATERIA MEDICA IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; PHYSICIAN TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL; ONE-TIME CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE UNIVERSITY OF PENN- SYLVANIA; LAUREATE OF THE ROYAL ACADEMY OF MEDICINE IN BEL- GIUM, OF THE MEDICAL SOCIETY OF LONDON - , MEMBER OF THE COMMITTEE OF REVISION OF THE UNITED STATES PHARMACOPOEIA OF 1905. ELEVENTH EDITION, ENLARGED, THOROUGHLY REVISED AND LARGELY RE-WRITTEN. ILLUSTRATED WITH 113 ENGRAVINGS AND 4 COLORED PLATES. LEA BKOTHEKS & CO., PHILADELPHIA AND NEW YORK. 1905. LIBRARY of iONSI esj TWi.: OOPJtfe flitK&vsu OCT iyod , GWiyruEni tnsw OOPV B« Copyright, 1905, by LEA BROTHERS & CO. Authority to use for comment the Pharmacopoeia of the United States of America (Eighth Decennial Revision), in this volume, has been granted by the Board of Trustees of the United States Pharmacopoeial Convention; which Board of Trustees is in no way responsible for the accuracy of any translations of the Official Weights and Measures, or for any statement as to strength of Official Preparations. DORNAN, PRINTER, PHILADELPHIA. PREFACE TO ELEVENTH EDITION. When the first edition of this book appeared, fifteen years ago, the author stated in the preface that his object was to provide the physician or undergraduate student of medicine with a reliable guide in the study of Therapeutics, or the application of remedial measures for the cure of disease. It was written because, in the belief of the author, most of the text-books on this subject treat of it as if the student were already a skilled physician or experimental pharmacolo- gist. As a consequence, two classes of undergraduate readers exist. One finds that the mixture of science and empiricism is too difficult for him to fathom, and is hopelessly confused; the other simply learns the remedies and doses by heart and gives drugs with little idea as to what they are to do. Further than this, the physician is often at a loss to decide when a remedy is indicated, even though his theoretical knowl- edge of the subject be very thorough. Thus, he is told that ammonium chloride is a remedy in bronchitis, but the exact stage at which it is to be employed is often not stated, or he knows that digitalis does good in cases of cardiac disease, but fails to recognize the fact that it is only when compensation is lacking that the drug is needed. For this reason Part IV., on Applied Therapeutics, was written, not with the object of providing a rigid system for treating disease, but rather for the purpose of bringing together the best remedies, and of showing how and why they are given. The appearance of the new United States Pharmacopoeia in the sum- mer of 1905 has necessitated a large number of alterations in the text of this volume. Many preparations heretofore official have been excluded and new ones introduced. A large number of tinctures have been changed in their strength, and therefore in their doses. In many instances the names of drugs used by physicians for years have been greatly changed, as, for example, the substitution of acet- phenetidinum for phenacetin, or hexamethylenamine for urotropin. In cases such as these the author has intentionally allowed the older name to head the article on the subject at issue and given the new (v) Vi PREFACE TO ELEVENTH EDITION. name under it so that the reader may not be subjected to the annoy- ance of a cross-reference and may gradually become accustomed to the new nomenclature. It will be noticed that fluid extracts are now classified under the compound Latin term "Fluidextractum." Throughout this book, in every part where drugs or diseases are considered, the writer has arranged the titles in alphabetical order, according to the name commonly employed. This has been done because it is desired to afford the reader a ready reference book to which he may turn at short notice for desired information, for at present the state of pharmacology is so unsettled that a true classifi- cation is impossible. Thus, morphine may be classed by one writer as a nervous sedative, by another as a sleep-producer, by a third as a bitter substance, and by a fourth as a respiratory depressant. Bromide of potassium may, with equal propriety, be called a spinal sedative or a cerebral sedative, or caffeine be classed as a cerebral stimulant, a circulatory stimulant, or a diuretic. In order to make the book more complete, the preparations of the British Pharmacopoeia have been introduced; and with the same object in view, a dose list of drugs, both official and unofficial, has been appended for ready reference. The subject of medical electricity has heretofore commonly found a place in most text-books on thera- peutics, but has been advisedly omitted in this instance, since electrical therapeutics has outgrown any work save one devoted to that subject alone. For many of the articles on treatment the author wishes to thank friends who have earned prominence in connection with their specialties. Thus, Dr. G. E. de Schweinitz has contributed the articles on the treat- ment of diseases of the eye ; Dr. Edward Martin those on the treatment of venereal diseases and on antisepsis; Dr. Barton C. Hirst those on the treatment of diseases of the puerperal state. All of these articles enhance the value of the book to so great an extent that the author feels sure they will be sought out and read with interest. In addition to the general index, a copious and explanatory index of diseases and remedies has been appended, which will prove sug- gestive and valuable to practitioners. H. AH. N. W. COR. SPRUCE AND 18TH STS., PHILADELPHIA, 1905. CONTENTS. PART I. PAGE General Therapeutical Considerations .,.„.. 17 PART II. Drugs . . 53 PART III. Remedial Measures other than Drugs . . . . . .461 Feeding the Sick , .' . 542 PART IV. Treatment of Diseases 555 Table of Doses of Medicines ......... 821 Index of Drugs and Remedial Measures 837 Index of Diseases and Remedies 863 1 vii ) COMPARATIVE TABLE SHOWING THE STRENGTH OF THE MORE IMPORTANT PHARMACOP03IAL PREPARATIONS IN THE PRE- CEDING AND IN THE PRESENT PHARMACOPEIA. Title. Acidum sulphuricum aro- ) maticum . . . . $ Alcohol dilutum .... Caffeina citrata effervescens Calx chlorinata . Emplastrum belladonnae . Extraetum belladonnae colchici cormi hyoscyami nucis vomicae opu . ... physostigmatis stramonii Fluidextractum aconiti belladonnae radicis cinchonae colchici seminis . conii .... guaranae . . Hydrastis hyoscyami ipecacuanhas . nucis vomicae pilocarpi stramonii Liquor ferri chloridi . ammonii acetatis . tersulphatis . Lithii citras effervescens . Mangani dioxidum praecip- ) itatum . . . . j Oleatum hydrargyri . Opii pulvis .... Opium deodoratum . Pancreatinum Potassii citras effervescens Spiritus frumenti Suppositoria glycerini Syrupus ferri iodidi . Tinctura aconiti . . . -j aurantii dulcis belladonnae foliorum < Chief constituent. H 2 S0 4) by weight. Absolute alcohol, by weight. Absolute alcohol, by weight. Citrated caffeine, by weight. Available chlorine, " Mydriatic alkaloids, " Mydriatic alkaloids, ' ' Colchicine, by weight. Mydriatic alkaloids, by weight. Strychnine, by weight. Morphine (cryst.), by weight Ether-soluble alkaloids, by weight. Mydriatic alkaloids, by weight. Aconitine, by weight. Mydriatic alkaloids, by weight. Anhydrous ether-soluble alkaloids, by weight. Ether-soluble alkaloids, by weight. Colchicine, by weight. Coniine, by weight. Alkaloids, by weight Hydrastine, by weight. Mydriatic alkaloids, by weight. Alkaloids, by weight. Strychnine, by weight. Alkaloids, by weight. Mydriatic alkaloids, by weight. Anhydrous FeCl 3 , by weight. Tincture of ferric chloride. Fe 2 (S0 4 ) 3 , by weight. Lithium citrate, by weight. Manganese dioxide. Yellow mercuric oxide, by weight. Morphine (cryst.), by weight Morphine (cryst.), by weight Potassium citrate, by weight Absolute alcohol by weight Glycerin (half their former size). Ferrous iodide, by weight. Aconitine, by weight. Aconite. Sweet orange peel. Mydriatic alkaloids, by wt. Belladonna leaves. Pharm. 8th Revision. About 18.5 per ct. About 20.0 per cent. About 91.0 per ct. " 92.3 About41.0per ct. " 41.5 • " 2.0 gm.in 100 gm. 4.0 gm. in 100 gm. At least 35.0 per ct. At least 30 per cent. Standard not fixed Not 1 ess than 0. 38 per cent, nor more than 42 per ct. " *' 1.4 per cent. " " 1.4 " " 0.3 15.0 per cent, total 5.0 alkaloids 18.0 per cent. 20.0 Standard not fixed 2.0 " 1.4 « 0.4 gm. in 100 c.c. " " 0.5 " 100 " 1.5 gm. total alka- loids in 100 c.c. Standard not fixed 37.8 per cent. 2 c.c. in 100 c.c. 28.7 per cent. About 17.0 per ct. At least 66 per ct. 20.0 per cent. 13 to 15 per cent. 13 to 15 per cent. Standard not fixed About 48.0 per ct. 44 to 50 per cent. 6 gm. each About 10 per ct. Standard not fixed 1 gm.in 2. 85 c.c. Igm.in5.0cc. Standard not fixed 1 gm. in 6.67 c.c. 4.0 0.5 0.5 0.45 3.5 2.0 0.075 1.75 1.0 0.4 0.35 100 100 100 100 100 100 100 100 100 100 100 29.0 per cent. 4.0 C.C. in 100 c.c. 36.0 per cent. About 5.0 per cent. At least 80 per cent. 25.0 per cent. 12 to 12.5 per cent. 12 to 12.5 At least 1 part digests 25 parts of starch. About 20.0 per cent. 37 to 47.5 3 gm. each. About 5 per cent. 0.045 gm. in 100 c.c. 1 " 10 " 1 2 " 0.035 " 100 " 1 " 10 " ( viii ) STRENGTH OF PHARMACOPCEIAL PREPARATIONS. IX Title. Chief constituent. Pharm., 1890. Pharm. 8th Revision. Tinctura benzoini composita Benzoin. 1 gm. in 8.33 c.c. 1 gm. in 10 c.c. calumbse Calumba. 1 " 10.0 " 1 " 5 " cannabis indicae . Indian cannabis. 1 " 6.67 " 1 " 10 " cantbaridis . . Cantharides. 1 " 20.0 " 1 " 10 " capsici .... Capsicum. 1 " 20.0 " 1 " 10 " cardamom i . Cardamom. 1 " 10.0 " 1 " 5 " cinnamomi . Saigon cinnamon. 1 " 10.0 " 1 5 " colchici seminis . . -J Colcbicum seed. 1 " 6.67 " 1 '* 10 " Colchicine, by weight. Standard not fixed 05 " 100 " digitalis . Digitalis. 1 gm.in 6.67 c.c. 1. " 10 " ferri chloridi . Anhydrous FeCl 3 ,'by weight. 13.6 per cent, by 13.28 per cent, by weight. weight. gambir composita . Gambir. 1 gm. in 10.0 c.c. 1 gm.in 20 c.c. gelsemii .... Gelsemium. 1 " 6.67 " 1 " 10 " bydrastis Hydrastine, by weight. Standard not fixed 0.4 " 100 " byoscyami . . . \ Mydriatic alkaloids, by wt. Hyoscyamus. 1 gm. in 6.67 c.c. 0.007 " 100 " 1 " 10 " kino .... Kino. 1 " 10.0 " 1 " 20 " lobelia .... Lobelia. 1 " 5.0 " 1 " 10 " nucis vomicae Strychnine, by weight. 0.3 gm. total alka- 0.1 gm. strychnine loids in 100 c.c. in 100 c.c. opii Morphine (cryst.) by weight. 1.3 to 1.5gm. in 1.2 to 1.25 gm. in 100 c.c. 100 c.c. opii deodorati Morphine (cryst.) by weight. 1.3tol.5gm. in 1.2 to 1.25 gm. in 100 c.c. 100 c.c physostigmatis . . -J Physostigma. Ether-soluble alkaloids, by weight. 1 gm.in 6.67 c.c. Standard not fixed 1 gm. in 10 c.c. 0.014 " 100 " quassiae .... Quassia. 1 gm. in 10.0 c.c. 1 5 " rbei Rbubarb. 1 " 10.0 " 1 5 " sanguinarise . Sanguinaria, 1 " 6.67 " 1 " 10 " scillse ; Squill. 1 " 6.67 " 1 " 10 " serpentarise . Serpentaria. 1 " 10.0 " 1 5 " stramonii . . . -j Stramonium. 1 " 6.67 " 1 " 10 " Mydriatic alkaloids, by wt. Standard not fixed 0.03 " 100 " stropbantbi . . Strop hanthus. 1 gm. in 20. c.c. 1 " 10 " tolutana .... Balsam of Tolu. 1 " 10.0 " 1 5 " veratri .... Veratrum. 1 " 2.5 " 1 " 10 " Trochisci cubebse Oleoresinof cubeb,by weight 0.25 gm. in each 0.125 " each Unguentum cbrysarobini . Chrysa robin, by weight. About 5.0 per ct. About 6 per cent. pbenolis. Phenol, by weight. " 5.0 " " 3 sulpburus Washed sulphur, by weight. " 30.0 " " 15 Vinum album Absolute alcohol, by weight. 10.0tol4.0 " 7 to 12 colchici seminis . Fluidextract of colchicum 1 gm. colchicum 1 c.c. fluidextract seed. seed in 6.67 c.c. of colchicum seed inlOc.c. ergotse .... Fluidextract of ergot. j 1 gm. ergot in 1 c.c. fluidextract 6.67 c.C. ergot in 10 c.c. rubrum .... Absolute alcohol, by weight. 10.0 to 14.0 per ct. 7 to 12 per cent. PAET I. GENERAL THERAPEUTICAL CONSIDERATIONS Before entering into a study of the action of drugs upon the living body, it is necessary that the student should possess a clear idea of what the word " therapeutics " means, that he should comprehend fully the reason why resort is had to drugs, and, more important than all, that he should grasp the limitations which govern the adminis- tration of remedies. Two unfounded ideas have been put forward by certain persons — one being, that medical therapeutics is useless; and the other, that this branch of medical knowledge is not advancing with so great a stride as are pathology and surgery. The individuals who deride the use of drugs in disease belong to one of two classes: either they have never tried them or have used them wrongly. The statement that therapeutics is to-day less advanced than are pathology and surgery is readily answered by a denial; for the thera- peutist is able to treat successfully many diseases of which the pathol- ogist knows nothing, and is obliged to rest his treatment on empiri- cism simply because he cannot tell how his drugs act if the pathologist cannot tell him in what the disease consists. Rheumatism and syphilis are good examples of this very point. In regard to surgery, every one must recognize the extraordinary advances made in this branch of medical science, yet comparatively few realize that it is solely by the proper use of drugs that all its tri- umphs are possible. The definition of the word "therapeutics" in Billings's Dictionary is: "That branch of medical science which treats of the application of remedies to the cure or alleviation of disease"; and practically the term is almost universally used to signify the employ- ment of drugs for such purposes. The credit for the introduction of new instruments and operations may be accorded to surgery, but the discovery of new drugs must be accorded to therapeutics. We find, then, that ether and chloroform began to revolutionize surgery more than sixty years ago, and that corrosive sublimate and other drugs have revolutionized it once more within the lifetime of every one who reads this book. Cocaine has changed the entire aspect of eye surgery and other minor operations, and has immediately averted an enormous 2 (17) 18 GENERAL THERAPEUTICAL CONSIDERATIONS. amount of pain and suffering which the surgeon could not mitigate, much less remove, in the absence of its influence. To the accusation of backwardness the therapeutist can well reply by asking the champion of any other branch of medical science to put forward one discovery which equals antipyrine or acetanilid in power to relieve pain; and last, but by no means least, he can point to those triumphs of modern therapeutics — the use of suprarenal gland as a vasoconstrictor, of thyroid gland for myxcedema, and of antitoxin for diphtheria. The man who does not believe in the proper use of remedies for the cure of disease lacks the very keystone of the arch upon which all medical investigation rests, for the ultimate aim and object of all medical thought and effort are the cure or alleviation of disease. Like every other thing requiring a thorough knowledge of its component parts, methods of treatment are often much abused by the careless and ignorant, but are a power for good in the hand of the properly educated physician. Further than this, therapeutics is the only universally used part of medicine, for each and every branch must resort to it, and the most expert operator who fails to treat his cases medicinally with equal skill will have worse results than he who, though bungling in his surgery, yet uses drugs intelligently after his operation is finished. Homoeopathy depends upon more than one reason for its existence. If infinitesimal doses are given, the patient is satisfied that he is receiv- ing medicine, and Nature often produces her most rapid cures when left alone. Again, the entire basis of homoeopathic therapeutics rests not upon the study of the causes of diseases, but upon the symptoms which constantly present themselves. As a result of this, many minor symptoms are relieved and the patient's confidence is won, although nothing is done to control the pathological process itself. No detail of diagnosis or treatment should be too small to attract the attention of the regular physician. The first duty of the physician when called to a case of illness is to reach a diagnosis as to the cause of the ailment, and not until he has formed a definite idea as to the condition which confronts him should he prescribe any medicinal agent. In certain cases where the symp- toms are severe or indicative of immediate danger it may be necessary to give relief by the use of temporary remedies, not only to save life, but also to remove symptoms which, because of their severity, mask the condition so that a diagnosis is impossible. Thus a patient may be found in collapse or in a state of syncope. The cause of this state may be obscure, but the pulse, heart-sounds, and respiratory action may indicate the need of immediate stimulation. In another instance agonizing pain, as that due to a crisis in locomotor ataxia, or renal or hepatic colic, may require a hypodermic injection of morphine as soon as the physician assures himself that the pain complained of is genuine. In other instances the case may be so obscure that several days of careful study may be necessary to reach a correct diagnosis, and during this time palliative remedies may be required. GENERAL THERAPEUTICAL CONSIDERATIONS. 19 Before ordering a drug or method of treatment the physician should have a clear conception of what he is trying to accomplish. No remedy should be given unless there is a distinct indication for its use. The old-fashioned "shotgun" prescription, containing many ingredi- ents, one or more of which might hit the mark, should be supplanted by the small-calibre rifle-ball sent with directness at the condition to be relieved. Having decided upon the remedy indicated, the physi- cian must next determine the dose required. This latter decision is almost as important as the first, for very often an error in dosage will cause failure of the remedy. A large part of the therapeutic skill of the physician consists in fitting the dose to the needs of his patient. In the treatment of all forms of disease the physician must never forget the following influential factors in the case, which are often of greater importance than the measures devoted to the treatment of the disease itself: 1. The maintenance of vital resistance by proper feeding. 2. The elimination of effete materials by the kidneys, bowels, and skin. 3. The relief of annoying symptoms which sap the patient's vitality and often obscure the true state of the system. 4. That sufficient physical and mental rest and sleep are obtained if. possible. 1. That the proper use of food in both acute and chronic illness is of great importance is not only manifest, but it has been proved by scientific investigation that lack of food often prevents the system from successfully combating the entrance and growth of infecting micro-organisms. The patient who has a greatly lowered vital resist- ance not only suffers from the effects of the particular disease by which he has been attacked, but not rarely dies from the growth of other micro-organisms which find him a fair mark for their attacks, thereby producing what Flexner has well called "terminal infections," and causing Osier to say that "a man rarely dies of the disease from which he is suffering," meaning by this that though he may be ill of a specific infection, other germs really produce the fatal issue. Care in feeding is therefore never to be ignored, and the various ways of feeding and preparing foods must be carefully studied. (See Part III.) 2. It would seem hardly necessary to insist on the importance of maintaining the active elimination of impurities from the body were it not that so little attention is paid by some physicians to these functions. In all infectious diseases the kidneys are required not only to eliminate the ordinary waste products of the body, which usually escape in this way, but in addition the increased waste produced by the fever and the poisons produced directly and indirectly by the growth of the invading micro-organisms. It is essential therefore that the patient shall pass urine in sufficient amount to carry off these substances, and this result often may be obtained by giving plenty of water to drink and increas- ing diuresis by the use of sweet spirit of nitre and citrate or acetate 20 GENERAL THERAPEUTICAL CONSIDERATIONS. of potassium. Nor is it sufficient to determine that the quantity of urine is normal. Estimations of the urea should be made in all serious cases, to ascertain whether the eliminating function of the kidney is active, for sometimes the flow of urine is sufficient, but the quantity of urinary solids is far below what it should be. Not rarely in disease, and even in apparent health, the patient states that his bowels have moved daily, and the physician is content with this report without making inquiries as to the quantity of the feces or whether the quantity is adequate in regard to the amount of food ingested. Even when the bowels are moved daily we may find after some days that there has been a partial retention of fecal matter, so that the colon becomes filled with feces. Sometimes moderate diarrhoea is an effort of nature to eliminate poisons, and is to be regarded as an aid to the patient, and not to be arrested by constipating remedies. It is also to be recalled that one of the functions of the liver is the elimination and destruction of toxic materials, and therefore the use of a cholagogue not only unloads the bowels, but also aids the liver in one of its most important duties. As the skin is an important eliminating organ, it must be kept clean by frequent washing, and if inactive it must be stimulated to increased activity by rubbing, and in some cases by hot packs or Turkish baths. (See Heat.) 3. It is of importance, as already stated, that symptoms which accompany the progress of various forms of diseases should be modified or removed if they become sufficiently active to produce much discom- fort or disturb the patient's rest. Headache, backache, itching, wind colic, etc., can often be entirely removed by simple means, and some- times without the internal use of drugs. It is, on the one hand, impor- tant to avoid unnecessary discomfort; and, on the other, care must be taken that in the use of remedies to relieve annoying symptoms we do not mask important diagnostic factors in the case or influence unfavorably the course of the malady. Thus in appendicitis it is wise, as a rule, not to give morphine to relieve the pain, as it will quiet the patient so as to lead him and his attendants to regard the condition as actually healed, when in reality the pathological process is rapidly progressing. Only when the pain is agonizing ought sufficient of the drug be given to allay the excess of pain, and never enough to mask the real condition. It is of vital importance that the physician be not content with the relief of symptoms alone, but that he shall regard them as of little importance, while he searches for and, having found, tries to remedy the diseased state itself. Thus it would be folly to treat the headache of unemia and fail to treat the cause producing it. Not infrequently care is not taken to discover whether the patient has sufficient sleep or rest. It is perfectly true that if a sick man lies awake an hour he is apt to believe he has been awake all night; but, on the other hand, in severe illnesses prolonged actual wakefulness is a very exhausting feature of the attack. Every one of experience has seen cases rally when apparently in a most serious state, and con- MODES OF ADMINISTERING DRUGS. 21 valesce, when a good sleep has been given them by the aid of judiciously used drugs. If the patient is getting about the normal amount of sleep in the twenty-four hours, hypnotics should be as much avoided as if they were poisons. MODES OF ACTION OF DRUGS. Drugs act in two ways, which are sometimes called near and remote, direct and indirect. The near, or direct, action of a drug is that influ- ence which is felt by the exercise of its effect directly upon the tissues with which it comes in contact; the indirect, or remote, influence is that result which comes as a sequence of its primary effect. As an illus- tration of this we may take the local use of cantharides. The local, near, or direct effect of this is a blister; the remote or indirect effect is the absorption of exudates or the influencing of inflammatory processes. If pilocarpine is used, its direct effect is the sweating which ensues, while its indirect effect is the relief of dropsy through the removal of exudate by the increased action of the skin, salivary glands, and the kidneys. MODES OF ADMINISTERING DRUGS. Drugs may be administered for the purpose of affecting the general system in many ways, but practically we employ only eight methods, as follows: 1. By the mouth or stomach; 2. By hypodermic injection; 3. By inhalation; 4. By the rectum; 5. By inunction; 6. By fumigation; 7. By the endermic method; 8. By cataphoresis. By far the most usual manner of administering drugs is by way of the mouth, which is the natural means of entrance into the body for foreign substances. Whenever medicines are used in this way the physician should clearly bear in mind what the medicine is to do after it is swallowed. Thus, if the drug is intended to act directly upon the stomach, it should not be given after meals, but some time before, since the food and gastric juice may afterward so cover the gastric mucous membrane that the medicament cannot act upon it. Thus, in a case of chronic gastric catarrh or gastric ulcer, the nitrate of silver which is used should always be given half an hour or an hour before meals. On the other hand, if an ulcer or other trouble exist in the small intestine, the pill should be given some time after meals, and if a heavy meal is taken, three or four hours after, since under these 22 GENERAL THERAPEUTICAL CONSIDERATIONS. circumstances the medicine is swept out into the intestine almost at once, without remaining any time in the stomach, where it may be chemically altered. Very often it is necessary to give a medicine soon after food is taken in order that it may not act in too powerful or con- centrated a manner upon the viscus which receives it or upon the general system by reason of its rapid absorption in concentrated form. The general rule, however, may be laid down that all medicines are to be taken after rather than before meals, unless a local gastric effect or very rapid absorption is desired. Next to the use of drugs by the mouth, by far the most popular method is their administration by means of the hypodermic needle and Fig. 1. Method of giving a hypodermic injection. The skin having been sterilized, the needle is then pushed into the subcutaneous tissues, as shown in the illustration. If the injection is given into the forearm, the skin of the part into which the injection is to be given is to be raised by grasping it between the thumb and fingers of the left hand to aid in holding the forearm steady. syringe. The logic of this method rests upon the absorption of all soluble substances from the subcutaneous tissues with great rapidity. Any substance soluble enough or suspendable enough to pass through a hypodermic needle without forming an obstruction may be employed, provided it is not too irritating and that it is " clean." The proper places to give such injections are the forearm on the extensor surface, 1 the calf of the leg, the buttock, or the broad of the 1 Hypodermic injections into the anterior aspect of the forearm often cause much pain in the hand by irritating temporarily the branches of the radial or ulnar nerves. MODES OF ADMINISTERING DRUGS. 23 back — in other words, any spot where the tissues are not dense and unyielding. The skin of the part is to be grasped or pinched up with the thumb and forefinger of the left hand and the needle sent well into this raised fold, preferably above the finger and thumb, so that the pressure of the fingers may prevent pain and hold the part steady. The needle should always penetrate well into the loose connective tissue, so that the liquid injected may find lodgment in the relaxed and spongy subcutaneous tissues without separating the skin from its rather close adhesions to the tissues below or from the bloodvessels supplying it, for if separation occurs abscess and a slough may result. Meltzer and Auer have shown that the rapidity of the absorption of a drug when given by the hypodermic needle is greatly increased if it be injected into the belly of one of the larger muscles. This rapidity of action almost equals that of an intravenous injection. The dangers from hypodermic injections are chiefly two. First: The needle may enter a vein, and the entire dose be carried at once, en masse, to the vital centres. Second: The solution or needle used may not be sterile, and an abscess result. The first danger is to be avoided by injecting into parts not well supplied with veins, and the second by thoroughly washing both syringe and needle with sterile water the instant before they are used, pushing a fine wire through the needle, and in some cases by soaking the instrument in carbolized oil. The solution injected should be prepared by using freshly boiled water and adding thereto carbolic acid in such proportion that one- half drop is present in each injection if a solution is to be permanent. It is claimed by some that this use of carbolic acid seriously hinders absorption, and in cases of urgency it should not be used. Most physicians now make a solution for immediate use by adding a small tablet of the required drug to 20 minims of water at the moment it is needed. A third danger supposed to exist by some persons, but prob- ably more feared than need be, is the injection of air into a vein with the medicament. It is well to see that all air is expelled from the syringe before making the injection. Most hypodermic syringes hold from twenty to thirty minims. When drugs are given by the rectum, we employ them for three purposes: first, to influence the general system by their absorption; secondly, to act locally upon any disease which may be present in this particular locality or in the colon; and, finally, to dislodge substances or parasites which it is desired to bring away. The word "enema" is loosely used to denote all these injections, be their purpose what they may, and is synonymous with "rectal injection " or the more old-fashioned word "clyster." If nourishment is being given, the injection is called a "nutrient enema." Sometimes these injections are called "lavements." In this mode of administration it is very necessary that the physi- cian should use the medicaments in proper bulk; and it may be laid 24 GENERAL THERAPEUTICAL CONSIDERATIONS. down as a rule that no more liquid should be injected than is neces- sary to convey the medicine or food, unless the injection is for the purpose of emptying the bowel of fecal matter or other materials, or it be desired to distend the bowel in order to overcome obstruction, or to influence the colon by drugs. The reason for this lies in the fact that any large bulk of liquid sent into the rectum so stimulates the walls by distention as to cause spasmodic contraction, with expulsion of all the rectal contents, which is just what is needed when fecal matter is to be removed, but the opposite of what is desired when retention of a remedy or food is necessary for absorption or local action. In rectal catarrh or ulcers two to four ounces of liquid are usually sufficient in an adult to accom- plish any medicinal influence locally or by absorption, while as a laxa- tive enema one to two pints may be employed. In the use of injections the rectum frequently becomes irritable, and resists all efforts to force the entrance of liquids or solids. This is to be avoided by giving the injection so gently that the bowel fails to recognize, as it were, the entrance of the liquid, and by introducing a few drops of oil and laudanum in each injection. A large amount of distress often follows the gradual accumulation of fecal masses in the colon which are not passed with the daily move- ment of the lower bowel. These can readily be removed by large injections of warm water or by the use of medicated liquids. A very important use of injections by the rectum is in the treat- ment of the various causes of intestinal obstruction. Here the greatest caution should be exercised that the injection be made with all possible gentleness, and be introduced slowly, the liquid being allowed to dribble into the bowel rather than to force its way. It is dangerous to use a greater pressure than is given by a fountain syringe at the height of two or three feet, as rupture of the peritoneal coat of the bowel may occur. Where a large quantity of water is used, it should be warmed to 100° F. or a little more, and it is well to add salt to it, so that it will represent the normal saline strength of blood-serum, namely, 0.7 per cent. (For use of injections in special diseases see Part IV., and for Enteroclysis, Part III.) Suppositories are another means by which medicines are introduced into the bowel, either for local effect or to act, after absorption of their contents, upon the general system. When drugs are given by inhalation they are generally employed with the object of affecting the respiratory tract alone ; notable excep- tions are ether, chloroform, nitrous oxide gas, and other volatile sub- stances. Aside from anaesthetics, are such remedial measures as the inhaling of steam laden with the drugs employed, the respiring of air charged with the fumes of the medicament, or the inhalation of gases, and last, and most commonly resorted to of all, the use of the vapor- izer, which, if properly made and employed, so minutely divides the liquid containing the medicament that the inspired air carries it to the MODES OF ADMINISTERING DRUGS. 25 farthest bronchiole and pulmonary vesicle. (See Part III.) Atomized sprays have also been found to possess great penetrating power in the treatment of inflammations under the skin or mucous membranes, as, for example, boils and carbuncles. As an example of the rules governing the administration of drugs in this manner we find that compound tincture of benzoin may be taken by inhaling the steam arising from hot water containing it, but cannot be used in a spray because it occludes the fine points of the atomizing tubes. In a similar manner the smoke of belladonna or tobacco-leaves may be inhaled to relieve asthma, or the fumes of chloride of ammo- nium for bronchitis in its later stages. Fumigation with mercury, the sublimed vapor being inhaled, is also useful in syphilis. Finally, we find that oxygen is sometimes very useful, the gas being readily inhaled, with good results in proper cases. The "spray" or atomizer is made in two forms — one form of appa- ratus being operated through the agency of compressed air, the other through the escape of steam from a small boiler. Very few of the compressed-air atomizers throw a spray sufficiently fine to reach the deeper parts of the lungs, particularly if the air is compressed by the hand; but all instrument-makers now sell vaporizers or nebulizers which so minutely divide the liquid medicament that it readily enters the deeper parts of the lungs. The inhalation of moist air is very useful in bronchitis, and greatly aids other remedial measures. Steam may be disengaged in a room by means of a kettle of boiling water or by placing pieces of unslaked lime in a pan of water. Inunctions consist in the rubbing into the skin of medicines generally of an oily or fatty nature, or which assume this character through embodiment with oil or fat. The three substances most commonly used in this way are cod-liver oil, mercurial ointment, and iodine oint- ment. They should always be applied on some part where the derm is thin and well supplied with subcutaneous lymphatics, as in the axillae, the groins, or the insides of the thighs. Other substances have been and may be used by inunction; but as this method is neces- sarily a disagreeable and dirty one, it is rarely resorted to unless the stomach is disordered or it is necessary to cause absorption of the drug by the system by every possible avenue of entrance. The endermic method consists in the use of a blister, by means of which the epiderm is raised, when a little morphine or other alkaloid may be slipped under it and so absorbed through the true skin. It is a painful method, almost never to be resorted to, having been supplanted by the hypodermic method of medication. Drugs are also sometimes caused to enter the body through the skin by placing them in plasters or poultices, or by the electrical process called cataphoresis. (Part III.) 26 GENERAL THERAPEUTICAL CONSIDERATIONS. Remedies are administered in a number of forms, but chiefly as follows : Abstracts are dry powdered extracts mixed with sugar of milk until they are twice as strong as the crude drug. Abstracts are no longer official in the United States Pharmacopoeia. Aceta, or vinegars, are solutions of the active principles of drugs in vinegar or dilute acetic acid. There are two in the United States Phar- macopoeia (Acetum Opii and Acetum Scillce) and three in the British (Acetum Cantharidis, Acetum Ipecacuanha?, and Acetum Scillw). Alkaloids are organic bases, forming salts with acid radicals, gen- erally occurring in crystalline form and abstracted from crude drugs. They nearly always represent the active principle of the drug. Aqtle, or waters, are used as vehicles either for the dilution of strong medicines or for the purpose of carrying minute amounts of flavoring materials. Cataplasms are not official in the United States Pharmacopoeia. They are virtually poultices made of linseed-meal or of bread-crumbs. Cerates are ointments containing wax to render them harder than would ordinary fats. Chart.e, or papers, consist of bibulous paper soaked in a solution of the drug which they are intended to carry. Confections are sometimes called electuaries or conserves, and are soft pastes which contain the drug mixed with sugar or honey. Decoctions are solutions of drugs made by boiling and then strain- ing while hot. Elixirs are diluted tinctures rendered pleasant to the taste by the addition of aromatic substances and sugar. Emplastra, or plasters, are made up of adhesive substances placed upon a backing of cloth or leather and designed to adhere to the skin, being so applied for the purpose of holding a medicinal substance in contact with the body, of acting as a protective, or of aiding in the approximation of the edges of a wound. Emulsions are liquid preparations which consist of oily substances minutely subdivided and held in suspension usually by some gummy material mixed with water. Extracts consist of the soluble parts of plants reduced to a semi- solid or solid condition by evaporation; the soluble constituents being taken from the plant by water or alcohol. Fluid Extracts are made in the same way as solid extracts, except that they are not so completely evaporated. Glycerita, or glycerites, are solutions of various substances in glycerin — the glycerin being used as a vehicle. Infusions are made by pouring boiling water on the crude drug and allowing it to stand for a short time until the water cools, after which the liquid is strained. Sometimes cold water is employed. Liniments are made of oily substances often mixed with powerful drugs to increase their efficiency. DOSAGE. 27 Liquors are usually watery solutions of non-volatile drugs. Mixtures are composed of two or more drugs or of a single drug partly dissolved and partly in suspension. Pills are small round masses which, as a general rule, should not weigh more than three grains, in order to avoid too great bulk. If the material is a heavy one, as much as five grains may be placed in each pill. Pills may be without covering or coated with sugar or gelatin to preserve them and prevent the patient from tasting their contents. Sugar-coated pills must always be fresh and the sugar- coating pure. Gelatin is the best coating for pills. Many pills are fraudulently coated with varnish and are insoluble. Spirits are alcoholic solutions of volatile substances. Suppositories are small masses made into a cone shape and having for their basis cacao butter. They are designed to carry into the rectum certain medicines for absorption into the system or for local action. Syrups are solutions of sugar or gummy substances in water. They are used as vehicles. Tablets. — Under this name manufacturing pharmacists and others prepare compressed pills or lozenges, generally of small size, the mass being made to adhere by means of its being subjected to great pressure by special machinery. Smaller tablets are used for carrying powerful drugs for hypodermic use. These, however, are often only lightly pressed, so as to render them easily soluble. Tinctures are solutions of the active principles of drugs in alcohol or in mixtures of alcohol and water. Triturates are made by adding 10 per cent, of the active medicine to 90 per cent, of milk-sugar, These are then carefully rubbed together until the two are intimately mixed. Triturates are valuable in the administration of medicines to adults or to children. These trit- urates are often made into tablets, forming what are known as "Tablet Triturates." Troches, or lozenges, are flat, hardened, medicated masses designed to be held in the mouth, so that they may be slowly dissolved, thereby affecting the local mucous membrane. Ointments, or unguents, consist of the mixture of some kind of fatty substance with the medicine which they are designed to carry. Wines are made in the same way as tinctures — strong white wine being used in the United States, and sherry or orange wine in Great Britain, in place of ordinary alcohol. DOSAGE. For several reasons there is no absolutely fixed rule which can be applied to dosage. In the first place, the individual may not be readily affected by drugs, or the disease-process present may so antagonize them as to render very large doses necessary. Further, 28 GENERAL THERAPEUTICAL CONSIDERATIONS. the age and sex of a patient have much to do with the regulation of the proper amount of a drug to be employed. Finally, that curious but common condition of susceptibility to various remedies, that we call idiosyncrasy, creeps in as an important factor in the decision as to the dose which should be given in each case. By far the nearest approach which can be made to absolute accuracy in dosage is to use drugs according to the weight of the patient, but this method possesses the disadvantages that we cannot always weigh our patients, and that the presence of a large amount of fat or of dropsy will make an unknown quantity in the calculation as to the true weight of the active part of the individual. At present we are accustomed to be governed by a list of doses to be given to all adults within certain limitations, and which are varied sufficiently to permit of great differences in the effects obtained. It is in this very point that the success of many a physician chiefly rests; for the use of a dose by "rule of thumb" is as empirical and lacking in thought as is use of a remedy, not because we have a definite action for it to carry out, but because it did some one else good who was suffering from what appears to have been a similar attack. The dose must be varied to fit the case in the same manner that the cut of a coat must be varied to fit each individual. There are a number of approximate rules in regard to the doses which are to be given in treating the diseases of children, the best of which is Young's rule. This is as follows: Add 12 to the age and divide by the age. Thus, if a child is two years old, we have the following formula: 2+12=14^-2=7, or, one- seventh of the dose for an adult is the dose for a child of two years. This rule is not a law, however, for of narcotics children should receive less than this (one-half), and of purgatives or laxatives more than this (two or three times). When drugs are given hypodermically the dose should be generally one-half to one-quarter of that given by the mouth; and if any sus- picion of idiosyncrasy exist, the dose should be smaller still at first if powerful remedies are to be used. By the rectum the dose should be twice the amount given by the mouth, unless the drug be very powerful or capable of very rapid absorption. When ordering liquid medicines in small amounts the prescription should always call for minims rather than drops, for the size of a drop varies with the particular liquid with which we are dealing and the shape of the mouth of the vessel containing it. This is well shown in the following table, compiled by Kinsey, and originally published in the American Journal of Pharmacy : DOSAGE. 29 Acetum lobeliae , Acetum opii Acetum sanguinariae . . . Acid, acetic Acid, acetic, dilute . . . . , Acid, carbolic Acid, hydrobromic. ... Acid, hydrochloric. . . . Acid, hydrochloric, dil. . . Acid, nitric Acid, nitric, dilute . . . . , Acid, nitrohydroehloric. . Acid, nitrohydrochloric. di lute Acid, phosphoric Acid, sulphuric Acid, sulphuric, dilute . . . Acid, sulphuric, aromatic. , Aqua ammoniae Aqua destillata Liquor potass, arsen Oleum anisi Oleum amygdalae amar. . Oleum cari Oleum chenopodii Oleum carophylli J Oleum cinnamomi Oleum crotonis Oleum cubebse Oleum gaultheriee Oleum hedeomse Oleum lavandulae Oleum monardae Oleum menthse pip Oleum menthae viridis . . . Oleum myristicee Oleum origani , Oleum pimentae Oleum rosmarini Oleum sassafras Dropped from & o 51 66 102 82 94 82 57 60 70 82 63 87 54 160 57 97 45 64 58 76 102 108 94 98 77 84 95 105 82 88 95 98 91 102 92 83 74 54 43 152 '47 94 41 '61 73 77 84 75 75 73 62 80 93 83 78 76 73 81 83 83 86 88 77 as 3 s 64 65 92 101 99 110 70 96 62 124 81 92 62 62 172 60 144 54 61 77 112 75 133 129 133 112 104 120 136 130 133 125 132 132 128 133 133 133 142 Oleum tanaccti . . . Oleum terebinthinee . Spiritus ammon. ar. . Spiritus camphoree . Spiritus aether, comp. Spiritus aether, nitr. . Spiritus menthse pip. Syrupus scillae comp. Tinctura aconiti . . Tinctura asafcetidae . Tinctura belladonnae Tinctura benzoini co. Tinctura cannabis ind Tinctura cantharidis Tinctura capsici ... Tinctura colchici . . Tinctura digitalis . . Tinctura ferri chlor. Tinctura hyoscyami Tinctura ignatiae . . Tinctura iodi .... Tinctura kino .... Tinctura krameriae . Tinctura lavand. co. Tinctura lobeliae . . Tinctura myrrhae . . Tinctura nucis vomicae Tinctura opii .... Tinctura opii cam ph. Tinctura opii deodor. Tinctura rhei .... Tinctura sanguinariae Tinctura stramonii . Tinctura tolutani . . Tinctura veratri virid Vinum aloes ... Vinum colchici rad. . Vinum colchici sem. Vinum ergotae .... Vinum opii Dropped from 110 103 108 98 120 88 98 106 120 102 94 98 124 118 116 86 114 108 114 112 112 116 117 97 110 100 112 98 94 109 98 110 100 120 108 71 92 86 148 87 102 85 81 81 120 97 88 97 100 79 95 105 92 82 a I ss 136 142 139 140 140 144 143 122 164 145 128 146 98 136 143 124 145 139 147 140 144 148 150 141 138 145 148 143 135 141 144 134 120 156 152 94 95 105 122 102 Fig. 2. Fig. 3. Fig. 4. Graduated medicine glasses. Doses are also ordered in teaspoonful, dessertspoonful, and table- spoonful quantities. Sometimes they are given by the wineglassful, meaning by this term a sherry-glassful. Roughly estimated, a tea- 30 GENERAL THERAPEUTICAL CONSIDERATIONS. spoonful equals a fluidrachm (4.0), a dessertspoonful two fluidrachms (8.0), and a tablespoonful half a fluidounce (15.5). As spoons and wineglasses vary considerably in capacity, it is always best to use a graduated medicine glass, such as is shown in Figs. 2, 3, and 4. WEIGHTS AND MEASURES. There are two systems of weights and measures employed in the United States at the present time. The one most commonly used is the old-fashioned system of Apothecary weights for solids, and the Wine, or Apothecary, measures for liquids. The newer and more accurate system is that known as the Metric, or Decimal system of weights and measures, which is now recognized and recommended by the Pharmacopoeias of the United States, Great Britain, Germany, and France. The divisions of Apothecary weights are the pound, the ounce, the drachm, the scruple, and the grain. The scruple, which equals 20 grains, has dropped out of use, chiefly because the scruple mark when written somewhat resembles that of the drachm. We may say, therefore, that the Apothecary weights consist of a pound, equalling 12 ounces, or 96 drachms, or 5760 grains; that the ounce represents 8 drachms, or 480 grains; and that the drachm equals 60 grains. The abbreviation for the word grain is "gr."; for the drachm, 3; f° r the ounce, 5 \ an d the pound, lb. In the Wine, or Apothecary, measures we have the gallon, the pint, the fluidounce, the fluidrachm, and the minim. In each gallon there are 8 pints, 128 fluidounces, 1024 fluidrachms, and 61,440 minims. In each pint there are 16 fluidounces, 128 fluidrachms, and 7680 minims. In each ounce there are 8 fluidrachms and 480 minims. In each drachm there are 60 minims. The abbreviation of the Latin word " minimum " or " minim " is n\ ; of the fluidrachm, f 3 ; of the fluidounce, f g ; of a pint, or "octarius," O; and of the gallon, or "congius," Cong. The British Pharmacopoeia has adopted the Avoirdupois system of weights, and thereby has a system which differs somewhat from the Apothecary weights of the United States Pharmacopoeia. The Avoirdupois pound represents 16 ounces, or 7000 grains; the Avoir- dupois ounce, 437.5 grains. It will be seen, therefore, that the Apothe- cary pound contains 1240 grains less than the Avoirdupois pound, but that the Apothecary ounce contains 42J grains more than the Avoirdupois ounce. Fortunately, however, the grain, both of the Apothecary and Avoirdupois systems, is of identical value. So, too, the British Pharmacopoeia uses what is known as the Imperial system of measures in place of the Wine measures used in the United States. Thus, the Imperial gallon represents 8 pints, 160 fluidounces, 1280 fluidrachms, and 76,800 minims; the Imperial pint, 20 fluidounces, 160 fluidrachms, and 9600 minims; and the fluidounce, 8 drachms or 480 minims. The fluidrachm equals 60 minims. It will be seen, there- WEIGHTS AND MEASURES. 31 fore, that the Imperial measure differs from the Wine measure chiefly in having 20 fluidounces in each pint, instead of 16. So, too, the weight of the Imperial fluidounce contains the same number of grains as the Avoirdupois ounce, which is 18.2 grains less than the weight of the United States fluidounce, which is 455.7. These differences between the weights and measures used in the United States and Great Britain are, therefore, of little importance when we are employ- ing grains or minims, but they become of great importance when we employ ounces, and of still greater importance when we employ pounds or pints. In the average prescription, however, which rarely exceeds three or four ounces, the difference in quantities in the United States and Great Britain are not of very great importance. The advantages of the metric system over these irregular systems of weights and measures are the same as those of the decimal system of currency over the English system of pounds, shillings, and pence. The unit of all calculations is the metre, which in the metric system is the unit of length. From this is derived the unit of capacity, the litre, which is the cube of one-tenth of a metre; and from the litre is derived the unit of weight, the gramme, which is the one-thousandth part of the weight of a litre of distilled water at its maximum density. As a matter of fact, the metric system is no more difficult to master than is the system of dollars and cents. The great difficulty is that the majority of physicians having learned the doses of various prepara- tions in the Apothecary weight find it difficult to begin using the metric system, and do not take the trouble to convert the Apothecary doses into this system. In the metric system we have the gramme, which may be said to be the equivalent of the dollar; the decigramme, or one-tenth of a gramme, which represents the dime; the centigramme, or one-hundredth of a gramme, which represents the cent; the milligramme, or the one- thousandth of a gramme, which represents the mill. Above the gramme in quantity we use what is known as the decagramme, which corresponds to the gold eagle, or ten dollars; the hectogramme, which corresponds to one hundred dollars ; and the kilogramme, which corre- sponds to one thousand dollars. When we come to the use of the metric system for fluids, we use as the unit the cubic centimetre (c.c.) in place of the gramme; a cubic centimetre representing 1 fluid gramme. When it is wished to convert grains into their metric equivalent, it must be remembered that 0.065, or 65 milligrammes, is the equiva- lent of 1 grain. Therefore, the following examples may be used: 3 grains are 60 grains " i grain is equal a to 3 X 0.065 = 0.195 " 60 X 0.065 = 3.9 " \ of 0.065 = 0.0162 gramme. grammes. 1 gramme. rb g rain is ti " T ^ of 0.065 = 0.00065 Usually considered 4.0. gramme. 32 GENERAL THERAPEUTICAL CONSIDERATIONS. To convert grammes into grains, instead of multiplying by 0.065, we divide, thus: Gramme 0.12 is equal to 0.12 Grammes 3.9 are " " 3.9 Gramme 0.06 is " " 0.06 Gramme 0.0006 " " " 0.0006 0.065= 1.8 grains. 0.065 = 60 grains. 0.065= 0.9 grain. 0.065= 0.0092 grain. When we wish to convert apothecaries' drachms into grammes, we multiply the number of drachms by 3.9, or more commonly, though less accurately, by 4.0. Thus: 10 drachms X 4.0 == 40 grammes, or, more accurately, 10 drachms X 3.9 = 39 grammes. When grammes are to be converted into drachms, we divide the number of grammes by 3.9, or approximately 4.0. Thus: 10 grammes -r- 3.9 = 2.56 drachms, or, less accurately, 10 grammes -=- 4.0 == 2.5 drachms. When Apothecary ounces are converted, we multiply by 31.1; or, if grammes are to be converted into ounces, we divide by 31.1. Thus: 2 ounces X by 31.1 = 62.2 grammes. 40 grammes -r- by 31.1 = 1.25 ounces. As accurate translation of apothecaries' weights into the metric system leaves a fractional quantity in almost every instance, and as the translation of the metric system into apothecaries' weights does likewise, the author has for the sake of presenting even figures, and therefore rendering the interchange practicable, considered that the Apothecary ounce and the fluidounce are equal to 30 grammes or 30 cubic centimetres, although a more accurate estimate of the ounce is 31.1 and of the fluidounce is 29.57. WEIGHTS AND MEASURES. 33 TABLES OF RELATIVE WEIGHTS AND MEASURES IN THE METRIC AND APOTHECARIES' SYSTEMS. (See Oldberg's Manual of Weights and Measures.) Milligrammes in Grains. Milligramme Grain. Milligrammes. Grain. Milligrammes. Grain. 0.1 == ~sm 1 = eV 8 = 1 8 0.2 = SWU 1.2 = l 9 = y 0.3 = l 2^0" 1.6 = A 10 = i 6 0.4 = 1 T50 2 = sV 12 = * 0.5 = T20" 3 = ^ 16 = 1 4 0.6 = TOO 4 = tV 20 ■ = * 0.7 = 9 X 5 = A 30 = 1 0.8 = & 6 = A 60 = 1 0.9 = yV 7 = 1 C CENTIGRAMMES in Grain s. Centigrammes Grain. Centigrammes. Grains. Centigrammes (or Cent.) (or Cent.) (or Cent.) Grains 1 = I 6 = 1 18 = 3 2 = l if 7 =3 1* 25 = 4 3 = 1 2 9 = H 50 = 8 4 = 2 10 = if 75 = 12 5 = f 12 = 2 . 100 = 16 Grammes in Grains. Grammes. Grains. Grammes. Grains. Grammes. Grains. 0.001 = l SO 11 = 176 27 = 432 0.010 == * 12 = 192 28 = 448 0.100 = If 13 = 208 29 = 464 0.250 = 4 14 = 224 30 = 480 0.500 = 8 15 = 240 31 = 496 0.750 = 12 16 == 256 32 = 512 1 = 16 17 = 272 33 = 528 1.50 = 24 18 = 288 34 = 544 2 = 32 19 = 304 35 = 560 3 = 48 20 = 320 36 = 576 4 = 64 21 = 336 37 == 592 5 = 80 22 = 352 38 = 608 6 = 96 23 = 368 39 = 624 7 = 112 24 == 384 40 == 640 8 = 128 25 = 400 50 = 800 9 = 144 26 = 416 100 = 1600 10 = 160 34 GENERAL THERAPEUTICAL CONSIDERATIONS. Cubic Centimetres (or Fluidgrammes) in U. S. Apothecaries' Fluidrachms. Cubic Centimetres. 1 2 3 4 5 6 7 U.S. Fluidrachms. 1 4 l 2 If = 2 Cubic Centimetres. 9 ' 10 11 12 13 14 15 U.S. Fluidrachms. = 2| = 2i = 2f = 3 = H = 3* = 3f Cubic Centimdtres. 16 20 24 28 32 48 64 U.S. Fluidrachms. 4 5 6 7 8 12 16 ABSORPTION OF DRUGS. Knowledge of the rapidity with which certain drugs are absorbed from the various surfaces with which they come in contact is of impor- tance in order that we may know when to repeat the dose if the first amount does not produce the desired effect. The rapidity of absorption depends upon a number of factors. If the circulation is active, absorp- tion is rapid; but if it be depressed, absorption is slow. Thus, in a person apparently drowned, absorption may not occur at all until the vital functions are restored, and repeated doses given to the patient while unconscious, acting together, in the end poison him. This is often the case in delirium tremens when hypodermic injections of morphine are given or when the drug is administered by the mouth. In dropsy absorption is peculiarly slow, and a medicine may remain in the tissues for days, only to be absorbed with the exudate after severe purgation or profuse diuresis, or tapping. In general dropsies hypodermic medication is nearly always worse than useless. When the stomach or bowel is empty absorption from either is rapid, but when they are full it is very slow. In this fact we find the reason for the popular idea that a glass of whiskey when a man is hungry makes him drunk, whereas twice the quantity after a meal does not do so. Drugs in the stomach or bowel have no influence upon the general system unless they are irritants. They only act when taken into the blood or lymphatics. Recent studies show that alcoholic solutions of drugs are more rapidly absorbed than are watery solutions or those made with glycerin or milk. When the stomach is atonic and its powers of absorption impaired, the addition of some irritant or stimulant, such as capsicum, will often aid in the absorption of the necessary drug. COMB IN A TION OF BE UGS FOB JOINT EFFECT. 35 DURATION OF ACTION OF DRUGS. The duration of the action of drugs depends partly upon their rapidity of absorption, but chiefly upon the rapidity or slowness of their destruc- tion in the body or their elimination from it. Thus, volatile substances, such as ether, chloroform, and nitrite of amyl, act only for a short time and are quickly eliminated; whereas bromide of potassium and digitalis continue active during many hours, and are slowly eliminated, as in the case of the former, or oxidized, as in that of the latter. Again, if curare is given hypodermically it will cause paralysis, but if taken by the stomach in moderate amount it will be eliminated by the kidneys as rapidly as it is absorbed, and produce no effects if these organs are active. From studying the rapidity of the elimination of a drug we learn how often to order a dose. Thus, digitalis may be given once, twice, or thrice a day, but carbonate of ammonium every two or three hours. When the physician is not careful in the use of a potent drug which is eliminated slowly, it may suddenly develop so severe an effect as to cause alarm, owing to its accumulation in the body. This is called "cumulative action." COMBINATION OF DRUGS FOR JOINT EFFECT. The study of the physiological action of drugs has aided very greatly in improving our therapeutic measures, Thus, we now know that chloral is a heart-depressant and cannot be used in very full doses, or pushed to produce sleep in persistent insomnia, without grave danger; whereas morphine, which also produces sleep, but does not depress the heart, but does depress the respiration, can be combined with it, and the two acting together, each in small dose, produce a heavy sleep, although so little chloral is present that the heart is safe, and so small an amount of morphine is used that the respiration does not suffer. Another example of this is found in certain purgative pills where the purgative agent is assisted by belladonna and nux vomica, the first of which relaxes muscular spasm, while the second acts as a tonic to the alimentary tract, the drugs combining to accomplish one result. Skill in the combination of drugs, not only for increased physiological effect, but also for the purpose of making their administration pleasant to the taste, has much more to do with professional success than is generally supposed. This is particularly so in regard to children, for parents dislike forcing their children to take doses which they them- selves regard as unpleasant, and they are ever ready to believe that as long as a medicine tastes good it is better than one which tastes other- wise. The medical practitioner who prescribes never so wisely and appro- priately for a patient, but who is utterly regardless as to his combina- 36 GENERAL THERAPEUTICAL CONSIDERATIONS. tions of drugs so far as taste is concerned, will sooner or later see a more ignorant man take from him that practice which his greater wisdom entitles him to, but which is driven from him by his own errors in this matter. While in some cases there is no alternative but to give an unpleasant dose, in others a little thought and care will often avoid offending the taste of the patient. STRENGTH AND RELIABILITY OF DRUGS. If a census could be made of those who die annually from the use of drugs which are impure or useless from weakness, the writer believes that a most alarming array of figures would be presented. For many years this was unavoidable to a great degree, either because our knowl- edge of the active principles of drugs and the methods of isolating them was deficient, or because the time consumed in their transportation by sailing vessels or on the backs of natives from the countries in which the natural products yielding the drugs were obtained, permitted deterioration to take place. At present these difficulties have been largely overcome. The trained pharmacist is taught how to make an assay for active principles in most of the valuable alkaloidal drugs, and every physician should make careful investigation into the quality of all preparations which he employs. That these remarks are not out of place will be seen by the fact that not long since an intimate friend of the writer bought from five of the leading druggists of Phila- delphia six ounces of tincture of nux vomica which were stated to have been made according to the directions of the United States Pharma- copoeia. That made by perhaps the leading druggist of the five con- tained twice as much strychnine and brucine as it should, and had twice as much solid residue; or, in other words, a physician prescribing this tincture in full dose would probably have poisoned his patient and reported the case as one of unusual susceptibility to drugs! On the -other hand, the author has recently seen a tincture of nux vomica which contained only a trace of alkaloid, but had much inert solid residue. In neither instance was the druggist dishonest intentionally, but one had used a crude drug which was unusually rich in alkaloids, while the other had purchased nux vomica beans which, by reason of immaturity, bad surroundings, or exposure to weather, were very poor in active principles. All these disadvantages may be avoided if physi- cians will insist that the druggists who dispense the drugs they order shall either themselves prepare assayed products, or purchase such products from any one of the large manufacturing chemists who put assayed goods on the market. When this is impossible, the physician should employ the alkaloids in pill form, or, if solutions are desirable, the alkaloid may be added to alcohol or water and given by drops, as is the case with any ordinary tincture. Digitalis, veratrum viride, and ergot are practically the only drugs of importance of which an assay IDIOSYNCRASY. 37 cannot be made; in the first and third the action of the drug does not depend upon a single active principle, but upon a number difficult of assay, and in the second the relative proportions of jervine and veratroidine cannot well be estimated. All drugs should be physiolog- ically tested when their chemical assay is impossible. Not long since several thousand pounds of ergot were found to be worthless on being tested physiologically by one firm; but it was put on the market never- theless, for certain manufacturers do not employ this method of exam- ination. Constant uncertainty is a dangerous element when dealing with patients who are desperately ill; and in many cases failure and discouragement may both be avoided if the physician will see to it that the drugs which he administers are capable of doing what he requires of them. A poor drug to the physician is worse than a rusty knife to the surgeon; for the injury in the one case is unknown, while in the other it can be carefully watched and guarded. IDIOSYNCRASY. This is one of the most interesting features of the study of the action of drugs. It is a frequent cause of disappointment to both patient and physician, and an equally frequent cause of excessive action from what the medical attendant has thought to be a moderate dose. No rule can be laid down for the discovery of idiosyncrasy in a given case, except that females, particularly of the hysterical type, are more sub- ject to it than are males, although certain men often present marked evidences of this tendency. No better illustration of idiosyncrasy can be adduced than the case which here follows, nor than that of a friend of the author who cannot eat a strawberry without suffering from a violent attack of hives. The first case is that of a woman of thirty years, suffering from severe headache, who received an eighth of a grain of the hydrochlorate of pilocarpine, hypodermically, every twenty minutes, until nearly three-fourths of a grain was taken, without any evidence of its action either in salivary flow or sweat. But the tolerance of drugs did not stop here. Twenty drops of tincture of cannabis indica every four hours failing to relieve the pain, half -grain pills of the solid extract were ordered, two of which commonly affect a grown man most markedly. The extract had been proved to be active to other patients. In order to avoid any failure in absorption the pills were each cut in half before they were given, and forthwith administered, one every three hours, without any effect after ten had been taken. Twenty more of the pills from the same manufacturers, but from a different retailer, were now given, one every hour with the exception of a few irregularities in administration during the night, the entire twenty being swallowed between four o'clock one afternoon and two o'clock the next after- noon. The thirty pills (fifteen grains) were taken in less than forty- eight hours without producing a single physiological sign of the slightest 38 GENERAL THERAPEUTICAL CONSIDERATIONS. character. That the doses were really swallowed would seem to be undoubted, for their administration was carried out by a trained attendant, and their black color forbade their expulsion from the mouth on the bed without attracting attention. The hypodermic injections were given by the author, and, as the solution was used as fast as it was made, the patient must certainly have received all of the pilocarpine. As there was daily an afternoon rise of temperature amounting to several degrees, quinine bisulphate was ordered in the dose of fifteen grains, to be given after six powders of one-sixth of a grain of calomel had been taken; this not only failed to control the fever, but also produced no buzzing in the ears. The writer was now inclined to consider all the symptoms as hysterical, even including the evening rise of temperature. Twenty-four hours after the last dose of cannabis indica the attendant gave the patient, without orders, no less than sixty grains of antipyrin in sixteen hours without any physio- logical symptoms, and, under orders, she took from forty to fifty grains of bisulphate of quinine every day for three days without any signs of cinchonism. Wide experience has taught us, however, that several conditions act fairly constantly in regard to some idiosyncrasies. Certain dis- eased conditions— such as peritonitis or pain — allow large doses of opium to be given, and in lead-poisoning and paralysis patients may require enormous doses of active purgatives to move the bowels. The climate in which the patient lives, or has been accustomed to live, renders him more or less susceptible to certain remedies. Thus the East Indian runs amuck after eating hasheesh or cannabis indica, or the Chinaman goes into a delightful dreamland from smoking opium, whereas the Anglo-Saxon experiences no such agreeable sensa- tions, as a general rule. Southerners generally require larger doses of purgatives than Northerners, often because their livers are not so active. The temperament of an individual is also a highly important matter to be considered. It is a notorious fact that phlegmatic dark-skinned individuals usually yield to drugs less readily than blondes and nervous persons, more especially in respect to the drugs which act on the ner- vous system. Nervous light-haired women stand belladonna very badly as a general rule, while children will take large doses often with- out discomfort. Opium is usually badly borne by children. Habit is another important factor governing idiosyncrasy. We all know how rapidly one becomes accustomed to tobacco, and how morphine habitues take enormous amounts of their favorite drug without effect. INDICATIONS, CONTRAINDICATIONS AND DEFINITIONS. 39 INDICATIONS AND CONTRAINDICATIONS AND DEFINITIONS. The indication for a drug is any symptom or series of symptoms which we know the drug will relieve without causing at the same time an evil effect to be felt by other parts of the body. A contra- indication is any coexisting state or tendency which will be made so much worse by the drug as to forbid its use. Thus, one might be tempted to give quinine in meningitis for the fever, yet this would be bad therapeutics, since quinine is contraindicated because it will increase the congestion. Abortijacients form a class of drugs which, as such, ought never to be employed. If pregnancy is to be interfered with, the interruption should be produced by instrumental means, and then only after con- sultation with another practitioner to get his views and protect one's self from possible legal difficulties. Alteratives are indicated where cell-growth is active to excess, but contraindicated where tissue break-down is present, or there exists a tendency thereto. Anesthetics are used to abolish sensation. They are either local or general. Many of the local anaesthetics produce loss of sensation through benumbing the parts by the cold they produce. Cocaine is an example of a local anaesthetic which causes anaesthesia by a direct paralyzant action on the peripheral sensory nerves. The general anaesthetics are taken by inhalation and act upon the higher centres in the brain. Anaphrodisiacs are used to diminish sexual desire. Antacids are employed in cases where, as a result of morbid pro- cesses, lactic and butyric acids, or even hydrochloric acid, are found in abnormal quantities in the stomach. Anthelmintics are used for the purpose of removing intestinal worms. Antiarthritics is the name given those drugs which are employed for the purpose of relieving inflammations occurring in joints, whether these be in an acute or chronic condition of disease. Antihydrotics are used to prevent excessive sweating, either local or general. Camphoric acid is probably the best general antihydrotic. Antiperiodics is a term applied to drugs or remedies employed for the prevention or cure of malarial poisoning. They are so named because they tend to diminish or arrest the periodicity of the attacks, which periodicity is a characteristic of such diseases. Antiphlogistics are employed to prevent the progress of inflam- matory processes. They axe nearly all contraindicated in the presence of tissues possessing impaired vitality through previous conditions of disease. Aphrodisiacs are used to increase sexual desire and power. 40 GENERAL THERAPEUTICAL CONSIDERATIONS. Astringents are employed for the purpose of contracting or con- stringing tissues. They act either by coagulation of albumin, by pre- cipitating albumin, or by making the tissues more dense by concentra- tion. Theoretically, all astringents should be non-irritating, but practically they possess irritant properties, and are, in consequence, contraindicated in the presence of very acute inflammations as a rule. Three of the mineral astringents, however, possess marked sedative properties in addition to their astringent power, and can therefore be used freely in acute inflammations when locally applied. They are nitrate of silver, subacetate or acetate of lead, and the subcarbonate or subnitrate of bismuth. Bitters are designed to increase the activity of the mucous mem- brane of the gastro-intestinal canal by increasing its tone. They may be divided into simple bitters and complex bitters. The first depend upon their bitterness solely for their activity; the second class is well represented by quinine and strychnine, both of which are exceed- ingly bitter, but, in addition to their local effect on the gastro-intestinal mucous membrane, act as stimulants to other portions of the organism. A good example of a simple bitter is columbo. Many bitters contain so much tannic acid that they are not generally useful, and for this reason very few can be used with preparations of iron, since a tannate of iron would be formed. Cardiac sedatives decrease the force of the heart, and, as a class, the amount of blood expelled at each beat of the ventricles. They are indicated in arterial excitement, and contraindicated in arterial depression. Cardiac stimulants increase the force of the heart, thereby increas- ing the quantity of blood expelled from the ventricles. Their effect may be accomplished by an increase in the rapidity of the beats or by a greater output of blood at each contraction, the diastole being sufficiently prolonged to admit of the ventricles being well filled. They are contraindicated in the presence of arterial excitement, and indicated in arterial depression. Carminatives are given for the purpose of expelling flatus, particu- larly if there is reason to believe that the "wind" has accumulated because of intestinal torpidity. Many of the carminatives are neces- sarily possessed of irritant properties, and are therefore contraindicated in the presence of flatulence due to intestinal atony arising from inflammation. The best carminative is spiritus setheris compositus, or Hoffmann's Anodyne. Cathartics. — These are drugs employed when a positive and decided action of the bowels is desired. They occupy a position between the purges and the drastics. (See Purges and Drastics.) A good example of a cathartic is senna when given in full dose. Cholagogues are used to exert a stimulant influence over the flow of bile. Nitro-hydrochloric acid and mercury bichloride are perhaps the best types of pure cholagogues, while podophyllum and calomel INDICATIONS, CONTRAINDICATIONS AND DEFINITIONS. 41 represent the class of cholagogues which increase intestinal peristalsis in addition to stimulating the flow of bile. Cholagogues are, as a rule, contraindicated in the presence of acute inflammation of the gall- bladder or liver. Counterirritants are used to produce irritation at a spot distant from a painful or inflamed area, in order to relieve the diseased parts by reflex action exerted through the nervous system upon the painful nerve or disordered capillary network. Demulcents are used to protect from irritation any exposed parts of the body. Diaphoretics produce an increased secretion from the sweat-glands. They may be considered as internal and external. The internal are represented by pilocarpine, which stimulates the sweat-glands them- selves; the external are represented by the Turkish and Russian baths, which, by increasing bodily heat and dilating bloodvessels, cause a profuse sweat. Diuretics are used to increase the flow of urine from the kidneys. They act by stimulating the renal epithelium to greater activity, thereby increasing the excretion of both the watery and solid con- stituents of the urine ; or they simply increase the watery constituents by increased blood-pressure in the kidney. It is to be remembered that the vegetable salts of potassium and the lithium salts increase the solids in the urine, not by stimulating the secreting epithelium of the kidney, but by uniting with insoluble material in the system, forming soluble compounds which are then readily eliminated. (See Eliminators.) They are indicated in con- ditions of renal inactivity due either to functional or organic causes. Irritating diuretics, such as cantharides, for example, are contraindi- cated in acute nephritis. Such a diuretic is only to be used where the kidneys are inactive through atony or prolonged chronic or subacute disease. Eliminators are drugs which, by forming soluble compounds with insoluble substances in the body, render them capable of being excreted by the excretory organs, such as the skin, kidneys, and bowels. Emetics are used to produce vomiting. They act centrally when, as is the case with apomorphine, they stimulate the vomiting centre; peripherally when they irritate the walls of the stomach. They are indicated when we wish to unload the stomach of undesirable materials, or when we desire to cause an increased flow of bile from the gall-bladder, which is accomplished by the pressure exerted upon this viscus when the abdominal walls and diaphragm contract in retching. When the ducts are mechanically obstructed by a gallstone emetics are dangerous, as they may cause rupture of the gall-bladder. Sometimes we are able by the use of emetics to rid the lungs and stomach of mucus in bronchitis or gastric catarrh. The contraindications to emetics are cerebral congestion or menin- gitis, gastritis, gastric ulcer, advanced pregnancy, and hernia. 42 GENERAL THERAPEUTICAL CONSIDERATIONS. Emmenagogues are used to produce or increase the menstrual flow. They are of two classes — direct and indirect. The direct are most of them irritants, and are seldom of much value; the indirect are used to overcome the morbid condition underlying the men- strual disorder, and are therefore more rational. Thus iron and arsenic may be used with beneficial result in amenorrhcea due to anaemia. Expectorants are employed when it is desirable to promote secretion or to get rid of secretion in the bronchial tubes. Thus, in the early stages of an acute bronchitis the mucous membrane is hyperaemic and swollen, but dry and irritable. Ipecac and citrate of potassium form at this time a sedative expectorant mixture, which, while allay- ing irritation, promotes secretion and so relieves the engorged area. On the other hand, after the acute stage is passed, there may be so much atony of the mucous glands that the secretion is either too scanty or too viscid to be coughed up. Stimulant expectorants, such as chloride of ammonium, eucalyptus, and terebene, are now to be em- ployed. These latter drugs are contraindicated in the acute inflam- matory stage of the disease, as they would simply stimulate the mucous membrane to greater irritation. Hypnotics are used to produce sleep. They may be divided into those which produce sleep and relieve pain, and those which have no analgesic power. The latter are therefore not to be employed in sleeplessness due to pain, and the former are contraindicated when pain is absent. Thus, chloral produces sleep if it be ordinary func- tional insomnia; but if the sleeplessness is due to pain, opium is the drug to be employed. Chloral, in ordinary doses, is the purest hypnotic that we have. Mydriatics produce dilatation of the pupil, or mydriasis. Condi- tions of the eye associated with increased intraocular tension are contraindications to mydriatics, as a rule. Myotics cause contraction of the pupil or myosis. They are best represented by eserine. Nervous sedatives are indicated and contraindicated in a reverse manner to nervous stimulants. Nervous stimulants are contraindicated in nervous excitement, and indicated in nervous depression. Oxytoxics increase the expulsive power of the uterine muscular tissues. Revulsives are used to produce increased activity of the general system or parts thereof through reflex influences — that is, they cause a determination of blood to one part, thereby relieving an engorged area. Thus, in cerebral congestion or effusion a vigorous purgative or cathartic may give relief by exercising a derivative effect. Revulsives are closely allied to counterirritants. Roborants are devoted to the repair and building up of tissues in the body, and comprise both food and drugs. Roborant treatment INCOMPA TIBILITY. 43 also includes hygienic surroundings, fresh air, light and healthful employment. Tonics are used to increase vital activity. They are indicated in local or general, systemic depression, and contraindicated in cases of inflammation or excitation with excessive functional activity. (See Bitters.) Vasomotor depressants decrease arterial pressure by an action on the vasomotor nervous system rather than by an action on the heart. They act by relaxing the bloodvessels. Vasomotor stimulants increase arterial pressure by an action on the vasomotor system, thereby producing contraction of the blood- vessels. INCOMPATIBILITY. One of the uses of a knowledge of chemistry and pharmacy to a prac- titioner of medicine is the avoidance of what is known as an ''incom- patibility/' or the placing in a prescription of two or more substances which will undergo chemical interchanges, decompositions, precipita- tions, or cause the formation of explosive mixtures. It is impossible to detail all the incompatibilities, and only the most dangerous and common possibilities of error can be considered: 1st. An acid should never be combined with an alkali. 2d. A strong acid should not be added in any quantity to a tincture. The following prescription is an illustration of this : Jy — Potassii iodidi o i j - Acidi nitro-muriatici f5j- Ti\ cinchonse comp q. s. fSiij. — M. S. — Use as directed: a teaspoonful. In this ridiculous mixture the acid is incompatible with the iodide of potassium, forming a chloride and setting free iodine, and would also change part of the alcohol in the tincture into an ether. 3d. Alkalies and neutral bases should not be combined with the alkaloidal salts. 1^ — Strychninae sulph. . gr. j. Potassii iodidi 5ij. Syr. sarsaparillse comp. fBiij. — M. S. — Teaspoonful t. i. d. In this prescription the strychnine would be precipitated by the potassium salt, and the patient would get nearly all the strychnine in the last dose. 4th. Potassium chlorate should not be ordered to be rubbed up with tannic acid nor any other organic substance capable of oxidation, as it will explode. Permanganate of potassium is subject to the same rule. 44 GENERAL THERAPEUTICAL CONSIDERATIONS. 5th. Chlorate of potassium and ammonium chloride when mixed together may ignite. 6th. Iron is incompatible with tannic acid, as it forms a tannate of iron, or ink. As all the vegetable astringents contain tannic acid, they should none of them be used with iron except chiretta and columbo. 7th. Tannic acid should never be added to solutions of alkaloids. 8th. Gum arabic is not to be added to solutions of iron, lead, or the mineral acids. 9th. Alcoholic solutions of camphor and similar resinous substances are incompatible with water. 10th. Fluid extracts are incompatible with water, as the addition of water will precipitate them. 11th. All salts not acid but alkaline in reaction are decomposed by acids. 12th. All salts which are acid are decomposed by alkalies. 13th. All vegetable acid salts are altered by mineral acids and are decomposed by alkalies. 14th. Iodine and the iodides should not be given with alkaloids. 15th. Corrosive sublimate, the salts of lead, iodide of potassium, and nitrate of silver should always be prescribed alone, except in the follow- ing instances: (a) Corrosive sublimate may be given with potassium iodide, since it will throw down a precipitate which redissolves and forms a double salt. (6) Nitrate of silver maybe used with extract of opium or hyoscyamus. 16th. Syrup of squill should not be given with the carbonate of ammonium, as it contains acetic acid. Chloride of ammonium is not incompatible with it. 17th. Cherry-laurel water should not be prescribed with morphine, as it may form the poisonous cyanide of morphine. 18th. Chloral and cyanide of potassium should never be placed in the same prescription, as they will decompose each other, setting free hydrocyanic acid. 19th. Cocaine and borax when added together form an insoluble borate of cocaine. Boric acid and cocaine do not result in this forma- tion. 20th. Calomel and antipyrin are incompatible, as are also sweet spirit of nitre and antipyrin. 21st. Waters cannot be used in preparing saturated solutions of drugs, as they are already loaded with the volatile substance. 22d. Pepsin and pancreatin should not be used together, since the former can only act in an acid and the latter in an alkaline medium, and the pancreatin is destroyed by the acid gastric digestive process Further, one ferment may neutralize the other. CLASSIFICATION OF DRUGS. 45 THE IMPORTANCE OF DIETETIC TREATMENT. Many physicians fail to pay proper attention to the regulation of the diet when treating those who are ill or "out of sorts." As a matter of fact, the administration of medicine often fails to produce good results simply because the patient, by persisting in the use of improper food and drink, is perpetuating the difficulty of which he is trying to get rid. There is scarcely a case in which some regulation or alteration of the diet will not be of advantage to the sick man. (See Foods for the Sick.) Further than this, failure to give directions as to diet is apt to give the patient the idea that the physician is careless, whereas care in this respect will greatly enhance his estimate of the physician's ability to attend to important details of the case. CLASSIFICATION OF DRUGS. In order that the student may gain a definite idea as to the various actions of different remedies the following list of drugs is appended, which is of necessity somewhat arbitrary, and is not intended to be exhaustive, for many remedies might be placed in several classes. The endeavor has been made to place the best or most powerful drug of each class first in the list. It is to be remembered that a strict physiological classification is impossible. '. Alteratives. III. Antacids. 1. Mercury. 1. Ammonia. 2. The iodides of potassium and so- 2. Sodium and its salts. dium. 3. Liquor potassse. 3. Iodine. 4. Magnesia. 4. Iodoform. 5. Lime. 5. Iodol. 6. Arsenic. 7. Cod-liver oil. IV. Anthelmintics. 8. Colchicum. Those that are used against the round 9. Ichthyol. worm are — 10. Taraxacum. 1. Santonica. 11. Mezereum. 2. Spigelia. 12. Nuclein. 3. Chenopodium. 4. Azedarach. I. Anesthetics. .. 5. Santoninate of sodium. 1. Ether. 2. Nitrous oxide gas. 3. Chloroform. Those used against the tape-worm are— 4. Cocaine. * 1. Pelletierine. 5. Eucaine. 2. Aspidium. 6. Bromide of ethyl. 3. Pepo. 7. Chloride of ethyl and of methvl. 4. Pomegranate. 8. Pental. 5. Brayera. 9. Bromoform. 6. Kamala. 10. Carbolic acid. 7. Turpentine. 11. Antipvrin. 8. Chloroform. 12. Menthol. 46 GENERAL THERAPEUTICAL CONSIDERATIONS. Those used against the seat-worm, or Oxyuris verraicularis, are — 1. Quassia. 2. Turpentine. 3. Tannic acid. 4. Chloride of sodium. 5. Vinegar. V. Antiseptics. (See also Disinfect- ants. ) 1. Corrosive sublimate in weak so- lutions. 2. Carbolic acid in weak solutions. 3. Peroxide of hydrogen. 4. Creolin. 5. Lysol. 6. Boric acid. 7. Permanganate of potassium. 8. Salicylic acid. 9. Sulphate of iron. VI. Antipeuiodics or Antimalarials. 1. Cinchona. 2. Eucalyptus. 3. Warburg's tincture. 4. Arsenic. 5. Methylene blue. VII. Antipyretics. 1. Antipyrin. 2. Acetanilid or antifebrin. 3. Phenacetin. 4. Guaiacol. 5. Phenocoll. 6. Quinine. 7. Salicylic acid. 8. Thallin. 9. Carbolic acid. 10. Kairin. VIII. Antispasmodics. 1. Amyl nitrite. 2. Chloral. 3. Bromides. 4. Opium. 5. Belladonna. 6. Camphor. 7. Hoffmann's anodyne. 8. Asafoetida. 9. Musk. 10. Valerian. 11. Monobromated camphor. 12. Amber. 13. Cimicifuga. 14. Hops. IX. Astringents. Vegetable : 1. Tannic acid. 2. Hsematoxylon. 3. Kino. 4. Catechu. 5. Rhatany or krameria. 6. Rhus glabra. 7. Geranium. 8. White oak. 9. Black oak. 10. Gallic acid. 11. Rosa centifolia. 12. Rosa gallica. All of these depend chiefly upon tannic acid for their active principle. Mineral : 1. Sulphuric acid. 2. Alum. 3. Lead. 4. Nitrate of silver, 5. Nitric acid. 6. Sulphate of copper. 7. Bismuth. 8. Sulphate of zinc. X. Cardiac Sedatives. 1. Aconite. 2. Veratrum viride and album. 3. Antimony. 4. Hydrocyanic acid. 5. Veratrum sabadilla. XL Cardiac Stimulants. 1. Digitalis. 2. Strophanthus. 3. Ammonia. 4, Ether. 5. Alcohol. 6. Caffeine. 7. Nux vomica. 8. Ignatia. 9. Adonis vernaiis. 10. Convallaria majalis. 11. Sparteine. 12. Amyl nitrite (momentarily) 13. Opium. XII. Counter-irritants. Those counter-irritants that blister are called epispastics. They are — 1. Cantharides. 2. Thapsia. 3. Ammonia or chloroform when under a watch-glass. Those that redden or produce local hyperemia of the skin are — 1. Mustard. 2. Capsicum. 3. Turpentine. 4. Ammonia. 5. Chloroform. 6. Burgundy pitch. 7. Canada pitch. 8. Most of the spices. Under the name of Escharotics are grouped a number of substances capable of acting as "destructive agents upon the soft tissues of the body. They are — 1. Chromic acid. 2. Nitric acid. CLASSIFICATION OF DRUGS. 47 10. 11. 12. Sulphuric acid. Nitrate of mercury (solution), Bromine. Caustic potash. Caustic soda. Burnt alum. Arsenous acid. Chloride of zinc. Vienna paste. Canquoin's paste. XIII. Diaphoretics. The only ones that we know as direct stimulants to the glands are — 1. Pilocarpus or jaborandi. 2. Warburg's tincture. The others are — 3. Hot dry and hot moist baths. 4. Dover's powder. 5. Alcohol (particularly when hot). 6. Nitrous ether. XIV. DlGESTANTS. 1. Pancreatin. 2. Pepsin. 3. Hydrochloric acid. 4. Diastase. 5. Papain. XV. Disinfectants. 1. Corrosive sublimate. 2. Chlorine or chlorinated lime. 3. Formaldehyde. 4. Carbolic acid. 5. Chloride of zinc. XVI. Diuretics. Those that increase both the solids and liquid constituents are probably — 1. Caffeine. 2. Squill. 3. Cantharides. 4. Buchu. 5. Vegetable salts of potassium. 6. Lithium. 7. Juniper. 8. Turpentine. 9. Uva ursi. 10. Chimaphila. 11. Cubebs. 12. Pareira brava. 13. Blatta. Those which increase the watery con- stituents of the urine without in- creasing the solids proportionately are — 1. Digitalis. 2. Nitrous ether. XVII. Elimi natives. 1. The iodides. 2. The salicylates. 3. The vegetable salts of potassium and the purgatives. 4. The lithium salts. 5. Jaborandi. 6. Colchicum (probably). XVIII. Emmenagogues. The direct emmenagogues are — 1. Apiol. 2. Binoxide of manganese. 3. Permanganate of potassium. 4. Cantharides. 5. Aloes. 6. Myrrh. 7. Kue. 8. Savine. 9. Tansy. 10. Pennyroyal. 11. Guaiac. The indirect are — 1. Iron. 2. Arsenic. 3. Copper. 4. Tonics in general. XIX. Emetics. The direct are represented by — 1. Apomorphine. 2. Ipecac (which is both centric and peripheral). 3. Tartar emetic (which is both centric and peripheral). The peripheral are — 1. Sulphate of zinc. 2. Mustard. 3. Alum. 4. Sulphate of copper. 5. Turpeth mineral. XX. Expectorants. Sedative : 1. Citrate or acetate of potassium. 2. Ipecac. 3. Antimony. 4. Lobelia. Those which act as stimulating expeo torants are — 1. Ammonium chloride. 2. Apomorphine. 3. Creasote. 4. Eucalvptus. 5. Tar. 6. Terebene. 7. Terpine hydrate. 8. Oil of sandal-wood. 9. Sulphur. 10. Grindelia robusta, 11. Garlic. 12. Squill. 48 GENERAL THERAPEUTICAL CONSIDERATIONS. Besides these we have nux vomica, 1 3 - Coca. which increases expectoration by stimu- 4. Kola. lating the nervous system to coughing, 5. Caffeine. and thus expels the mucus. Opium and the bromides depress the nervous system XXIV. Oxytocics. and allay cough, and so decrease expecto- 1. Ergot. ration. 2. Cotton-root. XXI. Hypnotics. 3. Ustilago maydis. 1. Chloral. And indirect when in labor : 2. Bromides of potassium, sodium, 1. Quinine. etc. 2. Kola. 3. Opium. 4. Sulphonal. XXV. Purgatives. 5. Trional. 6. Tetronal. Laxatives : 7. Paraldehyde. 1. Cascara sagrada. 8. Chloralose. 2. Sulphur. 9. Chloralamide. 3. Rhubarb. 10. Hypnal. 4. Frangula. 11. Hyoscine (in mania). 5. Cassia fistula. 12. Duboisine (in mania). 6. Euonymus. 13. Cannabis indica (in large dose). 7. 8. Magnesia. Manna. XXII. Nervous Sedatives. 9. Fruits. 1. Chloral. 2. Opium (in full doses). Cathartics (mineral) : 3. The bromides and hydrobromic 1. Magnesium sulphate. acid. 2. Magnesium citrate. 4. Chloroform. 3. Sodium phosphate. 5. Amyl nitrite. 4. Potassium and sodium tartrate. 6. Nitrites of potassium and sodium, 5. Sodium sulphate. and nitroglycerin. 6. Mercury. 7. Ether. 8. Bromide of ethyl. Cathartics (vegetable): 9. Nitrous oxide. 1. Castor oil. 10. Bromoform. 2. Senna. 11. Belladonna. 3. Aloes. 12. Antipyrin. 4. Podophyllin. 13. Acetanilid. 14. Phenacetin. Cathartics (hydragogue) : 15. Calabar bean. 1. Elaterium. 16. Hydrocyanic acid. 2. Jalap. 17. Lobelia. 3. Colocynth. 18. Conium. 4. Croton oil. 19. Cannabis indica. 5. Gamboge. 20. Sulphonal. 6. Scammony. 21. Croton chloral. 7. The saline purgatives, if co 22. Paraldehyde. centrated solutions are used. 23. Camphor. 24. Monobromated camphor. XXVI. Tonics. 25. Asafcetida. 1. Cinchona. 26. Amber. 2. Nux vomica. 27. Hoffmann's anodyne. 3. Calumba. 28. Cimicifuga. 4. Arsenic. 29. Musk. 5. Phosphorus. 30. Valerian. 6. Mercury (in minute doses). 31. Humulus. 7. Copper. 32. Castor. 8. Iron. 33. Hypnal. 9. Hydrochloric acid. 34. Tobacco. 10. Nitro-hydrochloric acid. Nitric acid. Phosphoric acid. XXIII. Nervous Stimulants, 11. 12. 1. Nux vomica. 1-3. Coridurango. 2. Ignatia. 14. The vegetable bitters in general PRESCRIPTION WRITING. 49 XXVII- Vasomotor Depressants. XXVIII. Vasomotor Stimtjxants 1. Amyl nitrite. 1. Belladonna. 2. Nitroglycerin and other nitrites. 2. Hyoscyamus. 3. Veratrum viride. 3. Digitalis. 4. Antimony. 4. Nux vomica. 5. Aconite. 5. Ergot. 6. Veratrum album. 6. Stramonium. 7. Veratrum sabadilla. 7. Caffeine. 8. Alcohol (in excessive doses). 8. Convallaria. 9. Jaborandi. 9. Suprarenal gland. PRESCRIPTION WRITING. When a physician directs a patient how to regulate his diet, what exercise he is to take, and how many hours a day are to be devoted to recreation and work, he prescribes for him quite as much as when he writes a prescription calling for one or more drugs which are to be dispensed by the druggist and swallowed by the individual who is ailing. Nevertheless, the word "prescription" is usually applied to the piece of paper on which is written the physician's order to the druggist. In writing prescriptions physicians usually employ Latin terms. There are several reasons for this. In the first place, it is a custom which has been followed since the time when medical science was in its infancy, and medical men were wont to write what they had to say in Latin. Secondly, the botanical names of plants are usually given in Latin : first, because scientific men give them their names, and, second, because not infrequently the English name for a plant in one part of a country has an entirely different application in another. Thus, nearly every State has a drug called "Snake-root," yet in each instance a different plant may be so designated. Again, it is often advisable that a patient be kept in ignorance of the character of the drug which he is taking, lest he attempt to use it without a physician's advice on another occasion, and thereby do himself injury. Thus the physi- cian might wish to give a patient a dose of coca as a powerful nervous stimulant, yet would fear that it might be taken without advice later, and do harm. By using the word " Erythroxylon " the druggist knows what to dispense, but the patient does not recognize the term used and fails to remember it. All prescriptions should be written on sheets of paper on which are printed the physician's name, address, and office hours. This informa- tion is obviously necessary, and particularly is it useful to the druggist, who may wish to communicate with the physician in case he thinks that a poisonous dose has been ordered by mistake. The name and address of the patient should be written on the prescription-blank, so that the druggist may know where the medicine is to be sent when it is prepared. The prescription is to be accurately dated. The first symbol or mark placed on a prescription-blank after writing the name of the patient and his address is "I$," which stands for 4 50 GENERAL THERAPEUTICAL CONSIDERATIONS: "Recipe," which is the second person singular of the imperative present of the Latin verb "Recipio," meaning "I take." Recipe or fy there- fore, says to the druggist "Take thou" of whatever substances the physician desires. As he is to take a given quantity of his stock and place it in the mixture, the name of the drug is put in the partitive genitive case. When, however, a pill or other finished or complete product is ordered, so that not part of the stock, but the whole article is desired, the name of the medicine is placed in the accusative case, since it is the object of the verb. The nouns or names of drugs belong to one of the five Latin declen- sions, and are most of them declinable. Those of the first declension end in the letter "a" in the nominative singular, and in "se" in the genitive singular, or "arum" in the genitive plural, except in the case of the word aloe, the genitive singular of which is aloes. Thus aqua is the nominative, aquas is the genitive singular, and aquarum is the genitive plural. The nouns of the second declension end either in "us" if masculine, or "um" if neuter. Their genitive singular ends in "i" and the geni- tive plural in "orum." There are several nouns of this declension which end in "on," like "mematoxylon," which also end in "i" in the genitive singular. Thus we find that Syrwpus is the nominative, Syrupi the genitive singular, and Syruporum the genitive plural. In the third declension the nouns end in a, e, i, o, y, c, 1, m, r, s, t, and x. The genitive singular ends in "is" and the genitive plural in "um." Thus, Miher in the genitive is Miheris, and the genitive plural Mtherum. When the noun ends in "s" the genitive takes a "t" before the "is." Thus boras is the nominative singular, boratis the genitive singular, and boratum the genitive plural. In the fourth declension the masculine nouns end in "us," and the neuter nouns in "u." The genitive singular of the masculine noun ends, as does the nominative, in "us," and the neuter noun like the nominative ends in "u," while the genitive plural ends in "um." Thus, Spiritus, of which the nominative singular ends in "us," is spiritus in the genitive singular, and spirituum in the genitive plural. In the fifth declension the nominative singular ends in "es," the genitive singular in "i," and the genitive plural in "rum." Thus Res has as its genitive singular rei, and as its genitive plural rerum. Adjectives used to qualify nouns agree with them in gender, number, and case. After the ingredients and their quantities have been signified the physician expresses his wishes further, and writes the word "Misce," "mix" the ingredients. If the prescription is put up in fluid form, he next writes the signatura, and writes the word Signa, usually abbreviated by Sig., which tells the druggist to write the directions, which follow in English, on the label of the bottle. If the prescription consists in a powder and is to be put in papers, after the word Misce, or the letter "M.," which stands for misce, the PRESCRIPTION WRITING. 51 physician adds et divide in chartulas No. xx. — that is, divide into twenty small papers or powders. If pills are desired, he writes M. fiant (often written "ft.") in pilulce No. xx. — that is, make into 20 pills. Or fiat unguentum, let an ointment be made. Or the imperative may be used by the employment of the word fac, as fac swppositorias numero v. — that is, "Make thou 5 supposi- tories." If capsules are desired, the druggist is directed to mix the ingredients, and the physician adds et pone in capsulas No. xx. — that is, mix and put into 20 capsules. A prescription is often composed of a basis or the drug that is most important, an adjuvant or the drug to aid the basis, a corrective to over- come some effect which is undesirable, and a vehicle to give bulk and to carry the active substances into the body. After the name of the vehicle, which is also designed to bring up the mixture to an even quantity, we add the words quantum sufficit ad (a sufficient quantity to), usually abbreviated to "q. s. ad," to make the number of ounces desired. A complete prescription may therefore be written as follows: For Mr. John Jones, 111 Blank Street, October 31, 1901. ^ — Bismuthi subnitratis gr. xl. Creosoti ..'•■'• n l x - Misce et pone in capsulas No. xx. Signa. — Take one after each meal. Or 1^ — Acidi sulphurici aromatici . . . . . f 5ij- Extracti hsematoxyli fluidi ..... fjiv. Spiritus chloroformi fgj. Syrupi zingiberis q. s. ad f g iij. Misce. Signa. — Take 1 dessertspoonful in water every three hours. In the last prescription the sulphuric acid is the basis, the hgema- toxylon and spirit of chloroform are the adjuvants, and the syrup of ginger is the vehicle. > 52 GENERAL THERAPEUTICAL CONSIDERATIONS. CHANGES IN THE STRENGTH OF OFFICIAL TINCTURES IN THE U. S. P. OF 1905. Name. Aconite . Belladonna leaves Calumba Cannabis Indica Cantharides Capsicum Cardamom Cinnamon Colchicum seed Digitalis Gelsemium Hyoscyamus . Kino Lobelia . Physostigma . Quassia . Rhubarb Sanguinaria Squill Serpentaria Stramonium . Strophanthus . Tolu Veratrum viride Tincture of nux vomica (1905) will contain 1 grm. of strychnine in 1000. It will be noted that the strength of all the tinctures of powerful drugs is 10 per cent, of the crude drug except tincture of nux vomica, which is 1 of alkaloid per 1000 of tincture. Grms. of drug in 1000 c.c 1900. 1890. 100 350 100 150 200 100 100 150 100 50 100 50 200 100 200 100 100 150 100 150 100 150 100 150 50 100 100 200 100 150 200 100 200 100 100 150 100 150 200 100 100 150 100 50 200 100 100 400 PAET II. DRUGS. ACACIA. Acacia, U. S., Acacice Gummi, B. P., Gum Arabic or Gum Acacia, is a gummy exudate from the stems and branches of small trees known as Acacia Senegal, and other acacias growing in Northern Africa and in Australia. As sold in the stores it consists of irregular semitrans- parent lumps, which are either smooth or angular, according to whether the substance has been preserved in the original beads or broken by handling. Its color is slightly yellow or almost white, both color and transparency depending largely on the amount of the impurities by which it is contaminated. Acacia is devoid of physiological action. Therapeutics. — Acacia is employed in medicine as a local applica- tion to inflamed and irritated mucous membranes, particularly of the upper air-passages, and also when dissolved in water in the form of a drink when the same conditions exist in the mucous membranes of the alimentary canal and genito-urinary tract. In all these states it is use- ful as a vehicle for more powerful remedies. Made into a mucilage with flaxseed, to which liquorice may be added, it is largely employed as a drink to loosen a hacking cough in children or in adults. The flaxseed should not be boiled, but allowed to stand on a moderately warm part of the " range," and the gum-arabic solution added with a little lemon-juice for flavoring purposes. Acacia is chiefly used in pharmacy for making pills, emulsions, and similar preparations, and is official in the form of the mucilage of acacia (Mucilago Acacia?, U. S. and B. P.) and the syrup of acacia (Syrupus Acacia?, U. S.), the first containing 340 grms. of acacia, lime-water 330 grms., and water enough to make 1000 grms., and the second 25 c.c. of the mucilage to 75 c.c. of syrup. ACETANILID, or ANTIFEBRIN. Acetanilidum, U. S. and B. P., is a white crystalline material only slightly soluble in water, but completely soluble in alcohol and ether. Applied to the tongue, it causes a slight burning sensation. It is made by the action of glacial acetic acid upon aniline, forming aceta- (53) 54 DRUGS. nilid or phenyl-acetamide. The word antifebrin is a registered name, and its use should be avoided by the profession, since its employment obliges the druggist to use the acetanilid made by one firm instead of the compound made by other chemists who manufacture the drug as an ordinary chemical compound, and do not charge so high a price as do those who market the registered product. Physiological Action. — Acetanilid has been studied experimentally and clinically to a very great extent, and fairly definite outlines of its action have been mapped out. Nervous System. — On the nervous system acetanilid has been found to act as a sedative, the sensory portion of the nerves and spinal cord particularly being quieted. After a poisonous dose general anaes- thesia comes on, with total loss of reflex action and with motor and sensory paralysis. The portions of the nervous system affected in these changes are, primarily, the sensory side of the spinal cord and the sensory nerves, the motor apparatus being least influenced. The muscles are only indirectly influenced by the poison. Circulation. — On the circulation acetanilid has but little direct influence except when used in poisonous doses. Applied to the frog's heart, it at first accelerates its beat and increases its force, but soon causes a weakening, ending with arrest in wide diastole. Upon the higher animals it causes, in toxic dose, an immediate fall of arterial pressure with a diminution in the size of the pulse-waves and all the evidences of cardiac and circulatory depression, notwithstanding the fact that death ensues from respiratory failure. The cause of this fall of blood-pressure is a direct depressing action on the heart asso- ciated with failure of the vasomotor system, as asphyxia causes no rise in pressure. In medicinal dose acetanilid causes no circulatory changes of moment in the healthy individual. Sometimes the pulse-rate is in- creased, sometimes diminished. The tendency is, however, toward depression rather than stimulation of the circulation. Blood. — When used in large doses, the action of this drug upon the blood is more pronounced than its influence upon any other part of the body, causing this tissue to become brownish-red, decreasing its oxygen-carrying power, and, finally, reducing the hemoglobin to methsemoglobin to a very considerable extent. The question as to the influence of acetanilid upon the corpuscles is still undecided, some observers declaring that these bodies are disorganized, while others assert that they remain intact. In moderately large poison- ous doses it may not affect the corpuscles, but if its use in large amount be continued for some days, or a very large amount be used at one time, corpuscular destruction certainly occurs, free haemoglobin appearing in the urine in its characteristic forms. The normal alka- linity of the blood is decreased, and the urine becomes dark and brownish in color, and the blood-crystals of Teichmann are found in it. In medicinal doses the blood shows no change except in cases ACETANILID, OR ANTIFEBRIN. 55 where idiosyncrasy is present or the doses are unusually large. Under these circumstances the blood in the arterial system becomes more blue than normal. Respiration. — No effect is produced upon this function by acetanilid when given in moderate doses. When poisonous doses are used, the breathing at once becomes rapid and labored. Large doses produce death by paralysis of the respiratory centres. These effects are primarily due to the alterations in the blood, which so influence oxygenation of the tissues as to spur the respiratory centre to greater effort, while at the same time it is beginning to be directly depressed by the drug itself, so that impairment of its function is soon manifest. Bokai asserts that the drug paralyzes the peripheral motor nerves, which, if true, brings forward a third factor in the respiratory failure. Temperature. — When given in full medicinal doses, acetanilid lowers the normal bodily temperature or else fails to produce any change. In poisonous doses it produces a decrease in temperature depending on the amount employed, and may cause collapse and rigors. On a fevered temperature it acts as a powerful and fairly constant antipyretic, lowering the fever by decreasing heat-production and increasing heat-dissipation, heat-production being the function most affected. 1 Whether the decrease in heat-production is due to an action on the heat-centres in the nervous system, or upon other causes, is not known. Some investigators have claimed that the fall depends upon the partial reduction of the haemoglobin of the blood, whereby less oxygen is carried to the tissues and less combus- tion ensues. This seems doubtful in view of the fact that spectroscopic examination of the blood fails to show any such change from the use of medicinal doses. That the fall of temperature is not dependent on the sweat produced is proved by the fact that the temperature falls even if enough atropine be given to stop all perspiration. Kidneys, Tissue-waste, and Urine. — Much contradictory evi- dence exists in regard to the changes which occur in these organs and their excretory products under the influence of acetanilid, but most observers agree that the excretion of urea is increased, and it is a fact that the researches which have been undertaken have reached a similar result (Lepine, Chittenden, and Taylor). Less uncertainty exists as to its influence on the elimination of uric acid, which is in- creased rather than diminished by the drug. After excessively large doses the urine becomes dark from the presence of broken-down blood- coloring matter. Elimination. — The drug is eliminated by the kidneys as para- amido-phenol sulphate, and is entirely passed out of the body in about twenty-four hours. 1 The author's reasons for holding to the opinions stated can be found in his Roylston Prize Essay of Harvard University, on Antipyretics. 56 DRUGS. Antiseptic Action. — Acetanilid possesses distinct antiseptic powers, but is not capable of acting as a disinfectant. (See Therapeutics.) Toxic Changes from Prolonged Use. — Although it has been asserted that no untoward effects result from the prolonged use of acetanilid in large doses, there can be no doubt that this assertion is untrue. Under these circumstances congestion of the liver, kidneys, and spleen occurs, and if the dose be poisonous, clots may be found in the cardiac cavities. There may be also a progressive decrease in the number of the red blood-corpuscles. Poisoning. — In man this drug in toxic quantity causes the lips to become blue, and the face livid, cyanosed, expressionless or anxious. The forehead and cheeks become covered with sweat, which gradually extends over the rest of the body. The pulse is soft and compressible, but slow, and finally very weak. The respirations become slow and shallow. . The treatment of a case of poisoning by acetanilid should consist in supporting measures, the use of stimulants, external heat, bella- donna to maintain blood-pressure, strychnine to aid the respiration, and oxygen inhalations if they are necessary to combat cyanosis. Therapeutics. — The employment of acetanilid in fevers must depend very much upon the condition of the patient and the character of his disease. The mere existence of a high temperature is not, correctly speaking, an indication for any particular remedy. The phase of the disease must be recognized, and the question as to whether the fever which is present is harmful must be duly weighed. (See Treat- ment of Fever, Part IV.) In typhoid fever, though the drug possesses decided antipyretic power, it often causes great depression and collapse, and in no way influences favorably the duration or general course of the disease. For the same reasons the use of acetanilid in phthisis is inadvisable, for, although it greatly affects the hectic fever, it is very apt to cause collapse, profuse sweating, and depression. Thus the writer has repeatedly seen cases of phthisis in which the attempt to control the fever by this drug resulted in the symptoms just named; and Riese points out, what the author has also noted, namely, that in this dis- ease cyanosis is very apt to come on after the use of the drug. In regard to the employment of acetanilid in sthenic fevers, it at once becomes evident that a drug absolutely unsuited to a case of asthenic disease may, on the other hand, agree with a sthenic-fever patient very well. In consequence of this, we find that the sweating produced by acetanilid is not so marked or troublesome in diseases of a dynamic type, and that, in consequence, it more rarely causes collapse ; but even in this class of cases, and particularly in both varieties of pneumonia, the use of acetanilid is rarely advisable. Indeed the anti- pyretic use of this and similar compounds is yearly becoming less and less. In much the same manner that antipyrin was found, some time ACETANILID, OR ANTIFEBRIN. 57 after its introduction, to be possessed of pain-relieving power, so ace- tanilid has been discovered to possess similar properties. Almost every form of nerve-pain seems to indicate its employment. It has been successfully used in the crises of ataxia, the agonizing dartings of gastralgia, in cases of sciatica, and severe headaches often yield to its influence. Experience has proved it to be of value in epilepsy. The employment of acetanilid in acute rheumatism may be separated, if desired, into that devoted to the cure of the disease, with the relief of pain, and the reduction of pyrexia. There can be no doubt what- ever of the ability of the drug to control the fever of this disease, and the question as to whether it favorably influences the severity of the pain of the malady is to be answered strongly in the affirmative (See Rheumatism, Part IV.) The dose for cases of rheumatism should be 4 (0.25) to 6 grains (0.4) three times a day. In subacute rheumatism of the muscular type acetanilid will often give marked relief. Acetanilid in dry powder is of value in the treatment of chancroids, and in the antiseptic dressing of wounds when used alone or with equal parts of borax. In many cases of obstinate vomiting, particularly that following surgical operations when an anaesthetic has been used, acetanilid is a useful remedy. The drug is usually best given in the dose of 1 grain (0.06) every half-hour until 6 grains (0.4) have been taken; and the following prescription may be used in compressed tablet, pill, or powder, preferably the latter, in order to increase the sedative effect on the stomach and steady the heart. 1$ — Acetanilidi . . . gr. vj (0.4). Caffein. citrat . gr. iij (0.2). Camphor, monobromatae gr. vj (0.4). — M. Ft. in pil. vel chart. No. vi. S. — Wash down with a little water or else dissolve powder in a drachm of brandy; pour over cracked ice, and give it from a spoon. Acetanilid has been recommended as a local haemostatic in epistaxis, and has been given internally with asserted advantage in haemoptysis. Acetanilid distinctly increases the susceptibility of a patient to cold, and for this reason it should not be used for the relief of neuralgic or other pain before leaving the house in cold weather if it can be avoided. Untoward effects are not common if acetanilid be used with care. The writer has collected a number of cases (thirty-eight) in which unfavorable signs appeared after its use, but utoward action was never seen unless the dose given was excessive for the case which received it. The dose most commonly producing such symptoms was from 3 (0.2) to 10 grains (0.6). In only three instances of the series did death occur — one from heart-clot and two from excessive dosage. No deaths were reported from moderate amounts, although some of the cases were alarming. Very rarely symptoms of poisoning by acetanilid, such 58 DRUGS. as are described on p. 56, follow its general use as a dusting-powder over wounds and other breaks in the skin. Administration. — Acetanilid may be given in doses varying from 2 (0.12) to 10 grains (0.6), the last-named amount being usually ex- cessive. As it is virtually insoluble in water, it should always be administered in wine or spirit, in which it is soluble, or in capsules or pills. The antipyretic effect is manifested about one hour after the drug is taken. When neuralgias are to be treated or similar forms of pain are present, monobromated camphor, in the dose of \ grain (0.03), may be combined with acetanilid with advantage. The prescription given above may be used, or the Pidvis Acetanilidi Compositus (U. S.) composed of acetanilid, caffeine, and sodium bicarbonate, a new U. S. P. formula, may be used for the same purpose in the dose of 5 grains (0.3). This pill is not to be used if there is reason to believe that marked renal congestion or irritation is present. ACETATE OF POTASSIUM. Potassii Acetas, U. S. and B. P., is a deliquescent neutral white salt of saline taste, readily soluble in water. It was at one time largely used in the treatment of acute rheumatism in the "alkaline method," as when it enters the blood it is changed into an alkaline carbonate. It has been supplanted by the salicylates in the treat- ment of most cases of rheumatism. The dose should be from -g- to 1 ounce (16.0-30.0) a day, A combination of 10 grains (0.6) of the iodide of potassium and 30 grains (2.0) of the acetate is useful in subacute rheumatism in some instances. In hepatic torpor acetate of potassium is exceedingly efficacious, and aids in promoting the flow of bile as well as that of the urine. It has been used in the treatment of the so-called uric-acid diathesis, and quickly renders an acid urine alkaline. At one time it was sup- posed to purify the blood by aiding in the oxidation of effete mate- rial. The dose of potassii acetas is from 20 grains to 2 ounces (1.3-60.0), the latter dose being employed only when a purgative effect is desired ; but other drugs are more suitable for this purpose. ACETIC ACID. Acidum Aceticum, U. S. and B. P., as used in medicine, is a clear liquid composed of 36 per cent, of glacial acetic acid and 64 per cent, of water, and having a sweetish odor. It is obtained from wood by destructive distillation. Acetum, or Vinegar, is practically dilute acetic acid. ACONITE, OB MONKSHOOD. 59 Therapeutics. — Acetic acid is seldom used internally. As a pow- erful escharotic the glacial or absolute acetic acid (Acidum Aceticum Glaciate, U. S. and B. P.) is used. It may be applied to warts and other growths, and to old sores where the granulations are profuse and healing is slow. The dilute acid {Acidum Aceticum Dilutum, U. S. and B. P.) is used as a lotion in night-sweats and to arrest epistaxis and other minor hemorrhages. As a lotion to be employed it should be diluted one-half. Vinegar, or dilute acetic acid, has been used internally to decrease obesity, but is a harmful and useless remedy, disordering digestion and reducing the patient's strength. Inhalation of vinegar fumes from a cloth saturated with this liquid sometimes will control vomiting after the use of an anaesthetic. In the following mixture acetic acid may be used for the removal of vegetations about the external genitals: 1^ — Acid, salicylic gr. xxx (2.0). Acid, acetic f§j (30.0).— M. S. — Apply with a camel' s-hair brush. Only slight pain is caused by this application. Poisoning. — When overdoses of acetic acid are taken, the treat- ment consists in the use of large draughts of milk, alkaline liquids, such as lime-water, soap-water, etc., and the general measures suitable for the treatment of gastro-enteritis. (See Gastro-enteritis, Part IV.) Contraindications. — Nursing mothers should not take freely of vinegar, as it may produce a troublesome diarrhoea in the nursling. ACOINE. Acoine is a synthetic substance introduced into ophthalmic surgery as a local anaesthetic and antiseptic. It is used in a 1 or 2 per cent, solution. ACONITE, or MONKSHOOD. The aconite of the U. S. and B. P. is derived entirely from the tuberous root of Aconitum Napellus. At one time the leaves were official, but are so no longer, and for this reason the term " radix " is not to be employed, as it is a useless distinction. Aconite is indigenous in Germany, France, and Switzerland, and is cultivated as a garden-plant in Europe and America. The root resembles so strikingly that of horseradish as to be readily confused with that condiment, but does not emit the pungent fumes of the latter when it is scraped or broken. It is also to be remembered that aconite produces a sensation of heat in the mouth when chewed. The active principle upon which the therapeutical value of aconite would appear to depend is aconitine, but there is reasonable doubt whether this can be relied upon as completely as the preparations of the crude drug; the aconitine of commerce, moreover, varies very much in strength, because some of it is amorphous and impure, while 60 DRUGS. Fig. 5. other samples are pure and crystalline. Further than this, even the crystalline form is exceedingly variable in strength. In addition to aconitine, Dunstan asserts that there are two amorphous alkaloids — namely, benzaconine and aconine. Aconitine is 200 times as toxic as benzaconine and 2000 times as toxic as aconine. Physiological Action. — When aconite is placed on the tongue it produces a sensation of tingling and burning which extends over the pharyngeal surface, and into the stomach if the drug is swallowed. This is due to its primary irritant and secondary benumbing action on the sensory nerve-endings of the mucous membrane. It sometimes causes a sensation of constriction in the fauces. Nervous System. — In full medicinal dose aconite depresses the functional activity of the perceptive centres in the brain, the sensory side of the spinal cord, but chiefly de- presses the peripheral ends of the sen- sory nerves. Applied to a mucous membrane, it acts as a local anaes- thetic, but is too irritating for this use in the eye. On the motor portion of the body it exerts little influence unless given in poisonous doses, when it par- alyzes the motor tract of the spinal cord and the peripheral motor nerves. Circulatory System. — When aco- nite is given in moderate medicinal dose it exercises no marked effect on any part of the organism save the circulation, which becomes somewhat slower from stimulation of the vagus centres and A, vagus centre stimulated by aconite, h 7 the dm g ^ tin g aS a Sedative to the which slows pulse; B, heart-muscle de- heart-muscle itself. The arterial preSS- pressed which slows pulse; c, vasomotor ure j s slightly decreased by these doses, centre depressed, which lowers arterial -\ • n i i i • v s> tension; d, respiratory centre depressed, chiefly by the decrease m cardiac force. If large doses are used, the pulse be- comes still more feeble and slow, and the arterial pressure falls from depression of the vasomotor centre. When a poisonous dose is given, it causes first a marked fall in pulse-rate and arterial pressure, pre- ceded sometimes by a quickening due to a condition of weakness and abortive cardiac action: this condition gradually passes into diastolic arrest of the heart, the viscus becoming paralyzed and refusing to respond to stimuli. Respiration. — In moderate doses aconite quiets the respiratory movements slightly, particularly if the breathing is hurried. In poison- ous doses it paralyzes the respiratory centres, and so causes death. Temperature. — Aconite acts as a distinct reducer of fever, proba- bly because of increased heat-radiation arising from relaxation of the capillaries and impaired circulation. ACONITE, OR MONKSHOOD. 61 Absorption and Elimination. — Aconite is rapidly absorbed and destroyed by oxidation, so that its effects do not last for any length of time. The effect of aconite when given in a large medicinal dose lasts for about three hours. It usually increases the urinary flow. Poisoning. — When aconite is taken internally in excessive amount, it causes tingling of the mucous membranes wherever it touches them, which sensation finally amounts to severe burning. This soon passes away, and is followed by a sense of tingling about the lips and finger- tips or all over the skin. At the same time the patient feels relaxed; the pulse at first becomes weak and slow, but later may be rapid and running, so that it seems a mere trickle under the finger; sweating is more or less marked, and fainting may ensue. Vomiting may occur, but is rare. The respirations now become slow and shallow, seeming to expand the lung to the smallest possible extent consistent with life. The face is pallid and anxious. Consciousness is pre- served unless lost through an attack of syncope. There may be exophthalmos, or the eyes may be sunken and dull. The sclerotic is pale and pearly-looking. There is excessive pallor of the face. Clonic convulsions of unknown origin sometimes occur. There may be marked anaesthesia of the skin. The pupils may be normal, con- tracted, or dilated widely. The temperature of the body is sub- normal. Death may be gradual or sudden, the slightest movement of the body which throws any strain on the heart stopping that organ in diastole. Treatment of Poisoning. — The patient is to be placed in a prone position on a bed or board, with the feet higher than the head, in order to confine the circulation as far as possible to the vital centres at the base of the brain. Hot bottles or bricks are to be placed about the body for the purpose of maintaining the bodily heat. Emetics are not to be given if the symptoms are severe, as vomiting may cause cardiac failure, owing to the muscular effort involved, or the stomach may be so depressed that emetics will not act. If vomiting comes on, the vomitus should be received into a towel, the patient not being allowed to raise his head. The stomach is to be washed out by means of a stomach-pump or a siphon of rubber tubing. Ether may be given hypo- dermically, and followed by alcohol, and this again by digitalis. The ether acts at once, and stimulates while the alcohol is being absorbed, and the alcohol supports the heart until the digitalis, which is the physiological antagonist of aconite, but slow and more prolonged in its effects, asserts itself. Atropine, because of its stimulating effect on the vasomotor system, may also be used. If the breathing fails, artificial respiration is to be employed, or if the heart seems about to cease its action, a whiff of nitrite of amyl may start it going again, but only a few drops of the nitrite should be used, as large amounts depress this organ. Full hypodermic doses of strychnine, such as A" to A (0.003-0.006) grain, may be given to stimulate the respira- tion and heart. 62 DRUGS. Untoward Effects. — Aconite may cause in susceptible persons a vesicular, or even a pustular, eruption, or instead intense itching of the skin may be developed. Therapeutics. — The employment of aconite in disease is one of the most universally recognized procedures in medicine. It fulfils indi- cations which nothing else can, and lends itself to the control of a large number of morbid processes, its effects being uniformly explain- able by its known physiological action. It is used chiefly for its influ- ence as a cardiac and circulatory sedative, for its effects on the periph- eral sensory nervous system, as in the vomiting of pregnancy , and in those states in which, through inflammation elsewhere, the nervous system needs a sedative which will simultaneously reduce arterial tension. In the early stages of all acute inflammations aconite is of service. It may be applied locally over superficial nerves in neuralgia in the form of an ointment (2 grains [0.12] to 1 drachm [4.0], or as the oleate of aconitine, 2 grains [0.12] of the oleate to 100 [6.6] of sweet oil). In the earlier stages of gonorrhoea aconite in small doses frequently repeated is a most valuable remedy, and later in the disease tends to prevent chordee by its influence on the nervous centres. It is useful in croup, quinsy, sore throat, severe colds, bronchitis, and asthma due to exposure, in their early stages. When suppression of menstruation follows exposure to cold, this drug, given with a hot drink and a hot sitz-bath, will often restore the flow. In pericarditis it is valuable to allay the inflammation and quiet the excited heart, and it is also of marked value in the earliest stages of sthenic pneumonia if arterial excitement is present. Aconite is by far the best circulatory and nervous sedative for children suffering from sthenic fevers, particu- larly of the irritative type. It ought not to be used in adynamic, asthenic affections. Aconite is harmful in prolonged acute diseases, such as scarlet fever, if constantly employed. In persons who suffer from asthma which is preceded by coryza aconite does good if given in the earliest stages. tn nervous palpitation of the heart and in the palpitation of exces- sive cardiac hypertrophy aconite is valuable. In many cases of this character where there is not only hypertrophy, but also impaired inner- vation, the use of a prescription containing aconite and digitalis proves of service, for the minute doses of digitalis stimulate the vagus nerves, and the aconite not only steadies the heart by its stimulant effect on the vagus, but also counteracts the stimulant effect of the digitalis on the heart-muscle: R — Tinct. aconiti Tinct. digitalis . Tinct. belladonna? Tinct. gentian, comp. S. — Teaspoonful every six hours • f3ij(8-0). . fflxlv (3.0). . f3iss(6.0). q.s. ad fjiij (90.0).— M. In the epistaxis of full-blooded people aconite often affords great relief. AGARICIN. 63 Full doses of Duquesnel's crystalline aconitine are of value in some cases of obstinate neuralgia. This crystalline salt is about 4 times stronger than the amorphous variety. Administration. — As a general rule, small divided doses of the drug in the form of the tincture, \ to h minim (0.015-0.030) given every fifteen minutes, will act better than a full dose given at once, unless the condition of the patient requires very active treatment. Preparations. — Tincture of aconite (Tinctura Aconiti, U. S. and B. P.) is used in the dose of 3 to 20 minims (0.20-1.30) in water, repeated every hour if needed. A very useful way of employing it is in the form of tablet triturates. The extract of aconite (Extr actum Aconiti) is given in the dose of \ to f grain (0.015-0.045), while of the abstract 1 grain (0.06) is used. The fluid extract (Fluidextractum Aconiti, U. S.) is given in the dose of 1 to 2 minims (0,05-0.1). Fleming's tincture ought never to be used. The dose of the active principle of aconitine (Aconitina, U. S. and B. P.) is -yj-g- to y-g-g- grain (0.0003-0.0006), but it ought never to be used internally. The B. P. preparations that are not official in the U. S. P. are : aconitine ointment (Unguentum Aconitince) and aconite liniment (Linimentum Aconiti). ADONIS VERNALIS. From Adonis vernalis, a plant indigenous in Europe and Asia, is derived a glucoside, Adonidin. When given to one of the mammalia - — the dog, for instance — it causes an increase in heart-force and a rise of arterial pressure. In the frog poisonous amounts arrest the heart in diastole. The indications for the use of adonidin are all conditions of cardiac failure, particularly the presence of cardiac dropsy. It is much infe- rior to digitalis and caffeine, but may be employed when these fail, as it sometimes succeeds under such circumstances. Within the last few years adonis vernalis and bromides have been combined in the treat- ment of epilepsy with asserted success. The dose of adonidin is \ to \ grain (0.008-0.015) three times a day; or 4 to 8 parts of the plant — all portions of which are employed — may be added to 180 parts of water, and of this infusion a half ounce (16.0) may be given every four hours. AGARICIN. Agaric, or Touchwood, or Punk, has been used in the Southern United States very largely in the dose of 5 grains (0.3) every few hours in the treatment of the night-sweats of phthisis; and agaricin, the alcoholic extract of the drug, has been used with extraordinary results, under these circumstances, by certain German and English physicians, in the dose of from 1 to 2 grains (0.06-0.12) every five 64 DRUGS. hours. Its physiological action is unknown, but it is supposed to act upon the nerve-filaments in the sweat-glands. The writer has em- ployed it frequently in varying dose, and has never seen any decrease whatever produced by it in the sweats of phthisis, although he has watched its action most closely. Sometimes agaricin causes nausea and diarrhoea. ALCOHOL. Ethyl Alcohol (Alcohol Ethylicum) is the only alcohol used in medi- cine. Some of the other alcohols are exceedingly poisonous. Amylic alcohol is fusel oil. Alcohol is a liquid resulting from the fermentation of starches or sugars in the presence of heat. It is official in three forms — namely, as Alcohol, U. S., containing 92.3 per cent, by weight of the spirit and 7.7 per cent, of water; Alcohol Absolutum, U. S. and B. P., containing not more than 1 per cent, by weight of water; and Alcohol Dilutum, U. S., or dilute alcohol, 41.5 per cent, by weight of spirit and the remainder water. The drug is generally given in the form of whiskey or brandy, and when the word alcohol is used in the saying, "Give the patient alcohol/' one of these two liquids is always meant unless it is other- wise stated. Notwithstanding the almost universal use of alcohol as a stimulant by the laity and the medical profession, it cannot be denied that evidence of scientific character and weight is constantly being brought forward which shows that its dominant action is depressant upon all parts of the body. It is claimed that under its influence the total amount of work accomplished in a given space of time is less than when it is not taken, and that the quickening of the pulse under its influence is more apparent than real. On the one hand, therefore, a vast mass of evidence seems to exist against the general employment of alcohol as a stimulant; while on the other clinical experience, too great to be ignored, stands for the continued employment of the drug. While the author is forced to admit that the pharmacological evidence is too strong to be denied, he still deliberately allows the therapeutic advice which follows to remain as in earlier editions, still employs alcohol as a stimulant as before, and fully believes that its administration is often followed by most beneficent results which other drugs will not produce. It is possible that the drug does not act as a stimulant in the ordinary sense of the term, but nevertheless readjusts the circulation or influences the protective power of the body by affecting the blood-cells or the blood- serum or the lymph. This belief seems to find support by reason of recent experiments carried out by himself, in which he was able to show that alcohol produces a distinct increase in the bacteriolytic power of the blood in disease, probably by increasing the activity of the complemental body. This is perhaps the explanation of the good results which follow the use of the drug in clinical medicine, ALCOHOL. 65 Physiological Action. — Nervous System. — Alcohol never acts as a true stimulant to the brain, the spinal cord, or tne nerves. On the contrary, its dominant influence is depressant. The increased activity of thought and speech after its use is not due to stimulation, but to depression of the inhibitory nervous apparatus. The activity is there- fore that caused by lack of control, and is not a real increase in energy. So far as the brain is concerned, it does not increase the vigor of thought nor its depth, nor does it enable a man to work out a problem which is difficult. On the contrary, it rather benumbs the activity of mental processes. The effect of moderate doses differs from the effect of large ones in degree, but not in kind. Reflex action may be increased by the same depression of inhibition, but not by reason of any true stimulation of the cord. Locally applied in small amounts to the peripheral nerves, it excites them at first and paralyzes them afterward. In large doses it produces lack of co- ordination by depression of the brain and lower nervous system, the loss of co-ordination being due largely to impairment of sensation, so that the sense of touch and the muscle sense are interfered with. This effect makes a drunken man fail to recognize the angles or uneven surfaces of surrounding objects, and the impaired men- tal power and disordered judgment, combined with the imper- fectly acting motor and sensory pathways, cause him to stumble and fall. Circulatory System. — Careful scientific research has proved that alcohol is in no sense a true stimulant to the circulation. Given in such a dilute form that it cannot act as a local irritant to the stomach, it produces no change in pulse-rate or pulse-force. If the dose is large enough to cause any appreciable change in the circulation, it is in the nature of depression rather than stimulation. These results are obtained at the laboratory and bedside. Alcohol does, however, pro- duce very marked alterations in the distribution of the blood, as is seen in the flushing of the capillaries of the skin after its moderate use. Whether this altered distribution depends upon an influence exerted upon the vasomotor centre or nerves has not been determined. Meltzer thinks it is due to a stimulation of the vasodilators or to inhibition of the vasoconstrictors. The beneficial action following the use of alcohol in disease when it is thought to act as a stimulant probably depends upon the improved distribution of blood it produces, just as the use of the sponge bath or cold plunge in typhoid fever readjusts the circula- tion and restores vascular tone. Little if any effect is exercised by alcohol upon arterial pressure when given in medicinal dose. In very large toxic doses alcohol depresses and finally paralyzes the heart and vasomotor system. Respiration. — Respiration is not materially affected by alcohol. Temperature. — Alcohol never increases the number of heat units in the body, for though in its oxidation more heat is made than when no alcohol is used, the increased radiation, or loss of heat, from the 5 qq DRUGS. skin and lungs under its influence more than counterbalances the gain caused by the drug. By its irritating effect on the mucous membrane of the mouth and stomach it produces a sensation of warmth, and warms the ex- tremities at the expense of the body by increasing the circulation of blood in those parts. This increase in the peripheral circulation is due to an increase in the rapidity of the flow of blood and to dilatation of the peripheral capillaries. If it be used to excess, the temperature rapidly falls, owing to the increase of heat-radiation produced by the free distribution of blood, as has just been described, and secondarily by the depression of the vital forces, for in overdose alcohol always acts as a depressant. Bodily Metabolism. — The quantity of carbonic acid given off by the body under the use of alcohol is not materially altered. Some observers have noted an increase, some a decrease, and some no change at all when alcohol is taken. These results have probably depended upon the work required at the time the alcohol is in the body, for the influences of exercise and rest are potent factors in determining the activity of combustion or oxidation processes in the economy. Alcohol always conserves the body-fat and in all probability the body proteids as well. That is to say, alcohol, by being burned up in the body, yields energy and so saves tissues which would otherwise be oxidized if no alcohol were taken. To express it in still another way: alcohol, by its oxidation,, adds force, but not tissue, to the body. Elimination. — Alcohol is rapidly absorbed and rapidly destroyed by or eliminated from the body. In medicinal doses it is largely " burnt up"; but when taken in excess of the body's oxidizing power it is eliminated by the lungs and by the skin, kidneys, and intestines. Digestion. — Alcohol added in any amount to food in a test-tube containing digestive ferments retards or inhibits digestion, but in the stomach, on the other hand, when used in moderation, it assists the process; for by reason of its irritant and stimulating properties it induces the secretion of an excess of the digestive juice. When exces- sive amounts are ingested it disorders digestion by inhibiting the action of the digestive ferments. Therapeutics. — The chief uses of alcohol are as a rapidly-acting stimulant in all forms of cardiac failure due to shock or to poisons, and as a systemic support and stimulant in low fevers and prolonged wasting diseases, in old age, and in convalescence from acute disease. In both croupous and catarrhal pneumonia alcohol is useful, and par- ticularly is this true when these affections occur in children. (See Pneumonia, Part IV.) Some additional conditions, to state them specifically, in which alcohol is indicated are fainting, snake-bite, surgical shock, chronic 'pneumonia in its later stages, and excessive wasting due to prolonged suppuration. Alcohol should never be given in the presence of circulatory excite- ALCOHOL. 67 ment, but whenever the circulation fails during the progress of an acute disease it is useful. In the pneumonia of children, whether it be croupous or catarrhal, brandy or whiskey is very useful in the dose of 5 to 60 minims (0.3-4.0) every two hours in a little water or milk when the circulation seems feeble. (See Administration.) In exhaust- ing fevers, such as typhoid or typhus, alcohol finds its true usefulness. While it is well to give alcohol in some cases of enteric fever from the beginning to the end of the attack, for the double purpose of aiding digestion and of supporting the system, its administration should not be a mere matter of routine, but should be based upon clear ideas of the indications it is calculated to fulfil. If the pulse is weak and the patient seems to be sinking, or the appetite is failing and adynamia is a pressing symptom, alcohol is indicated; but if the pulse is good, and the passage of the patient through his illness is not a stormy one, alcohol should be excluded from the sick-room. Sometimes ordinary whiskey or brandy will in severe typhoid fever disorder the stomach. The physician should then employ an old brandy or wine which has acquired by age an aroma which is called a "bouquet." In persistent vomiting the use of small doses of good brandy poured on cracked ice will often do much good. Alcohol is not only of service internally, but it is also useful exter- nally as a wash or evaporating lotion over bruises, inflamed joints, and wounds of a contused character. It acts as a cooling and anti- septic dressing. When used for its influence as a local antiseptic it acts best in the strength of 60 to 70 per cent, by volume, as the presence of the 30 or 40 per cent, of water, by softening the bacterial envelope, enables the alcohol to destroy the germ. Absolute alcohol is there- fore much less serviceable than the dilute form. Alcohol is also useful for washing the skin of invalids, and "salt and whiskey" applied by rubbing is an excellent mixture to stimulate the skin of unhealthy persons. Acute Poisoning. — In advanced poisoning by alcohol, with coma and total relaxation, external heat and hypodermic injections of digi- talis and strychnine are indicated if the heart or respiration seems to be failing. Belladonna should be administered to stimulate the vaso- motor system if the skin is relaxed and clammy, and counterirritation to the back of the neck is to be employed if any brain symptoms are present. The after-treatment consists in the use of substances stimu- lating to the stomach, such as ammonia, spirit of Mindererus, and spices, unless there is gastric inflammation, when emollient substances should be used to quiet the irritation. If persistent vomiting comes on, it must be quieted by the patient swallowing pieces of ice, by cocaine,, or minute doses of ipecac. Counterirritation should be applied over the belly. If the emunctories are not acting freely, thor- ough purgation by jalap or elaterium (40 grains [2.6] of jalap powder or J grain [0.008] of elaterium) should be employed; or full doses of calomel followed by a saline may be given if milder effects are 68 DRUGS. sought. For the morning vomiting of drunkards Fowler's solution of arsenic is often a valuable remedy. In view of the frequency with which alcoholic and opium poisoning are confused, the following table is appended, which will be found of value in making a differential 'diagnosis as to the condition of the patient: Alcoholism and Opium Poisoning, Alcoholism. Opium Poisoning. 1. Pupils normal or dilated 1. Pupils contracted. 2. Respiration nearly normal. Pulse 2. Respiration and pulse slow and rapid, and finally feeble. full. 3. Face may be pallid. 3. Face suffused and cyanosed. 4. Skin cool, perhaps moist. 4. Skin warmer than in alcoholic poisoning. 5. Pulse rapid, at first strong, then 5. Pulse slow, strong, and full till weak. late in poisoning. There is scarcely any difference as to consciousness in the two conditions. In medico-legal cases the urine should be preserved in hermetically sealed vessels for examination. Acute alcoholism and apoplexy are often confused. They are differentiated in the following table: Acute Alcoholism and Apoplexy. Alcoholism. Apoplexy. 1 . Pulse rapid, compressible, and weak. 1 . Pulse apt to be strong and slow. 2. Skin moist, or relaxed and cool. 2. Skin hot or dry. 3. Bodily temperature lowered. 3. Bodily temperature raised. 4. Pupils equally contracted or dilated; 4. Pupils unequal, generally dilated. 5. No hemiplegia. 5. Hemiplegia: one side moved, the other remaining motionless. 6. Breathing not so stertorous nor so 6. Respiration stertorous, the lips one-sided in lips. being inflated on one side on expiration. 7. No facial palsy. 7. Facial palsy. 8. Unconsciousness may not be com- 8. Unconsciousness complete, plete. . The odor of alcohol in the breath is no guide, as acute alcoholism may have caused the rupture of a cerebral bloodvessel. Chronic Poisoning or the Alcoholic Habit. — Chronic poisoning by alcohol results in very characteristic changes in the tissues. As the liver receives the alcohol from the stomach diluted only by the portal blood, it is often affected very early, and cirrhosis of this organ comes on with its accompanying gastric and nutritional symptoms. Mental disturbances are common, and neuritis may develop and produce paralysis or symptoms resembling locomotor ataxia. 1 The treatment of chronic alcoholic poisoning may be carried out in two ways : First, by the isolation of the patient and the complete with- drawal of the drug at once ; secondly, by a better plan, a gradual taper- ing-off in the daily amount of the spirit. In either instance isolation must be absolute, and all smuggling of alcohol to or by the patient 1 See author's work on Diagnosis, Lea Brothers & Co., Philadelphia. ALCOHOL. (jo prevented. The attendants must be absolutely trustworthy. Care- ful scrutiny of bed-clothes and closets will often be rewarded by finding hidden whiskey-bottles. The depression of the patient when recov- ering from alcoholism must be met by the use of nutritious broths, highly seasoned in order to stimulate the stomach, by easily digested or predigested foods, and by small doses of morphine or coca if the patient be very weak and need such a stimulus. Koumyss is an exceedingly valuable and nutritious preparation under these circum- stances. In the treatment of the atonic stomach of drunkards a valuable aid is to be found in the following pill : 1^ — Oleoresin. capsici rrix (0.60). Olei caryophylli TTlx (0.60). Hvdrarg. chlor. mit gr. xx (1.3). Aloe -..".. gr. xl (2.6).— M. Ft. in pil. No. xx. S. — One three times a day after or before meals. If this pill fails to move the bowels, a saline purgative should be used. The following are the principal points in the differential diagnosis of Chronic Alcoholism and the General Paralysis of the Insane. Chronic Alcoholism. Paretic Dementia. 1. Attacks shorter, and more widely 1. Attacks more prolonged, separated by intervals of sanity. 2. Delirium may be of any character. 2. Delirium of grandeur more marked and defined. 3. Visions more characteristic, and are 3. Visions often not evil, but pleas- evil, ant. 4. Tremors confined to head and arms. 4. Tremors more diffused 5. Tremors removed by dose of alcohol. 5. Tremors made worse by alcohol. 6. Mental symptoms temporarily re- 6. Mental state made worse by al- moved, or at any rate improved, by al- cohol. cohol. 7. Tremors occur chiefly in the morn- 7. Tremors not confined to the morn- ing, ing. There is danger of pneumonia from failure of the right side of the heart in subacute and chronic alcoholism, and the physician should ahvays be on the lookout for this complication. Aministration. — Brandy and whiskey are generally used as rapidly- acting stimulants. They should be exhibited in the form best adapted to the work they are intended to perform. If the action must be instantaneous, as in a case of fainting, they should be employed hot and concentrated, so that the stomach has not to warm the liquid before absorption. They are to be used hypodermically if still more rapid action is required. If administered to aid digestion and support the system, then they should always be given with the food — never alone, and never concentrated. They may be given as milk-punch or as eggnog, the latter being the "heavier" of the two so far as diges- 70 DRUGS. tion is concerned. In fevers of a typhoid type the dose of whiskey o^* brandy should be for an adult from J to 2 ounces (15.0-60.0) ever? three or four hours. More than a pint in twenty-four hours is rarely required, but this amount often does great good and is not excessive if the patient is accustomed to its use and need stimulation. When brandy or whiskey is given to children, the following rules as to dosage may be used as indicating the approximate proper dose : 5 to 10 minims (0.30-0.60) every four hours for a child one month old; 10 to 20 minims (0.60-1.30) for a child two months old; 20 to 30 minims (1.3- 2.0) for a child three months old; 30 to 40 minims (2.0-2.6) for a child over three months old; 60 minims (4.0) for a child over four months old. In some cases, however, it is well to use half these doses every two hours. In all cases the liquor should be diluted with hot. or cool water. Wine-whey is very light and useful. Mulled wine and champagne are particularly useful in the treatment of irritable stomach. (See Foods for the Sick.) Champagne when used as a medicinal stimulant should always be as devoid of sugar as possible — that is, what is known as "extra dry" or "Brut." Gin is rarely employed as a stimulant, except when the kidneys are torpid. Stout and porter are of value in wasting diseases, in convalescence from acute diseases, and for nursing women. Contraindications. — All states of cerebral excitement, unless due to exhaustion, acute inflammations, the alcoholic habit, apoplexy, meningitis, acute nephritis, aneurism, and advanced atheroma, con- traindicate the use of alcohol, as does also the history of the alcoholic habit. The official preparations of alcohol are as follows: Whiskey (Spiritus Frumenti, U. S.) should be at least four years old, and be made, in America, from rye, for medicinal purposes./ Brandy (Spiritus Vini Gallici, U. S. and B. P.) is obtained by the distillation of fermented grapes or fruits, and should be from three to five years old before use. Cologne-water (Spiritus Odoratus) is used solely as a lotion and perfume. Red wine (Vinum Rubrum, U. S.) is made from grapes not deprived of their skins. White Wine (Vinum Album, U. S.) is the fermented juice of grapes the skins of which have been removed. Dilute Alcohol (Alcohol Dilutum, U. S.), pure alcohol (Alcohol, U. S.), and absolute alcohol (Alcohol Absolutum, U. S. and B. P.) are also official. The unofficial preparations are: Rum, which is made from the fermentation of molasses, and con- tains about 40 to 45 per cent, of alcohol. Gin is made from rye or barley, with the addition of juniper-berries and hops. (Good "dry" gin and the Spiritus Juniperi Compositus of the U. S. P. are virtually identical therapeutically.) W r hen diuresis is required and atony of the kidneys is present, without inflammation, gin / ALLSPICE. 71 is a useful medicament, provided that a stimulant is indicated. Gin is one of the alcoholic drinks most apt to produce cirrhosis of the liver. Port Wine (Vinum Portense) is a fermented wine, to which pure spirit is added to increase its strength. It is one of the strongest table wines, and is useful as a stimulant in convalescence. Sherry (Vinum Xericum) has about 30 per cent, of alcohol in it. It is not official in the U. S. P. Beer is made by a slow fermentation, while ale is made by a more rapid fermentation at a higher heat. Most of the beer in America contains about 4-6 per cent, of alcohol. Porter resembles the other malt liquors closely, except that it con- tains more solids, due to a scorching of the grain by a high heat. The B. P. preparations that are not official in the U. S. P. are rectified spirit (Spiritus Rectificatus) , sherry (Vinum Xericum), and Mistura Spiritus Vini Gallici, which is a useful, pleasant, and nutri- tious stimulant made by beating up the yolks of two eggs with half an ounce of sugar, and then adding four ounces each of brandy and cinnamon-water. This is sometimes called "egg-flip." ALLIUM. Garlic, or Allium Sativum, is a stimulant to digestion, owing to the volatile oil it contains, which by its somewhat irritating proper- ties excites the gastric mucous membrane to increased secretion. In persistent colds, where the bronchial tubes are particularly affected, a garlic poultice made by pounding the bulbs in a mortar, is a very efficient though disagreeable remedy. If the skin is too delicate to permit of the use of pounded garlic alone, it may be mixed with equal parts of bran, and a poultice or plaster made thereof. Employed in this form, allium is useful if applied over the spine or feet in the treatment of the cerebral and spinal convulsions of infants; placed over the belly in cases of g astro-intestinal catarrh, it acts almost as well as a spice poultice. In the treatment of children with chronic colds garlic may be used boiled in milk, and the liquid given as a drink, warm or cold; or the oil of garlic may be given in emulsion in the dose of 1 or 2 minims (0.05-0.10). It ought not to be given during the febrile stage, as it is stimulating. Allium-juice has also been used in the dose of 2 to 5 drops (0.1-0.3), to relieve nervous vomiting. The dose of the syrup (Syrupus Allii) for a child is 1 drachm (4.0), but 4 drachms (16.0) may be given to an adult. ALLSPICE. Allspice, or Pimenta (U. S. and B. P.), is the nearly ripe fruit of Pimenta officinalis, a tree of the West Indies. It contains an official volatile oil (Oleum Pimento 3 , U. S. and B. P.), used for flavoring pur- 72 DRUGS. poses, as a constituent of spice plasters, in diarrhoea mixtures, or as a carminative. It will also prevent the griping of purgative medicines. The dose of the oil is 1 to 5 minims (0.05-0.30). Aqua Pimentoe (B. P.) is given in the dose of 1 to 2 ounces (30.0-60.0). ALMONDS. Almonds are official in the form of the bitter almond {Amygdala Amara, U. S. and B. P.) and the sweet almond (Amygdala Dulcis, U. S. and B. P.). Bitter almonds develop hydrocyanic acid in the presence of water, by the reaction between the amygdalin and water in the presence of the emulsin contained in them; this is not the case with sweet almonds. Sweet almonds, when rubbed up in a mortar with water, form a pleasant-tasting emulsion of an agreeable odor that is very useful as a vehicle for remedies having a disagreeable taste. Almond bread has been proposed as a food for diabetics, owing to its containing virtually no starch; but it is requisite that the oils and saccharine constituents of the almond shall first be removed. (See Foods for the Sick.) When half an ounce of sweet almonds are rubbed up with thirty grains of gum arabic and two drachms of sugar, to which is added gradually a half-pint of distilled water, the mixture being then strained, an emollient and soothing drink is formed, which is very useful in irritations of the stomach and intestines and of the air-passages and pharynx. The expressed or fixed oil of almonds is a useful demul- cent, and has been recommended in the cough of phthisis, given in the dose of a \ drachm (2.0) in emulsion. Bitter almonds yield an oil (Oleum Amygdala? Amara?, U. S.) which is exceedingly poisonous owing to the prussic acid which it contains, and it is said that one drop will kill a cat, while seventeen drops have killed a man. Oil of bitter almond should contain from 2 to 4 per cent, of hydrocyanic acid. Bitter almonds are used to allay irritable coughs and similar states, but are not frequently employed because other drugs are less danger- ous, more stable, and more active as remedial agents. The emulsion of bitter almonds is made as is that of sweet almonds, and may be used in teaspoonful doses for the same purposes and as a vehicle in cough mixtures. Both emulsions are useful as vehicles in the treatment of gonorrhoea, as they diminish the burning on urination. Almond emulsions, when locally applied, are supposed to be of value for the removal of freckles and sunburn. The preparations of sweet almonds are: an emulsion (Emulsum Amygdala?, U. S., and Mistura Amygdala, B. P.), dose 1 to 2 ounces (30.0-60.0); a syrup (Syrupus Amygdala, U. S.), dose 2 drachms to 2 ounces (8.0-60.0) ; a compound powder (Pulvis Amygdala? Composi- tus, B. P.), given in the dose of 1 to 2 drachms (4.0-8.0); and the oil (Oleum Amygdala? Expressum, U. S., and Oleum Amygdala, B. P.), ALOES. 73 the dose of which is 1 to 4 drachms (4.0-16.0). Aquce Amygdalae AmaroB (U. S.) is prepared from the oil of bitter almonds. The dose is 30 to 60 minims (2.0-4.0). ALOES. Aloes, or Aloe of the U. S. P., is derived from Aloe Perryi, or Aloe vera. Both Socotrine and Barbadoes are official under Aloe in the U. S. P. of 1900. Aloes is the inspissated or dried juice of the leaves of the plant. It is also probably derived from several other species than those just named. Aloes contains an active principle known as aloin (Aloinum, U. S. and B. P.), which is a crystalline substance. As generally sold aloin is, however, an amorphous powder of extremely bitter taste. Physiological Action. — Locally applied to the tongue, aloes is a bitter of rather a persistent taste. According to the studies of Ruther- ford, the drug increases very considerably the flow of bile in the dog, but in man it cannot in any sense be regarded as a medicament for the production of an increased biliary flow. Rutherford's doses given to the dog amounted to as much as sixty grains, equal to three or four drachms in a man. In the lower animals and in man aloes acts very slowly, requiring many hours for its influence to be manifested unless the dose be toxic in amount. Its chief influence is on the lower bowel (Fig. 6). As much as four drachms of aloes have been injected into the veins of a horse without inducing purgation, probably because four drachms were not enough to affect the bowels. Aloes has been used endermically, and when so employed is said to act thoroughly. It is eliminated in the milk of nursing women, and will cause purga- tion in an infant put to the breast of a patient taking it. If the doses be quite large (10 to 20 grains), the passages will be watery; but if the dose be more moderate (2 or 3 grains), the stools will be thick and pultaceous. Therapeutics. — Aloes should be used only when a somewhat slow stimulant to peristaltic movement is desired, and never where the object of the physician is to relieve congestions by depletion through the intestine. It is a favorite remedy in cases of subacute or chronic constipation, but it is distinctly harmful if continued for any length of time, as it seems to produce atony of the bowel. Owing to its bit- ter properties it acts as a tonic to the stomach, and is often given with iron, as clinical experience indicates that their conjoint use is bene- ficial. Its good effects depend upon its preventing any constipation which might be produced by the chalybeate. When taken in a sufficiently large dose to produce a copious pas- sage, aloes nearly always produces a feeling of weight and fulness in the region of the rectum after the evacuation, and the writer has seen severe rectal catarrh produced in this way in very susceptible persons. If given alone, it is very apt to produce griping, and it 74 DRUGS. ought always to be combined with other drugs whose tendency is to prevent intestinal spasm. In cases of hemorrhoids in individuals suffering from general muscular relaxation and atony, aloes is said to do great good, but its use under these circumstances is by no means universal or generally accepted as correct. For weak, anaemic persons leading sedentary lives it may be combined with tonics to relieve the constipation so often an urgent symptom in these cases. In amenorrhoea dependent upon atony of the sexual system, or amemia, or constipation, it is thought to have a specific emmenagogue influence. Locally applied in the form of the glycerole of aloes, it has been employed in the healing of old or recent fissures of the rectal mucous membrane, and even in bed-sores. The glycerole of aloes is to be made by evaporating four to eight parts of tincture of aloes and gradually adding thirty parts of glycerin. 8 J Fig. 6. A, chief effect of aloes is exercised on lower bowel or colon. Contraindications. — Constipation occurring in plethoric persons should not be treated by aloes, and it should not be used if any irrita- tion or catarrh of the intestine is present. Pregnant women should use aloes most carefully lest abortion be produced, and if hepatic conges- tion or inflammation is present it ought not to be used. Fever is also said to contraindicate the use of aloes, as does also rectal catarrh. Administration. — Aloes is generally given in a pill, combined with spices and belladonna. (See Constipation, Part IV.) The dose should be 1 to 5 grains (0.06-0.3) as a laxative, and 10 grains (0.6) as a purge. The Aloe Purificata, U. S. P., should always be used. The official preparations most commonly employed are the pill of aloes (Pilulce Aloes, U. S. and B. P.), 2 grains (0.12) each of aloes and soap; the pill of aloes and myrrh (Pilula? Aloes et Myrrha, U. S. and B. P.), 2 grains (0.12) of each constituent; the pill of aloes and ALUM. 75 mastich (Pilules Aloes et Mastiches, U. S.), 2 grains (0.12) of aloes, or the " Lady Webster dinner pill"; the pill of aloes and iron (Pilules Aloes et Ferri, U. S. and B. P.), 1 grain (0.06) of aloes and 1 grain (0.06) of dried sulphate of iron. The dose of all these is one or two pills. Aloes is also official as Extractum Aloes, dose 1 to 2 grains (0.06-0.12). Aloin is an ingredient of the Piluloe Laxatives Compositor, U. S., which also contain extract of belladonna, strychnine, and ipecac. The liquid preparations are the tincture (Tinctura Aloes, U. S. and B. P.), dose 1 to 2 fluidrachms (4.0-8.0); the tincture of aloes and myrrh (Tinctura Aloes et Myrrhw, U. S.), 1 dose 1 to 2 fluidrachms (4.0-8.0). The B. P. preparations, besides those given, are the Decoctum Aloes Compositum, dose J to 2 ounces (15.0-60.0), and the Extractum Aloes Barbadensis, the dose of which is 2 to 6 grains (0.1-0.40). ALUM. Alum (Alumen, U. S. and B. P.) is the sulphate of aluminum and potassium in the U. S. P., but in the B. P. both it and the sulphate of aluminum and ammonium crystallized from a watery solution are official. At present much of the alum of commerce is obtained as a by-product in the manufacture of coal-gas for illuminating purposes, and it is therefore very cheap. It occurs in the form of octahedral crystals, and has an astringent taste and acid reaction. After the crystals are exposed to the air for some time they become covered with a white coating. Physiological Action. — When alum is brought in contact with a mucous membrane it produces whitening, constriction, and puckering of the part, and applied to the skin thickens and hardens it by means of its astringent action. In either case it decreases secretion and causes contraction of the local bloodvessels and capillaries. Large amounts given internally for any length of time seem to increase secretion. Poisoning. — Very large amounts are necessary to produce death. As much as two ounces will not kill a sickly dog. This is largely due to the fact that the vomiting and purging rid the animal of the drug, for if vomiting is prevented death rapidly ensues from gastro-enteritis. Injected into the blood, alum produces embolism and thrombosis. Therapeutics. — Alum is used at present in a number of diseases, chiefly as a local application. In cases of ordinary sore throat applications of a strong solution (20 grains to the ounce of water — 1.3-30.0) on a swab are very useful. It would be of much service in this condition were it not that it possesses a destructive action on the teeth. In hemorrhage, when the leaking bloodvessels can be directly reached, alum is a powerful haemostatic, aiding in the arrest of the bleeding in three ways — namely, by coagulating the albumin, by con- stringing the parts, and by crystallizing when applied in large amounts 1 Sometimes called Elixir Proprietatis. 76 DRUGS. on lint, and thereby affording a surface which is rough and aids coagu- lation. In hemorrhage after tooth-extraction its application is a very useful treatment. Dissolved in water or alcohol, 2 grains to the ounce (0.1-30.0), it makes an exceedingly efficient application for sponging in night-sweats or localized sweating of the feet or hands. In haemop- tysis a fine spray of a strong solution of alum, 20 grains to the ounce (1.3-30.0), may be employed, the necessity of the spray being made very fine being constantly borne in mind. This method may also be resorted to in bronchorrh&a or chronic bronchitis with excessive secre- tion, and in chronic catarrh of the pharynx and larynx. In mercurial ptyalism the drug may be used on a swab. Bathing with an alum solution the parts affected is said to be an efficient remedy in chilblains, and for pruritus vulvae. As a vaginal wash for profuse leucorrhaa, in the strength of from 10 to 20 grains to the ounce (0.65-1.3 to 30.0) of water, alum is of value. Some observers claim good results from its use in diphtheria and tonsillitis. In follicular tonsillitis the alum-stick may be deeply inserted into the depressed follicles or applied to the swollen surface of the gland. In ingrowing toe-nail with granulations a piece of twisted absorbent cotton soaked in strong alum solution and inserted under the edge of the nail will in most instances produce a cure. Dried alum (Alumen Exsiccatum, U. S. and B. P.) is useful as a dressing for old ulcers and sores, and has been highly recommended as an application for swollen gums where they press upon and over- ride a tooth, particularly at the back of the jaw. The possibility of its exercising an evil effect on the teeth should not be forgotten when this treatment is resorted to. Internally, alum has been used in diabetes, gastralgia, and dysen- tery of an acute and chronic type. In conjunction with morphine it seems to be of value to allay the pain in lead colic. At one time alum was largely employed in membranous croup in emetic dose for the dis- lodging of the membrane and for the astringent effect exercised as it was swallowed and expelled. Alum may be used as an antidote in acute lead poisoning, as it is a soluble sulphate and also an emetic. The emetic dose of powdered alum is a heaping teaspoonful for a child or a tablespoonful for an adult. Glycerinum Aluminis (1 to 5) is official in the B. P., and is used as a local astringent application. AMBER. Succinum is derived from a fossil resin found in Prussia and in Bohemia, and is used in the form of the oil (Oleum Succini), which is volatile, quite irritant, and obtained by destructive distillation from the deposits named. Therapeutics. — Oil of Amber is one of the best remedies for per- sistent hiccough that we have. It is very useful as a counterirritant AMMONIA. 77 over rheumatic joints, and has been used in asthma, whooping-cough, and hysteria with good results. In the bronchitis of infants, with nervous disturbance, oil of amber in the proportion of 1 to 3 parts of olive oil applied to the back and front of the chest is of service. In adults suffering from acute laryngitis with extension of the inflam- mation into the bronchial tubes, full doses of sodium bromide given internally, with this proportion of amber oil and olive oil rubbed into the neck and chest, are useful. The dose internally is 2 to 6 minims (0.1-0.4) given in emulsion. AMMONIA (NH 3 ). Ammonia is a gas of a very acrid, burning taste, capable of producing death very rapidly when inhaled, by reason of the inflam- mation of the air-passages and the spasm of the glottis which ensue. It is made in large amounts in the manufacture of coal-gas. Physiological Action. — When ammonia comes in contact with the tissues of the body it acts as a most powerful irritant, causing a red- dening of the parts, followed, if the exposure be sufficiently prolonged, by local death and sloughing. If it be inhaled as a gas, it may pro- duce rapid death by spasm or oedema of the glottis, and if a strong solution of it is swallowed, the same accident may occur. Following more moderate inhalations severe bronchitis or pulmonary oedema may develop. Nervous System. — If ammonia be injected into the blood of animals, violent convulsions at once ensue which are largely tetanic in type and depend upon a spinal action of the drug, since they are not stopped by division of the spinal cord, as they would be if the con- vulsive movements had their origin in the brain. The drug in moderate amounts acts as a spinal excitant, increasing reflex action and all the evidences of spinal activity. If applied directly to a nerve, either motor or sensory, it paralyzes the nerve ; but if the drug be in a very weak solution, seems to increase the functional activity of the nerve. Circulation. — Upon the circulation ammonia acts as a powerful but fleeting stimulant, increasing the pulse-rate, pulse-force, and arterial pressure. The cause of the increased pulse-rate depends upon stimulation of the accelerator nerves of the heart and of the heart itself, while the increase in force is due to the same cause, for Ringer and Sainsbury found the strength of the ventricles much increased. The rise of arterial pressure is due to the increased amount of blood pumped into the arteries by the stimulated heart, and probably by a stimulant action on the vasomotor centre, although this is denied by some authorities. As the drug acts as a stimulant on the respiratory centre, which is very near the vasomotor centre, it probably increases the functional activity of both. If by means of intravenous injection the ammonia reaches the heart in large amount in concentrated form, this organ ceases to beat at once, owing to paralysis of its muscular walls. 78 DRUGS. The Blood. — In moderate amounts the drug has no effect on the blood, but when injected in poisonous quantities it causes the blood to fail to take up the oxygen, according to Feltz and Ritter. Respiration. — The injection of ammonia in moderate quantities into the blood causes an acceleration of the rate of respiration due to a stimulation of the respiratory centre, the respiratory movements becoming not only more full, but also more rapid. If the drug is inhaled in small amounts or swallowed, the same action is seen in a less degree, the changes both in breathing and circulation being partly due under such circumstances to a reflex irritation transmitted along the sen- sory nerves. Elimination. — Ammonia when taken into the body is so extremely fleeting in its action that the question as to its escape from the system is of interest. If large amounts are taken, it is partly given off by the breath, but more of it is burnt up in the system, and, according to Bence Jones, elimi- nated as nitric acid by reason of its being oxidized in the body. Some think that it is in part excreted as urea. Therapeutics. — Ammonia is employed for four distinct purposes in medicine — namely, as a circulatory and a respi- ratory stimulant, as a counterirritant, and as an antacid. The indications for the use of am- monia in the first class of cases are all forms of sudden cardiac failure where there is no time or oppor- tunity to use the more stable and slowly-acting drugs. These emer- gencies occur in snake poisoning, in syncope from fright or other shock or indigestion, in sudden cardiac failure during the course of fevers and in pneumonia, and in all cases where rapid cardiac stimulation is needed. It is claimed, without much justification, that ammonia will aid in preventing heart-clot or thrombosis in cases of severe hemor- rhage and in pneumonia. In the most pressing cases it should be injected directly into a vein of the leg, so as to act more quickly. If put into the subcutaneous tissues, it is almost certain to cause a slough, and if injected into a vein of the arm, it may reach the heart in too concentrated form and cause cardiac depression. Ringer has found that the drug has the extraordinary power of causing a heart stopped or depressed by chloroform to resume its beating. In prolonged diseases the employment of ammonia is not particu- larly advisable, owing to its fugacious action, although it is largely Ammonia stimulates: A, the accelerator nerves; B, the heart-muscle itself, and so quickens pulse-rate and force. It stimu- lates the vasomotor centre C, and the respiratory centre D. AMMONIAC. 79 used, for the frequent administration necessarily required is apt to produce gastric disorder. Some writers claim that ammonia is useful as a sedative in drunkenness, but this is doubtful. In gastric acidity due to fermentation, with the development of abnormal acids, ammonia is the most active remedy we can employ, but it is not to be given if acute irritation of the stomach exists. Locally applied, strong ammonia-water may be used to produce a blister by placing a few drops on the skin under an inverted watch- glass. Ammonia-water may also be applied, often with great relief, to the spot stung by insects. The waters of ammonia are used exter- nally in stimulating liniments, and hypodermically when the drug is so given. The stronger water ought not to be employed for the latter purpose. The aromatic spirit is generally used internally in the dose of \ drachm to 1 drachm (2.0-4.0), well diluted. This is also the dose of the ordinary spirit. Administration. — Ammonia is never employed in medicine as pure ammonia gas, but in the form of the stronger water (Aqua Ammonia? Fortior, U. S.; Liquor Ammonia? Fortis, B. P.), containing 28 per cent, by weight of the gas, and the weaker water (Aqua Ammonia?, U. S.; Liquor Ammonia?, B. P.), which should contain about 10 per cent, by weight of the gas. The spirit of ammonia (Spiritus Ammonia?, U. S.) is given in the dose of 30 to 60 minims (2.0-4.0) in water, and the aromatic spirit of ammonia (Spiritus Ammonia? Aromaticus, U. S. and B. P.) in the dose of 30 to 60 minims (2.0-4.0) in water. The latter preparation is composed of carbonate of ammonium, the oils of nutmeg, lemon, and lavender, with alcohol and ammonia-water. Spiritus Ammonia? Fa?tidus (B. P.) contains asafcetida, and is used in place of the aromatic spirit. Ammonia liniment (Linimentum Am- monia?, U. S. and B. P.) is used over tender joints and muscles. AMMONIAC. Ammoniac (Ammoniacum, B. P.) is a resinous gum obtained from Dorema Ammoniacum, and is little used in medicine at the present time. Internally and externally it produces some irritation when brought in contact with the tissues, and may be used internally in the dose of 10 to 30 grains (0.60-2.0) in pills in cases of chronic bronchitis devoid of any active inflammatory process. Mistura Ammoniaci (B. P.) is used in chronic bronchitis in the dose of a tablespoonful (15.0). 80 DBUGS. AMMONIUM (NH 4 ). The following salts of ammonium are official, and are used for various purposes: Acetate of Ammonium. Acetate of Ammonium is used in medicine in the form of the spirit of Mindererus (Liquor Ammonii Acetatis, U. S. and B. P.), dose 1 to 2 fluidrachms (4.0-8.0), for the purpose of acting as an antacid in gastric indigestion, and also as a mild diaphoretic which is inferior to sweet spirit of nitre. Benzoate of Ammonium. Benzoate of Ammonium (Ammonii Benzoas, U. S. and B. P.) is employed chiefly for its diuretic influences, which depend entirely upon the benzoic acid present in the compound. It should be kept in well-stoppered bottles. As benzoic acid is eliminated as hippuric acid and ammonia as nitric acid, this drug may be employed in cases where the physician desires to make the urine decidedly acid; as, for example, in patients suffering from catarrh of the bladder, when the urine is loaded with phosphates, which are dissolved by this acidula- tion. The dose is 10 to 30 grains (0.60-2.0), which should be dis- solved in water, or, better, administered in cachets or capsules. Bromide of Ammonium. Bromide of Ammonium (Ammonii Bromidum, U. S. and B. P.) is really a crystalline salt, but is generally found in commerce as a white granular powder, which, when exposed to the atmosphere, becomes slightly yellowish. It is readily dissolved in water. Physiological Action. — Applied to the mucous membrane of the mouth, the bromide of ammonium produces a salty taste, is markedly pungent, and dissolves readily in the oral secretions. If large amounts are swallowed, it causes burning pain in the belly and evidences of gastro-enteritis. Nervous System. — The action of this drug upon this part of the body is its most important effect. Given to the lower animals, it pro- duces in frogs total loss of reflex activity, preceded, it is said, in some cases by tetanic convulsions, although no such motor disturbances may take place. In a series of studies undertaken by the writer to determine the effect of the drug it was found that the spinal cord was depressed, both on its motor and sensory sides, while the nerves and muscles escaped. These results are in accord with those of other investigators, who also found that the nerves are unaffected. On the cerebral cortex it acts as a distinct sedative. Circulation. — Upon the circulation bromide of ammonium acts as a stimulant in small doses, but as a cardiac paralyzant if a large AMMONIUM. 81 amount comes in contact with the heart. In medicinal dose it is distinctly stimulant to the circulation, but not sufficiently so to render it valuable as a circulatory stimulant, to the exclusion of other more powerful preparations. Therapeutics. — The bromide of ammonium may be used in nearly every instance where bromide of potassium may be employed, and possesses the distinct advantage of being less depressant to the general system than the latter drug. It is, however, more apt to disorder the stomach even if given in moderate doses. In epilepsy it would seem to be of as much value as the potassium salt, and may be combined with it in some cases with success. (See article on Epilepsy, Part IV.) According to J. M. Da Costa, the drug is of distinct value in rheu- matism in the dose of 60 to 80 grains (4.0-5.3) a day, well diluted with water, although its manner of action in this disease is not known. The usual dose is 10 to 30 grains (0.60^2.0). It is incompatible with spirit of nitrous ether. Carbonate of Ammonium. Carbonate of Ammonium (Ammonii Carbonas, U. S. and B. P.) undoubtedly has an action exactly like that of the liquid preparations of ammonia, and is used either alone or with the chloride in the treat- ment of bronchitis, particularly when this disease occurs in babies and young children. It is also largely employed by surgeons in the treat- ment of children after a surgical operation to overcome the respiratory and circulatory depression produced by the anaesthetic. The dose is 2 to 10 grains (0.12-0.60) in syrup of acacia and water. It is a rapidly acting cardiac and respiratory stimulant. Bf — Ammonii carbonat , gr. xlviij (3.2). Syrup, acacise f§j (30.0). Aquae dest ". . q. s. ad f Siij (90.0). — M. S. — Teaspoonful (4.0) every two hours for a child of three or four years. Chloride of Ammonium. The Chloride or Muriate of Ammonium (Ammonii Chloridum, U. S. and B. P.) has an entirely different action and therapeutic use from the rest of this group. It possesses almost no influence over the heart and respiration, but does exercise a very stimulant effect on mucous membranes, increasing the secretion of mucus. The consideration of its use in diseases of the lungs can be found in the articles on Pneu- monia and Bronchitis. Chloride-of-ammonium fumes can be obtained from a few grains of the drug heated in an iron spoon over a gas-jet or by means of a set of three wash-bottles. In one of these is placed stronger water of ammonia, in another muriatic acid. Each of these is connected with a third bottle by means of glass tubing, this bottle being partly filled with water, through which the fumes in passing become purified and form the fumes of chloride of ammonium. The drug may also be used in a spray from an atomizer. Where it is 6 82 DRUGS. desirable to maintain the effect of the drug over a long period of time, as in chronic bronchitis, the following method may be followed, as recommended by Mew: A soup-plate is placed upon the floor of the room, and from 3 to 4 ounces (90.0-120.0) of sulphuric acid are placed in it. Into a neighboring saucer are poured 2 ounces (60.0) of strong ammonia, and then about a tablespoonful (15.0) of ordinary table- salt is sprinkled upon the acid. In less than a minute the room becomes filled with dense fumes of nascent chloride of ammonium, which can be readily maintained by renewed charging of the soup- plate and saucer. In this way the patient may be made to inhale chloride of ammonium fumes for a long period of time with very advan- tageous results. This is a particularly useful method in cases of fetid bronchitis. Chloride of ammonium has been employed in intermittent fever, but has gone out of use, and has also been vised in neuralgias of the ovarian type by Goodell and others. In the treatment of chronic torpor of the liver and subacute hepatitis, and even in cirrhosis and hepatic abscess, it has been thought of value. Many clinicians have found it useful in the treatment of the gastric and intestinal catarrhs of children of a very subacute type, and it is the routine treatment for all such cases which come under observation at the hospital and elsewhere where the author has charge. The dose is 2 to 15 grain:; (0.12-1.0), preferably given with liquorice and water to mask the taste. R — Ammonii chloridi gij (8.0). Fluidextracti glycyrrhizae f,^j(30 0) Aquae dest q. s. ad f'giij (9U.0). — M. S. — Teaspoonful (4.0) t. i. d. after meals for a child of five to ten years. The chloride of ammonium may, however, be given in compressed tablets, provided a large draught of water or milk is taken simulta- neously to protect the stomach. (See article on Bronchitis for other prescriptions.) Gillespie asserts that 10 grains (0.60) of chloride of ammonium given half an hour before meals gives extraordinary relief in painful dyspepsia due to hyperacidity of the stomach. Chloride of ammonium, in a lotion of the strength of 1 ounce (30.0) to 2 quarts (2 litres) of water, is an efficient remedy for the dermatitis caused by poison-ivy. Iodide of Ammonium. Iodide of Ammonium (Ammonii Iodidum, U. S.) should be kept in dark, well-stoppered bottles, and if deeply colored should not be dispensed. It may be employed in the dose of 2 to 5 grains (0.12-0.3) in all cases where the iodide of potassium is indicated, and seems to possess alterative influences equal to those of that salt. It has been r commended as a local application in cases of enlarged tonsils in the form of a solution of 30 grains (2.0) of the salt to the ounce (30.0) AMYL NITRITE. 83 of glycerin, particularly if struma is the cause of the enlargement. The application is to be made once a day with a swab or camel' s-hair brush. It is necessary that this solution be not exposed to the air or it will undergo decomposition. Valerate of Ammonium. Valerate of Ammonium (Ammonnii Valeras, U. S.) is the salt of ammonium commonly used in the nervous unrest of pregnant or hysterical women, or at the menopause in the peculiar nervous dis- orders apt to occur at that period. In poisonous doses it paralyzes the spinal cord in the lower animals. It is usually given in the form of the elixir of valerate of ammonium, the dose of which is a tea- spoonful to a dessertspoonful, or it is combined with the bromides, under which circumstances it is much more efficacious. The dose of the salt itself is 10 to 15 grains (0.60-1.0). The sulphate of ammonium is never used in medicine. The phos- phate of ammonium is employed in rheumatism in the dose of 10 to 20 grains (0.60-1.3). It is no longer official. The B. P. preparations besides those already given are: Oxalate of Ammonium and Liquor Ammonii Citratis, dose 2 to 6 fluidrachms (8.0-23.0). AMYL NITRITE. Amyl Nitrite (Amyl Nitris, U. S. and B. P.) is a very volatile, somewhat oily liquid possessing a peculiar penetrating pear-like odor. It is made by the action of nitric and nitrous acids upon amylic alcohol, and is not to be confounded with nitrate of amyl, which has a different physiological action and is never used medicinally. Nitrite of amyl should be protected from light and heat. Physiological Action. — When swallowed or inhaled, the drug pro- duces staggering, fulness in the head, roaring in the ears, duskiness of the face, and finally complete muscular relaxation, so that the animal or man falls to the ground. The heart beats very rapidly and forcibly, and the respiration becomes gasping. Nervous System. — Nitrite of amyl is the most rapidly acting of all the nervous depressants and sedatives known, except prussic acid. Experiments show that its dominant action is on the motor side of the spinal cord. The motor cortex of the brain and the motor nerves are only affected by large amounts. Upon the nervous apparatus of sensation nitrite of amyl has no effect in medicinal amounts, and should never be used to relieve pain unless it be due to spasm or to angina pectoris. The muscles are depressed by toxic amount. Circulation. — When nitrite of amyl is used, the pulse becomes exceedingly rapid, while the arterial tension progressively falls. The increase in pulse-rate is due to depression of the centric inhibitory 84 DRUGS. Fig. 8. V V apparatus (vagus centres) of the heart and to the sudden relaxation of the bloodvessels, by reason of which, the resistance being taken away, the heart beats faster. The fall of arterial pressure is due to depression of the vasomotor centres and the muscular coats of the bloodvessels. In very small amounts the drug stimulates the heart- muscle (Reichert), but its dominant action is that of a depressant. The Blood. — In medicinal dose this drug produces a chocolate color of the arterial blood, due to the change of oxyhemoglobin into methsemoglobin. Urine and Elimination. — The urine sometimes contains sugar after the use of the nitrite of amyl, and there is increased diuresis. The drug is eliminated very rapidly from the body by the lungs and kidneys. Temperature. — If the nitrite of amyl be employed for any length of time, a most remarkable fall in bodily temperature ensues, which is probably due to diminished oxidation, but possibly to some effect on the heat-centres governing heat-production and dissi- pation. The vascular dilatation also tends to aid greatly in the loss of bodily heat produced by the drug. Therapeutics. — Nitrite of amyl is used to relax general or local muscular spasms, for the relaxation of the spasm of epilepsy and for aborting an on-com- ing fit, for the prevention and subjugation of strych- nine convulsions and tetanus, and for the relief of angina pectoris, provided the attack is accompanied by high arterial tension. It may be used in puerperal of' amyl de- eclampsia, but it is a dangerous remedy because of presses the motor or its relaxation of the uterus and the consequent danger crossed pyramidal £ p 0S t-partum hemorrhage. In dysmenorrhea with tracts of the spinal r . r • p • T > xt» ■ cord. uterine spasm it often gives great relief. Nitrite of amyl has been used in cases of sea-sickness as a prophylactic and cure with considerable success. In cardiac fail- ure from fright or anaesthetics amyl nitrite is often of great value in single whiffs. If it does not act at once under these circumstances, it is worse than useless to push it. . It has also been found of value in whooping-cough, laryngismus stridulus, asthma, spasmodic croup, and infantile convulsions. In migraine with local vasomotor spasm and true hemianopsia it is very useful. In strychnine poisoning and tetanus it must be used between the spasms or else given hypoder- mically, as the respiratory cramp prevents its inhalation. Administration. — The drug may be given by placing three to five drops on a handkerchief and inhaling the fumes, or it may be dropped on sugar and taken by the mouth in the same quantity. It is important to remember the fact that the effects of the drug are more severe for a moment after its use than during its inhalation. V V Nitrit< ANTIMONY. 85 The physician should warn the patient that the effect of the drug- is sudden and alarming, and in nervous cases should direct that the inhalations be made slowly, as a very full inhalation may produce unpleasant sensations of cardiac failure. The best way for patients to use the drug is to have it in pearls of glass, each holding 3 minims (0.15). One or more of these may be crushed in a handkerchief and the fumes inhaled. Some of the pearls made by careless manufacturers are of such thick, strong glass that they are difficult to break, and if broken are apt to cut the fingers. These are, of course, to be avoided. ANTHRAROBIN. Anthrarobin seems to possess equal value with its relative chrys- arobin, and to be capable of acting as efficaciously as this substance in the treatment of skin diseases. It is a yellowish powder, tolerably stable in a dry atmosphere, not soluble in acids or water, but readily soluble in dilute alkaline solution or alcohol, at first making a solution of a brown color, which, as oxygen is taken up, changes to a green and finally to a violet. Therapeutically, anthrarobin has been employed by Rosenthal and by Behrend, and more recently Kobner has recorded his experience with it, employing it with good results in a 10 to 20 per cent, solution in the various forms of tonsurans as a wash. Rosenthal has used it in psoriasis and pityriasis versicolor and herpes, and Behrend asserts that it is often better in its effects upon the skin than chrysarobin, as it produces less inflammation and discolors the skin only slightly. It also possesses the additional value of making so slight a stain on the linen that it can be removed by washing. According to most authorities, it is best to keep the drug in alcoholic solution, and, if the bottle is well corked, such a mixture remains stable for a week. ANTIMONY. Antimony itself is rarely used in medicine, owing to its insolubility, but is generally employed as the tartrate of antimony and potassium, or Tartar Emetic (Antimonii et Potassii Tartras, U. S.; Antimonium Tartar alum, B. P.), or in the form of the sulphide (Antimonii Sul- phidum); purified sulphide (Antimonii Sulphidum Purificatum; Anti- monium Nigrum Purificatum, B. P.); and sulphurated antimony (Antimonium S ulphuratum, B. P.), sometimes called Kermes Mineral. The last three drugs are very rarely employed and are unreliable preparations, although some practitioners use kermes mineral as an alterat've circulatory depressant and sedative expectorant in the dose of -g- grain (0.01) every hour or two. As an emetic the dose of Kermes Mineral is 1 to 4 grains (0.06-0.25). The oxide of antimony (Antimonii Oxidum, B. P.) forms part of the Pidvis Antimonialis , 86 DRUGS. Fig. 9. Tartar Emetic. Tartar Emetic (Antimonii et Potassii Tartras, U. S.; Antimonium Tartaratum, B. P.) is made by boiling the oxide of antimony with bitartrate of potassium and water. Although it is really crystalline, it is generally sold as a fine powder, owing to the crystals being easily pulverized. It is insoluble in absolute alcohol, but is soluble in ordinary water, and still more so in boiling water. In dilute alcohol it is partly soluble. Owing to its chemical consti- tution tartar emetic should never be given with either acids or alka- lies, and all drugs containing tan- nic acid are also incompatible with it, owing to the fact that an insoluble tannate is rapidly formed, which is absorbed very slowly if at all. So complete is the insolubility of the compound so formed that tannic acid is the best antidote to the drug that we possess. Physiological Action. — Tartar emetic, when applied to mucous membranes, produces a burning sensation, and upon the skin it may readily cause intense irrita- tion if the part be delicate. If kept in contact with a mucous membrane, very distinct inflam- matory changes occur, and if it be applied to the skin for any length of time, redness, followed by acne of a pustular character, appears, which finally ends in ulceration and sloughing if the use of the drug is persisted in. Under these circumstances the vitality of the parts seems interfered with, and, as a result, healing takes place very slowly indeed. Nervous System. — Antimony is a depressant to the sensory side of the spinal cord and a paralyzant to all the spinal centres, motor and sensory, in poisonous dose. It is stated that when an animal is under its influence sensation to heat and acids is lost before the ordinary sense of touch is destroyed. A, antimony depresses the heart-muscle; B, antimony depresses the peripheral portions of the vasomotor system in the bloodvessels; C, antimony depresses the vasomotor centre; D, the respiratory centre. ANTIMONY. 87 Fig. 10. The convulsions which sometimes ensue after poisonous doses in the lower animals are due to anaemia of the brain brought on by the cir- culatory depression. Ringer and Murrell have proved antimony to be a motor-nerve and muscle poison. Circulation. — The chief influence of antimony is exerted upon the circulation. In small doses it lowers the pulse-rate by a direct depression of the heart-muscle, and simultaneously decreases arterial tension by an action upon the peripheral portions of the vasomotor system in the walls of the bloodvessels, but the vasomotor influences may be in part centric, and this question must be considered as sub judice. The fall of arterial pressure is also due to failure of heart- force. With the lowering of the pulse-rate there is nearly always a corresponding decrease in cardiac power. When poisonous doses are employed, death ensues after great cir- culatory and respiratory depression, as will be seen below. The heart is found after death relaxed and flabby and wholly unresponsive to all stimuli, although in one of the lower animals, such as the frog, if the dose has not been very excessive and digitalis is freely employed, the heart may be made to beat again. In man, it is hardly necessary to state, the digitalis must be used early to render much service. The drug in poisonous doses is thought to de- press the peripheral ends of the vagus nerves. Respiration. — The drug has little or no effect upon respiration except when given in lethal doses. Under these circumstances death is pro- duced in three ways, all of them acting together. Primarily, the res- piratory centre in the medulla is de- pressed, and the governing nerves of breathing, the pneumogastrics, are also rendered inactive; secondarily, the cardiac failure readily causes pulmonary congestion; and, thirdly, the drug causes such an outpouring of liquid mucus into the bronchial tubes that the patient is drowned in his own secretions, which he is too weak to expel. Stomach and Intestines. — Antimony in toxic doses is a powerful irritant to these portions of the body In full medicinal amounts it acts as a slow but powerful emetic, producing much nausea. The vomiting is due to an action on the vomiting centre in the medulla and to a direct action on the stomach itself. The drug is, therefore, a centric and peripheral emetic. Very full doses produce watery purging, attended with some griping and tenesmus. A, antimony stimulates the vomiting centre; B, antimony irritates the gastric mucous membrane. 88 DRUGS. Elimination. — Antimony escapes from the body in all the secre- tions, but largely by the bowels. The latter method of elimination seems chiefly to follow poisonous doses, and purging is an effort at elimination. Therapeutics. — Tartar emetic is employed for at least five separate purposes, the most usual of which is as a circulatory quieter and seda- tive. The indications for antimony as a circulatory depressant are not so generally recognized at present as they were at one time, on account of the introduction of other drugs. All states of sthenic inflammation with a bounding pulse, high fever, and symptoms showing the patient to be possessed of robust constitution permit of its use, while all asthenic conditions most emphatically contraindicate its employment. In the treatment of colds, to break forming diseases, and to allay inflammation it is given in moderate dose. It is useful in sthenic bronchitis as an expectorant. Under these circumstances it may be given in emetic dose; or, if emesis is not desirable, minute amounts given hourly are of value, such as -^ grain (0.001) every hour, or a teaspoonful of a solution of \ grain (0.03) to 4 ounces (120 c.c.) of water every hour may be used. This is a particularly useful method in children, as the solution is tasteless and it does not produce nausea and vomiting. In the acute catarrh of children, which affects the stomach and entire alimentary canal and is associated with little fever, the use of the drug is extremely valuable, and often aborts an attack when given in the same dose as just described. As an emetic antimony is slow but forcible. It ought not to be used in cases of poisoning by other drugs, owing to its slowness of action. Before the introduction of anaesthetics emetic doses were employed to relax the muscles in reducing dislocations and fractures. Tartar emetic is harmful if irritation of the stomach is present or if kidney changes are rapidly progressing. If one good-sized emetic dose is not sufficient to produce vomiting, it should not be repeated, but some other emetic or the stomach-pump be used, lest antimonial poisoning complicate the case. The emetic dose must be large enough to be effective, or none at all should be given. If this rule is dis- regarded, systemic changes come on with undesirable severity in those cases where emesis fails to occur because of small doses. As a counterirritant antimony is employed in the form of an oint- ment whenever a very slowly acting and prolonged counterirritation is to be maintained, as on the back of the neck in epilepsy or similar chronic states, and in old enlargements of the joints. Antimony acts well as a diaphoretic, but its use is undesirable, owing to its disagreeable effects, such as nausea and intestinal disturbance, and because other, more pleasant, drugs act equally well. Administration. — The dose of tartar emetic when there is an excited circulation is 2V to tV g ram (0.003-0.006) every three hours until an effect is obtained. As an emetic the dose is h to 1 grain (0.03-0.06), ANTIMONY. 89 The wine of antimony (Vinum Antimonii, U. S.; Vinum Antimoniale, B. P.) contains only 2 grains of tartar emetic to each ounce, and may be used in the dose of 15 to 30 minims (1.0-2.0), or as an emetic in the dose of 2 to 4 drachms (8-16). The compound pill of antimony (Pilules Antimonii Composites, or Plummets pill) is used as an alterative, and contains sulphurated antimony \ grain (0.03), calomel \ grain (0.03), guaiac 1 grain (0.06); the dose is one to three pills. The ointment of antimony (Unguehtum Antimonii Tartarati) is used externally as a counterirritant spread on a rag or piece of lint. Antimonial powder (Pulvis Antimonialis , B. P.), or James's pow- der, contains oxide of antimony and phosphate of calcium, and is given occasionally as an antipyretic in the treatment of rheumatism and fever in the dose of 3 to 10 grains (0.20-0.60) ; it is best given in a pill. The compound syrup of squill (Syrwpus Scillce Compositus, U. S.), otherwise known as "Coxe's Hive Syrup/' contains f grain (0.045) of tartar emetic to the ounce. The dose is 20 to 30 minims (1.3-2.0) for an adult as a sedative, or from this amount to 1 drachm (4.0) to a child as an emetic. Poisoning. — When toxic doses of tartar emetic are taken, the pulse at first becomes slightly weaker and slower, the skin becomes moist and relaxed, a general sense of relaxation comes on, and simultaneously a sensation of severe nausea and gastric distress appears. Following this condition violent vomiting asserts itself. The ejected mass consists of the contents of the stomach — mucus, bile, and watery fluids, perhaps blood. Purging appears almost as early as the vomiting, and consists first of the normal contents of the intestines, then mucus, then bile, and, very rarely, blood. These signs may rapidly pass away and the characteristic peculiar " rice-water" stools 1 of antimonial poisoning appear. The general condition of the patient is now most serious. The face is pinched, livid, and covered with a cold sweat. The pulse is rapid and shuttle-like — to and fro — or lost at the wrist; the arterial tension is almost nil. The respirations are faint and fluttering, and so shallow as hardly to be seen or heard. Cramps in the calves of the legs attack the patient, due to the abstraction of water from the tissues by the violent purging, and the temperature falls lower and lower as death approaches. The general condition is such that all the signs point to Asiatic cholera, and antimonial poison- ing cannot be distinguished from this disease during an epidemic without a history of the case or a chemical analysis of the secretions, which ought always to be preserved. 2 1 A "rice-water" stool is one which, on standing in a glass, separates into two layers, the lower white and flocculent, the upper watery and almost clear. 2 This is a good opportunity to state that the secretions and excretions of a person dying of any poison should be placed in a chemically-clean jar capable of being sealed. The same rule of cleanliness applies to the jars holding organs at the post-mortem. The jars should be at hand, and no intermediate vessel used. They should be sealed at once, and kept so until claimed by the authorities. 90 DBUGS. The treatment of antimonial poisoning consists in the internal administration of large amounts of tannic acid to form the insoluble tannate of antimony, in the use of the stomach-pump, and in the maintenance of an absolutely prone position. When tannic acid cannot be had, ordinary tea-leaves may be boiled and the decoction given as an antidote and stimulant. The patient should vomit into towels and not raise the head from the pillow; the head, indeed, should generally be placed lower than the heels. External heat, alcohol, and digitalis should be used freely, and opium should be employed hypodermically to allay pain and irritation unless the respirations are too feeble. If the opium is greatly needed because of pain, and yet seems contraindicated because of depression, it should be accompanied by strychnine to stimulate the respiratory centre and overcome any depression produced by the opium. Fatty degeneration of all organs may occur after acute antimonial poisoning. Chronic poisoning by antimony is quite a rare affection, but it occurs chiefly in type-founders and type-setters. Mc Walter has reported instances in which peripheral neuritis, disorders of the bladder, and irritability of the prostate developed in these artisans. Headache, abdominal tenderness, and an irritable state of the mucous mem- branes were also present, associated with profound mental depression and circulatory feebleness. These facts are of interest because it is a superstition among some of the lower classes that the administration of antimony will cure the alcoholic habit, and if given for a long time these symptoms and fatty degeneration might ensue, leading to a sus- picion of attempted murder by poison. ANTIPYRIN. Antipyrin (Antipyrinum, U. S.; Phenazonum, B. P.) is a derivative of coal-tar, its chemical name being phenyldimethylpyrazolon. It was discovered by Ludwig Knorr in 1884, and introduced into medi- cine by Filehne. Antipyrin is a white powder of a somewhat bitter taste, and is very soluble in water, less so in ether, alcohol, and chloro- form. When antipyrin is given to a man in full medicinal amount, it causes a sensation of buzzing and tightness of the head not unlike that pro- duced by quinine. The bodily temperature, if normal, is depressed a fraction of a degree, but no other symptoms are manifested. If the dose be quite large, some blueness of the lips and finger-nails appears, chilly sensations are experienced, and finally a profuse sweat breaks out over the entire body, which is more severe if fever has previously existed. Large doses sometimes cause nausea and vomiting. Physiological Action. — Nervous System. — When a large poisonous dose of antipyrin is given to one of the lower animals, relaxation, com- plete loss of reflex action, and total inability to move come on at once, ANTIPYRIN. 91 and death ensues. Somewhat smaller doses produce exceedingly severe tetanic and epileptiform convulsions, but consciousness seems to be preserved. It has been proved that the chief cause of the convul- sion is an action of the drug on the brain. 1 Very large toxic doses, therefore, decrease reflex action, and smaller ones increase it, though medicinal amounts certainly lessen reflex activity to a notable degree. The cause of this failure of reflexes is depression of the sensory nerves and the receptive centres of the spinal cord. Medicinal amounts must, therefore, be regarded as very distinct nervous sedatives, acting much more actively on the nerves of sensation than on those of motion. Injected beneath the skin or applied to a mucous membrane, antipyrin is a powerful local anaesthetic, the anaesthesia lasting often for several days. Circulation. — The studies of a very large number of pharma- cologists prove most conclusively that antipyrin has no effect on the circulation of the lower animals in moderate doses unless these be so frequently repeated that cumulative effects ensue. Many reliable clinical observers have asserted that the drug depresses the circula- tion in man in some cases, and antipyrin is certainly not a cardiac stimulant. The writer is confident, however, that antipyrin is not so distinctly a cardiac depressant as some believe. On the other hand, there can be no doubt that in some persons it tends to lower arterial tension and so to produce syncope. It must therefore be used with caution in cases which have a feeble circulation. Large, poisonous doses lower blood-pressure unless convulsions are present, when the pressure is raised. In many of the cases where vascular depression and collapse have followed its use it has been employed in excessive amounts or the fall in bodily temperature has caused the untoward symptoms. (See Fever and its Treatment.) Blood. — No spectroscopic changes in the blood follow the use of medicinal doses of antipyrin in the ordinary individual, but in poison- ous amounts it produces methsemoglobin. If the doses be toxic or idiosyncrasy exists, cyanosis may come on. That the blood is not destroyed by small amounts is proved by the absence of hsematin in the urine of persons taking the drug. The corpuscles suffer no changes except in very pronounced poisoning, when they are said to become crenated and shrivelled. Respiration. — When antipyrin is given in lethal doses, death results from failure of the respiratory centre. Ordinary doses have no effect on this function, but large ones make the breathing more rapid. Temperature. — In normal men and animals antipyrin in medici- nal dose may be considered as without effect so far as bodily tempera- ture is concerned. In fevered animals it has been found to lower temperature by decreasing heat-production and increasing heat-dissi- 1 See author's Boylston Prize Essay of Harvard University, on Antipyretics. 92 DRUGS. pation. That it does not do this by an action on the blood seems proved by the fact that the blood is not affected by medicinal amounts. The sweating does not cause the fall since it takes place when no sweating occurs. It may, therefore, be considered that the drug directly affects the nervous heat-mechanism of the body. Kidneys, Tissue-waste, and Urine. — A large number of studies made upon man and the lower animals by competent investigators have brought about very considerable advances in our knowledge of the influence of antipyrin upon tissue-waste. It is useless to burden this volume with a discussion of their methods and results, which may be found in the author's Essay on Antipyretics. Suffice it to say that, while all observers are not agreed as to the effects produced, the deduc- tions apparently to be drawn are that the drug diminishes the quan- tity of the urine excreted, and also decreases the elimination of the results of nitrogenous tissue-metamorphosis — or, in other words, is a conservator of the tissues of the body. Elimination. — The elimination of antipyrin goes on very rapidly indeed, and begins almost at once after its ingestion. Maragliano and Reihlen state that it appears in the urine in three hours after it is taken, so that at the fourth hour elimination is at its height, although it continues to be eliminated for twenty-four or perhaps thirty-six hours. According to Pavlinow, part of the antipyrin ingested is elim- inated by the salivary glands. Poisoning. — The treatment of poisoning by antipyrin consists in the administration of stimulants, the maintenance of bodily heat, the use of atropine to restore the tone of the vascular system, and, if cyanosis is alarming, the employment of oxygen inhalations. Antiseptic Power. — Antipyrin exerts a very distinct antiseptic action in small amounts, delays all forms of fermentation, and destroys germs when it is present in large quantity. Therapeutics. — Antipyrin is employed in medicine for two great purposes — namely, for the reduction of fever and the relief of pain — but its employment as an antipyretic is now surpassed by its use as an analgesic. As an antipyretic, antipyrin should be given in a few full doses rather than frequent small ones, as a general rule, since if the fever is of any severity the latter method of administering it will have no effect, and the constant dosing will produce a gradual saturation of the system without causing a fall of temperature. On the other hand, too large doses may depress the temperature to a point below normal and induce collapse. In the article on Fevers (Part IV.) the conditions are indicated in which the drug is best employed, these being the sthenic fevers as a rule, or instances where excessive outbursts of fever necessitate prompt reduction of temperature. In excessively high temperature in pneumonia it may prove of value, and in scarlet fever and smallpox antipyrin is occasionally of service, although in pneu- monia, as a rule, the condition of the patient indicates the use of cold ANTIPYRIN. 93 to the chest as a local measure for the reduction of congestion or cold sponging to relieve fever. (See Pneumonia.) The use of the cold applications is always to be preferred to antipyrin in the reduction of fever, since, they are safer, more reliable, and do not strain the kidneys, reduce the blood, or depress the heart in feeble patients. (See Cold and Fever.) When cold water cannot be used, then antipyrin may be employed. In phthisis antipyrin generally increases the sweat- ing, produces oppression, and either fails to act as an antipyretic or causes collapse by exercising too great an effect. In sunstroke it frequently fails to influence the temperature, and ought not to be used. Be the fever what it may, provided it be associated with any dis- ease process, antipyrin is useless so far as any influence over the course of the disease itself is concerned. It is a remedy to be used in the treatment of the symptoms, not for the removal of the cause of the fever. As an analgesic antipyrin is the peer of opium. Although the latter drug will relieve all forms of pain if it be pushed, it possesses many disadvantages not found in antipyrin. In deep-seated pains due to disease of the organs of the body, in inflammations and similar dis- turbances, antipyrin is useless. In neuralgic affections of all kinds it finds its sphere, particularly if the disorder be rheumatic, gouty, or due to nervous depression from nervous exhaustion or disease. Under the latter circumstances it is best combined with caffeine and a little bromide of potassium. (See Neuralgia.) In rheumatism it will give relief in a fairly large number of cases, not only relieving the pain and fever if they be present, but also actually modifying the disease. It seems, however, to increase sweating in acute articular rheumatism. In gout it is stated to have a specific curative effect upon the disease over and above the relief of the pain, but this is questionable. Its use in dys- menorrhea has been recommended, but its beneficial influence in such cases is doubtful. At one time it was thought that its use would relieve the pains of labor entirely, but this has, unfortunately, proved untrue. It may, however, be tried, when the suffering is very severe, in the dose of 15 grains (1.0). In the severe lancinating or dart- ing pains of locomotor ataxia, and in the laryngeal and gastric crises complicating this disease antipyrin is an invaluable remedy. Curiously enough, it seems to subdue acute attacks of pain in posterior sclerosis, but fails to control the slighter pains and muscular twitchings sometimes seen in this disease and in myelitis. Some clinicians have used antipyrin with asserted great success in diabetes mellitus. In such instances the disease often depends on a gouty diathesis, and can be well relieved by salicylates. Antipyrin may be used hypodermically in the region of a hypersen- sitive nerve as a local anaesthetic. The anaesthesia produced by it lasts for several days, but the pain immediately after the injection is severe, Antipyrin is a very useful remedy in epilepsy. (See Epilepsy.) 94 DRUGS. In whooping-cough antipyrin has more frequently given relief in the writer's experience than any other remedy. It should be given to a child of five years in the dose of 2 grains (0.12) every four or five hours, the patient being watched for cyanosis and the drug stopped as soon as this symptom appears. Antipyrin generally decreases the frequency rather than the severity of the attacks of cough. In malarial diseases antipyrin certainly exercises no antiperiodic influence, although it controls the febrile paroxysms to a great extent. Yet, while this is the opinion of the majority of those who have used it, it cannot be said that every observer has reached similar conclu- sions,, Potter reports cases where the results obtained from its use were most satisfactory, particularly in the intermittent form of malarial poisoning. One cannot help thinking that frequently where antipyrin has been reported as acting as an antiperiodic it has simply lowered the fever, and so seemed to influence the disease. In acute coryza the temporary relief produced by applying cocaine to the engorged Schneiderian membrane may be prolonged indefinitely by the use of a spray of antipyrin in the strength of 4 per cent. This produces a smarting sensation, which speedily passes away. The same treatment is of value in inflammations of the larynx and pharynx. Should cocaine solutions not precede the antipyrin, the primary irritant effects persist unless the strength of the solution of antipyrin is reduced to 1 or 2 per cent. It is always better to precede its use by cocaine. Locally applied, antipyrin possesses very distinct hemostatic prop- erties, and for this purpose may be used in a 4 per cent, solution, either in liquid or in a spray. Under these circumstances it seems to act not by producing clots, which are disadvantageous from the standpoint of antisepsis, but by constringing the bleeding vessels. This haemostatic property is very materially increased if a solution of tannic acid is added to it, when it forms a glutinous precipitate which controls the hemorrhage. The precipitate is best applied by means of a swab. Antipyrin may be given with cocaine in suppository to check bleed- ing from hemorrhoids and relieve rectal pain. The cocaine must be used to prevent the antipyrin from causing pain when the suppository is first introduced. Untoward Effects. — Aside from the results of poisonous doses, a cer- tain number of cases taking this drug present slight cyanosis or duski- ness of the hands and of the face about the nose and lips; the fingers may be cold and clammy, and the feet are often very cold ; sweating is a very common symptom of the untoward influence of antipyrin, and pricking or tingling of the skin is not uncommonly seen. By far the largest number of these cases, however, suffer from disorders associa- ated with the skin, and erythematous patches may be seen every- where, more particularly on the hands and feet and about the face, arms, and chest. Occasionally pemphigus-like spots appear, and often large bullae have been noted as present. Elsewhere are pub- lished the statistics, collected from medical literature, of 121 cases ANTIPYRIN. 95 of untoward effects exercised by antipyrin. 1 An analysis of these shows that females were much more frequently affected than males, and that the most susceptible age was decidedly that of full adult life - — namely, from thirty to forty years in both sexes. The dose causing these effects was most commonly a moderate one — from 10 to 15 grains (0.60-1.0), or even from 4 to 10 grains (0.25-0.60). This fact holds good with regard to both sexes. The time of onset of the symp- toms varied somewhat according to whether the drug was given in one excessive dose or in frequently-repeated medicinal doses. In many instances the appearance of the symptoms was sudden rather than gradual. As a rule, the duration of the symptoms did not exceed one to three hours, three days being the longest time mentioned. It is interesting to note, however, that of all these cases only six proved fatal, and in these there was ample cause for death aside from any effect of the drug. We can rest assured, therefore, in ordinary cases of disease that patients exhibiting untoward effects of antipyrin are not in any acute danger, although the symptoms may be temporarily most alarming. Typhoid fever seems, according to the statistics collected by the writer, to be the disease in which this unexpected influence manifests itself most frequently, but this may be due to the fact that it is so common a malady and is so frequently treated by means of antipyretics. Brunton is responsible for the statement that antipyrin is particularly prone to produce collapse in menstruating women. Falck has collected a large number of cases of antipyrinism, and quotes Pusinelli as having seen vomiting often follow the use of this drug. Antipyrin very distinctly increases susceptibiliy of patients to taking cold, and ought not to be used by those who are forced to go out of doors in cold weather. Administration. — Owing to the solubility of antipyrin, it is most readily given in a little water in a wineglass or spoon. If its slight taste is disliked, it may be dissolved in any one of the aromatic waters or in syrup of bitter orange-peel or some similar vehicle. Most per- sons prefer to take it with water. The amount which may be given at a dose is 5 to 20 grains (0.3-1.3), but 3 to 5 grains (0.20-0.3) is the best dose in most cases, at least until it is seen how it is borne. Incompatibles. — When added to sweet spirit of nitre, antipyrin in the course of a few moments produces a blue, changing to a dark- green, color, owing to the formation of iso-nitroso-antipyrin, which is not poisonous, but when in the form of a dry powder is readily oxidized on exposure to slight heat. If this color is not formed, the spirit of nitre lacks its nitrous ether, and is worthless, so that we have not only another incompatibility to remember, but a new means of testing the therapeutic value of all samples of sweet spirit of nitre which may be dispensed. Antipyrin is also incompatible 1 See author's Boylston Prize Essay of Harvard University, on Antipyretics. 96 DRUGS. with the salts of iron, calomel, corrosive sublimate, and carbolic acid. With salicylate of sodium it forms a pasty mass; with chloral an oily liquid. Beta-naphtol and tannic acid are also incompatible with it. Tannic acid and non-alcoholic solutions of tannic acid form an insol- uble precipitate with antipyrin, as does also the tincture of iodine. ANTITOXIN. (See Part III.) APIOL. Apiol is a camphoraceous body, derived from common parsley or Petroselinum. As its melting-point is very low, it cannot be kept in solid form, and is always dispensed in 75 per cent, solution. So far as is known to the author, no careful study of its physiological action has ever been made, but two French observers, Joret and Homolle, state that in overdose it causes ringing in the ears, intoxication, and severe frontal headache. Therapeutics. — Originally introduced to combat malarial fevers, because of a fancied resemblance in its toxic action to quinine, apiol has found its level as a remedy in amenorrhea, given in the dose of 2 to 8 minims (0.1-0.5) three times a day for a week before the expected date of menstruation. It should be given, if possible, in capsules, owing to its unpleasant taste. It is said not to possess any abortifacient influence, although it is often taken with this object in view. Apiol is imported from France in capsules containing a little less than 3 minims (0.20), and is also put up in soft elastic capsules in the United States. APOCYNUM. Apocynum Cannabinum should not be confused with Apocynum Androsima? folium, which has few of its properties, but which is often employed by mistake for the real drug. When good effects do not follow the use of the drug another sample should be tried. The remedy in overdose is capable of causing vomiting and purging through gastro- intestinal irritation, but in medicinal dose rarely does so. It is employed in medicine for the relief of cardiac and renal dropsy of the subacute or chronic type, and is best given in the form of the tincture or fluid extract in the dose of 5 to 20 minims (0.30-1.3) of the former or 1 to 5 minims (0.05-0.30) of the latter. Under its influence profuse diuresis occurs, and the fluid is removed so rapidly that the drug has been called the " vegetable trocar." Physiological studies show that the action of the drug on the heart is similar to that of digitalis, as it slows the pulse and raises blood- pressure, APOMORPHINE. 97 APOMORPHINE. Apomorphine is an artificial alkaloid obtained by the action of hydro- chloric acid upon morphine in a sealed tube to which is applied a high heat. It is a whitish or gray powder, made up of minute crystals, which rapidly undergo decomposition when exposed to the air. The drug should be kept in dark bottles well stoppered. A very important point to remember is that solutions rapidly decompose, and, if employed, may produce poisonous symptoms. The drug ought to be freshly dissolved each time it is used. If the salt imparts an emerald-green color to 100 parts of water when shaken a few times, it should be rejected, unless it is found that the water contains small amounts of ammonia, which is supposed to be active in causing such a change. Fig. 11. A, apomorphine stimulates vomiting centre in the medulla. According to Boyer and Guinard, there are two kinds of apomor- phine sold. Each has a physiological effect different from that of the other. The crystalline form, which is the one always to be em- ployed, causes, in overdose, irritation, spasms, trismus, vertigo, and hyperesthesia; while the amorphous form (never to be used) .causes collapse, hypothermia, general weakness, feebleness of the heart and respiration, and anaesthesia. Physiological Action. — One of the best studies of this drug is that of Reichert, who found that in poisonous doses it produces convulsions, and finally paralysis, both of which are chiefly spinal in origin. Nervous System. — On the nervous centres in the brain apomor- phine acts as a stimulant, but the convulsions produced by poisonous doses are probably spinal. The motor and sensory nerves are par- alyzed by poisonous doses, and even the muscles become poisoned and incapable of contraction. Medicinal doses have no effect, 7 98 DRUGS. Circulation. — When given in moderate amounts, apomorphine increases the rapidity and force of the pulse and raises arterial pressure by stimulation of the accelerator nerves and the vasomotor centre. In large doses it acts as a circulatory depressant. Respiration. — After ordinary amounts no changes in respiration occur, but after poisonous doses the breathing becomes rapid and irregular. Vomiting. — Vomiting is produced by a direct action of the drug upon the vomiting centre in the medulla, and not by an action on the stomach. Apomorphine is, therefore, a typical centric emetic. Therapeutics. — Apomorphine is useful in nearly all cases where an emetic may be employed. In poisoning from other drugs, particu- larly depressants and narcotics, we have little knowledge of its safety, but unless the stupor or circulatory change is very profound, the drug may be used with care. In subacute and chronic catarrh of the stomach and air-passages it may aid in getting rid of the mucus by emesis, and in non-emetic dose it is a useful remedy in acute bron- chitis when it is necessary to quiet irritation and relieve excessive cough, or when the secretion is very scanty. Non-emetic doses of fa grain (0.002) have been used as often as every three hours with asserted success in producing nervous quiet in alcoholic excitement and delirium tremens. Untoward Effects. — Apomorphine rarely causes disagreeable effects, but there are cases on record in which it has produced serious symp- toms even when given in ordinary doses. These symptoms have con- sisted in depression and collapse. One-fifteenth grain is said to have caused death in a woman who had bronchitis, but was other- wise healthy. Probably in these cases the amorphous form was used. Administration. — The drug when used as an emetic should always be given hypodermically and the solution be freshly prepared. The emetic dose is about y 1 -^ grain (0.006), but as much as \ grain (0.012) may be used in strong patients. The expectorant dose is fa to fa grain (0.0015-0.003) by the mouth. No nausea is usually felt. The drug nearly always acts badly in children, and it is better not to use it in this class of patients. The salt used is Apomorphine Hydro- chloridum, U. S. and B. P. An injection (Injectio Apomorphincp Hypodermica) — 1 grain (0.06) dissolved in 100 minims (6.6) of cam- phor-water — is official in the B. P. ARISTOL. (See Thymol Iodide.) ARNICA. Arnica is derived from Arnica montana, a native plant of the Western United States and Europe. It holds a very high position ARSENIC. 99 in domestic medicine as a local and internal remedy in sprains and bruises, and in the treatment of passive hemorrhages, amenorrhea, and similar states. Physiological Action. — When arnica is applied to a delicate skin, it produces burning and irritation, and even extensive skin lesions. x\ccording to the studies of the author, it slows the pulse, raises the blood-pressure slightly, and stimulates the vagus nerves. Toxic doses produce a rapid pulse from paralysis of these nerves. Administration. — Arnica is rarely given internally. If it is so used, the dose of the tincture of the flowers (Tinctura Arnica?, U. S.) is 15 to 30 minims (1.0-2.0), and the same amount of tincture of the root (Tinctura Arnica? Radicis) may be employed. The plaster (Em- plastrum Arnica') is very useful in external applications. The tincture of arnica is the preparation usually applied to sprains and bruises, and the alcohol contained in this preparation accomplishes a large part of the good achieved. The only British preparation is the tincture (Tinctura Arnica), which is given in the dose of 30 minims to 1 drachm (2.0-4.0). ARSENIC. Arsenic (Arsenum) itself is never employed in medicine, but it is used in the form of arsenic trioxide or the arsenate of sodium, potas- sium, or copper. When a physician speaks of giving arsenic to a patient he usually refers to arsenic trioxide. Arsenic trioxide is con- verted into arsenous acid when dissolved in water. Arsenic trioxide (Arseni Trioxidum, U. S.; Acidum Arseniosum, B. P.) is derived from arsenic- bearing ores by roasting them in a reverberatory furnace, when it rises in the form of a vapor which adheres to the walls of the furnace, requiring a second sublimation, owing to the first deposit being quite impure. It is soluble in water, is without odor, and when heated gives off the odor of garlic. Physiological Action.— The effects produced in man by poisonous doses will be found considered under the heading of Poisoning. Applied to the normal skin, arsenous acid produces no change of any moment, but if the surface be broken or a wound or sore exist, its action is very powerful, and it destroys the tissues to a consid- erable extent. For this reason it has been employed as a caustic by "quacks" and to some extent by regular physicians, the latter using it to remove warts, condylomata, and similar growths, while the former have employed it chiefly as a "cancer cure," asserting that it would take the disease "out by the roots," which is of course untrue. Nervous System. —In medicinal amounts the drug probably acts as a stimulant to the trophic nervous apparatus. Circulation. — In moderate amounts arsenic has little or no influ- ence upon the circulation. Large doses cause marked decrease in •' 0$ 100 DRUGS. the force and frequency of the pulse, accompanied by a decided fall in arterial pressure, and in these amounts it is to be regarded as a distinct cardiac depressant which depresses all the heart's component parts, such as the ganglia, muscle, and nerves. The fall of the arterial pressure is due to vasomotor depression with relaxation of the general bloodvessels, more especially those of the abdominal cavity. According to Lesser, small doses cause it to act as a cardiac stimulant, increasing the pulse-rate. Arsenic is absorbed by the bloodvessels. Respiration. — In small amounts arsenic very distinctly stimulates the respiratory centre, and Lesser asserts that small doses stimulate the peripheral ends of the vagi in the lungs, but that in toxic quan- tities arsenic acts as a powerful respiratory depressant. Absorption, Elimination, and Retention. — When arsenic in any of its soluble forms and in medicinal or moderately poisonous dose enters the body by way of the alimentary canal, or through a break in the skin, or by way of the lungs, it is speedily absorbed and distributed to all parts of the body by the blood and lymph. The rapidity of its absorption depends upon the activity of the circulation in the part with which it comes in contact, and when it is taken by the mouth upon the quality and quantity of the food and drink which may be present in the stomach. If these are considerable in amount, its absorption is of course delayed, as is also its local effect upon the mucous membrane. When brought in contact with the tissues in concentrated form, it acts so powerfully that it may destroy them and so for a time at least prevent its own absorption because the bloodvessels and lymph channels are prevented from carrying their normal fluids. When the dose is medicinal or slightly toxic, the drug is eliminated chiefly by the kidneys, although it escapes to some extent by all the secretions, such as the bile, the sweat, the saliva, and even in the milk of nursing women, and it may produce in the nursling symptoms of gastro-intestinal irritation by this means. The rapidity with which it escapes from the body after it is absorbed varies greatly in different persons. It does not as a rule appear in the urine very promptly after it is taken, and it continues to be eliminated over a long period of time in some cases. Thus cases are on record in which it was found in this secretion several months after its use had been stopped. When a large poisonous dose of arsenic is taken by a human being, the greater part of it escapes from the body by reason of the vomit- ing and purging which it induces. It is possible for these efforts at elimination to be so prompt and complete that very little of the poison gains access to the general system. A large poisonous dose may there- fore be less capable of producing death than one which is smaller in amount but nevertheless lethal in its effects. If the drug when taken in A BSE NIC. 1()1 these poisonous doses is absorbed, it escapes, as it does in medicinal doses, chiefly by the kidneys, the feces, and by the other secretions named, and it is important to recall the fact that the amount of arsenic found in the feces does not represent alone that quantity which has passed through the alimentary canal unabsorbed, but also that it rep- resents some of the poison which has entered the general system, because the liver and gastro-intestinal mucous membrane eliminate the drug by this pathway. During the time the arsenic remains in the body after absorption it is deposited chiefly in the liver and in the kidneys, in the walls of the stomach and bowels, and even in the muscles and bones. It has also been stated that it is deposited in the white matter of the brain in quantities which are considerable. When seeking for arsenic in a case of suspected death from this cause, it is important to examine the bones, because in some instances the drug is found in them in large amounts after it is no longer to be found in other organs. It is from these "storehouses" of arsenic that eliminating organs obtain their daily supply for elimination. Arsenic is so rapidly eliminated in some cases of fatal poisoning that only a trace of it can be found on chem- ical analysis after death. Tissue-waste. — According to Chittenden and Cummins, arsenic in medicinal amount distinctly decreases tissue-changes. Large doses, however, greatly increase nitrogenous metamorphosis. Therapeutics. — Arsenic is used in chorea, in which it is almost a specific, acting in an unknown manner. The dose should be increased rapidly, as patients soon get accustomed to the drug, and large doses are essential to produce a cure in most cases. Cases are on record, however, in which the continued use of large medicinal doses has developed arsenical neuritis. As a tonic combined with iron it is invalu- able in simple anaemia, malarial anaemia, and cachexia. In atony of the mucous membrane of the stomach and intestine it is exceedingly useful, and in ordinary anaemia and debility, combined with a simple bitter tonic, it is invaluable. Arsenic is of value, too, for the improvement of depraved mucous membranes of the respiratory tract, particularly in those persons who have not true tuberculosis, but phthisical tendencies; and in individuals who continually have colds in the head, chest, or elsewhere. Arsenic offers the best chance of benefiting cases of per- nicious anemia, but how it acts is not known. In leucocyth&mia and pseudoleukemia arsenic is again the remedy, and it must be constantly given up to the point of intolerance to be of value (Fig. 12) . In the latter disease good results have followed its use when intraglandular and intra- splenic injections of 4 minims (0.25) of Fowler's solution were used, and any case of severe anaemia where the stomach is disordered may be treated by giving by the rectum in starch-water three times the ordinary dose by the mouth or by its use hypodermieally in the pro- portion of 4 parts of water to 1 of Fowler's solution. 102 DRUGS. In malaria arsenic acts as a prophylactic, as a cure, and as an aid to convalescence. When the attacks of intermittent fever occur at long intervals arsenic is useful as an antiperiodic, quinine being withheld for use during the attack itself. Fig. 12. A case of typical spleno-medullary leuksemia in which under the effects of arsenic the spleen decreased in size more than one-half, as shown in outline, and the white cells dropped from 342,000 to 32,000. There was a gain in weight of twenty pounds. No drug is so universally abused as is arsenic in the treatment of skin diseases: it should never be employed in "wet" skin diseases; that is, those associated with much proliferation of new cells and the exudation of serum. Its field of usefulness is in the dry, scaly skin affections. ARSENIC. 103 Where the skin is affected in its lower layers arsenic is useless, and should be used only where the epiderm is diseased (Duhring). In psoriasis arsenic at first makes the skin more red and seemingly worse, but this passes off and the patient gets well. This is important to remember, as otherwise the drug may be stopped just when doing good. Pemphigus, lichen, and lepra all yield to its influence in many instances. In the treatment of diabetes and pruritus vulva? the drug is said to be of value when given internally. In gouty diabetes the use of the carbonate of lithium and the arsenate of sodium is often of great service. In asthma, particularly where the mucous membranes are at fault, arsenic is one of the best remedies that we have, either given internally or smoked in arsenic cigarettes, which are to be made as follows: 1 Py — Belladonnas foliorum gr. xcvi (6.4). Hyoscyam. foliorum gr. xlv (3.0). Stramonii foliorum gr. xlv (3.0). Extract, opii gr. iv (0.25). Tabaci gr. lxxx (5.3). Aquae Oj. (480.0).— M. Ft. sol. et adde Potassii nitratis gr. clx (10.6). Potassii arsenitis gr. cccxx (21.3). — M. Bibulous paper is to be wetted with this compound, and after drying is to be rolled up and smoked as a cigarette. A more simple procedure is to wet bibulous paper in a solution of arsenite of potassium of the strength of 15 grains to the ounce, dry it, and smoke it in the form of a cigarette. In chronic rheumatism arsenic is very valuable in certain cases, but often fails to be of service. In chronic coryza, in cancrum oris, severe sore throat, and chronic nasal coiarrh it is to be employed internally, and in some cases of hay fever undoubtedly affords relief. The use of arsenic in all stages of phthisis often gives the most surprising results. In gastric cancer and ulcer, given in small amounts frequently repeated, arsenic will often do good by relieving the pain and checking the vomiting through its tonic influence on the gastric mucous membrane. It may be tried in the vomiting oj pregnancy with some chance of suc- cess, and is often of value in the vomiting of hand-fed babies who are suffering from chronic gastric catarrh. It is also useful in the morning vomiting of drunkards. In atonic dyspepsia associated with chronic diarrhoea and with a tendency to dysentery arsenous acid is of service, and in small amounts it is very valuable in frequently repeated doses (tto g ra i n [0.0006] every hour) in all forms of serous diarrhwa. For gastric atony or torpidity the following prescription is useful, but if irritation of the stomach is present it should not be employed : 1 Philadelphia Hospital Pharmacopoeia. 104 DRUGS. Iy — Liq. potassii arsenitis f 5ss (2.0). Tr. micis vomicae -' 5 j (-4.0) vel f oij (8.0). Aquee q. s. ad fgiij (90.0). — M. S. — Shake the bottle. Teaspoonful (4.0) t. i. d. in water after meals. In old persons whose feet become swollen and hot after prolonged standing, and who have shortness of breath on exertion, arsenic does good, particularly if the cause be cardiac feebleness, when it increases the efficacy of digitalis or strychnine so greatly as to be generally indi- cated when these drugs are given. Locally applied to warts and other growths of the skin for several days in the form of Liquor Arsenicalis (B. P.) or Liquor Acidi Arsenosi (U. S.) or of Fowler's solution, it causes the growth to drop off or to become loosened. Where the growth is very hard and horny, its surface should be softened by the application of liquor potassse before the arsenical liquor is applied. The same treatment may be used for corns. Where large malignant growths with extensive surfaces are to be attacked locally, the physician must use arsenic most boldly or not at all. The danger of absorption is only escaped when the drug is used so freely as to destroy the tissues before they can carry on any absorp- tion of the poison. A very large area should not be treated at one time. Marsden recommended the use of 1 ounce (30.0) each of arsenous acid and powdered gum acacia to 5 drachms (20.0) of water as an application to epitheliomatous growths. A less painful application, because of the anaesthesia caused by orthoform, is as follows: ^— Orthoform. 5j (4.0). Arseni trioxidi 3j (4.0). Alcohol fgv (150.0). Aquae destillat f§v (150.0). Still another is: 1$ — Arseni trioxid gr. lxxv (5.0). gr, lxxv (5.0). gr. xxx (2.0). mxxx (2.0). q. s. Pulv. acacias Cocain. hydrochloridi Glycerin Aquae destillat. . M. ft. paste. S. — Apply locally. The Marsden paste should be applied to the thickness of about one- quarter of an inch, overlapping the edges of the sore, and then covered with patent lint. The application is continued from twenty-four to forty-eight hours, and then a poultice is applied and the slough removed after from five to ten days. Administration. — Children generally bear arsenic better than adults, proportionately, but Ringer states that boys bear less than girls. The drug should be given before meals if it is designed to act on the stomach as a tonic, but in other conditions it should generally be administered after meals, as it is apt to irritate the stomach if given in full doses ARSENIC. 105 when this viscus is empty. Whenever a patient is given arsenic, he should be cautioned to watch for any puffiness about the eyes, par- ticularly in the morning on arising, and for slight laxity and griping of the bowels. These are signs that the drug should be stopped for a day or more. The swelling under the eyes may spread if the use of the drug is persisted in, and finally amount to general anasarca. This is due at first to a cellulitis, and afterward to a true effusion. (See Untoward Effects.) It is important from a medicolegal point of view to bear in mind the fact that arsenic is one of those drugs to which it is possible to induce tolerance. That is to say, by the prolonged and gradual adminis- tration of arsenic in ascending doses individuals can finally take very large quantities with apparent impunity. Cases are recorded in which as much as 7 grains could be taken at one dose without any evil effects. The official preparations are: Arseni Trioxidum, U. S.; Acidum Arseniosum, B. P., the dose of which is fa to fa grain (0.0015-0.003) ; the solution of the arsenite of potassium (Liquor Potassii Ar senilis, U. S. ; Liquor Arsenicalis, B. P.) or Fowler's solution, the dose of which at first is from 1 to 5 minims (0.05-0.3) in water; the solution of arsenate of sodium (Liquor Sodii Arsenatis, U. S. and B. P.), or Pearson's solution, the dose of which is 1 to 5 minims (0.05-0.3); and the solu- tion of arsenous acid (Liquor Acidi Arsenosi, U. S.), the dose of which is 1 to 5 minims (0.05-0.3). This is more irritating to the stomach than the other preparations. The iodide of arsenic enters into Dono- van's solution (Liquor Arseni et Hydrargyri Iodidi, U. S. and B. P.), the dose of which is 2 to 10 minims (0.1-0.60), well diluted. Iodide of arsenic (Arseni Iodidum, U. S. and B. P.) is given in fa grain (0.003) doses, and arsenate of sodium (Sodii Arsenas, U.S. and B.P.) in the dose of fa to fa grain (0.002-0. 006), and the exsiccated sodium arsen- ate (Sodii Arsenas Exsiccatus, U. S) , dose -fa to 2V grain (0.0001-0.003). Liquor Arsenici Hydrochloricus is also official in the B. P. Untoward Effects. — If arsenic is taken in full dose by a susceptible person, it may cause a marked dermatitis, with a sensation of severe burning in the skin and sometimes herpes zoster (Fig. 13). Pustu- lation may occur, and Falck asserts that an erysipelatous state may arise. Almost any form of skin lesion may follow its use internally or externally, but nearly all show irritation of the true skin. Even a scarlatiniform eruption followed by desquamation may ensue. In other cases the mucous membranes become inflamed and coryza may develop. (See Administration.) The prolonged use of arsenic, according to de Schweinitz, may produce vitreous opacities. Acute Poisoning. — The symptoms of acute poisoning by arsenic, that is, those following the ingestion of one or more large doses of the drug, are chiefly due to its irritating properties, but in part to the effects which it exercises upon the general system after it is absorbed. Usually within an hour after the poison is swallowed the patient experiences abdominal distress, a sense of constriction in the pharynx and oesoph- agus, and in a short time suffers from violent abdominal pain with 106 DRUGS. vomiting and, later, profuse serous diarrhoea. As soon as the bowel has been well emptied of its feces this diarrhoea becomes a symptom which is to some extent pathognomonic, that is to say, the stools become clear and may be like the so-called rice-water stools of cholera, containing flakes of mucous membrane floating in serum. These stools also appear in antimonial poisoning, but in arsenic they are often Fig. 13. Herpetic eruption along the course of an intercostal nerve due to the use of 16 drops of Fowler's solution three times a day. streaked with blood, whereas in antimonial poisoning blood is rarely if ever seen. The urinary flow is decreased, and it may be suppressed because of three factors: (a) the profuse purging drains the body of fluid; (b) the passage of the arsenic through the kidneys produces an intense toxic nephritis, and (c) the vomiting prevents the ingestion of water. If urine is secreted, it is concentrated and albuminous. The general symptoms associated with those just described consist ARSENIC. 107 in pains in the extremities, probably due to the abstraction of fluid by the purging, great general depression and collapse, with increasing feebleness of the circulation and respiration, and finally death from the general intoxication produced by the drug, combined with exhaus- tion. As death approaches convulsions or coma may develop. Very commonly about the third day, if the patient survives so long, an inter- mission in the symptoms appears, which will be followed by a return of all the symptoms, so that the physician must not give a favorable prognosis. In this symptom (remission) the course of arsenical poison- ing resembles phosphorus poisoning and yellow fever. Death gen- erally occurs about the fourth or sixth day, and on or about the third day a peculiar skin eruption sometimes appears which may be of any character. In rare cases sudden pain, collapse, and death may take place within twelve hours after the ingestion of the poison, or uncon- sciousness or heavy sleep, with entire absence of gastro-intestinal symp- toms, ensues, death speedily coming on. Widespread multiple neuritis may be brought on if the case survives for several days. It is to be remembered that acute arsenical poisoning may resemble poisoning by any substance capable of producing intense gastro-intes- tinal irritation. The symptoms may also be closely allied to those of cholera morbus and Asiatic cholera, while in still others the predomi- nance of nervous twitchings and coma may be confusing. After death from acute arsenical poisoning certain definite lesions are found, which are as follows: The mucous membrane of the stomach and bowel is reddened and inflamed, and it may be dotted by areas of hem- orrhagic exudate. This is not due, however, solely to a corrosive influ- ence of the poison, for arsenic is not, strictly speaking, a corroding drug, as are the mineral acids, for example. The epithelial lining of the ali- mentary canal is easily slipped off as if corroded, but the actual lesion consists in the degenerative changes produced in it and the finer blood- vessels by the poison. Filehne has expressed the opinion that the epithelium is primarily devitalized by the arsenic and then softened and digested by the digestive juices. A typical change always present in acute poisoning when the patient lives for any length of time is fatty degeneration of all the viscera. The exact fatal dose of arsenous acid is unknown because the indi- vidual susceptibility and readiness of absorption vary greatly. It is generally considered that from one and one-half to two and one-half grains is a lethal dose. Smaller amounts than this have, however, caused death and much larger ones have been survived. Treatment of Acute Poisoning. — In addition to washing out the stomach by the stomach-pump, applying external heat and stimulants, the ingestion of the proper antidotes should be at once employed, and the only ones of any value are the freshly-precipitated hydrated sesqui- oxide of iron and magnesia. (See below.) The first is to be prepared by the precipitation of iron from one of its fluid preparations by the use of an alkali. Ammonia added to the tincture of the chloride of iron is 108 DRUGS. efficacious, but the precipitate has to be repeatedly washed to rid it of an excess of this irritant. Magnesia is a better precipitant, because it not only precipitates the iron, but is also an antidote itself. Monsel's solu- tion and the so-called dialyzed iron may be employed in place of the tinc- ture, but Monsel's salt is too irritating. Dialyzed iron is so readily precipitated that it needs no alkali, but may be given pure. Magnesia is a useful antidote when given alone. Under the name Ferri Hydroxidum cum Magnesia the U. S. P. recognizes an antidote for arsenic; this is often called the "antidotum arsenici." The U. S. P. directs that this antidote should be kept on hand for immediate use in the following manner: Mix 10 fluidrachms (40.0) of the official solution of the tersulphate of iron (Liquor Ferri Tersulphatis) with 4 ounces (120.0) of water, and keep the mixture in a well-stoppered bottle. Rub 150 grains (10.0) of magnesium oxide with a little water to a smooth and thin mixture; transfer it to a bottle capable of holding 33 ounces (1000.0), and fill the bottle with water. When the antidote is to be used, add the magnesia solution slowly and shake the two fluids until a homogeneous mass results. (See Iron, Hydrated Sesquioxide of.) After the use of the antidote emetics should be used, opium should be administered to allay irritation and pain, and large draughts of water be given to flush the kidneys and dilute the poison. In the later stages the danger from arsenical poisoning arises from the changes produced in vital organs. Subacute Poisoning. — When the dose of arsenic has not been large enough to produce death rapidly, the symptoms manifested are somewhat modified. The vomiting and diarrhoea are less severe, but the abdominal tenderness and distress are notable. The kidneys are manifestly irritated by the drug, for the urine is scanty, bloody, or albuminous. In these cases sufficient time elapses for the secondary nervous lesions produced by the drug to result in outbreaks of various eruptions on the skin and for localized palsies due to neuritis to ensue. The mouth is parched, thirst is excessive, the liver is enlarged and tender, and the skin hot and dry. Chronic Poisoning. — Arsenic very frequently gains access to the body in many remarkable ways. It may be taken in cheap beers made from glucose, which in turn has been made with sulphuric acid prepared from iron pyrites contaminated by arsenic. In other in- stances it is obtained from wall-papers laden with arsenical pigments; in still other instances it develops in artisans who handle arsenic in large amounts. In rare instances the ingestion of a few large doses which usually produce acute poisoning has resulted in subacute or chronic poisoning because of slow absorption and rapid elimination. Chronic poisoning may ensue by the drug entering by the mouth, lungs, or skin. The symptoms of chronic arsenical poisoning may for convenience be divided into three classes, although they are not so separated in the ASAFCETIDA. 109 patient as a rule, being often interwoven in such a manner as to make a diagnosis difficult. In one class we find pigmentation of the skin, and nervous symptoms due to inflammations of the nerves, such as sharp attacks of pain, tingling in the extremities, patches of anaesthesia, and localized loss of motor power. Thus it not infrequently happens that there develops paralysis of the extensor muscles of the toes or of the peroneal muscles. In other cases the flexors of the foot suffer chiefly, while in still others the feet escape and the hands are involved in the loss of power. In cases of acute poisoning the paralysis may appear as early as the third day, while in other cases it may be delayed several weeks. The anaesthetic areas are generally confined to the extremities, and extend only to the first or the second joint above. Sometimes the multiple neuritis caused by arsenic gives rise to symp- toms which resemble those of locomotor ataxia. In other cases the manifestations of irritation of the mucous mem- branes are the predominant symptoms associated with disturbances in the nutrition of the skin, so that eruptions are produced, with falling of the hair and the development of cachexia. When the poison is inhaled, violent attacks of coryza or of asthma may occur and chronic bron- chitis ensue. Chronic arsenical poisoning must be differentiated from chronic lead poisoning and chronic alcoholism. All three of these states may occur simultaneously. From lead poisoning it is to be separated by the absence of the blue line on the gums, by the fact that in plumbism there is rarely much disturbance of sensation and that the motor palsy of lead commonly affects the extensors of the forearm rather than the muscles of the leg, as does arsenic. The history of the patient is also of great aid in the differentiation. It is also said to be a fact that muscular atrophy is more rapid in its progress in arsenic intoxication than in that due to lead. In lead poisoning eruptions and discolorations of the skin are rare. Alcoholic neuritis is to be differentiated by the history and appear- ance of the patient, by the absence of disorders in the skin, and by the presence of mental deterioration. Chronic poisoning is to be treated by withdrawal from the exposure and by the use of iodide of potassium to aid in the elimination of the arsenic. The special symptoms are to be treated by the application of electricity, tonics, out-of-door life, and such measures as will im- prove the general condition of the patient. ASAFCETIDA. Asajcetida, U. S., Asajetida, B. P., is a gum obtained by making an incision into the root of Ferula joetida. It occurs in irregular masses of a dark-yellow or reddish color, which become still more red if exposed to the light and air, Asafcetida in tears is a term applied to the drug 110 DRUGS. when it appears in the shape of drops or pearls, and is a form seldom seen. Its odor is penetrating and strong, and resembles that of garlic. When taken internally, it causes a sensation of warmth and acts as a stimulant and carminative in the alimentary canal. Therapeutics. — Asafcetida is used in medicine as a carminative which will particularly affect the lower bowel, and is useful in the intestinal indigestion of old persons when associated with flatulence, and in the flatulent colic of children. In the form of rectal injections it is of value for the relief of the tympanites of children and in that of adults during typhoid fever and pneumonia. It is also used as a stimulating expec- torant in the later stages of bronchitis. In the nervous irritability of children it is often of service. Administration. — Asafcetida is given in pills of asafcetida (Pilula? Asafwtida, U. S.), of which two or three may be taken, each one con- taining 3 grains (0.20) ; the emulsion or milk of asafcetida (Emulsum Asafatidoe, U. S.), the dose of which is \ to 1 ounce (16.0-30.0); and the tincture (Tinctura Asafwtidw, U. S. and B. P.), J to 1 fluidrachm (2.0-4.0). The suppositories contain what is equal to 40 drops (2.6) of the tincture. The plaster of asafcetida (Emplastrum Asafwtida) is used where a mild counterirritant and antispasmodic is needed. When intestinal indigestion and flatulence occur in old people, the following pill is of service: 1$ — Ext. nucis vomicae gr. v (0.30). Ext, kolae gr. v (0.30). Asafcetida? , gr. xl (2.6).— M. Ft. in pil. No. xx. S. — One night and morning. The B. P. preparation, not official in the U. S. P., is Pilula Galbani Composita, composed of asafcetida, galbanum, and myrrh; dose 5 to 15 grains (0.30-1.0). ASPIDIUM. Aspidium, U. S., Filix-mas, B. P., or Male Fern, the rhizome of Dry- opteris Filix-mas (or Aspidium Filix-mas, B. P.), is employed in medi- cine as a tseniacide or remedy for the tape-worm, and is a very efficient and valuable drug under such circumstances, being, perhaps, the most reliable of all the vermifuges except pelletierin. When employed, the directions and precautions given in the article on Worms must be strictly followed (Part IV.). Male fern taken in overdose is capable of producing poisoning, and when taken in such a dose causes, according to Quivill, irritation of the gastro-intestinal mucous membrane and diarrhoea. If absorbed, it acts on the central nervous system and causes paralysis, collapse, and death. The form and method by which it is eliminated are unknown. It may in overdose cause albuminuria and glycosuria. To give more than \\ drachms (6.0) of the oleoresin at a dose is dangerous. AZEDARACH. HI Administration. — Male fern is rarely, if ever, used at present in its crude form, being employed most commonly in the United States in the form of the oleoresin (Oleoresina Aspidii, U. S.) ; dose \ to 1 fluidrachm (2.0-4.0) in capsule, or as follows: 1$ — Oleoresin. aspidii, Tinet. vanillae . . . aa Tllxlv (3.0). Pulv. acacise 5ss (2.0). Aq. destillat f§j (30.0).— M. S. — Take entire amount after fasting, and follow in two hours by a full dose of sulphate of magnesium. The dose of the liquid extract (Extractum Filicis Liquidum) of the B. P. is 15 minims to 1 fluidrachm (1.0-4.0). Katamaya and Okamoto, two Japanese investigators, and Poulssen, state that castor and other oils should not be used after filix-mas is given, as oils increase the absorption of the active principle, and so predispose to the development of poisoning. ASPIRIN. Aspirin is acetyl-salicylic acid, and occurs in white crystalline needles which melt at 135° C. and dissolve in water up to the strength of 1 per cent. It is readily dissolved in alkaline fluids. Owing to its chemical constitution, aspirin has been recently introduced into medicine as a substitute for the ordinary salicylates; and as it is dissolved and absorbed in the bowel, as is salol, it is said not to irritate the stomach. Unless well diluted, however, it causes gastric distress. It is also not so disagreeable to the taste as are most of the salicylate prepara- tions, and it is claimed is less likely to cause tinnitus. The dose of aspirin as a remedy for acute rheumatism is 10 to 15 grains (0.60-1.0) three times a day or oftener. It may also be employed as an intestinal antiseptic. Aspirin may be given in capsule or in pill-form. Some- times it is given in syrup of acacia and water, the mixture being well stirred or shaken before the dose is poured from the bottle. AZEDARACH. Azedarach is the bark of Melia Azedarach, or Pride of China, as it is sometimes called. It is found in Syria, Persia, the north of India, and in the Southern United States. The berries have but little toxic power, and children may eat of them largely without ill effect, but the bark is poisonous when taken in over- dose, and produces symptoms resembling those of poisoning by spigelia or belladonna. It is employed as a remedy for the round-worm, and should be given in decoction made by boiling 2 ounces (60.0) of the bark in 1J pints (720 c.c.) of water until only a pint (480 c.c.) of liquid remains. Of this, from 1 to 2 tablespoonfuls (16.0-30.0) are 112 DRUGS. to be given a child, and repeated every two hours until the bowels are opened. It has also been used as a fluid extract prepared by the ordi- nary means with alcohol, to which some white sugar should be added. The dose of this extract is a teaspoonful (4.0), and it is not to be repeated. The decoction is the best form in which to use the drug. BARIUM CHLORIDE. Barium chloride slows the heart very greatly, steadies its rhythm, and at the same time increases the volume of blood thrown out of the ven- tricle. It also increases blood-pressure, and Robert has, from a series of experiments, concluded that it brings about this change by an action on the muscular coats of the bloodvessels. If large doses are used in the lower animals, the heart suffers systolic arrest from overstimulation, and the strongest irritation of the vagus nerves fails to relax the systolic contraction. Still more interesting is the statement that this failure of the vagi to inhibit the heart is not the result of paralysis of these nerves, but is simply due to the excess of cardiac contractile power. The slowing of the pulse is not due to inhibitory influence, but depends solely upon the stimulation of the heart-muscle, although it would seem probable that the vasomotor stimulation, by increasing the arterial resistance, may be at least a factor in the reduction of the pulse-rate. In most works on chemistry barium is stated to be an irritant poison, but to produce such evidences of its presence the dose given must be extremely large, and many times greater than any amount useful for medicinal purposes. Therapeutics. — Barium chloride may be used in all forms of cardiac disease in which failure of the heart-muscle is present. In the treat- ment of varicose veins it is said to be of value, both when given inter- nally and applied locally over the distended vessels. A point worthy of remark is the character of the pulse-wave pro- duced. While its volume is increased, it does not give that sensation of tenseness to the finger that does the pulse produced by digitalis., and the pulse-wave seems to be very considerably prolonged — a fact that the sphygmograph also records. Administration. — The solution of barium chloride to be used inter- nally should have the strength of 5 grains to the ounce (0.30-30.0) of water, and of this 1 or 2 drachms (4.0-8.0) are to be given three times a day. BELLADONNA. Belladonna is botanically known as Atropa Belladonna, and is official in the form of the root (Belladonna? Radix, U. S. and B. P.) and leaves {Belladonna? Folia, U. S. and B. P.). Its popular name is "deadly nightshade." The drug belongs to a very large class of plants, namely,, the Solanacea>, all of which have a similar physiological action. Bella- BELLADONNA. 113 donna contains an active principle in the form of an alkaloid known as atropine (Atropina, U. S. and B. P.), which is insoluble in water. The sulphate of atropine (Atropine Sulphas, U. S. and B. P.) is soluble, and is the salt commonly used. Physiological Effects. — In man, full medicinal doses produce flush- ing of the face, redness and dryness of the fauces, dilated pupils, some- times an erythematous rash over the skin, rarely diplopia and delirium. If the dose be still larger, the delirium becomes marked, and is wild and talkative. The pulse is rapid and wiry. The rash which appears resembles that of scarlet fever, but lacks the punctations. The skin may desquamate after the lapse of several days if the rash is severe. In children belladonna is usually borne very well. When the action of belladonna asserts itself in children and in susceptible adults the respira- tion is quickened, the eyes become bright and the cheeks red, but lines of pallor reach from the malar bones to the angles of the mouth, giving to the face a curious expression. Absorption. — This drug is very rapidly absorbed. Nervous System. — Belladonna when given in medicinal amount approaching the toxic dose acts as a powerful excitant of the brain, producing talkative delirium. Locally applied, it depresses the periph- eral sensory nerves. When very large doses are given to animals, paralysis of the spinal cord comes on, followed by tetanic spasms, and finally by recovery. The primary loss of power is due to paralysis of the entire cord, and the second state, of convulsions, to the escape of the motor and sensory pathways from the paralysis before the inhibitory centres recover. As a result, any peripheral irritation causes violent explosions of motor power. 1 Even in large medicinal dose belladonna may be considered as a depressant to the motor nerves and as a quieter to sensory nerve- filaments. On voluntary muscles the drug has no effect, but upon unstriped muscles it acts as a sedative and antispasmodic. It dis- tinctly lessens reflex action. Circulation. — Belladonna quickens the pulse by depression of the peripheral vagi and by stimulating the cardiac muscle and the acceler- ator nerves. It produces a rise of arterial pressure by stimulating the vasomotor centre and by the increased heart-action which it causes. In poisonous doses it causes a fall of arterial pressure due to centric vaso- motor palsy, and depression of the muscular coats of the bloodvessels, but not to cardiac depression, as has been generally taught, for Reichert has proved that the drug is not a heart-depressant unless the dose is simply overwhelming. Sometimes when belladonna is given the pulse 1 If a homely simile, found useful by the writer in teaching, may be used, the inhibitory centres may be represented by a schoolmaster and the motor and sensory centres by two boys. The escape of chloroform in the room paralyzes them all, but, finally, the boys recover before their master and go off as truants (convulsions); at last the master (inhibitory centres) recovers, and order, or health, is restored, 114 DRUGS. becomes slow, but in these cases the slowing is due to temporary stimulation of the peripheral vagi or to momentary depression of the cardiac motor ganglia. (See Figs. 14 and 15.) Respiration. — Atropine is a stimulant to the respiratory centre in ordinary amounts, but recent careful studies show that its high reputation as a respiratory stimulant is not based either on clinical or experimental evidence. In many cases it fails to increase the respiration at all, and it is certainly inferior to caffeine and strych- nine in the treatment of opium poisoning. In large doses it is a depressant and paralyzant to respiration, and produces death from respiratory failure due to paralysis of the motor nerves supplying the respiratory muscles, and probably by depressing the respiratory centres. Fig. 14. A, atropine depresses the peripheral vagi and stimulates the accelerator nerves C. It raises arterial pressure by stimulating the vasomotor centre B. Abdominal Viscera. — Belladonna increases peristalsis by depress- ing the peripheral ends of the inhibitory fibres of the splanchnic nerves, and by diminishing any tendency to spasm on the part of the muscular coats of the intestine. Action on Secretion. — The drug decreases all the secretions of the body except the urine, which is sometimes increased in amount under its use. The decrease of secretion is due to paralysis of the peripheral nerve-filaments supplying the secretory cells of the glands. Bodily Heat. — When belladonna is used in large amounts there is nearly always a rise of temperature, which in children may amount to one or two degrees. In advanced poisoning the temperature rapidly falls. Elimination. — Atropine is eliminated by the kidneys and bowels with extraordinary rapidity, and this is one of the reasons why death BELLADONNA. 115 from poisonous doses of the drug is so rare. J. Harley asserts that it is entirely eliminated in two hours, and Meuriot states that not a trace of it can be found after twenty-four hours, and that it is partly destroyed in the liver. In a case of suspected poisoning the urine of the patient may be dropped into the eye of an animal, when, if atropine or belladonna has been taken, mydriasis will result. Eye. — On the eye belladonna produces dilatation of the pupil in part by a depressant action on the endings of the oculomotor nerve in the iris, by causing a paralysis of the muscle fibre in the iris and per- haps by a stimulant effect on the peripheral sympathetic nerve-fibres. The dominant action of the drug is undoubtedly the depression of the circular muscular fibres of the iris. Associated with mydriasis there is also paralysis of accommodation due to the paralysis of the ciliary muscle by the effect of the drug on the oculomotor nerve. Belladonna generally increases intraocular tension. Poisoning. — Poisoning by atropine is an exceedingly common occur- rence, but death is rarely produced by it, partly because its influence is not very actively exercised on vital parts, and partly because it is eliminated by the kidneys almost as rapidly as it is absorbed from the stomach. Recovery has occurred after as much as one grain of atro- pine has been taken by a child of three years. Aside from the symp- toms of mild poisoning detailed under the heading of physiological action, severe poisoning is characterized by deep sleep, preceded, it may be, by convulsions, violent delirium, blindness, and sometimes loss of speech. Treatment of Poisoning. — Poisoning by belladonna is to be treated by emetics, the application of external heat if the patient passes into collapse, and the use of strychnine if respiration fails. Opium may be employed in carefully graded doses as the physiological antag- onist; but large doses are of doubtful service, particularly if the respi- rations are not in a satisfactory state. Therapeutics. — Belladonna is used to allay -excessive secretion, to act as an antispasmodic, and to influence the circulatory apparatus when local inflammations are beginning, particularly in secretory glands, and to act as a vasomotor stimulant (Fig. 15). In cardiac palpitation small doses of belladonna internally, or its external use over the praecor- dium in the form of the plaster or ointment, is very valuable. It is the most useful vasomotor stimulant in collapse. For the relief of local nerve-pains it is of value, and probably acts by quieting the irritated nerve. It should be applied in these cases in the form of an ointment or plaster, and if the ointment is used it should be well rubbed into the part affected. To check secretion in night-sweats it is one of the most powerful remedies we have, and it is useful in excessive idiopathic ptyalism, as seen in children, or in that due to mercurialization. In bromidrosis of the feet and other localized sweatings it is useful, and may be employed locally or taken internally for their cure. It is the most 116 DRUGS. efficacious drug we have for checking the secretion of milk in an inflamed breast, and under these circumstances it is to be smeared over the gland in an ointment. Belladonna may be used in serous diarrhoea, as it checks the disorder by stimulation of the splanchnic vasomotor filaments of the intestinal bloodvessels, which being inactive permit a transudation of liquid into the bowel. Trousseau recommended as a local remedy 1 to 2 grains (0.06-0.12) of the extract of belladonna with 6 to 8 grains (0.40-0.50) of tannic acid in leucorrhoea dependent upon disease of the uterine cervix. This should be placed on a pledget of cotton and applied to the affected part daily, being allowed to remain all day. Ringer states that if pain is also present in these cases the following injection is of value : 1^ — Sodii bicarbonatis ^j (4.0). Tr. belladonna? f sjiij (12.0). Aquas dest q. s. ad Oj (480 c.c.).— M. This is to be injected into the vagina, the woman first being placed on the back with the buttocks raised, so that the drug may bathe the uterine cervix for some minutes. As an antispasmodic, atropine is to be used in acute torticollis, in- jected directly into the muscle itself, so as to act on its motor nerve- fibres; it may be given in spasm of the intestine with cramps and griping. In cramps in the legs and body, either as a local application by means of liniments or when employed internally, it is of service. In asthma of the spasmodic type belladonna is a sovereign remedy, particularly if it be combined with morphine. It may be used both as a prophylactic and as a cure during the attack. Belladonna-leaves may be smoked by asthmatics by rolling them into a cigarette or put- ting them into a pipe. This drug is used in whooping-cough at all ages and in all stages, but it must be given in large amounts in this disease to be efficacious. In spasm of the sphincter ani, whether it be due to fissure or other cause, belladonna in the form of an ointment or suppository is of value. In spasm of the urethra and bladder the drug may be used internally and externally, and in the former state the ointment should be smeared along the under surface of the penis every night. This treatment is also useful in chordee. In the colic resulting from the passage of hepatic and renal calculi belladonna in full dose will very often give relief. Where urinary incontinence depends upon spasm of the bladder belladonna should be used. (See Incontinence of Urine.) In dys- menorrhea in nervous women, with spasm of the cervix uteri, it is of great value applied as an ointment or in a vaginal suppository, or when given by the mouth. For the nervous cough of children and adults belladonna is one of the best remedies we have. In constipa- tion it does good by depressing the inhibitory nerves of the intestine. It is also of value in laryngismus stridulus and in hiccough. In spasms from peripheral irritations belladonna is useful. BELLADONNA. IV In iritis atropine is used to dilate the pupil and prevent adhesions. The solution to be dropped into the eye should contain 1 to 4 grains (0.06-0.25) of atropine sulphate to the ounce (30.0) of water. (See Iritis.) Atropine sulphate is also used for the purpose of producing mydriasis before ophthalmoscopic examination, in solutions of the strength just given. It increases intraocular tension and is contra- indicated in glaucoma. Fig. 15. \j\fWVi\^^ II III IV Tracing showing the effect of atropine as a vasomotor stimulant (after Schmiedeberg) : I. Normal tracing of pressure (126) and pulse 28 in 10 seconds. II. Pressure lowered by pilocar- pine to 96, pulse 19. III. Tracing continued, pressure 70. IV. Atropine has been given, raising the pressure to 145, pulse 30 in 10 seconds. When employed to act on the circulation, it is to be used in shock and collapse from injury or in the course of severe disease. (See Shock.) During the progress of a case of pneumonia, typhoid fever, or other severe disease belladonna should be kept in the house, and administered freely if collapse or vasomotor relaxation suddenly asserts itself. Particularly is this true in the case of pneumonia. The vas- cular system after the crisis of this disease will often be found much relaxed, and heart stimulants do not seem to do much good. The administration of atropine or belladonna will dry the leaking skin, and by increasing the vasomotor tone produce great improvement. 118 DRUGS. In mastitis, or inflammation of the breast, even where pus is beginning to be formed, belladonna, if pushed, will give surprisingly good results if given internally and applied locally. In acute sore throat, when there is a sensation of rawness in the pharynx, while the local capillaries appear injected and red, belladonna is often of the greatest service if given in full dose, aborting the "cold." In exophthalmic goitre belladonna is thought to act by stimulating the sympathetic nerves, and certainly gives relief in some cases, par- ticularly if combined with stro'phanthus or digitalis. In headache occurring in young persons, often due to ocular over- work, with pain in the eyeballs and forehead and a sensation as if the orbits were too small for the eyeballs, belladonna is of service. In intercostal neuralgia or pleurodynia belladonna plasters may be applied to the spot where the pain is felt, with relief. Use of Atropine in Poisoning. — xltropine is a physiological antidote to opium, Calabar bean or physostigma, and jaborandi. In opium poisoning it acts as an antidote in all parts of the body except the eye, and in jaborandi poisoning the same holds true; but in the former condition, although it has been largely used, it is no longer regarded as a satisfactory antidote; and caffeine and strychnine are preferable. The condition of the pupil is not a guide as to the effect of atropine in opium poisoning, because opium acts centrically and atropine acts peripherally on the nerves governing the iris. Atropine should be used in aconite, antimony, and hydrocyanic acid poisoning for its stimulating influence on the vasomotor system, the respiratory centre, and the heart, and for the purpose of maintaining the bodily heat, the dissipation of which it retards by preventing vasomotor palsy and consequent dilatation of the peripheral bloodvessels. Atropine is a valuable physiological antidote to poisonous mush- rooms, particularly the Amanita, as it is antagonistic to their poison, muscarine. The dose given should be large, and, if need be, repeated. Administration. — The dose of the sulphate of atropine (Atropine Sulphas, U. S. and B. P.) is ^ihr to to g rain (0.0004-0.0015). The alcoholic extract (Extractum Belladonna? Foliorum, U. S.) is given in ¥ t° i grain (0.01-0.015) doses, and the tincture (Tinctura Belladonna? Foliorum, U. S. ; Tinctura Belladonna?, B. P.) in the dose of 5 to 15 minims (0.3-1.0). Both these preparations are derived from the leaves. The fluid extract (Fluidextr actum Belladonna Radicis, U. S.) is given in 1- to 2-minim (0.05-0.10) doses, while the extract (Extrac- tum Belladonna? Liquidum) of the B. P. is given in J- to 1 -minim (0.015-0.05) doses. These preparations are derived from the root. Belladonna liniment (Linimentum Belladonna?, U. S. and B. P.), belladonna plaster (Emplastrum Belladonna?, U. S. and B. P.), the ointment (Unguentum Belladonna, U. S. and B. P.), and the oleate of atropine (Oleatum Atropine), are for external appli- cation. The preparations of the B. P. not official in the U. S. P. are Liquor Atropines Sulphatis, dropped in the eyes in the dose of J to 1 minim (0.025-0.05) ; Lamella? Atropines, each of which BENZOIN AND BENZOIC ACID. 119 contains ^oVo" g ra and the bismuth subsalicylate (Bismuth Sub- salicylas, U. S.). The first and second are identical in their dose (5 to 20 grains — 0.3-1.3) and action, and may be employed interchange- ably. The third and fourth are more astringent and more irritating than the others, and must be given in a smaller dose, which is 2 to 4 grains (0.12-0.25). Formerly this drug was supposed to be capable of producing gastro-enteritis when given in large doses, but this was due to con- tamination by arsenic. Bismuth may produce chronic poisoning after prolonged use on wounds or when internally administered in excessive doses for some time. Ordinary doses are innocuous. As much as 4 to 5 drachms a day may be given for a short time without harm. The changes which ensue when the drug is abused are the formation of black sloughs in the mouth and gastro-intestinal tract, desquamative nephritis, and albuminuria. The preparations of the B. P. not official in the U. S. P. are Liquor Bismuthi et Ammonii Citratis, dose J to 1 fluidrachm (2.0-4.0), and the troche (Trochiscus Bismuthi Com- positus), 2 grains (0.12) in each. Bismuthi Carbonas, B. P., is the same as the subcarbonate of the U. S. P. Bismuthi Oxidum, B. P., is given in the dose of 5 to 20 grains (0.3-1.3). Physiological Action. — Bismuth in the form of the subnitrate and subcarbonate is devoid of effect upon the general system, and locally applied externally, or when given internally, exercises a mild astringent and protective influence upon mucous membranes, Therapeutics. — Bismuth is used as a mild astringent in large doses to cover the surface of inflamed mucous membranes and so to allay irri- tation. It is useful in irritative vomiting for this reason, and in diar- rhea of a similar type in which the stools are serous. If the passages are mucous, castor oil should precede bismuth in order to rid the ali- mentary canal of the mucous secretion already poured out. It is very useful when combined with carbolic acid in serous diarrh&a, given in capsules containing 10 grains (0.60) of bismuth subnitrate and 1 minim (0.05) of carbolic acid. It may also be used as a slowly acting and feeble antacid. Bismuthi et Ammonii Citras is very astringent, and should be used in chronic serous diarrheas in the dose of 5 grains (0.3) every two or three hours. The other preparations of bismuth are BISMUTH. 121 insoluble, and they should not be given in water, but this preparation is soluble and may be given in solution. Bismuth is of service in dyspepsia when lactic- and butyric-acid fermentation is present with excessive belching, and may be employed in gastralgia and gastric ulcer and gastritis as a sedative and astringent. Bismuth and ammo- nium citrate should never be employed if acute inflammation exists. When the salts of bismuth are used for any length of time, they cause the odor of garlic in the breath, which is due to the presence of an exceedingly slight trace of tellurium in the bismuth. The stools are apt to become black under the influence of bismuth, and the tongue, if furred, may also be black about the centre when bismuth is used. Where there is chapping of the hands or cheeks from exposure to cold or wet the following prescription is useful: 1$ — Bismuthi subnitratis 3iij (12.0). Zinci oleatis 5iij (12.0). Lycopodii §ij (8.0).— M. S. — Apply to the parts t. i. d. Bismuth Benzoate. This is a preparation which has been highly recommended in Ger- many, and to some extent in the United States, within the last few years, in the treatment of chancroid. Under its influence the sore heals with great rapidity and leaves a comparatively small cicatrix. It may also be used in the treatment of all specific sores and for the dressing of indolent or sloughing ulcers. Benzoate of bismuth, when properly applied, should be preceded by a careful washing of the diseased sur- face with a very weak bichloride-of -mercury solution, after which the bismuth is to be sprinkled over the wound and the entire surface cov- ered with cotton, which should be held in place by an adhesive strip. The only disadvantage of this dressing lies in the fact that it has to be changed once or twice in every twenty-four hours. Immediately after it is applied it may produce tingling or burning, but this is never severe. Bismuth Subsalicylate. Subsalicylate of Bismuth (Bismuthi Subsalicylas , U. S., and Bis- muthi Salicylas, B. P.) is a white, soft powder, insoluble in water, alcohol, ether, and chloroform, but soluble in acids. It is largely used by some practitioners as an intestinal antiseptic in cases in which there is diarrhoea due to fermentation or putrefaction. It may be given in powder, or, better still, in capsule, in the dose of 3 to 15 grains (0.20-1.0). Bismuth Subgallate. Dermatol, or the subgallate of bismuth (Bismuthi Subgallas, U. S.), is a fine yellow powder which is unaffected by prolonged exposure to light and air, is odorless, and is supposed to contain 55 per cent, of 122 DRUGS. oxide of bismuth. Its external uses are identical with those of iodo- form, and it probably acts in much the same manner as does the latter drug — namely, by so drying the wound that it becomes an unfavorable site for the growth of germs. As dermatol is an astringent, it cannot be employed in the treatment of indolent ulcers, which need stimulation rather than an astringent influence, and it would seem probable on theoretical grounds that it is not to be compared to iodoform in the treatment of cases in which tubercular processes are active. There is no doubt that dermatol is less poisonous than iodoform, but it must be capable of producing some untoward effects if used freely for any length of time, since poisoning follows the prolonged em- ployment of other bismuth preparations, as has been determined by Balzer, Dalche, and Villejean, for the symptoms of which see the article on Bismuth. Dermatol may be tried in cases of skin disease in which there is much secretion, as in weeping eczemas and similar states, either in the form of a dusting-powder or in an ointment with vaseline or lanolin in the proportion of \ to 1 drachm to the ounce (2.0-4.0 : 30.0). Some- times its efficiency can be much increased by the addition of a drachm (4.0) of oxide of zinc to the prescription just given. Dermatol has been used with marked success in cases of purulent otitis media as a dusting-powder, and in other states requiring similar drying and astringent effects. Internally, it has been highly recommended in cases of fermentative dyspepsia in the dose of 5 to 10 grains (0.3-0.60), but its real value in this condition is as yet undetermined. BITARTRATE OF POTASSIUM. Potassii Bitartras, U. S., Potassii Tartras Acidus, B. P., is some- times called " cream of tartar" or acid tartrate of potassium. It is a white gritty powder which may occur in rhombic crystals. Owing to its stability, it has been thought that it escapes from the body without oxidation, and so to differ from the other potassium salts formed by vegetable acids. Therapeutics. — The bitartrate of potassium is the most diuretic of the potassium salts, and is used in chronic nephritis with gin or com- pound infusion of juniper, for the purpose of removing dropsy. 1 ounce (30.0) of the salt is added to a pint (480 c.c.) of the infusion of juniper- berries, and the entire quantity taken in divided doses in twenty-four hours. In acute renal disease the drug should be used without the juniper. In large doses — J ounce (15.0) — it acts as a watery purge, but is rarely so used. Where the urine is thick and alkaline, bitartrate of potassium is a useful remedy to neutralize it and make it clear and normal in appearance. BOM AX AND BORIC ACID. 123 BORAX AND BORIC ACID. Borax (B. P.), or Sodii Boras, U. S., may be made by the action of boracic or boric acid upon soda, but the drug as it appears in commerce in America is derived entirely from natural deposits found on the shores of lakes in California and Nevada. The natural product has to be purified before it is marketable. Borax is soluble in twelve times its weight of water. Both borax and boric acid have been supposed to act as efficient germicides in strong solutions, but this has been proved incorrect. They are antiseptics, however, even in weak solutions. Upon the body borax has little effect in any dose which is given for a medicinal effect. It is rapidly eliminated and renders the urine alka- line, and it is too rapidly absorbed from the alimentary canal to permit it to act as an intestinal antiseptic. Boric acid exercises even less effect upon the system than borax. In the form of a lotion boric acid has been used with some success as a remedy for erysipelas, and it may be similarly employed in burns and scalds. Borax may also be used as a gargle in diphtheria and in aph- thous stomatitis, cancrum oris, and gangrenous stomatitis. In the treat- ment of pruritus ani and vulva" and in bromidrosis and jetid sweating it is of great value when used as a wash. Strong solutions, locally applied, are useful in tinea tonsurans and tinea circinata. Borax has been used very largely in the treatment of epilepsy, with asserted success in some cases. Its employment is purely empirical. The dose used is from 8 to 15 grains (0.5-1.0), gradually increased until it produces disturbance in the alimentary canal. As the taste is very disagreeable to most persons, the drug should be used with liquorice, strong coffee, or syrup of bitter orange : K — Sodii boratis ^ss (16.0). Glycerin f§H30.0). Fluidext. glycyrrhiz f M i j (60.0). Aquae dest q. s. ad fgvj (180.0).— M. S. — Dessertspoonful (8.0) in water after each meal. If larger doses than 15 to 30 grains (1.0-2.0) a day are continued after the convulsions are decreased in number, there are two difficulties : first, that the good effect is rapidly lost; and, second, that untoward symptoms, such as nausea and diarrhoea, with emaciation and the formation of a scarlatinal, eczematous, or papular eruption, appear. A peculiarity of the last two eruptions is that they are distributed around the joints. Borax should not be used with glycerin, as an acid reaction is apt to occur. A very useful wash for oral and nasal mucous membranes is " DobelPs solution," which is composed of — & — Sodii boratis, Sodii bicarbonatis aa ^j (4.0). Phenol gr. xxx (2.0). Glycerini f jfj (30.0). Aquse parse Oij (960 c.c). — M. 124 DRUGS. Boric acid (Acidum Boricwn, U. S. and B. P.) is one of the most commonly used substances in eye-washes, either alone or with cocaine. When used with cocaine or other drugs it is employed to prevent the destruction of the alkaloid or glucoside, as the case may be, by the growth of mould. The following formula may be employed : 1$ — Cocain. hydrochlor gr. iv vel viij (0.25-0.5). Acid, boric gr. x vel xx (0.65-1.3). Aqme dest fgij (60.0).— M. S. — To be used by dropping into the eye. The official ointment (JJnguentum Acidi Borici, U. S.) or the follow- ing makes a very useful application for the skin of the face and hands to prevent chapping: B— Acid, boric. 3J (4.0). Cerae albse gj (4.0). Paraffini 31J (8.0). 01. amygdala 1 express f^ij (8.0). — M. S. — To be thoroughly mixed and applied night and morning. Boric acid may be given internally in cystitis to render the urine acid, and is useful in the removal of freckles when applied as a wash to the skin. In persons having an idiosyncrasy to boric acid a bullous erup- tion of the skin may follow its use. Borated lint is made by dipping lint into a boiling saturated solution of boric acid or borax. It is a simple, inexpensive antiseptic surgi- cal dressing, and contains nearly one-half its weight of the drug. Mel Boracis, B. P., is not official in the U. S. P. It is used as a local application for sore mouth. BOROGLY0ERIN. Boroglycerin (Glycerinum Acidi Borici, B. P.) is made by mixing 62 parts of boric acid with 92 parts of glycerin in a tarred porce- lain capsule at a temperature of not more than 302° F. The acid is added to the glycerin gradually, with constant stirring. When the mix- ture has been reduced to the weight of 100 parts, it is poured on a flat surface wet slightly with petroleum, and on hardening is cut into blocks, which should be placed at once in a well-stoppered bottle. When used for medicinal purposes the glycerite of boroglycerin (Glyceritum Boro- glycerini, U. S.) should be employed, which may be made by adding 1 ounce (30.0) of the boroglycerin in solid form to 1 ounce (30.0) of glycerin and heating in a dish while stirring. It is soluble in water. Locally the glycerite of boroglycerin is used as an antiseptic and as a vehicle for carbolic acid, chrysarobin, and the vegetable alkaloids in the treatment of skin diseases, and in diseases of the eye, such as puruleni ophthalmia. BROMIDES. 125 BROMETONE. Brometone is produced by the action of caustic alkalies upon bromoform and acetone; it occurs in fine white prismatic crystals which possess a camphoraceous odor and taste. Its melting point is about 167° C. It is soluble in most of the organic solvents, a ; alcohol, ether, benzine, etc., slightly soluble in cold and more soluble in hot water. Its chemical name is tri-brom-tertiary-butyl -alcohol, and it contains 77 per cent, of bromine. The physiological action of brometone is nearly identical with that of the older bromides. Given in full doses it may, in susceptible persons, produce some dizziness, vertigo, loss of appetite, or mental heaviness, which are, however, only fleeting in their nature. Brome- tone may, therefore, be used as a substitute for the other bromides. It possesses the advantage of being powerful and therefore is efficacious in small doses varying from 2 to 10 grains (0.12-0.6) which are best given in capsules. BROMIDES. Bromides of Potassium, Sodium, Lithium, Calcium, Gold, Nickel, Ammonium, Strontium, and Hydrobromic Acid. Bromide of Potassium. Bromide of Potassium (Potassii Bromidum, U. S. and B. P.) is the most commonly used and an important member of the group above named, and will therefore be spoken of before the others. It is prepared by precipitating freshly-made bromide of iron with pure carbonate of potassium, or by a process more readily carried out and recommended by the B. P. It occurs in colorless transparent crystals, which are stable in dry air, but absorb moisture in a damp atmosphere. It is very soluble in water, but less so in alcohol. This bromide has a salty taste, and is distinctly irritant to mucous mem- branes if locally applied in concentrated form. A certain portion of its depressant influence, particularly when it is given for long periods of time, depends upon the potassium as much as upon the bromine, and for this reason the sodium salt is preferable. Physiological Action. — Bromide of potassium has an action upon the animal economy which is clearly defined and closely followed by all the other bromide salts, so that what is said in this place concerning its effects may be taken as representing the whole class of bromides, except in the instances where slight differences exist, which will be pointed out under the various names of the respective salts. When taken internally in full doses it produces drowsiness, sleep, and a decrease in all the reflexes. (See effects of Prolonged Use.) Nervous System. — The bromide of potassium acts as a distinct de- pressant to the motor and to the intellectual portions of the cortex cerebri. It slows the development of thought and decreases the excitability and 126 I)R UGS. power of the motor cells of the brain (Albertoni). Upon the spinal cord it acts as a marked sedative, affecting chiefly the sensory tracts, and causing thereby loss of reflex action and a decrease in the ability to recognize pain. It also depresses, but to a less extent, the motor pathways in the cord. Motion is maintained after sensations to pain and reflexes are lost. The drug depresses the peripheral parts of the sensory nerves, and after very large doses the motor nerves and muscles are similarly involved. Circulation. — If the drug be injected in ordinary dose into the jugular vein, it causes at once a fall of arterial pressure and pulse-rate. These changes are due to a direct action of the bromine and the potas- sium upon the heart. When given to a man in therapeutic doses by the mouth, its circulatory effect is so slight as not to be worthy of considera- tion unless the dose is very large and repeated. Respiration. — In toxic dose bromide of potassium is a depressant to the respiratory centre. In medicinal dose it does not affect the breath- ing, except when the amounts given are large and the drug persistently administered, when the breathing becomes slower. Fig. 16. A, the bromides depress the motor areas and B, intellectual areas in the brain; C, they depress the sensory tracts in the spinal cord; D, they depress reflex action by depressing the sensory cells in the cord a. Digestion. — The bromides may disorder the stomach by irritating its mucous membrane or by so decreasing reflex action that the proper secretion of gastric juice is retarded, with the result that digestion does not take place with sufficient rapidity. For similar reasons they may cause constipation. Temperature. — No effect upon this function is noted unless the dose be enormous: when such a dose is given the bodily heat is pro- gressively diminished, the fall of temperature being probably due to the circulatory and nervous depression produced, associated with the gen- eral failure in vital power. BROMIDES. 127 Elimination. — The drug escapes unchanged very slowly with all the secretions, and is found in the sweat, urine, tears, semen, milk, and feces. Tissue-waste is decreased when the animal economy is under the influence of one of the bromides. Therapeutics. — From what has been said, it is evident that bromide of potassium is a remedy to be devoted almost entirely to the treatment of disorders of the nervous system, and its uses are, therefore, as various as the manifestations of perversion of nervous action can be various. In a word, it may be said that bromide of potassium is to be used wherever over excitement of nervous protoplasm is present, but never where nervous symptoms are due to depression. In epilepsy, which, to the best of our knowledge, is due to explosive impulses arising in the cerebral cortex, it is one of the best drugs we have if given in sufficient dose; and in all forms of minor spasm, due to heightened reflex activity, it is of service. Care should be used in giving this drug in epilepsy that maniacal excitement does not supplant the attacks of epilepsy. (See Epilepsy, Part IV.) In cases of spasmodic contractions, in the treatment of hysterical females, in nervous stariings and alarm at sudden noises in adults and children, and in the nervous symptoms accompanying pregnancy and the meno- pause the bromides will be found of great value. The following pre- scription was recommended very highly by Goodell, and will be found of service in the latter states: 1$ — Ammonii bromidi 5ij (8.0). Potassii bromidi 5iv (16.0). Spts. ammon. aromat f ovj (24.0). Aquae camphorse q. s. ad t'ovj (180.0). — M. S. — A dessertspoonful (8.0) to a tablespoonful (16,0) every four hours. In headaches due to uterine trouble the pain is often felt at the top of the skull or at the back of the neck near the occiput. The cause of this trouble will sometimes be found to be in the cervix uteri, and relief under these circumstances can only be obtained when the uterus is treated and the bromides administered. In convulsions in children- and adults, combined with chloral, bro- mides are most efficient, and are sometimes of service in incontinence of urine due to vesical spasm. In seminal emissions due to a morbid excitability of the centres in the spinal cord, bromide of potassium is one of the best remedies we have, and in satyriasis and nymphomania it is of great service. In cases where undue irritability of the pharynx and larynx prevents examination of these parts, one or two full doses will render an exami- nation easy of performance by decreasing the local reflex activity. This is a useful point to be remembered in relation to the treatment of pharyngeal and laryngeal disease. In cases of acute laryngitis full doses of the bromides (60 to 120 grains [4.0-8.0] a day) are very useful to allay the pain and hoarseness. The bromides are found to be of service in the laryngeal crises of locomotor ataxia, the explanation of this fact being as follows: The 128 DRUGS. adductor centre of the larynx is situated in the brain, and the abduc- tor centre in the spinal cord. The first closes the larynx, the second opens it, and in health they maintain a patulous tube by their oppo- sition. In disease the spinal centre (the abductor or opener) fails, and the adductor in the brain, being unopposed, produces closure of the tube with disastrous results. The bromide, by quieting reflex action, as well as depressing the adductor centre in the cerebral cortex, prevents this accident. In whooping-cough with much mucous exudation the drug is rarely of benefit, and had better not be used. In laryngismus stridulus or any form of spasm depending upon local irritation the local trouble must, of course, be removed if possible and the bromides given. In teething the drug may be used to decrease reflex irritation and prevent convulsions, and it will decrease the night-screaming of children — which is often due to bad dreams — to a very extraordinary degree, even if the dose be quite small. As a soporific for the insane and in the insomnia of the overworked and that of nervous women the bro- mide of potassium is of great service, but ought to be used as a tem- porary measure only. (See Insomnia.) It may also be employed with good results in chronic alcoholism and morphiomania, given in doses of 40 to 60 grains (2.6-4.0). In migraine and neuralgia due to eye-strain or nerve-strain, combined with caffeine the bromides are almost specifics. The caffeine seems to stimulate the depressed nerve up to the normal level, and the bromide to deaden* the perception of the pain. The following is a most valuable remedy in migraine, and also in sick headache. It ought not to be used in bilious headache, which will often be made worse by it: R — Antipyrinae gr. xxv (1.6). Caffeinae citratae gr. x (0.60). Potassii bromidi gr. xxv. (1.6). — M. Ft. in chart. No. v. S. — One powder as needed. In the treatment of dysmenorrhea and menorrhagia, ' particularly in young subjects, the bromides are also of service. (See Goodell's prescription, page 127.) When the flow is too profuse, the drug should be begun a week before the expected epoch, and given in the dose of 5 to 10 grains (0.3-0.60) night and morning. In cases where the epochs follow one another too closely the drug should be used continuously. After an apparent cure ensues the bromide should be continued for a few periods to avoid a relapse. For sea-sickness the bromides are the best prophylactics we possess, and should be used in the dose of 5 to 10 grains (0.3-0.60) three times a day for several days before the patient sails, in order to quiet the vomiting centre. After sea-sickness begins they should not be given in ordinary solution, but in an effervescing draught made as follows: 1$ — Acid, .citric oij (8.0). Aquae dest fgiv (120.0).— M. Ft. sol. BROMIDES. 129 1$ — Potassii bromidi 5j (4.0). Potassii bicarbonatis 3j (4.0). Aquae dest fgiv (120.0).— M. Ft. sol. S. — A tablespoonful (16.0) of each of these solutions should be added to one another and taken during effervescence. This prescription will also be found of value in the persistent vom- iting of pregnancy and in that following prolonged etherization or other states. If the vomiting is excessive, the dose ought to be reduced to 2 teaspoonfuls (8.0) of each solution, and be given every half-hour until half of each mixture is taken or the patient is relieved. In cases where this cannot be retained, a rectal injection of the following will be found of value: Py — Sodii bromidi gr. xxx vel 3j (2.0-4.0). Tinct. opii deodorat TTlxxx (2.0). Aquae amyli fgvj (180.0).— M. S. — To be injected gently into the empty rectum and retained as long as possible. This method is the most reliable plan that can be followed. Bromide of potassium may be used to prevent the development of symptoms of cinchonism, which often ensue after the use of quinine and salicylic acid, and it is said to prevent the nausea and depression so apt to follow the use of opium. Administration. — The dose of bromide of potassium is from 5 to 120 grains (0.3-8.0) a day. It should be given at long intervals, as it is slowly absorbed and very slowly eliminated. After the patient is fully under its influence its effects can be maintained by smaller doses. The best way to order it is in a watery solution with a little syrup. Use of Bromides in Poisoning. — Bromides are useful in nearly all convulsive attacks consequent upon the ingestion of poisons, and they may be used to allay any nervous symptoms arising from this cause which are of an exciting nature. Poisoning. — Acute poisoning by the bromides is rare, but if half to one ounce is taken they produce a sense of warmth in the epigastrium, general feebleness, frontal headache, stupor, aphasia, and amnesia. The pulse-rate decreases 15 to 20 beats a minute; the pulse is irreg- ular and compressible. Recovery takes place, as a rule, unless pul- monary oedema sets in. Effects of Prolonged Use, or Bromism. — After the drug has been used for some time in large doses acne appears about the face and extends over the entire body; the breath becomes fetid, the patient is dull, expressionless, and heavy, and remains buried in sleep during nearly every hour of the day. During this time he can be aroused, but at once sinks to sleep again. The gait becomes weak and feeble, the movements slow and prolonged. Taste is lost and hearing is benumbed, while the intellectual faculties of the brain are almost in abeyance. Loss of sexual power is an early symptom. In other 130 DRUGS. cases evidences of mental aberration develop, the patient becoming irritable, morose, and even homicidal. Sometimes, however, we find melancholia and hallucinations, and rarely exalted ideas. 1 In still others a dangerous suffocative bronchitis develops, the patient may become profoundly cachectic, or the condition may resemble typhoid fever. The acne may be prevented to some extent by the use of arsenic, and when the bromides are given to women this drug may be given simultaneously to prevent the eruption. As Fowler's solution is com- patible with the bromide in solution, it is the best form of arsenic to employ. As the acne is due to a torpid state of the skin-glands, it is also well in these cases to order the patient to wash with warm water and Castile soap every night, and afterward to dry the face by a vigorous rubbing with a rough towel. Fere has asserted that the maintenance of intestinal antisepsis by the use of naphtol or salol will prevent the development of acne and digestive disorder when the bro- mides are given. Contraindications. — The bromides are contraindicated wherever there is general asthenia and feebleness of the nervous system, as, for example, in post-typhoidal and post-puerperal insanity. In senile softening of the brain they are also harmful. When the mucous membrane of the gastro-intestinal tract is irritated, they do harm. When the patient is subject to acne, they should be used with caution or avoided. Bromide of Ammonium. (See Ammonium Bromide.) Bromide of Calcium. Calcium Bromide (Calcii Bromidum, U. S.) was introduced into medicine as a nervous sedative and hypnotic, and was thought at one time to be an efficient substitute for the bromide of potassium. Its action on the nervous system is virtually identical with that of the potassium salt, and it has been found to be far less irritant and depres- sant than the latter. For some unknown reason it has never won the confidence of the profession, but it may be given with very good results in the dose of from 30 to 90 grains (2.0-6.0) a day, or even more in cases which are not readily affected by bromides. It may be employed in hysteria and epilepsy and in all the conditions in which the other bromide salts are indicated. It is sometimes of value combined with the potassium salt, since under such circumstances better results are gained than if a single salt is employed. Bromide of Gold. The Bromide of Gold has been employed in epilepsy by a number of clinicians with great success in the dose of from ^ to J grain (0.012- 1 See Collective Investigation by author in the Therapeutic Gazette of June 15, 1897; also article on Epilepsy, Part IV. BROMIDES. 131 0.03) three times a day in pills. Physiological studies have proved that the drug is a direct sedative to the motor cells in the cortex cerebri. Bromide of Lithium. Bromide of Lithium (Lithii Bromidum, U. S.) is much weaker than the other salts, and must be given in larger dose. S. Weir Mitchell states that it is of value in epilepsy when the potassium salt fails. The dose is 30 to 90 grains (2.0-6.0) a day. Bromide of Nickel. Bromide of Nickel is a green salt quite irritant to the stomach. The author has made an experimental study of this salt and found it practically identical with the bromide of potassium in physiological action. It should be given well diluted or in an effervescing draught, as it is apt to disorder the stomach if used in concentrated solution. The effervescing form of the drug is made by mixing the salt with bicarbonate of sodium and tartaric acid, moistening with alcohol, passing the moist powder through a sieve, and then drying it in a warm closet. Bromide of Sodium. Bromide of Sodium (Sodii Bromidum, U. S. and B. P.) is to be used in every instance where bromide of potassium can be employed. Its dose is the same, although it is asserted to be a little weaker physiologically, grain for grain, than the potassium salt. It is far less apt to disorder the stomach, and is not so generally depressant as is the bromide of potassium. Bromide of Strontium. (See Strontium.) Hydrobromic Acid. Hydrobromic Acid is an extremely irritant preparation, but is thought to be less apt to cause acne and other untoward effects than the other bromides. It is only to be used in the form of the official dilute acid (Acidum H ydrobromicum Dilutum, U. S. and B. P.), and to be given in the dose of from 1 drachm to § ounce (4.0-15.0) Well diluted with sweetened water. It is highly recommended by de Schweinitz and others for headaches due to eye-strain in nervous women. Bromide of Ethyl. (See Ethyl Bromide.) 132 I) BUGS. BROMINE. Bromine (U. S.) is a dark-red liquid of an excessively pungent odor, like that of chlorine, possessing extraordinary power as a caustic when applied to the tissues" of the body. It is the most severe caustic we possess, and penetrates very deeply. It may be applied in hospital gangrene and other large sloughs by means of a glass rod. Bromine should be kept in glass-stoppered bottles in a cool place. BROMOFORM. Bromoform, or Tribromomethane, is a clear, colorless liquid hav^ ing a peculiar odor and sweet taste. It is readily soluble in alcohol, but slightly so in water. Bromoform which is to be used medicinally should be protected from sunlight and air, and must be free from color and from acid. Therapeutics. — Although bromoform has been found capable of producing anaesthesia when given by inhalation, its employment in medicine is practically confined to the treatment of whooping-cough, when it is given internally in the dose of 2 to 5 minims (0.1-0.3) three times a day for the relief of the spasmodic cough. Bedford has sug- gested the following formula for its internal use: I$— Bromoform mxvj (1.0). Alcohol foij (8.0). Glycerin.. . . fSxij (45.0). Tinct. cardamomi comp. . . . q. s. ad f Sij (60.0). — M. S. — Teaspoonful (4.0) t. i. d. in water. This prescription should be compounded by adding the ingredients in the order named. Bromoform tends to depress the vasomotor system, but does not seem to depress the heart itself. While it seems to possess therapeutic value, the large number of cases reported in which it has caused alarm- ing symptoms has prevented the author from employing it. BRYONIA, or BRYONY. Bryonia is a remedy very largely used by irregular physicians, and is probably too much ignored by reputable physicians, for it possesses very great power, and often relieves conditions which are obstinately persistent under other treatment. It is the root of Bryonia alba or Bryonia dioica. The preparation commonly employed is the tincture (Tinctura Bryonia?). The dose of the powdered root as a drastic purge is 10 to 40 grains (0.6-2.6). Physiological Action. — In overdoses bryonia acts as a hydragogue cathartic and gastro-intestinal irritant. On serous membranes it exercises an irritant influence, and may produce symptoms of menin- gitis when given in poisonous doses. In moderate doses bryonia causes some flushing of the face and neck and headache in susceptible BUCSU. 133 persons. The drug needs studying from a pharmacological point of view. Therapeutics. — Although one of the oldest of remedies, bryonia has been given a new impetus by the homoeopaths, who employ it in a number of affections. In the treatment of dyspepsia depending upon gastric and intestinal atony or the abuse of alcohol or other similar causes bryonia often gives relief. Its influence is exerted through the irritant effects it produces, for by this means it stimulates or spurs the atonic digestive glands to increased activity. For this reason it has been found particularly useful in children who suffer from constipation resulting from insufficient secretion on the part of the intestinal glands. When the passages are dry and friable and resemble in character those of a dog, bryonia is of great value. The dose for a child is about 10 to 30 minims (0.60-2.0). The drug has been praised as a remedy in the treatment of rheumatism and in pleurisy, but little is recorded as to its real value in these diseases. In pleurisy with effusion drastic doses have been used, but the saline purgatives are safer and more efficacious remedies. Administration. — The dose of the tincture of bryonia (Tinctura Bryonia?) is from 1 to 2 fluidrachms (4.0-8.0) as a laxative; but the so-called mother-tincture of the homoeopaths is perhaps the best preparation for ordinary use. The proper amount to be used in the treatment of a case of dyspepsia is from 5 to 40 minims (0.3-2.6), unless the mucous membranes are very torpid, when this quantity may be increased. BUCHU. Buchu (U. S.) is derived from Barosma betulina, a plant of Africa. It contains a volatile oil, which is probably the active principle, and a bitter extractive. It is official, under the name of Buchu Folia, in the B. P. Therapeutics. — Buchu is used when it is desired to affect the mucous membranes of the genito-urinary tract which are chronically diseased, and particularly when these parts are below their normal tone. It does not increase the urinary flow to any great extent, but acts on the mucous membrane of the genito-urinary passages as a stimulant. It is employed in pyelitis, cystitis, and vesical irritation of a chronic type. The following prescription is useful: 1^ — Potassii citratis 3iv (16.0). Spt. chloroformi . f5iij (12.0). Tinct. digitalis tTVxxx (2.0). Infusi buchu q. s. ad f oviij (240.0).— M. S. — Two tablespoonfuls (30.0) three times a day. Shake the bottle before using. If the urine is continually highly acid, muddy, laden with salts, and productive of incontinence by reason of the vesical irritation which it produces, buchu in the form of the fluid extract, in the dose of a teaspoonful (4.0) three times a day, combined with an equal amount of sweet spirit of nitre and 20 grains (1.3) of acetate of potas- 134 DRUGS. sium, will be of great service. For a child the dose of the fluid extract should be about 10 to 30 minims (0.6-2.0). If the vesical irritation is acute, buchu is contraindicated. Administration. — The fluid extract (Fluidextractum Buchu, U. S.) is the only official preparation, and it should be always well diluted before it is given, in the dose, to an adult, of 1 drachm (4.0) three times a day. The infusion is not official, but is made by adding 1 ounce (30.0) of the leaves to a pint (480 c.c.) of water. The dose of this is J ounce (16.0) to 1 ounce (30.0). The official B. P. prepara- tions are the infusion (Injusum Buchu), dose 1 to 4 fluidounces (30.0- 120.0), and the tincture (Tinctura Buchu), dose 1 to 2 fluidrachms (4.0-8.0). CACTUS GRANDIFLORUS. This is a plant of Mexico and the West Indies. There are other species of Cactus possessing medicinal power, but Cactus grandi- florus is the most active so far as a medicinal effect upon the heart is concerned. Cactus grandiflorus is best given in the form of the tincture or the fluid extract made from the green plant. Physiological Action. — The drug has been studied by Myers and Boinet and Teissier, who have found that it causes a distinct increase of arterial pressure, but does not slow the pulse, sometimes increasing its rapidity. Myers has also shown that the drug is a stimulant to the vasomotor centres and to the motor ganglia of the heart-muscle. It also acts as a stimulant rather than a depressant to the spinal cord. Therapeutics. — Cactus grandiflorus has proved itself a good sub- stitute for digitalis in certain diseases of the circulatory apparatus, such as cardiac palpitation and weakness. It has also been found very serviceable as a remedy in cardiac failure the result of valvular disease, but in all such cases seems to act best when added to some more powerful drug, such as digitalis, as it takes the part of an adjuvant,, Cactus also acts well in some cases of angina pectoris. Administration. — The dose of the tincture of cactus is 2 to 8 minims (0.1-0.50) and of the fluid extract 2 to 4 minims (0.1-0.25). Untoward Effects. — It is claimed that these do not occur, and that the drug never produces a cumulative effect. CAFFEA. 1 Caffeine (Cafjeina, U. S. and B. P.) is an alkaloid derived from the berries of Cafjea Arabica, which also contain, upon roasting, an empyreumatic oil, caffeol or caffeone. Caffeine is usually employed in medicine as caffeine and the citrated caffeine (Cafjeina Citrata, U. S.; Cafjeina? Citras, B. P.). Citrated caffeine is not regarded by 1 Theine, derived from tea, caffeine, the active principle of coffee, and the alkaloid of guarana from South America, are chemically identical. Much of the caffeine of commerce is really theine, although it is claimed that pure theine has a very different physiological action. CAFFEA. 135 Fig. 17 chemists as a chemical compound, but as a mixture of citric acid and caffeine; therefore " citrate of caffeine " is an incorrect term. It is soluble in 3 parts of water. If more water is added, it is partly precipi- tated, but when 25 parts are added it is redissolved. In the U. S. P. another official preparation of caffeine, the Cafjeina Citrata Ejferves- cens (Caffeines Citras Effervescens, B. P.), has been introduced as an agreeable preparation for use in cases of headache, particularly if combined with one of the bromides and antipyrin. The dose is from i to 2 drachms (2.0-8.0). The empyreumatic oil, of which there is about one-half to one tea- spoonful in each well-made breakfast-cup of coffee, has no physiologi- cal effects. It is perhaps the cause of the " biliousness" sometimes produced by the habitual use of coffee, due to the faulty digestion of this oil, which is also prone to dis- order the digestion if taken alone. Physiological Action. — Nervous System. — On the nervous system caffeine acts as a rapidly-acting stimulant, exerting its chief influ- ence on the brain and spinal cord. By its cerebral effect it causes in- creased rapidity of thought, and by its influence on the spinal cord it increases reflex activity, and for this reason is said to make people "ner- vous." It is important to remem- ber that it has no effect on brain protoplasm except to stimulate it, and that ultimately a brain driven along by caffeine breaks down by the concentration of its energy for the time being in one effort. Circulation. — Caffeine has been supposed to increase the pulse-rate and blood-pressure by stimulating the heart-muscle, but from recent studies in the United States and abroad it would seem probable that these changes are indirectly pro- duced and due solely to its stimu- lating action on the nervous system. Clinically, it certainly seems to raise the blood-pressure in almost every instance where it is used. Kidneys, Tissue- waste, and Elimination. — Caffeine increases diuresis by causing dilatation of the renal vessels, particularly in the glomerules, and by preventing the absorbent action of the tubules. It also exerts a direct stimulating influence on the secretory epithelium Caffeine dilates bloodvessels of the Mal- pighian tuft (A) and stimulates the secreting epithelium lining the uriniferous tubules (B). 136 DRUGS. of the kidney, and therefore increases the amount of solids as well as of the liquids in the urine. Upon tissue-waste the drug acts as a depressant, and is therefore a conservator of the tissues. It is oxidized and destroyed in the body. Respiration. — Caffeine acts as a powerful stimulant to the respira- tory centre. Therapeutics. — Caffeine is a valuable cardiac stimulant and tonic as well as a renal stimulant. It acts equally w T ell in cardiac and renal dropsies for this reason, and is an invaluable remedy in such cases. So useful is caffeine in cases of cardiac disease that it has largely sup- planted digitalis in the hands of some practitioners. In acute renal inflammation it is contraindicated, because all stimulants are contra- indicated when the part they influence is inflamed. In opium poison- ing, owing to its stimulant effect on the respiratory centre, caffeine is very valuable. Under these circumstances it may be given by the mouth or rectum in the form of strong black coffee, which will also aid in keeping the patient awake and add heat to the body, which is often very cold. A cup of strong black coffee is often useful in relieving a paroxysm of asthma. In headache due to nerve-strain caffeine com- bined with antipyrin and one of the bromides is of the greatest service. (See Neuralgia.) Roasted coffee is sometimes used to mask the taste of disagreeable medicine. After it is roasted and ground it may be employed as an antiseptic and deodorant dressing for wounds when the common anti- septics are not obtainable. Administration. — The ordinary dose of caffeine is 2 to 4 grains (0.12-0.25). Cafjeina, U. S. and B. P., cannot be used hypodermically, owing to its decomposition in the presence of water. The following solution may, however, be used hypodermically: Salicylate of sodium, 30 parts; caffeine, 40 parts; and distilled water, 60 parts; or, in other instances, the following preparation, recommended by Huchard, may be employed: Benzoate of sodium, 45 grains; caffeine, 30 grains; dis- tilled water, 75 grains. This mixture is to be heated, and 10 minims (0.60) given at a dose. Untoward Effects. — Caffeine often produces so much insomnia when given in cases of cardiac disease that its use has to be discon- tinued. If its use is persisted in, it may produce a condition of delirium closely resembling that of alcoholism; and if too large doses are used, or it is too frequently repeated, it may cause a decrease in urinary flow by causing spasm of the renal vessels. The writer has also seen a marked rise of temperature follow its use in the dose of 2 grains (0. 1 2) three times a day, but this is unusual. In certain persons the habitual use of coffee may cause insomnia, tremors, palpitation, tin- nitus aurium, gastralgia, and emaciation. CALCIUM. 137 CAJUPUT OIL. Oil of Cajuput (Oleum Cajuputi, U. S. and B. P.) is a volatile oil distilled from Melaleuca Leucodendron, a tree of the Molucca Islands. It is a stimulant, and in large amounts an irritant, to mucous mem- branes, but acts as an efficient carminative and parasiticide in mod- erate amounts. As a remedy for tinea tonsurans and pediculi it should be applied pure to the part affected and used with caution, for cajuput oil is capable of irritating the skin. In diarrhoea of a serous type it is of value in the dose of 10 to 20 minims (0.60-1.30). (See Diarrhoea.) Spiritus Cajuputi is official in the B. P.; dose J to 1 fluidrachm (2.0-4.0). CALCIUM. Calcium is official in a number of forms, and is to be distinctly separated in the mind of the student from calx or lime, which is an oxide of calcium. It is never employed as calcium, but as one of its salts. These are as follows: bromide of calcium (Calcii Bromidum, U. S.); precipitated carbonate of calcium (Calcii Carbonas Proecipi- tatus, U. S. and B. P.) ; chloride of calcium (Calcii Chloridum, U. S. and B. P.); hypophosphite of calcium (Calcii Hypophosphis, U. S. and B. P.); and as precipitated phosphate of calcium (Calcii Phosphas Proecipitatus , U. S. ; Calcii Phosphas, B. P.). Calcium sulphate is official in the B. P. All salts of calcium are incompatible with acids. The precipitated carbonate of calcium is used in the treatment of serous diarrhoea as an antacid, and as a local protective in cases of chapped skin or intertrigo, particularly in young children. When given internally the dose is from 10 to 30 grains (0.60-2.0), but by far the best method for its administration is in the employment of chalk mixture (Mistura Cretoe, U. S. and B. P.), which contains about 30 grains of the chalk to each ounce (2.0-30.0) of liquid. The dose of this mixture is from 1 drachm (4.0) for a young child to an ounce (30.0) for an adult. In the treatment of cases of serous diarrhoea chalk mixture is best given in combination with tincture of kino or the compound tincture of catechu and paregoric, in some such form as follows: 3— Tr. kino . . fSj (30.0). Tr. gambir comp f 3 i j (8.0). Misturae cretae . . - . . . . q. s. ad fgvj (180.0). — M. S. — A dessertspoonful (8.0) every three hours till diarrhoea ceases. It is to be remembered that the chalk mixture acts very slightly as an astringent, and chiefly as an antacid and mechanical agent in the alimentary canal. Precipitated carbonate of calcium is the slowest acting antacid which we possess, and for this reason the remedy is to be employed in acidity of the intestines, as it passes through the stomach to a very great 138 DRUGS. extent unchanged. (For the varieties of diarrhoea in which it is to be used see article on Diarrhoea.) As an external operation it is used in sweating of the feet and hands, and sometimes as a dry dress- ing to ulcers. It may also be used over burns. Calcium chloride, when taken internally in large amount, acts as an intense gastro-intestinal irritant, and may produce death by this means. It is to be distinctly separated from the chlorinate or chloride of lime, w T ith which it is sometimes confused, for the latter is hydrate of lime or slaked lime, containing 35 per cent, of chlorine, while chloride of calcium is a hard, vitreous, friable substance, giving off no odor of chlorine and utterly different in its use, action, and appearance. Chloride of calcium is used in medicine by some physicians in the treatment of scrofulous enlargements of glands in the neck and else- where, and is even said to cause calcification and encysting of tuber- cular nodules. In cases where deficient bone-formation is evident it often does good, but the other salts of calcium, such as the lactophos- phates, are better. In cases where boils mature slowly a poultice made by adding a solution of chloride of calcium to the mass may be used to hasten suppuration. The dose internally is 5 to 30 grains (0.30-2.0), best given in a solution made by adding water in the pro- portion of 1 drachm (4.0) to each 5 grains (0.30) of the drug. Another use of calcium chloride which is one always worthy of trial is its employment in the treatment of itching. It should be given in the dose of 20 grains (1.3) three times a day to an adult, and may be prescribed as follows: I£— Calcii chloridi 3ij (8.0). Tinct. aurantii flor f5vj (24.0). Aquae chloroformi q. s. ad §vj (180.0). — M. S. — One to two tablespoonfuls (16.0-30.0) three times a day. Smaller doses may be needed if the stomach is irritable. These doses usually produce some thirst, and they should be taken about one hour after a meal. Small doses of calcium chloride have also been used to increase the coagulability of the blood in "bleeders," and to prevent attacks of urticaria by an influence on the blood-plasma. It should not be given longer than four days, as after this time it decreases the coagulability of the blood. When used, the dose should be 15 to 30 grains (1.0-2.0), followed by 5 grains (0.3) every hour till five or six doses have been taken. Unfortunately, as already stated, it is apt to disorder the stomach. MacCallum has recently shown that calcium chloride inhibits intes- tinal peristalsis, and suggests that it be used to control serous diarrhoea due to nervous atony. The hypophosphite of calcium and the precipitated phosphate of calcium are used for the treatment of scrofulosis or strumous states CALCIUM. 139 and allied conditions, sucn as rachitis, generally in the form of the Syrupus Hypophosphitum, U. S., Syrupus Hyposphitum Compositus, U. S. and the Syrupus Calcii Lactophosphatis , U. S. and B. P. The large amount of phosphate of calcium normally present in the bones and tissues renders it a useful drug when the body is starved of its proper proportion of salts, and its use has been found, in animals, to cause a great increase in bony growth, not only in the earthy, but also in the animal, constituents of the osseous tissues. The hyposul- phite has a similar effect. In rickets and in fractures where the bone is slow in uniting, and in some cases of phthisis and scrofula, the lactophosphates and hypo- phosphites are of service. It is worthy of note that these salts are of little value in tubercu- losis after it is well developed. They do good chiefly in the so-called pretubercular or beginning stages of the disease; and the good effects of the so-called syrups of the hypophosphites depend more upon the other ingredients present in them than upon the calcium salts they contain. In dental caries, particularly that occurring in nursing women, and in the anaemia of this class of patients, they are useful. The lactophosphates are better than the hypophosphites, as the latter are probably changed into phosphates in the stomach as soon as they enter that viscus. The dose of either the lactophosphates or the hypophosphites is 10 to 30 grains (0.60-2.0) three times a day, or of the syrups just named a teaspoonful to a tablespoonful (4.0-16.0). The difference between these salts and phosphorus, both in thera- peutical effect and in physiological action, is to be clearly borne in mind. The lactophosphates and hypophosphites are simply convenient modes of administering calcium, potassium, or other substances, while phosphorus acts as a stimulant to bone-growth, and not by its deposi- tion in the bone. Phosphoric acid does not act any more like phos- phorus than does sulphuric acid act like sulphur. Sulphate of calcium is not to be confounded with calx sulphurata, often wrongly called sulphide of calcium. (See Boils and Calx.) Chalk. Chalk is a native calcium carbonate, chiefly obtained from shells. Prepared chalk (Creta Pr¶ta, U. S. and B. P.) is given in the dose of 20 to 60 grains (1.3-4.0). Other preparations are compound chalk powder (Pulvis Cretw Compositus, U. S.), composed of prepared chalk, acacia, and sugar, and given in the dose of 10 to 60 grains (0.60-4.0), and troches of chalk (Trochisci Cretw). Mistura Creta?, or Chalk Mixture, is mentioned on p. 137. Preparations official in the B. P., but not in the U. S. P., are aromatic powder of chalk (Pulvis Creta 3 Aromaticus) , dose 10 to 60 grains (0.60-4.0), and Pulvis Creta? Aromaticus cum Opio, dose 10 to 60 grains (0 60-4.0). 140 DRUGS. CALUMBA. Calumba (Calumba? Radix, B. P.). Columbo, or Columba, is the root of Jateorrhiza Palmata. Its taste is bitter and its color is slightly aromatic. Two alkaloids are found in it, berberine and colum- bine, and a third substance known as columbic acid. Calumba is one of the purest bitters known, as it does not contain tannic acid. Therapeutics. — Calumba is one of the best simple tonics that can be used, owing to its lack of astringent effect and to its favorable action on mucous membranes. In cases of gastro-intestinal atony, particularly that following fevers and similar states, calumba will be found of service, and it is a valuable remedy in the convalescent stages of summer complaint and serous diarrhoeas. The following prescription of Dr. George B. Wood is very useful in intestinal atony when associated with flatulence, although its bulk is disadvantageous and its taste bitter: &— Calumbse pulv. 3ss(16.0). Zingiberis pulv Jss(16.0). Sennse fol gj (4.0). Aquae bullientis Oj (480 c.c). — M. Ft. in infusum. S. — A wineglassful t. i. d. Administration. — The fluid extract (Fluidextractum Calumba;, U. S.) is given in the dose of 15 to 60 minims (1.0-4.0); the tincture {Tinctura Calumba 3 , U. S. and B. P.), dose \ to 2 fluidrachms 2.0- 8.0 c.c). The dose of the infusion (Infusum Calumba 7 , B. P.) is \ to 1 fluidounce (16.0-30.0). Liquor Calumba Concentratus, B. P., is given in the dose of \ to 1 drachm (2.0-4.0), CALX. Calx (U. S. and B. P.), or Lime, or Oxide of Calcium, is an alkaline earth which is incompatible with acids, ammoniacal and metallic bases, borates, alkaline carbonates, and astringent vegetable infusions. It is prepared by burning pure white marble, oyster-shells, or the purest calcium carbonate. Therapeutics. — Lime is used for the purpose of acting as an eschar- otic, particularly on old ulcers and on hairy growths. It is never given internally except in the form of the hydrate or slaked lime. As an escharotic application lime is used in the official caustic Potassa cum Calce. When given internally it should always be used as Liquor Calcis, U. S. and B. P., or lime-water, and under these circumstances it acts as an antacid, as an aid to the digestion of milk by preventing too rapid and solid coagulation of the casein, and by exciting an increased gastric secretion. It is also feebly astringent. Given to infants and nursing women, it is probably utilized in the body in the formation of bone. It is also of value in diabetes, in the uric-acid diathesis, and in the excessive nausea and vomiting often seen in adults and children and due to acidity of the stomach. Teaspoonful doses of milk and lime-water, equal parts, will often CAMPHOR. 141 be retained by such patients when nothing else will remain in the stomach. The dose of lime-water is 1 drachm (4.0) to 1 ounce or even 2 ounces (30.0-60.0). Externally applied, lime-water is of value in tinea capitis and similar states, and it is a good application in burns, when mixed with equal parts of linseed or olive oil, forming Linimentum Calcis, U. S. and B. P., or Carron oil. As a local application in membranous croup and diphtheria lime-water has a high reputation, and is believed to dissolve the membrane, but it does not compare in usefulness with peroxide of hydrogen. It may be used as a spray or by means of a swab. Liquor Calcis, or lime-water, is to be made by adding a piece of unslaked lime as large as a walnut to 2 quarts of boiled and filtered water in an earthen jar; after stirring it thoroughly allow it to settle, and pour off the clear liquid into a bottle. More water may then be added to the lime until it is all used. Sulphurated lime (Calx Sulphurata, U. S. and B. P.) is useful to check inflammation and hasten suppuration; the dose is T V to J grain (0.006-0.03). It is of great value in acne pustulosa and all forms of cutaneous suppuration. Where sulphurate of lime is not obtainable and successive crops of boils appear, it is often possible to relieve the patient by baking egg-shells in an oven, powdering them, and then letting the patient eat 1 drachm (4.0) or more of the powder each day. The preparations of the B. P. that are not official in the U. S. are the saccharated solution of lime (Liquor Calcis Saccharatus) , dose 15 to 60 minims (1.0-4.0), and slaked lime (Calcii Hydras), used in mak- ing different preparations. (For Calx Chlorinata, see Chlorinated Lime.) CAMPHOR. Camphor (C amphora, U. S. and B. P.) is derived from Cinna- momum Camphora, which grows chiefly in China and Japan. The camphor used in the drug-stores is refined camphor, and is obtained by repeated sublimation. It is a volatile irritant stearopten, produc- ing a burning sensation in the mouth and possessing a peculiar odor, soluble in 1000 parts of cold water and in 1 part of strong alcohol. Camphor is so volatile that if exposed to the air for any length of time it is wholly volatilized. It is an exceedingly combustible sub- stance, burning with a smoky flame. It may be white or pinkish in color. Physiological Action. — If taken in large amount, camphor pro- duces epileptiform convulsions, preceded by vertigo, roaring in the ears, and delirium. The pulse soon becomes rapid, feeble, and run- ning, and the skin livid, cold, and covered with sweat. Intense heat and burning may be felt in the belly, and, if the poisoning be slow, evidences of gastro-intestinal and renal inflammation ensue. In small 142 DRUGS. doses it acts as a stimulant and gives a sensation of warmth to the stomach, while the pulse may become more rapid and stronger under its influence. At the same time there is a sedation of the nervous system and a general feeling of contentment. In large medicinal dose camphor is thought by some to act as a sexual stimulant, and by others as a sexual sedative. The stimulant effect is probably only produced by doses large enough to produce irritation of the genito- urinary tract. The convulsions following poisonous doses are due to the action of the drug on the brain. The drug, although largely destroyed in the body, is chiefly eliminated by the kidneys as campho- glycuric acid, and also escapes by the breath and the perspiration. Therapeutics. — Internal Use. — Camphor is employed for the purpose of acting as a nervous sedative and antispasmodic in the treat- ment of nervous women and children, and as a carminative in indi- viduals who suffer from intestinal flatulence. It is of value in nervous dysmenorrhea and headache, and is best combined with one of the new analgesics, such as antipyrin and acetanilid given in tablet-form. As it is virtually a volatile oil so far as its physiological action is con- cerned, it will be found useful in cholera and in cholera morbus, and in all forms of serous diarrhea, but rarely in mucous diarrhoea. (See Diarrhoea.) In chordee, combined with bromides and similar depress- ants to the spinal cord, camphor is of great service in some cases, particularly late in the disease. In adynamic fevers it has been used as a diffusible stimulant by Graves and by many others since his time with success. Camphor is a very useful remedy in sudden nervous depression coming on in the course of acute or prolonged exhausting diseases. It may be given by the mouth or, if the emergency is a pressing one, by hypodermic injection. Under these circumstances it is best given in the form of camphorated oil in the strength of 1 part of camphor to 9 of sweet oil, which last should be perfectly sterile. The dose of this solution is 15 minims (1.0). When used in the nervous depression of phthisis, Alexander asserts that its continuous injection may result in cumulative action and develop the symptoms of mild camphor poisoning. In hiccough it is of great service, and in cardiac palpitation due to functional irritability it is of value. In old or atonic cases of capillary bronchitis and catarrh of the air-passages it is useful. In chronic nasal catarrh spirit of camphor when inhaled from the mouth of a vial gives off enough of the drug to stimulate secretion and tone up the parts. It is also of value as a mouth-wash in persons who have fetid breath. Camphor may be inhaled or taken internally in cases of cold in the head, in the early stages, with great relief, and exercises a decided influence in aborting the attack. The following formula may be employed : Be — Camphorae gr. ij (0.12). Fluidextract. belladonnas .... TTLjss (0.08). Quininae sulph gr. ij (0.12). — M. Ft. tabellae No. x. S. — One every hour for lour or five doses. CAMPHOR MONOBROMATE. 143 After the attack is well developed this is useless, but used early it will decrease the frontal headache and the sneezing and running at the nose. In coryza from unknown causes with much lachrymation and incessant sneezing, camphor will be found of benefit. It may be snuffed up the nostril in a fine powder, or powdered camphor may be put in boiling water and the fumes inhaled. The spirit may also be inhaled from a handkerchief. External Use. — Externally camphor may be used as a stimulant to indolent sores and as a useful addition in small amount to the pre- cipitated carbonate of calcium as a dusting-powder in intertrigo. In the form of a liniment camphor is used over inflamed joints from sprains or rheumatism, and in myalgia and neuralgia to relieve the pain and stiffness. Camphorated alcohol, spirit of camphor, is a useful application for abortive purposes when used over boils in their early stages, if repeated two or three times a day for a few moments at a time. Following these applications, the skin should be dried and camphorated oil applied. Ringer and Tilt recommend that Eau de Cologne, saturated with camphor, be rubbed into the scalp in the drowsiness and headache of the menopause, and a lotion of equal parts of aqua ammonia and spirit of camphor dabbed on the painful or hyperaesthetic spots at the top of the head, so commonly felt by nervous women at the change of life or during menstruation, will be found to give relief. Administration. — Camphor is used internally in the form of the camphor-water (Aqua Camphors, U. S. and B. P.), dose i to 2 fluid- ounces (16.0-60.0) ; the spirit of camphor (Spiritus Camphors, U. S. and B. P.), dose J fluidrachm (2.0), or in the form of the camphor itself, in pill, in the dose of 1 to 3 grains (0.06-0.20) in each pill. The best preparation for internal use is the spirit, or the gum cam- phor itself may be given. For external use we have, official, camphor liniment (Lini- mentum Camphors, U. S. and B. P.) and soap liniment, or Lini- mentum Saponis, U. S. and B. P., which is the milder of the two. Ceratum C amphora? is also official. A compound tincture of camphor (Tinctura C amphora? Composita), composed of opium, benzoic acid, camphor, and oil of anise, is official in the B. P., dose 15 minims to 1 fluidrachm (1.0-4.0). This preparation is practically equivalent to ''paregoric." Linimentum Camphora? Ammoniatum, B. P., is com- posed of camphor, rectified spirit, and stronger ammonia. CAMPHOR MONOBROMATE. Monobromated Camphor (C amphora monobromata, U. S.) is made by heating together in a sealed tube camphor and bromine. It occurs in colorless crystals or scales, and has a mild taste resembling camphor. It is almost entirely insoluble in water, but is freely soluble in alcohol, ether, and chloroform. 144 DRUGS. Physiological Action. — Monobromated camphor possesses powers partaking of the bromides and of camphor. In the frog it causes loss of reflex action, motor palsy and death by respiratory failure, and in warm-blooded animals violent convulsions, Cheyne-Stokes respirations, muscular tremblings, and weakness. The pulse is at first more rapid than normal, then slow and weak, death ensuing in coma or during the convulsions. Therapeutics. — When combined with other drugs monobromated camphor will generally be found most useful for pain, particularly in lumbago, or ths pain due to nervous disturbances. If used in hysterical females, it will often produce sleep, and is of value to those who are addicted to the alcohol-habit, as it acts as a hypnotic and warms the stomach. Like camphor itself, it is a gastric irritant, and should not be employed where gastritis exists. It has been used in sperma- torrhoea with great success, and in delirium tremens has been found of benefit in cases where the gastric mucous membrane is depressed and the nervous twitchings are troublesome. In ivhooping -cough it may be tried, and it has been used in chorea, epilepsy, and petit mal. In the nervous depression and pains of epidemic influenza monobromated camphor has been largely used. (See Acetanilid.) Administration. — This drug should never be used hypodermically, as it is too irritating, but administered in the dose of 5 grains (0.32) three times a day in pill, or in an emulsion made by dissolving it in six times its weight of expressed oil of almonds and then forming an emulsion with gum-arabic water in the usual manner. CAMPHORIC ACID. Camphoric Acid (U. S.), made by the oxidation of camphor through the influence of acids, is the best remedy for the night-sweats of phthisis. In a large number of cases suffering from night-sweats the author has found this drug to act very favorably indeed where other remedies failed, and he has never seen it produce disagreeable symptoms. It may be given in the dose of from 20 to 30 grains (1.3-2.0), taken an hour or two before the sweat is expected. In very obstinate cases as much as 60 grains (4.0) should be given, but under these cir- cumstances it should be used in two separate doses of 30 grains (2.0) each, two hours apart, in order to avoid irritating the stomach. It is best given in capsule or cachet, as it is insoluble in water. In other instances camphoric acid may be given in the following formula: 1$ — Acid, camphoric oiv (16.0). Alcohol. - . "fgij (60.0). Mucilag. acaciae f5iij (90.0). Syr. aurantii corticis q.s. ad fgvj (180.0) .— M. S. — Dessertspoonful (8.0) to a tablespoonful (16.0) one hour before sweat is expected. In the writer's experience, it is worthy of note that camphoric acid is possessed of little power in cases of bromidrosis. CANNABIS INDICA. 145 CANNABIS INDIGA. Indian Hemp (Cannabis Indica, U. S. and B. P.) is the flowering tops of the female plant of Cannabis sativa. It is to be distinctly separated from the so-called American, American-Indian, or Canada hemp, or Apocynum Cannabinum, which in full doses is an intense irritant and drastic. The selection of this drug is attended with peculiar difficulties because of the fact that only the non-fertilized female flower-spikes are possessed of therapeutic activity, the male spikes and female flower- tops which are bearing seed being inert. The three varieties resemble one another so closely that when crushed and intimately mixed in a bale it is practically impossible for even a drug expert to distinguish the active from the inert part of the plant. Physiological Action. — Given in full dose to man, this drug causes exhilaration and incessant laughter arising from the slightest cause, the person seeming convulsed with merriment; in other cases the sensations are disagreeable, and even death may seem imminent to the deranged mind. Sometimes the sensation of very full breathing comes on, and the patient thinks he is about to burst from the inflation of his lungs. After this, deep sleep ensues, lasting for many hours, even as many as fourteen or fifteen, without intervals of wake- fulness. One of the most constant and marked symptoms in poisoning in man is the sensation of prolongation of .time, so that minutes seem like hours, and, in addition to this, a peculiar separation of the mental powers occurs, during which both hemispheres of the brain seem to think differently on the same subject. If the dose be very large, the respirations are slowed very considerably, but no death from the use of cannabis indica by man is on record, and enormous amounts have been given to the lower animals without causing a lethal effect. 1 Applied to mucous membrane, it acts as a severe irritant, and then as a local anaesthetic, but the primary effect is so powerful as to prevent its application to mucous membranes for the relief of pain. Therapeutics. — Cannabis indica is one of the best additions to cough mixtures that we possess, as it quiets the tickling in the throat, and yet does not constipate nor depress the system as does morphine. In advanced phthisis it is justifiable to keep the patient constantly in a state of quiet comfort by its use. For the relief of pain, particularly that depending on nerve-disturbance, hemp is very valuable. Before the introduction of antipyrin and its congeners, tincture of gelsemium and the tincture or extract of cannabis indica were our best remedies in the treatment of migraine. The gelsemium in such cases should be given in full dose, 20 drops (1.3) of the tincture, and be followed by 1 The author has injected as much as 5 drachms of a fluid extract, active in the dose, of 10 minims to man, into the jugular vein of a small dog without producing death for many hours, 10 146 DRUGS. 10 to 20 drops (0.60-1.3) of the fluid extract of cannabis indica, it being known that the sample about to be used is active. After this dose of gelsemium the patient should be carefully watched, lest he suffer from an excessive influence of the drug, as such an amount may produce great depression in susceptible persons. In true migraine with hemianopsia this treatment is often most effectual in aborting the attack. The prevention of further attacks is to be attained by the use of smaller amounts of the cannabis indica during the intervals, the gelsemium only being used at the onset of the symptoms. In paralysis agitans cannabis indica may be used to quiet the tremors, and in spasm of the bladder, due to cystitis or nervousness, it often gives great relief. In sexual impotence, not dependent upon organic disease, it is said to be of value combined with strychnine or nux vomica and ergot. In headaches at the menopause cannabis indica is useful, and if the headaches are associated with constipation and anaemia, iron and aloes should be given simultaneously. Where headaches are due to retinal asthenopia a very useful prescription, according to de Schweinitz, is as follows: 1$ — Tr. nucis vomicae f5ij (8.0). Tr. cannabis indicse f 3ij (8.0). — M. S. — 15 drops (1.0), in water, twice or thrice a day. The following prescription has been found to be very efficient in the hands of the author in treating gastralgia and other forms of abdominal pain : R— Tr. capsici f.^j (4.0). Tr. cannabis ind f.^ss(16.0). Tr. opii deodorati f §j (30.0). Spt. chloroformi f|j(30.0). Tr. lavandul. comp. . . . q. s. ad f^iv (120.0). — M. S. — Teaspoonful (4.0) every hour until pain is relieved. In cases of uterine subinvolution, chronic inflammation, and irrita- tion cannabis indica is of great value, and it has been found of service in metrorrhagia and nervous and spasmodic dysmenorrhea. Not only does it relieve the pain, but it also seems to act favorably upon the mus- cular fibres of the uterus. In acute and chronic Brighfs disease cannabis indica often allays the painful sensations over the renal region, and has been recom- mended by some writers in the cases in which bloody urine is present. In gonorrhea it is said to decrease the discharge and prevent chordee, and it has supplanted the use of copaiba and cubebs in some practi- tioners' hands. It should not be used in the early stages of gonor- rhoea, but in the later or subacute stages. There is some foundation for the belief that in small doses it acts as a sexual stimulant. The advantages possessed by cannabis indica are that it does not constipate nor cause after-depression and nausea. On the contrary, there is often an increase rather than a decrease of the appetite under CANTHABIS. 147 its influence. In the Anglo-Saxon race the cannabis indica habit is practically unknown, but in the East Indies when used to excess it sometimes causes maniacal insanity, from which the patient nearly always recovers after some days, weeks, or months. Administration.— The employment of this most valuable remedy is handicapped by its frequent lack of power — a fault which is largely dependent upon reasons already given. Only a preparation which has been physiologically tested should be used. The drug as prepared by Parke, Davis & Co. has proved efficacious in the author's hands for a number of years. The physician should always employ some prepa- ration known by him to be active by personal trial before condemning the drug as a failure in a given case. The dose of the solid extract (Extraction Cannabis Indicw, U. S. and B. P.) is from \ to \ grain (0.015-0.03), that of the fluid extract (Fluidextractum Cannabis Indica;, U. S.) from 4 to 20 minims (0.25- 1.3) and that of the tincture (Tinctura Cannabis Indica?, U. S. and B. P.) from 15 minims to 1 drachm (1.0-4.0). CANTHARIS. Cantharis (U. S. and B. P.), or " Spanish Fly," is really a beetle, known as Cantharis vesicatoria, and as such appears with iridescent coverings or wing-sheaths of a bluish or greenish hue. The insects come chiefly from Spain, Italy, and Sicily, and from the southern parts of Russia. Those from Russia are supposed to be the best. Accord- ing to Leidy, the vesicating substance is in the blood, the eggs, and the secretions of the generative apparatus. The blistering substance contains cantharidin as an active principle, but cantharidin is not medicinally employed. Physiological Action. — Locally applied to the skin, cantharides causes irritation and finally vesication. The blister produced may be quite large, and enough of the drug may be absorbed to cause fever and nervous excitement. The ingestion of a moderate dose of cantharides produces a sensation of warmth in the stomach and slight stimulation of the genito-urinary system, particularly the kidneys and urinary tracts. Large amounts produce great pain in the lumbar region, a sen- sation of heat in the bladder and the urethra, priapism, agonizing vesical tenesmus, widespread acute nephritis, bloody urine, which is scanty at first, and finally suppressed, with great irritation of the exter- nal openings of the genito-urinary apparatus. The inflammatory changes may cause sloughing of the penis or of the labia in the female. Violent gastro-enteritis is nearly always a pressing condition. A diagnostic sign of cantharidal poisoning, when the beetles have been swallowed, is the appearance of pieces of the iridescent wing-sheaths or coats in the vomit. Thirst is always a prominent symptom of poisoning by cantharides. 148 DRUGS. Therapeutics.— Can tharides are employed internally and externally. When given by the mouth the tincture is used as a uterine stimulant, to affect the uterine mucous membrane and relieve amenorrhea in cases in which atony and depression are the cause of the depression. Some persons teach that the tincture of cantharides is a valuable remedy in small doses in the second stage of acute desquamative nephritis, but in the instances where the writer has seen it used it has aggravated the condition, although it is supposed to decrease the excretion of the albumin and blood. In the later stages, where the kidneys are relaxed and torpid or where albuminuria comes on on the slightest exertion, tincture of cantharides in the dose of i minim (0.025) three times a day is of service. In cases of chronic parenchymatous nephritis, particularly where alcoholism is the cause of the disease and the kidneys are inactive, can- tharidal tincture is very useful. In pyelitis and in chronic cystitis it is of service, and it has been recommended highly in drop doses in irritability of the bladder in women and children. In these cases the bladder must not be inflamed, but irritable from depression. The use of cantharides is of value in incontinence of urine of a minor degree, as that occurring in elderly or nervous females when coughing, sneezing, or laughing, and will often give relief after years of suf- fering. In chordee, in the dose of J minim (0.025) twice or thrice daily, it is sometimes of service. For impotence depending upon sexual excess Ringer asserts that the use of 5 to 8 minims (0.30-0.50) of the tincture of cantharides, with full doses of the tincture of the chlo- ride of iron and nux vomica, will often relieve the patient and enable him to beget children. This dose of cantharides must be given with caution. The drug has no true aphrodisiac influence except when given in almost toxic dose. In gleet of a very chronic type and in prostatorrhwa it is of service. Dermatologists have used cantharides internally as a remedy in psoriasis, eczema, lichen, and prurigo, with asserted great success. The dose should not be large enough to irritate the stomach or kidneys. Externally, cantharides are used in the production of blisters for the purpose of causing the absorption of effusions or as a counter- irritant of some severity in cases of deep-seated inflammations. (See Counterirritation.) Care should be taken that a sufficient amount of the drug is not absorbed to cause strangury and renal irritation. In renal congestions and inflammations the use of cantharides as a counter- irritant is often contraindicated because of this danger. Huchard and others have reported cases in which, without disease of the kidney, a cantharidal blister has produced violent acute nephritis, with result- ing uraemia. In the proportion of J minim (0.025) of the tincture of cantharides to 40 (2.6) of water it is said to be an efficient application for burns, but how it acts is not known. Administration. — The dose of the tincture (Tinctura Cantharidis, U. S. and B. P.) is from J to 5 minims (0.025-0.30), and it is the only CAPSICUM. 149 preparation used internally. The cerate (Ceratum Cantharidis, U. S.) is used, spread upon muslin, to produce a blister, and the cerate of the extract, which is no longer official, is used for the same purposes and in the same manner. The cantharidal collodion (Collodium Cantharida- tum, U. S.; Collodium Vesicans, B. P.) is a method of applying the blister which is most cleanly, but there is more danger of absorption of the drug if it is used. The collodion acts as a protective to the part. Liquor Epispasticus, B. P., is employed as a counterirritant. " Warming plaster " (Emplastrum Picis Canthari datum) is a mild counterirritant plaster to be employed where a blister is thought to be too severe. The preparations of the B. P., other than those named, are Emplastrum Cantharidis and Unguentum Cantharidis. The unofficial plasters of cantharides are the best preparations to use for the production of a blister. In order to obtain a perfect effect the skin should be washed thoroughly with soap and water and dried with a towel, which should be rough enough to produce reddening of the cuticle. After this the skin should be moistened with vinegar, and while wet the blister is to be applied. CAPSICUM. Capsicum, U. S., Capsici Fructus, B. P., or Cayenne Pepper, is the fruit of Capsicum jastigiatum or minimum, a native of tropical Africa and of Central America. It occurs in long, ovoid pods, which, when ripe, are scarlet red and possess a very hot, burning taste. The active principle is capsicine, which is a dark reddish liquid, and which is a volatile alkaloid. Physiological Action. — Locally applied to the skin or mucous mem- branes capsicum causes redness, and finally, in the case of mucous membranes, vesication. The alkaloid will also produce these changes in the skin. When used internally for any length of time in ex- cess capsicum will cause a chronic or subacute gastritis with pain and discomfort over the liver and stomach. If single large doses are used, renal irritation and inflammation ensue, with strangury and the passage of concentrated urine. Taken internally, capsicum is said to act as a circulatory stimulant. Therapeutics. — In cases of atony of the stomach due to general debility, errors in diet, and alcoholism of the chronic type capsicum is one of the best remedies we have. When the patient is suffering from acute alcoholism the gastric mucous membrane is often too much irri- tated to permit of its use, but after the lapse of some days it may be found of benefit for the purpose of increasing the digestive power. As a remedy for subacute alcoholism it is useful, since by its stimulating effect and hot sensation it often satisfies, at least to some degree, the craving for alcohol. Under these circumstances it should be used in the dose of 3 to 5 minims (0.20-0.30) of the tincture every four or five 150 DBUGS. hours, or as the oleoresin in pill in the dose of \ to 1 grain (0.03-0.06). The following prescription has been found of great service in these cases : fy — Tr. capsici f^iss (6.0). Tr. opii deodorat foij (8.0). Spt. aether, nitrosi f 3iv (15.0). Tr. lavandulse comp q. s. ad fgiv (120.0). — M. S. — Dessertspoonful (8.0) every four or five hours. In the flatulent colic of old persons and young adults capsicum will be found not only to act as a carminative, but also to prevent the develop- ment of the gas. In low fevers it has been used as a diffusible stimulant, but it is of doubtful value. It is rather in the anorexia of convalescence that capsicum acts most favorably. In chronic nephritis it is of con- siderable service, and it tends to check albuminuria, but it is only to be used in the chronic forms and stages of renal disease or in the treatment of functional torpidity of the kidney. The tincture is to be given under these circumstances in the dose of 10 minims (0.60) or less, but in some cases which are very chronic as much as 20 minims (1.3) may be used. In sore throat and simple tonsillitis the tincture of capsicum and glycerin, half and half, form a very useful local application applied by means of a swab. The same preparation may be used as a gargle for relaxed uvula and sore throat. Capsicum may be used as a gastro-intestinal stimulant to aid in the absorption of other drugs. Applied externally, capsicum acts as a counterirritant, producing redness of the skin, but not a blister in the ordinary individual. It is one of the best moderate counterirritants which can be used, and it may be employed by repeatedly saturating blotting-paper in the tincture of capsicum, allowing the paper to dry between each dip. This paper should finally be placed when warm and wet over the part, and held closely to the skin by a compress. Capsicum plaster (Emplastrum Capsici, U. S.) is useful in lumbago and rheumatism when placed over the affected muscles, and in headache when applied to the nape of the neck. The tincture is sometimes painted over chilblains which are unbroken. The following method, given by Ringer, is very efficacious in this annoying affection: "Make a strong tincture of capsicum-pods by steeping them for several days in a warm place in twice their weight of rectified spirit of wine. Dissolve gum arabic in water to about the consistence of treacle. Add to this an equal quantity of the tincture, stirring together with a small brush or a large camel's-hair pencil until they are well incor- porated. The mixture will be cloudy and opaque. Take sheets of silk or tissue-paper; give them, with the brush, a coat of the mixture; let them dry, and then give another coat. Let that dry, and if the surface is shining, there is enough of the peppered gum; if not, give a third coat. This paper should be applied in the same way as court-plaster to chil- blains that are not broken and burns that are not blistered, and it will speedily relieve the itching and pain. It acts like a charm and effects CARBOLIC ACID. 151 a rapid cure. The same is true of discolored bruises. It likewise allays rheumatic pains in the joints."' The dose of capsicum is 1 to 2 grains (0.06-0.12) in powder, on food or in pill. The dose of the tincture of capsicum (Tinctura Capsici, U. S. and B. P.) is 5 to 10 minims (0.30-0.60), and of the oleoresin (Oleoresina Capsici, U. S.) J to J minim (0.015-0.025). The dose of the fluid extract (Extraction Capsici Fluidum, U. S.) is 1 to 3 minims (0.05-0.20). The plaster (Emplastrum Capsici, U. S.) is useful for external applications. An ointment (Unguentum Capsici) is official in the B. P. CARBOLIC ACID. Carbolic Acid (Phenol, U. S., and Acidum Carbolicum, B. P.) is also known as Phenylic Alcohol and Phenic Acid. Not only is it an acid, but in addition it is an alcohol of the peculiar group known as the phenols, which are derived from coal-tar by a process of distillation. Its acidity is, however, very feeble. Phenol is sold in several grades, No. 1 being the purest. Both Nos. 1 and 2 are crystalline, while Nos. 3, 4, and 5 are impure because of the presence of cresylic acid and other foreign substances. Only No. 1 should be ordered when phenol is to be given by the mouth. Phenol has a characteristic odor, and varies in color according to its method of preparation and purity. It is soluble in 20 parts, of water, but it is liquefied by the addition of 8 per cent, of water. Phenol should be kept in dark amber-colored, well-stoppered bottles. If the crystals be exposed to the air, they undergo liquefaction, and in consequence the purest phenol is usually prescribed in minim doses rather than in grains. It is soluble in alcohol, ether, chloroform, glycerin, and most oils. It unites with alkalin bases to form salts, carbolates; but these are readily decomposed, even by the feeblest acids, such as carbonic acid. Physiological Action. — Locally applied to the skin, phenol produces at first a burning sensation, accompanied by a diffuse reddening of the surface. If the solution be strong, the part at once becomes tem- porarily painful, then bleached and numb, so that tactile sensibility is destroyed. Applied to mucous membranes, it causes similar changes, but to a more marked degree, and may even act as a moderately severe caustic of a superficial type. Owing to the coagulation of albumin pro- duced when it is applied, it cannot cauterize the tissues very deeply. Nervous System. — Phenol acts as a depressant and paralyzant to the peripheral sensory nerves when locally applied. Upon the higher centres in the brain the acid produces a condition of depression and stupor. The convulsions which sometimes occur after toxic doses have been taken are spinal in origin, as they occur after section of the spinal cord. The motor nerves escape almost untouched, as do also the muscles. 152 PBUGS. Circulation. — Upon the circulation in the higher animals the drug exercises a distinct depressant influence, stopping the heart in diastole in lethal dose, and paralyzing the vasomotor centre even before the car- diac muscle is affected. These changes follow only lethal doses. Small medicinal doses have no effect of any moment upon the circulation. Respiration. — After large doses the breathing becomes more rapid and full. These changes, according to Salkowski and others, are due to stimulation of the respiratory centres and the peripheral vagi. Lethal doses almost invariably kill by failure of respiration due to depression of the respiratory centres. Temperature. — Phenol acts as a feeble depressant to normal bodily temperature even when given in medicinal dose, and also decreases the bodily heat in fever. It lowers fever by diminishing heat- production and inc. easing heat-dissipation. This antipyretic power is hardly sufficient to permit of its use in disease for this purpose. Kidneys and Elimination. — When phenol is given in overdose, the kidneys may become so irritated that total urinary depression may occur. When taken in large quantity, it causes the urine to become brownish -black. This discoloration is due to an educt of phenol which is not yet isolated, perhaps hydrochinon. Phenol is eliminated in the urine as a sulphocarbolate of sodium and potassium and as glyco-uronic acid and hydrochinon. Part of it is burnt up in the body. It is to be distinctly understood that the dark urine of phenol poisoning is not due to the presence of blood or of any of its educts. Poisoning, Prolonged and Acute. — As the changes produced in. the tissues of the body by acute and subacute poisoning by phenol are in many respects identical, they may be considered together. Phenol is one of the most deadly and rapidly acting poisons known, although this fact does not seem to be generally recognized. If a large lethal dose be swallowed by a man, he may drop dead from its effects before he can go more than a few feet from the spot where he stood when drinking the drug, or he may live a few hours. In cases where death has occurred suddenly from taking this acid the direct cause has been failure of respiration. If the patient does not die at once, all the evidences of gastro-enteritis come on. Violent vomiting and purging may ensue, and burning pain in the entire abdomen is a prominent symptom. The skin is wet with sweat, the face pinched and anxious. Collapse, with a thready, imperceptible pulse and extreme dyspnoea, may be present. The mouth and lips may not smell of the drug, but the mucous membrane will be seen to be corrugated and stained black if impure acid has been taken, or be whitish if the pure drug has been used. The eschar on the mucous membrane is a peculiar one, and is pathognomonic of the poison, having a white centre sur- rounded by a reddened and inflamed zone, the centre sometimes becom- ing dark brown or black. The post-mortem will show these spots in the oesophagus and stomach, and even in the intestines. All the inter- CARBOLIC ACID. 153 nal organs, as the brain, kidneys, liver, and spleen, will be found filled with dark grumous blood, and on opening the body the odor of the acid will be perceived. A peculiar croupous exudate is sometimes found in the bronchial tubes, and fatty degeneration of a more or less widespread type often follows phenol poisoning. Langerhans has noted that in some of these cases evidences of croupous pneumonia exist. A very common symptom is hoarseness of the voice due to an effect on the larynx after the drug is absorbed, and not from its local influence. A large number of cases are on record in which subacute carbolic-acid poisoning has been produced by its absorption from surgical dressings. The earliest signs of such an accident are the darkened, smoky hue of the urine and slight nervous unrest or cerebral disturbance. Very often pain in the lumbar region indicates kidney irritation. The dressings should be, of course, at once removed. Treatment of Poisoning. — The chemical antidotes to phenol are the soluble sulphates, such as Epsom or Glauber salt, which form insoluble sulphocarbolates, and which are preferable to other soluble sulphates in that they also act as purgatives if freely used, and so wash out the bowel. The further treatment consists in the administration of warm mucilaginous drinks, hot applications to the extremities, the hypodermic injection of cardiac and respiratory stimulants, such as digitalis and strychnine, morphine to relieve pain, and the use of counterirritation over the abdomen. Emetics and the stomach-pump should be used if possible, but the former are generally useless because of tjie state of the stomach. When phenol has been spilled on the hands, its effects can be over- come if the hands are immersed at once in absolute alcohol. There is no satisfactory explanation of this extraordinary effect. Alcohol may also be used internally as an antidote; but as it cannot be taken in concentrated form, its internal use is not of much value in this condition. Therapeutics. — Internally phenol is little used, but, nevertheless, has a very favorable effect in certain states. In nervous vomiting or in that due to gastric irritation the drug does good in \ to 2 minims (0.025-0.10) doses by depressing the sensory nerves in the stomach. In diarrhcea depending upon fermentation from 2 to 4 minims (0.10-0.25) of the acid do great good, particularly if combined with 10 to 20 grains (0.60-1.30) of bismuth administered in powder or capsule. In gangrene and tuberculosis of the lung a spray of the acid in water in the strength of 5 to 15 minims (0.3-1.0) to the ounce (30.0) may do some good, and at least control the cough and relieve the irritation and tickling in the throat. 1 (See Part III., Inhalations.) Creosote is, how- ever, generally preferred in these conditions at the present time. 1 The spray must be a very fine one, or it will not carry the drug far enough down into the lungs to be efficacious. 154 DRUGS. In diphtheria, ulcerated sore throat, and even in ordinary stomatitis, phenol will be found of value when used in a spray or mouth-wash in the proportion of 1 part to 75 parts of water; and in ordinary sore throat or that due to sepsis, in the strength of 1 part to 100 of water it will be found, when applied on a swab or by a gargle, to relieve the pain and inflammation. By means of a stick it may be applied pure to the spots in aphthous stomatitis. In the treatment of burns phenol- ized sweet oil in the proportion of 1 drachm (4.0) of the drug to each 6 ounces (180.0) makes one of the best dressings that can be used. By means of the local anaesthesia produced by the drug, minor operations, such as eversion of an ingrowing toe-nail or opening a felon, may be performed by applying the pure drug by means of a brush to the line of the incision. Phenol may be used as a lotion in the itching of jaun- dice in the proportion of 10 grains (0.60) of the drug to 2 drachms (8.0) of glycerin and 2 drachms (8.0) of water, or, better still, 4 drachms (16.0) of sweet oil. In the form of an ointment phenol may be used in the strength of 10 minims to the ounce (0.60-30.0) of a simple cerate, particularly in cases of subacute eczema where there is a great amount of weeping. In cases of eczema with much itching, and in pruritus and lichen planus, the following ointment is useful : R— Menthol gr. v (0.30). Phenol gr. x (0.60). Ung. aquse rosse . %] (30.0). — M. S. — Apply locally. Several clinicians have recommended the treatment of smallpox by touching the vesicles in limited areas each day with a small brush or a stick dipped in the pure drug. It is claimed that in this way pustulation is decreased, secondary fever is diminished, and pitting is lessened. In enlarged glands which have not gone on to suppuration intra- glandular injections of phenol by means of a hypodermic needle are of value in a large number of cases, the solution used being no weaker or stronger than 2 per cent.; 5 to 10 minims (0.30-0.60) of this solution are sufficient for each gland. In the treatment of buboes 10 minims (0.6) of a solution of 8 grains (0.5) to the ounce (30.0) may be injected into the swelling, the skin being first benumbed by an ether spray. This is the most successful treatment. The same treatment may be applied in chronic synovitis and repeated every three days, and boils and car- buncles may also be so treated with great success if the measure be used early enough to abort the trouble. Phenol is rarely used directly over wounds in dressings at present unless the dressing be one of carbolized oil. Other drugs or rigid asepsis have supplanted it when used in this way, but surgeons have returned to its employment as a useful antiseptic when used in pure form to swab out open wounds that are infected. The use of the phe- nolized spray over wounds has been found to do more harm than good, and it ought never to be employed. PLATE II. PHENOL GANGRENE. Appearance of a finger four weeks after the appli- cation for twenty-four hours of a dilute solution of phenol. The finger was wrapped in cloths which were saturated with the carbolic solution not stronger than five per cent. Amputation necessary. Inflammatory process at the base of the finger shown by the reddened tissues. (Harrington's ease.) CARBON {CHARCOAL). 155 As a disinfectant phenol ranks among the poorest: 1 to 2 per cent, solutions, however, kill most spores and germs. Untoward Effects. — Phenol when applied as a dressing, even in as weak a strength as 3 per cent., to a finger or toe may cause gangrene of the part severe enough to destroy it or to require amputation. Such strengths applied to the skin of the trunk rarely produce evil effects, probably because the circulation is not so completely cut off by the action of the drug on the bloodvessels. (See Plate I.) Administration. — Phenol ointment (Unguentum Phenolis, U. S.; Un- guentum Acidi Carbolici, B. P.) and the glycerite (Glyceritum Phenolis, U. S.) and liquefied phenol (Phenol Liquefactum, U. S.) are the only official preparations of phenol in the U. S. P. In the B. P. the follow- ing preparations are official : Acidum Carbolicum Liquefactum, given in the dose of 1 to 2 minims (0.05-0.10); Glycerinum Acidi Carbolici, Trochiscus Acidi Carbolici, and Suppositorium Acidi Carbolici. CARBON (CHARCOAL). Carbo Ligni,]]. S. and B. P., or Charcoal, is prepared by the exposure of soft wood to a red heat, air being prevented from coming in contact with the wood during the process. Charcoal when used for medicinal purposes should be a black, brittle, somewhat shiny, porous substance, devoid of taste and odor, and completely insoluble in water. Therapeutics. — Charcoal is used externally as an application to old sores or sloughs to act as a deodorant and antiseptic. These things it accomplishes by the absorption of any liquids which may be present, thereby depriving germs of a nidus, and by its distinct oxidizing power. It may be applied in the form of a dry powder or in a poultice, which is, however, so uncleanly that other antiseptic dressings are preferable. The poultice (Cataplasma Carbonis), if used, should be made in the following manner: Take of powdered wood-charcoal \ ounce (16.0), bread-crumbs 2 ounces (60.0), linseed meal \\ ounces (45.0), and add boiling water 10 fluidounces (300.0). Macerate the bread-crumbs and meal for ten minutes over a fire, and then stir in the charcoal to the extent of half the amount just named. Spread out the poultice and sprinkle the remaining half of the charcoal over its surface, and apply while hot to the part affected. Internally, charcoal is used in powder in many conditions, and acts very well indeed in cases of so-called "sour stomach' " from which eructations of gas or sour liquids take place. The following prescription will also be found useful in the atonic or subacute gastric catarrh of persons who are careless in eating and who have much belching: Py — Oleoresin. capsici gtt. x vel xx (0.60-1.3). Pancreatin. . . . . . . . . gr. xx (1.3). Pulv. zingiberis gr. xl (2.6). Pulv. carbon, ligni gr. x! (2.6). — M. Ft. in pil. No. xx. S. — One or two t. i. d. 156 DRUGS. As ordinary charcoal is not always obtainable, it may be substi- tuted by pieces of very thin toast burnt through and through till they resemble charcoal. If the attack is very severe and vomiting eventu- ally ensues, the ejecta will commonly be found to be odorless and not sour, and the stools will also be almost odorless, though black. In fermentative and acid diarrheas in adults this method of treatment is often of value, the prescription given above being a valuable means of cure. When charcoal is used in any condition associated with irritation of the mucous membranes of the gastro-intestinal tract, it should always be very finely pulverized, and if the stomach or bowels are inflamed the capsicum must be excluded from the prescription. As a filter for impure water, charcoal, in mass or in powder, is one of the most satisfactory substances we have. CARDAMOM. Cardamom (Cardamomum, U. S.) is the fruit of Elettaria Repens, and is a bitter tonic possessing some aromatic properties. It is useful in cases of atony of the stomach and small intestine, particularly if com- bined with a mineral acid or some other bitter tonic, such as gentian. Cardamom is official in the B. P. as Cardamomi Semina. If the intestine is atonic and secretion is deficient, the following prescription will be found of value: If- Acid, nitric, dil. f 3j (4.0). Tr. cardamomi comp q. s. ad f §vj (180.0). — M. S. — Dessertspoonful (8.0) after each meal. 1 Administration. — The official preparations of cardamoms are the tincture of cardamoms (Tinctura Cardomomi, U. S.), dose 1 to 2 drachms (4.0-8.0) ; and the compound tincture ( Tinctura Cardomomi Composita, U. S. and B. P.), which is to be given in the same dose as the tincture. This tincture also contains cochineal, cinnamon, caraway, and glycerin. Cardamom is also a constituent of the official aromatic powder (Pulvis Aromaticus, U. S.). GASCARA SAGRADA. Cascara Sagrada (B. P.) is the bark of Rhamnus Purshiana, U. S., a plant growing in California. It is sometimes called California buckthorn, to distinguish it from ordinary buckthorn or Rhamnus Frangula, which it closely resembles in many ways, and which may be used as a substitute for cascara sagrada in some cases. Therapeutics. — Cascara sagrada ought never to be used as a purge, but only as a laxative. It is by far the best remedy we have when employed simply to empty the bowel of fecal matter in cases of con- 1 While the rule that an acid is incompatible with a tincture is not recognized in this mixture, the quantities of acid and alcohol are so disproportionate that ether in any amount is not devel- oped. CASTOR OIL. 157 stipation, since it not only performs this function without intestinal disturbance, but also simultaneously acts as a tonic to the intestine, and so prevents the constipation which usually follows the use of all other drugs of its class In the United States cascara sagrada is most commonly employed in the form of the fluid extract (Fluidextr actum Rhamni Purshiance, U. S., or Extraction Cascara? Sagradw Liquidum, B. P.), in the dose of from 10 to 20 minims (0.60-1.3) at night or morning and night. If 20 minims (1.3) fail to act, 30 minims (2.0) may be used; but if larger doses are required, other drugs should be employed as adjuvants, as fluidrachm doses of the fluid extract of cascara may produce irritation of the bowel, and enteritis or intestinal catarrh. The objection to cascara sagrada is its bitter taste, which may be partially disguised by the additional use of Syrupus Aurantii, in the proportion of 1 part of the cascara extract to 2 parts of the syrup of orange-peel. The B. P. has a preparation, Syrupus Cascara? Aromaticus, which is given in the dose of 1 to 4 drachms (4.0-16.0). Some of the preparations of this drug are now made in an almost tasteless form, such as "Cascara Cordial," an aromatic preparation useful for children who are constipated, or the non-bitter fluid ex- tract made by a prominent firm in the United States and called "Cascara Evacuant," and used in the dose of 20 minims (1.3). The solid extract (Extractum Rhamni Purshiana?, U. S. ; Extractum Cascara? Sagrada, B. P.) is given in the dose of 2 to 8 grains (0.12-0.5) in pill. CASSIA FISTULA. Cassia Fistula, U. S., is the fruit of Cassia Fistula, or Purging Cassia, as it is sometimes called, and occurs in long, dark-brown pods containing a dark pulp in each segment. This pulp is the useful part of the drug, and is official in the B. P. as Cassia? Pulpa. Cassia fistula ought never to be used alone, as it is too apt to cause pain and griping, but it is officially present in the Confection of Senna (Con)ectio Senna>, U. S. and B. P.), and may be given in the dose of J to 1 drachm (2.0-4.0) as a laxative, or as much as \ ounce (16.0) may be used if a purgative effect is desired. CASTOR OIL. Castor Oil (Oleum Ricini, U. S. and B. P.) is a fixed oil derived by expression from the beans of Ricinus Communis, a plant of the United States and elsewhere, but originally derived from India. It contains an acrid substance, ricinoleic acid. Physiological Action. — The manner in which castor oil purges is somewhat in doubt, but its activity probably depends upon the pres- ence of the acid just named and the fact that it is an oil. As is well known, oils — such as olive oil, for example — if given in 158 DRUGS. considerable quantity, tend to move the bowels, and the ricinoleic acid, which is somewhat acrid, stimulates the small and large gut, and so develops peristaltic movement. According to some writers, this acid is not set free until the oil is attacked by the pancreatic juice. That this acid possesses purgative properties of itself seems proved by the fact that the oil will purge when it is rubbed on the skin, and that nurs- ing mothers on taking the oil eliminate the acid in the milk to such an extent that the suckling is purged. According to the studies of Ruth- erford and Vignal, the oil has no effect over biliary secretion other than that violent purgation indirectly increases the flow, and the researches of Hess have shown that the oil acts more rapidly in the small than in the large gut, and only produces peristalsis by coming in contact with the mucous membrane. Therapeutics. — Castor oil is the blandest and most unirritating purge we have, with the exception of the sulphate of magnesium, which is depletant and much more rapid in its effects. While Epsom salt will act in one-half to one hour if the stomach is empty, castor oil will generally act in four hours, or perhaps five. Castor oil is used whenever irritant materials, such as bad food, putrid flesh, or decaying or green vegetables, have been eaten, even if the inflammation set up after them is very active. If hard bodies, such as broken cherry-stones, have been swallowed, castor oil is a far better purge than sulphate of magnesium, as it is more gentle and lubricates the gut, thereby preventing scraping and irritation. Where mucus has accumulated in the bowel in children, and must be gotten rid of before other treatment is resorted to, castor oil should be used. Previous to parturition it has been largely used to relieve the bowels of fecal matter, and is said by some practitioners to make the labor easier than if any other purge is used. This is doubtful. It is also employed in the constipation following acute diseases and in that occurring in infants and children. The disadvantages of castor oil lie in its taste, the fact that it is oily, that it tends to produce hemorrhoids if used constantly, and finally that its frequent use, or even a single dose, is generally fol- lowed by more obstinate constipation than existed before, so that the dose must be rapidly increased in size to be effective. This is one of the reasons why it is useful in irritative diarrhoeas, for, having swept out the mucus and offending matter, it checks the movements of the bowels afterward. The purgative effect of castor oil is very much increased if a little bicarbonate of sodium is given with it. Recent reports show that some cases of severe neuralgic headache may be cured by the use of small daily doses of castor oil. How it acts is not known, unless it unloads the bowels and so prevents toxaemia, which, in turn, has caused nervous irritation. Administration. — Castor oil is very much more agreeable to the taste if pure than if poorly prepared. It is also true that too great purification renders it less active. CAUSTIC POTASH. I59 The methods directed for taking castor oil are as various as the tastes of individuals. Its odor may be masked by a drop or two of the oil of bitter almonds, but emulsions of the oil are not of any ser- vice, save to interfere with its efficiency. Some take the oil in the foam of beer or porter, others in syrup of sarsaparilla and soda-water, and still others in milk or cream. A good way to take it is to eat one or two strong so-called cream peppermint drops, or even the crys J al- line peppermint drops, swallow the oil from a spoon which is to be placed well back in the mouth, and immediately eat several other peppermints. This plan is improved by using the oil in milk or water, so that the liquid carries the oil down into the oesophagus without its touching the mucous membranes. It may also be taken in highly seasoned beef-tea. Ringer recommends the following: \ ounce (16.0) of oil, fresh syrup of acacia 3 drachms (12.0), and distilled water 5 drachms (20.0), flavored with a little oil of lemon or peppermint. Wood advises that it be mixed with glycerin, equal parts, to which is added a drop or two of oil of gaultheria or oil of cinnamon. By far the best way of administering it is in soft capsules containing from \ to 1 drachm (1.0-4.0). Most persons can swallow as much as a tea- spoonful in capsule, and several capsules containing this quantity, or a smaller amount, may be given at once to complete the necessary dose. The capsules should be dipped in water in order to render them slippery and so more easily swallowed. The dose of castor oil for an infant is 1 to 2 fluidrachms (4.0-8.0), and for an adult \ to 1 fluidounce (16.0-30.0). Often, however, small doses will act when it is desired to sweep out of the bowel foreign matter that is causing diarrhoea. Owing to the fact that the oil will very frequently produce griping, a few drops of laudanum should be added to it, or tincture of bella- donna may be used. If these cannot be employed, a drop of the oil of cinnamon is equally useful for this purpose. Under the name of Mistura Olei Ricini the B. P. recognizes a mix- ture of castor oil made into an emulsion and given in the dose of 1 to 2 fluidounces (30.0-60.0). CATECHU. (See Gambir.) CAUSTIC POTASH. Caustic Potash (Potassii Hydroxidum; Potassa Caustica, B. P.) is a hard white solid, which readily deliquesces; it possesses great caustic pow r er, and is used in medicine for the purpose of burning away growths or exuberant ulcers. In small cutaneous cancers it is applied to the spot for a minute or two after the protecting scab is removed. The parts are then poulticed for several days, when the slough comes away. A piece of the drug, placed on the skin by means of a pair of forceps, will at once soften and burn the tissues for some distance. The surrounding 160 DRUGS. skin should be protected by wax, suet, or oils, and a piece of adhesive plaster with a hole for the growth should first be applied to prevent action on the surrounding healthy tissues. The burn produced by caustic potash is very painful, and cauterization through its influence should not be practised if it can be avoided. When the caustic has acted sufficiently, it is to be washed off with vinegar or other dilute acid to neutralize it. Vienna paste (Potassa cum Calce) is used for the same purpose as is caustic potash. CAUSTIC SODA. Caustic Soda (Sodii Hydroxidum, U. S.; Soda Caustica, B. P.) is milder than caustic potash, and its action is more readily controlled. It should be used in the same way and for the same purposes as is caustic potash, and the surrounding skin ought to be protected by adhesive plaster and oil or ointment. The soda must be kept in well-stoppered bottles made of hard, strong glass. The only official preparation of caustic soda in the U. S. P. is Liquor Sodii Hydroxidi, or solution sodium hydroxide. CERIUM OXALATE. Cerium Oxalate (Cerii Oxalas, U. S. and B. P.) is a white granular powder, permanent when exposed to the air, odorless and tasteless, and insoluble in water and alcohol, but freely so in hydrochloric acid. Therapeutics. — Cerium oxalate is often used instead of or combined with bismuth in the treatment of the vomiting of pregnancy or that due to uterine disorders and displacements, and in some cases of gastric acidity. The dose is from 2 to 5 grains (0.12-0.3), given in pill-form every four or five hours. CHENOPODIUM. Chenopodium is the fruit of Chenopodium ambrosioides, or Ameri- can wormseed. The seeds contain a volatile oil and have a distinct and rather disagreeable aromatic odor. These seeds, rubbed up into a powder, form with a syrup an electuary which is a most efficient remedy for Ascaris lumbricoides, or round-worm, as it occurs in children. The dose of the powdered seeds is from 10 to 30 grains (0.60-2.0). The better way of using chenopodium is in the form of the oil {Oleum Chenopodii) in the dose of 10 minims (0.6) to a child of five years, either on sugar or in an emulsion made of gum acacia. If the patient is old enough, capsules may be used. The general dietetic measures adopted for the removal of worms should be insisted upon before the drug is given. (See article on Worms.) CHLORAL {HYDRATED CHLORAL). 161 GHIMAPHILA. Chimaphila (U. S.), or Pipsissewa, is the leaves of Chimaphila umbellata, an evergreen found in America, Europe, and Asia. Therapeutics. — Pipsissewa is a drug employed in atonic renal con- ditions, particularly of the functional type, as a stimulating diuretic, which will bring into activity the secreting structure of the kidney and the mucous membrane of the genito-urinary tract. It is also a tonic to the stomach. For this reason it is often placed in mixtures given to dropsical patients if debility and anorexia are present. In the treatment of ulcers of the skin due to struma it is said to be of ser- vice, and it probably has some slight alterative power. The drug may be used in the form of a decoction, which is not official, in the dose of 1 to 3 fluidounces (30.0-90.0), and as the fluid extract {Fluidextr actum Chimaphila?, U. S.) in the dose of \ to 1 drachm (2.0-4.0). CHIRETA. Chireta (Chirata, U. S. and B. P.) is the plant Swertia Chirata, which is a native of India. It is a bitter tonic, possessing a very dis- tinct influence over the liver, and, unlike many bitter tonics, is devoid of tannic acid. For this reason it may be used with preparations of iron. Chireta may be given in cases of indigestion and loss of appetite, particularly where the liver is torpid or if any tendency to constipation is present, although it is not directly laxative. When given in powder the dose is 20 grains (1.3) ; the dose of the fluid extract {Fluid- extr actum Chirata?, U. S.) is 30 minims to 1 drachm (2.0-4.0), while that of the tincture (Tinctura? Chirata?, B. P.) is 1 to 4 drachms (4.0-16.0). The unofficial solid extract may be given in pill in the dose of 2 to 4 grains (0.12-0.25). The dose of the infusion (Infusum Chirata?, B. P.) is a wineglassful (30.0). Liquor Chirata? Concentratus, B. P., is given in the dose of 1 drachm (4.0). CHLORAL (HYDRATED CHLORAL). Although the name Chloral is applied to the substance used in medicine, chloral itself is never so employed, hydrated chloral (Chlor- alum Hydralum, U. S.; Chloral Hydras, B. P.) being the real prep- aration. Hydrated chloral is a white, crystalline body, but is often sold in irregular broken masses, which are generally impure. It should be kept in tight bottles in a cool, dark place. Physiological Action. — When chloral is applied to a mucous mem- brane, it causes distinct reddening and burning pain, and finally acute inflammation. It is, therefore, a local irritant. Chloral acts in the body as chloral, and is not broken up into formic acid and chloroform, as was taught at one time. Nervous System. — In medicinal and toxic dose chloral produces sleep by quieting the intellectual centres in the brain, at the same 11 162 DRUGS. time depressing the motor tract of the spinal cord and the motor nerves. In medicinal amounts it does not decrease sensation, but in toxic doses it does. Very often hyperesthesia of the skin results from small doses. Reflex action is decreased by its sedative influence on the motor portions of the spinal cord. Circulation. — A dose of 10 to 20 grains (0.60-1.30) in the healthy adult rarely causes any circulatory change, but larger amounts pro- duce a fall of arterial pressure and a slow, feeble, or sometimes a rapid- running pulse, due to a direct depression of the heart-muscle, for chloral in overdose is a cardiac paralyzant Fig. 18. Fig. 19. Fig. 21. D F Fig. 20. Fig. 18. — A, chloral causes sleep by quieting intellectual centres in brain. Fig. 19. — B, depresses motor centrifugal tracts of cord; C, depresses motor nerves; D, does not depress the muscles. Fig. 20. — E, depresses heart-muscle. Fig. 21. — F, depresses the respiratory centre in the medulla. After death from chloral the blood may be found dark and grumous- looking, with the corpuscles broken down, but these changes occur only after very large doses. Respiration. — In moderate amounts no respiratory effect is felt, but in toxic doses the breathing becomes slower and slower and more and more shallow, until it stops in death. When death is caused by chloral it is primarily due to respiratory failure, but there is an almost simultaneous arrest of the heart. CHLORAL. 63 Temperature. — Chloral tends to lower bodily heat, and in large doses produces a marked fall of temperature, which does much toward causing death. Brunton has found that animals will survive very large doses of the drug if external heat is supplied to them. The fall of temperature is, at least in part, due to failure of the circula- tion and to vascular dilatation. Kidneys, Tissue-waste, and Elimination. — Chloral is elimi- nated by the kidneys in the form of uro-chloralic acid and, if given in excess, as chloral. Poisonous doses irritate these organs, and may produce bloody urine, owing to the nephritis which is set up as the drug passes through the renal structures. After chloral is ingested the riune of a patient will often react to Fehling's test for sugar. Poisoning. — When a poisonous dose of chloral is taken, the individ- ual soon falls asleep and then sinks into a deep coma. The respi- rations become at first slow and labored, then shallow and feeble. The pulse, at first perhaps a little slowed, soon becomes thready and shuttle-like, and is finally lost at the wrist. The face is white and livid, the forehead and the hands covered with a cold sweat, and the pupils, which are at first contracted, soon become widely dilated. Absolute muscular relaxation is present, and it is impossible to arouse the patient. Fig. 22. I ii in a (Id y yiill 1 fl 1 \ 1 " ft \ \ 1 11 | \ U UU uu U uu IJ nil ^> J uu IU w u u y Jy i Shows the effect of digitalis in raising blood-pressure and pulse-force in chloral poisoning (after Schmiedeberg): In I the pressure is very low because of the effect of a large dose of chloral; the blood-pressure is 40; in II, after the injection of digitalis, it is 60; and in III it is 125, and the individual pulse-beat is far stronger than before. Very large doses of chloral have been swallowed and retained without causing death. Acher has recorded a case in which 330 grains (80.0) of chloral and the same amount of bromide of potassium were taken at one dose with the recovery of the patient. 164 DRUGS. Treatment of Poisoning. — The physician should apply external heat and use emetics in the early stages, or, if the case is seen too late for emetics to act because of systemic depression, he should use the stomach-pump. This latter means of removing the drug from the stomach is safer and more reliable, because the production of vomit- ing may result in efforts which will strain the heart. Strychnine should be given in full dose, 2V t° to" g ram (0.003-0.006) to stimulate respiration, or atropine may be used for the same purpose. The heart is to be supported by 10-minim (0.60) doses of tincture of digitalis, given hypodermically every twenty minutes until some effect is noted; and, as the digitalis is rather slow in its action, it may be preceded by ether and ammonia or brandy or whiskey. The patient must not raise the head to vomit, and the head should be placed on a lower level than the heels to aid in maintaining the circulation of blood in the vital centres at the base of the brain. In chronic poisoning by chloral or in cases in which the patient has come to use the drug as a habit the patient suffers from weakness, men- tal and physical, with sudden flushings due to vasomotor disorder, from palpitation of the heart, and finally from petechial eruptions, bed-sores, ulcerations, and sloughs. Therapeutics. — Chloral is one of the purest hypnotics that we have, and may therefore be used where simple nervous insomnia is present, but not when sleeplessness is due to pain. When pain is present it is to be employed in the combination of 10 grains (0.60) of chloral with \ grain (0.01) of morphine, as a much more powerful hypnotic effect is produced by the combined action of the two drugs than by the use of either one of them alone. The following prescription may be used: K— Chlorali hydrati gijvel iv (8 0-16.0). Morphinse sulphatis gr. ij (0.12). Syr. lactucarii f^ij (60.0). Aquae dest q. s. ad f 3 ii j (90.0). — M. S. — Dessertspoonful (8.0), in water, at 10, and at 11 p.m. if necessary. In tetanus and strychnine poisoning chloral is one of the best remedies we have, as it depresses the motor tract of the spinal cord. In such a case it should be given in 20-grain (1.3) doses combined with 60 grains (4.0) of bromide of potassium. If the convulsion prevents deglutition or is brought on by swallowing, these remedies should be used by the rectum dissolved in starch-water; and if the spasm expels them from the rectum, the patient should be chloroformed long enough to allow the injection to be given and absorbed. The same remedies in small doses are to be used in infantile convulsions and in infantile colic in the dose by the mouth of J to 1 grain (0.03-0.06) of chloral to 2 grains (0.12) of bromide of potassium or sodium in a teaspoonful of peppermint-water and syrup. In chorea, paralysis agitans, and delir- ium tremens chloral is of great service, but must be given cautiously in the last-named condition, for fear it may depress the heart, which is already diseased by alcoholic excess. Cases are on record in which CHLORALFORMAMIDE [CHLORAL AMIDE). Ift5 chloral has caused sudden death from cardiac failure in alcoholics with fatty heart — an accident the liability to which is increased by the fact that owing to the addiction of the patient to a narcotic drug it requires large doses to produce sleep. In urcemic convulsions chloral has been highly extolled, but if any acute renal trouble is present, it must not be used lest it irritate the kidneys. In puerperal convulsions not dependent upon nephritis 20 to 30 grains (1.3-2.0) of the drug may be given, and repeated in one or two hours. Hiccoughs, nocturnal epilepsy, and whooping-cough are all indica- tions for its use, but in asthma it rarely does good, and if pushed is dangerous to the heart. Untoward Effects. — Chloral sometimes causes nausea, purging, and vomiting by reason of its irritant action. In susceptible persons doses of 10 to 15 grains (0.60-1.0) have produced marked redness and swelling of the conjunctiva. Sometimes the last-named symptoms are only produced when an alcoholic beverage is taken simultaneously. In still other cases an erythematous, papular, urticarial, vesicular, or petechial eruption may ensue, the latter forms being seen as a rule in cases of chronic chloralism. Administration. — Chloral is best given in syrup of acacia, simple syrup, or water. It should always be well diluted. The syrup of chloral (Syrupus Chloral, B. P.) is given in the dose of 1 fluidrachm (4.0). The following prescription is useful in insomnia: & — Chloralis hydratis . . ... . . 3 j vel ij (4.0-8.0). Potassii bromidi 5ij (8.0). Syr. pruni virginianse f§j (30,0). Aquse q. s. ad foiij (90.0) — M. S. — Dessertspoonful (8.0) at night. Sometimes chloral can be well given in junket by adding it to a liquid rennet, and then adding the rennet to the milk. (See Junket, Part III.) The question as to the safe dose of chloral is one largely governed by the susceptibility of the patient, but alarming symptoms have fol- lowed a dose of 30 grains, and death after from 30 to 45 grains. Thirty grains in twenty-four hours are certainly ample in most cases. CHLORALFORMAMIDE (CHLORALAMIDE). Chloralformamide (Chloral] or mamidum, U. S.) is a compound formed by the addition of formamide to anhydrate of chloral, and is a colorless crystalline substance without odor and of a somewhat bitter taste. It is soluble in 9 parts of water and 1J parts of alcohol. Chloralformamide keeps well in watery solution without decomposi- tion. Its physiological action s closely allied to that of chloral, except that it is not quite so depressing to the circulation. Upon the nervous system it acts chiefly upon the brain and spinal cord, and produces sleep — a result to be expected, since both chloral and form- amide are hypnotics It is said not to irritate the stomach and kidneys, but it probably is only less irritant than chloral. 166 DRUGS. Therapeutics. — Chloralformamide may be employed in medicine whenever chloral may be used. It is decidedly a nervous sedative, and in the wakefulness of nervous Insomnia is very useful. Sleep generally ensues about thirty or forty-five minutes after it is taken. According to most of the reports published so far, the drug relieves pain as well as produces sleep, and is therefore distinct in its actions from chloral. In neuralgia it is very useful, and it has been found of value in the pains of tabes dorsalis. The dose is 10 to 30 grains (0.60-2.0), which may be repeated in three or four hours, although the sleep generally lasts five to eight hours. The following formula may be used for its administration : R. — Chloralformamidi . . gr. xl (2.6). Acid, hydrochloric! dil rriv (0.3). Syrupi" f 3 i j (8.0). Aquae dest fgij (60.0).— M. S. — Take in two doses in a little water. The late Professor Charteris claimed very extraordinary results in the treatment of sea-sickness by the use of equal parts of chloralform- amide and bromide of potassium. He gave it in the dose of 30 grains (2.0) with an equal amount of the bromide. It is necessary for the patient to take a cholagogue for two days before starting on the voyage, and as soon as he boards the ship to take the dose named on an empty stomach, and at once go to bed and sleep. If this is done, Charteris claimed that the patient will awake feeling bright and well, and remain so for the rest of the voyage. This combination under the name of "chlorobrom" has been also largely used as a hypnotic in the treatment of the insomnia due to melancholia and acute mania. CKLORALOSE. Chloralose is a compound made from anhydrous chloral and glu- cose, is soluble in hot water and alcohol, and was introduced into medicine as a safe hypnotic and substitute for chloral. Unfortunately its taste is acrid, and to some persons nauseous, particularly if taken in water. Physiological Action. — The physiological action of chloralose is practically identical with that of chloral, but much more mild if the researches of Mosso are correct. Its dominant effect is on the brain, and full doses depress the spinal cord and heart. Poisonous doses may produce hemoglobinuria. Therapeutics. — The indications for the drug are junctional insom- nia, and the beginning dose is 2 to 7 grains (0.12-0.5), but the smaller dose should always be tried first, particularly in women. Sleep follows its ingestion in about half an hour. The best way to administer the drug is to give it in capsule or cachet, and to follow it with a glass of water or milk. Untoward Effects. — Sometimes chloralose produces diplopia, muscu- CHLORATE OF POTASSIUM. 167 lar tremors, or constant passing of the hands over the head and face. If a habit is induced by its constant use, it is a noteworthy fact that its power to produce sleep is decreased, while the untoward effects are more likely to be marked. In nervous and tuberculous patients it sometimes causes tetanic or cataleptic symptoms with disturbed intel- lection. CHLORATE OF POTASSIUM. Chlorate of Potassium (Potassii C Moras, U. S. and B. P.) is a salt of potassium differing entirely in its physiological action from all the other potassium salts, and, with the exception of the cyanide of potas- sium, is certainly the most poisonous. Not only is it, when locally applied, an irritant to mucous membranes, but when absorbed into the blood it causes changes of a serious character in this fluid, and produces acute nephritis if given in overdose. In dry form chlorate of potassium ought never to be rubbed with organic substances in a mortar, as an explosion may occur. Physiological Action. — It has been thought by some that chlorate of potassium gives up a large amount of oxygen to the body, and that for this reason it would be of value in cases of slow asphyxia, such as results from pneumonia or phthisis. It has even been recommended to travellers crossing high mountains where the rarity of the air pro- duced disagreeable effects; but nothing is more absurd than the belief that it gives up oxygen to the body. Chlorate of potassium does give off oxygen when exposed to high heat, but not at the temperature of the body. Nearly all of it escapes from the body unchanged. When overdoses of the chlorate are taken, it produces sickness of the stomach, headache, pain in the loins and belly, dyspnoea, cyano- sis, heart-failure, and great weakness. Poisonous doses cause the blood to be of a chocolate color, this change being due to the produc- tion of methamioglobin. The blood-corpuscles are crenated and broken down, and after death the liver, kidneys, and spleen are found softened and filled with broken-down and disorganized blood. Therapeutics. — Chlorate of potassium is useful in stomatitis and in mercurial sore mouth as a mouth-wash, or, given internally, in the following mixture: 1^ — Potassii chlorat gr. xlviij (3.2). Tr. myrrh foss (2.0). Elixir calisayse q. s. ad f §iij (90.0). — M. S. — Teaspoonful (4.0) every five hours, or use as a mouth-wash. Owing to the fact that the drug is eliminated by the saliva to a great extent, the mucous membranes affected by stomatitis are constantly bathed by the solution of the chlorate when it is taken by the stomach. If any irritation of the stomach or kidneys exist, the medicament must be used on a swab and none of it swallowed. In diphtheria chlorate of potassium is very commonly employed, but its use is exceedingly dangerous. Death in many cases of diph- theria is due to the renal irritation present, or, in other words, to an 168 DRUGS. acute nephritis, and this drug simply increases the inflammatory process. If the chlorate of potassium is employed in diphtheria, it should be used in solution and applied by means of a swab. (See Diph- theria.) In acute follicular pharyngitis chlorate of potassium is a useful gargle, and Wood recommends the use of a solution made by adding 1 ounce (30.0) of sumach-berries, \ ounce (16.0) of chlorate of potas- sium, and 1 pint (480 c.c.) of boiling water to each other, and allowing them to simmer for a few hours, when the mixture should be strained, cooled, and used as a gargle. The following is equally serviceable: & — Potassii chloratis gj (4.0). Fluidext. rhois glabrae f*ss (16.0). Aquae dest q. s. ad fgiij (90.0).— M. S. — To be added to an equal quantity of water in a glass and used as a gargle every two hours, after stirring. This prescription makes an abominable-looking pharmaceutical prepa- ration, but an exceedingly useful one. In acute rectal catarrh with mucous diarrhea and tenesmus a solution of chlorate of potassium in water, 20 grains (1.3) to the ounce (30.0), injected into the bowel, will often produce a cure after one or two injections. Not more than 4 ounces (120.0) should be used, and it ought to be retained for twenty minutes. Often it will be well to add the saturated watery solution of the chlorate to an equal quantity of starch-water, as the latter aids in allaying the local irritation. This same method can be used in the treatment of hemorrhoids, and a few drops of laudanum, if added to this solution, will be found of great service. The troches (Trochisci Potassii Chloratis. U. S. and B. P.) are given in the dose of 1 to 6, each lozenge containing 5 grains (0.3). They are intended to be dissolved in the mouth to affect the oral mucous membrane, but if many are used they are apt to disorder the stomach by reason of the drug being swallowed in the saliva. GHLORETONE. Under the name chloretone a substance, which is trichlor-tertiary- butyl-alcohol, has recently been introduced as a hypnotic and nervous sedative closely allied in its uses to chloral, yet differing in the impor- tant particulars that it does not depress the heart or respiration unless given in excessive quantities, and does not irritate the stomach, but acts as a sedative to this organ. For this reason it can be used with advantage in vomiting due to irritation and in gastric carcinoma to relieve pain. Given in the dose of 10 to 15 grains (0.60-1.0) before etherization, it will often prevent after-vomiting, and if vomiting has already begun is a valuable agent for its relief. When used to pre- vent ether vomiting, it should be given in powder one hour before the ether is used. The author has also found it of value in relieving the pain of gastric CHLORINATED LIME. 169 ulcer and of gastralgia. As it is both anaesthetic and antiseptic, it can be employed as an application to burns, scalds, and lacerations in 10 per cent, ointment, and local anaesthesia may be produced by the subcutaneous injection of it in a 1 per cent, solution of alcohol 15 per cent, and water 84 per cent. It may be dissolved in oil of cloves and applied on a cotton pledget with advantage in cases of toothache. It may also be used to benumb a painful dental nerve by mixing equal parts of ether and chloretone and applying this in the cavity. Pow- dered chloretone mixed with equal parts of powdered boric acid and dusted over painful ulcers, burns, and lacerations or wounds acts as an efficient antiseptic dressing, but it may increase the burning at first. Chloretone and antipyrin may be given in capsule in the dose of 3 to 6 grains (0.20-0.4) each and used in restlessness and neuralgia pain. The mixture of these substances results in liquefaction, but this does not interfere with their therapeutic efficacy. Chloretone is efficient in doses of from 10 to 20 grains (0.60-1.3), and is best given in sugar-coated tablets of about 3 grains (0.20) each. CHLORINATED LIME. Chlorinated Lime {Calx Chlorinata, U. S. and B. P.) is the hydrate of lime, containing 35 per cent, of chlorine, provided it is of official strength. It is an exceedingly irritant substance because of the chlorine which it contains, and is never used internally. Much of the chlorinated lime sold is useless, containing too little or no free chlorine. Good chlorinated lime should be so laden with the gas that the face cannot be held near it without the eyes being severely irritated. Unless the chlorine is present, the lime is of no value, for the employment of chlorinated lime as a disinfectant depends upon the action of this gas, the lime being used merely as a vehicle and oxidizer, the gas by itself being difficult of application. Uses. — As a disinfectant for privies, drains, and sinks chlorinated lime is one of the best, if not the best, we possess. A few pounds of it may be added every week to the contents of a privy vault with great advantage, and a solution of it may be used in bed-pans and urinals. When the passages of a patient having typhoid fever are to be received in a bed-pan, a chlorinated-lime solution should be placed in the receptacle beforehand, so that the fecal matter or urine will fall at once into a disinfecting fluid. The solution should be of the strength of 1 pound to 2 gallons. As it is one of the most powerful deodorizers, chlorinated lime should be placed liberally over and about decaying animals, and in exhuming corpses sheets wrung out in a solu- tion made as directed above will, if wrapped about the body, be found of service to destroy the stench. Water which has become fetid by stagnation may be rendered drinkable by adding 1 to 2 ounces of the chlorinated lime to every 65 gallons, and standing the solution aside for some hours until pre- cipitation and exposure to the air have gone on for some time. 170 DRUGS. Chlorine fumes will bleach many dyed goods, and therefore colored fabrics should not be exposed to them. Chlorine gas, in a diluted form, has been used for the treatment of aphonia due to cold in cases where the aphonia persists for some weeks. It can be liberated by allowing a few drops of hydrochloric acid to fall upon chloride of lime or chloride of sodium. The placing of chlorinated lime in saucers about sinks and closets for the purposes of disinfection is useless, as the amount of chlorine liberated is very slight as compared to the volume of air in the room. Where the chlorine is present in a sufficiently concentrated form to kill germs, it will also kill the occupant of the chamber. A deodorant effect may be obtained, but a bad smell, if it exists, even when over- come by a greater one, is not really gotten rid of. The official prepa- rations of the B. P. are Liquor Calcis Chlorinate and Vapor Chlori. CHLORODYNE. Chlorodyne is a preparation used largely for the treatment of serous diarrhoeas or cramps in the abdomen. Its constitution varies considerably, but the formula most commonly employed is as follows : fy — Morphinae hydrochlor gr. viij (0.5). Aqme dest f5ss (2.0). Heat together, and as soon as the morphine is dissolved and the liquid cooled, add Acid, hydrochlor. dil f 3ss (2.0). Chloroformi f3iss (6.6). Tr. cannab. indicae f 3 j (4.0). Acid, hydrocyanic, dil Hl x ij (0.8). Alcoholis f jss(16.0). 01. menth. piperit TTJxij (0.8). Oleoresinse capsici TTU (0.05). — M. g. — 5 to 15 minims (0.30-1.0) for an adult, in water, every two hours for three doses. More than this quantity is dangerous. A formula closely allied to this is used in tablet form in repeated doses. CHLOROFORM. Chloroform (Chloroformum, U. S. and B. P.) was discovered by Guthrie (1831), of Sackett's Harbor, New York, and was first used medicinally (1847) by Simpson, of Edinburgh. It is a clear liquid with an exceedingly hot, burning, sweetish taste, of a rather agreeable odor, and is very volatile. Its chemical name is trichlormethane. Chloro- form should be kept in a dark, cool place. There are two kinds of chloroform— the purified (Chloroformum, U. S.) and the commercial chloroform (Chloroformum Venale). If exposed to the light for any length of time, chloroform develops carbonyl chloride, hydrochloric acid, and chlorine, which render it. unfit for use. If the acid is present, it will turn blue litmus red; and if chlorine is present, it will form a white precipitate with nitrate of silver. CHLOROFORM. 171 Such impure chloroform may be rectified by shaking it with slaked lime and filtering till the irritating products are gotten rid of. If impure because of improper methods of manufacture, an oily odor will be left on the hand after evaporation takes place. We find, therefore, that chloroform suitable for anaesthesia should be transparent and color- less, neutral to test-paper, non-irritating when inhaled, and should evaporate completely when placed on a watch-glass, leaving no residue or odor. It should have a specific gravity not below 1.476, should form no precipitate with AgNO a , should not become brown when heated with caustic potash, and only very faintly brown, if at all, when shaken with concentrated H 2 S0 4 . The method of manufacture of Pictet, by which the chloroform is purified by crystallization, probably gives the purest article. In America the chloroform made by Squibb, of Brooklyn, is almost universally employed. Chloroform vapor in the presence of gas-flame undergoes certain changes which result in the development of noxious and irritating fumes, consisting principally of hydrochloric acid and chlorine, which produce laryngeal and bronchial irritation. The deleterious effects of these fumes can, however, be neutralized if a cloth or towel wet with aqua ammonia be hung up in the operating-room. Physiological Action. — Locally applied to the skin, chloroform may produce some tingling and burning even if evaporation be not inter- fered with. If confined under a watch-glass on the skin, it will cause a blister and act as a counterirritant. When inhaled, chloroform produces a sensation of warmth in the mouth and throat, a feeling of relaxation, and finally unconscious- ness. The respirations are at first full and deep, but soon become rapid and shallow. The pulse may be somewhat stronger and fuller for a short interval, probably because of mental excitement, but soon fails in strength and becomes more rapid. The irritation produced in the air-passages by its inhalation is slight, and no primary arrest of respiration ensues, as is generally seen after ether is first giVen. The pupils are at first slightly dilated, but are contracted during anaes- thesia. If the pupils dilate during the use of chloroform after the con- traction just named, danger is imminent and death may suddenly occur. In some persons the first effects of chloroform are violent struggles, and there is danger in trying to overcome these struggles by pushing the drug very rapidly. This struggling is particularly apt to be met with in athletes and drunkards. Total muscular relaxation should never be produced by the drug. Nervous System. — Chloroform first affects the brain, then the sensory part of the spinal cord, then the motor tract of the cord, then the sensory paths of the medulla oblongata, and finally the motor por- tion of the medulla, thereby producing death from failure of the vaso- motor centre and of the respiratory centre, unless, as rarely occurs, the heart has already succumbed to the drug. On the sensory and motor nerves, when locally applied, it acts as an irritant and anaesthetic. 172 DRUGS. Upon these nerve-trunks, when taken by inhalation, it has little or no effect. Meyer and Overton believe that chloroform acts as an anaesthetic by solution of the liquid or fatty constituents of the brain cells. The solution is intercellular and the fat is not removed from the cell. The concentration of chloroform in the blood serum necessary to cause anaesthesia is from 1-6000 to 1-4500. Fig. 23. Fig. 24. Fig. 25. Fig. 23. — A, chloroform depresses the vasomotor centre; B, chloroform dilates the heart and depresses it; C, chloroform depresses the respiratory centre. Fig. 24. — A, chloroform produces anaesthesia by depressing the perceptive centres in the brain, and later depresses the (B) intellectual centres, and finally depresses the (C) motor centre. Fig. 25. — D, depresses the sensory paths in the spinal cord; E, finally depresses motor tracts in the cord. Circulation and Respiration. — The effects of chloroform upon these vital functions have been for many years a subject of hot dis- CHLOROFORM. 173 pute between surgeons and pharmacologists. On the one hand is the school originally led by Syme, of Edinburgh, which has asserted that death or danger from chloroform lay in failure of the respiration and that this was the function to be watched while chloroform was being used; on the other hand, the so-called London school asserted that death arises from cardiac failure and that the pulse is the thing to be watched during the use of chloroform. The number of clinical and laboratory researches which have been carried out to determine which of these opinions is correct has been very great, both in England and in America, but it has only been within the last twenty years that the most competent studies have been undertaken, of which the best known is the series made through the munificence of His Highness the Nizam of Hyderabad in India, and known as the "Reports of the Hyderabad Chloroform Commissions Nos. 1 and 2." The conclusions of the first commission having been criticised adversely because it asserted that the cause of death was respiratory failure, a second commission was formed, and, under a grant of $5000 from the Nizam, Sir Thomas Brunton of London was sent out to direct the second investigation. Although a teacher of the theory that death from chloroform is due to cardiac failure, this gentleman returned to England converted to the idea that the cause of most of the fatal accidents under this drug is respiratory failure, and the conclusions of Commission No. 2 were also criticised by numerous clinicians and pharmacologists in Eng- land and America. About this time H. C. Wood and the author published a paper in which they expressed their belief in the depress- ing effects produced by chloroform upon the heart ; and Mac Williams of Glasgow proved by experiment that chloroform causes cardiac dilatation and enfeeblement. Shortly afterward the author of this book was requested by the government of His Highness the Nizam, through Colonel Edward Lawrie, the Residency Surgeon, to carry out a series of studies 1 designed if possible to reconcile the contra- dictory results reached by the Hyderabad Commissions and other investigators, and simultaneously Gaskell and Shore in Cambridge University, England, were asked to do likewise. The result has been to confirm in every way the results of all previous studies in one respect — namely, that the primary action of chloroform on the vital functions of circulation and respiration is greatly to depress the vasomotor system, thereby causing an extraordinary fall of blood-pressure. Gaskell and Shore, to be sure, assert that anaesthesia can be produced by chloro- form without causing this fall, but the author has never been able to do so (Fig. 18). They also believe that the fall is chiefly a result of cardiac failure. From this view the author dissents, because their experiments upon which these assertions are based were too complex to give prac- tical results; and second, because his own studies and those of others show the vasomotor system to be depressed. There is of course some cardiac enfeeblement and dilatation, which adds to the fall of pressure. 1 See Therapeutic Gazette, October, 1893. 174 DRUGS. As with other discussions in medicine, the truth of the question as to whether chloroform causes death by respiratory failure or cardiac failure lies, as it were, half-way between the two antagonistic opinions; and, further than this, the somewhat startling statement may be made that it is not directly due, in the majority of cases, to either of these causes. On the contrary, the cause of death from chloroform is usually vasomotor depression, whereby the arterioles allow the blood to pass too freely into the great bloodvessel areas which exist in the capillaries and veins, and as a result the man is suddenly bled into his own vessels as effectually as if into a bowl. When it is remembered that the capil- lary network of the body will, with the relaxed veins, hold many times the normal quantity of blood, and when it is remembered that we can inject salt solutions into the vessels to the extent of several times the Fig. 26. "Vv i i i i i i i i n i i i n i t 1 i i n i i i ) m 1 n m i 1 i m m 1 i i i i i i l I l 1 M 1 M l I I ) I 1 II I l I I N l I 1 I I M I l 1 I I I I I 1 l I Tracings showing the pulse and blood-pressure depressed by chloroform. Note the fall of blood-pressure which begins in the upper tracing and becomes marked in the second tracing. Also notice the weak pulse shown in the third tracing, illustrating the final depressant effect of the drug on the heart. The respiration ceased at X, but the heart continued to beat. The blood-pressure failed first, then the pulse, then the respiration, and last of all the heart stopped. (Reduced from natural size.) normal quantity of blood without raising the blood-pressure, it at once becomes evident that the complete vascular relaxation caused by chloro- form results in failure of all the vital functions, not because the drug has paralyzed the heart or respiratory centre, but because these parts are deprived of blood by its stagnation in the widely dilated capillaries and abdominal veins. Studies by Leonard Hill on The Physiology and Pathology of the Cerebral Circulation show that this is the case, for he asserts that when the blood is no longer flowing to the res- piratory centres the heart is still beating, because its coronary arteries, being lower down, are more easily supplied by the small CHLOROFORM. 175 blood-stream received by the heart from the veins. These studies are proved by the experiments of the author and his assistant, Dr.Thornton, 1 by every tracing of the Hyderabad Commissions, and all other tracings we have ever seen. We may conclude, therefore, that while chloro- form without doubt acts as a powerful depressant poison to the respira- tory centre and the heart in the same manner as it paralyzes all living protoplasm when applied in excess, that when properly given by inhala- tion it produces a death equivalent to that resulting from hemorrhage, which is a failure of the respiration not so much from a direct depression of the respiratory centre as from its deprivation of blood ; and while the tendency of the drug is to depress and dilate the heart, just as it dilates the vessels of which the heart is merely a highly specialized part, the failure in the pulse is due to vasomotor palsy, the patient becoming pulseless because the heart has not blood to pump. Let us see what evidence supports this view: First, we have the laboratory tracings of many independent investigators extending over many years and made in all parts of the world, all of which show a fall of blood-pressure. Among these may be named Bowditch and Minot, of Boston; Coats, H. C. Wood, Gaskell and Shore, the Hyderabad Chloroform Commissions; the studies of Wood and the author in 1889 and 1890, and of the author and Thornton in 1892 and 1893. They are confirmed by Hill, who has seen the abdominal vessels engorged with blood under chloroform, the medulla almost bloodless, and the heart still pumping though respiration had ceased. They are confirmed by the author's own experiments, in which he proved that even after the respiration had stopped and the carotid was empty, and the dog appar- ently dead, it could be resuscitated by visceral compression and artificial respiration, and by inversion, whereby the blood left the dilated ab- dominal veins for the heart and brain. Again, if a needle was inserted through the chest-wall, the heart was found to be beating, for the needle moved to and fro; and finally if the chest was opened the heart could still be found beating feebly — dilated, it is true, but beating. So much for the laboratory evidence. What have we in clinical evi- dence ? Equally positive proofs of vasomotor palsy, and none of death being purely cardiac or respiratory. For years Chisolm of Balti- more, and later Howard Kelly and a large number of others have used inversion with compression of the floating ribs in artificial respiration, which has forced the blood into the chest and saved life again and again. For years the literature of medicine has teemed with reports of death from chloroform while the patient was sitting up or half recum- bent, because, the blood-paths being dilated, this posture favored anaemia of the vital centres. Again, it has been proved that the best vasomotor stimulant — belladonna or atropine — given before the chloro- form is used increases the safety of the patient, and that compression of the limbs by bandages does likewise. Finally, Hill has shown that abdominal compression also aids resuscitation by forcing the blood to 1 Therapeutic Gazette, October, 1893. 176 DBUGS. the heart. On the contrary, saline transfusion, which would seem to be indicated, is useless, because the dilated blood-paths will receive all the saline for a long time before they will overflow toward the heart, for as fast as the fluid flows in they dilate. The author therefore believes that while chloroform in its general depressing power depresses all vital functions, it is a question of blood- pressure which is most important in the healthy individual, although the heart may fail if it be damaged by disease before the drug is used. Therefore in the use of chloroform we should always keep the head low, precede its use by atropine hypodermically, bandage the limbs if the case is feeble or already bloodless, and if necessary place com- presses on the belly and press them deeply into the abdomen if failure of the circulation develops. The primary action of the chloroform is to depress the blood-pressure chiefly by its vasomotor effect, secondly by its cardiac effect, and finally, while the drug does exercise a depressant effect on the respira- tory centre, the failure of this centre is chiefly due to anaemia. As, however, an intact respiratory centre means regular breathing, we watch this function to determine the dose of chloroform actually inhaled, and because any variation in this function, as shown in irregular breath- ing, means that the chloroform is disordering arterial tension. Death from chloroform in a healthy organism, then, is usually a vasomotor death, for an intact arterial system is as important to vital function as an intact cardiac apparatus. Blood. — Upon the blood in the body chloroform has little or no effect when it is inhaled. Shaken with chloroform in a bowl the blood becomes scarlet in hue. Temperature. — Chloroform when taken by inhalation distinctly lowers the bodily temperature, probably by aiding in the dissipation of heat and by its action on the nervous mechanism of heat-production. Elimination takes place by the lungs and by the kidneys, and goes on very rapidly, owing to the great volatility of the drug. If large amounts are eliminated by the kidneys, these organs are apt to become irritated and inflamed. Antiseptic Power. — Chloroform, when it is added to organic fluids, prevents all changes which depend upon the growth of micro-organ- isms. Therapeutics. — The first and most important use of chloroform is as an ansesthetic, and at this point we come to a question which has been for many years a matter of contention between different sections of the medical profession — namely, as to whether its use is dangerous. In the Southern and Western parts of the United States chloroform is nearly always used, but in the Eastern and Northern portions it is rarely employed. Southerners certainly seem to take chloroform better than Northerners or those living on the Atlantic coast. It is impossible to go into a general discussion of this question here; suffice it to state that even the most enthusiastic supporters of the use of chloro- CHLOROFORM. 177 form confess that it is a more dangerous drug than ether if carelessly used, and, while the advantages of chloroform are many, this one great disadvantage overshadows them all. 1 The advantages are — its more agreeable odor and the fact that it does not irritate the air-passages, owing to the small amount necessary to cause anaesthesia; the fact that its use is less apt to be followed by nausea and vomiting; the rapidity of its action ; and the small bulk which has to be carried by the surgeon. Its disadvantage is — the possibility of its killing the patient. We come, then, to the all-important questions: 1 . Is chloroform a safe anaesthetic ? 2. Are we to watch the pulse or respiration during t" _e use of the drug, and what are the signs in the respiratory function indicative of danger to the patient ? 3. What is the true cause of death from chloroform? 4. Is death from chloroform possible when it is properly admin- istered ? 5. Under what circumstances is the surgeon to use chloroform in preference to the less dangerous anaesthetic, ether ? 6. What is the best way of administering chloroform? To the first question the answer is, Yes for the majority of cases, provided it is given by one who is skilled in its use, and not only knows how to give it, but also how to detect signs of danger. It is not so safe as ether at any time, other things being equal, and never safe in the hands of a tyro. To the second question the answer is, Watch the respiration, because as soon as enough chloroform is used to endanger the circulation the respiration will show signs of abnormality, either in depth, or shal- lowness, or irregularity. In other words, the very effect of the drug may be to cause such deep and rapid respirations that an excessive quantity of the drug is taken into the lungs and continues to be absorbed even after the inhaler is withdrawn. As there is always a fall of blood-pressure under chloroform, it is difficult to feel the radial or temporal pulse, and the respiratory centre recognizes the degree of arterial depression which its sister vasomotor centre has permitted by finding that its blood-supply is insufficient. As respiration fails first, it should be watched first. It is only by watching the respiration that we can tell how much chloroform the patient is getting. We do not watch this function for danger alone, but to determine the dose. Every one is agreed that the patient taking chloroform should have plenty of fresh air, and in India, to all intents and purposes, patients are operated on in the open air, at least as compared to the closed rooms necessary in America and Europe. This free supply of air is 1 The mortality based upon many tens of thousands of cases in which chloroform has been used is about 1 in 2039 (Gurlt); or according to the combined statistics of Julliard and Ormsby, in 676,767 administrations there were 214 deaths — 1 in 3162, 12 178 DRUGS. important, whether death is believed to be imminent from cardiac or respiratory failure; but this supply of air matters little to the patient if he does not breathe freely, nor does the quantity of chloroform amount to aught if it is not drawn into the lungs. The dose of chloroform is not the amount on the inhaler, but the amount taken into the lungs, and, finally, the amount absorbed by the bloodvessels. The rapidity and depth of respiratory movements is, therefore, as Lawrie asserts, the key to the situation. We withdraw chloroform, as Lawrie says, whenever respiration becomes disturbed in rhythm or when struggling disturbs it, because it is the first indication that the drug's action is uncertain, and because there is no means of determining the dose which is absorbed. While watching the respiration will not warn us of a sudden cardiac arrest in fatty heart plus chloroform depression, neither will the pulse give us such warning; and we are confident that the statement of the Hyderabad Commission, that the respiration should be watched, is correct, for we believe, from a series of observations that gradual cardiac failure never occurs without producing respiratory changes from the very first. In other words, we do not believe that in a healthy heart chloroform can cause serious disorder without, as a result of beginning disorder, disturbing respiration; and, second, that in the healthy heart a quantity of chloroform sufficient to disorder it will by its direct action disorder the respiration. If, as an extra precaution, one assistant watches the pulse while another watches the respiration, very well, for though the respiration is the more important function to watch, the man watching the pulse might dis- cover an irregularity which the ansesthetizer may not see reproduced in the respiratory action; but as. divided attention generally means a slighting of both objects in view, Lawrie is right in insisting on the pulse being ignored. The answer to Question 3 is that death is always due in the healthy person to vasomotor failure accompanied by respiratory depression, the vascular relaxation being severe enough to cause death even if artificial respiration is used skilfully. The answer to Question 4 is, Yes. The physician having a case of heart disease requiring surgical interference should always advise the patient of the danger of any anaesthetic, and he should remember, whether it be wise to tell the patient or not, that anaesthesia always means an approach to death even in the healthiest of men. In the event of a death under chloroform the physician is blameless if he has taken suitable preliminary precautions and given the chloroform properly. To Question 5 we have several answers to make : 1. Chloroform maybe used in hot climates (when ether is inap- plicable), where a free circulation of air increases the safety of the patient. 2. Chloroform may be used whenever a large number of persons are to be rapidly anaesthetized, so that the surgeon may pass on to others CHLOROFORM. 179 and save a majority of lives, even if the drug endanger a few, as on the battlefield, where only a small bulk of anaesthetics can be carried. 3. The employment of chloroform is indicated in cases of Bright's disease requiring the surgeon's attention owing to the fact that anaes- thesia may be obtained with such a small quantity of the drug that the kidneys are not irritated, whereas ether, because of the large quantities necessarily used, would irritate these organs. Quantity for quantity, ether is, however, the less irritant of the two. 4. In cases of aneurism or atheroma of the bloodvessels, where the shock of an operation without anaesthesia would be a greater danger than the use of an anaesthetic, chloroform is to be employed, since the struggles caused by ether and the stimulating effect which it has on the circulation and blood-pressure might cause vascular rupture. 5. In children or adults who already have bronchitis, or who are known to bear ether badly, or, in other words, have an idiosyncrasy to that drug, chloroform may be employed. Other indications for the use of chloroform in preference to ether are in the performance of brain surgery, where ether is apt to produce meningeal congestion by vomiting. In performing tracheotomy, if the case is urgent and the ether produces respiratory irritation, chloro- form may be used with advantage . Chloroform inhalations have been recommended in excessive chorea and in puerperal convulsions, and are of great service in the reduction of hernia, owing to the muscular relaxation produced. Sometimes a few whiffs will put a nervous patient to sleep, but its use as a hypnotic is very dangerous, as it may produce a habit, and the habit is apt to end fatally. Parturient women seem able to take chloroform with more safety than other women. There are four important factors in lessening the danger of chloroform in this class of cases: 1st. Less chloroform is given than is usual in surgical operations. 2d. The pregnancy may produce immunity by reason of the slight cardiac hypertrophy pro- duced at this time. 3d. The absence of fright, for the woman welcomes the anaesthetic. 4th. The frequently recurring pains of labor so stimulate the vasomotor centre that the dominant action of chloroform — namely, vasomotor depression — is combated. In severe whooping-cough a few drops of chloroform may be poured on the hand of the attendant and the hand held before the child's face. While the child may at first dislike the odor of the drug, the relief given soon teaches the patient its value, and he will ask for it when he feels the attack coming on. If the attack is prolonged and violent, this treatment must be used with caution, owing to the strained condition of the heart-muscle, which may be still further depressed by the frequent use of the drug. The drug should not be poured on a cloth, but on the nurse's hand. In this way too much of it cannot be given to the patient at one time. 180 DBUGS. Administration. — When chloroform is given it should be poured drop by drop upon a folded napkin or towel, and the cloth should then be held about three to six inches from the mouth and nose, so that the vapor may be thoroughly mixed with air in the proportion of 2 per cent, of vapor to 98 of air; 0.5 per cent, does not cause uncon- sciousness and 5 per cent, is dangerous. The administration must be gradual, as " pushing " the anaesthetic is dangerous. The safest method of administration is by Lawrie's or Esmarch's inhaler, because these provide a free circulation of air and the atten- tion of the anaesthetizer is not distracted from the respiratory move- ment by the manipulation of complicated apparatus. The dangers of chloroform seem to be considerably decreased by the simultaneous administration of oxygen gas with the anaesthetic vapor. (For the best method of using oxygen and chloroform together see Oxygen, Important.) Fig. 27. Esmarch's inhaler and chloroform bottle. The inhaler consists of a wire frame covered by a piece of thin flannel. The author largely agrees with Lawrie's published conclusions, which are as follows with slight modifications: 1. The chloroform should be given on absorbent cotton, stitched in an open cone or cap. 2. To insure regular breathing, the patient, lying down, with every- thing loose about the neck, heart, and abdomen, should be made to blow into the cone, held at a little distance from the face. The right distance throughout the inhalation is the nearest which does not cause struggling or choking or holding of the breath. 3. The administrator's sole object while producing anaesthesia is to keep the breathing regular. As long as the breathing is regular and the patient is not compelled to gasp in chloroform at an abnormal rate, there is comparatively little danger. CHLOROFORM. 181 4. Irregularity of the breathing is generally caused by insufficient air, which causes the patient to struggle or choke or hold his breath. There is little or no tendency to either of these untoward effects if sufficient air is given with the chloroform. If they do occur, the cap must be removed and the patient allowed to take a breath of fresh air before the administration is proceeded with. 5. Full anaesthesia is estimated by insensitiveness of the cornea. It is also indicated by stertorous breathing or by relaxation of the muscles. Directly the cornea becomes insensitive or the breathing becomes stertorous inhalation should be stopped. The breathing may become stertorous while the cornea is still sensitive. The rule to Fig. 28. Lawrie's collapsible inhaler, made of four small pieces of bamboo covered with muslin. The chloroform may be dropped on the sides of the inhaler. stop the inhalation should, notwithstanding, be rigidly enforced, and it will be found that the cornea always becomes insensitive within a few seconds afterward. Above all, it is necessary to remember the fact that a person hav- ing taken chloroform twenty times before does not show he is not in danger on taking it the twenty-first time ; and it is also to be borne in mind that many of the sudden deaths from chloroform have occurred during the first stage of the inhalation of the drug, before conscious- ness has been lost, and, therefore, when an accident was least expected. In operations about the mouth chloroform may be employed by passing a soft catheter through the nose and then by means of a hand- bulb attached to a small wash-bottle containing chloroform or by 182 DRUGS. Fig. 29. Krohne and Seseman's modification of Lawrie's inhaler, with feather respiration- indicator attached. The inner lining is of white felt, the outer case is of leather. The chloroform may be poured on the felt a hot, burning taste aboilt through a small hole in' the leather on the top of the inhaler. means of a Junker inhaler introducing into the post-nasal spaces chloroform vapor mixed with air. It is often a good plan to give atropine or suprarenal gland, pref- erably the former, before using chloroform in order to avoid, if pos- sible, vascular relaxation. Individuals who are robust and strong, and who struggle violently, are in greater danger from the use of chloroform than the sickly and weak, probably because the struggles cause deep inhalation of the drug, exhaust the vasomotor system, strain the heart, and tend to dilate its walls. The question has arisen a number of times whether it is possible to chloroform a person who is asleep without his being wakened. This has been decided by numerous tests to be possible, particularly if the sleep be heavy. Chloroform, when taken inter- nally by the mouth, causes a sensa- tion of warmth in the stomach and the lips and buccal mucous membrane. In overdose it has produced death when taken in this manner. Although rarely used in internal medi- cine, chloroform in the form of the spirit of chloroform (Spiritus Chloroformi, U. S.) or water of chloroform (Aqua Chloroformi, U. S.) is useful in cough mixtures, which are given to persons having an irri- tative cough, and in cases where, through nervousness or other cause, tickling in the throat or bronchial tubes keeps the patient continually in a state of unrest. (See Bronchitis.) In gastric or intestinal flatulence 1 or 2 minims (0.05-0.10) of pure chloroform, or 10 to 20 minims (0.6-1.3) of the spirit of chloroform, will often give relief. The following prescription is useful in all forms of abdominal pain and is harmless in ordinary dose: fy— Spt. chloroformi f5ss(16.0). Spt. camphorse f5ij (8.0). Tr. lavandul. comp q. s. fgiij (90.0). — M. S. — Dessertspoonful (8.0) in water every twenty minutes for 4 doses. In the treatment of serous diarrhea the spirit of chloroform when combined with astringents and opium is most useful, provided that the irritating cause is first removed. In renal or hepatic colic a few inha- lations, not sufficient to disturb consciousness, will not only give tem- porary but sometimes permanent relief by relaxing spasm. Hypo- dermic injections of 10 to 15 drops (0.60-1.0) of pure chloroform, reaching down to a painful sciatic nerve, have been recommended by Bartholow. This is a very painful treatment, and may cause a slough. CHLOROFORM. 183 Rubbed on the chest in the form of chloroform liniment, this drug will sometimes prevent asthmatic attacks, but chloroform ought not to be inhaled, except most carefully, in this affection, because of the strained condition of the right side of the heart. In drachm (4.0) doses chloroform has been used as a remedy for tape-worm, but ought never to be so employed. When placed in liniments of a stimulating character chloroform is a very useful application over muscles affected by soreness and stiff- ness, as in lumbago and gout, and chloroform liniment may also be used over neuralgic areas for its local anaesthetic effect. Contraindications. — Chloroform is not to be used in cases of fatty heart or dilatation of the heart, in those with a known idiosyncrasy, nor in so-called lymphatic persons with overgrowth of lymphoid tissues, as, for example, adenoids. In the latter class it is particularly apt to cause sudden death. In valvular disease of the heart chloroform may be used with cau- tion, although ether is preferable. Given a case of valvular disease that must be subjected to operation, the chances are bettered with an anaesthetic than without it, as the pain and mental shock are worse for the heart than is the anaesthetic. Fig. 30. Showing the attitude in which the head should be held to permit the easy passage of air through the glottis. This position raises the epiglottis and lifts the soft palate from the tongue. (Martin and Hare's method.) Untoward Effects and their Treatment. — Alarming effects produced by this drug are far more apt to appear in males than in females, the rela- tive proportion being about 6 to 1. Sometimes during the adminis- tration of chloroform the heart or respiration suddenly ceases, and in some cases this change is preceded by a peculiar shade or cloud which passes over the face of the patient ; but death may come suddenly and without warning. If untoward effects appear, the anaesthetic must be at once withdrawn and artificial respiration resorted to. Injections of ether and hot brandy should be given beneath the skin, and the poles of a battery with a rapidly interrupted current swept over the body, 184 DRUGS. but not held over the pnrenic nerve or diaphragm. 1 The patient must be held head downward, so that the blood will flow to the brain, as Fig. 31. Showing the inversion of the patient as adopted by Kelly, and the method of performing artificial respiration simultaneously. The chest is expanded by drawing its lower segment toward the operator. Leonard Hill and the author have shown that the chief cause of death is vasomotor relaxation with accumulation of the blood in the abdominal vessels. Bandages should be applied to the limbs and 1 While few text-books give any specific directions concerning the practical application of the methods which are to be employed in such emergencies, those that do so force the physician to a procedure at once dangerous and impractical; for the directions usually given are, to place the positive pole of the battery on the phrenic nerve as it crosses the anterior scalene muscle at the root of the neck, the negative pole being pressed against the lower margin of the ribs. A rapidly interrupted current is now to be used with the purpose of causing contraction of the diaphragm by the direct action of the electricity upon the nerve. Even theoretically this is a possible source of danger, and practically the writer has proved danger to be ever present under such treatment. The cardiac inhibitory nerves run so closely to the phrenic fibres, and respond so readily to elec- trical stimulation, that it is difficult to imagine how they can escape stimulation if a current be used of sufficient strength to excite the phrenic nerves near by. By practical experiment the writer has proved that inhibition of the heart may not only be possibly brought about by this method, but also that it is nearly impossible to avoid such an effect if the phrenics are to be reached at all. CHLOROFORM. 185 compression by means of a bandage and large compress be exercised on the abdominal contents, and active artificial respiration practised for a long period of time as the most important measures for the patient's relief. External heat should be applied. Atropine, strychnine, and digitalis may be used to stimulate the heart and respiration. Of these, strychnine is the most valuable. (See directions under the article on Ether.) Adrenalin chloride given hypodermically is also of value. Fig. 32. t'fi 4 Same as Fig. 31, except that the floating ribs are compressed to expel the air from the chest. In some cases, with the movements of artificial respiration an assistant may grip the tip of the tongue with a pair of forceps and draw it out of the mouth and upward from ten to fourteen times a minute, in order to stimulate the diaphragm. (See Asphyxia, Part IV., for detailed directions for resuscitation.) In a certain number of cases patients apparently dead from chloroform have been resuscitated by repeated compression or massage of the prsecordium. The measures adopted for resuscitation should not be stopped for at least one hour, as individuals have recovered as long as this after an accident from chloroform. 186 DRUGS. Ostertag has found that very prolonged inhalations of chloroform in the lower animals produce widespread fatty degeneration. Before closing the consideration of the use of chloroform for anaes- thetic purposes mention should be made of the so-called anaesthetic mixtures. Of these the A. C. E. is the best known. It consists of a mixture of 1 part of alcohol (sp. gr. 0.838), 2 parts of chloroform (sp. gr. 1.497), and 3 parts of ether (sp. gr. 0.735). Billroth's A. C. E. mixture is composed of chloroform 3 parts, and ether and alcohol 1 part each. The Vienna mixture consists in 1 part of chloroform and 5 of ether, and the so-called methylene mixture is 30 percent, methylic alcohol; and 70 per cent, chloroform. The object of all these mixtures is evident — namely, to get the anaesthetic effect of the ether and chloroform without the cardiac and respiratory effects of either, and the alcohol when added is to act as a stimulant. As the volatility of each ingredient varies, the mixture is useless, for the ether evaporates first, and the chloroform next, and the alcohol last. The A. C. E. is popular in England, but not in the United States. The rapidity with which any drug, which produces anaesthesia by being inhaled, acts is governed in part by its boiling- or most rapid evaporation-point. The higher this point, the greater is its rapidity of action and the more prolonged its effects. Thus we find that in the case of chloroform, the evaporation-point of which is 65° C, anaes- thesia speedily follows its administration in small amounts and lasts for some time. Once in the system it is eliminated slowly, because the bodily heat is less than its point of most rapid evaporation. On the other hand, sulphuric ether boils at 34° C, and for this reason acts more slowly and more transiently, because for every breath of ether vapor which is inhaled an equal quantity of ether is exhaled, since its evaporation-point is less than the normal temperature of the body. Schleich has found that if chloroform, sulphuric ether, and petroleum ether are mixed, they form a fluid the evaporation-point of which varies from 38° C. to 42° C, according to the proportions of the in- gredients. By the use of such a fluid for anaesthetic purposes we avoid the overeffects of chloroform when used alone and the neces- sity of using excessive amounts of ether, and the patient speedily returns to consciousness after the inhalation ceases. Further dis- agreeable after-effects are said to be not so common or severe as with a single drug. These so-called mixtures of Schleich may be made in three ways: No. 1 is composed of: Chloroform 45 parts. Petroleum ether . 15 " Sulphuric ether 180 " The boiling-point of this mixture is 38° C, and as the lower the boiling-point the more transient the anaesthesia, it is to be employed in operative procedures of about twenty minutes' duration. About 1 ounce, CHE OMIC ACID. 187 or 30 grammes, will be required, given best in an ordinary ether cone, made of cardboard and a towel. About three ounces will be needed for a period of one hour. If a more prolonged and powerful effect is desired, then one of the following mixtures is used, No. 3 being more powerful than No. 2, because its boiling-point is higher. No. 2: Chloroform 45 parts. Petroleum ether 15 Sulphuric ether . 150 " The boiling-point of this mixture is 45° C. No. 3: Chloroform 30 parts. Petroleum ether 15 " Sulphuric ether 80 " The boiling-point of this mixture is 42° C. The petroleum ether has no deleterious effects, and seems to modify the effect of the chloroform and dilute the sulphuric ether without altering its general influence. It is to be remembered that only petro- leum ether which boils at 60° to 65° C. is to be used. The ordinary petroleum ether, or benzine, of the drug stores, which boils at 55° C, is not suitable. Aside from the disagreeable odor of the benzine, these mixtures are said to cause less cyanosis, less mucous secretion, and other disa- greeable effects than any single anaesthetic known, and to be safer in every way. These mixtures have not proved popular in America, and have been abandoned. The author has allowed this description of them to stand in the text in this edition as part of the recent history of anaesthesia rather than because he thinks it wise to use them. Local Use and Internal Administration. — The official preparations of chloroform are a liniment (Linimentum Chloroformi, U. S. and B. P.); a water (Aqua Chloroformi, U. S. and B. P.), dose J to 2 ounces (16.0- 60.0); a spirit {Spiritus Chloroformi, U. S. and B. P.), the dose of which is 20 minims to 1 fluidrachm (1.3-4.0); and an emulsion (Emulsum Chloroformi, U. S.), composed of chloroform, gum traga- eanth, oil of almonds, and water, given in the dose of 2 to 4 fluidrachms (8.0-16.0). The B. P. recognizes, besides those given, Tmctura Chloroformi et Morphince Composita, dose 5 to 10 minims (0.3-0.60). CHROMIC ACID. Chromic Acid (Chromii Trioxidum, U. S. ; Acidum Chromicum, B. P.) is not a true acid, but an anhydride, and occurs in the form of brilliant red crystals, which are deliquescent and possess a sour, metallic taste. The acid should be kept in glass-stoppered bottles. It should never be mixed with sweet spirit of nitre, strong alcohol, or glycerin, or any organic matter, as under these circumstances an explosion may result. 188 DRUGS. Therapeutics. — Chromic acid is used solely as a caustic for the destruction of growths on the skin or mucous membranes. When a limited area is to be destroyed, a small crystal is placed on the part to be cauterized ; but if a larger area is to be attacked and severe action is required, the liquid resulting from its deliquescence on exposure to the air may be employed by means of a glass rod. The surrounding tissues should always be protected by lard or adhesive strips. J. William White has recorded a death from the application of this acid to a large number of condylomata about the buttocks and vulva. Where the drug has been swallowed, the patient should be treated for gastro-enteritis, and dilute alkalies and lime-water be used, as well as emetics and demulcent drinks. If a superficial action is desired, a solution containing 100 grains to the ounce (6.6-30.0) of water is sufficient, and for small warts and similar growths this solution will be found sufficiently strong. Liquor Acidi Chromici, B. P., is composed of 1 part of acid to 3 of water. CHRYSAROBIN. Chrysarobin (Chrysarobinum, U. S. and B. P.) is a mixture of the proximate principles derived from a powder found in the wood of the tree Andira Araroba, which was originally used for medicinal purposes in Brazil. In the East Indies it is called " Goa powder." Chrysarobin is sometimes misnamed chrysophanic acid, and is a yellow, tasteless powder, soluble in solutions of alkalies, in acids, and in ether. Therapeutics. — Chrysarobin is given internally in the dose of J grain (0.008) in psoriasis and parasitic diseases of the skin, but more commonly is employed externally in the form of the official ointment (Unguentum Chrysarobini, U. S. and B. P.), which is too strong for direct use, and should be mixed with 4 or 5 parts of benzoated lard before application to the skin. Even when so diluted, chrysarobin may cause great swelling and inflammation of the skin, with desqua- mation of the cuticle. Should the surface be broken, the drug may be absorbed and cause vomiting. As chrysarobin stains the skin a dark brown, it ought not to be used on the face; but should this accident occur, the discoloration may be removed by the application of a weak solution of chlorinated lime. In psoriasis the following may be employed after the patient has taken a bath to soften the scales: 1^— Chrysarobini . . 3j (4.0). ^Etheris, Alcoholis . aa q. s. ut ft. sol. Collodii f§ij (60.0).— M. S. — Apply with a brush to the part affected. C1M1CIFUGA. 189 CIMICIFUGA. Cimicifuga (U. S.) is derived from Cimicifuga Racemosa, other- wise known as black cohosh or black snake-root. It contains a resin and a volatile oil, upon which its medicinal powers are supposed to depend. The fluid extract and tincture should always be freshly pre- pared from the fresh crude drug. It is official in the B. P. as Cimici- fuga Rhizoma. Physiological Action. — In large doses cimicifuga paralyzes the sensory side of the spinal cord of the lower animals, and in consequence lowers reflex activity. It has no effect on the nerves and muscles. On the circulation the drug acts by depressing the heart and vasomotor system. Death is due to respiratory arrest. In small dose it is a feeble cardiac stimulant. When full medicinal doses are given to man it nearly always produces frontal headache. Its known physiological effects have no direct bearing upon its use in medicine. Therapeutics. — Cimicifuga is, excepting arsenic, the best remedy we have for chorea, particularly if the patient is otherwise in good health, but it should be used with careful attention to the regularity of the bowels and often be accompanied by iron. It is also indicated where there is, in addition to St. Vitus's dance, a rheumatic tendency. In chronic bronchitis it is asserted to be of value, and in rheumatism of a subacute or chronic type cimicifuga sometimes gives relief. Cimicifuga has been highly praised in the treatment of neuralgia particularly of the ovarian type, and in amenorrhea, subinvolution and tenderness of the womb. To women who state that they cannot step off a step without paining or hurting the uterus or ovaries cimi- cifuga often gives relief. Some writers assert that it is an efficient heart tonic in cases of fatty and irritable heart when digitalis fails. There can be no doubt that it is a powerful uterine stimulant, and it ought to be used with caution during pregnancy for fear of abortion. There are, however, some practitioners who commend its use for the prevention of this accident. By reason of this power it may be employed instead of ergot during labor, and is said to be better in some cases, because it produces normal, not tonic contractions. As a matter of fact, it is little used for this purpose. In the treatment of headache arising from overstraining of the eyes cimicifuga is said to be beneficial. The drug is official as the extract (Extr actum Cimicifuga, U. S.), dose 1-5 grains (0.06-0.3), the fluid extract {Fluidexir actum Cimici- fuga, U. S., or Extractum Cimicifuga Liquidum, B. P.), the dose of which is 10 to 30 minims (0.60-2.0) or even 1 drachm (4.0), In addition the B. P. contains Tinctura Cimicifuga, the dose of which is 1 to 2 drachms (4.0-8.0). 190 DRUGS. CINCHONA. Cinchona, U. S., is a name applied to the bark of all the trees belong- ing to the genus Cinchona, provided they contain not less than 5 per cent, of anhydrous cinchona alkaloids, at least f of which should be soluble in ether. There are thirty-one species of this genus, but only a comparatively small number can be included in the list of those which contain 5 per cent, of alkaloids. These are Cinchona Calisaya, or Cin- chona calisaya, which contains the most quinine, Cinchona Ledgeriana, Cinchona Officinalis, Cinchona Succiruba, or Cinchona Rubra,\J. S., Cin- chona Rubra Cortex, B. P., and Cinchona Pitayensis. (The first is called yellow bark, the second pale bark, the fourth red bark.) The alkaloids of the quinine series derived from these barks are quinine or quinina, quinidine or quinidina, and quinicine, which is an artificial alkaloid. Of the cinchonine series we have cinchonine, cinchonidine, and cin- chonicine, which last is also an artificial alkaloid. Besides these alkaloids there are present kinic and kinovic acids and other inert and useless substances. As quinine is the most important of the group, and as its physio- logical action is virtually identical with that of the rest, whatever is said hereafter in this article refers to quinine unless otherwise stated. All the alkaloids of cinchona which have been named are not employed as pure- alkaloids, but as salts formed by adding sulphuric, hydrochloric, or other acid to increase their solubility. Physiological Action. — When quinine is taken in overdose, it causes ringing in the ears, dizziness, disorders of taste and smell, disturbance of vision in some cases, and fulness in the head. Deafness often comes on, and is generally, with the roaring in the ears, the most annoving symptom. Headache is not uncommon. (See Untoward Effects.) Nervous System. — Upon the cerebrum quinine acts as a stimu- lant, and finally as a congestant if given in excessive dose. If poison- ous doses are used, intense cerebral congestion ensues, and finally unconsciousness ensues. On the spinal cord of the lower animals the drug first causes a decrease in reflex action by stimulating Setschenow's reflex inhibitory centre, and finally by depressing the spinal cord and nerves. The latter changes occur only after poisonous doses. Circulation. — If quinine, even in small amount, be injected into the jugular vein of a dog, so that it goes in concentrated form to the heart, cardiac paralysis will result. If this does not occur, the drug simply decreases pulse-force, pulse-rate, and arterial pressure. When given to man in small medicinal doses by the mouth, the drug acts as a general stimulant to the entire body, and so tends to support the circu- lation, increasing to a slight degree the pulse-rate and blood-pressure. If the dose by the mouth be very large (15 grains), the pulse is depressed. Full doses in fever therefore act as vascular sedatives. CINCHONA. 191 Blood. — After poisonous doses the blood is more coagulable than normal, but in medicinal amounts no such effect is produced. The effect of quinine on the blood-corpuscles is of great interest. Even in full medicinal doses it arrests diapedesis of the white cells from the capillaries by a direct action on these cells, and if the drug be applied to the mesentery of a frog the cells already extruded cease their move- ment, but the intravascular cells do not. On the other hand, if qui- nine be given internally in so small a dose that the proportion to the blood is as 1 to 20,000, the white cells in the vessels cease to migrate, but those cells in the surrounding tissues do not (Binz, Hare, Dissel- horst). This is perhaps the explanation of the effects of quinine in acute inflammations, for it arrests inflammatory exudation and allows the extruded cells to wander from the diseased area. It is stated, however, that this is not the case with all animals. Binz asserts that in the proportion of 1 : 20,000 quinine diminishes the number of white cells. Medicinal amounts gradually increase very materially the num- ber of red blood-corpuscles in man. It is said that quinine inhibits the oxygen-bearing powers of the red corpuscles, but this probably does not occur from medicinal doses. Respiration. — Upon respiration quinine acts as a slight stimulant in small doses, but as a marked depressant in poisonous amounts, death being most commonly due in animals to failure of respiration if it be taken by the stomach in lethal dose. Temperature. — Quinine lowers bodily temperature in health very little if at all, and in fevered states its influence is governed by the cause of the fever. Thus in malarial fevers quinine is a powerful indirect antipyretic, by reason of its peculiar powers o^er the infection, and not because it has any direct influence over heat production and dissipation. Absorption. — Quinine is absorbed from the stomach, not from the intestine, and it is precipitated by the alkaline juices of the bowel. For this reason it should be given in cachet, capsule, or powder, rather than in compressed tablet, so that it may be absorbed by the stomach before it reaches the intestine. If pills are used, only those which have been freshly made should be employed. Kidneys, Elimination, and Tissue-waste. — Quinine escapes from the body chiefly through the kidneys, although some of it is destroyed by oxidation in the liver and tissues. The excretion of quinine is by no means rapid so far as the entire quantity to be eliminated is concerned. While in rare instances it may be found in the urine in fifteen minutes from the time it is given, it does not disappear from this secretion for about twenty-four hours. In the urine it is found as quinine and as dihydroxyl quinine. Upon tissue-waste quinine acts as a depressant and decreases the elimination of nitrogenous materials. Digestive Tract. — Quinine has a bitter taste in as small a pro- portion as 1 : 10,000 of water. Upon the stomach it acts as a tonic and 192 DRUGS. stimulant, but if given too frequently, or in large doses, it may irritate this viscus. Moderate doses are slightly constipating, and very large doses may induce colicky pain. Poisoning and Untoward Effects. — Severe poisoning from quinine rarely occurs except in persons who have an idiosyncrasy to the drug. Roberts has recorded the case of woman, aged thirty-six years, who took 5 drachms (20 grammes) and survived, after suffering from deep coma, shallow breathing, slow pulse, absolute deafness and blindness. The loss of sight lasted two weeks, but the retinal changes persisted for several months. Death from an overdose of quinine is exceedingly rare. The cases in which death has followed its use are medical curiosities. Bouchardat has recorded the case of an adult male who died as a result of taking from 45 to 65 grains of the drug. Whether this was the real cause of death is doubtful. Soullier quotes Tarnier and Budin as asserting that enough quinine may be eliminated by the milk to produce death in a nursling. This seems hardly possible. "Untoward effects" is the best term with which to qualify the dis- agreeable symptoms which sometimes come on in persons having an idiosyncrasy to the drug and who are in reality poisoned by small doses. In these cases, sudden, complete, but temporary blindness is often met with. De Schweinitz has shown that in dogs quinine produces in toxic doses constriction of the retinal arteries, thrombosis of the central vein of the retina, and permanent optic atrophy; and Holden has proved that there is degeneration of the nerve-fibres and ganglion cell-layers of the retina. In other instances complete deafness asserts itself, due to congestion of the middle ear, while skin eruptions, generally of the nature of erythema, are not rarely seen. In other instances petechial and vesicular eruptions are developed, and swelling of the gums with a tendency for them to bleed may appear (Schulz). After lethal doses hemorrhage into the middle ear may be found, and severe epistaxis may ensue after so small a dose as 4 grains ^(0. 25) .^ The buzzing in the ears can generally be relieved by the administration of 10 grains (0.60) of bromide of sodium combined with a little ergot. Karamitsas has proved that quinine may produce hemoglobinuria in persons suffering from malarial poisoning, and apparently may even develop bilious remittent fever. 1 Irritability about the neck of the bladder may sometimes be produced by quinine. Therapeutics. — Quinine is employed in medicine to fulfil three great offices, although its influence in other directions is hardly less powerful. These are as an antiper iodic or antimalarial, as an anti- pyretic, and as a tonic possessing peculiar virtues. For many years physicians employed this drug empirically, not knowing the cause of the disease called malaria. We now know that the theory of Binz, advanced as long ago as 1867, is correct, and 1 See collective investigation of this subject by the author in Therapeutic Gazette for July, 1892; also article in New York Medical Record, January 7, 1899. CINCHONA. 193 that malaria is due to the presence of a germ, the plasmodium malarise, which was first accurately studied by Laveran and named by Marchia- fava and Celli. These and other investigators have found that quinine acts as an active poison to these germs, even in so weak a solution as 1 : 20,000. For the reasons given in the preceding paragraph quinine is the best remedy for malarial fever as a prophylactic and cure, and it should be given in doses which are indicated by the state of the patient. (See Malarial Fever.) If possible it should always be preceded by a purge having an hepatic action. This preliminary treatment is particu- larly important in bilious or remittent fever. The drug should be given in hourly doses, or in one or two large doses in such a way that its influ- ence is fully exercised, not only at the time of the expected paroxysm, but about an hour or thirty minutes before that time. If the paroxysm is near at hand, the drug should be given in solution, bitter though it be, in acidulated water. If the attack be so far advanced as the sweating stage, it should be given nevertheless to destroy the spores just set free. (See Intermittent Fever.) As a prophylactic against malaria the dose of quinine should be 2 to 4 grains (0.12-0.25) or more three times a day. In hemorrhagic malarial fever quinine sometimes seems to do more harm than good. Under such circumstances the danger in using quinine consists in irritating the engorged kidneys after the chill has passed. Quinine is not a haemostatic, and only does good in malarial hematuria by preventing the paroxysm which produces the bloody urine. In hematuria occurring in persons broken down in health as a result of chronic malarial infection quinine is of no value unless an examination of the blood reveals the presence of parasites due to a new infection. To give quinine after this symptom appears is to "lock the door after the horse is stolen" unless the parasites are found in the blood. Indeed, it would seem from the studies of many physicians in America, Greece, and Italy, that the use of quinine is capable of developing a hematuria. 1 (See Hematuria.) If, however, an examination of the blood reveals the malarial parasite, the drug should be freely used. In pernicious malarial fever quinine should be given by the mouth, by the rectum, and hypodermically, and even intravenously, as much as 60 to 70 grains (4.0-4.6) being used. In brow ague or malarial neuralgia quinine often acts most usefully, and this is also true in some cases of nerve-pain not dependent upon a specific disease. For the reduction of the pyrexia of typhus' or typhoid fever quinine is inferior to the new antipyretics, even when given in very large dose, and it ought to be used rarely, if at all, for this purpose. In 1 See collective investigation of this subject by the author in Therapeutic Gazette for July, 1892; also article in New York Medical Record, January 7, 1899. 13 194 DRUGS. all fevers it will seldom cause a fall of temperature before crisis or lysis, but will aid in the fall very actively after these changes have occurred. In those cases of fever in which the use of quinine is fol- lowed by marked improvement the good results are due either to its specific antimalarial influence or to its stimulating influence on the general system. As a tonic quinine acts not only as a simple bitter, but also seems to have a direct effect in increasing the number of the red blood-corpuscles. The tonic dose should be 1 to 2 grains (0.06-0.12) three times a day. Quinine has been used to overcome uterine inertia in weak women, but it is a feeble remedy, and is seldom resorted to by progressive obstetricians. (See Kola.) It will not of itself cause abortion, but in nervous, hysterical women who have a tendency to abort, and to whom it is necessary to give full doses of quinine during pregnancy, it may be well to combine some sedative, as one of the bromides or opium, with the antiperiodic. In the lobar pneumonia of children quinine should be used in sup- positories in the dose of 2 grains (0.12) three times a day. Acting on the belief that chorea is due to lack of inhibitory control of muscular movements, Wood has urged the use of quinine in large doses in this disease as a stimulant to inhibition. Whether the good which sometimes follows this treatment is due to any specific effect of the drug is doubtful. In cases where prolonged mental or physical strain is to be under- gone, quinine in the dose of 2 to 4 grains (0.12-0.25) will often pre- vent exhaustion and support the system. The internal use of quinine is a wise procedure in whooping-cough , and the proper dose, according to a careful series of studies by Baron, is 1| grains (0.08) for each year of the child's age, to be given at 6 a.m., 2 p.m., and 10 p.m. A much more agreeable method of pursuing this treatment in whooping-cough is to give the patient the so-called quinine chocolates, which contain 1 grain (0.06) of tannate of quinine and chocolate in each. The taste of quinine in such chocolates is scarcely noticeable if they are well made. Used in solution in the form of a spray by the atomizer, quinine is of undoubted service in whooping-cough, and will often prevent the spread of the disease to other children if they be subjected to its use. This solution should contain from 1 to 2 grains (0.06-0. 12) to the ounce (30.0) and be employed every few hours. It is well to remember that quinine is not tasted by the tip of the tongue, but by the back portion. The tip of the atomizer should therefore be carried well back of the root of this organ, and a 1 per cent, solution of cocaine painted over the dorsum of the tongue in cases where the taste of the quinine is objected to strongly. This solution of quinine used, by means of an atomizer, in colds in the head and in fetid sore throat is often of service. High rectal injections of quinine in the CINCHONA. 195 strength of 1 : 3000 are useful in amoebic dysentery, as this drug destroys Amoeba coli. Administration. — When prescribing quinine the physician should employ the hydrochloride (Quininoe Hydrochloric! am, U. S. and B. P.), as it contains a high percentage of alkaloid and is very soluble. An acid hydrochloride (Quininoe H ydrochloridum Acidum) is also official in the B. P. The hydrochloride of quinine is stronger in alkaloid than the bisulphate of quinine (Quininoe Bisulphas, U. S.), which is, however, soluble in the proportion of about 1 to 8 of water. The hydrobromide of quinine (Quininoe Hydrobromidum, U. S.) is another useful salt, which is soluble in the proportion of 1 to 16 of water. The valerianate of quinine (Quininoe Valeras) possesses no particular value. Quininse Salicylas, U. S., is also official. The sulphate of quinine (Quininoe Sulphas, U. S. and B. P.), the least soluble of all these salts, is by custom most commonly administered. The tannate of quinine is a salt not so bitter as the other salts, and is weaker in relative alkaloidal strength. One grain (0.06) of the tan- nate equals about J grian (0.015) of pure alkaloid. The bisulphate equals about § and the sulphate f grain of the pure alkaloid. The dose of all the salts of quinine varies from 1 to 4 grains (0.06-0.25) as a tonic, and from 4 to 60 grains (0.25-4.0) for antimalarial pur- poses. The B. P. recognizes a pill of quinine, Pilula Quininoe Sulphatis, a tincture (Tinctura Quininoe), a wine (Vinum Quininoe), and an ammoniated tincture (Tinctura Quininoe Ammoniata). In regard to the administration of quinine, it may be said that it ought never to be given in solution if it can be avoided, because of its disagreeable taste. If it is given in solution, the liquid should be well acidulated, as under these circumstances it will not taste so bitter as when a weakly acidulated solution is employed. In adults and chil- dren quinine should be used preferably in small capsules or in pills, which may be gelatin- or sugar-coated. Another means for adults is the use of cachets. If pills or capsules are employed, care should be taken that the sugar is not hardened by age, and that the gelatin is thin, for if the pill or capsule escapes into the intestine before it is dissolved the quinine is precipitated and is not absorbed. If the case is that of a child too young to take a pill, the drug may be given in the following manner without tasting very disagreeably: 1$ — Quininae hydrochlor. gr. xvj (1.0). Fluidext. glycyrrhiz foj (4.0). Syrupi aurantii cort f§ij (60.0). — M. S. — A teaspoonful t. i. d. for a child of three years. In some cases quinine chocolates may be used, but unless they are well made the after-taste of quinine is well marked. When they are used tannate of quinine should always be placed in them. In other cases quinine may be used in suppository in the dose of 2 to 3 grains 196 DRUGS. (0.12-0.20), care being taken that irritation of the rectum does not ensue. For suppositories the best salt to employ is the hydrochloride. For hypodermic use the hydrochloride of quinine should be used most commonly, as it is soluble in about 10 parts of water, and con- tains more of the alkaloid than the more soluble bisulphate of quinine. It may be employed in the following manner: ~fy — Quininse hydrochloridi gr. vij (0.5). Glycerini, Aquae dest aa f5ss (2.0). — M. S. — Warm solution before using it, and do not add acid. 1$ — Quininse hydrochloridi gr. xv (1.0). Alcoholis rrixv (1.0). Aquae dest f 5jss (6.0).— M. S. — Add a few drops of hydrochloric acid to complete solution before using. If the bisulphate is used hypodermically, to its solution should be added a little tartaric or sulphuric acid to prevent precipitation of the drug in the alkaline juices of the connective tissues before it can be absorbed. The tartaric acid should be present in the proportion of about 1 grain (0.06) to each 5 grains (0.3) of the quinine. Should it be necessary to use the sulphate of quinine hypodermically, 10 grains (0.60) should be added to 1 drachm (4.0) of water and sulphuric acid added drop by drop until the salt is dissolved. The hydrobromide of quinine, the solubility of which is about 1 to 54 of water, may also be used hypodermically, as may also the bimuriate of quinine and urea (Quinince Bimuriatica Carbamas), which, however, is scarcely more than half as strong in quinine as the other salts. The best place to give the hypodermic injection is in the buttock, between the trochanter and the tuberosity of the ischium. Injections into the calf of the leg are very painful. In Italy, Baccelli has resorted to the intravenous injection of quinine in severe cases of malarial infection. He employs the following solution for this purpose: Tys — Quininse hydrochloridi ..... gr. xv (1.0). Sodii chloridi gr. xv (1.0). Aquoe dest fSijss (10.0).— M. S. — This should be injected, after an ounce (30.0^ of distilled water has been added to it. The solution should be boiled and filtered, and used while warm. As quinine in a concentrated form is a powerful heart-depressant, the drug should be injected very slowly into a vein of the leg when intravenous injections are employed. The alkaloids of cinchona other than quinine which are commonly used in medicine are cinchonidine, cinchonine, quinidine, and the impure substance chinoidinum. Cullen, Sinkler, and de Brun have all found the sulphate of cin- chonidine (CinchonidinoB Sulphas, U. S.) very useful in malaria, and it is less bitter and more soluble than is quinine. Sinkler states that it does not produce the severe head-symptoms caused by quinine. CINCHONA. 197 The dose of quinidine sulphate (Quinidina Sulphas) is about twice that of quinine, as is also that of cinchonine sulphate (Cinchonina Sulphas, U. S.) and cinchonidine sulphate (Cinchonidina Sulphas, U. S.). Chinoidinum is a resinous mass obtained in the preparation of the alkaloids of cinchona, and contains amorphous alkaloids. It possesses distinct antiperiodic power, and was used freely when quinine was a very expensive drug. Its dose is three or four times that of quinine. The liquid preparations of cinchona are the infusion (Injusum Cinchona), dose a wineglassful (30.0); the tincture (Tinctura Cin- chona, U. S. and B. P.), one or two teaspoonfuls (4.0-8.0); and the compound (Huxham's) tincture (Tinctura Cinchona Composita, U. S. and B. P.), a teaspoonful to a tablespoonful (4.0-16.0). Huxham's tincture is a most efficient and elegant bitter tonic in debility and con- valescence from low fevers. It is too weak in alkaloids to be used in malarial poisoning. Under the name of elixir roborans, or Whytt's tincture, a similar mixture is employed for the same purposes. The other liquid preparation is the fluid extract (Fluidextr actum Cin- chona, U. S., or Extractum Cinchona Liquidum, B. P.), dose 5 to 15 minims (0.3-1.0). A solid extract (Extractum Cinchona) is given in the dose of 5 to 10 grains (0.3-0.60). The B. P. preparation not official in the U. S. P. is the Injusum Cinchona Acidum, dose 1 to 2 fluidounces (30.0-60.0). Contraindications. — Quinine is contraindicated in gastritis, cystitis, meningitis, epilepsy, cerebritis, and middle-ear disease, because it con- gests, irritates, or stimulates those areas which are diseased, and in those cases which have an idiosyncrasy to its action. CINNAMON. Cinnamon (Cinnamomum saigonicum vel zeylanicum, U. S. ; Cinnamomi Cortex, B. P.) is the inner bark of a plant, a native of Ceylon or of the species indigenous to China. It contains a volatile oil and tannic acid. In overdose the oil acts as a soporific and kills by failure of respiration. Therapeutics. — Cinnamon is used, as are all the drugs of its class, for flavoring, as a carminative, and as an intestinal stimulant in serous diarrhaas. It has the peculiar power of acting as a haemostatic in uterine hemorrhage where the flow is oozing and not active, thereby differing from the other volatile oils, with the exception of that of erigeron. The oil of cinnamon is a powerful antiseptic, which can be used in dilute form in the dressing of wounds and by injection in gonorrhaa. J. Chalmers Da Costa employs a spray of oil of cinnamon and benzoinol in the proportion of 1, 2, or 3 minims (0.05-0.10-0.20) of the oil to 1 ounce (30.0) of benzoinol, or it may be used by injection. It seems to act best in the early stages of gonorrhoea. ]98 DRUGS. Cinnamic acid, a derivative of oil of cinnamon, is also used for the same purposes; but its chief employment has been in the treatment of tuberculosis. This consists in injecting hypodermically and intra- muscularly 2 minims (0.1) of the acid. This produces burning pain, which soon disappears. The patient, however, feels fatigued, has vertigo and cerebral congestion. Gradually the dose is increased to 15 minims (1.0), and after several weeks the patient is said to cough less, to gain in weight, and to improve in physical signs. The treatment is so painful that it has not gained favor. Administration. — The dose of the oil {Oleum Cinnamomi, U. S. and B. P.) is 1 to 5 minims (0.05-0.3); of the water (Aqua Cinna- momi, U. S. and B. P.), a wineglassful (30.0) or less; of the spirit (Spiritus Cinnamomi, U. S. and B. P.), 5 to 30 minims (0.3-2.0); of the tincture (Ti?ictura Cinnamomi, U. S. and B. P.), J to 1 drachm (2.0-4.0). Under the name of Pulvis Aromaticus, U. S. (Pulvis Cinnamomi Compositus, B. P.) a carminative powder, consisting of cinnamon 35 grammes, nutmeg 15 grammes, cardamoms 15 grammes, and ginger 35 grammes, is official. The B. P. preparation does not contain nutmeg. Aromatic powder is useful in the treatment of the flatulence of adults and children. The latter should take about 10 grains (0.60) at a dose, an adult 30 grains (2.0). CITRIC ACID. Citric acid (Acidum Citricum, U. S. and B. P.) is chemically iden- tical with the acid of the lemon, but has not identical influences upon the body as has lemon-juice. Not only does the lemon owe its acidity to this acid, but most of the other edible fruits, such as strawberries and raspberries, depend upon its presence for their acidity. Therapeutics. — Citric acid is used in scurvy, or scorbutus, as a prophylactic and cure. For some unknown reason, pure lemon-juice seems to benefit these cases more than citric acid itself, and it is there- fore to be preferred to the latter whenever it can be had. In order to keep lemon-juice from decomposition on long voyages, it should be boiled, and poured while hot into bottles until it nearly reaches the cork; the remaining space is then filled with a thin layer of sweet oil and the bottle corked and stood upright. Under these circumstances the juice may be kept indefinitely. In rheumatism, either acute or chronic, lemon-juice may be em- ployed in the dose of 1 to 2 ounces (30.0-60.0) four times a day, well diluted, or 2 drachms (8.0) of citric acid may be given. The acid is also of value in hepatic inactivity and catarrhal jaundice. (See Citrate of Potassium.) The preparations containing citric acid are Syrupus Acidi Citrici, U. S., Succus Limonis, B. P., and Syrupus Limonis, B. P. COCA AND COCAINE. 199 CLOVES. "* Cloves (Caryophyllus, U. S.; Caryophyllum, P. B.) are the unex- panded flowers of Eugenia aromatica, sl plant of the East and West Indies. They possess an aromatic odor and the pungent taste of a typical spice. They contain a volatile oil (Oleum Caryophylli, U. S. and P. B.), which is yellow when fresh, but very da T k-colored when old. It should contain 80 per cent, of Eugenol, U. S. Therapeutics. — Cloves or their oil are used in medicine for their carminative effect. They are also employed as a stimulant and tonic to the stomach to prevent griping during an attack of diarrhea, or that caused by purgatives, to act as a flavoring agent, as a counterirritant, and, finally, as a parasiticide and local anaesthetic. The oil of cloves possesses great power for good in many cases of pulmonary tuberculosis, partly by its germicidal influence upon the bacillus. It should be given in the dose of 5 minims (0.3) in capsule after food three or four times a day, and a hypodermic injection of ster- ilized sweet oil, containing in each dose of 30 minims (2.0) 5 minims (0.3) of the oil of cloves, should be administered once a day The injection should be given into the subcutaneous tissues of the flank or abdomen, and is painful, but the decrease in the cough and expectora- tion amply repays the patient for the pain. Like all volatile oils, this oil is an efficient local application for Pedicidus pubis and similar parasites. It may be used in toothache because of its anaesthetic powers, placed on a pledget of cotton in the cavity of the aching tooth. In the treatment of myalgia or mus- cular rheumatism oil of cloves is often placed in a liniment for its counterirritant effect. Doses of \ to 1 minim (0.025-0.05) of the oil in a little water will sometimes control excessive vomiting. In addition to the oil the B. P. has an official infusion, Infusum Caryophylli, the dose of which is 1 to 2 fluidounces (30.0-60.0) In overdose oil of cloves acts as a soporific, and kills by failure of respiration and the production of severe gastro-enteritis. COCA AND COCAINE. Coca is official in the U. S. P. as Coca, and as Coca? Folia in the B. P.; but in the U. S. P. of 1880 it was known as Erythroxylon. Cocaine (Cocaina, U. S. and B. P.; Cocaince Hydrochloridum, U. S. and B. P.) is the alkaloid derived from Erythroxylon Coca, which is a shrub of Peru and Bolivia. When cocaine is heated with hydrochloric acid it is split into several substances, among others a base called ecgonine, which has wholly different properties from cocaine, and is perhaps responsible for some of the evil effects which have resulted from improperly prepared cocaine. It is to be dis- 200 DRUGS. Fig. 33. tinctly understood that Erythroxylon Coca is not the same as chocolate or Theobroma Cacao. Physiological Action. — Coca and its alkaloid cocaine, when taken internally, produce a sense of exhilaration and pleasure. Often mus- cular and mental power is temporarily increased under their influence. When locally applied to a mucous membrane, cocaine causes blanching followed by marked congestion. Nervous System. — The dominant action of cocaine, when locally applied to the peripheral sensory nerves, is to paralyze them (Fig. 33). When taken internally it stimulates the brain to an extraordinary degree, but exercises no effect upon the sensory nerves. Sometimes its internal use produces a decrease of sensation, which Mosso believes to be due to an influence on the spinal cord. This effect is, however, very feeble. If the dose be a poisonous one, convulsions of cerebral origin ensue, and are both clonic and tetanic in type. The sensory nerves are paralyzed by enormous doses both when the drug is directly applied and when it is taken in- ternally. Upon the muscles, when taken internally, Mosso has proved the drug to be a direct stimulant, and it is particularly active after starvation or fatigue. Muscular power is increased temporarily by cocaine. Circulation. — Cocaine acts as a stimu- lant to the heart and circulation in mod- erate amounts, but its effects are not marked except in poisonous dose. Respiration. — The drug acts as a pow- erful respiratory stimulant, producing in thetized by cocaine paralyzing the \ aY g e d ose a great increase in the rapidity ends of the sensory nerve at B. « R ~ j. i . • • oi the respiratory movements, but in poison- ous dose it kills by failure of respiration associated with exhaustion from the accompanying convulsions. Temperature. — Cocaine raises bodily temperature to an extraor- dinary degree if given in overdose, this rise being due to an increase of heat-production (Reichert). In moderate or medicinal amounts it has no such effect. Kidneys, Elimination, and Tissue-waste. — The drug is elimi- nated by the kidneys, but is chiefly destroyed by oxidation in the body. Under its influence, the quantity of urine passed is increased and the nitrogenous elements eliminated in this fluid are slightly diminished. Eye. — Owing to its powerful action as a local anaesthetic, cocaine has been used largely in diseases of the eye, and it is particularly effi- cacious in this organ because of the delicacy of the conjunctiva, which it readily penetrates and so paralyzes the peripheral sensory nerve- A, sensory nerve supplying mu cous membrane B, which is anses COCA AND COCAINE. 201 endings. The anaesthesia comes on in from one to five minutes after the use of the drug, according to the strength of the solution used. When cocaine is applied to the eye, it causes distinct enlargement of the palpebral fissure and an apparent prominence of the eyeball. This is due to a stimulant effect of the cocaine upon the sympathetic nerve-fibres which supply the unstriped muscle-fibres of the lids. This is accompanied by marked dilatation of the pupil, which Koller asserts is due to constriction of the bloodvessels of the iris, the muscular fibres being untouched. Ophthalmologists, however, gen- erally assert that this mydriasis is due to the fact that the drug stim- ulates the peripheral ends of the sympathetic nerve. It is important to remember that this dilatation, unlike that produced by mydriatics, such as atropine, is not accompanied by paralysis of accommodation, and the dilatation of the pupil can be overcome at once by the use of eserine or pilocarpine. The drug does not cause a forcible mydri- asis, and is never used for the prevention of adhesions in iritis unless combined with atropine. Therapeutics. — Cocaine hydrochloride (Cocaines Hydrochloridum, U. S. and B. P.) is used as an anaesthetic in the eye in the dose of from 3 to 5 or more minims of a 1 to a 4 per cent, solution. The strength of 2 and 3 per cent, is perhaps most commonly employed. It is worth remembering that cocaine is soluble in fats, whereas its salts are not. Cocaine itself should therefore be used in anaesthetic salves, and is official for this purpose in an oleate (Oleatum Cocaines, U. S.) which contains 5 per cent, of cocaine. The conditions indicating its use in the eye are all operations of a painful character, and it may also be used for the relief of pain when an acute inflammation or foreign body is causing suffering. The following formula will be found useful in these states : 1^ — Cocainse hydrochlor gr. viij (0.50). Acid, boric gr. vij (0.46). Aquae dest fgj (30.0).— M. S. — Use with a dropper in the eye every half hour until relieved. Cases of keratitis are recorded in which cocaine has produced per- manent corneal opacities, and it may cause dryness and roughening of the corneal epithelium even in the normal eye. Cocaine is often used in 2 per cent, solution upon cracked nipples just before nursing, to relieve pain. The drug must be carefully washed off before the baby is put to the breast. It is asserted, how- ever, by Guenel and Desamaux that this treatment may permanently stop the flow of milk. Owing to the density of the mucous membranes of the vagina and rectum, cocaine has little effect upon them unless used in 10 per cent, solution and freely applied. In the mouth cocaine may be used in cases of stomatitis where a spot is to be cauterized, in pharyngitis, and in soreness and tenderness of the gums. While it gives much tem- porary relief in pharyngitis, the subsequent effects are often exceed- 202 DRUGS. ingly disagreeable, the congestion looking more angry and being more painful than before, and the experience of the writer indicates that it will only act in a curative manner if applied before the capillaries become relaxed or paralyzed by the severity of the inflammatory process. In coryza and hay fever a powder consisting of cocaine, morphine, and bismuth in the proportion of 1 part each of the two alkaloids and 5 parts of the bismuth will often be of service if snuffed into the nostrils. If cocaine be applied to a large nerve- trunk, am- putation of the tributary limb may be performed without pain, but so large an amount of the drug must be used that there is great danger of poisoning the patient. Cocaine is generally used at present in the place of ether in cases requiring amputation of the fingers or in cases of minor surgery where the action of the drug can be confined to the part injured. A cord should be tightly bound around the base of the finger and a 4 to 8 per cent, solution injected into the part, the ligature about the base of the digit being used to prevent hemorrhage and systemic absorption of the drug. After the operation is completed slight hemorrhage should be allowed to occur, to sweep out the drug and thereby avoid systemic effect. Not more than \ grain of cocaine should be injected. When operations on a foot or hand have been done under cocaine anaesthesia, and larger amounts than this have been used, the constricting band- age should be allowed to remain in place some time, since the tissues destroy the drug, so that when the bandage is removed less is absorbed. (Holscher and others.) When a limb is to be amputated under cocaine, the main supplying nerve should be exposed by the aid of infiltration anaesthesia (see below), and then the nerve-trunk is to be anaesthetized by the injection into its sheath of so weak a solution of cocaine in normal saline fluid as 1 per cent. Under the name of "infiltration an&sthesia" Schleich has introduced a method of abolishing sensation in localized areas which often gives good results for minor operations. He injects into the skin, as super- ficially as possible, a sufficient amount of a solution of common salt, cocaine, and morphine to produce local oedema, and thereby pressure on the nerve-filaments, which are also depressed by the cold liquid coming in contact with them. He also believes that the local anaemia so caused aids in decreasing sensation. The injection is given so gently that a sort of wheal or cedematous spot is produced where the incision is to be made. As soon as this spot is developed the needle is inserted into its margin and carried under the skin a little farther, and then the injection is repeated. In this way the line of an extensive incision can be anaesthetized progressively. If deep incisions are necessary, the injections are made into the deeper tissues as well. The injections must always be made into healthy skin, as if it is diseased a slough may result. Schleich asserts that similar injec- tions under the periosteum permit of operations on the bones. The COCA AND COCAINE. 203 amesthesia lasts twenty-six minutes. The solution is of three strength as follows : Solution. Cocaine hydrochloride . Morphine hydrochloride Sodium chloride . Sterilized distilled water I. gr. iv(0.25). gr. I (0.03). gr. iv(0.25). f^iv (120.0). II. gr. ij (0.12). gr. J (0.03). gr. iv (0.25). fgiv (120.0). III. gr. 1 (0.012). gr.^ (0.006). gr. iv (0.25). f£iv (120.0). To each of these solutions 3 minims of a 5 per cent, solution of carbolic acid are added. The second solution is the one commonly used. The first is employed where acute inflammation is present, and the third where repeated injections are necessary. (See Fig. 34.) This method of producing anaesthesia has now been tried long enough to define its limits of usefulness. For minor localized operations it is very satisfactory; but for long and deep incisions it is of little value, as its effects are too superficial, and be- cause it in no way diminishes the fear and mental suffering of the patient, in whom the dread of the operation is worse than the actual pain. Under certain cir- cumstances, however, it may be used in major surgery, such as tracheotomy, the removal of small superficial tumors, and in those patients who are so profoundly ill that it is dangerous to use a general anaes- thetic, as, for example, in intestinal per- foration in typhoid fever, an operation which has been done many times with this method. As the operation proceeds the needle is inserted f e * ch su , cc f- , . L . . \ , . n , sive point as numbered until the deeper tissues are anaesthetized by mnltra- Une of anaesthesia is complete. tion if possible, and are cut, not torn, as the tearing produces great pain. Great care is necessary that the fluid injected is sterile. In some instances in which we are fearful of the effects of prolonged ether or chloroform anaesthesia we can use alternately ethyl chloride locally, infiltration anaesthesia, and, finally, the general anaesthetic when deeper tissues are reached and the major portion of the opera- tion is to be performed. Morphine may be given before the operation in such instances to benumb the nervous system. When skin-grafting is to be done, we may resort to the use of cocaine anaesthesia of the skin produced by the aid of cataphoresis. (See Cataphoresis.) Within the last few years cocaine and eucaine have both been used to produce anaesthesia of large areas of the lower portions of the body and limbs by injecting them into the subarachnoidean cavity below the Infiltration anaesthesia. The 204 DRUGS. Fig. 35. termination of the spinal cord by means of a long hypodermic needle, which is usually introduced between the fourth and fifth lumbar verte- brae. By this means the cocaine is brought in contact with the cord and its nerve-roots, and anaesthesia in all the tributary parts is produced. The operation is performed more easily with the patient in the sitting posture, very slightly bent forward, than when he is recumbent, but it is safer as far as disagreeable effects are concerned that he should be re- cumbent. The skin over the last lumbar vertebra is carefully sterilized and then infiltrated with Schleich's fluid. A long needle is then inserted at the side of the third or fourth lumbar vertebra in a line drawn between the iliac crests across the back. (Fig. 35.) It can be felt to pass between the bodies of the vertebrae. (Fig. 36.) If there is no escape of subarachnoid fluid, the needle is not in the right place. As soon as this fluid appears the syringe, already filled with a 2 per cent, cocaine solution, is attached to the needle, and from 10 to 15 minims (0.60-1.0) are injected. Anaesthesia is developed in from two to fifteen minutes, and lasts from one to five hours. It is need- less to point out that not only the skin, but also the needle, the syringe and the solution should be most carefully sterilized before the oper- ation. This method has been resorted to in cases demanding operation below the area injected, and in case of labor, which is thereby rendered painless. Con- siderable fever, nervous and circu- latory disturbance may arise in susceptible persons; but Marx asserts that if ^ho grain (0.0003) of hyoscine is given hypodermi- cally these symptoms are prevented. In the opinion of the writer, this practice will soon cease to be employed except in a few instances in which some extraordinary contraindication to ether and chloroform exists, as it is unsatisfactory and dangerous. A number of deaths have followed its use. In Hahn's statistics there were 8 deaths in 1708 operations. It would seem, therefore, more dangerous than chloro- form, and it is certainly not so satisfactory. The proof of its ineffi- ciency lies in the fact that it is not generally used. Internally, cocaine or the fluid extract of coca may be used as a temporary supportant and stimulant in low fevers, and in cases where great physical and mental strain must be borne. Its use for any length of time is dangerous and harmful. Thorington has found cocaine of great value in yellow fever as a stimulant for a short A, space between the third and fourth lum- bar vertebra? for subarachnoidean injection (Quincke's area). B, area of puncture sug- gested by Turner. COCA AND COCAINY. 205 time and as an anti-emetic. In the vomiting o) pregnancy and other forms of excessive emesis it is of great service by depressing the gastric sensory nerves and thereby decreasing the irritability of the stomach. Cocaine is stated to be an antidote to morphine poisoning. Fig. 36. Showing the introduction of the needle between the last two lumbar vertebrae to produce spinal anaesthesia. The syringe is attached to the needle to provide a handle. After the physi- cian believes that the needle point is in the subarachnoid space, the syringe is detached from the needle in order to see if any cerebrospinal fluid escapes. If it does, this proves that the puncture has been successfully performed. The syringe filled with the fluid to be injected is then attached to the syringe and the injection given. (See Fig. 35.) Cocaine is undoubtedly of service in the opium habit, but if con- tinuously used soon evolves the patient from a morphinomaniac to a "coca fiend." The dose of the fluid extract (Fluidextr actum Coca, U. S., and Extractum Cocce Liquidum, B. P.) is from \ to 1 drachm (2.0-4.0) ; that of cocaine, from \ to| grain (0.015-0.03). The other B. P. prepar- ations are Lamellce Cocaina, each disk containing fa grain (0.0012) of 206 DRUGS. cocaine hydrochloride, and Unguentum Cocaince and Injectio Cocaines Hypodermica, given in the dose of 1 to 5 minims (0.06-0.3). The cocaine habit is a condition unfortunately frequently met with since the introduction of this drug into therapeutics. It is often com- bined with the morphine habit, and sometimes cocaine is employed as a substitute for morphine. The symptoms of the cocaine habit consist of marked loss of flesh, disorders of the circulatory system, mental failure, and delusions sometimes resembling those of chronic alcohol- ism. Often disagreeable hallucinations are present. The habit is difficult to cure, for relapses are frequent. The sudden withdrawal of cocaine from a patient may result in profound collapse. According to Magnan, a pathognomonic symptom of chronic or subacute cocaine-intoxication is a sensation of a crawling worm or bug under the skin. Untoward Effects. — Loss of speech, blindness, nausea and vomit- ing, syncope, and unconsciousness have followed the internal use or local application of cocaine. Epileptiform convulsions have also been noted, while the circulation and respiration have been disordered in every possible manner. In many of these cases the urine passed after the poisoning has been copious, limpid, and contained albumin. Curiously enough, a large number of cases of severe poisoning have followed the injection of cocaine into the urethra previous to oper- ation for the relief of chronic gonorrhoea or stricture. The hypodermic injection of cocaine as a stimulant sometimes causes vomiting. The treatment of the poisoning consists in the use of ammonia, coffee, strychnine, or ether and alcohol if the symptoms are those of depression. If they are convulsive in type, then the treatment to be instituted is identical with that of strychnine poisoning (which see). Reichert asserts that morphine is the best antidote to cocaine poisoning. Of 250 cases of accidental poisoning arising from the medicinal use of the drug, but 13 proved fatal. CODEINE. Codeina, U. S. and B. P., is an alkaloid derived from opium, and is often contaminated by morphine. The sulphate of codeine (Codeina Sulphas, U. S.) is generally used, as it is more soluble than codeine itself. Codeine phosphate (Codeina' Phosphas, U. S. and B. P.) is also official. Physiological Action. — Codeine resembles morphine very decidedly in its physiological action, the chief difference being that it possesses less narcotizing power, but in large amount more readily produces tetanus and final paralysis of the peripheral motor nerves in the lower animals (Dott and Stockman). It does not arrest secretion in the respiratory and intestinal tract, as does morphine, and therefore is less apt to cause constipation COD-LIVER OIL. 207 Therapeutics. — Codeine has been highly recommended for years as a nerve quietant, and in the United States in nervous cough and in cases where the cough is excessive in bronchitis and phthisis. In diabetes mellitus some clinicians have found it of value, while others have been disappointed in its use. It should, however, always be tried in this disease, in the hope that it may exercise a favorable effect. When given for cough it should be used in the dose of from \ to 2 grains (0.03-0.12) three or four times a day, in the syrup of wild- cherry bark. When given for diabetes the dose should be much larger, beginning at 1 or 2 grains (0.06-0.12), and rapidly increasing it till the glycosuria is diminished. Sometimes as much as 20 or 30 grains (1.3-2.0) or more may be given daily. The B. P. recognizes a syrup (Syrupus Codeinoe) given in the dose of 1 to 2 drachms (4.0-8.0). COD-LIVER OIL. Oleum Morrhuce, U. S. and B. P„, sometimes called Oleum Jecoris Aselli, is a fixed oil obtained from the fresh livers of Gadus Morrhua, or cod-fish. There are several species of cod from which the oil is obtained other than the one named, but that given is the chief source of supply. The oil is pale or dark according to its freedom from foreign materials, Although the paler oils are generally pre- scribed, there can be little doubt that the darker ones are more medici- nally active. The most prominent inorganic constituents of the oil are iodine j bromine, and sulphuric and phosphoric acids. It also contains more or less of the biliary salts. Lofoten cod-liver oil, obtained from cod caught near the Lofoten Islands, is generally considered the best for medicinal use. Physiological Action. — Cod-liver oil depends on a number of sub- stances for its peculiar effect. The iodine certainly exerts definite alterative powers, and the oil seems peculiarly adapted to digestion and absorption, for cod-liver oil passes through animal membranes very readily, probably owing to the biliary salts contained in it. The oil aids in the maintenance of bodily temperature by its oxi= dation, and causes a deposit of fat in the tissues. It also seems to influ- ence the blood directly, for clinical observation shows that ansemic persons become healthy-looking under its use, and Cutler and Brad- ford have found that this apparent improvement is a physiological fact by the use of Malassez's blood-cell-counting apparatus, the red corpuscles being always increased. It has been proved by experiment that cod-liver oil is more readily oxidized than any other oil. The belief among physicians that the effects of cod-liver oil are dependent upon some peculiar combination of substances has shown itself in the attempts of physiological chemists to isolate the combina- tion. One of the best results reached is the so-called "morrhuol' 5 ' of Chapoteau, who seems to have isolated a crystalline substance con= taining phosphorus, iodine, and bromine: 3 to 5 grains of this prepa= 208 DRUGS. ration are said to represent 1 drachm of the pure oil, and it is certainly of value as a medicament in most of the states in which the oil itself is used. In "colds " which "hang on " and are not readily gotten rid of, morrhuol is best given in capsule or pill. This substance is put on the market in gelatin-coated pills or capsules. It does not possess the nutritive value of the oil itself. Therapeutics. — Cod-liver oil is useful in those persons who have no tubercular lesion in the lung or other tissues, but have mucous mem- branes which are very susceptible to disease. This state has been called the pre-tubercular stage of phthisis. Cod-liver oil possesses no curative power in cases of well-developed and rapid phthisis, and its administration in many cases serves only to nauseate the patient or to produce an oily diarrhoea through failure of digestion. It does good in the early stage of the disease in that it acts as a food peculiarly suited to a wasting malady, and its mild alterative effects are also of value. It maintains the patient's strength and general nutrition, and so favorably influences the pulmonary lesion. In chronic rheumatism the drug is often of great service, particularly if the disease is largely muscular. Strumous skin lesions depending for their existence not only upon scrofulosis, but also upon anaemia, often yield to its use. In enlargement of the lymphatic glands, where they are not undergoing acute active suppuration, cod-liver oil given internally does good. This is a statement requiring explanation. By acute active suppura- tion is meant the early formation of pus or the molecular death of the parts — not the slow formation characterized by no active change, but represented by cold abscess or old sores. If the suppurative process is chronic, the oil does good by maintaining the patient's nutrition. In cases of strumous ophthalmia cod-liver oil is of great service. In advanced syphilis cod-liver oil is most useful, and in the early stages of rickets it ought always to be employed. In marasmus, when used by inunction or given internally if the stomach will stand it, it is one of the best drugs we have. If a few grains of bile-salts, consisting of glyco- cholate and taurocholate of sodium, be added to each drachm of oil, it will be more readily absorbed, from the skin when applied by rubbing, or when taken internally. 1 At the present time capsules of cod-liver oil, to which has been added some bile-salts to aid in the absorption of the oil, can be obtained in the market. In sciatica and lumbago and in neuralgia cod-liver oil is of service, particularly if those disorders are dependent upon anaemia or an impoverished state of the system. In emphysema of the lungs it is 1 These salts may be bought, or made as follows: To about 300 c.c. of ox-gall is added nearly thrice that quantity of ordinary alcohol, and the flask shaken thoroughly. All the mucus is now precipitated and the supernatant fluid is filtered. To the filtrate is added a large excess of sul- phuric ether, and after a time a plaster-like mass forms at the bottom of the vessel, which slowly becomes crystalline. These crystals are now placed on a filter-paper and washed with a mixture made of ether and alcohol, equal parts. The filter-paper is dried and the substances then seen are the taurocholate and glycocholate of sodium. Having carefully removed these salts from the paper, they are ready for use COD-LIVER OIL. 209 said to be of value, and certain writers commend its use in gout, although others have asserted that it is of no value. Sometimes old persons, whose digestion is not disordered and who have no organic brain disease, complain of giddiness. The best treatment for this con- dition, in many cases, is cod-liver oil with small doses of quinine, or if these fail wine of ergot and one of the bromides may be used. Administration. — Owing to its disagreeable taste and smell most patients rebel against taking cod-liver oil; but these objections can, with a little persistence, be readily overcome, so that finally the patient may not object to the remedy, but actually like it. This is particularly true of young children. The secret of reaching this much-to-be-desired state lies in the use at first of doses which may be dropped into a teaspoon and the spoon then gently submerged in a glass of milk. The oil floats off onto the milk in a globule in the centre of the tumbler, and if the milk be rapidly gulped down without the oil touching the sides of the glass, it will not be tasted. The first gulps must be large enough to include the oil. The oil may be taken on a full stomach, but as a gen- eral rule it is best digested if taken about two or three hours after meals, when the gastric contents are about to be passed into the small bowel, where the oil is digested; and if it be immediately followed by a little pancreatin, its digestion will be much aided. Other modes of ingestion consist in the placing of the oil in whiskey or brandy, in the manner which has been described with milk. This method possesses the advantage that the alcohol by its stimulating effect aids very distinctly in the digestion of the oil. Sometimes a pinch of salt placed in the mouth before and after the oil is taken aids in masking its taste and in its digestion. (See Indigestion.) Oil of eucalyptus in the proportion of 1 to 100 of the cod-liver oil will disguise the latter's taste, but many persons dislike the eucalyptus more than the cod-liver oil. The addition of an equal quantity of glycerin, with \ to 1 minim (0.025-0.05) of the oil of bitter almonds to each dose, is often of service. Syrup of bitter orange-peel is one of the best masks to its taste. Tomato ketchup has also been used with good results. Chewing a piece of smoked herring before and after taking the oil is of value to disguise the taste in some cases. The oil is readily taken in soft capsules holding from \ to 1 drachm (1.0-4.0). Few patients are unable to swallow such capsules if these are first made slippery by dipping them in water. Cod-liver oil is most readily digested when given in single nightly doses after supper or after a light meal just before going to bed. After a few days it may be given after dinner, and in the course of a week after breakfast. If the patient is once nauseated by overdoses, it is almost impossible to make the stomach retain the oil. If there is diffi- culty in digestion, a drachm of ether aids in its absorption, or a drink of whiskey or brandy may be used instead. Often a simple bitter, such as a dessertspoonful (8.0) of compound tincture of cardamom, taken in water immediately after the oil is swallowed, aids in its diges- tion. 14 210 DRUGS. A large number of preparations of cod-liver oil are on the market in emulsion, pancreatized, and purified till they are nearly tasteless. Two emulsions are official in the U. S. P. of 1900: Emulsum Olei Morrhuoe and Emulsum Olei Morrhuce cum Hypophosphitibus, each containing 50 per cent, of oil, and given in the dose of 2 to 4 flui- drachms (8.0-16.0). Many of the permanent or perfect emulsions contain more Iceland moss or acacia than oil. The pancreatized emulsions are the best if the oil is present in sufficient quantity to do good, as the very fact of the oil being artificially digested adds to its value and makes it possible to put more oil into the emulsion. Gil devoid of smell is probably devoid of medicinal value, as all the peculiar properties have been " purified " out of it. Quite recently it has been suggested that cod-liver oil be given by the rectum, a full dose of pancreatin being mixed with it to increase its assimilability. Sometimes creosote is placed in this injection in 5- to 10-minim (0.30-0.60) doses to prevent decomposition-changes in the oil and after absorption to a t as an c xpectorant. COFFEE. (See Caffeine.) COLCHICUM. Colchicum is the corm (Colchici Cormus, U. S. and B. P.) and seed (Colchici Semen, U. S. ; Colchici Semina, B. P.) of Colchicum Autum- nale, or Meadow Saffron, a plant of Europe, containing an alkaloid, colchicine (Colchicina, U. S.) which may be still further changed into colchiceine. The drug is official in the form of the seeds and root. Physiological Action. — Colchicum is a very powerful drug, and when locally applied is an irritant to the skin. Taken internally in overdose, it also severely irritates the gastro-intestinal mucous membrane. According to the studies of one of the writer's students — Dr. Ferrer y Leon — the drug has little or no effect when given in mod- erate dose on the nervous system, circulation, respiration, or tem- perature, producing changes in these parts only when given in poi- sonous doses. In full doses it greatly increases the flow of bile, and may cause bilious vomiting and purging. Jacobi asserts that death is produced by respiratory failure, the heart continuing to beat for many minutes after respiration ceases. The violent gastro-enteritis which is present in colchicum poisoning in man certainly has much to do with the usual fatal result. Therapeutics. — The employment of colchicum in medicine centres around its use in gout and similar states, such as chronic rheumatism. It is almost a specific in acute gout, provided that it be pushed until it causes slight griping or laxity of the bowels. Colchicum does not seem to possess any marked beneficial effect in preventing attacks. Indeed, while it relieves one attack it often seems to hasten the onset of the next. In acute gout it is usually well to unload the bowels by COLCHICUM. 211 a small dose of compound extract of colocynth, with some hyoscyamus added to it to stop griping. Thus R — Ext. colocynth. comp gr. x vel xx (0.60-1.3). Ext. hyoseyami gr. ij (0.12). — M. Ft. in pil. No. iv. S. — One as soon as threatened by an attack. This pill is particularly needed if constipation be present and the belly hard. After this has acted the colchicum may be given. Thirty to 40 minims (2.0-2.6) of the wine of the root should be given, and 20 minutes more in twelve hours. In some cases of subacute or chronic gout or chronic rheumatism, iodide of potassium should be used in conjunction with the colchicum. The following may be ordered: R — Potassii iodidi ....... 3 ss vel. 3 j (2.0 vel 4.0). Vini colchici seminis f.^ij (8.0). Vinialb q. s. f Jiij (90.0).— M. S. — Tablespoonful (16.0) three times a day after meals. Shake well before using. The use of colchicum in such doses as to cause severe purgation or emesis is dangerous, and ought not to be resorted to. Colchicine, U. S., can be used successfully in gout in the dose of t ^-q to -j-q grain (0.0006-0.0012) three times a day. There are now on the market capsules or pearls of colchicine with oil of gaultheria, each pearl con- taining from y^-q to -g 1 ^ grain (0.0006-0.001) of colchicine. They are very efficacious and are largely used. Poisoning. — The symptoms of poisioning by colchicum are nausea, griping, agony in the belly, purging followed by the passing of thick mucus, with great and increasing tenesmus, profuse salivation, col- lapse, and death from exhaustion and gastro-enteritis. Bloody purg- ing is almost never seen. The poisoning is one of the most painful, slow, and hopeless poisonings known, and a man taking as much as an ounce of the wine of the root or the seed is almost inevitably doomed to a terrible death. Tannic acid may be used as a partial chemical antidote, and the stomach washed out by the administration of emetics and the use of the stomach-pump. Opium is to be used to relieve the pain and irritation, and oils are to be given to soothe the inflamed mucous membrane. If collapse comes on, external heat and stimu- lants are to be used, and atropine may prove of service under these circumstances. Aministration. — Colchicum ought never to be used in substance, but should be employed in the form of wine of the seed (Vinum Colchici Seminis, U. S.) in the dose of 20 to 40 minims (1.3-2.6), although if a marked effect is required 60 minims (4.0) may be used. The extract (Extractum Colchici Cormi, U. S.) is given in the dose of \ to 2 grains (0.03-0.12) and the fluid extract of the seed (Fluidextr actum Colchici Seminis, U. S.) in the dose of 2 to 4 minims (0.10-0.25.) 212 DRUGS. The tincture of the seed, (Tinctura Colchici Seminis, U. S. and B. P.) is given in 15 to 60 minim (1.0-4.0) doses. The B. P. pre- parations are Vinum Colchici, dose 10 to 30 minims (0.6-2.0), and Extractum Colchici, dose J to 1 grain (0.015-0.06). Colchicine (Colchicina, U. S.) is given in pill in the dose of to ^ grain (0.0006-0.0012). To"o C0LL0DI0N. Collodium, U. S. and B. P., is a solution of gun-cotton or pyroxylon in alcohol and ether, and is a clear, syrupy fluid, smelling strongly of ether. Therapeutics. — Collodion is used as an air-tight dressing for small wounds and abrasions and for rendering small dressings waterproof. A difficulty in its use consists in the contraction which takes place as it dries, which draws and puckers the parts sufficiently to cause not only discomfort, but also acute pain. It should be applied with a camel 's- hair brush. In boils, when they are beginning in a small pustule or papule with an inflamed zone, collodion painted over the spot, except at its very centre, will generally abort the suppuration. If the boil has burst, this treatment is useless; but if it has not, the pus should not be liber- ated, but allowed to become inspissated. By this treatment and by the frequent application of a coat or two the local trouble eventually disappears. This rule applies only to certain cases, and if pain is caused by the retention of the pus, it must be evacuated with antiseptic precautions. In smallpox the flexible collodion may be used to pre- vent pitting. In gouty inflammations of the joints an application of collodion mixed with iodine, equal parts, will often diminish the pain, although at first the suffering may be increased by this treatment. Flexible Collodion. Flexible Collodion (Collodium Flexile, U. S. and B. P.) is made by adding Canada turpentine 5 parts and castor oil 3 parts to 92 parts of ordinary collodion. It does not contract or become hard, and is generally to be preferred to ordinary collodion in the dressing of wounds. Styptic Collodion. Styptic Collodion (Collodium Stypticum, U. S.) contains tannic acid, and is employed to check small hemorrhages. It is seldom used, and its employment is a dirty way of controlling bleeding. COLOCYNTH. 213 Cantharidal Collodion. Cantharidal Collodion (Collodium Cantharidatum, U. S.) has been referred to under the head of Cantharides. Collodium Vesicans, B. P., is identical with this preparation, and is used for the same purpose. COLOCYNTH. Colocynthis, U. S., is the fruit of Citrullus Colocynthis, a plant at present largely grown in all parts of the world. It contains an alka- loid, colocynthine, and a resin. Neither of these is used in medi- cine. Colocynth causes large watery evacuations, and may, in very large dose, produce fatal gastro-enteritis. It is official in the B. P. as Colocynthidis Pulpa. Therapeutics. — Colocynth is never used alone, but always in com- binations with other drugs of its class as a hydragogue cathartic. In cases of chronic dropsy and for the relief of serous effusions this drug is generally given in the form of the compound extract of colocynth (Extractum Colocynthidis Compositum, U. S. and B. P.), which con- tains 160 grms. of colocynth, 500 grms. of purified aloes, 140 grms. of the resin of scammony, 60 grms. of cardamom, and 140 grms. of soap. In the dose of 5 to 20 grains (0.3-1.3) this acts as a powerful watery purge useful in dropsy. The extract (Extractum Colocynthidis, U. S.) is given with other drugs in the dose of 2 to 5 grains (0.12-0.3) as a purge. The following is a useful form in which to administer it: 1$ — Extract, colocynth gr. xxx (2.0). Extract, belladonnas gr. ij (0.1). Extract, nucis vomicae gr. ij (0.1). — M. Ft. in pil. No. x. S. — One each morning. Colocynth is one of the principal ingredients in compound cathartic pills (Pilula? Cathartics Composites, II. S.). Each pill contains: com- pound extract of colocynth, IJ grains (0.08); resin of jalap, J grain (0.02); and calomel, 1 grain (0.08); gamboge, i grain (0.015). This pill is not to be used constantly, as it eventually makes the bowels more constipated than before. The U. S. P. of 1900 also orders a pill (Pilula? Cathartics Vegetabiles, U. S.) which contains compound extract of colocynth, extract of hyoscyamus, resin of jalap, extract of leptandra, resin of podophyllin, and oil of peppermint. This is given in the dose of 1 to 2 pills. The preparations of the B. P. not official in the U. S. P. are : Pilula Colocynthidis Composita, composed of colocynth-pulp, aloes, scam- mony, sulphate of potassium, and oil of cloves, dose 5 to 10 grains (0.3-0.60) ; Pilula Colocynthidis et Hyoscyami, dose 5 to 10 grains (0.3-0.60). 214 DRUGS. CONDURANGO. Condurango is the bark of Condurango Blanco, a tree of Colombia, South America. Martindale and Westcott state it is Gonolobus Condurango. It was introduced into medicine in 1873 as a cure for gastric cancer, and at one time had a favorable reputation. It is now known that, so far as the morbid growth is concerned, its action is valueless, but there is no doubt that it diminishes the severity of the symptoms in many cases by exercising a favorable effect on the gastric mucous membrane. It also tends to relieve the accompanying gastric catarrh through its action as a stomachic. The bark is never employed as the bark, but in the form of the fluid extract, dose 1 to 2 drachms (4.0-8.0), or the wine, dose \ to 1 ounce (16.0-30.0). Sometimes it is given in the form of a decoction made by adding 1 part of the bark to 8 parts of water, which is given in the dose of 1 tablespoonful (16.0) three times a day. Often it is advisable to add to the prescription a little hydrochloric acid to take the place of the natural acid of the stomach, which is usually lacking in such cases. CONIUM. Conium (U. S.) is the leaves and fruit of Conium maculatum. The plant grows in Europe and the United States, and contains a liquid alkaloid known as conine. Conium is official in the B. P. as hemlock-leaves {Conii Folia) and hemlock-fruit (Conii Fructus). Physiological Action. — Conium in full medicinal dose produces a feeling of relaxation and loss of muscular power, and if the dose be very large it causes giddiness, staggering gait, and disordered vision, with failure of the circulation. Nervous System. — Conium depresses the motor nerves, and, if the dose be extraordinarily large, the sensory nerves. Upon the spinal cord it exerts a slight depressing influence, but has no positive effect, while the fact that consciousness continues almost up to death shows that the intellectual portion of the cerebrum escapes its influence. Circulation. — The action of the drug upon the circulation is depressant. It causes at first a fall of arterial pressure; then, if the dose be large, a rise, due to the asphyxia caused by nervomuscular failure of the respiratory apparatus. Finally, a fall of pressure takes place. Respiration is depressed because of the paralytic influence of the drug on the nerve-trunks supplying the respiratory muscles. Therapeutics. — Conium holds an unimportant place in the drug-list of to-day. It has little value except in spasms due to irritation of a nerve-trunk, when it may be of service. In spasms of cortical or spinal origin other drugs should be used, as it is evident that conium has no effect in quieting the central nervous protoplasm, but only pre- vents the impulses which are sent out from manifesting themselves CONVALLARIA. 215 in movements of the muscles. The powdered leaves or other prepara- tions may be smeared over poultices to relieve the pain of ulcers and Fig. 37. cancers, arid they certainly do good in such instances. Administration.— The dose of the alcoholic extract (Extraction Conii) is from J to 1 grain (0.03-0.06), and of the fluid extract (Fluidextractum Conii, U. S.) 2 to 6 minims (0.1-0.4). The dose of the tincture (Tinctura Conii, B. P.) is 10 to 30 minims (0.60-2.0). Conine is a liquid alkaloid which should never be used. The dose of the hydrobromide of conine is said by Helbing to be |- to -§- grain (0.01-0.03.) The preparation in the B. P. made from the leaves is Succus Conii, dose 1 to 2 flui drachms (4.0-8.0). Vapor Conii consists of the juice of hem- lock (Succus Conii) \ ounce (15.0), liquor potassse 1 drachm (4.0), and distilled water 1 ounce (30.0). Twenty minims (1.3) of this mixture are placed in hot water in an inhaler, and so employed for the relief of irritative coughs or spasmodic asthma. Unguentum Conii is official in the B. P., and is used in pruritus ani. Tt s to be remembered that the varia- bility of the drug, so far as power is concerned, is very great — so great as to make it unreliable. For this reason a small dose should be given at first and the amount gradually increased. Poisoning. — A prominent symptom of poisoning by Conium is dropping of the eyelids (ptosis), due to par- alysis of the oculomotor nerves, and staggering and inability to walk. Its treatment consists in the use of strychnine as a respiratory and nervous stimulant, the employment of external heat, and the use of cardiac stimulants if the circulation fails. The stomach is to be emp- tied by emetics or the stomach-pump before the antidotes are used. conium acts as a depressant to the motor nerve-trunks. CONVALLARIA. This drug is derived from* the rhizome and root-stalk of Conval- laria majalis. It is employed in medicine as a cardiac tonic to fulfil the indications which direct us in the use of digitalis. While by no means so valuable a drug as foxglove, it sometimes acts better in an individual case than the older remedy. The heart is not greatly slowed by it, but the drug is particularly useful in cases of arrhythmia and "oardiac hurry." 216 DRUGS. The dose of the fluid extract (Fluidextractum Convallarioe, U. S.) is from 4 to 8 minims (0.25-0.5) three times a day. The tincture (Tinctura Convallarioe) is given in the dose of 5 to 20 minims (0.3-1.3). Convallamarin is a glucoside of convallaria which has been used in the dose of \ grain (0.03) three times a day. Some clinicians think it ought to be given but once a day on account of the danger of cumulative action. COPAIBA. The Copaiba of the U. S. and B. P. is the balsam or the oleoresin of Copaifera Langsdorffi, and is a clear, transparent liquid of oily consistence, of a pale-yellow color and a peculiar odor. From it is distilled an oil (Oleum Copaiba?, U. S. and B. P.) which is of little value. As copaiba is an oleoresin, the term " oleoresin of copaiba" is often used to distinguish it from the oil. Therapeutics. — Copaiba is used for the purpose of stimulating the mucous membranes of the genito-urinary tract, particularly when they are depressed after a period of inflammation, as in the later stages of gonorrhoea. In cases suffering from chronic urethritis with anaemia and debility the following prescription is useful. (See also Methylene-blue.) 1$ — Oleoresinse copaibse 5j (4.0). Oleoresinse cubebse gtt. iv (0.25). Ferri et ammonii citratis gr. xx (1.3). — M. Pone in capsulas No. x. S. — One t. i. d. after meals. Copaiba is employed in subacute and chronic bronchitis as a stimu- lant expectorant. In the treatment of subacute pyelitis, cystitis, and dysentery it is of value. In dropsy due to slow renal changes it is of service as a renal stimulant and diuretic. Administration. — Copaiba itself is given in the dose of 5 to 20 minims (0.3-1.3) in capsule or in emulsion. The oil of copaiba (Oleum Copaibas, U. S. and B. P.) is given in capsule or emulsion, preferably in the former, in the dose of 10 to 20 minims (0.60-1.3) two to four times a day. Sometimes it is dropped on sugar and so administered. Massa Copaiba?, U. S., is made by rubbing copaiba with magnesia, but this is a useless and clumsy way of using it in the pill form. The drug is eliminated in the urine, and gives the test for albumin with nitric acid. Copaiba sometimes causes urticaria, which soon disappears on withdrawal of the drug. COPPER. Cuprum is never used in the form of the metal itself, but chiefly as the sulphate, which appears in commerce as a blue, clear, somewhat efflorescent salt. It is soluble in 4 parts of cold water, and 2 of boiling water, but it is not soluble in alcohol. COPPER. 217 Physiological Action. — Copper sulphate, when locally applied to a mucous membrane, acts as a powerful astringent, or on the surface of an ulcer as a mild and superficial caustic. When given in overdose by the stomach, it causes death by violent gastro-enteritis and exhaustion. Generally the symptoms do not come on for an hour, and consist in burning pain in the stomach, a coppery or metallic taste in the mouth, followed by vomiting of bluish liquids and glairy mucus. With the vomiting, purging comes on, the passages at first containing the con- tents of the intestine, and finally mucus and blood. Convulsions of an epileptiform character are present, and constant and profuse saliva- tion is not infrequent. After death fatty degeneration of the liver and kidneys has been noted, and it is not uncommon for jaundice to appear after the first twenty-four hours, if the patient survives so long. This jaundice is dependent upon changes in the blood. The treat- ment of the poisoning consists in the primary use of the chemical anti- dote, which is the yellow prussiate of potassium, and the administration of emollient or demulcent substances, such as sweet oil and white of eggs, followed instantly by emetics or the stomach-pump. If emesis and purgation are already active, emetics are of course contraindicated, and counter-irritation is to be employed over the stomach and intes- tines in the shape of a mustard plaster of moderate strength, and opium given to allay irritation and relieve pain. Chronic copper poisoning is almost never seen, and, although the metal is widely used for coloring canned green vegetables, it seems to be harmless when ingested in such small amounts. Therapeutics. — Sulphate of copper (Cupri Sulphas, U. S. and B. P. in the dose of 5 to 7 grains (0.3-0.46) may be used as a rapidly acting emetic which acts only upon the stomach, but not uron the vomiting centre. As it is irritant, the emetic dose ought not to be repeated, but if emesis does not occur the sulphate of zinc or mustard should be used to empty the stomach. Indeed, it may be said of sulphate of copper that it should never be given as an emetic if any other emetic can be found. Thornton has proved in the Laboratory of Experimental Therapeutics of the Jefferson Medical College that an antidotal dose of copper sulphate given to a dog poisoned with phosphorus may produce death before the phosphorus can cause a lethal result. The drug is therefore a theoretical but not a practical antidote to phosphorus. In pill form it is sometimes given in diarrheas depending upon ulceration of the bowels. The dose should be J to 1 grain (0.015-0.06) combined with opium. In some states of the body, particularly in skin diseases of the dry type and in individuals with tubercular tendencies, copper seems to act like arsenic, and may be used in doses of -^ grain (0.006) or less three times a day where arsenic is not well borne. In small doses it is said to be a direct stimulant to the tissues, and to increase the firmness of the flesh and strength of the normal man. Very recently strong claims for copper as a remedy for anaemia have been 218 DRUGS. advanced, particularly if it is employed as the arsenite of copper, when the conjoint action of the arsenic and copper produces a good effect. Sulphate of copper in the proportion of 1 to 50,000,000 or 1 to 5,000,000 has been proved to be exceedingly valuable for the purpose of puri- fying water potable except for the growth of algse, which make it foul. In these proportions it also destroys the typhoid bacillus, and it should be placed in all springs, ponds, or reservoirs which may be contaminated by these germs. In these quantities it is harmless to man and animals. Locally applied, sulphate of copper is useful, in the solid form or in powder, in the treatment of indolent ulcers. In chronic conjunctivitis or in cases of tinea tarsi — that is, tinea on the margin of the eyelids — a crystal of the sulphate may be drawn over the diseased spot; or a solution of 1 to 3 grains (0.06-0.20) to the ounce (30.0) of water may be dropped into the eye in subacute conjunctivitis. In relaxed sore throat, as a gargle, in the strength of 4 grains (0.25) to the ounce (30.0), it is often of service. COTARNINE. Cotarnine is prepared from narcotine, one of the alkaloids of opium, but its physiological effect is closely allied to that of hydrastinine, derived from hydrastis. In the form of cotarnine hydrochlorate it has been placed on the market as "Stypticin," and this is used as a remedy for oozing hemorrhages, such as menorrhagia and metrorrhagia, and as a local application in epistaxis. It may be given in the dose of from ^ to 4 grains (0.03-0.25) three times a day in pill, tablet, or elixir, or in capsule, or by the hypodermic syringe in the dose of 1 to 2 grains (0.06-0.12). CREOSOTE. Creosote (Creosotum, U. S. and B. P.), as employed in medicine, should always be derived from the destructive distillation of beech- wood and be designated "beechwood creosote." Much of that sold is derived from coal-tar, and is far less useful. Chemically, creosote is almost identical with carbolic acid; clinically, it is very different. Beechwood creosote is an almost colorless or yellowish liquid about as thick as olive oil, and possessing a penetrating odor and a burning taste. Its physiological action is almost identical with that of carbolic acid, and in poisoning by creosote the same antidotes as are employed in carbolic-acid poisoning — namely, soluble sulphates — should be used, as has been proved in experiments by the author. Creosote contains 60 per cent, of guaiacol and 40 of cresol, not creosol. Guaiacol is sometimes used in place of creosote in the dose of 1 to 2 minims (0.05- 0.10). (See Guaiacol.) Creosote is a powerful antiseptic. According to the studies of Imbert, creosote is eliminated chiefly by the kidneys in the form of guaiacol sulphate and creosol sulphate of potassium. Elimination is not rapid, for this investigator did net find CREOSOTE. 219 Fig. 38. it completed for about twenty-eight hours. A small amount, of the drug is eliminated by the lungs. Therapeutics. — During the past few years creosote has been largely prescribed in pulmonary tuberculosis and chronic bronchitis, and some of the results reached by its use have undoubtedly been of value in these affections. (See article on Tuberculosis.) It has also been inhaled from sponges with great relief, and even has been injected into the lungs by way of the trachea or through the chest-wall. In the treatment of chronic bronchitis creosote may be placed in boiling water and inhaled in the steam. Under these circum- stances it lessens the fetor of the breath, and this method often gives more rapid relief than any other measure in the treatment of ordinary subacute inflammation of the bronchi. (See Inhalations.) The beginning dose when the drug is given internally is 2 to 5 minims (0.1-0.30). It is useless to attempt to cure pul- monary tuberculosis by the admin- istration of creosote, and its chief value in the disease depends upon its action as an expectorant affecting favorably the profuse bronchial se- cretion associated so often with the involvement of the lung tissues by the tubercular process. Creosote does good, indirectly, by relieving this complication; but it is apt to disorder the digestion. It ought not to be employed in every case, since its value in relieving the bronchial disorder is far outweighed by the disturbance of digestion in many instances. If fever or haemoptysis is present, the use of creosote is contraindicated. When it is desired to relieve profuse mucopurulent expectoration creosote may be given in capsule or as follows : R— Creosoti (beechwood) fgiij (12.0). Tinct. gentian, comp fSj (30.0). Spt. vini rectificati i% vii (240.0). ViniXerici Oij (960.0).— M. S. — A tablespoonful in a wineglassful (16.0 : 60.0) of water three times a day. In other cases the creosote may be dropped into half a glassful of milk and taken in this three times a day. Often as much as a drachm a day can be given by gradually producing tolerance through ascending doses; and it is worthy of note that in most instances large doses are required if satisfactory results are to be obtained. (See article on Tuberculosis, Part IV.) Yeo's inhaler, made of perforated zinc, bound on the edges with chamois, and sup- plied with elastic loops to go back of the ears. On a sponge placed in front of the inhaler is dropped the medicament to be inhaled. 220 DRUGS. In the advanced stages of phthisis inhalations of the drug often decrease the cough, relieve the laryngeal dryness, and promote expec- toration. When creosote is used hypodermically in phthisis, it may be given in the following formula: R— Creosoti fgij (8 0). Olei amygdal. express f^ij (8.0). — M. S. — 10 minims (0.60) to be injected deeply into the tissues below the scapula. This method is not to be employed except in rare cases. Indeed the author has jet to see a case in which its use seemed beneficial. In the treatment of subacute laryngitis a fine spray of 1 to 2 minims (0.05-0.1) of creosote, 4 grains (0.25) of menthol, and 1 ounce (30.0) of albolene, is of service used several times a day; or a mixture com- posed of creosote 10 minims (0.60), chloroform spirit 10 minims (0.60), and alcohol 20 minims (1.3), may be placed on the sponge of an inhaler and inhaled. It is also claimed that wetting cloths with creosote and hanging them in the air of a nursery are of great value in whooping- cough. (For methods, see Inhalations, Part III.) Sometimes creosote is given by enema in pancreatized cod-liver oil to children with pulmonary or peritoneal tuberculosis, in the dose of from 5 to 15 minims (0.3-1.0). Creosote is a valuable remedy in cases of indigestion with fermenta- tive changes in the gastric contents when these arise from the deficient digestion of meats or the use of sweets, given in the dose of \ to 2 minims (0.025-0.1) after meals, preferably in tablet or capsule. Applied on a pledget of cotton to the cavity of a carious tooth, creosote often relieves toothache by virtue of its anaesthetic influence over peripheral sensory nerves. While ordinary medicinal doses of creosote rarely cause disagreeable symptoms except some disorder of the stomach or bowels when it is given in full doses, the physician who is ordering large amounts should be always on the lookout for toxic symptoms. These consist in vertigo, headache, and a tendency to stupor, and the urine may become smoky in appearance, as in carbolic-acid poisoning. If any of these signs of overdosing appear, the drug must be reduced in dose or stopped altogether. The preparations of creosote are Aqua Creosoti, U. S., which is given in the dose of 1 to 3 fluidrachms (4.0-12.0); Mistura Creosoti, B. P., dose 1 to 2 fluidounces (30.0-60.0); Unguentum Creosoti, B. P., for local application. CREOSOTE CARBONATE. Creosote carbonate, sometimes called "Creosotal," is a combination of creosote with carbonic acid. Over 90 per cent, of creosote carbonate is said to be creosote. It is a thick, oily fluid of an amber color, with but little taste or odor, and is insoluble in water, dilute alcohol, and glycerin, but is soluble in 95 per cent, alcohol, in ether, chloroform, and CBOTON CHLORAL. 221 in cod-liver and olive oils. It is said to be less irritating to the stomach than creosote. The drug is dissolved and absorbed chiefly in the intes- tine. The dose of creosote carbonate is identical with that of creosote itself, and it is used as an expectorant in pulmonary tuberculosis and as an intestinal antiseptic. It is best given in capsule. (See also Guaiacol, Carbonate of.) It has been claimed that this drug possesses virtue in cases of croupous pneumonia, but careful clinical research fails to show that this is true. CREOLIN Creolin is a liquid cresol, a coal-tar product, possessing marked antiseptic but comparatively slight poisonous properties. It is a dark-brown fluid, is derived from soft coal, and is of the consistence of syrup. When added to water it forms a white cloud and mixes thoroughly, forming an emulsion up to 12 per cent, of the drug. Therapeutics. — Creolin is used as an antiseptic in the lying-in state, as a wash for the hands, and for vaginal irrigation. It cannot be used as a solution in which to place instruments, as the mixture with water is so opao^e as to prevent their being seen when lying at the bottom of the dish. When used as a vaginal douche it should be employed in the strength of 2 per cent. One of its properties which is of value is that it forms a slippery coating over the maternal parts during parturition. In the treatment of cystitis in the female, Parvin highly recommended it as a vesical wash in the strength of a 1 per cent, solution, or, after the bladder becomes accustomed to its use, in a 2 per cent, solution. According to Kretzschmar and others, a solution of 1 to 500, used with a syringe, is useful in otorrhea, 1 to 100 in nasal ulcers, and 1 to 1000 as a nasal douche in rhinitis when there is much discharge with the forma- tion of crusts. Creolin has also been used as an injection in the pro- portion of 5 parts in 1000 of water for dysentery and colitis with success. In the eye Alt has used with good results a 1 to 2 per cent, solution in the treatment of blepharitis, keratitis, and phlyctenular ophthalmia. CROTON CHLORAL. Croton Chloral, or Butyl Chloral Hydras, B. P., has a physiological action closely » allied to that of chloral itself, but it possesses more analgesic power and is much less depressant to the heart and circu- lation. The dose for the production of sleep is the same as chloral, 5 to 20 grains (0.3-1.3) in syrup. Therapeutics. — Croton chloral is preferable to chloral in sleepless- ness due to pain. In facial neuralgia and migraine it is exceedingly efficacious, par- ticularly if the fifth nerve be involved. In headaches due to eye-strain, and in those associated with sick stomach, but not due to gastric indi- gestion or nervous debility, croton chloral is of service. Curiously 222 DRUGS. enough, it is valueless in toothache, but is useful in the neuralgia due to deayed teeth. Administration. — Croton chloral should be used in pill form in the dose of 3 to 5 grains (0.2-0.3) every two hours till the pain is relieved or sleep comes on, or it may be given in solution or syrup of acacia and water, or water and glycerin. It has been used in as large a dose as 60 grains (4.0), but 20 to 30 grains (1 .3-2.0) ought to be the maximum dose as a general rule. CROTON OIL. Croton oil {Oleum Tiglii, U. S.; Oleum Crotonis, B. P.) is an exceed- ingly irritant oil derived from Croton Tiglium, a small tree of India. The oil is pale yellow in hue and of a complex character. Applied to the skin for any length of time, it is an intense irritant, producing blisters or pustules. 1 minim (0.05), placed on the tongue with 5 minims (0.30) of sweet oil, acts as a violent watery purge, and, owing to the smallness of its dose, it is frequently employed to revulse the unconscious, as in cere- bral congestion. In delirium it is used for the same purpose, and may be given to maniacs who are suffering from an attack of cerebral con- gestion or obstinate constipation, owing to the smallness of its dose and rapidity of action. The dose is 1 minim (0.05) placed on the tongue with sweet oil or given in emulsion or in pill. It ought never to be used when there is any irritation of the stomach or bowels. As a counter- irritant it is sometimes applied over a tender nerve or to the chest in the treatment of bronchitis, in the proportion of half-and-half with sweet oil. Thus applied, it may be absorbed and cause purging. The treatment of poisoning by croton oil is identical with that of gastro-enteritis. (See Gastro-enteritis.) Linimentum Crotonis is a preparation of the B. P. which is employed as a counterirritant liniment for sprains and in muscular rheumatism. CUBEBS. Cubebs (Cubeba, U. S., and Fructus, B. P.) are the unripe fruit of Piper Cubeba, a plant of Java. They are wrinkled or rough black bodies about the size of small peas, and have an aromatic, pungent taste. They contain a volatile oil, cubebic acid, and cubebin. The drug should not be kept in powdered form, as it loses its powers, but should be powdered as needed. Overdoses of cubebs cause gastro- intestinal and genito-urinary inflammation. Therapeutics. — Cubebs are used in the advanced stages of gonor- rhea where a tendency to a chronic discharge is present. Some sur- geons have used them in the early stages as an abortive treatment, but this is a bad practice. In cold in the head the powdered berries may be snuffed up the nostril when the stage of secretion is well estab- lished. They ought not to be used before this stage. In the treatment of chronic or subacute bronchitis the oleoresin of cubebs is very useful in some cases (see Bronchitis), and in the form of cubeb cigarettes the drug is much used as a remedy for hoarseness due to subacute laryngitis. DERMATOL. 223 Administration. — Cubebs may be given in powder in the dose of 10 to 60 grains (0.60-4.0), in [the fluid extract (Fluidextractum Cubebop, U. S.) 10 to 30 minims (0.60-2.0), and in the form of the tincture (Tinctura Cubeboe, B. P.) in the dose of 10 minims to \ ounce (0.60-16.0). The dose of the oleoresin (Oleoresina Cubeboe, U. S.) is 2 to 20 minims (0.1-1.3) three times a day, and it may be given in capsule or emulsion. The troches of cubebs (Trochisci Cubeboe, U. S.) are used for the relief of pharyngitis of a chronic type. The dose of the oil {Oleum Cubeboe, U. S. and B. P.) is 5 to 20 minims (0.3-1.3). cusso. Cusso, U. S. and B. P., sometimes called Kousso, is derived from Brayera Anthelmintica, a plant of Abyssinia. In the U. S. P. of 1880 it was called Brayera. It contains a volatile oil, tannic acid, and koosin or taeniin. The drug is used to expel the tape-worm, and is most valuable as a vermifuge, also possessing the advantage of safety. It should be used in an infusion (Infusion Brayerae) in the dose of h ounce (16.0) of the powdered flowers to a pint (480 c.c.) of water, and be taken in the morning on an empty stomach. (See Worms.) Koosin may be used in the dose of 20 to 40 grains (1.3-2.6) in capsule. The fluid extract (Fluidextractum Cusso) is given in the dose of \ ounce (16.0). It has been claimed that the drug is apt to cause abortion in pregnant women, but this is not known to be a fact. CYANIDE OF POTASSIUM. Cyanide of Potassium (Potassii Cyanidum, U. S.) is used in the same way and for the same purpose as hydrocyanic acid. (See Hydrocyanic Acid.) The dose is T V to T V grain (0.006). The following prescriptions may be used in cases suffering from bronchitis or phthisis accompanied with excessive cough : 1$ — Potassii cyanid gr. ij (0.12). Morphinae sulph gr. j (0.06). Syr. pruni virginianse . . . q. s. ad f ^iij (90.0). — M. S. — Teaspoonful (4.0) three to five times a day. Or as follows : Py — Potassii cyanid g;r. ij (0.12). Ammon. chloridi oij (8.0). Elix. calisayse q. s. ad f§iij (90.0). — M. S. — Teaspoonful (4.0) three or four times a day. DERMATOL. (See Bismuth Subgallate.) 224 DRUGS. DIASTASE. The word diastase is applied to substances found in certain of the digestive juices of the animal body and present in processes connected with the fermentation of grain, as, for example, in the manufacture of alcoholic beverages. Whatever diastase may be, we recognize that it belongs to the same class of enzymes as pepsin and pancrea- tin, and that it has the power of converting starch into sugar. Many preparations of malt contain some diastatic power, but there is only one preparation of diastase which possesses no other property save that of aiding the digestion of the starches — namely, one prepared originally by a Japanese investigator, Takamine, and called from his name "Taka-diastase." It is used to relieve cases of indigestion of starchy foods in the dose of 2 to 5 grains after meals, in tablet or capsule or in a solution, and is a most efficient remedy. A useful formula is as follows: 1^ — Taka-diastase gr. xlv (3.0). Cupri arsenit gr. \ (0.01). Extract, nucis vomicae gr. iv (0.25). — M. Form in capsules No. xx. S. — One capsule with meals. Often a little capsicum may be added to this prescription, in the treatment of atonic dyspepsia, with advantage. DIGITALIS. Digitalis, U. S., is the leaves of Digitalis purpurea, or Foxglove, of the second year's growth. The leaves are official in the B. P. as Digi- talis Folia. It contains a number of substances, no single one of which acts as do preparations of the crude drug. In other words, all these compounds must act together to produce therapeutic effects similar to those obtained when digitalis leaves are given. Among the sub- stances so far isolated from digitalis by chemists may be named digi- talin, digitalein, digitoxin, digitin, and digitonin. Several of these are probably compounds of the others. Digitalin, so called, occurs in two forms, amorphous and crystalline. The crystalline digitalin (French) is largely digitoxin, while the amorphous form is composed of digitonin, digitalein, and digitalin. A pure digitalin has, however, been isolated, which can now be obtained from Merck. Digitoxin and pure digitalin are the two most active principles yet found. None of these substances should be used in medicine to take the place completely of digitalis, but digitalin may be used as a heart stimulant. In the early part of this volume the necessity of employing reliable drugs was pointed out. In the instance of digitalis this is particularly important, because the cases in which it is used are often serious, and because digitalis varies greatly in strength. As a rule, DIGITALIS. 225 the wild digitalis is stronger than the cultivated, and the English or German digitalis is better than the American. The preparations of digitalis should therefore be obtained from a reputable manufacturing pharmacist after they have been physiologically tested. Physiological Action. — Digitalis is apt to irritate mucous membranes which are already slightly out of order, and for this reason should not be given by the mouth in cases of gastritis and allied states if it can be avoided. Nervous System. — The action of digitalis upon the nervous system is only manifested when poisonous doses are used. Small toxic doses Fig. 39. A, digitalis stimulates the heart; B, stimulates the vagus centres; C, stimulates the peripheral ends of the vagi; D, stimulates the vasomotor centre; E, stimulates the walls of the blood- vessels. decrease reflex activity by stimulating Setschenow's reflex inhibitory centres in the medulla, and finally by depressing the spinal cord. Convulsions are sometimes seen as a result of the action of decom- position products of digitalis — namely, toxiresin and digitalresin. Finally, the motor nerve-trunks themselves are depressed and the muscles are paralyzed. Circulation. — Upon the circulatory system digitalis exerts its chief influence. In moderate or medicinal amounts it increases the pulse- 15 226 DRUGS. force and arterial pressure, slows the pulse, and increases the size of the pulse-wave. The increase of pulse-force is due to a stimulating influence exercised upon the cardiac ganglia and the muscular fibres of the heart; the rise of arterial pressure is caused by the increase in pulse-force and pulse-volume, and by a stimulation of the vasomotor centre and the muscular coats of the bloodvessels, whereby a con- traction occurs in the walls of the arteries and arterioles. The slow pulse is produced by stimulation of the pneumogastric centre and the peripheral ends of the vagus nerves. The increase in the volume of the pulse is due to this influence on the vagi, for, the pneumogastric nerves being stimulated, the diastole of the heart is more full and com- Fig. 40. I \AAA/yyV\M/\ II f III AnJ^\ Showing the effect of digitalis on the circulation. (After Schmiedeberg.) I. Before digitalis was used: blood-pressure 86, pulse 21 in ten seconds. II. After the use of digitalis: blood- pressure 150, pulse 22 in ten seconds. III. After another dose: blood-pressure 164, pulse 20. IV. After another dose: blood-pressure 210, pulse 40. plete and occupies a greater length of time. The result of this delay is that the ventricles become thoroughly distended, and on contracting drive out a much larger wave of blood through the aorta than is nor- mally sent out (Figs. 39 and 40). This is important to remember when using the drug in heart disease and other states. While it is not known that the vagi are the trophic nerves of the heart, there is a large amount of evidence in favor of such a view, and it has long been thought that digitalis was not only a heart stimulant, but a remedy that increased the growth of its muscular tissue as well. If the trophic nerves of the heart are stimulated by digitalis, it becomes evident that it is a doubly DIGITALIS. 227 useful remedy. 1 (See the article on Heart Disease in Part IV. of this volume for a further explanation of the influence of digitalis in improving the nutrition of the heart muscle.) When full medicinal doses of digitalis are repeatedly given, or when poisonous doses are ingested, the action of the heart becomes exceed- ingly irregular, hobbling, and dicrotic. (See Poisoning.) What the cause of this irregularity is we do not know. It is certainly not due to weakness, for the cardiac beats, when they occur, are in themselves more forcible than in health. The probable explanation of this peculiar cardiac irregularity lies in a disturbance of the co-ordinating apparatus of the various parts of the heart muscle. By this the author does not refer to the so-called co-ordinating centre of Kronecker and Schmey, which probably does not exist, but to the changes which may take place in the so-called " contraction wave," which is found to begin in the normal heart at the great veins and passes from them through the auricular walls to the walls of the ventricles. It has been found by Wooldridge and by Tigerstedt that if the auricle and ventricles be separated by a ligature or clamp, they still continue beating, but no longer do so synchronously, or, in other words, the centres of each set of walls act independently of the others. The irregular action of the heart under digitalis is probably dependent upon a disassociation of these centres ; and this theory is substantiated still farther by the experi- ments of Roy and Adami, who have proved that independent con- traction of the various parts of the heart can be produced by stimula- tion of the peripheral end of the cut vagus, a part of the nerve which is stimulated by digitalis in the large doses which we have been consider- ing. In man this irregular pulse is replaced sometimes by an ex- ceedingly rapid pulse, which is shuttle-like in character; and whether the pulse be irregular or rapid, the arterial pressure is always low, owing, first, to the imperfect action of the heart, and, second, to a depression of the vasomotor centres and the muscular coats of the bloodvessels. The rapid pulse, when it occurs, is probably due to a depression of the peripheral ends of the vagus nerves. In the frog digitalis causes, when given in full doses, systolic arrest of the heart, but in man the arrest is in diastole. If a patient who has taken a poisonous dose be suddenly placed in an upright posture death may ensue, owing to the disturbance of the contraction-wave in the heart produced by the erect posture. Under these circumstances the heart beats so abortively that the circulation fails. Respiration. — Digitalis has almost no effect on this function unless the amount be poisonous, when respiration is slowed. Temperature. — Upon the normal bodily temperature digitalis has little or no effect in medicinal dose. In poisonous dose it lowers tem- 1 In an original study by the author he found that when digitalis is given continuously for a long period of time there results cardiac hypertrophy independently of any valvular lesion. See Therapeutic Gazette, December, 1897. 228 DRUGS. perature. In fever the drug seems to cause a slight fall with some con- stancy, but it can rarely be used for any antipyretic influence. High temperatures prevent digitalis from slowing the pulse, because, as proved by Brunton and Cash, fever depresses the vagus centres in the medulla, and also in all probability, when the temperature is very high, the peripheral ends of the vagus. This is an important point to be remem- bered in the therapeutic use of this drug. Kidneys, Tissue-waste, and Elimination. — Digitalis has almost no effect upon the kidney structure itself, and does not to any extent stimulate the renal epithelium. The cause of the increased urinary flow produced by digitalis in cases of cardiac dropsy depends upon the removal of congestion of the kidneys and the increased arterial pressure and improved circulation brought about by the drug. It is important to remember that digitalis, if given in overdose, may cause a spasm of the bloodvessels of the kidney, and so cause sup- pression of urine. This is usually followed by the development of cumulative effects. Upon tissue-waste digitalis seems to have little effect, but there is still some discrepancy in the reports as to the amount of urea excreted under its use, some investigators saying it is increased, others that it is diminished. It is not known how the drug is eliminated, as chemists have never been able to detect it in the urine. It is probably oxidized in the body. Poisoning. — The slow, full pulse, followed by the hobbling, dicrotic, shuttle-like pulse-beats, and the angry, tumultuous cardiac beat afford a combination of symptoms characteristic of the overaction of digi- talis. The pulse may be full and slow when the patient is recum- bent, but at once becomes irregular on his sitting up. As the poisoning progresses vomiting may come on, exophthalmos occurs, and a peculiar blue pearliness of the sclerotic is seen. Con- sciousness is generally preserved nearly to the last. Death from digitalis poisoning may not take place for days or may occur in two hours or even less. Headache is often a severe symptom. Treatment of Poisoning. — Tannic acid is to be given as a chemi- cal antidote; emetics and the stomach-pump are to be used, the former only when the drug has not been absorbed, for if the heart is much affected emetics are dangerous. External heat is to be applied, particu- larly about the abdomen ; the maintenance of a horizontal position must be insisted upon for several days after active symptoms have subsided, for sudden death on sitting up has occurred. The use of tincture of aconite, as the physiological antidote, may be resorted to. Therapeutics. — Much misunderstanding concerning the action of digitalis has arisen, and, while some call it a circulatory stim- ulant, others think it a circulatory depressant. The first class base their belief on the signs of increased arterial pressure and cardiac power, the others on the fact that it slows and steadies an irritable, rapidly acting heart but overlook the other signs. Digitalis is a cardiac DIGITALIS. 229 stimulant, and not a depressant. The quieting of irritability by it is the quietness produced by the drink of whiskey or coffee taken by the pugilist before he enters the ring, to steady his nerves and make him firm. If digitalis is used to decrease arterial tension, its dose must be dangerously large. (See Physiological Action.) Digitalis is of value in all cases of cardiac disease where the con- dition is one in which the heart fails to do its proper amount of work. If simple hypertrophy or excessive compensatory hypertrophy exists, it is harmful. It is of less value in aortic regurgitation than in any other lesion, because the prolongation of diastole allows greater oppor- tunity for the bldbd to fall back into the ventricle, although in the second stage of this lesion, when the mitral orifice and valve are begin- ning to be affected, it is often very useful. In some instances of mitral regurgitation the drug does harm by overdistending the auricle through ventricular stimulation, which results in an increase in the regurgitant flow, and we can never tell before trying it which cases will be so affected. In cases where the heart is irritable, palpitation present, and indigestion not the cause of the trouble, digitalis is of service. (See Heart Disease. 1 ) It is also useful in cardiac dilatation and asthenia, and in that condition which Da Costa called a " tired heart." In the second stage of pneumonia if the heart is laboring and unable to do its work properly, digitalis is often invaluable (see Pneumonia), and as a heart tonic during the course of exhausting fevers, in small doses, is of great service. In congestion of the lungs in the typhoid state it will drive out the blood from the part congested and relieve stasis unless the temperature is so high that it cannot act. In cardiac weakness from collapse, injury, poisoning, or shock digi- talis is of service, particularly in aconite poisoning, in which it is the physiological antidote. Owing to its tardy action it should, however, be preceded by ammonia and alcohol where the need is pressing. In muscarine poisoning digitalis and atropine are the antidotes. As a diuretic digitalis is most useful when the kidneys are congested and the circulation is sluggish from cardiac feebleness. When the renal structure is diseased, other drugs should take its place, or it should be combined with more active renal remedies, such as squill or caffeine, or with compound spirit of juniper in very chronic cases of kidney trouble. As digitalis acts very slowly and maintains its effect for a long time, it may be given only once a day after its effects have been obtained, for the purpose of continuing its influence. Often when the patient has by error received too much of the drug the finger can scarcely note any pulse at the wrist, yet the ear when placed over the heart finds it to be beating wildly, as though it would break out of the chest. It is important that the weak pulse at the wrist be not taken as the only guide as to the state of the patient for 1 It is absolutely necessary for the student to turn to the article on Heart Disease, and to read it carefully, in order to understand the action of digitalis in disease. 230 DRUGS. this very reason, and the physician should always auscult the prsecor- dium before reaching an opinion as to the action of digitalis. Untoward Effects. — Digitalis sometimes causes nausea and indigestion by irritating the stomach. In children it is very apt to produce marked irregularity of the pulse. When given in full doses, the patient should always remain in bed and not be allowed to sit up suddenly, as syncope may occur. It is particularly important that this rule be enforced if the patient desires to empty the bladder, for cases are on record in which a patient has risen suddenly, emptied the bladder, and fainted or even died in syncope. In some cases a cumulative action occurs, which consists in a sudden development of the effects of the drug to an excessive degree, so that the symptoms resemble those seen after a poisonous dose has been taken. This is particularly prone to occur when ascites or dropsy is removed by tapping after the drug has been taken for a long period. It is thought that the sudden withdrawal of pressure upon the great vascular trunks of the body-cavities causes the absorption of the drug with the juices of the tissues where it has remained inactive. Such an accident also sometimes occurs when a fever ends by crisis and digitalis has been given. It also takes place whenever full doses are given so frequently as to be in excess of elimination, for the drug is slowly eliminated, and so rapidly accumulates in the body. Cumu- lative action is often preceded by a scanty passage of urine. A decrease in the quantity of the urine when digitalis is being used should cause the physician to stop its administration or be most cautious in its con- tinuance. Contraindications. — In cases of marked atheroma of the bloodves- sels, in aneurism and apoplexy digitalis is a dangerous drug, because it raises arterial pressure, and it is because of this effect that it is harmful in the presence of arterial excitement. In fatty degeneration of the heart the remaining healthy muscular fibres of this organ are, it is true, stimulated by the drug, but at the same time it also increases arterial tension to such an extent as to increase the labor of the failing heart. Administration. — The official preparations of digitalis are the tincture (Tinctura Digitalis, U. S. and B. P.), dose 5 to 30 minims (0.30-2.0); the infusion (Infusum Digitalis, U. S. and B. P.), 1 to 4 drachms (4.0-16.0); the fluid extract (Fluidextractum Digitalis, U. S.), dose 1 to 4 minims (0.05-0.25); the extract (Extractum Digitalis, U.S.), J grain (0.015); and the powdered digitalis leaves (Digitalis Folia, B. P.), dose 1 to 4 grains (0.06-0.25), generally given in a pill. Some choice should be exercised in the use of the various prepara- tions made from digitalis leaves, because the different active ingredients of the drug possess different solubilities and exert different effects on the circulation. Thus digitalin, digitoxin, and digitalein all act as powerful stimulants to the heart muscle. Digitalin also stimulates the vagus peripherally and centrically. All three of these raise arterial DIGITALIS. 231 pressure by stimulating the vasomotor system peripherally and eentri- eally. Digitonin, on the other hand, does not stimulate the heart muscle, but rather depresses it. It also depresses the vagus, and thereby somewhat antagonizes the digitalin, 1 digitoxin, and digitalein. If we now turn to a consideration of the solubilities of these prin- ciples, we can readily explain the different effects produced by the infusion and tincture or fluid extract. Digitonin is soluble in water, as is digitalein; but digitalin is only slightly soluble and digitoxin is scarcely at all soluble in water. As a result, the use of the infusion in a case of heart disease would not give the patient the same degree of cardiac power as the use of the tincture, for not only would the most powerful stimulant of all to the heart, vasomotor system, and vagi — namely, digitalin — be present in small amount, but in addi- tion the large proportion of digitonin would antidote it. On the other hand, digitonin is sparingly soluble in alcohol, while digitalin and digitalein are readily soluble in it, digitoxin being slightly so. It would seem, therefore, that in the presence of a failing heart and circulation the tincture and the fluid extract are the preparations greatly to be preferred to the infusion, because they contain large amounts of the active stimulant ingredients. The reason that the infusion acts efficiently as a diuretic in some cases probably depends upon the fact that as it does not contain so much digitalin it is less apt to cause spasm of the renal vessels ; but if the heart is feeble and there is renal stasis, the tincture is probably the better preparation to overcome this state, because it both aids the heart and by contracting the renal vessels overcomes the stasis. The use of digitalin is inadvisable unless we are sure that we get that made according to the process of Schmiedeberg, for the other digitalins usually sold are very uncertain. The infusion is far more apt to disorder the stomach than the fluid extract or tincture, because of the irritating digitonin. The dose of digitalin, which ought not to be used as a sub- stitute for digitalis, is -^ grain (0.001). When digitalis cannot be swallowed there is little, if any, use in giving any of the official preparations hypodermically for they are precipitated in the tissues. Digitalin may be used at such a time. Its absorption may be brought about by the use of a poultice made by placing some digitalis leaves in a small bag and steeping it in hot water. The bag is then placed over the loins. This plan of treat- ment must be cautiously employed to avoid poisoning, because we cannot tell how much digitalis is absorbed. Attention has been called to the necessity of using a preparation which has been subjected to a physiological test by the manufacturer before it is placed on the market. This is important because the crude drug varies so greatly in strength that even the most careful 1 By digitalin, reference is made to that prepared by Merck, and sometimes called the digitalin of Schmiedeberg, and not the amorphous form of Homolle nor the crystalline digitalin of Nativelle. 232 DRUGS. pharmacist cannot be sure that each lot of leaves is of equal medicinal strength, and chemical analysis of its complex make-up is practically impossible. Often when a patient has been taking an ordinary prepa- ration of digitalis without good results the writer has seen the use of a physiologically tested and active preparation do much good. Under the name of " Digitalone " Houghton has devised an excellent liquid preparation of digitalis suitable for use by the mouth or hypodermic needle, since it represents the full therapeutic value of the drug and is readily absorbed without causing irritation, which is not true of tincture of digitalis. The dose is from 5 to 20 minims (0.30-1.3). DIURETIN. (See SODIO-SALICYLATE OF THEOBROMINE.) DORMIOL. This drug is closely related to chloral, being a compound of chloral and amylene hydrate, and is a colorless fluid, tasting somewhat like camphor and being slightly pungent to the oral mucous membrane. It is miscible with water, and is marketed in 50 per cent, watery solu- tion, which is further diluted by 4 additional parts of water when it is prescribed. It is used as a hypnotic, as its name indicates, and as a substitute for chloral, but is probably not so powerful as a sleep- producer. Its dose is J to 1 drachm (2.0-4.0) of the 10 per cent, solution just named, which may be mixed with syrup of raspberry, or water, to dilute it if desired. DUBOISINE. Duboisine is the alkaloid of the leaves of Duboisia myoporoides, a plant of Australia. The crude drug is little used in medicine, but duboisine sulphate is used as a mydriatic under the same conditions as is atropine, and more largely still as a hypnotic in insanity, inter- changeably with hyoscine. The dose of duboisine sulphate hypodermi- cally as a hypnotic is -£$ to -^ grain (0.0008-0.001). The clinical experience so far adduced would seem to indicate that it tends to decrease urinary secretion and to disorder the digestion, producing at the same time a soapy taste in the mouth, with excessive dryness of the mucous membranes. Rarely it causes profuse salivation or sweating in those who have an idiosyncrasy to its use. In a large number of insane and hysterical cases de Montyel found its use was followed by vomiting of part of the food, but the patients seemed to have no nausea. The sulphate has been used with much asserted success in the treat- ment of paralysis agitans. Usually the dose by the mouth for this pur- pose has been yj-g- grain three times a day. Cividati and Gianelli assert that duboisine is useful in epilepsy, particularly in its psychic forms. ERGOT. 233 ELATERIUM. E later lum, B. P., is a sediment obtained from the juice of Ecballium Elaterium, or squirting cucumber. It appears in small, friable, thin, grayish-green flakes, having a bitter taste. Elaterium is not official in the U. S. P., but its active principle, elaterin (Elaterinum, U. S. and B. P.), is official. Notwithstanding this fact, the crude drug is largely used. Physiological Action. — Elaterium is a decided irritant to all mucous membranes, and even to the fingers of those who handle it. Its chief effect when taken internally by man is to cause profuse watery stools, but for some unknown reason it rarely acts upon animals in this manner. Therapeutics. — This drug is the best hydragogue purge which we have, causing large watery passages, but not producing much pain when used in proper dose. For this reason it is useful in the treat- ment of local serous effusions, as in pericarditis and pleurisy, and in dropsy and ascites or general anasarca. It ought never to be used in cases of marked exhaustion, and may be advantageously followed, soon after it acts, by alcoholic stimulants. In uraemia with dropsy it is thought to aid in the elimination of the uraemic poison by the bowel. In cerebral congestions or effusions the drug is of service by depleting the diseased vessels. In poisoning by elaterium the symptoms are those of violent gastro- enteritis, and must be treated accordingly. (See Gastro-enteritis.) Administration. — The dose of elaterium is J grain (0.01), given in a freshly made pill. Elaterin is best given in the dose of from -^ to -^ grain (0.003-0.006), as follows: Py — Elaterini gr. iv (0.25). Alcoholis fgiv (120.0).— M. Dissolve by gentle heat. S. — Half a drachm contains T ^ grain (0.004), or one full dose. The official preparation of elaterin, the active principle of elaterium, is Trituratio Elaterini, U. S. (elaterin 1, sugar of milk 9), given in the dose of \ to 1 grain (0.03-0.06). Pulvis Elaterini Compositus, B. P. (elaterin 1, sugar of milk 39), is given in the dose of 1 to 5 grains (0.06-0.3). ERGOT. Ergota, U. S. and B. P., is derived from the spawn or mycelium of the fungus known as Claviceps purpura, which grows in the flower and replaces the grain in common rye, or Secale cereale. Many so-called active principles have been isolated by chemists, and named ecbolic acid, ergotic acid, sclerotinic acid, and ergotin. None of these represent the entire drug, the nearest in its approach 234 DRUGS. Fig. 41. being ergotin, and ergotin is not an isolated principle, but a com- bination of principles. Robert teaches that there are three principles — namely, ergotinic acid, cornutine, and sphacelinic acid — and that cornutine is a true alkaloid. Further, that it is upon this cornutine and sphacelinic acid that the chief activity of the drug depends. Tan- ret, on the other hand, denies the existence of cornutine as an alkaloid. Physiological Action. — Nervous System. — Upon the nervous sys- tem ergot exercises little, if any, effect. Circulation. — Ergot when injected into the circulation causes a primary fall of arterial pressure, followed by a slight rise. The domi- nant action is represented in the rise. This rise is due to a stimulation of the vasomoter centres, but the primary fall is caused by its direct depressant effect upon the heart muscle, resulting from the direct contact of the drug en masse with the heart. If the dose be very large, and the fall of pressure is not recovered from, progressive paralysis of the vasomotor apparatus and heart occurs. When given in medicinal doses by the stomach the drug causes a rise of arterial pressure, chiefly by an action on the heart and the muscular coats of the bloodvessels. Uterus and Unstriped Muscular Fibre. It has been commonly taught that the contrac- tions of the uterus produced by medicinal doses of ergot are due to the stimulating influence of this drug upon the muscular fibres of this organ; and while this is probably the case, it is also a fact, as shown by the careful studies a, ergot stimulates the of Hemmeter, that the drug causes uterine uterine centres in the spinal contractions by stimulating the centres in the cord, and B, the muscular 1 •, ,- * ,i • i 1 i • 1 fibres in the uterus itself . lumbar portion of the spinal cord which con- trols this viscus. On the uterus ergot in full medicinal dose exerts its influence not by increasing the normal pains of labor, but by causing a tetanic, tonic, unyielding uterine spasm which drives all before it. In very small doses it may assist the normal contractions without causing them to become tetanic. Ergot acts as a stimulant to all unstriped muscular fibres. Acute Poisoning. — The symptoms of overdosing from ergot, when the effects are slowly produced, are sometimes great hunger or craving of food, at other times nausea and vomiting, If the poisoning is quite severe, there are great restlessness, headache, delirium, and coldness of the surface of the body. Chronic Poisoning. — Two forms of poisoning from the prolonged use of ergotized rye bread sometimes occur. One is characterized by spasmodic muscular contractions, the other consists in the formation ERGOT. 235 of gangrenous sloughs. In the first of these forms it is not very uncom- mon for cataract to develop, and it is stated that the spams are due to the influence of one of the principles of ergot — namely, cornutine. Therapeutics. — Ergot is given to parturient women for the prevention or arrest of post-partum hemorrhages. For the prevention it should be given to the woman by the mouth just as the head of the child is about to slip over the perineum, and not before, but in the majority of instances its use is needless. When administered to check a hemorrhage already flowing, the doses should be large, as much as 1 to 2 drachms (4.0-8.0) of the fluid extract or 1 wineglassful (30.0) of the wine of ergot. The drug should produce its effects in about fifteen minutes, and may be repeated every fifteen minutes till it acts. The action lasts about half an hour. Ergot should not be given in the early stages of labor, but this rule may, under certain conditions, be modified. If uterine inertia comes on in the course of a normal labor, which cannot be overcome by the use of coffee or kola, or other nerve-stimulant, a small dose of ergot may be employed. Such a small dose does not cause a constant tetanic uterine contraction, but simply brings on the " to-and-fro " movements. By a "small dose" the writer means from 5 to 20 minims (0.30-1.3) of the fluid extract. Caution must be used even with this dose. If the birth-canal is obstructed, ergot should never be employed, and, unless the os uteri is well dilated, should not be given in any dose. In post-partum hemorrhage of a severe character it is well to give ergot aseptic or ergone hypodermically. " Ergot aseptic " is dis- pensed in sealed and sterile glass bulbs, and is a concentrated preparation of ergot intended for hypodermic use. Each bulb holds one dose, and the drug is drawn directly from it into the syringe. This is a most useful preparation. When ergot is given, care should be taken that the uterine cavity is free from all clots or placental fragments, lest closure of the os uteri under the influence of the drug imprison these harmful materials. According to many obstetricians, whose results have been confirmed by a number of special studies, ergot in moderate doses very distinctly aids in overcoming subinvolution of the uterus. In hemorrhages from the lungs and kidneys or other unapproachable parts ergot is thought by some to be very useful when given by the mouth, but it is probable that it rarely achieves any good. Par- ticularly is this the case in pulmonary hemorrhage, since a vaso- motor system practically does not exist in the pulmonary vessels, and the increased pressure caused by the ergot in the general systemic cir- culation may increase the pulmonary leakage. The truth is, that in pulmonary hemorrhage little real good can be obtained by internal medication. In epistaxis, menorrhagia, and metrorrhagia, and in some cases of night-sweats, ergot is of service. In hypostatic, pulmonary, and other congestions it is useful, particularly if employed with digitalis. 236 DRUGS. In dysenteries with bloody stools and in serous diarrhoea ergot some- times does good. Some persons suffer from vertigo associated with hyperesthesia of the scalp and headache. Relief can often be obtained in such cases by the use of 20 minims (1.3) of the fluid extract of ergot and 5 to 10 grains (0-30-0.60) of bromide of potassium three times a day. Ergot has been used very largely in the treatment of uterine fibroids as an expulsive remedy and cure. It is only of value in those cases where the growths are just beneath the mucous membrane. By the contractions of the uterine muscular fibres the blood-supply of the growth is decreased, the recurring hemorrhages cease, and the tumor is finally expelled, having sloughed out of its bed. This method is far inferior to the knife, and very painful and prolonged. Large growths cannot be so treated. Ergot is sometimes useful in the treat- ment of bleeding hemorrhoids, and it has been given with success in diabetes insipidus, when it is well to combine with it the bromide of sodium. Administration. — Ergot is official as the fluid extract (Fluidextractum Ergota;, U. S.) ; Extractum Ergotw Liquidum, B. P.), dose J to 1 drachm (2.0-4.0); and the extract (Extractum Ergotw, U. S. and B. P.), dose 5 to 30 grains (0.30-2.0). The wine (Vinum Ergotw) is given in the dose of 4 to 8 drachms (16.0-30.0). Bonjean's ergotin is made by a special process, and it or the solid extract can be given hypodermically if ergot aseptic cannot be had. The B. P. preparations are In- fusum Ergotce, 1 to 2 fluidounces (30.0-60.0), and Injectio Ergoto? Hypodermica, B. P., given in the dose of 3 to 10 minims (0.20-0.60) by subcutaneous injection. The B. P. also recognizes an ammoniated tincture of ergot (Tinctura Ergots Ammoniata). Ergotin (Ergotinum) is given in the dose of 2 to 5 grains (0.12-0.30). As ergot is a drug that varies greatly in physiological activity in its crude state, and cannot be chemically assayed with advantage, the physician should always use a preparation which has been physiologi- cally tested by the manufacturer before it is placed on the market. This may be done by studying its effect on the uterus of a pregnant animal, or by giving it to animals and observing its effect on the calibre of the small vessels. If the drug is active, it causes stimulation of the muscular coats of the vessels; and if its use is persisted in, it finally occludes them. Houghton has shown that an active ergot will cause gangrene of the rooster's comb if it is given constantly. Inert ergot will not do this. Much credit is due to Houghton for having per- fected this valuable pharmacological test. ERIGERON, or FLEABANE. Oil of Erigeron (Oleum Erigerontis, U. S.) is a yellowish volatile oil of a peculiar, not unpleasant, taste, closely resembling that of tur- pentine, which is distilled from the fresh flowering herb of Erigeron ETHER. 237 canadense. It is by far the best medicinal remedy for the treatment of passive uterine oozing, or a "show," as it is sometimes called. In epistaxis and other hemorrhages of moderate degree it is useful. In some instances it is used in place of copaiba and cubebs in the later stages of gonorrhoea. It is best given in capsule or on sugar in the dose of 10 to 30 minims (0.60-2.0) after meals, or oftener if needed. ERYTHROL TETRANITRATE. (See article on Nitroglycerin.) ETHER. Sulphuric ether is official as /Ether, U. S. and B. P., and in the U. S. Pharmacopoeia of 1880 was called Mther Fortior. Pure ether {Mther Purificatus, B. P.) is practically free from alcohol and water. Ordinary ether is not generally used as an anaesthetic, but for the abstraction of oils and for other pharmaceutical purposes. Ether is made by the action of sulphuric acid on ethylic alcohol, and is sometimes called, in consequence, ethyl oxide. Ordinary ether contains about 74 per cent, of ethyl oxide and 16 per cent, of alcohol, with a little water. On the other hand, the stronger or official ether contains about 96 per cent, of ethyl oxide and 4 per cent, of alcohol, with water. Both prepara- tions boil when held in the hand in a test-tube if a piece of broken glass is added to the liquid. The stronger ether boils much more vigorously than the weaker under these circumstances. Ether is a colorless, volatile, and very inflammable liquid possessing a peculiar penetrating odor, a hot, burning taste. For this reason it should never be held near a fire or light, and, as its vapor is heavier than air, any fire in the room should be above the patient, not below him. No flame should be held nearer to the ether than five feet. Physiological Action. — The action of ether on the animal organism is very rapid and powerful, but temporary. Except for the rapidity of its effects it is very much like that of alcohol. When applied to the skin, it causes intense cold by its evaporation, and may be used in the form of a spray to benumb or locally freeze a part. Upon mucous membranes ether as a liquid or in vapor acts as an irritant, and causes, when its vapor is first inhaled, great irritation of the fauces and respiratory tract, so that temporary arrest of respiration is not uncommon. The face becomes suffused and red and the conjunc- tiva injected. Owing to these conditions the patient often is restless or struggles to move his face away from the vapor, but a stage of quiet soon succeeds this primary stage of struggling. During this period of quiet the breathing is generally full and deep and the pulse rapid but strong, while the ocular reflexes are at its beginning intact. Following this stage a second period of restlessness or struggling may come on, In which the patient becomes absolutely uncontrollable except by brute 238 DBUGS. force. Yelling, shouting, cursing, or laughing and crying, may be prominent symptoms, and the individual is pugilistic, caressing, or ill-tempered, according to his temperament. If the drug is now pushed, a condition of total anaesthesia is soon attained, and quietude takes the place of the struggles. This is the time for the operation to be carried on, for if it is attempted in the earlier stages the struggles of the second stage prevent any operative procedures. (See Therapeutics, below.) It is not proper to push the drug till the muscular relaxation amounts to complete flaccidity, as this endangers the respiration. Nervous System. — In producing its effects, ether acts first on the brain, then on the sensory tracts of the spinal cord, then on the motor tracts, then on the sensory side of the medulla oblongata, and finally Fig. 42. B -E Ether produces anaesthesia by depressing the perceptive areas in the brain, A. Later it depresses the intellectual areas, B, and the motor areas, C. After this the sensory paths in the spinal cord are depressed, D, and finally the motor tracts in the cord, E. upon the motor side of the medulla, and thereby produces death from respiratory failure if given to excess. Upon the nerve-trunks it exerts no effect unless it is directly applied to them. Ether does not produce anaesthesia by influencing the blood, coagulating the protoplasm of the nervous system, or by any other destructive influence. It simply inhibits, for the time being, the vital functions of the parts affected by it. The anaesthesia from ether develops when the ether vapor is present in the blood serum in the proportion of 1 to 400. Circulation. — Ether is one of the most diffusible and rapidly act- ing cardiac stimulants which we possess, and is correspondingly fleet- ing in its effects. It increases the pulse-rate and force by stimulating the heart and the arterial pressure by increasing the activity of the vaso- motor centres. In overdoses it acts as a cardiac depressant, but only when the amount is very large. Upon the blood, the author's col- ETHER. ' 239 league, J. Chalmers Da Costa, has shown that ether, when given by inhalation, decreases the haemoglobin richness of each corpuscle, although there is an apparent increase in the number of the corpuscles themselves, particularly in those persons who are already somewhat anaemic. Respiration. — As already stated, when ether is first inhaled it often causes arrest of respiration. According to Kretzschmar, this is due to an irritation of the trifacial nerve, which causes a reflex spasm of the glottis, and not to irritation of the peripheral vagi in the lungs. This is only partly true, for the author has proved that section of the vagus nerves prevents this occurrence, so that both the vagal and tri- geminal irritations are responsible for the arrest. In patients under ether the movement of the diaphragm is an exceed- ingly interesting study, for before the condition known as surgical anaesthesia is developed, while there is still some rigidity and the throat reflex is not completely abolished, the contractions of the dia- phragm are frequently so violent that unless the laryngeal opening be absolutely free the intercostal spaces are depressed and the abdomi- nal contents thrust violently downward and outward. Just so soon, however, as the chin is pulled forward and a free access of air is allowed, the abdominal displacement, though it is still present, is not so great, and the chest movement is no longer reversed. As the ether is pushed the respiration becomes purely thoracic, the diaphragm no longer taking part in the respiratory cycle, or becoming so relaxed that it allows the chest on expansion to aspirate the abdominal viscera upward, as is shown by the retraction of the belly-walls at a time when they should normally expand with the thorax in inspiration. This obser- vation would seem to point to the fact that the primary stimulant action of ether upon the respiratory apparatus is particularly felt by those centres which govern the movements of the diaphragm, and that, as this is the case, these centres later are the first to feel the paralyzing effect of still larger amounts of the drug. These facts give us, therefore, a danger-signal during the adminis- tration of ether, and the integrity of the diaphragmatic function, as represented by the movement of the belly-walls, should be as care- fully observed as are the thoracic excursions, the character of the pulse, or the condition of the pupil. The rule may therefore be laid down that when the diaphragm ceases to act anaesthesia has been carried to its extreme legitimate limit, and that the use of an anaes- thetic after this time must be carried on with the greatest care and watchfulness. The diaphragm is the first part of the respiratory mechanism to yield to respiratory paralysis. In death from any cause the progress of failure of respiration will, in the vast majority of cases, be denoted by a failure on the part of the diaphragm primarily, with compensa- tory excursions of the chest ; and it is also to be noted that as the chest movements fail the accessory muscles of the neck come into play. These muscles in time cease to act, the hyoidean group lose their point 240 DRUGS. d'appui, the chest remains motionless, the lower jaw is dropped, and the scene is closed by a few gasps in which the muscles of the neck may be the chief factors. Upon the respiratory centre ether acts as a powerful stimulant when used in ordinary amounts; in overdose it paralyzes this part of the nervous system. Temperature. — Prolonged etherization lowers the bodily heat very greatly. That of the dog may be lowered some 9° F. in an hour if the drug be pushed, and as great a fall has been known as 4° F. in man. The fall is partly due to the depression of the nervous system and the chilling of the body and lungs by the evaporation of the drug. Elimination. — Ether escapes from the body by the lungs and kidneys. Untoward Effects. — Ether, while safer than chloroform, is not abso- lutely devoid of dangerous effects. 1 Sometimes, when the drug is pushed too strongly, deep cyanosis with pulsation of the jugular veins shows deficient oxygenation of the blood and cardiac distention. In other, very rare, instances sudden cardiac failure has occurred or total arrest of respiration ensued. In nearly all cases of sudden death from ether grave kidney or heart lesions have been found at the autopsy. Rarely the rise of arterial pressure which it produces has caused apoplexy. The treatment of accidents during etherization consists in the with- drawal of the ether, the use of artificial respiration, and the placing of the body, if the face is pale, head downward. On the other hand, if the face is flushed and cyanotic it indicates respiratory, not cardiac, failure, and this position is not to be resorted to. The physician should also employ hypodermic injections of strychnine, atropine, and digi- talis, or, more rarely, an intravenous injection of ammonia, which is more dangerous, but better than the others in a pressing emergency because it is more rapid in its action. Ether is often given hypoder- mically under such circumstances, and may occasionally do good; but its use is a bad practice, as, if the heart or respiration is already depressed by ether, the employment of still more of the drug simply makes matters worse. The cases in which such a line of treatment is followed by good results are those in which the failure of respiration is not due to a saturation of the body with ether, but to asphyxia pro- duced by mechanical interference with free breathing, as, for example, the presence of mucus in the air-passages or a too close application of the towel to the face. In such cases the hypodermic injection of ether causes so much local pain and irritation as reflexly to excite respiratory movements, as well as to stimulate directly the respiratory 1 The mortality due to etherization is about 1 in 20,000; or, according to the combined statistics of Julliard and Ormsby, in 407,553 cases there were 25 deaths, or 1 in 16,302, (Compare Chloro- form.) ETHER. 241 centre to greater effort. 1 Alcohol ought not to be used if the other drugs named can be obtained, because alcohol is so nearly allied physiologically and chemically to ether. Frictions, hot applications, and artificial respiration should be practised. (See article on Asphyxia.) The diaphragm being the most important muscle of respiration, the physician should seek to stimulate it by resorting to Laborde's rhythmic traction of the tongue, which consists in rhythmically drawing this organ outward and upward from the mouth ten to fourteen times a minute. Fig. 43 Illustrating how traction on the tip of the tongue draws the epiglottis away from the glottic opening and permits free ingress of air. Also showing how letting the tongue fall back in the mouth in anaesthesia would close the air-passages and permit the epiglottis to interfere with breathing. For a full description see article on Asphyxia. (From a research by Martin and the author.) As ether is at hand, it may be dashed on the chest and abdomen to cause inspiration by reflex action; in lieu of cold water, which wets the clothes and does not evaporate rapidly. In some cases great nausea and vomiting follows the use of ether. This can generally be prevented by the avoidance of food for twelve hours before the operation, and by the administration of cracked ice 1 As consciousness is not necessary to the carrying out of a reflex action, this is perfectly possible and probable. 1G 242 DRUGS. Fig. 44. and small doses of acetanilid and brandy after the operation. (See Vomiting.) This condition may also be avoided in many cases by giving oxygen gas with the anaesthetic. (See Oxygen, Important.) Severe bronchitis may occur in invalids and children after the inhala- tion of ether, and in many cases this is due more to the exposure than the drug. Pulmonary complications, while possibly due to the direct effect of the ether, are probably chiefly the result of the inspiration of particles of food, foul secretions from the mouth, and perhaps blood, into the lungs, the glottis being anaesthetized and unable to protect the lungs from the invasion of foreign matter. Great cleanli- ness of the mouth is essential before every operation, and care should be taken during and after the operation that profuse secretions are not inspirated. Total or partial anuria may develop after etherization, particularly after abdominal operations. This is a very dangerous symptom, which can sometimes be removed by giving nitroglycerin and a large rectal injection of normal saline solution. It has, however, been proved, both experimentally and clinically, that ether is not capable, in the ordinary patient, of producing renal disorder of any moment unless the kidneys are already diseased or the patient is soaked with the drug, as sometimes occurs when it is improperly given. Weir asserts that ether is not dangerous even in those with moderately diseased kidneys. The employment of ether in diabetic patients is dangerous; the patient often never re- gains consciousness after its use. Not uncommonly after the use of ether in the case of an old person or a child the bronchial tubes so fill with mucus that there is danger of the patient drowning in his own secretions. A full dose of atro- pine, which checks secretion, given hypo- dermically is useful at such times. Sometimes after an anaesthetic is given the patient is found to have a monoplegia. This is not due to the anaesthetic, but to pressure exercised upon the nerve supplying the part during the opera- tion. It is a true pressure-palsy. Therapeutics. — Ether is used chiefly as an anaesthetic by means of inhalation. One method consists in forming a cone out of a towel and a piece of paper and placing a small sponge in its apex. Upon this sponge the ether is poured, and the large open mouth of the cone is placed over the face. If this be done suddenly, the sensation of suffocation is generally so great as to cause fright and struggling, which is inadvisable. The better way is to hold the cone at some dis- tance from the face, and gradually bring it nearer as the effects of the ether are developed. As the vapor of ether is heavier than air, it Allis inhaler. ETHER. 243 falls over the patient's face in concentrated form, even if the distance between the inhaler and the patient amounts to several inches. There is therefore no justification in applying the cone to the face at the very beginning of the inhalation. After partial anaesthesia is attained the cone should be placed closely over the face and the vapor be pushed in as concentrated a form as possible, whereas when chloroform is used its vapor should be well mixed with a great amount of air. Care should be taken that the ether does not get into the eyes of the patient, either in vapor or liquid form, owing to the irritation which it will set up. To prevent this a piece of thin muslin wet with water will be found of service if placed over the eyes. A large number of ether-inhalers are employed in preference to the towel; the best is that known as the "Allis Inhaler," fitted with a web of muslin. (See Fig. 44.) (For the use of oxygen with ether, see Oxygen.) Much of the irritation of the upper respiratory passages produced by ether may be avoided by wetting the inhaler with a drachm or two (4.0-8.0) of an alcoholic solution of menthol (50 per cent.). When ether is to be given no food ought to be allowed the patient for twelve hours preceding its use, in order to avoid vomiting during and after the operation. The patient should not be allowed to retain any tobacco or artificial teeth in the mouth, as either may slip into the larynx and cause death while the anaesthetic is being given. Under the name of the A. C. E. mixture there is used a compound of alcohol, chloroform, and ether, which is properly but rarely used in America. (See Chloroform.) Ether may be used as a local anaesthetic in an atomizer spray, owing to the cold produced by its evaporation when it strikes the skin. Thus it is particularly useful in cases where thoracentesis or 'paracen- tesis abdominis is to be performed, and also in cases of superficial neuralgia, where the benumbing of the nerve often effects a permanent cure. Internally, by the stomach, ether is very useful in colic, although for -flatulence of adults and children Hoffmann's anodyne is a more efficient remedy. In cases of collapse ether given by means of the hypodermic needle or by the stomach is of great service, particularly when cardiac action is very feeble, and it will give relief by inhalation in some of these cases more rapidly than the nitrite of amyl. In hiccough a few inhalations of ether will often stop the spasmodic movements, and other local muscular spasms can be relieved in this way. In other instances a few drops scattered over the belly wall may arrest it. Large doses of ether given by the mouth or hypodermically have been highly recommended in the treatment of uraemia. They are most serviceable in the forms in which cardiac and respiratory com- plications are marked. Ether may be used by inhalation to produce muscular relaxation when the surgeon desires to reduce a strangulated hernia by taxis, 244 DRUGS. In cases where cod-liver oil cannot be digested ether may be given in 20-minim (1.30) doses in ice-water or capsule, either with the oil, or some minutes after it is taken, to aid in its digestion and absorption. Internal Administration. — When used internally, ether should be given in ice-cold water, or, better still, in capsule, in the dose of 30 minims to \ ounce (2.0-16.0). If cold water is not used to dilute it, so great is the irritation of the fauces produced by the fumes of the drug that deglutition is impossible. The B. P. recognizes a spirit (Spiritus Miheris) given in the dose of 1 to 2 drachms (4.0-8.0). Contraindications. — Ether should not be used by inhalation in bron- chitis or acute nephritis, because of its irritant properties; in perito- nitis or gastritis, because it is apt to induce vomiting; in aneurism or in the presence of marked vascular atheroma, because it may rupture a bloodvessel by raising arterial pressure; nor in diabetes, lest it pro- duce diabetic coma; and if anaemia is present and an examination of the blood shows that the haemoglobin is below 50 per cent., the use of the drug should be avoided if possible. ETHYL BROMIDE. Bromide of Ethyl is obtained by distilling a mixture of alcohol, sulphuric acid, and bromide of potassium, and is a colorless fluid of neutral reaction, having a pleasant odor resembling chloroform. It evaporates with great rapidity, and any sample which does not do this is to be discarded. Poured on the hand, it should leave no fatty feeling. It should be remembered that the drug is decomposed by sunlight and when in contact with the air. In the presence of lamp- light the fumes form bromal hydrate and bromine. The drug should be kept in dark-glass bottles. The physician should distinctly sepa- rate in his mind bromide of ethyl from bromide of ethylene. The latter is a chemical product possessing very dangerous properties, and should never be used in medicine. There is reason to believe that unfavorable symptoms follow the use of bromide of ethyl only when the drug is impure or is improperly used. Physiological Action. — According to the studies of Thornton and Meixell in the author's Laboratory at the Jefferson Medical College, the dominant action of the bromide of ethyl is on the respiratory, not on the circulatory, system. This effect is depressant, but this influence is only met with after excessive doses. The blood-pressure falls under its influence to a slight degree, and the pulse is slowed through an influence probably exercised on the inhibitory nervous mechanism of the heart. Therapeutics. — Bromide of ethyl is a useful anaesthetic for short operations, such as opening boils or abscesses, or for the relief of the pain in other brief surgical procedures. Originally introduced into general use in this country by Levis, it has been found unsuited to ETHYL CHLORIDE. 245 major surgical cases, because if continued for a long time it seriously depresses the respiration. Bromide of ethyl has been found of the greatest value by Montgomery, of Philadelphia, as an anaesthetic in labor and for minor gynecological operations in office practice. He finds that the patient may be allowed to inhale the drug from a Haw- ley inhaler, for as soon as she has had enough to produce anaesthesia the inhaler drops from her hand. The patient is also more obedient to the physician's directions, because of the fleeting influence of the drug, than when chloroform or ether is taken, and post-partum hemorrhage through uterine relaxation is not so apt to occur. A very great advantage possessed by bromide of ethyl is the rapidity of its action. A few whiffs are generally all that is needed to cause anaesthesia. It rarely produces disagreeable effects. Cases of sudden death under its use are, however, on record, and in some instances nervous twitchings, and even tetanic spasms, have been known to follow its employment. These tetanic symptoms are, however, fleet- ing and generally of little importance. Nausea and vomiting rarely follow its employment, but it is apt to leave an unpleasant garlic-iike taste in the mouth, and a similar odor of the breath is frequently noted for several days after its use. Administration. — Bromide of ethyl should be administered for but a brief period, but when taken should be inhaled freely. It cannot be given carelessly with good effect. If a good sample is employed, 45 minims to 3 drachms (3.0-12.0) is a sufficient amount to induce anaesthesia. This quantity should be used at once, instead of added to the inhaler drop by drop, as in the case of chloroform, and the cloth or inhaler should be held close to the mouth and nose, instead of at a little distance, as is often necessary with other anaesthetics. ETHYL CHLORIDE. Ethyl chloride is a liquid of a strong etherea. odor, made by the action of hydrochloric acid upon ethylic alcohol. It is used in the form of a spray, as is methyl chloride, for the purpose of producing anaesthesia by freezing the part of the body with which it is brought into contact. This liquid is used not only as a local anaesthetic by virtue of its freezing properties, but also by inhalation. It is neces- sary when it is given by inhalation, because of its great volatility, that it should reach the patient in concentrated form, and not have an opportunity to be dissipated into the surrounding air without first entering the lungs. For this reason it should be used by the aid of a mask such as that employed in the administration of nitrous oxide gas. The mask should be applied in such a way as to cover tightly the nose and mouth, and the ethyl chloride is then projected on to a compress which is placed inside of it. Where it is impossible to obtain an inhaler made for this purpose, a tin or glass funnel may be used 246 bRUGS. as a substitute. The large end of this may be placed over the mouth and nose, the neck of the funnel containing absorbent cotton. Through the small end of the funnel the chloride of ethyl is sprayed upon the cotton. By the careful adaptation of the hands to the sides of the funnel and the cheeks it is possible to make this a very close inhaler. A good way to keep ethyl chloride is in the form of a graduated glass container so constructed that the drug is measured as the spray is forced from it by the heat of the hand. The drug is placed upon the market for this purpose in gradu- ated glass containers, under the name of "Kelene." Anaesthesia produced by this method usually develops within a verv few moments, and it is claimed that Fig. 45. Hp- 50 31= 4C I'- -30 ll. — i !-— - 1 |j— -2( ^Jr^ -id Hfe i «ft2E *j Fig. 46. The cap unscrews and the drug escapes as a fine spray through a small hole in the end of the glass. Showing use of a glass funnel as an inhaler for ethyl chloride. there are very slight changes in the pulse and respiration under its influence. One or 2 drachms (4.0-8.0) of ethyl chloride are usually sufficient to produce an anaesthesia lasting from five to ten minutes. Larger amounts than this may be employed when a longer anaesthesia is desired. It is a noteworthy fact that the pupillary and corneal reflexes are not lost under its influence except in children, and this drug cannot be used as an anaesthetic where muscular relaxation is indispensable. After the mask is removed the patient rapidly recovers consciousness and often experiences no unpleasant symptoms, although vomiting may occur in some cases. It is, so far as is yet determined, a safe anaesthetic. A disadvantage of this form of anaesthesia is its cost. EUCAINE HYDROCHLORATE AND LACTATE. 247 In 2550 cases recorded by Lotheisen 1 death occurred under its effects, but this may have been due to organic disease of the coronary arteries, which was present. Seitz has collected 1600 cases with 1 death due to disease of the coronary arteries. ETHYL IODIDE. Ethyl Iodide is a colorless, non-inflammable liquid, which should be called hydriodic ethyl. Ethyl iodide must be kept in dark-colored bottles in a dark place to prevent it from undergoing decomposition. It is very volatile, and the fumes arising from it are slightly pungent, but not irritating in ordinary amounts. Unfortunately, the odor is disagreeable to most persons. Physiological Action. — Very little is known of the general physio- logical action of iodide of ethyl, and the drug would be a good one for laboratory investigation. It does not produce anaesthesia except in very large amounts. Therapeutics. — Iodide of ethyl is used in medicine entirely by inhala- tion for the treatment of subacute or chronic catarrh of the air-passages and for the purpose of rapidly impressing the system with iodine for alterative purposes, for it is the iodine in the remedy which produces the curative effects desired. In catarrhal states of the bronchial tubes the stimulating effect of the iodine is supposed to cause free secretion and to prevent abnormal thickening of the mucus and dilata- tion of the air-passages. For this reason iodide of ethyl is supposed to be of service in asthma and its resulting emphysema. Bartholow recommended this drug in the treatment of pneumonia. It was said by that writer to be particularly useful in the later stages of this disease, to aid in producing resolution, but the author has never seen it pro- duce much effect. (See Inhalations.) Administration. — 10 to 20 minims (0.65-1.3) may be placed upon a handkerchief and inhaled, or a small vial filled with the drug may, be held in the hand under the nostrils. Under these circumstances the heat of the hand sets free the necessary amount of vapor. EUCAINE HYDROCHLORATE AND LACTATE. Eucaine hydrochlorate is a synthetic substance having a chemical formula closely resembling that of cocaine. The drug is now mar- keted as a substitute for cocaine, it being claimed that it does not affect the heart as does the latter drug. Eucaine does not cause a primary contraction of the bloodvessels when locally applied, as does cocaine, but a hyperemia of the parts affected. Two forms of eucaine have been used, eucaine "A" and eucaine "B"; but the latter is now employed for ordinary local anaesthesia, and for use in ophthalmic and genito-urinary surgery, as it is less irritating. Used by the process 248 DRUGS. for producing infiltration anaesthesia (see Cocaine) , eucaine causes con- siderable pain before acting as an anaesthetic. For infiltration it should be used dissolved in the following formula and warmed before being injected: ~fy — Beta-eucain gr. j (0.06). Sodii chloridi . . gr. x (0.60). Aquae destillat fgiij (90.0). In ophthalmic practice it is employed in 2 per cent, solution, and to ordinary mucous membranes in 5 per cent, solution — that is, 25 grains (1.6) to the ounce (30.0) of water. One advantage of eucaine is that it forms a permanent solution with water in 3J per cent, strength. Fur- ther, eucaine solutions can be boiled and thereby sterilized before they are used without causing decomposition of the drug. Recently eucaine lactate has been introduced to take the place of the hydrochlorate, as it is very much more soluble, namely, to the extent of 25 per cent. Eucaine hydrochlorate possesses a distinct disadvantage in its inability to cause primary contraction of the bloodvessels when locally applied, and this effect of cocaine is often most valuable to overcome local engorgement. Further, it causes severe smarting pain when dropped into the eye. Eucaine is also capable of producing internal effects resembling those due to overdoses of cocaine, and these must be treated by the use of strong coffee, alcohol, digitalis, and strychnine. If the case is urgent, ether, ammonia, and nitroglycerin may be used as rapidly acting stimulants. EUCALYPTUS. Eucalyptus, U. S., is the leaves of Eucalyptus globulus, or Blue- gum tree, a native of Australia, but grown at present all over the world. Its chief medicinal constituent is the oil of eucalyptus {Oleum Eucalypti, U. S. and B. P.), from which is derived Eucalyptol, U. S., which is a camphoraceous body obtained by redistillation with caustic potash or chloride of calcium. The oil of eucalyptus and eucalyptol are used for the same purposes, but the latter is the refined product of the former. Physiological Action. — Locally applied, the oil is a decided irritant. 10 to 20 minims (0.60-1.3) taken internally cause slight stimulation, followed by a sense of calm ; while larger doses produce disturbed diges- tion and loose, oily-odored stools. The pulse is increased in frequency and force, and intense headache may come on. After very large doses there is a fall in pulse-force, bodily temperature, and strength of limb, and the respirations are decreased. A peculiar loss of sen- sation in the lower limbs may occur. If death takes place, it is due to respiratory failure. The drug is eliminated by the skin, kidneys, EUONYMUS. 249 bowels, and lungs. The urine may have the odor of violets, as it sometimes does after the use of oil of turpentine. The oil of eucalyptus has considerable antiseptic power. Therapeutics. —Eucalyptus is used in malarial fever where quinine cannot be had nor be borne by the patient owing to idiosyncrasy. In bronchitis in an emulsion or in capsule, it is of great value in the later stages (see Bronchitis), since in its elimination by the lungs it acts locally upon the inflamed mucous membrane, and it may be used in the subacute forms of gonorrhoea in the same manner. The following pre- scription will answer: 1$ — Olei eucalypti . foj (4.0). Olei amygdalae express foj (4.0). — M. Ft. in capsule No. x. S. — One t. i. d. after meals. Oil of eucalyptus is very useful in some forms of rheumatic headache or in headache dependent upon malarial fever. Eucalyptol, U. S., is obtained from oil of eucalyptus, and is largely employed by rhinologists and others in lotions and other nasal appli- cations. It may be used in solutions of fatty oils, but is insoluble in water, although it is soluble in alcohol and ether. Administration. — The fluid extract (Fluidextr actum Eucalypti, U. S.) is given in the dose of 10 minims (0.60) to 2 drachms (8.0), the oil {Oleum Eucalypti, U. S. and B. P.) in the dose of 5 minims (0.30). The dose of eucalyptol is 5 grains (0.30) in capsule. Trochiscus Eucalypti Gummi and Unguentum Eucalypti are official in the B. P., but are seldom used. EUDOXINE. Eudoxine is the bismuth salt of nosophen. (See Nosophen.) It occurs as an odorless, tasteless, insoluble, reddish-brown powder, containing less than 60 per cent, of iodine. Eudoxine is employed in medicine as an intestinal antiseptic and antifermentative. It is used in the diarrhoeas of children in the dose of \ to 5 grains (0.03-0.3), and given to adults for the same purpose in the dose of 5 to 20 grains (0.3-1.3). The range of usefulness of this drug is much the same as bismuth in such cases, except that it is less astringent, but more anti- septic and alterative. Because of the latter influence it is indicated in subacute chronic catarrhal inflammations of the bowels. EUONYMUS. Euonymus, U. S., Euonymi Cortex, B. P., or Wahoo, is the bark of Euonymus Atropurpureus , a native plant of the United States. It contains an active principle, Euohymin, B. P. As a laxative its action 250 DRUGS. is very slow and mild; it is thought to act particularly on the liver, and may be used when moderate hepatic torpor is present. Administration. — The dose of the solid extract (Extractum Euonymi, U. S., Extractum Euonymi Siccum) is 3 to 10 grains (0.20-0.60). Of euonymin the dose is \ to 1 grain (0.03-0.06). EUPATORIUM. Eupatorium, U. S., Thoroughwort or Boneset, is the leaves of Eupa- torium perfoliatum, an American plant which is largely used as a simple bitter tonic and diaphoretic in household medicine. The drug is generally given in hot infusion in cases of arrested menstruation due to cold or in the chill of a remittent or intermittent fever, and also for anorexia and debility. Its taste is very disagreeable. In the dose of a pint (480 c.c.) of the cold infusion it has been used as an emetic. The fluid extract (Extractum Eupatorii Fluidum, U. S.) is given in the dose of 30 minims to 1 drachm (2.0-4.0). EUPHORBIA PILULIFERA. This herb is sometimes called Snake-weed or Cat's Hair, and is a native of Australia and the West Indies, where, like stramonium, it grows profusely as a weed by the roadside. Physiological Action. — In toxic doses the drug kills small animals by failure of the respiration and circulation, these two vital functions being greatly affected by doses which exert no great influence on the rest of the body. In full dose it may cause some gastric irritation. Therapeutics. — Euphorbia pilulifera is one of the latest remedies introduced into medicine for the relief and cure of asthma, in which disease the results obtained, after other remedies fail, are very extraor- dinary if the reports of those who have given it a thorough trial can be accepted without reserve. As yet we do not know the form of asthma which is most relieved by its use, and its employment is purely empir- ical. It has also been highly praised in the treatment of chronic bron- chitis and emphysema. Administration. — Euphorbia pilulifera is best given in the form of the fluid extract in the dose of 30 minims to 1 drachm (2.0-4.0). The decoction is made by adding a " handful of stalks with the leaves on them to 2 quarts (2 litres) of boiling water, and boiling down to 1J quarts (H litres)." Of this decoction the dose is a small wineglass- ful (60.0) three times a day. (See Asthma.) EUPHTHALMIN. Euphthalmin is a synthetic alkaloid used as an active mydriatic. It possesses an effect upon the general system very like that of atro- EXALG1NE. 251 pine, but when first dropped into the eye may cause slight salivation through irritation of the secretory fibres of the chorda tympani, which it reaches after absorption. The pupil under its influence begins to dilate in from fifteen to twenty minutes after a few drops of a 2 to 10 per cent, solution are instilled. The maximum dilatation is reached in about an hour, and disappears in about five to eight hours. Vinci states that the mydriasis is due to paralysis of the oculomotor nerve- endings, and that the sympathetic is not affected. EUROPHEN. Europhen is the result of the action of iodine on isobutylortho- cresol, in the presence of an alkali, and appears as a fine yellow powder, soluble in alcohol, ether, chloroform, and oils, but insoluble in water. It was introduced because it was hoped that it might prove a useful substitute for iodoform. One advantage claimed for it is that it parts with its iodine very slowly, and so is not apt to produce toxic symptoms as rapidly as does iodoform. For this reason, however, it lacks the remedial power of the older drug, except in those instances in which a drying power is needed which will keep the wound pure by making it too dry to be favorable to the growth of germs. When such an action is desired, europhen possesses the additional advantage of being five times as bulky as iodoform. In the treatment of tuberculous growths europhen has proved itself very inferior to iodoform. Owing to its stability, it fails to part with its iodine except in the presence of moisture, and is useless in dry skin diseases. It has been found useful in scrofuloderma, ulcer of the legs, and lupus. Europhen may be employed externally in a salve of the strength of from 5 to 10 per cent., or with olive oil or lanolin. It can also be added to flexile collodion. The drug does not possess the odor of iodoform, but experience will probably prove it to be more irritating than the latter drug. The internal dose is 1 to 3 grains (0.06-0.20) in cases of syphilis. Europhen is incompatible with metallic oxides and the preparations of mercury, and also with the starch and zinc paste largely used by dermatologists. EXALGINE. This substance is really methyl-acetanilid, and closely resembles acetanilid or antifebrin in its effects. It is given for the same purposes as are acetanilid and antipyrin — namely, for the relief of pain in loco- motor ataxia and other nervous affections — but never as an antipyretic. When used, exalgine should be given night and morning as a rule, so that the doses shall not be near together. The beginning dose should be from 2 to 4 grains (0.12-0.25), and not more than 15 grains (1.0) 252 DRUGS. should be given in twenty-four hours. It is stated by those who have used the drug that fever contraindicates its employment. The following prescriptions will be found applicable: 1^— Exalgini gr . xxx (2.0). Tincturae aurant. dulcis f3ij (8.0). — M. Ft. in sol. et adde Syr. aurantii fgss (16.0). Aqua? menth. piperit. . . . q. s. ad f giv (120.0).— M. S. — A tablespoonful night and morning. Or, Ifc— Exalgim • gr. xxx (2.0). Spt. frumenti fgss (16.0).— M. Ft. in sol. et adde Syr. simplicis f§j (30.0). Aquas dest q. s. ad f §iv (120.0).— M. S. — Tablespoonful night and morning. FLAXSEED. Flaxseed or Linseed (Linum, U. S. and B. P.) is the seed of Linum usitatissimum, or flax from which linen is made; it is official in the B. P. as Lini Semina. These seeds contain an oil and a mucilage, the first of which is largely used in the arts, and the second is some- times employed in medicine. The oil (Oleum Lini, U. S. and B. P.) is also used by physicians and pharmacists for various purposes. Therapeutics. — Flaxseed acts as a demulcent to inflamed mucous membranes, and is used largely in the treatment of acute cystitis, bronchitis, gastritis, nephritis, and similar states, in the form of flax- seed tea. This is prepared by mixing together 3 drachms (12.0) of flaxseed, not ground, 30 grains (2.0) of extract of liquorice, 10 ounces (300.0) of boiling water, and allowing the mixture to stand one to four hours in a warm place. If the mixture is boiled, the oil is set free and makes the dose disagreeable. This infusion may now be made more tasteful and useful by the addition of a little lemon-juice and sugar and by the placing of from 1 to 2 drachms (4.0-8.0) of gum arabic in the pitcher containing it. If the cough is excessive, a little paregoric may be added. Linseed oil is used sometimes as a laxative in the dose of 2 ounces (60.0), and is said to be of service when so given in the treatment of hemorrhoids. Flaxseed meal (Lini Farina) when moistened is employed uni- versally as a useful poultice. Under the name of Carron oil (Linimentum Calcis, U. S.) an emulsion of lime-water and linseed oil, equal parts, is the standard application for limited or extensive burns, FORMIC ALDEHYDE (FORMALDEHYDE). Formic aldehyde is a gaseous body difficult of application because of its physical characteristics, but nevertheless possessing very great FORMIC ALDEHYDE {FORMALDEHYDE). 253 power as a disinfectant or germicide. It is prepared by subjecting methyl alcohol to oxidation, and almost every instrument-maker has a device whereby this gas may be generated, and the room formerly occu- pied by a sick person thereby disinfected far more efficaciously than can be accomplished by burning sulphur. The doors and windows of the room should be tightly shut during the process of disinfection and for several hours after the formaldehyde generator is exhausted. As the gas is exceedingly irritating to the eyes and respiratory passages, no one should attempt to enter the room. After the disinfection is completed the room should be aired for some hours, or, if it must be used at once, it may be rendered capable of habitation by spraying a 20 per cent, solution of ammonia to neutralize the acid atmosphere. The great advantage of formaldehyde for these purposes is the fact that it per- meates every nook and cranny, and yet does no injury to colored fabrics, as does chlorine gas under similar circumstances. Such generators as have been named can be had for about four dollars. Liquor Formaldehydi, U. S. is an aqueous solution of formaldehyde which contains 37 per cent, by weight of the gas. It forms a clear, colorless liquid of a pungent odor, which is particularly irritating to mucous membranes. It can be mixed with water and alcohol in all proportions, but on standing its solution becomes milky because of the separation of paraformaldehyde. It should be kept in a cool place protected from light. The official solution of formic aldehyde, in the strength of 37 per cent., has been widely used of late for disinfectant and antiseptic pur- poses. For all these purposes it is usually diluted still further by the addition of water. A 1 per cent, solution is usually quite active enough for surgical antisepsis, and is far less poisonous than is the bichloride of mercury. A similar percentage, or a little stronger, may be used to preserve pathological specimens, and it is stated that in the propor- tion of 1 to 32,000 it will preserve milk for several days. Taken inter- nally in small amounts, it does not possess any toxic properties. Concentrated undiluted formaldehyde solution may be used for the purpose of cauterizing syphilitic sores. The safety, efficiency, and cheapness of formaldehyde gas as a dis- infectant, and of the solution, render this agent a most valuable one. (See Disinfection.) Formaldehyde is useful to check excessive fetid sweating by virtue of its antiseptic effect and because it hardens and contracts the skin. The solution used may be made by diluting the 37 per cent, com- mercial solution with 4 to 6 parts of water, or using Euformol diluted or pure as a lotion. Euformol contains eucalyptus, gaultheria, menthol, boric acid, and formaldehyde, and is pleasanter to use than the crude preparation. Diluted in the proportion of 1 to 4 of water, it may be employed as a lotion to the entire body to check colliquative sweats. Under the name of "Glutol" a compound of formaldehyde and gelatin is used as an antiseptic powder, which, drying the surface of 254 DRUGS. the wound or ulcer, seals it and renders it sterile. It is claimed to be a particularly efficient dressing for bums. GALLIC ACID. Acidum Gallicum (U. S. and B. P.) is usually prepared from tannic acid. It occurs in nearly colorless, long, needle-like crystals, which are soluble in 100 parts of cold water, 4J parts of alcohol, and 3 parts of boiling water. Physiological Action. — Gallic acid is an astringent, but not a coag- ulator of blood. Locally applied in bleeding, it is useless, but given internally in hemorrhages which cannot be acted upon by the direct local application of tannic acid, it is thought to be useful as a haemo- static because it contracts the bloodvessels. It is eliminated from the body by the kidneys as gallic acid. Therapeutics. — Gallic acid may be used with some success in hcema- turia, hcemoptysis, colliquative sweats, and in chronic bronchitis with profuse expectoration. Combined with opium, it is one of the best remedies in diabetes insipidus, and is also useful in diabetes mellitus. In albuminuria dependent upon a relaxed, atonic state of the kidneys and in acute or chronic diarrhea gallic acid may be used with advan- tage. In the form of the ointment it is useful in the treatment of psoriasis, and in the cure of ulcers and sores which are actively dis- charging. A very useful application to external hemorrhoids is equal parts of stramonium ointment and gallic acid. Administration. — Gallic acid is given in the dose of 2 to 40 grains (0.12-2.6) in pill or solution. It ought never to be used with any salt of iron, as it is chemically incompatible. The preparation used locally is Unguentum Acidi Gallici. Nut-gall. Nut-galls (Galla, U. S. and B. P.) are the small excrescences found upon the oak (Quercus lustianica) formed by the ova of the fly Cynips Gallon tinctorial. Their sole value depends upon the tannic acid con- tained in them, and they are official in the form of the tincture (Tinc- tura Galla?, U. S.), dose h to 2 fluidrachms (2.0-8.0), and the ointment (Unguentum Galla?, U. S. and B. P.). Unguentum Galla? cum Opio is official in the B. P., and is used as an astringent and sedative oint- ment. GAMBTR. 255 GAMBIR. Gambir is an extract derived from the leaves and young shoots of Ouronparia Gambier. It takes the place held by catechu. Gambir depends for its medicinal value upon the astringent properties which it possesses. Beyond this power it has no particular value. It is of a dark-red color, has a somewhat sweetish taste, and is insol- uble, like most extracts, in water. Therapeutics. — Like all the vegetable astringents, gambir is used as a remedy for diarrhoea, particularly that of the serous type or that in which the stools are of too fluid a consistence. If large amounts of mucus in the passages show a catarrhal state of the bowel, the mucus should be displaced by a purge of castor oil or sulphate of magnesium before the astringent is used. Gambir may or may not be combined with opium in cases of diar- rhoea, but the following prescription will be found of service in many instances : For an adult : Ji — Tinct. gambir composit f^ij (60.0). Tinct. opii camphoratae ^2^ (60.0). Misturae cretse fgij (60.0).— M. S. — Dessertspoonful (8.0) every four hours till relieved. To be shaken before using. In cases of sore throat where the secretion is excessive and the inflam- mation subacute, gambir may be used as a gargle. In cases of spongy gums gambir is sometimes useful as a mouth- wash. If the powdered gambir is used internally, the dose is 20 to 30 grains (1.3-2.0). The dose of the Compound Tincture of Gambir (Tinctura Gambir Composita, U. S.) is 1 to 2 fluidrachms (4.0-8.0). Its only constituent besides the gambir is cinnamon. The Troches of Gambir (Trochisci Gambir, U. S.) are to be employed in sore throat, and are to be held in the mouth. They are not generally used. In the B. P. gambir is still official as catechu and the following preparations are also official: Trochisci Catechu; the tincture (Tinc- tura Catechu), dose 1 to 2 fluidrachms (4.0-8.0); and a compound powder (Pulvis Catechu Compositus), composed of catechu, kino, and rhatany, the dose of which is 20 to 4 grains (1.3-02.6). GAULTHERIA. Wintergreen, or Gaultheria procumbens, is an x\merican evergreen containing a volatile oil. The oil possesses a peculiar, exceedingly penetrating odor and a warm aromatic taste. It is about 96 per cent, salicylate of methyl. Salicylate of Methyl (Methyl Salicylas, U. S.) is an artificial product made official in the last revision of the tl S^ P„ 256 DRUGS. Physiological Action. — Owing to the large amount of salicylate of methyl contained in the oil, its physiological action is almost identical with that of salicylic acid. Therapeutics. — Aside from its use as a flavoring substance, oil of gaultheria may be used in place of the ordinary salicylates in all forms of rheumatism in which they are useful. This oil (Oleum Gaultheria?, U. S.) is best given in capsules or emulsion or dropped on a teaspoonful of sugar three times a day after meals. The dose may be as high as 100 minims (6.6) a day, but if 60 minims (4.0) three times a day are without effect, pushing it further is useless. Very few patients can take more than 30 minims a day without suffering from a disordered stomach. Lannois and Limousin have highly recommended the application of this oil to acute and chronic rheumatic joints. The oil is placed on lint, and then the lint is wrapped around the part affected, evaporation being prevented by applying a gutta-percha covering. They assert that this treatment gives rapid relief, although they admit that after it the skin may desquamate. The spirit of gaultheria (Spiritus Gaultheria?, U. S.) is given in the dose of 10 to 20 minims (0.60-1.3). GELSEMIUM. Gelsemium, U. S., and Gelsemii Radix, B. P., or Yellow Jasmine, as used in medicine is the rhizome of Gelsemium sempervirens, & climbing plant of the Southern United States. It contains an alkaloid, gelsemine, and gelseminic acid. Physiological Action. — Nervous System. — Gelsemium paralyzes the spinal cord, particularly on its sensory side (?), although the motor side is certainly ultimately depressed. It does not influence the nerves or muscles except those of the head, on which it acts as a paralyzant, particularly affecting the motor fibres. Circulation. — Gelsemium is a depressant to the circulation, act- ing particularly on the heart. It paralyzes the vagus and lowers blood- pressure. Respiration. — Gelsemium kills by paralyzing the respiratory cen- tres (Sanderson, Ringer, and Murrell). Temperature. — In overdose the drug lowers bodily heat very markedly. Eye. — Gelsemium is a mydriatic of considerable power, causing, when dropped into the eye, wide dilatation of the pupil, a result due to paralysis of the oculomotor nerve peripherally. Therapeutics. — Gelsemium is used in headache and migraine depend- ing on nervous troubles or upon eye-strain. It is particularly useful in combination with cannabis indica. (See Cannabis Indica and Migraine.) GENTIAN. 257 In malarial fever it is said to be of service, but this is doubt- ful. In the early stages of pneumonia and pleurisy it has been highly spoken of by Bartholow. Gelsemium has also been found of value in asthma, whooping cough, laryngismus stridulus, and nervous cough. In localized muscular spasm, such as is seen in torticollis or wryneck, and in spasmodic dysmenorrhea, it is of considerable service. It ought not to be used if the system is already depressed, but only in sthenic cases. When used as a mydriatic, Tweedy recommends gelsemine as equal to atropine in effect, but much more transient in its influence. He uses a solution of 8 grains of gelsemine to the ounce (0.5-30.0) of water instilled, drop by drop, into the eye every fifteen minutes for one hour, and then every half -hour for two hours. Poisoning. — The most prominent symptoms of gelsemium poison- ing are ptosis and dropping of the jaw. These are preceded by a sensation of languor, a desire to lie down, relaxation, and muscular weakness. Gelsemium is apt to cause temporary internal squint, owing to its paralyzant action on the sixth pair of cranial nerves. The pulse becomes rapid and feeble, the skin wet and cold, the face pinched and anxious, the voice is lost, and death ensues from centric respiratory failure and an almost simultaneous cardiac arrest. Sen- sation in man is impaired very late in the poisoning. The treatment of the poisoning consists in the use of cardiac stimu- lants, such as ammonia and digitalis, the application of external heat, and the employment of atropine and strychnine for the purpose of stimulating the respiratory centre. Emetics and the stomach-pump are, of course, to be employed if the patient is strong enough. Administration. — The fluid extract (Fluidextractum Gelsemii, U. S.) is given in the dose of 2 to 5 minims (0.10-0.30), and the tincture (Tinctura Gelsemii, U. S. and B. P.) 5 to 15 minims (0.30-1.0). In some parts of the United States physicians largely employ a very strong unofficial tincture of gelsemium, the dose of which is 1 to 2 minims. Gelsemine may be used in the dose of -fo grain (0.001). GENTIAN. Gentiana, U. S., is the root of Gentiana lutea, or Yellow Gentian, a European plant. It contains gentianine and gentisic acid, and has a bitter taste. This drug is official in the B. P. as Gentiana? Radix. Therapeutics. — Gentian is one of the most efficacious bitter tonics that we possess. In the anorexia following acute diseases and in gout and malarial poisoning with dyspepsia it is of value. Combined with bicarbonate of sodium, it is of great service in the treatment of the subacute gastric and intestinal catarrh of children. Administration. — The compound tincture (Tinctura Gentians Com- posita, U. S. and B. P.) is given in the dose of 1 to 2 drachms (4.0- 17 258 DRUGS. 8.0), the fluid extract (Fluidextr actum Gentianoe, U. S.) in the dose of 30 minims to 1 drachm (2.0-4.0), and the solid extract (Ex- traction Gentianoe, U. S. and B. P.) in the dose of 1 to 8 grains (0.06- 0.50). Injusum Gentians Composition, B. P., is given in the dose of 1 to 2 fluidounces (30.0-60.0). The compound tincture and com- pound infusion are composed of gentian, bitter orange-peel, and car- damoms. The following prescription is an excellent one for use in convalescence from prolonged fevers: 1^— Acid, nitro-hydrochlor. dil. . . . f 5j vel f 5 ij (4.0-8.0). Tr. nucis vomicae f3j (4.0). Tr. cardamomi comp f^ij (60.0). Tr. gentianse comp. . . q. s. ad fgiv (120.0). — M. S. — Teaspoonful (4.0) in water after meals. GERANIUM. Geranium, U. S., is the rhizome of Geranium maculatum. It con- tains tannic and gallic acids, and is useful as an astringent in cases of serous diarrhoea. It is not the common red geranium seen in flower- gardens. In infantile diarrhea geranium-root, boiled in milk in the propor- tion of one or two roots to the pint, will be found of great service and is tasteless. The dose of the drug itself is 20 to 60 grains (1.3-4.0), and that of the fluid extract {Fluidextr actum Geranii, U. S.) \ to 1 fluidrachm (2.0-4.0.) GINGER. Zingiber, U. S. and B. P., is the rhizome of Zingiber officinale, sl plant of Hindostan, Jamaica, and other tropical countries. Black ginger is the dried rhizome with its bark, while white ginger has this covering removed. It contains a hot volatile oil and an aromatic resin, and is largely used in domestic medicine as a carminative and stomachic. In the treatment of menstrual cramps it is often given, and is particularly useful in those cramps due to suppression from exposure to cold. Ginger is often combined with purgative medicine to stop griping and for its pleasant flavor. Of itself it is decidedly constipating, and when used in diarrhoea mixtures is of value other than as a flavoring addition to the prescription. Administration. — The fluid extract {Fluidextr actum Zingiberis, U. S.) is given in the dose of 10 to 30 minims (0.60-2.0), well diluted; the tincture (Tinctura Zingiberis, U. S. and B. P.), dose 20 minims to 2 drachms (1.3-8.0); the syrup (Syrupus Zingiberis, U. S. and B. P.), dose 30 minims to 2 drachms (2.0-8.0); the oleoresin (Oleoresina Zingiberis, U. S.), dose h to 1 minim (0.03-0.05), well diluted or in pill; and the troches (Trochisci Zingiberis) used as stimulants to salivary secretion. GLANDULAR EXTRACTS. 259 GLANDULAR EXTRACTS. Within the past two decades physiological investigations have proved that several glands in the body not only secrete substances in the body-cavities, but also pour out into the blood- or lymph-vessels ferments or substances which perform definite physiological functions in the system. Disease of these glands perverts these functions, and secondary disorders follow. Acting upon the discoveries just named, some persons have attempted to show that nearly all of the organs of the body, be they glands or not, possess these functions, until they have reached a reductio ad absurdum. On the other hand, some of the glands are now used, when derived from the lower animals, for definite therapeutic purposes, such as the thyroid gland and the supra- renal bodies, for example. The use of the glands will be found dis- cussed under their own names, but unimportant glands in therapy, or those in regard to which doubt exists, are included under the general heading here given. The employment of testicular juice, or the dried gland itself, has been practically abandoned, but the extract of the ovary seems to possess considerable power. It has been used to combat the symptoms follow- ing double oophorectomy and those common to the menopause, and also for aphrodisiac purposes. On the ground that chlorosis is due to a faulty internal secretion of the ovary, it has been given in this condi- tion with asserted good results, and also in osteomalacia, neurasthenia, and hysteria in females. The dose is from 2 to 4 grains (0.10-0.20) a day. (See Ovarian Extract and Mammary Gland.) The use of cerebral and spinal extracts has proved futile, as has also the use of bone-marrow, in pernicious anamiia. The pancreas has been used in pancreatic diabetes, but its value is in doubt. The liver has been given in the dose of 3 ounces (90.0) of fresh gland a day to combat the delirium of cirrhosis, with asserted good results (Carnot), and has been thought to do good in alcoholic cirrhosis with icterus, in that the hemorrhages were arrested, the delirium ceased, and the patient generally improved. The same treatment has been tried in diabetes. It is difficult to see how it can be of benefit. While glandular therapeutics gives promise of aiding greatly in the treatment of disease, and while for this reason the cautious phy- sician should not oppose resort to the use of glandular extracts, he should, nevertheless, always study the physiological function of the gland to be employed in order that he may reach a clear idea of its remedial possibilities. The extraordinary effects of some glands do not prove that all animal extracts are of value, nor does the failure of others indicate that all are useless. 260 DRUGS. GLYCERIN. Glycerinum, U. S. and B. P., is a liquid obtained by the decom- position and distillation of fats. It possesses great power in absorbing water and of dissolving many substances. Even if pure it irritates the skin of susceptible persons when applied locally, by its absorption of water, and often causes a slight rash. Physiological Action. — Injected into the circulation in large amounts, glycerin causes convulsions, which are due to its hygroscopic power. According to the clinical researches of Pavy, glycerin increases the polyuria of diabetes almost one-half, and for this reason he thinks it is not to be employed in this class of cases as a substitute for sugar. Other clinicians, however, disagree with him and use it constantly for this purpose with asserted advantage. Therapeutics. — Glycerin may be employed as a sweetening agent in the food of diabetics and in cases where sugar cannot be used. It has also been given as a laxative in 1- or 2-drachm (4.0-8.0) doses by the mouth, and in enema — 1 to 4 drachms (4.0-16.0) with or without equal parts of water. In some cases it may be used in suppository in the official Suppositoria Glycerini, U. S. and B. P. This latter method is very successful in chronic constipation. Its continued use by sup- pository may, however, result in rectal irritation. As an antiseptic it is used for preserving specimens and for keeping alkaloids in solution for hypodermic use. In acute coryza, applied by a spray or brush to the nostrils, it is sometimes of service; for this purpose it should be diluted four or five times with water. If used on the skin, it should be diluted one-half with water. In cases of impacted cerumen in the external auditory canal glycerin is often of service in softening the mass. The uses of glycerin, other than those mentioned, are many. In the proportion of equal parts of glycerin and water it makes a very useful mouth-wash for the sore and dry mouth of typhoid fever and for the removal of sordes. The same wash, with lemon-juice added to it, is very agreeable and will relieve the dry, glazed tongue of advanced phthisis. Owing to the fact that glycerin is hygroscopic, it may be used as a depletant on a pledget of cotton in congestion of the uterine cervix, the tampon being renewed daily. (See Boric Acid and Boroglyceride.) For the prevention of bed-sores Ringer recommends the daily wash- ing and rubbing of the part likely to be affected, followed by the appli- cation of glycerin and water, with a draw-sheet placed smoothly against the patient to protect the bedding. Glycerin and whiskey is a favorite household remedy for colds and coughs, but is not very useful. Glycerite of starch {Glyceritum Amyli, U. S. ; Glycerinum Amyli, B. P.) is used as a protective over super- ficial irritations of the skin. Glycerite of yolk of egg {Glyceritum I ^itelli) is used in making emulsions. GR1NDELIA ROBUSTA. 261 A very useful ointment for the application of medicinal substances to the skin may be made by constantly mixing in the presence of heat 1 part of potato starch and 15 parts of pure glycerin. The result is a clear, transparent, jelly-like substance which does not decompose, and has the advantage of holding the medicament which it carries in solu- tion rather than by mechanical suspension. The B. P. preparations of glycerin are as follows: Glycerinum Acidi Carbolici, Glycerinum Acidi Tannici, Glycerinum Aluminis, Glycerinum Acidi Borici, Glycerinum Plumbi Subacetatis, Glycerinum Tragacanthce, Glycerinum Boracis, Glycerinum Pepsini, Glycerinum Amyli, and Unguentum Glycerini Plumbi Subacetatis. GOLD. Gold itself is not official in the U. S. P., but has been recom- mended very highly by Bartholow in chronic Brighfs disease in the form of the chloride of gold and sodium (Auri et Sodii Chloridum, U. S.). The dose of this substance is ^ to ^ grain (O.C03-0.006) once, twice, or thrice a day. The author has not found it of much value. Gold has also been strongly recommended for indigestion with epigastric pain after eating when looseness of the bowels is present, and it is said to act as a powerful sexual stimulant and to be of service in impotence dependent upon inability to obtain an erection or when there is deficient glandular action. It has also been used in excessive nocturnal emissions in masturbators, with asserted great success. In overdoses the drug causes gastro-enteritis. Magruder has recommended chloride of gold and sodium in the treatment of pertussis. GRINDELIA ROBUSTA. Grindelia, U. S., is an American plant (Grindelia robusta) containing a resin, a volatile oil, and an alkaloid. Physiological Action. — Upon the lower animals and man this drug is not very powerful in its action, but may cause, in large doses, par- alysis of the peripheral sensory nerves, the sensory centres in the spiral cord, and finally the motor centres and nerve-trunks. It slows the heart by stimulating the vagi, and raises blood-pressure by stimulating the vasomotor centre. Therapeutics. — Grindelia robusta is an exceedingly useful remedy in some cases of asthma and in bronchitis in its later stages. It may be given in the dose of 20 to 60 minims (1.3-4.0) of the fluid extract (Fluidextractum Grindelia?, U. S.), or by inhaling the fumes of burning grindelia-leaves, which have been previously soaked in a solu- tion of nitre, dried, and burned on a plate or rolled into a cigarette and smoked. In chronic cystitis it stimulates the bladder and is of service. By diluting it 1 to 10 with water it forms one of the best 262 DRUGS. lotions that we have for the relief of the dermatitis produced by poison ivy or Rhus Toxicodendron. Administration. — The only preparation which is official is the fluid extract (Fluidextractum Grindeliee, U. S.), dose 20 to 60 minims (1.3-4.0). GUAIAO. Lignum Vitse, or Guaiacum officinale, a West Indian tree, is used in medicine as guaiac resin {Guaiacum, U. S. ; Guaiaci Resina, B. P.), or guaiac, which is soluble in alcohol, ether, and chloroform, but is insoluble in water. Therapeutics. — Guaiac has been largely used in syphilis, but is now rarely, if ever, so employed. Given in acute tonsillitis in the dose of 30 grains in an emulsion made by the use of white of egg, it will often abort an attack. In rheumatism it has been largely used. In the treatment of gout, Luff has highly commended it as a preventive, given in cachet or capsule in the dose of 5 grains (0.3) of the powdered resin three times a day and gradually increased to 10 grains (0.60) at a dose. The ammoniated tincture of guaiac is sometimes employed in the treatment of sore throat, particularly if it be rheumatic in type, but is a disagreeable preparation to take into the mouth, and the sali- cylates may always be used in its place. Administration. — The tincture (Tinctura Guaiaci, U. S.) is given in the dose of 5 to 60 minims (0.30-4.0), and the ammoniated tincture (Tinctura Guaiaci Ammoniata, U. S. and B. P.) is used in the same dose, preferably in milk. Mistura Guaiaci, B. P., is given in the dose of 1 to 2 fluidounces (30.0-60.0). Trochiscus Guaiaci Resina are official in the B. P. 6UAIAC0L. Guaiacol (U. S.) is a liquid constituting from 60 to 90 per cent, of creo- sote. It is obtained by the distillation of beechwood creosote, followed by a complicated process which it is not necessary to describe. In other cases guaiacol is obtained from beechwood creosote by precipitation with barium hydrate. In still other instances a very pure crystalline solid guaiacol is made synthetically from pyrocatechin. Much of the "absolute guaiacol" of commerce is impure. Chemically pure guaiacol, obtained by the process last named, is a light-colored solid of an agreeable odor and soluble in water in the proportion of 1 to 85 Helbing). It is readily soluble in alcohol and ether. As it melts at 83.5° F., it usually is dispensed in a fluid form. Therapeutics. — Guaiacol has been largely used by some practition- ers, chiefly in Europe, in the treatment of tuberculosis as a substitute for creosote, because it is the principal ingredient of that drug. (See GUAIACOL. 263 Creosote.) It was thought by Guttmann, Sommerbrodt, and others that the good effect of creosote was due to its destructive action on the bacillus, or that it so improved digestion as to increase the resistance of the patient to the spread of the disease. Recently Hoelscher and Seifert have asserted that guaiacol and creosote produce their good effects by forming compounds with the toxins or poisonous albumin- oids formed by the bacilli, which are then eliminated from the body. There is no proof of this. The same rules govern the use of guaiacol as govern the employment of creosote. It is best given with brandy, wine, or other alcoholic drink, or in capsule with cod-liver or sweet oil. 5 or 10 minims (0.30-0.60) of guaiacol may be added to a pitcher of hot water and the vapor inhaled three or four times a day in cases of subacute and chronic bronchitis. The dose by the stomach is 5 to 20 minims (0.30-1.3). In acute follicular tonsillitis pure guaiacol may be painted over the tonsils with advantage. Indeed, it is the best application for this purpose. Clinical observations prove conclusively that guaiacol possesses powerful antipyretic influences. As pointed out by Sciolla in 1893, guaiacol when painted on the skin of a febrile patient causes a pro- nounced fall of temperature, which begins soon after the application is made, but is not fully accomplished for from two to three hours. The application may be made to the skin of the abdomen, thighs, or chest, about 30 to 40 minims (2.0-2.6) being used with a brush. When a full effect is required, it is well to place an impermeable dressing over the part painted to prevent evaporation and aid absorption. These applications may be resorted to as often as is necessary for the reduc- tion of the fever, and, although the fall of temperature is sometimes very rapid and very great — as much as 7 degrees F. in two hours — Da Costa has never seen serious nervous or cardiac symptoms produced, but other observers have noted such untoward results. The temperature is very apt to rise speedily after the reduction, and this rise is often preceded by a chill. These applications cannot supplant the cold bath, although they undoubtedly do reduce the temperature. The true sphere of usefulness to be assigned to guaiacol as an antipyretic seems to be that of a less valuable therapeutic measure than the bath, and one equally powerful and about as dangerous as are the antipyretic drugs of coal-tar derivation. The studies of Stolzenberg show that if frequently and constantly used guaiacol produces in febrile patients a tendency toward depression. Thayer finds that great sweating and depression generally follow its external use in fevers. Future reports will probably develop the fact that in cases of renal irritation guaiacol will prove harmful. Guaiacol has been used by painting it on the affected part in the treatment of superficial neuralgias, and in deep-seated nerve-pains, as in sciatica, it has been given hypodermically, in the dose of 2 minims in 10 minims of spirit of chloroform, injected deeply into the neighbor- hood of the painful nerve. 264 • DRUGS. If guaiacol is placed upon the skin by means of a small compress, which has been wet with it and bound tightly to the part, local anaes- thesia is rapidly developed; but if left in place too long, it may be absorbed in sufficient amount to cause depression or a fall of tempera- ture. Belfield highly recommends painting the scrotum with guaiacol 15 minims (1.0) and glycerin 45 minims (3.0) for orchitis, or an ointment of guaiacol 1 drachm (4.0) to 4 drachms (16.0) of lanolin may be rubbed into the scrotum and applied on lint. This should be applied every other day. A serious objection to the external use of guaiacol is its disagreeable odor. GUAIACOL CARBONATE. Carbonate of guaiacol {Guaiacol Carbonas, U. S.) is a white, crystal- line powder, consisting of 91.5 per cent, of pure guaiacol and 8.5 per cent, of carbonic acid. This powder is insoluble in water, soluble in 48 parts of alcohol and 1.5 parts of chloroform, neutral in reaction, and is said to be without irritating effect on the stomach. Taken by the healthy individual, it is decomposed into guaiacol and carbonic acid in the bowel, but not in the stomach, and it is used for this reason, as salol is, as an intestinal antiseptic, in the various forms of fsrmentative diarrhoea and typhoid fever. The drug is said to be slowly absorbed, but after absorption is rapidly eliminated. Its therapeutic applications in tuberculosis are practically identical with those of pure guaiacol, save that it is more readily borne by the stomach than the latter drug. Guaiacol carbonate may be given in capsule or pill, or it may be given in dry powder on the tongue in the dose of 2 to 10 grains (0.12-0.60). Usually in typhoid fever the dose is about 2 grains (0.12) every three hours, and in tuberculosis of the lungs 5 grains (0.30) three times a day. H^MATOXYLON. Hcematoxylon, U. S., Hoematoxyli Lignum, B. P., or Logwood, is the heart-wood of Hcematoxylon campechianum, a tree of the American tropics. It contains an active principle, hsematoxylin. Therapeutics. — Hcematoxylon is a mild astringent, very useful in serous diarrhoeas and the diarrhoeas of young children, as children do not dislike it, owing to its agreeable taste. (See article on Diarrhoea.) As it colors the stools and urine red, the nurse should be warned lest she be alarmed at the sight of what looks like blood on the diaper after the drug is given to infants. If the urine is alkaline, the color may be violet or red. In leucorrhoea its internal use is of service. The extract (Extr actum Hoematoxyli, U. S.) is given in the dose of 8 to 30 grains (0.5-2.0), and Decoctum Hoematoxyli, B. P., in the dose of 1 to 2 fluid- HEROIN. 265 ounces (30.0-60.0) . An unofficial fluid extract is often to be found in the shops. The dose of this is £ to 2 fluidrachms (2.0-8.0\ (See article on Diarrhoea.) HAMAMELIS. Hamamelidis Cortex and Hamamelidis Folia, U. S. and B. P., Witch-hazel, or Hamamelis virginiana, is a plant of the United States, devoid of any active principle, but possessing extraordinary remedial power. Therapeutics. — Hamamelis is to be employed in relaxed sore throat resulting in congestion and hyperemia upon exposure or where mild catarrhal states are present. Similarly, it is employed in an atomizer, after attacks of acute coryza, to tone up the nasal mucous membrane. The strength of the solution should be 20 to 60 minims (1.3-4.0) of the distilled extract to the ounce (30.0) of water. Hamamelis when taken internally is often very successful in the treatment of uterine oozing from small bloodvessels, seems to do good even in hamiatemesis and haemoptysis, and will sometimes arrest hematuria when all other remedies fail. Applied by means of cloths to recent leg ulcers, it rapidly relieves the angry-looking skin surrounding the ulcer. The limb should be elevated and at rest while the treatment is pursued. In bleeding from the bladder it may be injected into this viscus daily in the form of the distilled fluid extract. Taken internally and applied locally, it is of value in the treatment of bleeding and the so-called blind files. (See Hemorrhoids.) Administration. — The official preparations in the U. S. P. are the fluid extract (Fluidextractum Hamamelidis Foliorum, U. S. ; Extractum Hamamelidis Liquidum, B. P.), dose 5 to 20 minims (0.30-1.30), and the distilled extract (Aqua Hamamelidis, U. S., which is a perfectly clear fluid, given in the dose of from 30 minims to 1 drachm (2.0-4.0), and is much the best preparation for internal and external use. The B. P. recognizes a solution, Liquor Hamamelidis, Tinctura Hamamel- idis, and Unguentum Hamamelidis. HEROIN. Heroin is the diacetyl-acid-ester of morphine, and is a white crystalline powder without odor and possessing a slightly bitter taste. It is used in medicine for the, purpose of controlling excessive cough. Unlike mor- phine, its effect on the respiratory centre is stimulant rather than depressant when it is given in medicinal doses. Under its influence the respirations are usually slightly slowed and deepened. The dose is 2V to -g- grain (0.003-0.01) three times a day. Large doses do not act as well as small ones as a rule. It is said to be of value in urcemic 266 DRUGS. dyspncea. The fact that it does not stupefy the patient nor produce constipation is strongly in its favor. As heroin is insoluble, the hydro- chloride of heroin is the preparation used for watery solutions; or heroin itself may be dissolved in water to which a little acetic acid has been added. It may also be given in pill or powder with white sugar. HOFFMANN'S ANODYNE. Spiritus Mtheris Compositus, U. S. and B. P., consists of alcohol, ether, and the heavy oil of wine. The writer has experimentally studied very thoroughly the action of the last-named ingredient, and finds: First. That the belief in heavy oil of wine being the quieting agent in Hoffmann's anodyne is fallacious. Second. The calmative effects of this mixture depend largely on the ether, rather than on the oil. Third. It would seem probable that in Hoffmann's anodyne we possess an agent in which there are linked together three drugs of undoubted power, each one of which successively substitutes the other, stimulating the system in the order here named — viz., ether, alcohol, and the heavy oil of wine. Therapeutics. — Hoffmann's anodyne is the best carminative that we possess for general use, and is one of the best remedies for singultus or hiccough. This effect is accomplished by the alcohol and ether acting as irritants or stimulants to the stomach and intestine, so that free peristalsis results. In angina pectoris this drug is often the best remedy we have during the attack. In the cardiac palpitation of tobacco-heart or in that arising from indigestion and in the nausea and depression seen after excessive smoking it is also very useful. Hoffmann's anodyne should always be given in capsule or in cold water, preferably ice-cold, in order to prevent too rapid volatilization of the ether and consequent difficulty in swallowing the liquid. The dose is 1 to 2 drachms (4.0-8.0) to an adult. The vapor of the ether is so irritating that the drug is difficult of administration to very young children. H0L0CA1NE. Holocaine is a synthetic substance allied to phenacetine, which is almost insoluble in cold water, and which is therefore commonly employed in the form of the soluble hydrochloride. This salt is a white crystalline body, which is stable when brought in contact with many agents, but is readily decomposed by alkalies. Solutions of this preparation possess distinct antiseptic power, and therefore do not \ HONEY. 267 require boiling in order that they may be sterile. As the drug when in solution gradually loses its anaesthetic power, it should be freshly dissolved each time it is needed. Holocaine is used as a local anaesthetic for the eye in place of cocaine, usually in the strength of 1 per cent. Its effects begin in about fifteen seconds to one minute, and last about five to fifteen minutes. It does not dilate the pupil as does cocaine, nor does it affect intraocular ten- sion or roughen the corneal epithelium. Holocaine has not supplanted cocaine, but, for the reason just given, is useful in cases requiring anaesthesia and yet at the same time suffering from keratitis or iritis. It does not cause primary ischaemia or secondary hyperaemia of the mucous membrane. HOMATROPINE. Homatropine is an artificial alkaloid obtained by prolonged and gentle heating of a solution of equivalent quantities of tropine 1 and toluic acid in hydrochloric acid. The hydrobromide of homatropine (Homatropinas Hydrobromidum, U. S. and B. P.) is a crystallizable salt of homatropine, soluble in 10 parts of distilled water. The B. P. recognizes discs of homatropine (Lamellae Homatropince). Hydrobromide of homatropine, properly applied by frequent instil- lations, is a reliable mydriatic when it is desired to correct anomalies of refraction in healthy eyes. Experience is not at hand to determine its value for this purpose in eyes affected with retinal-choroidal disturbance. Atropine and hyoscyamine are preferred under such circumstances, for the obvious reason that their prolonged action is desirable as a method of treatment. The danger of systemic disturbance from homatropine is remote, even when repeated instillations have been made, and its temporary action upon the pulse causes no inconvenience to the patient. Slight hyperaemia of the conjunctiva almost invariably follows its use, but true conjunctivitis, if it occurs at all, must be excessively rare. According to the studies of de Schweinitz and the writer, the drug has a physiological action closely allied to that of atropine, from which it is derived. Homatropine mydriasis generally lasts from thirty-six to forty-eight hours, that of hyoscyamine eight to nine days, and that of atropine ten to twelve days. For the production of ordinary mydriasis the drug should be used in solution of the strength of 4 grains (0.25) to the ounce (30.0) of distilled water, which is to be dropped into the eye every five or ten minutes. As the drug is expensive, only a few drachms of the solution of the strength named should be ordered for a patient. HONEY. Honey, or Mel, U. S., is the saccharine fluid deposited in combs by the honey-bee, or Apis mellifica. It is used in medicine to mask the 1 Tropine is a product obtained by splitting up atropine into tropine and tropic acid. 2Q$ DRUGS. taste of disagreeable medicines. When it is abstracted from a par- ticular variety of flowers, it frequently has the odor of the flowers, and when taken internally may even produce the physiological or poisonous effects of the plant from which it is gathered. This accident occurs commonly in those parts of the country where the bees have had access to mountain laurel and similar plants. Therapeutics. — Honey mixed with water is used as a vehicle in gargles and to relieve cough and dryness of the mouth and fauces. When used as a gargle it very distinctly increases the secretion of the mucous membrane, and so relieves the congestion. Under the name of Oxymel the B. P. recognizes a mixture of 8 parts of honey, 1 of acetic acid, and 1 of water. This is generally used as a vehicle for more active remedies in gargles or even for expectorant mixtures. Melted and strained honey, to which a small proportion of glycerin is added, is known as Mel Depuratum, U. S. and B. P. There are also a honey of roses (Mel Rosce, U. S.) and a confection (Confectio Rosa?, U. S.), used as vehicles for other drugs. Mel Boracis, B. P., is used for the same purposes and for stomatitis. The objection to the use of honey in vehicles for active medicines is the fact that it is apt to disorder the stomach. HOPE'S CAMPHOR MIXTURE. This is a mixture originally made with nitrous acid, but largely used at present with nitric acid, owing to the fact that nitrous acid is changed into nitric acid when water is added to it. The nitrous acid is, however, more efficacious than nitric acid in the serous or choleraic diarrheas which it is used to combat. The formula is as follows : Bf— Acidi nitrosi . foj (4.0). Aquae camphorce f § vii j f 240.0). Et adde Tinct. opii gtt. xl (2.6).— M. S. — One-fourth of this in water every three or four hours. HOPS. HumuluSy U. S., is the strobiles of ordinary hops, or Humulus Lupulus. These contain a liquid volatile alkaloid, lupuline, and a bitter principle, lupulinic acid. Hops are known under the name of Lupulus in the B. P. Much confusion has arisen in regard to the preparations of this drug, partly because Humulus is the official name in the U. S. P. and Lupulus in the B. P. This confusion has been increased by the fact that the alkaloid of hops is called lupuline, while the powder which is found on the strobiles is called lupulin. Those preparations in the U. S. P. having the word "humulus" in their name are made from HYDRASTIS. 269 the hops themselves, those with "lupulin" in their name from the powder of the strobiles. Therapeutics. — Hops are used as antispasmodics and nervous seda- tives in cases of hysteria and nervousness. In priapism, vesical irrita- bility, and renal irritation they are of service. Even in delirium tremens they seem to be of value. For local application a hop poultice may be made by placing the powdered strobiles in the mass, and employed in this way they are a favorite domestic remedy for local painful inflammations. Hops have been used in the form of a hop pillow in nervous insomnia, but the soporific influence is largely imaginary or depends on the fumes of the alcohol with which the pillow is moistened. Administration. — The tincture (Tinctura Humuli) is given in the dose of \ to 3 ounces (16.0-90.0). Lupulin (Lupulinum, U. S. and B. P.), which is the powder found on the strobiles of hops, is given in the dose of 2 to 5 grains (0.12-0.30) or more; the oleoresin of lupulin (Oleoresina Lupulini, U. S.) is given in dose of 10 to 40 minims (0.60-6.20) in capsule; and the fluid extract (Fluidextr actum Lupulini, U. S.), in the dose of 30 to 120 minims (2.0-8.0). The preparations of the B. P. are the infusion (Jnjusum Lupuli), dose 1 to 2 fluidounces (30.0-60.0), and the tincture (Tinctura Lupuli), dose i to 2 fluidrachms (2.0-8.0). HYDRASTIS. Hydrastis, U. S., or Hydrastis Rhizoma, B. P., is the rhizome of Hydrastis Canadensis, sometimes called Golden Seal, containing two alkaloids known as hydrastine and berberine, and, perhaps, xantho- puccin. Physiological Action. — When given to one of the lower animals in poisonous doses hydrastis may cause spinal convulsions followed by paralysis, according to the quantity of berberine or hydrastine present. The latter is more convulsive in its effects than the former. Upon the circulation hydrastine, when injected into the jugular vein, causes a primary fall of arterial pressure, succeeded by a decided rise, and the studies of Cerna have proved that it is an active poison. When given to man in medicinal amounts its effect on vital functions is very slight indeed. Therapeutics. — Hydrastis is of service in chronic gastro-intestinal catarrh, particularly that following the abuse of alcohol, and may be used as a stomachic and tonic after malarial fever and similar depress- ing diseases. Wherever membranes are in a condition of lowered tone this drug is indicated. Thus in catarrhal jaundice of a subacute type, in uterine catarrh, in leucorrhwa dependent upon a relaxed state of the vagina, and in chronic nasal inflammations and irritations it will be found useful. 270 DRUGS. Tincture of hydrastis is said to possess a distinct antimalarial influ- ence, but this is doubtful. One of the best remedial measures that we have in the later stages of gonorrhea, when the acute period has passed, is the local and inter- nal use of hydrastis. If it is used as an injection, 5 grains (0.3) of the commercial hydrastine to each ounce (30.0) of water should be em- ployed twice a day. Belfield has highly recommended the following formula for use in this disease prior to the tenth day: ]^ — Hydrastin. hydrochloride gr. v (0.3). Protargol gr. v (0.3). Glycerin f3ss (0.2). Aquse destillat q. s. ad f §j (30.0).— M. S. — Precede with a hot-water injection and use four to six times daily, telling the patient to retain it five to ten minutes each time. The following infusion will be found of service in vaginal gonorrhea and leucorrhcea: Take 1 drachm of the powdered root and add it to 8 ounces of boiling water; \ to 1 drachm of the fluid extract may also be added to a pint of water and used as a wash. Administration. — The fluid extract (Fluidextractum Hydrastis, U. S. : Extractum Hydrastis Liquidum, B. P.) may be given in the dose of 5 to 30 minims (0.30-2.0), while the dose of the tincture (Tinctura Hydrastis, U. S. and B. P.) is from 30 minims to 2 drachms (2.0-8.0.) The Glyceritum Hydrastis, U. S., is used as a healing application to mucous membranes. Much doubt exists as to the dose of hydrastine. This arises from the fact that two forms of it are sold. The most commonly seen is a dark-brown mass which is very impure, and contains berberine and other substances. Its dose is 3 to 10 grains (0.20-0.60). The pure hydrastine (Hydrastina, U. S.), as made by Merck, is given in the dose of J to \ grain (0.015-0.03). Hydrastinine hydrochloride, an artificial alkaloid of hydrastine, is official in the U. S. P., dose \ to 1 grain (0.03-0.06). HYDROBROMIC ACID. (See Bromides.) HYDROCHLORIC ACID. Acidum Hydrochloricum (U. S. and B. P.) is a clear, colorless liquid, possessing an acid odor and taste, devoid of astringency, but in concentrated form decidedly caustic. It should be kept in dark- colored bottles. In the strength of 0.2 per cent, it is normally present in the gastric juice, and aids the pepsin in the conversion of proteids into peptones and in the formation of pepsin from pepsinogen. Therapeutics. — Hydrochloric acid is indicated only in certain forms of indigestion. With new methods of studying gastric secretions we have learned that it is of value in those cases in which the gastric secretion of HC1 is deficient. Thus it is given to aid digestion during HYDROCYANIC ACID. 271 and after fevers, when this acid is apt to be absent from the gastric juice, particularly in typhoid fever. In cases of gastric cancer, when this acid is usually absent from the gastric secretion, and in the sick stomach following an alcoholic debauch, it is of great service. In some cases of chronic gastric catarrh with dilatation, in which there is atrophy of the gastric tubules, it should be used freely. The dose of the dilute acid (Acidum Hydrochloricum Dilutum, U. S. and B. P.) is 5 to 20 minims (0.30-1.3). A useful prescription in such cases is: fy— Acid, hydrochloric, dil f 3ij (8.0). Pepsin, essence . . f 5j (30.0). Tinct. gentian, comp. . . . q. s. ad f§iv (120.0). — M. S. — Dessertspoonful (8.0) in a little water with meals. This acid is combined with nitric acid to form dilute nitro-hydro- chloric acid (Acidum Nitro-hydrochloricum Dilutum, U. S. and B. P.), the dose of which is 10 to 30 minims (0.60-2.0); also the pure acid (Acidum Nitro-hydrochloricum, U. S.), dose 1 to 5 minims (0.05-0.30). Hydrochloric acid causes, when taken in poisonous doses, violent gastro-enteritis and corrosion of the gastric walls, and its action should be combated by alkalies, soap, oils, and white of egg, and the use of opium to relieve pain and irritation. HYDROCYANIC ACID. Hydrocyanic or Prussic Acid is a transparent, colorless, very volatile liquid, giving rise to vertigo when inhaled in minute amounts and capable of producing death if the fumes be concentrated. If the bottle containing the pure drug be opened, it should be done where there is sufficient draught between windows to prevent any contamination of the atmosphere of the room by the acid. Pure hydrocyanic acid is never used in medicine; the form employed is the dilute acid (Acidum Hydrocyanicum Dilutum, U. S. and B. P.), which contains about 2 per cent, of the drug. It must be kept in dark, tightly-stoppered bottles. Physiological Action. — This is one of the most rapid (if not the most rapid) of the lethal poisons, only being approached by carbolic acid and nitrobenzole in the violence of its effects. Owing to its volatility, it is absorbed with great rapidity, and acts upon the respiratory centre and the heart, being eliminated almost immediately afterward. Because of its fleeting character, the survival of a patient twenty or thirty minutes after the ingestion of a poisonous dose is a favorable sign for his recovery. The drug is an active paralyzant and exerts a lethal influence over every part of the body. The nervous system, heart, respiration, brain, and all vital parts are killed at once if much of it is present. Poisoning. — When a lethal dose of hydrocyanic acid is taken, death either comes at once, so that the person drops dead with a gasp, is for a 272 DRUGS. moment convulsed, the face cyanotic, the eyes wide open, with the teeth tightly clinched, and the lips covered by a bloody froth, or three stages of poisoning may ensue if the dose has not been large enough to result in immediate death, owing to its slow absorption. In the first of these stages there are difficult respiration, slow cardiac action, and disturbed cerebration. In the second stage, which is convulsive, there are present wild cries, dilated pupils, unconsciousness, vomiting, spasmodic urination and defecation, erections of the penis, and ejacula- tions of semen. In the third stage there are asphyxia, collapse, and paralysis, ending in death. The blood is found to be dark and venous-looking, but does not give the spectrum bands of cyano- hsemoglobin. These bands only appear when the drug is shaken with blood outside the body. The diagnostic signs of death from prussic acid are the odor of the body, the wide-staring eye, the clinched teeth covered with froth, and the livid, cyanosed face. If the body be opened, the odor of hydro- Fig. 47. Tracing of the deep stormy respirations of an animal under the influence of hydrocyanic acid. (After Schmiedeberg.) I. Normal respirations; II. Acid inhaled; III. Violent deep respirations; IV. Arrest of respiration. cyanic acid is marked, but this rapidly passes away, owing to the vola- tility of the drug. The only poison producing symptoms resembling those which have just been described is nitrobenzole or essence of mirbane, which has a somewhat similar odor, but which is, however, more permanent, the odor remaining for hours in the opened body, Therapeutics. — Hydrocyanic acid is useful in cases of gastralgia of purely nervous origin, and in some cases of nervous vomiting, and in irritable stomach, where, owing to hyperesthesia of the mucous mem- branes, the taking of food produces discomfort. In irritable coughs, due to tickling in the throat and bronchi, it is very extensively used, and has received high praise by those best qualified to judge. On the other hand, it has been claimed that owing to the extreme volatility of the drug it acts only for the moment, and that a dose every ten or fifteen minutes is necessary to produce any constant effect. However this may be in theory, practically the acid HYDROGEN PEROXIDE. 273 certainly does aid in relieving cough. In these states the following prescription will be found of service: 1^— Acid, hydrocyan. dil f 3j (4.0). Syrup, pruni virg fgiij (90.0). — M. S. — Teaspoonful (4.0) every four or five hours to an adult. In enteralgia or neuralgia of the intestine dilute prussic acid is often a very useful remedy. Externally, the drug is useful in pruritus and other forms of itching skin diseases, and the following formula will be found of service in pruritus vulva?: 1 Bj, — Hydrarg. chlor. corros gr. iss (0.09). Acid, hydrocyanic, dil f5j (4.0). Aquae amygdal. amarse fovj (180.0). — M. S. — Poison! For external use. Apply to the itching surface with a small rag. The same prescription may also be employed in pruritus without the bichloride, if so desired. The dose of dilute hydrocyanic acid is 1 to 5 minims (0.05-0.30). In certain forms of irritable cough inhala- tions of the vapor (Vapor Acidi Hydrocyanici) are recommended; this is prepared by adding 10 to 15 minims (0.60-1.0) of the diluted acid to 1 fluidrachm (4.0) of water, which is then placed in a suitable apparatus, from which is inhaled the vapor that arises. HYDROGEN PEROXIDE. Peroxide of Hydrogen is a clear, odorless, syrupy fluid of a specific gravity of 1.452, possessing a harsh, bitter taste. It is readily soluble in water, and its chemical formula is H 2 2 . Pure peroxide of hydrogen is never used in medicine, but in solutions of varying strength. The ordinary solution, as found in the shops and that now official (Aqua Hydrogenii Dioxidi, U. S.; Liquor Hydrogenii Peroxidi, B. P.), is about 3 per cent., or, as it is generally called, a 10- volume solution. This term, "10 volumes," signifies that it can yield 10 volumes of available oxygen; and it is upon this yield of oxygen that its activity depends. The specific gravity of this official solution is 1.006 to 1.012 at 59° F. The reaction is acid, but this is due to a small amount of acid added to the solution to preserve it. The official solution of peroxide of hydrogen, while the most stable that can be prepared, is neverthe- less readily deteriorated by exposure to heat, sunlight, or prolonged shaking. If placed in an absolutely clean, smooth glass vessel, it may be concentrated for immediate use by exposing it to a temperature of 140° F.; but exposure to a temperature above this point may result in its decomposition with explosive violence. Practically, this means of concentration is not convenient for the practitioner, and the ordinary official solution fulfils all ordinary requirements unless it has deterio- rated by age. The great difficulty in the use of the solution of the peroxide is its liability to undergo a change and become practically 18 274 DRUGS. worthless. Wallian states that as a rough test for the value of a given solution a few crystals of permanganate of potassium may be placed in a test-tube, and 1 or 2 drachms (4.0-8.0) of the solution added. The violence of the resulting effervescence is in direct ratio to its value as a remedial agent. Marshall has proved that the constituent of blood and pus that sets free the oxygen from this drug is globulin. Therapeutics. — The most valuable use of the peroxide-of-hydrogen solution in medicine is in the treatment of diphtheria. So far as we know, it is the best application for the destruction and removal of the false membrane. There is no injury to the normal tissues, nor is there the danger of poisoning which sometimes follows the use of such drugs as carbolic acid. Applied to the false membrane, there is at once an active effervescence with some local tingling of the part. The mem- brane can afterward be removed in shreds. The solution should be applied by means of a swab or spray, but if the latter is used a glass atomizer must be employed, as the peroxide is decomposed by coming in contact with metals. Peroxide of hydrogen is also a very valuable application for cases of follicular tonsillitis with profuse exu- dation, to cleanse the parts prior to the use of guaiacol. (See Guaiacol.) In the treatment of abscess-cavities, tubercular or septic in character, the peroxide of hydrogen is a very valuable application, and its use will often decide the presence of pus, since when it meets with this material active effervescence ensues; but care must be exercised that free vent is allowed for the gas that is given off, as if confined it will force the septic material into the surrounding healthy tissues. Simi- larly, it is a valuable preparation for cleansing ulcers and malignant growths which have ulcerated. Hydrogen peroxide is a useful agent for the removal of powder- stains in recent cases. It is stated that the application of this liquid to the spot affected by a hornet's sting will give instant relief; and applied by means of an atomizer it is the best fluid to aid in the painless removal of ad- hesive strips. The part of the strip next the skin should be sprayed as it is gradually pulled off. It is also used on plaster-of-Paris dressings to soften the material so that it can be cut with a knife or shears. Where the peroxide is used as a gargle it may produce pain through its attacking cavities in the teeth or the metallic substances with which they are filled. The employment of the peroxide internally, with the idea that it will yield oxygen to the body in cases in which this gas is lacking in the blood, is futile. Even if the oxygen entered the blood, the amount disengaged from a possible dose would be too small to be of value. Taken internally, the peroxide of hydrogen is not poisonous. The internal dose of the Aqua Hydrogenii Dioxidi of the U. S. P. is from 1 to 4 drachms (4.0-16.0), well diluted with water, and taken from a porcelain, not a metal, cup or spoon. It possesses no distinct value in internal medication. HYOSCYAMUS. 275 HYOSCYAMUS. Hyoscyamus, U. S., or Henbane, is a plant of the Northern United States and Europe. The leaves (Hyoscyami Folia, B. P.) only are used, and from them are obtained two alkaloids — one known as hyos- cyamine, the other as hyoscine. The first has practically the same physiological action as atropine, save that it is much more sedative in its effects on the nervous system. (See Belladonna.) The second is quite different in its influence over the body. The only marked differ- ence in the action of hyoscyamine and atropine is in the mydriasis pro- duced by each. While that of atropine lasts, in man, from twelve to fourteen days, hyoscyamine generally remains for only seven to nine days. Sometimes the development of mydriasis is preceded by violent pain in the eye due to a cramp of the ciliary muscle. If so, the drug must be pushed to overcome the spasm. The strength of the solution to be used in 2 grains (0.12) to the ounce (30.0). Owing to the presence of hyoscine in hyoscyamus, it is more quieting and depressing to the nervous system than is belladonna. Therapeutics. — Hyoscyamus is used in every condition indicating the employment of belladonna; or, in other words, wherever local spasm or arterial relaxation exists or where pain is due to spasm. It has been particularly recommended in nervous cough, in whooping- cough, and in colic, and probably is better in its influences in these states than is belladonna. In combination with nitrate of silver the extract may be used with advantage in chronic gastric catarrh and gastric ulcer. In urinary incontinence due to irritable bladder it is very serviceable, and particularly is this true of this affection in chil- dren and old persons, provided that the urine is first rendered normal by the use of acidifying drugs or by the use of alkalinizing drugs if it is abnormally acid. Administration. — The drug itself is official in four forms and as hyoscyamine sulphate and hydrobromide. The dose of the tincture (Tinctura Hyoscyami, U. S. and B. P.) is 10 to 40 minims (0.60-2.60) ; the alcoholic extract (Extractum Hyoscyami, U. S., and Viride, B. P.), dose i to 1 grain (0.03-0.06) ; the alkaloid (Hyoscyamine Sulphas, U. S. and B. P., vel Hydrobromidum, U. S.), dose -fa to -fa grain (0.001-0.0015) ; and the fluid extract (Fluidextr actum Hyoscyami, U. S), dose 2 to 10 minims (0.10-0.60). The B. P. preparation, besides those given, is the juice (Succus Hyoscyami), dose 30 minims to 1 fluidrachm (2.0-4.0). Hyoscine. This is one of the alkaloids derived from hyoscyamus, and is a thick, syrupy substance which forms a crystalline salt with an acid. It has been entirely supplanted by scopolamine, to which the name Hyoscine has been given. 276 DRUGS. Hyoscine is official in the form of Hyoscine Hydrobromide (Hyos- cinoB Hydrobromidum, U. S. and B. P.). b Physiological Action. — Hyoscine quiets the cerebrum and produces deep sleep in a certain class of patients. In the lower animals or in man it may cause sleep or wild delirium. It causes loss of reflex action in overdose, which is due to depression of the spinal cord and not of the nerve-trunks. Upon the circulation it has little effect, but it is worthy of note that it influences the vagus nerves, as does atropine, stimulating them at first, but finally depressing them, although the contrary has been asserted. In any event, the circulatory effect is a minor one. In cases where hyoscine has acted in excess, or where an overdose has been given, pilocarpine may be used as a physiological antidote in full doses if the heart is sound. Therapeutics. — Hyoscine is of value as a hypnotic in a very limited class of cases, and in this class generally acts most favorably. These cases consist of those who, from acute mania, hysteria, or similar cause, suffer from insomnia, and perhaps struggle violently against proper control or refuse to swallow or retain food. The drug may be given to such persons hypodermically, in the dose of tfo ^To g ram (0.0006), or by the mouth in the dose of ■£$■ to -g 1 ^- grain (0.0008). The fact that it possesses no taste and is small in bulk renders it readily employed. In some persons it utterly fails even in this particular type of case. In delirium tremens it may cause evidences of cerebral congestion and Cheyne-Stokes breathing, but, on the other hand, it very commonly aids in combating chronic alcoholism when given in very large dose. (See below.) Some patients are not quieted by the drug, but pace up and down in a semi-sane con- dition until its action wears off. Such symptoms can best be overcome by using larger doses. Recently hyoscine has been highly recommended in the treatment of the morphine and alcohol habit, and there can be no doubt that it is an excellent remedy. The patient must be under complete control and should be given enough hyoscine hypodermically to be thoroughly under its influence, as much as ^p- grain being given every two hours if need be to keep him quiet. Aside from great dryness of the tongue and the characteristic delirium caused by the drug, no evil effects ensue and the patient usually without much suffering, recovers from the effects of the narcotic drug to which he is a slave, and in a good general state so far as his nerves are concerned. Hyoscine is of great value in some cases of spermatorrhea and nocturnal emissions if given in the dose of ytto g ram (0.0006) at bed- time. The drug is contraindicated in the sore throat of scarlet fever, as it may cause a sensation of pharyngeal constriction. In the insomnia of heart disease with nervousness it will cause sleep, but often fails. Hyoscine is used by ophthalmic surgeons, and in the eye is far less irritating than atropine. Indeed, it may be considered as being dis- ICHTHYOL. 277 tinctly sedative in plastic iritis. Its effects are not, however, so last- ing as are those of atropine; ^g-g- grain dropped into the eye in one dose produces mydriasis in eighteen minutes and ciliary paralysis in twenty-three minutes; this mydriasis lasts about twenty-two hours, and the ciliary paralysis about ninety-six hours. (Oliver.) It finds its greatest usefulness in the early stages of iritis, when a rapidly acting and efficient sedative mydriatic is demanded. Hyoscine is best used for thii purpose in the strength of 0.2 per cent. (1 : 500) in water. This solution may be dropped into the eye every twenty minutes till one hour has elapsed. As this use of the drug is slightly painful, it is well to place a few drops of cocaine solution in the eye before each instillation of hyoscine. HYPNAL. The chemical name of this substance is monochloral-antipyrine, and it is, as its name indicates, a compound of chloral and antipyrine. There is also a dichloral-antipyrine, which contains more chloral. The compound is employed in treating those patients who suffer from pain and insomnia combined, the antipyrine relieving the pain and the chloral producing sleep. Opium is the only drug known which can be relied upon to act in this double manner, and the disadvantages of that medicament are often so prominent as to prevent its use. The drug has been used in neuralgic insomnia, but for some reason has not proved as popular as was expected when it was introduced. The dose is from 5 to 20 grains (0.3-1.3), best given with simple syrup and water or with syrup of orange-peel, or it may be used as follows: 1^ — Hypnal gr. xv (1.0). Chartreuse f 3j (4.0). Distilled water f §ss (16.0).— M. S. — The entire amount to be taken in one dose. ICHTHYOL. The substance sold in the shops and employed in medicine under the name of ichthyol is a salt formed by the bibasic acid ichthyo- sulphuric or sulpho-ichthyolic acid with ammonium. In other words, it is ammonium ichthyol, which is a semi-solid substance. The ichthyo-sulphuric acid itself is derived from a crude oil, which in turn is obtained by destructive distillation from a deposit of fossil fish found in the Tyrol Mountains. When combined with sodium, forming sodium ichthyol, a more solid substance than ammonium ichthyol is formed, which can be employed if it is desired to use the drug in pill form. Both the ammonium and sodium ichthyol contain about 10 per cent, of sulphur, and it is largely upon this that their therapeutic activity depends. They are both soluble in water, and have a dark- 278 DBUGS. brown, tarry appearance. Their disagreeable odor is due to an inseparable volatile oil. Therapeutics. — Ichthyol is without doubt one of the most remark- able substances introduced for medicinal purposes within the last few years, both because of its curious origin and its therapeutic value in a large variety of ailments. In the author's hands it has proved most efficacious in the treatment of the inflamed areas in acute articular rheumatism. When used in this disease an ointment composed as fol- lows is to be smeared over the inflamed part, and then spread on lint, which is wrapped about the limb. This usually relieves the pain and tenderness of the part to a great extent. The same application, accom- panied by rubbing or applying massage to the joint, is of value for the pain and stiffness met with after the acute manifestation of the disease has passed by: I*— Ichthyol 5ss (16.0). 01. citronellse gtt. xv vel xxx (1.0-2.0). Adipis vel lanolini §j (30.0). — M. The same prescription is also the best external treatment of erysip- elas that we have. The skin should be carefully and gently washed, and then anointed with the ointment and covered by lint smeared with this ointment. If the disease be in the skin of the face, holes are to be cut in the lint for the mouth, nose, and eyes. Ichthyol is also a very useful drug in the treatment of chronic skin diseases associated with atony and induration of the deeper layers of the skin, such as acne, eczema, and even lupus and keloid in their chronic stages. It is always better to use ichthyol in ointment form, but some practitioners have employed it by painting it on in watery solution with a cameFs- hair brush. In frostbites, chilblains, and in burns it is of service, and Agnew recommended it highly when rubbed into lymphatic enlarge- ments. Ichthyol has proved remarkably efficacious in removing peri- uterine and other pelvic exudations when used as a salve with pelvic massage or in a vaginal suppository. For acute sprains, and for the removal of the swelling following such injuries, its influence is extraordinary if it be well rubbed into the part affected. In severe cases of cracked nipples, with much induration, an oint- ment of ichthyol, 1 to 4 drachms (4.0-16.0) of lanolin, will prove of value, but it must be wiped off before each nursing or the child will not take the breast. Often the odor remains and prevents nursing. The dose of ichthyol internally is 1 to 10 grains (0.06-0.60), given in pill. Ichthyol is a very useful remedy for the treatment of fetid ozama. (See Nasal Catarrh, Atrophic? Part IV.) IODIDES OF AMMONIUM AND ETHYL. (See Ammonium and Ethyl Iodide.) IODIDE OF POTASSIUM, 279 IODIDE OF POTASSIUM. The physiological effects of iodide of potassium (Potassii Iodidum, U. S. and B. P.) are entirely comparable to those of iodine itself (see Iodine), but it is employed for somewhat different purposes, is less irritant, more readily given, and perhaps more readily absorbed. When it is given in very large doses or for a long period of time, the fact that the potassium base is a depressant poison is to be remembered, and it is well to use iodide of sodium instead. Physiological Action. — Circulation. — Upon this part of the sys- tem when in health iodide of potassium produces effects differing very slightly, if at all, from those caused by potassium itself. Small amounts raise the blood-pressure, and large quantities lower it (Prevost and Binet), but if atheroma of the bloodvessels be present with high arterial tension in association with it, iodide of potassium acts as a valuable remedy in reducing the vascular spasm. It therefore lowers arterial pressure. Absorption and Elimination. — Iodide of potassium is very rapidly absorbed and eliminated, appearing in the urine, according to Doux, in thirteen minutes after it is ingested, and the daily amount excreted equals about 80 per cent, of the dose taken. Some of the drug tends to accumulate in the body. It is evident, therefore, that in the use of iodide of potassium we should give it freely and frequently at first until the residual amount has reached its limit, when smaller doses may be given, and given less frequently, for the purpose of maintaining the iodine influence. That is to say, the drug should be given up to the point of tolerance, whatever that may be, and then a smaller dose will be sufficient to maintain its influence by replacing the albuminoid compounds of iodine as they are slowly eliminated. On the other hand, if the iodide is being given for the purpose of eliminating some poison, as lead, for example, here the dose cannot be greatly decreased, because in addition to the ordinary quantity eliminated a portion is passed out as a double soluble iodide of lead. This theoretical deduc- tion seems to find support in the fact that after the syphilographer reaches the full effect of the drug he often cuts the dose down to what he calls the "tonic dose/' and so maintains the constant alterative effect without disordering the functions of the body. If he does not do this, the drug accumulates and causes chronic iodine cachexia, a state which it is important to avoid in grave diseases like syphilis, which depend for their relief so largely on the maintenance of vitality in the patient. All traces of the iodine in the urine disappear four or five days after the last dose is administered (Elhers). Therapeutics. — The medicinal uses of iodide of potassium may be divided into three great divisions, each of which is important. It is also employed for many conditions not included in these classes : 1. Syphilis. — The use of iodide of potassium in syphilis is recog- nized as a part of all treatment for its relief. Elsewhere Dr. Martin has, in his excellent article (see Syphilis), treated of this question, and 280 DRUGS. it is only necessary to call attention to the fact that the drug is generally well borne in large amounts by advanced syphilitics, although this is not always the case. The term "therapeutic test" is applied by one eminent teacher to signify a state of the system produced by syphilis in which a diagnosis may be made by the fact that large doses of the iodide are borne without inconvenience. This resistance does not always prove the presence of syphilis, nor does the absence of this resistance prove the absence of this disease. Persons having hereditary asthma, gout, rheumatism, or some similar diathetic malady often resist the iodide, and, on the other hand, some syphilitics exhibit "iodism" after very small doses. In treating syphilis the drug should be used in the dose of 10 grains (0.60) three times a day, and this amount gradually increased a grain a day until symptoms of "iodism" occur. The quantity borne often amounts to from 100 to 200 grains (6.6- 13.2) a day, and as much as 400 grains may be taken by some persons. The best way to use the iodide of potassium is to order for the patient a saturated solution of the drug, which contains in each drop about 1 grain, and at the same time a bottle of the compound syrup of sarsa- parilla. To a tablespoonful of the latter the patient is to add the iodide solution, beginning with 10 minims (0.60) three times a day, and increasing a minim every twenty-four hours. The iodide acts more slowly as an antisyphilitic than does mercury. In tertiary syphilis the iodide is invaluable. In nervous syphilis, be its manifestations what they may, iodide of potassium is the standard remedy, being supplanted by mercury only when it is necessary to break down a growth whose existence is a daily menace to the patient's life, as, for example, a brain tumor which causes pressure near vital areas. It is not curative in sclerotic post- syphilitic changes nor in locomotor ataxia due to syphilis, except in the earliest stages, because destroyed cells cannot be restored, but it can be used to arrest further advance of the disease. It may greatly improve the patient's condition by preserving cells not as yet entirely destroyed. The therapeutic effect of this drug is much increased if hot vapor baths are used simultaneously with its internal administration. 2. Metallic Poisoning. — Owing to the fact that iodide of potas- sium forms soluble double salts with all the metals in the tissues in chronic poisoning, thereby aiding in their elimination, it should always be employed in chronic lead, zinc, arsenic, or mercurial poisoning. 3. Antirheumatic. — Iodide of potassium is best suited, not to acute articular rheumatism, when the joints are very hot and painful, but to the secondary or subacute types, when the joints are enlarged • and the case " hangs on" — now better, now worse. It acts best, under these circumstances, if combined with wine of colchicum-root. (See Rheumatism.) It is also to be tried in sciatica, lumbago, and rheumatic neuralgia, and it may be employed in chronic pleurisy, pericarditis, and hydrocephalus to cause absorption of the fluids. In these con- ditions, however, it often fails and cannot be relied upon. In aneurism, particularly that of the aorta, the drug often does good, IODIDE OF POTASSIUM. 281 but its value rests largely upon the cause of the disease. If it is due to syphilis x the aneurism may speedily cease to grow under its influence, and the pain, swelling, and pulsation gradually decrease. In asthma iodide of potassium is valuable if the disease is of the pure bronchial type, but it ought not to be employed if the cause is associated with gastric irritation or indigestion, as it makes the condition of the stomach worse. In bronchitis and intestinal catarrh where the con- dition of the mucous membranes is semi-chronic, and not relieved by chloride of ammonium, iodide of potassium should be used. If the bronchitis is chronic and the secretion profuse (bronchorrhcea), iodide of potassium will make it worse. The dose for an adult in all these instances should be about 3 to 5 grains (0.20-0.3) three times a day, for small doses tend to increase secretion far more than large ones, which often seem to decrease it. In "pulmonary emphysema iodide of potassium is often of great value. In chronic interstitial nephritis small doses (5 grains [0.3] t. i. d.) are thought by some to check the disease, but it is to be remembered that the drug may produce untoward symptoms if the kidneys do not eliminate it, so that, if used at all, it must be given with great care. If the drug is well borne in chronic parenchymatous nephritis, it will cause an extraordinary increase in the urinary flow, and will often relieve very rapidly any dropsy which may be present. In bronchocele the employment of iodide of potassium internally and tincture of iodine externally is the best treatment we can use, and in acute coryza, or "cold in the head," 10 grains (0.60) taken at the begin- ning of the trouble will often abort the attack. In hepatic cirrhosis, in its early stages, the iodide often does good in arresting the overgrowth of connective tissue, and in arteriosclerosis or atheroma of the bloodvessels it is of great service. Thus in the latter conditions a combination of iodide of sodium or potassium with a little digitalis will relieve vascular spasm and support a feeble heart. A very important use of iodide of potassium is for the removal of enlargements of the cervical glands and those occurring in other parts of the body. Full doses are useful in actinomycosis. In the later stages of pneumonia the iodides are useful to aid in the absorption of any exudates, but they are contraindicated in phthisis, except in the fibroid form and in those cases which are dependent upon syphilis as an underlying dyscrasia, as they aid in the breaking down of the lung. Untoward Effects. — In some persons, after the use of the iodide, coryza comes on, so that the edges of the eyelids become reddened and the nose runs constantly; and it is a curious fact that small doses are more apt to produce such a result than large ones. This is followed, if the drug is pushed, by the more positive signs of "iodism" spoken of under Iodine. In other cases acne breaks out on the face and disorders of digestion and gastric irritability come on. The acne can nearly always be pre- vented by giving arsenic at the same time with the iodide. In some cases petechial rashes break out on the legs, while in others great 282 DRUGS. mental and physical depression appears, so that listlessness or 'melan- cholia may develop. Sometimes iodide of potassium causes diarrhoea. In persons susceptible to iodide of potassium care should be exer- cised when it is first administered lest sudden and dangerous oedema of the glottis occur. Eisner has reported a case in which death due to this cause followed the administration of 30 grains of the iodide of potassium. Multiple hemorrhages from the skin and mucous mem- brane occurred. If bullae or blebs follow the use of the iodides or other rashes appear, it is said that atropine will afford relief. Sometimes the iodide of ammonium or iodide of sodium will be borne when the iodide of potassium will not. Administration. — The iodide of potassium, owing to its exceed- ingly disagreeable taste, should be given with the compound syrup of sarsaparilla, as already described, with fluid extract of liquorice, or in milk. Large amounts of these vehicles are to be used. A good way tc fi^ive it is to add the drug to one of the liquid pepsins, and then to add this to warm milk, as in the directions for the preparations of junket given in Part III. The curd largely disguises the taste of the drug. The dose usually varies from 5 to 60 grains (0.30-4.0) three times a day,, according to the condition of the patient. It is best given an hour after meals, so that it will not disorder digestion by irritating the stomach or interfere with the action of the gas ric juice. One of the best ways to take the drug is in capsule, but if this is done a drink of milk or water or other fluid should precede or follow it, in order to prevent the drug from coming in contact with the stomach in concentrated form. The preparations of the iodide of potassium are — Unguentum Potassii Iodidi, U. S. and B. P., and the liniment (Lini- mentum Potassii Iodidi cum Sapone, B. P.). The former should always be freshly prepared. IODIDE OF SODIUM. Sodii lodidum, U. S. and B. P., is used in the same doses and for the same purposes as the iodide of potassium, and is less irritant than the latter salt, as well as less depressant to the general system. IODINE. lodum, U. S. and B. P., is a non-metallic element found largely in seaweed and in mineral iodates and iodides. It is soluble in ether and alcohol, but slightly so in water, and possesses an acrid, burning taste and a neutral reaction. Physiological Action. — The physiological action of iodine, so far as its alterative powers are concerned, is absolutely unknown. Applied to the skin, it stains it yellow, brown, or black according to the free- dom of its application, and it acts without pain if the skin is intact. IODINE. 283 If very large amounts are used, it produces vesication. Upon mucous membranes iodine acts as a powerful irritant. Germain-See believed it to be a stimulant to the nutritive processes of the body and to the circulatory system, and he was certainly correct in regard to the influ- ence it exercises over nutrition. Absorption and Elimination. — The drug is rapidly absorbed, escapes from the body chiefly through the kidneys, the skin, the salivary glands, and it even appears in the milk of nursing women to such an extent that the nursing infant may be affected by iodism and suffer from gastro-intestinal disturbance in consequence of ingesting it. Poisoning. — The symptoms of acute poisoning by iodine are those of acute gastro-enteritis, such as severe pain in the oesophagus, stomach, and abdomen, accompanied by violent vomiting and purging. An early symptom is the persistent strong metallic taste in the mouth, with markedly increased salivation. The pulse becomes rapid, run- ning, and feeble, the face deathly pale, total arrest of urinary secretion takes place through renal irritation, and death occurs by failure of respi- ration, which is accompanied by loss of all vital power. If the poisoning is not severe enough to cause death at once, a fatal result is, nevertheless, reached after a few days by reason of the severe gastro-enteritis and the widespread fatty degeneration of the tissues which iodine produces. The treatment of the poisoning consists in the use of large amounts of starch in any of its forms as the antidote, the employment of emetics and the stomach-pump, the application of heat to the body and extrem- ities, and, finally, the employment of hypodermic injections of alcohol, digitalis, and atropine or strychnine for the purpose of maintaining the strength of the circulatory and respiratory systems. Untoward Effects. — Under the name of "iodism" the profession recognizes a state of the body brought on by the prolonged and excessive use of iodine in any of its forms. The earliest notable signs of this state are a peculiar metallic taste in the mouth, particularly in the morning, slight tenderness of the teeth and gums, increase of salivary secretion, a little morning nausea, and a lack of appetite for breakfast, and perhaps some coryza or evidence of gastric irritation. Acne rosacea often comes on very early during the use of full doses of iodine. If the drug is continued, all these symptoms become more marked and the coryza becomes intense. Frontal headache and sore throat often appear, and the pustular and bleb-like changes in the skin go on to active suppuration. Sometimes large boils appear or purpura hemor- rhagica (iodic purpura) comes on. Slight catarrhal fever may develop. In other cases the nervous system chiefly suffers. Twitchings of muscles, neuralgic pains in the trunk and extremities, and wasting of the testicles, mammse, and all other tissues occur as the result of trophic disturbances. Anaemia amounting to an actual cachexia is commonly produced. Loss of vision and paralysis may ensue in extreme cases. Soullier asserts that albuminuria may be developed in children after 284 DRUGS. tincture of iodine has been freely applied to the skin, by reason of its absorption and irritation of the kidneys. Therapeutics. — In all cases where the glandular system is in a state of chronic perverted functional activity, as in those diseases associated with disorder of the processes of nutrition, and often included under the single name of scrofulosis, iodine is of service. In enlargement of the lymph-glands it is, in its various forms, one of the best remedies we possess, but it ought not to be employed in those cases where rapid changes are going on in the gland, such as the formation of pus, since under these circumstances it will increase the size of the slough. Neither will it benefit the glanular enlargements of Hodgkin's diseased or lymphatic leukaemia, The drug ought never to be used in rapid phthisis, because it tends to disintegrate the tissues, and this is pre- cisely what the disease is doing. In the exceedingly chronic form of pulmonary disease known as fibroid phthisis iodine may often be used with advantage. When inhaled as vapor it may be of service as a stimulant to the mucous membranes, but is never of value in phthisis so far as combating the true pathological change is concerned. In coun- tries where goitre is very prevalent iodine ranks as a most efficient remedy, but it must be used with caution, and in case of exophthalmic goitre it is probably harmful in that the hypertrophied gland probably produces some of its symptoms by excreting too much iodine. In cystic or vascular enlargement of the thyroid gland it is valueless, but in simple overgrowth of the connective tissue of the gland iodine is of some value. Sometimes it is injected by means of a hypodermic needle into the gland. The usual dose is 10 to 15 minims (0.60-1.0) every second or third day till twenty or more injections have been used. Meltzer states that while this treatment is sometimes efficacious, it is not devoid of danger, for at least thirty deaths have resulted from it. In chronic bone disease iodine applied about the affected joint in the form of the ointment diluted one-half with lard, or in the pure tincture will be found of service, and if an&mia exists the syrup of the iodide of iron should be given internally. The other uses of iodine externally are many and important. As a slow counterirritant, which does not produce pain if properly employed, it is particularly useful in children, and may be employed in one to three coats, and no more, applied by means of a camel's-hair brush. The proper way to use the tincture of iodine as a local counter- irritant for adults is to give one good black coat at one sitting and not to repeat it until the skin has desquamated and become well renewed. If iodine is applied after desquamation of the skin has begun, it will cause agonizing burning pain, which nothing will relieve except the removal of the iodine by the use of cologne- water, alcohol, whiskey, or gin. The application of any of these liquids causes such an increase in the pain as to be almost useless after the skin is broken. The best solution for its removal is one of iodide of potassium, which should be followed by a starch poultice. A good rule to follow, is never to cause pain by IODINE. 285 the use of iodine, as the drug acts equally well if applied in such a way as to avoid suffering. A stronger and more active preparation of iodine in solution for external use is that recently suggested by Elsberg. This preparation is of 20 per cent, strength, whereas the ordinary tincture is about 10 per cent. It is composed of iodine, 5 drachms (20.0) ; alcohol and ether, of each, 10 drachms (40.0). One or two coats of this solution painted upon the skin will produce as much effect as several of the ordinary tincture, and as it dries very rapidly it does not soil the clothing. Iodine in the form of the tincture is applied as a counterirritant paint to the skin of the chest in pleurisy, both to abort an attack and to aid in absorption of the fluid after it is passed out into the chest. In harassing, irritative cough it may be painted over the supraclavicular spaces, and it will sometimes lessen the secretion in chronic bronchitis if used in this way. In chronic rheumatism affecting the joints and muscles it does good when locally applied. Often in synovitis the local application of iodine causes increased swelling for some days. This should not cause alarm, for ultimately the swelling decreases greatly, and the cases in which this occurs are generally the best from a prog- nostic point of view. In the course of phthisis every now and then a "spot" in the chest will become "sore," probably due to a limited area of pleurisy, and under these circumstances tincture of iodine locally applied will give relief. In lupus the tincture may be painted around the edges of the growth, and even over its surface, with the object of retarding its spread. In chilblains an application of iodine ointment gives the greatest relief if diluted one-half with lard, and its use is probably the most efficacious measure at our disposal. In certain individuals who have "pains in the chest" iodine ointment may do good if rubbed in over the affected spot. As has been pointed out by others, iodine does good if muscular tenderness is present, while it fails if pleurodynia or intercostal neuralgia is the cause of the suffering. The latter troubles should be removed by the use of belladonna. In certain forms of skin diseases, such as tinea tonsurans and circinata, tincture of iodine may be applied with a camel's-hair brush, and even the entire scalp may be painted. A better way is to apply it to different spots each day. When erysipelas is present, the tincture may be painted around the edges of the inflamed area in order to prevent its spread. In old persons or those in middle life retraction of the gums from the teeth sometimes comes on, and dentists recommend for this disorder the use, by means of a earner s-hair brush, of a watery solution of iodine of the strength of 1 grain to the ounce (0.06-30.0), to be followed at once by a thorough rinsing of the mouth with pure water. In hydro- cele iodine in the form of the tincture is the best drug for effecting a permanent cure. The sac should first be emptied by the use of a trocar and canula, and the iodine alone or mixed with glycerin injected with a syringe, and then allowed to escape. As the pain produced by this 286 DRUGS. injection is most atrocious, the patient should first be put under the influence of ether or other anaesthetic. Injections of iodine have been made into various serous cavities for the relief of chronic inflammatory processes. This is sometimes fol- lowed by unfavorable symptoms, and after the injection of tincture of iodine into the pleural cavity in hydrothorax symptoms of poisoning have come on in some cases, the most common complication being convulsions. These are epileptiform in character and are followed by coma or collapse. In empyema a solution of iodine 6 grains (0.40), iodide of potassium 6 grains (0.40), and water 1 pint (480 c.c.) may be used daily as an irrigating fluid with good results; but this practice is not entirely devoid of danger, as too much of the iodine may be absorbed or the irritation produced in the chest by its injection may cause reflex and severe nervous symptoms. Iodoform is better. The tincture of iodine may be used, according to Ringer, as an inhalation with signal benefit in the following three instances : 1. In the chronic forms of phthisis (fibroid lung). When the expec- toration is abundant and when the cough is troublesome, its inhalation, used both night and morning, will generally lessen expectoration and allay the cough. 2. In children six to ten years of age, who after meals, or, independ- ently of them, on exposure to cold, are seized with hoarseness, a hoarse, hollow cough and some wheezing in the chest. This affection, involv- es © > mg the larynx, trachea, and larger bronchial tubes, and often proving very obstinate, is apt to return and to persist for some time. 3. Some persons suffer with itching of the nose, of the inner canthus of one or both eyes, sneezing, running at the nose, of a watery fluid, weeping of the eyes, and severe frontal headaches; and these patients of various ages are greatly troubled, often for many years, with daily attacks of this character, lasting, it may be, several hours. Iodine inhaled often relieves this affection at once, ■ lessening the headache and discharge from the nostrils. Its effect is most marked in respect to the itching. Ringer generally adopts the following simple, handy, cleanly, and effectual plan of inhalation: Heat well a jug capable of holding' about 2 pints, by rinsing with boiling water; then partly fill with boiling water, into which pour 20 to 30 minims (1.3-2.0) of the tincture of iodine; then direct the patient to put his face over the mouth of the jug and breathe the iodized steam, covering the head to prevent escape of the vapor. This inhalation should be used night and morn- ing for five minutes or a little longer. Occasionally an excess of iodine will temporarily produce a sensation of soreness in the chest and throat, accompanied with redness of the conjunctiva, running from the nose, and pain in the head. In some cases of acute coryza much relief may be obtained by sniffing the fumes of tincture of iodine from a bottle, as in the use of "smell- IODOFORM. 287 log salts." The heat of the hand is sufficient to disengage the vapor in proper quantity. Administration. — Iodine is never used in solid form, and it has been taught that the tincture (Tinctura Iodi, U. S. and B. P.) should not be given internally, on the ground that it is precipitated in the stomach. Whether this be true or false, it is a fact that the tincture has been largely used in the vomiting of pregnancy and that occurring after the use of anaesthetics with very good results. The dose is 5 to 10 minims (0.30-0.60), well diluted. Under the name of Lugol's solution (Liquor Iodi Compositus, U. S.) iodine is frequently used internally; the dose is 5 to 10 minims (0.30-0.60), in water. Liquor Iodi Fortis, B. P., is used as a liniment or local application. Unguentum Iodi, U. S. and B. P., is used locally over enlarged glands. In the case of children or adults who have delicate skins the ointment should be diluted one-half with lard. This ointment should always be freshly made. Contraindications. — Iodine is contraindicated in renal diseases, except in small doses, during the progress of acute inflammation, and whenever tissues are rapidly undergoing a breaking-down process. IODOFORM. Iodoform (Jodoformum, U. S. and B. P.) occurs in small saffron- colored crystals which possess a characteristic, penetrating odor and strong taste. It is soluble in alcohol, ether, chloroform, benzol, and in fixed and volatile oils, but is insoluble in water. Physiological Action. — The effects of iodoform upon the circulation, respiration, and other vital functions are very slight when the drug is used as a surgical dressing in ordinarv amounts or when it is given bv the mouth. in average doses. It acts as an anaesthetic upon mucous membranes, and produces those changes which we are wont, for want of a better term, to call ''alterative," in the tissues with which it comes in contact. Iodoform is eliminated in the urine as iodine or as alkaline iodides, chiefly iodide of sodium. The drug also escapes by the saliva as an alkaline iodide. Poisoning. — If applied to an absorbing surface in susceptible indi- viduals, iodoform may cause general systemic poisoning. This poison- ing may be mild, in which case there is a general feeling of malaise, with nausea and the perception of various odors which are in reality not present. There may be headache and vomiting. If the system is still more impressed by the drug, these symptoms are followed by cerebral excitement, insomnia, loss of memory, loss of appetite, and a rapid pulse. In grave cases convulsive movements and maniacal delirium, alternating with coma, may be the dominant symptoms. The pulse is small and rapid, and there is often retention of urine or hematuria. Loebisch asserts that the mental excitement cannot be quieted by narcotics. If death occurs, the heart and respiration fail simultane- 288 DRUGS. ously. In addition to the fatty degeneration which such poisoning pro- duces in all the vital organs, there is sometimes found an cedematous condition of the pia mater or a low-grade leptomeningitis. These symptoms seem to occur more commonly in the aged. In the graver cases the onset of the poisoning is apt to be sudden, though from twenty-four hours to several days usually elapse between the applica- tion of the drug and the onset of the symptoms of poisoning. Treatment of the poisoning by iodoform consists, according to Soullier, in the administration of bicarbonate of sodium to unite with the iodine and so aid in its elimination; the use of alcoholic stimulants to support the system; the employment of diuretics, and wrapping the patient in hot blankets to encourage free sweating, so relieving the kidneys. Kocher advises saline transfusion in such cases. Untoward Effects. — It is not to be forgotten that iodoform when applied as a dressing may produce less violent symptoms than those just described, and capable, because of their aberrant character, of seriously misleading the physician. Thus a scarlatinal rash may develop with fever, malaise, and nervous disturbances. Therapeutics. — Iodoform is used chiefly as a surgical dressing, but is by no means so popular for this purpose as it was at one time. It is antiseptic, but not germicidal. Germs may be found in powdered iodoform, and will even grow in it. When used locally, the drug does good by absorbing the liquids of the wound, and thereby removing the nidus for germ-growth, and when applied to large moist surfaces gives off free iodine and acts as well as a protective. There can be no doubt that iodoform when applied to a wound does good, not by destroying the bacteria directly or indirectly, but by inducing chemical changes in their toxins. In syphilitic sores the following dressing will be found of great service: iodoform, 20 grains (1.3); oil of eucalyptus, | fluidounce (16.0); or a powder of iodoform \ ounce (16.0), camphor 75 grains (5.0), and essence of roses 2 drops (0.1), may be employed. In eczema, with tingling and itching, the following application will give relief (Ringer) : 1$ — Iodoformi gr. iv (0.25) Olei eucalypti . f5j (4.0). Petrolati §j (30.0).— M. S. — Apply locally. Internally, iodoform is used in tertiary syphilis in all its forms in the dose of from 1 to 5 grains (0.06-0.30). Bartholow has recommended it most highly in catarrhal jaundice and in the early stages of hepatic cirrhosis. The influence of iodoform upon the tubercle bacillus is very great, and it is largely used in the treatment of tubercular disease of the joints and pleura. The pus is allowed to escape under antiseptic pre- cautions; the cavity is washed out with warm boric-acid or carbolic-acid solutions of low strength, and from 1 to 6 drachms (4.0-24.0) of an IODOL. 289 emulsion of iodoform and sterilized sweet oil are injected and allowed to remain. The strength of the iodoform-and-oil emulsion should usually be 10 per cent. Should the abscess cavity fail to heal after these injections have been repeated every few days for some time, it must be reopened, scraped, and injected again or packed with iodoform gauze. The iodoform also promotes healing through its alterative influence, which aids in the absorption of the inflammatory exudate. Should tubercular glands be present, injections may be made into them even if pus has not formed. Used by means of a powder-blower, iodoform will often relieve the hoarseness and discomfort of laryngeal phthisis, but it must be pulver- ized most minutely. Sometimes a spray may be used, which should consist of spirit of turpentine and sweet oil, half-and-half, and con- tain 2 grains (0.12) of iodoform to each ounce (30.0). This mixture may also be used in chronic bronchial catarrh to lessen the cough and fetid discharge. In the early stages of phthisis several clinicians claim to have obtained good results by the daily hypodermic injection into the back of 30 minims (2.0) of a 1 : 100 solution of iodoform in oil of sweet almonds, but this treatment has not found favor, in the United States at least. For fissure of the anus and irritated hemorrhoids 5 grains (0.30) of iodoform in a suppository may be placed in the rectum, and after it has remained there a few minutes defecation may take place with little or no pain. The pain following operations on the female perineum may also be much relieved in this manner. In the tenesmus of cholera infantum an injection of 1 ounce (30.0) of sweet oil with 5 grains (0.30) of iodoform will give great relief if used after or before enterocylsis. Administration. — The ointment of iodoform (Unguentum Iodoformi, U. S. and B. P.) is useful when applied over fetid sores. It should always be freshly made. The drug itself may be given in 1- to 5-grain (0.06-0.30) doses three times a day. The suppositories (Suppositoria Iodoformi) are official in the B. P.; each one contains 3 grains (0.20) of iodoform. (See also Nosophen, Europhen, and AristoL) IODOL. Iodol is a dark, dirty-yellowish-looking powder, soluble in alcohol, ether, and oils, but only slightly so in water. It should be kept in amber-colored bottles. Its uses in medicine are identical with those of iodoform, and it possesses the advantage of having a less penetrating odor than the latter drug. In tubercular laryngitis the very finely powdered drug may be blown into the larynx without disagreeable results and with a favorable effect on the disease process. Cerna has found iodol of great service in diabetes when given internally in the dose of from 2 to 6 grains (0.12- 0.40) three times a day, and it is said to be of value in tertiary syphilis in the same quantity. 19 290 DRUGS. A useful antiseptic dressing for small wounds and abrasions is made by adding 1 part of iodol to 10 parts of ether and 5 of gun-cotton, thereby preparing an iodol collodion. Ingalls recommends the following prescription in cases of eczema or abrasions of the upper lip and nostrils : 1$ — Acid, carbolic. . . v\x (0.3). 01. rosse tt\v (0.3). Iodol gr. xxv (1.6). Lanolin |ss (16.0).— M. IPECACUANHA. Ipecacuanha, U. S., or Ipecacuanha? Radix, B. P., or Ipecac, is the root of Cephaelis Ipecacuanha (Psychotria Ipecacuanha, B. P.), a small shrub of Brazil. It contains an alkaloid, emetine, and ipecac- uanhic acid. Physiological Action. — Locally applied to mucous membranes, ipe- cac acts as an irritant, and if applied for a long period to the skin pro- duces vesicles and irritation. Fig. 48. Very minute doses have little noticeable effect, but large ones produce nausea, relaxation, vom- iting, free secretion into the bron- chial tubes, and a profuse flow of saliva. The emesis is due both to the irritation of the stomach and to an effect upon the vomit- ing centre in the medulla (Fig. 48). The drug acts as a depress- ant to the spinal cord (Pecholier), and it also depresses the heart if given in large doses and retained by the stomach long enough for it to be absorbed. Ipecac is eliminated by the kidneys, the gastro-intestinal mucous mem- brane, and the skin (Binz). If emetine is given in lethal dose to one of the lower animals, death is due to failure of respiration. Therapeutics. — Ipecac is used as an emetic where a fairly rapid action is required. It is particularly useful where the stomach of a child is overloaded with food. In cases of poisoning it is hardly active or rapid enough as an emetic, and is not so good as mustard or sulphate of zinc. In babies and young children an attack of bronchitis often causes digestive disorders by reason of the mucus coughed up from the lungs being at once swallowed instead of spat out of the mouth. In these cases the stomach may be relieved and the state of the lungs improved by the use of an emetic dose of syrup of ipecac, 2 to 3 drachms A, vomiting centre in the medulla stimulated by ipecac; B, nerves in mucous membrane of stomach irritated by ipecac. IPECACUANHA. 291 (8.0-12.0). Often if the dose be not large enough to produce emesis it will purge the child and remove the mucus by the bowel. In some cases of obstinate vomiting small doses of ipecac will act as a most successful cure, provided that the vomiting is due not to inflam- mation and excitement, but to depression. The irritant effect of the ipecac stimulates the depressed stomach to a normal tone. The proper dose of ipecac for this purpose is J to \ grain (0.008-0.015) or less every half-hour until five or six doses are taken. In some cases of the vomiting of pregnancy it is very useful, in others it utterly fails. 1 minim (0.06) of the wine or J to J grain (C. 008-0. 015) of the powdered ipecac, repeated every half-hour for six o; seven doses, is all that should be used. In the morning vomiting of drunkards ipecac is of service, but it is not so good a remedy as are small amounts of arsenic or hydrochloric acid. Ipecac is also said to possess marked oxytocic properties, similar to quinine, when given in small doses, 10 to 15 minims (0.60-1.0), of the wine every two or three hours. In true acute dysentery ipecac is one of the best remedies we possess. When the passages are large and bloody and the disease is malignant, as it occurs in the tropics, ipecac should be given in the following man- ner: The powdered ipecac is to be administered on an empty stomach in the dose of 30 grains (2.0) with 30 minims (2.0) of deodorized laudanum, which is used to decrease the tendency to vomit. Absolute rest is essential for success. Finally a profuse gray, mushy stool is passed. The passage of this stool is a most favorable prognostic sign, and its non-appearance is equally significant of failure. There are a decrease in pain and a lessening of the fever and of the bloody dis- charges. Woodhull, of the U. S. Army, states that retching, vomiting, delirium, and exhaustion do not contraindicate this plan of treatment, but that it is useful when these symptoms complicate this disease. If the first dose is rejected, it may be repeated in a few hours, preceding it by the laudanum. Counterirritation is to be applied to the belly, and stimulants freely used to avoid great depression. In choleraic diarrhoeas and cholera morbus ipecac is said to be of service in the dose of 3 grains (0.20) every two hours if opium is given to control nausea. No less a person than Trousseau asserted that ipecac was a haemo- static, and it is said to be a most effective remedy in small doses in haemoptysis, and in all hemorrhages which are capillary in character. Ipecac may be used in the early stages of bronchitis, to act as a seda- tive to the inflamed mucous membrane and to promote secretion. Under these circumstances it is best combined with citrate of potas- sium. (See Bronchitis.) Ringer and Murrell have found that inhaling ipecac spray is very useful in chronic winter cough or bronchitis, particularly when there is present shortness of breath. The pure wine may be used in a spray apparatus or be diluted one-half with water. While the throat may 292 DRUGS. seem temporarily worse, the shortness of breath rapidly decreases and marked improvement takes place in the cough. In order to prevent the wine which collects in the mouth from being swallowed, and nausea and vomiting thereby induced, the patient should be directed to rinse his mouth thoroughly every few minutes. The inhalation should not last at first over three or four minutes, and, until it is known how well the patient will bear the application, the wine should be diluted twice or thrice with water and alcohol, equal parts. It is stated that powdered ipecac made into a paste and smeared on the skin will greatly relieve the pain and swelling produced by the stings of bees. Administration. — The syrup (Syrupus Ipecacuanha?, U. S.) is given in the dose of \ to 1 drachm (2.0-4.0) as an expectorant, or in the same dose as an emetic to an infant. The wine (Vinum Ipecacuanhce, U. S. and B. P.) is given in the same dose as the syrup and the fluid extract (Fluidextractum Ipecacuanha?, U. S. ; Extractum Ipecacuanha? Liquidum, B. P.) in the dose of 30 minims (2.0) as an emetic to an adult. The troches (Trochisci Ipecacuanha?, B. P.) contain \ grain (0.015) each. Trochisci Morphine ei Ipecacuanha?, B. P., each of which contains 3 X g- grain (0.002) of morphine and y 1 ^ grain (0.005) of ipecac, are used in sore throat, dissolved in the mouth. Dover's powder (Pulvis Ipecacuanha? et Opii, U. S.; Pulvis Ipecacuanha? Compos ita?, B. P.) is given in the dose of 5 to 15 grains (0.30-1.0). It contains 1 part (0.06) of opium, 1 part (0.06) of ipecac, and 8 parts (0.5) of sugar of milk. (See Opium.) Emetine may be given in the dose of -^ to \ grain (0.005-0.01) as an emetic, but is very rarely so employed. The additional British preparations are the pill of ipecac and squill (Pilula Ipecacuanha? cum Scilla, B. P.), given in the dose of 5 to 10 grains (0.35-0.65), and the vinegar of ipecac (Acetum Ipecacuanha?, B. P.), given in the dose of 5 to 30 minims (0.3-2.6), which are used as expectorants. IRON. Iron (Ferrum, U. S. and B. P.) is a metal which is used both as a medicine and a food — a food because it forms part of the body when taken into the organism and is used by the system in the making of blood. The number of its official salts and compounds is far in excess of the needs of practical physicians, and half the preparations are rarely, if ever, used, Physiological Action. — Iron has little or no effect upon the system when given in a single dose, but repeated doses cause an increase in the number of red blood-corpuscles, and plethora, or an increase in the quantity and quality of the blood. Much discussion has arisen as to whether iron is absorbed when given as a drug in the form of one of the inorganic salts. One theory has been that only the organic iron of IRON. 293 the food is absorbed, and that metallic iron when given freely allows this absorption to go on both by stimulating the bowel and by entering into combination with the sulphuretted hydrogen in the intestine, thus permitting the organic iron to escape into the system. That both forms of iron are absorbed and eliminated is now certain. (For a discussion of some of these views see article on Anaemia.) If, however, iron is given in excessive doses, much of it remains unabsorbed, is changed into the sulphide of iron in the bowels, and escapes with the feces. Careful studies have shown that the iron, when once absorbed, escapes from the body very slowly, and that its pathway of escape is not by the bile or in the urine, but by the walls of the intestine which excrete it, so that it may be recovered from the feces. It has been asserted that it is never released from the body, but this is untrue. Whether it acts as a stimulant to blood-manufacture or simply supplies the glands with blood-making material is not known, but the latter is probably the correct view. Iron causes oxidation to go on more rapidly by reason of its peculiar power of converting oxygen into ozone, and in this manner acts as a stimulant to nutrition and bodily activity. The preparations of iron consist in the soluble and insoluble salts or forms. Of these the insoluble are better than the soluble, because nearly all the soluble salts of iron are precipitated by the gastric juice and have to be slowly redissolved. Nearly all iron preparations are capable of acting as more or less powerful astringents, and so are apt to cause constipation and to disorder digestion if given in large doses. The most astringent of all these preparations are Monsel's salt (the Ferri Subsulphas, U. S., B. P.) and the sulphate (Ferri Sulphas, U. S. and B. P.). Closely following these in astringency are the ammonio- ferric alum (Ferri et Ammonii Sulphas, U. S.) and the chloride of iron (Ferri Chloridum, U. S.). The least astringent preparations are Quevenne's iron, or iron by hydrogen (Ferrum Reductum, U. S. and B. P.), carbonate of iron (Ferri Carbonas Saccharaius, U. S. and B. P.), Basham's Mixture (Liquor Ferri et Ammonii Acetatis, U. S.), the citrates, tartrates, and the lactate and phosphate of iron. Therapeutics. — The chief indications for the administration of iron are those forms of anaemia (see Anaemia) characterized by a decrease in the normal quantity of haemoglobin in the blood as determined by the haemoglobinometer, as, for example, chlorosis. Its chief contraindica- tion is plethora. When used in small dose (\ to \ grain — 0.015-0.03) it is quite as efficacious as in large amounts, and less apt to disorder the stomach, but the doses given in this article are the classical ones usually prescribed by physicians. In some cases of anaemia of a semi-pernicious type large doses of iron are really needed, probably because the system is deranged in such a manner that an excessive loss or elimination of iron is constantly present. Large doses compensate for this leakage and afford the quantity needed for physiological purposes. Iron should not be used as a tonic unless some direct indication for its employment is present, and no drug is more abused in this respect than iron. As 294 DRUGS. every preparation possesses some peculiarity, the use of each will be considered separately. Ammonio-ferric Alum. Ammonio-ferric Alum (Ferri et Ammonii Sulphas, U. S.) is often given in cases of atonic leucorrhaa associated with chlorotic tendencies in the dose of 2 to 5 grains (0.12-0.30). It is quite astringent, and should not be given in cases of gastric irritability, as it is not suited to such a condition. Aromatic Mixture of Iron. The Aromatic Mixture of Iron (Mistura Ferri Aromatica) contains so little iron that it should not be administered in cases where a very marked chalybeate influence is desired; it is, however, a useful tonic for cases of debility and slight anaemia following long illnesses, given in the dose of 1 to 2 fluidounces (30.0-60.0) after meals. Aromatic mixture of iron contains cinchona-bark, calumba, cloves, iron, com- pound tincture of cardamoms, tincture of orange-peel, and pepper- mint-water. Arsenate of Iron. Arsenate of Iron (Ferri Arsenas, B. P.) is used in the dose of yg to y 1 ^- grain in anaemic subjects who are suffering from the dry, scaly forms of skin disease which indicate the use of arsenic. (See Arsenic.) It is also of value in the anaemia of chronic diarrhoea, as both iron and arsenic are useful, not only for the anaemia, but for the control of the intestinal disorder. Basham's Mixture. Under the name of Basham's Mixture (Liquor Ferri et Ammonii Acetatis,\J. S.) a very useful and elegant preparation of iron is employed. It is particularly useful in the ancemia of acute and chronic parenchy- matous nephritis, as it also acts as an efficient diuretic and diaphoretic. It is made up as follows: Tincture of chloride of iron .... 4 parts. Dilute acetic acid 6 Spirit of mindererus 40 Elixir of orange 10 Glvcerin 15 Water 25 " The dose is from 1 to 4 drachms (4.0-16.0), well diluted. Bromide of Iron. Bromide of iron (Ferri Bromidum) is said to be useful in ancemia, when this state is associated with chorea, in the dose of 5 to 20 grains (0.30-1. 3)'given in syrup. In other nervous diseases accompanied by anaemia and insomnia the syrup of the bromide of iron (Syrupus IRON. 295 Ferri Bromidi) is useful in the dose of J to 1 fluidrachm (2.0-4.0), but its sedative properties are not sufficiently marked to render it of much value in overcoming true insomnia unless it is fortified by one of the other bromides. Cacodylate of Iron. Under the name of cacodylate of iron a compound has been intro- duced which is given in cases of anamiia, in which the haemoglobin and the corpuscles are lacking, since by this means we obtain the effect of both iron and arsenic. The salt may be given by the mouth in the dose of \ to 1 grain (0.015-0.06) three times a day, in solution, or in urgent cases in the dose of J to \ grain (0.008-0.015) by the hypodermic needle three times a day. It is asserted by Gilbert and Tereboullet that this is not productive of local or renal irritation, and in the albuminuria of tuberculosis may even be beneficial. Arsenate of iron is more useful. Carbonate of Iron. The Carbonate of Iron (Ferri Carbonas Saccharatus, U. S. and B. P.) is very slightly astringent, and may be used in pill form under the name of Piluloe Ferri Carbonatis, U. S. (Pilidce Ferri, B. P.), sometimes called "Blaud's pill," or in Griffith's pill, which also con- tains myrrh. The dose is about 3 grains (0.20). This preparation of iron is largely used for the treatment of amenorrhcea dependent upon anaemia. Under the name of Mistura Ferri Composita, U. S. and B. P., or Griffith's mixture, a liquid preparation is used for the same purposes as the pills just named, in the dose of 1 to 2 tablespoon- fuls (15.0-30.0). Massa Ferri Carbonatis, U. S., sometimes called Vallet's mass, is given in pill in the dose of from 1 to 10 grains (0.06- 0.60). Chloride of Iron. Tincture of the Chloride of Iron (Tinctura Ferri Chloridi, U. S.; Tinctura Ferri Perchloridi, B. P.), often called Tincture of the Muriate of Iron, is one of the best and most useful preparations of iron. It is the most diuretic preparation of iron. This diuretic effect does not depend upon the presence of muriatic ether, as has been taught, since it is not present, and is difficult to prepare except there is an excess of chlorine. According to researches of Dr. S. Weir Mitchell the only ether present is nitrous ether, and this is devoid of power and in small quantity. As chloride of iron itself is diuretic, it is probably upon this that the diuresis produced by it depends. The dose of the chloride of iron (Ferri Chloridum, U. S.) is 1 to 3 grains (0.06-0.20). Tincture of the chloride of iron is considered a specific in erysipelas, and should be given in full dose and frequently repeated if it is to be of any service. (See Erysipelas.) 10 minims (0.60), well diluted, every hour are not too much if the stomach of the patient does not rebel. In chronic Briqhfs disease it is of value and decreases the albuminuria. 296 DBUGS. In ancemia it is useful, and owing to its acid content is a doubly effective tonic. In cases of slight ansemia in which high arterial pressure exists Dr. Mitchell uses a purely milk diet, and an ounce of an old tincture of iron in the twenty-four hours. While he recognizes the fact that iron preparations are generally supposed to raise blood-pressure, he asserts that in this instance the blood-pressure is lowered. The dose of Liquor Ferri Chloridi, U. S., is 4 to 10 minims (0.25-0.60). It is rarely used internally, but chiefly as a powerful local astringent. Liquor Ferri Chloridi is identical with Liquor Ferri Perchloridi, B. P. Tinctura Ferri Perchloridi, B. P., is used internally in the dose of 10 to 20 minims (0.60-1.3). As a local application tincture of the chloride of iron is useful in diphtheria and membranous croup, and even in tonsillitis. In each of these maladies large doses of the tincture internally, with counter- irritation over the neck, are most useful. When used internally it should be well diluted with water and taken through a glass tube, to protect the teeth. The strong solution of perchloride of iron (Liquor Ferri Perchloridi Fortis, B. P.) is a powerful styptic. Citrates and Tartrates of Iron. The four citrates of iron are soluble in water and very useful for this reason because they are readily added to liquid prescriptions, and they are also of value because they are slightly irritant and astringent and do not disorder the alimentary canal. Ferri Citras, U. S., and Ferri et Ammonii Citras, U. S. and B. P., occur in garnet-red scales, and are given in the dose of 5 grains (0.30). The solution of the citrate of iron (Liquor Ferri Citratis) is given in the dose of 10 minims (0.60). The Ferri et Quinine Citras, B. P., and the Ferri et Strychnine Citras, U. S., are usually given in the dose of 5 to 15 grains (0.30-1.0) and 1 to 3 grains (0.06-0.20), respectively. The new official Ferri et Quinine Citras Solubilis,\J. S., is given in the dose of 1 to 2 grains (0.06-0.12). Besides these citrates there are three tartrates — Ferri et Ammonii Tartras, U. S., and Ferri et Potassii Tartras, U. S., and Ferrum Tar- taratum, B. P., all given in the dose of 5 grains (0.30). Dialyzed Iron. Dialyzed iron (Ferrum Dialysatum) is a very feeble preparation of iron, lacking in astringency, easily precipitated from the solution in which it occurs, but at one time largely used in anemia by some prac- titioners. The dose is 10 to 20 minims (0.30-1.3) in water three times a day. Sometimes river-water, if it contains much inorganic or organic matter, will precipitate it. Owing to the instability of dialyzed iron, it may be used as an antidote to arsenic without further preparation. 1B0N. 297 Hydrated Sesquioxide of Iron. Hydrated Sesquioxide of" Iron (Ferri Hydroxidum, U. S.) is the antidote to arsenic, but to be efficacious it must be freshly prepared. It is to be made by precipitating any liquid preparation of iron by the addition of an alkali, such as ammonia, or by the addition of magnesia. The resulting precipitate is the antidote, and the supernatant liquid is to be poured off. If ammonia is used, the precipitate must be washed with water several times to get rid of the alkali, which will render the antidote too irritant to be swallowed if it is allowed to remain with the precipitate. Magnesia is an antidote in itself, and should be preferred under all circumstances. The antidote should be given in excess, and as much as a pint of the iron solution should be precipitated. The magnesia should be freely added, as too much of it cannot be given. The antidote to arsenic is official as Ferri Hydroxidum cum Mag- nesia, U. S. In the Prussian Pharmacopoeia this is known as the Antidotum Arsenici. (See Arsenic, Poisoning by, for official method of preparing antidote.) Iodide of Iron. The Syrup of the Iodide of Iron (Syrupus Ferri lodidi, U. S. and B. P.) is a transparent liquid of a sweet, iron-like taste. It should con- tain no free iodine, and if a sample of it strikes a blue color with starch it should be discarded. It is largely used in anosmia associated with scrojulosis and struma, and is useful in the eczema of young children when this is dependent upon lack of vitality or anaemia. The dose to a child of two years is 3 to 6 minims (0.20-0.40), well diluted, and to an adult 30 to 40 minims (2.0-2.6) in water, to be taken through a glass tube to protect the teeth. The saccharated iodide of iron (Ferri Iodidum Saccharaium) is used in place of the syrup in the dose of 2 to 5 grains (0.12-0.3). The official pills (PiluloB Ferri lodidi, U. S.) each contain \ grain (0.01) of reduced iron and \ grain 0.008) of iodide, and are given in the dose of one to three pills. Subsulphate of Iron, or MonseFs Salt. Monsel's Solution (Liquor Ferri Subsulphatis, U. S.; Liquor Ferri Persulphatis, B. P.) is sometimes wrongly called the solution of the Persulphate of Iron, and is one of the most powerful styptics or haemo- statics that we have. It is never to be employed where a hemorrhage is to be controlled through the circulation, but only when the solution can come in direct contact with the bleeding spot. The objection to its use is the hard, black, and dirty clot which it forms on coming in con- tact with blood. In haemoptysis Monsel's solution may be used in fine spray consisting of from 10 to 60 minims (0.60-4.0) to the- ounce (30.0) of distilled water. In uterine hemorrhage from any cause the dilution 298 DRUGS. may be half-and-half, or if the hemorrhage be from a polypus or the cervix uteri the pure solution should be used, locally applied. In nose- bleed Monsel's solution may be employed diluted one-half or pure; but its use is not to be commended, because of the hard, black clot which is formed and the uncomfortable sensations and pain produced in the nasal chambers. Plugging the nostrils, and if need be the posterior nares, with pledgets of cotton is generally sufficiently efficacious. For the intestinal hemorrhage occurring during or after typhoid fever Monsel's solution has been given, but ought not to be so employed, as it is decomposed in the stomach before it reaches the intestine. In its stead Monsel's salt (Ferri Subsulphas) should be given in pills of 3 grains (0.20) each, the pills being made hard enough to escape into the intestine before the stomach dissolves them. One, two, or three pills may be given, and repeated in an hour in pressing cases. Hamiatemesis due to bleeding in the stomach may be treated by 3-minim (0.20) doses of the solution in a little water. It should be remembered, however, that the drug is irritating if frequently repeated. In tonsillitis and pharyngitis a most efficient application is pure Monsel's solution applied by means of a pledget of cotton or camel's- hair brush, or equal parts of the solution and glycerin may be used. This application is often as painful as it is efficient, and care must be exercised that an excess of the fluid be not present, as it may drop into and irritate the larynx. In diphtheria this method of treatment may be used if peroxide of hydrogen cannot be obtained. The antidote to Monsel's solution is common soap. Oxalate of Iron. Oxalate of Iron (Ferri Oxalas) is given in the dose of 2 to 3 grains (0.12-0.20). It possesses no advantages peculiar to itself. Phosphates of Iron. There are two phosphates of iron — Ferri Phosphas Solubilis, U. S., or Ferri Phosphas, B. P., and Ferri Pyrophosphas Solubilis, U. S., Phosphate of iron itself is insoluble and is rarely used. The official forms are, however, quite soluble, and useful in the dose of 2 to 5 grains (0.12-0.30). Syrupus Ferri Phosphatis, B. P., is given in the dose of 1 fluidrachm (4.0). Phosphate of iron is one of the ingredients of the syrup of iron, quinine, and strychnine (Syrupus Ferri, Quinine- et Strychnine Phosphatum, U. S.; Syrupus Ferri Phosphatis cum Quinina et Strychnina, B. P.), which is given in the dose of 1 fluidrachm (4.0), and of the elixir of iron, quinine, and strychnine (Elixir Ferri, Quinine et Strychnine Phosphatum, U. S.), given in the same dose as the syrup. Reduced Iron. Quevenne's Iron (Ferrum Reductum, U. S., Ferri Redactum, B. P.) is an iron-gray or reddish powder which is frequently adulterated with lampblack. If it is pure, it should burn in sparks when dropped IRON. 299 into a flame; but if lampblack is present this will not occur. It should also yield no sulphuretted hydrogen on adding sulphuric acid to it. It is tasteless, and may be given to children for this reason in pills or gum-drops, or placed inside of small chocolate creams, or in the form of troches (Trochisci Ferri Redacti, B. P.), each lozenge containing 1 grain (0.06) of the reduced iron. It is used solely in ancemia, and is one of the least astringent of the iron preparations. Dose y^- to 2 grains (0.006-0.12). Lactate of Iron. The Lactate of Iron (Ferri Lactas) is soluble in 48 parts of water, and is given in the dose of 5 grains (0.30). It is used for the same purposes as the other preparations of iron. Lactate of iron is one of the ingredients of the formerly official Syrupus Hypophosphitum cum Ferro, the dose of which is \ to 1 fluidrachm (2.0-4.0). Sulphate of Iron. Sulphate of Iron (Ferri Sulphas, U. S. and B. P.) is used internally in the dose of 5 grains (0.30) in pill form in chronic diarrhoea with an&mia. Externally, in a solution of the strength of 5 to 25 grains to the ounce (0.30-1.6:30.0), it is used as an astringent lotion. Two other forms of the sulphate are also employed — namely, the dried Ferri Sulphas Exsiccatus, U. S and B. P.) and the granulated (Ferri Sulphas Granulatus, U. S.), each of which is given in the dose of 3 grains (0.20). Valerianate of Iron. Valerianate of iron (Ferri Valeras) is sometimes used in hysteria with an&mia, given in the dose of 1 grain (0.06) or more. It possesses a very feeble influence as a nervous sedative. Wines of Iron. The Bitter Wine of Iron (Vinum Ferri Amarum, U. S.) is useful as a bitter tonic in anaemia in both children and adults, and may be advan- tageously accompanied with cod-liver oil. It is given in the dose of 1 to 2 fluidrachms (4.0-8.0) or more. This wine is composed of soluble citrate of iron and quinine, tincture of sweet orange-peel, syrup, and stronger white wine. Wine of the Citrate of Iron, or Vinum Ferri, U. S.; Vinum Ferri Citratis, B. P., is composed of the citrate of iron and ammonium, tincture of sweet orange-peel, syrup, and stronger white wine. The dose is identical with that of the bitter wine, and it is used for the same purposes. The plaster of iron (Emplastrum Ferri) is prepared from the hydrated oxide of iron. The Liquor Ferri Acetatis, B. P., is given in the dose 15 minims to 1 fluidrachm (1.0-4.0). 300 DRUGS. Untoward Effects of Iron. — Iron is apt to cause gastric distress and frontal headache in persons who are susceptible to its use. Even one dose will cause this trouble in some patients. In many instances the frontal headache will be found to be due to the constipation which has been brought on by the iron, and will be relieved if mild laxatives or purges are used. The state of the bowels should always be inquired into when iron is being used, and laxatives given whenever constipation is present. In rheumatic and gouty persons frontal headaches are a common symptom when iron is given, and purgatives will not generally give relief. Garrod and Haig have shown that iron decreases the elimination of uric acid, and they think this may account for the pro- duction of headache in the case of rheumatic patients under its influence. Sometimes salts of iron produce vesical irritation and a constant desire to urinate, causing mucus to form in abnormal amount in the bladder. In children its use may result in nocturnal incontinence of urine. JALAP. Jalap {Jalapa, U. S. and B. P.) is the tuberous root of Exogonium Purga (Ipomoea Purga, B. P.), a native of Mexico. It contains two resins, jalapin and convolvulin, neither of which is used in medicine by itself, though both of them enter into the Resin of Jalap of the U. S. P. The term jalapin is sometimes employed to designate the resin. In overdose jalap or its resin causes vomiting and purging, with gastro-enteritis. Therapeutics. — Jalap is used in medicine as a hydragogue purge to relieve dropsy of any origin. It may be used to deplete in cases of general plethora with cerebral congestion, and owing to its tastelessness is a useful active cathartic in children if given in the proper dose — ■ namely, 1 to 2 grains (0.06-0.12) in \ ounce (16.0) of syrup of rhubarb. Combined with calomel, it is preferred to all other purges by some practitioners, particularly if the liver is torpid. Jalap in large doses must be used with caution in persons who are feeble, and it is contraindicated in cases suffering from gastric or intestinal irritation. Administration. — Jalap may be given in the form of a compound powder (Pulvis Jalapa? Compositus, U. S. and B. P.), dose 15 to 40 grains (1.0-2.6), which is composed of 35 parts of Jalap and 65 parts of bitartrate of potassium; and the resin (Resina Jalapa?, U. S. and B. P.), dose for an adult 2 to 4 grains (0.12-0.25). Owing to the small size of the dose of the resin and its lack of taste, this prepara- tion is to be preferred for children in the dose of \ to J grain (0.015- 0.O3). The tincture (Tinctura Jalapa?, B. P.) is given in the dose of J to 1 fluidrachm (2.0-4.0) ; the extract (Extractum Jalapa, B. P.) is used in the dose of 5 to 15 grains (0.30-1.0). JUNIPER. 301 JEQUIRITY. This is a plant known as Abrus precatorius, the seeds of which are poisonous when applied to a wound. An active principle, abrin, is com- posed of paraglobulin and a-phytalbumose, which closely resemble snake-venom in their action. Jequirity is never used internally in medicine in the United States. An infusion of the powdered seeds, made by adding \ a drachm to an ounce (2.0-32.0) of water at 140° F., may be painted with a brush on the inside of the eyelids in cases of chronic granular conjunctivitis, in order to produce an acute diphtheritic inflammation that will so change the chronic process present as to per- mit of cure. If an excessive action is developed, it may be controlled by hot compresses made of very dilute solutions of corrosive sublimate. The solution of the drug undergoes decomposition with great rapidity, and should be freshly prepared each time it is used, or 4 to 8 grains (0.25-0.5) of boric acid should be added to preserve it. The drug is a powerful cardiac depressant poison when injected into the circulation. Whether the seeds produce poisoning when swallowed is doubtful, some asserting that they cause gastro-enteritis, others that they are harmless. Probably much depends on the activity of digestion and absorption at the time of ingestion. JUNIPER. Juniperus is the fruit or berry of Juniperus communis, an evergreen of Northern Europe and America. It contains a volatile oil and an amorphous principle, juniperin. Physiological Action. — Juniper acts as a gastric stimulant and tonic, as a mild diaphoretic if combined with alcohol, and as a marked stim- ulating, exciting diuretic. It escapes from the body by the kidneys. Therapeutics. — Juniper is valuable as a stimulant to the genito- urinary tract whenever it is depressed or chronically diseased, as in chronic pyelitis, nephritis, and chronic catarrh of the bladder. In con- gestion of the kidneys, particularly that due to feeble circulation, if not accompanied by active renal changes, it relieves these organs and does away with albuminuria. Used after an attack of acute Bright's disease when reaction has set in and the secreting epithelium of the kidney is atonic, it is of value; but care should be taken that all inflammation has passed by or it will make the patient worse. In the later stages of scarlet fever, in which the renal condition corresponds to that just described, juniper is also useful. In old persons a sensation of weight across the lumbar region is often quickly removed by the use of juniper if the kidneys are inactive. Administration. — Juniper is used in the form of the compound spirit (Spiritus Juniperi Compositus, U. S.), composed of the oils of juniper, caraway, and fennel, combined with alcohol and water, in the 302 DRUGS. dose of 1 to 4 drachms (4.0-16.0). Gin is virtually identical with the compound spirit. The infusion of juniper is made by adding an ounce (30.0) of the berries to a pint (480 c.c.) of boiling water and allowing it to stand in a warm place for an hour. The entire quantity is to be taken in twenty-four hours. This infusion is often combined with an ounce (30.0) of acetate of potassium or of the bitartrate of potassium in the treatment of dropsy. The spirit (Spiritus Juniperi, U. S. and B. P.) is given in the dose of 30 minims to 1 drachm (2.0-4.0). The oil (Oleum Juniperi, U. S. and B. P.) is used in the dose of 1 to 4 minims (0.05-0.25). KAMALA. Kamala, or Rottlera, as it is sometimes called, is the glands and hairs from the capsules of Mallotus philippinensis, a plant of Abyssinia, India, China, and Australia. It contains an active principle, rottlerin, which is not official. Given in the dose of 1 to 2 drachms (4.0-8.0), kamala acts as a drastic purge and as a remedy for tape- worm, and is sometimes used for the removal of ascaris lumbri- coides. It should be administered in a syrup in which is placed some hyoscyamus to prevent griping, and the dose is to be repeated in eight hours if no effect is produced. (See Worms.) KAOLIN. Kaolin (Kaolinum, U. S. and B. P.) is a soft white powder, a decomposition-product containing feldspar. It is used externally as a dusting-powder in eczema. Cataplasma Kaolini, U. S.) is used as a poultice. KINO. Kino (B. P.) is the insipissated juice of Pterocarpus marsupium, a tall tree of India. It contains kinotannic acid, and is used as an astringent in the treatment of serous diarrhoea. It is official in the form of the tincture (Tinctura Kino, U. S. and B. P.), and is given in the dose of 2 fluidrachms (8.0). Kino may be used as a gargle in sore throat and for relaxation of the uvula. Under the name of Compound Powder of Kino (Pulvis Kino Compositus, B. P.) an efficient and pleasant antidiarrhcea powder is used. This powder is not official in the U. S. P. The formula for each powder is 15 grains (1.0) of powdered kino, 4 (0.2) of powdered cinnamon, and 1 (0.06) of powdered opium. KOLA. This drug is the nut of Kola acuminata, a tree growing in certain parts of Africa. The nut depends for its chief medicinal activity upon the LEAD. 303 caffeine which it contains. In addition to this alkaloid it contains some theobromine and kolatannic acid,which latter ingredient may explain the good results which have followed the use of kola in cases of diarrhoea. Physiological Action. — The physiological action of kola is, as far as we know, nearly identical with that of its near relatives coffee and coca, Therapeutics. — In cases of feeble heart associated with general debil- ity kola often proves a valuable stimulant to the heart and general sys- tem, as well as to the kidneys. It has also been used with asserted success in sea-sickness and to sober drunken individuals, although the latter power is to be doubted. Its use will sometimes relieve sick and neuralgic headache. Recently a large number of semi-proprietary articles have been introduced to the laity with the statement that they increase muscular strength. Except for their temporary stimulating power they are useless for this purpose. The drug is, however, of value in cases of uterine inertia during labor in the dose of 30 minims to 2 drachms (2.0-8.0) of the fluid extract. Administration. — Kola is not official. It may be given in the form of the fluid extract (Extr actum Kolw Fluidum), dose 10 to 30 minims (0.60-2.0), or in an elixir. A very useful preparation, known as the Compound Elixir of Kola (Elixir Kolae Composita), contains kola, coca, and guarana, and may be given in the dose of 2 drachms (8.0). This forms a useful tonic in some cases of debility, particularly if arsenic is added to it. Thus : 1$ — Liq. potassii arsenitis ttlxvj (1.0). Elix. kolse compositat. ..... f§iv (120.0). S. — Dessertspoonful (8.0) after meals. LANOLIN. Lanolin, which is practically Adeps Lana? Hydrosus of the U. S. and B. P., is a fat derived from the wool of the common sheep, and is a whitish substance of peculiar stability, very difficult of saponification, and incapable of becoming rancid. Unna states that ointments of acids, hydrogen peroxide, and other substances may be made by it. One great objection to lanolin is its stickiness, which is avoided by adding one-third of vaseline. Lanolin is supposed to possess very remarkable penetrating powers when applied to the skin in cases where much infiltration is present, particularly if it is combined with resorcin or some similar medicament. In itself it has little curative power, and is but little better than lard, suet, or any common fat as a basis for ointments. In some rare cases it causes irritation of the skin. LEAD. Plumbum, or Lead, is a metal possessing more or less influence over the organism according to the salts which are employed. It is not official as lead itself. 304 DRUGS. Physiological Action. — Lead, in one of its soluble salts, if applied to a mucous membrane, by reason of its astringent effect produces a blanching which is particularly noticeable where the blush of inflam- mation has previously been present. It has little effect when given in a single dose, except by an indirect influence over the circulation, nervous system, or respiration. (For a description of the effects of lead in overdoses see " Poisoning," below.) The most irritant and poisonous of the soluble salts is the nitrate, the next the subacetate, and the least poisonous of the soluble salts is the acetate. The insoluble salts rarely cause acute poisoning, but frequently produce chronic plumbism. Acute Poisoning. — When the acetate of lead is taken in poisonous amounts, it produces a sweet metallic taste in the mouth, followed by pain in the epigastrium and the vomiting of white, milky-looking liquids or white curds mixed with food. The white color is due to the presence of chloride of lead formed by the acid of the gastric juice. The pain rapidly increases in severity, and diarrhoea due to gastro- enteritis may be set up, or, in other cases, obstinate constipation is present. The passages are generally black, this color being due to the presence of the sulphide of lead. At the same time the pulse becomes rapid, tense, and cord-like, but after a time weak and compressible. The face is anxious and pale or livid. The thirst is excessive and cramps in the calves of the legs or muscular twitchings may ensue. It is said that the characteristic blue line on the gums may occur in acute poisoning, but this is rarely if ever seen. If coma comes on in the course of acute lead poisoning, death is almost certain. The treatment consists in the use of the chemical antidote, a soluble sulphate, in large quantity, in the administration of emetics, and the use of the stomach-pump if the vomiting produced by the drug is not sufficient to rid the stomach of all the poison. The best soluble sul- phates to employ are Epsom and Glauber salts, because they are always at hand, are readily soluble, and, in excess, act as purges which will wash out the intestinal canal. Hot applications should be applied to the belly and feet, and the pain and irritation which are present should be relieved by opium. Chronic Poisoning. — Chronic lead poisoning is rarely produced by the soluble salts of lead, nearly always being due to the insoluble salts. The symptoms of chronic lead poisoning, or plumbism, are as various as it is possible to find variety in the signs of disease of every kind. There is no train of symptoms which may not occur, and the occurrence of rare, anomalous symptoms in a given case should at once bring to the mind of the physician the thought of lead poisoning or syphilis. Chronic poisoning occurs in painters, manufacturers of lead salts, and every one who is largely brought in contact with the metal in the arts. It occurs from the use of hair-dyes containing the acetate of lead, from drinking water which has passed through new lead pipe, and even LEAD. 305 from the biting of silk threads weighted with salts of lead. Chroruate of lead has been used to color sponge-cake when eggs were thought too expensive for the purpose, and has killed many persons. Millers who have filled the holes in grindstones with lead have caused widespread epidemics of what has been called "dry cholera," and many persons have suffered from lead poisoning from eating apple-butter kept in jars glazed with lead. One of the most prominent, but by no means the most constant, symptoms of chronic plumbism is bilateral wrist-drop, due to palsy of the extensor muscles of the forearm. The short extensor of the thumb generally escapes the drug's influence, as does also the supinator longus. Sometimes internal squint arises from paralysis of the external rectus muscles by the lead. Another very common symptom is severe colic centering around the umbilicus and radiating through the belly and loins. Obstinate constipation often accompanies these symptoms, and the feces, when passed, are white and clay-colored, owing to a deficient secretion of bile. During an attack of lead colic the arterial tension is increased very markedly, the tongue is coated and whitish, and the bowels are obstinately confined. If these early warnings are disregarded and the exposure to the lead is continued, cerebral symptoms may come on, the result of encephalo- pathia saturnina, or saturnine cerebritis. Saturnine epilepsy is not very rare. If convulsions come on, death generally ensues. The con- vulsions in some cases are not due to a cerebral effect of the lead, but to ursemia due to the renal changes which it has caused. Renal disease is very commonly produced by lead, and it is not uncommon for chronic contracted kidney to be found at the autopsy of a sufferer from chronic lead poisoning. If a patient with chronic lead poisoning have a urine with a persistent low specific gravity, the prog- nosis is grave, as evidencing advanced kidney involvement. Asthma due to the inhalation of lead-dust is sometimes met with. The most important confirmatory evidence of chronic lead poisoning is a blue line on the gums just where they join the teeth. Its absence is not a negative sign, however, as poisoned persons cleanly in respect to their mouths often do not have it. Marked cachexia or anaemia is commonly seen in chronic lead poisoning. After prolonged lead poisoning the nerve trunks are found atrophied, and finally changed into fibrous cords. Anterior poliomyelitis may be present, but true locomotor ataxia is rarely caused. If ataxic symp- toms exist, they are most probably dependent on pseudo-tabes pro- duced by a plumbic multiple neuritis, and can be separated from true tabes dorsalis by the absence of several of the important true tabetic symptoms — such as slow onset, the Argyll-Robertson pupil, etc. — while the presence of marked wasting and loss of power, and some- times tenderness over the nerve-trunks, points to neuritis. In some cases trophic changes in the joints ensue, and plumbic gout is not rarely seen, or even lead arthralgia, with deposits of urates in the 20 306 DRUGS. joints. This condition is due to the fact, pointed out by Garrod and Haig, that lead forms insoluble salts with uric acid. Lead escapes from the body in the urine, the feces, and all secre- tions. It is chiefly eliminated by the liver in the bile. Treatment of Chronic Poisoning. — The treatment consists in three classes of remedial measures: 1st, the removal of the cause; 2d, the removal of the poison in the body; and, 3d, the treatment of the lesions produced by the poison. In lead colic hepatic purges, such a; jalap and calomel, combined with opium to prevent pain, are indicated, and alum and opium or morphine are said to be almost specifics, the alum in 2-grain doses, the others in full amounts. In many cases purges fail to move the bowels of a person suffering from chronic lead poisoning, and succeed only when morphine is given to overcome the intestinal inhibition produced by the irritation caused by the lead. In the cerebral inflammation of lead poisoning a blister to the back of the neck, revulsives, and a pilocarpine sweat may be resorted to. To aid in the elimination of the lead, iodide of potassium, which forms double soluble salts in the tissues w T ith the metal, is to be used, 10 to 20 grains (0.60-1.3) three times a day. If progressive paralysis is present, Wood insists on the use of large doses of strychnine at the same time that the iodide is given, The strychnine should not, of course, be given in the same mixture as the iodide, as it is incompatible. Electricity should be used as a remedy to restore lost function. If the faradic current makes the muscles contract, it should be employed, and if not, the galvanic current should be used. Curiously enough, partial voluntary power sometimes returns before the muscles will react at all to electricity. It is said that baths of sulphuret of potassium do good in chronic plumbism, 5 or 6 ounces (180.0) of the salt to each bath, which is to be given in a wooden tub. The patient should afterward be well soaped, then thoroughly rinsed off, and rubbed down with a rough towel. As the salts of lead are used for different purposes, the therapeutics of each one will be taken up separately. Acetate of Lead. Acetate of Lead (Plwnbi Acetas, U. S. and B. P.), or Sugar of Lead, has a sweet, astringent taste, and is soluble in water, but the solution formed is slightly milky in appearance. Therapeutics. — Acetate of lead may be used, and is largely employed in the following pill in the treatment of serous diarrhoea: 1^— Plumbi acetat. : - . . gr. xl (2.60). Pulv. opii x (0.60). Camphorse gr. xl (2.60).— M. Ft. in pil. No. xx. S. — One every four hours. LEAD. 307 This pill may also be given in cases of dysentery. The acetate of lead in proportion of 1 to 8 grains (0.06-0.5) to the ounce of water may be used as an injection for gonorrhoea. Lead acetate is also a useful application for the dermatitis produced by poison ivy, as this drug precipitates the sticky, non-volatile oil of Rhus toxicodendron, recently studied by Pfaff. The acetate should be dissolved in alcohol in the proportion of \ grain to the ounce (0.03-30.0) and used as a wash. After this the inflamed parts should be treated by cooling applications, but ointments are not to be used, as they dissolve the poisonous oil and spread the irritation. Administration. — The B. P. recognizes the following preparations of lead acetate : Piluloz Plumbi cum Opio, dose 3 to 5 grains (0.12-0.3) ; Suppositoria Plumbi Composita, each suppository containing 1 grain (0.06) of opium to 3 grains (0.20) of lead acetate; and an ointment {Unguentum Plumbi Acetatis), Carbonate of Lead. Carbonate of Lead {Plumbi Carbonas, B. P.), or White Lead, is insoluble, and is used as a coating or dressing for burns, scalds, or ulcers when rubbed up with linseed or other oil, or in the form of the ointment {Unguentum Plumbi Carbonatis, B. P.). If an extensive surface is covered with this ointment, it may cause subacute lead poisoning by absorption. Carbonate of lead may be used in the treatment of sunburn in the following prescription : 1^ — Plumbi carbonat 5j (4.0). Pulv. amyli 5j (4.0). Unguent, aquae rosse Sj (30.0). Olei olivse . . . f 5ij (8.0).— M. S. — Apply to the inflamed skin. Iodide of Lead. Iodide of Lead {Plumbi Iodidium, U. S. and B. P.) is occasionally employed in medicine; the dose is \ to 2 grains (0.03-0.12). Emplas- trum Plumbi Iodidi, B. P., and Unguentum Plumbi Iodidi, B. P., are used as external astringent and alterative applications, but are rarely useful. Liquor Plumbi Subacetatis. Liquor Plumbi Subacetatis, U. S., and Liquor Plumbi Subacetatis Fortis, B. P., or Goulard's Extract, is a colorless liquid, much used externally, when diluted with laudanum, for sprains, bruises, and local inflammations, under the name of " lead-water and laudanum." "L» and L.," as it is often called in the hospitals, is a useful applica- tion in the dermatitis produced by poison ivy. The proportion should be 4 parts of the undiluted lead-water, diluted with 16 parts of water 308 DRUGS. to 1 of laudanum, but this is varied as the inflammation or pain is the more severe. The official liquor is also official in a dilute solution (Liquor Plwnbi Subacetatis Dilutus, U. S. and B. P.), and as such is too weak for ordinary use, although it is commonly employed. The strong solution should be used in the strength of from 1 to 4 ounces (30.0- 120.0) to the pint (480 c.c.) of water. This solution should never be employed if the skin is broken, as absorption may occur, and, what is more important still, the drug prevents healing by constringing the edges of the wound. If some bread-crumbs be saturated with the solution just named and applied to an inflamed finger, a felon can often be aborted in the early stages. The official dilute solution is useful as a lotion in eczema which itches and tingles and is not dry in character. It should be applied once or twice a day, and it is well to follow the application of lead with a weak sulphur bath or alkaline wash. (See Eczema.) Lead-water is also useful in pruritus pudendi. The cerate (Ceratum Plumbi Subacetatis, U. S.), the liniment (Linimentum Plumbi Subace- tatis), and the glycerin (Glycerinum Plumbi Subacetatis, B. P.) may be used for the same purposes as Goulard's extract. Lead acetate is used for the preparation of lead plaster (Emplas- trum Plumbi, U. S. and B. P.), sometimes called " Diachylon plaster." Hebra recommended for sweating of the feet an application of equal parts of lead plaster and linseed oil, applied on linen and wrapped around the feet every third day. Litharge. Litharge (Plumbi Oxidum, U. S. and B. P.) is used in the prep- aration of the solution of subacetate of lead. Nitrate of Lead. Nitrate of Lead (Plumbi Nitras, U. S.) is never used internally, but as a powder, in the treatment of cases of onychia maligna and in the formation of Ledoyen's disinfecting solution. The latter dis- colors the paint in water-closets, dissolves the solder in drain-pipes, and is not a good preparation for general use. LEPTANDRA. The medicinal portion of Veronica virginica is the rhizome and rootlet, from which are made the official extract of leptandra (Extrac- tum Leptandrce, U. S.) and the fluid extract (Fluidextractum Lep- tandrw, U. S.). The dose of the former is from 1 to 8 grains (0.06-0.5) and of the fluid extract 5 to 40 minims (0.3-2.6). LIPANIN. 309 Physiological Action. — Very few experiments have been made as to the action of this remedy, and the only ones of importance are those of Rutherford and Vignal, who found that it possesses a moderate influence in increasing the flow of bile. In overdose it causes violent purging. Therapeutics. — In the official preparations of leptandra, which are not so active as is the fresh drug, are excellent substitutes for calomel, according to many clinicians. Those who have used leptandra also believe it to be of the greatest value in the indigestion of the intestinal type sometimes called "duodenal atony." (See also Podo- phyllin.) The following pill is a good method of using the drug in these cases: 1^ — Ext. chiratse gr. xx (1.3). Ext. leptandrse gr. xx (1.3). — M. Ft. in pil. No. x. S. — One pill after each meal. Under the name of leptandrin we have an impure resin which is given in the dose of 2 to 5 grains (0.12-0.3). An alkaloid of doubtful existence is called leptandrine. LEVULOSE. Levulose is a monosaccharide sweeter than cane-sugar, and if pure free from glucose. It is used in medicine as a substitute for sugar in the dietetic treatment of diabetes, and is absorbed as levulose and is readily oxidized in the body. Levulose may be taken by diabetic patients in the dose of 1 to 2 ounces a day without injury in many instances, and tends to promote nutrition. It has also been used with advantage in poorly nourished children and by tuberculous persons whose digestion cannot cope with cane-sugar. One firm places it on the market under the name of "Diabetin." LIPANIN. Lipanin is an artificially prepared mixture devised by von Mering as a substitute for cod-liver oil, and consists in 6 parts of oleic acid added to 100 parts of olive oil.- The advantages possessed by it are its lack of disagreeable odor and taste and its ready emulsification and digestibility. The commencing dose is 1 drachm (4.0), which may be increased to 4 drachms (16.0). This mixture has been found of value in most of the wasting diseases in which cod-liver oil is em- ployed, and in the opinion of von Mering its efficacy is greatly increased if the hypophosphites of lime and sodium are used at the same time in the dose of 10 grains (0.60) three times a day. Iodine or one of its compounds may also be given if it is desired to exert an alterative influence. 310 DBUG& LIQUORICE. Liquorice (Glycyrrhiza, U. S., and Glycyrrhiza? Radix, B, P.) is the root of Glycyrrhiza glabra, a plant of Southern Europe and Asia. In the form of a solid extract it is used to increase secretion in the mouth, and when dissolved in water to form a vehicle for other drugs, particularly if they have a disagreeable taste. The powdered solid extract is a very mild and useful laxative. Administration. — The solid extract (Extractum Glycyrrhiza?, U. S. and B. P. is used in a dose varying from 5 to 120 grains (0.30- 8.0). The pure extract (Extractum Glycyrrhiza? Purum, U. S.) is used in the same quantities as the ordinary extract. The fluid extract (Eluidextr actum Glycyrrhiza?, U. S.) or the liquid extract (Extractum Glycyrrhiza? Liquidum, B. P.) is used in 1- to 2-drachm (4.0-8.0) doses, and enters into the preparation of adjuvant elixir (Elixir Adjuvans, U. S.). Under the name of Brown Mixture or " Compound Liquorice Mixture" a very efficient expectorant solution is official (Mistura Glycyrrhiza? Composita, U. S.), which contains as its most important ingredients 12 parts of paregoric, 6 parts of wine of antimony, and 3 parts of sweet spirit of nitre. The dose of Brown Mixture is 1 to 4 drachms (4.0-16.0). Pulvis Glycyrrhiza? Compositus, U. S. and B. P., or compound liquorice powder, contains, according to the U. S. P., 18 per cent, of senna, 23.6 per cent, of liquorice, 4 per cent, of oil of fennel, 8 per cent, of washed sulphur, and 50 per cent, of sugar. According to the B. P., it should contain 2 parts of senna, 2 of liquorice-root, 1 of fennel-fruit, 1 of sublimed sulphur, and of sugar 6 parts. The dose is 1 to 4 drachms (4.0-16.0). It is largely used as an efficient laxative after childbirth and in cases which suffer from constipation chiefly due to the inactivity consequent upon being in bed. The troches (Trochisci Glycyrrhiza? et Opii, U. S.) contain -^ grain (0.003) of opium and 2 grains (0.12) of extract of liquorice. Finally we have Glycyrrhizinum Ammoniatum, U. S., which is the sweet principle of liquorice rendered soluble and easily tasted by the addition of ammonia. The dose of this preparation is 5 to 15 grains (0.3-1.0). LIQUOR POTASSII HYDROXIDI. Liquor Potassii Hydroxidi, U. S. ; Liquor Potassa?, B. P., is a solu- tion of potassa containing about 5 per cent, of potassium hydroxide and is a clear, odorless liquid of caustic taste and strongly alkaline reaction. It is used in medicine as an antacid and for the purpose of decreasing the acidity of the urine. Its dose is 5 to 30 minims (0.30-2.0) well diluted with water. In cases of ingrowing toe-nail it is often used to soften the nail prior to packing with cotton or partial evulsion. LOBELIA. 311 LITHIUM. Lithium is used in several forms, but its salts may be divided into two classes — those which act as lithium and those which act as the acids forming them. In the first class are the carbonate (Lithii Carbonas, U. S. and B. P.), dose 2 to 10 grains (0.12-0.60), the citrate (Lithii Citras, U. S. and B. P.), dose 5 to 20 grains (0.3-1.3), and the effervescent citrate (Lithii Citras Effervescens, U. S. and B. P.), dose 1 to 4 drachms (4.0-16.0). In the second class are the ben- zoate (Lithii Benzoas, U. S.), dose 5 to 30 grains (0.3-2.0); Lithii Bromidum, U. S., dose 10 to 40 grains (0.60-2.60), and Lithii Salicylas, U. S., dose 10 to 30 grains (0.60-2.0). The carbonate and citrate are used in gout and rheumatoid arthritis for the purpose of entering into combination with the uric acid in the body to form soluble urates and prevent deposits in the joints. They have been said to dissolve calculi, but this is untrue, though they are used when it is desired to render the urine alkaline. Haig has pointed out that although lithium forms salts with uric acid in the test- tube, in the body it has a greater affinity for the acid sodium phos- phate in the blood, and practically leaves the uric acid to itself. This is an important point, since it proves that the large amount of water generally taken with lithium salts has more to do with relieving gout than has the lithia. The carbonate is not soluble in water, and should be given in capsule or freshly-made pill, but the citrate is soluble. The latter may be made from the former by taking 50 grains (3.5) of the carbonate, 90 grains (6.0) of crystallized citric acid, and warm dis- tilled water 1 fluidounce (30.0). The acid should be dissolved first, and the carbonate added to the solution. The solution should then be kept hot until effervescence ceases. In cases of diabetes depending upon a gouty taint remarkable results are said to be obtained from the use of the citrate or carbonate of lithium and arsenic. The dose should be -^ grain (0.C02) of arsenite of sodium and 10 grains (0.60) of the lithium salt three times a day. It is worthy of note that in some cases citrate of lithium will dis- order the stomach and produce vomiting; and overdoses produce gen- eral relaxation of the system with a sense of feebleness. (For the use of other salts of lithium see the articles on the Bro- mides, Salicylic Acid, and Benzoic Acid.) (See also article on Mineral Springs.) LOBELIA. Lobelia, U. S. and B. P., is the leaves and tops of Lobelia infata, a common weed of the United States. It contains an alkaloid, lobe- line, and lobelic acid. 312 DRUGS. Physiological Action. — When taken in overdose lobelia causes erne- sis, intense prostration, a feeble pulse, pale skin, livid face, muscular relaxation, and a cold sweat. Violent purging may be present. It is said to paralyze the motor nerve-trunks, and it causes a fall of arterial pressure, followed by a rise, the latter change being due to the asphyxia which it finally produces. Ultimately it paralyzes the respiratory centre and the peripheral vagi. The treatment of the poisoning is to administer opium to allay irritation and check vomiting, to give alcohol and ammonia to support the heart, and the use of external heat. Therapeutics. — Lobelia is used chiefly as an antiasthmatic, and has been equally praised and condemned by eminent authorities. The reason for this lies in the fact that it is generally useless in asthma unless given in almost poisonous dose. Wood teaches that it should rarely if ever be used, because of its poisonous effects even in doses medicinally active, while Sydney Ringer says that the drug is erro- neously thought to be dangerous. In asthma both of the gastric and bronchial form lobelia is undoubtedly of service. In some cases it fails as signally as it succeeds in others. If the asthma is due to or associated with cardiac disease, lobelia should never be employed. The drug should be taken in the dose of \ drachm (2.0) to 1 drachm (4.0) of the tincture at the first sign of an attack, or in 10-minim (0.60) doses every fifteen minutes until distinct nausea occurs or relief is obtained. If the heart is feeble, its use is contraindicated. In atonic constipation with great dryness of the feces 10 minims (0.60) of the tincture of lobelia at bedtime are often of service, particularly if it is combined with cascara sagrada. (See Cascara Sagrada.) Administration. — Lobelia is given in the form of the tincture (Tine- tura Lobelia?, U. S.), in the dose of 10 to 60 minims (0.60-4.0), as a sedative, or 2 to 4 drachms (8.0-16.0), as an emetic. The vinegar (Acetum Lobelia:) is no longer official, but is given in the dose of 20 to 30 minims (1.3-2.0), and the fluid extract (Fluidextr actum Lobelia?, U. S.) in the dose of 1 to 5 minims (0.05-0.30), or as an emetic in the dose of 15 minims (1.0). In the form of the infusion lobelia is useful as a lotion in the treat- ment of the dermatitis produced by poison ivy. The proportion used should be an ounce (30.0) to the pint (480 c.c.) of water. The preparation of the B. P. is Tinctura Lobelia? Miherea, dose 10 to 30 minims (0.60-2.0). LYCETOL. (See PlPEKAZINE.) LYCOPODIUM. Lycopodium is a pale-yellow powder derived from Lycopodium clavalum, a species of moss. It is used by pharmacists as a MAGNESIUM. 313 powder in which to roll pills, and by physicians and nurses to prevent the intertrigo or chapping of the skin of infants and adults. LYSOL. Lysol is a preparation made by dissolving in fat and saponifying with alcohol that part of tar oil which boils between 190° and 200° C, and is a brownish, clear, oily fluid, smelling somewhat like creo- sote. It is used for the same antiseptic purposes as creolin (see Creo- lin) , but possesses the advantage of forming a clear, soapy fluid when mixed with water, in which instruments can be seen. If small instru- ments are used, the solution is so soapy that it renders them too slippery for ready use. Those who have used lysol claim that it does not affect the skin of the operator's hand except to render it soft and flexible. Used upon mucous mem6ranes, a solution of lysol should not be stronger than 2 per cent. Liquor Cresolis Compositus, U. S., is similar to Lysol. MAGNESIA. Magnesia is the oxide of magnesium (Magnesii Oxidum, U. S.), made by exposing the carbonate of magnesium to a red heat. It is used in the form of the light magnesia (Magnesia Levis, B. P.) as a dusting-powder. The troches (Trochisci Magnesia?) each contain 3 grains (0.20). Magnesii Oxidum Ponderosum, U. S., is official in the B. P. as Magnesia Ponder osa. Magnesia is an antidote to arsenic, and when employed to precipi- tate a soluble preparation of iron it forms the Antidotum Arsenici (Ferri Hydroxidum cum Magnesia, U. S.). It is important that the student should not confuse magnesia and magnesium. The first is the oxide of the second, and is sometimes called calcined magnesia or "Husband's Magnesia." Magnesia is of little value in internal medicine except as a feeble antacid. Magnesia and the carbonate of magnesium may be used interchangeably. MAGNESIUM. Magnesium is a metal never used as such, but always in the form of one of its salts, which are the sulphate, citrate, carbonate, and sul- phite. The sulphite is a natural salt found in sea-water and in caves or in the water coming from the latter. The citrate and carbonate are derived from the sulphate. The carbonate is insoluble in water and alcohol. The others are soluble. Magnesium Carbonate. The Carbonate of Magnesium (Magnesii Carbonas, U. S.) is official in the form of the heavy and light powder (Magnesii Carbonas Pon- 314 DRUGS. derosus and Levis, B. P.), and these two substances do not differ in respect to their effects. The light magnesium is never given internally, because of its bulk, but it is used as a dusting-powder in intertrigo, and in the form of white cubes rubbed on the skin to prevent exces- sive perspiration and as a cosmetic. The heavy magnesium is used as an antacid, and is not, as has been thought by some, in any sense a laxative, as it possesses no such power. When the stomach or intes- tines contain much acid from fermentative changes, these acids may, however, unite with the magnesium and form a slightly laxative salt. In sick headaches due to excessive gastric acidity carbonate of magne- sium is often of service. The dose of the carbonate is from 5 to 60 grains (0.3-4.0). It should not be used constantly, as there is danger that it will accumulate in the intestines. Liquor Magnesii Carbonatis, B. P., is given in the dose of 1 to 2 ounces (30.0-60.0) as a laxative. Magnesium Citrate. The Citrate of Magnesium (Magnesii Citras) is a more irritating purge than the sulphate, but it is more agreeable to the taste. It is official as Liquor Magnesii Citratus, U. S., which is effervescent and should never be us 3d unless freshly prepared. It is made by add- ing bicarbonate of potassium to a syrupy solution of the citrate of magnesium containing an excess of acid, and corking the bottle tightly, the cork being tied down with a strong cord. Care should be taken that the bottle is a strong one, as the development of large amounts of carbonic acid gas may burst it if it be weak. The dose is half to one bottle, which contains about 12 ounces (360 c.c). It is too irritating to be used where inflammation of the alimen- tary canal exists, but is useful in the treatment of sick and bilious headache. The Granulated Citrate (Magnesii Citras Effervescens) is less agreeable to take than the solution just named. It should be dis- solved in water, about 1 to 3 drachms (4.0-12.0) of the salt being used in each dose, and swallowed while the solution is effervescing. It must be kept in bottles tightly corked. Magnesium Sulphate. Sulphate of Magnesium (Magnesii Sulphas, U. S. and B. P.) is a white granular powder of neutral reaction and salty taste, and is sol- uble in water. It is generally known as "salts," although in some parts of the United States this term also includes the sulphate of sodium and "Rochelle salt," or the tartrate of sodium and potassium. Sulphate of magnesium is a purge by reason of its abstraction of water from the intestinal bloodvessels, because it stimulates peri- stalsis directly and by reason of the fact that solutions of it are not readily absorbed. As a result of these three factors free passages MAMMAE Y GLAND. 31 5 are produced, the bowel being filled by the water of the original solu- tion and the liquid poured out by the bowel wall. x*Ul strong saline solutions above the strength of 7 per 1000 abstract liquids from the tissues when brought in contact with them, and therefore whenever a thorough purgative action is required — that is, where depletion of the intestine or absorption of exudations is to be attained — the magne- sium should be given in concentrated form, so as to make its solution as of high a percentage as possible. In cases of dropsy the use of concentrated solutions is particularly necessary if free watery evacuations are desired, and from 1 to 2 ounces should be given before breakfast or on an empty stomach in as little water as will dissolve the salt. (See Dropsy.) Generally it is better to give this quantity divided into small doses every fifteen minutes till it is all taken. In enteritis and peritonitis the use of magnesium is widely recog- nized as a proper measure for its depletant effects, and it is claimed to be better than ipecac in the treatment of tropical dysentery. When used for the latter purpose it should be given in drachm (4.0) doses of a saturated solution with 10 to 15 drops (0.60-1.0) of aromatic sulphuric acid every two hours. The sulphate is not irritating, and may be given freely when inflammation exists. (See Peritonitis.) Magnesium sulphate forms a large part of most of the natural purgative waters, but in them is present in very dilute form. These waters act partly by supplying the contents of the bowel with fluid and thereby softening the feces, the solution not being absorbed because of the salt contained in it. Sometimes severe attacks of renal pain occur in middle-aged persons who have frequent attacks of gravel, and the urine will be found to contain octahedral crystals of calcium oxalate. A useful treatment is to give h to 1 drachm (2.0-4.0) of magnesium sulphate with equal parts of citrate of potassium twice or thrice a day, in water, for a considerable period of time. Magnesium sulphate may be given by enema with the double pur- pose of unloading the bowels and acting as a depletant. The best mixture for this purpose seems to be that of Watkins — namely, 2 ounces (60.0) of magnesium, 1 ounce (30.0) of glycerin, and 4 ounces (120.0) of water. The U. S. P. and B. P. contain an official preparation called Mag- nesii Sulphas Effervescens, which is granulated, and is given in the dose of 4 to 8 drachms (16.0-30.0). MAMMARY GLAND. The extract of mammary gland of the common sheep has recently come into general use in the treatment of cases of subinvolution of the uterus and for the purpose of arresting metrorrhagia or other forms of loss of blood from the uterus. It is said by some physicians to 316 DRUGS. exercise a good effect upon the bleeding and growth of many uterine fibroids, but cannot, of course, cure the condition. The dose of extract of mammary gland is 5 (0.3) grains three times a day, or, if hemor- rhage is free, as much as 6 doses a day may be used. Overdoses cause cardiac palpitation, but moderate doses seem to affect general nutrition favorably. Bleeding from soft fibroids is not so favorably affected by its use as that from hard fibroids. MANGANESE. MaDganum, or Manganese, is official in the U. S. P. in the form of the black oxide (Mangani Dioxidum Pracipitatum) , the sulphate (Mangani Sulphas), and the hypophosphite (Mangani Hypophosphis) . The first of these, under the name binoxide of manganese, has been highly praised in amenorrhea dependent upon functional distuibance and anaemia. The dose is 3 to 5 grains (0.20-0.3) three times a day, in pill form, and the drug should be taken for a few days before the expected or proper date for menstruation. The sulphate is rarely if ever employed, but may be tried in malarial jaundice. The dose is 1 to 2 grains (0.06-0.12). The hypophosphite enters into the com- pound syrup of hypophosphites. MANNA. Manna , U. S., is the concrete saccharine exudation of Fraxinus ornus, a tree of Europe. It occurs in roundish masses of varying size, looking somewhat like a gray-colored gum arabic. It has a sweet taste and odor. Sometimes the taste is a little bitter. Therapeutics. — Manna is the most feeble of the laxatives, and causes slight flatulence in some persons. In children fed by the bottle one of the most frequent disorders is obstinate constipation, and for its relief 1 to 2 drachms (4.0-8.0) of the sweet variety of manna may be dissolved in the milk of each bottle. When given to older children or adults, manna is always combined with other more power- ful drugs, chiefly to disguise their taste. It may be combined with advantage with rhubarb and senna, and it enters into the official Infusum Sennw Compositum, U. S., the dose of which is from 1 to 4 fluidounces (30.0-120.0). MATRICARIA. Matricaria, U. S., German Chamomile, consists in the flower-heads of Matricaria Chamomilla, a European plant, possessing mild bitter tonic properties when given in moderate dose. In larger amounts it acts as an emetic and anthelmintic. In the form of an infusion of the strength of 1 to 2 ounces to the pint (30.0-60.0 : 480 c.c.) it has been largely used as a diaphoretic, and, in small doses, to prevent colic in teething children. MERCURY. 317 MENTHOL. (See Peppermint.) MERCUROL. Mercurol is a chemical compound of mercury and nuclein, and possesses active germicidal power over pyogenic organisms. It is said to be particularly destructive to the gonococcus and to be of value in both gonorrhoea and gonorrheal ophthalmia. It does not coagulate albumin nor act as an irritant, and is readily soluble in water. In making the solution it should be placed on the surface of the fluid, as it dissolves best in this way. The solution for gonorrhoea should be of the strength of J to 1 per cent. In very obstinate cases as strong a solution as 2 per cent, may be needed. It is best given by injection into the urethra in normal salt solution. MERCURY. Hydrargyrum, U. S. and B. P., Mercury or Quicksilver, is a heavy fluid metal of a peculiar color and appearance. As metallic mercury it is used in medicine in the form of the ointment, the plaster, gray powder, and blue mass and the unofficial gray oil. Physiological Action. — When mercury is taken into the body in one of its insoluble and mild preparations, it may cause no evidence of its presence until by frequent and excessive dosage the system in general begins to feel its influence. The first evidences of this are to be found in the mouth, and consist in tenderness of the teeth when the jaws are firmly and quickly closed, fetid breath, sponginess of the gums, which finally may bleed at the slightest touch, swelling of the tongue, and, most prominent of all, excessive salivation, a condition sometimes called ptyalism. If the use of the drug is persisted in, all these symp- toms grow worse. Eczema, and finally sloughs of the chin and chest develop as the result of the constant dribbling of saliva and the direct depressing effect of the drug on the tissues. The teeth drop out, the maxillary bones undergo necrosis, and amid a general melting down and decomposition of the tissues the patient dies. The blood is affected and becomes very thin, fluid, and poor in its corpuscular elements. These symptoms ensue on the use of mercury in continued overdoses, and rarely follow exposure to the drug in the processes of the arts. In the arts — as, for instance, in the making of looking-glasses — work- men are often affected by various trains of symptoms varying very widely in their course. In some cases the nervous system becomes chiefly affected. Tremors of all sorts arise, paralysis agitans is devel- oped, and the results of peripheral neuritis ensue; but it is worthy of note that the ocular muscles are rarely involved in mercurial tremor, 318 DRUGS. . while in disseminated sclerosis nystagmus is not rare. Similarly the tremors of mercurial poisoning often affect the head and neck alone, while in pa alysis agitans this is rarely the case. Chorea often comes on in chronic mercurial poisoning, and the occurrence of choreic movements in an adult should cause inquiry as to any possible exposure to mercury. In other cases brownish discoloration of the skin, resem- bling Addison's disease, appears. Blindness, deafness, sensory disturbances, such as hyperesthesia and anaesthesia, may be devel- oped, and localized wasting of muscles or groups of muscles may assert itself. In still other cases the blood becomes impoverished and mercurial cachexia is developed. It is worthy of note that children under three years are rarely sali- vated by the use of mercury, but this is no reason for using this drug carelessly in this class of cases, since the other changes in the organism nevertheless occur. Absorption and Elimination. — The rapidity of absorption and elimination of mercury depends to a great extent on the variety of it which is given. The drug in some forms is so insoluble that great delay in its elimination must often ensue because it is slowly absorbed. Several opinions are held as to the form in which mercury is absorbed. It is usually taught in France that the theory of Miahl is correct; this is, that the mercurial preparations are transformed in the stomach and intestine into the bichloride, which in turn unites with the sodium chloride in the blood and circulates as a double chloride of mercury and sodium. In Germany it is taught that it forms an albuminate of mercury and so circulates (Henoch's theory), or that it forms a chloro-albuminate (Voit's theory). All these theories as to its absorption are open to grave criticism.. As to the elimination of mercury, it is known to escape as an albuminate by every excretion of the body — the urine, feces, sweat, tears, milk, and saliva. After a single dose the drug begins to be eliminated in about two hours according to Byasson, and it is entirely gotten rid of in twenty-four hours. If, however, the doses are repeated, it gradually accumulates in the body, and is so slowly eliminated as to remain for almost in- definite periods of time, and is found deposited in all the organs. In other words, the doses of mercury ordinarily given are always large enough to produce cumulative effects. Thus while Balzer and Klumpke agree with Byasson as to the rapidity of elimination of a single dose, they find from an experimental study that the amount of mercury which can be eliminated by the kidneys for many weeks when the body is saturated with the drug is only one-sixteenth of a grain a day. It is evident, therefore, that after a full mercurial effect is produced it is well to decrease, as do most syphilographers, the dose of mercury and give only sufficient to maintain the effect. It is also evident that the plan of using iodide of potassium every now and again to aid in the elimination of the residual mercury is advisable. MERCURY. 319 Therapeutics. — The employment of mercury in medicine centres around four great points — viz.: 1st, its value in syphilis and kindred states; 2d, its use as a purge; 3d, its power as an antiseptic and germ- icide; and 4th, its action as an antiphlogistic; the first and fourth points are fulfilled by all the mercury salts more or less perfectly, the second only by blue mass and calomel, the third by the bichloride and biniodide of mercury. As an Antisyphilitic. — In syphilis mercury is to be given, not because the patient is in this or that stage of the disease, but because the conditions present call for its employment. Many writers have Fig. 49. Lamp for mercurial fumigations. This lamp is made of wire gauze, and resembles the safety lamp of miners, thereby guarding against sudden explosions of the alcoholic vapors. insisted that it ought only to be employed in the secondary stages, and while this is, as a general rule, correct, certain conditions may call for it at any time. Of all the preparations of mercury used in the treatment of syphilis, the protoiodide is the most popular, and deservedly so. (See article on Syphilis.) Mercury is often administered by means of fumigations or inhala- tions both for the removal of local and general syphilitic disorders. The best apparatus for either purpose is one devised by Bumstead, and it is both simple and inexpensive. It consists of a sheet-iron cup so bent that the bottom of the vessel, instead of being flat, projects up- ward into the centre of the cup, thereby forming a raised centre with 320 DRUGS. a little ditch about it. The top of this projection is flattened, and on its apex is placed the calomel which is to be sublimed. The surround- ing ditch is then filled with hot water, and the cup placed over an alcohol flame, which disengages the vapor of the calomel and water. (See Fig. 49.) Fig. 50. A patient prepared for the use of mercurial sublimations. A blanket having been pinned tightly around the neck after the patient is stripped, the fumigator shown at his feet is placed under his chair and the calomel placed on the central disc, as shown in the illustration. Water is in the little ditch around it and an alcohol lamp under it. The patient should be given a full, warm bath beforehand to cleanse and prepare the skin for absorption. When inhalations are used the face should be held some six or eight inches from the cup to permit the fumes to pass through the air. Under these circumstances the quantity of calomel used should not exceed 4 or 5 grains (0.25-0.30), and the mouth should be rinsed out to prevent mercurial stomatitis unless a local action on the buccal mucous membrane is desired. Not more than eight or ten inspira- tions should be taken at one sitting. MERCURY. 321 If general fumigations are to be practised, the patient places the lamp and cup with 30 grains (2.0) of calomel on it under a chair, on which he sits wrapped in a heavy blanket, and subjects himself not only to these fumes, but to a home-made Russian bath, which relaxes his skin and aids absorption. (See Fig. 50.) I believe that the ultimate conclusion of the profession in regard to the hypodermic injection of mercurials in syphilis will certainly be identical with that governing this use of quinine in malarial fever. There can be no doubt that a certain number of instances do arise in which, by reason of severe infection, susceptibility of the patient, or inability to take mercury by the ordinary means, hypodermic injec- tions are absolutely necessary. In the same way that we give quinine by the mouth, the rectum, and hypodermically in pernicious malarial fever, so do we give mercury by the mouth, by inunctions, by sub- limation, and by the hypodermic needle in malignant syphilis. The reasons for believing that hypodermic injections of mercurials are not to be resorted to in the routine treatment of syphilis are several. In the first place, all forms of hypodermic medication possess disadvan- tages not possessed by the use of drugs by the mouth. There is always danger of entering a vein, of producing an abscess, or of causing local pain. When mercurials are so employed, the danger of abscess, of pain, or of milder inflammatory manifestations is greatly increased, and the presence of an indurated spot where the hypodermic injection has been given proves that it is not the best form of medication in syphilis. Of the mercurial preparations which may be administered hypodermically in syphilis, the two which surpass all others are un- doubtedly the bichloride of mercury, in the dose of J grain, dissolved in 10 or 15 minims of distilled water, every second or third day, and gray oil (Oleum Cinereum), which was first introduced into medicine by Lang, of Vienna. (See Gray Oil, under Mercury.) In all cases the injection should be given slowly and deeply into some portion of the body in which the tissues are loose, as the buttock or the broad of the back, and the skin of the part where the injection is to be made should be carefully washed and sterilized by the use of green soap and alcohol. The intravenous injection of bichloride of mercury has been proved so dangerous as to be properly considered unjustifiable. It is to be recalled that the herpes seen in advanced syphilitics is usually made worse by mercury. Also, that headache due to syphilis, if due to a cerebral growth, is benefited by mercury; while that due to ansemia and debility complicating syphilis is increased by this drug. As a Purge. — The employment of mercury as a purge or laxative having a special action on the liver is constantly resorted to. The two preparations used are blue mass and calomel, but the latter is more active. They both cause soft or watery stools, according to the dose in which they are given, but the blue mass is rarely, if ever, used except for the production of a laxative effect 21 322 DRUGS. Much discussion has arisen as to whether mercury affects the liver, and whether the peculiar greenish or brownish-yellow stools produced by it are due to the presence of bile or mercury. If there is one point firmly fixed in the mind of the average practi- tioner of medicine, it is that the mild chloride of mercury increases the quantity of bile in the intestine. If such a believer is questioned as to whether this increased amount of biliary fluid is due to a true increase in secretion or simply to an increase in the flow of bile from the gall-bladder, he will either state that he is unable to answer the question or that he believes that it is an increased secretion. Practically, the position of the profession in general in regard to the purgative influence of calomel is that the drug exercises a stim- ulating effect upon the biliary gland. Experimentation upon the lower animals by several competent observers, and studies made by physio- logical chemists, fail, however, to give much light upon this sub- ject. It is held by some that calomel never acts as calomel, but is converted by the hydrochloric acid of the gastric juice into cor- rosive sublimate, and that this drug then stimulates the liver to increased activity. On the other hand, the best chemical investigations show positively that the feeble acidity of the gastric juice and the temperature to which the calomel is exposed are not favorable to the conversion of a sufficient quantity of calomel into corrosive sublimate to account for any hepatic influence. Thus it was found by Ruther- ford and Vignal, in their well-known series of studies of the influence of drugs upon the secretion of bile, that if 5 grains (0.30) of calomel are subjected, at 100° F., for seventeen hours to the action of normal gastric juice, not more than -^ of a grain of mercuric chloride is produced. As calomel does not remain in the human stomach for more than a day at the utmost, and generally but a few hours, it is not likely that as much as -^ of a grain of mercuric chloride is produced from the moderately large dose of 5 grains (0.30). In con- tradiction of this, Bucheim, Winkler, and others assert that no con- version whatever takes place at the temperature of the body, and Jaennel's later studies support this view. The other theory as to the change which takes place in calomel prior to its action upon the liver is that it escapes into the intestines, where it is decomposed and the gray oxide of mercury precipitated, which may, however, be held in solution by any fatty materials, which, being mixed with alkaline liquids, practically form soaps. It is thought by Wood and others that this is the more probable result, particularly in view of the fact that calomel acts more like blue mass than cor- rosive sublimate. Further than this, these opinions are confirmed by the fact, with which all of us are familiar, that the hepatic influence of calomel is much more positively asserted if at the same time small doses of the bicarbonate of sodium are administered. Under these circumstances the bicarbonate of sodium naturally diminishes, to some extent at least, the acidity of the gastric contents, and also directly MERCURY. 323 or indirectly tends to increase the alkalinity of the contents of the duodenum. As if to increase the complexity of the problem, the studies of Rutherford and Vignal seem to prove conclusively that, in the dog at least, mercuric chloride has a direct stimulant effect upon the hepatic cells; whereas calomel, while producing purgation by increas- ing the secretion of the intestinal glands, in no way increases the secretion of the bile; and this would seem to indicate that, after all, the influence of calomel upon the liver is due to a very minute portion of it being changed into corrosive sublimate. Probably the truth of the matter is, that we have as yet no definite scientific explanation of how calomel really does act. It may be that the solution of the problem lies in the hepatic influence exercised by the presence of minute quan- tities of corrosive sublimate, and the purgative effect produced by that portion of the calomel which has not been converted into the strong chloride of mercury. This is rendered the more likely in view of the fact that the corrosive sublimate has been found a feeble intestinal stimulant, while the calomel has been found to produce active purga- tion in dogs, without producing an increase in biliary flow, when the drug has been introduced into the duodenum. It has been suggested, too, that calomel itself may stimulate the bile-expelling mechanism, while the minute portion of corrosive sub- limate increases the secretion of the liquid; and, again, that by means of the purgative effect that it produces certain substances which have been in the intestine are immediately removed, and, as a consequence, a depressant influence upon the hepatic cells no longer exists. Quite a number of physicians have studied the effect of the various so-called cholagogue drugs upon the flow of bile in human beings who have had biliary fistula. Perhaps the best studies are those of Pfaff and Balch, and more recently those of Joslin, upon women with biliary fistula. Calomel and the bichloride of mercury seemed invariably in these cases to decrease rather than increase the biliary flow. Ox-gall was the only drug which did increase it. This subject also is of interest to the practical physician in rela- tion to the administration of calomel in compressed tablets or other preparations when mixed with what might be called excipients. Under these circumstances, if one of the excipients is bicarbonate of sodium the tablet after a time almost always undergoes a change and becomes of a gray color. Those who have used pills or tablets of calomel which have been kept for a long period of time seem to be universally in accord with the statement that they have lost the hepatic effect which a recently prepared powder always possesses. Thus it has been fre- quently found that no biliary flow occurs under the use of stale tablets, whereas free bilious purging follows the administration of freshly prepared powders. Calomel and blue mass are largely used in the condition known as biliousness, and undoubtedly give relief. (See Biliousness.) If the 324 DRUGS. tongue is heavily coated, the breath foul, the conjunctiva a little icteroid, and headache is present, one of them should be employed. In remittent malarial fever the use of small repeated doses of calomel will often bring relief from the vomiting, and it should always be given in the treatment of malarial disease before quinine is used if a thorough action of the antiperiodic is required, as it aids in the absorption of the drug. As a Disinfectant. — The disinfectant and germicidal power of bichloride of mercury and of the biniodide is well established by clinical experience and experimental investigation. The strength of the bichloride in solution for antiseptic purposes may vary from 1 to 2000 to 1 to 20,000 of water, and for disinfectant use from 1 to 500 to 1 to 1000. (See Antiseptics.) In using the bichloride of mercury as an antiseptic it is necessary to add a few grains of tartaric acid to the solution to prevent its unit- ing with the albumin of the tissues to form an insoluble and useless albuminate. The same is true of the use of mercury biniodide. As an Antiphlogistic. — Formerly it was the belief of a large number of physicians that mercury possessed distinct antiphlogistic power in the early stages of acute sthenic inflammations, particularly if they involved serous membranes. It was the custom to administer full doses of calomel guarded with opium when traumatic meningitis was feared, and in endocarditis, pericarditis, pleuritis, and peritonitis its use was largely resorted to. More recently this plan of treatment has become almost obsolete, not because any deleterious effects have followed its use, but apparently as a matter of fashion. The writer believes that this is a mistake and that in acute inflammations in sthenic individuals in the early stages of disease mercury may do good. One of the best ways to employ all of the various forms of mer- cury is in the form of triturates, which may be prepared by triturating 10 parts of the drug with 90 parts of milk-sugar. The minute sub- division of the medicament aids in its efficiency, because of its more ready absorption. Leaving the general subject of mercury, we may now consider each individual preparation. Ammoniated Mercury. White Precipitate, or Ammoniated Mercury of the strength of 10 per cent, with lard (Hydrargyrum Ammoniatum, U. S. and B. P), is used in an ointment (Unguentum Hydrargyri Ammoniati, U. S. and B. P.) in various skin affections, when a stimulating application is needed, as, for example, in psoriasis and chronic dry eczema. It is also sometimes employed as a parasiticide in cases of tinea. The official ointment should generally be diluted with lard, as it is far too strong and will often induce a dermatitis if used undiluted. MERCURY. 325 In ozcena, whether syphilitic or not, Trousseau has recommended the employment of the following powder as a snuff: 1^ — Hydrargyri ammoniati gr. iv (0.25). Pulv. sacchar. alb ^ss(16.0). — M. S. — To be used as a snuff, after thoroughly blowing the nose. The red precipitate may be used instead of the white. The treat- ment removes the stench and may cure the complaint. It may, how- ever, irritate the mucous membrane, in which case it should be used in the strength of 2 grains to the J ounce (0.12-16.0). Ammoniated mercury is never used internally. Bichloride of Mercury. The Bichloride of Mercury, or Corrosive Sublimate (Hydrargyri Chloridum Corrosivum, U. S.; Hydrargyri Perchloridum, B. P.), as it is called, is an exceedingly poisonous and irritating substance when taken internally in concentrated form. Taken internally, it causes violent pain in the stomach, vomiting, purging of mucus, blood, and the contents of the intestine, collapse, syncope, and death. If taken in poisonous amount, the patient should be made to swallow large quantities of the antidote, white of egg, the stomach should be washed out with the stomach-pump, heat should be applied about the body, and the proper stimulants be given if the pulse or respiration fail. If death does not occur at once, the patient generally has a protracted convalescence or else dies from the organic changes produced in the gastro-intestinal tract, such as stric- tures, sloughs, destruction of the peptic glands, and ulcerations. Not only does the bichloride of mercury produce symptoms of acute poisoning when taken in large doses, but it is also capable of causing a form of subacute poisoning in those patients who have it applied too freely as an antiseptic wash or lotion. Particularly are these symptoms developed after intra-uterine or vaginal irrigations with bichloride solutions. The symptoms are abdominal pain, diarrhoea with tenes- mus, and finally sanguinolent discharges. There is also scanty urina- tion or the activity of the kidneys is entirely suppressed. Sometimes death comes rapidly and sometimes even the symptoms do not develop for several days after the drug is employed. The bichloride of mercury is an exceedingly useful preparation of mercury for hypodermic injection in syphilis, and is better than calomel for this purpose. About -g- grain (0.01) may be injected deeply and gently into the cellular tissues every two or three days. When the injections are made the greatest possible cleanliness should be obtained. The needle should be aseptic and the hands of the opera- tor well disinfected. The best place for the injection is in the gluteal region or between the shoulder-blades. Mercury bichloride, aside from its antiseptic use (see Antiseptics), is of great value when given internally, not only in syphilis, but in 326 DRUGS. other states not associated with any such depraved condition, as in chronic contracted kidney. In diphtheria it may be used to prevent fibrinous exudation as readily as calomel (see Diphtheria), and in ton- sillitis, where the inflammation is severe, it is often used with great service. (See also Mercury Biniodide.) In small amounts — that is, in -fo to -J^ grain (0.001-0.0015) three times a day — the bichloride is one of the best remedies for the treatment of anaemia depending upon a deficient number of blood cells. If the anaemia is syphilitic in origin, it is, of course, peculiarly useful. Bichloride of mercury is of value in minute doses of -g-J-g- grain (0.0001) for the ill-smelling green stools of summer diarrhoeas in adults and children, and it has been recommended that a solution be made of \ grain (0.03) in 5 ounces (150.0) of water, and a tea- spoonful given every hour until relief is obtained. The water used in making the solution should be distilled, and it may be well to add to it a little tartaric acid to prevent precipitation of the bichloride by organic matter which may have gotten into the water. This treat- ment is particularly useful in mucous diarrhoea in which blood and mucus are thoroughly mixed. Patients in the dispensaries often speak of these passages as containing "corruption/' and others think they consist of "lumps of flesh," owing to the masses of blood and mucus. Whether the disease be acute or chronic, the bichloride, used in the way just described, will be found of service. In dysentery and the diarrhoea of adults the same treatment may be resorted to, using 2 teaspoonfuls of the solution instead of 1. It is hardly necessary to add that the greatest care must be bestowed upon the diet and clothing. The author has treated a child suffering from persistent diarrhoea for months with varying success, only to succeed when, it being found that the abdomen was exposed to the air, the mother was forced to apply and keep on the child a flannel binder. In some cases in which an obstinate syphiloderm is present. \ ounce (16.0) of corrosive sublimate and 1 ounce (30.0) of chloride of ammonium may be added to a warm bath, which should be taken every few days. One-half a grain (0.03) of the bichloride of mer- cury in 6 ounces (180.0) of water is said to be most efficient as an injection in gleet, if used every three or four hours. (See Gonor- rhoea.) In all parasitic affections of the skin a solution of 2 grains (0.12) of bichloride to the ounce (30.0) of water may be sopped on the part three times a day. A solution of perchloride of mercury (Liquor Hydrargyri Perchloridi) is official in the B. P.; it is prepared by add- ing \ grain (0.03) of the perchloride of mercury to 1 ounce (30.0) of water, with \ grain (0.03) of ammonium chloride to hold it in solu- tion. (For the antiseptic uses of the bichloride of mercury see Antiseptics and Disinfectants.) MERCURY. 327 Biniodide of Mercury. Mercury Biniodide (Hydrargyri Iodidum Rubrum, U. S. and B. P.) is a bright-red powder, possessing irritant powers equal to or greater than those of the bichloride, and causing symptoms, when taken in over- dose, closely resembling those produced by the latter drug. Owing to the formation of the salt, it is thought to be particularly useful in the later stages of syphilis. The dose is -^ to -^ grain (0 002- 0.004). (See Syphilis.) An ointment (Unguentum Hydrargyri Iodidi Rubri, B. P.) is useful as an application in goitre and obstinate skin diseases. In the dose of -^-q grain every hour for 4 or 6 doses this drug is a most useful remedy to abort acute tonsillitis. At one time it was thought that biniodide of mercury was a better antiseptic than the bichloride, but recent researches have proved that this is not a fact. Black Wash. Black Wash (Lotio Hydrargyri Nigra, B. P.) is made by adding 1 drachm of calomel to a pint (4.0:480 c.c.) of lime-water. It is used as a stimulant, application for washing syphilitic sores and wounds in various forms of eczema. Blue Mass. Blue Mass (Massa Hydrargyri, U. S.; Pilula Hydrargyri, B. P.) is made by rubbing up metallic mercury with liquorice and other excipients, and is often called Blue Pill. Each grain of the mass con- tains J grain (0.02) of mercury, and it may be given in the dose of from \ to 20 grains (0.03-1.3) for the same laxative purposes for which calomel is used. Blue mass is rarely employed to produce systemic effects. Calomel. Calomel (Hydrargyri Chloridum Mite, U. S.; Hydrargyri Subchlo- ridum, B. P.), or the Mild Chloride of Mercury, is an insoluble salt which is, nevertheless, freely absorbed. Calomel when used as a laxative purge should be given in the dose of \ to \ grain (0.01-0.03) every half-hour or every fifteen minutes until 1 or 2 grains (0.06-0.1) are taken, as it will often act as efficiently in this way as if 10 grains (0.60) are given at one dose, and there is no danger of producing ptyalism. The reason that small doses are as efficient as large ones lies in the fact that only the calomel which is changed into the gray oxide is active, and, as the amount of alkaline juice in the intestine is small, only a minor part of a large dose of calomel acts, the major portion escaping unchanged. This is the reason that bicarbonate of sodium is added to calomel powders, to aid the intestinal juice in the reduction of the salt. While this statement is true of the use of calomel in temperate climates, it does not hold 328 DRUGS. good in hot climates, where much larger doses, amounting to 10 (0.60) or even 20 grains (1.3) are often given to affect the flow of bile, the hepatic gland being made torpid by heat. If purgation does not occur after a full dose of calomel, a saline purge must be given at the end of the twenty-four hours, and this must always be used if large doses of the mercurial are employed, to avoid possible mercurialization. Mercury in the form of calomel has been used hypodermically in the treatment of syphilis, being held in solution by a mucilage. Best of all, however, is the employment of chloride of sodium in water with the calomel, in the proportion of 5 parts each to 50 parts of water. It should be injected deeply into the tissues, not immediately under- neath the skin, the greatest cleanliness being necessary to avoid abscesses. The best place for these injections is in the fold of the buttocks, but sloughing, tetanus, and even gangrene, have followed its employment in this way. (See also Salicylate of Mercury and Bichlo- ride of Mercury and Gray Oil.) In dysentery of the acute form calomel and ipecac are valuable remedies. (See Dysentery and Ipecac.) The calomel should be given in small doses, repeated every hour or half-hour until a favorable change in the number and character of the stools appears. Calomel is not to be used if great asthenia complicates the disease. In children who seem constantly " under the weather" and never quite well, who have flatulence, fetid breath, and ill-smelling, pasty stools, calomel often gives great relief in the dose of 2V grain (0.003) every half-hour until four doses are taken, this treatment being pur- sued every fourth or fifth morning. In jaundice due to exposure to cold and to slight hepatic conges- tion J grain (0.01) of calomel every half -hour until 1 grain (0.06) is taken will often bring relief. Calomel is generally prescribed in conjunction with sugar of milk, white sugar, or bicarbonate of sodium, which are added to increase the bulk and wieldiness of the powder, and, in the case of the latter ingredient, to increase its activity. Owing to its lack of taste, calomel is often placed on the tongue in children, and for this class of patients white sugar is to be used in small quantity, as the other vehicles are less agreeable. The most pleasant form of administration is by means of triturates. These should not be compressed. It is important to remember that calomel when used as an anti- syphilitic produces salivation much earlier than the other mercurials. Sometimes calomel is of value when dusted into the eye in cases of phlyctenular conjunctivitis which are strumous. This practice must not be resorted to if iodine or iodides are being taken internally, as the iodine is eliminated by the tears and forms a compound which burns the conjunctiva. A very important use of calomel and one which has been brought forward very recently as new, but which is really many years old, is its employment in dropsy as a diuretic, either alone or combined with MEHCUBY. 329 squills or digitalis, or with opium to prevent purging. The dose is small, about 1 grain (0.06) thrice a day, and if a diuretic influence does not assert itself in forty-eight hours it should not be continued. How calomel acts to produce the increased urinary flow under these circumstances is not known. Some suppose that it aids the absorption of liquid from dropsical tissues, and so increases urinary secretion; others think that it stimulates the renal epithelium to greater activity. The latter view seems the least probable of the two, but neither theory has been proved correct, although experimentation supports the view first named. The full urinary effect of the drug is not felt till the second or third day of its use, and speedily passes away, par- ticularly as purging is often induced very early. Still another use of calomel is in typhoid fever, in which disease it has been highly recommended in small repeated doses, particularly if constipation is present. In the opinion of the author this is disadvantageous as a routine measure and entirely uncalled for, although in the very early stages of the disease, when the bowels are confined and the tongue coated, a dose of 1 grain (0.06) in fourths with a little bicarbonate of sodium is useful. Sydney Ringer has called attention to the fact that in constipation or in "biliousness" podophyllin does more good than calomel, pro- vided that the stools are dark in color, whereas if the same signs are present, but the stools light and clayey in color, calomel is more efficient. The author has proved the correctness of this assertion so frequently that he is convinced of its truth. Calomel has been recommended in the condition of anorexia and depression following acute diseases, and when the tongue is covered by a thick yellow coat it is the remedy for the gastro-intestinal torpor always present. While purgative doses of calomel certainly are of value, the use of freshly-prepared nitromuriatic acid is, however, highly prefer- able to the mercurial salt in many such instances. Both of these drugs should not be given simultaneously, because they are incompatible. Calomel is often given in small doses to " settle the stomach." Sometimes it will act in this way, but in other cases it will seem to increase the nausea and bring on vomiting. This is true of both adults and children, and it is impossible to tell beforehand which will occur. Ringer asserts that in a peculiar form of vomiting occurring in very young children, which comes on immediately after the food is swallowed the rejection of milk being forcible, and perhaps so sudden that it is not even curdled, and which is not accompanied by much straining, calomel will often give relief when all other remedies fail. It should not be resorted to until some evidences of wasting occur, as this action of the stomach in many children only rids that organ of that part of the milk which is in excess, and is a purely physiological regurgitation. The calomel may be given in the dose of y^ grain (0.005) every hour, or, if preferred, gray powder in the dose of J grain (0.02) every hour for three doses, is equally efficient in these cases. 330 DRUGS. Calomel in a fine powder will often remove syphilitic condylomata if dusted over them for some time, and an ointment made of 1 drachm (4.0) of calomel to 1 ounce (30.0) of lard is very useful in pruritus ani. The B. P. contains a pill mass of calomel, called Pilula Hydrargyri Subchloridi Composita, which contains antimony, guaiac resin, and castor oil. Its dose is 2 to 8 grains (0.12-0.5). Calomel ointment (Unguentum Hydrargyri Subchloridi, B. P.) is often useful in the treatment of small patches of eczema, or the fol- lowing prescription may be given for its use: 1^ — Hydrarg. chlor. mit gr. xl (2.60). Magnesiae carbonatis gr. xl (2.60). Unguent, aquae rosse §j (30.0). — M. Gray Oil. Gray Oil {Oleum Cinereum) is prepared as follows: 2 drachms (8.0) of lanolin are rubbed up with sufficient chloroform to emulsify it. The rubbing process is continued until most of the chloroform is evaporated, and while the mixture is still in a fluid state metallic mercury, in double the amount of lanolin, 4 drachms (16.0), is added and the trituration continued. By this means an ointment of mercury is left which equals 2 parts of mercury and 1 of lanolin. This is some- times called Strong Gray Ointment. For hypodermic injection 3 parts of this gray ointment are added to 1 part of olive oil, or it may be still further diluted by adding olive oil in the proportion of half- and-half. Of this mixture 1 to 2 minims (0.05-0.1) may be injected every second or third day. By some practitioners this preparation is considered much better than any other for hypodermic use in syphilis. Mercury with Chalk. Mercury with Chalk {Hydrargyrum cum Creta, U. S. and B. P.), or Gray Powder, is slightly purgative, but is chiefly employed in the treatment of infantile syphilis, as it will not freely purge. It is com- posed of 38 parts of mercury, 12 parts of sugar of milk, and 50 parts of prepared chalk. The dose is 1 to 10 grains (0.06-0.60). Children suffering from syphilitic marasmus seem fairly to fatten on it. This preparation is also of service in the syphilis of adults, and may be employed whenever the laxative effect of mercury is not desired. In the treatment of infantile diarrhea with watery, colorless stools containing undigested food gray powder in small doses is often very useful. Mercury Ointment. The Ointment of Mercury, Mercurial Ointment {Unguentum Hydrargyri, U. S. and B. P.), sometimes called Blue Ointment, is made by rubbing up mercury with suet and lard until the mercury is MERCURY. 331 extinguished, or, in other words, until the globules of mercury cannot be seen with a magnifying power of ten diameters. A dilute ointment of mercury (Unguentum Hydrargyri Dilutum, U. S.) containing 67 parts of mercury ointment in 100 is also official. The ointment of mercury is used externally in skin affections and for the purpose of influencing the general system. In syphilis where a mercurial effect is to be reached the ointment in small amounts should be thoroughly rubbed into the skin in various parts of the body — one evening in the left groin, the next evening in the right groin, the following evening in the left axilla, and the fourth evening in the right axilla, beginning on the fifth evening in the left groin once more. This avoids local irritation of the skin by too frequent applications, places the drug on spots where it is readily absorbed, and rapidly influences the system of the patient. In infantile syphilis this method may be employed, or a flannel binder covered with the ointment may be placed about the belly. The clothes should not be changed too frequently, as their saturation with the drug aids in pro- ducing the impression upon the system, and the wearing of an under- shirt saturated with the ointment is a valuable, though somewhat dirty, method of producing mercurialization. The ointment of mercury is sometimes rubbed into the skin over enlarged glands. Under the name of Oleate of Mercury (Oleatum Hydrargyri, U. S. ; Hydrargyri Oleas, B. P.) a very efficient and more agreeable appli- cation than the ointment is used in its place or still further diluted with lard, when it becomes the Unguentum Hydrargyri Oleatis, B. P. It is made from the yellow oxide of mercury. (See Oxides of Mercury.) For pediculus pubis, or in any case where parasites, such as the flea or louse, infest the region of the genitals or any spot covered by a hairy growth, mercurial ointment may be used as a remedy, owing to its lethal influence over these pests. Care should be taken that it does not cause salivation of the patient, and it must not be allowed to remain on the parts, but be wiped off in the course of an hour or two or less. The following words of Dr. Joseph Leidy are suffi- ciently interesting to demand a place at this juncture: "We may here say that if it is once understood that all insects, including lice, are destroyed quickly by the application of any fixed or volatile oil, physicians will see there is no necessity of employing remedies of a noxious character to the patient. The fat of mercurial ointment is probably more active than the mercury itself." Linimentum Hydrargyri, B. P., and Emplastrum Hydrargyri, U. S. and B. P., are used for the same purposes as is the ointment of mercury. The plaster is made with olive oil, resin, and lead plaster instead of ordinary suet or lard. Nitrate of Mercury. The solution of Mercuric Nitrate (Liquor Hydrargyri Nitratis, U. S., and Liquor Hydrargyri Nitratis Acidus, B. P.), Acid Nitrate 332 DRUGS. of Mercury, is an exceedingly active, penetrating caustic, so rapid in its effects that it seems to drop through the tissues. It may be em- ployed for the removal of epitheliomata and large warts, and should be applied by means of a glass rod. This treatment may also be resorted to with advantage in lupus until the surface of the growth is level with the skin. The surrounding parts should be protected by lard or oil. As this treatment is very painful, the spot may be first cocainized and afterward covered with flexible collodion. Citrine Ointment (Unguentum Hydrargyri Nitratis, U. S. and B. P.) is used as a stimulating application in cases of chronic skin diseases of the scalp and trunk. It is too strong for ordinary use, and should be diluted one-half or less with lard according to the stim- ulating effect required; the dilute ointment is official in the B. P. as Unguentum Hydrargyri Nitratis Dilutum. Oxides of Mercury. The Yellow and the Red Oxide of Mercury (Hydrargyri Oxidum Flavum, U. S. and B. P., and Hydrargyri Oxidum Rubrum, U. S. and B. P.), Red Precipitate, are used largely as a dressing for syph- ilitic sores when diluted about one-half with chalk or other powder. If used pure, they are somewhat caustic. From the yellow oxide is made the Oleate of Mercury (Oleatum Hydrargyri, U. S.), which is used for the same purpose as ordinary mercurial ointment. In intestinal and gastric indigestion, with foul belching and very ill-smelling stools which are due to intestinal fermentation, the yellow oxide is sometimes given in the dose of -g 1 ^- to ^ grain (0.001-0.0012) in a triturate. Red Precipitate Ointment (Unguentum Hydrargyri Oxidi Rubri, U. S. and B. P.) and the Ointment of the Yellow Oxide (Unguentum Hydrargyri Oxidi Flavi, U. S. and B. P.) are largely used, diluted one-half with lard, for chronic scaly skin affections, in obstinate con- junctivitis, and in granular lids and styes. (See Styes.) They should always be freshly prepared. Protiodide of Mercury. Mercury Protiodide (Hydrargyri Iodidum Flavum, U. S.) is much more mild than the biniodide, and is given for exactly the same pur- poses. It is very useful in chronic Brighfs disease. It is to be remem- bered as the best mercurial preparation for ordinary cases of secondary syphilis. (See Syphilis, Part IV.) It should be given in ascending doses. The dose is J to | grain (0.01-0.015) three times a day. Salicylate of Mercury. Salicylate of Mercury is a drug which has come into quite general use since the introduction of the hypodermic method of administer- METHYL BLUE. 333 ing mercury in syphilis. It is to be suspended in paraffin oil in the proportion of 22 grains (1.5) of the salicylate of mercury to 3 drachms (12.0) of the oil, and before it is used the bottle must be well shaken in order that the insoluble mercury may not remain at the bottom. It is of great importance that the needle and syringe shall be thor- oughly cleansed after each injection, as the insoluble drug readily clogs the instrument. At first 1 minim (0.05) of the mixture just named should be injected deeply into the gluteal region every fourth day, and this may be increased to every second day if no systemic evidences of the action of the drug appear. Yellow Sulphate of Mercury. Hydrargyri Subsulphas Flavus has been used under the name of Tur- peth Mineral as an irritant in chronic ophthalmia and also as a prompt emetic in croup. It is a quick and certain emetic, and, it is claimed, does not produce depression, but the writer would recommend great care in its use. The dose for a two-year-old child is 2 to 5 grains (0.12-0.30), repeated in fifteen minutes if necessary. If as much as 5 grains (0.30) has been given, and emesis does not follow, other emetics or the stomach-pump must be used to prevent gastro-intestinal irritation. Yellow Wash. Yellow Wash (Lotio Hydrargyri Flava, B. P.) is made by adding 30 grains (2.0) of corrosive sublimate to a pint (480 c.c.) of lime-water. It is used for the same purposes as the black wash already mentioned, but is much more stimulating. Incompatibles. — Bichloride of mercury should never be given with any other substance except iodide of potassium and chloride of ammo- nium, as it is incompatible with almost every other drug. With the iodide of potassium it may be used because the precipitate formed is at once redissolved and the resulting mixture is highly alterative. Calomel should never be given with iodides or bromides, and hydro- chloric acid may convert it into the bichloride if the acid is present in any amount. It is also incompatible with antipyrin. METHYL BLUE. Methyl Blue, or Methyl Violet, is an aniline dye often sold under the name of Pyoktanin. When used medicinally, it must be perfectly pure and deprived of its usual contaminating matter, arsenic, which if present causes local irritation of the part to which it is applied. Pyok- tanin was introduced to professional notice under this name by Still- ing as an antiseptic, but careful study has proved it to possess but 334 DRUGS. feeble power over the growth of germs. In all conditions of the eye in which antiseptic lotions are indicated pyoktanin has been stated to be of value, but elsewhere in surgery it is practically useless as an antiseptic. Even in the eye it possesses, according to de Schweinitz, a limited range of usefulness, being no better than the older antiseptics, except in diseases of the lachrymal apparatus. The fact that pyoktanin stains everything it touches is a great disadvantage in its use. It may be tried in blepharitis, eczema of the eyelids, conjunc- tivitis, both simple and phlyctenular, and in the treatment of corneal ulcer. When so employed, it should be applied in the strength of 1 to 1000 of water. It should be remembered that any pure aniline dye may be used in place of pyoktanin. Thus some physicians have used yellow pyok- tanin or auranine. Methyl blue and similar aniline substances have been largely employed by some physicians in the treatment of malignant neoplasms. The solution (1 to 500 of water) should be filtered through hot asbestos to render it sterile, and every antiseptic precaution carefully observed in giving the injection. The dose is J to 3 drachms (2.0-12.0) of this solution every other day or every third day, and the injection is to be given either into the growth itself if it is large, or just at its side, in the healthy tissues, if it is small. Too much should not be injected into one spot lest it cause a slough. This treatment does not cure the disease. It relieves pain and so quiets the patient, and in rare cases checks the growth of the tumor. If the growth sloughs, com- plete antiseptic dressing is necessary. An antiseptic pyoktanin-gauze dressing should always be used while the treatment is under way. METHYL CHLORIDE. Methyl Chloride is a colorless gas, easily liquefied under pressure, with an odor resembling that of ether and chloroform, and is used to produce local anaesthesia, which it does by absorbing a large amount of heat on passing from the liquid to the volatile state as it strikes the skin. It is usually kept in a small flask which has its open end covered by a metal cap. When this cap is removed the heat of the hand volatilizes the drug, which is then forced out of the flask in a fine spray. The nozzle should be held ten to twelve inches from the part to be frozen. Before the spray is used the skin of the part to be anaesthetized should be washed with soap and ether to remove all fatty substances. Under these circumstances the skin becomes pale in a few seconds, and afterward white and parchment-like in appearance. Local anaesthesia is now complete, and minor surgical operations, such as opening boils or abscesses, can be performed without pain. The spray should not be continued more than two to four minutes, as local death of the tissues may result. Advantages of the spray of methyl METHYLENE BLUE, 335 over that of ether are its slight inflammability and rapidity of action. Methyl chloride should not be confounded with methylene chloride. The first is monochlormethane, the second dichlormethane. METHYLENE BLUE. Methylene Blue (Methylthionince Hydrochloridum, U. S.) is to be distinctly separated in the mind of the student from methyl blue, which is practically what is known by the trade name of " Pyoktanin." The latter ought not to be used internally. The methylene blue can be distinguished from methyl blue by this test: With sodium hydroxide methyl blue gives a purplish red, while methylene blue turns a deep violet. Also when a solution of the former is made in a test-tube the meniscus is blue, whereas with methylene blue it is greenish. Methylene blue has been employed in the treatment of malignant growths and in malarial fevers with asserted success, although its successful use in the first group of cases is decidedly problematical. When used in the treatment of sarcoma and cancer, from ^ to 2 grains (0.03-0.12) in watery solution are injected daily or on alternate days directly into the growth. The neoplasm, it is said, ceases to grow, shrinks, and comes away, leaving a fairly healthy sloughing surface. This treatment is so uncertain that it should only be tried in inoper- able cases, and in this class of patients its local use often seems to relieve the pain and check the fetor. In malarial fever of the intermittent type methylene blue seems to possess distinct curative powers. It is not so powerful as qui- nine by any means, but has its chief sphere of usefulness in patients who cannot take quinine or where quinine has been tried unsuccess- fully. This antimalarial influence is due to its destruction of the plasmodium malaria?, but its administration must begin from seven to ten hours before the expected intermittent paroxysm and be con- tinued after the attacks have ceased and for some little time after the physician fails to find the micro-organism in the blood, as relapses are common. Particularly good results seem to follow the use of methylene blue in children suffering from malaria. Untoward symp- toms from its use are not common, but when they do occur consist in slight vertigo, nausea, and some strangury, which latter symptom can be prevented to a great extent if powdered nutmeg (equal parts) is given simultaneously. The urine is always blue from the elimination of the drug through the kidneys. Recently Levy has employed methylene blue in the dose of from 1 to 2 grains (0.06-0.12) four times a day in the treatment of migraine. It is to be given in capsule with kola. He states that as much as 15 grains (1.0) may be given in a day with safety. Methylene blue has been highly recommended by Horwitz in the 336 DRUGS. treatment of the earlier stages of gonorrhoea, as it shortens the course of the disease. He suggests the following formula: Methylene blue 2 grains (0 12). Oil of sandalwood 3 " (0.2). Oleo-resin of copaiba 3 " (0.2). Oil of cinnamon 1 minim (0.05). To be made in one capsule, three of which are to be taken each day. Injected into a muscle in the dose of 1 grain in 10 minims of water, methylene blue is used to test the activity of the eliminative function of the kidneys. In health it should appear in the urine in fifteen to thirty minutes, and persist for thirty-six hours. . When the kidneys are healthy the same test may be made to deter- mine whether an effusion in the pleural cavity or peritoneum is capable of being absorbed as a result of purgation. From 1 to 3 grains in solution are injected into the fluid in the chest, or abdomen, and a purge given. If the blue does not appear in the urine, this fact shows that absorption from the pleura has not occurred, because the lymphatics are blocked by inflammatory exudate. The ordinary dose in the treatment of malaria is 2 to 4 grains (0.12-0.25) every four hours to adults, or 1 to 2 grains (0.06-0.12) to children of five years, preferably given in capsule. METHYLENE CHLORIDE. Methylene Chloride is made from chloroform or by the action of chlorine on marsh-gas, and is a colorless liquid resembling chloroform in odor. It is readily decomposed by light, which change may be hindered by the addition of a little absolute alcohol. Therapeutics. — Methylene chloride is employed as an anaesthetic in a manner like chloroform, and was introduced as a substitute for that drug, but is of doubtful safety and is little used. It has been used as a spray for the production of local anaesthesia. As stated under Methyl Chloride, it is not to be confounded with that drug. In England, under the name of methylene chloride or methylene, a mixture of ethyl and methylene chloride has been widely employed by inhalation as an anaesthetic. This preparation is, of course, to be distinguished from true methylene chloride. The amount of this mix- ture used to produce anaesthesia is 1 to 2 drachms (4.0-8.0) for minor and 3 to 6 drachms (12.0-24.0) for major operations. The term "methylene chloride" has also been applied to a mixture of chloroform and methyl chloride. MUSK. Musk (Moschus, U. S. and B. P.) is obtained from the preputial follicles of Moschus moschiferus, or musk deer of Thibet, and is a MUSTARD. 337 substance possessing remarkably penetrating powers, so far as odor is concerned. Very little of the musk for sale in the shops is pure, and most of it is not musk at all. Its price varies greatly, but if sold for less than twenty-five cents a grain it is probably worthless or impure. Therapeutics. — For some unknown reason musk acts as a diffusible stimulant and supports the system. It is also an antispasmodic and nervous sedative. In all low fevers where the strength of the patient is fast ebbing and the nervous symptoms are those of the most advanced depression, rectal injections of musk in starch-water may be employed. The dose should be 5 to 10 grains '(0.30-0.60). This drug is of value where either nervous excitement or nervous collapse is present, but is not to be employed until it is absolutely needed to carry the patient past a crisis. If frequently employed, it loses its power and the expense is a needless one. Musk is one of the best remedies in obstinate hiccough. The dose of the tincture (Tinctura Moschi, U. S.) is 40 minims to 1 drachm (2.0-4.0), and of musk itself 5 to 10 grains (0.30-0.60). MUSTARD. Mustard is official in the form of Sinapis alba, U. S., and Sinapis AlboB Semina, B. P., or white mustard, derived from the seeds of Sinapis alba, and Sinapis nigra, U. S., and Sinapis Nigra" Semina, B. P., or black mustard, derived from the seeds of Brassica nigra. Both of these contain an irritant oil (Oleum Sinapis Volatile, U. S. and B. P.) as their chief active constituent. Therapeutics. — Mustard is often used in the form of mustard flour as an emetic when stirred in water in the proportion of 2 table- spoonfuls to a glass of water. It is also employed as a counterirritant and as a condiment. If given in excessive dose, it will cause violent gastritis, and chronic gastritis is often set up by its constant use in excess. Its internal use is contraindicated during the existence of acute gastritis and all states of gastro-intestinal irritation. When used as a counterirritant mustard is applied to relieve the pain of colic due to flatulence and acute inflammation of the abdominal and thoracic viscera, that due to muscular rheumatism, inflamed joints, and neuralgia, and it may be applied at the nape of the neck in cases of headache and cerebral congestion. When applied to the skin of an ordinary individual, it will produce a severe burn if left on more than a few minutes, and it should be mixed with wheat flour in the proportion of half-and-half when used upon tender skins. Children generally will not tolerate more than one-fourth mustard. The plaster should be made by mixing mustard flour and wheat flour together and then moistening the mixed flours with warm water or warm vinegar, or a little brandy may be used. 22 338 DRUGS. The scald or burn produced by mustard is peculiar in its slowness to heal and in the fact that it is tender and reddened for days. Often it produces a permanent stain of the skin. If the burning of the mus- tard becomes excessive, it should be treated by applying a piece of lint soaked in lime-water and olive oil, half-and-half, or olive oil alone may be used. The oil of mustard is very irritant, and almost epispastic in its effects. It is sometimes given in the treatment of the atonic stomach of drunkards in the dose of \ to \ minim (0.015-0.03). Charta Sinapis, U. S. and B. P., or mustard-papers, are sometimes called sinapisma, and these afford a ready means of applying this counterirritant. They are generally very strong, and one or two layers of thin and moistened linen should be placed between the skin and the sinapism to prevent too great an action. (See Counterirritation.) The compound liniment (Linimentum Sinapis Compositum; Linimentum Sinapis, B. P.) is composed of the oil of mustard, castor oil, extract of meze- reum, and alcohol. The mezereum is omitted in the British prepara- tion, which is twice as strong in mustard oil as that used in the United States. MYRRH. Myrrha, U. S. and B. P., is a gum-resin obtained from Commiphora myrrha, a tree of Arabia. It occurs in dark-colored tears, and contains an active principle, myrrhin. Therapeutics. — Myrrh, in medicinal amount, is a stimulant to the circulation and to the uterine and the bronchial mucous membranes. In amenorrhea due to functional inactivity or anemia, "iron and myrrh" is a standard remedy. The tincture of myrrh, diluted one-half, is useful in ulcerated sore throat as a gargle, and the pure tincture is sometimes applied with a small brush or by the end of the finger to spongy or tender gums. In leucorrhcea depending upon uterine trouble and in chronic cystitis myrrh is often of service. Sometimes it enters into expectorant mixtures given in the later stages of bronchitis. The dose of the tincture (Tine- tura Myrrhoe, U. S. and B. P.) is 10 to 30 minims (0.60-2.0). It also enters into the* composition of Pilule Aloes et Myrrhe, U. S. and B. P., dose two to five pills, and Tinctura Aloes et Myrrhe, U. S., the dose of which is 1 to 2 fluidrachms (4.0-8.0). NAPHTHALIN, or NAPHTALENE. Naphthalenum, U. S., is a coal-tar derivative occurring in color- less mica-like crystals, possessing a peculiar smell, and soluble in alcohol to some slight extent. Helbing states that naphthalin when pure is colorless and without action on moist litmus-paper. It should NARGOL. 339 also dissolve without color in concentrated sulphuric acid when gently warmed. After it is taken for some time, or even after the first dose, the patient will state that when he belches the gas has the smell and taste of burning rubber. The drug possesses distinct antiseptic power, and for this reason has been employed in certain gastric and intestinal diseases asso- ciated with fermentative changes or dependent upon ulceration and organic lesions. In fetid diarrhoea it may be given as a deodorant and cure. When given to children, as in summer diarrhea, the dose should be \ to \ grain (0.01-0.015) every two or four hours, but adults may take as much as 5 to 10 grains (0.30-0.60). More than this will dis- order the stomach. The drug should be given in powder, with sugar, or in capsule. It has not been so widely employed as was expected when it first came to the notice of the profession, and certainly often fails to do good. In cats and rabbits naphthalin, when administered continuously for a considerable period of time, produces cataract. NAPHTOL. Beta-naphthol, U. S., and Naphthol, B. P., is generally prepared from naphthalin. It is used externally in antiseptic dressings. Intern- ally it is an excellent remedy for gastric fermentation and flatulence, as it acts as an active antiseptic. It is also useful in fetid diarrhoea of the serous type. The dose is 2 to 5 grains (0.12-0.3) in capsule or cachet. Beta-naphtol-bismuth, or Orphol, is a neutral, odorless, and tasteless powder designed to combine the sedative effects of bismuth with the antiseptic properties of beta-naphtol. It is used in cases of serous and fermentative diarrhoea in adults in the dose of 5 to 15 grains (0.3-1.0) and in infants in the dose of 2 to 5 grains (0.12-0.3) every few hours in capsule. Benzonaphtol is used as a substitute for beta-naphtol in fermentative dyspepsia. The dose is about 10 grains (0.60) three times a day, and it is best given in cachet. NARGOL. Nargol is a chemical compound of silver and nucleinic acid, which is readily soluble in water, and possesses a more penetrating power and more lasting effects than other silver preparations. It is not pre- cipitated by coming in contact with albuminoids, and it does not undergo change when boiled. Nargol contains about 10 per cent, of metallic silver, which is more than that contained in the other organic silver compounds now obtainable by physicians. 340 DRUGS. Therapeutics. — Nargol is employed in the treatment of gonorrhoea in the form of injections in the strength of 0.25 to 1 per cent.; although in chronic cases the strength may be increased up to 5 per cent. It destroys the gonococcus, seems to penetrate into the crypts and deeper-lying tissues, and is said to produce little or no pain if not in too strong solution. It diminishes the discharge quite rapidly. By ophthalmologists it is employed in the strength of 5 per cent, in the treatment of the various inflammations of the conjunctiva, but is not sufficiently strong for granular conjunctivitis. It is, how- ever, a valuable drug in gonorrheal ophthalmia and in ophthalmia neonatorum. It has also been employed in gonorrheal vaginitis, and as an ointment in the strength of 5 or 10 per cent, with cosmoline or lanolin upon suppurating ulcers and burns. It is without odor, and therefore possesses a great advantage over iodoform and similar substances which have been used in this manner NITRATE OF POTASSIUM. Nitre (Potassii Nitras, U. S. and B. P.), or Saltpetre, occurs in long, needle-like crystals and has a sharp, saline taste. Sal prunella is saltpetre melted and run into moulds. Next to the cyanide and chlorate of potassium, this is the most poisonous of the potassium salts, and produces when taken in over- dose symptoms of violent gastro-enteritis. While it does not affect the blood, it is more irritant than the chlorate. Nitrate of potassium is rarely employed at present, and has been very properly put aside as inferior to the harmless vegetable potas- sium salts (the citrate, acetate, and bitartrate). If used in rheuma- tism, the dose should be 1 ounce (30.0) in a pint (480 c.c.) of barley- water or syrup of acacia and water, to be taken in divided doses of a tablespoonful every three hours. Nitrate-of-potassium papers (Charta Potassii Nitratis) are made by dipping unsized paper in a solution of the drug of the strength of 20 parts of the salt to 80 parts of distilled water. They are rolled into cigarettes and smoked by asthmatics, or burned in a pan and the fumes arising from them inhaled. Their efficacy may be increased in cases where the respiratory mucous membrane is irritable by dipping them in compound tincture of ben- zoin and exposing to the air long enough to dry. They should then be protected from the air until used. The paper used should be moderately thin bibulous paper. NITRATE OF SILVER. Nitrate of Silver (Argenti Nitras, U. S. and B. P.) is a heavy crys- talline salt of silver readily soluble in its own weight of water. NITRATE OF SILVER. 341 It is official as the pure nitrate {Ar genii Nitras, U. S. and B. P.) and as the sticks or fused rolls {Ar genii Nitras Fusus, U. S.), or lunar caustic. The latter are never used in medicine internally, only the crystals being employed. Applied to the tissues of the body or other substances, nitrate of silver causes a brown and finally a black stain, which is due to the formation of an oxide of silver. Physiological Action. — Nitrate of silver is one of the few astringent substances which are applicable to inflamed mucous membranes, as it is, with lead, bismuth, and zinc, one of the few drugs of this class which is not irritant as well as astringent. Locally applied, it acts in pure form, as a powerful caustic, which is, however, very superficial in its effect, as the drug coagulates the albumin with which it comes into contact and thereby forms a coat which protects the tissues beneath. The action of the drug upon the circulation, respiration, and similar vital functions is only partly known, and has no relation to its employ- ment in medicine. Nitrate of silver is eliminated from the system very slowly. Poisoning. — Almost immediately after the ingestion of a poisonous dose of nitrate of silver violent pain in the belly, with vomiting and purging, is felt. At the same time evidences of widespread gastro- enteritis develop. The abdominal walls are knotted and hard, and perhaps scaphoid. The face is anxious and livid and covered with a sweat. When vomiting occurs the ejecta are brown or blackish, or they may be white and curdy. The lips are at first white, but quickly become brown, then black. In some cases the nervous symptoms are severe, and convulsions with delirium may occur. The convulsions are epileptiform. Death ensues either from gastro-enteritis or from centric respiratory failure, accompanied by a profuse exudation of liquid mucus into the bronchial tubes. The treatment consists in the use of common salt, which is the chemical antidote, the employment of opium and oils to allay irrita- tion, and in the ingestion of large draughts of milk and of soap and water for the purpose of diluting the poison and protecting the mucous membranes of the oesophagus and stomach from the action of the irritant. The bodily heat must be maintained. Chronic Poisoning. — This is a form of poisoning quite frequently seen. The most prominent symptom is the pale slate-blue color of the skin, which causes the individual to be livid and death-like in appearance. Argyria, as chronic silver poisoning is called, is caused by the con- tinued employment of the drug until it is deposited in the tissues. It is then found in every part of the body. The first signs of dis- coloration can generally be seen in the darkening of the conjunctiva over the sclerotic coat of the eye or in a dark line on the inner part of the lips. The treatment of argyria is not hopeful so far as the color of the skin is concerned, but the discoloration may be slightly modified in 342 DRUGS. some cases by the prolonged use of iodide of potassium to aid in the elimination of the silver. Therapeutics. — Internally this salt is used as a cure for gastric ulcer, and it is certainly the best remedy we possess if combined with extract of hyoscyamus or opium and given in pill form. In chronic gastric catarrh and gastritis nitrate of silver is very useful when the patient is troubled with sour eructations or when vomiting occurs after meals. When used in these states, it should be given in \ to \ grain (0.01- 0.015) doses, half to one hour before each meal, in order that the stomach may be exposed to its effects and not be protected by food. In intestinal ulceration the drug has been highly recommended by Pepper, and under these circumstances should be given in hard or keratin-coated pills, in order that it may pass through the stomach without being chemically changed. In ulceration of the c&cum and rectum and in acute and chronic dysentery the disease may be attacked by rectal or colonic injections of nitrate of silver. If the caecum is involved, the solution must be given in large quantity in order to reach the part affected; but if the rectum is diseased, the amount of liquid injected should not exceed 4 ounces, the bowel in either case being washed out beforehand by warm water to rid it of feces. Soap and water and salt and water must not be used for this purpose, as the soap or salt which remains in the bowel will prevent the silver salt from acting. The strength of the solution employed should be 1 drachm to 3 pints (4.0-1440 c.c.) of water in csecal trouble, and 3 grains (0.20) to each 4 ounces (120.0) in rectal trouble. If the latter condition is very obstinate and chronic, the strength may be increased to 5 grains (0.3) to each 4 ounces (120.0). Whenever nitrate-of-silver injections are used in this way, a solu- tion of salt and water should be ready for use, and injected if the action is too severe or as soon as it is thought that the drug has acted with sufficient thoroughness. Nitrate of silver was at one time thought to be of value in lateral and posterior spinal sclerosis, but rarely does good. Nitrate of silver has been largely used in epilepsy and chorea, but is now seldom so employed, and does little good in most cases. Pepper thought highly of the continual administration of nitrate of silver in pill form in the dose of ^ to \ grain (0.01-0.015) through the entire course of typhoid fever, and believed that it greatly modified the severity of the disease. Externally, nitrate of silver is used for many purposes, and will often prevent the pitting of smallpox if on the fourth or fifth day the vesicles are punctured by a needle dipped in a solution of nitrate of silver in the strength of 20 grains (1.3) to the ounce (30.0) of water. Others simply paint the skin over the eruption with a solution of 5 to 10 grains (0.30-0.60) to the ounce (30.0), claiming that this method is equally effective and prevents inflammation and suppura- tion. NITRA TE OF SIL VER. 343 Higginbottom has highly recommended the use of nitrate of silver upon erysipelatous inflammations, but the practice is not often resorted to, and is now supplanted by better measures. (See Erysipelas.) In other inflammations of a superficial character nitrate of silver is of great value. Painted in strong solution over the scrotum in the early stages of orchitis or epididymitis, it will often relieve the pain and diminish swelling, and felons may sometimes be aborted by its early application in concentrated solution over the surface of the finger. In all inflammations of the pharynx, larynx, fauces, and mouth solutions of silver nitrate may be used in varying strength. Some- times after slight exposure to cold or dampness the posterior wall of the pharynx suddenly becomes sore and raw, feeling as if the mucous membrane had been scarified. A solution of nitrate of silver will relieve this condition, and if it is employed in the strength of 60 grains (4.0) to the ounce (30.0) of water, the application will be more efficacious and less painful than if weaker solutions are employed. In laryngeal phthisis a spray, from an atomizer, in the strength of J to 2 grains (0.03-0.12) to the ounce (30.0) of water may do good service. In whooping-cough Ringer recommends the use of a spray in the strength given above for the purpose of relieving the cough in vio- lence and frequency and of obtaining a good night's rest. The appli- cations should be made when the stomach is empty, as they are apt to bring on retching. The tip of the atomizer must be within the mouth or the skin of the face will be stained. In the subacute stages of gonorrhea an injection of nitrate of silver of the strength of h grain (0.03) to 3 ounces (£0.0) of water is useful. (See Gonorrhoea, Part IV.) In uterine ulceration and in leucorrhcea when the cervix is boggy and tender, the application of the solid nitrate-of-silver stick is of service. Its use is often followed by headache about the vertex, and this in turn is to be relieved by 10-grain (0.60) doses of the bromides. In pruritus pudendi vel ani and vulva? a solution of 4 to 6 grains to the ounce (0.25-0.40:30.0) should be painted with a camel's-hair brush over the parts to relieve the itching. The application is to be made from two to four times a day. Bed-sores may be aborted if, . as soon as the skin reddens, an aqueous solution of nitrate of silver of the strength of 20 grains to the ounce (1.3-30.0) is applied with a brush to the part. For obvious reasons this measure often fails in paralytics. Boils which begin in a small limited papule with a surrounding area of inflammation may sometimes be aborted by painting a strong solution of this salt around them. In granular lids, conjunctivitis, and similar affections about the eye nitrate of silver in stick form or in solution is largely and successfully employed. (See Conjunctivitis.) When it is desired to remove nitrate-of-silver stains, they should be washed with a solution made of cyanide of potassium 2 \ drachms 344 DRUGS. (10.0), iodine 15 grains (1.0), and water 3 ounces (90.0); or dissolve 15 grains (1.0) of corrosive sublimate in 7 ounces (210.0) of boiled water, add about 45 grains (3.0) of table salt (a scant teaspoonful) just before using, lay the stained materials in the mixture for about five minutes, and then wash them two or three times in pure water. Administration. — The dose of nitrate of silver is ^ to J grain (0.01-0.015) in pill form. Mitigated caustic, or diluted nitrate of silver (Argenti Nitras Mitigatus, U. S. and B. P.), is composed of equal parts of nitrate of silver and potassium nitrate, and is good as a mild caustic. The drug when given continuously should be discontinued for two weeks at the end of the eighth week, as it is so slowly eliminated that it accumulates in the body and causes argyria; but Lewin and Soullier assert that the smallest aggregate amount on record which has produced argyria is 1 ounce. NITRIC ACID. Nitric Acid (Acidum Nitricum, U. S. and B. P.), the strongest and most corrosive of the mineral acids used in medicine, is a clear liquid, becoming slightly yellow with age. It should be kept in dark, glass- stoppered bottles. Physiological Action. — When in pure form, nitric acid acts upon the tissues of the body as a powerful caustic. Applied to the mucous membranes, well diluted, it acts as an irritant or astringent, and when taken internally it exerts a stimulating influence over the secretory glands of the stomach and small intestine. It does not tend to relax the bowels, as does nitro-hydrochloric acid. Continued for a long period of time in small doses, it is said to cause slight salivation and looseness of the teeth. Nitric acid coagulates albumin. Poisoning. — When nitric acid is taken in concentrated form, it pro- duces a widespread gastro-enteritis, intense pain in the mouth, oesoph- agus, and abdomen, and finally death from the inflammation induced or from collapse. If the patient survives the acute stages, he may die from secondary cringes in the stomach and bowels, such as stric- ture or destruction of the peptic tubules. The stain made by the acid about the mouth and on clothing is deep lemon-yellow. Renal irri- tation is often a severe symptom, and the urine and the passages from the bowels may be bloody. The antidotes are any mild alkali, as magnesia, chalk, or plaster from the walls of the room, the use of oils and opium to relieve irritation, and the maintenance of bodily heat. Therapeutics. — Nitric acid is used externally in medicine'as a caustic for chancres and chancroids, the surrounding tissues being protected by oils or ointments. Nitric acid may also be used on warts, in cases of gangrene to destroy the tissues, and on phagedenic ulcers. Whenever the acid is to be applied NITRITE OF POTASSIUM. 345 for such purposes, a solution of soap and water should be at hand to neutralize the effects as soon as it has acted deeply enough. Nitric acid is also used externally in a dilute form, 5 to 30 minims to the ounce (0.30-2.0:30.0), as a stimulant and astringent to indolent ulcers. Internally, nitric acid is used as a tonic and astringent. In the oxalic-acid diathesis when oxaluria is present, nitric acid will give relief when nitromuriatic acid cannot be obtained, although the latter is preferable. When small ulcers exist in the mouth or stomatitis is present, 3 minims (0.20) of nitric acid at a dose, in water, will often be of service, but it should be taken through a tube to protect the teeth. In gastric indigestion in which, sometimes after a meal, undigested food regurgitates into the mouth, a few drops of nitric acid in water after meals will often give relief. In intestinal dyspepsia coming on some hours after meals, and in which not only discomfort but pain may be felt in the hypochondrium, nitric acid with some bitter tonic is most efficient, and it will often cure the green diarrhoea of children, particularly that met with in summer, bringing about these changes not only by its astringent power, but also by its stimulating effect on the intestinal glands. Combined with some good pepsin, it will give relief in the chronic diarrhoea of children associated with lientery, and in which the stools may be pasty or watery and at the same time ill- smelling. Ringer recommends the employment of nitric acid in the treatment of piles. The strong acid should be used, and simply touched to one or two points, not swept over the whole surface. The pain is slight, or none at all may be felt. A slough results, and finally comes away, leaving a cicatrix which as it contracts diminishes the size of the pile. The same author also states that a lotion of nitric acid in the proportion of \ to 1 drachm to a pint (2.0-4.0:480 c.c.) of water is of service in bleeding hemorrhoids, arresting the bleeding, constring- ing the parts, and relieving the sensation of weight and fulness so often a pressing symptom. The dose of dilute nitric acid (Acidum Nitricum Dilutum, U. S. and B. P.) is 3 to 15 minims (0.20-1.0), well diluted, and taken through a tube to protect the teeth. An exceedingly strong preparation, Acidum Nitricum Fumans, is official in the B. P. NITRITE OF POTASSIUM. Nitrite of Potassium is a salt used largely in modern medicine to take the place of nitrite of amyl, but it possesses greater stability, and is, therefore, more lasting in its effects. It is used for the relief of angina pectoris or heart-pang, in the treatment of gastralgia, and in epilepsy. The dose is from 3 to 5 grains (0.20-0.3), although much larger doses have been employed. These larger doses are, 346 DRUGS. however, not devoid of danger. Nitrite of potassium is eliminated by the lungs and by the kidneys as a nitrate. (See Nitroglycerin.) Cobalto-nitrite of Potassium. This preparation has been employed successfully as a substitute for the nitrite of potassium. As it is a more stable compound, it is less rapidly broken up in the system, and so exercises a more pro- longed influence. For this reason it does not act so vigorously or suddenly, which is a great advantage in some cases. Its use is identical with that of the rest of the nitrite group. The dose is \ grain (0.03) every three hours. NITRITE OF SODIUM. Sodium nitrite (Sodii Nitris, B. P.) is used for the same purposes as nitrite of potassium in the dose of 1 to 2 grains (0.06-0.12) given in pill or cachet. NITROGLYCERIN. Nitroglycerin, sometimes called trinitrin or glonoin, is a compound which, in its pure state, is used largely as an explosive, but it is employed in medicine in a dilute form as a useful drug in those instances where a somewhat rapid and powerful effect is to be exercised over the vas- cular system. As its influence lasts but a short time, it should be given every three or four hours. Its physiological action is identical with that of the nitrites, such as the amyl nitrite (which see), except that it is not so violent or fugacious as the latter nor so persistent in its effects as the nitrites of sodium and potassium. The dose is 1 to 2 minims (0.05-0.10) of a 1 per cent, solution in a little water or in a pill, and no more than this may be employed at one dose unless the patient takes the remedy for a considerable period of time, when as much as 60 minims may be administered. Often good results are obtained only by giving ascending doses. It is noteworthy that patients rapidly become immune to the drug, and Reading has recorded a case in which, after a year of treatment, 1 drachm (4.0) of a 10 per cent, solution was taken daily with good effect. The author has given as much as 1\ grains a day. The drug is largely employed in angina pectoris (see Part IV.), and sometimes in epilepsy and chorea and in gastralgia. Da Costa and others have highly commended this drug in the treatment of chronic parenchymatous nephritis, as it distinctly decreases the excretion of albumin from the kidneys. In interstitial nephritis, with cardiac disturbance resulting from the renal changes, in which there is a marked increase in arterial pressure, so that auscul- tation reveals at the second right costal cartilage an accentuated second sound due to the forcible closure of the aortic leaflets, nitroglycerin often produces a good effect by reducing the pressure and relieving NITRO-HYDROCHLOMC ACID. 347 the heart of strain. This use of the drug is its most important applica- tion. (See article on Heart Disease, in Part IV.) It is when attacks of angina pectoris seem to be accompanied or preceded by marked vascular spasm that nitroglycerin is chiefly indicated. In cases of asthma dependent upon spasm and engorgement of the mucous mem- branes of the bronchial tubes it is serviceable. Humphreys asserts that nitroglycerin is a most valuable drug in vomiting of all kinds, except that of pregnancy and peritonitis. Given in the dose of ^ijo" grain (0.0003) hypodermically with morphine it prevents the after- nausea usually produced by opiates. Nitroglycerin usually causes a considerable increase in urinary flow by reason of the relaxation of the renal bloodvessels which it produces, particularly in Bowman's capsule. Because nitroglycerin relaxes arterial tension and so relieves the heart of a certain amount of labor in cases characterized by high arterial tension, thereby doing good when the heart is tired because of the labor required of it, many physicians have come to employ it as a cardiac stimulant in acute diseases without high tension of the blood- vessels. There is no justification for this use of the drug, for it is not a stimulant. The watery solution used in medicine is too weak to be explosive. Tablets of nitroglycerin (Tabellce Trinitrini, B. P.) each contain -^-q grain (0.0003). The Spiritus Glycerylis Nitratis is an alcoholic solu- tion of glyceryl nitrate. It should be kept in tightly-stoppered tins, never in glass, and be stored in a cool place, away from heat. Its explosiveness is in direct ratio to the evaporation of its alcohol. The dose of the spirit is the same as that of the watery solution — namely, 1 to 2 minims (0.05-0.1). Liquor Trinitrini, B. P., is practically identical with the spirit just named, and is given in the same dose. Erythrol Tetranitrate. Erythrol Tetranitrate is a white crystalline substance, soluble in alcohol, but insoluble in water. It is explosive on percussion or trituration, and is employed in the place of nitroglycerin for the pur- poses just named. It is not so useful, however. Its dose is J to \ grain (0.015-0.03), given in solution or in tablets. NITRO-HYDROCHLORIC ACID. Nitro-hydrochloric Acid (Acidum Nitro-hydrochloricum, U. S.) is a liquid giving off a distinct odor, possessing caustic power, and staining the tissues of the body a light yellow. It is official in the form of the dilute acid (Acidum Nitro-hydrochloricum Dilutum, U. S. and B. P.), in which form it is useless except as an ordinary acid. When it is wished to use the acid for its own peculiar effects, the official dilute acid ought always to be supplanted by the freshly-mixed strong acid, which should be of an orange color. If this cannot be 348 DRUGS. obtained, the physician should prepare the compound himself by adding 4 parts of medicinally pure nitric acid to 16 parts of hydro- chloric acid, and allowing the mixture to stand in an open bottle until fumes are no longer given off in excess, when it should be tightly corked and kept in a dark place. This acid ought to be freshly prepared every few days. Poisoning. — The symptoms caused by poisonous doses are those of violent gastro-enteritis with vomiting and purging of bloody materials. Death may occur from perforation of the alimentary canal, from inflam- mation of the abdominal viscera, and from destruction of the peptic tubules or constrictions of the oesophagus or bowel. The treatment consists in the use of alkalies, such as magnesia, lime, plaster, soap, and oils, with opium to allay irritation. The use of external heat to prevent collapse is also to be resorted to. Therapeutics. — Nitro-hydrochloric acid is an invaluable remedy in many cases of indigestion arising either in the stomach or bowels, as it acts as a tonic and stimulant to secretion. Upon the biliary flow its action is marked, and it may even cause bilious purging if administered in full doses for some days. It is therefore largely used in hepatic torpor, either acute or chronic, and in the early stages of hepatic cirrhosis should always be resorted to. In the chronic hepatitis of hot climates it is exceedingly useful, but it is not to be employed in acute sthenic hepatitis, as it is a stimulant to the liver, which, under these conditions, needs quieting. When used in chronic hepatitis it should be given in full dose and pushed to its physiological limit, as evidenced by the bilious purging produced or by signs of gastro- intestinal irritation. A useful additional means for obtaining the beneficial effects of this acid is to use it by means of the foot-bath or general bath. As used by Johnson in India, the acid for this bath is prepared by slowly and carefully adding together 2 parts of nitric acid and 3 parts of hydro- chloric acid, and after twenty minutes mixing carefully with these dis- tilled water 5 parts. For the general bath (in a wooden tub) take 5 pailfuls of water, 64 fluidounces (2 litres + ) of the acid mixture, and enough boiling water to raise the temperature to 98° F. Keep the patient in the bath twenty minutes. Then rub him thoroughly with warm towels and place him in a dry, warm bed. For the foot-bath add 6 ounces (180.0) of the acid to 2 gallons (7 litres) of water at 98° F., and bathe the thighs and calves of the legs for twenty minutes with a sponge wet with the mixture. This is a very useful treatment, according to Stille, for cases of alcoholic hepatic torpor. If in either case the skin becomes irritated, less acid is to be used. In ordinary so-called biliousness, which is not biliousness, but intes- tinal indigestion, this acid is often of great service. (See Indigestion and Biliousness.) It is also of value in lienteric diarrhoea where the dysentery results from defective secretory action on the part of the glands which pour out the proper fluids for digestion. NITROUS OXIDE. 349 Another very important action of nitro-hydrochloric acid is the remedial influence it exerts in cases suffering from oxaluria, par- ticularly if this be associated with melancholia or great mental depression. Administration. — The strong, freshly-mixed acid should be given to the adult in the dose of 3 to 5 minims (0.20-0.3) three times a day, well diluted, and taken through a tube, after meals. If the patient is intelligent, he should be ordered J ounce (16.0) of the pure acid and told how to drop it. If he is not, the physician must order it partly or entirely diluted in the prescription, and in so small an amount that it will be renewed before it loses any of its power. Warning should be given of its effects on clothing with which it may come in contact, and care should be taken that the bottle is held some dis- tance from the face when the cork is withdrawn, as the acid, if freshly mixed, may spurt and burn the eyes and skin. NITROUS OXIDE. Nitrous Oxide, or Nitrogen Monoxide, is sometimes called protoxide of nitrogen, or " laughing gas." Its power to relieve pain was first recognized by Sir Humphrey Davy more than one hundred years ago. As with ether, so with nitrous oxide, its first use as a surgical anaesthetic was by an American, Horace Wells, a dentist. This gas is obtained by a complicated process which requires the use of such cumbersome apparatus that its manufacture is out of the question for the ordinary practitioner of medicine, while the fact that several firms prepare the gas and market it in cylinders ready for use renders its preparation on a small scale unnecessary. The gas is devoid of odor, but possesses a slightly sweet taste. It may be kept in gaseous form, or liquefied and allowed to become gaseous as it is used. Physiological Action. — Owing to the symptoms sometimes produced in patients inhaling this gas, it has received the popular name of " laughing gas/' but a condition of hilarity is rarely seen when the inhalations are full and deep, and only comes on in the majority of cases where the gas is given in small amounts or inhaled very slowly. When used properly, the patient is directed to take long, deep inspira- tions from the tube placed in the mouth, the nose being held so that the nostrils are closed. Under these circumstances the face becomes for a moment flushed, then of a deadly pallor, and finally the jaw drops if the effect is complete. At this time anaesthesia is complete and the operation is to be rapidly performed. Owing to the fact that when pure it is devoid of irritant properties, this gas can be used when ether and chloroform are contraindicated. According to some careful studies upon the action of this gas (Kemp), it has no direct effect on the heart and vasomotor system , but indirectly it causes a rise of arterial pressure by the slight asphyxia which is pro- 350 DRUGS duced. The anaesthesia may be due in part to the non-oxygenation of the blood during the time the gas is in this fluid, but the gas pro- duces anaesthesia aside from any such influence by a direct action on the cerebral cortex. It is a curious fact that the conjunctival reflex is often preserved after general anaesthesia is present. It has been thought that the use of this drug produces temporary glycosuria, but recent studies render this doubtful, to say the least. Where permanent gly- cosuria has been produced, some injury to the vascular system in the region of the diabetic centre in the floor of the fourth ventricle has in all probability occurred. Nitrous oxide gas when inhaled rarely pro- duces any disagreeable after-effects, save a little light-headed sensation or dizziness for a few hours. Therapeutics. — Nitrous oxide is a useful anaesthetic in all minor operations, such as opening an abscess, boil, or felon, or even ampu- tating a digit. It is used by many surgeons at the present time for the purpose of beginning an anaesthesia which is to be continued by ether or chloroform. The gas possesses two disadvantages, the first of which is its brevity of action ; the other, the difficulty in carry- ing it from place to place. It possesses a great advantage in almost absolute safety, very few deaths having been caused by it directly. It is the safest of all anaesthetics, not even excepting cocaine, which latter drug has largely supplanted the gas for many minor surgical operations. When teeth are to be extracted, a plug or cork is placed between the jaws before the gas is given, to keep them apart. The cork should always be attached to a string, so that if it slips into the back part of the mouth it can be withdrawn before it chokes the patient. Oxygen gas may be combined with nitrous oxide gas with as great advantage as with the vapor of ether or chloroform, although its use may delay to a slight extent the development of anaesthesia. The fol- lowing classes of persons, according to Hewitt, do better with the mix- ture of oxygen and nitrous oxide than with the nitrous oxide alone: 1. Children (who with nitrous oxide alone are liable to inconvenient jactitation). 2. Anaemic and debilitated patients, who, like children, quickly exhibit muscular contractions, and, in addition to this, remain but a very short time under the influence of nitrous oxide alone. 3. Any one who has previously exhibited great susceptibility to nitrous oxide per se (such patients are difficult subjects to manage in dental practice because of the short period of available anaesthesia). 4. Patients who, under nitrous oxide alone, have experienced highly unpleasant sensations. 5. Patients very advanced in years. 6. Patients with very large tonsils. 7. Patients suffering from heart or lung affec- tions. Contraindications. — The gas ought not to be given to those who are advanced in years or have atheromatous bloodvessels, since the rise of arterial pressure consequent upon the asphyxia may rupture a cere- bral bloodvessel and thereby cause an apoplexy. NUTMEG. 351 NOSOPHEN. Nosophen is a substance obtained by the action of iodine on solutions of phenolphthalein, and is a light impalpable powder, without taste or odor, and of a yellowish-gray color. It is said to contain 61.7 per cent, of iodine. Nosophen is insoluble in nearly all solvents, but is soluble in alkaline solutions, and with alkalies it forms salts. The uses of this substance are practically identical with those of iodoform in that it exercises a favorable effect on tissues by reason of its content of iodine and drying properties. Its bulk is four times greater than an equal weight of iodoform. When used as an , antiseptic on sores it should be brought directly in contact with the living tissue, and not simply applied to the pus or scab covering the part. As it will withstand a high heat, it can be sterilized by exposure up to 220° F. without decomposition. Its lack of odor is a great advantage. NUCLEIN. Nuclein has been used with asserted success in the treatment of the ordinary forms of pulmonary tuberculosis and for septicemia. Theo- retically it should prove useful in combating any infectious process, but practically nuclein has proved of little value and is not generally employed. Administration. — The proper way to use the nuclein solution is to give 10 to 60 minims (0.60-4.0) hypodermically once, twice, or thrice a day under careful antiseptic precautions; or to give a tea spoonful (4.0) in a wineglassful of water on an empty stomach thrice during the day and at bedtime. Capsules which contain 2 grains (0.12) of nucleinic acid may also be used. Contraindications. — The nucleins should not be given for a long period of time to gouty persons; these patients usually have uric-acid troubles under their use, as nuclein is an antecedent of uric acid. NUTMEG. Myristica, U. S. and B. P., or Nutmeg, is the kernel of the seed of Myristica fragrans, an East and West Indian plant, mace being the outside covering of the same. Nutmeg is a soporific and nervous sedative, exercising a peculiar influence over the cerebrum. It is also used as a flavoring substance in somnifacient mixtures, and is of value in prescriptions for serous diarrhea. The oil {Oleum Myristiccs, U. S. and B. P.) is given in the dose of 1 to 3 minims (0.05-0.20). The spirit or essence (Spiritus Myristica?) is used in the dose of 1 to 2 fluidrachms (4.0-8.0). Several instances of poisoning by nutmeg are reported; a severe case by Dr. Reading, of Woodbury, N. J. The symptoms closely resemble those produced by excessive doses of cannabis indica. 352 DRUGS. NUX VOMICA Fig. 51. Nux Vomica (U. S. and B. P.) is the seeds or beans of Strychnos nux-vomica, an East Indian tree. It contains two alkaloids, strych- nine and brucine, and depends largely for its medicinal power on the former. For this reason the statements made in regard to the physiolog- ical action of strychnine may practically be considered as applicable to the entire drug. Physiological Action. — When strychnine is given to man or the lower animals in full medicinal dose it increases reflex activity, respiratory rate, pulse-force, arterial pressure, the acuity of smell, vision, and hearing, and causes general systemic irritation or excitement. Nervous System. — On the nervous system strychnine exerts its chief influ- ence. It excites the spinal cord in its motor tracts, and probably increases the receptive activity of the sensory centres. It also has some slight influence in increasing the conductive power of the motor and sensory nerves. In overdose strychnine produces spinal or tetanic convulsions by an action exerted on the spinal cord. When enormous doses are given intravenously, total par- alysis, resembling that caused by curare, precedes the convulsions, and if artificial respiration is not used the animal dies from failure of respiration. If death A nux vomica stimulates .the motor ta fc es p l ace f rQm fae effects of the drug, tracts in the spinal cord and to a slight .-. L , P i , i i extent the nerve-trunks; b, in large, the motor nerves are found to be de- poisonous doses it depresses the motor pressed, partly as the result of the poison- nerve-plate in the muscle and exhausts QUS ^ f ^ strychnine, and partly the nerve-trunks. J ' . r J as the result of the exhaustion of the nerve-trunks by the convulsing impulses which they have carried (Fig. 51). Circulation. — Nux vomica increases the force of the pulse-beat and the pulse-rate by a stimulation of the heart-muscle and its ganglia, while the rise of arterial pressure which it causes is due to stimulation of the vasomotor centre. If very poisonous doses are injected intra- venously, a fall of arterial pressure occurs instead of a rise, which is due to vasomotor depression and paralysis. NUX VOMICA. 353 Respiration. — Strychnine is one of the most constant and powerful stimulants of the respiratory centre that we have, and it not only increases the rate, but also the respiratory capacity. Temperature. — Ordinary doses have no effect upon temperature, but poisonous doses may raise it by reason of the convulsions. Elimination. — Strychnine is eliminated from the body by the kid- neys as strychnine and strychnic acid. Most of it is oxidized and destroyed by the liver. Therapeutics. — Nux vomica, or its chief alkaloid strychnine, is used for several purposes in medicine. Owing to its bitter character, it may be employed as a simple bitter tonic or as one especially influencing the nervous system. It may also be used as a respiratory, cardiac, and ocular stimulant. In cases of junctional nervous atony, or depression, strychnine does good; but in organic disease of the nervous system, if used during the period of acute inflammation, as soon after an apoplexy or in acute infantile palsy, it is distinctly harmful. Some persons who have suf- fered from apoplexy can never take the drug without a spasm com- ing on in the paralyzed part or parts, probably through irritation of the probably degenerated pyramidal tracts. In acute or subacute neuritis strychnine ought never to be used, as the nerves are already inflamed, and are not to be still further irritated by the employment of nerve excitants. In progressive lead palsy large doses of strychnine should be constantly used to check the progress of the disease, iodide of potassium also being employed to cause elimination of the lead. In amaurosis dependent upon the excessive use of tobacco or alcohol strychnine is almost a specific, and in eye-strain resulting from insuffi- ciency of the ocular muscles it does great good, curing the insufficiency and improving the general condition of the muscles. According to de Schweinitz, the patient should use ascending doses of the tincture of nux vomica, beginning with 3 minims (0.20) three times a day, and increase the amount 2 minims (0.1) a day until distinct physiological effects are produced. Sometimes 60 minims (4.0) may be taken in twenty-four hours. Recent experiments by the author indicate that constantly increasing doses, instead of decreasing the person's sus- ceptibility to the drug, actually increase it, so that a moderate dose produces greater effects after some days of use than a full dose does at first. In pneumonia and all other acute diseases in which sudden collapse is liable to occur strychnine is of the greatest service at the time of need. Often it will pull the patient out of a sinking attack which seems certain to end in death. It should be used freely by the hypo- dermic needle, and is often aided in producing its good effects by the addition of yl-g- to - T -J- - grain (0.0004-0.0006) of atropine to each injec- tion. (See Pneumonia and Shock.) The author desires to protest most emphatically against the common practice of the day, which consists in the use of strychnine as a circur 23 354 DRUGS. latory stimulant through prolonged exhausting illness. It is essentially a whip to the flagging heart, to be used at a crisis, but not continued for days. Cases are constantly seen in which the persistent use of the drug in fever produces a rapid running pulse and great nervous irritation and prolongation of the febrile movement. There is no drug known which is so antidotal to the effects of over- doses of chloroform as is strychnine. In cases of sudden accidents, with arrest of the heart or respiration during the use of this anaesthetic the physician should give a hypodermic injection of y^- grain (0.006) of strychnine as a powerful, rapidly acting cardiac and respiratory stimu- lant, which dose may be repeated in ten minutes if no effect is produced. Strychnine is a valuable remedy in surgical shock, and is a better antidote to opium than is belladonna. In dyspnoea from any cause, such as that of old persons suffering from winter cough or bronchorrhoea, in emphysema, phthisis, and in shortness of breath, strychnine is of service, and it is a valuable drug for the treatment of opium poisoning, because it preserves the reflexes and stimulates the respiratory centre. In atony of the bowels strychnine is of service, and it is to be added to purgative pills to avoid their depressing after-effect on the intestines. In cases of hemiplegia, strychnine may be used to keep up the nutri- tion of the limbs, which are paralyzed ; but if the paralysis be due to disease of the trophic cells in the spinal cord, it does little good except to stimulate the remaining cells to greater effort. According to Ringer, sick headaches, due to errors in diet and without much nausea, can be relieved for the day by the use of 1 minim (0.05) of the tincture of nux vomica in a teaspoonful (4.0) of water every five or ten minutes until 10 minims (0.60) are taken. Strychnine possesses no curative properties in chronic alcoholism. Owing to its powerful stimulant properties it may temporarily brace the nervous system, but its prolonged use is dangerous. It should be employed temporarily only to combat great depression of the system. Untoward Effects. — Care should be exercised in giving strychnine to children, as they are more susceptible to the drug than are adults. The proper beginning dose of strychnine by the mouth for a child of five or six years is not more than yj-j- grain (0.0006). In some cases of exhausting disease the prolonged use of full doses of strychnine may produce a talkative delirium with great peevishness, and, if the drug is continued, this condition may pass into a state of temporary insanity. Brunton asserts that nux vomica may induce malarial chills in those predisposed to them. He also asserts that strychnine acts more power- fully when given by the rectum than by the mouth. This is doubtful. Administration. — The extract of nux vomica (Extr actum Nucis Vomica?, U. S. and B. P.) is given in the dose of -J- to J grain (0.01- 0.015); the fluid extract (Fluidextractum Nucis Vomica?, J]. S.); Ex~ tractum Nucis Vomica? Liquidum, B. P.), in the dose of 1 to 5 minims (0.05-0.3) ; the tincture (Tinctura Nucis Vomica?, U. S. and B. P.), in NUX VOMICA. 355 the dose of 5 to 40 minims (0.3-2.6). Strychnines Sulphas (U. S.), Strichninoe Nitras (U. S.), and Strychnine? Hydorchloridum B. P.) are given hypodermically in the dose of -^ to 2V grain (0.002-0.003), and by the mouth in the same amounts. In cases of severe surgical shock as much as J grain (0.015) may be used hypodermically. The B. P. recognizes a solution (Liquor Strychnine Hydrochloride ; dose, 2 to 8 minims (0.1-0.5). Poisoning. — When a poisonous dose of strychnine is taken, it acts either suddenly or gradually. If suddenly, the man or animal may, without premonition, be thrown several feet and become rigid by contraction of his muscles. If the onset is gradual, some stiffness at the back of the neck and uneasy startings may precede the general nerve-storm. The convulsions are tetanic, or, in other words, tonic, and the body is thrown into opisthotonos: that is, resting on the head and heels at each convulsion. Rarely the trunk is twisted sidewise or the flexion of the body is forward (emprosthotonos). The eyes are open and fixed, the corners of the mouth drawn back into risus sardonicus, and respiration during a severe convulsion is impossible owing to the respiratory muscles being in a state of tetanic rigidity. The slightest noise, draught of air, or touch may cause a convulsion or convulsion after convulsion, because the sensory impulse, reaching the spinal cord, causes a spasmodic motor impulse to be sent out to the muscles. The convulsions are not absolutely continuous, but periods of utter or partial relaxation occur, during which the patient breathes easily. The cramp-like contractions of the muscles are exceedingly painful, and the patient either dies of cramp asphyxia — that is, through failure of respiration because his chest muscles are locked in spasm — or, much more rarely, from exhaustion. After death the posture of the body may or may not be typical of the strychnine spasm. Usually it is not typical, although the severe muscular exertion of the attack may result in the early development of marked rigor mortis. Reichert has shown that it requires five hundred times the ordinary fatal dose of strychnine to cause death in animals if artificial respiration is properly main- tained. The average fatal dose for an adult is 1J to If grains (0.10- 0.12). Death has occurred from \ grain (0.03) and recovery after swallowing 19 grains (1.25). Treatment of Poisoning. — The attendant should give at once, if no symptoms have appeared, inhalations of nitrite of amyl, and mean- while employ the stomach-pump, using the nitrite to prevent any con- vulsive tendencies during the operation. Draughts of water containing tannic acid, as the chemical antidote, are to be administered, and after the stomach is washed out 60 grains (4.0) of bromide of potas- sium and 20 grains (1.3) of chloral in solution are to be given. These are the physiological antidotes, for the bromide of potassium depresses the sensory tracts of the spinal cord, and the chloral depresses the 356 DRUGS. motor tracts. If the convulsions prevent swallowing, the patient must be chloroformed with care, and the physiological antidotes given in starch-water by the rectum, muscular relaxation being maintained by the anaesthetic until the drugs are absorbed. Ether cannot be used as a relaxant, as it is too irritant and too slow. Nitrite of amyl is a physiological antidote, but it is useless if a complete convulsive attack is present, as it cannot be inhaled if the chest is immovable. Neither can any other relaxant, such as chloroform, be used under these circumstances. These drugs should be gently given between the paroxysms. If relaxation does not occur, the nitrite of amyl should be injected hypodermically. While a light touch may produce a spasm, it is said that a firm, hard grasp of the limb often relieves the pain of the cramp. Sensation and consciousness are preserved in strychnine poisoning unless the asphyxia obtunds them. Differential Diagnosis. — The convulsions of strychnine poisoning do not resemble those of epilepsy, because they are distinctly tonic and never clonic. From tetanus, strychnine poisoning is to be differentiated by the fact that in tetanus the locking of the jaws comes first, while in strychnine poisoning it comes last. The convulsions of tetanus rarely, if ever, completely relax, while those of strychnine do have periods of relaxation. There is a different history in each case — in one perhaps of an injury, as of a nail run into the foot; in the other, of a dose of poison having been swallowed. The differential diagnosis of strychnine poisoning from hysterical convulsions is more difficult. The convulsions are rarely so persist- ently tonic in hysteria, and the peculiar expression of the hysterical face is often seen in such cases. The history of the patient, if obtain- able, will throw much light on the case and aid very materially in the differentiation of the two conditions, while the peculiar variations in cutaneous sensibility, such as areas of hyperesthesia and anaesthesia, which are so characteristic of hysteria, may render the diagnosis possible. As the treatment of all these states is virtually identical, the employ- ment of the measures just suggested may be resorted to in each instance, and the diagnosis made afterward. OPIUM. Opium (U. S. and B. P.) is the juice or milky exudation appear- ing on the surface of the unripe capsules of white poppy, or Papaver somniferum, a native plant of Asia, now grown in many other parts of the world. Good opium, according to the U. S. P., should contain at least 9 per cent, of crystalline morphine, but the powdered opium (Pulvis Opii, U. S.) should contain not less than 12 nor more than 12} per cent, of morphine, OPIUM. 357 The chemical composition of this drug is very complex, no less than seventeen alkaloids having been obtained from it, the most important of which are morphine, codeine, narcotine, thebaine, narceine, papaver- ine, pseudomorphine, and laudanine. It also contains meconic acid and meconine. Physiological Action. — The action of opium upon man and the lower animals varies with the degree of intelligence or cerebral development. It quiets the brain and excites the spinal cord. Nervous System. — The dominant action of opium upon man is to produce nervous sedation in small doses and sleep when given in larger amounts. Sometimes, however, in persons who are accustomed to its use, it produces a state of restless insomnia or quiet, wakeful apathy. When given to frogs, it often produces tetanic convulsions, owing to its primary stimulant effect on the spinal cord. In dogs it increases the reflexes and produces drowsiness, and in man sleep. If, however, the patient be a member of one of the lower races or a young child, the spinal irritation may be as manifest as the cerebral sedation. If large doses are given, sleep is produced in all animals, and both the brain and spinal cord are depressed. The sensory nerves are also markedly benumbed, and the motor nerves may finally be rendered inactive. Circulation. — Small therapeutic doses of opium have no effect upon the circulation, but large ones slow the pulse, increase its force, and slightly raise arterial pressure. The slowing of the pulse depends upon stimulation of the pneumo- gastric nerves peripherally and centrically; the increase in pulse-force results from the stimulation of the heart-muscle and its ganglia; the rise of pressure is due chiefly to the increased heart-action. After poisonous doses the pulse becomes rapid and feeble, due to depression of the vasomotor centre and the heart, and the gradually increasing asphyxia. Respiration. — In very minute doses opium is a feeble stimulant, or at least not a depressant, to the function of respiration. In over- dose it is one of the most powerful paralyzants of the respiratory centres in the medulla oblongata, causing death by this action. Temperature. — The bodily temperature is raised slightly by full doses and lowered by poisonous amounts of opium. Tissue-waste. — Opium acts as a preventive to tissue-waste, decreas- ing the elimination of urea and other results of nitrogenous breakdown. Elimination. — If given in excess, the drug escapes from the body as morphine, by way of the intestine and kidneys, but most of it is destroyed by oxidation in the liver and tissues. Experiments made by Alt and Tauber show that morphine is largely eliminated by the stomach, and that if this viscus is frequently washed out during a case of poisoning, recovery is much aided, as by this means resorption is prevented. Pupil. — Opium contracts the pupils by a centric stimulation of the oculomotor nerves, and perhaps by depression of the sympathetic fibres. 358 DRUGS. Stomach, Intestines, and Secretion. — Opium depresses the motor activity of the stomach and intestines and produces constipa- tion. It does this by stimulating the splanchnic inhibitory fibres of the intestine and thereby preventing peristalsis. In very large doses it increases peristalsis by paralyzing these fibres. Opium checks every secretion in the body except that of the skin. Acute Poisoning. — When opium is taken by man in overdose, it causes drowsiness, deep sleep, full breathing, a slow, full pulse, a warm, dry skin, contracted pupils, and pleasant — or, more commonly, in the Anglo-Saxon race, disagreeable — dreams or no dreams at all. Preceding this period there may be a brief one during which the individual feels self-satisfied and contented. The duration of this agree- able sensation lasts only a short time, and if the dose is large does not occur or is evanescent. It has been called the first stage, while the more marked symptoms first FlG - 52 - described have been grouped into a so-called second stage. During the sleep of the second stage the patient may be roused by shouting in his ear or by violent shaking, but sinks into slumber at once when not disturbed. Many of the symptoms resemble those of congestion of the brain. a, opium produces sleep by depressing The face is suffused and reddened, the intellectual centres of the brain, and 1 _ 1 n ll J* j.' xi B, relieves pain by depressing the perceptive an /* m W be fina % distinctly Cyan- centres in the brain. otic. The breathing may be puffing and stertorous. When the patient is awakened, he breathes more rapidly, and for this reason the duski- ness of the face disappears and the normal hue returns. Death never occurs in the second stage of opium poisoning from the poison alone, but if a complicating disease is present death may take place at this time. The third or fatal stage emerges from the second by a process so gradual that no abrupt line of separation can.be noted. The face becomes at first more cyanotic, then pale and livid; the respirations, which have been 8 . to 10 to the minufe, are now only 4 or 5, and finally such prolonged pauses occur that all hope of another respi- ration is lost by the attendant. While the slow breathing is at first deep, it soon becomes shallow, and muscular relaxation is present to the greatest degree. The skin, previously dry, is wet with the sweat of death, the patient is so deeply narcotized that nothing can arouse him, and he dies from respiratory failure, although the heart may cease almost simultaneously from the asphyxia. The pupils do not dilate in the third stage, except in the relaxation of death. Treatment of Acute Poisoning. — After employing the usual methods resorted to for the purpose of emptying the stomach, and OPIUM. 359 after giving permanganate of potassium or tannic acid, .preferably the former, as the chemical antidote, the patient should receive by the rectum one or more cups of black coffee, hot and concentrated. The heat in the liquid is useful in maintaining bodily temperature, and the caffeine stimulates the respiratory centre and keeps the patient awake. Coffee should be used even before any symptoms come on, in order to prevent their onset if possible. If strychnine is at hand and the respi- rations are becoming very slow, -g^ to -^ grain (0.002-0.006) should be given hypodermically. Strychnine is much better than atropine as an antidote to opium, and should be given hypodermically in full dose, repeated frequently enough to keep the nervous system of the patient active and respiration intact. The pupil is no guide as to the action of atropine in opium poisoning, as the influence of these two drugs (opium and atropine) on the eye is not directly antagonistic. Cocaine is thought by some physicians to be a satisfactory physiological anti- dote to opium. Alcoholic stimulants may be called for, and ammonia as a cardiac and respiratory stimulant may be resorted to. In the third stage heat should be applied to the trunk and extrem- ities. Much emphasis has been placed on keeping the patient awake, and it has been thought that the cause of death was the deep sleep. This is not so. The man must be kept awake in order that he will supplement the efforts of his depressed respiratory centres by volun- tary breathing. If he sleeps, he forgets to breathe, and sleep means death for this reason, and not because sleep in itself produces death. Besides the use of hot strong coffee, the patient may be kept awake by lashing him with switches or by walking him up and down between two attendants. Both of these measures are reprehen- sible if anything better can be done — the first method because it covers the patient with cuts and bruises, the second because it may aid in the production of death by exhaustion. If an ordinary medical faradic battery is at hand, the full force of the current may be allowed to come in contact with the skin from two small poles wet with salt water, or, better still, the dry or wire electric brush should be swept over the body while the negative pole is held in the hand of the patient or pressed against his skin. This causes the most exquisite pain in the normal individual, but if the brush is kept moving will not cause bruises or discoloration. (See Asphyxia.) Artificial respiration may be resorted to. As pointed out when discussing the elimination of opium, the drug is eliminated into the stomach from the bloodvessels and then reabsorbed. Frequent washing out of the stomach is therefore advis- able in cases of poisoning. Chronic Poisoning. — Morphine or opium when taken constantly generates a habit. The person — or morphine-habitue, as he is some- times called — depends for a comfortable existence on the drug, and 360 DRUGS. day by day increases the dose until the mc :t extraordinary amounts are taken by the stomach or by means of the hypodermic needle. If the drug is withheld, a train of symptoms typ^ving depression or exhaustion ensues. The pulse is scarcely to be feit, horrible mental depression and melancholia come on, the miserable man or woman wrings his or her hands, and begs, screams, howls, or yells for mor- phine, only to break down and cry on being refused the customary dose. Diarrhoea of a serous type and most violent in character, with cramps in the muscles, may assert itself, and must be controlled by astringents and an active line of treatment as far as possible free from opium. (See Diarrhoea.) A characteristic symptom of chronic opium-eating is the develop- ment of the most clever lying in previously truthful persons. In the same breath that the patient begs the physician to cure him, he will lie to obtain the drug in a surreptitious manner, and may even have the drug in his mouth at the moment he speaks. It will often be found hidden in the seams of the clothing, and the nurse must be absolutely reliable, above bribery, and forever on the watch lest the drug be obtained by smuggling. Any sudden improvement on the part of the patient should be placed to the credit of more morphine, not to professional skill. The well-known fact that certain races of mankind are affected by some drugs in quite a different manner from that exerted upon the white race finds an interesting confirmation in the opinion expressed by physicians and government officials who have investi- gated the subject in India and China, that a large number of Orientals use opium in moderation for years without deleterious effects. They remain well nourished, are able to perform labor requiring severe physical exertion, and the death rate among them is not higher than among other classes of people. Sometimes paregoric is taken in excess, and the writer has seen and treated a case in which over a pint of paregoric was taken every day. When a mother is an opium-eater, the new-born child often suffers from collapse on the second or third day after birth, owing to the lack of its customary dose of opium. Treatment. — The best way to decrease the use of the drug is to " taper off " the daily dose, and to decrease by a sixth or a fourth the total customary amount in each twenty-four hours. The sudden complete withdrawal of the drug is an unnecessarily severe measure, and its withdrawal in a slower manner than that named is simply prolonging the treatment beyond reasonable limits. A very valuable means of treatment is the use of massive doses of hyoscine hypodermically. If this plan is followed, the morphine may be withdrawn at once. (See Hyoscine.) If the circulation flags, digitalis and strychnine may be given and the remaining symptoms treated as common sense indicates. Cocaine has been used to tide over the crisis after the withdrawal of the morphine, but too fre- OPIUM. 361 quently the patient passes from opium to the cocaine, and finally to the alcohol habit, all of which are equally bad. Therapeutics. — Opium is used for the relief of five great conditions, which will be spoken of seriatim, the minor uses of the drug being considered afterward. These are pain, insomnia, inflammation and irritation, oversecretion, and systemic strain. Pain. — Opium is the best remedy that we possess for the relief of all forms of pain, except in those instances when neuralgia is present, when antipyrin and its fellow-compounds exceed it in medicinal value because they have no marked after-effects. It is to be remembered, however, that no drug has yet been discovered which equals its pain- relieving power in this or any other painful affection. In one form of pain opium is not to be employed — namely, that arising from cerebral congestion and cerebritis, for it is distinctly contraindicated in these affections, as it aggravates them. In acute or traumatic meningitis, however, opium is of great service, either alone or combined with mercury in sthenic cases. In the treatment of renal and hepatic colic associated with spasm, and in dysmenorrhea, belladonna and opium given together will relieve the spasm and pain, and yet so counteract each other elsewhere in the body as to be devoid of marked effect upon other organs. Usually in these severely painful affections it is best to give morphine and atropine hypodermically. Persons suffering from severe pain will always bear larger amounts of opium than individuals without pain. For the relief of violent pain physicians of experience usually employ morphine hypodermically as the most rapid and effective means of giving relief. If this is not possible, the morphine should be given by the mouth in a little hot water with or without whiskey or brandy added to it; or deodorized tincture of opium may be given in the same manner. If neither the hypodermic needle nor the draught can be resorted to, then the drug is best given in the form of the fluid extract, or tincture, by the rectum, being first mixed with warm starch- water. If the pain is chiefly in the pelvic viscera, the rectal adminis- tration of the drug is always advisable by injection or by suppository. When pain is due to violent sciatica or to muscular spasm, it is best relieved by injecting the morphine directly into the subcutaneous tissues over the affected part. In other instances local pain due to superficial inflammation may be relieved by compresses wet with laudanum and lead-water. To patients who are prone to frequent attacks of pain opium must be given with the greatest caution, as the " opium-habit " is easily produced. Insomnia. — Opium, while capable of producing sleep in almost every case in which it is given, save in those individuals who by rea- son of idiosyncrasy are made wakeful by it, is only to be used in those instances where the sleeplessness is due to pain. If constantly used for the relief of insomnia or pain, the opium habit is rapidly contracted, 362 DRUGS. and for this reason the use of this drug should be alternated with chloral, cannabis indica, and other soporific drugs. In some cases chloral and morphine, when given in small doses in combination, will so act upon the brain as to produce sleep. Thus, in the following prescription, the dose of both active ingredients is much smaller than would be needed if either was used alone, yet the result sought by their use — namely, sleep — is readily produced: K — Morphinae sulph. . gr. ij (0.12). Chlorali hydrati #j (4.0). Svrupi f|j (30.0). Aquas dest ^ij (60.0).— M. S. — Dessertspoonful (8.0) at 9 p. m., and, if needed, again at 10 or 11 o'clock. In the persistent insomnia of typhoid fever, croupous pneumonia, and all acute diseases in which nervous exhaustion is due to lack of sleep, a hypodermic injection of morphine will sometimes produce most excellent results, but the proper use of cold bathing is to be preferred for this purpose if it can be employed. (See Cold, Part III.) Inflammation and Irritation. — Opium seems to possess some influence over inflammation which we cannot explain, and both small and large doses are particularly valuable in inflammation of serous membranes, such as peritonitis, meningitis, and pericarditis. In peritonitis opium has been thought to be useful, but grave doubts are now entertained as to its value (See the article on Peritonitis in Part IV.) Opium allays the nervous excitement and cough following haemop- tysis, and the intense unrest caused by itching skin diseases, as, for example, the irritation of smallpox. Sometimes intense irritation or inflammation produces so great an effect upon unstriped muscular fibres as to cause spasm or paralysis, as in retention of urine, cystitis, or the constipation following inflamma- tion of the bowels due to the ingestion of irritating foods; under these circumstances the employment of opium is indicated, and is usually very successful. In irritative coughs morphine given in syrup of wild- cherry bark does good in the dose of -^ to -^ grain (0.005-0.006). In some cases of irritable cough due to a tickling sensation in the larynx, much relief can be had by inhaling the steam arising from a cup of boiling water in which has been placed a drachm or two of paregoric. Whenever cough is excessive — that is, greater than is necessary to free the lungs from mucus — morphine may be given in small doses. If the lungs contain more rales after its use than before, its use must be stopped, as the increase in the number of rales indicates an increased accumulation of mucus. In the treatment of strangury due to cystitis, and in rectal inflam- mation, provided they are not acute, and after operation on the pelvic organs, suppositories of the strength of \ to \ grain (0.015-0.03) of the watery extract of opium are useful. In excessive vomiting PLATE I. Chart showing the effect of opium in a ease of diabetes mel- litus. On the day of admission the patient was placed on a full house diet. The quantity of urine and fluid ingested at once increased. He then was placed on a restricted diet which caused a fall in the urine and fluids ingested but no decrease in sugar. Opium was now given and the sugar fell at once (see green line). Later on the house diet was resumed but the opium held the sugar in cheek. Note how the fluids increased on the 28th of May and how they fell when the opium was renewed and increased. The chart shows how the restricted diet governed the urinary flow and how the opium was needed to control the melituria. OPIUM. 363 from any cause, except it be from a previous dose of opium, an enema of deodorized laudanum 30 minims (2.0) and starch-water 4 ounces (120.0), with 40 grains (2.6) of bromide of sodium, will be found of value. (See Vomiting, Part IV.) In muscular rheumatism and similar states, and in the incipient stage of a "cold," opium in the form of Dover's powder in the dose of 5 to 10 grains (0.30-0.60) will often produce a cure, particularly if employed in combination with hot drinks and a hot foot-bath. Cam- phor can often be added to the Dover's powder with advantage. (See Coryza, Part IV.) For sprains and bruises lead-water and laudanum is one of the best applications. (See article on Lead.) If the skin is broken, the laud- anum may be used alone to relieve pain, and, by its alcohol, will act as an antiseptic. Opium is also a useful drug in the treatment of inter- nal and external bums to relieve the pain and irritation. Oversecretion. — In serous diarrhcea, diabetes insipidus and mel- litus, and in the treatment of oversecretion on the part of all secreting surfaces except the skin, opium may be used. Opium is said to decrease the amount of urine before decreasing the amount of the sugar in diabetes. However this may be, the employ- ment of opium or morphine or codeine in diabetes is a valuable form of treatment. The doses should be rapidly increased, as the effect is only obtained by ascending amounts, and diabetic patients seem peculiarly immune to the nervous influence of this drug and its alkaloids. Morphine is, therapeutically, the more powerful of the two alkaloids, but crude opium is more powerful for good in this affection than either. None of them, probably, cure the disease, but so modify it as to make life bearable, for the sugar is decreased in many cases, and the excessive hunger, thirst, and nervous irri- tability are relieved. Itching of the skin is also allayed in this class of patients by its use. (See Plate, and also article on Diabetes, Part IV.) The sudden withdrawal of opium from a case of diabetes may precipitate diabetic coma. Opium should not be used to arrest an attack of mucous diarrhoea until after the mucus which is already present in the bowel has been swept out of the intestinal canal by a dose of castor oil or magnesium sulphate. Minute doses of -£$■ to -g- 1 ^- grain (0.001) of morphine given hypodermically will sometimes check summer diarrh&a in chil- dren at once. (See article on Diarrhoea.) Morphine rather than opium is used to relieve pain because it does not cause so much constipation, but opium is better to check diarrhoea. Paregoric is particularly useful in diarrhoea because it contains a volatile oil and camphor. Systemic Strain. — In prolonged strain upon the system, as in great physical or nervous effort, or more frequently in old age to smooth the remaining years of life and decrease worry, opium is useful, but its use in young persons is most dangerous, as it is almost 3G4 D'RUGS. certain to produce the opium habit. In asthenic fevers opium is thought to be supportive, but its use is apt to cause so many other conditions, such as constipation, anorexia, or mental depression, that alcohol is much better for this purpose. In advanced phthisis it is often justifiable to give sufficient opium to keep the patient free from pain and discomfort for the remaining hours of his life, but care must be taken that the dose does not interfere with the breathing and so hasten death. In heart disease, particularly of the mitral valves, the patient can often breathe easily only when awake, starting up when he falls asleep and gasping for breath. It is stated by some writers that morphine will relieve this state and permit sleep, but that it will not be of service in aortic disease. While this may be partly true, the drug will often give great relief in all forms of cardiac dyspn&a, and ought always to be tried with caution, although it is contraindicated if the heart has undergone fatty degeneration. Care should be taken that the first dose is small, as in some instances it increases the discomfort. The relief obtained is supposed to be due to cardiac stimulation by the drug, and this is no doubt correct, since the other cardiac stimu- lants, such as digitalis, will often fail when morphine succeeds. The presence of cyanosis and lividity is said to be no contraindication to the hypodermic use of morphine under these circumstances, pro- vided the dose is not unreasonably large, and provided these signs are purely circulatory in origin. If they are due to pulmonary oedema or diffuse bronchitis, it is unsafe. Not rarely in the course of pneumonia and typhoid fever a state of nervous restlessness with active talkative delirium develops, in which the patient may die from lack of sleep. At such times a hypodermic dose of morphine may be most useful and save life. The drug should be given hypodermically for these purposes in the dose of about \ grain (0.015). Opium and morphine, particularly the latter, have been freely given to produce quiet in patients with uremic convulsions. The practice is a dangerous one, and should not be resorted to as a rule, as the impaired state of the kidneys prevents elimination of the drug. Administration. — Recent studies upon the action of opium and its alkaloids show that it acts in an inhibitory manner upon gastric diges- tion and absorption, decreasing the amount of hydrochloric acid in the gastric juice. For this reason, unless there is an excess of acid present in the stomach, it is well not to give opium or morphine at meal times, but some time after. Opium itself is used in the form of the powder (Pulvis Opii, U. S.) and in granulated form (Opium Granulatum, U. S.) in the dose of from J to 2 grains (0.015-0.12). The solid preparations are the deodorized opium (Opium Deodoratum, U. S.), which is deprived of its narcotine, dose § to 2 grains (0.03-0.12); the pills of opium (Piiula Opii, U. S.), each containing 1 grain (0.05); and the watery extract (Extractum Opii, U. S. and B. P.), dose \ to \ grain (0.0.15- 0.03). Of the liquid preparations we have paregoric (Tinctura Opii OPIUM. 365 Camphorata, U. S. ; Tinctura Camphorce Composita, B. P.), dose 1 drachm to 1 tablespoonful (4.0-16.0) ; laudanum (Tinctura Opii, U. S. and B. P.), dose 5 to 20 minims (0.30-1.30); the deodorized tincture (Tinctura Opii Deodorati, U. S.), dose 5 to 20 minims (0.30-1.30); Vinum Opii, U. S., or, as it is sometimes called, Sydenham's Lauda- num — dose 5 to 20 minims (0.30-1.30); and Acetum Opii, U. S., or Black Drop, dose 5 to 20 minims (0.30-1.30). As all the liquid preparations of opium in the U. S. P. are of 10 per cent, strength, except paregoric, which is about 2 grains to the ounce, the dose of all of them except paregoric is identical. This is a fact to be remembered by students. Under the name of Dover's Powder (Pulvis Ipecacuanha et Opii U. S.; Pulvis Ipecacuanha^ Compositus, B. P.), a powder containing 1 part of powdered opium, 1 part of powdered ipecac, and 8 parts of sugar of milk, is largely used. The dose is 5 to 10 grains (0.3-0.60). It is more efficacious if separated into fifths and taken in divided doses. The tincture of ipecac and opium (Tinctura Ipecacuanha et Opii U. S.) is given in the dose of 5 to 15 minims (0.3-1.0). The preparations of opium official in the B. P., other than those named, are Extractum Opii Liquidum, dose 4 to 20 minims (0.25-1.3) ; Pulvis Opii Compositus, composed of opium, pepper, ginger, caraway- fruit, and tragacanth, dose 2 to 5 grains (0.12-0.30) ; Tinctura Opii Ammoniata, dose h to 1 drachm (2.0-4.0). Pihda Saponis Composita, B. P., is really a preparation of opium. It is sometimes necessary to give this drug to patients without their knowledge, and it may be prescribed in this way, the patient not learning from the prescription the nature of the medicine. The dose is 2 to 4 grains (0.12-0.25). The B. P. also recognizes a liniment (Linimentum Opii) and a plaster (Emplastrum Opii) for local application. Untoward Effects. — When opium is given to some individuals it pro- duces for several hours marked wakefulness followed by sleep, and in many patients causes after its primary influence great nausea, and sometimes vomiting. The mental depression may be simply over- whelming, and the very fact of having to drag out existence is a curse. By far the most effective mode of preventing these very distressing effects of opium or its derivatives is to administer with this drug about 27J-Q- grain of nitroglycerin. One of the chief causes, however, of the nausea produced by the use of opium or morphine is the change in the body of morphine into oxy-dimorphine, which is eliminated into the stomach and there reabsorbed, and then induces these secondary effects. It is also a fact that these symptoms can be largely relieved by the use of 20 grains (1.3) of bromide of potassium, which must be taken at the same time as the opiate, and by employing the preparations of opium largely devoid of narcotine, such as the deodorized tincture or deodorized opium itself. Whenever possible these preparations should be used to the exclusion of the others. Haig is responsible for the assertion that, as opium frees the blood from uric acid by causing its 366 DRUGS. retention in the tissues of the body, the pleasant effects are so produced, and that, the retention being cumulative, no sooner does the effect of the opiate pass off than the uric acid is set free in the blood, and as a result depression ensues. He states that if salicylates are given with the opium retention does not occur, and the unpleasant sequelae are modified or prevented. After the untoward symptoms come on coffee and stimulants may be used with advantage to overcome them. In some persons the use of opium is followed by itching of the skin or by the development of an erythematous rash which may go on to desquamation. Children bear opium badly, and some children are very much more susceptible than others to its influence. One-eighth grain of morphine has caused death in an adult when given hypodermically, probably because it entered a vein. Sometimes the drug causes collapse, or in other cases an eruption upon the skin of the body. The use of repeated doses of morphine for several days often excites obstinate vomiting, due probably to the change of the drug into oxy- dimorphine or apomorphine. Codeine. (See p. 207.) Morphine. Morphina, U. S. and B. P., is the chief alkaloid of opium, but owing to its insolubility is rarely used, being generally given in the form of the sulphate. Sulphate of Morphine (Morphines Sulphas, U. S.) is given in the dose of J to \ grain (0.008-0.03), either by the mouth or hypoder- mically. Besides the sulphate of morphine we have the acetate (Morphine? Acetas, U. S. and B. P.), the hydrochloride (Morphine? Hydrochloridum, U. S. and B. P.), and the tartrate (Morphince Tar- tras, B. P.), all given in the dose of | to i grain (0.008-0.03). In the U. S. Pharmacopoeia of 1870 a solution of morphine was official, called Liquor Morphine Sulphatis (B. P.), dose 1 to 2 drachms (4.0- 8.0) ; but it is no longer official and should not be called for. Magen- die's solution of morphine is sixteen times as strong as the liquor just named (16 grains to the ounce), and is also not official. The words " Liquor Morphinse Sulphatis" will often cause Magendie's solution to be dispensed in New York State, and care should be taken that poisoning does not result. Pulvis Morphina? Compositus, U. S., or Tully's Powder, is given in the dose of 10 grains (0.60). It contains sulphate of morphine, camphor, liquorice, and precipitated calcium carbonate. It is used to check forming colds and as a nervous sedative. Troches of morphine and ipecac (Trochisci Morphina et Ipecacuanha^) are given one or two at a time for irritation of the pharynx. OX-GALL. 3G7 The following additional preparations of morphine are official in the B. P. : Liquor Morphine? Hydrochloridi and Liquor Morphine? Tartrates, dose 10 to 40 minims (0.60-2.6) ; Tinctura Chloroformi et Morphinoe Composiia, dose 5 to 10 minims (0.30-0.60) ; Suppositoria Morphine?, each suppository containing J grain (0.015) of morphine; Trochiscus Morphinoe and Trochiscus Morphine? et Ipecacuanha?, each lozenge containing -^ grain (0.002) of morphine, dose 1 to 4. Liquor Mor- phine? Acetatis is given in 20- to 40-minim (1.3-2.6) doses. Injectio Morphine? Hypodermica, B. P., contains 1 grain (0.06) of the tartrate of morphine in each 22 minims (1.4) of water. Its dose is 1 to 5 minims (0.05-0.30). Incompatibles. — Morphine is incompatible with potassium perman- ganate and with tannic or gallic acid or solutions containing them; with alkalies, such as potassium, sodium, and ammonium salts, but with the chloride of ammonium it is not incompatible. With tincture of chloride of iron it forms a deep-red color (meconic acid). 0RTH0F0RM. Orthoform is a colorless, bulky, odorless, and tasteless powder which is slightly soluble in water. It is used as a local anaesthetic and anti- septic dressing for small wounds and burns, and is said to be non-toxic, but this is an error. It may be applied in powder or ointment. The latter is usually of the strength of 2 drachms to the ounce of lanolin (8.0-30.0). It may be given by the stomach in cases of epigastric pain to determine its source. In cases of gastric ulcer it may relieve the pain, but if the pain be due to gallstones it will fail. OVARIAN EXTRACT. The ovarian gland , in the form of the dried gland substance or in that of an extract made from it, has been used for relief of the nervous and nutritional disturbances of the menopause, whether they be the result of age or of operative removal of these bodies. It is said to be most efficacious in those instances in which the ovaries have been removed from young women. As the use of the ovarian extract in medicinal doses seems to be harmless, it may be given for a long time without danger. The beginning dose should be 2 to 4 grains (0.12- 0.25) a day, and this be gradually increased until some effect is produced or it proves useless. The best method of giving it is in compressed tablet or in capsule. Professional opinion as to its value is very contradictory. OX-GALL. Inspissated Ox-gall (Fel Bovis, U. S ) is, as its name implies, dried ox-bile, derived from the gall-bladder of the common ox (Bos Taurus). It is used in medicine for the purpose of relieving certain forms of 368 DRUGS. indigestion which result from deficient secretion of bile or which occur in persons who digest fats with difficulty. In full doses it is apt to cause some looseness of the bowels, and it may be given with the object of producing this condition. When it is used, the fact should be remem- bered that bile prevents the gastric juice from acting upon proteid or albuminous substances, shrivelling them up, and in addition so alters the gastric liquids as to decrease their digestive power. We know, therefore, that this drug must be administered some hours after meals, as a rule, or, in other words, when gastric digestion is ended and intestinal activity is beginning. The dose of inspissated ox-gall, which is dried by evaporation from 100 to 15 parts, is 5 to 15 grains (0.30-1.0). Purified Ox-gall {Fel Bovis Purificatum, U. S.; Fel Bovinum Purificatum, B. P.) is given in the same dose as the inspis- sated bile. It is made by evaporating 3 parts of pure ox-gall to 1 part, and then adding to this part an equal amount of alcohol, which constituents are mixed thoroughly, and after standing twenty-four hours the clear liquid is decanted and the residue evaporated to a consistence capable of forming a pill. OXIDE OF ZINC. Commercial Oxide of Zinc (Zinci Oxidum Venale) is not used in medicine, but in the purified form is largely employed as Zinci Oxidum, U. S. and B. P., which is insoluble in water. In the form of the oxide-of-zinc ointment (Unguentum Zinci Oxidi, U. S. and B. P.) this drug affords one of the most generally used applica- tions in the treatment of skin diseases, burns, and sores. In all states where the surface of the skin is dry it is contraindi- cated, but where the eruption is moist it is useful. In the treatment of the chloasma of pregnancy the following prescription is of service: gr. iij (0.2). gr. j (0.06). 3ijss (10.0). 5ijss (10.0). gtt. x (0.60).— M. 1$ — Zinci oxidi . Hydrarg. ammoniat. Olei theobromse . Olei ricini Essent. rosse S. — Apply to the face night and morning. In eczema with many vesicles use — 1$ — Pulv. camphorse 5ss (2.0). Pulv. zinc, oxidi 3iij (12 0). Glycerini gtt. xl (2.60). Adipis benzoinati Bj (30.CT). — M. S.— Apply to the part without other treatment or precede it by powdered bismuth. Unna's Dressing (composed of gelatin 4 parts, water 10 parts, glycerin 10 parts, and zinc oxide 4 parts) is a useful application for ulcers and eczematous patches on the legs or arms. It is par- ticularly useful for leg ulcers. The gelatin and cold water are put in a basin over a fire and a solution made; then the glycerin is added, OXYGEN. 3G9 and then the oxide of zinc is slowly added, with constant stirring. After the mixture is complete it is poured into a can and allowed to cool, when it is ready for use. This application decreases swelling and is soothing and supporting. It is applied as follows: The part affected is well washed with water and soap, and then with alcohol. The paint having been warmed and melted, a large three-inch paint- brush is used to apply a coating to the limb all around the ulcer, and over this a single layer of gauze is applied. The gauze bandage should be two inches wide. The bandage must be laid on evenly and the ulcer covered by a pad of absorbent cotton. After one layer is applied it is cut and another coat of paint applied over it. Then another layer of gauze and another of paint are used, until several layers are in place. It is best to begin at the toes and work up toward the knee. All parts should be equally well covered. Finally the entire dressing is covered by a cotton roller bandage, which is removed in twenty- four hours, leaving what looks like a white rubber dressing on the limb. If the liquid from the ulcer oozes through the dressing profusely, a window is to be cut over the ulcer, and it can be locally treated by astrin- gents or other measures. The patient should keep the limb elevated for a day or two, but can then walk with far more comfort than if a rubber supporting bandage is used. In powdered form zinc oxide is useful in the treatment of intertrigo and for conjunctivitis. Mixed with bismuth subnitrate and pepsin, it is largely used by some practitioners in the treatment of the summer diarrhoea of infants or adults In the night-sweats of debility or of 'phthisis oxide of zinc in the following formula has been highly recommended, but the prescription probably depends largely for its action on the second ingredient: ^— Zinci oxidi gr. xxx (2.0). Extract, belladonna? . . . . . . gr. iij (0.20).— M. Ft. in pil. No. x. S. — One at night before going to bed. Bartholow recommended the oxide of zinc for asthma and whoop- ing-cough, given to an adult in the manner just indicated. OXYGEN, The gas Oxygen is now widely used in medical and surgical practice in three ways, as follows: By the inhalation of the gas itself from a cylinder in which it is compressed until 40 gallons occupy a very small space; by drinking oxygen-water, which is distilled water saturated with the gas; and finally, by the use of the dioxide or peroxide of hydrogen, which is applied locally to diseased surfaces. (See Hydrogen Peroxide.) • ' Inhalations of oxygen are useful in the second and third stages of pneumonia where the patient seems about to die from deficient 24 370 DRUGS. aeration of the blood, with resulting heart-distention. They are also of value in advanced bronchitis, particularly that of old persons, and for the resuscitation of individuals asphyxiated by coal-gas (Hare and Martin). In phthisis and other exhausting diseases oxygen will allay dyspnoea and oppression. Oxygen inhalations are also of service in the treat- ment of anosmia in all its forms and give relief even in pernicious anosmia and in leukosmia. Often a mixture of oxygen gas 60 parts and nitrous oxide gas 40 parts is used as a stimulant inhalation and nervous sedative. The clinical results which have so far been obtained from the admin- istration of ether and chloroform vapor when combined with oxygen gas seem to prove beyond all doubt that the oxygen decreases the danger of the anaesthetic and to a large extent obviates the difficulties which attend the administration of these drugs, and most of the untoward effects which result from their use. Thus, when oxygen is given with ether, vomiting is less frequently met with, excessive pallor is rarely seen, and post-operative depression seems to be largely avoided. As a general rule, however, it has been the custom of physicians and surgeons who have employed oxygen gas in combination with ether or chloroform, to place the anaesthetic in a wash-bottle and then to allow the oxygen gas to pass through it in such a way that the patient received in the inhaler a mixture of anaesthetic vapor and oxygen, the mixture resulting from the passage of the oxygen gas through the liquid anaesthetic in the bottle. An evident disadvantage of this arrangement is that the quantity of anaesthetic which is volatilized can only be in direct proportion to the volume of oxygen gas which is forced through the wash-bottle, and therefore with every increase in the quantity of vapor which the patient receives he must also receive an increased quantity of oxygen. It has been claimed, too, by those who have employed the ether and oxygen combination most frequently, that in a large proportion of cases a greater length of time is required for the anaesthetizing of the patient, and that in some cases it seems almost impossible to get the patient under the direct influence of the drug. This difficulty lies in the fact that as soon as a large quantity of oxygen gas is used to convey a large quantity of anaesthetic vapor to the lungs, the patient rapidly passes into a condition which is called by physiologists apncea. The respiratory centre is no longer irritated by the normal proportions of carbonic acid in the blood, and therefore sends out feeble respiratory impulses; and as the patient does not breathe so rapidly or so deeply as before, the result is that very small quantities of the anaesthetic are taken into the body. The apparatus which the author has employed with success, and which he suggests as a substitute for the one heretofore employed, con- sists of a somewhat funnel-shaped piece of leather having a greater diameter in one direction than in another, and into which is fitted as an inner lining a piece of soft felt or spongiopiline almost a quarter of PANCREATIN AND PANCREATIC EXTRACTS. 371 an inch thick. In the under surface of the leather cone is inserted a small metal tube, and at the opening of this tube a small hole is cut in the spongiopiline. The ether is poured upon the spongiopiline in the cone, in the apex of which is placed some absorbent cotton. The oxygen enters the cone by means of a rubber tube attached to the metal entrance which has been mentioned. By this arrangement several objects are accomplished. In the first place, the supply of oxygen can be delivered to the patient in varying quantities without altering the amount of anaesthetic which is being given. In the second place, any quantity of anaesthetic can be employed without necessarily increas- ing the oxygen. Thirdly, the leather cone prevents the rapid evapora- tion of ether from the outer side of the spongiopiline. And fourth, the spongiopiline, being much more porous than an ordinary towel, will retain a large quantity of ether in liquid form when this drug is poured upon it. Finally, if desired, the same apparatus can be used for the administration of chloroform by removing the metal cap on the smaller end of the cone, as in this way the patient will receive not only the anaesthetic vapor and the oxygen, but also fresh air through the end of the cone, in such quantities as the physician deems wise. In these cases it is best to use the attachment known as the Krohne and Sesemann "respiration-indicator," which consists of a small feather on a pivot which moves to and fro with the motions of respira- tion, thereby providing the physician with a gauge as to the rapidity and force of the respiratory movements. The soft felt is very cheap, and a new piece can be used for each patient. In conclusion, the writer cannot condemn too strongly the method of employing chloroform vapor and oxygen by passing the oxygen directly through the chloroform without the free administration of air in addition, for, after all, air is what we are intended to breathe, and not oxygen gas alone, although it may be advantageous at times to add an increased quantity of oxygen to the air. Still more severe condemnation should be directed toward the attach- ment which is placed on some of the Junker inhalers, and which con- sists of a small rubber bag which, instead of acting as a reservoir of fresh anaesthetic vapor and oxygen, is inflated and collapsed by the expiration and the inspiration of the patient, who does not receive even fresh oxygen and anaesthetic vapor, much less fresh air, but, on the contrary, inhales again and again air, oxygen, and vapor which are loaded with the impurities of frequent expiratory efforts. (For the directions for using oxygen with nitrous oxide as an anaes- thetic see the article on Nitrous Oxide.) PANCREATIN AND PANCREATIC EXTRACTS. Under these names a number of firms now sell an extract from the pancreatic gland or juice, and the U. S. P. recognizes such a product under the name of Pancreatinum, Pancreatin should convert 25 372 DRUGS. times its own weight of starch into substances soluble in water (U. S.). It contains, or should contain, the four pancreatic ferments — trypsin, which digests proteids (meat, eggs, etc.) ; steapsin, which splits up and emulsifies the fats; amylopsin, which has diastatic power (that is, converts starch into sugar), and finally a milk-curdling ferment. Pancreatin may be made by the physician in the following manner: Take the pancreas of a pig which has been killed about six hours after a full meal, the organ being therefore active, and, after chopping it finely, add to it four times its weight of dilute alcohol and allow it to stand for twelve hours. Decant or filter off the alcohol, and give the filtrate in the dose of 1 to 2 drachms (4.0-8.0). Or, better still, as follows: Wash and chop finely a fresh pancreas, and allow the gland to soak in alcohol (absolute) twenty-four to forty-eight hours. Then squeeze out the alcohol and add to the gland ten times its weight of glycerin. The mixture must stand forty-eight hours and then be filtered, and may be used in doses of 30 minims (2.0) to each glass of milk. (For the use of pancreatin in artificial digestion see the article on Peptonized Foods in Part III.) Pancreatin, as prepared for the market, is a dry powder, given in the dose of 2 to 20 grains (0.12-1.3) after meals or during them. Pancreatin should usually be prescribed with bicarbonate of sodium to aid it in its digestive action. It is indicated in all cases of lienteric diarrhoea and in many cases of deficient digestion. Pancreatin, or the powdered pancreas, may also be freely used in those cases of diabetes mellitus in which the disease depends upon a lesion of the pancreatic gland, as carcinoma or atrophy from other cause. Some doubt has been cast upon the usefulness of the employment of pancreatin in foods unless this ferment was allowed to act upon the aliment before it was swallowed by the patient, on the ground that pancreatin is destroyed and rendered inert in the presence of the acid which it meets in the stomach. This objection is not a valid one, because food remains in the stomach for from fifteen minutes to half an hour before enough gastric juice is secreted to interfere with the pancreatic action. It is during this preliminary period that the work of the pancreatin is accomplished. Pancreatized or peptonized foods should not be employed unless really needed, nor continued for any length of time, as digestion is finally impaired by torpor of the glands arising from disuse. The B. P. recognizes a solution (Liquor Pancreatis); dose 1 to 2 drachms (40-8.0) . The dose of pancreatin is from 2 to 20 grains (0.12-1.3). PAPAIN, PAPAYOTIN, AND PAPOID. Papain, Papayotin, and Papoid are names given to a digestive fer- ment derived from the juice of Carica papaya. This ferment pos- sesses the power of changing proteids into peptones in the presence PEPO. 373 of an acid or an alkali, or even in a neutral mixture, thereby differing from pepsin and pancreatin. This power would be of great value, since the drug would then be useful in all forms of dyspepsia, were it not that careful experimentation renders it doubtful whether papain, papayotin, or papoid can really supplant either of the animal ferments named above. The dose of all these products is from 1 to 8 grains (0.06-0.50) given in solution, or better in pill. The plant itself, taken internally, has the reputation of being capable of causing abortion. PARALDEHYDE. Paraldehydum, U. S. and B. P., is a form of aldehyde used as a soporific and nervous sedative, and is a clear, colorless liquid with an ethereal odor and a burning, followed by a cool, taste. It should be kept in dark, well-stoppered bottles in a cool place. Paraldehyde is readily soluble in alcohol, moderately so in cold water, less so in hot water. It possesses the great disadvantages of being necessarily given in large dose and of having a disagreeable taste and odor. It is also very apt to disorder the stomach. Paraldehyde kills by respiratory failure when taken in overdose, but is not so depressant to the heart as is chloral. The drug soon loses its power as a soporific. The dose is 20 minims to 1 drachm (1.3-4.0) in capsule, or, better still, it may be used, after the formula of Yvon, as follows: 3— Paraldehyde gijss (10.0). Alcoholis (90 per cent.) . . . . . f§jss(45.0). Tincturse vanillse f5ss(2.0). AquEe destillat foj (30.0). Syrupi q. s. ad fgiv (120.0).— M. S. — A dessertspoonful (8.0) every half -hour until sleep is obtained. PAREIRA. Pareira, U. S. (Pareirce Radix, B. P.), is the root of Chondoden- dron tomentosum, a plant of Peru and Brazil, and is used as a diuretic of an alterative or stimulant character and for the relief of chronic inflammations of the genito-urinary tract in general, such as pyelitis, cystitis of a subacute type, and similar pathological states. The dose of the unofficial infusion is a wineglassful (30.0), and the fluid extract (Fluidextractum PareircB, U. S.) is given in the dose of a teaspoonful (4.0) three times a day. The B. P. preparation of this drug is Ex- traction Pareirce Liquidum, dose 1 to 2 drachms (4.0-8.0). PEPO. Pepo (Cucurbita pepo), U. S., Pumpkin-seed, the seed of the ordinary domestic pumpkin, is a useful and efficient vermifuge for the tape- worm. The seeds are not only efficient, but are harmless to the host 374 DRUGS. of the worm. The outer coverings of the seeds should be removed, and the remaining part rubbed up into an emulsion with water or into an electuary with sugar, the dose of the seed being 2 ounces (60.0). This mass should be taken on an empty stomach, and followed in from one to two hours by an active purge. PEPPER. Piper, U. S., or Black Pepper (Piper Nigrum, B. P.), is the unripe fruit of Piper nigrum, a vine of India, Java, Borneo, and Siam. It contains a neutral principle, piperin, which is official. Therapeutics. — Black pepper may be used externally as a counter- irritant or internally as a carminative and stimulant to the alimentary canal. It may also be used in all cases of atony of the mucous membranes of the genito-urinary system, but is contraindicated whenever acute inflammation is present, as in acute gonorrhoea. It may be used with marked relief in the treatment of intestinal flatulence. Piperin (Piperina, U. S.) has been used as an antiperiodic with varying success, and is given in the dose of 1 to 5 grains (0.06-0.3). The oleoresin of pepper (Oleoresina Piperis, U. S.) is given in the dose of J to 2 minims (0.015-0.1) in laxative pills, to prevent griping. A confection (Confectio Piperis) is official in the B. P., given in the dose of 1 to 2 drachms (4.0-8.0). PEPPERMINT. Mentha Piperita, U. S., is official in the form of the leaves and tops of Mentha piperita. It has an aromatic odor and taste and con- tains an oil. Locally applied, the oil acts as an irritant and local anaes- thetic. From this oil is obtained menthol, a camphoraceous substance of a hot, burning taste, possessing marked power as a local anaesthetic. (See Menthol, below.) Therapeutics. — Peppermint is used very largely as a domestic rem- edy for flatulence and infantile colic. Sometimes the oil is added to purgative pills to prevent griping, and it may be employed to disguise the taste of any medicines which are disagreeable to take. In this respect it is used as are all the volatile oils. In the colic of children of six months to a year of age, when it is unusually severe and associated with nervous symptoms, the following will be found of value: fy— Chloralis gr. xvj (1.0). Potassii bromidi gr. xxxij (2.0). Aq. menth. piperit . . fgij (60.0). — M. S — Teaspoonful (4.0) in a little warm water every four hours. When used in the treatment of neuralgia, oil of peppermint should be placed on a piece of linen or muslin rag and applied over the affected PEPPERMINT. 375 spot. Care must be taken that it does not blister the skin. If, after its removal, the burning is too severe to be borne, a little cosmoline or olive oil should be applied. Oil of peppermint is sometimes placed on cotton and inserted into dental cavities for toothache. It is to be remembered that the more menthol is present in the oil the more active will it be as an anaesthetic, and that the Chinese oil contains more menthol than the American oil. Administration. — Peppermint is used in the form of the oil {Oleum Menthoe Piperita, U. S. and B. P.), dose 1 to 4 minims (0.05-0.25); the spirit {Spiritus Menthoe Piperita, U. S. and B. P.), dose 10 to 30 minims (0.60-2.0); the water {Aqua Mentha Piperita, U. S. and B. P.), dose 1 to 2 drachms (4.0-8.0; and, finally, as the Troches ( Trochisci Mentha Piperita) , to be held in the mouth in indefinite number. Menthol. Menthol, U. S. and B. P., or Mint Stearopten, or, as it is called, Mint Camphor, is derived chiefly from the essential oil of pepper- mint. It occurs in colorless prismatic crystals with a strong odor of pep- permint. Upon it rests much, if not all, of the therapeutic activity of pep- permint. Menthol is slightly soluble in water, very soluble in alcohol, ether, and in oils. Menthol has been used in the vomiting of pregnancy with great advantage in hourly doses of a tea- spoonful of the following: Fig. 53. 1^— Menthol . . Spt. frumenti Syrupi gr. xv (1.0). f5vj (24.0). m (30.0). Menthol has also been used as a carminative and in gastralgia in the dose of from 1 to 2 grains (0.06-0.12) three times a day in pill or in alco- holic solution. It is contraindicated in acute inflammation of the gastric mucous membrane. As menthol exercises a local anaes- thetic effect on the skin as well as on mucous membranes, it is used exter- nally over the course of neuralgic means of menthol pencils. Menthol when applied to the mucous membrane of the throat or nose causes a contraction of the local bloodvessels, which is not fol- lowed by the excessive dilatation produced by cocaine. In acute Nebulizer. The small pump on the right side forces air through the black tube in the glass jar. This air escapes from an aperture in the side of the tube and draws up the medicated liquid, which is then driven forcibly against the side of the glass. The finely comminuted fluid then passes as a vapor through the exit tube. nerves and for migraine by 376 DRUGS. coryza its local application to tHe mucous membrane by a spray or dropper is often a source of great relief in a solution of about 1 grain (0.06) to the ounce (30.0) of water, or 3 grains (0.20) of menthol in \ ounce (16.0) of albolene. (See Coryza, Part IV.) Another very useful method of applying menthol is by means of a simple inhaler consisting of a small glass tube of about one-quarter of an inch in diameter and two and a half inches in length. Both ends are closed by a piece of gauze and two perforated corks, the menthol being placed in between. The air is now drawn through this tube, and, being heavily loaded with the fumes, clears the nares and relieves the stuffiness. It is not to be only smelled, but also inhaled. Care should be taken that the crystals are not allowed to enter the nostrils, as they are almost cauterant in power. Sometimes, where great excoriation of the alse of the nose exists, the too persistent use of the menthol may produce small herpetic spots about the nostrils. When menthol is inhaled for a long time or swallowed in any quantity it is apt to pro- duce severe congestive headache. Still another method is by the use of a nebulizer. (Fig. 53; also article on Inhalations, Part III.) The following mixture is placed in the glass jar, and the air being driven through the tube a vapor of the drugs is given off which is a valuable sedative to the entire respir- atory tract: -Chloretone . Menthol. . . Camphor. 01. cinnamomi Petrolat. liquid. gr. ij (0.12). gr. xx (1.3). gr. xx (1.3). Ttlij (0.10). fgj(30.0).-M. S. — Use in a vaporizer every three hours for a period of about ten minutes. Sometimes menthol in 50 per cent, alcoholic solution is dropped on the cone with which ether is given, to diminish the irritation caused by that drug when it is inhaled. Menthol vapor is also useful in spasmodic croup. (See Part IV.) Emplastrum Menthol, B. P., is used as a mild local irritant and anaesthetic. PEPSIN. Pepsinum, U. S. and B. P., is the digestive ferment of the gastric juice. That sold in the shops is generally derived from the pig, and is prepared by manufacturers in many ways. Much of the pepsin of the market contains more peptone than pepsin, and much mucus and albumin. Used with hydrochloric acid in weak solution, pepsin carries out the digestive action of the stomach. Pepsin containing peptone has the peculiar musty smell of peptone, and if the peptone is in excess will absorb moisture and become sticky on exposure to the air. According to the U. S. P. official pepsin must have the power to digest three thousand times its weight of albumin. PERMANGANATE OF POTASSIUM. 377 Therapeutics. — Pepsin is a much over-rated remedy for indigestion, which in many cases is due to hepatic disorder or to actual disease of the stomach which it cannot relieve. Pancreatin will nearly always be found more serviceable, and should be given either during or one or two hours after meals. Pepsin should be used immediately after the food is taken or with it. Hydrochloric acid should always be given with pepsin to aid its action, and because it converts the pepsinogen in the gastric tubules into pepsin. Liquor Pepsini is given in the dose of 2 drachms (8.0). Pure pepsin should be given in 5- to 15-grain (0.30-1.0) doses. A glycerite (Glycerinum Pepsinum) is official in the B. P. Very useful and readily taken liquid preparations are Pepsin Essence and Cordial, which are given in the dose of 1 to 2 drachms (4.0-8.0) after meals. A nutritious article of diet can be made by adding one teaspoonful of either of these liquids to a half-pint of warm milk, and allowing it to cool, thereby forming " curds and whey" through the action of the milk-curdling ferment.. (See Part III.) PERMANGANATE OF POTASSIUM. Potassii Permanganas, U. S. and B. P., is a salt of a dark purplish- red color, appearing in small crystals and readily soluble in water. In the presence of moisture it rapidly gives up the oxygen which it contains and becomes the binoxide of manganese. By reason of this oxidizing power the permanganate of potassium is useful as an antiseptic and deodorant. It should not be employed as a disinfectant for filth, because its action is too fleeting, but in satu- rated solution, followed by oxalic acid solution, it proves itself one of the best disinfectants for the hands in surgical practice. (See Anti- sepsis.) Permanganate of potassium is given in the same dose for amenor- rhcea as the binoxide of manganese, but is much less efficacious. It is also very apt to irritate the stomach. The permanganate is thought to be useful in dyspepsia, flatulence, lithamiia, and obesity, and in the first two states is often of service, being a destroyer of the abnormal products by oxidation. Owing to this oxidizing power, it has been asserted, by Weir Mitchell and Reichert, to be the most efficient antidote to snake-venom if placed in the wound before the poison is absorbed. It should also be injected hypodermic- ally about the seat of the bite. Permanganate of potassium is the best chemical antidote in poisoning by morphine and in that caused by many other vegetable alkaloids. It is also a good chemical antidote in phosphorus poisoning. Owing to its rapid evolution of oxygen it acts as an antiseptic, and may be used to wash wounds, ulcers, and sores, and as a lotion in the form of a gargle or on a swab in the sore throat of diphtheria and scarlet fever. The solution used should be from 20 to 60 grains (1.3-4.0) to the pint (480 c.c.) ; the former is 378 DRUGS. used on mucous membranes, the latter for sores and wounds. In fetid rhinitis and otitis media permanganate solution is useful as a wash in the proportion of 1 grain (0.06) to the ounce (30.0). When given in solution permanganate of potassium should be dissolved in distilled water, and it should never be mixed in a mortar with any organic matter, as it will explode. A solution (Liquor Potassii Permangana- tis) is official in the B. P. PETROLATUM. Under the name of Petrolatum, U. S., or Soft Petrolatum, or Un- guentum Petrolei, is sold a semisolid substance derived from certain kinds of petroleum, and sometimes called Cosmoline or Vaseline. Owing to its soothing powers and non-rancidity, it is used as an emollient dressing in sores and skin affections. It has no value except as a protective, and may be given in capsule in cases of gastrointes- tinal irritation in any quantity as a soothing treatment. It does not affect the passages from the bowels and is not absorbed, although assertions to the contrary have been made. Cosmoline is a useful ointment base for medicaments for the skin. Under the name of fluid or liquid petrolatum (Petrolatum Liquidum, U. S.) a fluid form is sold, which is much used in the form of a spray in the treatment of rhinitis and after irritant applications to the nasal cavities. Petrolatum Album (U. S.), or White Petrolatum, is a purer product, being devoid of coloring matters. PHENACETIN. Phenacetin (Acetphenetidinum f U. S. ; Phenacetinum, B. P.) is a coal-tar product introduced several years ago as an antipyretic of the same character as an ti pyrin. It occurs in white, glistening, crystal- line scales without odor or taste, and, while more apt to disintegrate the blood than some of the other drugs in its class when given in large amounts, is not very dangerous, because its influence upon other vital parts is not severe. It is only slightly soluble in water. Acetanilid and antipyrin are sometimes substituted for phenacetin. Pure phenacetin when shaken with nitric acid is colored yellow, which color persists when it is heated. This is not the case with the other products named. When this drug is carelessly made, an impure product is the result, which produces irritation of the kidneys, and, in consequence, causes grave complications. Reuter states that the impurity may be dis- covered by placing a small amount of chloral hydrate in a test-tube, melting it at a temperature just sufficient to liquefy it, and then adding the suspected sample of phenacetin in the proportion of one- PHENACETIN. 379 fifth. If the phenacetin is impure, it will become purple, then red, and finally blue. Physiological Action. — Unfortunately, our knowledge of the physio- logical action of phenacetin upon the nervous system is not so thor- ough as is desirable. We know, however, that it is a distinct nervous sedative, and that it acts particularly on the spinal cord in its sensory tracts. Upon the circulation the drug has little or no effect unless given in doses exceeding, those generally employed or continued in overdose for some time. The blood after the ingestion of these doses becomes dark and blackish from the formation of methsemoglobin, and the urine becomes dark yellow and reacts with Fehling's solution. Upon normal bodily heat and the heat of fever the drug exerts a depress- ing effect, decreasing the production and increasing the dissipation of heat. Therapeutics. — Our knowledge concerning the influence of phen- acetin upon the human body in disease may be divided into two sepa- rate parts in much the same manner that we divide the uses of anti- pyrin — namely, its uses as an antipyretic and as an analgesic. Like the other members of the antipyretic group which possess this double action, its antipyretic influences were first observed, and will therefore first be spoken of. The employment of this drug in medicine was first attempted by Hinsberg and Kast, who from the very first spoke of it in the highest terms of praise. They found that it seldom, if ever, caused serious untoward effects, and that its power over fever, in the dose of from 3 to 8 grains (0.20-0.5), was extraordinary. Shortly after the paper of these writers appeared Kohler published the report of its use in some fifty cases in the clinic of Bamberger, of Vienna. He found, as have most of his successors, that the fall of fever does not occur for nearly half an hour after the dose is taken, and that the stage of apyrexia continues for from four to eight hours afterward. As a general rule, sweating is not noted as being present to any great extent, but in phthisis and advanced typhoid fever there can be no doubt that chilliness and an abnormal fall of temperature may come on under its influence. Cyanosis and vomiting did not occur in a single one of Kohler's cases. The remarks made in the article on Fever (Part IV.) clearly show why phenacetin should not be used as an antipyretic, for all antipyretic drugs are, as a rule, deleterious. It is far better to reduce the fever with cold applications. (See Cold in Fevers, Part III.) Upon the nervous system phenacetin acts as an antineuralgic, and is of service in migraine and ordinary headache from eye-strain, in the pains of tabes dorsalis, in intercostal neuralgia, and in rheumatism. Sometimes it cures these troubles when antipyrin fails. Altogether, we may consider phenacetin a rival of antipyrin in the power to relieve pain. 380 DBUGS. For neuralgia the following prescription may be ordered : J£ — Phenacetin gr. x (0.60). Caffeinse citratse gr. v (0.30). Sacchar. lactis gr. xx (1.3). — M. Ft. in chart No. v. S. — One or two powders every two hours while the pain lasts. In subacute rheumatism and in the lumbar or muscular pains of influenza a powder or pill of 4 grains (0.25) of phenacetin and 5 grains (0.30) of salol given three or four times a day is most efficient. Under the name " Lactophenin," a nearly related compound of phenacetin is sometimes used for the same purposes. In phenacetin one atom of hydrogen is replaced by an acetic-acid radicle; in lacto- phenin this atom of hydrogen is replaced by a lactic-acid radicle. Similarly "citrophen" is made by replacing the atom of hydrogen by a citric-acid radicle. It is also used as a substitute for phenacetin. The dose of these drugs is about the same as that of phenacetin, or a little larger, about 5 to 10 grains (0.30-0.60) three times a day. PHENOCOLL. Phenocoll is a compound closely allied to phenacetin. It is always used in the form of the hydrochloride of phenocoll, which occurs in a fine white powder, and which is soluble in water and forms a neutral solu- tion. It is incompatible with alkalies, and is used as an antipyretic. Physiological Action. — A number of studies of the action of phe- nocoll hydrochloride upon the animal organism have been made by Kobert and von Mering in Europe, and by Wood and Cerna and Ott in America. These investigators have found that it is differ- ent from most of the coal-tar antipyretics in that it has little effect on the red blood-corpuscles. It does not cause so great a sweat when the fever falls as do its near antipyretic relatives. Von Mering has shown that phenocoll has little lethal power, but Ott asserts that in poisonous dose it kills by failure of respiration, and causes paraplegia, cyanosis, and depression of the heart. Therapeutics. — As pointed out in the article on the treatment of Fever, antipyretic drugs are of little value as compared to bathing. Phenocoll may be given for the same purpose and under the same circumstances in the presence of fever as antipyrin or acetanilid, but, like these drugs, is contraindicated in advanced exhausting dis- eases, such as consumption. A number of clinicians have tried pheno- coll hydrochloride for the relief of acute rheumatism and neuralgic pain, with asserted success. The dose of phenocoll hydrochloride is 5 to 8 grains (0.30-0.50) two to five times a day. It is best given in capsule. PHENOL. (See Carbolic Acid.) PHOSPHATE OF SODIUM. 381 PHENOLSULPHONATES OF ZINC AND SODIUM. The phenolsulphonates of zinc (Zinci Phenolsulpkonas, U. S., Zinci Sulphocarbolas, B. P.) and sodium (Sodii Phenolsulpkonas, U. S., Sodii Sulphocarbolas, B. P.) are largely employed by some practitioners as mild antiseptic local stimulants, either in powder or in solution, on ulcers and sores. Much more commonly they are given internally for the production of gastro-intestinal antisepsis when there is diarrhoea with fetid, ill-smelling stools, as in the bowel disorders of hot weather in children or adults, or in the course of typhoid fever. How much good they do in the latter disease, so far as the disease itself is concerned, is uncertain, but they undoubtedly render the stools less foul and tend to check the diarrhoea. The phenolsulphonate of zinc is the better of the two for these purposes. The dose is 2 to 3 grains (0.12-0.20) in pill four or five times a day. The phenolsulphonates are probably eliminated from the body unchanged. Sometimes good results follow the use of cascara sagrada with these salts in cases of constipation with flatulence and signs of autointoxication. PHOSPHATE OF SODIUM. Sodii Phosphas, U. S. and B. P. is a preparation which has been used with the idea that it can supplant phosphorus. This is, of course, an error, as it has an entirely different effect. It is particularly useful for bottle-fed children, who continually alternate between diarrh&a and constipation, and is also useful in cases of rickets to regulate the bowels. It should be added to each bottle of milk in the dose of 2 to 4 grains (0.12-0.25). Phosphate of sodium in small doses is slightly laxative, and large doses are purgative. Bartholow believed phosphate of sodium to be the best remedy in hepatic cirrhosis and jaundice. To adults it should be given in the dose of 20 grains to 2 drachms (1.3-8.0) once, twice, or thrice a day according to the laxative effect desired. It is best given dissolved in a teacupful of hot water. Many cases of general wretchedness or headache due to an excess of uric acid in the blood are relieved by the acid phosphate of sodium or of calcium, since both substances cause disappearance of the acid from the blood, not by causing its elimination, but by causing its deposit in the tissues in the form of urates. The continued use of these so-called acid- phosphates is therefore ultimately harmful in gouty or rheumatic persons. The U. S. P. and B. P. also recognize a preparation called Sodii Phosphas Effervescens; dose 2 to 4 drachms (8.0-16.0). Sodii Phos- phas Exsiccatus (U. S.) is about twice the strength of the ordinary phosphate ; dose -I to 1 drachm (2.0-4.0). (For an explanation of the purgative action of most salines see article on Magnesium Sulphate.) A solution of sodium phosphate (Liquor Sodii Phosphatis Com- positus) has been introduced into the U. S. P. of 1900. As each fluidrachm contains one drachm of sodium phosphate, the dose is the same as that of the salt. 382 DRUGS. PHOSPHORIC ACID. The pure acid is rarely employed in medicine, but when given is used in 2- to 8-minim (0.1-0.5) doses. In the form of dilute phos- phoric acid {Acidum Phosphoricum Dilution, U. S. and B. P.) it is widely employed in the dose of 20 minims to 1 drachm (1.3-4.0) as a tonic and gastric stimulant. It is not a food to the nervous system, does not resemble phosphorus in its physiological action, and is not to be employed in its place. It does good in nervous exhaustion simply by stimulating the stomach and thereby aiding that organ in the diges- tion of food. Phosphoric acid is also official in the B. P. as Acidum Phosphoricum Concentratum. PHOSPHORUS. Phosphorus, U. S. and B. P., is a non-metallic element, generally obtained from bones, and is very soluble in oils, less so in ether and alcohol. Its odor is characteristic and peculiar. When placed in a dark room after exposure to light it is luminous, and if exposed to the air will ignite. It should be kept under water in tightly- stoppered bottles. Very commonly it is contaminated by arsenic and sulphur. Physiological Action. — Phosphorus is found in large amount, com- paratively speaking, in the bones and in the nervous system, and is a stimulant to the growth of both. It acts, therefore, as a direct tonic to nervous tissue and is a producer of bone. Upon tissue-waste the drug acts as a depressant, thereby preserving the body, as it decreases the elimination of urea and diminishes the quantity of carbonic oxide exhaled. Upon the growth of bones phosphorus has a most remarkable influence, causing, when it is given to young animals, great increase in the size of these parts. The first change noted is an enlargement, which consists in a jelly-like mass containing little or no bone salts, and this is finally converted into a very hard material which may fill the entire canal in the centre of the bone. Kissel has stated that this does not occur, but his results must be doubted in view of the thorough studies of Wegner. Acute and Chronic Poisoning. — When phosphorus is taken in poi- sonous dose, often from the ends of matches, no symptoms may come on for eight or ten hours. At the end of that time the peculiar taste of phosphorus may be noted in the mouth, the breath is heavily laden with its odor, and burning pain in the oesophagus, stomach, and abdo- men becomes a pressing symptom. Vomiting and purging now assert themselves, and both the matters which are vomited and those which are passed from the bowels may be luminous in the dark, owing to the presence of phosphorus. The vomit at first consists of food, then mucus, then bile, and then perhaps blood. All the symptoms of a mild gastro-enteritis may develop, but it is to be noted that constipation of PHOSPHORUS. 383 an obstinate type may be present instead of purging. Very soon the liver increases in size, and gives rise to general hypochondriac pain and tenderness as well as local swelling. At the end of twenty-four hours, or perhaps after the second day, a cessation in the symptoms occurs, and, if the physician be not on his guard, this will lead him to a hope- ful prognosis, but in the course of a few hours jaundice begins in the conjunctiva and then extends over the entire body. With the onset of jaundice the vomiting and pain return with renewed vigor. The matters vomited have often the color of "coffee grounds," due to exuded and altered blood. The bowels are absolutely confined, or the few hard masses of fecal matter which are passed are white and clay-like Fig. 54. 1 ^ '■ mm >mmm Showing the fat-granules produced in the liver in phosphorus poisoning. (Kast and Rumpler.) because of the absence of biliary coloring matter. There is no bile in the vomit in this stage, because the hepatic ducts have been closed by the inflammation which has been produced in the liver. Later, nervous symptoms ensue. Muscular twitchings, headache, vertigo, wild delirium, erotic convulsions, and finally unconsciousness and death, occur. Sometimes the convulsions occur just before dissolu- tion. Even if the patient survives the acute stage of the poisoning, he generally dies of the changes produced in his vital organs, which con- sist in widespread fatty degeneration. These fatty changes occur 384 DRUGS. even in the acute form of the poisoning. Atrophy of the liver, destruc- tion of the gastric tubules, pancreatic involvement, and kidney degen- erations aid in producing the ultimately fatal results. During poisoning by phosphorus the urine is scanty and perhaps albuminous, and is peculiar because of the unusual substances which are found in it. The most unusual of these is sarcolactic acid, which results from breaking down of the muscular tissues. Leucin and tyrosin are also found, and tube-casts with fatty globules in them are seen. Free fat-globules may also occur. Bile acids and bile color- ing matter are found in large amount, and the urine is generally dark- colored for this reason. As phosphorus is eliminated in the urine as hypophosphoric acid, this substance is also present. The symptoms of phosphorus poisoning may so closely resemble those of acute yellow atrophy of the liver as to make a differential diagnosis impossible unless some evidence of the presence of phos- phorus is obtainable. In chronic poisoning by phosphorus, when, by the inhalation of its fumes, systemic changes occur, the most common lesion is necrosis of the lower jaw, which may be widespread or limited. It never occurs in those who have no solution of continuity in the teeth or gums, and for this reason it is necessary that the employes in match factories should have their teeth and gums constantly attended to. It has been said that pans containing turpentine when set around the work-room will protect the workmen, but this is certainly incorrect. Treatment of Acute Poisoning. — The antidote to phosphorus is generally taught to be the sulphate of copper, which will also act as an emetic if given in excess, but studies made by Thornton in my labo- ratory at the Jefferson Medical College prove that it is as dangerous a poison as the phosphorus. Peroxide of hydrogen and permanganate of potassium are probably the best antidotes. Oil of turpentine, in America, is not only valueless as an antidote, but harmful, for only old, ozonized French oil of turpentine is antidotal in its influence. As phosphorus is soluble in oils, we simply aid in its absorption if any such substances are given. Therapeutics. — Owing to its influence on the development of bone, phosphorus is very useful in rhachitis and osteomalacia. It is also useful in the sweats of general or nervous debility and in nervous ex- haustion, and in some cases of melancholia depending upon overwork. In the course of prolonged exhausting diseases, as typhoid fever or typhoid pneumonia, the drug is of service if the nervous system seems to be particularly affected, and in convalescence it is of service in aid- ing to build up the shattered forces of a patient. In the sequelae of acute and chronic alcoholism and in morphiomania it is of service. Phosphorus is also employed in sexual exhaustion or abuse. In boils and carbuncles and similar disorders phosphorus is very useful, particularly so in acne indurata. In pneumonia some physicians use minute doses with the belief that it aids in the produc- PHYSOSTIGMA. 385 tion of resolution. Probably it does good in these cases by stimulating or supporting the nervous system. In the neuralgia from nerve-depression and in cerebral softening and meningitis of a chronic type phosphorus may be given with ad- vantage. The dose of phosphorus is jfa to -g- 1 -^ grain (0.0006-0.0012) in pill form (Pilulw Phosphori, B. P.) , but it may be gradually pushed to Yq- grain (0.003) if urgently needed. Phosphorated oil (Oleum Phos- phoratum, B. P.) and Spiritus Phosphori, are given in the dose of 1 to 5 minims (0*05-0.30) . Elixir Phosphori is given in the dose of 15 minims to 1 drachm (1.0-4.0). The beginning dose of phosphorus should not be above j-J-q grain (0.0006), for fear of some idiosyncrasy. PHYSOSTIGMA. Physostigma, U. S. (Physostigmatis Semina, B. P.), is a seed derived from Physostigma venenosum, a tree of West Africa, often called Calabar bean. It contains two alkaloids, eserine or physostigmine and calabarine. The former is the most important from a medical point of view. Physiological Action. — When a moderate dose of physostigma is given by the mouth it often produces some pain in the stomach and a sense of oppression and weakness. The pulse becomes slow, the respi- ration is depressed, and the pupils are contracted. Calabar bean in poisonous dose is a general paralyzant, but if the alkaloid calabarine be present in excess, it may be a convulsant. Nervous System. — On the spinal cord in poisonous dose this drug acts as a depressant poison, particularly affecting the sensory tracts. On the motor nerves it exerts no influence unless given in toxic doses, when it depresses their peripheral ends. The sensory nerves escape, but sometimes even they are involved. On the voluntary muscles the drug in these doses causes twitchings. In medicinal doses the drug is a stim- ulant to unstriped muscular fibre and acts as a mild nervous sedative. Circulation. — Calabar bean causes little circulatory change, but poisonous doses at first produce a rise of arterial pressure, due to a direct stimulation of the heart and of the muscular coats of the vessels. It slows the pulse by peripheral stimulation of the vagi. In medicinal dose its circulatory effect is not marked, but is depressant rather than stimulant. Respiration. — In moderate amount Calabar bean does not affect respiration, but in poisonous dose it produces death by paralysis of the respiratory centre. Pupil. — Physostigma causes myosis or contraction of the pupil by stimulation of the circular muscular fibres of the iris, and not by depres- sion of the sympathetic fibres, nor by stimulation of the oculomotor fibres, nor again by causing contraction of the bloodvessels of the iris. It decreases intraocular tension, produces temporarily an increase in the 25 386 DBUGS. power of accommodation for near objects, and then causes spasm of accommodation. The myosis usually develops in about eight to four- teen minutes after the drug is dropped into the eye, and reaches its maximum in thirty minutes, lasting for from six to eight hours. The partial influence may last, however, for four or five days. Alimentary Tract. — Physostigma is a stimulant to intestinal peristalsis, increasing the muscular activity in the walls of the gut and acting as a tonic to these fibres. Poisoning. — Poisonous doses of physostigma cause muscular trem- ors, followed by complete muscular relaxation. The pupils contract, the respirations become slow and irregular, and all reflex action fails. Vomiting or purging may or may not occur. Treatment of Poisoning. — This consists in the use of atropine, which is the physiological antidote; in the application of heat to the body, and the use of respiratory and cardiac stimulants, such as digi- talis, alcohol, or ammonia. Therapeutics. — Calabar bean has been employed in many affections, such as trismus neonatorum, tetanus, and other spasms, with only mod- erately good results. It is, however, of value in atony of the bladder and intestine and in catarrh of the bowels. Combined with nux vomica the author has used it with advantage in cases of gastric and intestinal dilatation. Some physicians think it of value in cases of tympanites, but in a limited use of it in certain severe cases of pneumonia with tympanites the writer has not found it of value. In bronchial asthma and emphysema it aids in expulsion of the mucus by its influence over the muscular fibres in the walls of the air-tubes. It is also useful in purgative pills to stimulate the mus- cular fibres of the intestine. (See Constipation.) In the eye,in the strength of 1 to 2 grains to the ounce (0.06-0. 12 : 30.0) of water, eserine is used in the treatment of corneal ulcerations, for the relief of glaucoma, and to diminish high intraocular tension. If, for any reason, atropine mydriasis is to be rapidly overcome, eserine may be used, but it is not so powerful a myotic as atropine is a mydriatic, and it requires larger amounts of the solution to produce contraction than it took of atropine to cause mydriasis. Administration. — Physostigma is used in the form of the extract (Extractum Physostigmatis, U. S. and B. P.) in the dose of -J- grain (0.008), which may be readily increased to J grain (0.015). The tincture (Tinctura Physostigmatis, U. S.) is given in the dose of 5 to 30 minims (0.3-2.0). Eserine is usually employed in the form of one of its salts. Phy- sostigmin(B Salicylas, U. S., and Physostigmina? Sulphas, U. S. and B. P., may be used in the dose of -^ grain (0.0008) three times a day. The sulphate is much more soluble, and is generally to be employed. The salicylate is largely used, nevertheless, by ophthal- mologists. Lamella? Physostigmina?, B. P., each contain 10 1 00 grain (0.00006) of physostigmine sulphate. The dose of both salts of eserine is y^o to -gV grain (0.0006-0.0008). PILOCARPUS. 387 PICRIC ACID. Picric Acid, or Trinitrophenol, occurs in light-yellow scales or needles without odor, and is chiefly used in the arts as a dye. Its uses in medicine are limited. Recently it has been found exceedingly effica- cious in solution in the treatment of burns and scalds. This solution is made as follows: 1$ — Acid, picric gr. lxxv (5.0). Alcohol fgiiss (75.0). Aquse destillatse Oij (960 c.c). — M. After the burn is cleansed of dirt and charred clothing, .strips of ster- ilized gauze are soaked in this solution and applied to the part. Over this is placed a pad of dry absorbent cotton which is fastened by a light bandage. The dressing rapidly dries, and may be left in place for several days. It is then moistened with the solution so as to soften it, is removed, and then a fresh dressing is applied for a week. All blisters should be pricked. This dressing relieves pain, prevents suppuration, hastens healing, and results in a smooth cicatrix. As this dressing stains the hands, the physician should use rubber gloves when applying it. PILOCARPUS. Pilocarpus, U. S. (Jaborandi Folia, B. P.), is derived from the South American tree, Pilocarpus selloanus or Pilocarpus jaborandi. It contains two alkaloids, known as pilocarpine and isopilocarpine. Jaborine is a combination of these alkaloids and a resinous substance. The alkaloid pilocarpine is non-crystallizable and occurs as a soft mass, but the salts of pilocarpine are crystallizable. Physiological Action. — When jaborandi is taken in medicinal dose by a healthy man, it causes a deep flushing of the face and neck, fol- lowed by the outbreak of a profuse sweat, which, though beginning in these regions, rapidly spreads over the entire body. Accompany- ing the sweat, salivation is often exceedingly profuse, so that saliva dribbles from the mouth. The sweat lasts from two to five hours. Nausea frequently comes on, and severe vomiting may appear in susceptible persons either during or after the sweating. Some individuals are singularly insusceptible to the diaphoretic influence of pilocarpus, and this is particularly so, according to Ringer, with children, who will often take as much as 60 grains (4.0) of the crude drug before they perspire. 1 Nervous System. — Moderate doses given to men have no effect on this part of the body. Circulation. — In large doses there is no doubt that jaborandi acts as a cardiac depressant rather than a stimulant. The drug causes in the lower animals a slow pulse and decreased arterial pressure, in moderate quantities, the first change being due to an action on the inhibitory centres in the heart or on the peripheral vagi. (See Fig. 1 The writer has reported a case (see Idiosyncrasy) in which a woman of thirty years received % grain of the muriate of pilocarpine hypodermically in half an hour without any effect. 388 DRUGS. 55.) In man the drug does not slow the pulse, but quickens it very markedly, often as much as forty to fifty beats per minute. Although the pulse in animals is generally made stronger by its use, in man it is generally made weaker. Stomach. — Jaborandi sometimes produces nausea and vomiting by irritating the stomach and perhaps the vomiting centre. Temperature. — Jaborandi lowers bodily temperature to a con- siderable degree, probably by the dilatation of the peripheral capil- laries and the profuse sweat which it produces. This fall is sometimes preceded by a brief rise. Kidneys and Tissue-waste. — Upon the kidneys jaborandi acts very slightly or very strongly, according to the dose that is given. Large doses, which produce a profuse sweat, naturally decrease the Fig. 55. \i\(WW\q|WV II III IV Parts of a tracing showing the effect of pilocarpine in depressing blood-pressure, and the stimu- lant effect of atropine upon blood-pressure in the circulation of a dog. (After Schmiedeberg.) I. Shows the pulse-rate and blood-presure unaffected by drugs. II. Pilocarpine injected, which slows the pulse from 28 in ten seconds to 19 in ten seconds, and lowers the blood-pressure from 126 to 96. III. Further depression and slowing; pressure, 70. IV. Atropine given, which raises blood-pressure to 145 and pulse-rate to 30. urinary secretion, but small ones undoubtedly increase it. Upon the tissue-changes in the body under pilocarpine no researches have been made, but it is an undoubted fact that in disease the excretion of urea is largely increased under the influence of this drug. PILOCARPUS. 389 Eye. — Jaborandi contracts the pupil by stimulating the peripheral ends of the oculomotor nerve in the iris. Skin and Secretion. — The amount of sweat caused by the drug in man may equal as much as a pint, and it is generally first acid, ficm the secretions of the sebaceous glands, then neutral, and finally alka- line. The sweating is not primarily due to vasomotor palsy, but to stimulation of the ends of the nerves supplying the glands and of the sweat-glands themselves. The sweat usually lasts about two to five hours. Sometimes excessive salivary secretion supplants that of the skin. Pilocarpine increases the gastric, salivary, and lachrymal secretions, as well as that of the skin and kidneys. It also seems to have con- siderable influence over the secretion of milk. Therapeutics. — Jaborandi, or, better still, its alkaloid, pilocarpine, is of some value for the relief of dropsy of the renal type. In that due to cardiac disease it is generally too depressing, and the author knows of a case in which a fatal result speedily followed its use under these circumstances. It may be used to abort an attack or paroxysm of malarial fever, but because of its depressant influence should never be employed in asthenic fevers, such as typhoid fever. In pleurisy with effusion it has been used, but more efficient remedies are elaterium, or salines given in concentrated form and at the proper time of the day. (See Magnesium Sulphate and Dropsy.) Better than all these is thoracentesis. Spaulding and de Schweinitz have both recommended very highly the hypodermic use of pilocarpine in the dose of yj to Y 1 ^ grain* (0.005-0.006) a day for opacities of the vitreous humor of the eye. The fluid extract of jaborandi may be employed, but is apt to nauseate the patient. Diaphoresis should not be produced. Because of its myotic influence on the pupil pilocarpine is of very great value in the treatment of all conditions of the eye associated with increased intraocular pressure. It is so good a myotic as to be rapidly supplant- ing eserine for this purpose with some clinicians. The strength of pilo- carpine solution for this purpose is 1 to 4 grains (0.06-0.25) to the ounce (30.0). It should be dropped into the eye, 1 or 2 drops at a time, every hour until the patient is relieved. Pilocarpine is also use- ful as an ocular tonic to relieve eye-pain after excessive use of the eyes, in the strength of -^ grain (0.006) to the ounce (30.0). A few drops of this solution may be dropped into the eye three times a day. This solution should have a little boric acid (4 grains) added to it to prevent fungus growth. (See Asthenopia.) Clinical reports show that pilocar- pine in small doses is a good remedy in tobacco and alcoholic amblyopia. Mitkowski has tried pilocarpine in catarrhal jaundice of a persistent type with great benefit, in the hypodermic dose of J grain (0.01) every other day for three weeks. In uremic poisoning pilocarpine is theoreti- cally the most efficient and rapidly acting remedy that we have, and when used in Bright' 's disease it may be of value in several ways — first, by removing the strain on the kidneys; second, by eliminating the uraemic poison; and, third, by decreasing the inflammatory condition in 390 DRUGS. the kidneys by lowering the blood-pressure, which it will be remem- bered, is the more constant effect of the drug in man. Care should always be exercised in the use of the drug lest cardiac depression ensue, and alcohol or strychnine may often be used with advantage to guard against this accident. The general consensus of opinion is that in the nephritis of middle years or advanced life with cardiac changes it is contraindicated. The author never uses it in chronic parenchymatous nephritis. In the ursemic convulsions of pregnancy pilocarpine, while theoretically useful, has been proved by experience to do more harm than good through its depressing influences, although the drug in small doses certainly increases renal activity. The hypodermic dose of pilo- carpine as a renal stimulant should be about ■£■$ to ■£$ grain (0.002- 0.003). In some forms of p-ofuse sweating, such as come on at night in cases of general debility, pilocarpine, if given hypodermically or by the mouth about two hours before the sweat in the dose of -^ grain (0.003), is often useful even where atropine fails. The good effect is produced by stimulating the sweat-glands and so overcoming their atony. Da Costa, Salinger, and Barr have highly recommended the hypo- dermic injection of pilocarpine in erysipelas as a preventive and cura- tive measure in the early stages of this disease, and their reports are so encouraging as to warrant a careful trial of the method. The proper dose is \ grain (0.01) every three hours until free sweating ensues. After this is accomplished the doses may be repeated every four or six hours. The author would fear that such active treatment might seri- ously affect the strength of the patient unless stimulants were also used. In cases of obstinate aural vertigo a most efficient treatment is the hypodermic use of pilocarpine every few days in sufficient dose to pro- duce some salivation. The patient has to lie down or go to bed after the dose is given. Pilocarpine certainly has a decided effect in encouraging the growth of hair, and applied locally will often do good in partial baldness. If too much pilocarpine is used, it is apt to cause the development of small pustules about the hair-follicles. Bartholow recommended the following application for baldness: 1^— Extract, pilocarpi fluid fgj (30.0). Tincturae cantharidis foss (16.0). Liniment, saponis f ojss (45.0).— M. The author has found the following prescription very efficacious in falling of the hair: ty — Extract, pilocarpi fluid f"5j (4.0). Tr. capsici . fgj (30.0). Tr. cantharidis f3ss (2.0). 01. ricini f 5 j (4.0). Alcohol q. s. f 5iv (120.0).— M. S. — Apply with friction in spots to the scalp, night and morning. Antagonisms of Jaborandi. — Jaborandi is a physiological antidote to atropine and to agaricin. Four times the dose of pilocarpine must PIPEBAZINE. 391 be used to counterbalance a dose of atropine. Vomiting produced by pilocarpus is to be antagonized by morphine. Untoward Effects. — Dimness of vision, vomiting, sudden collapse, swelling of the salivary glands and tonsils, hiccough and strangling are sometimes met with after using pilocarpus. Sometimes bloody leucorrhcea is seen. The vomiting can usually be prevented by full doses of chlorodyne. Prentiss has called attention to the fact that the continued use of pilocarpine may cause the hair to become coarse and dark. Administration. — The dose of jaborandi is 40 grains (2.6) used in the form of the powdered leaves in infusion. The fluid extract (Fluid- extractum Pilocarpi, U. S.; Extractum Jaborandi Liquidum, B. P.) should be used in the dose of 10 to 40 minims (0.60-2.6). Pilocar- pine is far superior to jaborandi,. in that it does not so often produce nausea and vomiting. It is used in the form of the hydrochloride (Pilocarpine Hydrochloridum, U. S.), in the dose of from J to \ grain (0.008-0.03) hypodermically, or J to \ grain (0.015-0.03) by the mouth. The additional preparations of the B. P. are — the tincture (Tinc- tura Jaborandi), dose \ to h fluidounce (8.0-16.0); and the nitrate of pilocarpine (Pilocarpine? Nitras), \ to \ grain (0.008-0.03). PIPERAZINE. Piperazinum is a substance, the chemical formula of which is C 4 H 10 N 2 , which has been recently introduced into medicine for the treating of the uric-acid diathesis. It is not stable, and when exposed to the air attracts water and carbonic acid ; so it must be kept in tightly-stoppered bottles. Aqueous solutions are decidedly alkaline, but do not have any distinct taste. Piperazine is peculiar in its power to dissolve uric acid, dissolving twelve times as much as will carbonate of lithium, while it is also entirely soluble in water, which lithium is not. When taken into the body the drug is partly oxidized and partly eliminated unchanged. Theoretically, piperazine, when taken into the body, forms with uric acid a urate of piperazine, which is soluble and readily eliminated. Experiments to determine this point have been made with very satis- factory results, and repeated clinical observation has shown that the administration of the drug causes an increase in the amount of urea in the urine with a decrease in the uric acid, indicating that under its influence oxidation is more complete. Therapeutics. — Piperazine is used for the purpose of preventing the formation of renal and vesical calculi in the uric-acid diathesis, and also in cases where the excess of uric acid in the urine tends to pro- duce irritation of the bladder. Similarly, its action has been found of value in treating vesical irritation due to this cause by washing out the bladder with a solution of piperazine of the strength of 1 per cent. Piperazine has also been injected into uric-acid deposits about the 392 DRUGS. body or applied to the broken-down surfaces of these deposits in 1 per cent, solution, but the author has not been favorably impressed with this method, and would advise against its use — first, because it does little if any good, and, second, because the method is painful and apt to cause sloughs by interfering with nutrition of the skin, which is already lacking in health. The dose of piperazine is 15 grains (1.0) in twenty-four hours. It is best given by dissolving this amount of the drug in 1 pint (480 c.c.) of water, and directing the patient to take a wineglassful of the solu- tion frequently through the day. Owing to the effect upon the drug of exposure to air, it cannot be given in pill or powder, and should be freshly mixed each day. The writer has failed to obtain any results from the use of this drug in his practice. Stewart has noted, as untoward effects of full doses of piperazine tremors, hallucinations, and clonic spasms. Lycetol is a substance closely allied to piperazine, and is used in medicine for the same purposes. Dissolved in water it has a taste somewhat like lemonade. Unlike piperazine, it is not hygroscopic and will keep indefinitely. The dose of lycetol is 15 to 30 grains (1.0-2.0) a day, well diluted with water, to which a little sugar may be added to improve the taste. Usually it is best to give the drug in carbonated water, and to begin with small doses, which are to be gradually in- creased in size. PISCIDIA ERYTHRINA. Piscidia Erythrina is a drug which is stated to possess marked nar- cotic and pain-relieving properties. It is sometimes called Jamaica dogwood. Its powers as a soporific and analgesic do not compare with those of opium, but it is stated to be devoid of the unpleasant after-effects of the latter drug. Further studies concerning its effects on the animal economy are needed. According to Dr. Isaac Ott and Dr. Nagle, the drug has little or no effect on the motor and sensory nerves, and its dominant effect on the circulation is to increase arterial pressure through stimulation of the vasomotor system. The indica- tions which have been met best by piscidia are dysmenorrhea due to irregular flow and spasm of the uterine cervix and fundus, to allay nervous irritability, and to relieve pain or insomnia due to pain. Administration. — The dose of the fluid extract of piscidia erythrina is £ to 2 drachms (2.0-8.0); of the solid extract, 2 to 10 grains (0,12- 0.60). The alkaloid piscidine is not known to represent all the prop- erties of the drug, and is not used in medicine. PITCH. Fix is a resinous exudation derived from several species of pines, firs, and spruces, and is, in one of its forms, obtained by the evapora- tion of wood-tar. It is used for various purposes, according to its deri- PODOPHYLLUM. 393 vation. Burgundy Pitch (Pix Burgundica, B. P.) is derived from Norway spruce, or Abies (Picea, B. P.) excelsa, a plant of Europe and Asia. It softens and melts at the temperature of the body and is useful for plasters. In muscular rheumatism and in chronic bronchitis pitch is a mild and fairly useful local remedy for external use. In the form of the plaster (Emplastrum Picis, B. P.), and in the form of warming plaster (Emplastrum Picis Cantharidatum) , it is employed for the relief of deep-seated sprains and bruises, and acts as a mild counterirritant, which may blister a tend r skin. Canada Pitch (Pix Canadensis) is obtained from the hemlock spruce of Canada and the United States, and is used for the same purposes as Burgundy pitch. The Canada-pitch plaster (Emplastrum Picis Canadensis) is employed for the same conditions as the plaster of Burgundy pitch. PODOPHYLLUM. Podophyllum, U. S., May Apple or Mandrake, is the rhizome and small roots of Podophyllum peltatum, a plant of the United States and Canada. Podophyllum contains a resin, podophyllin. Therapeutics. — Podophyllum is the slowest-acting purge official in the Pharmacopoeia. In small doses it is laxative, but is purgative and almost drastic in larger amounts. In overdose it may produce gastro- enteritis. The drug particularly excites the flow of bile, and is used as a cholagogue. It is best given when the stools are dark in color, calomel being indicated when they are light. The author has found the follow- ing prescription useful in cases of intestinal flatulence and indigestion with constipation: R— Podophyllin gr. v. (0.30). Euonymin gr. v. (0.30). Leptandrin gr. v. (0.30). Ext. chiratae gr. xlv. (3.0). Creasotse gr. x. (0.60). — M. Ft. in pil. No. xx. In children one or two months old who have hard, stony stools podo- phyllin is a good remedy. The dose should be given by dissolving a grain of the resin in a drachm of alcohol and using 2 drops or more of this on sugar once or twice a day. In children who suffer from summer diarrhea, in which the passages consist almost entirely of water, which have a peculiar musty smell or a mouse odor, podophyllin in the dose of g^ to -5^ grain (0.001-0.0012), repeated every few hours, is of service, seeming to control the passages and make them normal. This treatment will often succeed when all else fails. This statement is also true in regard to the chronic diarrhoeas of adults, though the drug should be given in somewhat larger amounts in such cases. Podo- phyllin will also check vomiting in these doses in some instances, pro- vided that the stomach is depressed and the liver is torpid. It should 394 DRUGS. not be employed if the vomiting is due to irritation or inflammation of the stomach. Administration. — Podophyllum is used in the form of the extract (Extraction Podophylli), dose 1 to 5 grains (0.06-0.30) ; the fluid extract {Fluidextr actum Podophylli, U. S.), dose 2 to 20 drops (0.12^1.3); and, more commonly than all, as the Resina Podophylli, U.|S. and B. P., or podophyllin, which is the best preparation. The dose of this preparation is from fa to fa grain (0.003-0.006) as a feeble laxative, and from fa to \ grain (0.006-0.03) as a purge. The tincture of resin (Tinctura Podophylli, B. P.) is given in the dose of 5 to 15 minims (0.3-1.0). POMEGRANATE. Although Granatum, U. S. (Granati cortex, B P.), is official, it is almost never used in America in its crude form. It contains an alka- loid known as pelletierine, this alkaloid being a colorless liquid, soluble in 20 parts of water and readily miscible with ether, chloroform, and alcohol. When acids are added to it it forms crystalline salts, of which four are used — namely, the tannate, the sulphate, the hydrobromate, and the hydrochloride. The first is most commonly employed, and is a yellowish powder possessing an astringent taste. It is soluble in 700 parts of water and 80 of alcohol. Its physiological action needs further investigation, but the drug in poisonous amounts paralyzes the peripheral ends of the motor nerves in a manner closely resembling the action of curare. Sensibility is preserved The loss of power is chiefly manifested in the lower limbs, in which at first there may be cramps. There may also be nausea and vomiting. Therapeutics. — Originally, pomegranate was largely used in the form of the rind of the fruit in decoction as a vegetable astringent, but this practice has ceased because of its disagreeable taste and effect upon the stomach. The ailments which were supposed to indicate its employment were serous diarrhoea and profuse sweats. In some trop- ical countries the bark of the root is used as a vermifuge, and it is very efficient in removing the tape-worm. It is said that the bark of the root of the wild shrub is much more efficacious than that of the cul- tivated and more handsome plant. To be effective the dose of the decoction of the bark must be large. The drug is prepared by soak- ing 2 ounces (60.0) of the bark in 2 pints (960) of water for twenty- four hou^s and then boiling down to a pint (480). A wineglassful (30.0) of this is the dose which is generally given, and it may be repeated every hour until the whole amount is taken. The objection to this line of treatment is that it is unnecessarily severe, often purging and vomiting the patient excessively. The nausea produced is often great. Should purging fail to occur, it is necessary to give castor oil or other purge to dislodge the worm, and it is always necessary to starve the patient for twelve hours before the remedy is tried. POTASSIUM CITRATE. 395 The dose of pelletierine is 3 to 5 grains (0.20-0.30), and the tannate (Pelletierinoe tannas, U. S.) is the salt usually employed. Practically, the only pelletierine used is that of Tanret, and his preparation is a syrupy solution in each bottle of which is one dose of the drug. As large doses as 20 grains (1.3) of pelletierine have been used, but as serious paralytic symptoms have ensued after the ingestion of 5 grains by a susceptible woman, not more than this amount should be given. When pelletierine is used, it should always be followed in two hours by a purge. Those who have used it most place great reliance on it. The fluid extract (Fluidextr actum Granati, U. S.) is given in the dose of 20 to 30 minims (1.3-2.0). The B. P. con- tains one official preparation of pomegranate — namely, the Decoctum Granati Corticis, the dose of which is 1 to 2 fluidounces (30.0-60.0). POTASSIUM BICARBONATE. This salt (Potassii Bicarbonas, U. S. and B. P.) is used for the same purposes as the citrate and acetate of potassium, and, as it is much less agreeable in taste, should not be employed when they can be obtained. From the bicarbonate of potassium are made several very useful preparations: the liquor potassii citratis, by adding 120 grains (8.0) to 90 grains (6.0) of citric acid and 10 ounces (300.0) of water; the neutral mixture, by adding to 1 pint (480.0) of lemon-juice enough of the potassium salt to neutralize it. The dose of potassii bicarbonas is 5 to 40 grains (0.3-2.6), or even as much as 2 drachms (8.0) may be given if well diluted with water. POTASSIUM BROMIDE. (See Bromide of Potassium.) POTASSIUM CARBONATE. Carbonate of Potassium (Potassii Carbonas, U. S. and B. P.). Tj^is salt is never used in medicine, except to prepare other salts, as it is dis- agreeable to the taste and is an irritant. (See Potassium Citrate.) POTASSIUM CITRATE. Citrate of Potassium (Potassii Citras, U. S. and B. P.) is a white, granular, deliquescent salt, almost neutral in reaction and very solu- ble in water. It is by far the most agreeable of all the salts of potas- sium to the taste. In the early stages of bronchitis it is of the greatest value when combined with ipecac (see Bronchitis), and it is also use- ful as an alkaline diuretic. In bronchitis the dose should be 20 grains (1.3) every four hours, and in urinary incontinence due to acid and concentrated urine the dose should be equally large. 396 DRUGS. Under the name of neutral mixture (Mistura Potassii Citratis), made by adding to 1 pint (480 c.c.) of lemon-juice enough bicarbonate of potassium to neutralize it, we have a useful febrifuge drink in fevers, particularly those of childhood. The dose is J to 1 ounce (16.0-30.0) every few hours. Liquor Potassii Citratis, U. S., is made in the same manner as is the neutral mixture, except that citric acid is substituted for the lemon- juice (citric acid 6 grm., potassium bicarbonate 8 grm., and water ICO c.c). The neutral mixture is the better preparation of the two, but more expensive. A very refreshing and agreeable way of prescribing this drug is in the form of "effervescing draught," made by mixing two solutions which are prepared as follows: 1. Lemon-juice and water, equal parts, enough to make 4 ounces (120 c.c). 2. Bicarbonate of potassium 1 drachm (4.0) and water 3 ounces (90.0). These solutions are to be mixed in the quantities desired, and taken while effervescing. If lemon- juice is not at hand, a solution of citric acid of the strength of 2 drachms (8.0) to 4 ounces (120.0) of water should be employed in its stead. Under the name of Potassii Citras EJfervescens the U. S. P. of 1900 calls for an official powder possessing the advantages of the mixture just named. POTASSIUM IODIDE. (See Iodide of Potassium.) PROTARGOL. Protargol is a new silver preparation containing 8.3 per cent, of silver, and occurs as a yellowish powder readily dissolved in cold and hot water, forming a clear solution. It is employed in gonorrhea and in gonorrheal conjunctivitis because it is destructive to the gonococcus. (See Conjunctivitis.) It is not precipitated on contact with albumin of alkalies, nor by dilute hydrochloric acid. It therefore has distinct advantages over nitrate of silver. Al to 5 per cent, solution of pro- targol is the strength ordinarily used in the treatment of gonorrhoea, and these solutions may also be employed in the eye. (See Conjunc- tivitis.) If used on a camePs-hair brush or swab, the solution may be as strong as 5 per cent. ; but if the drug is used as a collyrium its strength should not exceed 1 : 400 or 1 : 200. PRUNUS VIRGINIANA. Prunus Virginiana, U. S., and Pruni Virginian® Cortex, B. P. — Wild Cherry, as it is incorrectly called — is the bark of Prunus sero- tina, a large tree of the United States and Canada. It contains a substance, known as amygdalin, which when it comes in contact with QUASSIA. 397 water forms hydrocyanic acid through the action of another substance, known as emulsin. Therapeutics. — Wild-cherry bark is largely used as a domestic tonic, and in the form of a syrup as a vehicle for cough mixtures. It has been supposed that the hydrocyanic acid present allays the cough, but this is doubtful, as the acid is fleeting in its effect and is present in very small quantity. Administration. — As a tonic prunus virginiana is used in the form of the infusion (Infusum Pruni Virginianoe, U. S.), dose \ to 1 ounce (16.0-30.0), and the fluid extract (Fluidextractum Pruni Virginianoe, U. S.), dose 30 minims to 1 drachm (2.0-4.0). The syrup (Syrupus Pruni Virginiana?, U. S. and B. P.) is given in the dose of 1 to 4 drachms (4.0-16.0). The B. P. also contains a tinc- ture (Tinctura Pruni Virginiana?), given in the dose of 1 to 2 drachms (4.0-8.0). PYOKTANIN. (See Methyl Blue.) PYROGALLOL. Pyrogallol, U. S., sometimes called Pyrogallic Acid, is a triatomic phenol obtained by dry distillation of gallic acid, and should be kept in dark, well-stoppered bottles. It occurs in light white scales or crystals, has no odor, but a bitter taste. If exposed to the light, it becomes dark. It is soluble in 2\ parts of water, and readily so in ether and alcohol. Therapeutics. — Pyrogallol is used in parasitic skin diseases, irv ointment, in the strength of 30 to 100 grains (2.0-6.6) to the ounce (30.0). The stronger ointments exercise a mild caustic effect. It may be employed in place of chrysarobin in psoriasis. It stains the skin a deep brown. QUASSIA. Quassia, U. S. (Quassia? Lignum, B. P.), is the wood of Picrasma excelsa, a large tree of Jamaica and other islands of the West Indian group. It contains an active principle, named quassin, which is in- tensely bitter and an irritant to mucous membranes. Quassia is a simple bitter tonic which has been used very largely in domestic medicine and by the medical profession. It is very efficient as a tonic, is supposed to be particularly useful in the anorexia follow- ing malarial fevers, and has even been thought to possess antiperiodic power. In simple dyspepsia with eructations after meals, due to gastric inactivity, it is very serviceable. In the treatment of seat-worms (Oxyuris vermicularis) , or thread- worms, as they are often called, injections of the infusion of quassia are the most efficacious and useful remedial measures we possess, and 398 DRUGS. yet are harmless to the patient. The bowel should be well washed out with soap and water, and J pint to 1 pint of an infusion, made by adding 1 to 2 ounces (30.0-60.0) of quassia chips to a pint (480) of water, should be injected and retained for some minutes. A few such injections will invariably kill the parasites, provided the bowel is first well washed out with soap and water and enough fluid is injected to reach high up into the rectum. Administration. — The tincture (Tinctura Quassias, U. S. and B. P.) is given in the dose of J to 1 drachm (2.0-4.0), the fluid extract (Fluidextractum Quassias, U. S.) J drachm (2.0), and the solid extract Extractum Quassias, U. S.) 1 to 3 grains (0.06-0.2). The infusion (Infusum Quassias, B. P.) is given in the dose of \ to 2 ounces (16.0-60.0), and is made by macerating 1 drachm (4.0) of quassia with 10 ounces (300.0) of water, and allowing it to stand twenty- four hours or more. Liquor Quassias Concentratus is official in the B. P. Its dose is 1 drachm (4.0). QUERCUS. Quercus, U. S., or White Oak, in infusion made either from the crude drug 1 ounce (30.0) to the pint (4S0 c.c), or by adding the fluid extract (Fluidextractum Querci, U. S.) to water, is used as an astringent injection in gonorrhoea and vaginitis in women, where a large amount of fluid is necessarily employed. It is also used in prolapse of the rectum, in hemorrhoids, in leucorrhasa, and as a gargle in sore throat. It stains the clothing very slightly. Quercus Tinctoria is equally efficient, but is seldom used because it stains the clothing. In the form of the powdered bark it is often used as an astringent poultice to freely running sores, to check the discharge. RESIN, or ROSIN. Koolna, 0. S. and B. P., is Resin or Rosin, the mass left after the distillation of turpentine, and enters largely into plasters, cerates, and similar preparations. Its fumes when it is burnt are said to be of value when inhaled in cases of chronic bronchitis. Ceratum Resiim, U. S., is used in chilblains and superficial scalds. Ceratum Resinw Compositum, U. S., popularly known as Deshler's Salve, is used as a stimulating application. Unguentum Resince is a B. P. preparation used for the same purposes as the cerate. RESORGINOL. Resorcinol, U. S. (metadioxy benzol), is the raefa-com pound of the group of which hydrochinone is the para- and pyrocatechin the ortho-, and occurs in clear crystals of a slightly reddish hue. It is quite soluble in water, alcohol, and ether. RESORCINOL. 399 Physiological Action. — Resorcinol is an irritant to mucous mem- branes, and when taken internally in poisonous doses causes deafness, giddiness, salivation, profuse sweat, unconsciousness, and clonic con- vulsions. The heart of the dog under its influence is at first slowed by vagal stimulation, and then becomes very rapid from vagal palsy. Therapeutics. — Resorcinol has been found of service as a remedy for whooping-cough, given in the dose of 10 minims (0.60) of a 2 per cent, solution or used in a spray of the same strength, the latter being the better method of using the drug. Resorcinol has also been employed in a spray in 2 per cent, solution in hay fever with remarkably good effects. It has been used as an antipyretic, but is not serviceable and has little power over fevers. The chief use of resorcinol is in skin affections of a subacute or chronic character, such as eczema with much induration, and in psoriasis. In these states an ointment of the following character, well applied, is of service: R— Resorcinol 3J (4.0). Zinci oxidi ^j (4.0). Ung. aquae rosse 5 x (40.0). — M. S. — Apply to the part affected twice a day. After mixing the ointment heat it until the resorcinol crystals melt, to prevent any irritation of the skin. Resorcinol is also of service in weak solution in allaying itching of the skin due to erythematous eczema. For this purpose it should be used in watery solutions of about 10 or 15 grains to the ounce, and a little salt added to aid in its absorption by the skin. This should be dabbed, not rubbed, on the part: R— Resorcinol gr. xv (1.0). Glycerin T^x (0.60). Liquor calcis fgj (30.0).— M. In the slowly spreading epithelioma of the face the following plaster, recommended by Hartzell, is useful: R — Resorcinol gr. lxxij (5.0). Cerse flav. et pulv. resinae gjss (6.0). 01. Olivse q. s.— M. Another valuable use of resorcinol is in the treatment of seborrhea capitis of the dry, scaly type: R— Resorcinol 3J (4.0). 01. ricini r^xxx (2.0). Alcohol f|ij (60.0). Spt. myrciae q. s. f|iv (120.0).— M. S. — Use as a lotion to the scalp, after washing with castile soap and water, once a day. Within the last few years resorcinol has been employed with good results in the treatment of gastric ulcer in the dose of 2 to 4 grains 400 DRUGS. (0.12-0.25) before each meal in pill or capsule. It is supposed to act by reason of its analgesic, antiseptic, and haemostatic power. RHIGOLENE. Rhigolene is a product of petroleum obtained by repeated redistillation until the liquid resulting from this process boils at 64.4° F. It evap- orates more rapidly than any other known liquid, except cymogene, which boils at 32° F., and is used in a spray for the production of localized numbness or freezing before minor painful operations, such as the use of the actual cautery. RHUBARB. Rheum, U. S. (Rhei Radix, B. P.), is the root of several species of Rheum, a plant of Thibet, but which is cultivated in America and elsewhere. It is also derived from China, and this variety is known as Chinese rhubarb. Several alkaloids are contained in it, all of which are unimportant and never used alone, except chrysophanic acid. Physiological Action. — According to the studies of Prevost and Binet, rhubarb acts inconstantly upon the flow of bile, sometimes increasing it, sometimes having no effect; but, on the other hand, according to those of Rutherford and Vignal, it never fails to stimu- late biliary secretion. Owing to the astringent properties possessed by rhubarb, it does not purge excessively, and improves the appetite, digestion, and intestinal tone. Its constant use produces chronic con- stipation. Therapeutics. — Whenever it is desired simply to unload the bowels without affecting the general system rhubarb may be employed. In children a state is very commonly seen in which constipation is replaced by diarrhoea if any ordinary laxative is employed, and in these instances rhubarb is the best remedy, as it is astringent and prevents any after- effects other than those directly produced by the dose. In the summer diarrhwa of children, when the stools are green, rhubarb is often used to empty the bowels of fermentative products before direct treatment is instituted. Rhubarb, because of its chrysophan, may stain alkaline urine car- mine or acid urine yellow. Administration. — The preparations of rhubarb are unnecessarily numerous. Rhubarb itself may be given in the dose of 20 grains (1.3) in powder, and small pieces of the root are habitually chewed by some persons for the relief of constipation. Extr actum Rhei, U. S. and B. P., is given in the dose of 5 to 10 grains (0.30-0.60) in pills. Pilula? Rhei, U. S., of which each pill contains 3 grains (0.20) of rhubarb, is given in the dose of one to three pills; and Pilula Rhei Compositoe, U. S., and Cornposita, B. P., which con- tain 2 grains (0.12) of rhubarb and lj (0.09) of aloes, are given in BOCHELLE SALT. 401 the same dose. Pulvis Rhei Compositus, U. S. and B. P., contains rhubarb, magnesia, and ginger, and is given in the dose of 20 to 40 grains (1.3-2.6); Fluidextr actum Rhei, U. S., is given in the dose of 20 to 30 minims (1.3-2.0). Syrupus Rhei, U. S. and B. P., is given in the dose of 1 drachm (4.0) to a babe, and 4 drachms (16.0) to an adult, although rarely used for older persons. Syrupus Rhei Aro- maticus, U. S., is given in the same dose and to the same class of cases. Tinctura Rhei, ll. S., is used in the dose of \ to 2 drachms (2.0-4.0), Tinctura Rhei Aromatica, U. S., Tinctura Rhei Composita, B. P., is used in the dose of \ to 1 drachm (2.0-4.0), and Tinctura Rhei Dulcis, U. S., 2 to 3 drachms (8.0-12.0). The aromatic syrup is commonly employed for children, and the compound pills for adults. Infusum Rhei, B. P., is given in the dose of 1 to 2 ounces (30.0-60.0), and Mistura Rhei et Soda?, U. S., in the dose of 2 drachms to 3 ounces (8.0-90.0). Liquor Rhei Concentratus is official in the B. P. Its dose is 1 drachm (4.0). RHUS AROMATICA. Sweet Sumac is unofficial, but has been so largely used of late that it deserves notice. In hematuria, menorrhagia, diabetes insipidus, and in urinary incontinence in children depending upon vesical atony it has been highly praised. In the latter affection a sufficient amount of experience has been acquired to show that it really is of benefit. Rhus aromatica should be used in the form of the fluid extract, derived from the bark of the roots according to the general directions in the Pharmacopoeia for making fluid extracts. The dose as a remedy for urinary incontinence is 15 minims (1.0) of this preparation. Adults may take from 15 to 60 minims (1.0-4.0). The drug is best given with glycerin and water. RHUS GLABRA. Rhus Glabra, U. S., Smooth Sumac, is the fruit of Rhus glabra, and contains tannic and malic acids as its chief constituents of medi- cinal value. In the fluid extract {Fluidextr actum Rhois Glabrae, U. S.) we have an official preparation which is very efficient as a gargle for sore throat when diluted with glycerin and water or prepared accord- ing to the formula given under Chlorate of Potassium. ROCHELLE SALT. Potassii et Sodii Tartras, U. S. (Soda Tartarata, B. P.), is largely used as a saline cathartic in the dose of J ounce (16.0), and is preferred by many patients to Epsom salt because its taste is not so disagreeable. It is, however, more irritating. Rochelle salt is the purgative constituent of Seidlitz powder. 26 402 DRUGS. ROSA GALLIGA. Rosa Gallica, U. S. (Rosoe Gallicce Petala, B. P.), Red Rose, con- tains gallic and tannic acids, and is astringent. From it are pre- pared the Fluidextractum Rosa?, U. S., dose 5 drops to 2 drachms (0.30-8.0), used to flavor other extracts, and the Confectio Rosa?, U. S., and Confectio Rosoe Gallicce, B. P., which are used as bases for pills. Mel Rosoe, U. S., or honey of rose, is employed as a local application or as a vehicle for gargles, and the Syrupus Rosoe, U. S. and B. P., dose 1 to 2 drachms (4.0-8.0), as a flavoring substance. The acid infusion (Infusum Rosx Acidum, B. P.) is given in the dose of 1 to 2 ounces (30.0-60.0). Aqua Rosoe, U. S. and B. P., is used as a diluent or solvent for preparations, such as astringents, which are to be employed locally, as in injections for gonorrhoea. It may also be used internally for these purposes. Unguentum Aqua" Rosa?, U. S. and B. P., is "cold cream," and is largely used as an emollient application to small burns, sores, cuts, scratches and chapped hands and lips. It is much improved if a little glycerin and benzoic acid are added to keep it sweet in warm weather. RUBUS ID^IUS, or RASPBERRY. Rubus Idams, or Raspberry, is used for the preparation of a syrup (Syrupus Rubi Idai), which is employed very largely as an elegant vehicle or flavoring mixture. The leaves are often used in domestic medicine in a decoction or infusion for the cure of diarrhwa when an astringent is needed. RUE. Ruta graveolens is the source from which is derived the Oil of Rue. Physiological Action. — Locally applied, rue is an irritant, producing vesication, and if taken internally in large amount gastro-enteritis, which may be very severe. It is eliminated by the lungs, kidneys, and skin, and its odor is easily recognized in all these secretions. If the dose be poisonous, vomiting, great pain in the belly, and epileptiform convulsions come on, but death has rarely occurred. Therapeutics. — Rue has been used as an abortifacient, but with great danger to the mother. Its action is most uncertain even when poisonous doses are employed. It has been given in colic as a carminative, and seems to be valuable in atonic menorrhagia and metrorrhagia. Oil of rue has been employed for the removal of lumbricoid or rounds worms, but ought not to be so used. The dose of the oil is 3 to 6 minims (0.20-0.40), best given in capsule. SALIC YLIC A OID. 403 SACCHARIN. Saccharin (Benzo-sulpkanidum, U. S. ; Glusidum, B. P.) is a com- pound first prepared by Fahlberg, under the direction of Professor Remsen, of Johns Hopkins University. It is a remarkably sweet substance, two hundred and twenty times stronger than sugar in sweetening power and is a white crystalline powder which is almost odorless. It is used largely to sweeten glucose and in confections. Saccharin escapes from the body unchanged, and is used in place of sugar to sweeten coffee, food, or medicine in cases of diabetes and % ont The dose is indefinite, but it is to be noted that a very few grains will sweeten a large bulk of material. As 1 grain (0.06) is equiva- lent to about 1 teaspoonful (4.0) of sugar, less than 1 grain is the quantity usually given. It is commonly sold in small tablets contain- ing half a grain each (0.03). Physiological Action. — Upon the circulation and similar vital func- tions saccharin has no effect, but Plugge has proved it to retard the action of all the digestive ferments, and to be in consequence harmful to diabetics whose digestion is impaired. SALICIN. Salicin (Salicinum, U. S. and B. P.) is a glucoside obtained from several species of Salix and Populus. In other words, it is obtained from willow-bark. It is crystalline, without odor, and quite bitter, and is soluble in 28 parts of water and 30 of alcohol. Salicin is highly thought of by many practitioners as a substitute for salicylic acid in the treatment of acute articular and muscular rheumatism. It has also been largely used in the treatment of influenza. The dose is from 5 to 40 grains (0.30-2.6) every four hours, and it is best given in capsule or cachet, and washed down with a draught of water or milk after food has been taken. SALICYLIC ACID. Salicylic Acid (Acidum Salicylicum, U. S. and B. P.) occurs in fine white crystals or in fine white powder. It has a sweet yet acrid taste, and is derived from carbolic acid by treating it with caustic soda and carbonic acid at a moderate heat. Sometimes it is derived from plants in which it exists in combination, although the artificial acid is chiefly used. If the crystals are pinkish in hue, the acid should not be used, as it is probably impure. It is soluble in 500 parts of water and 4 parts of alcohol. 404 DRUGS. Physiological Action. — On mucous membranes salicylic acid acts as an irritant. (See Poisoning.) Nervous System. — Upon the nervous system salicylic acid exerts a moderate influence when given in medicinal doses, and causes buzzing in the ears and decrease of the reflexes. In poisonous doses epileptiform convulsions are produced by an action on the brain. Circulation. — Upon the circulation the effects of salicylic acid are not very marked in medicinal dose. It undoubtedly has a depress- ant rather than a stimulant effect, but the depression is very slight. It is sufficient, however, to make the use of the drug in cases of feeble circulation worthy of thought and care. Respiration. — Salicylic acid feebly stimulates the pulmonary vagi and respiratory centre, but if the dose be poisonous death is due to respiratory failure. Medicinally it does not affect this function, Temperature. — The effect of salicylic acid on temperature has been studied by the author with a good deal of care. The drug acts as a distinct antipyretic upon fevered states, and is a slight depressant of normal bodily heat. The studies of Gedl, Fiirbringer, and See also show this, and those of Danewsky point to it. In the experiments of North upon man, after and during exercise, the antipyretic effects were marked. According to the author's studies, the drug lowers fever by diminishing heat-production and increasing heat-dissipation, but this is by no means positively decided as a fact. Absorption and Elimination. — Salicylic acid is absorbed from the stomach as a salicylate of sodium, and so circulates in the blood. It is eliminated by the kidneys and by all the secretions. In the urine it appears as salicyluric acid. According to Kolbe, after a dose of 1 ounce (30.0) elimination does not commence for three hours, but Fleischer found the drug in the urine in one and a half hours. Usually, however, it is far more rapidly eliminated, and, as pointed out by Soullier, after a dose of 15 grains (1.0) it appears in the urine in ten to twenty minutes and after 30 grains (2.0) in five minutes. The elimination continues for a period of from thirty-three to fifty-six hours (Weill). The urine after very large doses is dark olive-green, and this change in color is due to the presence of indican and pyrocatechin, which are formed by the action of the pancreatic juices upon the drug in the intestine. The presence of salicyluric acid in the urine is to be discovered by the addition of a solution of the chloride of iron to that fluid, which causes the appearance of a violet color. Poisoning. — Salicylic acid when taken in excessive dose causes profuse sweating, roaring in the ears, dimness of vision, headache, partial or total deafness, and a decided fall in temperature. The pulse becomes weak and relaxed, and finally ptosis, strabismus, and general paralysis ensue. The urine and feces are passed involun- tarily, and the urine is olive-green in color. The respirations at first are quickened and deepened, but finally become shallow and feeble, death ensuing from respiratory failure. SALICYLIC ACID. 405 If the dose is sufficiently large, the blood is involved and the corpuscles rapidly break down. Therapeutics. — Salicylic acid, owing to its close resemblance to quinine, was first introduced as an antiperiodic and antipyretic, but soon was found to be of inferior value in these states and of super- lative value in rheumatism. At present it is rarely if ever used for either of the former pur- poses, but is largely employed as a standard remedy for the latter disease. (See Rheumatism.) The value of salicylic acid in rheumatism limits itself solely to the relief of pain and the cure of the malady without preventing the complications incident to its course. That is to say, the changes in the joints or heart in rheumatism are only of less frequency after the use of salicylic acid because the drug shortens the disease, and not because it prevents these changes by a direct influence; this is also true of rheumatic hyperpyrexia, where salicylic acid is of service in shortening the attack, though it often fails to control the temperature to any great extent. In acute rheumatism 15 to 20 grains (1.0-1.3) should be given every four hours until marked physiological symptoms occur. With these doses it is wise to give 10 to 15 grains (0.60-1.0) of sodium bicarbonate to prevent irritation of the stomach and because clinical experience has shown that this combination acts better for the cure of the disease than the salicylates alone. Another method is to give 30 or 40 grains at 7 and 9 p.m., with a copious draught of milk, so that the main effects will be produced during sleep. It is to be remembered, however, that in many cases the salicylates seem to be of no value whatever, merely producing sweats and headaches, and it is also worthy of note that nothing else does these cases much good, as they seem bound to run a given course before the patient recovers. If a cure does take place, relapses are very common indeed, and the drug should always be continued for many days after all symptoms cease. Haig has proved that the salicylic compounds all aid in the excretion of uric acid, and thinks they relieve rheumatism in this manner. In gonorrheal rheumatism salicylic acid is of little value, for it has no influence upon the gonococcus in the joints. In rheumatoid arthritis it is valueless. The question as to the value of the salicylates in cases of gout is one open for debate. Some physi- cians regard it as useful, others as useless. Thus Duckworth states that in his experience and that of his friends the salicylates do not compare with colchicum. On the other hand, See, Jaccoud, and Haig find them useful. If they are of any value, it is only when the dose is very large, and even then their usefulness seems to be doubt- ful. In subacute rheumatism citrate or acetate of potassium may be used in place of salicylic acid in the dose of 30 to 60 grains (2.0-4.0), and these salts are to be taken just before going to bed. In lumbago, sciatica, and similar states salicylic acid is a very useful remedy. While it is not so good as phenacetin in neuralgia, it is of great 406 DRUGS. service in the migraine of rheumatic persons, often curing the disease. (See article on Migraine.) Brunton has highly recommended the use of the salicylates with the bromides in the nervous irritability of gouty or lithsemic persons. Salicylic acid has been largely used for the removal of pleural effu- sion if the effusion be serous. Dock believes that the duration of treatment is less with the salicylates than by the use of diuretics, alteratives, or purgatives, but the author has not reached good results from this plan of treatment. The dose should be from 1 to 2 drachms (4.0-8.0) daily. Doses larger than this are not necessary. How sali- cylic acid does good in pleural effusion is not known, for its diuretic properties are not sufficiently great to drain away the liquid by this means. In quinsy or true tonsillitis the drug is thought by some practitioners to act as a specific, particularly when this condition is associated with a rheumatic tendency or goutiness. It will often prevent suppuration, shorten the attack, and relieve the pain and swelling. The doses should be small, say 3 grains (0.20) at each dose, and given hourly. In stomatitis, after the blisters have broken, the burning and pain are often intense, and a mouth-wash of salicylic acid in the proportion of 1 to 250 of water is useful. Ringer recommends the use of the following salve in pruritus of the anus and vulva: fy— Acid, salicylic. . 3ij (8.0). 01. theobromatis 5v (20.0). Cetacese 3iij (12.0). 01. myristicse f3iss (6.0). — M. In the treatment of corns there is probably no better application than lint soaked in a solution of salicylic acid, or the use of the follow- ing formula as a paint, which should be applied after soaking the foot in hot water: 1^ — Acid, salicylic . gr. xxx (2.0). Ext. cannab. indicse gr. v (0.30). Collodii f gss (16.0).— M. S. — Apply with a brush until a good coat is formed. After a few days the corn can be peeled off with ease. A useful salve for the soreness following horseback or bicycle riding is one composed as follows: 1$ — Acid, salicylic. ........ gr. x (0.60). Adip. benzoinat !j (30.0). — M. S. — Apply to the sore part. A solution of salicylate of sodium or of bicarbonate of sodium, applied on lint to inflamed rheumatic joints, often gives great relief. Smearing an ointment of salicylic acid over the joints not only pro- duces good effects locally, but by absorption of the drug influences the disease. (See Rheumatism, Part IV.) SALIC YLIC A CID. 407 In gastric dilatation or catarrh, where vomiting occurs and the matters vomited contain sarcina?, salicylic acid will be found of ser- vice, as it acts as an antiseptic in the stomach. In adults suffering from ascaris lumbricoides , or round-worms, salicylic acid may be used in the dose of 8 grains (0.5) every hour till 40 grains (2.60) are taken. This treatment should be followed by the use of a purge. For thread- or seat-worms the following injection will be found of service: fy— Acid, salicylic 3ss (2.0). Sodii borat gss (2.0). Aquae Oj (480).— M. S. — Warm, and inject into the bowels. For a child reduce this one-half in all its parts. In bromidrosis of the feet (excessive sweating with fetor) salicylic acid may be dusted over the parts, or the following powder used: Py — Acid, salicylic, Pulv. amyli aa gss (16.0).— M. S — Apply to the feet, In eczema of the face and hands, where the eczema is of the wet or weeping variety, salicylic acid, locally applied, is often of great service. ]$ — Acid, salicylic gr. v vel x (0.3-0.60). Pulv. amyli 5ij (8.0). Pulv. zinci oxid 5ij (8.0). Petrolati §ss (16.0).— M. S. — Apply locally. If the eczematous process is subacute and needs stimulation, the salicylic acid may be increased to 20 or 30 grains (1.3-2.0). Contraindications to the use of the salicylates are meningeal inflam- mation or congestion, middle-ear disease, albuminuria, inactivity of the kidneys, particularly that occurring in pregnancy and in Bright's disease. Antiseptic Use. — Salicylic acid is employed as an antiseptic in the treatment of wounds as a local remedy and as a dressing, but should not be applied over too large an area, as it may be absorbed and pro- duce constitutional symptoms. As an application to small burns a mixture of 1 drachm (4.0) of salicylic acid to 8 ounces (240.0) of olive oil is of service. In the treatment of soft chancres and venereal sores salicylic acid has been largely used by some practitioners either as a salve or as a dusting-powder, as follows: fy — Acid, salicylic gr. xx (1.3). Alcohol gtt. xlv (3.0). Adipis benzoinat oij (60.0). — M. Py — Acid, salicylic gr. xv (1.0). Pulv. amyli vel cretae 3ij (8.0). — M. 408 DRUGS. Salicylic acid may be added to urine to prevent its decomposition, but will sometimes cause the reactions for sugar to appear. Patients taking salicylic acid often notice that the urine is odorless after stand- ing, and that it will remain fresh for many days because of the salicyluric acid present in it. It may cause, when taken internally, the reaction of sugar in the urine with Trommer's test. Untoward Effects. — Salicylic acid, as already stated, may produce headache and roaring sounds in the ears. In persons with middle-ear disease it is contraindicated unless urgently called for, as it often makes the deafness permanently worse. Sometimes erythema or acne follows its employment, and blindness and retinal hemorrhages have occurred. Strumpell asserts that delirium of an active character sometimes appears after full doses of salicylic acid, which delirium is usually happy in its type, and is seen most commonly in young girls. Sometimes full doses produce visions which may be seen only when the eyelids are closed. It would be impossible to enumerate all the untoward effects which have been noted, but it is worthy of remark that very few deaths have taken place. 1 Binz thinks that full doses of salicylic acid may produce abortion in women who already have a tendency to abort, and Vineberg thinks that menorrhagia and metror- rhagia are caused by it. Administration. — Salicylic acid has a nauseous taste and is irritant to the stomach. It may be given in a solution of glycerin and water, or its taste may be masked by the use of syrup of bitter orange-peel or syrup of ginger. The following formulae may be used: 1^— Acid, salicylic. 3ij (8.0). Tinct. lavandulse comp f 3iv (16.0). Glycerini fgss (16.0). Aquse destillat q. s. ad f gviij (240.0). — M. S. — A tablespoonful (16.0) every two hours. Or, 1^— Acid, salicylic 3ij (8.0). Glycerini. f 5ss (16.0). Syrup, aurantii f Siv (120.0). Aquse destillat q. s. ad fgviij (240.0).— K. S. — A tablespoonful (16.0) every two hours. Salicylic acid may be used in pill or capsule, but as it is irritant to the stomach in so concentrated a form, it must be taken with water or milk, and should follow rather than precede meals. If buzzing in the ears produced by this acid is annoying, bromide of sodium in the dose of 20 grains (1.3) will generally give relief. Salicylic-acid ointment (Unguentum Acidi Salicylici, B. P.) is a useful preparation for external application in chronic, deep-seated skin diseases. 1 See author's Boylston Prize Essay of Harvard University on Antipyretics. SALOL. 409 Salicylate of Methyl. (See Gaultheria.) Salicylate of Sodium. Salicylate of Sodium (Sodii Salicylas, U. S. and B. P.) is a less irritant and somewhat less disagreeable preparation than salicylic acid. Its internal action, use, and doses are the same as those of the acid. It may be given by dissolving it in milk, and then adding rennet to produce a curd, which disguises the taste and protects the stomach. Other salicylates are largely used by some practitioners. Salicylate of lithium is supposed by some physicians to be of more value than the other salts. (See Aspirin and Salophen.) SALOL. Phenyl Salicylas, U. S., Salol, B. P., is a white crystalline powder, faintly aromatic and almost without taste. It is not soluble in water, but is in alcohol, and an alcoholic solution forms an imperfect emulsion when mixed with water. Salol is also slightly soluble in copaiba, in the oils of sandal-wood and of turpentine, and in mineral oils. This solu- bility is very useful in prescribing it with these remedies in certain diseases of the genito-urinary apparatus. (See Gonorrhoea.) Salol is a compound of 60 parts of salicylic acid and 40 of carbolic acid, and is decomposed by the pancreatic juice into these two sub- stances. For this reason overdoses are capable of producing symp- toms of carbolic-acid poisoning. Thus 20 grains of salol (1.3) taken five times a day will cause a man to take 40 grains (2.60) of carbolic acid, which is almost a poisonous dose. Hesselbach has proved that large doses of salol are very apt to affect the kidneys unfavorably, and rightly believes it to be contra- indicated in all cases of renal inflammation of an acute type. It is worthy of note that the drug rarely produces untoward effects, although at one time a number of observers accused it of frequently doing so. Salol is used for the same purposes as salicylic acid in the treat- ment of rheumatism when the stomach is so irritated that it cannot bear the latter drug, as salol is dissolved in the small intestine. A dose often used is 5 grains (0.30) an hour, but this is too much, as a rule, and may produce renal irritation. Salol is also useful in muscular rheumatism and neuralgia due to exposure. In pharyngitis 5 grains (0.30) of salol, given three times daily, is a valuable part of the treat- ment of the affection, and in persons subject to chronic sore throat due to the uric-acid diathesis this treatment will often produce ex- 410 DRUGS. traordinary results. It is of the greatest use in duodenal catarrh and catarrhal jaundice to arrest intestinal fermentation. In the treatment of gonorrhea in all its stages salol may be employed by the mouth, as in its elimination it sterilizes the urine and tends to disinfect or sterilize the urethra at each act of micturition. (See Gonorrhoea.) Salol is of great value in intestinal indigestion and fermentation, and is sometimes used in cases of mild or pernicious anamia when it is thought that the development of decomposition products is their cause. (See Ansemia.) In diarrh&a dependent upon such causes salol is one of the best remedies we have, since it renders the intestinal canal antiseptic, and so removes the cause of the disorder, instead of locking the putrid material in the bowel, as does opium. In cholera morbus the following is very useful: 1$ — Phenyl salicylatis 5j (4.0). Bismuth, subnitrat 5ij (8.0). Misturse cretse q. s. ad fgiij (90.0). — M. S. — Two teaspoonfuls (8.0) every two hours. Wide experience with the drug in the treatment of cholera during recent epidemics has proved it to be one of the best remedies that can be employed in the treatment of this disease. Salol may be given in wafers, capsules, or pills, in the dose of 5 grains (0.3) or more. SALOPHEN. Salophen (Salophenum) has been introduced into medicine as a sub- stitute for salol, and is said to possess the advantage of being far less poisonous than salol, because in this case the phenol of the salol is replaced by a compound of phenol which is innocuous. Experiments on animals seem to indicate that these theoretical advantages are present in fact. Like salol, salophen is broken up in the intestine by the juices there present, and the result is salicylic acid and acetyl- paramidophenol. Salophen contains about 10 per cent, less salicylic acid than does salol (51 per cent.), and appears in the form of thin, white laminse nearly insoluble in water. It is tasteless. Therapeutics. — For the therapeutics of salophen the reader is referred to the article on Salol, as the indications for both drugs are identical, save that salophen can probably be used when salol cannot be em- ployed. The dose of salophen is from 5 to 20 grains (0.30-1.3) three times a day. It can be very effectually combined with phenacetin in the treatment of neuralgia. In subacute rheumatic affections it is certainly very useful. SANDAL- WOOD OIL. Sandal-wood Oil (Oleum Santali, U. S. and B. P.) is derived from the wood of Santalum album, a tree of India, and has a hot, burning taste. The odor is very pleasant, and the oil has been used as a per- SANTONIN. 411 fume. In overdose the oil is capable of producing great irritation of the genito-urinary passages. Therapeutics. — The oil of sandal-wood is much used by genito- urinary surgeons in chronic gonorrhoea and gleet for the purpose of stimulating depraved mucous membranes to proper action, and in chronic cystitis to act as a tonic to the bladder. In the subacute or later stages of bronchitis, when the expectoration is thick and ropy and the cold is not readily "thrown off," the oil of sandal-wood is efficacious. Daggett strongly recommends its use in cases of asthma associated with marked catarrhal symptoms, and 'in the excessive cough following influenza it is of great value. In all cases it should be given in capsule in the dose of 5 to 20 minims (0.30-1.3), 5 minims (0.30) being usually sufficient, although drug- gists generally keep it in 10-minim (0.60) capsules. Oil of sandal- wood may irritate the stomach, but it is not so apt to do so as is cubebs or copaiba. SANGUINARIA. Sanguinaria, U. S., or Blood-root, is the rhizome of Sanguinaria canadensis, and has been largely used in medicine, but is a dangerous remedy, possessing more power for harm than good. Its chief alkaloid is sanguinarine. Poisoning. — Sanguinarine in poisonous dose causes vomiting, purg- ing, profuse salivation, and finally tonic convulsions which are spinal in origin. Death is due to respiratory failure, but the circulation is much decreased in force and frequency. Therapeutics. — The employment of sanguinaria in chronic bron- chitis is about the only purpose for which it is now employed to any extent. As an emetic in croup it has been largely used, but is too irritating and depressing, and ought not to be so employed. According to Bartholow, the drug acts as an hepatic stimulant, and is of service in g astro-intestinal catarrh and jaundice. Administration.— The dose of the fluid extract (Fluidextr -actum Sanguinaria?, U. S.) is 1 to 5 minims (0.05-0.30) as an expectorant, or 10 to 30 minims (0.60-2.0) as an emetic. If the drug does not cause vomiting after an emetic dose, it must not be allowed to remain in the stomach, as it is poisonous. The tincture ( Tinctura Sanguinaria?, U. S.) is the best preparation to use, and may be given in 20- to 30- minum (1.30-2.0) doses as an expectorant, and 1 to 3 drachms (4.0-12.0) as an emetic. The vinegar (Acelum Sanguinaria:) is no longer official, but is given in the dose of 10 to 30 minims (0.60-2.0), and as an emetic in the dose of 2 to 4 drachms (8.0-16.0). SANTONIN. Santoninum, U. S. and B. P., is neutral in principle derived from Levant Worm-seed or Santonica, which is the unexpanded flower- heads of Artemisia pauciflora (Maritima, B. P.), a plant of Asia 412 DRUGS. Minor and Turkestan. Santonin is soluble in alcohol and chloro- form, but less so in water. Santoninic acid is formed by warming santonin with alkalies, and Hesse has found that santonin is an anhydride of santoninic acid. Santoninic acid is more soluble than santonin. Poisoning. — Santonin causes, when taken in overdose, muscular tremors, convulsive movements, unconsciousness, and sometimes epi- leptiform convulsions. One of the most common symptoms of the poisoning is chroma- topsia or xanthopsia, during the existence of which all objects look yellow. This is due to the staining of the humors of the eye by the drug. This may go on to total blindness or pass away in a few days. If the vision is not yellow, it may be green. The urine is also stained — ■ first yellow, then saffron, and finally purple-red, or is bloody-looking. This is not due to the presence of blood, but to the drug. Poisonous doses of the drug do not cause gastro-enteritis. Therapeutics. — Santonin is used for the removal of the round-worm, and is very efficacious. It has no influence on the tape-worm. It should be given in the manner of all vermifuges (see Worms) — namely, at a time when the alimentary canal is empty. Santonin is said to have a distinct influence over vision, increasing, in medicinal amount, its acuity whenever the optic nerve is at fault. In urinary incontinence santonin will often produce a cure after all other remedies fail. Santoninate of sodium (Sodii Santoninas) is a useless, harmful preparation, never to be employed except for the benefit of the eye when vision fails through disease of the optic nerve. Introduced into medicine because of its solubility, it is absorbed into the system, which is just what is least desired in an anthelmintic, which should seek the worm in the bowel, not by entering the blood. In eye affec- tions the dose may be from 2 to 8 grains (0.12-0.50) a day, accord- ing to the age of the adult. Santonin may also be given in the dose of 1 to 2 grains (0.06-0.12) to an adult in capsule or wafer. The crystals should be used, not the powdered santonin. Immediately after the drug is used, a 2- or 3-grain (0.12-0.20) dose of calomel is to be taken, and followed by a saline purge six hours later, as the flow of bile caused by the mercurial is particularly useful in making the worm let go its hold. Untoward Effects. — In addition to the curious effects already named santonin may cause urinary incontinence even in medicinal dose. Administration. — Santonin is best given in the form of a troche or lozenge (Trochisci Santonini, U. S. and B. P.), 1 grain (0.06) each, but it is to be distinctly borne in mind, and written on the prescrip- tion, that the Trochisci Sodii Santoninatis of the U. S. P. of 1880 are not to be sold to the patient. The troches of santonin itself are now official in the U. S. P., but if the physician prefers to write for troches, they can be made as follows: SA VINE. 413 Py — Santonini gr. v (0.3). Pulv. sacchari alb 5iij (12.0). Pulv. acacise gr. viij (0.5). Misce bene, et adde Acacise mucilag gtt. xvj (1.0). Aquae q. s. Ft. in troches No. x. S. — One or two lozenges, as directed. SARSAPARILLA. Sarsaparilla, U. S., is the root of Smilax officinalis, Smilax ornata, and other species of Smilax, growing chiefly in Central America. It is known in the B. P. as Sarsce Radix. The drug is devoid of any marked physiological action, yet seems to possess some power over the general condition of the system. Thus while sarsaparilla seems utterly with- out effect in the hands of most physicians when given alone, it often seems to do good and to increase the effects of other drugs when com- bined with them, so that some cases of syphilis which are of an obsti- nate character are said to yield to iodide of potassium and sarsapa- rilla when the iodide alone fails. Sarsaparilla is largely used in domestic medicine as a " blood-purifier," and is a prominent con- stituent of many patent medicines. It is useless for such purposes and is a much overrated remedy. Administration. — Sarsaparilla is most commonly given in the form of the compound syrup (Syrupus Sarsaparilla Compositum, U. S.), composed of sarsaparilla, sassafras, liquorice, gaultheria, anise, and senna, dose 1 to 4 fluidrachms (4.0-16.0). (See Iodide of Potassium.) The other official preparations of the U. S. P. are the compound fluid extract (Fluidextr actum Sarsaparilla Compositum) , similar to the syrup in composition, dose J to 1 fluidrachm (2.0-4.0) ; and the fluid extract (Fluidextr actum Sarsaparilla) , dose | to 1 fluidrachm (2.0-4.0). The B. P. preparation is a liquid extract (Extractum Sarsa Liquidum), dose i to 4 fluidrachms (2.0-16.0); and Liquor Sarsa Compositus Concentratus, dose 2 to 8 drachms (8.0-30.0). i SAVINE. Sabina, U. S., is the tops of Juniper us sabina, an evergreen shruo of Northern Europe, Asia, and America. It contains and official volatile oil (Oleum Sabina, U. S.). Locally applied, it is more of a counterirritant than is turpentine, and if swallowed in poisonous amount causes nausea, vomiting, gastro-enteritis, unconsciousness, suppression of urine and death. If the individual be a pregnant female, abortion takes place as death approaches, but very rarely before this time. Profuse flooding nearly always accompanies the abortion and the drug cannot be used to empty the uterus with any safety. 414 DRUGS. Therapeutics. — The oil, taken in the dose of 5 to 10 minims (0.30- 0.60), repeated every three or four hours, acts as a powerful stimulant to the uterus and ovaries, causing hyperemia and aiding in the pro- duction of menstruation in cases of amenorrhoea. It may also be employed with advantage in some cases of menorrhagia. The drug is best given in emulsion or capsule. The fluid extract (Fluidextractum Sabince, U. S.) is given in the dose of 5 to 15 minims (0.30-1.0). SCAMMONY. Scammonium, U. S., Scammonia? Radix, B. P., is a gum-resin from the root of Convolvulus scammonia, growing in Asia Minor and Syria. Its active principle is sometimes called jalapin. Therapeutics. — Scammony is an irritant, drastic, hydragogue purge, which causes a good deal of griping and exerts a cholagogue effect. If an inflammatory condition of the bowels is present, its use is contra- indicated. The ingestion of poisonous doses is to be followed by treatment suitable for gastro-enteritis. Scammony is given in the dose of 2 to 5 grains (0.12-0.30), always in combination with some other similar drug — as, for example, colocynth. Scammony forms part of the com- pound extract of colocynth (Extractum Colocynthidis Compositum, U. S. and B. P.), the dose of which is 1 to 3 grains (0.12-0.20) as a laxative or 5 to 20 grains (0.30-1.3) as a purge. The resin (Resina Scammonii, U. S.; Scammonice Resina?, B. P.) is given in the dose of 3 to 8 grains (0.20-0.50). The B. P. preparations of scammony are Pilida Scammonii Composita, dose 5 grains (0.30); and Pulvis Scammonii Compositus, dose 10 to 20 grains (0.60-1.3). The last two preparations are composed of scammony, ginger, and jalap. SCOPOLAMINE. Scopolamine, or Hyoscine, is an alkaloid derived from scopola (U. S.) the root of Scopolia atropoides, a plant of Southern Europe, which possesses medicinal powers closely resembling those of bella- donna and its sister drugs. Its physiological action is closely allied to that of the alkaloids of hyoscyamus. As stated in the article on Hyoscine, it has been introduced in its stead. The terms hyoscine and scopolamine are used interchangeably. (See Hyoscine.) Hyoscine itself is rarely employed, the hydrobromide (Scopolamine Hydrobromidum, U. S.) being preferable. It also occurs as the hydrio- date and hydrochloride. The extract of scopola (Extractum Scopola?, U. S.) is given in the dose of i to \ grain (0.008-0.015) and the fluid extract (Fluid- extractum Scopola?, U. S.) in the dose of \ to 3 minims (0.025-0.20). SCOPARWS AND SPARTEINE. 415 SCOPARIUS AND SPARTEINE. Scoparius, U. S. (Scopari Cacumina, B. P.), or Broom, is the tops of Cytisus scoparius. It contains scoparin and sparteine, the first being a crystalline principle and the second a liquid alkaloid. The second (sparteine) is the alkaloid used in medicine in the form of a sulphate (Sparteine? Sulphas, U. S.), which is a crystalline salt readily soluble in water. Physiological Action. — As scoparius depends for its medicinal value almost entirely upon sparteine, what is here said applies to both the crude drug and the alkaloid. Nervous System. — Sparteine acts on the nervous system very decidedly if given in large doses, depressing the brain and spinal cord, chiefly in the motor tracts of the latter, thereby causing a decrease of reflex action and motor power, ending in complete paralysis. These changes occur both in man and in the lower animals. Circulation. — Upon the circulation sparteine acts as a stimulant. It quickens the pulse-rate in moderate doses, and also raises arterial pressure. The force of the contraction • of the ventricles is also in- creased. In large poisonous doses the drug acts as a circulatory depressant. Respiration. — Upon this function sparteine, in small amounts, has no effect, but poisonous doses kill by paralysis of the respiratory centre. Poisoning. — The symptoms of poisoning consist in trembling and inco-ordination of movement, and clonic and tonic convulsions, fol- lowed by a second stage of depression of the nervous system and general enfeeblement. Therapeutics. — Sparteine has been recommended in all states of the heart in which digitalis is of service, and it is sometimes useful in those fairly frequent cases where digitalis fails. In cardiac arrhythmia or palpitation it is thought to be of great service by those who have used it most. Clark found it of value in Graves' disease and in nearly every circulatory abnormality, but in the judgment of the author sparteine is not a very useful drug — one only to be turned to as a last resource after more generally used remedies fail ; or, in other words, it is not a remedy to be employed as a " stand-by " in the manner in which digitalis is used. While some clinicians have found sparteine of value, many have not. In the few cases in which it has been used by the writer it failed to be of service, perhaps because the cases were desperate and the drug was tried after all the other remedies had failed. The dose is as variable as its action. Some state it to be 2V g ram (0.003), while still others recommend 2 to 4 grains (0.12-0.25). A small dose should be used at first, and rapidly increased until some effects ensue. To get the 416 DRUGS. best effects it should be given every two hours in the dose of \ grain. The drug should be given in watery solution. Potts claims to have found sparteine of value in the treatment of tremor, as in paralysis agitans, in the dose of \ to J grain (0.015- 0.03) three times a day. Scoparius itself is used in decoction, made by adding \ ounce (16.0) of the broom-tops to a pint (480) of water, and boiling them down to a i pint (240). Of this, an ounce should be taken every three houis. This decoction is one of the most efficient diuretics in cardiac dropsy. The official preparations of the B. P. are an infusion (Infusum Scoparii), and the juice (Succus Scoparii), dose 1 to 2 drachms (4.0-8.0). SEIDLITZ POWDER. Under the official name of Pulvis Effervescens Compositus the U. S. P. recognizes a purgative powder {Pulvis Soda? Tartar ata? Effervescens, B. P.) made by taking the bitartrate of sodium and potassium, or Rochelle salt, 120 grains, and bicarbonate of sodium 40 grains, which are wrapped in blue paper, and 35 grains of tartaric acid placed in a white paper. The contents of each paper are dissolved in water — half a tumblerful — and the two solutions added to one another and swallowed during effervescence. As much as two powders may be used, but this is generally too large an amount unless full purgation is needed. In sick stomach associated with constipation, when a whole powder cannot be retained, the two powders should be divided into fourths, and a fourth added to a fourth dissolved in a half-wineglassful of water and taken every fifteen minutes until the entire powder is ingested. This will often settle the stomach and produce pur- gation. SENEGA. Senega, U. S. (Senega? Radix, B. P.), is the root of Polygala senega, a small plant of the United States, containing a principle known as polygalic acid and senegin. Therapeutics. — Senega is used in medicine as a stimulating expec- torant in the subacute and chronic forms of bronchitis. It has also been employed as a diuretic in cardiac dropsy or that due to renal disease. In cardiac disease it should not be used, and indeed it is rarely employed at present except in combination with other drugs in expectorant mixtures. Administration. — Senega is used in the form of the fluid extract (Fluidextr actum Scnegoe, U. S.), dose 10 to 20 minims (0.60-1.3) and the syrup (Syrupus Senega?, U. S.), dose 1 to 2 drachms (4.0-8.0). It SENNA. 41 7 is also used in Coxe's Hive Syrup. The official preparations of the B. P. are — a tincture (Tinctura Senega?), dose 1 to 2 drachms (4.0-8.0), and an infusion (Injusum Senegce), dose 1 to 2 ounces (30.0-60.0). SENNA. Senna, U. S., is the most drastic of the laxative purges used for the relief of constipation. It is the leaflets of Cassia acutijolia and Cassia angustifolia, and contains a very acrid irritant purgative principle known as cathartic acid. Senna is official in the B. P. as Senna Indica and Alexandrina. Physiological Action. — Senna acts as a purge, producing copious stools, often with much griping if it is used alone. According to Rutherford and Vignal, it materially increases the flow of bile, but it is seldom, if ever, used in medicine as a cholagogue, although, according to Prevost and Binet, cathartic acid has an influence over biliary secretion. Hess has found that the drug acts directly as a stimulant upon the mucous membranes, and so produces a local peri- stalsis as it is moved along. It is also known that the drug is eliminated in the milk, and for this reason care should be taken in giving the drug to nursing mothers, as it will purge the nursling. Administration. — Senna is generally combined with other drugs for the relief of constipation, but may be used alone. If this is done, the fluid extract (Fluidextr actum Senna?, U. S.) may be employed in the dose of 1 to 2 drachms (4.0-8.0) to a child or 4 drachms (16.0) to an adult. It is, however, always better to give children the more agreeable confection (Confectio Senna? , U. S. and B. P.) in the dose of | drachm (2.0) to a child, or 1 to 2 drachms (4.0-8.0) to an adult. As the confection is apt to cause gastric disorder if used continuously because of the sugar contained in it, its use is limited to a small class of cases. In the treatment of the constipation of pregnancy senna is thought to be very useful. In these cases and in others where cascara sagrada alone will not move the bowels, senna may be prescribed as follows: J^— Ext. sennae fluid. . . . . . . f §ij (60.0). Ext. cascarse sagradae fl. . . . . . f§j (30.0). — M. S. — Teaspoonful (4.0) at night, or night and morning. Should this produce griping, \ to 1 minim (0.025-0.05) of fluid extract of belladonna may be added to each dose. Under the name of Black Draught a mixture of senna, manna, fennel, and sulphate of magnesium has been largely used (Injusum Senna? Compositum, U. S.) in the dose of 4 ounces (120.0). It is an active hydragogue purge. The syrup (Syrupus Senna?, U. S. and B. P.) is given in the dose of 1 to 4 drachms (4.0-16.0). 27 418 DRUGS. One of the best ways to use senna is in the compound liquorice powder (Pulvis Glycyrrhizce Compositus, U. S. and B. P.), which is a good laxative in the dose of 20 to 30 grains (1.3-2.0). Compound liquorice powder is composed of senna, liquorice, oil of fennel, washed sulphur, and sugar. Injusum Serines, B. P., is given in the dose of 1 to 2 ounces (30.0- 60.0); Mistura Sennoe Composita, B. P., in the dose of 1 to 2 ounces (30.0); and Tinctura Serines Composita, B. P., in the dose of 1 to 4 drachms (4.0-16.0). Liquor Senna? Concentratus, B. P., is given in the dose of 1 drachm (4.0). Senna, because of its chrysophan, may stain the urine carmine if that fluid is alkaline, or yellow if it is acid. No alarm should be felt if either color appears in this secretion. Often it is necessary to warn the parents of a child of the possibility of such an occurrence, in order to prevent alarm on the part of the mother, who otherwise might think that hematuria was present. SERPENTARIA. Serpentaria, U. S. (Serpentaria? Rhizoma, B. P.), or Virginia Snake- root, is the rhizome and rootlets of Aristolochia serpentaria and Aristo- lochia reticulata, plants of the Southern United States. It contains an active principle, aristolochin, which is never used in medicine. Therapeutics. — Owing to the rather pleasant, warm taste of ser- pentaria, and the fact that it stimulates secretion, it is used largely as a vehicle for other more potent remedies. It has tonic properties, and in consequence has been largely used in the treatment of atonic dyspepsia and indigestion. It is said to be a sexual stimulant, but this is doubtful, to say the least. In overdose it is an irritant, and will cause vomiting and purging if large amounts are taken. Administration.— Serpentaria is given in the form of the fluid extract (Fluidextractum Serpentaria?, U. S.) in the dose of 10 to 40 minims (0.60-2.6), and the tincture (Tinctura Serpentaria, U. S. and B. P.) in the dose of J to 1 drachm (2.0-4.0). It also enters into Huxham's Tincture of Cinchona (Tinctura Cinchona? Composita, U. S. and B. P.). Injusum Serpentaria?, B. P., is given in the dose of 1 to 2 ounces (30.0-60.0). SILICATE OF POTASSIUM OR SODIUM. Soluble Glass, or Silicate of Potassium or Sodium, occurs as a clear, syrupy fluid. It is used as a splint in the dressing of fractures and sprains, as it rapidly becomes hard and immovable when painted over the bandages. Silicate of. potassium or sodium may be universally substituted for plaster of paris. The solution of silicate of sodium is no longer official. SOAP. 419 SOAP. Sapo, U. S. (Sapo Durus, B. P.), is prepared from any alkali and fixed oil, although soda and olive oil are most frequently employed in the manufacture of the soaps which are used medicinally. Castile soap, if good, is the best representative of a pure soap. Soap may be cut into the form of a suppository and used to pro- voke movements of the bowel in young children who are suffering from constipation, by placing it just inside the anus, having previously dipped it into water an instant to make it slippery. It may also be used as an enema, dissolved in warm water, or a mixture known in Philadelphia as the "House Mixture" may be employed in the case of an adult. This consists of a mixture of water, soft-soap, and molasses in varying proportions, and if flatulence is present turpentine and olive oil are added to it. The preparation is as efficient as it is cheap aud dirty. Soap is also used as an antidote to many poisons and as an aid to emetics. Green Soap (Sapo Mollis, U. S. and B. P.) is not generally green, but brown. It is a soft soap made by the use of potash and olive oil, and is largely used by dermatologists in the treatment of eczema and similar skin diseases where a detergent, stimulating application is needed. It is sometimes called " German soft soap," to distinguish it from the ordinary soft soap, or the common sapo mollis, of the United States, which is an impure substance often made of rancid fats, containing a large excess of alkali and never used except for scour- ing purposes. Green soap is employed not only as green soap, but also in the liniment (Linimentum Saponis Mollis), which is to be thoroughly rubbed into the part when used medicinally, well washed off, and afterward simple cerate or some other soothing salve applied. Soap Liniment (Linimentum Saponis, U. S. and B. P.), or Opo- deldoc, as it is called in domestic medicine, is largely used for rubbing stiff muscles and sprains. It is generally employed to carry more active external remedies, such as opium or aconite. 1$ — Tinct. aconiti, Tinct. belladonnae, Tinct. opii . . aafgij (8.0). Liniment, saponis . . . . q. s. ad f J vj (180.0). — M. Soap plaster (Emplastrum Saponis, U. S. and B. P.) is used as a thick, heavy protective for bed-sores or where the formation of bed-sores is feared. It is also used as a support about sprained joints. 420 DRUGS. SODIO-SALICYLATE OF THEOBROMINE. This compound, known as Diuretin (or sodio-theobromine-salicy- late), derives its name from the extraordinary power which it is said to possess of producing a great increase in the urinary flow from the kidneys. This power depends entirely upon the theobromine, which is a crystallizable, volatile, bitter alkaloid, closely allied to caffeine and xanthine, and derived from the seeds of Theobroma cacao, or the source of ordinary chocolate. Owing to the insolubility of theo- bromine, it has been found necessary to combine it with sodium salicylate, as under these conditions it is readily absorbed. The diuretic properties of this alkaloid were first discovered during a series of experiments made by Schroder, in Strasburg, in 1889, who found that the diuresis produced in man and the lower animals was marked. Many clinical trials in Europe and America have confirmed his observations, but there are a number of cases in which it signally fails, particularly in chronic Bright's disease. Theobromine does not have so stimulating an effect on the heart as does its relative caffeine, so that the circulatory effect, while showing a stimulant rather than a depressing tendency, is very slight. It slightly increases muscular power, but its peculiar affinity for the renal struc- tures surpasses all its other activities. As the action of the drug depends upon its ability to stimulate the secreting epithelium of the kidney, the physician should remember that in cases of advanced renal disease, where the secreting structures are almost entirely destroyed, no result can be expected from its administration; but it is probable that the drug is useful in almost all conditions of dropsy, whether due to renal inactivity or cardiac disease, and is harmless to the patient even if the diuretic effect does not ensue. The only contraindication to the use of theobromine or diuretin is the presence of acute nephritis, when, of course, sedatives rather than stimulants are needed. So far as the writer is aware, no study as to the proportion of solids and liquids in the urine of patients under the influence of this drug have been made, but the fact that it stimulates the epithelium or secreting structures of the kidney would indicate that the solids are increased. As diuretin contains only from 30 to 50 per cent, of theobromine, it has to be given in very large amounts, as much as 1 to 2 drachms (4.0-8.0) in twenty-four hours, preferably in divided doses of from 10 to 20 grains (0.60-1.3) in capsule or in warm water. The former method is the better, as the taste of the drug is disagreeable and soapy. Diuretin must not be exposed to the air, as it undergoes decom- position. In all the cases in which the writer has tried sodio-salicylate of theo- bromine he has failed to see any effect produced, and, while he has no confidence in the drug, he mentions it because others claim to have obtained good results from its use. SODIUM. 421 SODIUM. Sodium is a metallic element, the salts of which are usually white and colorless. It is not used in medicine, but many of its salts are employed. While potassium acts as a depressant to the body, sodium seems to exert comparatively little effect upon the animal economy. The salts vary in their power with the acid forming them. (See Ben- zoate of Sodium, Chloride of Sodium, Salicylate of Sodium, etc.) Acetate of Sodium (Sodii Acetas, U. S.) is rarely if ever used in medicine as a substitute for acetate of potassium. The dose is 20 to 40 grains (1.3-2.60) three times a day. Sodium Bicarbonate. Bicarbonate of Sodium (Sodii Bicarbonas, U. S. and B. P.) is largely used as an antacid in gastric fermentation and in sick headaches arising from this condition. Combined with calomel in powder, it certainly adds to its efficiency in increasing biliary flow, as all alkalies of this class liquefy and thin the bile. The drug has been widely employed in the treatment of rheumatism, and is found to be of great service in allaying pain and soreness in the joints when used in a lotion made by dissolving it in water and applying it to the part on lint or rags. In acidity of the stomach the following effervescing powder is useful: Bicarbonate of sodium (Sodii Bicarbonas) , 30 grains (2.0) in one paper, and in the other 5 grains (0.3) of tartaric acid (Acidum Tartaricum). These are each dissolved in half a tumbler of water, added to one another, and swallowed during effervescence. Sodium Cacodylate. Cacodylate of sodium is a white amorphous powder which readily dissolves in water. Its uses in medicine are practically identical with those of arsenic. (See Arsenic.) The drug is capable of being admin- istered hypodermically without disagreeable local or general symptoms. It has seemed to act well in the debility and anosmia of tuberculosis. The dose is \ to \ grain (0.015-0.03) subcutaneously, and 2 to 4 grains (0.12-0.25) by the mouth. Some of those who have used it most assert that its use by the stomach causes not only a strong, garlicky odor on the breath, but also gastric irritation. Gautier has advised the following formula for hypodermic use: i& — Sodii cacodylat '. . gr c (6.6). Aquae destillat fgiij (90.0). Phenolis . n\J (0.05). This mixture is to be boiled, filtered through a sterile filter, and 3 ounces (90.0) of distilled, sterile water added. The hypodermic dose of this is from 15 to 20 minims (1.0-1.3). 422 DRUGS. It is important to remember that the reason cacodylate of sodium can be taken in such large doses is that it is too stable to be broken up in the body, and therefore is, in large part, useless for the purpose of producing a rapid arsenical effect. Sodium Chloride. Chloride of Sodium (Sodii Chloridum, U. S. and B. P.), or Common Salt, is a useful drug and food, aiding in maintaining the alkalinity of the blood and tissues and in the formation of gastric juice, being changed by the lactic acid of the stomach into lactate of sodium, thereby setting free hydrochloric acid, which acts not only by aiding digestion, but in the production of pepsin from the pepsinogen of the gastric tubules. The dose is 10 to 20 grains (0.60-1.3). Sodium Ethylate. Sodium Ethylate is a whitish powder, decomposed in the presence of water into alcohol and caustic soda, but soluble in absolute alcohol without decomposition. Sodium ethylate is employed in medicine as a depilatory — that is, for the purpose of removing hairy growths. To accomplish this pur- pose it is necessary that the growth be clipped close to the skin, and that the drug be dissolved in absolute alcohol and applied over the roots of the hair with a glass rod. Soon after this application a crust forms, which should not be detached for two or three weeks, but which, on its removal at the end of this time, generally shows that all the roots of the hair have been destroyed. If not, the operation may be repeated as soon as the skin is in a condition to bear it. To prevent pain, a 5 per cent, solution of cocaine may be used hypodermically at the spot to be cauterized. It is worthy of remem- brance that moles and small birthmarks, or nsevi, may be removed by a similar application. Small scars may result. A solution, Liquor Sodii Ethylatis, is official in the B. P. Sodium Sulphate. Sodii Sulphas, U. S. and B. P., or Glauber's Salt, is one of the most irritant of the saline purges, rarely used in medicine for human beings, but largely employed by veterinarians. The purgative dose for man is \ to 1 ounce (16.0-30.0). If any intestinal inflammation is present, it is contraindicated. It produces large watery stools, with a good deal of griping. Sulphate of sodium is a prominent constituent of Carlsbad water, Hunyadi Janos, Hunyadi Arpad, and similar waters. (For an explanation of the action of salines in producing purgation, see Magnesium Sulphate.) Reverdin has recently claimed that small doses of 2 grains (0.12) of SOMNAL. 423 sulphate of sodium every hour are of great value in controlling capil- lary hemorrhages and for graver hemorrhages. It must be given by the mouth or intravenously. If given hypodermically he asserts it is useless. Under the name Sodii Sulphas Efjervescens the B. P. recognizes an effervescent preparation of sodium sulphate, given in the dose of 2 to 4 drachms (8.0-16.0). Sodium Sulphocarbolate. (See Phenolsulphonates.) Sodium Thiosulphate. Thiosulphate of Sodium, U. S. or Hyposulphite of Sodium, occurs in large, transparent, colorless plates which effloresce when exposed to the air. It has a slight alkaline reaction, and is soluble in about equal parts of water, but insoluble in alcohol. Therapeutics. — Thiosulphate of sodium is used in the proportion of 1 drachm (4.0) to the ounce (30.0) of water or lard in the treatment of parasitic skin diseases, particularly those due to the tricophyton fungus, such as pityriasis versicolor. It is also efficacious, locally applied, -in rhus poisoning, and in cases of pruritus due to other causes, in the strength of \ drachm (2.0) to the ounce (30.0) of water. In malarial hematuria hyposulphite of sodium is often given with advantage in the dose of from 10 to 30 grains (0.60-2.0) every four hours. How it acts in this condition is not known. SOLANUM CAROLINENSE. Solanum Carolinense, or Horse Nettle, is a low perennial plant of the natural order Solanaceee, a native of the Southeastern United States. According to studies made by Thornton, the drug depresses the cerebrum, but excites the spinal cord. It has been introduced into medicine for the purpose of relieving epilepsy, particularly when the disease occurs in childhood. In a limited employment of the drug the author has found it serviceab e in diminishing the frequency and severity of the attacks. The beginning dose of the fluid extract is 15 to 60 minims (1.0-4.0) three times a day, but it may be increased to as much as 2 drachms (8.0) at a dose with advantage. SOMNAL. Somnal is stated to be ethylated chloral urethane, and seems to possess marked hypnotic power. It is a clear, colorless liquid, possess- 424 DRUGS. ing a hot, burning taste, resembling that of sweet spirit of nitre. The dose is 20 to 40 minims (1.3-2.6) in liquorice-water or syrup of rasp- berry, and the sleep produced by it is said to last seven to eight hours. In a number of cases in which the writer has used it, it acted satisfactorily, although drowsiness was usually present the next day. S0Z0I0D0L. Sozoiodol is an antiseptic preparation first made and employed by one of our own countrymen in San Francisco, but at that time the preparation of it was so imperfectly carried out that foreign matters made it too irritating for general use. It was therefore discarded, only to be better prepared and more widely used in Germany some years later. Therapeutics. — Sozoiodol has been found of value as an antiseptic and disinfectant in the treatment of wounds which are in an unhealthy state, and for acute stomatitis and pharyngeal catarrh it may be em- ployed locally in the form of a 5 per cent, watery solution. It has also been found useful in acute 'purulent conjunctivitis and in oph- thalmia neonatorum, in the proportion of 2 parts of sozoiodol to 30 parts of water. In urethritis of a specific type the preparation known as zinc-sozoiodol may be employed in a 2 per cent, solution with advantage, and this compound is also of value in mild and malignant vaginitis if preceded by pyroligneous acetic acid or nitrate of silver, applied by means of a speculum. In the treatment of gynecological cases, particularly in catarrh of the cervix uteri, Nitschman uses sozoiodol in the form of a powder applied by means of a tampon with good results, and it would seem to be worthy of trial in many other states of the mucous membranes than those just named. SPIGELIA. Spigelia, U. S., Pinkroot, is the root and rhizome of Spigelia mari- landica, or Carolina Pink, a plant of the Southern United States. Poisoning. — The symptoms of poisoning by spigelia closely resemble those of belladonna poisoning. Therapeutics. — Spigelia is one of the most efficient remedies in the treatment of round-worms, and is not dangerous when given with care. When employed for the removal of worms, the usual precaution should be taken in regard to the ingestion of food (see article on Worms), and the drug should be followed by a purge to sweep out the worm while it is narcotized. The purge should be one which is rapid in its action, such as the sulphate of magnesium. Administration. — The dose of spigelia in the form v>( the fluid extract (Fluidextr actum Spigelia*, U. S.) is 2 drachms (8.0) ; that of the un- SQUILL. 425 official fluid extract of spigelia and senna (Pluidextractum Spigelian et Senna) is J to 1 drachm (2.0-4.0) for a child of two years of age; \ ounce (16.0) is the dose for an adult. The addition of fluid extract of senna makes the drug more efficient, and the mixture is generally not disliked by children It is to be remembered that this latter mixture is no longer official. SQUILL. Scilla', U. S. and B. P., is the sliced bulb of Urginea maritima (Scilla, B. P.), a plant of the countries bordering on the Mediterranean. It contains scillin, scillipicrin, and. scillitoxin, all of which possess poison- ous properties, and none of which is used in medicine alone, except, by few practitioners. Poisoning. — In poisonous ! doses squill produces vomiting, purging, dulness, stupor, intermittent palsy, convulsions, and death in ten to twenty hours. These symptoms are preceded by a marked fall in tem- perature. The urine is suppressed or bloody and acute nephritis is produced. Gastro-enteritis may be marked. Therapeutics. — Squill is largely used as a stimulant or irritant diuretic, not to affect the renal epithelium directly and promote secretion, but rather to tone up and excite to normal effort a kidney depressed by disease, as in chronic Brighfs disease or renal congestion from cardiac trouble. In cardiac dropsy, combined with digitalis squill is a standard and much-used remedy, and is undoubtedly of value in aiding in the absorption of effusions in the pericardium, pleura, and abdomen. Squill is usually given in dropsy, in pill form, as follows: I$— Pulv. scillse gr. x (0.60). Pulv. digital, fol. 3j (1.3).— M. Ft. in pil. No. x. S. — One t. i. d. after meals. The employment of squill in bronchitis, although largely resorted to, is not to be commended, since its irritant action on the kidneys and stomach may cause trouble. The period for its administration is in the beginning of the second stage, when secretion is scanty or so excessive as to need proper stimulation of the mucous membranes to bring on a healthy action. At one time Coxe's Hive Syrup was largely used, either as an emetic in drachm doses every ten minutes until it acted, or as an expectorant in the dose of 30 minims to 1 drachm (2.0-4.0) three times a day for an adult. As it contains antimony, it should be given with care. Administration. — The fluid extract (Fluidextr actum Scilla) is much used in the dose of 1 to 5 drops (0.05-0.3); the tincture (Tincturee Scilla, U. S. and B. P.) in the dose of 5 to 30 minims (0.3-2.0) ; the vinegar of squill (Acetum Scilla, U. S. and B. P.) in the dose of 10 minims to \ drachm (0.60-2.0). The compound syrup (Syrupus 426 DRUGS. ScilloB Compositus), or Coxe's Hive Syrup, is composed of the fluid extract of squill, fluid extract of senega, tartrate of antimony and potassium, precipitated phosphate of calcium, sugar, and water, and is given in the dose of 20 minims (1.3) as a sedative to an adult and 1 drachm (4.0) as an emetic to a child. The following prescription will be found useful in bronchitis in its subacute stages in a child of one to five years: 1^ — Vini ipecac foj (4.0). Tincturae scillse f§ij (8.0). Syr. tolutan f5v (20.0). Aquae f Sj (30.0).— M. S. — Teaspoonful (4.0) every three or four hours. The plain syrup (Syrupus Scilloe, U. S. and B. P.) is given in the dose of \ to 1 drachm (2.0-4.0), the honey (Oxymel Scilloe, B. P.) in the dose of \ to 1 drachm (2.0-4.0), and the compound pill (Pilules Scillce Composita, B. P.) in the dose of 5 to 10 grains (0.3-0.60). STARCH. Amylum, U. S. and B. P., is wheat starch, but good corn starch is frequently employed. In very fine powder starch is used as a dust- ing-powder in intertrigo or chafing. Its more important uses are, however, in the form of starch-water for carrying drugs into the rectum, and in the form of a poultice for cases of skin diseases where it is desired to remove crusts. Starch-water is made by adding 2 tablespoonfuls of starch to 1 pint of water, then boiling it to a paste and diluting it by the addition of warm water to the consistence of syrup. Starch-water is not only useful as a vehicle for drugs given by the rectum, but also as a sedative injection in proctitis and rectal irritation. The starch poultice is made by boiling the starch to a pasty con- sistence or by adding enough boiling water to a paste made by rubbing cold water and starch together to produce a gelatinous mass. Thirty grains (2.0) of boric acid to the ounce (30.0) render it antiseptic. STILLINGIA. Stillingia, U. S., Queen's Root, is the root of Stillingia sylvatica, a plant of the United States, the active principle of which is stillingin. Physiological Action. — There can be no doubt that this drug acts in two ways: first, by its immediate effects on the system, and, second, by its more slowly-shown alterative influences. In overdose it causes bilious purging, increased heart-action, and active secretion from the bronchial mucous membrane. Therapeutics. — Stillingia is highly recommended in habitual con- stipation, as it increases intestinal secretion, and it is even said to act STRONTIUM. 427 as a specific in hemorrhoids dependent largely for their existence upon hepatic engorgement and intestinal atony. Bartholow recommended the following prescription under these cir- cumstances : 1^— Extract, stillmgiae fluid fov (20.0). Tincturae belladonnse, Tincturae nucis vomicae, Tincturae physostigmatis . . . . aa f 3j (4.0). — M. S. — 20 drops (1.3) in water t. i. d. before meals. Tincture of aloes may also be added to this prescription if constipa- tion is present. In syphilis of a severe type stillingia should be used as an aid to other drugs. In pasty-looking, white, "putty-faced" children, who are anaemic or strumous, and who never have any appetite, or are subject to middle-ear trouble and general debility, stillingia is of value. Under these circumstances it should be used for some time. The only official preparation is the fluid extract (Fluidextr actum Stillingia, U. S.), which should always be made of the fresh root, the dose of which is 10 to 60 minims (0.60-4.0). STRAMONIUM. Jamestown Weed, or Datura Stramonium, is official in the form of the leaves (Stramonium, U. S. ; Stramonii Folia, B. P.). It contains an alkaloid, known as daturine, which is physiologically identical with atropine. Physiological Action. — (See Belladonna.) Therapeutics. — The uses of stramonium are identical with those of belladonna. Administration. — The extract (Extr actum Stramonii, U. S. and B. P.) is used in the dose of £ to i grain (0.01-0.03), the fluid extract (Fluidextractum Stramonii, U. S.) in the dose of 1 to 5 minims (0.05-0.30), and the tincture (Tinctura Stramonii, U. S. and B. P.) in the dose of 5 to 30 minims (0.3-2.0). The ointment (Unguentum Stramonii) is also used for the same purposes as is belladonna oint- ment. The dose of daturine is ^ to -fa grain (0.0005-0.0008). STRONTIUM. This metal has been introduced into medicine in the form of the bromide (Strontii Bromidum, U. S.), iodide (Strontii Iodidum, U. S.), salicylate (Strontii Salicylas, U. S.), the lactate and phosphate, largely through the studies of Laborde, See, Paul, and others. Bromide of strontium is used for precisely the same effects as are the other bromides, but it is claimed that, as the strontium has 428 DRUGS, a distinct nutritive influence over the system, the disadvantages of the potassium salt are avoided. The dose of bromide of strontium is from 30 to 60 grains (2.0-4.0). In addition to the ordinary effect of bromides, See found the bromide of strontium to be useful in overcoming attacks of gastric indigestion associated with pain in the stomach and hyperacidity; and the author has confirmed this state- ment. The lactate of strontium seems to be indicated chiefly in cases of albuminuria due to renal atony. It does not increase, urinary flow, and is contraindicated in the presence of the uraemia and the high fever of acute parenchymatous nephritis. In chronic parenchy- matous nephritis, such as is due to rheumatism or gout, it is of value. Unfortunately, as soon as the lactate of strontium is withdrawn the albuminuria is apt to recur. The writer has often been much disap- pointed in the use of the lactate of strontium in albuminuria, but others of wide experience seem to regard it as constant in producing good results. The dose of the lactate of strontium is 60 to 100 grains (4.0^6.6) a day. The salicylate of strontium is a valuable preparation, because it is not so disagreeable to the taste as the corresponding salt of sodium; and, more important still, it is far less apt to disorder the stomach than salicylic acid itself or any of its other salts. The author has found it for these reasons very useful in acute articular rheumatism when the progress of the patient was delayed by the inability of his stomach to retain the ordinary antirheumatic remedies. The salicylate of strontium is best given in capsule or cachet, and should always be followed by a draught of milk or water to prevent its coming in con- tact with the stomach in too concentrated form. The dose is, for all practical purposes, identical with that of the salicylate of sodium. Strontium possesses no toxic power whatever, and overdoses are not followed by unpleasant consequences. If the strontium is contami- nated by barium, serious effects are produced. STROPHANTHUS. Strophanthus, U. S., Strophanthi Semina, B. P., is an African plant (Strophanthus Kombi), from the seed of which the natives make kombe arrow-poison. There are many varieties of Strophanthus. The active principle is strophanthin, from which is derived strophan- thidin. It has been claimed that strophanthus contains a local anaes- thetic principle, but de Schweinitz and the author found it to be possessed of this power only in dogs, and not in man. Physiological Action. — Strophanthus acts as a stimulant to the heart muscle and its ganglia, but does not slow the pulse by its action on the vagus as does digitalis. While it raises arterial pressure by the increased heart action, it does not stimulate the vasomotor system to any extent. It is therefore useful in cases of weak heart with arterial SUGAR OF MILK. 429 spasm, since it helps the heart, but does not increase its work, by ■raising arterial tension. Therapeutics. — Strophanthus may be used to supplant digitalis in all forms of cardiac disease, but it is not its equal. From the cases of cardiac disease seen frequently by the writer he has reached the conclusion that digitalis gives relief to patients under the age of twelve years in a much smaller proportion of cases than it does in adults, and that, though the stomach is no more frequently disordered, increased dyspnoea, nervous irritability, and cyanosis often follow its use. Strophanthus generally gives good results in this class of cases. On the other hand, strophanthus is better than digitalis in cases of weak heart with high arterial tension, as it exerts no effect upon the bloodvessels, as does digitalis. As is well known, there are a certain number of cases in which digitalis seems to do harm in adults, the explanation being that under such circumstances the ventricle is so overstimulated that the auricle cannot empty itself thoroughly, and becomes congested in consequence. Strophanthus acts exceedingly well in those instances where digitalis fails, and this is particularly true in children. It will relieve cardiac dropsy by its action on the heart, but does not possess marked diuretic properties. Untoward Effects. — Strophanthus when given in full dose frequently causes diarrhoea. Aministration. — Strophanthus is given in the form of the tincture (Tinctura Strophanthi, U. S. and B. P.) in the dose of 5 to 15 minims (0.30-1.0) three times a day. The extract of strophanthus {Extr actum Strophanthi) is now official in the B. P. The dose is J grain (0.015). Strophanthin (Strophanthinum, U. S.), a mixture of alkaloids, may be given hypodermicaliy in the dose of y^-g- to ^ grain (0.(004-0X012). Its effects when so used are said to last a week, but this statement can scarcely be correct. SUGAR. Saccharum, U. S. (Saccharum Purificatum, B. P.), is the refined juice of Saccharum ofjicinarum, or Sugar-cane, or the juice obtained from the Sugar-beet. It is an antiputrefactive, but not an antifer- mentative. Mixed with iron preparations, it prevents oxidation. As it is a hydrocarbon, it is a nutrient and a developer of adipose tissue, or, in other words, is a food. Its use is contraindicated in obesity, during the existence of fermentative changes in the stomach and intestine, and in diabetes mellitus. SUGAR OF MILK. Saccharum Lactis, U. S. and B. P., is derived from the whey of cows' milk by evaporation, in the proportion of about 5 per cent., and 430 DRUGS. is then purified by re-crystallization. It has little sweetening power com- pared to cane-sugar and possesses a peculiar insipid taste. It is, how- ever, less apt to ferment and is better for infants than is cane-sugar. Milk-sugar is largely used in triturations, because by its hardness it aids in the subdivision of the medicament. It is also used to increase the bulk of small powders where such drugs as podophyllin and calo- mel are prescribed. Recent studies, both scientific and clinical, have shown lactose to be possessed of great diuretic power when given in full doses. The advantage claimed for lactose as a diuretic is its direct action on the kidney and the slight effect exercised upon the rest of the organism. It is, therefore, in renal dropsy or renal inactivity that this substance is particularly indicated. The dose of lactose in cases of dropsy should be as great as from 2 to 4 drachms (8.0-16.0), given daily, dissolved in a quart (960 c.c.) of water. It has been found that the lactose acts best in those cases in which there is no albuminuria. These recent studies are of interest in view of the well-known clinical fact that the addition of lactose to the milk of bottle-fed babies always causes profuse diuresis. SULPHONAL. Sulphonmethanum, U. S., Sulphonalum, B. P., is a synthetically prepared substance first manufactured in Germany by Baumann, and possesses the chemical name of diethyl-sulphon-dimethyl-methane. It is a colorless, odorless, solid substance, soluble in 360 parts of cold and 15 parts of boiling water, and in 47 parts of alcohol and ether. The drug is not affected by any of the ordinary acids, and is very stable. Physiological Action. — In medicinal doses the effect of sulphonal upon the lower nervous system is practically nil. The dominant effect is on the brain. The drug is completely changed during its passage through the body. On the circulation the drug has but little effect; upon the respiration it acts as a depressant when given in full doses. Therapeutics. — Sulphonal finds its place in medicine as a somni- facient or hypnotic, valuable when junctional nervous insomnia is present, useless where advanced disease, such as cardiac trouble, is responsible for the wakefulness. In insanity it often produces sleep, and is of great service in the various mental disturbances character- ized by lack of sleep and often affecting persons of unsound mind. Sulphonal may be defined very briefly by any one who has largely used it or watched the reports made of its progress. This definition is that the drug does possess sleep-producing power of moderate amount — not equal to chloral, but greater than that of paraldehyde — and that it will sometimes succeed where the other hypnotics fail. It has the great advantage of not being a depressant to the heart. SULPHUR. 431 Administration. — Sulphonal being virtually insoluble in cold water, may be given in large capsules or in mucilage of acacia, so as to be held in suspension until swallowed. The insolubility and bulki- ness of the drug render its use difficult. It is best given in hot water (about 6 ounces), as suggested by Stewart. This makes a solution, and as soon as the liquid is cool enough to be swallowed it should be taken before precipitation occurs as the result of cooling. Sulphonal should be used several hours — say two or three — before the patient retires. If taken late at night, the patient frequently fails to sleep until the morning hours, and is heavy and drowsy all the next day. This difficulty is partly avoided by the use of a hot solution, but even then is apt to arise. The dose is 20 to 40 grains (1.3-2.6). It is wise not to use sulphonal continuously for more than a few days. Untoward Effects. — When sulphonal is taken in full dose for long periods of time, great sleepiness and weariness, with an unsteady gait, develop, which may go on to paralysis of the lower extremities if the use of the drug is persisted in. In some cases the paralysis is progressive, and in others hyperesthesia and abnormal sensations develop. In all such cases there is great disturbance of digestion with scanty secretion of urine, which contains an unusual substance, giving this secretion the color of port wine (hrematoporphyrinuria). This is partly due to a cumulative effect of the drug. Sulphonal often produces mental heaviness and a staggering gait the day after it is taken. This can to some extent be avoided by giving a dose of some laxative when the drug is taken, so that the bowels will be moved thoroughly the next morning. There are a number of cases of death on record from acute and chronic poisoning by sulphonal. In both classes of cases the death was by respiratory failure preceded by pro- found unconsciousness. As much as 120 grains (8.0) have been taken, however, without ill effect, and Neisser has reported a case which recovered after 1400 grains had been taken. Probably but a small amount of this dose was actually absorbed. In cases of subacute or chronic poisoning the prognosis is unfavorable if the symptoms are well developed. SULPHUR. Sulphur is a non-metallic element official in three forms in the U. S. P. — namely, as Sulphur Sublimatum, U. S. and B. P., or sub- limed or flowers of sulphur; Sulphur Prcecipitatum, U. S. and B. P., or precipitated sulphur; and Sulphur Lotum, U. S., or washed sulphur. Much confusion exists among students as to the differences between these various forms of sulphur. Sulphur itself is an element which is prepared for medicinal uses by being heated and sublimed (Sulphur Sublimatum), or flowers of sulphur. Sulphur lotum, or washed sul- phur, is prepared in order to get rid of sulphuric acid and other con- taminating substances, and is made from sublimed sulphur. Sulphur 432 DRUGS. prsecipitatum is also made from sublimed sulphur, and is more bland and minutely subdivided. Some believe it differs from sublimed sulphur in its therapeutic properties by reason of a small amount of water supposed to be present. It is sometimes called milk of sulphur. When sulphur is prescribed for internal use the sublimed sulphur is generally designated. Physiological Action. — Sulphur has little physiological influence over the general system. When taken internally it causes a soft, mushy stool of a yellow color with a strong odor of hydrogen sul- phide. The drug acts particularly on the skin and mucous mem- branes as a gentle alterative. The juices of the intestines break up some of it into sulphuretted hydrogen and sulphides. Therapeutics. — Sulphur is used as a mild laxative, never as a purge. In stricture of the bowel the soft stools produced by it will often slip by the obstruction, and it is worthy of note that sulphur will some- times overcome constipation when nothing else will give relief. It is particularly valuable in the treatment of constipation where there are hemorrhoids, and in chronic rheumatism and sciatica it is thought by some to effect a cure. Sulphur is of service in the treatment of chronic bronchial affections, but for some curious reason its use has become almost obso- lete. The so-called Bergeon's method of treating phthisis by rectal injections of carbonic acid gas with sulphuretted hydrogen was simply a revival of a custom of our great-grandfathers, who often used sulphur-waters by the mouth in the treatment of catarrhs or other disorders of mucous membranes. Bergeon took the trouble to go to the rectum to accomplish what was done two hundred years ago by the mouth, and the only novel part of his method was his unusual way of using the remedy. Graves recommended 5 to 10 grains (0.30-0.60) of sulphur three times a day wherever bronchial secretion was excessive, and found that it rid the lungs of mucus and relieved the cough. The external use of sulphur is very much more important than its internal use, in so far as regards affections of the skin. Of itself, the drug exercises little effect over the cuticle when used in powdered form, but combination with an ointment makes it at once active. Even irritations of the skin may ensue from its constant use in large amount. In scabies, or itch, sulphur ointment (Unguentum Sulphuris, U. S. and B. P.) is the best remedy we have. The female parasite burrows under the epiderm and deposits the ova as she moves about, while the male does not burrow, but stays on the surface. The ointment will kill him, as he is readily attacked, but the female is protected by her burrowing propensities. To get at her and the ova the burrows must be opened, and this may be accomplished by a thorough soaking of the body with soap and water, thereby softening the epiderm covering the parasite, which can then readily be removed by rubbing the patient with a rough towel. The towel should be boiled at once to prevent PLATE III. J • Stomach Corroded by a Poisonous Dose of Sulphuric Acid (Kast and Rumpler.) SULPHURIC ACID. 433 its conveying the parasite to others. The ointment, if now applied, relieves the patient almost at once. It is important that the skin be well softened and rubbed, in order to keep open every burrow. The ointment should be allowed to remain on the part all night and be used for three or four nights consecutively. Young women often suffer from acne, particularly about the men- strual epoch, the skin also becoming at this time sallow and muddy. The following ointment is one which is very successful in promoting a cure: 1$ — Sulphuris prsecipitat 3j (4.0). Lanolini §j (30.0).— M. S. — Apply once or twice daily. Administration. — Sulphur is given in the dose of 10 to 20 grains (0.60-1.3) three times a day as an alterative, and from 1 to 2 drachms (4.0-8.0) at night as a laxative, with a little molasses to form a paste. A confection (Confectio Sulphuris) is official in the B. P., dose 10 grains to 2 drachms (0.60-8.0), as is also Trochiscus Sulphuris. Sulphide of Calcium. (See Calcium, Calx, and Sulphides.) SULPHURIC ACID. Acidum Sulphuricum, U. S. and B. P., Sulphuric Acid, or Oil of Vitriol, is a powerful irritant and escharotic, rapidly dehydrating and carbonizing the tissues, causing them to become black. It is the most astringent of the medicinal mineral acids, and when absorbed it unites with bases to form sulphates, and is so eliminated by the kidneys, the lower bowel, and the skin. It coagulates albumin. Poisoning. — The symptoms produced by poisonous doses are those of a gastro-intestinal inflammation of the most severe type, or the patient may drop to the floor almost at once, owing to collapse depend- ent upon perforation of the walls of the oesophagus or stomach by the acid and its consequent escape into the peritoneal cavity. If the patient lives to the fourth day, the parotid glands may become swollen as the result of stenosis of the salivary ducts of Steno, and violent inflammation of the kidneys may appear from the passage of the drug through these organs in the process of elimination. If partial recovery takes place, the patient often dies from inanition due to the formation of strictures in the alimentary canal or to destruction of the peptic tubules. The stain about the mouth is black, and if any of the acid is spilt on the clothing the characteristic burn is to be seen. The treatment consists in the use of alkalies, such as chalk, mag- nesia, whitewash off walls, and soap. Opium and oils are to be given to allay irritation, and external heat is to be applied. 28 434 DRUGS. Therapeutics. — Sulphuric acid is sometimes employed as a caustic to venereal sores, warts, and slowly-healing ulcers, but is most com- monly used internally, as it fulfils several pressing indications. As a remedy for serous diarrhea, particularly if combined with some vegetable astringent, it is unsurpassed, and its use in cholera deserves great attention. (See Diarrhoea.) In the Philadelphia Hospital dur- ing an epidemic of cholera some years since every case which received sulphuric acid improved or failed to be attacked, whereas those who did not receive it were either very ill or died. The proper way to use the drug as a prophylactic during cholera epidemics is in the form of "sulphuric-acid lemonade," made so that each wineglassful of water contains 5 drops (0.30) of the aromatic sulphuric acid. The same solution may be used in acute lead poisoning in order to form an insoluble sulphate of lead, and may be taken by artisans exposed to chronic lead poisoning as a prophylactic for the same purpose. Sulphuric acid combined with belladonna or morphine is often useful in the night-sweats of phthisis. Administration. — The dose of the dilute acid (Acidum Sulphuricum Dilutum, U. S. and B. P.) is 5 to 20 minims (0.30-1.3), and of the aromatic acid (Acidum Sulphuricum Aromaticum, U. S. and B. P.) 5 to 20 minims (0.30-1.3). The latter is the best preparation for general use. It contains ginger and oil of cinnamon. Both prepara- tions should be thoroughly diluted before they are administered. SUMBUL. Sumbul, U. S., is a root of undetermined origin. The dose of the root (Sumbul Radix, B. P.) is 10 to 40 grains (0.60-2.6). On the nervous system sumbul acts as an efficient nerve tonic, and was largely employed by Goodell in cases of nervous exhaustion and in the unrest of nervous females. It is official in the fluid extract (Fluidextractum Sumbul, U. S.), dose 5 to 20 minims (0.30-1.30), and the extract (Exlractum Sumbul, U. S.), dose 1 to 5 grains (0.06-0.30). The tincture (Tinctura Sumbul, dose 1 to 4 drachms (4.0-16.0) is official in the B. P. Goodell used the following formula: R — Extract sumbul gr. xx (1.3). Ferri sulph gr. xx (1.3). Asafceditse gr. x (0.60). Acid, arsenosi gr J (0.03). — M. Ft. in pil. No. xx. S. — One t. i. d. after meal. To be of any value the drug must be fresh, and care must be taken that the crude drug from which it is made is a good sample. SUPRARENAL GLAND AND ADRENALIN. 435 SUPRARENAL GLAND AND ADRENALIN. The suprarenal gland, or its active principle, has become within the last few years one of our most valued remedies. Its chief use in medicine depends upon its extraordinary power of producing contrac- tion of small bloodvessels and capillaries with which it is brought in contact. It also exercises a marked constricting effect on the blood- vessels of the general arterial system when given intravenously. Fig. 56. TX ^mmm^ Showing the rise of arterial pressure produced by the injection of 0.00004 of adrenalin into the vein of a dog. The medullary portion of the glands is chiefly concerned with the elaboration of the active physiological principle, which has been isolated by a Japanese chemist, Takamine, and called adrenalin. Adrenalin occurs in tiny, almost microscopic, white crystals of various forms, which are soluble in water after slight acidulation with hydro- chloric acid. Physiological Action. — When locally applied to mucous membranes extract of this gland, or adrenalin, produces great blanching by reason of its powerful constriction of the capillaries of the part. So great is this constriction that the superficial tissues are practically blood- less while its influence lasts. This local effect is due to stimulation of the muscular fibres in the bloodvessel walls. Its use is not followed by the great relaxation and congestion seen after the local application of cocaine to a mucous membrane. Given internally, it slows the pulse by stimulation of the vagus nerves and by the increased arterial pressure due to the contraction of the muscular coats of the blood- vessels, which causes an increase in the resistance to the free flow of blood. This effect is due to the action of the drug on the vessel walls and not to a centric vasomotor influence. Upon the venous system its effects may be ignored. It also increases the force of the systole of the heart by stimulating its muscular fibres. Therapeutics. — Because of its extraordinary power in constricting bloodvessels of small calibre adrenalin is a remedy in all forms of 436 DRUGS. hemorrhage from such vessels, particularly if it can be locally applied. Thus it can be employed in epistaxis, menorrhagia, metrorrhagia, and for the purpose of controlling hemorrhage in operations on the nose, throat, ear, or larynx. It can also be employed to relieve the engorge- ment of the nasal mucous membrane in cases of coryza and hay fever, and in trachoma and conjunctivitis. When given intravenously adrenalin is employed in cases of cardiac and vasomotor failure or lack of vascular tone, and to overcome the dangerous vascular relaxation sometimes occurring in chloroformi- zation. It has also proved itself a valuable agent in controlling surgical shock. Under these circumstances the vasomotor centre is depressed or paralyzed and death ensues because of the vascular relaxation. The use of strychnine for the purpose of stimulating the vessels through the vasomotor centre is often useless because it is too depressed to respond. Under these conditions the intravenous injection of adrena- lin acts directly upon the muscular fibres in the vessel walls and raises blood pressure so that life is saved. When adrenalin is used in this way the ordinary 1 : 1000 solution in which it appears on the market should be added to the extent of 1 to 2 drachms (4.0-8.0) to a pint of normal saline solution and given intravenously or by hypodermoclysis. Strong solutions should not be used hypodermically because they cause ischaemia of the part injected, and this in turn permits germs to grow and so a slough may ensue. Administration. — Suprarenal gland may be given in desiccated form (Glandulw Suprarenales Sicca;, U. S.) in the dose of 3 to 10 grains (0.20-0.60), or as an extract of the gland, in the dose of 3 to 5 grains (0.20-0.30) three times a day or oftener. By far the best form in which to use it is adrenalin chloride in normal salt solution, 1 : 10,000 to 1:1000. Adrenalin may be given internally in tablet or capsule, but if it is being used in a case of shock its action by this method is too slow and the gastric juice probably diminishes or destroys its effects. When used locally it is employed by wetting a pledget of cotton with the solution named and then pressing it lightly against the part which it is desired to affect. Blanching comes on in a few moments. A solution of 1 : 10,000 or stronger may also be brought in contact with the part by means of an atomizer. SWEET SPIRIT OF NITRE. Sweet Spirit of Nitre (Spiritus Mtheris Nitrosi, U. S. and B. P.), or Spirit of Nitrous Ether, is a mixture of alcohol, water, and ethyl nitrite. Spirit of Nitrous Ether should contain 4 per cent, of ethyl nitrite. It is upon this last constituent that most of its value as a remedial agent depends. The drug when sold by pharmacists or others who are not careful to keep fresh preparations is no better than alcohol and water alone, since the ethyl nitrate readily escapes, SWEET SPIRIT OF NITRE. 437 and deterioration at once takes place. Until recently the profession have had no ready means of protecting themselves from such poor preparations, but at present we know that all that is necessary to dis- cover this absence is to add a grain or two of antipyrin to a \ ounce or less of the spirit. If the ethyl nitrite be present, a purple color fol- lowed by a green precipitate will be formed. This green precipitate is iso-nitroso-antipyrin, which is not in the least poisonous. Physiological Action. — Sweet spirit of nitre is a sedative to the cir- culatory and nervous system, as are all the nitrites (see Nitrite of Amyl), and a diaphoretic and diuretic, according to the manner in which it is administered. If given in very full doses, it rapidly produces the cyanosis characteristic of the full effects of any one of the nitrites. (See Amyl Nitrite.) Therapeutics. — There is probably no drug so widely employed by the laity as a household remedy which is so potent for good, and yet so harmless, if wrongly used, as is this one. Physicians often place less reliance upon it than it deserves, and in nearly every instance where it fails it is either not indicated or the nitrous ether has escaped and left it powerless. In incontinence of urine in children the combination which follows is very useful in certain cases. (See also Incontinence of Urine, Part IV.) In these instances the urine will be found high-colored and concentrated, and therefore capable of irritating the bladder and genito-urinary tract: R— Potassii citratis 5j to 5ij (4.0-8.0). Spt. aetheris nitrosi f§ss (16.0). Aquae destill q. s. ad fgiv (120.0).— M. S. — Dessertspoonful (8.0) every five hours until the urine becomes clear. As soon as the urine is clear and neutral, belladonna may be used, the citrate of potassium and spirit of nitre being continued or not as the case demands. When the spinal centres are depressed and there is general atony of the system, it may be well to substitute the fol- lowing pill for the belladonna: & — Arseni trioxidi gr. 4; (0.015). Extract, nucis vomicae gr. ij (0.12). Quininae Sulphatis gr. xx (1.3). — M. Ft. in pil. No. xx. S. — One pill t. i. d. after meals. The diuretic action of sweet spirit of nitre is best obtained by using the drug in ice-cold water and keeping the patient lightly covered and cool. On the other hand, if a diaphoretic influence is desired, it may be given simultaneously with warm lemonade, and the patient should be well blanketed. This last action of sweet spirit of nitre has made it a remedy of common use in treating acute colds in adults and children, and in diminishing the fever of these conditions in the latter class as well. Sweet spirit of nitre is a distinct antispasmodic, and can be well employed where slight nervous excitement accompanies fevers or in other states associated with nervous irritation in infancy. 438 DRUGS. The dose for an adult is from 20 minims to 1 drachm (1.3-4.0), and for a child of one year 5 to 10 minims (0.30-0.60). It should always be given in cool water to the latter class of patients. TAMARINDS. Tamarindus, U. S. and B. P., is the preserved pulp of Tamarindus indica, sl tree of the West Indies. The taste is a peculiar mixture of bitter and sweet. As a laxative it exerts little power over that of any ordinary fruits, such as apples, but it enters into the confection of senna (Confectio Sennas, U. S. and B. P.). Patients often find tamarinds a very agreeable laxative when they are taken before going to bed or eaten as a confection after meals. TANNIC ACID. Tannic Acid (Acidum Tannicum, U. S. and B. P.) when pure is an uncrystallizable, white or yellowish-white powder, without bitter taste and very soluble in water and glycerin. It is not soluble in alcohol or ether. It is the chief active principle of vegetable astringents, and occupies the relative position of an alkaloid to a crude drug, so far as the active portion of these vegetable astringents is concerned. Tannic acid is derived from nut-gall. Physiological Action. — Tannic acid when brought in contact with any of the tissues of the body constringes them and decreases their vascularity for a time, by causing contraction of their bloodvessels. For these reasons it stops secretion and condenses parts of the body which are relaxed and feeble. Mixed with blood, it forms a clot with great rapidity through coagulation of the albumin. Tannic acid is absorbed as gallic acid and eliminated as such, only acting as tannic acid before absorption. This is important to remember, since we learn from this that tannic acid is to be used to check hemorrhage only where the drug can be brought in direct contact with the bleed- ing point. If a hemorrhage is to be reached through the circulation, as in renal bleeding, gallic acid is to be given, as it is absorbed at once without change. Therapeutics. — Tannic acid is used in medicine to control hemor- rhage, and to act as an astringent to relaxed tissues, as in diarrhoea of the atonic or serous type, or in localized or general sweating. It is also of service for the purposes of toughening mucous membranes or parts of the skin which are exposed to much rubbing, as in the case of the nipples of a primipara, or where the feet become macer- ated and sore or sweat profusely on exercise being taken. In the treatment of haemoptysis tannic acid may be dissolved in water in the proportion of 5 to 10 grains (0.30-0.60) to the ounce (30.0) and used in a fine spray delivered from an atomizer. Glycerite of tannin is made by adding 2 ounces (60.0) of tannic acid to a \ pint (240 c.c.) of glycerin, and mixing at a gentle heat until solution occurs. It is use- ful as an application to indolent ulcers and depressed mucous mem- TAB. 439 branes, as after an attack of stomatitis. In hemorrhoids of the bleed- ing type tannic-acid suppositories are often very useful, and cotton saturated with tannic-acid solution is often used as a packing in vaginal leucorrhcea. Administration. — The dose of tannic acid is 2 to 10 grains (0.12- 0.60), best given in pill. The official preparations are — the troches (Trochisci Acidi Tannici, U. S.), each containing 1 grain of tannin the Glyceritum Acidi Tannici, U. S.; Collodium Stypticum, U. S. and an ointment (Unguentum Acidi Tannici, U. S.). The B. P preparations are — Glyceritum Acidi Tannici; Suppositoria Acidi Tannici, each containing 3 grains (0.20) ; and Trochisci Acidi Tan- nici, of which each contains h grain (0.03) of the acid. TANSY. - Tansy (Tanacetum). The leaves and tops of Tanacetum vidgare yield a* volatile oil (Oleum Tanaceti) which possesses emmenagogue powers and has been largely used as a uterine stimulant. It is also used as an anthelmintic. In poisonous dose it causes epileptiform convulsions in some cases, and deep coma, with death from respiratory failure. The dose of the oil as an emmenagogue is 1 to 3 drops (0.05-0.20). In domestic medicine tansy tea, made by adding 1 ounce (30.0) of the leaves or tops to. 1 pint (480) of water, and given in the dose of 1 to 2 ounces (30.0-60.0), is largely employed as a remedy for amenorrhea. TAR. (See p. 392.) Under the name of Pix Liquida, U. S. and B. P., or Tar, we have an empyreumatic oleoresin obtained by destructive distillation from Pinus palustris (Sylvestris, B. P.) and other varieties of pine. It is a thick, dark oil, slightly soluble in water and soluble in alcohol, oils, and solu- tions of potassa and soda. By distillation of tar we obtain oil of tar (Oleum Picis Liquids, U. S.), which is sometimes used for bronchitis by inhalation from an atomizer, but is not a particularly useful applica- tion. It should be diluted with some other oil or with fluid cosmoline. Tar itself is used in subacute and chronic bronchitis in 2-grain (0.12) pills, and as a remedy for gastro-intestinal catarrh. Externally, it is used in psoriasis and other skin diseases needing stimulation. For the relief of obstinate diarrhea Wood has highly recommended a mixture of tar made as follows : Add a pint of tar to a gallon of lime-water, and allow this solution to stand one week, stirring it every few hours. Decant the clear liquid and percolate it through powdered wild-cherry bark, allowing 1 ounce of the bark to be present for each pint passed through it. The dose is a wineglassful (30.0). 440 DRUGS. In chronic bronchitis tar-water is largely used, as a popular remedy, in Europe and England. Tar-water is made by shaking 1 part of tar with 4 parts of water several times during twenty-four hours, decanting, and filtering. The dose is from 1 to 2 pints (J-l litre) a day as a drink. It at first increases the expectoration, but finally decreases it. Syrup of Tar (Syrupus Picis Liquidce, U. S.) is simply sweetened tar-water. In skin diseases of the dry, scaly sort, such as psoriasis, tar oint- ment (Unguentum Picis Liquids, U. S. and B. P.) is very useful if frequently applied, or the following may be used: ]$ — Sulphur, prsecipitat., Picis liquidse aa 3vj (24.0). Saponis viridis, Adipis aa §ij (60.0). Pulv. cretse 3iv (16.0J. If the skin is tender, this prescription should be diluted with lard. Sometimes children will suffer from a persistent dry chronic eczema which resists all treatment; the following may then be employed with advantage : IV- Picis liquid 3ss (2.0). Sulphur, prsecip 3ss (2.0). Unguent, zinc, oxidi . §j (30.0). S. — Apply night and morning. Tar should not be used on the face, as it will stain the skin. Wine of Tar (Vinum Picis) is made by adding together tar 1 pint, glycerin, white wine, and honey, of each \ a pint, dilute acetic acid 1 ounce, and 3 parts of boiling water, and shaking constantly at a temperature of 160° F. for several hours. This mixture is then set aside for some days and repeatedly filtered or strained through muslin. The dose is 1 to 4 ounces (30.0-120.0). It may be used instead of tar-water or tar-syrup. TARAXACUM. Taraxacum (Taraxaci Radix, B. P.), Dandelion, is a very old remedy for hepatic torpor and the dyspepsia resulting therefrom. It should be prepared from the fresh leaves or roots, as the dried plant is inert. From disregard of this fact much disappointment has arisen. Owing to its being bitter it acts as a tonic. The extract (Extractum Taraxaci, U. S. and B. P.), dose 5 to 30 grains (0.30- 2.0), and the fluid extract (Fluidextractum Taraxaci, U. S.; Liquidum, B. P.), dose 1 to 3 drachms (4.0-12.0), are the only official prepara- tions. Succus Taraxaci, B. P., is given in the dose of 1 to 2 drachms (4.0-8.0). TEBPINE HYDRATE. 441 TARTARIC ACID. Acidum Tartaricum, U. S. and B. P., is derived from crude potas- sium bitartrate, and is much less powerful than acetic acid, but capable of producing very severe gastro-enteritis if taken in overdose and in concentrated form. It is rarely used alone, and is most commonly employed to act upon sodium or potassium bicarbonate to form effer- vescent drinks. (See Seidlitz Powder and Effervescing Draughts.) The dose is 5 to 20 grains (0.30-1.3). When tartaric acid is taken in poisonous dose, lime-water, alkalies, and magnesia are the antidotes, and opium is to be given to allay irritation. If necessary, emetics are to be used. TEREBENE. Terebenum, U. S. and B. P., is a clear, colorless liquid, insoluble in water, having a peculiar odor like that of new pine sawdust, and is made by the action of sulphuric acid upon oil of turpentine, which is then distilled at about 160° F. Therapeutics. — Terebene is a useful stimulating expectorant, in the late stages of acute or in chronic bronchitis to liquefy and get rid of the mucus which is clogging the bronchial tubes. The drug may be given by way of the stomach or by inhalation. A useful mixture in the later stages of bronchitis when the mucus is very thick and tenacious is one composed of equal parts of terebene, iodide of ethyl, and chloroform, placed on a sponge and held some two or three inches from the face. It has also been employed in genito-urinary inflammations of a subacute or chronic form in place of oil of sandal- wood or copaiba as a stimulant. In fermentative dyspepsia it is of service as an antiseptic. The drug should always be given in cap- sule in the dose of 5 to 10 minims (0.30-0.60), or by dropping it on sugar in the same amount. This dose may be repeated every three hours. Unfortunately, terebene is very apt to irritate the stomach or to produce diarrhoea, and it sometimes irritates the kidneys. TERPINE HYDRATE. Terpine Hydrate (Terpini Hydras, U. S.) is prepared by a process, unnecessary to explain here, from a mixture of pure oil of turpentine, alcohol, and nitric acid. In this manner large colorless crystals, with- out odor and with a faint taste, are formed, and in this form the drug appears on the market. Terpine hydrate is soluble in 250 parts of cold, 32 parts of boiling water, and in 10 parts of alcohol. Of ether it requires 100 parts for its solution, and of chloroform 200 parts. Therapeutics. — Terpine hydrate is used for the purpose of increas- ing secretion from the pharyngeal, laryngeal, and bronchial mucous 442 DRUGS. membranes, and is a useful remedy in subacute or chronic bronchitis to rid the tubes of mucus. The drug has also been satisfactorily employed in the treatment of hay fever when given in full doses. The remedy, while useful in only a limited number of conditions, certainly seems to be very useful in the diseases named. The dose as generally given is 2 to 3 grains (0.12-0.20), but it may be given in the dose of 15 to 20 grains (1.0-1 3) three times a day in hay fever. Ter- pine hydrate may be prescribed in pill, capsule, and in alcoholic solu- tion flavored with some of the aromatic waters and with the addition of a little syrup. Thus: 1$ — Terpin. hydrat gr. lxxv (5.0). Spt. vini gallici fgij (60.0). Syrup, lactucarii, Syrup, tolutan. . . . . . . aa fgiij (90.0). — M. S. — 1 to 2 dessertspoonfuls (8.0-16.0) three or four times a day. Or we may prescribe — R— Terpin. hydrat gr. xl (2.60). Acid benzoic gr. xl (2.60). Codeinae gr. v (0.3). — M. Ft. in pil. No. xx. S.— 1 pill three or four times a day. An elixir of terpine hydrate with heroin is now widely sold, and is a useful preparation to act as an expectorant and allay excessive cough. TERPINOL. Terpinol is derived from terpine hydrate by boiling the latter with dilute mineral acids. Terpinol is an oily substance with an odor resembling that of hyacinths. It is almost insoluble in water, but dissolves readily in ether and alcohol. It is used for the same pur- poses as terpine hydrate, in the dose of 8 to 20 grains (0.5-1.3), in capsule or pilL This dose may be given twice or thrice a day. The drug may irritate the stomach and kidneys when given in overdose. THAPSIA. Thapsia garganica is an umbelliferous plant of Southeastern Europe, employed for the purpose of producing a blister. It is gen- erally used under these circumstances in the form of a plaster. The resin, obtained from the bark of the root, is the form in which it appears in medicine. When applied continuously it produces great irritation, and finally sloughs result. THIOCOL. Thiocol is derived from guaiacol, the chief active ingredient of creosote, and is, technically speaking, potassium guaiacol-sulphonate. THIOSINAMINE. 443 It is a white fine, crystalline powder, readily soluble in water and in diluted alcohol, and possessing a slightly bitter, salty taste. Thiocol is used in medicine as a substitute for creosote and guaiacol in the treatment of chronic bronchitis and tuberculosis of the lungs, and is given in the dose of 10 to 30 grains (0.60-2.0) three times a day. Its advantages are its comparative tastelessness, its ready absorbability, and the fact that it does not irritate the stomach. It may be given in powder on the tongue or in capsule. THIOL. Thiol was introduced into medicine as a substitute for ichthyol, as the latter drug possesses the disadvantage of having a disagree- able odor. It is derived from brown-colored paraffin or gas oils by a complicated process. The product obtained is evaporated in vacuo to a thin extract called Thiolum Liquidum, or still further to dryness, or Thiolum Siccum. The liquid thiol occurs as a thin, brownish- black, neutral fluid, smelling somewhat like birch oil. It is slightly soluble in alcohol and ether, and quite soluble in water, forming a clear mixture, which is rendered more perfect by the addition of glycerin. Thiol sicca may appear in lustrous scales. It is much cheaper than ichthyol. Therapeutics. — The question which arises at once in regard to thiol is, whether the fact that thiol is practically an artificial ichthyol neces- sarily indicates that it can be used as a substitute for that substance? While they are both sulphur compounds, it is also true that ichthyol possesses extraordinary powers not met with in any other sulphur compound. Thiol has been used largely by skilful observers in diseases of the skin in moist eczema, scrofulosis of the skin, and in syphilides with asserted good results. In cases of moist eczema the thiol is used, after first washing the part with an antiseptic solution, by dusting it over the skin in the form of powder- Bidder uses compresses wet with thiol in 10 per cent, solution. While it is claimed that thiol will dissipate exudates about joints and elsewhere as effectively as ichthyol, sufficient evidence as to this point is not yet before the profession THIOSINAMINE. Thiosinamine is derived from volatile oil of horseradish, or more commonly from the volatile oil of mustard seed, by the addition of alcohol and ammonia-water and exposing it to heat. Under these conditions crystals of thiosinamine are deposited in prisms which are soluble in 2 parts of warm water, and in alcohol or ether. A solution of it should not redden litmus paper. 444 DRUGS. When given by the mouth the dose is j to 1 grain three times a day. Larger doses may disorder the stomach. If this does not occur, as much as 3 grains may be used. Thiosinamine is used also for the cure of lupus in scars, and keloid, and it has been used with asserted success in malignant growths. In a case of keloid the drug in 10 per cent, solution in absolute alcohol may be injected directly into the part affected in the dose of 10 to 20 minims (0.60-1.3) every third or fourth day. The part receiving the injection usually becomes con- gested and swollen and dark in hue. There is often a great increase in the quantity of the urine, and perhaps nausea and vomiting, and great pain where the injection is given. In cases of lupus it may be injected locally or at a distant spot, and produces a reaction like that caused by tuberculin. Before thiosinamine is used it is necessary to exclude the possibility of the presence of any other old inflammatory focus, particularly if it be tubercular in origin, since the drug may light up a partly healed lesion into an active inflammatory process. The effect of thiosinamine upon certain abnormal tissues is extra- ordinary. When injected subcutaneously, or when given by the mouth in some instances, it causes a local reaction in those parts of the body in which scar tissue exists or where poorly developed patho- logical tissues are present. Because of this reaction the part affected undergoes more or less resolution and absorption takes place. After a hypodermic injection the effect is produced in a few hours, but when given by the mouth the effect is produced more slowly. The duration of the effect of a single dose is about five hours. Because of the softening which it causes in sclerotic tissues it has been used for the removal of scars, for the dissipation of corneal opacities, and relief of the deafness due to thickening of the drum or fixation of the aural bones. THYMOL. Thymol, U. S. and B. P., is derived from the oil of thyme and other volatile oils, and occurs in large crystals. It is almost insoluble in water, but is freely soluble in fats and oils. Thymol is irritant in large amount. It is antiseptic and disinfectant, and has been employed in typhoid fever as an intestinal antiseptic by Henry and others. Under these conditions it should be used in gelatin-coated pill, and a glass of water or milk taken to avoid the burning sensation otherwise produced. In the treatment of stomatitis or tenderness of the gums after mercurialization the following mouth- wash may be used: R— Thymolis - . . gr. x (0.60). Sodii boratis gr. xv (1.0). - Aquae f^ij (60.0).— M. S. — Place a teaspoonful (4.0) of this in % a tumblerful of water and use as a gargle. Thymol has been used for dressing wounds, but is too costly for general use. In summer weather it cannot be employed, because of THYMUS GLAND. 445 its power of attracting flies, which make the patient's life miserable. The dose is J to 2 grains (0.03-0.12), in capsule or in wafer, and it is better to follow its use by a glass of milk to prevent the drug irritating the stomach. In typhoid fever as much as 30 grains (2.0) in twenty- four hours may be given as an intestinal antiseptic. If very large amounts (100 grains [7.0]) are taken in a day, poison- ing may result, but as much as this must be used before danger is present. Thymol Iodide. ThymolisIodidum,V.S.,3L compound of iodine and thymol, sometimes called aristol, but more correctly dithymol diiodide, was introduced into medicine for the purpose of acting as a substitute for iodoform. It should be kept in amber-colored glass vials to protect it from light. Its color varies from that of chocolate to reddish yellow. It is soluble in ether, chloroform, collodion, and in fixed and ethereal oils, but slightly soluble in alcohol. It is free from the unpleasant odor of iodoform, and it is stated to be less apt to produce poisoning by absorption. Much contradictory experience has accumulated as to its exact value, but the result of a careful examination of clinical reports is that in some respects it is a better drug than iodoform and in others not so good. TichhofT and Neisser state that when taken internally thymol iodide is incapable of causing toxaemia, but this can only be true when moder- ately large doses are given. Upon cocci and bacilli thymol iodide has less power than iodoform. In regard to the power of this drug in healing wounds or sores, the decision has been reached that when- ever secretion is free it is contraindicated, as the thymol seems to increase moisture. On the other hand, in those instances where in disease of the skin or mucous membrane an undue dryness is present the effect produced is often favorable. Upon lupus little effect is produced unless the surface is first curetted. Finely powdered thymol iodide has been found of marked value in the treatment of inter- stitial keratitis by de Schweinitz and Wallace when dusted into the eye each day. In an ointment of J to 1 drachm to the ounce of lard (2.0-4.0 : 30.0) thymol iodide may be used in psoriasis, but it is not so useful as is chrysarobin in this affection. THYMUS GLAND. The Thymus Gland has been used quite largely in certain diseases on the same principle as that governing the use of the thyroid, namely, that this gland possesses the function of internal secretion and will therefore benefit certain systemic conditions in persons in whom the thymus was atrophied too early in life. Others have used it as a substitute for the thyroid, intentionally or by mistake. Its chief use has been in the treatment of goitre (not exophthalmic). 446 DRUGS. It does not produce any disagreeable effects as does the thyroid. Usually the beginning dose is J ounce (16.0) administered sev- eral times a week. This dose is soon increased to an ounce (30.0) once a week. Parke, Davis & Co. prepare thymus gland in tablets and capsules ready for use, and this is the best form in which to prescribe it. THYROID GLAND. The Thyroid Gland has been introduced into therapeutics within the last few years for the purpose of relieving certain disturbances of nutrition of which the most characteristic are myxcedema and cretin- ism. The results obtained from its use in these states are extraordi- nary, and it is to be regarded as a specific. Its use is based upon the fact that in cases of myxcedema the thyroid gland is usually found atrophied, and upon the discovery by Reverdin, Kocher, Schiff, Fuhr, Horsley, Crede, Zesas, and others, that extirpation of this gland pro- duces myxcedema or a train of symptoms practically identical with it. Soon after these studies had been verified, it was suggested that myxce- dema might be cured if it were possible to transplant part or all of the thyroid gland of one of the lower animals to the body of the patient affected, with the hope that this healthy glandular tissue would become vascularized and exercise its beneficent influence on the disease process. This method has been attempted again and again, nearly always with good results, which, however, have been only temporary because the transplanted gland has not become well vascularized and has been gradually absorbed. The objections to this method are so numerous that Murray admin- istered thyroid gland by the mouth and its extract hypodermically, with great success, and he has been followed by many others. The gland itself may be eaten in the dose of from one-eighth to one whole lobe each day, but the latter is far too large a dose in most cases. As it is disagreeable when taken raw, it may be very lightly fried or broiled or even boiled before it is eaten : but these processes diminish its activity; or the gland may be minced and spread on bread with anchovy sauce. If fresh thyroid cannot be had daily, a glycerin extract may be used. The minced gland is covered by an equal weight of pure glycerin, and then after soaking for twenty-four hours is placed in a cloth and firmly squeezed for some time to extract the glycerin laden with the active ingredients of the gland. This will keep for a long time, and may be given daily in the dose of 3 to 15 minims. It is, however, far better for the physician to employ the desiccated thyroids (Glandules Thyroidce Sicca, U. S.) in powdered form or made into a tablet or placed in a capsule than to use the crude preparation just named. A number of firms in the United States and abroad prepare the gland and market it in this form, and also prepare an THYROID GLAND. 447 extract. Thus the extract of thyroid gland prepared by Parke, Davis & Co. is of such strength that 1 grain equals 10 grains of the crude gland or one-sixth of a desiccated thyroid. The dose of this is half a grain three times a day, which dose is gradually in- creased as the patient becomes accustomed to it. It is probably better, however, to use the desiccated powdered thyroid itself, and Meltzer states that Parke, Davis & Company's preparations have given better results than those of other firms, and caused none of the disagreeable untoward symptoms which will be named shortly. Two grains of Parke, Davis & Company's powder are equal to 5 grains of the fresh gland, the ordinary sheep's thyroid weighing about 24 grains. When the remedy is first employed we usually give about 1 grain of P. D. & Co.'s powdered gland, which is gradually increased a grain a day until about 6 grains a day are reached, when a halt is made and the effect of this dose watched for some days. If the patient does not manifest symptoms of overdose on the one hand or fail to improve on the other, then the dose may be gradually increased. No more than 15 grains of the dried gland should be given each day, and this quantity should be divided into several doses. Thyroid gland has been used very largely in the treatment of cre- tinism with success only second to that attained in the therapy of myxedema, and with asserted success in dwarfism, excessive obesity, psoriasis, and scleroderma. After marked improvement or apparent cure has been effected by the treatment, it is necessary for the patient to continue using thyroid extract indefinitely, for if it is discontinued the myxcedema returns. The remedy may be given in minute daily doses or in full doses for several days at the end of every three weeks or a month. Though the latter plan is the more disagreeable, it is asserted to possess a greater therapeutic and preventive value. The rapid growth of cretins under thyroid gland therapy may lead to bending of the bones, and care should be taken that too much exercise on the feet is prevented. When used in obesity, an increased amount of nitrogenous food should be supplied to prevent loss of strength, as this gland causes increased catabolism not only in the fatty, but also in the proteid parts of the body. Under its influence the body cannot assimilate glucose if it is ingested in full doses, and glycosuria develops. In obese diabetics the gland is probably a dangerous drug for this reason. In the author's experience its effects are inconstant in obesity. It benefits some patients and is useless in others. Because of the very great effect of this gland upon nutritional processes it has been employed in a host of ailments in which there has been no prospect of producing good effects. Among these, however, some experiments have resulted so favorably that the use of the gland has received recognition, although we do not understand exactly how it does good. Thus in the dose of from 5 to 20 grains (0.30-1.3) three times a day, according to the degree to which it produces its effects, it has proved of value in acute mania 448 DRUGS. and melancholia, puerperal and climacteric insanities, and in stuporous states with primary dementia. The treatment should be persisted in for at least thirty days, according to Mabon and Babcock. Recently the use of full doses of thyroid gland has been strongly recommended for the prevention and relief of the early symptoms of eclampsia on the ground that it relaxes the renal bloodvessels, increases urinary flow, and also increases the elimination of urea. It has also been asserted that thyroid therapy is useful in the treatment of exophthalmic goitre, but this is positively contradicted. Indeed, it is claimed by some that this disease is made worse by its use, since in overdose the gland causes symptoms like those of exophthalmic goitre. Prob- ably it will be found that true exophthalmic goitre is not benefited, but it may be that the gland is useful when overgrowth, with atrophy of the parenchyma, of the connective tissues of the thyroid produces the enlargement. Thyreoiodine and Iodothyrine have been introduced as representing the therapeutic activity of the crude gland; but while they possess some action, they cannot be so used with the expectation of such good results as when the desiccated thyroid gland itself is resorted to. The dried gland (Glandular Thyroidce Sicca?) has been made official in the U. S. P. of 1900. The dose is 1 to 5 grains (0.06-0.30). In the B. P. the dried gland (Thyroideum Siccum) is also official, as is the Liquor Thyroidei, dose 5 to 15 minims (0.3-1.0). Untoward Effects. — Overdoses of thyroid produce violent headache, feeble action of the heart, and sometimes diarrhoea and vomiting. Should any of these symptoms come on, they are an indication for the complete stoppage of the use of the drug for some days, and a return to its use must be gradual. These symptoms can be avoided by cautious dosing and by keeping the patient in bed for some days after the treatment is inaugurated. A vegetable diet will also aid the treatment. TRICHLORACETIC ACID. Trichloracetic Acid, U. S., is a compound of chlorine and acetic acid, occurring in deliquescent crystals, and used as a rapid, active escharotic upon venereal and other warts. A peculiarity in its effect is that it produces a dry scab which speedily falls off, leaving a heal- ing surface beneath. It is also claimed that its action is not followed by secondary inflammation and pain. It is used by applying a crystal to the wart or other growth. TRIKRESOL. Trikresol is a combination of ortho-, meta-, and paracresol, bodies allied to creolin and carbolic acid. Trikresol appears in commerce as a white liquid, smelling somewhat like creosote, and soluble in TURPENTINE. 449 water in the proportion of about 2\ per cent. It forms a clear solu- tion, and does not benumb the skin as does carbolic acid. It is also much less irritant and less poisonous than carbolic acid or bichloride of mercury. Therapeutics. — Trikresol is used as an antiseptic in surgery in 1 per cent, solution. In the strength of 1:1000 to 1:500 it may be employed as an antiseptic collyrium in ophthalmic practice, in which field it has proved very useful. TRIONAL. Sulphonethylmethanum, U. S., trional, is related, both chemically and therapeutically, to sulphonal, and is practically identical with that drug in its effects on the general system. It occurs in shining, odorless, colorless plates with a very faint, bitter taste, and is soluble in 195 parts of water. Trional is used for the relief of insomnia of a functional type, and the sleep produced ordinarily ensues in about twenty to thirty minutes after the drug is taken, and lasts five to six hours. The dose is 15 to 30 grains (1.0-2.0). Doses larger than 15 to 30 grains should never be given continuously, and it is always a good plan after the drug has been given for five or six consecutive days to stop its use for two or three days. It is well to order for the patient who is taking trional one of the saline purgatives daily, partic- ularly if there is any tendency to constipation. Trional is slightly soluble in water and very soluble in alcohol. Advantages in its use are lack of disagreeable taste and the absence of symptoms of circulatory depression. The best way to administer trional is in hot broth or tea or whiskey. It is wise to decrease gradu- ally the dose if the drug is taken night after night. Like sulphonal, trional is apt to make the patient drowsy the day after its ingestion. When trional is taken in full dose for several weeks, it produces alterations in the blood which are manifested by hsematoporphyrinuria — a state in which the urine is dark red or almost black. The drug should be stopped at once when the urine becomes red and saline purgatives must be used freely. TURPENTINE. Terebinthina, U. S., occurs in two forms — namely, as turpentine derived from the ordinary yellow pine (Pinus palustris) and other varieties of pine, and as Canada turpentine (Terebinthina Canadensis, U. S. and B. P.) derived from Abies balsamea, or silver fir, or species of cone-bearing trees other than Pinus palustris. The turpentine derived from the latter sources is sometimes called " Balm of Gilead." Much confusion often exists in students' minds as to the difference between oil of turpentine (Oleum Terebinthina, U. S. and B. P.) and 29 450 DRUGS. spirit of turpentine, both of which are the same substance under a different name. This oil is not, however, the same thing as ''tur- pentine/' for the oil is distilled from turpentine. The distilled oil is a thin, clear fluid having a peculiar odor and taste, and is irritant to the skin and mucous membranes. It is exceedingly inflammable, should never be placed near a light, and if added to any strong mineral acid takes fire. When turpentine is spoken of in this book or in medicine generally, the doubly distilled oil of turpentine (Oleum Terebinthince Rectifica- tion, U. S.) is what is meant unless the contrary is stated. Physiological Action. — Turpentine when taken internally produces a sense of warmth in the stomach, a quickened pulse, a warm skin, and slightly accelerated breathing. In overdose it may cause intoxi- cation. Upon the circulation it produces a very slight rise of arterial pressure, increased pulse-rate, and increased heart-force. On the nervous system the drug, in large amounts, causes loss of sensation before it affects voluntary motion. The drug is eliminated by the kidneys and lungs, and gives the odor of violets to the urine. Poisonous doses cause strangury, bloody urine, renal inflammation, and cyanosis, with dilated pupils and gastro-enteritis. In persons with an idiosyncrasy to this drug, erythematous, papular or vesicular eruptions may follow its external or internal use. Therapeutics. — External Use. — Turpentine is used as a local application for the purpose of producing counterirritation over any area where deep-seated inflammation exists. Under these circum- stances it is almost always used in the form of a stupe, made as fol- lows: Place a tin cup containing the turpentine in a vessel containing hot water, so that the turpentine may be warmed without coming near a flame. Dip a piece of flannel into very hot water and wring it out in a twisted towel, and when it is so dry that no water drips from it, dip it into the hot turpentine and wring it out again to free it from any excess of the drug. The cloth, while hot, should be applied, and allowed to remain until discomfort ensues, when it should be with- drawn, as it will blister the skin if left on too long. Children and adults suffering from bronchitis may be rubbed on the chest with tur- pentine with much relief, but it should be diluted with sweet oil, half and half, or even two-thirds of oil, particularly if the patient is a child . Internal Use. — Turpentine is used internally as a stimulant of a diffusible type in the course of the exhausting fevers, particu- larly if flatulence exists or if ulceration of the bowels is present. In typhoid fever turpentine stupes, turpentine enemata, and the administration of the drug by the mouth are the best ways to over- come tympanites. At the end of the second week, when the tongue is red, dry, cracked, and brown, the teeth covered with sordes, and tympany is well marked, turpentine may be used in emulsion in the dose of 5 to 10 minims (0.3-0.60) three times a day with advantage. TURPENTINE. 451 Again, in convalescence from typhoid fever, when diarrhoea is per- sistent and relapses are constant and due to an unhealed state of Peyer's patches, turpentine is the remedy par excellence. In intestinal and other passive hemorrhages, such as menorrhagia or hematuria, the drug is often of service. For the tape-worm, turpentine is given in the dose of J to 1 ounce (16.0-30.0), mixed with an equal amount of castor oil. This treatment is a somewhat dangerous practice, but is efficient. In chronic and well-advanced kidney disease large doses of powerful diuretics are often required to stimulate the kidneys sufficiently to increase urinary flow, and turpentine may be used under these circumstances; but it is contraindicated if any acute irritation is present, as it may under these conditions produce suppression. Turpentine is contraindicated in the presence of any acute inflam- mation of the gastrointestinal tract and in acute nephritis. In lumbago the dose of 2 minims (0.10) is said to be very useful, and many have found the vapor of turpentine of value in bronchitis of a subacute or chronic type when inhaled from boiling water. (See Inhalations, Part III.) In gleet it is given by the mouth to stimulate the genito-urinary tract. Turpentine has been found of value in the treatment of purpura hemorrhagica. Administration. — Turpentine may be given for the relief of flatu- lence by placing 5 minims (0.3) on a piece of sugar, or in emulsion (Emulsum Olei T erebinthinaz , U. S.) dose i to 2 fluidrachms (2.0-8.0). A more agreeable preparation, not to be used in typhoid fever, is that recommended by Bartholow, as follows: 1^— Olei terebinthinae f 5j (4.0\ Olei amvgdal. expres f Bss (16.0). Tincturae opii f 3ij (8.0). Mucil. acacias . # f5v (20.0). Aquae laurocerasi f§ss (16.0). — M. S. — A teaspoonful (4.0) every four hours for tympanites. When used as an enema the following is useful: j5j (30.0). fgjss (45.0). gr. xx (1.3). f" Sss (16.0). fgx (300.0).— M. ynipanites and to aid in the 1$ — Olei terebinthinae Olei olivae Camphorae . Mucil. acacise Aquae S. — To be injected as an enema for the relief of removal of hardened feces. Stir thoroughly before using. The author most commonly employs turpentine in enema by adding it to milk of asafcetida, 1 drachm to 2 drachms (4.0-8.0) to 6 ounces (180.0). The Liniment of Turpentine (Linimentum Terebinthinae, U. S. and B. P.) is largely used as a stimulating application to sprains and enlarged joints. Turpentine applied with a brush to the part affected is of service in ringworm. The ointment of turpentine is used as a counterirritant and stimu- 452 DRUGS. lant to the part to which it is applied. The liniment acts in the same way when applied to sprains and bruises. The following preparation is also official in the B. P. : Linimentum Terebinthina Aceticum. UROTROPIN. Uro tropin (Hexamethylenamina, U. S.) , made in the United States also under the name Uritone, is produced by the action of ammonia upon formaldehyde, and appears in colorless crystals which are odorless and have an alkaline reaction. At 77° F. it dissolves in 1.5 parts of water. When first introduced it was thought when taken internally to set free formaldehyde in the urine. Cammidge has proved this to be incorrect, and that the antiseptic power depends on other urotropin products. It is used to render the urine acid and clear when this secretion is excessively alkaline, loaded with phosphates and amorphous urates, and purulent. It allays irritability of the bladder due to this cause, as, for example, that due to ammoniacal cystitis. It is largely employed to render the urine sterile in cases of typhoid fever and to act as an intestinal antiseptic. For the former purpose it is of great value not Only in avoiding sec- ondary vesical disease, but in preventing the spread of the disease to others. The dose is 5 to 10 grains (0.30-0.60), taken twice or thrice a day, dissolved in a half-pint of carbonated or plain water. Several cases have been recorded in which the continued use of large doses has resulted in producing hematuria and strangury. UVA URSI. Uva Ursi, U. S., Bearberry, is the leaves of Arctostaphylos uva ursi, a widely distributed evergreen shrub. The drug is known in the B. P. as Uva ursi folia. Its active principle is arbutin, some- times called ursin. Therapeutics. — Uva ursi is employed in medicine as a weak, astrin- gent diuretic, possessing alterative power over the genito-urinary appa- ratus. It is used in pyelitis, cystitis, and in chronic gonorrhoea or gleet. When taken in overdose it escapes from the body as hydro- chinone, making the urine dark-colored or black. Administration. — Arbutin itself is often used in the dose of 3 to 5 grains (0.20-0.30). The dose of the extract (Extracturn Uva Ursi. is 1 to 4 grains (0.06-0.25), of the fluid extract (Fluidextractum Uva Ursi, U. S.) is 2 to 4 drachms (8.0-16.0) three times a day. An infu- sion (Infusum Uva Ursi) is official in the B. P., dose 1 to 2 ounces (30.0-60.0). VALERIAN. Valerian {Valeriana, U. S.) is the rhizome and rootlet of Valeriana officinalis, a plant of Europe, but cultivated in America. It is official in the B. P. as Valeriana rhizoma. Its active principle is apparently a volatile oil (Oleum Valeriana). It also contains valerianic acid. VERATMNA. 453 Physiological Action. — Valerian is a very feeble sedative to the nervous system, tending to produce nervous rest. In male cats it causes sexual excitement to a great degree, probably from its odor. When very large doses are given to man, it causes a sense of warmth in the stomach, a slightly quickened pulse, and sometimes nausea and vomiting. Still larger amounts produce purging and mental hebetude. Therapeutics. — Valerian is used alone or in combination with other drugs to quiet nervous females and to relieve nervousness and insom- nia. In hysteria it is often very serviceable, and combined with mor- phine it has been much used in the treatment of delirium tremens. Administration. — The fluid extract (Fluidextr actum Valeriana?, U. S.) is given in the dose of 1 fluidrachm (4.0), and the ammoniated tincture (Tinctura Valeriana? Ammoniata, U. S. and B. P.), in the dose of 1 to 3 drachms (4.0-12.0). These are the best preparations for ordinary use. The infusion, which is not official, is given in the dose of a wineglassful, while that of the simple tincture (Tinctura Valeri- ana?, U. S.) is 1 to 3 drachms (4.0-12.0). The dose of the oil (Oleum Valeriana?) is 2 to 4 minims (0.05-0.25). VALERIANIC ACID. Acidum Valerianicum is an oily, colorless liquid of a strong odor and burning taste, but is not employed in medicine except in the form of its salts, such as the valerianate of zinc, iron, quinine, or ammo- nium, all of which are employed, partly for their sedative effects and partly for their influence as tonics. The dose of Zinci Valeras is i to 3 grains (0.03-0.20), that of Quinina? Valeras 1 to 3 grains (0.06-0.20), of Ferri Valeras 2 to 10 grains (0.12-0.60), and of Ammonii Valeras 2 to 10 grains (0.12- 0.60). Under the name of "the pili of the three valerianates" Goodell recommended the following in nervousness and hysteria: K — Quininae valerat., Ferri valerat., Ammon. valerat aa 9JQ.3). — M. Ft. in pil. No. xx. S. — One or two three times a day VERATRINA. Veratrina, U. S. and B. P., is an alkaloid derived from the seeds of Asagrcea officinalis, and occurs in a grayish powder, which if it enters the nostrils produces violent sneezing which continues for hours. Physiological Action.— Nervous System. — Veratrine has little effect on the cerebrum, but it excites the spinal cord and the voluntary mus- cles, thereby giving rise to tetanic or tonic convulsions, which are never clonic or epileptoid. The dominant action of the drug is paralytic, 454 DRUGS. and the nervous symptoms just named soon give place to paralysis. The muscles lose their contractile power and the nervous centres are depressed. Circulation. — In poisonous dose the heart is slowed by the drug, greatly weakened, and finally stopped in diastole. After death the heart is found to be soft and flabby. In smaller doses it at first slows the pulse by stimulating the peripheral inhibitory nerves and the centres in the medulla, but later these parts are paralyzed. It first stimulates the vasomotor centre, then paralyzes it. Respiration. — The drug kills by failure of respiration, due to paralysis of the respiratory centres. Temperature. — Veratrine always causes a decrease in bodily heat. Poisoning. — The symptoms of poisoning in man are collapse, a pale, cold, wet skin, pinched features, and a rapid, thready pulse, accompanied by violent vomiting and muscular tremors. Tetanic convulsions may come on and resemble those of strychnine in that they arise from the slightest touch or draught of air; after death the muscles will be found to have lost their irritability. Therapeutics. — Veratrine is never used internally. It is employed chiefly in the form of an ointment rubbed into the skin over parts affected by muscular rheumatism and rheumatic joints and over neu- ralgic nerves. The official ointment (Unguentum Veratrinw, U. S. and B. P.) or the oleate {Oleatum Veratrinw, U. S.) should be used, the latter most carefully, as absorption of the drug may take place in sufficient quantity to poison the patient. . VERATRUM. Veratrum, U. S., Indian Poke, Poke Root, or Swamp Hellebore, is an American plant largely used for the purpose of allaying inflam- mation. Until recently it was official in the B. P. under the name of Veratri viridis rhizoma. It probably contains a number of principles, the chief of which are, however, jervine and veratroidine. Veratrum and aconite are the safest and best circulatory depres- sants for use in adults. Physiological Action. — The physiological action of this drug is to be considered under the effects of its two alkaloids before the com- plete effect is studied. Jervine. When jervine is given in full toxic dose it causes great slowness of movement, relaxation of the muscles, through which thrills con- tinually run, and finally the animal falls to the ground. Violent epi- leptiform convulsions may now ensue, but no tetanus is present. The convulsions soon give place to paralysis, and are characterized by VERATRUM VIRIDE. 455 their lack of force. Sensation is not affected until the near approach of death brings on anaesthesia. There is no evidence of gastro-enteritis and no vomiting or purging. The saliva is always increased and pours from the mouth. Death results by failure of the respiratory centres and an almost simultaneous failure of the heart. The heart and circulation are greatly depressed, and the pulse-rate and force are far below their normal rate and strength. The blood-pressure is very low, except when a convulsion pro- duces a temporary rise, but the condition of the vagi is apparently normal. Jervine acts as a direct depressant to the vasomotor centres. The convulsions are due to disturbance of the circulation at the base of the brain (Wood), and the spinal cord is directly depressed by the action of the jervine on its motor tracts. Veratroidine. This alkaloid is much more irritating than jervine, and in over- dose causes vomiting and purging. The muscular twitchings and convulsions caused by jervine are also produced by veratroidine, but are generally not so severe. It also depresses the spinal cord in its motor tracts. On the circulation veratroidine slows the pulse by stimulating the pneumogastric centres, but finally quickens it if given in very large doses, by paralyzing the peripheral vagi. The following summary, given by Wood, of the circulatory effect of veratrum, from a study of its alkaloids, is so brief and terse as to be worthy of insertion here: ''Veratrum slows the pulse by a direct depressant action on the heart muscle (jervine) and by stimulating the pneumogastric nerves (veratroidine); it lowers blood-pressure by an action on the heart muscle (jervine) and by depression of the vasomotor centre (jervine)." Poisoning. — Veratrum, while one of the most powerful drugs we have, is one of the least dangerous, since it almost invariably causes vomiting before enough of the drug is absorbed to produce serious consequences. The vomiting is partly due to the veratroidine and partly to the presence of an irritant resin. In poisoning, cardiac stimulants, atropine, external heat, the placing of the head below the feet on an inclined plane, and the use of strychnine as a respiratory and nervous stimulant are to be resorted to. Therapeutics. — The chief use of veratrum is as a circulatory seda- tive in acute, sthenic, or dynamic inflammations. In 'pneumonia, pleurisy, acute hepatitis, peritonitis, and cerebritis it is of the greatest value if given at the proper stage, when only congestion or hyperemia is present. After the onset of the lesions following this period its use is not only valueless, but harmful. The objection to the employ- ment of veratrum in peritonitis and cerebritis lies in its tendency to 456 DRUGS. produce vomiting, which is, of course, harmful when the peritoneum is inflamed. For this reason aconite is preferred to veratrum in peritonitis. Owing to its physiological influence, veratrum bleeds a man into his own bloodvessels, and the indications for its use are the same in inflammation as they would be for bleeding. In puerperal fever it has been highly recommended, but must be most carefully employed. Many practitioners consider veratrum by far the best remedy in puerperal eclampsia. If given in this condi- tion, the dose must be large, as much as 20 to 30 minims (1.3-2.0) of the fluid extract hypodermically, and followed by 5-minim doses till the pulse is reduced to the normal rate. These heroic doses are said to be absolutely necessary and not to cause any evil effects. Its use is indicated only in cases with high arterial tension, a bounding pulse, and suffused face. It probably acts in eclampsia chiefly by its depressant effect on the motor tracts of the spinal cord. It is also of value in excessive cardiac hypertrophy and in the irritable heart of strong, healthy men. In aneurism, where the circulatory disturbance is great and the arterial pressure high, the drug may be used, with great care, to decrease the pressure and prevent rupture of the dis- eased vessel. Contraindications. — Veratrum is contraindicated in all conditions of depression or exhaustion, and if vomiting is feared. It must not be given in peritonitis or gastritis, as it may cause emesis, and in this way disturb and irritate the abdominal contents. Administration. — In inflammation the drug should be given every half-hour or hour, and at least 1 minim (0.05) of the fluid extract should be used at each dose in a healthy adult. In the course of two or three hours or less the skin becomes moist or relaxed, the pulse slower and less excited, and slight nausea may be present. These symptoms show that the drug is exerting its influence, and it should now be withdrawn or in very sthenic cases pushed a little farther. If vomiting comes on before the drug has acted on the circulation, 5 to 10 minims (0.35- 0.65) of laudanum should be given fifteen minutes before each dose of veratrum viride. A good preparation to employ is the tincture (Tinctura Veratri, U. S.), dose 5 to 20 minims (0.30-1.30). The fluid extract (Fluidextr actum Veratri, U. S.) is given in the dose of 1 to 3 minims (0.05-0.20). Under the name of Norwood's Tincture a saturated tincture is largely sold. It is not official, and ought never to be used for this reason. VERONAL. Veronal is a compound of urea, its chemical name being diethyl- malomylurea. Its action is allied to that of trional and it is said to have no effect upon the blood or respiration. It is used as a hypnotic, to a limited extent as a pain reliever, and is commonly given in the dose of from 5 to 10 grains taken WARBURG'S TINCTURE. 457 before retiring for the night. The drug is prone to lose its effect if given continuously for more than two weeks. It may be given in capsule or solution. VIENNA PASTE. Potassa cum calce is a milder and more manageable escharotic than is caustic potash, and is used for the same purposes. (See Caustic Potash.) WARBURG'S TINCTURE. Warburg's Tincture is a complex liquid formed by the mixing together of no less than thirteen ingredients. Its inventor, Dr. War- burg, held its composition as a secret for a time, but finally made it public. Since he published the original formula it has been consid- erably altered, and some of the preparations now sold as Warburg's tincture contain none of the original ingredients. Further than this, some of these ingredients are now not obtainable. It ought to be made as follows, if possible: Aqueous extract of aloes 28 grains. Rhubarb 448 " Angelica-seed 448 " Elecampane •. . 224 Saffron 224 " Fennel 224 " Gentian 112 Zedoary-root 112 " Cubeb 112 " Myrrh 112 " White agaric 112 Camphor . 112 " Sulphate of quinine 1280 " Dilute alcohol enough to make 8 pints. The coarse vegetable portions of this list are to be ground into a coarse powder, and the myrrh and camphor, which have been pre- viously pulverized, added to them. The entire mass, less the quinine, is then digested for twelve hours in a well-covered vessel on a water- bath, the alcohol being prevented from evaporating as much as pos- sible. The liquid is now to be strained under pressure and the sulphate of quinine added and dissolved. Therapeutics. — Warburg's tincture, next to pilocarpine, is the most powerful sweat-producer that we have, and possesses in addition remarkable antimalarial power. Its advantages rest in its favorable action where congestions accompany the malarial paroxysm. Administration. — To be of value Warburg's tincture should be given according to the following rules: The bowels of the patient should be first opened thoroughly by a saline purge, and J ounce (16.0) of the tincture should be given in one dose undiluted, no other drink being taken. After the lapse of two or three hours a second J 458 DBUGS. ounce (16.0) is given in the same way, and very shortly a profuse sweat appears, which often marks the crisis of the disease, and recovery soon takes place. XKROFORM. Xeroform, or Tribromphenol-bismuth, is, as is seen from its second name, a combination of bromine, carbolic acid, and bismuth. It was introduced as a substitute for iodoform in surgical dressings. Its chemical constitution indicates that it possesses antiseptic properties, and its drying power and great volume enable it to render a wound antiseptic. As it does not contain iodine, it naturally lacks the peculiar virtues of iodoform, and, on the other hand, has none of its peculiar disadvantages. ZING ACETATE. Zinci Acetas, U. S. and B. P., occurs in the form of white mica- ceous crystals, which are efflorescent and quite soluble in water. It acts as a decided astringent to the skin and mucous membranes, but is less astringent than the sulphate of zinc. It is used as a collyrium in eye diseases, such as conjunctivitis, in the strength of 1 to 2 grains (0.06-0.12) to the ounce (30.0). In gonorrhoea it is often employed instead of the acetate of lead in injections of the strength of 1 to 20 grains (0.06-1.3) to the ounce (30.0) of rose-water. The treatment of poisoning by acetate of zinc is that adapted to gastro-enteritis. (See Gastro-enteritis, Part IV.) Chronic poisoning by zinc is very rare; the symptoms consist in muscular palsies, neuritis, and cachexia. ZINC CARBONATE. Precipitated Carbonate of Zinc {Zinci Carbonas Pracipitatus, U. S. ; Zinci Carbonas, B. P.) is used as a protective, rather astringent pow- der over surfaces affected by weeping eczema or other skin lesions accompanied by similar moist discharges. It may be employed to fulfil all the indications commonly treated by the oxide of zinc. It is very largely used, not as the precipitated carbonate, but as the impure or native carbonate, under the name of calamine. The following prescription is useful for moist eczema: I$— Calaminse . . 3j (4.0). Ung. zinci oxidi . 5vij (28.0).— M. S.- — Apply to the eczematous spot. In cases of infantile intertrigo, or redness of the buttocks and geni- tals, from maceration due to liquid feces in infants suffering from ZINC SULPHATE. 459 diarrhoea, or where the urine is irritating, the following lotion is useful : 1^ — Pulv. calaminae, Pulv. zinci oxidi aa 5ij (8.0). Glycerini 5iv (16.0). Alcoholis fgij (60.0). Aquae q. s. ad Oj (480 c.c). — M. S. — Apply with a mop after each removal of the diaper. ZINC CHLORIDE. Chloride of Zinc {Zinci Chloridum, U. S. and B. P.) is a white, crystalline, deliquescent powder, of caustic taste and acid reaction, possessing considerable disinfectant power. It has been used as an eye-wash in the strength of 1 to 2 grains to the ounce (0.06-0.12: 30.0), but is rarely so employed at present. The same solution may be used as an injection in the second stage of gonorrhoea. Small cutaneous cancers, particularly if near bloodvessels, may be advan- tageously treated by the following salve, which is efficacious and mummifies the tissues so that hemorrhage is prevented: 1$ — Zinci chloridi 3j (4.0). Pulv. amyli 3iij (12.0). Cocainae hydrochlorat gr. xxx (2.0). Aqua- destillat 5ij (8.0).— M. S. — Apply as a paste. Under the name of Liquor Zinci Chloridi, U. S. and B. P., is pre- pared a solution of the salt for disinfecting purposes of the strength of about 50 per cent. ZINC SULPHATE. Zinci Sulphas, U. S. and B. P., is a white, somewhat efflorescent salt, of a sharp, acid taste, and soluble in water. In large amounts it acts as an irritant, and is employed as an irritant peripheral emetic in the dose of 10 to 30 grains (0.60-2.0). It is not so severe as sul- phate of copper in its emetic and poisonous properties, and may be repeated if the first dose does not produce vomiting. In weak solu- tions it may be used as an astringent application by injection in gon- orrhoea and other affections of the urethral mucous membrane. In 2-grain (0.12) pills it is sometimes given in serous diarrhoeas, particu- larly if it be combined with opium or minute doses of podophyllin (-^ grain [0.001] at a dose). In conjunctivitis and other eye affections the drug is used in the form of a wash. (See Conjunctivitis.) PAET III. REMEDIAL MEASURES OTHER THAN DRUGS - FOODS FOR THE SICK. ACUPUNCTURE. Acupuncture is a term applied to the insertion of a small pointed instrument into the tissues of any part of the body for the purpose of relieving pain, swelling, or dropsies. When used in painful affections it accomplishes its best results in lumbago and sciatica, particularly in the former. When treating lumbago in this manner the writer places two darning-needles in boiling water to render them aseptic, inserts them at right angles to the skin to the depth of one to one and a half inches, and allows them to remain in place for several minutes. They are then slowly withdrawn, care being taken to prevent their breaking. Often after this treatment the patient can at once move more freely, to his great delight. Ringer, with his usual clear clini- cal insight, has noted that this procedure is more successful in those who have bilateral pain than in those who have unilateral pain, and the writer has found this invariably true. In sciatica acupuncture is less successful than in lumbago, but should always be tried. The needle should be inserted until it reaches the nerve, and perhaps pierces its sheath, and it must be absolutely aseptic. Bartholow has recommended the use of a. hypo- dermic needle for the simultaneous injection of a few minims of chloroform or morphine. Sometimes the best results follow from inserting the needle immediately below where the nerve finds exit from the pelvis. In other cases it is asserted that the insertion of a needle on the sound side over a spot corresponding to that which is painful may be beneficial. Acupuncture is useless in acute rheu- matism and for the lumbar pain accompanying fevers. Sometimes a rhigolene spray may be used to freeze the skin over the parts with advantage in lumbago or sciatica. Acupuncture is occasionally resorted to for the relief of dropsy, but it is not commonly employed, although it is often a useful measure in this condition. When the skin of the limbs becomes so tense with an effusion as to endanger its life, the tension should be relieved by incisions, not punctures; but saline purges are better for the re- ( 461 ) 462 REMEDIAL MEASURES OTHER THAN DRUGS. moval of dropsy, if they can be used. Punctures rapidly close and cause local indurations, while incisions remain open and permit free drainage. Immediately after the incisions are made the parts are to be dressed with cotton previously saturated with boric-acid solution and dried, or with absorbent cotton sterilized by baking in an oven. It is hardly necessary to point out that the incisions must be made with antiseptic precautions. (See Antiseptics.) ANTISEPTICS. The term "antiseptic," as generally used, does not necessarily imply the power to destroy pathogenic germs. Any substance which inhibits the growth of micro-organisms, which destroys or renders innocuous the poisonous products of their action upon the tissues of the body, or which retards or prevents the absorption of such products, is properly termed antiseptic. Since germicides necessarily possess antiseptic attributes, they should, strictly speaking, be classed with antiseptics; in this portion of the work, however, only such drugs as are sufficiently innocuous to allow of their use in the human body or upon its surface will be considered. Some of these — as, for instance, carbolic acid and bichloride of mercury — are efficacious solely from their germicidal properties. Others, and of this class iodoform is the most important and typical example, exert their influence, not upon the micro-organisms, but upon the toxic substances produced by these organisms. Of the long list of antiseptics which have within recent years received warm commendation at the hands of individual writers, compara- tively few have retained the confidence of the profession after pro- longed trial. Only these few well-proved drugs will be discussed in this section. Heading the list, and in its germicidal power surpassing all others, is Bichloride of Mercury. Long since, the researches of Koch have shown that this salt is efficacious as a germicide in a watery solution of 1: 50,000. He states, however, that where albumin is present the bichloride is decomposed and rendered inert. The same change is observed when solutions are allowed to stand for some length of time, even when distilled water is used as a solvent. By the addition of either sodium chloride or a weak acid such decomposition is prevented. From this it follows that under ordinary circumstances solutions of bichloride should be freshly prepared, or, if it is desirable to keep them for a long time, a sufficient amount of sodium chloride should be added to prevent precipitation of the sublimate. Koch advised that as much salt should be added as would equal the weight of the sub- limate. Other observers, however, have advised ten times this weight of sodium chloride. Since whenever bichloride solutions are used in wounds or in cavities of the body they are brought in contact with blood-serum or other ANTISEPTICS. 463 albumin-bearing substances, care must be taken that the antiseptic powers of the mercury lotion are not destroyed by the decomposition of its active principle. The power of the solution may be preserved by using it in such excess that the chemical change has practically no effect, or by combining with it, as stated above, an acid which will not in itself be unduly irritating to raw surfaces. This end is accomplished by tartaric acid. In making up a solution, 1 part of bichloride and 5 parts of tartaric acid are added to as much water as is needed. Thus, in making up a solution of 1 : 1000 for surgical purposes, the following prescription may be employed: R — Hydrarg. chlorid. corros. . . gr. xv (1.0). Acid, tartaric. . . gr. xv vel ^j (4.0). Aquse dest Oij (960 c.c.).— M. In the treatment of ordinary wounds bichloride solutions are used in the strengths of 1:500, 1: 1000, 1:2000, and 1: 4000. For the irrigation of large cavities solutions of a strength greater than 1 : 10,000 should rarely be employed; and even these dilute lotions have, when used in the peritoneal cavity, caused toxic symptoms. The 1 : 2000 solution is the one generally employed for sterilizing wounds and irri- gating during operations. Solutions of 1 : 500 or 1 : 1000 are used in cleansing the surface of the body. The ordinary method of preparing the surface of the body for oper- ation is as follows: The part is first thoroughly scrubbed with green soap and warm water, is shaved, and is washed as before. It is then cleansed with alcohol or ether, after wmich a scrubbing with bichloride solution of 1 : 1000 should follow. If no surgical interference is imme- diately indicated, the whole operative region should be enveloped in towels wrung out in a solution of 1: 2000, and kept thus protected until the surgeon is prepared to operate. The moment the skin is incised no lotion stronger than 1: 2000 should be employed; or if the more powerful solutions are used they should immediately be flushed out with one of less strength. The dressings, unless some particular form is used, may consist of boiled, bleached, and sun-dried gauze, soaked in a 1 : 500 bichloride solution and subsequently washed and wrung out in a 1 : 4000 dilution of the same antiseptic. Next in popularity among the antiseptic preparations is Carbolic Acid and its solutions. The particular value of this drug lies in the fact that its potency is equally developed in both albuminous and non-albuminous solutions. Like the mercury salts, its dis- advantage lies in its toxic properties. It is usually used in solu- tions of 1 : 20 and 1 : 40. The carbolic acid of commerce is found in liquid form. In making solution for surgical purposes an ounce of this liquid is added to 20 or 40 ounces of water, according to the strength of the solution desired. Although carbolic acid is soluble in 15 parts of water, solution does not take place immediately, and in making solutions of a strength of 1 : 20 either the water must be hot or a certain amount of time and considerable agitation of the 464 REMEDIAL MEASURES OTHER THAN DRUGS. mixture are required, otherwise globules of almost pure carbolic acid are deposited in the bottom of the tray or vessel into which the solution is poured, and these, on coming in contact with instruments or with the hands of the operator, exert an undesirable cauterant effect. The 1 : 20 solution is used for the disinfection of instruments and the cleansing of surfaces. For half an hour before an operation it is customary to submerge in a solution of this strength all instruments which will be required; and when the surgeon is ready to use the instruments the solution is diluted to 1 : 40 by the addition of an equal volume of water which has been boiled. If a carbolic solution is em- ployed for irrigation or for cleansing sponges during an operation, it should not be stronger than 1 : 40. A property possessed by carbolic acid, which renders it an unsafe medium for the impregnation of gauze, is its volatility. After exposure of a few hours to the atmosphere it wholly evaporates, leaving not an antiseptic, but simply a sterile, dressing. This fact is utilized by the surgeon in the preparation of the deeper layers of the dressing, which come in immediate contact with the edges of the wound. Since all antiseptics are more or less irritating to raw surfaces, healing will be promoted by a sterile rather than by an antiseptic application. By moistening in a carbolic solution of 1 ,: 20 a piece of boiled and sun-dried gauze sufficiently large to cover the wound-edges, the anti- septicity of this dressing is assured, and in a very few hours the heat of the body causes evaporation of all the carbolic acid, leaving a sterile, non-irritating surface in contact with the wound. If protec- tive is used or oiled silk is applied beneath the dressing, these materials should be treated with carbolic acid in the same way. In addition to the toxic effect upon the patient, carbolic acid greatly irritates the hands of the surgeon, and if used in a strength of more than 1 : 40 causes so much benumbing of tactile sensibility that manipu- lative skill is seriously interfered with. The cracked and fissured fingers resulting from the use of carbolic lotions are familiar to all, and at times produce far more serious results than temporary pain and discomfort: many recesses are provided in the depths of which septic germs may successfully resist the action of antiseptic washes. There can be no question that septic poisoning has been frequently due to this fact. It is absolutely impossible to disinfect cracked or fissured hands. A 40 per cent, aqueous solution of formaldehyde gas is a power- ful disinfectant, but when used in efficient strength is both painful and irritating. In the strength of 1 : 2000, using normal saline solution as the diluent, it may take the place of bichloride lotion for flushing large cavities or cleansing extensive granulating surfaces. The vapor has its most useful application in disinfecting rooms, barracks, dressings, and instruments. (See Disinfection.) Iodoform occupies a unique place among antiseptics in having ANTISEPTICS. 465 been ulmost universally accepted and used by surgeons and clinicians in spite of the fact that its germicidal action has been proved by laboratory research to be practically nil. It is found that nearly all forms of pathogenic germs grow abundantly upon culture materials the greater part of which is made up of iodoform, and that injections of such germs, mingled with large quantities of iodoform, produce the characteristic effect upon living tissues with almost as great cer- tainly as though this drug had not been used; furthermore, it has been shown that iodoform is not even sterile, and that as employed by surgeons it is frequently a cause of infecting previously aseptic wounds; moreover, it is poisonous. In spite of this overwhelming evidence against it the drug is still in favor. Recent researches have explained, in part at least, the reason for this contradiction between experimental and practical results. It has been well said that the human body is not a test-tube, and that bacteriological research cannot supplant the evidence of clinical observation. Elabo- rate investigation has shown that this drug acts as a powerful antiseptic, not by destroying germs, but by undergoing a decom- position in their presence, the products of which render the ptomaines, the result of germ-growth, inert. In this way suppuration is to a certain extent inhibited, or if present its disastrous effects upon the system at large are prevented, since these are due to ptomaine absorption rather than to a direct effect of the micro-organisms themselves. It has been apparently proved that ptomaines, in them- selves and without the presence of micro-organisms, can generate pus, but that where such ptomaines are mixed with iodoform before infection no pus is formed. If these septic chemical compounds are rendered inert, a powerful adjuvant to the destructive action of the germ upon living cells is removed, and thus the system is often enabled to overcome one enemy where two would have prevailed. The fact that iodoform is in itself not sterile is, from a practical stand- point, most important. Fortunately, sterilization is readily accom- plished. A thorough washing in a 1 : 1000 bichloride solution destroys all micro-organisms, and the powder, after being washed with freshly distilled water, may then be used without fear of producing infection. It will be readily understood from the foregoing that iodoform is of little service in aseptic wounds; that it becomes of utility in direct proportion to the foulness of discharge; and that -to exert its influence it must be applied directly to the part. It is liable, in suppurating wounds, to form a hard crust with the discharges, thus frustrating one of the most important indications in antiseptic surgery — i. e., drainage. Care should always be exercised to see that the exudation from the surfaces of a wound has a free exit. As employed in surgery, iodoform, after having been sterilized, is placed in small pill-boxes or wide-mouthed jars, over the opening of which is tied a single layer of antiseptic gauze; through this the iodo- form is sprinkled as desired over wound surfaces- 30 466 REMEDIAL MEASURES OTHER THAN DRUGS. Kreolin, or Creolin, a preparation obtained from English coal by dry distillation, has grown in popular favor, and because of its feeble toxic action is often preferred to carbolic acid. In addition to its powerful germicidal effect, it is non-irritant and practically non- toxic. The claim first advanced that this preparation was absolutely non-poisonous can no longer be supported, since cases have been reported where toxic symptoms have followed its use: these were probably due to individual idiosyncrasy, a factor which we can never hope entirely to overcome. It is certainly true that kreolin is the least poisonous of all the powerful antiseptics heretofore used. As an additional advantage in place of the harsh, irritating effect produced upon surfaces by carbolic acid solutions, kreolin exerts an influence very like that of an oily or mucilaginous preparation. The extravagant claims advanced for kreolin in regard to its germi- cidal power have not been confirmed by bacteriological investiga- tion. In solutions containing albumin it is not efficient as a germicide in strengths of less than 1 : 100, its power being somewhat less than that of carbolic acid; since, however, its toxic properties are much less marked than those of the latter drug, it can be safely used in stronger mixtures, and therefore, for practical purposes, its strength is greater. Kreolin, though insoluble in water, readily forms an emulsion quite as efficacious in its antiseptic properties as a true solution. Since this emulsion is opaque, it is scarcely applicable for immersing and steril- izing instruments, the latter not being readily found. It is admirably suited, however, for cleansing the hands, a 5 per cent, solution neither cracking the skin nor benumbing the sensory nerves. In irrigating large wounds, cavities of the body, and particularly as a means of preventing sepsis or aborting it in gynaecological work, kreolin can be warmly commended. It may be employed in a strength of from 0.2 to 5 per cent. Among the many antiseptic agents of less importance may be men- tioned Peroxide of Hydrogen. This drug comes in what is termed a ten- volume solution. By this it is meant that ten volumes of feebly combined oxygen are contained in each volume of the liquid. It is applicable, not to sterile surfaces, but to suppurating wounds and sinuses. It is alleged that peroxide of hydrogen immediately destroys the micro-organisms of pus, converting, in one or two applications, a septic wound into one which is sterile and which will promptly heal. It is used in the strength of from 5 per cent, up to full concentration. When this drug is poured into a suppurating sinus or cavity an ebullition takes place, which ceases only when the drug is exhausted or the dead material has been oxidized. It should never be used in a cavity from which the gas cannot readily escape. Chloride of Zinc has been extensively employed in some clinics as an antiseptic application. It is used in 10 per cent, solutions, and is applied when the field of operation is probably infected by pre-existing ANTITOXIN. 467 pus-formation. Although bacteriological research has shown that this agent possesses feeble antiseptic power, clinical experience demon- strates its value when applied to infected surfaces. Lately the Sulpho- carbolate of Zinc has to a great extent replaced the chloride, as it is less toxic and irritating and far more potent. For the sterilization of mucous surfaces a saturated aqueous solu- tion ^of Boric Acid is commonly employed. More potent than this are the silver salts, nargol, protargol, and silver nitrate in solutions of 1 : 2000 to 1 : 1000. An omission of the details of cleansing the hands of the surgeon and assistants in preparing for an antiseptic operation is scarcely permissible when writing upon the subject of antisepsis. The most approved method is as follows: The hands and forearms are thoroughly brushed in hot soap-suds for three minutes, after which the nails are carefully cleaned by wooden toothpicks and a brush, and the washing repeated; the hands are then washed in alcohol for one minute, special attention being paid to the nails; finally they are soaked for one minute in a solution of bichloride (1:1000), and during the course of the operation, if rubber gloves are not used, are occasionally washed in a solution of one-half this strength. If it is necessary to lift a chair, to turn the patient, or to touch any object which has not been previously steril- ized, the hands should be enveloped in towels wrung out in 1 : 1000 solution or immediately washed again. Another method which has been found by Kelly to be the best, bacteriologically and practically, is to cleanse the hands and nails by scrubbing with hot water and soap, and then to immerse the hands and arms in a saturated solution of permanganate of potassium made with hot water. After this the skin is decolorized by immersion in a saturated solution of oxalic acid. Finally, the oxalic acid is washed off with hot sterilized water. Any method which irritates or cracks the skin of the hand is dan- gerous. The only certain way of avoiding infection from the hands of the operator lies in the use of rubber gloves. ANTITOXIN. The method by which protection is obtained by the use of antitoxic serum is best explained by the hypothesis of Ehrlich, which has with- stood the test of scientific investigation very well and is now generally admitted to be the true explanation of this interesting subject. It is assumed that all cells have the power of combining with the food- products that are needed by them for sustenance by means of receptors or parts which have an affinity for each form of food required. A cell may have many of these receptors, each of which is suited to the appropriation of a definite kind of food-stuff, and is unable to appropriate or become attached to any other variety of food. As soon 468 REMEDIAL MEASURES OTHER THAN DRUGS. as a receptor has been utilized for the appropriation or attaching of a particle of food, the cell immediately makes another receptor, and, in many instances, makes a far greater number of these receptors than is necessary, particularly if the demand is very great. These extra receptors are, when made in excess, thrown off into the blood, where they exist unattached to the cells which originated them. The poisons or toxins of disease are knowm to be complex proteid bodies closely resembling food bodies, and therefore these poisonous products of bacteria unite with the receptors of a cell, and, instead of nourishing it, produce its death. An animal or a man may be naturally immune to a disease by reason of the fact that the cells in his body may be devoid of receptors capable of combining with a given poison, or by reason of the fact, which is the case in acquired immunity, that his cells have thrown off so many extra receptors into the blood that the toxins unite with them, and as they are unattached to cells the animal is not affected. These receptors are now called anti- bodies, and when the serum of a horse is injected into the tissues of a child suffering from diphtheria, this serum contains so many anti- bodies that the toxins of the disease are locked in the embrace of the antibodies in such large numbers that the cells of the body itself are not overwhelmed by the infection. In the case of diseases such as scarlet fever and smallpox, which rarely attack the same person twice, it perhaps may be said that immunity is conferred by the tissues being trained or educated, as it were, to prepare antitoxin in such large amounts when called upon that the entering wedge of a new attack is snapped off at the moment it begins to enter the field. The horse, being naturally able to resist diphtheria-infection to the extent of complete immunity, it becomes necessary, in order to make the resistance of his blood-serum absolute, to stimulate, if we may use such a term, his antitoxin-preparing powers, and with this object in view injections of the toxin derived from cultures of diphtheria germs are made into the blood of the naturally immune brute. As a result, the serum of the blood of the animal possesses the power of not only resisting diphtheria poison while in its own vessels, but also confers immunity of a temporary kind upon any other animal into whose body some of it is injected. It having been found experi- mentally that antitoxic horse-serum when injected into the susceptible guinea-pig renders that animal to a great extent insusceptible to inocu- lation by diphtheria, it was but a step to the use of the same agent for the protection of a child. Antitoxin for Diphtheria. While all of the antitoxins seem theoretically to promise well, in practice we find that only one is absolutely reliable, and it has received general recognition. This one is the antitoxin of diphtheria. The following process is followed in its preparation: a pure culture of the bacillus of this disease having been grown, colonies of the bacillus ANTITOXIN. 469 are picked up off the culture gelatin and placed in tubes of blood- serum, which in turn are placed in an incubator and kept there until the bacillus has developed its full virulency, when flasks of bouillon are inoculated by the germs. These flasks are then placed in an incubator, where there is rapidly produced the diphtheritic poison in the bouillon. After a length of time sufficient for the development of the poison the fluid has added to it a small amount of some pre- servative, and is then filtered through unglazed porcelain, whereby all the bacilli and other particles are separated, the filtrate being a clear, straw-colored fluid. This is the fluid containing the toxin. The toxin of each flask varies in its power, so it is necessary to deter- mine its activity. This is done by injecting it into guinea-pigs, which animals are very susceptible. Usually from 2 to 100 milligrammes are required to cause death within a few days. A young, healthy horse now receives about 1.0 c.c. of the toxin by injection into a vein; that is, ten times the fatal dose for the guinea-pig, provided the fatal dose was 0.1. Horses are chosen because they are naturally immune, have large amounts of blood-serum, and are easily handled. Gradually increasing doses are given until the horse can readily receive several hundred times the first dose without any ill effects. The horse is now capable of rendering antitoxic serum, and he is bled. The blood-serum is separated and purified and is then tested to determine its power. The tests applied are such that the strength of serum is measured by units. An antitoxin unit is approximately equivalent to the unit established by Ehrlich in the Koniglisches Institiit fur experimentelle Therapie, Frankfort-on=the-Main, Prussia. It can be defined approximately by the following description of the process used : Ten times the smallest fatal dose of toxin is injected into a guinea-pig, and at the same time 0.1 c.c. of the horse's serum is injected. If the guinea-pig survives, the serum is said to contain 1 unit of antitoxic power in each cubic centimetre, and as the dose given was only one-tenth of a cubic centi- metre it follows that each cubic centimetre is 10 times the amount of serum sufficient to protect a guinea-pig from 10 times a fatal dose of toxin. If this strength of serum were used, very large doses would have to be given to get any effect in man; so we are not satisfied with this result, and by continued dosing of the horse we may obtain, from his blood, serum which will be active in protecting the guinea-pig, not in the dose of 0.1 c.c, but in the dose of 0.001 c.c. Such a serum contains therefore 100 antitoxin units to the cubic centimetre. A dose of 5 c.c. of this strength would therefore give 500 antitoxin units. Even this is not satisfactory. Accordingly most of the serum on the market is so strong as to contain 500 or even 1750 antitoxin units in each cubic centimetre, so that 2 c.c. of the latter would be a dose of 3500 units. These very high potency serums lose their efficacy if kept for any length of time, and are therefore not so reliable as the lower potencies unless they are fresh. All serum of whatever strength should be obtained as fresh as possible. 470 REMEDIAL MEASURES OTHER THAN DRUGS. Antidiphtheritic serum has been used with asserted great success in cases of typhoid fever, epidemic cerebrospinal meningitis and in asthma. Under these circumstances it probably does* not exercise any specific effect, but is supposed to act by increasing leukocytosis and aiding in the elimination of poisons. McCallum states that its use improves the action of the heart and the tone of the vessels in typhoid fever. The use of antitoxin in diphtheria will be found discussed under that disease. (See Diphtheria.) Antitoxic serums have been used in tetanus and many other infec- tions. In none of them have results been obtained which render them equal in value with that used for diphtheria. Neither anti- pneumococcic nor antitubercular serums have proved of much value so far. Antitoxin fails in tetanus because the tetanus toxins unite so rapidly with the cells in the spinal cord and brain that by the time the symptoms are present and the antitoxin is given the damage is past repair, and the antitoxic bodies cannot combine with the toxic bodies because they are already combined with the cells of the tissues. If tetanus antitoxin is given at the time the wound is received, it is as efficacious as is antidiphtheritic serum in diphtheria. Antistreptococcus Serum. As is well known, infection by the streptococcus produces the more severe forms of septicaemia such as are met with in the puerperium, after injuries and operations, in erysipelas, and in association with such specific infectious processes as scarlet fever and diphtheria. In the latter diseases under these circumstances there is, of course, a double infection. While the theoretical basis upon which the use of this serum rests is quite as good as that of antitoxic serum for diphtheria, the results from its use have not been so valuable, probably because in many instances the infectious process has not been solely due to this micro-organism and the other disease organisms have produced their effects uninfluenced by the serum used. The best results have been obtained from its use in puerperal and post-traumatic sepsis, but only in the presence of well-marked and positive streptococcic infection would the writer resort to it. Its method of employment is identical with that of diphtheria antitoxin. Care should be taken to obtain the serum from a reliable manufacturer. It would seem probable that in some cases of ulcerative endocarditis this serum is the best treatment that can be used. The dose of this serum is usually 10 to 20 c.c. every twelve hours, according to the age of the patient and the severity of the infection. CLIMATIC TREATMENT. (See Springs and Climates.) COLD AS A RE MED Y. 471 COLD AS A REMEDY. Cold, or the rapid abstraction of heat, is a remedial measure that is nearly always available, and is possessed of very great power for good in properly selected cases. At the very first we may divide its use into its local application, for a superficial, limited, deep-seated, or distant influence, and its general application for the purpose of affecting the entire body. When cold is applied for its limited and local action, it is always used with two objects in view — namely, to cause localized contraction of bloodvessels which through inflammation are engorged so that the parts are reddened and swollen, or temporarily to anaesthetize or benumb a nerve- fibre for the immediate relief of pain, and with the hope that the temporary paralysis may ultimately result in such nerve- changes as to produce a cure. For these reasons cold, in some form, is a popular remedy for a burn or sprain or any injury likely to be followed by inflammatory processes. In some cases, it is true, hot water or dry heat is equally efficacious, and this fact will be referred to when speaking of heat. (See Heat.) It may, however, be stated, as an almost invariable rule, that the choice of heat or cold is to be governed by the sensations of the patient, who will generally assert that one of the two is the more agreeable. Cold or heat causes relief of pain in inflammation by producing con- traction of the local bloodvessel walls. As a result, inflammatory exu- dates do not occur, congestion is relieved, and as the pressure on the nerve-filaments ceases the pulsating pain of inflammation passes away. A very useful remedy for the sprain of an ankle when it is a recent accident is to let the patient sit with the foot elevated, with a cloth wrung out in ice- water or an ice-bag applied over the part affected. In the treatment of localized pain or inflammation cold is used in a number of ways, largely depending in their choice on the will of the physician and the means of the patient. The simplest, cheapest, and perhaps the most efficient method of using cold is to place cracked ice in a pig's or sheep's bladder or rubber bag, and, after tying the neck to prevent leakage, to lay it over the inflamed part, surrounding it with a towel, so as to prevent the moisture, which appears on the surface from condensation, from wetting the clothing. Where a very limited and comparatively transient effect is needed, chiefly for anaesthetic purposes, it is customary in hospital and private practice to use a piece of ice sprinkled with a little fine salt, and held against the skin by means of a towel in the hands of the physician. Actual freezing can often be produced very rapidly in this manner. Where a more rapid method is desired, sprays of various very volatile liquids may be driven against the part by an atomizer. Probably the most readily employed of these liquids is ether, which is fairly effective if it is used in a fine spray and driven against the skin in such a way 472 REMEDIAL MEASURES OTHER THAN DRUGS. as to favor rapid evaporation. Another of these agents is rhigolene, which is one of the lightest and most volatile of the liquid products of coal-tar, and is used in a spray from an atomizer in the same manner as is ether. Chloride of ethyl is a liquid used as a substitute for rhigo- lene as a local anaesthetic through the intense cold produced by its evaporation. The fluid is directed against the skin over the involved area by means of a nozzle attached to the cylinder containing it. (See Ethyl and Methyl Chloride.) It is hardly necessary for the writer to repeat that, as the last three liquids are very inflammable, they should not be used near a light or fire. Aside from the local effects of cold on inflammatory processes, it is largely resorted to for the relief of neuralgia of a superficial type, and has often been used for the cure of deep-seated neuralgias, as over the course of the sciatic nerve in sciatica. Generally, however, it is employed in neuralgia of the supraorbital nerve, where, owing to the superficial position of these fibres, the cold can readily reach them. The skin should be distinctly whitened and blanched, and even hard- ened, by the cold before its application is stopped, and if one applica- tion does not cause a cure, it may be repeated every day for several weeks in obstinate cases. Sometimes cold is used to benumb the skin or subcutaneous tissues in cases where a minor surgical operation is to be performed, but the pain of freezing an inflamed part is as great as that of the operation itself without an anaesthetic. Freezing is valuable when the physician is using the actual cautery, and in all these cases may be employed as is indicated above. The local employment of cold for the influencing of deeply seated organs is a well-recognized therapeutic measure of great practical and physiological interest, and is closely associated with the subject of counterirritation. (See Counterirritation.) According to Winter- nitz, cold applied to the feet affects the cerebral circulation, cold to the thighs the circulation in the lungs, and cold to the back the cir- culation around about the pituitary region. That these conclusions are true is not positively known, but the fact that Winternitz has reached them by a series of experimental studies indicates their cor- rectness to a great extent, and they also find additional support in the popular and medical confidence in the use of cold to the head and heat to the feet in cerebral affections. Practically, cold has been employed with no small degree of suc- cess in the treatment of pneumonia and pleurisy in the form of the ice-poultice or ice-jacket or the ice-coil. (Fig. 57.) The only thing needful for such treatment is a condition of strength on the part of the patient, for it should not be used in adynamic cases, as feeble patients cannot stand the abstraction of so much heat from their bodies. When the ice-poultice is used, it is made by taking a mass of finely chopped ice, draining it of all water, and mixing it thoroughly with dry saw- dust in sufficient quantity to absorb all the water derived from the COLD AS A REMEDY. 473 ice as it melts. The mass is then basted into a quilt, so arranged that all of the contents will not sag to the lower border, and wrapped around the chest. With this plan it is difficult to avoid wetting the clothing. Cold has also been highly recommended when used in pneumonia in another manner, and by no less an authority than Niemeyer, who speaks of it as follows: "I have made extensive employment of cold in the treatment of pneumonia, and, relying upon a large number of very favorable results, can recommend this procedure. In all cases I cover the chest of the patient, and the affected side in particular, with cloths which have been dipped in cold water and wrung out. The compresses must be reapplied every five minutes. Unpleasant as this procedure is in almost all cases, yet even after a few hours the patients assure Fig. 57. Showing the application of the cold-water coil to the chest in croupous pneumonia or pleurisy. Applied to the left side, it may be so used in pericarditis in place of the ice-bag. By suction on the lower end of the tubing a stream of water flows from one bucket to the other, and when the water has been transferred the stream may be reversed by changing the level of the buckets. me that they feel a material relief. The pain, the dyspnoea, and often the frequency of the pulse are reduced. Sometimes the temperature goes down an entire degree. My patients often retain this surpris- ing condition of improvement throughout the entire duration of the attack, so that their outward symptoms would hardly lead one to imagine the grave internal disorder. The relatives of the patient, too, who do not fail to perceive the improvement, now readily assist in the treatment to which at first they were opposed. In a few cases, and only in a few, the use of cold affords no relief, and the trouble- some manipulation for its application increases the distress of the suf- ferers so much that they refuse to keep it up. In such cases I have not insisted upon the further application of cold.' 1 In endocarditis, and especially in pericarditis, the use of an ice-bag placed over the heart is a valuable remedial procedure, for it relieves 474 REMEDIAL MEASURES OTHER THAN DRUGS. palpitation and quiets the heart, decreases the pain and diminishes the inflammation. It is also useful for cardiac palpitation and for the rapidly acting heart of fever during the course of pneumonia or typhoid fever. Cold affusions to the head, and, better still, the use of an ice-bag, have long been highly regarded in the treatment of meningitis and head injuries; and a hot bottle to the feet and cold to the head will often induce sleep in persons who habitually suffer from insomnia. This is particularly the case with those individuals who are wakeful from mental overwork. On the other hand, cases with insomnia from cere- bral anaemia do well if a cold plunge-bath is taken before going to bed, although in still other cases a hot bath is more efficacious. (See Heat.) The latter instances are not due to anaemia, but to nervous irritability, which the heat quiets, whereas the insomnia of cerebral angemia is relieved by a cold plunge by reason of the increased circu- FlG. 58. Showing the application of the cold-water coil to the head in cerebral congestion, headache, meningitis, and in fevers. latory activitv and equal distribution of the blood produced by the bath. (Fig. 58.) When cold is to be applied to the head continuously, it is often convenient to employ a coil made of rubber tubing and so shaped as to fit the vertex. One end of the tubing should reach to a tub of cold water on one side of the bed and the other to an empty tub on the other side. By sucking on one tube siphonage is established, and as soon as the liquid has been transferred from one tub the full tub is raised, the stream is reversed, and the water passes back to its former receptacle. Cold water dashed or sopped against the perineum or the scrotum and the lumbar region is a favorite remedy with some practitioners for nocturnal seminal emissions, and the scrotum may be submerged COLD AS A REMEDY. 475 in a tumbler of cold water for a few minutes at night for a similar purpose. A very useful treatment of dysentery is to inject gently into the rectum about one or two quarts of cold water — if necessary it may be ice cold; and a similar application for piles is a useful adjunct to all forms of treatment for these troublesome formations. So highly do some physicians praise this method that the writer has thought it proper to quote from a paper of J. William White upon this subject. He says: "I desire to call the attention of the profession to a method of treatment which, although not altogether new, is yet not appreciated as, in my judgment, it should be. I refer to a moderately forcible stream of water of varying temperature in the treatment of a number of affections of the rectum, anus, and genito-urinary apparatus. The tonic and astringent effect of such a stream of water upon any living tissue is, of course, a well-understood fact, and has been employed in the arrest of hemorrhage, in the treatment of inflammation, and in various conditions. But it has only been in exceptional cases, and usually by the aid of more or less troublesome apparatus, that it has been used in the class of cases to which I now refer. "The bidet, as I have now for a few years prescribed it, should be of the variety which can be attached to the water-closet seat habitually used by the patient. It should have a nozzle capable of throwing a stream of about the calibre of an ordinary lead-pencil or a little less. The head of water should be sufficient to make it impinge upon the parts exposed to it with enough force to excite there a little sensa- tion of smarting or tingling. That degree of force will, for example, be sufficient to enable the patient to take an enema, or, if a female, to take a vaginal injection. The bidet pipe should be movable by means of a handle, so that the stream can be directed against any portion of the external genitals, the perineum, the anus, or the sur- rounding parts. It should also have connection with the hot and cold water-supply of the house, so that the water may be used of any temperature which the physician may prescribe or which the sensa- tions of the patient may make desirable. Stopcocks should regulate the size and force of the stream, and should be so placed as to be easily reached by the hand of the individual sitting upon the water- closet seat. Such an apparatus can be put in place by any experienced plumber in any ordinary water-closet at an expense of from fifteen to twenty dollars, and, in Philadelphia at least, the usual head of water obtainable even in third-story rooms is quite sufficient for all thera- peutic purposes. "The diseases in which it may be desirable to use this method of treatment may be divided into two classes: First, those affecting the lower end of the bowel and its outlet; second, those involving the genito-urinary system. Among the first the most important are hem- orrhoids, internal and external; prolapsus ani, and slight cases of 476 REMEDIAL MEASURES OTHER THAN DRUGS. prolapsus recti; pruritus ani and eczema of the margin of the anus should also be included in this group of cases, in which it has now for some time been my habit to prescribe the systematic employment, twice daily, of the bidet, once immediately after the daily stool, and for the second time, by preference, just before going to bed. As a rule, in all the midwinter months the ordinary temperature of the Schuylkill water is that to be preferred, although I am largely gov- erned by the feelings of the patient in this respect. An enema should be taken at each of these times, the lower portion of the rectum being thus thoroughly washed out at least twice daily, after which the stream of water is allowed to play upon the affected region for a period of from five to fifteen minutes. The ordinary and useful effect of cool sponging or washing immediately after stool in cases of hemorrhoids is by this means enormously increased. Internal hemorrhoids will, under this treatment, in many cases almost entirely disappear unless they are exceedingly large and have been frequently inflamed or strangulated and badly neglected; external hemorrhoids, even when fleshy, will shrivel and become scarcely noticeable. "Perhaps nothing is more distressing among minor affections than the trouble described as pruritus ani, and variously attributed to liver disease, constipation, gastric troubles, latent gout, uterine disease, parasites, neuroses, and a number of other causes, varying from eat- ing of shell-fish or excessive smoking to alleged hereditary predis- position. There are very few practitioners of any experience who have not discovered how difficult it is in any particular case of pru- ritus to assign distinctly the annoying symptoms to any one of these causes. Often the whole list may be carefully gone through and eliminated, or the proper remedies may be applied successively, as different theories are adopted, without the slightest benefit resulting. Ointments, lotions, and ordinary cool bathing will be tried in great variety, but without avail, and such patients will often go from one physician to another or fall into the hands of quacks while seeking proper professional relief. My list of cases of this character which I have now treated by means of the 'bidet' comprises eight. "My second class of cases includes, chiefly, certain prostatic troubles, varicocele, atonic impotence in the male, and pruritus of the vulva or vaginitis in the female. In case of varicocele, although I have not succeeded in effecting a cure in any instance by this method, I have certainly seen advancing enlargements of the spermatic veins becoming stationary, long relaxed and pendulous scrotums become firm and much smaller, and the mental condition of the patient, which is so important an element in many of these cases, shares in the improve- ment. In chronic prostatitis, a most intractable and distressing ailment in many instances, it has come to be a part of my routine treatment to order the use of cold perineal douches by means of the bidet, asso- ciated with frequent cold enemata given in the same manner; ancTT" believe to-day that if I had to discard all therapeutic measures but COLD AS A REMEDY. 477 one in these cases, I would retain this one. In a certain number of cases of impotence associated with general muscular weakness, loss of tone, lack of general strength and vitality, accompanied by imper- fect or rapidly subsiding erections, I have found that the cold douche applied with some force and for considerable lengths of time to the perineum and testicles has been productive of marked benefit." The use of a cold bath for the purpose of increasing the tone of the system is as old a custom as any which we have, but, like all other things in medicine, cannot be used without distinct indications for its employment, or, to speak more correctly, the absence of certain con- traindications. The most universal exception to its use which we find is that class of persons with whom prolonged bathing of any kind, par- ticularly when it is frequently repeated, does not agree. The writer is sure that a much larger number of persons belong to this class than is generally recognized, and he has seen cases of nervous exhaustion and general loss of vivacity and vitality occur as a result of too fre- quent bathing. This is the case more especially with daily bathers who soak themselves in hot or warm fresh water, particularly if the bath be taken in the morning. Before passing on to the consideration of the physiological action of a bath, and why and when a bath should be used, it is proper to call attention to the fact that a very large proportion of children who are bathed daily are allowed to lie and soak in the tub, and as a result become debilitated and fretful, only to recover when the bath is used once or twice a week, and replaced in the interval by a nightly sponging with salt and whiskey or salt and water. Through practical experience and much experimental research of a reliable character we now know that the following phenomena accom- pany the use of a cold bath in a healthy person with whom such a bath agrees : On entering the water he shivers, thinks it almost unbearably cold, and he gasps if the cold suddenly touches the belly- wall or an equally sensitive surface. In a moment, however, reaction sets in, and the extremities, heretofore trembling and covered with cutis anserina, become warmer and flushed. The pulse is increased in force and frequency, and the respirations are deeper and more thoroughly per- formed. As a result of this each portion of the body receives a more perfect supply of blood and feels rejuvenated. Following this stage of exhilaration, a third stage comes on, in which the chilliness and depression of the first stage recur in an exaggerated degree, but this condition does not ensue unless the person remains too long in the water. If he leaves the bath while in the acme of exhilaration, the stimulus may remain with him throughout the rest of the day. The reason for the occurrence of this train of symptoms is not far to seek. The chilliness of the first stage shows that the great abstrac- tion of heat is lowering the bodily temperature, the centres for calori- fication in the body not producing sufficient heat for the preservation 478 REMEDIAL MEASURES OTHER THAN DRUGS. of the normal temperature. At first the cold drives the blood into the warm recesses of the body, leaving the surface cold; but in a few moments the system is aroused to the recognition of the fact that it must increase its exertions in the propulsion of blood and manu- facture of heat, and so with an effort it puts forth all its power, picks up each corpuscle in the internal organs that is hiding from the cold, and, after imbuing it with warmth obtained by increased heat-produc- tion in the sources of heat-manufacture, forces it out to the surface of the body along with its fellows, which are driven to all parts of the system. This is not a mere figurative way of putting the matter, for cold always contracts bloodvessels and reflexly stimulates the vital centres to increased activity. When the bath is too prolonged, the result of overstimulation ensues, and the depression of the nervous system and circulation may be suffi- cient to interfere greatly with normal functional activity. Just at this point it becomes clear why persons " catch cold," or, technically speaking, suffer from local or general congestions. An individual who is weak may never reach the stage of stimulation just spoken of, because his system has not enough units of force in it to expend them upon the functional activities named, and, as a consequence, the blood, which at the first shock has hurried into the internal viscera, is not driven back to its duty, but, sulking in its retreat like a deserting soldier, allows disaster and disease to ensue because its superior officer, the central nervous system, cannot gather together enough force or authority to make it do its duty. These cases present evidences, there- fore, of circulatory and systemic depression or have congestion of the lungs, liver, or other parts. In the strong person exactly the same state of affairs obtains in the tired stage of depression, but only after the strength of the system has been expended in the activity of the stage of exhilaration. Cold salt baths, particularly if they are sea baths, are more stimu- lating and not so relaxing as is fresh-water bathing. The use of a cold bath after a person becomes heated ls popularly supposed to be dangerous. On the contrary, every athlete knows that nothing is so refreshing and so preventive of muscular stiffness after severe exercise and sweating as a cold plunge- or shower-bath; but he also recognizes the fact that a plunge is all that is permissible, and it is only the person who possesses the healthy circulatory power which will enable him to rebound from momentary depression to increased activity that should resort to such procedures. The tonic effect of the so-called drip-sheet in certain neurasthenic cases is most marked. As has been pointed out, reaction must be pro- duced, since it is by the stimulation of the circulation and its readjust- ment or equalization that good is achieved. The duration of the use of the drip-sheet and the temperature of the water in which it is wrung out are governed by the ability of the patient to react. Very feeble patients must be gradually trained by moderate means to the colder COT.Ty AS A REMEDY. 479 temperatures, and, if need be, may stand in a tub containing a few inches of warm water if there is a tendency to coldness of the feet. The patient being stripped, the nurse takes a linen sheet previously dipped in water at any temperature that is not too low for reaction to take place, and throws it around the patient's body and over the head, so that in a moment the entire surface is in contact with it. Fig. 59. Drip-sheet wrung out and thrown about the patient, who rubs himself in front while the attendant applies friction to the back of the body and limbs. Then the nurse applies brisk friction all over the patient's body and limbs, while the latter rubs the front of the body with his own hands. The whole performance is over in a few moments, and the patient should then lie down, be lightly covered, and rest. Such a drip- sheet will often be a cure for insomnia depending upon faulty cerebral circulation or nervous tension. In other instances it seems to be stimu- 480 REMEDIAL MEASURES OTHER THAN DRUGS. lating, and to arouse dormant functions. Once a day is usually sufficiently often to use it, and when treating neurasthenics the morning is the best time to employ it unless it is designed to cause sleep. (Fig. 59.) Cold in Fevers. The proper manner to employ cold water in fever should be thoroughly understood. It may be used at varying temperatures, according to the effect desired, such as cool, moderately cold, and very cold. Very commonly in the course of a fever the patient is restless, uncomfortable, and sleepless, yet has not a temperature fraught with harm. Such a case may be sponged with tepid water or with alcohol and water, or salt and whiskey, with great benefit in the pro- duction of sleep, the reduction of fever, and the advantage of nervous quiet. Sometimes the sponging is successful when used only over the arms and legs, but more frequently it should be extended at least to the spinal column. If tepid sponging does not lower the fever in a given case, then ordinary cool tap- water should be employed ; and it is well to remem- ber that the secret of successful sponging lies in the use of a sponge not saturated to overflowing, but only sufficiently wet to leave a thin film of moisture on the skin, which cools the patient by its rapid evapo- ration and does not wet the bed-clothes. When we come to a study of the use of cold water in prolonged and severe fevers we find that its use is now universally recognized as the proper treatment, and with good reason. At one time it was believed that all the good results from cold bathing were due to the reduction of the fever, but it is now known that this is the least important effect of the bath except when there is such a hyperpyrexia that there is danger from that source. The benefit derived from the external use of cold water in infectious fevers rests upon the stimulation of the vasomotor system and general circulation, so that local stasis or congestions of blood do not occur in vital organs, in the stimulation of the processes of oxidation and nutrition, and in the elimination from the body by the skin and kidneys of toxic materials. Further, the more frequent cleansing of the skin aids its normal function, prevents chafing and bed-sores, and lowers the temperature by aiding in the dissipation of heat directly and through the sweat, which, even if imperceptible, is an important factor in reducing body-heat. Whenever cold is used for the reduction of fever and applied to the entire body, it should be applied rapidly and be accompanied by active rubbing of the skin of the entire body to bring the hot blood to the sur- face and to gain the valued effects of massage. As a rule, the water should be used at one temperature, and better results will be obtained if it is cold enough to produce something of a shock to the circulation and nervous system, for the effect sought is the production of a COLD AS A REMEDY. 481 " reaction " — that is, a redistribution of the blood and an awakening of all the vital processes. For this reason the writer does not approve of graduated baths — that is, the use of water which is gradually cooled while the patient is being bathed. The whole idea of the cold-bath treatment of fever is to produce the reactive stimulating effect sought by the well man who takes a sea bath. Consequently individuals too feeble to react should be bathed in slightly cooled water at first, and the temperature reduced each day a few degrees until it is quite cold. The exact degree of cold depends upon the need of the patient as stated below. Fever is then to be reduced by cool sponging, in old and feeble patients using water at 90°, 80°, or 70° F., according to the ability to react and the needs of the patient. Friction is to be used with one hand while the sponging is done with the other. If the patient is young enough and sufficiently strong to react, then the water used should be from 70° to 32° F., according to the needs of the case; and if the fever is persistent and difficult of reduction, the nurse may rub a piece of ice over the skin rapidly, applying friction constantly with the other hand. The patient should always be stripped and laid on a blanket spread over a rubber sheet which has been placed to protect the bed. It is essential when sponging is used that more of it be applied to the back than the front of the body, for at the back the great muscles and thick skin retain the heat, and these parts are not cooled if only the front of the body is sponged. Further, the posterior surfaces are the ones apt to be congested and sore from the dorsal decubitus, and therefore need the stimulant effect of the bath, as do the kidneys and other deeply situated organs. That this treatment is of value in those who react is shown by the marked redness of the skin, the improvement of the circulation and respiration, and the cleared mind. The use of the ice-rub with a piece of ice weighing about two pounds held in the nurse's hand requires more care than does the immersion bath, but I have yet to see the case of typhoid fever, after the first week, in which this plan fails to reduce the temperature if it is properly employed. Indeed, I have learned that when this method fails it is because the nurse does not know how to use it. The rubbing with the ice and with the other hand must be brisk and produce re- action. In some cases where sponging is not efficient the patient may be placed on a small canvas cot placed by the side of the bed and covered by a large rubber cloth, which, by being; raised at the head and depressed at the foot, forms a channel for the water. Over this, again, is placed an ordinary sheet. 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If the fever cannot be reduced to 101° F. by the methods of bathing just detailed, the patient should be subjected to the cold plunge or tubbing, the so-called "Brand bath," which has been employed almost exclusively in typhoid fever. The chief object sought by its use has already been described in discussing the effect of sponging. This object is reaction. The method consists in immersing the patient every three hours, if his temperature reaches 102° or 102.5° F., in a bath-tub of water at 70° F. and allowing him to remain there under friction for fifteen or twenty minutes, or until his temperature is reduced to 101° or 100° F. Before the patient enters the tub he is often given \ to 1 ounce (15.0- 30.0) of whiskey in a little milk or water to prevent depression. The Fig. 61. Bath stretcher. (F. E. Hare.) patient will generally complain bitterly of the cold, particularly at first, and will also appear blue and chilly after the bath, but these signs are not so dangerous as they are alarming. If there be persistent and prolonged coldness, then hot bottles may be applied to the feet and a little whiskey or brandy given. During all kinds of bathing an ice-bag should be kept to the head to prevent cerebral congestion. When the tub is used, it should always be placed near the patient's bed, so as to avoid unnecessary disturbance and mental excitement, for his strength must be conserved. In using the Brand bath, a patient should be lifted with care and gentleness from the bed to the tub. The water in the tub should be deep enough nearly to cover his body, and yet not so deep as to float him in the tub so that he feels uncertain of his position and has contin- ually to exert himself to keep his head above water. The lifting of a full-grown man into a tub, unless some mechanical aid is employed, requires several assistants, and, even when they are present, is very often a strain not only upon the nurses, particularly if a number of patients have to be bathed, but upon the patient as well. It is very important that patients should not exhaust themselves by making COLD AS A BEMED Y. 485 efforts under these circumstances. A number of devices have been invented for the transfer of the patient from the bed to the bath. Probably the simplest and best is that employed by F. E. Hare, of Fig. 62. The use of F. E. Hare's bath stretcher. First stage. Fig. 63. The use of F. E. Hare's bath stretcher. Second stage. Brisbane, Australia, as it is inexpensive, and can be employed by two persons unless the patient is unusually heavy. It consists, as shown in the accompanying figures, in a perforated board, from which the water 486 REMEDIAL MEASURES OTHER THAN DRUGS. readily drains when the patient is lifted from the bath. This board has a loose piece at the top, which by resting on the head of the tub prevents the patient's face from being immersed. A rubber sheet having been placed on the bed by the side of the patient, the board is laid on top of it, and the patient is then readily slid by a lateral movement on to the board, lifted up, and immersed in the tub. After the bath is over, the board is lifted, with the patient upon it, as high as the edge of the tub, a loose piece of board is slipped transversely Fig. 64. The use of F. E. Hare's bath stretcher. Third stage. across the foot of the tub, and on this and on the head of the tub rests the board upon which the patient is lying. In a few moments the excess of water drains off into the tub, and the board is then lifted on to the patient's bed, which is still protected by the rubber sheet. The patient is then slid off from the board on to the bedding and the neces- sary handling is completed. When a patient comes under observation as late as the third week of typhoid fever the cold bath is contraindicated, as a rule, because the patient does not react owing to his feebleness. If the bath is used from the beginning of the illness, it may be used all through the attack, as the system is then trained to react and is rarely so asthenic. Other contraindications are intestinal hemorrhage, nephritis, and great cardiac feebleness, but pneumonia is thought not to be a contrain- dication. With this view the writer disagrees unless the pneumonia be due to stasis and asthenic congestion. 1 i For a careful resume of the " Real Value of the Brand Bath in Typhoid Fever," by the author and Dr. C. A. Holder, see the Therapeutic Gazette, March 15, 1898. COLD AS A REMEDY. 487 The fever of enteric fever does not readily yield under the use of the bath in the first days of its course, whereas that of other maladies does do so. This is an important differential point. All cases of typhoid fever should receive the cleansing and reactive effects of sponging and rubbing at least once a day, even if the fever is not sufficiently high to need reduction. Whenever cold is used in febrile cases a thermometer should be placed in the mouth or pushed deeply into the rectum, and the fall in the temperature watched. As soon as it reaches 101° or 100° F. the bath must cease, lest the fall continue, reaction fail, and collapse ensue. Fig. 65. The use of F. E. Hare's bath stretcher. Fourth stage. On the removal of the patient the surface should be gently dried with towels, and the bed-clothing consist of only a sheet, or a sheet and one blanket in cold weather. Above all things, it must be remem- bered that the patient is not to be wrapped in a blanket, and not only this, but that he must not be placed in a blanket while still in a wet sheet. The wet sheet, if surrounded by a blanket, soon places the patient in a typical Russian or warm moist bath, calculated to raise instead of lower the fever. Where sunstroke (thermic fever) is present the patient may have ice rubbed over his body or be put directly into a bath-tub of ice- water; but in any event the attendants must rub the patient's skin to bring the hot blood to the surface and prevent congestions. Cold 488 REMEDIAL MEASURES OTHER THAN DRUGS. water may also be injected into the bowel in cases where the skin is cold but the central temperature very high. (See Enteroclysis.) The treatment of rheumatic hyperpyrexia by cold is quite as suit- able as is this treatment of other fevers when the hyperpyrexia is so excessive as to endanger life. Baruch, the apostle of hydrotherapy, has recently expressed some views in the following emphatic "Dont's," with which the author most heartily agrees : Don't bathe with cold water to reduce temperature, but to refresh the fever-stricken patient. Don't permit cyanosis or chattering of teeth; stop! Don't stop bathing because patient complains of chilliness, unless the teeth chatter. Don't raise bath temperature on the latter account; shorten bath and increase friction. Don't neglect friction during every cold procedure; it prevents chilling. Don't disregard the well-ascertained fact that the Brand bath (of 65° to 70° F. every three hours when awake, with active friction) is the ideal bath for typhoid fever only. Don't give up cold bathing because the ideal bath is not obtainable; other procedures are useful. Don't use the ice-coil to the abdomen; it has no refreshing effect and renders the skin beneath it cyanotic. Don't lose sight of the fact that the chief aim of all cold procedures is reaction. CO-ORDINATED MOVEMENTS FOR TREATING LOCOMOTOR ATAXIA AND MYELITIS. This plan of treatment is based upon the fact that great improve- ment in locomotion on the part of ataxic patients can be produced by causing the patient to make certain definite movements, the object of which is to re-educate his co-ordinating power. The power of co- ordination is lost partly by reason of the disease in the nerves and spinal cord, and partly because the patient has become bedridden, so that his otherwise healthy tissues waste from disuse. Definite exercises in such cases perhaps train collateral nerve-centres and nerve- tracts to do work not usually part of their function. In any event, such patients often greatly improve under this procedure. It is vitally important that the various movements should be made slowly and with as great nicety as possible. Exercises for the Lower Limbs. — The patient lies on his back on a firm couch and slowly lifts his fully extended leg until he touches with his toes the finger of an attendant, who holds his hand at a dis- tance of from eighteen inches to two feet above the bed. These exer- cises should be repeated several times with each leg. LOCOMOTOR ATAXIA AND MYELITIS. 489 Next, the patient completely flexes the leg on the thigh, and then the thigh on the abdomen. After this the limb is slowly extended until the toe once more touches the finger of the attendant, the leg being elevated at the same time that it is extended. After making this contact the extended limb is slowly lowered till it rests on the bed. A third exercise consists in having a board made with pigeon-holes attached to it, the tops of the pigeon-holes being taken off. A dozen of these holes should be made, and either lettered in the order of the alphabet or numbered consecutively. The patient lying on the back, with the heels resting in two of these pigeon-holes, is directed to raise a leg and to lower it so that the right heel will come down in the pigeon-hole named by the attendant; so that if the right heel is resting in pigeon-hole 1, it may be placed in pigeon-hole 4; and afterward the left heel, which may be resting in pigeon-hole 7, is placed in pigeon- hole 6. It will be readily seen that following these directions trains the co-ordinative faculty. The edges of the pigeon-holes should be smooth, and perhaps padded, to prevent the heel from being injured by striking against them. Fig. 66. mmm„ Showing the pigeon-holes into which the patient puts his heels when training his co-ordination and muscle-sense in locomotor ataxia. The Standing Exercises consist in endeavoring to stand with the eyes closed and the feet close together, and in trying to stand on one foot with the eyes open or closed. Another exercise is to paint a black stripe a foot wide across the floor of a room, and to direct the patient to walk along this stripe with or without support, being careful to keep his feet within its limits. He will usually do better with bare feet than if he has his shoes on. In taking this exercise the patient should be directed to bring the foot down in the natural position, and not upon the heel, as is so commonly done by tabetics; and also he must not evert the toes too much in walking, as is so commonly the habit. As the patient improves, the stripe upon which he walks may be narrowed. The next walking exercise consists in going up and down stairs. It is well to build a flight of stairs, consisting of five or six steps, with a platform, which is so securely built that there is no danger of a fall. A balustrade or railing is put on each side of the steps for lateral sup- port, and the patient is then made to ascend and descend the steps. Care must be taken that he mounts the successive steps by a proper contraction of his quadriceps rather than by pulling himself up by the aid of his hands. Many tabetics simply place the leg in a rigid position, and then use their arms to elevate themselves to the next step. Still another exercise is to place the patient in an arm-chair and 490 REMEDIAL MEASURES OTHER THAN DRUGS. teach him to lower himself into the chair without touching the arms of the chair with the hands. It is vitally important that these exercises shall not be continued until the patient is unduly fatigued. He should simply be slightly tired at the most, and usually a quarter of an hour, twice or thrice a day, is a sufficient length of time for the treatment. Exhaustion is dis- tinctly harmful under these circumstances. The patient should be urged to respond promptly to directions, as alacrity is important in training the co-ordinative faculties. Somewhat similar exercises may be devised for the arms in cases where the upper limbs are ataxic as well as the lower. ones. COUNTERIRRITATION. Counterirritation is a term applied to the use of substances irri- tating to the surface with which they come in contact, and is employed for the purpose of influencing morbid processes in more or less dis- tant parts or of affecting the general system. It has been thought that this method savors of the doctrine of "like cures like/' but in reality it is based on sound physiological laws, and is so logical as to have been described by the founder of homoeopathy as useless. The entire basis for the employment of counterirritation rests upon reflex action, or the conduction of a nervous impulse to a centre, which, when so stimulated, sends out an impulse to the part of the body which is diseased. The use of counterirritation may be divided into four parts or pur- poses: the first is for affecting inflammations or congestions; the second, for causing the absorption or removal of inflammatory deposits after true inflammation has ceased; while the third purpose is for the relief of pain; and the fourth for the effect which can be exercised upon the general system by blisters in systemic disease. In the same manner that we can divide the indications for counter- irritation into four parts, so can we also divide its forms into three varieties according to their severity. The most severe are the caustics or escharotics, the next the epispastics or blisters, and finally the rubefacients or reddeners. The proper manner of employing a counterirritant to affect inflam- mations is not to apply it directly to an actually inflamed area, but a little to one side of it or at a spot known to be connected intimately with the diseased area by nerve-fibres. Thus, it is well known that in diseases of the eye the blister should be applied back of the ear, and that in abdominal neuralgia or in pleurodynia the best results are reached, not from the application of a blister to the spot where the pain is felt, but to the point upon the vertebral column where the nerve at fault takes its exit. The reason for this is that pain is always referred to the peripheral end of an irri- tated nerve, and pleurodynia or abdominal pain often arises from verte- CO UNTERIRRITA TIOK 491 bral disease or inflammation about the spinal ligaments or the foramina of exit for the nerves. In a similar manner we sometimes apply a blister, in the early stages of hip disease, not to the knee or ankle, where the pain is felt, but at the seat of the trouble — namely, the hip. Counterirritation is contraindicated by the presence of any acute inflammation directly under the spot where it is proposed to place a blister; that is, if any reddening of the skin is present, the blister or other form of irritation must not be applied there. If used at all, it Fig. / Showing the areas in which blisters are to be placed : P, pericarditis; A, appendicitis; L, laryngitis; V, vomiting or gastritis; P L, pleuritis; E, inflammation in joint. must be some little distance away, or a series of small flying blisters should be placed around the inflamed zone. A flying blister is one which is small in area — say as large as a Lima bean — and of com- paratively slight action, the blister healing rapidly after its primary effects have passed by. Among the inflammatory affections in which counterirritation is found very serviceable may be mentioned pleurisy, pneumonia, iritis, synovitis (rheumatic or traumatic), cerebritis, and peritonitis (acute 492 REMEDIAL MEASURES OTHER THAN DRUGS. or chronic). A host of more subacute or chronic inflammations are also benefited by this measure, some of which are gleet, chronically enlarged joints, and inflamed glands. In all these states the blister, or more rarely a rubefacient, is to be resorted to; and while it is true that nearly all these conditions are accompanied by fever, and that fever is generally held to be a contraindication to the use of coun- terirritation, blisters undoubtedly do good in such states. In pneu- monia or pleurisy, along with the use of veratrum viride in the very earliest stages of the disease, a cantharidal blister of the size of a silver dollar should be applied near the spot where the pain is most felt or on the back near the spine. Where joints are inflamed, the blisters should be at some distance from the seat of the swelling, although it is often useful to place the counterirritant on the inner or outer aspect of the knee-joint if the skin is not reddened. In peritonitis the blisters are best applied directly over the seat of tenderness, and in cerebritis at the nape of the neck. In gleet a little cantharidal collodion may be painted along the under surface of the penis or upon the perineum with great advantage in obstinate cases. Where an inflammatory process is chronic and resists cantharidal blistering, then resort is often had to more severe forms of counter- irritation by means of the red-hot — not white-hot — iron, or the use of escharotics, such as caustic potash or caustic soda or arsenic. The reason for using these is that they all cause so much tissue-change in the part that the counterirritation is very prolonged. Sometimes antimonial ointment has been applied constantly until a slough forms, to accomplish the same purposes. For the removal of the products of inflammation resort is had to can- tharidal blisters or drugs possessing powers as local irritants and at the same time as alteratives. Thus, in pleurisy with effusion it is very proper to employ a good-sized cantharidal blister if the effusion has a tendency to remain unabsorbed, but if the pleural surface is covered with a fibrinous exudate the blister can do little good as far as the effusion is concerned till this is absorbed. Some have thought that the absorption which follows is due to the abstraction of serum which takes place in the bleb formed, but this is a mistaken idea, as one often sees an effusion absorbed which far exceeds in quantity the amount of liquid in the blister. Under these circumstances the spot for applying the blister is, as a rule, immediately under the arm, about two or three inches below the axilla. The blister, while it is useful in causing absorption in chronic effusions and deposits about joints, is not so good as are alterative irritants; for example, iodine, which in the form of a thorough application at one sitting until the skin is black — not yellow or red — is often of service. In very chronic cases iodine ointment, alone or with lard, may be rubbed into the parts with advantage, care being taken to stop its use for a day or two as soon as the skin reddens. This same treatment is also useful in treating enlarged glands in the neck and elsewhere before pus forms. CO UNTERIRRITA TION. 493 One of the best treatments for epididymitis is to paint the scrotum black with many coatings of a strong solution of silver nitrate or iodine, to insist on total rest in bed, and to resort to the local use of cold. The testicles should also be supported by a suspensory or adhesive strips during this treatment, and aconite given if fever is present. For the relief of pain resort is very commonly had to the rube- facients rather than epispastics, since the more moderate applications Fig. 68. Showing the areas in which blisters are to be placed : 0, earache or vertigo; M, men- ingeal inflammation or effusion at the base of the brain; H, haemoptysis; P L, pleuritis; I, intercostal neuralgia; K S, renal or spinal irritation; R, rheumatism or inflammation in joint. are equally effective in most instances, and do not leave skin lesions behind to remind the patient of his illness. Every one who has had stomach-ache and remembers the relief obtained by the use of a mustard plaster or spice plaster recognizes the value of this means of obtaining relief, and it only remains for 494 REMEDIAL MEASURES OTHER THAN DRUGS. the writer to state that headaches are often amenable to similar treat- ment. These headaches may be neuralgic or due to dyspepsia or to cerebral anaemia or congestion, but counterirritation will neverthe- less do good. If neuralgic, a little menthol or oil of peppermint may be applied over the course of the nerve, which application, if it be supraorbital, will require care lest the oil gain access to the eye. For the treatment of pain in the belly or chest or elsewhere we have four means of producing counterirritation in the shape of rubefacients: the first is mustard; the second, capsicum; the third, the turpentine stupe; and the fourth, the spice poultice. The mustard plaster should be made by mixing mustard flour with warm vinegar or water, and adding varying proportions of ordinary flour to modify its action. If the skin is tender, half mustard and half wheat flour may be employed; or if a child is to be treated, the proportion should be only one-fourth mustard. The plaster is made by placing a piece of stout paper on a table and putting over it a piece of heavy muslin or linen. On this is smeared the mustard, and over the mustard mass is placed a piece of thin linen, which pre- vents the poultice from adhering to the skin and modifies the burning according to its density. By folding the edges of the paper so that it resembles a picture-frame we have at hand a cheap, effective, and strong plaster, the back of which is supported by the paper. The spice plaster is made by mixing equal parts of allspice, cloves, cinnamon, and nutmegs, and adding thereto one-half part of black pepper. These constituents are made into a homogeneous mass by using a knife-blade to mix them, and are then sewed in a bag which is quilted to prevent sagging of the contents. One side of the poultice is now wetted with warm brandy, whiskey, or vinegar, and applied to the part desired. If the skin is tender, the proportions of pepper and cloves should be decreased. This plaster may be allowed to remain over the affected part for hours or even days, and is very useful in the treatment of gastric catarrh and indigestion, particularly those forms occurring in children. The turpentine stupe (see Turpentine) is not to be allowed to remain very long on the skin, as it may blister a tender cuticle, and the capsicum plaster may be so active as to produce unbearable pain. The proper way of treating all such burns from counterirritation is to apply simple cerate, cosmoline, or sweet oil, to which may be added carbolic acid in the proportion of 1 : 100. The carbolic acid acts not only as an antiseptic, but also as a local ansesthetic, while the oil serves as a protective from contact with the air. Much difference of opinion exists as to the proper treatment of the blister formed by cantharides. Where the blisters are small — that is, the size of the tip of a finger — they may be allowed to break of them- selves, and then be dressed with dry cotton; if they are large, the blebs should be punctured at their most dependent part with an antiseptic needle and dressed with dry absorbent cotton, as by so doing the new DISINFECTION. 495 skin rapidly forms underneath and is soon able to carry on its normal functions. The proper treatment of the blister while it is forming is to apply a poultice, which will decrease the pain and aid in the for- mation of the bleb. CUPPING. Cups are used in two forms, the dry cups and the wet cups. The first depend almost entirely upon their counterirritant effect for their therapeutic value. A hollow glass bulb fitted with a valve or stopcock is placed upon the skin and exhausted by means of a small hand pump. The stopcock is turned to prevent the entrance of air and the cup allowed to remain until sufficient air leaks into it to overcome the vacuum and let it fall off. Several such cups placed over the bases of the lungs or kidneys relieve congestion and stasis in these organs. Fig Dry cups applied to the chest, as in a case of pulmonary oedema, the early stages of pneumonia, or diffuse bronchitis. Dry cups are often employed, and are valuable aids in treating the conditions named. Dry cups are not to be used in acute pleurisy or peritonitis lest they injure the parietal serous membrane. A wet cup is applied as is the dry, but before it is placed on the skin the cuticle is incised by a scalpel in several places so that it will bleed freely when suction is produced in the cup. It is therefore both counterirritant and depletant, and is not to be used in feeble persons who cannot stand loss of blood. DISINFECTION. Before discussing the subject of Disinfection, attention must be directed to what is meant by the terms employed when speaking of this subject. At present we recognize that the word "germicide" is applicable solely to agents capable of killing the lower forms of life, whereas "antiseptics" are substances which render material with which they come in contact so antagonistic or unsuited to germ- development as to render it impossible, at least in an active state. To 496 REMEDIAL MEASURES OTHER THAN DRUGS. use a simile: the killing of the inhabitants of a district by shooting them would stop all growth and be germicidal, whereas the destruction of the crops in those same parts would only be antiseptic; or, in other words, the people might remain, but would starve to death. (See article on Antiseptics.) We speak of germicides as disinfectants, but never of antiseptics as disinfectants if we use these terms correctly, but "germicide" and "disinfectant" are synonymous words. From what has just been said, it is evident that when dealing with filth we should always resort to disinfectants rather than antiseptics, for although the latter are good, the former are better. We have three ways of destroying germs which are particularly useful: The first is the total destruction not only of the germs, but also of their resting-place, by means of fire, which may be used in the case of old furniture, mattresses, and similar materials, and which may be extended to everything which has been about the patient if it is necessary to stamp out a brisk epidemic before it can get well under way; the second is the use of moist heat in the form of super- heated steam, or, better still for common purposes, the use of boiling water; and, thirdly, by means of disinfectant materials which have a proved reliability. Moist heat in the form of superheated steam is infinitely preferable to dry heat, but as superheated steam cannot be readily obtained, physicians usually direct clothing to be boiled for at least two hours. Very often the bed-clothes are taken from a sick-room, trailed through the house, and finally deposited at any spot until a conve- nient time for boiling them occurs. This is radically wrong and capa- ble of causing a widespread distribution of the disease. In all such cases the bed-clothes should be rolled off the bed in a bundle and com- pletely submerged in a bucket or tub of boiling water, or, better still, in a corrosive sublimate solution of the strength of 1 : 1000, before they are taken from the room. This tub is now to be carried at once to the fire, and the clothes lifted out dripping wet and plunged into a clothes-boiler in which the water is actively boiling. The lid of the boiler is at once to be put on to increase the heat and prevent the escape of any germs in the steam or in the hot air which arises from the surface of the water. The active boiling should be continued for one or two hours, and water be continually added to prevent scorch- ing the contents of the boiler. It is important that food be not cooked on the stove at the time the clothes are being boiled, and no food should be in the room. If boiling cannot be resorted to for any reason, the clothes may be soaked in a 1 : 500 solution of corrosive sublimate, or a 1 : 20 solution of carbolic acid, although neither of these is so sure a method of dis- infection as boiling. The care of a room after it has been occupied by a case of infectious disease is of great importance, and is generally sadly mis- DISINFECTION. 497 managed. Disinfection is best accomplished by formaldehyde gener- ators, which act by disengaging the gas from pastilles of formalin, by the heating of wood alcohol, or by boiling a 40 per cent, solution of formaldehyde. The latter is the most efficient method. (See Formic Aldehyde.) It does not injure dye-stuffs. Novy has invented a very useful generator, and when it is used the following rules should be followed : 1. All openings in the plaster or in the floor, or about the doors and windows, should be caulked tight with cotton or with strips of cloth. Fig. 70. Novy's formaldehyde generator. 2. The linen, quilts, blankets, carpets, etc., should be stretched out on a line, in order to expose as much surface to the disinfectant as possible. They should not be thrown into a heap. Books should be suspended by their covers so that the leaves are separated and freely exposed. 3. The walls and floor of the room and the articles contained in it should be thoroughly sprayed with water. If masses of matter or sputum are dried on the floor, they should be soaked with water and loosened. No vessel of water, however, should be allowed to remain in the room, as it will absorb the gas. 4. One hundred and fifty c.c. (5 ounces) of the commercial 40 per cent, solution of formaldehyde for each 1000 cubic feet of space should 32 498 REMEDIAL MEASURES OTHER THAN DRUGS. be placed in the generating apparatus, and (the delivery-tube being in proper position) volatilized as rapidly as possible. The keyhole and spaces about the door should then be packed with cotton or cloth. 5. The room thus treated should remain closed for at least ten hours. If there is much leakage of gas into the surrounding rooms, a second or a third introduction of formaldehyde at intervals of two or three hours should be made. A good method of disinfection is to take all movable objects out of doors into the fresh air, and then to wash the floor, sills, and casings, using a scrubbing-brush, hot water, and soap. The water remaining in the bucket should afterward be boiled to kill the germs which may be in it. This scrubbing being accomplished, the same surfaces should be scrubbed a second time with a solution of corrosive subli- mate (1 : 1000 or 1 : 500) and left wet, so that the mercury salt may remain on them. Cracks and crannies are to receive particular attention. After this is done the floor should be flushed with a solu- tion of formaldehyde. An essential disinfectant for all diseases is good ventilation. Not only should as much air as possible be allowed to enter the sick-room, but after the patient has vacated the premises the windows should remain open for weeks if possible. Fresh air dilutes germs as fresh water dissolves or dilutes dirt. The question as to which are the best disinfectant substances is one that has attracted the attention of physicians and original inves- tigators for years. The result of a vast amount of study and expe- rience shows that formaldehyde in solution or in the form of gas is the best of all disinfectants (see also Formaldehyde, Part II.), and that next to formaldehyde in value is corrosive sublimate in the proportion of 1 : 250 to 1 : 500, or even weaker, but that for cheapness, activity, and general usefulness chlorinated lime is better still. The disad- vantages in the use of corrosive sublimate lie in its ready decompo- sition, its formation of an inert albuminate of mercury when albumin is present, its inertness where lead pipes are present, and, above all, its expense. Chlorinated lime depends almost entirely upon its chlorine for any disinfectant power which it may possess. Chlorine gas itself is not readily handled, but the lime enables us to put it where we will. It cannot be employed to disinfect colored fabrics, as it bleaches them. Whenever chlorinated lime is bought, the physician should see that all the chlorine has not departed from it, as much of the material kept in the stores is so old as to be almost worthless. For scrubbing floors, chlorinated lime may be made into a solution by adding a cupful to a bucket of water, and in privies it may be spread thickly over the surface of the mass of filth. It is useless to place chlorinated lime in saucers around a room for the purpose of disinfecting the air, as the amount of chlorine to the volume of air to be disinfected is as nothing. ENTEROCLYSIS. 499 Copperas, or sulphate of iron, while largely used as a disinfectant is in reality only an antiseptic. Disinfection of the discharges of the patient suffering from an infectious disease is an important duty to be remembered. (See Urotropin.) The urine and feces should always be received in a vessel containing enough corrosive sublimate solution (1 : 500) to kill all germs, and to prevent their escape into the air or into water or food when the discharges are thrown away. The disinfectant should be placed in the bed-pan before, not after, it is used. The bed-pan or chamber should not be allowed to stand in the room, but be removed and emptied at once in such a manner that its contents cannot contaminate any water or food. Its contents should not be thrown upon the ground, as the air will dry them and cause the germs to be disseminated in the form of dust. In very contagious diseases bathing or swabbing off the patient with weak antiseptics may be tried. Thus 1 : 10,000 solution of bichlo- ride of mercury may be used and the patient afterward wiped off with a wet towel. In other instances a 1 : 100 solution of carbolic acid in sweet oil may be employed to soften the skin, allay itching, and disinfect the patient. This is particularly useful in scarlet fever. ENTEROCLYSIS. Enteroclysis, or the washing out of the bowel by means of large and slowly injected clysters for the purpose of medicating or cleansing the large intestine, has within the last few years become one of the most valuable therapeutic measures we possess. It is of value not only for the purposes named, but also for the relief of intestinal obstruc- tion, for the maintenance of bodily heat by the use of hot water, and for the reduction of fever by the use of cold water. The treatment of choleraic diarrhoea in all its forms by enteroclysis was first used by Cantani. The method yielded such good results in his hands that he enthusiastically employed it in a large number of cases, and caused a number of other physicians to use it. The method consists in the slow irrigation of the large bowel by way of the rectum, using a solution urged on by the hydrostatic pressure of a fountain- syringe. The solution contains as its chief constituent tannic acid, which is added in the proportion of from 1 to 5 drachms (4.0-20.0) to 2 quarts (1920) of water, and 1J ounces (45.0) of wine of opium. Carbolic acid is too poisonous, salicylic acid too insoluble, corro- sive sublimate too poisonous and too easily decomposed, to be used in this manner. In some cases Cantani employed a mixture made of Infusion of chamomile-flowers 2000 parts. Tannic acid 10 " Gum arabic 30 " Tincture of opium 2 " 500 REMEDIAL MEASURES OTHER THAN DRUGS. Cantani considers that the passage of the ileocecal valve is essential for the success of his method, and if this is the case, the reporters who have failed to obtain satisfactory results from this treatment have probably failed to do more than irrigate the colon. In health it is not possible to urge fluid past the ileocecal valve by any degree of hydrostatic pressure that is safe. In cholera it would seem that the tissues composing the valve are so relaxed that water can enter the ileum under an amount of pressure which is within proper bounds. This treatment by tannic-acid injections is not founded upon mere empiricism, for Cantani and others have found that tannic acid, in the strength of 1 per cent., inhibits the growth of intestinal germs in one and a half hours at 98° F., while 0.5 per cent, in six hours greatly impairs their vitality. Cantani also asserts that tannic acid neutralizes the toxins formed by these micro-organisms. This treatment therefore contracts the leaking bloodvessels, inhibits the growth of the bacilli, prevents the absorption of toxins, acidifies the contents of the intes- tine, stimulates the nervous system, warms the body, and prevents anuria and collapse. The employment of irrigation of the colon in cases of dysentery is by no means of recent date. It is only, however, within the last few years that this method of treatment has been widely employed or studied. Aside from the fact that by this means we can bring medica- ments in direct contact with the diseased mucous membrane, there is no doubt whatever that the mere passage of normal salt solution at suitable temperatures over the bowel- wall is of value, for in this man- ner we remove mucus and pus, and so dilute the poisons manufactured by the germs of the disease that their further action is largely inhibited. In adults the use of irrigation in dysentery should be carefully carried out by means of an inflow and an outflow tube, the first being attached to a fountain-syringe. The outflow tube must be large enough to permit of the liquid leaving the bowel with a readiness equal to that of its inflow, and must be so straight and patulous as to permit of the fluid carrying away with it from the bowel any flakes of mucus or other foreign matter. The inflow tube should be introduced a consid- erable distance into the bowel and the outflow tube placed just within the sphincter. The method employed in giving the injection, the tem- perature of the water, and the gentleness of the operation are exceed- ingly important, and will be discussed below. The amount of water employed in irrigation of the bowel in dysentery is not to be measured by quarts, but by results. It should continue to flow in until it comes from the outflow tube perfectly clear, showing that our object — namely, thorough cleansing of the bowel — has been accomplished. The best medicament to be added to the water is boric acid or tannic acid, each of which is harmless and capable of doing much good. In nearly all instances in which we wish to cleanse the bowel a nor- mal salt solution should be employed rather than pure water, as the latter tends to irritate the intestinal wall. ENTER CL YSIS. 501 The question as to what is the best method of treating a ease of intestinal obstruction by other than operative means is one which is of interest to the physician as well as the surgeon. Such cases gen- erally come into the hands of the general practitioner first, and it is for him to decide, as a rule, whether the surgeon shall be called in consultation. Measures directed to the relief of the patient without the use of the knife are first to be tried. No one who has studied this subject can doubt that enteroclysis is a valuable measure in cer- tain cases. Used properly, there is little danger of its doing harm, and some chance of its accomplishing good. The author is not one of those who place much confidence in the reports of cases of volvulus overcome by this means. The true indication for rectal injections is intussusception or obstruction due to impacted feces. Even in such cases the injection treatment should not be persisted in for a period exceeding twelve hours. If the second injection fails to give relief, operation must be resorted to. A very important point to be decided in connection with this sub- ject is the amount of pressure that can be used with the stream of water which is employed, the length of time during which the injection may be given, and, finally, the temperature and character of the fluid injected. As is well known, the great majority of cases of intussus- ception take place at the ileocecal valve, and, if not here, in the sig- moid flexure. Pressure by injection is therefore readily brought to bear on the area involved. It has been claimed that certain pressures will cause rupture of the peritoneal coat of the intestine, but Dr. Martin and the writer failed to produce this lesion in the dog by any pressure we could employ, since before this occurred the liquid passed through the stomach and mouth. To employ a pressure exceeding eight pounds is, however, distinctly dangerous, not because the intestinal wall in health will not stand this as a rule, but because it is near the injury line, and if any disease or softening of the bowel exist, it is almost certain to cause rupture. A pressure of from two to five pounds is, as a rule, as much as may be employed, and this pressure should be reached by degrees, starting the injection at such a pressure that the flow amounts to hardly more than a trickle, and increasing the pressure as the antagonism of the bowel is overcome. Finally, when the bowel is fully distended up to the point of obstruction, the pressure on the no longer moving column of water may be increased, if necessary, to six or eight pounds by raising the bag of water not more than three feet. In infants, in whom invagination so often occurs, a pressure greater than two pounds is dangerous, and it is of vital importance that the pressure be employed properly, otherwise it will do more harm than good in several ways. As a rule, in our anxiety to give the patient relief at once we are inclined to use too much force and too large a bulk of water, and think that active force, if such a term may be used, is to be resorted to. Those who have seen these cases have learned by experience the harmfulness of such 502 REMEDIAL MEASURES OTHER THAN DRUGS. measures, and have also learned how great is the expulsive power of the bowel when it is excited to contraction. If this power be brought into activity, it will be almost impossible to inject fluid into the rectum, and, worse than all, the muscular fibres of the intussuscipiens take a still tighter grasp on the intussusceptum. The dangerous practice of using a Davidson or any other kind of hand force syringe in the treatment of this class of cases is to be condemned. Three unreported cases of rupture of the bowel and death from the employment of the Davidson syringe for this purpose have occurred, because the amount of force used was indeterminable, and because the fluid was injected with a jerking instead of a constant flow. The amount of fluid injected should be large, and if it is impossible to get a large amount into the bowel, it is probably because the inflow has been so rapid as to excite intestinal opposition. If, by a slow trickle of water into the bowel, gradually increasing the pressure, we are unable to give relief in forty-five minutes, it is necessary either to abandon this treatment as useless, or else allow the liquid to flow away and resort to the measure again after some hours. Practical experience has shown that the second or third injection sometimes succeeds, prob- ably because it is more skilfully given and the first has prepared the way for the others; but it is to be remembered that the chances for reduction of the obstruction are best with the first injection if it is properly given. Frequently repeated small injections are absolutely unjustifiable, as they tend only to cause spasm of the bowel. Finally, the author cannot leave this subject without saying a word concerning the temperature of the injected liquid and its constitution. An injection of this kind goes into the very heat-citadel of the body, and if too cold, as it often is, produces dangerous chilling of organs which are ordinarily especially protected from cold by the omental apron and intestines. By repeated experiments, Martin and the author found that w^ater at 65° F. lowered the bodily heat three degrees in thirty minutes. The use of colder water than this (52° F.) resulted in death in twelve hours, and the post-mortem showed intense conges- tion of the colon, which contained bloody mucus. The use of water of too high a temperature is also dangerous, lest it produce heat-stroke. Of course no one would use water hot enough to produce local harm, yet it is necessary to have just enough heat and no more. Martin and the author proved that the use of water at 115° F. caused in twenty-five minutes a rise of bodily temperature in the axilla of nearly five degrees, and developed marked symptoms of heat-dyspnoea. The temperature which it is right to employ we found to be 101° to 103° F. as the water entered the bowel, or even as high as 104° F. in the water-bag if a long tube were used, as under these circumstances the water is rapidly cooled. An interesting result of these experiments as to heat is that when cold water was used it took four times as long to make the injection as when moderately warm water was employed. GAVAGR 503 If very large injections are used, a normal saline solution of 7 : 1000 (1 drachm to 1 pint) should be employed to avoid the abstraction of vital salts from the intestinal wall, with consequent passage of water into the tissues, making them boggy, due to the law of osmosis. If the saline solution is stronger than this, it abstracts water from the bowel wall and causes thirst. Rectal injections are very useful to relieve thirst and keep the kidneys active after abdominal operations. Distention of the bowel by injection produces little if any effect on the circulation and respiration, but the passage of large amounts of warmed fluid directly into the closed abdominal cavity causes death rapidly. Fig. 71. Showing the introduction of a soft catheter through the right side of the nose in the practice of gavage. GAVAGE. Gavage is a term applied to the forced feeding of patients who will not or can not swallow food. The method is often employed in nourishing the insane who refuse food. A soft-rubber catheter is 504 REMEDIAL MEASURES OTHER THAN DRUGS. passed through one of the nasal chambers back into the pharynx, a small funnel is attached to its outer extremity, and the milk, or beef- broth, or other liquid food is by this means introduced into the pharynx, where the muscles of deglutition seize it. The term gavage is also correctly employed to the forced feeding of a patient by an oesophageal tube, as in the use of lavage. (See Lavage.) HEAT. Heat is used locally for a number of purposes in the same manner as is cold, and, as was stated in the article on Cold, the choice of heat or cold in the treatment of any acute form of inflammation depends almost entirely upon the wish of the patient, who generally can tell at once which will give him the greater comfort. In sprains of the ankle nothing compares to a hot foot-bath pro- longed for hours, the object being to decrease the pain and swelling, thereby regaining the use of the limb. The high degree of heat which can be borne by gradually increasing the temperature of the water by the addition of small quantities of scalding water is very extraordin- ary, and the favorable results obtained are in direct ratio to the height of the temperature. Between these soakings the part should be dressed with lead-water and laudanum, and rubbed with ichthyol ointment or camphor liniment and laudanum. In spasmodic affections involving either striped or unstriped mus- cular fibre the local application of heat is a very useful means of relief. Sometimes in lumbago, or muscular stiffness in other parts of the body, the use of an ordinary hot laundry iron over the affected parts will prove of great service, the skin being covered by several layers of newspaper to afford a smooth surface over which to pass the iron and to protect the parts from too great heat. In chordee the best means for rapid relief, other than the use of drugs or general relaxants, such as amyl nitrite, is to steep the penis in hot water. A hot sitz-bath before going to bed is a good prophy- lactic against this painful complication of gonorrhoea. In croup of the spasmodic type the local application of a hot com- press, made by wetting spongiopiline with hot water, is very useful, or, if spongiopiline cannot be had, several layers of flannel should be wetted, placed on the neck, and covered with cotton and oiled silk so as to prevent the roll becoming chilled. Nearly all forms of pain in the eyes can be much relieved by the application of heat. Thus iritis, corneal irritation and ulceration, and pain due to eye-strain can be greatly relieved by the use of hot water applied by cotton pledgets frequently renewed, but never allowed to remain on long enough to act as warm poultices. Another method is to allow water as hot as can be borne to drop upon the lids from a fountain- syringe. The water-bag should not be more than two feet above HEAT. 505 the patient's head, and the fluid should drop on the eyelid from the dis- tance of a few inches only. Where attacks of dysmenorrhea depend upon spasmodic closure of the cervix, with simultaneous spasm of the fundus uteri, a hot sitz- bath or hot vaginal injection is useful, and this treatment is also of value where uterine congestion results in leucorrhcea or a sensation of weight in the pelvis. Sometimes attacks of torticollis may be subdued by applying hot compresses to the sternomastoid muscle. The local application of heat may serve to determine whether the inflammatory process has gone on to the formation of pus. Before pus is formed heat decreases the pain, it is claimed by Lewin, but afterward greatly increases it. Heat is largely used at present for medicinal purposes, when the skin or kidneys are torpid, to aid in the elimination of impure and effete materials from the blood and tissues. It is employed in two forms, the dry and the moist, commonly called the Turkish and Russian baths respectively, and may be taken under home arrangements or in one of the establishments found in all large cities. The Turkish bath consists of a series of rooms ranging in tempera- ture from 100° to 1 50° F. or more, into which the individual passes successively until the hottest room is reached. In each chamber he lingers until the system becomes accustomed to the high tempera- ture, and perspiration is well established before he enters the hottest room, where he remains for a varying length of time according to the advice of his physician or his own whim or comfort. The rule governing his stay is that he must leave it at once if any sense of oppres- sion is experienced or if perspiration does not flow freely. Some- times a glass of cold water taken at this time causes a sudden profuse sweat, and also relieves any overheating by abstracting many units of heat. The cold water in the centre of the body causes contraction of the bloodvessels in these parts, and the blood, rushing to the surface, causes the sweat glands to pour out their secretion. Following the stay in the warm room, the individual passes into still another chamber, where he is shampooed from head to foot, well rubbed, and the blood made to circulate through the skin. The shower-bath is then used, at first hot or warm, and finally changed to a dash of cold, or, better still, the patient plunges into a long tank, swims to the other end, and is there met by an attendant who rapidly dries his skin, wraps a cover round him, and shows him to a lounge, where he is supposed to sleep for an hour or so. The air of this sleeping-room is at the ordinary temperature of a living- room. Reviewing for a moment the effects of this bath, we find that the first two-thirds are devoted to the opening and stimulation of the pores of the skin, while the last third is devoted to the contraction of these pores and their supplying bloodvessels. In other words, it 506 REMEDIAL MEASURES OTHER THAN DRUGS. is necessary to use the cold to prevent gradual chilling of limited areas, which would result in internal congestion. If the patient receives a cold douche, the natural rebound prevents congestion of a permanent nature, whereas if he is exposed to cold a long time, these stagnated areas become permanently diseased. The physician must always remember that this cold douche or plunge is a sine qua non, and that a rest after the bath before dressing is almost equally important. If the patient is too weak to bear the cold, he must not use the bath. The indication for the Turkish bath as a medicinal measure is any condition of the emunctories of the body whereby effete matters are not properly eliminated, as in Bright's disease in its various forms. The increased action of the skin not only casts off impurities for the time being, but frequent repetition of the bath causes functional hypertrophy of the sweat glands, and eventually enables them to do more work, or, in other words, to cast off an increased quantity of effete material. As a consequence of this the patient is able to decrease the tendency to uraemia or other evidences of Bright's disease, and, employing the normal epithelium still left in the kidney for constant use, uses the bath once, twice, or thrice a week with the object of abstracting the excess of impurities which the impaired kidneys cannot remove. The frequency of the bath depends, therefore, upon the rapidity with which the effete materials accumulate. In a case of Bright's disease the patient should not attempt to use the room con- taining high heat at first, and should be accompanied by a medical attendant to watch for untoward effects, particularly if the heart is diseased or uraemia is already shown by headache or other signs. If sweating does not come on at once, danger is at hand from acute uraemia, renal and cerebral congestion, or heat-stroke. Not only is the Turkish bath useful for kidney disease, but it is often of great service in rheumatism. The acute form of rheumatism is rarely so treated, because cardiac complications forbid exposure to heat, and fever is generally present. In subacute and chronic rheu- matism the case is different, and the enlarged joints or inflamed muscles greatly improve in some instances from such treatment. Further than this, the muscular stiffness following prolonged or severe effort can be so avoided, and neuralgia depending upon rheumatic or gouty taint may be relieved by the hot-air bath. Acute colds affecting the nasal cavities or other parts of the body, at an early formative stage, can often be aborted by a thorough Turkish bath, and when further developed are often greatly relieved by the same means. If, however, congestion of the lung, pneumonia, or chronic bronchitis, with emphysema or a dilated weak heart, is present, the bath may be dangerous. In acute pharyngitis, in which the pharynx feels like a raw surface or "as if it were filed or scraped/' the bath will give relief in many instances. Sometimes in suppression of menstruation from cold the flow may be restored by a Turkish bath. HEAT. 507 Same persons complain that they are always catching cold upon the slightest exposure and apparently without cause. One class seem to have delicate mucous membranes readily susceptible to irri- tation and inflammation; the other have dilated or relaxed peripheral capillaries, which readily allow the blood in them to become chilled, and the individual consequently suffers from internal local congestions. Two separate means of treating such cases exist. The first class will do well on minute doses of arsenous acid (grain y^-g- to -^) three times a day, used for weeks; the second will be cured of their habit by the use of a Turkish bath twice or thrice a week, since by this means the peripheral capillaries are toned up and made more active. Fig. 72. A method of giving a bedridden patient a hot-air bath where a sweat is desirable, or where shock with a collapse temperature is to be controlled. The bed-clothing is raised by a cradle. An alcohol lamp is placed under the inverted funnel, and the hot moist air is carried in this way to the patient without any danger of fire or of burning the skin by hot bottles. The Turkish bath, as thoroughly carried out in large cities, is not obtainable for those living elsewhere, so it is well to describe a home modification which, with attention to detail and care, may prove almost, if not quite, as effective a remedy. (See Fig. 50, p. 320.) The patient is placed upon a wooden chair, naked, and under the chair a small alcohol lamp is put, which is lighted. The individual is now wrapped thoroughly, chair and all, with one or two large blankets, when the heat of the lamp soon causes profuse sweating. Many cases are, however, on record where the lamp has been upset and the patient badly burned. The best way is to have the lamp a little to one side and its flame immediately under the mouth of an inverted funnel attached to a piece of tin tubing, the free end of which is placed under the blanket, so that the hot air and vapor may surround the body. If the tube be covered with cloth, the loss of heat is slight and the 508 REMEDIAL MEASURES OTHER THAN DRUGS. danger of burning the patient is removed. If this is not practicable, several very hot bricks or stones, thoroughly heated in an oven, may be placed under the chair, or small heated logs of wood may be substituted. When the patient is too feeble to sit in a chair, then it is wise to place an alcohol lamp at the foot of the bed, with an inverted funnel attached to a tube which passes under the bed-clothing in such a way as not to bring the hot air directly against the skin of the patient. The bed-clothing may be slightly raised to allow the hot air to enter. The Fig. 73. Nurses using two broom-sticks to wring out a blanket dipped in very hot water for use in the hot pack. (From the author's wards.) vapor of the alcohol lamp tends to sweat the patient. This is also a valuable mode of using external heat in cases of shock. (Fig. 72.) The Russian bath differs from the Turkish in that the heat used is moist, not dry. As a consequence the danger of heat-stroke and similar states is much increased, because evaporation from the skin does not go on so rapidly and the body is not cooled so well. The hot moist bath can also be obtained by seating the patient on a wicker chair under which is placed a bucket of hot water. The patient is surrounded by a blanket, and a large hot iron or stone is HEAT. 509 put into the water, causing the development of a great amount of steam. This method of treatment is useful in the same states as is the Turkish bath, but is more rarely used. It may also be employed to develop the rash of any of the exanthematous fevers when it is sup- pressed by cold or is not "well out" on the skin. Under the name of the "hot pack" still another substitute for the Turkish or Russian bath is used, not only to cause sweating and so relieve the patient of poisons and fluid in renal diseases, but also to relax muscle spasm and to relieve nervous excitement and nervous insomnia. It is particularly efficacious in the insomnia of severe chorea in children, and mav be used in tetanus. Fig. 74. Showing arrangement of blankets in giving a hot pack for uraemia. (From the author's wards.) A bed is prepared by covering it with a rubber blanket. Over this is placed a dry woollen blanket. A large, heavy blanket is now dipped in very hot water and then wrung out (see Fig. 73), and the naked patient quickly wrapped in it, the dry blanket being folded over him after several hot-water bottles have been placed alongside the patient. Finally the sides of the rubber sheet are drawn around and over the patient and an ice-cap placed on the head. (Fig. 74.) A thermometer should be placed in the mouth every fifteen minutes, and if the patient's temperature becomes febrile (101° F.) he should be taken out of the blankets and rubbed dry. Ordinarily the bath should last about one hour, and if sweating does not speedily come on a glass of cold water should be taken to drive the blood to the skin. In adults a little gin may be added to it, or sweet spirit of nitre may be used in this way in children and adults. If no sweat develops and the temperature begins to rise, the patient must be taken out of the bath at once. Another wet pack, which speedily becomes a warm one, is used in cases in which, during the course of an eruptive fever, the eruption fades and it is desired to bring it out on the surface. It is also useful in those cases of severe chorea in which the child can withstand the first shock of the cold. It consists in wrapping the child in a cool wet sheet and over this wrapping one or two blankets. In a few minutes the 510 REMEDIAL MEASURES OTHER THAN DRUGS. sheet becomes heated by the body and the sweating which results is profuse. Whenever the Turkish or Russian bath or hot pack is used, except in the exanthematous fevers, it should be followed by a cold sponge, plunge, or douche. Although these baths have been used in the treatment of cases of heart disease to relieve dropsy and renal engorgement, they are not safe, and should not be generally employed. All acute or chronic diseases of the lung, except acute bronchitis of a mild form, contra- indicate their use. A valuable method for using moist heat in a mild form is the "bron- chitis tent." (See article on Bronchitis.) Ftg. 75. Frazier-Lentz hot-air apparatus. The use of a high degree of dry heat for the cure of inflammatory states of the sheaths of the joints and muscles has recently been made once more popular by the introduction of a double copper cylinder closed at one end, inside of which is placed the limb which is affected. The limb is prevented from coming in content with the cylinder by means of a board padded with asbestos and by putting pads of linen under the parts which touch the asbestos. A thermometer is placed so that its bulb extends into the cylinder, and a few holes permit of the moderate circulation of air. Bunsen burners or alcohol lamps are now lighted and placed under the cylinder, and the orifice through which the limb enters it is closed by drawing around the limb an HYPODERMOCL YSIS. 511 asbestos curtain. The temperature is allowed to rise to 200° to 300° F., and the treatment resorted to daily, or several times a week, the indi- vidual seance lasting about one hour. The free sweating of the limb and the circulation of the blood and lymph prevent it from being burnt, but care must be taken that it does not touch the metal. Usually the entire surface of the body sweats profusely during the sitting. Fig. 76. Kelley's hot-air apparatus. The author believes this method to be of great value in cases of chronic inflammatory joint-affections due to rheumatism or following injuries, but of little service in those due to gouty swelling. In sub- acute gout he has seen it precipitate an attack of universal acute gout, apparently by setting free large amounts of uric acid from the affected joints. This method of treatment is always to be considered as a valuable aid in the treatment of the more obstinate cases of the character described. The best form of this apparatus is expensive. A less expensive apparatus is shown in Fig. 76. HYPODERMOCLYSIS. Hypodermoclysis is a method of supplying fluid to the body to replace that lost through excessive purging, as in cholera, or in cases of hemor- rhage. Further, it may be used to wash from the body various impuri- ties circulating in the blood and lymph, and to flush the kidneys. In other instances it may be used to supply the body with liquid when the stomach will not permit liquid to be swallowed, as in vomiting, or gastric ulcer or after abdominal operations. It consists in the intro- 512 REMEDIAL MEASURES OTHER THAN DRUGS. duction into the subcutaneous tissues of normal saline solution, which is rapidly absorbed by the vessels. As is well known, a quantity of liquid equal to four times that of the normal amount of blood may be passed directly into the veins without producing a rise of blood- pressure, and experiment has shown that usually within fifteen minutes after the fluid flows into the subcutaneous tissues an increased flow from the kidneys takes place. It is not safe to infuse a greater quantity of liquid than 1 drachm to each pound of body-weight in each fifteen minutes, as, if this amount is exceeded, the accumulation of the liquid in the system is so great that the tissues become bathed and finally drowned, because the kidneys cannot excrete the liquid fast enough. To carry out the operation, the sterilized liquid to be infused — the formula on page 537 is the best — is placed in a glass irrigator jar oi Fig. The apparatus and method used in giving hypodermoclysis. The ordinary irrigator is attached to a small canula, and this is placed in the loose tissues of the belly-wall. rubber bag, which is absolutely aseptic. From the lower part of the vessel leads a rubber tube to which is attached a canula, also rendered sterile. The skin over the place where the liquid is to enter is to be rendered absolutely sterile, the trocar is then inserted into the subcutaneous tissue of the thigh, or, preferably, of the abdomen, or below the breast, and the liquid allowed to flow at a rate named, the pressure being obtained by raising the container two or three feet above the belly-wall. (Fig. 77.) As the liquid enters, a swelling appears in the subcutaneous tissues, which soon disappears INHALATIONS. 513 after the infusion ceases, and is much aided in its absorption by the use of very gentle rubbing or stroking. When hypodermoclysis is employed after hemorrhage, the results are often extraordinary. It is of great value in the collapse of cholera. The cyanosis decreases rapidly, the pulse improves, and respiration is no longer difficult. Some physicians have used hypo- dermoclysis with very good results in the treatment of uraemia, and the author believes that not only are the poisons washed out of the system by this method, but, in addition, that the dilution of the poisons prevent them from acting so severely. In septicaemia, diabetic coma, and similar states this method of treatment should be employed and the results carefully recorded. When general dropsy is present, it is manifestly useless. Hypodermoclysis has also been used with great advantage in the treatment of severe burns to overcome shock and toxaemia. In cases of surgical shock warm saline fluid used by hypoder- moclysis is often of great service. (See also Intravenous Injection; Transfusion.) INHALATIONS. The value of inhalations is not recognized sufficiently by the medical profession. As a matter of fact, they are capable of aiding us very much in the treatment of disease and of producing results otherwise unobtainable. The employment of inhalations may be divided into the properly modified use of atmospheric air and the employment of atmospheric air charged with medicinal substances. To carry on many of the forms of treatment which have been found of value requires cumbersome or costly apparatus which cannot be used except in insti- tutions; but nevertheless the general practitioner can employ remedial measures by way of the respiratory organs with great advantage to himself and his patients even when far removed from places where costly apparatus can be had. The first form of inhalation to be studied is that which is devoted to proper respiratory exercises. These exercises are required by patients who because of faulty development do not properly expand certain portions of the chest in the function of respiration and by those who have acquired impaired respiratory movements through the following of certain occupations or as the result of attacks of disease. There can be no doubt that pulmonary tuberculosis may be pre- vented, or even arrested in its earliest stages, by causing a patient to use proper thoracic exercises, which must usually be directed toward producing expansion of the apices of the lungs, a part of these organs which in many instances is but poorly filled and equally ineffectively emptied under ordinary conditions of life. The following inhalation exercises are to be directed for such cases: The patient stands with his back against a wall, holding himself as erect as possible and bringing his shoulder-blades flat against the 33 514 REMEDIAL MEASURES OTHER THAN DRUGS. plane behind him. He now takes a slow, deep, and full inspiration, drawing the air into the chest in a steady stream, and not by a sudden jerk of the respiratory muscles. The inspired air is to be held in Fig. 7* Standing erect. Fig. 80. Wing standing, side bending. Fig. 79. Stretch standing. Fig. 81. Wing standing, trunk rotation. the chest while the patient mentally counts three, and then allowed to escape gradually, and not forced out of the chest by sudden mus- cular effort. Usually four or five such movements night and morning INHALATIONS. 515 are quite sufficient for good results for the first week. After that time they may be gradually increased in number. Fig. 82. Fig. 83. Y"\ >?:\ r*t«fk'i Wing standing, knee bending or curtseying. Stride standing, forward bending, or hewing. Fig. 84. Fig. 85. Half wing, half stretch, standing; forward bending, or sawing. Wing standing, leg circling. Another movement may now be added to that just described. The patient, standing with the back against the wall and the shoulders well thrown back, .raises his arms, which are completely extended, 516 REMEDIAL MEASURES OTHER THAN DRUGS. from the sides until the hands are on a level with the shoulders, thereby fully expanding the sides of the chest. As expiration begins the arms are allowed to fall gradually to the sides. After this the arms may be carried above the head into a perpendicular position. A third exercise consists in inhaling as deeply as possible and then exhaling against resistance produced by closing the lips and forcing the air between them. The fourth exercise consists in lying upon a firm bed with a small pillow under the hollow of the back and no pillow under the head, and then taking slow, long-drawn inspirations and expirations as already described. These exercises are useful not only in persons with faulty chest development, but also in those who have poor expansion of a lung after a pneumonia, pleurisy, or empyema. The increase in the volume of air respired under gentle but per- sistently taken exercise of this character is quite remarkable and these movements often increase the appetite, the proportion of haemoglobin, and the general health of the patient. In addition to these exercises there are others which, while not directly connected with breathing, produce nevertheless deeper respira- tions and at the same time develop the chest muscles and cause the patient to hold himself erect, thereby preventing or correcting faulty pulmonary expansion. Nearly every physician can look back upon cases in which a slovenly carriage of the shoulders in early life has resulted in impaired chest expansion and finally in actual disease. The exercises to be ordered are shown in Figs. 78 to 85. The next class of exercises consist in using simple forms of apparatus in association with respiratory movements. These are advantageous not only because they are beneficial in themselves, but also because they interest the patient and cause him to take exercises of which he might tire if they were performed without appliances. The first of these consists in a pair of Wolff bottles joined together by a piece of rubber tubing. (Fig. 86.) The bottle nearest the patient is filled with water, and the patient after taking a deep inspiration at the moment of expiration places a mouth-piece attached to a rubber tube between his lips and forces the water over from the first to the second bottle. This is usually sufficient for an exercise, and later in the day the patient drives the fluid from one bottle to the other a second time. Such a procedure causes the patient to take full inspira- tions and forcible, though gradual, expirations, with the result that he fully expands portions of the lungs hitherto but imperfectly inflated. It is therefore of value in patients with poorly developed chests, in cases after an attack of pneumonia, when complete resolution is long delayed, and in instances of deficient pulmonary expansion because of adhesions following an attack of pleurisy. In cases of empyema after drainage is established it is useful in that it aids drainage, keeps the pleural cavity free from pus, and gradually causes the lung to descend INHALATIONS. 517 once more into the lower part of the thorax. This practice is a very useful one in children, who may otherwise suffer from deformity due to collapse of one side of the chest if the lung is not properly expanded. It is not to be practised immediately after the removal of a pleural effusion or empyema, because time must be given the lung to expand naturally and adjust itself to the relief of pressure. Fig. 86. Arrangement of bottles for promoting lung expansion. Another form of apparatus, designed for the same purpose as that just named, is "Denison's Resistance Inhaler." (See Fig. 87.) The physician having determined that the patient is to inhale air against Fig. 87. Denison's resistance inhaler. When in use the cap at the end of the inhaler is removed and air is drawn into the square chamber, which contains a piece of folded absorbent paper or cotton wet with some of the volatile oils named in the text. The air then passes to the patient by way of the mouth-piece, meeting, however, a resistance valve on the way designed to produce forced inhalations. On expiration the air goes through the mouth-piece as far as the perforated elevated column, where, by a valve, it escapes. By means of the cap on top of this column the resistance offered by the valve to the escape of the air is increased or diminished as is desired, so that the patient expires against resistance. resistance, the valve is fixed to yield to a pressure caused by his forcible inspiration. On the other hand, when the patient exhales the muscles of the chest must use sufficient pressure to force the air past the expira- tion valve. The result is that every part of the lung is expanded, the respiratory muscles are exercised and strengthened, and what might be called slovenly or imperfect breathing is corrected. 518 REMEDIAL MEASURES OTHER THAN DRUGS. We now pass to the consideration of inhalations designed to carry medicinal substances into the lungs for their effect on the respiratory tract or to influence the general system, not including, however, the use of general anaesthetics. The air respired may be medicated by the following methods: (1) Setting free in the air of the room volatile substances derived from chemical or vegetable sources, using materials which are naturally volatile or which can be made so by the aid of dry or moist heat. (2) The use of a mask or inhaler so arranged that a part at least of the inspired air must pass through or over a sponge or piece of cotton moistened with the medicament. (3) The nebulizing of substances which are not volatile, by the use of compressed air. The use of chloride of ammonium fumes in cases of chronic bron- chitis is described in the article on Ammonium Chloride. In cases Fig. Chamber inhaler (Hassall). The shelves are made of cotton cloth, upon which is poured the medicine to be employed. of spasmodic croup a few crystals of menthol placed in an iron spoon may be volatilized over a gas jet or lamp chimney, and so diffuse the vapor through the air. (See Croup.) Creosote is said to produce very good effects in whooping-cough, and in bronchitis in its later stages, if cloths wet with it are hung about the room. So, too, turpentine, terebene, eucalyptol, and similar substances can be used in place of creosote, and in doing so the apparatus for diffusing these drugs in the air described by Hassall may be employed. (Fig. 88.) In other instances it is better to set free these and other substances by the aid of steam, allowing the steam to escape freely into the air of the room or to enter a "bronchitis tent." (See article on Bronchitis.) 5 to 20 minims (0.3-1.3) of any of the substances just named may be INHALATIONS. 519 added to the water when it is boiling. Menthol may also be so used, placing 2 to 5 grains (0.12-0.3) in the hot water at a time. The steam allays irritation by increasing the moisture in the air of the room, checks coughing, and aids the action of the drugs. In the article on diphtheria an additional formula for such cases is also given for use in this manner. The drug to be used may be placed in the water in an ordinary teapot heated by a lamp, or gas jet, or the "croup kettle" may be employed (Fig. 89), or in its place the appliance shown in the article on Bronchitis. In other instances the apparatus shown in Fig. 90 may be used. In Fig. 89. mm ^jfejtf^ BH : i MB 9 Croup kettle and inhaler. this arrangement the medicated steam is generated in the boiler and then escapes from the upper end of the tube and is inhaled by the patient, who brings his face as near to the apparatus as the heat will permit. The following formula is useful in many cases of pulmonary tuber- culosis and bronchitis with a dry cough, if placed in such a steam inhaler: Ifc— 01. pini svlvestris f Bj (30.0). 01. eucalypti f 5j (30.0). Creosoti f gss (16.0).— M. S. — Place 1 to 3 drachms (4.0-12.0) in the water in the boiler and inhale the steam three or four times a dav. 520 REMEDIAL MEASURES OTHER THAN DRUGS, If there is excessive cough, J ounce (15.0) of spirit of chloro- form may be added to the above prescription with advantage. In many cases of acute laryngitis the following formula is of excellent service if used in this manner: Py — Tine, benzoin, comp foj (30.0). Menthol- gr. x (0.60). Spt. chloroform f oss (16.0).— M. S. Place 1 to 2 drachms (4.0-8.0) in the water in the boiler, inhaling the steam from a freshly made watery mixture several times a day. After using steam inhalations the patient must not inhale for several hours the outdoor air if it is cool. Fig. 90. Steam vaporizer. For use with the mask or face inhaler (Fig. 91) or Denison's inhaler (Fig. 87), the following formula is valuable in cases of chronic bronchitis with excessive cough: P,— Chloroform f§ss (16 0) S.- Creosoti foss (16.0). Menthol gr.x (0.60).— M. ■10 drops on the inhaler every three hours. INHALATIONS. 521 Any one of these ingredients may he used alone. Sometimes where it is desired to liquefy tenacious bronchial mucus 10 drops of iodide of ethyl may also be placed on the inhaler to act as a stimulant expec- torant. The mask or Yeo inhaler must be used almost constantly if it is to produce good results. Fig. 91. Yeo's inhaler, made of perforated zinc bound on the edges with chamois skin and supplied with elastic loops to go back of the ears or around the head On a sponge placed in the front of the inhaler is dropped the medicine to be inhaled. Small pocket inhalers containing medicated cotton may be used. A small glass tube is partly filled with cotton, and this is kept in place by perforated corks fixed in either end. Any of the medicaments named may be placed on this cotton, and the air inhaled through the Fig. 92. Evans' pocket inhaler. Half size. The finger of the patient may be placed over the opening marked 1 when exhaling, and over that marked 2 when inhaling. tube. A tube of this sort packed with crystals of menthol, and called a "Menthol Inhaler/' is largely sold at present. It is of value in acute colds. A useful modification of this straight tube is that of Evans. (Fig. 92.) In this apparatus the sponge in the bulb is wet with the medicament. 522 REMEDIAL MEASURES OTHER THAN DRUGS. There are on the market at the present time a large number of so-called vaporizers or nebulizers, which by the aid of compressed air force the medicament to be inhaled in a fine spray against the side of the glass containing it, in this manner still further comminuting it Fig. 93. Robertson's nebulizer attached to a tank of compressed air. The tubes are so arranged that one or all of the medicaments in the different bulbs can be delivered to the patient at one time. In addition to the tube which carries the nebulized drug to the patient there is an extra attach- ment for an atomizer, which is seen on the right-hand side of the figure. and causing it to escape from the bottle or bulb as an exceedingly fine vapor. The larger ones are supplied, as a rule, with compressed air from a force pump or large hand pump. The smaller ones are INHALATIONS. 523 worked by a small hand pump or rubber bulb. The forms employed largely by the writer are those of Robertson and Oliver. (See Figs. 93, 94.) For the satisfactory use of these nebulizers the medicament had better be dissolved in an oily fluid. The following formula may be used in such apparatus in coryza or acute inflammation of the upper respiratory tract: 1^— Menthol gr. xx (1.3). Camphorse gr. x (0.60). Alboleni (liquid) f Bj (30.0).— M. S — Place in the Debulizer and inhale the vapor several times a day. COn- A somewhat similar formula of even greater value than this ~ tains, in addition to the above, 2 to 5 grains (0.12-0.3) of chloretone, Ftg. 94. Oliver's nebulizer. which is useful in that it is anaesthetic and sedative to the mucous membranes. (See article on Peppermint.) Where the inflammation is very severe and acute, it is often well to substitute for the above formula the following one: 3$ — 01. sassafras gr. iij (0.2). 01. santali m v (0.3). Alboleni (liquid) f§j (30.0).— M. S. — Use in vaporizer. In such small amounts sandalwood oil is sedative. If we wish to use it as a stimulant expectorant, the quantity may be increased to 30 minims (2.0). An even more stimulant inhalation in cases of chronic bronchitis is as follows: 1^—01. eucalypti f5j (4.0). 01. picis liquid f 3ij (8.0). Alboleni (liquid) . . . . . . . f 5j (30.0).— M. S. — Use in nebulizer. 524 REMEDIAL MEASURES OTHER THAN DRUGS. INTRAVENOUS INJECTION. The intravenous injection of medicines is a method which is to be employed only under extraordinary circumstances and with only a few drugs. Thus in the case of pernicious malarial fever it may be advis- able to resort to an injection of quinine. (See Cinchona.) Under these circumstances the injection should be made into a vein in the leg, rather than one in the arm, as the drug under these circumstances does not reach the heart in so concentrated a form, and temporary cardiac depression is thereby avoided. The objections to intravenous injections are several. In the first place, the veins are apt to be collapsed and hard to find, and it is difficult to puncture one without wounding the opposite wall of the vessel. Again, phlebitis is a very probable sequel, and thrombosis and embolism are by no means impossible. It is needless to say that the solution of the drug which is injected into a vein should always be of a neutral or alkaline reaction in order to avoid coagulation of the blood. (For Saline Injections, see Trans- fusion.) KATAPHORESIS. By the term "kataphoresis" is meant a method having for its purpose the introduction into the body of drugs through the influence of galvanic electricity. Correctly speaking, kataphoresis is an osmosis of medicaments through the tissues, the osmosis being carried on by the galvanic current and the drug being carried through the tissues between the two poles. Quinine, cocaine, iodide of potassium, the various soluble salts of mercury, and chloroform and ether may be so used. The ordinary sponge or absorbent cotton tip of the positive electrode is to be saturated with the medicament to be used, and the constant current employed. The positive pole of the battery is placed over the affected part, and the negative pole at a little distance away. In cases of neuralgia, chloroform and alcohol, of each one-half, or even pure chloroform, may be employed, and in syphilitic nodules, when the patient's stomach will not tolerate drugs, kataphoresis with iodides over the part affected may be resorted to. The iodide of lithium is commonly employed in the strength of 5 per cent, in these cases. The strength of the current depends upon the size of the elec- trodes and the sensations of the patient. It is not necessary to use a stronger current than the patient can bear with comfort. LAVAGE. This is a term applied to washing out of the stomach in cases of gastric dilatation, chronic gastritis, and more rarely in cases of gastric carcinoma. It is particularly valuable in the two first-named condi- LAVAGE. 525 tions, not merely for its curative power, but also to rid the stomach of mucus and render it clean before fresh food is ingested. The liquid employed should always be warmed. For an adult a tube should be used of at least four and a half to five feet in length, of which eighteen inches pass into the mouth, the remaining portion reaching to the basin when lowered to allow siphonage. The ques- tion as to the variety of tube to be employed is a vital one, since a Fig. 95. The stomach-tube having been the funnel is filled from a pitcher and elevated to urge the water into the viscus. poorly devised apparatus not only gives no relief, but disgusts both the patient and the physician with the technique of the method. The tube should be more like a hollow bougie than a catheter, in order that its calibre may be great enough to carry off some of the semi- solid materials present. If this rule is not followed, two evil results follow: In the first place, the tube and its apertures rapidly, or even 526 REMEDIAL MEASURES OTHER THAN DRUGS. at once, become clogged; secondly, the liquid is drained away leav- ing behind a mass which is semisolid, to be sure, and less bulky, but which is nevertheless the quintessence of the nastiness of fermentation, and quite as qualified to contaminate any fresh food on its entrance as the liquid would be. The holes in the gastric end of the tube should therefore be of suffi- cient size to take in fairly large masses. In most cases the ordinary siphon may be used, but where there is any solid food or resistance suction by means of a stomach-pump is necessary. Fig. 96. » t-^ ■ * _A 1 WBgjjm^ | vg JnfSz: ^BB R ' ef * fH fltfi -*^P* I ¥9 Wp HmSI JSP *^|k.' - szzZ&tF 'm*~ „ _j Just as the last portion of the water is about to disappear down the tube the funnel end is lowered and the contents of the stomach are siphoned out. The best tube for adults is No. 10, made of red Para rubber with lateral holes. The methods by which lavage is employed, in addition to those which have been named, are as follows: The tube should be passed back- ward against the roof of the mouth, so that by following the curve of the hard and soft palates it is directed into the pharynx and oesophagus, and then by gentle pressure forced into the stomach. At the same time the patient should be directed to swallow. The mucus LEECHING. 527 in the throat sufficiently lubricates the tube, and oil is not to be used. If gagging is excessive, the pharynx may be first painted with cocaine. The irritability of the pharynx usually rapidly disappears, and it is surprising how quickly the patient becomes accustomed to the opera- tion, and submits to it without any feeling of discomfort. After the tube has reached the stomach a small funnel is to be fitted in its exter- nal end, which is then held above the head of the patient while water prepared in the way we have mentioned is poured into it until the stomach is filled, when the funnel end is lowered and the stomach is emptied by siphonage. The stomach-pump has one very serious disadvantage, which is present with even more force in the case of a child than in an adult — namely, the danger of injury to the coats of the organ. This appa- ratus is also more costly and cumbersome, and for children the siphon is powerful enough in its action to take away all excuse for the use of the more complicated apparatus unless the contents of the stomach are in bulk. It is particularly necessary in children, if a catheter is used and on account of the lack of intelligent aid and their liability to gulp, that every care should be taken that the tube does not slip entirely out of reach into the stomach; and for the prevention of this danger a string should be attached to the external end of the catheter before it is introduced, and the tube should always be at least thirty inches in length. LEECHING. Leeching is a method of abstracting blood for the purpose of reliev- ing local inflammations or acute congestions. There are two forms of leech commonly employed in medicine, both of which are imported. Fig. 97. * i ■ Showing the application of leeches in front of and behind the ear, for the relief of the early stages of acute otitis. The auditory meatus is plugged with cotton to prevent the leech from entering the canal by accident. A small leech is found in many streams in the United States. Leeches, after attaching themselves to the skin by means of their sucking appa- ratus and teeth, secrete a liquid which prevents coagulation of blood, 528 REMEDIAL MEASURES OTHER THAN DRUGS. and this accounts for the persistent hemorrhage sometimes seen after a leech-bite. Therapeutics. — The reasons for using venesection or depletion are considered further on, and we can therefore pass directly to the uses to which leeches are put. In cases of meningitis they may be applied to the temples or to the nape of the neck, and they are useful in the treatment of swollen joints, such as occur after sprains. In orchitis they should not be placed upon the scrotum, but on the peri- neum. In conjunctivitis or inflammation of the eye they should be applied upon the temple or back of the ears, not upon the lid itself. The effect of leeching is not only that of depletion, but also one of count erirritation. Application. — Leeches if singly applied may be placed on the skin under an inverted wineglass or under a large pill-box to prevent them from migrating before they take hold. If they will not take hold, a little sweetened milk may be placed on the skin or a drop of blood extracted from the finger may be placed there. In all cases the skin should be carefully washed before the leech is used. When the leech has taken enough blood, it can be made to let go its hold by sprinkling it with salt. Each leech will take about 1 drachm of blood. Leech- bites should be washed lest prolonged consecutive bleeding exhaust the patient. In case of such an accident a compress and styptics are to be employed. As leech-bites make small permanent scars, the creature should not be applied on the face or other exposed surface of the skin. REST CURE. The rest cure, so called, is a method devised and elaborated by Dr. S. Weir Mitchell, of Philadelphia, for the relief of a large class of patients who, for various reasons, are generally ailing from apparently no organic disease, and yet whose condition is often so alarming as to lead to the belief that some hidden cause of a severe train of symptoms must be present. In many such instances a careful study of the case will show that there is a cause, near or remote, which has exhausted the patient's vital forces without producing anything else than func- tional disturbances of the body. Thus a prolonged nerve-strain in nursing a sick relative may so exhaust the strength of a hitherto healthy woman as to produce hysteria, anaemia, and great disturbances of nutrition, or, in another instance, cause neuralgia, disordered menstru- ation, and uterine or ovarian pain. In males mental, sexual, or physical vigor may be impaired, owing to prolonged anxiety in busi- ness. Be the symptoms what they may, as long as they are depend- ent upon nerve-strain, this "cure" is to be resorted to, and if properly carried out is often attended with surprising results. Before describing the method in detail it is proper to state that its entire rationale rests upon the remembrance that every movement is an expenditure of force, and that a system which has already overdrawn its reserve fund BEST CUBE. 529 of strength must be as careful with its funds that remain as a bank should be under the same circumstances. It having been decided that the rest cure is to be employed, the directions are given as follows: A bright, airy, easily cleaned, and comfortable room is to be selected, and adjoining it, if possible, should be a smaller one for an attendant or nurse. The patient is put to bed and kept there for from three to six weeks, as may be necessary, and during this time is allowed to see no one except the nurse and the doctor, since the presence of friends requires conversation and mental effort. The patient in severe cases must be fed by the nurse in order to avoid the expenditure of the force required in the movement of the arms. No sitting up in bed is allowed, and if any reading is done it must be done by the nurse, who can read aloud for an hour a day. In the case of women the hair should be dressed by the nurse to avoid any physical effort on the part of the patient. To take the place of ordinary exercise two measures are employed, the first of which is massage or rubbing of the body, the second elec- tricity. By the kneading and rubbing of the muscles and skin the liquids in the tissues are absorbed and poured into the lymph-spaces and a healthy blush is brought to the skin. This passive exercise is performed in the morning or afternoon, and should last for from a half to one hour, every part of the body being kneaded, even the face and scalp. In the afternoon or morning the various muscles should be passively exercised by electricity, each muscle being made to contract by the application of the poles of the battery to its motor points, the slowly interrupted current being used. Both these forms of exercise do not call for any expenditure of nerve-force, though they keep up the general nutrition. The following programme for a day's existence is an example of what the physician should order: 7.30 a.m. Glass of hot or cold milk, predigested, boiled, or raw as the case requires. 8 a.m. The nurse is to sponge the patient with tepid water or with cold and hot water alternately, to stimulate the skin and circulation, the body being well wrapped in a blanket, except the leg or portion which is being bathed. After this the nurse should dry the part last wetted with a rough towel, using some friction to stimulate the skin. 8.30 a.m. Breakfast. Boiled, poached, or scrambled eggs, milk toast, water toast, or a finely cut piece of a mutton-chop or chicken. 10 a.m. Massage. 1 1 a.m. A glass of milk, or a milk-punch, or egg-nog. 12 m. Reading for an hour. 1 p.m. Dinner. Small piece of steak, rare roast beef, consomme soup, mutton broth, and any one of the easily digested vegetables well cooked. 3 p.m. Electricity. 4.30 p.m. A glass of milk, or milk-punch, or egg-nog. 34 530 REMEDIAL MEASURES OTHER THAN DRUGS. 6.30 p.m. Supper. This should be very plain, no tea or coffee, but toast and butter, milk, curds and whey, or a plain custard. 9.30 p.m. A glass of milk or milk-punch. In this way the day is well filled, and the time does not drag so heavily as would be thought. If the stomach rebels at overfeeding, the amounts of food must be cut down, but when all the effort of the body is concentrated on respiration, circulation, and digestion a large amount of nourishment can be assimilated by the exhausted body, which before this treatment is undertaken may have had its resources so shattered as to be unable to carry out any physiological act per- fectly. For the treatment to be successful the rules laid down should be rigidly followed, and the cure should last from three to six weeks or longer. MINERAL SPRINGS AND CLIMATE. This article is intended to give the practitioner and student a gen- eral idea of where to send patients who can afford to resort to treat- ment depending upon watering-places and climates. It is manifestly impossible to include the names of all the health resorts, and the object is to indicate the diseases which are benefited by these treat- ments, taking certain well-known resorts as types of each class. Springs. Medicinal springs are usually resorted to for the double purpose of drinking and bathing in the waters, although in many instances one of these methods so far exceeds the other in popularity that it alone is employed. For general purposes we may divide these medicinal or beneficial waters into four classes — namely, those which act, first, by their purity chiefly; second, by the presence of more or less active alkaline ingredients; third, by the heat which the waters contain as they leave the earth; and, fourth, by reason of the sulphur and iron which they contain. The first class — namely, those which act by reason of their purity — are indicated chiefly in cases where through high living or other cause the system becomes laden with impurities through imperfect elimination of tissue-waste. Most of the popular lithia waters depend chiefly upon this ability to dissolve effete materials, and very little upon the lithia, which is often present in very small amount. (See Lithium.) Aside from their purity, they also act by reason of the salts of sodium and calcium which they contain. Good results follow their use in the so-called uric-acid diathesis where the urine is scanty, high-colored, and acid. They do good in cases of irritable bladder by washing out this viscus with mild urine in large quantities, and because of this influence are credited with wonderful cures of vesical calculus. When vesical calculi have broken down while these waters were being taken, the fortunate result has been MINERAL SPRINGS AND CLIMATE. 531 coincidence rather than due to medicinal interference. It is impos- sible for them to dissolve stones, but their constant use may prevent the formation of new ones. Perhaps the best representative of such waters is Londonderry lithia water. A subdivision of this class consists of those waters which contain somewhat larger amounts of mineral substances, chiefly potassium, sodium, and calcium salts. Because of the power possessed by alka- line salts in aiding in oxidation, these waters are used in cases where the effete matters of the body seem to escape only partly oxidized, and where the kidneys, and perhaps the liver, seem torpid. Such springs are the Kissingen and Vichy at Saratoga. If very mild purgative properties are also desired, the Geyser Spring at Saratoga may be used. In Europe the most famous springs of this class are at Vichy (Grande Grille), Vals, and Contrexeville in France, and Kissingen in Bavaria. The second class of springs are those which contain salts of sodium, calcium, potassium, and magnesium in sufficient amount to possess very active diuretic and purgative properties. They find their thera- peutic application in cases of hepatic torpor or congestion associated with gouty or rheumatic tendencies, particularly in those individuals who have been high livers, who lay on too much fat, so clogging their organs, and, finally, in those who through illness or exposure to hot climates have subacute or chronic atony of the liver, of the organs of digestion, and of the lymphatics. Nearly always these patients also suffer from more or less constipation and gastrointestinal catarrh, and are often obese. The sulphate of sodium is an ingredient of many purgative mineral waters, and the activity of a water depends very often on the percentage of this salt which is present. The pur- gative action of a water also depends upon the time at wmich it is taken. When taken on an empty stomach it is of course more active. When taken early in the morning before eating and at the natural temperature, such a water produces a loose watery movement, not only unloading the bowel of fecal matter, but by its alkalinity loosen- ing catarrhal secretions and unloading the liver of congestion. The quantity to be taken in twenty-four hours varies from 1 to 4 pints, but this question can only be decided by the local physician, who studies the effect of the water on the patient. The best-known waters of this class are the Champion, Congress, Hathorn, and Carlsbad Springs at Saratoga, New York, the Crab Orchard in Kentucky, and the springs of Carlsbad and Marienbad in Bohemia, and Friederich- shall in Germany. The hot springs depend chiefly on their heat, as already stated, and differ in chemical composition. They find their value in the treatment of chronic skin diseases, specific or otherwise, and also are useful in aiding in the treatment of rheumatism, gout, and syphilis. Their good results are produced by their heat, which varies from 93° to 150° F., and the advantages always derived from properly 532 REMEDIAL MEASURES OTHER THAN DRUGS. employed hydrotherapeutic measures. It is in chronic or subacute cases that they do the most good. Hot baths are also of great value in the treatment of chancroid and malignant syphilis. The results achieved depend upon the increased activity of the skin, the improve- ment of the peripheral circulation, and the increased powers of absorp- tion produced through increased cellular activity. Patients should always select a competent local physician at such resorts. In cases of syphilis the methods of treatment to be followed are as follows: The patient should take the bath at a temperature of 90° F., and remain in it for about twenty minutes. After this he is rapidly but thoroughly dried by an attendant, who at once proceeds to rub into the skin of one thigh an amount of mercurial ointment varying from a few grains to a drachm. This is well rubbed into, not smeared over, the skin of a different limb after each bath. The number of baths and inunctions depends upon the condition and necessities of the case, care being exercised not to push the mercury too freely in those who are very susceptible to its effects. These baths also aid in the absorption of mercury when it is administered by fumigation. The most celebrated of these springs are the Hot Springs of Arkansas and those found at Aix-la-Chapelle (Aachen) in Germany. As types of the fourth class of springs we have the White Sulphur Springs in West Virginia and the Richfield Springs in New York, which are used for the relief of catarrhal inflammations of the mucous membranes of the alimentary canal and respiratory passages, and more rarely for catarrhal states of the genito-urinary tract. Not only do they exert the peculiar remedial powers long known to belong to sulphur and its compounds by reason of the sulphuretted hydrogen gas contained in them, but they also possess distinct purgative effects. Their chief mineral constituents consist of sulphate of sodium and magnesium, which unload the bowels and portal system in the same manner as do the Champion, Congress, Hathorn, and Carlsbad Springs at Saratoga and those at Crab Orchard. Taking the White Sulphur as a type of its class, it is better than the Saratoga springs in catarrhal states for the reasons given, Rockbridge Alum Spring in Virginia is used in cases of chronic diarrhoea with very useful results in many cases. It is not so useful in acute inflammations of the intestine as in the diarrhoea due to chronic disorder. As iron is present in it and in most alum springs in considerable amount, this water is useful in anaemic cases, but is contraindicated by fevers, by chronic congestions, chiefly of the liver, and by plethora. Often in place of alum we find salines associated with the iron, and these waters are particularly indicated in the catarrhs associated with anaemia. Such a spring exists at Bedford, Pennsyl- vania. In Europe the chief iron springs are at St. Moritz in Switzer- land and Tunbridge Wells in England. Neither of these contains much sulphur or alum. MINERAL SPRINGS AND CLIMATE. 533 Climates. The practitioner is most frequently consulted as to the possible benefit of climatic changes by persons suffering from pulmonary dis- ease, such as tuberculosis of the lungs, asthma, chronic bronchitis, and emphysema — more rarely by those convalescing from pneumonia or other severe acute illness. The general rules to be followed in all cases are — first, choose a climate having as large a number of clear days as possible, in order that an out-of-door life in the sunshine may be hacl constantly; sec- ondly, the nearest place to the home which is available in order to avoid fatigue, expense, and home-sickness; and thirdly, see that the resort chosen has comfortable accommodations, good food, good drug-supplies, and a capable physician at hand in case of need. In a case of tuberculosis and in all patients suffering from the pul- monary complaints named above the following rules may be adhered to, except in persons suffering from attacks of acute bronchitis, who always need a climate providing moisture and warmth. Some tuber- cular patients do best in a high, dry air, and others in a lower and more moist temperature — the first being represented by that of Colo- rado Springs (6000 feet) in America and by San Moritz (6000 feet) and Davos Platz (5000 feet) in Switzerland, where the altitude is not only very great, but the air very cold in winter. The days in these places are many of them clear, but in Colorado they are apt to be windy. Feeble persons cannot stand high winds, as a rule. The second climate is represented by that of Florida. In many cases, however, some more moderate climate is useful, and this can be obtained in Southern California, as at San Diego, a place where there is virtually perpetual summer, or at Asheville, N. C. (2200 feet), or Thomasville, Georgia (330 feet), where the air is mod- erately dry. In other words, a spot is desirable where a patient can remain the year round, and, if well enough, engage in business, avoid- ing the cold, sharp March winds of the Middle, Eastern, or North- western States, and the necessity of leaving Florida on the advent of summer. Physicians have attempted for years to formulate rules for phthis- ical patients as to the climate to be sought. In very many cases the various health resorts have to be chosen by experiment, not by judg- ment beforehand. In cases of phthisis with profuse bronchial secre- tion, a high, dry climate is generally the better unless the heart is feeble, but in cases which suffer from dryness of the air-passages a sea-voyage or a warm, moist climate is better, on general principles. It is probably true, however, that high altitudes and rarefied air are not to be sought where a distinct tendency to hemorrhage is present, unless the ascent or removal to the rarefied air is very gradual, several weeks being passed before the lung is exposed to the low pressure of great heights. The cases in which high altitudes do good are those 534 REMEDIAL MEASURES OTHER THAN DRUGS. which naturally have poor thoracic development or suffer from chronic pleurisy with deficient expansion of the lung after tapping. The following excellent advice given by White in his General Therapeutics, is worthy of repetition: "It is of such importance that only suitable cases should be sent to high altitudes that we must point out those that are unsuitable : "1. Those in whom there is considerable affection of the bronchial tubes, for the dryness of the climate increases the kind of bronchitis which commonly accompanies phthisis. "2. Patients with much emphysema or bronchiectasis, because of the probably diminished absorption of oxygen and the difficulty of respiration experienced on first arriving. "3. Patients with disease of the heart must not go to a high alti- tude, because of its effect upon the pulse and upon respiration. Fig. 98. Chest outline before residence at Davos After residence at Davos (Williams' diagram.) "4. Cases liable to acute febrile attacks, whether or not these indicate an occasional increase of mischief in the lungs, should remain on a low level. "5. Patients who are very excitable or suffer from insomnia should not go, for a visit to a place at a great elevation promotes these symp- toms. Women do not acclimatize so well as men. "6. Cases in which there are very extensive lesions, or which are very advanced, are unsuitable. "7. Pneumonic phthisis, if at all acute, is made worse by a high altitude. "8. Patients who cannot take exercise should not go. "9. The very old and the very young had better be treated at home. "10. Sir Andrew Clark (London Lancet, January 5, 1889) states that patients who go to Alpine health resorts suffering from albumin- MINERAL SPRINGS AND CLIMATE. 535 uria, or those who develop it whilst there, seldom derive any good from their change. "There are many conditions which have been thought to contra- indicate this treatment, but which do not, and they had therefore better be mentioned. They are: " Pulmonary Hemorrhage. — It is now known that this, so far from being a contraindication to treatment by high altitudes, is actu- ally relieved by it. The exact explanation cannot be given." With this the author of this work cannot agree. "Fever. — If this is not excessive, and if it does not indicate any active changes in the lungs, it is often improved. "Simple Diarrhcea and Simple Dyspepsia. — These are both benefited. "Night-sweats. — There is a common belief that these forbid this treatment; on the contrary, they often disappear on removal to a high altitude. "The Presence of Cavities. — This is not a contraindication unless a very large area of lung is destroyed." There is no need, after these two lists, to say what cases are suit- able for this climatic treatment: it may, however, be observed that those in whom there is threatened phthisis, with a strong hereditary predisposition, and those of imperfect thoracic development, are much benefited. According to most authorities, it cannot be too strongly urged that so long as the condition and disease of the patient allow the reverse indications to be neglected a mountain climate should be tried. To these rules the author would add the following invariable rule: viz., Do not send a case away to die. If the disease is so far advanced that no good can be derived from a trip abroad, it is cruel to make a wretched patient exhaust his strength, his money, and his happiness by seeking health which it is impossible for him to obtain. A patient of the writer's returned on one occasion from a stay of a few days at a noted Southern resort for consumptives, and, when reprimanded for his imprudence, replied: "I would rather be at home, and die at once, than drag out a few more years surrounded by a crowd of cough- ing, hawking, and wasting consumptives." This reply evidences clearly the necessity of avoiding "consumptive resorts" as much as possible in these cases, and in directing the mind of the patient from depressing thoughts and his own ailment, and that he may avoid secondary infection from other sufferers. In the treatment of renal and cardiac disease high altitudes are contraindicated, as a rule. The chief desideratum is out-of-door life with avoidance of chilling of the skin by sudden changes in tempera- ture or strong winds. San Diego represents the necessary climate in such cases. There is a class of persons who often have no actual disease of a chronic type, who nevertheless pass healthier lives if away from rig- 536 REMEDIAL MEASURES OTHER THAN DRUGS. orous climates for at least part of the year. Without having acquired tuberculosis, their lungs are delicate naturally or because of attacks of disease, or, again, they become asthmatic or rheumatic in cold weather. In this country Asheville, N. C, and Thomasville, Ga., or San Diego or Coronado Beach, California, afford the climate desired, while in Europe patients are sent to what is known as the "Riviera," which is the district bordering on the Mediterranean Sea from Genoa to Nice and which is dotted with climatic resorts. This district has often as many as two hundred clear days between October 1st and May 1st. In the French Riviera the resorts are Cannes, Nice, Monaco, Monte Carlo, and Mentone: in the Italian Riviera, Bordighera and San Remo. In Naples and Spezzia the climate is more damp and colder, but nevertheless quite sunny. So much depends upon the loca- tion of the hotels in these places, as far as their salubrity in relation to air and dampness is concerned, that the patient should always con- sult a local physician before settling down permanently at any of these resorts. SUSPENSION. The treatment of locomotor ataxia and allied affections by means of suspending the patient was for a time very popular, but it has now largely gone out of use. The method was not confined to cases depend- ing upon diseases of the vertebra? producing lesions in the spinal cord, but was also thought to be useful in instances where the lesion was primarily situated in the nervous tissues. The patient should use one of the apparatuses made by many makers of surgical instruments, which consists in a cushioned head-strap and a cushioned leather loop for each axilla. The traction on the head should not be sufficient to cause discomfort; in other words, the weight of the patient should be equally distributed between the shoul- ders and the head. A rope is run from the harness to a pulley in the ceiling, and by this means the patient may be slightly raised from his chair — say two inches — once a day, for thirty seconds at first, which may gradually be increased to ten minutes. The swinging should be resorted to at first every second or third, and finally every, day. If several pulleys are put in the circuit of rope, the patient can soon learn to lift himself, making the rope fast to a cleat in a heavy chair or table, or even holding it in the hands. It is important that the patient, after each swinging, should rest for thirty minutes to an hour, and when let down to his chair the movement should be most gentle and not jerking or sudden. The same rule as to gentleness applies to the raising of the patient. TRANSFUSION. The term Transfusion was originally applied in medicine to the transference of blood from a healthy person (the donor) to the sick patient (the receiver), who was usually suffering from the results of TRANSFUSION. 537 profuse hemorrhage. When direct transfusion was not resorted to, the blood was defibrinated after being drawn from the arm of the donor and the serum injected into the vein of the sick man. Both of these plans are now practically obsolete, for it has been proved that the blood-corpuscles of the donor always die in the vessels of the receiver and the kidneys are overwhelmed in an effort to eliminate the results of their destruction. Further, it is almost impossible to perform transfusion of pure or defibrinated blood without producing clots which will form emboli in the vessels of the patient. Finally, we now know that the blood-serum of one man differs greatly from that of another in its physiological effects, and is not to be regarded as identical- with the serum that is lacking in the patient. The use of milk as a trans- fusion fluid has been found to result in albuminuria, in infections of various kinds, and in the development of emboli. It ought never to be used for this purpose. At the present time the profession employ a saline solution, injected gently into a vein of the arm or leg, not only to overcome the collapse of hemorrhage, but — far more important — for the relief of various forms of toxaemia. Commonly in hemorrhage and in toxaemia 'hypo- dermoclysis is used, as already described, because the danger of embo- lism and the possible results of opening a vein are not to be disre- garded. Therefore, while hypodermoclysis is the safest and preferable method ordinarily, on the other hand when the case is very urgent, or the tissues are cedematous from dropsy, or the circulation is so feeble that absorption is impossible, then the intravenous or endogenous in- jection is to be employed without hesitation. Various formula? exist for the preparation of the so-called normal saline solution. Some persons are satisfied to employ the ordinary solution of common salt in the strength of 0.7 per cent. (I7 drachms to the quart), in distilled and sterilized water. Others prefer to use a formula suggested by the well-known French clinician, Prof. Hayem, as follows: Sodium sulphate 10.0 Sodium chloride 5.0 Distilled water 1000 c.c. A still better solution, however — because it at once supplants the blood which has been lost or is impure, and because it supports the heart — is : Calcium chloride 0.25 Potassium chloride . . . . . .0.1 Sodium chloride 9.0 Sterilized water . 1000 c.c. At the author's suggestion, there is now placed upon the market a concentrated saline solution in which the salts just named are dis- solved in one ounce of sterile water and placed in a sealed sterile bottle. The contents of one of these vials added to 1 quart (1000 c.c.) of pure sterile water make a normal saline fluid ready for instant use. 538 REMEDIAL MEASURES OTHER THAN DRUGS. • The method of injection is as follows: The thoroughly sterilized saline solution, after being warmed to the temperature of 101° F., is placed in a warm glass irrigation flask. The patient's skin over the elbow is bared and sterilized; the skin over one of the veins, which is made prominent by a bandage about the upper arm, is incised by a scalpel, and the sheath of the vein raised by means of a pair of dis- secting forceps. This sheath is thoroughly dissected off the vein until this vessel lies free from any attachments for the space of half an inch. A small and gentle bull-dog clip is applied on the vein at the proximal end of the incision so as to keep the lower part of the vein full of blood. A ligature is now passed around the vein at the distal end of the incision and tied. Another ligature is then passed under the vein and left untied. The distended area of the vein, between the ligature which has been tied and the clip, is now snipped by means of a pair of fine scissors ; and a glass canula, previously dipped in the saline solution to prevent the few drops of blood from coagulating on its tip, is inserted into the opening in the vein. The loose ligature is now tied around it and the vein, to hold the canula in place. This canula should have a shoulder at its tip to prevent the ligature from slipping off, and its other end should be attached to a piece of sterile rubber tubing not more than four inches long. By means of a steril- ized glass pipette some of the saline is now run into the rubber and glass canula until all air is displaced and they are filled to the utmost. The saline is then allowed to flow out of the tubing attached to the irrigator, which is armed by a glass tip, till all the air is displaced, when one tube is slipped inside the other. By this means all danger of air embolism is excluded. The irrigator is now held about two feet above the arm and the fluid allowed slowly to enter the vein, a half-hour being spent in injecting about a quart. (Fig. 99.) As the injection is given the pulse begins to improve, the respirations are deeper and less hurried, and if fever is present the temperature usually falls. The patient is evidently better, but soon enters the critical stage, which may come on in from two to thirty minutes. There are sometimes a violent chill, a strong, rapid pulse, and in the course of three-quarters of an hour a flushing of the skin, followed by a profuse sweat. The respiration may be labored. The urinary flow is also increased, and sometimes water escapes from the bowel. Several hours later the real benefit appears in convalescence or in marked improvement. The conditions in which the intravenous injections are to be per- formed are severe hemorrhage, toxoemia arising from the various forms of infection, as in septicaemia, uraemia, and the comatose state in dia- betes mellitus. They can be employed in threatened eclampsia, and even in the toxaemias of the infectious fevers. The author has used them in uraemic and septic intoxication with the best results. The principle of this treatment is that it causes the rapid elimination of impurities from the body. TRANSFUSION. 539 This method is to be regarded as a fairly promising mode of treat- ment for cases otherwise doomed to death, and will afford permanent or temporary relief according to the severity of the underlying dis- ease. When diabetes exists or Bright's disease is present, the benefit Fig. 99. Fig. 100. Fig. 101. Two types of apparatus used for hypodermoclysis and for the intravenous injection of saline solution. The flow of liquid in the rubber tube leading from the container is controlled by a clip. A large antitoxin needle like that shown in Fig. 99 may be used, or a trocar and canula, as in Fig. 101. The needle only is needed for hypodermoclysis. is often only temporary. The European clinicians are loud in their praises of the results they have obtained by this plan in the various forms of sepsis. In uraemia and in puerperal convulsions the patient should be bled if the arterial tension is high. Abdominal transfusion of both saline solutions and milk have been successfully carried out, the reason being that the peritoneal cavity is a vast absorbent surface which rapidly takes up liquids if the systemic vessels are not so full as they normally should be. The method con- sists in puncturing the abdominal wall as if for aspiration for dropsy. The tube from a hydrostatic syringe is now attached to the canula, 540 REMEDIAL MEASURES OTHER THAN DRUGS and the liquid, having been warmed, is allowed slowly to flow into the belly. This method is not to be relied on where death seems very imminent, and the use of milk is dangerous. There is also some danger of perforating the bowel wall. VENESECTION. Bleeding, or Phlebotomy, is so rarely practised to-day that very many of the profession have never abstracted blood for therapeutic purposes or have even seen it done by some one else. Furthermore, it is to be feared that many of the younger physicians' would hardly know how to bleed if called upon to do so at a crisis. All this is wrong, for bleeding is a measure undoubtedly of the greatest value, and one which every physician may be called upon to resort to. Like many therapeutic measures, it was sadly abused in the early part of the last century, and people when taken ill were bled with the same regularity that they were put to bed. The indications for venesection are as clear and well defined as are the indications for any remedy. Briefly stated, we may say that all states of the circulatory apparatus denoting high arterial tension and excitement are indications, and that weakness, low arterial tension, and systemic or circulatory depression are contraindications. Since the use of veratrum viride has become more common, the conditions indicating venesection have been lost sight of, because this drug so dilates the bloodvessels that a man is bled into his own bloodvessels. Having made clear the general indications for the use of venesec- tion, we may pass on to state some of the diseases in which it may be well resorted to. Of these, certain cases of pneumonia, pleurisy, meningitis, and peritonitis, if they are sthenic, are typical examples, since all of them are accompanied by arterial excitement and charac- terized by local congestions affecting the lung, pleura, cerebral mem- branes, or peritoneum. (See Pneumonia.) By the abstraction of blood the vascular tension is lowered and the engorged area relieved. In the first place, the congested area is made up of relaxed blood- vessels, whereas the remaining bloodvessels of the body are tense, and, as a consequence, the blood is urged to the spot already engorged. In the second place, the abstraction of blood from the tense bloodvessels renders the general pressure lower than that in the diseased area, and the congestion is relieved. In apoplexy the extravasation of blood into the brain causes great arterial excitement, and free venesection has been commonly per- formed to relieve this state. Recent studies by Cushing, however, indicate that bleeding under those conditions is contraindicated. (See Apoplexy.) The method by which venesection is practised is yet to be described. It is a very simple operation if an assistant is present to make pressure on the vein or entire arm. Often this pressure is best exercised by VENESECTION. 541 means of a handkerchief or bandage tightly twisted about the arm above the spot where the incision is to be made. Under these circum- stances the veins of the arm become prominent and distended, and one of them may be readily bared by a short longitudinal incision of half an inch, the fascia being separated until the glistening blue sur- face of the vessel appears free from fat or connective tissue. Into this vessel, with the edge of the knife turned upward, a small longi- tudinal incision is made, care being taken that the point of the blade is not driven in far enough to injure the posterior wall of the vein, or a pair of scissors is used and the vessel is nipped. If a clot forms and stops the flow, it must be removed by an aseptic cloth, while if the flow is to be stopped we may remove the bandage above and apply a compress over the incised vein, the compress being held in position by a bandage. Care should always be taken that the bandage on the upper part of the arm is not so tight as to cut off all blood-supply to the arteries of the lower part of the limb. FEEDING THE SICK, In the opening pages of this work the importance of properly feed- ing the sick has already been emphasized. It is manifestly impossible for the writer to go into details concerning the deep and difficult prob- lems of the changes in the food when taken into the body for assimila- tion. At this point it is necessary only to recall that the foods taken by man consist in proteids, carbohydrates, and hydrocarbons. In the albuminous or proteid articles of food nitrogen is a prominent con- stituent, and the type is egg-albumin. While most nitrogenous foods are animal in source, it must not be forgotten that gluten and legumen are nitrogenous and derived from vegetables. The carbohydrates consist of substances in which carbon, hydrogen, and oxygen are com- bined, the hydrogen and the oxygen in the proportion to form water, of which the types are starch, dextrin, cane-sugar, grape-sugar, lactose or milk-sugar. The hydrocarbons are composed of carbon, hydrogen, and oxygen, but the proportion of oxygen is insufficient to convert all the hydrogen into water. The types of this group are butter and other fats. The function of the proteid, or albuminous, foods is to contribute to the repair and formation of the body tissues, particularly those which are nitrogenous; they also contribute to the development of muscular and nervous energy and the production of heat, being split up into nitrogenous and non-nitrogenous parts, from the last of which fat may be formed and deposited or burnt up in the development of force. The carbohydrates are split up in the body into carbonic acid and water, and in this process yield heat and energy. Unlike the proteids, they do not enter the tissues of the body unless it be that they are con- verted into fat. By reason of the heat and energy which they con- tribute to the economy they protect the albumins and fats from demands which would otherwise be made upon them for these purposes. The hydrocarbons, or fats, are employed in the body to yield force and heat, and are stored up in the form of fat, so as to act as a reserve in case of need, so that by their use the albuminous portions of the body are saved from demands upon them. For these reasons hydro- carbons and carbohydrates can be well taken in large quantities by those who take much exercise, but are harmful if partaken of largely by persons leading sedentary lives. It is manifest, therefore, that for the maintenance of health we must (542) FEEDING THE SICK. 543 provide a patient, not with nitrogenous or carbohydrate foods alone, but with some of all the food articles, regulating the proportions of each to his needs and his ability to utilize them after they are ingested. The practical application of these facts is as follows : In fevers, in which there is an active wasting of the tissues of the body, we give albuminous foods to replace the tissues destroyed or to make up for their loss, and these consist of broths, soups, eggs, milk, and the gelatinous substances which, while not very nutritive, are what are known as "albumin-sparing" substances. As the secretion of the gastric juice is faulty in nearly all fevers, it is important to give these foods in semiliquid or liquid form, so that they can be readily digested, and we often aid their digestion by the use of pepsin and hydrochloric acid. As carbohydrates and hydrocarbons add force or energy to the body, and in their combustion protect the albuminous tissues, they also must be used, particularly the former. There is no doubt that physicians are far too prone to limit the patient's diet to proteids, and in the author's practice he invariably prescribes, in addition to the proteid foods, thin preparations of starch, such as strained rice, strained oatmeal, cracked wheat, and barley, aiding their digestion, if need be, with taka-diastase or pancreatin. In order that an approximate idea of the proportion of food-stuffs may be conveyed to the reader, it may be pointed out that the healthy human body must be provided in twenty-four hours with that amount of food which will yield his body 3650 calories. 1 This is best accom- plished by the use of the following proportions, according to Egleston : carbohydrates, 400 grammes ; fats, 150 grammes; proteids, 150 grammes. Nearly all food- stuffs contain the several classes of proteids, carbo- hydrates, and hydrocarbons in varying proportions. These are shown in the accompanying table, taken from Billings's Medical Dictionary, and it also shows the number of calories in each pound of the material. It is interesting to note how many more calories are provided by the hydrocarbons and fats than by the proteids, but it is also worthy of note that the proteids, while not providing calories, do provide the materials which are useful for the repair and growth of tissue. Water forms such an important part of the body that its free ingestion is advisable, if it is pure, in nearly all cases of disease. Having considered the general theory of feeding, we may now pro- ceed to the actual preparation of food for the sick. There are several important general facts to be borne in mind in this connection: 1. The food, when prepared, must be capable of ready assimilation. 2. It must be, as a rule, fairly concentrated in the sense of contain- ing great nutritive power in little bulk, since it is a mistake to weary a feeble patient with much swallowing. 1 A calorie is the French unit of heat, or that amount of heat required to raise the tempera- ture of one kilogram of water one degree Centigrade. 544 FEEDING THE SICK. Percentages of Nutrients {Nutritive Ingredients), Water, etc., and Estimated Potential Energy [Fuel-value) in Specimens of Food-materials. Edible Portion. Nutrients. Calories Refuse : bones, of poten- FOOD-MATERIALS. tial en- skin, ergy in shell, etc. Water. one Total. Pro- tein. Fats. Carbo- hydrates. Mineral matters. pound of each material. Animal foods as purchased, including edible portion, and refuse: pr. ct. pr. ct. pr. ct. pr.ct. pr. ct. pr. ct. pr. ct. Beef, side 1 . . . . 19.7 10.0 44.0 60.0 36.3 30.0 13.8 20.7 21.7 8.1 0.8 1.2 1170 Beef, round 1 . . . 725 Beef, neck 1 . . . 19.9 49.6 30.5 15.4 14.3 0.8 890 Beef, sirloin x . . 25.0 45.0 30.0 15.0 14.3 0.7 885 Beef, flank * . . . 11.7 24.2 64.1 10.6 52.9 0.6 2430 Mutton, side 1 . . 20.0 42.9 37.1 13.2 23.2 0.7 1225 Mutton, leg 1 . 18.4 50.4 31.2 15.0 15.5 0.7 935 Mutton, shoulder 1 16.8 48.7 34.5 15.0 18.7 0.8 1070 Mutton, loin (chops) 1 '. 16.3 41.3 42.4 12.5 29.3 0.6 1470 Smoked ham . . 14.0 36.3 49.7 14.6 34.2 0.9 1715 Pork, very fat . . 10.4 9.5 80.1 2.8 76.5 0.8 3280 Chicken 2 . . . . 41.6 42.2 16.2 14.2 1.2 0.8 315 Turkey ■ 35.4 42.8 21.8 15.4 5.6 0.8 525 Flounder, whole . 66.8 27.2 6.0 5.2 0.3 0.5 110 Haddock, dressed 51.0 40.0 9.0 8.2 0.2 0.6 160 Bluefish, dressed . 48.6 40.3 11.1 9.8 0.6 0.7 210 Brook trout, whole 48.1 40.4 11.5 9.8 1.1 0.6 230 Codfish, dressed 29.9 58.5 11.6 10.6 0.2 0.8 205 Whitefish, whole . 53.5 32.5 14.0 10.3 3.0 0.7 320 Shad, whole . . . 50.1 35.2 14.7 9.2 4.8 0.7 375 Turbot, whole . . 47.7 37.3 15.0 6.8 7.5 0.7 445 Mackerel, fat, whole . 33.8 42.4 23.8 12.1 10.7 1.0 675 Mackerel, lean, whole . 38.3 48.5 13.2 11.2 1.4 0.6 265 Mackerel, average, whole 44.6 40.4 15.0 10.0 4.3 0.7 365 Halibut, dressed . . . 17.7 61.9 20.4 15.1 4.4 0.9 465 Salmon, whole .... 35.3 40.6 24.1 14.3 8.8 1.0 635 Eel 36.0 42.1 33.8 40.3 30.2 17.6 8.6 16.0 21.0 0.4 0.6 1.2 1045 Salted codfish .... 315 Smoked herring . . . 50.9 19.2 29.9 20.2 8.8 0.9 745 Salted mackerel . . . 40.4 28.1 31.5 14.7 15.1 1.7 910 Canned salmon .... 4.9 59.3 35.8 19.3 15.3 1.2 1005 Canned sardines . . . 5.0 53.6 41.4 24.0 12.1 5.3 955 Lobsters 62.1 31.0 6.9 5.5 0.7 0.1 0.6 135 Oysters in shell . . . 82.3 15.4 2.3 1.1 0.2 0.6 0.4 40 Hen's eggs 13.7 63.1 23.2 11.8 10.2 0.4 0.8 655 A nimed foods, edible portion. Beef, side 1 54.7 45.3 17.2 27.1 1.0 1465 Beef, round 1 . . . . 66.7 33.3 23.0 9.0 1.3 805 Beef, sirloin x . . . . 60.0 40.0 20.0 19.0 1.0 1175 Mutton, side J . . . . 45.9 54.1 14.7 38.7 0.7 1905 Mutton, leg 1 . . . . 61.8 38.2 18.3 19.0 0.9 1140 Mutton, loin (chops) 1 . 49.3 50.7 15.0 35.0 0.7 1755 Flounder 84.2 15.8 13.8 0.7 1.3 285 Codfish 82.6 64.0 17.4 36.0 15.8 18.2 0.4 16.3 1.2 1.5 310 Mackerel, fat .... 1025 Mackerel, lean .... . . 78.7 21.3 18.1 2.2 1.0 430 Mackerel, average . . 1 ' ■ 71.6 28.4 18.8 8.2 1.4 695 1 From well-fattened animals. 2 Rather lean. FEEDING THE SICK. 545 Edibli Portion Nutrients. Calories Refuse : bones, of poten- FOOD-MATEKIALS. tial en- skin, ergy in shell, etc. Water. one Total. Pro- tein. Fats. Carbo- hydrates. Mineral matters. pound of each material. Animal foods, edible portion " pr. ct. 1 pr. ct. pr. ct. pr.ct. pr. ct. pr. ct. pr. ct. Salmon 63.6 36.4 21.6 13.4 1.4 965 Oysters, fat 81.7 18.3 8.0 1.7 6.7 1.9 345 Oysters, lean .... 90.9 9.1 4.2 0.6 1.8 2.5 135 Oysters, average . . . 87.1 12.9 6.0 1.2 3.7 2.0 230 Hens' eggs 73.1 26.9 13.7 11.7 0.5 1.0 760 Cows' milk 87.4 12.6 3.4 3.7 4.8 0.7 310 Cows' milk 90.7 9.3 3.1 0.7 4.8 0.7 175 Cheese, whole milk . . 31.2 68.8 27.1 35.5 2.3 3.9 2045 Cheese, skimmed milk . 41.3 58.7 38.4 6.8 8.9 4.6 1165 Butter . 10.0 90.0 1.0 85.0 0.5 3.5 3615 Oleomargarine .... 10.0 90.0 0.6 84.5 0.4 4.5 3585 Lard 1.0 99.0 99.0 4180 Vegetable foods: Wheat bread .... 32.7 67.3 8.9 1.9 55.5 1.0 1280 Wheat flour 11.6 88.4 11.1 1.1 75.6 0.6 1660 Graham flour . . . : 13.0 87.0 11.7 1.7 71.8 1.8 1625 Rye flour 13.1 86.9 6.7 6.7 78.7 0.7 1620 Buckwheat flour . . . 13.5 86.5 6.5 1.3 77.6 1.1 1620 Beans 13.7 86.3 23.2 2.1 57.4 3.6 1585 Oatmeal 7.7 92.3 15.1 7.1 68.1 2.0 1845 Corn (maize) meal . . 14.5 85.5 9.1 3.8 71.0 1.6 1650 Rice 12.4 87.6 7.4 0.4 79.4 0.4 1630 Sugar 2.2 97.8 0.3 96.7 0.8 1800 Potatoes 1 10.0 68.0 22.0 1.8 0.2 19.1 0.9 395 Potatoes 75.5 24.5 2.0 0.2 21.3 1.0 440 Sweet potatoes .... 75.8 24.2 1.5 0.4 21.1 1.2 435 Turnips 91.2 8.8 1.0 0.2 6.9 0.7 155 Carrots 87.9 12.1 1.0 0.2 10.1. 0.8 215 Cabbage 90.0 10.0 1.9 0.2 6.2 1.2 170 Melons 95.2 4.8 1.1 0.6 2.5 0.6 90 Apples 84.8 15.2 0.4 14.3 0.5 275 Pears 83.0 17.0 0.4 16.3 0.3 310 Bananas 73.1 26.9 1.9 0.6 Alco- 23.3 1.1 495 Beverages : hol. Lager beer 90.3 0.4 2.0 5.8 0.2 Porter and ale ... . 88.1 0.6 5.1 6.8 0.4 Rhine wine, white . . 86.3 9.3 2.3 0.2 Rhine wine, red . . . 86.9 8.1 3.0 0.3 French wine, claret 88.3 8.0 2.3 0.2 Sherry wine 1 • • 79.5 17.0 3.3 0.3 3. It must be easily swallowed. 4. It must be as attractive to the sight, smell, and taste as possible. When milk is given for any length of time its taste should be varied, if possible, by the addition of enough coffee, tea, cocoa, or sweetening to prevent the patient from taking a dislike to it. Its nutritive prop- erties may often be advantageously increased by the addition of some 1 As purchased, including refuse, skin, etc. 35 546 FEEDING THE SICK. of the well-known infant foods; and if it curdles too quickly in the stomach, this may be delayed by the use of barley-water in equal parts, or lime-water, or by the addition of thin oatmeal gruel or strained rice to the milk. Often the addition of salt improves the taste and aids its digestion, and its dilution by adding aerated or carbonated water from a siphon is also refreshing and aids digestion in some instances. In other instances the best results are produced by pep- tonizing the milk (see below). When broths are used, they may well be flavored with other things than the meat from which they are made. This is easily accomplished by placing in a small bag such vegetables as carrot, turnip, celery, parsnip, parsley, thyme, etc., and then cooking this bag and its contents with the broth, whereby the nutritive properties of the meat and vegetables and the flavoring of the latter are given to the soup. The following recipes will be found useful in many cases : PEPTONIZED MILK. Take a perfectly clean, clear glass quart bottle and place in it one of Parke, Davis & Co.'s peptonizing tablets, or the contents of one of Fairchild's peptonizing tubes, and a teacupful of cold water, and after shaking pour into the bottle a pint of perfectly fresh, cool milk and stir the mixture thoroughly. Next place the bottle containing the milk in a can of water at such a temperature that the whole hand may be submerged in it without pain. If complete digestion of the milk is desired, this application of heat may be continued as long as twenty minutes, but in most cases five minutes are sufficient. If carried on longer than five minutes, the milk will become bitter and dis- agreeable to the taste through the development of peptone in excess. Immediately after taking the bottle from the hot water it should be placed on ice, in order to check further peptonizing and to keep the milk from spoiling; or if ice is not available the water-bath should be quickly brought to a boil in order to prevent further action of the ferment, and the bottle corked and then be put in a cool place. This recipe may be used where it is thought necessary to digest the milk before it is swallowed. Where we desire simply to aid digestion it is best to follow the directions already given, except that the bottle is not heated, but at once placed upon ice and allowed to remain there, being slightly warmed when it is desired to give it to a child, or it may be given as a cool and refreshing drink to an adult, the heat of the body rapidly causing the ferment to do its work as soon as the food enters the stomach. When irritability of the stomach exists in adults, this peptonized milk may be made more agreeable to the taste by following the directions given in the first recipe, except that it must remain in the hot water for no less than two hours, when it is poured out into a tin cup or pan and rapidly brought to the boil- ing-point. After this it is strained through a piece of coarse muslin PEPTONIZED BEEF. 547 and placed upon ice. Before giving it to a patient this mixture may be flavored with lemon- or orange- juice or any form of acid that is desired, without the milk becoming curdled. Peptonized milk-punch is made from milk prepared in the way* already described in the first recipe by adding. St. Croix or Jamaica rum or brandy, and is a pleas- ant nutrient, particularly if the surface of the liquid is sprinkled with a little grated nutmeg. A very refreshing and agreeable drink may be made by diluting peptonized milk one-half with highly charged carbonic-acid water, and swallowing it while effervescing. PEPTONIZED BEEF. The following method of preparing Peptonized Beef is recom- mended by the Fairchilds, and is very useful, as is also peptonized oyster stew, as first introduced by the late Dr. N. A. Randolph. Take \ pound of finely minced raw lean beef; cold water, \ pint. Mix in a saucepan. Cook over a gentle fire, stirring constantly until it has boiled a few minutes. Then pour off the liquor for future use, beat or rub the meat to a paste, and put it into a clean fruit- jar with | pint of cold water and the liquor poured from the meat, and add Extract! pancreatis 20 grains (1.3). Sodii bicarb. 15 " (1.0). Shake well together, and set aside in a warm place, at about 110° to 115° F., for three hours, stirring or shaking occasionally; then boil quickly. The liquid may then be strained or clarified with white of egg in the usual manner, and seasoned to taste with salt and pepper. In the great majority of cases it is not necessary to strain the pep- tonized liquor, for the portion of meat remaining undissolved will have been so softened and acted upon by the pancreatic extract that it will be in very fine particles and diffused in an almost impalpable condition, and is therefore in a form ready for assimilation in the body. Peptonized Oysters. — Peptonized Oysters are prepared by mincing six to twelve large oysters, and adding to them, when mixed with a moderate amount of their own liquid, 5 grains (0.30) of pancreatin or peptonizing powder and 20 grains (1.3) of sodium bicarbonate. The cup containing this mixture is now placed in water at 100° F., and allowed to remain there from ten to twenty minutes, accord- ing to the degree of digestion desired. After this the liquid mass is quickly brought to a boil to cook the oysters and stop digestion, and served with pepper and salt as required. Any condiment or flavoring substance may be used. PEPTONIZED ENEMATA. A very useful nutrient enema may be prepared by following the directions given above for peptonizing milk, except that an egg, yolk 548 FEEDING THE SICK. and white, should be beaten up in the milk before the ferment is added. The effect of this enema may be increased by the addition of a teaspoonful to an ounce of whiskey or wine. This should be warm when injected into the rectum. As the rectum is apt to become irritable if injections are given frequently, and particularly if the same mixture is repeated a number of times, it is often well to substitute for the formula just given the following recipes: Von Leube recommends 5 ounces of scraped meat, chopped very fine, and to this are added 1^ ounces of finely chopped pancreas; the whole is suspended in 3 ounces of lukewarm water, and stirred to the consistence of a thick pulp. This makes one injection. Pan- creatin or peptonizing tablets can be as well used as the pancreas itself. Mayet uses 150 to 200 grammes of pancreas bruised in a mortar with water at a temperature of 100° F., and then strained through a cloth; 400 to 500 grammes of lean meat are chopped fine and the strained pancreatic fluid mixed with the mince, together with the yolk of 1 egg. This is allowed to stand for two hours, and should be administered at the body temperature: the quantity is sufficient for twenty-four hours' nourishment, and should be administered in two parts. Rennie's formula consists of \ pound of lean meat pulled into shreds and added to a pint of beef-tea; to this are added 1 drachm of fresh pepsin and \ drachm of dilute hydrochloric acid; the mix- ture is kept at a temperature of 99° F. for four hours, during which it is stirred constantly. If too great heat be employed, the digestive process will stop. An enema which Bidwell employs is made as follows: milk, 2 ounces; strong beef-tea, 2 ounces; yolk of egg, 1; pancreatic solution, 1 drachm. This is to be prepared one hour before use, and to be kept at a temperature of 100° F.; h to 1 ounce of brandy is added, when necessary, immediately before use. Greig Smith uses 1 egg beaten up in 6 ounces of milk with 2 or 3 teaspoonfuls of meat- jelly, or peptones may be added. This is admin- istered warm with or without \ an ounce of brandy every five or six hours. DIGESTED GRUEL. Digested gruel may be made by taking thoroughly boiled hot gruel made from oatmeal, barley, wheat, or from arrowroot, to the amount of \ pint (240 c.c), and adding thereto, while it is hot, \ pint (240 c.c.) of fresh, cold milk; to this may now be added the contents of one peptonizing tablet or tube, and the mixture allowed to stand in moderately hot water or in a warm place for twenty minutes before it is placed upon ice. DIET LIST. 549 KOUMYSS. This is a preparation of milk which is very useful for children and adults during convalescence from acute or subacute exhausting dis- eases. Even children of three or four years will acquire a liking for it if it is not made too sour by continuing the fermentation process too long. The liquid is prepared as follows: Add to 1 pint (480 c.c.) of cool, perfectly fresh milk 2 teaspoonfuls (8.0) of sugar, and place it, after shaking thoroughly, in a clean beer or claret bottle. Then add J of a cake of Fleischman's compressed Vienna yeast, and tightly cork the bottle, standing it in a warm place or in a water-bath at 99° to 100° F. for eight to ten hours. Then place in a cool place or on ice and use as needed. It must be remembered that the development of carbonic gas is very great in this liquid, and that if an ordinary cork is inserted it must be tied in before the heat is applied. Further than this, the cork must be pulled very gently or the liquid will spurt all over the room. The best thing to use when about to open a bottle of koumyss is a " champagne tap," by means of which the liquid may be drawn off as needed. DIET LIST. The following bills of fare are used in the Children's Hospital in Philadelphia with good results, are easily prepared, and the directions readily carried out by the inexperienced. Diet in Gastrointestinal Catarrh for a Child of Seven Years. Breakfast, 7.30 a.m.: Milk, with lime-water; 4 teaspoonfuls of lime-water to each tumblerful of milk. The lightly boiled yolks of two eggs, thin slices of well-toasted bread, or stale bread. Dinner, 12 m. : A mutton-chop without fat, broiled; or a slice of roast beef or mutton ; occasionally a bowl of meat broth. Stale bread or toast. Supper, 7 p.m.: Milk and lime-water. Stale bread or toast, or milk toast. For drink: Filtered or boiled water. Starch foods to be avoided as much as possible. Diet for a Child Two Years Old. Breakfast, 7.30 a.m.: Milk. The lightly boiled yolk of an egg. Thin bread and butter (the bread to be one day old). Lunch, 11 a.m.: Milk. A thin slice of bread and butter. Dinner, 1.30 p.m.: Beef- tea or small piece of minced roast beef or mutton devoid of gristle. One well-mashed potato, moistened with gravy. Rice and milk. Supper, 6 p.m.: Milk. Bread and butter. For drink: Boiled or filtered water. 550 FEEDING THE SICK. Diet for a Child One Year Old (5 meals a day). First meal, 7 a.m.: 2 teaspoonfuls of grated flour-ball (prepared as directed below) in J pint of milk. Second meal, 10.30 a.m. : \ pint of milk with 4 tablespoonfuls of lime-water. Third meal, 2 p.m. : The yolk of 1 egg beaten up in 1 teacupful of milk. Fourth meal, 5.30 p.m.: Same as the first. Fifth meal, 11 p.m.: Same as the second. Flour-ball is to be made by taking one pound of good flour — unbolted if possible — tie it up very tightly in a pudding-bag; put it in a pot of boiling water early in the morning, and let it boil until bedtime, then take it out and let it dry. In the morning peel off the surface and throw away the thin rind of dough, and with a grater grate down the hard, dry mass into a powder. To use this, take from 1 to 2 teaspoon- fuls of the powder, rub it down until smooth with a tablespoonf ul of cold milk, and add 1 tumblerful of hot milk, stirring it well all the time. Diet for a Child from Six to Twelve Months Old (5 meals a day). First meal, 7 a.m. : Mellin's food 1 tablespoonful or flour-ball grated 1 or 2 teaspoonfuls (prepared as directed above) ; hot water 4 table- spoonfuls; warm milk, enough to make J pint. Dissolve the Mellin's food or rub down the grated flour-ball in the hot water by stirring, then add the milk; mix thoroughly. Second meal, 10.30 a.m., and third meal, 2 p.m.: A breakfastcupful of milk with 4 tablespoonfuls of lime-water. Fourth meal, 5.30 p.m.: Same as first. Fifth meal, 10.30 p.m.: Same as second. BEEF-TEA. Take 1 pound of lean beef and mince it. Put it with its juice into an earthen vessel containing a pint of tepid water, and let the whole stand for one hour; strain well, squeezing all the juice from the meat. Place on a fire, and slowly raise just to the boiling-point, stirring briskly all the time. Season with salt and pepper to taste. In admin- istering this always be careful to stir up the sediment. Or, take 2 pounds of beef without fat or bone, and half a breakfast- cupful of cold water; place in a jar in a saucepan of water; simmer four hours. RESTORATIVE BEEF ESSENCE (Ringer). Take 1 pound of fresh beef free from fat, chop it fine, and pour over it 8 ounces of soft water, add 5 or 6 drops of hydrochloric acid and 50 or 60 grains of common salt; stir it well, and leave for three hours in a cool place. Then pass the fluid through a hair sieve, press- WINE-WHEY. 551 ing the meat slightly, and adding gradually toward the end of the straining about 2 ounces more of water. The liquid thus obtained is of a red color, and possesses the taste of soup. It should be taken cold, a teacupful at a time. If preferred warm, it must not be put on the fire, but heated in a covered vessel placed in hot water. Should it be undesirable for the patient to take the acid, this soup may be made by merely soaking the minced beef in distilled water. Or, take 1 pound of beef free from fat and skin, chop it very fine, add a little salt, and put it into an earthen jar with a lid, such as is used for roasting venison; seal the edges with a thick paste, and place the jar in an oven for three or four hours; strain through a coarse sieve. Give the patient two or three teaspoonfuls at a time. Or, cut in small pieces 1 pound of lean beef from the sirloin or rump, and place it in a covered saucepan, with J pint of cold water, by the side of a fire for four or five hours ; then allow it to simmer gently for two hours, skim well, and serve. BARLEY-WATER. To prepare barley-water, put 2 good-sized teaspoonfuls of washed pearl barley with 1 pint of cold water in a saucepan, and boil slowly down to two-thirds. Strain. Barley-water for Adults. Take of finest barley J pound; to this add 1 quart of water and boil to 1 pint; strain and add 1 quart of boiled milk. To this add 6 ounces each of brandy and lime-water; sweeten to taste; flavor with nutmeg and rind of lemon rubbed with sugar. This forms a most nourishing and palatable drink when kept cold on ice. OATMEAL-WATER. Add 1 tablespoonful of oatmeal-flour to 1 pint of water and boil down to two-thirds of a pint. Strain. To this may be added, as additional nourishment, beaten white of egg. RICE-WATER. Rice-water is made by boiling 2 ounces of clean rice in 2 quarts of water for an hour and a half. WINE-WHEY. Boil 1 pint of fresh milk; while boiling pour in 1 small tumblerful of sherry wine (8 tablespoonfuls) ; bring to the boil a second time, being careful not to stir it; as soon as it boils set it aside until the curd settles, and pour off the clear whey. 552 FEEDING THE SICK. ALMOND BREAD FOR DIABETICS. Take of blanched sweet almonds \ pound; beat them as fine as possible in a stone mortar; remove the sugar contained in this meal by putting it into a linen bag and steeping it for a quarter of an hour in boiling water acidulated with vinegar; mix this paste thoroughly with 3 ounces of butter and 2 eggs. Next add the yolks of 3 eggs and a little salt, and stir well for some time. Whip up the whites of 3 eggs and stir in. Put the dough thus obtained into greased moulds, and dry by a slow fire. BRAN BREAD FOR DIABETICS. Take a sufficient quantity (say 1 quart) of wheat-bran; boil it in two successive waters for a quarter of an hour, each time straining it through a sieve; then wash it well with cold water (on the sieve) until the water runs off perfectly clear; squeeze the bran in a cloth as dry as possible, then spread it thinly on a dish and place it in a slow oven; if put in at night, let it remain until morning, when, if perfectly dry and crisp, it will be fit for grinding. The bran thus prepared must be ground in a fine mill and sifted through a wire sieve of such fineness as to require the use of a brush to pass it through; that which remains in the sieve must be ground again until it becomes quite soft, and fine. Take of this bran powder 3 ounces (some patients use 4 ounces), the other ingredients as follows: 3 new-laid eggs, 1J ounces (or 2 ounces if desired) of butter, and about \ pint of milk; mix the eggs with a little of the milk, and warm the butter with the other portion; then stir the whole well together, adding a little nutmeg or ginger or any other agreeable spice. Bake in small tins (patty-pans), which must be well buttered, in a rather quick oven for about half an hour. The cakes, when baked, should be a little thicker than ship biscuit; they may be eaten with meat or cheese at breakfast, dinner, and supper; at tea they require rather a free allowance of butter, or they may be eaten with curd or any of the soft cheeses. "It is important that the above directions as to washing and drying the bran should be exactly followed, in order that it may be freed from starch and rendered more friable. The bran in its common state is soft, and not easily reduced to fine powder. In some seasons of the year, or if the cake has not been well prepared, it changes more rapidly than is convenient, owing to moisture. This may be prevented by placing the cake before a fire for five or ten minutes every day." ALMOND MILK. Add 1 to 2 ounces of scalded sweet almonds, deprived of their skins, to a little hot water and thoroughly rub them into a pulp, adding nearly a pint of scalding water while rubbing. Then boil for fifteen JUNKET. 553 minutes; strain, and add enough water to make a pint. This may be sweetened with sugar if desired, and is excellent for children that cannot take milk. ARTIFICIAL MILK FOR DIABETICS. Williamson has given the following recipe: "To about a pint of water placed in a large drinking-pot or tall vessel, about two or three tablespoonfuls of fresh cream are added and well mixed. The mixture is allowed to stand for twelve or twenty-four hours, when most of the fatty matter of the cream floats to the top; it can be skimmed off with a teaspoon easily, and on examination it will be found practically free from sugar. The milk-sugar remains dissolved in the water. This fatty matter thus separated is placed in a glass and mixed with water. Then the white of an egg is added and the mixture well stirred. The water and white of the egg are added in sufficient quantities to make a mixture which has the exact color and consistence of ordinary milk. If a little salt and a trace of saccharin be added, a palatable drink is obtained which has almost the same taste as milk, and which contains a large amount of fatty material and is practically free from milk- sugar. With very little practice the right proportions can be easily guessed, and, of course, much larger quantities than those mentioned can be prepared." MULLED WINE. Boil some spices — cloves, nutmeg, cinnamon, or mace — in a little water, and add as much of this decoction as is necessary to flavor a wineglassful of sherry or any other wine. Add sugar to taste, and bring the mixture to the boiling-point. If claret is used, it will require more sugar than if a less sour wine is employed. The vessel for heating the wine should be scrupulously clean. WATERED TOAST. Brown several pieces of bread, and carefully butter the toast so that the butter is equally distributed. Place enough salt over the toast to flavor it and add pepper to taste. Finally pour as much boiling water on the edges of the crust as is necessary to soak them thoroughly, and serve. This is a more agreeable dish than would be imagined, and is useful where milk toast is distasteful. JUNKET. Add from \ to 1 teaspoonful of Parke, Davis & Co.'s pepsin cordial or Fairchild's essence of pepsin to a pint of milk, which should be at body-heat. Place the milk in a cool place, and after the curd has formed serve cold and flavor with powdered nutmeg or vanilla. If 554 FEEDING THE SICK. there be too great feebleness of digestion to digest the curd, the liquid whey may be given, as it contains the salts and soluble albuminoids of the milk. Junket may be considerably increased in nutritive value if to the milk before it is warmed is added an egg which has been thoroughly beaten. In place of the egg a tablespoonful of cocoa may be added to 2 teaspoonfuls of sugar and rubbed into a paste with a little water. This is added to the warm milk, and then the pepsin is added to make the junket. PART IV DISEASES. ABORTION, The treatment of abortion divides itself into three parts: the first for its prevention, the second for its arrest when threatened, the third for its proper care when inevitable. In the preventive means we find, as in nearly every branch of medicine, that the use of hygienic measures is more important than the employment of drugs. If previous abortions are known to be due to syphilis, endometritis, or uterine displacements, these conditions must be relieved by the proper remedies. If there exists no apparent cause for the interruption of normal gestation, the patient should use a simple diet, lead a quiet life, avoid all sexual intercourse, sleep on a hard bed, and resort only to gentle exercise. Fresh air is, however, a necessity, and should be plentifully supplied. The food should be light, but nutritious and palatable, and a sufficient variety supplied to avoid any repugnance to a given dish. In many cases abortion is due to deficient nutrition of the foetus, either by reason of faulty assimila- tion on the part of the mother or because of poor food, so that if anaemia, debility, or other impoverished states of the maternal system be present, these should be treated at once. The clothing should be loose, the night's sleep undisturbed and of full length, and the mind be set at rest as far as possible in respect to household and other worries, and particularly diverted from the thought of possible uterine disturbance. The use of drugs is to be limited strictly to the fulfilment of a dis- tinct indication, and the employment of cathartics is to be avoided, the bowels being kept in order by fresh fruits in moderate quantity or by mild laxatives, such as cascara sagrada in small doses and com- pound liquorice powder. If these fail, rhubarb may be resorted to, and castor oil in capsule may be used. Podophyllin, senna in full doses, saline purges in active amounts, and aloes are not to be used if they can be avoided. If the woman be exceedingly stout and ple- thoric, saline purges are indicated to act as depletants. It is hardly necessary to add that elaterium and scammony or jalap are not safe, and can only be used if dropsy and ascites are present, and where we must choose the least of two evils. Strychnine, which stimulates the (555) 556 DISEASES. spinal cord, should never be employed, and cantharides, oil of erigeron, and manganese ought not to be used unless they are for some reason very necessary. Although quinine is not of itself an abortifacient, it is unsafe in very large doses if an abortive tendency is present, and can only be used as a prophylactic in cases in which abortion is brought about by malarial infection. The only drug which seems to be of any service as a prophylactic to be taken all through pregnancy is the fluid extract of viburnum prunifolium, the dose of which is J to 1 drachm (2.0-4.0). This drug is said to be a uterine sedative and to have no injurious effect upon the mother or child. The arrest of threatened abortion is one of the most difficult duties which come to the physician, and there is no doubt that large doses of morphine or opium are the best means of quieting the uterus. While viburnum prunifolium may be resorted to, we do not know enough of it to rest assured of its value, but it should be tried if opium is not at hand or fails. The patient should be at once placed in bed in the most comfortable position, be so covered as to prevent overheating or taking cold, and receive by the hypodermic needle \ grain (0.015) of morphine, or, better still, a rectal injection of warm starch-water containing 45 minims (3.0) of laudanum. The bulk of the injection should be small in order not to disturb the bowels, and must be at the body temperature. If this is not done, a suppository of the aqueous extract of opium, containing J to \ grain (0.015-0.03), should be used. Ice-cold drinks should be given, and no tea or coffee allowed. This treatment quiets the uterus, allays nervousness and restlessness, and at least puts off the abortion for a few hours. Vene- section has been practised in very plethoric women with advantage. When an abortion is inevitable, it is to be treated by measures directed to the avoidance of hemorrhage, the thorough delivery of the ovum and its appendages, and the prevention of inflammation and septi- caemia. The latter accident is to be prevented by the most rigid asepsis of the patient and physician. For the prevention of hemorrhage a number of balls of aseptic absorbent cotton tightly wound with thread to the size of a small egg should be packed into the vagina back of and around the cervix until the bleeding is controlled, and, while a small amount of iodoform may be dusted over them before they are inserted, no astringents are to be applied, unless it be tannic acid to coagulate the blood in the cotton, as astringents cannot reach the bleeding spot. Sponges ought never to be used, as they often fail to control the bleeding and rapidly become septic. By means of this packing the blood in the uterus cannot escape, and as the uterine walls contract they urge the liquid between the membranes, thereby causing complete separation. After the tampons are applied ergot should be used in the dose of a fluidrachm of the extract or a tablespoonful or two of the wine, unless the uterine contractions are already active. Generally after twenty-four hours the removal of the tampons will ABSCESS. 557 show the ovum to be in the vagina, but if part of it remains in the uterus, the following measures should be resorted to: The administration of ergot should be stopped unless the hemorrhage is severe, and the uterine cavity is to be cleared by the use of the fingers of the attendant, who grasps the membranes and draws them away. In skilful hands the curette may be employed. If the cervical canal is too small, it must be dilated by dilators. After the membranes are removed the tincture of iodine may be applied to the inner surface of the uterus as a haemostatic, antiseptic, and alterative; or, better still, the uterus should be douched with a 2 per cent, solution of creolin in warm water, about a quart being used at a low hydrostatic pressure. A pumping syringe should not be used. The after-treatment consists in the use of small doses of ergot and quinine, of vaginal antiseptic irrigation, or even of uterine irrigation if it is needed, and the maintenance of perfect rest for one or two weeks, or longer if possible. Ergot ought not to be given if there is reason to believe that portions of the membranes or blood-clots are in the uterus, as by contraction of the os uteri it may imprison materials which then become septic. (See Puerperal Diseases.) If fever arise, the uterus should be carefully curetted and the intra-uterine douches of creolin continued until the fever disappears. ABSCESS. The medical treatment of abscess resolves itself into the use of drugs to prevent the further formation of pus, to cause its fatty degeneration and absorption, to quiet the systemic disturbance if inflammation be severe, and to support the body if the suppuration be prolonged or in large amount or if debility exists. The treatment may also be divided into that suited to acute and that to chronic abscess. As acute abscess in its early stages is simply a localized inflamma- tion with hyperemia and an outpouring of leukocytes, it may often be modified by the use of aconite or veratrum viride in full dose to quiet the circulatory excitement and relieve the congestion. This is particularly true where the pain is pulsating. At the same time, if the swelling is superficial, a poultice, made by moistening bread- crumbs with lead-water, should be placed over it, or lead-water may be placed on lint and applied in this way. Belladonna ointment smeared over the same area may be of service, and the tincture may be used internally if aconite cannot be used. If a gland be involved, the needle of a hypodermic syringe may be inserted obliquely into its centre and 5 to 10 minims (0.3-0.60) of a 2 per cent, solution of phenol injected into the swelling. This method has been found of singular efficacy in bubo when pus seems just about to form. It is very often curative, but should not be used in a stronger or weaker solution than that named. Another useful abortive method for the treatment of the early stages of abscess is the application, externally, 558 DISEASES. of a strong solution of nitrate of silver, 20 to 40 grains to 1 ounce (1.3-2.6:30.0) of water, by means of a camel's-hair brush, all over the skin covering the area involved, or by the use of the tincture of iodine in a similar manner. Internally, calx sulphurata, in the dose of y^- grain (0.006) given every hour or two, may be used as an abortive, or at least to promote arrest and cause absorption. If it becomes evident that pus is going to form, then resort must be had to poultices, which by their heat and moisture will aid in the formation of pus by favoring the escape of leukocytes and by softening the tissues. The best form of poultice for this purpose is to use lint which has been saturated with a 1 : 4000 solution of mercuric chloride, the moisture being retained by a piece of rubber dam placed over the lint. If pus forms and fluctuation ensues, the abscess should be freely opened, drained, washed out by a solu- tion of carbolic acid in the strength of 1 : 20, or of bichloride solution 1 : 5000, and dressed with antiseptic gauze. If it is tubercular, the abscess may be opened in the ordinary manner, all diseased tissues removed by scraping, and the cavity packed with iodoform gauze, or if it cannot be drained in this way it should be drained by aspiration, and an ethereal solution of iodoform injected and allowed to remain in the abscess-cavity if it is a small one. The opening is now closed by a pledget of cotton wet with tincture of benzoin, and an antiseptic dressing applied over it. Not more than 20 grains (1.3) of iodoform should be so used in the treatment of tubercular abscess, as larger amounts have caused poisoning. A very good treatment for slow abscess is to wash out the cavity with a 10- volume solution of peroxide of hydrogen, provided there is a free exit for the gas which is given off. If the abscess is chronic (cold abscess) and associated with great weakness, resort must be had to the internal use of iron in the form of the tincture of the chloride, cod-liver oil with hypophosphites, quinine as a tonic to prevent hectic fever, and the use of nutritious, easily digested food. Alcohol may be used, and should be given with milk or in egg-nog. The following tonic pill or solution is of service: 1$ — Strychninae sulph. gr. j (0.06). Ferri redact. . . . . . . . . gr. xv (1.0). Quininae sulph gr. xx (1.3). — M. Ft. in pil. No. xx. S. — One t.i. d. after meals. Or, 1$ — Tr. cinchonse comp., Tr. gentian, comp., Tr. cardamom, comp aa f §iij (90.0). — M. S. — Dessertspoonful (8.0) t.i.d. after meals. Having described the means of treatment, it is to be explained how these measures act. The aconite quiets the circulation and thereby relieves the inflammation, the lead-water acts locally as an ACNE. 559 astringent and sedative, while the belladonna by its action on the bloodvessels contracts the dilated capillaries and allays pain. When phenol is injected into an enlarged gland, it acts as an anaes- thetic, as an antiseptic, and as an astringent and stimulant. The nitrate of silver applications act by constringing the bloodvessels, as local sedatives, and as counterirritants. The iodine applications do likewise, and also exercise an alterative influence. The physiological action of calx sulphurata is unknown. The object in using the anti- septic irrigations is self-evident, and the employment of iodoform in tubercular abscess rests upon the studies of Bruns, of Tubingen, and many others, who have found by experiment that the use of iodoform is fatal to the bacillus tuberculosis. As large numbers of corpuscles are destroyed in the formation of pus, and other sources of vitality are sapped by its formation, the use of hypophosphites and iron to replace the loss is necessary, and of cod-liver oil and tonics to increase the blood-corpuscles and the ability to assimilate food. ACNE. This affection occurs in so many forms and arises from such dif- ferent causes that a thorough consideration of its treatment cannot be here given: suffice it to state that arsenic is a remedy which will often aid in the cure and prevent a relapse if used in small doses for a long period; that is, 1 to 3 minims (0.05-0.20) of Fowler's solution three times a day for a month or two. This is particularly useful if debility and anaemia underlie the disease. If the anaemia be marked, the proper treatment is that directed to the cure of this condition (see Anaemia); if obstinate constipation is present, relief must be obtained by saline purges and the bowels kept in order by cascara sagrada or some similar drug. If scrofulosis exists, cod-liver oil is of great service; or if much pustulation is present, calx sulphurata, in the dose of -3^ to J grain (0.006-0.008), may be used in pill form three times a day. In menstrual acne sulphur may be used internally, in the form of the confection of sulphur of the British Pharmacopoeia, to open the bowels, and applied as a wash to the face in the following form : fy— Sulphuris 3J (4.0). Glycerini f|j (30.0). Aquse rosse q. s. ad fgviij (240.0). — M. S. — Apply twice or thrice a day. Or the following may be used in cases of severe inflamed acne: 1$ — Sulphuris iodidi gr. xxx (2.0). Cerati simplicis . . . . .^ . . §j (30.0).— M. S. — Apply to the parts night and morning. If the skin is very atonic, muddy, and torpid, it should be bathed night and morning with hot water and castile soap, or even with the tincture of green soap, and well rubbed with a wet towel. After this the following salve may be thoroughly applied: 560 DISEASES. fy — Sulphur, prsecip 5ss (2.0). Lanolin., Adipis aa §ss (16.0). — M. S. — Apply as directed. If the green soap causes irritation, some bland application should follow it, such as simple cerate or the emulsion of the oil of sweet almonds. If the pustules be large, they may be incised and vent given to their contents, the sac being touched with a drop of carbolic acid. If induration is great, ichthyol ointment of the strength of 20 parts of ichthyol to 100 of lard should be well rubbed in, or resorcin, 10 to 20 grains to the ounce of lard (0.60-1.3 : 30.0), be applied. Mer- curial ointment may also be used to lessen induration, but several days should elapse between its use and that of sulphur, as otherwise a black sulphuret of mercury will be formed and stain the skin. The diet should be carefully regulated and fatty foods avoided. ADENITIS. Cervical adenitis is an inflammation of the lymphatic glands, usually due to tuberculosis unless there be some specific infection, such as syphilis, present. Occasionally it may arise from other forms of infec- tion in the mouth or tonsils. If the condition is a simple enlargement, it should be treated by inunctions of iodine ointment and lard, half-and-half, night and morn- ing, care being taken that the use of the ointment is stopped as soon as reddening of the skin appears or if fluctuation develops. If for any reason the ointment cannot be used, the tincture of iodine should be thoroughly painted over the swelling, but this treatment is less effica- cious. The following is a useful application: fy— Ichthyol. . m 3iy (16.0). Adipis benzoinat S i j (60.0). — M. . S. — Rub a small piece of the ointment into the swelling t.i.d. Syrup of the iodide of iron, in the dose of 5 to 20 drops (0.30-1.3), may be given, and tonics should be used to improve the systemic condition. As soon as fluctuation or reddening shows the forma- tion of pus, all abortive treatment should be stopped, and a poultice be applied for twenty-four or forty-eight hours till the swelling is ready for lancing. Lancing is better than allowing the abscess to break, as the scar left in after years is a mere line instead of a large cicatrix. If the pus is found to be tuberculous or if the swelling persists — and a large number of these cases are so infected — the following treatment, recommended by Treves and Griinfeld, is of value and should be insisted upon: The entire removal of the glands should be effected by dissection alone; directors, handles of scalpels, or fingers should be used to separate the glands from the surrounding cellular tissue as closely AMBLYOPIA AND AMAUROSIS. 561 from the capsule as a nerve is cleaned in the dissecting-room. When sufficient amount of the anterior surface is exposed, a thick thread is passed through the gland and drawn gently, when, by continuing the dissection, the operator may gradually get to the back of the gland, removing portions of the mass at a time. The cavity should be packed with iodoform gauze, and the walls scraped if an abscess has existed. ALCOHOLISM. (See Alcohol.) ALOPECIA. This affection, when due to a parasite, is best treated, according to Crocker, by first pulling out all the loose hairs around the bald spot and then painting the affected surface with linimentum cantharidis (liquor epispasticus) . Three coats of this liquid should be employed, and each coat allowed to dry before the next is applied. In other cases an ointment of chrysarobin, J to 1 drachm (2.0-4.0) to the ounce (30.0) of lanolin, may be used, but care must be exercised that too much staining of the skin and clothes does not result. Another equally good application is 2 grains (0.12) of mercury bichloride to 1 drachm (4.0) of rectified spirit and 7 drachms (28.0) of oil of turpentine. This mixture may be rubbed in with the finger over and around the patch. If the patient's skin will stand it, 5 grains (0.3) of the corrosive sub- limate may be used in place of 2 grains (0.12). AMBLYOPIA AND AMAUROSIS. Amblyopia (or dulled vision) and amaurosis (or blindness) usually refer to defective sight or its total loss, the result of functional dis- turbance of the retina, optic nerve, or visual centres, and unaccom- panied by changes in the eye-grounds in the beginning of the disease. These terms, however, also include cases of partial or complete blind- ness in which optic-nerve atrophy subsequently develops, and are often used to describe ocular disorders not limited by the definitions here employed. These cases may be gathered into certain groups: I. Congenital amblyopias and amblyopias from non-use of the eye. In these there is often a high degree of error of refraction, usually far-sightedness; the latter is seen when an eye is debarred from binocular vision by a squint. In both the treatment consists in as perfect a correction of the optical error as possible, and, in case one eye alone is involved, the separate exercise of its functions. Con- genital amblyopias may include incurable defects in the structure of an eye. II. Amblyopias the result of (a) general diseases or conditions — typhoid fever, the exanthemata, syphilis, scurvy, malaria, colds, etc.; (b) local diseases or conditions — hemorrhoids, hemorrhage, pregnancy, 36 562 DISEASES. disordered menstruation, kidney disease, diabetes, migraine, disorders of the nervous system, etc. The remedies indicated by the special cause are to be employed, the medicinal agents most usually needed being mercury, iodide of potassium, pilocarpine, particularly in uraemic amaurosis, emmena- gogues, and tonics, especially hypodermics of strychnine. As local measures repeated fly-blisters to the temples, wet and dry cups, and the constant electric current are used. The nape of the neck may be cauterized. In hysterical cases metallotherapy may be tried. III. Amblyopias the result of the action of certain medicinal and toxic agents. The abuse of alcohol, and particularly of tobacco, produces a form of amblyopia characterized by the development of a scotoma or an area in the centre of the field of vision in which the appreciation of red and green is lost or greatly diminished. Quinine in excess has, in a number of instances, been followed by temporary blindness, which is usually denominated quinine amaurosis. Methyl alcohol by itself or in the form of adulterated essence of ginger or bay rum, even in comparatively small quantities, may produce rapid blindness and atrophy of the optic nerve. Of less frequent occurrence are the cases of amblyopia produced by the toxic action of salicylic acid, lead, silver, mercury, osmic acid, nitrobenzol, filix mas, thyroid extract, and the vapor of bisulphide of carbon. In all instances the patient must be withdrawn from the influence of the poison; in tobacco amblyopia, in its early stages, this is usually sufficient to effect a cure. The rem- edies which have proved of the greatest utility are digitalis, inhalations of nitrite of amyl, nitroglycerin, and strychnine. Iodide of potassium should be exhibited in chronic cases, and always in amblyopias the result of lead-poisoning. The constant current has also been employed. IV. Amblyopias the result of direct or indirect injury or from reflex irritations. Traumatic amblyopias may follow a blow upon the eye itself or an injury of the skull or spinal cord. To carious teeth, intestinal irrita- tions, and the presence of parasites a certain number of amblyopias have been attributed, but while it is not possible to disprove the asso- ciation, such cases must be received with doubt. After the removal of the cause strychnine should be exhibited. Optic neuritis most frequently depends upon diseases of the brain (tumor, abscess) or inflammation of its membrane (meningitis). It is also a symptom of numerous disorders — suppression of the menses, exposure to cold, rheumatism, anaemia, syphilis, uraemia, lead-poison- ing, etc. The remedies are those naturally suggested by the disease or condition which has called it into existence. The prognosis depends upon the cause. Mercury, iodide and bromide of potassium, the sali- cylates, pilocarpine, local bloodletting, and fly-blisters are the remedies commonly employed. Optic-nerve atrophy is either primary or secondary to disease of AMENORRHEA. 563 the brain or spinal cord or consecutive to an antecedent neuritis. After all irritation has subsided the greatest improvement may be expected from hypodermic injections * 1 of strychnine, which should be pushed to the point of tolerance. Temporary improvement follows the inhalation of nitrite of amyl, and, in the hope of improving the circulation in the optic nerve, nitroglycerin, digitalis, and similar cardiac tonics may be employed. The constant electric current has been employed with benefit, especially by voltaic alternations, which are more active than simple closures. The following remedial agents have also been employed: suspension, stretching the optic nerve, Sequardian injections, nitrate of silver, lactate of zinc, phosphorus, and, quite recently, hypodermics of antipyrin. Mercury may be used with benefit in early stages of the degenerative process, but is of doubtful value in advanced cases. It may be administered in the usual manner or by subconjunctival injection in the dose of -£§ mg. Suspension and injections of testicular juice have little or nothing to commend them. Experience has shown that the arrays have no influence in restoring vision after atrophy of the optic nerve is established. Sufficient time has not elapsed to prove the value of radium and other radio-active substances under these circumstances. AMENORRHEA. This condition depends upon so many causes for its existence that it must be treated in many different ways. If ordinary anaemia or chlo- rosis shows that there is a deficient supply of blood, measures adapted to the relief of such a state are required. (See Anaemia.) In amenor- rhcea due to constipation saline purges or other laxatives may be used, and the best of these purges is aloes; and, as constipation and anaemia are often present simultaneously, a combination of aloes and iron in a pill is commonly resorted to. The iron improves the blood, and the aloes stimulates and congests the pelvic viscera by bringing blood to the sexual organs. Aloes also seems to increase the assimilation of iron in some unknown manner. The following pill is often of service, and was especially recommended by Goodell: 1^ — Extract, aloes 5j (4.0). Ferri sulphat. exsiccat oij (8.0). Asafcetidse . 5iv (16.0). Ft. in pil. No. c. S. — From one to three pills three times a day at each period. Cimicifuga has been highly recommended in chronic and apparently causeless amenorrhcea in the dose of 30 minims (2.0) of the fluid extract at the time for a proper flow to occur. Within the last few years the binoxide of manganese, in the dose of 1 to 3 grains (0.06-0.20), has come prominently forward as a remedy in simple idiopathic amen- orrhcea, and is undoubtedly of service, but it should be taken for at least two weeks before the date upon which each menstruation is 564 DISEASES. expected to occur. Potassium permanganate is also useful during the same period, but it is inferior to the binoxide of manganese in the author's experience. Apiol, the active principle of parsley, may be given in capsules in the dose of 3 to 10 minims (0.20-0.60) in the same manner, and the oils of rue, savine, and tansy have also been employed in capsule in the dose of 5 drops (0.30) three times a jlay. In all forms of amenorrhoea a hot sitz-bath at the time for the expected "period" is of service, more particularly if the patient has "caught cold." The bath should be persevered in for several nights, and care should be taken to avoid exposure. Often a little mustard added to the water will increase the efficacy of this treatment. Under the name of "Dewees's Emmenagogue Mixture," first devised by Professor Dewees, of Philadelphia, the following formula has been largely used in functional and organic amenorrhoea: 1^—- Tinct. ferri chloridi f 3iij (12.0). Tinct. canthan'dis f5j (4.0). Tinct. guaiac. ammon f3jss(6.0). Tinct. aloes . . - f gss (16.0). Syrupi ....... q. s. ad fgvj (180.0).— M. S. — Tablespoonful (16.0) three times a day. ANEMIA. It is, unfortunately, only too true that the entire subject of blood- making and blood-breaking is as yet very imperfectly understood, but many of our therapeutic facts rest on rational ground now, if not before, and if the pathologists will give us more information upon these sub- jects, new remedial measures will be introduced and the empirical employment of old ones placed on a rational basis. Practically speak- ing, the therapeutist recognizes two very important points, the causes of which the pathologist must eventually solve — namely, that one class of anaemias are due to defective or deficient haemogenesis, and another to excessive haemolysis. The former are generally believed to form the simple class, and the latter the essential or pernicious class. It is in the excessive hemolysis class that we most frequently fail to pro- duce good results. More than this, the causes of excessive haemolysis are so various that we can further divide them into removable and permanent, the removable being represented by the cases in which copraemia or autointoxication takes place, while the others are repre- sented by the true pernicious anaemia, about which we know very little, save that most observers find evidence of defective haemogenesis and of profound haemolysis in the percentage of iron in the liver, while in the dark-colored urine they believe a destructive agent exists which, prior to its excretion, has slaughtered many corpuscles. Unfortunately, f it is at present impossible for us to separate clinically the haemogenous anaemia from that of haemolytic excess, unless we find evidence of great corpuscular disintegration in a copious elimination of haemoglobin in ANjEMIA. 565 the urine, or a jaundice evidently hematogenous in character, or a large number of defective corpuscles, which would perhaps indicate defective haemogenesis rather than that they were scarred veterans of a battle with a poison in the liver cells or elsewhere. Post-mortem signs often aid us in the differential diagnosis, but this is too late to be of any benefit to the physician or patient. There is one point, however, about which there can scarcely be any doubt, and that is that in many cases iron is greatly abused, being given when there is no indication for it or more frequently given in excessive dose. By excessive dose the author refers to as much as 6 to 10 grains of reduced iron in a day. The amount of iron in the human body is very small, and every study made of its absorption and elimina- tion after absorption has shown that these processes are very slow. Hamburger recovered from the feces nearly all the iron administered, and Jacobi proved that even when the iron was injected into the veins 10 per cent, was at once eliminated by the bowels, liver, and kidneys, and the remainder deposited in the liver, spleen, and other tissues in the same manner as is any metallic substance. The researches of Gottlieb have also been in confirmatory lines. When we consider that there is in the human blood only about 39 grains of iron, all told, we can see that the use of 12 grains a day in the course of a little over three days places a double quantity of the metal in the economy, which is not needed, and is either cast out or deposited at any con- venient spot, there to lie undisturbed until it can be extruded. Much, of course, depends upon the cause of the anaemia, but there is only one excuse for the use of the large doses of iron just named — viz., a condition of the digestive apparatus which results in the forma- tion of a sulphide of iron in great quantity, so that only an infinitesimal amount escapes into the system. This perhaps explains the empirical fact that in some cases of chlorosis or intense anaemia iron has to be given in large doses to accomplish good results. One of the best studies on this subject is that of Ralph Stockman, who has given us a masterly summary of the subject of the absorption of iron in chlorosis. In this summary he points out that we have three chief theories as to the action of iron in anaemia. The first, the absorption theory, is based on the fact that as iron is taken into the body with the food, the iron of the haemoglobin must be obtained from this source, and therefore that medicinal iron given by the mouth must be absorbed. The second theory rests upon the belief that iron is not absorbed when given by the mouth in addition to that in the food, but simply acts as a stimulant to the mucous membrane of the alimentary canal, therefore increasing the digestion of food, and so overcoming anaemia by the general improvement coincident upon proper nutrition. The third theory is that of Bunge — namely, that in chlorotic conditions there exists an excess of sulphur or sulphuretted hydrogen in the bowel, which changes the iron in the food into a sulphide of iron, which Bunge states cannot be absorbed. He believes 566 DISEASES. that the inorganic iron which is given as a medicine saves the organic iron of the food by combining with the sulphur, and so indirectly cures the anaemia by the protection afforded the food-iron. It is important to remember that each of these theories has been supported by many careful experiments, but it is also well to bear in mind that the hypotheses and the experiments supporting them may be erroneously based. Thus, we have no right to imagine that the inorganic preparations of iron have a stimulating power over the ali- mentary mucous membrane, or, even if they have, that this power is exercised in the peculiar line of aiding in the absorption of the organic iron of the food. Again, the researches of Hamburger, Damaskin, Gottlieb, Muller, Jacobi, and Socin, which show that after the internal use of inorganic iron there is no increase in the iron in the urine, are valueless so far as the conclusions drawn by them are concerned — namely, that as there is no increase in iron in the urine, there is none in the blood, and therefore it is not absorbed. These conclusions are not justified, because they are based on the erroneous view that because iron is not in the urine it is not in the blood, and because it is not in the blood it is not absorbed. Every one knows that in the case of chronic lead-poisoning, when the body is saturated with the metal, there is often no lead in the urine, the poison being deposited in the tissues; and if this is true of lead, it may be of iron. Particu- larly is this to be remembered when we find Stockman quoting the researches of Mayer, Bidder, and Schmidt, and a host of others, who have proved that we are not to look to the kidneys as the path for the excretion of iron, but to the intestinal walls. Finally, Stockman has proved that when iron is used hypodermically it cures anaemia, although it cannot under these conditions stimulate the digestion or combine with sulphides. We learn from practical experience several things which science does not tell us — namely: Iron will not cure all cases of anaemia, even if they belong to a functional type, but other methods must be resorted to at the same time or separately for their cure. The insoluble salts of iron are better remedies for absorption than the soluble salts, because they are not precipitated in the stomach, and for this reason reduced iron is the best chalybeate for uncomplicated cases. Besides using iron in this form, we should employ laxatives if the bowels are confined; mineral acids, particularly nitric and nitromuriatic, for their effect on the function of the small intestine and liver; and, in addition, bitter tonics of a more or less simple form, according to the exigencies of the case, using quinine if malaria seems lurking in the body, simple bitters if the stomach lacks tone, aromatic bitters if from atony of the muscular coats the digestive tract seems sluggish, with a resulting formation and accumulation of flatus and digestive juices. In many cases of anaemia there exists, either as a cause or effect, well-developed intestinal indigestion, and it is thought this results in the production of poisons which are responsible for the decrease in ANAEMIA. 567 the corpuscular elements of the blood. The use of laxatives with the iron is not only necessary, as already stated, but in addition, to over- come this production of toxic products, intestinal antiseptics, such as salol and beta-naphthol, are found useful. The preparations of iron best employed in anaemia are the insoluble salts just named, such as Quevenne's iron and the carbonate, but there are indications for each salt which must be regarded. In many anaemic persons, particularly females, the tongue is broad and white, not from coating, but pallor — is flabby and torpid-looking. Under these circumstances the bowels should be kept moving by mild purges, and the sulphate or some other astringent preparation of iron be taken by the patient. In the anaemia caused by rapid childbearing and lactation cod- liver oil, the hypophosphites and lactophosphates of calcium, should be used, while iron and quinine in tonic dose may be also of service. With some practitioners Blaud's pill is very much used, made as follows: 1$ — Ferri. sulph. exsiccat., Potassii carbonatis aa 5ij (8.0). Syrupi q. s. — M. Ft. in pil. No. xlviii. S. — One to three pills three times a day, after meals. Although it is perfectly true that we have almost no knowledge of the manner in which alteratives act in instances of disease where, through morbid functional activity, enlarged glands or growths appear, it is evident that they must act upon the trophic nerves or directly upon the nutrition of the affected parts. One thing we do know, however, and that is that small doses of most of the so-called alterative drugs act as very distinct stimulants to the development of normal structures, and in no instance do we find this more typically repre- sented than in the effect which they exert upon the blood. Quite a number of years ago Keyes, of New York, emphasized the value of minute doses of mercury bichloride in syphilitic and other anaemias, and abundant clinical observation has certainly confirmed his views. The dose of bichloride of mercury in anaemia should be about -^ grain (0.0015). Not only will minute doses of the bichloride act in this way, but small amounts of calomel or mercury itself will have such an effect. Inunctions of very small amounts of mercurial ointment once a day or every other day, in adults and in children, will increase the fulness and redness of the cheeks and lips and the number of the corpuscles, the piece of ointment used being no larger than the half of a very small pea. This treatment will be found of service in cases not necessarily dependent upon specific taint. The marked increase in the nutrition of children of a syphilitic taint who are suffering from marasmus under the internal use of gray powder and full inunctions of mercurial oint- ment is most extraordinary. Arsenic is also of value in anaemic conditions, and may be employed 568 DISEASES. in relatively larger doses than mercury bichloride. Many clinicians have shown the value of this drug in anaemia. Any one of the prepa- rations of arsenic may be employed, and should the anaemia be per- nicious in its type, or should it depend upon leukaemia or pseudo- leukemia, the arsenic must be pushed in ascending doses until marked evidences of its general effects are manifested. After this, however, most of the drug is in excess and is cast off in the urine and feces unused and wasted, straining and irritating the emunctories of the body during its passage through them. Arsenic is of particular merit in those forms of ansemia in which the blood-cells are lacking in number rather than in haemoglobin. Arsenite of copper is also a remedy of very considerable value under these circumstances in the dose of from y^- to ■£$ grain (0.0006- 0.003) three times a day. A change of air and diet may often produce a cure which no drug can bring about. Diet is an important part of the treatment of ansemia. The food should be good, well flavored, and varied, as well as easy of digestion. It should contain, as far as possible, the remedies needed by the sys- tem, such as bone salts and iron, and its ingestion should be accom- panied by some red wine, such as port. At present we are forced to conclude that pathology has not found out the real cause of these troublesome cases, and that until physiology can put its finger upon the most intricate mechanism of blood-making with a positive, clear statement of its function and the physiological chemistry of the manufacture of haemoglobin, we must remain satisfied to resort to the remedies which experience or common sense tells us will be of value to our patients. ANAL FISSURE. This is one of the most painful affections to which man is subject, and requires intelligent treatment, generally by surgical means if the result is to be curative, although great relief can be obtained by the use of drugs. The most annoying feature of the lesion is the intensity of the pain on defecation, which is so severe that emptying of the bowel is post- poned as long as possible by the patient. To relieve this pain and enable the patient to have a fairly com- fortable stool, nothing is so good as an iodoform suppository contain- ing 2 to 10 grains (0.12-0.60) of the drug. Iodoform being a local anaesthetic, the passage may take place with very little suffer- ing. If much spasm of the sphincter is present, extract of bella- donna, \ grain (0.015), may be added to each suppository. For the cure of the fissure a drop of strong carbolic acid may be applied to the spot, and a lotion of tannic acid, glycerin, and water used if hemorrhoids are also present. Ringer highly recommends the appli- ANEURISM. 569 cation to the fissure, by means of a brush, of a solution of bromide of potassium, H drachms to 1 ounce (6.0 : 30.0) of glycerin. In order that the passages may be soft and yet the patient not be purged, sulphur may be given in the dose of 20 to 40 grains (1.3-2.6) every night, or, if this cannot be used, castor oil may be administered. The best way to give the sulphur is by combining it with powdered cinna- mon or aromatic powder. Sometimes relief is obtained by the use of flexile collodion painted over the fissure. Pure ichthyol locally applied sometimes does good. The radical means of cure consist in stretching the sphincter ani under anaesthesia. This is followed by incising the base of the fissure, curetting it, and then touching it with a stick of nitrate of silver. ANEURISM. The treatment of aneurism by drugs is not very successful, but is at least worthy of trial in all cases. Vascular disease resulting in such a lesion depends upon so many causes which may modify the treatment that the history of the case should be carefully considered. The most common causes are traumatism and syphilis, and very often injury is superimposed upon systemic infection. Whatever the cause of the disease may be, iodide of potassium is par excellence the remedy most apt to do good, even if it does not cure. The doses should be large, 10 to 20 grains (0.60-1.3) three times a day if the patient will bear them, and the prognosis under this treatment is far more favorable if the cause be syphilis than if the disease be idiopathic or traumatic. For successful treatment the recumbent position must be insisted upon, the patient being kept quiet in bed, changing his position as little as possible and confining himself to the most simple and easily digested diet, with entire avoidance of all stimulating substances either in the way of food or drink. Often it is best to adhere to an absolute milk diet. If the heart is excitable and irregular in its action, the vascular system irritable, and a high arterial tension is present, the circulation must be quieted by small doses of tincture of veratrum viride, say 1 or 2 minims (0.05-0.1) twice or thrice a day, but digitalis is not to be employed, since it increases the strain upon the aneurismal sac, although it quiets the irregular heart beat. Aconite may also be used with care, but it is inferior to veratrum viride. If the pain be very great — and it often is severe, particularly at night — opium is indicated, and sleeplessness should be allayed, not by full doses of morphine alone, but by morphine and chloral; or, better still, croton-chloral should be so ordered that the patient receives \ grain (0.008) of morphine and 10 grains (0.60) of croton-chloral in pill at bed-time. All attempts to cure aneurism by the use of other drugs unless syphilis indicates mercury, are useless when the lesion is tho- racic or abdominal; and when it occurs in the extremities, as in pop- 570 DISEASES. liteal aneurism, pressure or surgical measures are to be resorted to as the chief means of cure. If dyspnoea is marked in thoracic aneurism, slight inhalations or "whiffs" of chloroform are sometimes useful, as is also morphine, given hypodermically in the dose of ■§■ grain (0.008). Recently a number of French physicians, chiefly Lancereaux, Huchard, and Carnot, have recorded good results in hastening the formation of clots in the aneurismal sac by injecting a solution of gelatin into the subcutaneous tissues in other parts of the body. The formula used is as follows : R— Gelatini gr. xxx (2.0). Sodii chloridi . . . . gr. cl. (10.0). Aquae destillat. . . . fgiv vel fgx (120.0-300.0). About 2 ounces (60.0) of this are injected every second day into the loose tissues of the back or thighs, a different spot being chosen each time. About twenty injections are necessary before marked results are obtainable, and absolute rest should be insisted upon. The solution used should be carefully sterilized by boiling for several min- utes, because the bacillus of tetanus or its spores are often found in gelatin, and cases of tetanus in man have followed injections of imper- fectly sterilized gelatin. (See Hemorrhage.) The author has performed the operation of introducing gold wire and using electrolysis in thoracic aneurism a number of times, with great benefit to the patient. The operation is indicated in case of sacculated aneurism, but never in the fusiform type. This operation is the only hope of relief for the advanced sacculated forms of the disease. ANGINA PECTORIS. The exact pathological changes existing in angina pectoris are by no means clearly understood, but without doubt many attacks are due to spasm of the bloodvessels, which results in distention of the left side of the heart, which organ is already dilated or enfeebled by disease. Often, too, the coronary arteries have undergone degenerative changes, thereby increasing the cardiac debility. Remedies which ordinarily relieve pain act too slowly or too feebly to be of service in angina pec- toris, and even if successful would only relieve the symptom without removing the cause. The indication in the great majority of cases is to relax the vascular spasm, thus relieving the overburdened heart. As first pointed out by Brunton, the nitrites possess this power, and to him belongs the credit of first applying this class of drugs to this ail- ment. All the nitrites are useful, but the nitrite of amyl and nitro- glycerin are the best remedies for the attack itself, and the nitrite of potassium or sodium for the intervening periods or when the paroxysm is prolonged. The reason for this lies in the fact that the sodium and potassium compounds are more stable than the other two compounds, are more slowly broken up in the body, and therefore more prolonged in their effects. In an attack a few drops of the nitrite of amyl should ANGINA PECTORIS. 571 be given by inhalation from a handkerchief, or the nitroglycerin can be used in the dose of 1 minim of a 1 per cent, solution hypodermically. The dose of the sodium and potassium nitrites is 3 grains (0.15) three times a day, but all these drugs are useless unless the arterial tension is high and the action of the heart labored. If vascular relaxation is present, the nitrites should be supplanted by stimulants, such as alcohol, in full dose, in warm water. Ether given hypodermically is often of service, or Hoffmann's anodyne may be used instead of ether by the mouth or hypodermically with better results. Digitalone in the dose of 15 minims (1.0) may be given hypodermically during the attack to stimulate the heart if it is weak, and by the mouth, between the attacks, to improve its con- dition. The writer has found 20-grain (1.3) doses of antipyrin of great service in some cases. If the nitrite does not relieve the pain, or if it cannot be used because of some contraindication, morphine must be given hypodermically in the dose of J to ^ grain (0.015-0.03), but it should never be given by the mouth under these circumstances, as its absorption will be too slow and its effects will come on after the pain has ceased. The prevention of future attacks rests upon the elimination of all causes which can possibly produce a nerve-storm and cardiac irrita- bility, and in the administration, if the arterial tension is high, of nitroglycerin or one of the other nitrites in full dose for long periods of time. As a rule these drugs have to be gradually increased in dose in order to maintain their effect. Phosphorus is another remedy which is of undoubted value, and should always be tried in the dose of T ^ q- grain (0.0006) three times a day after meals. Arsenic is also useful as a tonic. The following is a valuable prescription for use between the attacks if the heart is feeble and the tension high : R— Tinct. digital f %) (4.0) vel f giij (12.0). Tinct. strophanti . . . n\,xxiv vel f gss (2.0). Nitroglycerini (1 per cent.) rr^xxiv (1.6) vel f £j (4.0). Tinct. cardamomi . . q. s. f^fiij (90.0). — M. S. — Teaspooni'ul (4.0) three times a day. The diet should be moderate and easy of digestion, and salads, lobster, and similar articles of food avoided. If the patient is inclined to take exercise of a violent character he must be restrained, but, on the other hand, some gentle exercise may be permitted if it is possible to take it without precipitating an attack. Tonics, fresh air, freedom from mental worry, and avoidance of exposure to cold are also necessary, and running for a car, or per- forming any act calculated to increase suddenly arterial pressure and cardiac work, is to be avoided. In that form of angina pectoris occurring in nervous females, some- times called pseudo-angina pectoris, 1 drachm (4.0) of ether in ice- water or capsule will often abort the attack, or if the paroxysm is caused by 572 DISEASES. dyspepsia and if the stomach be overloaded, the sufferer may be relieved by the stomach-pump. Between the attacks aconite tincture in the doses of 6 or 10 minims (0 4-0.60) three times a day is useful. ANOREXIA. Anorexia, or lack of appetite, is only a symptom of ill health, gen- erally associated with debility or other systemic disorder, such as anaemia, fever, and many exhausting diseases. It is best treated by a well-cooked and daintily prepared diet, the use of the bitter tonics, such as gentian, cardamoms, and the mineral acids, or by the use of one of the following prescriptions : H — Arseni trioxidi gr. J (0.03). Extract, nucis vomicae gr. iv (0.25). Quininae sulph gi\ xx (1.3). — M. Ft. in pil. No. xx. S. — One t. i. d. after meals. Or, 1$ — Acid hydrochlorici dil f 5ss (16.0). Tinct. cinchonae comp fovj (180.0). — M. S. — Dessertspoonful (8.0) three times a day, after meals, well diluted with water. (For the use of other bitter tonics see Calumba, Quassia, Chamo- mile, Cardamom, and Nux Vomica. None of these drugs is suitable if there is any acute irritation or inflammation of the stomach or intes- tines.) (See Indigestion.) APOPLEXY. Up to a recent period it has been held that the high arterial tension of apoplexy was evil in its effect because it increased the extravasation of blood through the leaking vessel, and for this reason venesection has been commonly employed. Studies carried on by Kocher, in Berne, and by Cushing, in Baltimore, seem to indicate that this high arterial tension is an effort of nature to drive sufficient blood into the cranium to maintain the circulation in the brain, which would otherwise be impaired by the pressure of the extravasated fluid, for great inter- cranial pressure depresses the vasomotor centres and with its failure the vital centres nearby fail to receive an adequate supply of blood. Some surgeons have advocated opening the cranium and removing the clot. The objection to this plan is that the soft tissues of the brain have been irreparably damaged by the rushing of the blood from the inflamed vessel. The condition is quite different from that found in meningeal hemorrhage. With our present knowledge it is probably best to use measures which are helpful and not radical. Hot mustard plasters must be applied to the feet, or a hot mustard foot-bath be used if this is practicable. Ice in an ice-bag or wrapped APOPLEXY. 573 in a towel may be applied to the head. If vomiting comes on, care must be taken that the stertorous breathing does not draw into the lungs particles of the half-ejected food. Sometimes croton oil, 1 minim (0.05), placed on the tongue with 5 minims (0.3) of sweet oil may cause a depletant catharsis which will relieve cerebral engorge- ment, or J grain (0.01) of elaterium may be used. The head must be kept high and the feet low. These are the methods to be used immediately after the rupture of the bloodvessel. The objects to be sought, after the "stroke" has occurred and the hemorrhage has ceased, are the removal of the extra vasated blood, the restoration of function in the paralyzed parts, and the prevention of secondary lesions consequent upon inflammation of the brain as a result of the injury to its substance. If the patient survives the attack, no drugs should be used for one or two days, until the clot in the ruptured vessel has become firmly fixed, unless symptoms of cerebritis arise, when vascular sedatives, such as aconite, must be pushed if the pulse is tense, and calomel administered in small doses, \ grain (0.015) of each every four hours. After the clot has firmly formed and has plugged the leak in the bloodvessel, we may proceed to take measures for the absorption of the exudate, the chief measure consisting in the use of iodide of potassium in as large doses as the patient will bear without the production of iodism. This drug should not be resorted to until several days, or even two or three weeks, have elapsed after the attack. Mercury in small doses may also be given. In order that the muscles of the extremities may not waste and become powerless from disuse, passive exercise, rubbing, and, if pos- sible, massage, must be resorted to. Electricity may be applied to them in the form of the slowly interrupted current, and strychnine may be used hypodermically or by the mouth as a stimulant to the trophic centres in the spinal cord. None of these measures is to be employed if any inflammation exists in the brain, as they will increase the cerebral disorder, and at least three weeks should elapse after the attack before they are resorted to. (See Strychnine.) Electricity applied to the head to remove the lesion is useless, as the current does not go through the brain, but around the skull by means of the scalp. A very careful diet is to be maintained. Meats are to be used very sparingly, the bowels maintained in perfect regularity, and no wines are to be taken nor any stimulants used lest they cause a second rupture of the weakened vessel in the brain. Apoplexy must be carefully differentiated from acute alcoholism and opium-poisoning, which it much resembles. (See Alcohol.) If respiration fails, nothing can be done with much advantage, but belladonna or strychnine may be given hypodermically. The use of electricity to stimulate the phrenic nerve and diaphragm when respi- ration fails is a remnant of senseless medical practice, and is partic- ularly useless in apoplexy. (See Asphyxia.) 574 DISEASES. Above all things, stimulants are contraindicated during the acute attack, even though the pulse fails, as they increase the hemorrhage into the brain. If the symptoms of apoplexy are produced by an embolus, bleeding is usually useless, and it may be harmful by decreasing arterial pressure and thereby delaying the establishment of collateral circulation. APPENDICITIS. It is to be remembered that many cases which years ago would have been called idiopathic peritonitis are now recognized as arising prima- rily from inflammation of the appendix vermiformis. For this reason it is incumbent upon every physician who is called to see a case of severe abdominal pain with symptoms of peritonitis or appendicitis to examine carefully into the condition of the appendix. No routine treatment for appendicitis can be followed, as each case possesses dis- tinct individuality. There are many surgeons, holding extreme views, who assert that the mere presence of appendicular inflammation for a few hours renders an extirpation of this organ necessary. On the other hand, there are doubtless many cases in which the physician postpones consultation with a surgeon until it is too late to save the patient. All cases of appendicitis may be divided into three classes: First, those which are fulminating or gangrenous, and very frequently result in death whether treated medically or surgically; second, those which will get well if they receive surgical aid; and third, those which undoubtedly get well, some of them permanently so, under proper medical treatment. With the first class we shall not deal, for obvious reasons, except to say that they should be promptly operated upon in the hope that they may be saved. In all cases of acute appendicitis of the third class which we have named the method to be followed is briefly as follows : The patient is to be put to bed and absolute rest on the back insisted upon. He must not rise to the sitting posture even for defe- cation or urination. An ice-bag is to be placed over the appendix, or, if this cannot be done, leeches may be applied in this region. If constipation has been present so that the bowels are loaded with feces, this should be removed by the use of half to one ounce of magnesium sulphate or magnesium citrate in official solution, but it is far better to unload the colon by rectal injections. After the bowels have been moved, sufficiently large doses of opium or morphine are to be given to relieve pain if it is severe enough to be agonizing. The doses should be of such size as to "take the edge off the pain," but they must not stupefy the patient, so that he fails to give clear answers to questions. If in spite of this treatment there is persistent tenderness in the right iliac region, with increase in the area of dulness on per- cussion over the appendix, and on palpating the abdomen a sense of muscular rigidity exists, then a surgeon should be at once called in — not, necessarily, to operate, but to decide as to the advisability of an APPENDICITIS. 575 operation, and to perform it if it is considered a wise procedure. Gen- erally, it is best to postpone surgical interference in mild cases until after the acute attack is over, but this preference is to be waived in pressing cases, where then are a rapid pulse, rigidity of the belly, and great pain. In the second class of cases which we have named the treatment is too largely surgical to be considered in a book devoted only to medical therapeutics. It is unnecessary to give a purgative before the opera- tion, unless we think the bowel contains undigested food, since the caput coli never contains feces in any quantity, and, furthermore, in those fairly severe cases which demand operation at once the possibility of perforation of the appendix, with escape of the contents of the bowel into the peritoneal cavity, is always to be remembered, for if perforation has occurred the purgative will force the feces out through the patulous appendix. In this connection it is of interest to consider the plan instituted by Ochsner, and w^hich has given results which demand attention. The determination of the character of the treatment to be carried out rests upon the condition of the appendix at the time the patient is seen. His views are best described as follows: 1. Patients suffering from chronic recurrent appendicitis should be operated on during the interval. 2. Patients suffering from acute appendicitis should be operated on as soon as the diagnosis is made, provided they come under treat- ment while the infectious material is still confined to the appendix, if a competent surgeon is available. With this opinion the author differs, because statistics show that a greater percentage of cases recover if operation is postponed until the interval than if operated on at once. Immediate operation is, however, required in fulminant cases. 3. In all cases of acute appendicitis without regard to the treatment contemplated the administration of food and cathartics by mouth should be absolutely prohibited and large enemata should never be given. 4. In case of nausea or vomiting or gaseous distention of the abdo- men, gastric lavage should be employed. 5. In cases coming under treatment after the infection has extended beyond the tissues of the appendix, especially in the presence of begin- ning diffuse peritonitis, conclusions 4 and 5 should always be employed until the patient's condition makes operative interference safe. 6. In case no operation is performed, neither nourishment nor cathartics should be given by mouth until the patient has been free from pain and otherwise normal for at least four days. 7. During the beginning of this treatment not even water should be given by mouth, the thirst being quenched by rinsing the mouth with cold water and by the use of small enemata. Later small sips of very hot water, frequently repeated, may be given, and still later small sips of cold water. There is danger in giving water too freely, and there is great danger in the use of large enemata, 576 DISEASES. 8. All practitioners of medicine and surgery, as well as the general public, should be impressed with the importance of prohibiting the use of cathartics and food by mouth, as well as the use of large enemata, in cases suffering from acute appendicitis. 9. It should constantly #)e borne in mind that even the slightest amount of liquid food of any kind given by mouth may give rise to dangerous peristalsis. 10. The most convenient form of rectal feeding consists in the use of one ounce of one of the various concentrated liquid predigested foods, dissolved in three ounces of warm normal salt solution intro- duced slowly through a soft catheter inserted into the rectum a distance of two or three inches. 11. This form of treatment cannot supplant the operative treatment of acute appendicitis, but it can and should be used to reduce the mor- tality by changing the class of cases in which the mortality is greatest into another class in which the mortality is very small after operation. To this plan the author would add the use of normal saline solution by hypodermoclysis, with the object of allaying thirst and flushing the kidneys. , 4 If attacks of appendicitis are recurrent, the appendix should always be removed in an interval of quiescence. (See article on Peritonitis.) ASPHYXIA. When practising artificial respiration in cases of asphyxia Sylves- ter's method should always be employed. This consists of laying the patient on some hard, flat surface, kneeling above his head, and then, Fig. 102. Sylvester's method of artificial respiration. First movement: the patient's arms are placed at right angles to the trunk, the elbows resting on the floor, to expand or inflate the chest. after grasping the arms at the elbows, bringing them upward and outward, so that they follow the plane on which the body is extended. This movement causes expansion of the chest, or inspiration. After ASPHYXIA. 577 a moment's pause the arms are lifted up and brought toward one another, and then, while still approximated, pushed down to their original position upon the floating ribs, upon which they are pressed. This last movement drives out the air from the chest, or causes expi- Fig. 103. Sylvester's method of artificial respiration. Second movement: the patient's arms are drawn toward the physician, in order to expand the chest still further. ration. These movements should be at the rate of from sixteen to twenty per minute, about that of normal respiration, and be persisted in for at least forty-five minutes, even though the case seems hopeless, Fig. 104. Sylvester's method of artificial respiration. Third movement: the patient's arms are raised and the elbows approximated to contract the chest. as cases have recovered after as long a period of apparent death as an hour. While these movements are being carried on, the patulousness of the upper air-passages is to be maintained, if possible, by the meas- ures described below. 37 578 DISEASES. In some researches made by Dr. Martin and the writer the following rules regarding the position of the head, neck, epiglottis, and tongue were formulated: The fingers are passed behind the angles of the lower jaw and the latter is pressed forward; this elevates the epiglottis Fig. 105. Sylvester's method of artificial respiration. Fourth movement : the patients elbow and fore- arms are pressed forcibly upon the floating ribs to expel the air from the chest. and the base of the tongue about a quarter of an inch from the post- pharyngeal wall. Extending the head and pushing it forward so that the neck makes an angle of forty-five degrees with the plane of the table draws the base of the tongue and the hyoid bone far forward, this Fig. 106. Showing the attitude in which the head should be held to permit the easy passage of air through the glottis. This position raises the epiglottis, and lifts the soft palate from the tongue. (Martin and Hare's method.) motion being at the same time imparted to the epiglottis, so that the latter stands upright and is separated from the posterior wall of the pharynx by an interval of about an inch. By tightly closing the jaw the anteroposterior space is still further increased. ASTHENOPIA. 579 A very useful method of treating asphyxia is Laborde's method by rhythmic traction on the tongue. The tongue is grasped with forceps and pulled well forward and upward from ten to fourteen times a minute until voluntary respirations occur. The sensory nerves of the tongue carry impulses to the phrenic centre, which in turn causes the diaphragm to contract. A very large number of recoveries from apparent death as a result of its use renders this method most worthy of trial. Fig. 107. Illustrating how upward traction on the tip of the tongue draws the epiglottis away from the glottic opening and permits free ingress of air. It also shows how letting the tongue fall back in the mouth in anaesthesia would close the air-passages and permit the epiglottis to interfere with breathing. (From a research by Dr. Martin and the author.) The absurdity of the application of the rapidly interrupted electric current to the phrenic nerve is not alone dependent upon the points we have named. (See Ether.) It has recently been proved by careful observation on the part of Dr. Martin and the author that the applica- tion of the electrode over the phrenic nerve in the neck may cause cardiac arrest through diffusion of the current to the vagus nerve, and Griswold reached conclusions of an identical character in 1885. If electricity is used, it should be employed solely as a peripheral irritant, with the object of arousing the patient, as would a dash of cold water. ASTHENOPIA. Asthenopia, or weak sight, depends upon exhaustion of the power of accommodation in cases of refractive error, usually hypermetropia, or upon insufficiency of the external ocular muscles. The former is sometimes called accommodative asthenopia, and the latter muscular asthenopia. The treatment of these conditions requires the prescrib- ing of the proper pair of glasses, combined, if necessary, with prisms and with systematic exercise of the ocular muscles. Locally, a weak 580 DISEASES. solution of the sulphate of eserine or pilocarpine acts as a stimulant to the ciliary muscle, and good results follow the internal use of large doses of the tincture of nux vomica or strychnine. 1^— Eserinse sulph gr. -^ (0.016). Aq. destill. f gj (30.0).— M. S. — 2 drops (0.1) night and morning. Or, 1$ — Pilocarpin. nitrat. gr. ^ (0.003). Aq. destill fgj (30.0).— M. S. — 2 drops (0.1) night and morning. Another form of asthenopia is termed neurasthenic asthenopia, or retinal anaesthesia, and presents a number of eye-symptoms in con- nection with a general depression or debilitated state of the nervous system, the eye itself, however, being a healthy organ. The chief symptoms are fluctuation in visual acuity, rapid disappearance of objects looked at, contraction of the field of vision, imperfect retinal images, often associated with dread of light. The mere prescription of glasses in these cases to correct any refractive error is not sufficient. Much relief will often be obtained if compresses at 110° F. be applied to the closed eyelids for five minutes at a time. The patient requires the same general treatment that would be applied to any neurasthenic case. All the functions of the body must be carefully examined into and placed in as normal a condition as circumstances will allow. Especially valuable are rest, massage, salt baths, and full doses of strychnine, together with iron if there be ansemia. ASTHMA. Asthma is one of the most difficult diseases to treat successfully that the physician has to deal with. The disease in all its forms depends upon interference with the free entrance to and exit of the air from the lungs, and this is generally, if not always, dependent upon a spasm of the muscular fibres in the walls of the bronchial tubes, although it has been asserted to be due to a sudden swelling or hypersemia of the bronchial mucous membrane. Both of these states are probably present in varying degree in all cases. The spasm has been proved by Longet, Williams, Romberg, Paul Bert, Bierner, and more recently by Sandmann, to be due to a neu- rosis of the pneumogastric or vagus nerve, and the swelling of the mucous membrane has been seen by Stoerk and others. Thus two schools of teaching concerning the pathology of this disease have been formed, when a little attention to the physiology of the subject would at least show that no difference need exist, for the vagus nerves govern not only the muscular fibres, but also the bloodvessels of the bronchial tubes. The discovery of Michaelson that injury of the recurrent ASTHMA. 581 laryngeal nerves causes catarrhal inflammation of the bronchial tubes, particularly those of the upper lobes, renders the analogy between acute asthma and laryngeal spasm, which has been spoken of by many writers, still more interesting. One other step remains for a thorough understanding of the man- ner in which the disease is produced. Gastric, dyspeptic, or intestinal asthma arises from indigestion, as its name implies, and is caused by the irritation of the afferent filaments of the vagus in the walls of the stomach and intestine, thereby causing reflexly a contraction and hypersemia of the bronchial tubes. In a similar reflex manner hyper- trophies of portions of the nasal chambers or abnormal conditions of the nasal mucous membranes in general may result in an asthmatic attack. Having obtained some idea of the cause of an attack, let us turn to the treatment of the affection. One of the most serviceable remedies in asthma is belladonna, which, as has been pointed out when that drug was studied (see Bella- donna), exercises in medicinal dose a decided sedative and depressing influence on the peripheral filaments of the vagus nerves, not only so far as the heart is concerned, but also, through the pulmonary fibres, upon bronchial secretion, which is always diminished by the drug, probably by this vagal influence. It is evident, therefore, that the use of belladonna or atropine, although originally employed in an empirical manner, rests upon a rational basis, and as the physiological action of stramonium, hyoscy- amus, and similar members of this group is nearly identical with that of belladonna, their influence for good is also explained. The experi- ments of Ott prove that lobelia is a peripheral pneumogastric depressant, and those of Rosenthal and the author likewise showed that tobacco has a similar effect. The same is also true of nitrite of amyl and the other nitrites, which also relax unstriped muscular fibre. We have before us, therefore, a list of the most efficacious and best anti- asthmatics, all of them being depressant to the peripheral vagi. The other remedies commonly employed are chloroform by inhala- tion, which relaxes the spasm of muscular fibre by its local influence, and morphine, which acts as a nervous sedative, prevents reflex irri- tation, and quiets the patient, acting at the same time as a heart stim- ulant and unloading the engorged cardiac cavities. The relief obtained by the inhalation of the fumes of nitrate of potassium, See asserts, depends upon the formation of the protoxide of nitrogen and carbonic acid gas, which act as local anaesthetics. The practical treatment of an attack of asthma consists in the use of morphine hypodermically in the dose of -g- to J grain (0.01-0.015), alone or in combination with atropine. Cigarettes made of paper soaked in a solution of nitrate of potassium and belladonna may be smoked (see formula under Belladonna), or they may be made in the following manner: 582 DISEASES. 1$ — Foliorum belladonna? Foliorum hyoscyami Foliorum stramonii Extracti opii Aquae laurocerasi . gr. vj (0.40; gr. iij (0.2). gr. iij (0.2). gr. J (0.015). q. s. — M. These various leaves are broken up like commercial tobacco, and moistened by adding the cherry-laurel water, which should contain the opium. Finally, a whole leaf soaked in the same fluid is used as a cover, or a piece of cigarette paper may be employed in the same manner. In some cases a very useful treatment is the smoking of nitre-paper cigarettes, which are prepared, before rolling, not only by soaking the paper in a solution of nitrate of potassium (see Nitrate of Potassium), but also by dipping them, after drying them, in tincture of belladonna or stramonium, and allowing the alcohol to evaporate from the paper while it is hung in the air. Another remedy recently brought forward in this country for the relief and cure of asthma is euphorbia pilulifera, the fluid extract of which may be given in the dose of \ to 1 drachm (2.0-4.0) once, twice, or thrice a day. (See Euphorbia Pilulifera.) The author finds the following formula very useful in asthma : I$— Sodii iodidi gr. ij (0.12). Potas. bromidi gr. ij (0.12). Ext. euphorbia? pilulifera? fl tt\,iij (0.20). Nitroglycerin! gr. ^ (0.0003). Tr. lobelia? TT\> (0.25).— M. Ft. in tabel. vel capsul. No. i. S.— From 1 to 4 three times a day. If desired, this formula may be given in the form of an elixir. It will be seen that each ingredient of this recipe has a different action. The action of the iodides in asthma is well known, as is also that of the bromides. The euphorbia pilulifera has been found useful in asthma empirically. The nitroglycerin depresses the peripheral ends of the vagus nerves, and acts as a stimulant to the heart when engorged with blood by removing the inhibitory action of the vagus and relieving the bloodvessels elsewhere. The tincture of lobelia acts as a depressant to the vagus also. A valuable prescription for asthmatics to take between the attacks, particularly in those cases which have cardiac symptoms, is the one, calling for digitalis, strophanthus, and nitroglycerin, in the article on Angina Pectoris. Sometimes a cup of strong coffee taken at the beginning of a par- oxysm will abort it. The use of amyl nitrite by inhalation, 3 to 6 minims (0.20-0.4) on a handkerchief, is invaluable in many cases, and it rarely fails to relieve the spasm. Owing to the engorgement of the heart conse- quent upon the embarrassment of respiration, this nitrite must be used ASTHMA. 583 with care, and in one or two instances it has proved dangerous by causing cardiac failure. Sometimes tobacco may be smoked, and it is particularly efficacious in those who are not accustomed to its constant use. Lobelia when employed should be us£d in full emetic dose (2 drachms [8.0]), in the form of the tincture if an attack is imminent. If an attack is feared, 20 minims (1.30) of the tincture every four hours may be given if the heart is in good condition. A treatment of asthma which is very successful when it arises from nasal disorder consists in the application to the nasal cavities, at the onset of the attack, of the following solution by means of a brush or spray : 1$ — Cocain. hydrochloridi gr. xv (1.0). Aquae destillat q. s. ad f 5iv (16.0). — M. S. — Apply as directed. If this solution is thoroughly applied and the other directions given are carried out, very rapid relief will often be obtained. Under no circumstance is the patient to be allowed to make these applications, for if he does so he is almost certain to develop the cocaine habit. The physician should make them and not reveal the nature of the drug used. Unfortunately, we cannot readily separate those cases which are due to nasal disease and those produced by other causes, and in consequence this treatment when tried for the first time in a given case is purely experimental unless we can discover some hyper- sesthetic patch in the mucous membrane. The curative treatment of asthma to a very large extent rests upon the use of iodide of potassium, and in the careful regulation of the diet and bowels, particularly if the trouble seems to be dependent upon indigestion. As the attacks are generally nocturnal, the even- ing meal should be taken early, be light and easily digested, and tea and coffee should be avoided at this time. The patient should avoid dusty streets and live in the open air as much as possible, and a damp atmosphere is usually preferable to a dry one, provided it is not too cold. This rule is subject to many variations, and each case will be found to be a law unto itself. Each patient must try different climates until the proper one is found. Arsenic may be used, particularly if the mucous membranes are below par, and a dose of bromide of potas- sium or sodium, 30 grains (2.0) half an hour before retiring may be of service. Grindelia robusta is largely used as a prophylactic in the dose of 10 to 30 minims (0.60-2.0) of the fluid extract three times a day. Lobelia may also be used in the form of the tincture, 20 minims (1.30) three times daily. The use of compressed and rarefied air is sometimes of service. Inhalations of oxygen are valuable if the cyanosis is extreme. In many cases the greatest relief will be given by the use of the bronchitis-tent. (See Bronchitis.) 584 DISEASES. In those cases in which the presence of nasal polypi or other irrita- tions of the air-passages is the exciting cause of the attacks those causes must be removed before a cure can be attained. In other instances arsenical wall-papers are the cause of the trouble. In all cases of asthma the physician should from time to time examine the urine and the heart to determine if the attacks are due to disease of the kidneys or to congestion from cardiac failure. BED-SORES. Bed-sores depend upon disturbances of nutrition resulting from pressure exercised in such a manner that the local circulation is inter- fered with at a time when the vitality of all the tissues is depressed by disease or injury. In most instances the part involved becomes chafed by creases in the sheets, by crumbs of food, or by moisture from the discharges of the rectum and bladder. Bed-sores can usually be avoided by cleanliness unless they are dependent upon disease of the trophic nervous system. The chief indication is to prevent the trouble by careful nursing and cleanliness, which should be supplemented by measures devoted to the hardening and improving of the nutrition of the skin covering the parts where the sores are apt to appear, as over the buttocks and sacrum. To permit of a good supply of blood, the patient should be turned on one side or the other every few hours and the skin of the part which has been pressed upon rubbed thoroughly with a dry towel to cause a healthy transudation and absorption of the nutritive juices. Salt and whiskey, 2 drachms (8.0) to the pint (480.0), may be rubbed over the skin, and tincture of gambir or the dilute solution of the subacetate of lead applied to harden it. If this is not used, a mixture of alum and spirit of camphor is useful, made by adding 1 ounce (30.0) of pow- dered alum to the whites of 4 eggs and mixing this with 2 ounces (60.0) of the camphorated spirit. Where the skin is very red and angry- looking, but still intact, a solution of nitrate of silver of the strength of 20 grains to 1 ounce (1.3:30.0) is to be thoroughly painted over the spot. All these remedies act by hardening the skin through their astringency, or by acting as sedative astringents to the inflamed but relaxed capillaries of the part. When a bed-sore is developed, measures must be taken for its cure and the prevention of its spread. With this object in view the body must not rest on the part affected if this can possibly be avoided, and in order that the sore may be protected and the pressure equalized, a large piece of soap-plaster, with its edges deeply incised to make them pliable, should be applied after the sore has been thoroughly washed out by means of a swab or syringe filled with a 1 : 5000 solution of bichloride of mercury, and afterward dusted with iodoform or with chloretone and boric acid in equal parts. Sometimes large squares of lint thickly covered with zinc ointment are serviceable in lieu of BILIOUSNESS. 585 the soap-plaster. If the sores spread and burrow through the parts, the sinuses should be freely opened and irrigated with peroxide of hydrogen, all dead tissues being cut away to avoid sepsis. Nitrate of silver in the strength of 20 grains to the ounce (1.3:30.0) may also be used locally as the patient recovers if the ulcers seem sluggish. A smooth slip-sheet should always be placed under the buttocks. If possible, supportive measures and an increased amount of predigested food should be given if the sloughs are large. The internal use of iron is particularly valuable in the form of the tincture of the chloride in full doses (say 20 minims [1.3]) every four hours. BILIOUSNESS. This is a term used to designate a state which presents different symptoms in different cases, but always includes languor, headache, or dizziness, perhaps some yellowing of the skin and conjunctiva, and a general sense of atony, mental depression, and discomfort. It depends not upon an excessive secretion of bile, but upon some perversion of the functions of the liver or the retention of bile in the bile-ducts. Further than this, most of the symptoms do not depend directly upon the changes in the bile, but upon failure of proper digestion in the stomach and intestine, coupled with the development of irritative decomposition-products of various kinds. The stomach, intestine, liver, pancreas, and their juices all form a complex interwoven chain of function in which if one link breaks the entire chain becomes dis- turbed. The entrance into the stomach of certain food-stuffs which are either ill-prepared or improper for gastric digestion rapidly causes the development of active fermentation, with the formation of lactic and butyric acids, which irritate the gastric mucous membrane, and thereby bring about a faulty gastric secretion of mucus, which makes still further trouble. By the same means the circulation of the stomach is disturbed and becomes abnormal, and the intestine, liver, and pan- creas receive reflex irritation to which they are not normally exposed. Further than this, the irritated stomach fails to convert its contents into peptones and the general features of chyme, and too early or too late drives out into the duodenum a mass of semidigested and fer- menting material utterly unfit for intestinal digestion and absorption, thereby disordering the functions of these parts still further at a time when they are not prepared for the reception of any food. The secre- tion poured out by the different glands varies from the normal; the alkaline juices are not able to overcome the normal acid of the gastric juice plus the lactic and butyric acids; and finally the reaction of the intestine becomes acid instead of alkaline, with resulting irritation and secretion of morbid juices and mucus. The trouble when existing in the stomach gives rise to headache and discomfort, a bad taste in the mouth, and perhaps pain, and is followed by fever, languor, jaun- dice, and flatulence when the intestine is affected. The cause of these 586 DISEASES. symptoms rests upon the fact that, while gastric juice and bile are antiseptic, pancreatic juice mixed with food undergoes rapid decom- position, with the development of products of decomposition, such as skatol and indol and a large number of poisonous alkaloids. Nor- mally, these are not allowed to form, owing to the presence of anti- septic bile, which also hurries on the absorption of the food; but if the bile is retained in its ducts, its secretion is impaired and its consti- tution altered by the disorder of the liver which results reflexly from the gastric and intestinal irritation. Unfortunately, the complication does not cease at this point, for the liver in health has other functions to fulfil, one of the most important of which is the arrest and destruc- tion of all poisons of an organic character which come to it from the stomach and bowel. Not only are decomposition-products destroyed by it, but all the vegetable alkaloids are rendered innocuous if present in ordinary amounts. 1 The disorder of hepatic function therefore permits the entrance into the general circulation of these substances, which are very various as regards their powers and effects. Thus, Brunton has pointed out that one of these compounds closely resembles curare, in that it poisons the peripheral ends of the motor nerves, and thereby is at least partly responsible for the muscular relaxation and languor often seen in patients suffering from so-called "biliousness." Other substances act as do digitalis, atropine, muscarine, and picro- toxin, and the number of these various compounds is infinite. 2 It is impossible to give space to a further consideration of these poisons, but what has been said shows clearly that " biliousness" only expresses a state in which absorption of the bile is not the sole cause of the symptoms, but that other poisons are at work. The methods of treating biliousness are therefore not to be considered as depending upon some regular routine, but upon a study of the case and its symp- toms. Very frequently, after several days of minor discomfort, the disorder culminates in a severe sick headache, after which vomiting comes on and relief is obtained almost at once. Such patients can generally be relieved in the very first part of their discomfort by emetic doses of ipecac or apomorphine, 30 to 60 grains (2.0-4.0) of the former, or Y3- grain (0.004) of the latter hypodermically, or by means of lavage. The manner in which this treatment does good is very evident. It compresses the liver and expels inspissated bile by the compression exercised by the abdominal walls and diaphragm in the effort of vomiting, and thoroughly excites to normal secretion the torpid glands of the stomach and intestine. The vomiting or lavage also rids the stomach of the fermenting masses and bacteria contained in them, and renders the alimentary 1 See studies of Schiff, Lautenbach, and many others, including Ludwig and Schmidt- Mulheim. 2 See the researches of Schweringer, Zuelzer and Sonnenscheim, Bence Jones, Dupre, Rorch and Fassbender, Brieger, Schmiedeberg, and Harnach. BILIOUSNESS, 587 canal more pure. This purity may be increased by giving draughts of hot water or hot water containing a few grains of bicarbonate of sodium or salicylic acid. When it becomes evident that an attack is about to begin — that is, when constipation, slight drowsiness, or languor after meals shows the tendency present — one of two drugs should be used, either podo- phyllin if the stools be dark, or calomel if they be light-colored: ^ grain (0.01) of the former to an adult is generally enough, or 1 grain (0.06) of calomel divided into six powders, one of which is to be taken every fifteen minutes, is a good dose, to be followed in four hours by a saline. If the attack is sudden in its onset, no time is allowed for these hepatic stimulants, and a saline purge should be used in a good- sized dose at once, not because it causes a flow of bile, but because it sweeps the poisonous matters out of the gut before complete ab- sorption can occur, and aids in restoring the normal intestinal alka- linity. The prevention of "biliousness" depends upon the maintenance of a normal, easily digested diet, upon the formation and excretion of normal bile, and the prevention of fermentation and decomposition in the alimentary tract. The term "normal diet" is a very elastic one, and varies with each case. While certain forms of food are generally considered good or bad, easy of digestion or difficult of assimilation, it nevertheless remains a fact that many of the simplest foods are capable of acting as poisons in susceptible persons. A large number of persons cannot take milk or eggs oecause their digestion of these substances is faulty, and the writer is cognizant of one case where lobster salad can be eaten at bed- time without discomfort, while an egg at breakfast will cause a severe headache or pain in the belly. Coffee is often the cause of bilious- ness. Rules as to diet must not be "ironclad," but based on observa- tion. By far the best means of maintaining hepatic activity in cases where this organ is torpid is horseback exercise, particularly if the exercise is taken on a trotting horse, as the jolting of the liver keeps the chain of digestive functions active and prevents the secretions from becoming clogged. Along with this exercise massage of the hypochondrium and belly- walls is useful, and the movements of stooping over, bending from side to side, and bending backward with the feet close together, are of value. The use of pure (undiluted) nitromuriatic acid in these cases in the dose of 3 minims (0.20) three times a day in half a tumblerful of water is invaluable, and the fluid extract of stillingia in the dose of 20 minims (1.3) is of service, as is also the solid extract of euonymus in the dose of 3 grains (0.20.) Five-grain (0.30) doses of extract of chirata in pill are also useful in pepatic atony of a mild type. 588 DISEASES. 1$ — Ext. chiratse .... Podophyllin .... Euonymin . Leptandrin Creosoti Ft. in pil. No. xx. . . . gr. xl (2.6). . . . gr. iv (0.25). . . . gr. viij (0.5) . . . gr. viij (0.5) . . . gr. x (0.60). S. — One pill every night. -m; The knowledge of the action of many of the poisonous materials formed in the alimentary canal renders it possible for us to relieve the patient by other means than those which may be generally resorted to when the attack is present. Thus if the pulse be slow and full, the arterial tension high, and there is throbbing in the head, with frontal headache, the alkaloid representing digitalis may be antidoted by the use of aconite. If nervousness and irritation are present, the bromides and chloral may be used. For some unknown reason the use of caffeine in the headaches of biliousness nearly always makes them worse, particularly if the head- ache is due to overindulgence in coffee. (See Headache.) If the face is flushed, a mustard plaster or dry cup to the nape of the neck may be used, and a hot foot-bath is often of service. In cases where the bilious attacks are associated with catarrh of the stomach, intestines, or bile-ducts, chloride of ammonium, in 5- grain (0.3) doses, three times a day, is very useful, as is also the pro- tiodide of mercury, when triturated with sugar of milk, in the dose of "ST to TU g ram (0.001-0.0015) three times a day. Frequently the use of salol or salophen in 10-grain (0.60) doses, three times a day, does much good in these cases, acting as an intestinal antiseptic. (See Salol.) BLEPHARITIS. Blepharitis is divided clinically into an ulcerative and a non-ulcera- tive variety. The indication of prime importance in the treatment of this affection is the removal of the scabs and crusts before the application of the local remedies. This may be accomplished by the use of alkaline solutions, bicarbonate or biborate of sodium (8 grains to the ounce [0.50:30.0]), or a 5 per cent, solution of chloral, as recommended by Gradle. The salves that have met with the greatest success are Pagenstecher's ointment (yellow oxide of mercury, 1 grain (0.06); vaseline, 1 drachm [4.0]), dilute citrine oint- ment, pyrogallic-acid ointment, or a 3 per cent, milk-of-sulphur oint- ment, to which resorcin may be added. The latter application is useful in the squamous variety alone. In the ulcerated form, if the crusts are tenacious, these, as well as the stunted cilia, must be removed with forceps, and yellow-oxide-of-mercury salve, or some similar application, applied. Excellent results follow touching with nitrate of silver the crater-like abscesses in the edges of the lid. If there is an accompanying conjunctivitis, a boric-acid solution is suitable, while under any circumstances obstruction of the lachrymal duct BOILS. 589 — a frequent accompaniment of the disease — must be removed and the nasal passages explored for any chronic inflammatory condition. The relation between this disease and the presence of refractive errors demands the correction of the latter, should these exist, before a hope for cure may be entertained. BOILS. Boils are dependent upon an impoverished state of the system, or, more rarely, on some local trouble situated in the skin, as in the persons of oil- or paraffin- workers. The constitutional treatment rests upon the use of fresh air, cod- liver oil, iron, arsenic, phosphate of sodium, and, if any boils are present, the use of the sulphurate of calcium in the dose of T ^ grain (0.006) every five hours. The sulphurate of calcium hastens the matura- tion of boils and prevents the formation of new ones, but is useless, according to its original user, Dr. Ringer, in the boils which appear during the course of some cases of diabetes. The local treatment of boils may be divided into the abortive and curative methods. The abortive method consists in painting the inflamed spot, when the trouble first begins, with solution of gun- cotton (collodion), and renewing the coat hour after hour until a heavy contractile covering is formed. If pus forms under this, it may be absorbed; but if this does not occur, then the boil must be opened under antiseptic precautions and properly dressed. A strong solution of nitrate of silver is also very useful at the beginning of the forma- tion of a boil if painted over the part in the strength of 20 grains to the ounce (1.3:30.0). The other local applications consist in the use of the extract of opium or belladonna over the part to relieve pain and decrease the inflammation. Poultices may also be used to relieve the sensation of tenseness and mature the boil, and should contain sweet oil and laudanum. Ringer recommends the application of alcohol and camphor over the skin in the ettdy stages. After the skin is wiped dry it is to be smeared with camphorated oil. Stelwagon uses the following: 3— Ichthyol 5j (4.0). Emplast. plumbi oij (8.0). Emplast. resinse (U . S. P. 1890) . . . 5ij (8.0).— M. S.— Apply to the part. He also approves of the injection of a few minims of a 5 per cent, solu- tion of carbolic acid into the apex of the boil if its formation is assured. When boils occur in the external ear, the canal should be frequently irrigated with hot water, and if the boil is mature it is to be incised. A useful pain-relieving dressing for the boil is as follows : R — Iodoform gr. iv (0.25). Menthol gr. ij (0.12). Petrolati £j (4.0).— M. S. — Smear on cotton plugs and insert in the ear twice or thrice a day. 590 DISEASES. BREAST (INFLAMED). Lactation should at once cease and the milk be removed by the aid of massage and the breast-pump. A bandage exercising pressure is now applied and an ice-bag placed over it. This is only useful in those cases in which the glands are the part affected. When the con- nective tissue is involved, lead- water and laudanum should be applied, and saline purgatives used. Belladonna ointment may be smeared over the breast with advantage in both forms to check secretion and allay inflammation. As soon as pus has formed it should be set free by an incision in the line of the ducts. If it be deeply situated, it should be incised close to the chest and the pockets opened by grooved director or dressing-forceps and packed with gauze. In the early stages of the inflammation, if the circulation is bounding, it should be thoroughly impressed by aconite or veratrum viride and belladonna. BRONCHITIS (ACUTE AND CHRONIC). In the early stages of bronchitis there is always present a very dis- tinct hyperemia, followed by a true inflammation of the mucous membrane lining the bronchial tubes. When these changes are con- fined to the larger bronchi the term " bronchitis " is employed, but when the minute bronchioles are invaded the disease is known as " capillary bronchitis." In the article on Pneumonia, and elsewhere in this book, the writer has spoken of the various stages of inflamma- tion, the . measures indicated under such circumstances, and has described the action of the various drugs. In many cases the phy- sician only sees the patient when the second stage of the disease is present, but if the individual presents himself promptly, the following history and physical signs will indicate the treatment to be employed: After exposure, more or less severe, to wet, dampness, or dry cold, a sensation of oppression comes on, associated with a feeling of "tight- ness across the chest" or a sensation as if a bolus of food was under the sternum. Aching and pain may then be traced over the lines of the bronchial tubes, while the dry, hacking cough increases the dis- comfort and seems to strain the tubes till each one can be outlined on the chest- wall by the patient. The cough, when it occurs, is virtually unproductive, and often causes pain in the larynx and throat. On making examination by auscultation there will be found over the posterior aspect of the chest, between the shoulder-blades, sounds of bronchial breathing, which are rougher than normal, and due to the air passing over an inflamed, swollen, and roughened mucous membrane. This bronchial roughening may be sufficient to cause a harsh inspiratory sound over the entire chest, and the expiratory sounds may be heard a little louder than usual. No other changes from the normal can be noted, but isolated spots of discomfort may BRONCHITIS {ACUTE AND CHRONIC). 591 be pointed out by the patient, where aches, "catches/' or "kinks'' seem to be present in a previously normal tube. Percussion, palpation, and inspection show nothing more of note. Some fever may be present. The patient should receive a hot foot-bath, take a glass of hot lemon- ade with a little whiskey in it, and go to bed at once, in order that, by inducing a profuse perspiration, he may relieve the bronchial con- gestion. Often a dose of Dover's powder is useful in hearty adults to aid in causing perspiration. In children the chest should be well rubbed with camphor liniment and a little tincture of aconite be given in water with sweet spirit of nitre every hour, as follows : I$— Tinct. aconit n\,xxiv (1.50). Spt. aether, nitros 1 . . f oij (8.0). Aquae destillat q. s. ad i'oj (30.0).— M. S. — A half-teaspoonful (2.0) to a child or a dessertspoonful (8.0) to an adult in water every hour In many adults 5 to 10 grains (0.3-0.60) of Dover's powder, with a hot drink, are better. If the attack is not aborted while the first stage is still present, before secretion is established, resort should be had to ipecac and to citrate or acetate of potassium, which act as sedatives to the inflamed mucous membranes and aid in the formation of secretion, moistening the inflamed surfaces and thereby overcoming the dryness and irrita- tion. These potassium salts also act as febrifuges, and should be used in full doses, as much as 40 grains to 1 drachm (2.6-4.0) in a day, in addition to the aconite already recommended. The following prescriptions illustrate their employment: 1$ — Syrupi ipecacuanhae f3j vel f5iij (4.0-12.0). Potassii citratis 5iv (16.0). Aquae destillat q. s. ad f ^vj (180.0). — M. S. — Dessertspoonful (8.0) every four hours for a child of five years. Py — Syrupi ipecac f B j (30.0). Succi limonis f §j (30.0). Potassii bicarbonatis 3iv(16.0). Spirit, aether, nitrosi f oj (30.0). Aquae destillat q. s. ad fgvj (180.0). — Tvi. S. — Dessertspoonful (8.0) every four hours for an adult. This mixture should not be corked for some time after it is made. For a child this prescription should be reduced just one-half in each part, with the exception of the water. In some cases, particularly if the patient be a child, large doses of the citrate or other salt of potassium exert a depressing influence and have to be decreased. Counterirritation may be applied to the chest in the shape of a mustard or spice plaster. If the soreness of the bronchial tubes is not relieved by this means, inhalations of steam arising from boiling water may be practised, either through a cone, one end of which covers the top of a pitcher and the other end of which covers the mouth and nose 592 DISEASES. of the patient, or by covering the head and pitcher with a towel. The usefulness of this method may be much increased by the addition of 1 tablespoonful of compound tincture of benzoin to each pint of water. In young children, particularly in the first stage of bronchitis and in the later stages, the use of the so-called "bronchitis- tent" is of great value. It consists of a canopy raised over the bed a sufficient distance to allow of the circulation of plenty of air. Through one side of this canopy passes a tube leading from an Arnold steam sterilizer, under which is an alcohol lamp to keep the temperature of the water suf- ficiently high. (Fig. 108.) By this means the air breathed by the patient is so saturated with moisture that the mucous membrane Fig. 108. Bronchitis-tent put up by aid of two sheets pinned together and four broomsticks lashed to corners of bed. The steam arises from an Arnold steam sterilizer to which has been attached a tube. When in operation the side flap of the tent is dropped. lining the air-passages is soothed and quieted. In order that the full benefit of this measure be understood, it must be remembered that a mucous membrane in the early stages of inflammation is always dry and red, lacking its normal moisture, and that the upper air-passages fail to catch upon their surfaces, by reason of their dryness, particles of dust, and do not moisten the air before it reaches the lungs. Again, it will be remembered that the bronchial mucous membrane is cov- ered with ciliated epithelium, which, by the constant, upward, wavy motion of its cilia, urges out of the lungs all impurities. Dryness of the surface at once stops this ciliated movement, with unfavorable BRONCHITIS {ACUTE AND CHRONIC). 593 results. The employment of the "bronchitis-tent" is equally useful in adults, but less readily employed, owing to the size of the bed. Having considered the treatment of the first stage of bronchitis, we pass to that of the second. The condition of the mucous membranes is now quite different from that which has just been spoken of. In the place of an absolute lack of secretion a profusion of cast-off epithelial cells, a large amount of mucus, and more or less liquid have been poured out upon the walls of the bronchial tubes, forming obstructions everywhere to the ready passage of air. The secretion is apt to be more or less viscid and ropy, and, when it is coughed up after considerable effort, appears in lumps, particularly in the morn- ing. This state is one in which the excitement of inflammation is followed by local depression and an effort on the part of the tissues to rid themselves of the congestion and of the useless epithelial forma- tions. The physical signs on listening to the chest are now found to consist in a large number of loose rales, which are distinctly wet and moist. Later they become markedly liquid and bubbling, and so cause gurgling on inspiration and expiration. Sometimes they are musical or squeaking. Generally the latter signs do not come on until the case is far advanced, and, if a cure is soon to be reached, they last only a few days or hours, as the mucus is so loose as to be easily coughed up and the lung readily cleared. The object of the physician is to use remedies which will stimulate the bronchial tubes and increase the volume of liquid poured out. For this purpose the bronchitis-tent may of course be employed, but the drugs to be used internally are the chloride of ammonium and the pitches and turpentines, such as terebene, or even turpentine itself. In the majority of instances an ammonium mixture will be the best and most serviceable prescription, in one of the following forms: B — Ammonii chloridi . . . . . . . 5ij (8.0). Ext. glycyrrhiz. fluid f 5ij (8.0). Aquae destillat q. s. ad fgiij (90.0). — M. S. — Teaspoonful (4.0) to dessertspoonful (8.0) every four hours. Or, 1$ — Ammonii chloridi 3ij (8.0). Mist, glycyrrhiz. comp f §iij (90.0). — M. S. — The same dose. The advantage of the latter prescription is the presence of antimony in the compound liquorice mixture, which tends to increase secretion, but which is contraindicated if debility exists. If the cough is troublesome, a little morphine or belladonna may be added, or the following be used, particularly if any signs of cardiac failure appear: 1^ — Ammonii chloridi 5j (4.0). Ammonii darbonatis • 5j (4.0). Ammonii bromidi 5j (4.0). Extract, glycyrrhiz. fluid f §iv (16.0). Aquae destillat fgvj (180.0).— M, S .— -Dessertspoonful (8.0) every four hours. 38 594 DISEASES. In this prescription the first constituent acts particularly on the air- passages, the second stimulates the heart and respiration, and the third allays the cough, while the liquorice masks the salty taste of the ammonium. Still another recipe is: 1$ — Codeinse sulphatis gr. ij vel iv (0.12-0.25). Ammon. chlorid 3j (4.0). Ext.glycyrrhiz.fi fgj (30.0). Aquae destillat q. s. ad fgij (60.0).— M. S. — Teaspoonful (4.0) every two hours in water. An oronasal respirator, with the sponge saturated with equal parts of terebene, iodide of ethyl, and chloroform, may be worn in order to allay cough and loosen the mucus. Sometimes the use of a nebulizer, as shown on page 522, is very useful, or Yeo's inhaler may be used. (See Creosote, Part II., and Inhalations, Part III.) If the administration of the chloride of ammonium does not aid in the expulsion and liquefaction of the secretion and rid the lungs rapidly of the mucus, the use of terebene in 5- or 10-minim (0.30-0.60) cap- sules may be resorted to with success. If capsules cannot be sup- plied, terebene may be made into an emulsion with acacia or trag- acanth and given in this way. Sometimes terebene will irritate the kidneys and produce a sense of weight across the loins; if this occurs, its use should be stopped. In other cases it will disorder the stomach or cause diarrhoea. These effects are not, however, commonly seen. Terpine hydrate in 10-grain (0.60) doses may be used three times a day, or terpinol in the dose of 8 to 10 grains (0.5-0.60) in capsules or pills. An excellent combination is the elixir of terpine hydrate with heroin, which may be given in the dose of a dessertspoonful (8.0) every four hours in a little water. Certain of the volatile oils and resins are also of value at this time, notably the oleoresin of cubebs and copaiba, which, however, possess the disadvantage of disordering the stomach. The oil of eucalyptus is also of great value, and may be given in capsule or emulsion in the dose of from 1 to 5 minims (0.05-0.30) every five hours. The oil of sandalwood in the dose of 5 to 10 minims (0.30-0.60) is very valuable, and is not so apt to disorder the stomach, bowels, and kidneys as are some of the other remedies named. While the proper use of these remedies usually brings about the results desired, in some cases a stage of profuse secretion comes on which in its treatment is identical with that seen in chronic bronchitis, and chronic "winter cough" with emphysema, so these diseases will therefore be considered together. In old persons suffering from dilated bronchial tubes, from emphy- sema, and from chronic bronchitis there is constantly poured into the air-passages so free a secretion that persistent coughing is necessary to rid the lung of enough of the mucus and liquid to enable them to breathe. Any excess of this exudation drowns him in his own secre- tions, and the constant obstruction to the ready flow of air and blood BRONCHITIS {ACUTE AND CHRONIC). 595 in the lung soon produces dilatation and weakness of the right side of the heart. The same condition in a more acute form sometimes asserts itself in young children and in adults. In children it sometimes comes on so suddenly as to be known as " acute suffocative catarrh/' while in older persons it appears with sufficient severity to make the con- dition of the patient most serious. Of the treatment of the latter state the writer will speak at once. The objects desired are to rid the lung of the liquid secretions, to pre- vent the outpouring of more exudate, and to support the patient until the crisis is past. Digitalis should be administered to support the heart, and strychnine be employed in full dose to stimulate the respiratory centre and excite the nervous system, which is generally depressed by the increasing carbonic acid in the blood. For the same purpose caffeine or strong coffee may be used. Oxygen may be inhaled, and to check the profuse secretion atropine should be used by the mouth or hypoder- mically. When cyanosis is marked and the patient is a child, it may be alternately dipped in a tub of hot and cold water to cause reaction and stimulate the dormant nerve centres to greater activity, and so by reviving the patient sufficiently respiration is maintained until voluntary efforts are made by the patient. Sometimes letting the patient hang his head over the side of the bed when he coughs may aid in the expulsion of the liquid. The treatment of the more moderate condition of excessive secre- tion in the bronchitis of old persons, which is more slow in its progress, but which may end as fatally as like attacks in the young, is some- what similar to that just given. Injurious results are often produced by the physician failing to recognize that the secretion is sufficiently fluid, and that ammonium chloride and such expectorants are not only useless, but distinctly harmful because they increase the quantity of these liquids. Under these circumstances the application of several dry cups over the bases of the lungs posteriorly often gives a great deal of relief ; or if cups cannot be obtained, then active counterirritation by means of a mustard-plaster or turpentine stupe is advisable. The cups are, however, the remedy of choice. Belladonna, which checks secretion, stimulates the respiratory centre, and is for this reason a doubly useful remedy. Strychnine is, however, the best of remedies to help the patient get rid of the sputum. It should be given in the dose of -^V grain (0.006), or more, three times a day. When the condition is pressing atropine and strychnine should be used hypodermically. The use of remedies designed to allay the cough in these cases is absolutely unjustifiable, as it results in retention of the profuse secre- tion. The question as to whether the cough is excessive or not must depend on the ability of the lungs to rid themselves of the secretions in the bronchial tubes. 596 DISEASES. BURNS AND SCALDS. The treatment of burns and scalds is both internal and external, the first being devoted to the quieting of the nervous system after the injury, the relief of pain, and the treatment of shock; and the second to the care of the injured surfaces. Immediately upon being called to a severe case of burn it is the duty of the physician to determine how badly shocked the patient is, what the condition of the pulse may be, and whether or not the lungs and air-passages are involved. After these mental notes he should give a hypodermic injection of \ to § grain (0.015-0.03) of morphine and ^ho of atropine (0.0006), and then roll the entire body in a large quilt to maintain the bodily heat, while the sufferer is being transferred to the hospital or the house to which he belongs. In some cases the shock is so great that the pulse flags at once, the temperature falls, and collapse ensues. Stimulants hypodermically, external heat, and drinks of hot water and whiskey are indicated, fol- lowed by y-o grain (0.003) of strychnine and 5 minims (0.3) of tincture of digitalis if the circulation does not respond to the less powerful stimulants. Adrenalin chloride, 1 drachm (4.0) of a 1 : 1000 solution, may be given intravenously in a pint of normal saline solution in severe cases. A very useful treatment under these circumstances is to immerse the patient in water hot enough to maintain the bodily temperature. Often while in this bath the burned cuticle is easily removed with but little pain, and the protection from the air decreases dermal irritation. By far the best dressing is lint wrung out in a mixture of picric acid. (See Picric Acid, Part II.) Another useful application is linseed oil and lime-water, equal parts, or, if desired, the oil may be rendered antiseptic by the addition thereto of 1 part of carbolic acid to 20 parts of oil. This mixture is also of service in that it acts as a feeble local anaesthetic. The cloths should be renewed every twelve or twenty-four hours, as may be needed, or they may be substituted by lint wrung out in a saturated watery solution of boric acid. A useful application for severe burns is a dusting-powder composed of: 1^ — Chloretone, Acid, borici aa gss (16.0). — M. S. — Dust the injured surface with this powder and dress it with dry gauze. Still another very efficacious application to burns is that of the late Professor Rice. It is better than Carron oil or any of the prepa- rations ordinarily used. It is as follows: fy— White gelatin gviiss (225.0). Glycerin. . . f 5j (30.0). Carbolic acid f 3j (4.0). Water fgxvj (480.0). Soak the gelatin in the water until it is soft; then heat it on a water-bath until it is melted. Add the glycerin and continue heating until a firm, glossy skin begins to form on the surface of the mixture, in the intervals of stirring. Now add the carbolic acid and mix intimately. CHANCROID. 597 This mixture may be kept ready prepared, and is best preserved in well-closed glass or porcelain jars. When wanted for use, it is heated on a water-bath until just melted, and applied with a soft flat brush over the burned part, where it forms a strong flexible skin. If the burn is not very extensive, a solution of the tincture of canthar- ides, 1 part to 40, upon a rag, is said to relieve pain and aid in healing, but if the burned surface be large this treatment should not be resorted to, owing to possible irritation of the kidneys, which are already over- taxed by the interference with the functions of the skin. In compara- tively small burns a saturated solution of carbonate of sodium (wash- ing soda) often does great good in relieving the pain. This relief may depend on the solvent power of this salt upon albuminous deposits, formed by the heat, which irritate the peripheral nerves. A very important point in the subsequent treatment of burns is the remembrance of the close relationship existing between the internal organs, particularly the duodenum and the kidneys, and the cuticle. When we recollect that we try to influence internal congestions — such as pulmonary congestion, for example — by the application of irrita- tion to the skin of the chest, we see at once that a widespread and severe burn is practically a huge counterirritant and must reflexly affect the viscera. Again, the skin, being prevented from excreting impurities, forces the kidneys to do the work, and if they fail under the strain death results. Whenever the urine is high-colored and cloudy the citrate of potassium should be freely given, 20 grains (1.3) in water three times a day, combined with 30 minims (2.0) of sweet spirit of nitre. In dressing very severe burns the use of a general anaesthetic, such as chloride of ethyl by inhalation, or chloroform, is proper, but it must be used with great caution. CHANCROID. The chancroid is a contagious ulcer which has no definite period of incubation, is distinctly inflammatory in type, and is usually multiple. It is further distinguished from the primary sore of syphilis by the fact that it is autoinoculable, is not followed by secondary eruptions, and, if it involves the lymphatics at all, produces an acute inflammatory swelling which frequently attains a considerable size and suppurates. Chancroid, being purely a local affection, would seem to require nothing more than local treatment : this is true of the uncomplicated sore, but where phagedena or serpiginous ulceration sets in, the ques- tion of constitutional treatment is of paramount importance. The treatment of uncomplicated chancroid in its early stage is as simple as it is efficient. One thorough cauterization converts the sore into a healthy ulcer the cicatrization of which is quickly and surely accomplished. 598 DISEASES. As the most efficient means of thoroughly destroying chancroidal ulcerations the actual cautery is chiefly commended. This is, how- ever, objectionable to patients. Sulphuric or nitric acid will be found equally serviceable. The pain of these applications may be greatly lessened by the previous employment of a 20 per cent, solution of cocaine. When the surface involved is large, the patient should be etherized. The cardinal point in the cauterization of chancroids is to reach and destroy all the diseased area. Each pocket and sinus must be thoroughly acted upon, otherwise it remains as a focus for reinfec- tion. A convenient way of both destroying the chancroid and pro- viding for the after-dressing is offered in the application of Ricord's paste. This is made by adding to finely powdered charcoal enough strong sulphuric acid to form a paste of about the consistency of castor oil. This is then applied to every portion of the ulcer. The acid shortly dries out, leaving a dressing of charcoal, which in a few days drops off, exposing a healthy, nearly healed, granulated surface. Where nitric acid is applied the subsequent dressing consists, preferably, in the application of dusting-powders, iodoform being the best. There has been a tendency of late years to substitute for this treat- ment one less radical, more acceptable to the patient, and in many cases almost equally satisfactory in results. It is certainly true that many of the chancroids as found in persons of robust health show little tendency to spread beyond comparatively narrow limits, and are amenable to mild treatment. It must be remembered, however, that as long as the smallest portion of such an ulcer remains unhealed it may at any time take on all the features of a virulent ulceration. Moreover, the patient is constantly exposed to the risks of a chan- croidal bubo — a complication so troublesome that the possibility of its development constitutes the strongest argument against palliative in distinction from radical treatment. Where the ulceration is entirely superficial, constituting the erosive form of chancroid, iodoform, dusted over the surface of the carefully cleansed granulations, offers the best form of palliative treatment. As a cleansing and stimulating wash to precede the application of the iodoform, 1 drachm (4.0) of nitric acid to the pint (480 c.c.) of water is most satisfactory. The objection to iodoform lies in its disagreeable and penetrating odor. To overcome this, great care should be exer- cised in applying the powder to see that none is distributed elsewhere than upon the sore. The odor can also be disguised to some extent by thoroughly mixing with the iodoform a small quantity of one of the essential oils, such as oil of peppermint, or attar of roses, using not more than 5 minims (0.30) to 1 drachm (4.0) of the powder. There is no dusting-powder which can entirely take the place of iodoform, yet, when the objections to the use of the latter are insuperable, aristol or iodol may be substituted, or a mixture of 1 drachm (4.0) of zinc oxide and 3 drachms (12.0) of snbnitrate of bismuth, or equal parts of calo- CHANCROID. 599 mel and bismuth. Where the discharge is profuse, powdered tannin may be combined with the dusting-powder in the proportion of 1 part to 4. In the ordinary uncomplicated chancroid these dry dressings are greatly to be preferred to wet applications: when, however, the sore is attacked by a high grade of inflammation and becomes indurated, prolonged immersion of the part involved or of the whole body in hot water may be followed by the application of dressings kept constantly wet with the dilute nitric-acid lotion, as given above, or with weak carbolic solution, 5 grains to the ounce (0.30 : 30.0) of water, or with lead-water and laudanum. Where the chancroid assumes the phage- denic type, extending with great rapidity and causing extensive slough- ing and destruction of tissue, free cauterization, either with the hot iron or by means of nitric acid, should be instituted immediately, every portion of the ulcerating surface being thoroughly destroyed. This should be followed by prolonged hot sitz-baths or general warm baths, the patient remaining in the water for days at a time if necessary, and, if practicable, eating and sleeping with the body still immersed. If this is not possible, baths of from two to four hours' duration should be given two or three times daily. After cauterization, powdered iodoform is the best local application in phagedenic cases. In addition the patient may be given full doses of opium, and should receive a tonic and supporting treatment. Should the chancroid assume the serpiginous type, slowly extending in spite of treatment, till in the course of months or years large areas are destroyed by the process, the warm bath, continued night and day for weeks at a time, together with thorough cauterization of the entire diseased surface with the hot iron, represents the most satisfactory method of treatment. In all such cases a thorough trial should be given to the treatment appropriate to tertiary syphilis. The chancroidal bubo is best avoided by prompt and thorough cauterization of the sore: when it occurs, however, it should be first treated by rest, pressure, and counterirritation, since it may be a simple inflammatory adenitis, and with care may not go on to sup- puration. Iodine may be painted around the swollen area, the patient should be put to bed, and a compress should be applied wet with dilute lead- water and alcohol, and held in place by a spica bandage of the groin, or this may be substituted by a hot bag placed upon the inflamed gland. At the first sign of suppuration the bubo should be punctured by a tenotome, evacuated, and washed out with a bichloride solution (1:1000), and dressed antiseptically. If there be a reaccumulation of pus, the puncture and washing should be repeated. If inflamma- tory symptoms still persist, the diseased gland should be thoroughly removed by dissection or the curette through a free opening, the resulting wound being drained by gauze and sutured. If the bubo takes on phagedenic action, it should be treated as the phagedenic chancroid. 600 DISEASES. CHOLERA, ASIATIC. The treatment of this exceedingly dangerous disease is prophylactic, curative, and convalescent. The first measures consist of strict quarantine, both public and private, the avoidance of all water for culinary purposes which has not been boiled at least an hour and cooled in a place devoid of germs, the use of no uncooked food which may be contaminated, and the employment of those foods which, while preserving the normal bodily health, in no way predispose to intestinal disturbances, as do some of the fruits, as melons and grapes. If these precautions are observed, little remains to be done; but sulphuric acid may be taken as a pro- phylactic. The use of a remedy originally proposed by Dr. R. G. Curtin has been proved by recent study to be eminently rational. This agent is sulphuric acid. This drug not only is acid, and so deleterious to the bacillus, but, in addition, is astringent, and is probably elimi- nated as a sulphate by the lower bowel. As is well known, ordinary cholera morbus yields readily to its influence. Dividing the disease into three stages, we find as the earliest symp- tom some disturbance of peristaltic movement, with or without pain, or in other instances the patient is attacked with a sudden flux of the intestinal contents. If there is a history of the ingestion of bad or indigestible food, there is no doubt whatever that this foreign material must be gotten rid of by the use of castor oil or sulphate of magnesium, the latter being the best because it is more rapid and less apt to cause griping. No purgative should be given unless the history of the ingestion of bad food is most direct and clear. When the attack is sudden in its onset, as is usual, the question arises, Shall we resort to opium by the mouth? The answer, after having carefully considered the statements of a large number of authors, is that opium should not be used by the mouth or hypoder- mically except in cases where the pain or cramps are so severe as abso- lutely to require the drug. In other words, it is to be given for the pain, not for the diarrhoea. Should opium be used, it is infinitely better to employ it by the rectum in the manner to be described later; and if it is necessary to use it by the mouth, only deodorized opium or deodorized laudanum should be employed, since these preparations are less apt to cause nausea than their fellows. Camphor, on the other hand, seems to be universally regarded as a most useful drug, tending at once to check diarrhoea and relieve the pain and cramps from the beginning to the end of the attack. Whether camphor exercises any germicidal effect on the cholera bacillus we do not know. Certain it is that volatile oils all possess distinct antiseptic powers. Aside from any such influence, camphor is useful as a gen- eral systemic stimulant, and has been proved by wide clinical observa- tion to have a very extraordinary power in the control of all forms of CHOLERA, ASIATIC. 601 serous diarrhoea, particularly that of true cholera. The spirit of camphor has proved most effective in cholera epidemics. Frequently the use of camphor so controlled the diarrhoea and stimulated the torpid kid- neys that anuria was relieved in twenty-four hours. Under these conditions camphor wine has been found very useful; it is made by adding 75 grains of finely powdered camphor to a quart bottle of strong red wine, to which are also added gum arabic and alcohol. The camphor is first dissolved in the alcohol, and then thoroughly mixed with the wine. The dose of this mixture is a tea spoonful, in peppermint tea, every hour to a child of six years, for an older child a dessertspoonful, and for an adult a wineglassful. Those who first used this mixture were wiser than they thought, for the recent studies of Pick have shown that both red and white wine are dis- tinctly inhibitory to the growth of the spirillum of cholera, probably because of the tannic or other acid which they contain, as well as the alcohol. A remedy, the use of which is based on very rational grounds, is salol, and probably the newer drug salophen, which, theoretically, is much better than the former, because it is less poisonous. According to the interesting studies of Lowenthal, salol seems to be peculiarly antagonistic to the bacillus of cholera. This investigator added to a 50-gramme alkaline solution of pancreatic juice 10 grammes of salol, and to tins mixture 3 cubic centimetres of a virulent bouillon culture of the bacillus. Examinations in forty-eight hours to a week showed this to be absolutely sterile. It was further proved that the salol was inactive until broken up into its component parts — phenol and salicylic acid. Hueppe also asserts that the use of salol prevents the development of anuria. In addition to the treatment already given, which may be used in the second as well as in the first stages, we have measures which must be resorted to for the relief of the dominant symptoms which mani- fest themselves as the disease progresses. The symptoms now to be combated are vomiting, excessive purging, cramps in the extremities, and, as the result of these, exhaustion, collapse, and the advent of the algid stage. By far the best results obtained by any one line of treatment at this time certainly follows the employment of salol and camphor by the mouth, with enteroclysis and the use of hot baths ; or, if these are not possible, hypodermoclysis and the employment of a hot- water bed; or, finally, hot bottles and bricks, for the patient largely dies of cold and of internal congestion of thickened blood, the circulation of which the heart and vasomotor system are unable to control. Atropine and strychnine are very useful, but ether is better than either, given subcutaneously or by the mouth, as a diffusible stimulant. Very remarkable results are said by Italian observers to follow the rectal injection of a solution of common salt in the proportion of 1 drachm to the pint (4.0 : 480 c.c.) of warm water. In other instances 602 DISEASES. the use of tannic acid in the strength of from 1 to 8 drachms to the pint (4.0-30.0 : 480 c.c.) of water has proved very satisfactory. The amount used at each injection should be about 2 quarts (960 c.c), and the injection made as gently as possible in order to urge the fluid high into the bowel. The inflow tube should be a soft female catheter, and the overflow tube twice as large as the inflow tube. The tubes are to be' inserted side by side, after thorough oiling. The injection may be used every two hours and continued till the outflow is clear. This is done to wash out poisonous materials and to supply liquid to the system. A solution much stronger or weaker than that named is dangerous, for similar reasons to those given under the head of Dropsy and Saline Purgatives. (See, also, Enteroclysis, Part III.) Another useful measure is hypodermoclysis, or the passage of a solution similar to that just named into the subcutaneous tissues of the thigh or belly- wall. It should always be practised if collapse is present. (See Hypodermoclysis, Part III.) If made slowly, these injections are absorbed readily and supply liquid to the depleted blood- vessels. (See article on Diarrhoea.) CHOLERA INFANTUM. Cholera infantum is a term often applied to all forms of active serous diarrhoea afflicting children in the summer months, whether its cause be exposure to high heat, the use of bad food, or both. The treatment by the use of drugs is identical in all forms of serous diarrhoea in children as far as the purging is concerned, but the cause requires great care in its discovery and skill in its removal if that be possible. Diarrhoea occurring in an infant in hot weather is to be regarded by the physician as a fireman regards a fire. The only way to prevent a calamity is to regard it seriously and use every effort to prevent its further development. In cities, where the heat is often great, the air damp and impure, and the food not always fresh, cholera infantum often appears as a form of thermic fever or heat-exhaustion, or, in other words, as sun- stroke. Often in these cases the temperature in the rectum will be found febrile, while that of the axilla is below normal, and, as pyrexia does harm to the internal organs, the internal temperature must be lowered by cool drinks, by administering pieces of ice, and the irriga- tion of the bowel which will be described shortly. The diarrhoea in such cases is dependent upon a relaxation of the bloodvessel walls in the intestine by reason of the influence of the high heat upon the splanchnic nerves, and to irritant matters derived from germs and result- ing from defective secretion of the digestive juices. If the thermometer placed high up in the rectum shows a subnormal temperature, heat- exhaustion is present, not thermic fever, and the treatment is reversed. Hot drinks are to be used, external heat applied, and friction of the limbs resorted to, or the child may be put in a hot bath at a temperature CHOLERA INFANTUM. . 6Q3 of 103° F., the child's temperature being carefully watched lest it rise suddenly to a point above the normal. Avoidance of milk and the use of a few drops of beef-juice in water for twenty-four hours are the best orders as to diet. If vomiting is active and collapse is threatened, a drop or two of good brandy should be used in each teaspoonful of food, and the value of atropine and adrenalin as vasomotor stimulants is not to be forgotten. There is another form of cholera infantum which is not due to a high atmospheric temperature alone, but more commonly to the ingestion of irritant foods or foods unsuited to a child, obtained by the patient surreptitiously or through the ignorance of the parents. If there is such a history and the probable cause is discovered by reason of some of the masses of undigested food having been passed, a purgative dose of castor oil (1 to 2 teaspoonfuls [4.0-8.0] to a child of two years), with 20 minims (1.3) of paregoric, should be used to sweep out the offending materials and allay irritation, and be fol- lowed at once by the treatment which will be spoken of later. Care, of course, should be taken to maintain the bodily heat, or lower it if it is much above the normal, and a watch must be kept upon the pulse and breathing to note any changes requiring stimulants. There is still another class of cases. The physician will be called to see a child with the same history of having taken indigestible food or of there being curds in the stools. Careful examination will show that there is much bearing down, or in other cases a simple running off of the liquid from the bow T el almost without effort. Very soon, indeed, the passages become entirely colorless, except for a speck or two of green, which shows the presence of the peculiar micro-organism which produces this color. The diapers have a peculiar mousy odor, and are characteristic — that is, they seem to be only wet and musty, and contain no solid matter. If closely examined, they will be seen to be soiled by a small amount of a whitish substance, looking like a paste made of water and fine chalk. Such a passage bodes ill for the child unless treatment is instituted. The physician should order, at once, -^j- grain (0.003) of podophyllin for a child of six months, to be taken in two doses, half an hour apart, in 20 drops of brandy with a little water. Two hours after this the dose should be repeated, and again in two hours more if necessary. By the end of the fourth hour there will be generally seen in the movements of the bowels a trace of color, and this will gradually become more marked if the case is to have a favorable termination. Calomel may be used instead of podo- phyllin. As soon as the movements have changed from the pasty-white motions named to those having a bilious color, then, and not till then, are astringents to be employed. If they are used before this, the diarrhoea may become less for a few hours, but the child absorbs poisons from its alimentary canal and rapidly goes into collapse. The rationale of this treatment rests upon the fact that owing to the 604 . DISEASES. disease every gland connected with the alimentary canal has become inactive. It is absolutely necessary to bring about glandular activity, and podophyllin, in the experience of the author, is the best remedy for this purpose. During the period that the podophyllin is acting it is well to apply a spice plaster to the belly or to immerse the child for short intervals in a hot bath to maintain its bodily temperature. In practically every case of cholera infantum it is of the utmost importance to stop milk-feeding absolutely for a few days. Nothing in the way of food may be given except Valentine's Beef Juice, 10 minims (0.60) every two hours with a little cold water, or beef- juice expressed from rare rump steak, until curds and undigested food are no longer found in the stools. After these measures have been resorted to, and the chief object — namely, a bilious stool — obtained, the diarrhoea must be stopped grad- ually. The medicinal treatment should consist in the use of a mixture such as the following for a child of a year or eighteen months : 1^ — Acid, sulph. aromat gtt. xxx (2.0). Tr. opii camphorat f 3hj (12.0). Elixir. curacoss . . . . . . . f3ij (8.0). Aquae cinnamomi q. s. ad f 5iij (90.0). — M. S. — Teaspoonful (4.0) in a little water every two hours. Or, 1$ — Acid, sulph. aromat gtt. xxx (2.0). 01. caryophylli fflviij (0.5). Tr. opii camphorat. f 5j (4.0). Spirit, chloroformi gtt. xlviij (3.2). Syr. zingiberis q s. ad f §iij (90.0). — M. S. — Teaspoonful (4.0) every two hours. If preferred, the tincture of kino or compound tincture of gambir may be substituted for the oil of cloves or the spirit of chloroform, or, again, the fluid extract of hsematoxylon may be taken in the place of either of these. (See Cholera Morbus, next page.) Where the vomiting is very severe and incessant, the purging pro- fuse but free from undigested curds, a rectal injection of starch-water, 2 ounces (60.0), containing 10 drops (0.60), of laudanum, is to be employed, and at the same time J grain (0.01) of gray powder (hydrargyrum cum creta) given every hour if the podophyllin is not well retained. The gray powder may in turn be substituted by ■£% grain (0.005) doses of calomel. Very minute doses of arsenic given by means of the following solution are often of service in checking the vomiting and purging, and should be resorted to if necessary: 1$ — Liq. potassii arsenitis gtt. j vel ij (0.05-0.10). Aquae cinnamomi f oj (30.0). — M. S. — Teaspoonful (4.0) every fifteen minutes until four teaspoonfuls (16.0) are taken. In some cases the remedies named above only check the diarrhoea for the time being, and it returns as soon as they are withdrawn. In such a case the following is of value to restore the lost tone of the parts involved : CHOLERA MORBUS. 605 1$ — Resinae podophylli gr. | (0.03). Liq. potass, arsenit gtt. iij vel vj (0.20-0.40). Liquor calcis f o iij (90.0). — M. S. — Teaspoonful (4.0) every five hours. Shake well before using. Or a powder may be used : r| — Resinse podophylli gr. \ (0.015). Pulv. ipecac. * gr. j (0.06). Sacchar. lact gr. xx (1.3). — M. Ft. in chart. No. x. S. — One powder every five hours. A very important, never-to-be-forgotten measure in cholera infantum is the use of counterirritation over the belly by means of a mustard plaster (1 part of mustard flour to 4 of wheat flour) or by a spice plaster. The plaster should be renewed as often as it cools, and kept on con- tinuously if the skin will stand it. (See Counterirritation.) A remedial measure carried out with great success in cities in the treatment of cholera infantum is the use of irrigation of the bowels, or rather washing out of the colon. This is accomplished by the use of the solution named in the articles on Cholera and Ehteroclysis. The inflow tube should be of soft rubber, like a female catheter. The outflow tube should be larger, in order to carry off particles of food or flakes of mucus. They may be inserted side by side after being oiled. The pressure used should be that of a fountain-syringe raised not more than three feet above the buttocks, and the outflow should be unobstructed. The irrigation may be resorted to every few hours, and continued each time until clear fluid flows away. The solution should, of course, not be too cold nor too hot — say 100° F. (See article on Diarrhoea.) Hypodermoclysis is to be resorted to for collapse. CHOLERA MORBUS. This acute, painful, rapidly exhausting disorder arises from exposure to cold, the ingestion of poisonous or irritating foods, exposure to excessive heat, and a number of similar causes. In reality, it may be regarded in one instance as a gastroenteritis, and in another as an acute serous diarrhoea associated with much pain of a griping, rending character. Nothing compares to counter- irritation for the purpose of affording relief. A large mustard or capsicum draft should be placed over the abdomen and allowed to remain as long as it can be borne. If the patient knows that he has taken irritant foods, \ ounce (16.0) of castor oil with 15 to 20 minims (1.0-1.3) of laudanum added to it, to prevent griping, should be employed to sweep out the offending masses before any other remedies are used, and be followed by an antidiarrhoea mixture, such as here follows : Rf— Acid, sulph. aromat f'oij vel f5iv (8.0-16.0). Extract, hsematoxvli fluid. . . . f 5ij (8.0). Spt. chloroform! ' f oss (16.0). Syr. zingiberis q. s. ad f o iij (90.0). — M. S. — Dessertspoonful (8.0) every two hours. (506 DISEASES. If the pain is very severe, the patient should be given morphine (gr. J [0.015]) and atropine (gr. -jt~o [0.0004]) hypodermically. (See articles on Diarrhoea and Cholera, Asiatic.) CHLOROSIS. (See Anemia.) CHOREA. St. Vitus' Dance is a nervous affection, generally occurring in chil- dren, yielding to treatment quite readily in some cases, and in others remaining persistently severe, and even becoming worse, under the physician's care. The disease is always to be treated by the removal of all sources of reflex irritation, such as worms, a long prepuce if it is irritated by retained urine or smegma, or other trouble of this character, and in the avoidance of punishment or severe rebuke on the part of the attend- ants. This advice is given not because chorea is produced by such irritating conditions, but because they tend to impair the nervous tone of the patient. Except in that form of the disease closely associ- ated with or dependent upon rheumatism, the profession universally employ arsenic in one of its forms as a specific remedy. Generally Fowler's solution is used, and, unless the parents are intelligent enough to drop medicine carefully from a bottle or dropper, the physician should order a 3-ounce mixture (90.0) with 60 minims (4.0) of Fowler's solution, so that each teaspoonful will contain a little less than 3 minims of the drug. Very frequently, to be effective, arsenic must be used in ascending doses, increased 1 minim (0.05) a day, and in consequence the dilution just spoken of is to be avoided, and the importance of care in measuring the pure drug impressed upon the patient's relatives. Whenever arsenic is used the physician should instruct the attend- ants to stop administering the drug if any puffiness under the eyes is seen in the morning on arising from bed, or if any pain in the bowels ensues, as these symptoms show that the full medicinal action of the drug is being felt. When arsenic fails, cimicifuga in the dose of 20 to 30 minims (1.3-2.0) of a fresh fluid extract for a child of ten years may be used as the next best remedy. Where the disease is associated with rheumatism, recent or remote, the salicylates or iodides may be of value, and should be thoroughly tried. In some cases of chorea the muscular jerkings are so severe that sleep is impossible, and the patient has to be held in bed and the bed- covers tied down. These cases will often obtain a quiet night by the use of the hot pack at bed- time. (See Heat.) The child should be placed in a blanket previously dipped in water as hot as can be borne COLIC {HEPATIC). 607 by the patient and thoroughly wrapped up in another (dry) blanket to retain the heat, and then be allowed to sweat. Care must be taken that a heat-stroke does not result, and, if sweating does not come on and oppression ensues, the blanket must be removed. The sheets should be ironed to have them warmed for the patient when she is returned to bed, and it is often better to let her sleep between dry blankets. The efficacy of this treatment is increased by the use of a dose of bromide of sodium or potassium and a little chloral, as follows; 1^— Chlorali hydrati 5j (4.0). Sodii bromid 3 ij (8.0). Aquae dest q. s. adfoiij (90.0). — M. S. — A dessertspoonful (8.0) in water every five hours for three doses. COLIC (HEPATIC). This exceedingly painful condition, due to the passage of a gall- stone through the bile-duct, is always associated with faintness and nausea. The object of the physician must be to relieve this pain, not only by the use of anodynes, but also by aiding in the escape of the stone into the bowel. To relieve the pain a hypodermic injection of mor- phine \ to \ grain (0.015-0.03), accompanied by t Jq grain (0.0006) of atropine, is indicated. The morphine not only decreases the pain, but allays spasm, and the atropine relaxes the spasm of the muscular coats of the ducts and allows the stone to pass through the relaxed passage-way. Hot applications, such as turpentine stupes, may be used over the liver, but relaxation is not to be obtained by the use of nauseating emetics, as the retching or vomiting may rupture the distended gall-bladder. Energetic rubbing should not be used for the same reason. Quite recently the use of olive or cotton-seed oil has been largely resorted to in this affection, and while we are not sure of the manner in winch it acts, the studies of Rosenberg and others point to the chang- ing of the oil into glycerin and fatty acids, the first of which liquefies and increases the flow of bile. Often the large dose of oil causes nausea, and this, by producing general relaxation, may aid in the escape of the stone. The oil is used during the attack of pain, and must be swallowed in the dose of half a pint at least ; smaller quantities do not suffice. Its action may be aided and its retention in the stomach promoted by the addition of a drachm of ether to each dose. Shortly after the oil is swallowed sudden relief often occurs, due to the escape of the stone into the bowel. The stools should then be carefully watched for gallstones, but care should be taken that the lumps of soap wmich are passed, made from the oil by the alkaline juices in the intestines, are not mistaken for true biliary calculi. If the pain does not yield to morphine, chloroform or ether may be inhaled for the relaxation of the spasm and the relief of pain. In the endeavor to render our treatment of a patient with gallstones 608 DISEASES. rational, we naturally study the causes which induce their formation and the manner in which we can expel those stones which have formed before the case has come under proper care, or in spite of any preventive measures which we may have attempted. Unfortunately, we are met at the very beginning of our study by the fact that the physiologist and the pathologist have not as yet discovered the exact characteristics of the general systemic conditions which underlie their formation; but, on the other hand, experimental and clinical studies have developed a number of facts which are of great value. Thus, we now know that there are a number of local causes which distinctly predispose to the formation of gallstone, and that these causes are commonly found in that very class in which the systemic tendency to stone-formation is most marked. In the first place, a catarrhal state of the biliary passages favors the formation of gallstone by providing an excess of mucin, with the aid of which the stone maybe formed; secondly, this catarrhal state is commonly associated with, or produces of itself, a diminished alkalinity of the bile, whereby the cholesterin becomes more readily precipitated, and at the same time, it would appear, causes the deposition of an abnormal amount of lime salts, brought from elsewhere in the body and passed out through the mucous membrane. This latter fact seems proved by the circumstance that bile itself contains very little lime, and that more lime is found in stones lying against markedly catarrhal mucous membranes than in stones not so situated. Again, it sometimes happens that the nidus for a stone consists of agglutinated typhoid bacilli in the gall-bladder or duct. So far, then, we have a simple, pathological process pro- viding no less than three ingredients of stone-formation — namely, mucin, cholesterin, and stearate or some other salt of lime. There are still two other important factors at work — namely, the systemic state, gouty or otherwise, which tends to stone-formation, and the stasis of the bile in its ducts, because the catarrhal process in the mucous membrane blocks its passage toward the bowel. Recognizing these etiological factors, it now becomes our duty to oppose them, and we have the following indications to fulfil: 1. By causing a free secretion of bile to produce a rapid flow of fluid which shall be normally liquid and probably normal in its constituents. 2. By the use of alkalies to antagonize the development of acid ten- dencies and to aid in the solution of mucus. 3. By regulating the diet prevent those hepatic and systemic disorders which tend to the forma- tion of stone. 4. As catarrhal states are often due to or aided by bac- terial infection, to produce intestinal asepsis as far as possible. The normal secretion and flow of bile are best brought about by exer- cise of a gentle and wisely directed nature, taken continually and regularly, and particularly those forms of exercise which call into play the abdominal muscles and diaphragm or cause hepatic movements. The chief and best of these is horseback riding, or, if the patient is too feeble for this, massage should be resorted to, the hypochondrium COLIC {HEPATIC). 609 being well but gently kneaded and rubbed daily for a considerable period of time. If the liver seems very torpid, calomel in small divided doses of a fraction of a grain may be given several times a week, or nitromuriatic acid may be more rarely used. In other instances, where there is reason to believe that the flow is sluggish and the bile not sufficiently alkaline, that catarrh and putrefactive ten- dencies are present, the administration of benzoate or salicylate of sodium, in 10- or 20-grain doses, will result in increasing the flow, increasing the alkalinity, overcoming the catarrh, and then arresting intestinal putrefaction. If the catarrhal process is very marked, chloride of ammonium will act even more satisfactorily. This treat- ment seems especially valuable when the stones that are passed are very dark in color, indicating that much pigment and little cholesterin is present. In respect to the use of alkalies, the patient should drink freely of those mineral waters which will provide alkaline substances, such as Contrexeville, Vichy, and Kronenquelle, and it is useful in many such cases to relieve any tendency to constipation or duodenal catarrh by the administration of hot Carlsbad water before breakfast daily. In the matter of regulating the diet, all rich or fatty foods are to be prohibited. Meat should be used in moderation, preferably white meats, and green vegetables largely eaten. The catarrhal condition, associated with marked bacterial infection, as may be evidenced by some febrile movement, is best controlled by the use of turpentine, chloroform, and ether, given internally, and accompanied by the application externally of hot poultices to the hepatic area. These poultices may or may not be fortified by mustard, and when removed should be replaced by a warm pad to prevent chilling of the surface of the body. Of the internal remedies just named, turpentine is the most useful, since it liquefies mucus, aids the flow of bile, and is thought by some physicians to cause expulsion of the stone by stimulating the walls of the ducts, and to dissolve the stone. The latter action is impos- sible. Nevertheless, its continual use seems to prevent the formation of stone. Ralfe states that it is best given as follows: R— 01. terebinthinsB Itlv (0.30). Syrup, acacise f^ss(16.0). Sodii phenolsulphonat gr. xx (1.30). Spt. setheris composit. . ■ . . . . Tftxv (1.0). Aqua menthse piperitae . . . .q. s. f § j (30.0). — M. S. — To be taken twice or thrice a day. We would prefer adding compound spirit of lavender instead of pep- permint-water. If this mixture cannot be retained by the stomach, the turpentine may be given in capsule, and followed by a draught of milk. Finally, a most important factor in the prevention of gallstone formation in susceptible persons is the avoidance of exposure and wet, and, if possible, residence in a sunny climate during winter months. 39 610 DISEASES. CONJUNCTIVITIS. Simple Conjunctivitis, sometimes called catarrhal, acute, or muco- purulent ophthalmia, is characterized by congestion of the conjunctiva, loss of transparency of the palpebral portion, and some dread of light, with a discharge sufficient only to glue the lids in the morning or free and mucopurulent. In the milder stages the use of a boric-acid lotion (10 grains to the ounce [0.60 : 30.0]) is suitable, and the lids should be frequently washed with neutral soap and water; if there be much mucopurulent discharge, the lid should be everted and an application made of a solution of nitrate of silver (from 2 to 5 grains to the ounce [0.12-0.30:30.0]). If the discharge becomes profuse, bichloride of mercury, 1 : 10,000 may be employed with advantage and the nitrate-of-silver solution increased 10 grains to the ounce (0.60-30.0), the excess being neutralized with a solution of salt or washed away with tepid water. In place of nitrate of silver pro- targol and argyrol are preferable remedies, and may be employed in a strength varying from 5 to 20 per cent., according to the severity of the symptoms. Much inflammatory reaction in this disease may be alleviated by iced compresses. Patients suffering from catarrhal conjunctivitis should be protected from tobacco-smoke, bright light, dust, or any mechanical irritant. Atropine usually is unnecessary unless a corneal ulcer complicates the affection. The patient may wear smoked glasses, but under no circumstances must the eyes be bandaged or have poultices applied to them. Domestic medication of this sort may change a simple ophthalmia into a serious and purulent inflammation. Topical medications other than those mentioned are biborate of sodium (gr. iv-viij to the ounce), alum (4 to 8 grains to the ounce [0.25-0.5:30.0]), sulphate of zinc (1 to 2 grains to the ounce [0.06-0.12:30.0]), which maybe suitably combined with boric acid solution or peroxide of hydrogen. During the subsidence of the inflammation, and if it shows any tendency to become chronic, the application of an alum crystal or a solution of tannin and glycerin (10 grains to the ounce [0.60: 30.0]) is suitable. It should be remem- bered that mucopurulent conjunctivitis may become epidemic in crowded institutions, and great care should be taken to isolate cases. One soiled towel may be the source of infection to a great number of children. Constitutional treatment ordinarily is not required, but proper hygiene, fresh air, good food, the intelligent use of laxatives, and tonic doses of quinine are useful. Conjunctivitis may be associ- ated with nasal catarrh, bronchitis, a general cold, eczema of the face, and the exanthemata. Acute contagious conjunctivitis, vulgarly known as "pink eye," does not greatly differ in its manifestations from ordinary simple con- junctivitis, except that it is more violent and is more apt to be associ- ated with hemorrhages beneath the conjunctiva. As its name indicates, it is highly contagious, and sometimes appears in an epidemic form. CONJUNCTIVITIS. 611 It is due, in the great majority of instances, to the Koch- Weeks bacillus. A very similar form of epidemic conjunctivitis is caused by the pneu- mococcus. The treatment is the same as that already described. A solution of sulphate of zinc, 1 or 2 grains to the ounce, is particularly efficacious. Burns of the Conjunctiva. — Immediately after the accident all foreign particles should be removed; then a few drops of cod-liver oil may be instilled and atropine employed (suitably incorporated with liquid vaselin) to prevent iritis. The chief danger lies in the forma- tion of severe corneal inflammation and symblepharon ; the latter may sometimes be prevented by daily breaking up the granulation- tissue or by the insertion of a piece of goldbeaters' skin between the inner surface of the lids and the eyeball. The associated conjunctivitis and keratitis require treatment differing in no way from that described in connection with idiopathic forms of these affections. Purulent Conjunctivitis, which is commonly seen in the adult in the form of gonorrheal ophthalmia and in the infant as ophthalmia neonatorum, is produced in both varieties by the introduction into the eye of a specific virus from either the urethra or the vagina. The chief danger of the disorder is destruction of the vitality of the cornea and loss of sight. The most important indication is to prevent this danger by reducing the amount of swelling of the lids and conjunctiva and the profuse discharge, which are the characteristics of the disease. These indications are met best in the following manner: Hourly cleansing of the eyes with an antiseptic solution, preferably bichloride of mercury (1 : 8000) or a saturated solution of boric acid. During the acute inflammatory stage, and before the discharge is profuse, astringents and cauterants must not be applied. When this stage has arrived and the conjunctiva is profusely covered with discharge, the lids should be carefully everted once a day, wiped clean of every par- ticle of pus, and carefully touched with a solution of nitrate of silver (10 to 20 grains tothe ounce [0.60-1.30: 30.01), and the excess neutral- ized with a few drops of a solution of common table salt. 'In place of the nitrate of silver treatment in recent times protargol and argyrol have found much favor. The best method is, after each irrigation of the eye, to instil a few drops of the protargol solution (20 per cent.) or of the argyrol solution (25 per cent.) in the conjunctival sac, rather than to diffuse itself over the entire mucous membrane and to remain in contact with it. In the early stages iced compresses frequently changed will help to reduce the reaction, or these compresses may be made by placing squares of lint upon a block of ice and thus securing intense cold. If the vitality of the cornea is threatened, it is advisable, in many instances, to substitute for the cold applications compresses at a temperature of 110° F. These may be applied for from ten to twenty minutes every two or four hours, according to the exigencies of the case. The appearance of ulceration in the cornea calls for the use of atropine. In adults high reaction and 612 DISEASES. violent inflammation may be alleviated by the use of leeches to the temple. Bleeding of any sort is not applicable to newborn infants. Other applications which have met with favor are: alum (grains 4-8 to the ounce), sulphate of zinc (grains 2 to the fluidounce), aqua chlori, cyanuret of mercury (1:1500), permanganate of potassium (1:2000) employed in copious irrigations, formaldehyde (1:3000), argentamin (1 : 5000), and protargol (4-5 per cent, solution, applied to the everted mucous membrane, or a 0.25 to 0.5 per cent, solution used as a collyrium). The preventive method of treating ophthalmia neona- torum that has yielded the happiest results is that instituted by Crede — namely, the dropping of a 2 per cent, solution of nitrate of silver into the eyes of the newborn infant. This method should be employed in all infected cases, and in cases from which the suspicion of infection has not been removed; but it is unnecessarily severe if pre- vious examination has demonstrated the entire absence of infection. Under the last-named condition careful cleansing of the lids of the eye and flushing of the conjunctival sac with a mild antiseptic lotion are usually sufficient. If it is desired to employ nitrate of silver, 1 : 500 is the strength. There is much evidence to show that protargol and argyrol are useful under these circumstances. If one eye alone is attacked, the other should be protected by covering it with a Buller shield, which consists of a watch-glass fixed in a square of plaster, which is applied so that the crystal comes directly in front of the eye, and the plaster covers the surrounding area. Chronic Conjunctivitis may result from an antecedent acute inflam- mation of the conjunctiva or exist as an idiopathic affection, especially in elderly people, in whom it sometimes becomes a troublesome symp- tom, especially if complicating cataract. The characteristic lesions are roughness of the papillae of the conjunctiva, swelling of the caruncle, and soreness of the angles of the eyelids. There are no granulations, although the disease is sometimes inaccurately spoken of as granular lids. A soothing wash is indicated (10 grains of boric acid to the ounce [0.60: 30.0] of water), to which may be added 2 grains (0.12) of cocaine, provided the cornea is not ulcerated, and for which a similar boric-acid lotion with 4 grains (0.25) of salt to the ounce (30.0) may be substituted. A very suitable local application is lapis divinus (sul- phate of copper 1 part, alum 1 part, nitrate of potassium 1 part, fused together, and camphor equal to one-fiftieth of the whole added; the mass is run into sticks, and the application made to the everted lids, or 1 grain (0.06) of the same preparation to the ounce (30.0) of water may be dropped into the eye). Other useful applications are tannin and glycerin (10 grains to the ounce [0.60:30.0]), yellow oxide of mercury salve, and alum crystal. If refractive error exist, this should be corrected. It is to be remembered that chronic conjunctivitis dis- tinctly contraindicates any operative interference in the eye, as, for instance, cataract extraction. There is an interesting form of chronic conjunctivitis, or, perhaps, more accurately, subacute conjunctivitis, CONJUNCTIVITIS. 613 which runs a course lasting from eight weeks to several months, and which is characterized by very slight objective symptoms, that is due to the presence of the diplohacillus of Morax and Axenfeld, and which is promptly cured by the application of a solution of sulphate of zinc, 1 or 2 grains to the ounce. The conjunctival secretion of stubborn cases of conjunctivitis should always be examined for this bacillus. Lachrymal Conjunctivitis is a name given to a chronic form of inflammation of the conjunctiva associated with obstruction in the lachrymal duct, and characterized by a tear-soaked appearance of the eye, small pustules at the roots of the lashes, and a gummy discharge along the palpebral margin. This can be cured only by relief of the stricture of the nasal duct which causes it, but may be alleviated with the same remedies recommended in the treatment of chronic con- junctivitis. Good results are reported from the use of pyoktanin. Follicular Conjunctivitis — a disease sometimes mistaken for granu- lar lids, but having a distinct clinical difference, inasmuch as the swollen follicles are absorbed without the production of cicatricial changes in the conjunctiva — requires for its local treatment weak astringents and antiseptic lotions, and the application to the swollen follicles of an ointment of sulphate of copper (gr. \ to the drachm [0.03 : 4.0]), dusting in calomel either alone or with equal parts of subnitrate of bismuth, or iodoform or aristol used in the same way. If the disease is stubborn, the swollen follicles should be crushed with forceps. This disease, or one analogous to it, is sometimes produced by the prolonged instillation of atropine, and less frequently by eserine and cocaine. If this is its cause, the drug must be suspended and the surface painted with an alum crystal. Granular Conjunctivitis. — This disease may be divided into acute and chronic granulations. In the former astringents and caustics are inadvisable, the eyes requiring weak antiseptic solutions like boric or salicylic acid and the instillation of atropine. Leeches to the temple will aid in reducing the inflammatory reaction. In the chronic disease the object of treatment is to bring about absorption of the granulations which are its characteristic lesion, not by an application so caustic as to destroy the mucous membrane around them, but of sufficient vigor to produce healthy reaction. The following applica- tions comprise those which have been employed with the greatest success: 10-grain (0.60) solution of nitrate of silver, if there is dis- charge, applied once a day with neutralization of the excess ; sulphate of copper in the form of a crystal, carefully applied to the everted lids and the retrotarsal folds; glycerole of tannin (tannic acid 30 grains [2.0], glycerin 1 ounce [30.0]), best applied with a cotton applicator; boroglyceride from 20 to 50 per cent, according to the vigor of the granulations. Strong solutions of corrosive sublimate are employed in the following manner : Solutions of the strength of 1 : 300 or 1 : 500 are painted on the everted lids every second day, the pain of the appli- 614 DISEASES. cation being alleviated by the previous instillation of cocaine, while three times daily the eyes are irrigated thoroughly with a solution of the mercury salt, 1 : 7000. Among the many other applications which may be used in this disease the following may be mentioned: liquor potassa, beta-naphthol, iodoform or aristol in powder or salve, an oint- ment of the yellow oxide of mercury, calomel, and hydrastin. The surgical means which are employed to destroy the granulations are scarification of the conjunctiva, an inadvisable method; excision of the granulations, useful if these exist in isolated groups; crushing the granulations with specially devised forceps, a method often followed by satisfactory results; scarification, followed by a vigorous brushing of the affected tissue with a brush containing short bristles, previously dipped in a strong (1 : 500) solution of corrosive sublimate (Grattage); electrolysis; and excision of the fornix conjunctivae. In long-standing cases associated with inveterate pannus de Wecker has proposed the use of an infusion of jequirity (3 per cent.). This produces an intense membranous conjunctivitis, which must be treated by iced compresses or similar measures to reduce its reaction, but when it has subsided the pannus is often relieved. This method has not been employed in recent times to the extent that it was practised when first introduced, but jequiritol has been tried with reported success. Diphtheritic Conjunctivitis is rare in this country, but on the con- tinent of Europe occasionally occurs as an epidemic. It may appear alone or in association with diphtheria of the throat and nose. The initial subjective symptoms are those of purulent ophthalmia; the characteristic objective symptoms, a board-like infiltration of the lids with a deposit of gray membrane upon the palpebral conjunctiva. More than in any other eye disease destructive inflammation of the cornea is threatened. In the early stages the eye should be frequently cleansed with boric acid or bichloride of mercury solutions, and atro- pine instilled, while hot compresses help to maintain the nutrition of the cornea more perfectly than the cold compresses which were for- merly recommended for antiphlogistic purposes. The constitutional measures for diphtheria are necessary, and the best treatment is the employment of injections of diphtheria antitoxin. Chemosis of the Conjunctiva, in which this membrane is infiltrated with serum, is usually a symptom of other ocular disorders, and sub- sides under the general treatment directed to their relief. Good results may follow nicking the swollen tissues with a pair of scissors, the application of a warm, moist compress, and the use of astringents, especially alum. Hemorrhage beneath the Conjunctiva (subconjunctival ecchymosis) may follow an injury, occur during a paroxysm of whooping-cough, and occasionally, in elderly people, may appear spontaneously. Recur- ring subconjunctival hemorrhages in elderly people are indicative in many instances of renal disease, having much the same significance as hemorrhages in the retina. No treatment materially hastens absorp- CONSTIPATION. 615 tion of the blood, unless it be massage of the globe through the closed lid; any associated conjunctival irritation may call for a boric acid and cocaine wash. CONSTIPATION. This troublesome state depends on a number of causes, the most common of which is the following of a sedentary life, totally devoid of the exercise intended to keep the intestinal and hepatic secretions in an active state. Another frequent cause is simple laziness, which causes the patient to resist the call of the bowel for evacuation until this part of the body becomes indolent and atonic, while modesty often causes constipation in females, because a woman prefers to suffer rather than go to a closet which may be somewhat publicly situated. In other instances constipation seems to be hereditary, and to depend upon deficient nerve-supply or muscular weakness and lack of secretion in the lower bowel, or upon hepatic torpor. Whatever the causes are, they should be sought for, and, if possible, removed, the physician not being content to order purgatives, which, while they may give temporary relief, soon lose their power. Further than this, it must be remembered that hygienic measures always take first place in the method of treatment, and, if possible, drugs should occupy a very secondary role. Particular attention should be paid to diet, and the physiology of peristalsis must be well borne in mind. It has been proved by a large number of studies, both in the normal intestine and by the use of purgatives, that peristalsis is almost entirely a reflex action depending for its existence upon the integrity of the nervous plexuses in the intestinal walls — namely, those of Auerbach and Meissner — the first of which are situated between the longitudinal and circular muscular fibres which they supply, the latter existing in the submucosa and supplying the walls of the villi, the glands of Lieberkiihn, and the small arteries and venules. It has also been found that the vagus nerve, when stimulated reflexly or directly, increases peristalsis, and that moderate stimulation of the splanchnic nerve decreases it. 1 It at once becomes evident that any decrease in the normal activity of these nerves and nerve-centres must speedily result in constipation, and the costive condition conse- quent upon hepatic torpor is due to the fact that the intestinal walls do not receive the proper stimulation from the bile to set in motion a reflex peristaltic wave, the result of which will be evacuation. This fact rests upon the results of direct experiments, which prove the bile to be primarily an intestinal stimulant, antiseptic, and promoter of secretion. Other series of experiments have shown that the circulation of the blood through the intestines greatly influences peristalsis, and disorders in the blood-supply readily bring on intestinal disorder. 1 Some persons believe that Meissner's plexus receives impulses from the walls of the intestine and transmits them to the motor plexus of Auerbach, which then sets in motion peristalsis. 616 DISEASES. The deductions to be drawn from these facts are many. In the first place, it is evident that the maintenance of an active, normal circulation of blood in the abdomen and a free pouring out of bile from the liver and gall-bladder are necessary to a healthy peristalsis; and we find that, aside from drugs, there are a number of remedial measures which may be resorted to according to the means of the patient. By far the best of these is horseback exercise for at least an hour a day or every other day, which by the motion actively stirs up and excites the abdominal viscera as no other measure can do. If for any reason horseback exercise is impossible, then abdominal massage, carried out by a capable " rubber, " is to be tried, the hands following more particularly the course of the ascending, transverse, and descend- ing colon, the kneading movements being also applied to the hypo- chondriac regions. If neither of these measures can be used, then the patient must resort to those gymnastic movements which involve the abdominal muscles, either by the use of dumb-bells or pulleys, such as are sold under the name of "home gymnasiums," or by bend- ing the body forward, backward, and laterally, with the fists pressed into the hypogastrium. At the same time that these measures are directed the diet of the patient must be so regulated that the food shall contain a large amount of residue — that is, after digestion enough of the husk of the grain or enough vegetable fibre must be left free in the intestines to form a stimulus to the intestinal wall as it slips over the mucous membrane. If a meat diet is largely used, so little residue is left after digestion that constipation ensues, but if vegetables are largely eaten the reverse is the case. No better evidence of this can be adduced than the hard, clay-like passages of the dog and the soft passages of the cow. Very often a plateful of cracked wheat (wheaten grits) eaten at breakfast each morning, or the use of bran bread, will relieve a tendency to chronic constipation. In these cases milk as a prominent article of diet is to be avoided above all things, since it is almost entirely assimilated and leaves no residue, though it supplants other foods. Green or canned corn is of great service. Fruits do good in constipation in one of two ways — they contain either residual materials or sufficient vegetable acid salts to be laxative. Figs, by reason of their many small seeds, which scrape the mucous membrane during peristalsis, are particularly valuable, and apples, prunes, dates, and tamarinds are all useful. It must be remembered that strawberries, raspberries, and blackberries are generally constipating rather than purgative. In regard to drink, nothing is so good as a glass of cold water taken on arising in the morning or just before breakfast, or, if the cold can- not be borne, then a glass of as hot water as can be swallowed with comfort may be substituted. Coffee is constipating to most persons, largely because of its empyreumatic oil, and tea has the same tendency because of its tannic acid. Brandy, as every one knows, is distinctly constipating, and whiskey possesses so little power to the contrary as CONSTIPATION. 617 to be devoid of influence in either direction. Beers differ in their properties, some of them increasing and some of them decreasing intestinal activity. The patient suffering from constipation should go to stool regularly after breakfast every day even if the attempt is abortive, and so train the bowel to having a movement at this time. The use of drugs for the relief of constipation is capable of division into two parts: first, the employment of remedies to unload the bowel, which has become filled; second, the use of drugs which will so influ- ence the intestines as to cause evacuation and produce normal activity, or, in other words, drugs which will cure the tendency instead of giving temporary relief. Of the first class we find the various pur- gative salts, jalap, colocynth, senna, mercury, castor oil, and rhubarb; of the second class, aloes, cascara sagrada, manna, tamarinds, rhamnus frangula (buckthorn), phosphate of sodium, and small doses of podo- phyllin. The physician should bear in mind that defecation is a nor- mal physiological act which must be continued all through life, and it is almost as foolish to stimulate the bowel continuously to peristalsis as perpetually to employ heart stimulants or respiratory excitants. Although habitually employed by many persons in daily doses, the purgative salts if given in concentrated form are exceedingly harmful in such instances, rapidly losing their power and decreasing the patient's strength by the abstraction of liquids and salts from the blood. They often produce anaemia when constantly used. These salines are to be employed simply to unload the bowel when an excess of fecal matter has accumulated or when irritant materials are to be swept out of the alimentary canal. In some cases of pelvic conges- tion associated with constipation magnesium sulphate may be given by enema in the proportion of 2 ounces (60.0) of the salt, 1 ounce (30.0) of glycerin, and 4 ounces (120.0) of water. In other instances, where great plethora exists, a course of Hunyadi water, Friedrichshall or Carlsbad waters, which depend chiefly upon magnesium and sodium sulphate for their activity, is of service. When used habitually they should be diluted with hot water and given half an hour before breakfast. The patient should then take some exercise before taking food. Jalap, colocynth, and senna are not to be used constantly, as they are too active and the reaction from their effects causes consti- pation. Rhubarb is commonly used, but is of its class peculiarly unfitted to its task. Although it purges, it is distinctly astringent, and is therefore constipating afterward. Mercury is exceedingly harmful if used continuously as a purge, and may be the cause of much ill-health, of decayed teeth, and of digestive troubles. Castor oil is notorious for its tendency to cause ultimate constipation. Of the curative class of laxatives none compares to cascara sagrada, particularly in the form of the aromatic fluid extract or cascara cordial. Originally this drug, as prepared, was very bitter, but it is now made 618 DISEASES. almost tasteless by certain manufacturers. This is the only drug which alone moves the bowels and at the same time tends to make future passages more easy and regular; the dose is 10 to 40 minims (0.60-2.60) of the fluid extract or 1 to 6 drachms (4.0-24.0) of the cordial. There is almost no griping produced by it. For the regula- tion of the bowels of young children, particularly if the case have a tendency to rickets, phosphate of sodium in the dose of 5 to 10 grains (0.30-0.60) in milk is a useful laxative, and the same salt may be used in 30- to 60-grain (2.0-4.0) doses in adults. Manna is to be classed as a laxative, but even it sometimes makes the intestinal torpidity ultimately much worse. The two remaining drugs of this class, aloes and podophyllin, should always be used in combination with other non-purgative drugs, as is seen in the following formulae : K— Aloes gr. xx velxl (1.3-2.6). Extract, nucis vomicae gr. iv (0.25) Extradt. physostig gr. iij (0.20). Extract, belladonna? gr. iv (0.25). — M. Ft. in pil. No. xx. S. — One pill at night or night and morning. Or, Be — Resinse podophylli gr. ij vel iv (0.12-0.25). Extradt. nucis vomicae gr. iv (0.25). Extract, physostigmatis gr. iij (0.20) Extract, belladonna gr. iv (0.25). — M. Ft. in pil. No. xx. S. — One pill night and morning. The object of using several of these drugs is seen at a glance. We have already learned that nearly all purgatives tend to produce griping. The nux vomica acts as a bitter tonic and stimulant, and prevents subsequent atony of the mucous membrane, as well as increases reflex action, and consequently improves peristalsis; the physostigma is a tonic to the unstriped muscular fibre and gives it strength; the bella- donna aids peristalsis by depressing the inhibitory fibres of the splanch- nic nerves, by allaying spasm, and by decreasing griping. In using these drugs, aloes and podophyllin, it should be remembered that aloes is slow and acts particularly on the lower bowel, and that podophyllin acts chiefly on the upper bowel and is the slowest in the list of purges. In obstinate constipation we are sometimes forced to resort to the compound cathartic pill of the U. S. P., or its modified form known as the Pilula cathartica vegetabilis (see Colocynth). After the bowels have been well emptied by this pill we can often regulate them by cascara sagrada with or without other laxatives, and by prescribing a proper diet and exercise. In the flatulence of old persons associated with constipation a little asafcetida or capsicum should be added to the pill of aloes just named. In some instances constipation arises from reflex irritation or from ovarian or bladder trouble or from chronic lead poisoning. This form of constipation may resist all purgatives and yield to opium or to COBYZA {ACUTE). 619 tobacco, which quiets reflex action. Tobacco depresses the inhibitory nerves of the gut, and devotees of the " weed" often smoke it for its laxative effect. The employment of enemata as a routine practice is to be discour- aged. In cases where it is necessary to use them for temporary relief and to get rid of flatulence, a little soap, common salt, or a few drops of turpentine may be added to the water. The injection of glycerin (1 to 2 ounces [30.0-60.0]) has been largely resorted to, either pure or diluted one-half, and this method has been improved upon by the use of glycerin suppositories containing many drops of the drug. Glycerin acts in these cases as an irritant to the mucous membrane, and causes secretion by this means and by its abstraction of water from the tissues by reason of its hygroscopic powers. It is capable, however, of causing a good deal of rectal irritation in some persons. CORNS. These troublesome formations are best treated by the use of sali- cylic acid, the following formula being applied night and morning for several days, after which the part should be well soaked in hot water, when the entire corn will readily come away, but in some cases several attempts will be necessary: 1^ — Acid, salicylic gr. xxx (2.0). Extract, cannab. indicse gr. x (0.60). Collodii f gss (16.0).— M. S. — Apply with a camel's-hair brush. The same acid may be used in alcohol, and lactic acid in the same proportion is often of service. In the so-called "soft corns," with much inflammation, the foot should be washed and dried, and a saturated solution of nitrate of silver, 60 grains (4.0) to 2 drachms (8.0) applied to the part every four or five days. CORYZA (ACUTE). The treatment of coryza of the acute variety, the form which most frequently presents itself to the physician for relief, is followed in many instances by such marked amelioration of the symptoms and shorten- ing of the attack as to encourage medical interference. It must be remembered, however, that the duration of the condition before the patient presents himself has much to do with the prognosis, for if the tissues of the nasal chambers have become boggy and swollen with exudate recovery must be more delayed than if remedies are applied in the early stages of the catarrhal process. The local treatment con- sists in the following measures for relief: By means of a medicine- dropper or an atomizer a few minims of a 4 per cent, solution of cocaine are dropped into the nostrils, the patient's head being well tipped back. If there is any contraindication to cocaine, adrenalin 1 : 10,000 may 620 DISEASES. be used in many cases. After the constringing influence of the cocaine has shrunken the congested mucous membrane, so that the patient can draw air through the nostrils, the nasal chambers should be washed clean of mucus by means of the following lotion in an atomizer: 1$ — Sodii chloridi gr. xv (1.0). Acid, boric gr. x (0.60). Sodii borat gr. x (0.60). Aqiuedest f^iij (90.0).— M. The parts being thoroughly cleansed, a fine spray of the following should be used as antiseptic, sedative, anaesthetic, and protective: 1$ — Menthol gr. viij (0.5). Camphor gr. v (0.3). Albolene f 5j (30.0).— M. In this prescription the menthol exerts an anaesthetic effect, and pro- longs the constriction of the parts produced by the cocaine, so avoiding the secondary capillary dilatation due to that drug. The camphor exercises its well-known soothing influence, and the albolene protects the membrane from dust and irritants. It is well to use a solution of antipyrin 2 to 4 grains to the ounce (0.12-0.25 : 30.0) of water as a spray to prolong the effect of the cocaine. The albolene spray should follow, not precede, the antipyrin, as the oil would prevent the antipyrin from acting. Under no circumstances should the antipyrin be used without the cocaine preceding it, as the pain is too severe. The internal treatment consists, in the very beginning of the attack, of the use of the formula for this purpose composed of belladonna, camphor, and quinine, and recommended in the article on Camphor. Much benefit often follows the use of 30-grain doses (2.0) of sodium bicarbonate every two hours for three doses. A hot foot-bath, with mustard in it, and the taking of a hot drink, such as lemonade with whiskey in it, on going to bed, are useful. Often 20 or 30 minims (1.3-2.0) of sweet spirit of nitre added to this drink will increase its diaphoretic effect. In other cases, particularly in strong, hearty men, 5 to 10 grains (0.3-0.60) of Dover's powder at bed-time will be better. This line of treatment is of little value after secretion has been fairly established, and in its place supportive measures are indicated. Small tonic doses of quinine, 2 to 4 grains (0.12-0.25) three times daily, some- times combined with the use of 5 to 10 grains (0.3-0.60) of chloride of ammonium, as prescribed in the article on Bronchitis, are useful. Where much headache is present full doses of the bromide of potas- sium or sodium are to be given, and the spray treatment already named for the purpose of cleansing the nasal chambers is to be per- sisted in while the attack lasts, but the cocaine ought not to be employed at this time unless absolutely needed. (See Camphor.) CYSTITIS {ACUTE). 621 CROUP. (See Diphtheria.) CROUP (SPASMODIC). As this is a spasm of the glottis depending for its causation upon catarrh of the mucous membrane of the larynx, and as it is due most commonly to some reflex irritation, such as dentition, indigestible food, or sudden atmospheric changes, or to rhachitis, or to the presence of postnasal adenoids, the treatment is both prophylactic and curative. Prophylaxis consists in the avoidance of cold; the use of a simple diet, particularly at the evening meal ; the rendering of the air of the bed- room moist by means of steam, or at least by the avoidance of dust- laden, furnace-heated air, and by the removal of dental irritation and nasal hypertrophies, which make the child a " mouth-breather." Iron and arsenic are useful tonics if the child is anaemic and rachitic. Much relief can be provided such patients by having them sleep in a "bronchitis tent." (See article on Bronchitis.) Small doses of the bromides, chloral, belladonna, or opium may be resorted to at bed- time. A very useful prescription for this purpose is that which follows : P^— Sodii bromidi 3j (4.0). Syrupi lactucarii fgij (60.0).— M. S. — Teaspoonful to a dessertspoonful (4.0-8.0) on going to bed, and once or twice during the night if needed. When the attack is present, a cold cloth should be wrapped about the neck and the child placed at once in a hot bath, the air of the room being moistened by the steam escaping from a kettle of boiling water or by pouring water upon unslaked lime. If the paroxysm is very severe, a few whiffs of amyl nitrite may be employed. It is also useful to disseminate the fumes of menthol through the air of the room by heating some crystals in an iron spoon. If the fumes are strong enough to produce a distinct odor, they are present in sufficient amount. CYSTITIS (ACUTE). If, by reason of exposure to cold, injury, the introduction of foreign bodies, such as dirty catheters, or the presence of gonorrhoea or other disease due to an infection, an acute inflammation of the bladder ensues, it is accompanied by a sensation of weight and vesical fulness, by pain, tenesmus, and inability to retain the urine. Sometimes the last-named condition may be reversed and retention of urine be present. If the general system responds to the local inflammation, as evidenced by increased arterial excitement and fever, aconite in full doses of the tincture should be used, and it should be combined with small amounts of sweet spirit of nitre and citrate of potassium, as follows: 622 DISEASES. -r 1$ — Tinct. aconiti . f 3 iij (12.0). Spirit, aether, nitrosi i'oj (30.0). Liquor potassii citratis . . . q. s. ad f§vj (180.0). — M. S. — Dessertspoonful (8.0) every four hours until all fever ceases and the pulse is quiet. At the same time a hot compress should be applied over the bladder, but it should not contain turpentine or any irritant substance which may be absorbed from the skin and when eliminated by the kidneys irritate the bladder-walls. Leeches may be placed upon the perineum or cups applied to the region of the sacrum. In some cases belladonna may be used with or without aconite in the dose of 5 to 10 minims (0.30-0.60) of the tincture three times a day, and it is worthy of note that this drug is particularly serviceable in cystitis due to cold. If the urine is acid and irritating, 5 minims of liquor potassse every four hours, or the citrate or acetate of potassium, may be used. If there is much pain and bearing-down, an enema of 30 minims (2.0) of deodorized laudanum in 2 ounces (60.0) of starch- water may be employed, or the opium may be given in suppository. Sometimes a belladonna suppository is of more service, and an iodoform suppository will often relieve the pain by its local anaesthetic effects. Hot enemata, without any drugs, are often valuable as a means of relief, and a hot sitz-bath is very efficacious. Cannabis indica, if an active preparation can be had, may be better than opium in some cases to relieve the pain, since it seems to aifect the bladder favorably. The other curative measures are hygienic, and consist in maintenance of the recumbent posture, absolute physical and mental rest, avoidance of all foods which are stimulating, as rare meats and highly seasoned dishes, and abstinence from all varieties of alcoholic beverages. Should the inflammation be severe enough to become purulent, the physician should order phenyl salicylate in the dose of 10 grains (0.60) three times a day. This drug, being broken up in the bowel into phenol and salicylic acid, is so eliminated that it renders the urine antiseptic; or in other instances, if the urine is alkaline and phos- phatic,hexamethylenamine (urotropin or uritone) in the dose of 5 to 10 grains (0.30-0.60) should be given in capsule after food or drink three or four times a day. Laxatives are to be employed with persistence if the bowels are confined, and saline purgatives in the early stages are generally better than vegetable purges. Quinine should not be used against the fever, as it is contraindicated, owing to its irritant effects upon the bladder. CYSTITIS (CHRONIC). The treatment of chronic cystitis is entirely different from that of the acute form, and consists in the use of remedies which will stim- ulate the diseased mucous membrane, cause a normal secretion of mucus, and so influence the urine that the mucus already formed will * CYSTITIS {CHRONIC). 623 be passed out and the fluid rendered alkaline or acid, as may be desired. When the secretion of mucus in large amount is persistent, the urine should be rendered alkaline by the use of liquor potassse or the citrate of potassium. The bitartrate of potassium, unlike the other vegetable salts of potassium, such as the acetate or bicarbonate, is eliminated as the bitartrate of potassium, and, as it is acid, cannot be employed. We acidify the urine when it is necessary to dissolve the phosphates and to prevent deposits in the bladder and elsewhere. The three best drugs for this purpose are hexamethylenamine (urotropin or uritone) in the dose of 5 grains (0.3) three or four times a day, boric acid in the dose of 5 to 10 grains (0.30-0.60), or benzoate of ammonium 10 to 20 grains (0.60-1.3) three times a day. The rule may be laid down that if the urine is high-colored and is strongly acid, alkalies are use- fid ; whereas if it is light in color, but loaded with phosphates, urotro- pin or uritone should be employed. Hexamethylenamine or urotropin, uritone, or phenyl salicylate may be given to prevent decomposition of the bladder contents. The remaining remedies which are employed internally in chronic cystitis are those which are directed to the improvement of the mucous membrane of the bladder, and consist of buchu in the form of the fluid extract in the dose of h to 1 drachm (2.0-4.0), well diluted; arbutin or ursin, 3 to 5 grains (0.20-0.30) ; or the fluid extract of uva ursi, dose 30 minims to 1 drachm (2.0-4.0). All of these are better fitted for the treatment of subacute than chronic cystitis, as they are not sufficiently active for the chronic forms. In cystitis of a very chronic type, with great vesical atony, strychnine is of service, and drop-doses of tincture of cantharides do great good. Turpentine may also be used with advantage in 5- to 20-minim (0.3-1.3) doses, as may also the oils of eucalyptus, sandalwood, cubebs, and copaiba. One of the best measures for the relief of chronic cystitis is to irrigate the bladder daily with pure warm water or water containing bichloride of mercury in the proportion of 1 : 10,000, as this washes away all mucus and uric-acid deposits and prevents irritation. Solutions of nitrate of silver have been used with great success where the urine is mucopurulent, and Thompson recommends the use of a solution of the strength of 1 grain to 4 ounces (0.06 : 120.0) of water, gradually increased to 2 grains to the ounce (0.12 : 30.0). Others, such as Gard- ner, Richardson, and Potter, recommend the use of stronger solutions, 5 grains to the ounce (0.30 : 30.0) of water, claiming that while these amounts may produce serious effects in some instances, they are very efficacious in obstinate cases. The physician should have at hand a solution of common salt, which he should inject into the bladder at once if the effect of the silver solution is too painful or seems excessive. This treatment is suited only to the most chronic cases. A weak solution of mercurol and a saturated solution of chloretone may also be used with advantage. 624 DISEASES. All these measures are suitable for the treatment of cystitis in the male and female, but it is to be noted that injections into the female bladder are made much more readily than into that of the male, because of the shortness of the female urethra. In either case the operation is best performed by attaching a small funnel to a soft-rubber catheter and filling the bladder by raising the funnel when full of water above the patient's belly. Creolin has been highly recommended by Parvin in the strength of from 1 to 2 per cent, with water. The irrigation is to be performed every twenty-four hours. DIABETES INSIPIDUS. Diabetes insipidus is a profuse urinary flow dependent upon some disorder of the innervation of the kidney or upon atony or relax- ation of this organ. Its treatment consists in the use of astringents and tonics, and in some cases in the employment of opium or bella- donna, particularly if the oversecretion is due to nervous irritability. Gallic acid may be used in 20-grain (1.3) powders three times a day, and the fluid extract or wine of ergot is often of service given in the dose of 30 minims to a drachm (2.0:4.0) of the former or a wine- glassful (30.0) of the latter. As tonics the sulphate of iron and strych- nine are indicated. Suprarenal gland may be employed with advantage in some cases. DIABETES MELLITUS. In the treatment of this affection it should be remembered that it is the result of disordered function, and is not a disease in itself, but a symptom of several disease-processes. For this reason a remedy which succeeds in one case may fail in another. The treatment of diabetes mellitus is both dietetic and medicinal, of which the more important part is the diet since diabetes is a state of the body in which the system is unable to utilize properly the carbo- hydrate portions of the food, and as a result sugar is passed out in the urine. Glycosuria, or the mere presence of glucose in the urine, is not diabetes, although if it is constant it may be the early stage of the disease. Manifestly, both of these states are to be treated by decreasing the intake of those articles which will produce glucose, namely, the starches, and therefore the carbohydrates are to be greatly cut down in all antidiabetic diet-lists; but changes in the diet should be very gradually instituted, since sudden cutting off of certain articles may cause marked nutritional disturbance. In a certain number of patients it is possible for them to make glucose out of proteid matters, and therefore even a total abstinence from starch does not cause the sugar to disappear from the urine, for the sugar is then made from meat food or from the patient's tissues. This does not occur with fats, and for this reason these are important articles to the diabetic. We must prescribe fat meats, and, contrary to old teaching, order rich milk DIABETES MELLITUS. 625 instead of skimmed milk. The following articles should be allowed: 1 Meats of all kinds (except liver), eggs, fish, cheese, butter, and cream; oyster-plant, asparagus (?), tomatoes, almonds, pecan nuts, butternuts, walnuts, and cocoanuts; string-beans, beet tops, radishes, mushrooms, lettuce and water-cress, cauliflower, spinach, and onions. Celery and cucumbers may also be permitted. Of the foods and drinks to be avoided, we have all forms of sugar, all forms of starch, such as ordinary flour, cornmeal, arrowroot, sago, tapioca, oatmeal, barley, carrots, beets, parsnips, pie-plant, peas and beans, chestnuts, and most of the fresh fruits, cider, beers, champagne, sweet wines, and honey. A useful artificial milk will be found described in Part III. The patient should have a diet so arranged as to give all the calories he needs without starch, and this may be accomplished if he takes daily 2 ounces (60 grammes) of butter, 2 eggs, 2\ drachms (10 grammes) of olive oil, 1 ounce (30.0) of fat cheese, 1 quart (960 c,c.) of milk, and 1 ounce (30.0) of alcohol. This will give the man 1600 calories and he needs but approximately 2400 to 3000, which can be obtained by additional food. The treatment of diabetes by drugs is varied by the condition of the patient, the cause of his disease, and the quantity of sugar in the urine. While the drugs most commonly employed are used in many instances without any knowledge of how they act, and have each of them warm supporters among authorities, much of the treat- ment must depend upon whether or not a rheumatic or gouty taint is the cause of the trouble, or whether it is due to high living and little exercise, producing a plethoric, congested, overloaded system. In the first class of cases iodide of potassium and the salicylates will be most serviceable; in the second class, a restricted diet, moderate exer- cise, and purgation to relieve engorgement of the hepatic and gastric veins may be needed. In the cases of gouty diabetes, where relief does not follow the use of the iodides and colchicum, resort must be had to arsenic and lithium citrate or carbonate, a combination pecu- liarly adapted to such a condition according to several authorities. Indeed, arsenic is a sheet-anchor with many practitioners in all forms of diabetes, and should be given in fairly large, constantly repeated doses for a long time. A very much larger body of medical men rely on opium or one of its alkaloids, such as morphine or codeine. The former is used in the dose of \ to \ grain (0.015-0.3) three times a day; the latter, 1 to 5 grains (0.06-0.30) three times a day, and the writer has found them very useful. The morphine is by far the most powerful for good. Patients who are diabetic must take large ascend- ing doses of opiates, which they bear very well. (See article on Opium.) The chloride of gold and sodium (y 1 -^ grain [0.006]) has been highly 1 It is worthy of note that certain persons having a slight glycosuria without serious injury waste under a limited diet, and require ordinary fare to support the body plus the diabetic drain, 40 026 DISEASES. recommended by Bartholow, and ergot by Wood and Da Costa. In cases depending upon a gouty diathesis the use of salicylic acid is often of great value, the dose being 10 to 15 grains (0.60-1.0) three times a day. In those cases of diabetes in which diet will control the disease the best clinicians insist that drugs should be avoided, for when opium or any of its alkaloids are used it is necessary to give rapidly increasing doses, which finally become enormous, as much as 7 grains (0.45) of morphine a day being taken by some persons. Once having begun the use of drugs in severe cases, it is very dangerous to stop them, for clinical experience has shown that many of these patients waste rapidly and generally break down when this is done. In regard to the time of day at which to give the morphine or codeine, they are gen- erally given about one hour after meals. Under these circumstances the drugs seem to decrease diuresis more than if the dose precedes the meal; further than this, the stomach is not disordered. In some cases results will be obtained from opium when its individual alka- loids fail. Careful observation of the patient should be carried out to determine the proper beginning and subsequent doses, and if at first the opiates fail to give relief discouragement .should not be felt. Jambul is a remedy which has been widely used by clinicians for the relief of diabetes with such varying results that its position in therapeutics is uncertain. This is probably because it is effective in one form of diabetes and not in another, and we are unable to make the clinical distinction. Jambul is used in powder or the powder is placed in capsules or pills. The dose is 5 to 30 grains (0.3-2.0) once to thrice daily, and gradually increased. As much as an ounce (30.0) has been given in twenty-four hours. This medicament is said to be advantageously combined with a pure meat diet in diabetic cases. The excessive thirst of diabetes can be best allayed by the use of acidulated water or alkaline waters containing non-purgative salts. It is useless to cut off the water-supply, to the production of great suffering, but the patient should use moderation in drinking so far as possible, because the overloading of the stomach tends to disturb digestion. The wasting coming on in diabetes is to be treated by careful diet, rest, and the supply of all the food which the patient can digest. In many instances the amount of aliment ingested is extraordinarily large, while in others digestion is so impaired that food cannot be freely taken. If cachexia comes on, iron, strychnine, bitter tonics, and the lacto- phosphates of lime and sodium are to be used to support the circulatory and nervous systems. Tea and coffee and all forms of food needing sweetening may be rendered palatable by the use of saccharin or of glycerin. The former passes through the body unchanged; the latter increases the glycogen in the liver, but checks the formation of sugar. Unfortunately, we have no positive knowledge as to the causes DIARBHCEA AND D YSENTER Y. 627 of diabetes, and in consequence cannot explain the manner in which opium, codeine, or other drugs produce relief. Diabetic coma is a most dangerous complication of this disease, and should be treated as actively as our knowledge of its cause permits. It is thought by some that the symptoms are entirely dependent upon the presence in the blood of oxybutyric acid, and that hypo- dermoclysis or the intravenous injection of normal saline solution (7 : 1000) should be resorted to. Stadelman insists upon the employ- ment intravenously of 150 c.c. of normal salt solution to which 7.2 gm. of sodium carbonate and 4.6 gm. of sodium bicarbonate have been added. The injection is continued until the urine is alkaline. Unfortunately, the statistics of this method of treatment are not good so far as permanent recovery is concerned, but some form of transfusion should be used. (See Transfusion.) As the condition is a typical toxaemia, a full dose of sulphate of magnesium or sulphate of sodium should be given, to aid elimination by the bowels if they are loaded with feces. Otherwise purgatives should not be used, as they con- centrate the blood. Hypodermic injections of ether should be resorted to to support the heart. In severe cases of diabetes in which coma is feared because of a sudden increase of acetone in the urine or in which mild premonitory drowsiness is present, bicarbonate of sodium should be given in full doses, as much as J to 1 ounce (16.0-30.0) a day. This treatment should be instituted whenever the urine gives the characteristic reaction for acetone with perchloride of iron. DIARRHOEA AND DYSENTERY. 1 Diarrhoea is a term loosely applied, perfectly correctly, to all forms of intestinal disturbance accompanied by the passage of liquid stools, and its meaning, "to run through," expresses the state it represents. The treatment of each form of diarrhoea depends upon its cause, and no case can be intelligently treated in which the physician fails to recognize this aspect of the case. Diarrhoea is but a symptom, not a disease, and must be regarded solely as an evidence of intestinal disorder. While the same drugs are prescribed in many forms of the trouble, we may divide cases of diarrhoea into four classes, as follows : (a) those in which the laxity is due to a catarrh, acute or chronic, of the intestinal mucous membrane, causing the passages to contain mucus; (b) those in which, owing to disordered innervation, a profuse outpouring of liquid takes place from the bloodvessels into the intes- tinal lumen; (c) those in which, owing to disease, the glands fail to prepare juices to digest the food properly; and finally (d) those cases in which ulceration causes irritation and bloody purging. 1 The articles on Cholera, Cholera Morbus, and Cholera Infantum should be carefully read in connection with this article. 628 DISEASES. The treatment of the catarrhal form first named consists primarily in regulation of the diet, which should be made up chiefly of milk, boiled or predigested, or of milk whey, and in the administration of castor oil or other mild purge, such as sulphate of magnesium, to sweep out fermenting food and mucus. Enough laudanum should accompany this oil to prevent griping, and it is well to add bicarbonate of sodium, grains 20 to 30 (1.3-2.0) to the dose, both to aid the action of the oil and to render the bowel alkaline in reaction (normal) instead of acid, as caused by the fermentation abnormally present. A mustard plaster or other counterirritant should be applied to the abdomen. Often in the milder forms of mucous diarrhoea this is all that is needed, but more frequently it must be followed by the use of tonics and astringents, such as nitrate of silver and hyoscyamus, in the following pill: 1$ — Argenti nitratis gr. ij (0.12). Extract, hyoscyami gr. v (0.3). — M. Ft. in pil. No. x.*^ S. — One three times a day. Or, 1$. — Plumbi acetatis gr. ij (0.12). Extract, opii gr. ij (0.12).— M. Ft. in pil. No. x. S. — One three times a day. If these stop the diarrhoea, yet there still seems to be a tendency for it to return or atony is present, we should use a pill containing the extract of chiretta or employ nitromuriatic acid, or, better still, dilute nitric acid and compound tincture of cardamoms, because the constant tendency to relapse indicates a deficient secretive action on the part of the intestinal glands, which these remedies are prone to improve: 1^— Acid, nitric, dil foj (4.0). Tr. cardamomi comp f§ij (60.0). Tr. gentian, comp f gij (60.0). — M. S. — Dessertspoonful (8.0) every four hours. In the second form of diarrhoea named — that in which serous or watery purging is present — the treatment is radically different. In these cases the bloodvessels of the gut are relaxed and leaking, and must be contracted and made water-tight. This dilatation may result from fear (" nervous diarrhoea"), from exposure to cold, or from exhaustion, extreme heat, and irritant food. If from irritant foods, they are generally swept out in the first flush of liquid. The measures to be adopted consist in those directed to the con- traction of the dilated and relaxed bloodvessels and the restoration of the proper nerve-supply to the parts. As the splanchnic nerves are the vasomotor nerves of the intestine as well as the inhibitory nerves of peristalsis, it is evident that drugs must be used which will cause stimulation of these fibres, and the chief of these is found to be opium, which diminishes intestinal per- istalsis and secretion by just such an influence. In the same way DIARRIKEA AND DYSENTERY. 629 small doses of volatile oils are of service, and camphor and spirit of chloroform may be used. As there is relaxation, astringents are indi- cated; and as sulphuric acid is not only astringent, but is eliminated by the lower bowel, it is peculiarly serviceable. We find, therefore, that the following prescription fulfils every indication: R — Acid, sulph. aromat. Olei cajuputi Fluidext. hsematoxyli Spt. chloroformi Syr. zingiberis . . . f3ss(16.0). . . . gtt. xl (2.60). . . . f^ij (8-0). . . . fziv (16.0). q. s. ad fgiij (90.0).— M. S. — Teaspoonful (4.0) in water every two or three hours. If desired, kino or gambir may be used in lieu of the hsematoxylon, or the oil of cloves substituted for that of cajuput. Camphor or paregoric may also supplant these drugs: 1$ — Acid, sulph. aromat f ojss (6.0). Spt. chloroformi i'oij (8.0). Tr. opii camphorat f §ij (60.0). Syr. zingiberis q. s. ad f §iv (120.0). — M. S. — Dessertspoonful (8.0) in water every two hours. Or, I$— Tr. kino f 5j (30.0) Tr. gambir comp f 5 j (30.0). Misturse cretse f oiij (90.0). Aquae cinnamomi . . . . q. s. ad f §vj (180.0). — M. S. — Shake well before using. Tablespoonful (16.0) every three hours. In some instances these attacks appear to depend upon hepatic disorder, and the only cure, aside from partial relief, is to be obtained by the use of 2 to 6 grains (0.12-0.40) of mercury with chalk (hydrar- gyrum cum creta) or calomel, given in \ to \ grain (0.01-0.03) doses until 1 or 2 grains (0.06-0.12) have been taken. What is said of intestinal disorder from lack of secretion under the heading of Cholera Infantum applies very forcibly to these cases, and diarrhoea may persist for weeks, or only temporarily be held in check by the most powerful drugs, until the physician thoroughly flushes the intestine with bile by the use of calomel. For the purpose of establishing intestinal antisepsis, phenyl salicy- late may be used, and naphthalen, thymol, or other drugs of this class may be employed, particularly salicylic acid. In other cases phenol- sulphonate of zinc in the dose of from 1 to 4 grains (0.06-0.25) in powder or capsule is beneficial. Phenyl salicylate combined with chalk mixture may also be advantageously used. (See prescriptions under Salol.) Eudoxin, one of the new bismuth salts, is also of value. It is doubtful if true intestinal antisepsis can be produced by drugs ; and if they can, they probably destroy useful benign organisms as well as those which are malignant. Wood has highly recommended the use of a bismuth powder con- taining a minim or two of phenol. The regulation of the diet, which should consist in sterilized milk 630 DISEASES. or koumyss, the former being predigested, is of the greatest impor- tance. The after-treatment consists in the use of tonics and a carefully regulated diet, which should be largely composed of milk and milk foods. The third class of cases consists chiefly of children who pass fetid, "mousy" smelling stools in summer diarrhoea, with green, spinach- like masses of semidigested food or distinct lientery. These cases may be due to deficient glandular action in any part of the alimentary canal, and are often cured by the use of pepsin and hydrochloric acid to aid the gastric processes. In other instances the duodenum is at fault, and should be stimulated by small doses of nitromuriatic acid ; or by podophyllin in the dose of -fo to ■£$ grain (0.0012-0.0015), with a little milk-sugar, or given in alcoholic solution. Similarly, ipecac in powdered form may be used in the dose of \ to J grain (0.015-0.03) three times a day. In the case of children who are sufferers from rickets, phosphate of sodium, lime-salts, and common salt should be freely given. (See Cholera Infantum.) The fourth type, generally known as dysentery, is due in nearly all cases to the micro-organism of Shiga, to the drinking of impure water, exposure to heat or cold and the use of improper food. It is in most cases a very obstinate form of diarrhoea, requiring much skill and patience for its cure. There are three remedies which are far above all others in value and should always be resorted to. The first of these is sulphate of mag- nesium with sulphuric acid; the second is calomel; the third ipecac. The magnesium salt should be used in a special manner to be effective. (See Magnesium Sulphate.) If calomel is used, it must be given in full purgative amounts, but is contraindicated if much weakness is present. The third remedy, ipecac, is never to be forgotten. (See Ipecac- uanha.) If Flexner's studies are completed, it is probable that an effective antidysenteric serum will be discovered. If the passages are slimy and bloody, ¥ io" grain (0.0003) of bichloride of mercury every hour or two is of service, and if much blood is present high rectal injections of hamamelis water and water half and half are of value. In some forms of dysentery, due to acute inflammation, large enemata of iced water are of the greatest value. The water should be ice-cold, and at least a quart injected by hydrostatic pressure. This method can only be used in strong persons, and is very useful in that it also aids in reducing any fever which may be present. The following mixture may be injected into the bowel in place of cold water in feeble cases : Ifc— Sodii boratis 3j (4.0). Tinct. benzoin f oj (4.0). Spt. camphorse f oj (30.0). Aqua? ferventis Oij (960 c.c.).— M. DIAREHCEA (CHRONIC). . 631 If the ulcers are very old and chronic, nitrate-of-silver injections of the strength of 10 to 20 grains (0.60-1.3) to the pint (480 c.c.) of water may be employed in large bulk, a salt solution being at hand for the precipitation of the silver salt if the local action which ensues is too severe. . Recently the injection of water or medicaments into the bowel for the purpose of influencing the intestinal wall has given way to irri- gation by means of an inlet and an outlet tube. The inlet tube should be attached to a fountain syringe, and the outlet tube be long enough to reach to a vessel by the side of the bed, and of sufficient calibre to carry off flaky mucus. In many cases of dysentery of a mild form rectal irrigation will suffice, but if the entire colon is involved higher injections are necessary. The irrigation should be continued until the returning fluid becomes perfectly clear and free from foreign particles. If the bowel movements are very frequent, the injections may be made every three hours. Probably the best solution to employ for irrigation where much mucus and pus is present is one of bichloride of mercury, 1 : 5000. When this is used, a pure water injection or one of 1 : 30,000 should follow it, in order to prevent absorption of too much mercury into the system. If for any reason the effect of the bichloride is feared, boric acid may be used in the proportion of 1 drachm (4.0) to the pint (480 c.c), or 15 grains (1.0) of phenolsulphonate of zinc added to 1 quart (960 c.c.) of hot water be injected. If the dysentery is due to the amoeba coli, large rectal injections of a solution of quinine in the proportion of 1 : 3000 should be used, as this drug destroys that organism. (See Enteroclysis, in Part III.) Tannic acid is an intestinal antiseptic, and can be employed in the strength of 1 drachm to the pint (4.0 : 480 c.c.) for irrigation purposes. DIARRHOEA (CHRONIC). 1 This is one of the most obstinate conditions which the physician is called upon to treat. It may be due to nervous irritability of the bowels, so that the entrance of food or drink sets up an excessive peristalsis which so hurries the food and drink through the alimentary canal that digestion and absorption are imperfectly performed. Chronic diarrhoea may also be due to chronic intestinal catarrh, to ulcerations of the small or large intestine, as after typhoid fever, or to rectal dis- ease, which reflexly causes hyperperistalsis. Fissure of the anus often causes persistent diarrhoea by reflex irritation. In those cases due to hyperperistalsis an advantage is often gained by directing the patient to take as little liquid as possible, particularly at meals, and to avoid coffee or other stimulants to reflex activity. Highly seasoned foods are also to be avoided. Meats should be preferred to vegetables, and 1 Read with this article those on Diarrhoea and Dysentery and Enteroclysis. 632 DISEASES. an absolute diet of peptonized milk may be ordered, the milk being given in tablespoonf uls every few minutes, rather than in large amounts. The patient should remain in bed. Gounterirritation, constant and as severe as the patient can stand, should be used over the abdomen. Suppositories and rectal injections seldom benefit this class of cases, but a pill composed as follows may be useful: H— Argent, nitratis gr. iv (0.25). Ext. hyoscyami gr. x vel xxx (0.60-2.0). Ext. opii * gr. ij vel iv (0.12-0.25). — M. Ft. in pil. No. xx. S. — One pill one hour before each meal. This pill should be coated with phenyl salicylate so that it will pass through the stomach before dissolving. In other instances some of the astringent prescriptions given under the article on Diarrhoea are better than the above. If the catarrhal state is persistent, no remedy compares to the chloride of ammonium, dose 5 grains (0.3) every four hours in liquorice and water. Where the catarrhal state is exceedingly chronic and obstinate it is well to employ 3- to 5-grain (0.20-0.3) doses of potas- sium iodide. In many cases where the condition of mucous diarrhoea becomes chronic it is necessary to resort to enteroclysis (Part III.) and the treatment needed in cases of chronic intestinal catarrh. (See Diarrhoea, Chronic.) In the cases due to ulcers of the rectum injections of nitrate of silver 2 grains to the ounce (0.12 : 30.0) are of value, particularly if followed by a 5- or 10- grain iodoform suppository. Operative pro- cedure against anal fissure will often cure a diarrhoea due to this cause. In cases of so-called morning diarrhoea abstinence from liquids before going to bed the night before and a very dry and small break- fast are to be strongly recommended, with rest in bed during the morning hours. Rockbridge Alum water, which contains iron and alum, is useful in cases of diarrhoea with anaemia. DIPHTHERIA AND MEMBRANOUS CROUP. Diphtheria is at first a distinctly local disease, the membrane in the upper air-passages forming a nidus from which the entire body ulti- mately becomes poisoned by the toxins of the micro-organism peculiar to the malady. While it is true that in some cases of membranous pharyngitis or laryngitis the true Klebs-Loeffler bacillus cannot be found, it is a fact that all cases should be treated as if they are true diphtheria, since in this way much good can be done, and no harm follows if the malady fails to develop. The best local application to the throat is peroxide of hydrogen. A cotton swab should be soaked with the undiluted 10- or 15-volume solution and pressed against the mucous membrane which is diseased; PLATE IV, III u Showing the Effect of Antitoxin on the Local Diphtheritic Process. The figures on the left show the gradual increase of the false membrane from the first to the thirty-sixth hour. The figures on the right show the disappearance of the membrane during the next thirty-six hours as a result of the use of antitoxin. DIPHTHERIA AND MEMBRANOUS CROUP. 633 or, if this cannot be done, a spray, from a glass atomizer, of the strength of 1 : 4 of water may be employed. The effect is often extraordinary. After a few applications the false membrane appears to exist only in disorganized shreds. If the nasal chambers become affected, a tepid solution of odinary salt (7: 1000) should be used in a spray or by means of a fountain syringe. The child is placed with its hips on the lap of one nurse and its head on the lap between the knees of another, the dress of the nurse being protected by a rubber sheet, and the nasal cavities irrigated. The position of the child should be on its side, not on its back, and the face should be turned down sufficiently to allow the liquid, after entering the upper nostril, to flow out the lower one with ease, the child breathing through its mouth. The applications should be made as frequently as the membrane forms. Antitoxin Treatment. — This treatment excels all others in efficacy and usefulness, and should displace all other plans of treatment except the local applications. Of all the extraordinary advances made in pathology and therapeutics, the introduction and proof of the value of antitoxin in cases of diphtheria are perhaps most worthy of note, (For the study of Antitoxin itself, see Antitoxin, in Part III.) There are several facts in connection with the use of the diphtheritic antitoxin which should be borne in mind. The syringe for injecting it should have a glass barrel in order that any foreign bodies or air-bubbles can be seen and removed before the injection is given. The packing of the piston should be made of asbestos or rubber, since it is practically impossible to sterilize leather or other packing; and the different parts of the syringe should be easily disjointed in order to permit thorough cleansing and sterilizing. Immediately before and after the use of the syringe the needle should be removed and the cap taken off so that the sterilizing fluid may readily enter the syringe and needle, and then they should be placed in warm water which is brought to the boil- ing-point. By this gradual heating breaking of the glass barrel is avoided. It is best to employ one of the syringes made for the purpose. The injection is to be given slowly into any part of the body which has loose subcutaneous tissues, such as the broad of the back, the side of the abdomen, or the outside of the thigh. The skin at the place of injection should be thoroughly sterilized beforehand, and after the injection the fluid should be allowed to diffuse itself and not be spread by rubbing. At the present time some manufacturers of antitoxin put up their product in hermetically sealed bulbs, or in special containers from which the serum may be directly injected without the use of an extra syringe. The advantage of this plan is that the physician is saved the trouble of sterilizing a syringe and can use a fresh piece of apparatus for each injection. (See Figs. 109 and 110.) The dose of antitoxin serum is to be judged by its known strength or power of conferring immunity and by the severity of the disease and the susceptibility of the 'patient. Not less than 4000 units should be 634 DISEASES. given as an initial dose and be repeated in twelve hours. The dose should be repeated every six or twelve hours in severe cases, and doubled in amount in very malignant cases or in those with deeply seated cervical induration or laryngeal or nasal diphtheria. Small doses are not required by young children. The fact that they suc- cumb more quickly to the disease than older children makes a large dose necessary. It has been urged against serums containing over 250 units per c.c. that their use is apt to be followed by untoward effects such as skin eruptions and local irritations. On the other hand, if the weaker serums are employed, such large amounts have to be given that very considerable swelling of the area in which the injection is given is pro- duced, and, of course, valuable time is lost before the whole dose is Fig. 109. Fig. 110. I L^ > ^rz^^dZD £ 33a o== Fig. 109 shows an antitoxin container from which the antitoxin is expelled into the subcu- taneous tissues by means of a rubber bulb. At the other end a sterile hypodermic needle is attached. Fig. 110 represents another form of container shaped like a syringe. In it is a piston into which is screwed a rod Avhen the antitoxin is to be used. At the other end is attached a needle for the injection after the cup is removed and the glass tip is broken. absorbed; whereas if serums containing high immunizing power are employed, the small dose is quickly absorbed. In urgent cases of nasal or laryngeal diphtheria the stronger serums are indicated, whereas in the more moderate cases the lower grades of strength may be used. Professional opinion the world over is strongly in favor of the use of antitoxin in diphtheria. So far there have been published an immense number of reports and statistics concerning its use, and it is a fact that the use of antitoxin is of the greatest value. Whereas the average death-rate without antitoxin varies from 25 to 65 per cent, according to the severity of the epidemic, with the use of anti- toxin it falls as low as 16 or even 8 per cent. The author cannot too strongly urge upon the reader the vital DIPHTHERIA AND MEMBRANOUS CROUP. 635 importance of using antitoxic serum early and freely. The reports in which it has been condemned are imperfect and unreliable. It has been claimed by some persons that since the use of antitoxin more cases of complications or sequelae are met with than ever before. The reason is manifest, viz., that before antitoxin was used all the very malignant cases died, whereas a large percentage of these are now saved, and suffer from lesions which if antitoxin had not been used would have been fatal. Every patient who apparently suffers from the disease should receive this remedy, so potent for good and so lacking in harmful qualities even when given to non-diphtheritic persons. The physician who can obtain the serum and does not use it is not doing the best thing for his patient. Much depends upon the early use of the remedy, for after degen- erative changes have taken place in the heart and kidneys the damage is done. Statistics show that in cases which receive the antitoxin on the first day the mortality is often only 3 to 5 per cent., whereas with each day of delay the percentage rises, so that when it is not given till the fourth day the mortality is as high as 40 per cent. As the use of antitoxin does no harm, it should be employed in all doubtful cases of diphtheria without waiting for a bacteriological diagnosis. When the antitoxin is given, general improvement usually takes place in twelve to thirty-six hours, and the temperature falls. The spread of the membrane is arrested and its separation soon begins. Although the use of antitoxin for immunizing purposes when persons have been exposed to infection has been resorted to, it is not practised by the general body of the profession to the extent that it should be. The use of 1000 normal antitoxin units will usually pro- duce immunity for three or four weeks. Full doses of antitoxin of the higher potencies sometimes give rise to pains in the joints or to an erythematous eruption, which are without danger and need not excite alarm. The only new local application which promises much is that of Loeffler. He directs that the mucous membrane shall be carefully wiped off by a pledget of cotton, and after this is done that a second pledget dipped in the following solution shall be pressed against the diseased area for ten seconds at three-hour intervals: menthol 2\ drachms (10 grammes) dissolved in 9 drachms (36 c.c.) of toluol, to which are added 1 drachm (4 c.c.) of liquor ferri chloridi and absolute alcohol 2 ounces (60 c.c). This solution, if kept in a dark glass bottle, well stoppered, will keep for months. The author prefers to use per- oxide of hydrogen in all cases, as it is efficacious and painless, whereas the application of Loeffler's solution is apt to be very painful. The local use of iodine, phenol, and similar irritating and poison- ous substances is not justifiable. Great care as to the prevention of the disease is needful. All cases should be carefully isolated ; children who have been exposed should be quarantined for fourteen days; persons in perfect health who have 636 DISEASES. been nursing such patients should also be quarantined, for in the secretions of the throat diphtheria bacilli may be carried by an appar- ently healthy nurse to another patient. The nurse and physician should therefore gargle with saline solutions and follow this by anti- septic mouth washes, using the greatest cleanliness as to the hair, hands, face, and clothing. The maintenance of the patient's strength during an attack of diphtheria is of great importance. Simple, easily swallowed, and easily digested food should be freely given, and plenty of water pro- vided to allay thirst and flush the kidneys of poisons. Milk, pre- digested or plain, is useful, as is also properly made beef -tea (see Feeding the Sick); soft eggs, etc., are to be given; and if swallowing is difficult because of soreness or paralysis, then we must feed by the use of the soft-rubber nasal tube, inserted through the nasal cavities into the pharynx after being well oiled with albolene. (See Gavage, Part III.) Such a method of feeding may be resorted to in cases of inability to swallow arising from paralysis and consequent regurgi- tation; in coughing which prevents swallowing, as in tracheotomy cases; and in the vomiting which sometimes follows swallowing, but often does not follow nasal feeding. It is best to use throat applica- tions before giving the food, in order to avoid vomiting. Feeding by the rectum may also be resorted to, and hypodermoclysis is not to be forgotten for the purpose of supplying fluid to the tissues. Tincture of the chloride of iron, quinine, and strychnine are of service to keep the kidneys active, to stimulate the heart and respira- tion, and to support the vital forces. The dose of the tincture of iron may be as much as 2 minims (0.1) every hour to a child of four years. Steam set free in the air of the room is very useful as an adjuvant to local treatment, and the bronchitis-tent may be used in laryngeal cases. A method of using turpentine by inhalation was highly recommended by J. Lewis Smith. The following prescription is placed in water in the proportion of 2 tablespoonfuls (30.0) to a quart (960 c.c.) , and this mixture is then placed on a gas or oil stove in a broad, open vessel and allowed to boil constantly. The air of the sick-room is soon laden with the vapor, which is not offensive. The prescription is as follows: R— Phenol., Olei eucalypti aafgj(30.0). 01. terebinthinae '. fgviij (240.0).— M. S. — Use as directed. Label: Poison if taken internally. In other cases there is no doubt that calomel by sublimation does great good. The child is placed in a bronchitis-tent and from 45 to 75 grains (3.0 to 5.0) of calomel are placed in a sublimator and gradually vaporized into the air the child breathes. When the glands of the neck threaten to suppurate, ice-bags should be applied to the throat and pieces of ice held constantly in the mouth, while the tincture of iron is pushed in as full amounts as possible. DROPSY. g37 If suffocation is imminent, inhalations of oxygen are to be used and atropine or strychnine employed, but intubation or tracheotomy is usually the safer plan of treatment. Chlorate of potassium has been used purely empirically in the treat- ment of this disease, but it should never be given internally, as the kidneys are already overburdened, and this drug is not only useless when so given, but is in addition a renal irritant. Although the author has been criticised for this last statement, he is convinced of its truth. DROPSY. Dropsy is to be regarded as a symptom (not as a disease in itself) which may arise from many causes, such as cardiac, pulmonary, or renal diseases, or it may depend upon obstruction, from various causes, to the normal flow of the blood and lymph through the vessels and tissues. Its existence is dependent upon so many causes of a still more indirect nature that it is almost impossible to notice all of them, but the following consideration of the subject will at least make clear some of the reasons for its occurrence and indicate the means which are to be taken for its relief. At the very start we are confronted by facts which seem para- doxical, but which are in reality quite reconcilable. These are, that low arterial pressure predisposes to dropsy, and that high venous pressure does likewise, or, in other words, that the cause of exudation on one side of the circulation is its prevention on the other. The explanation of these statements lies in a thorough under- standing of the physics of the circulatory system and its anatomical structure. It will be remembered that dropsical exudation takes place from the capillaries, and that the integrity of the walls of the bloodvessels and lymphatics depends upon normal nutrition, or, in other words, upon a proper blood-supply. As a consequence, dropsy may be due to poorly nourished vessels as much as to any other cause. The force exercised upon the column of blood as it is driven out by the heart into the aorta may be considered as the chief support of the capillary circulation, so that if the heart be weak the pressure falls in the arteries, and in consequence the rapidity of flow is de- creased in the capillaries, while, on the other hand, an increased cardiac activity hastens the capillary circulation. As the arterial pressure and force depend not only upon the heart force, but also upon the tonicity of the arteries which carry the blood-stream, it becomes evident that dilated arteries must lower blood-pressure even if the heart be strong, although practically the heart and vasomotor system generally fail or increase in tone together. We find, there- fore, that a weak heart or a relaxed artery tends to cause stagnation of the blood in the capillaries, and, having found that such stagnation is productive of exudation, it is not difficult to understand why low arterial pressure aids in the development of dropsy. 638 DISEASES. Having shown this to be true, let us turn to an explanation of the fact that a high pressure in the veins is productive of the same changes. Here the normal pressure is almost nothing, being much less than in the arteries, and considerably less than in the capillaries. The result of this is, that in health the blood flows rapidly from the high pressure of the artery to the low pressure of the vein, and passes through the small veins under a gradually decreasing pressure until it reaches the heart. Any obstruction to this venous flow must increase the venous pressure, and, the venous pressure being increased, the rapidity of flow through the capillaries must be decreased. The whole subject may be made more clear by the following example: Suppose that two iron tubes are connected at the ends by several lines of rubber tubes (the capillaries), and that water is flowing into the first tube, or the artery, under a pressure which is represented by the figure 100, while the resistance to the flow in the second tube, the vein, is represented by the figure 0. It at once becomes evident that the rapidity of the flow through the connecting rubber tubes will be very great, whereas if the pressure in the first or arterial tube is decreased to 50, the rapidity is decreased to one-half, or if the pressure in the second tube be increased to 50 instead of remaining at 0, the same changes will occur; in either instance capillary flow is lessened and exudation is caused. This is a crude explanation of what may be called the mechanical pathology of dropsy. There can be no doubt that even more important causes are altera- tions in the vessel walls and in the constitution of the blood-serum as to salts. In cardiac disease dropsy is due to a weak heart being unable to supply the arteries with enough blood to maintain the normal pressure, or to a damming-up of blood in the venous system as the result of the imperfect emptying of the cardiac cavities. In the first instance low arterial pressure produces dropsy; in the second, high venous pressure has a similar effect. 1 In renal troubles the dropsy depends more upon the lack of proper nutritive processes in the capillary walls and upon changes in the blood and blood-pressure than upon other causes. If the kidney is diseased, it may not be able to eliminate the proper quantity of liquids, which accumulate and finally escape into the tissues, while the same failure in renal function causes disease of the bloodvessels themselves, and often produces cardiac complications. Hepatic troubles cause dropsy by producing pressure upon the large bloodvessels going to the liver, and, in consequence, the exudate is generally confined to the lower limbs and abdomen. If the hepatic trouble be severe, some failure in the nutrition of the bloodvessels and changes in the quality of the blood may ensue. Pulmonary disease rarely causes dropsy unless the venous pressure 1 For an explanation of these changes in the action of the muscles, valves, and cardiac action in heart disease, see the article on Heart Disease, DROPSY. 639 is greatly increased and productive of cardiac dilatation, or, as in phthisis, where the changes in the nutrition of the body involve the bloodvessel walls and the blood. Having spoken of these causes of dropsy, it remains to con- sider its treatment, which may be divided into two parts — namely, that directed to its removal after the liquid is poured out, and its relief or cure by direct attention to its causes. The means for the removal of the fluid are suitable to all cases, be the cause what it may, unless the dropsy be of renal origin. Whenever an accumulation of liquid takes place in the tissues, drugs or measures must be resorted to which will cause the emunctories of the body to get rid of it. We may employ elaterium in the dose of \ grain (0.01), or elaterin in the dose of -%~w g ram (0.003), placed in the mouth and washed down by a little water, or the compound jalap powder may be re- sorted to in the dose of 20 to 30 grains (1.3-2.0), and to it may be added, to increase its efficiency, 15 grains (1.0) more of bitartrate of potassium than the official powder contains. These two remedies are particularly serviceable in renal dropsies, since the elaterium is supposed to aid in the elimination of urea by the bowel, while the cream of tartar in the jalap powder increases the action of the kidneys. The cream of tartar is not to be employed in cases of acute nephritis. Compound extract of colocynth may be employed in the dose of 5 to 15 grains (0.3-1.0), according to the state and idiosyncrasy of the patient. All these remedies relieve dropsy by causing so great an outpouring of liquid from the bloodvessels of the intestine that the liquids in the tissues are taken up by the depleted bloodvessels to replace the loss through the action of the purgative. In other words, these purgatives render the alkalinity of the blood greater by concentration, and absorption of fluid occurs by reason of the following physiological and physical facts: As is well known to every physiologist, the passage through a blood- vessel of a salt solution of less than 0.7 per cent, causes an abstrac- tion of salts from the surrounding tissues by the circulating fluid, in order that the amount of salts in the vessels and tissues may be identical. At the same time the tissues become infiltrated with liquid. On the other hand, if the solution be stronger than the normal, the liquid leaves the tissues to enter the vessels, and the tissues in consequence shrink. When salines are given to relieve dropsy, they must be admin- istered in concentrated or saturated solution and on an empty stomach, total abstinence from the drinking of water being insisted upon until they have fully acted, for the reasons given in the last paragraph. For this reason they should be given an hour or so before breakfast. If these directions are not followed, this method of treatment is useless. (See Magnesium Sulphate.) 640 DISEASES. The other means which we possess for the removal of dropsy are by way of the kidneys and skin. If the kidneys are hopelessly dis- eased, that pathway is almost useless; but if they are only passive or partly inactive, diuretics may be used to stimulate their secreting structure and to increase the leakage of liquid through them by increas- ing blood-pressure. Such patients should be placed almost entirely on a milk diet, and many of them will greatly improve under the use of buttermilk to the exclusion of other nourishment. If this cannot be taken, sugar of milk may be employed as an active diuretic. (See Sugar of Milk.) Often the kidneys will be found inactive because, owing to conges- tion from cardiac trouble, they cannot act. Under these circumstances digitalis, in 5- or 15-minim (0.30-1.0) doses of the tincture, given three times a day, will be of value, and its efficacy will be increased by the addition of 1 minim (0.05) of the tincture of cantharides if the renal lesion is exceedingly chronic or mere torpidity exists. Digitalis and squill, in pill form, as follows, may be used: Py— Pulv digital. . . . gr. xx (1.3). Pulv. scillse gr. xx (1.3). — M. Ft. in pil. No. xx. S. — One every five hours. Or digitalis and calomel may be employed in pill form in renal and cardiac dropsies. Apocynum cannabinum is also a useful drug in this state. (For another useful formula see article on Heart Disease.) Caffeine is also a useful diuretic, particularly in torpidity of the kidney, as it stimulates the secretory epithelium, thus eliminating urea and other effete matters, and increases the passage of liquids by the increased blood-pressure which it produces. That a large amount of liquid may be gotten rid of through the skin under the influence of heat is well known. (See Heat, Part III.) In addition to external heat pilocarpine has been used by the mouth or hypodermically in localized dropsies, to produce absorption and con- sequent elimination of liquid by sweating. No drug should ever be given hypodermically in dropsy of a general character, as it will not be absorbed from the water-soaked tissues with any rapidity, if at all. The chief means of relief to be resorted to in cases of ascites istapping. Efforts to remove effusions in the peritoneal cavity by medicinal measures are rarely followed by success. In reality, tapping is far less heroic treatment than purgation, and the old theory that it is dangerous has been disproved. It has been found that tapping not only removes the fluid, but may in some unknown manner pro- duce a permanent cure after from one to twenty or more operations. In performing tapping, the patient is to be placed in a sitting or semi- recumbent position, and directed to evacuate his bladder, so that there will be no danger of this viscus being injured by the trocar. The skin of the abdomen in the middle line one or two inches below the umbilicus is next benumbed by salt and ice held against it. The DYSMENORRHEA. 641 physician then takes a trocar and canula, at least four inches long, and pushes it through the abdominal wall until by the decrease in resistance he knows its point has entered the abdominal cavity. It is well to have a broad abdominal bandage placed around the belly, so that an assistant by pulling on its ends may support the belly-walls when relaxed by the escape of the effusion. As a rule, not more than one-half or three-fourths of the liquid should be removed at one sitting, as its entire removal may be followed by collapse. The value of iodide of potassium in cases of ascites is not to be forgotten, but it must be given cautiously if renal disease is present. Where the tenseness of the skin in the lower extremities causes danger of local sloughs, several free incisions for the escape of the liquid should be made, the limbs being encased in sterilized absorbent cotton to absorb the liquid. DYSENTERY. (See Diarrhoea.) DYSMENORRHEA. The existence of dysmenorrhea depends upon so many conditions that the treatment employed in one case is seldom productive of success in the next. This is not the place for a consideration of the surgical measures adopted for the cure of this symptom, and only the medical treatment will be spoken of. When dysmenorrhcea results from the taking of a cold, and is accompanied by uterine congestion and irritability, the following measures are particularly valuable, and may do good in many cases depending upon other causes: The patient should take a hot sitz- bath, and immediately get into bed as soon as the buttocks are dried, being well covered while in the tub and afterward by a blanket. A turpentine stupe is now to be used (see Turpentine), and 10 grains (0.60) of Dover's powder to be administered unless an idiosyncrasy toward opium is known to exist, when a half or a fourth of this amount may be employed. Often when the attack is accompanied by consti- pation a purgative dose of Epsom salt is of service. If the pain is persistent and severe, a belladonna suppository, of \ grain (0.03) of the extract, may be inserted into the rectum, or in other cases belladonna ointment smeared over the os uteri will be found of service. The latter method is generally impracticable and is rarely resorted to. Very commonly belladonna tincture, by the mouth, is of service in relaxing the spasm of the cervix and of the uterine fundus. Some practitioners resort to the use of opium at each epoch, and keep the patient partially narcotized until menstruation is passed. This is unjustifiable and born of ignorance and bad practice, since the physician is simply dodging effective treatment of the trouble 41 642 DISEASES. and predisposing the patient to future attacks by reason of the consti- pation and the resulting habit which is almost sure to appear after the repeated employment of opiates. When the dysmenorrhea is due to obstruction of the cervical canal by organic changes or flexions, these conditions must, of course, be relieved before a cure can be expected, and the medical treatment can be directed only to alleviation of the pain. Divulsions or slow or rapid cervical dilatation should be carried out by the use of instru- ments. In neuralgic dysmenorrhea, dependent rather upon nervous dis- order accompanying menstruation than upon menstruation itself, measures directed to the improvement of the nervous system and the nutrition of the patient are necessary. (See Rest Cure.) These cases generally occur in nervous, anaemic women run down by excessive dancing or other gayety or by the bearing and care of a large family of children. A course of strychnine or quinine and iron in small doses is often beneficial in these cases, and horseback exercise between the men- strual periods, out-of-door life, and avoidance of excessive dancing and exhausting exercise are to be ordered. Cannabis indica and gelsemium are often of great service, both as cures and alleviators of the pain, and antipyrin, acetanilid, and similar drugs may be resorted to while the attack lasts if it be neuralgic. Sometimes bathing the loins, between the periods, with alternate dashes of hot and cold water may do good in atonic patients. In other cases a hot vaginal douche at the onset of pain may give relief. When the pain seems to be greater than the patient can bear, enough ether or bromide of ethyl should be given by the physician, by means of inhalation, to produce the primary stages of anaesthesia; but chloro- form is not advisable, as the patient, if taught its value by the medical attendant, may resort to this dangerous drug without advice and die from an overdose. DYSPEPSIA. (See Indigestion.) DYSPNCEA. Shortness of breath, or dyspnoea, arises from asthma, cardiac weak- ness, abnormal innervation resulting in cardiac palpitation, from the accumulation of fluids in the chest, from the involvement of the lungs by any disease process in such a way that respiration becomes im- paired, or it is produced by indigestion, or, finally, by the encroach- ment on the lungs or chest- walls of morbid growths. It may also be due to uraemic or diabetic toxaemia. Each of these states must be removed to effect a cure, but it is only of the relief of the symptoms that we will speak. EARACHE. 643 In old persons who suffer from dyspnoea the result of bronchor- rhcea, where a large amount of liquid fills the bronchial tubes and shortness of breath follows exertion, strychnine is the best remedy. Its value depends upon its powerful influence over the respira- tory centres, on which it acts as a stimulant; and as these cases very commonly also have dilatation of the right side of the heart, with consequent cardiac enfeeblement, strychnine is of additional service through its influence upon the circulation. These individuals are not to be given opium or its alkaloids or any sedative drugs, as such medicines, while giving temporary relief from cough, only serve to depress the respiratory apparatus and cause an accumulation of liquid mucus in the chest as a result of the prevention of cough and expectoration. The cases in which opium, or morphine, does good are those in which, through nervousness or functional nervous disorder, the respiratory cycle is imperfect, and, above all, in those instances in which dyspnoea occurs as the result of cardiac disease. In these cases the attacks of oppression and suffocation can often be entirely prevented by the use of \ to \ grain (0.008-0.015) of morphine, given every night or each night and morning. If these doses fail, larger ones may be cautiously used. Hyoscine, instead of causing sleep, nearly always makes these cases worse. Sometimes a little carbonate of ammonium is useful as a respiratory and cardiac stimulant in cases of dyspnoea. Dry cupping applied over the back of the chest may also be service- able when shortness of breath from cardiac or pulmonary trouble is present. In cases of dyspnoea due to emphysema and pulmonary inflam- mation of a chronic type, or in those persons who take cold on the slightest exposure, particularly after attacks of asthma, arsenic is useful if continuously employed. If pleural effusion be present, relief of a positive and lasting nature can only be obtained through aspiration, or, in other words, by the operation known as paracentesis thoracis. EARACHE. Earache may arise from a great number of causes, all of which are, practically speaking, inflammatory. The pain may be the result of acute or chronic inflammation of the middle ear, with a serous or purulent exudate, or of furunculosis of the external auditory canal. In other cases an eczema of this part is very painful. The treatment of an acute earache is systemic and local, the former being based on the general rules governing the management of inflammatory processes, the latter according to the area involved and the cause of the trouble. Cardiac sedatives are indicated, but quinine is distinctly contraindicated, as it tends to cause aural con- gestion. In the general treatment several leeches may be placed in 644 DISEASES. Fig. 111. front of or behind the ear, and heat in a dry form is to be applied to the head on the side affected, by means of a hot-water bottle or water- bag. Poultices, oil and laudanum, and similar applications are not to be re- sorted to, as they may ultimately produce too extensive suppuration, and they do not always give even temporary relief, but tincture of belladonna and tinc- ture of opium in equal parts carefully warmed may be dropped in the ear in the dose of 5 to 10 minims (0.30-0.60) when necessary. A very efficient means of relieving the pain is to irrigate every hour or two the ear by means of a fountain syringe with normal salt solution, used as hot as can be borne. (Fig. 111.) If a cold in the head is present, and with it acute myringitis, it is important to establish a free opening through the nostrils, particularly if the middle ear also is involved, in order to clear the orifice of the Eustach- ian tube. This is to be accomplished by dropping into each nostril adrenalin chloride (1:5000 solution) or 1 to 3 minims (0.05-0.20) of a 4 per cent, solution of cocaine, and, as soon as the engorged mucous membrane is anaesthetic and shrunken, to use the following solution in an atomizer with a fine spray attachment : Aural irrigator. 1^ — Acid, boric. . Sodii chlorid. Sodii borat. . Aq. rosse . . S. — Use as a spray. q. s. ad gr. x (0.60). gr. xij (0.8). gr. x (0.60). fgiij (90.0).— M. This should be followed by a spray of menthol and albolene, 3 grains to the ounce (0.20: 30.0), in order that the menthol may prolong the effect of the cocaine and prevent secondary congestion. This is to be followed by inflation of the Eustachian tube with a Politzer air-bag. Only in most obstinately painful cases of acute middle-ear catarrh is paracentesis of the drum to be performed. Should true septic otitis media develop and drainage of the middle ear become impossible through blocking of the Eustachian tube, then the physician must very gently irrigate the external auditory canal with as hot water as can be borne, and render it aseptic by insufflations of boric-acid powder. These injections should be frequently practised, and if the pain persists and the tympanic membrane is bulging, para- centesis must be performed in the most bulging part of the lower quadrant. After the paracentesis needle is withdrawn the discharge should be allowed to flow freely. The canal is then to be well irrigated with hot carbolized water (1 :50), and as the discharge is constant a ECZEMA. 645 piece of sterilized cotton should be inserted and removed as often as soiled. In the case of eczema of the ear hot irrigation, followed by the application of powdered iodoform, is perhaps the best application for temporary treatment. In furunculosis of the ear hot irrigation and free incision, with an iodoform dressing, are also useful. When foreign bodies cause the pain, they are best removed by repeated and gentle syringing with hot water. Forceps are dangerous instruments in the hands of a novice treating the ear. In earache due to neuralgia a small compress wet with chloroform may be applied to the skin in front of and behind the ear. ECZEMA. This is probably the most common form of skin disease which the physician is called upon to treat, with the exception of acne. Dermatologists divide it into many forms and stages, but in this book a consideration of its forms is out of place, and only the treat- ment for its stages is proper. In the first place, it may be stated that the treatment is a quadruple one — namely, dietetic, hygienic, external, and internal. In regard to diet, the patient should be told to avoid salty foods, such as salted fish or pork and corned beef; greasy foods, such as bacon and fried dishes; pastry and cheese. At most only moderate amounts of wine and beer can be taken, and foods difficult of digestion are to be stricken off the bill of fare. In the way of hygienic measures, fresh air, the avoidance of sedentary habits, horseback exercise or walking are to be recommended. External treatment is the most important of the two measures in which drugs are employed, and its course is perhaps best described by taking a case of ordinary eczema as an example and treating it through its entire course. In the early stages of an acute eczema, when the process is very active and the erythematous reddening is merging into the forma- tion of vesicles or pustules, with the formation of large scabs, no application is better than oxide-of-zinc ointment, thoroughly applied night and morning. If the eczema be situated upon the scalp, the hair must be invariably clipped short or shaved off in such a way as to prevent the gluing of the hair into a mat by reason of the discharge. The ointment may be smeared over the part or applied on a piece of lint in a thick layer. Nearly always the ointment should be used in conjunction with black wash (calomel 1 drachm [4.0], lime-water 1 pint [480.0]), which should be applied twice a day, just before the zinc ointment is resorted to, by means of a swab or a sop, and allowed to dry. In other cases the powdered oxide of zinc is dusted over the part if the discharge is very watery and profuse, or the following ointment, recommended by McCall Anderson, is very efficacious: 646 DISEASES. ty— Bismuth, oxidi ........ gj (30.0). Acid, oleic, pur. ....... Bviij (240.0). Cerse albae ......... giij (90.0). Petrolati . §ix (270.0). Olei rosse mv (0.3).— M. Ft. in unguent. S. — Apply to the part affected. As the quantities of this prescription are large, they may be reduced one-half for use in localized eczema. Where the proliferation of cells and the secretion are very profuse it may become necessary to remove the crusts before the local remedies can reach the skin, and for this purpose poultices may be used; or, if the disease be on the face, the parts should be anointed with olive oil, containing 1 or 2 minims of carbolic acid to the ounce (0.05-0.1 : 30.0), to soften the crusts, which are readily removed in a half-hour by the use of castile soap and water. The soap is not to be used if the inflammatory area is very angry-looking. Whenever itching is an annoying factor, the parts should be protected by lint smeared with some simple ointment, which may be carbolized both for its anti- septic and local anaesthetic effect. English and American dermatolo- gists use what is known as liquor carbonis detergens very largely in the acute stages of eczema. It should not be used pure, but diluted in such a way that for each 4 ounces (120.0) of water 2 drachms (8.0) of the pure liquor are present. Liquor carbonis detergens is made by taking 9 ounces (270.0) of tincture of soap-bark (quillaia-bark) and 4 ounces (120.0) of coal-tar, mixing and allowing them to digest for eight days, after which the mixture is filtered and is then ready for use. When the disease has passed from the acute, active inflammation of the first stage to the subacute form of the second stage applications of a mildly stimulant character are necessary. Before this the aim has been to soothe the parts; now they must be excited to normal activity. For this purpose resorcinol in the proportion of 2 to 30 grains to the ounce (0.12-2.0 : 30.0) of lard, according to the severity and induration of the lesion in the skin, should be used. Stelwagon recommends the following: 1$ — Unguent, picis liq 3j (4.0). Unguent, zinci oxidi . . . . . . 3vij (28.0). — M. S. — Apply to the parts. Where the disease is chronic and very persistent, and sluggish or atonic in its course, still more powerful remedies are necessary, such as salicylic acid, tar, or tincture of green soap used with hot water until the skin beneath is bared, dressing this by means of zinc ointment or resorcinol ointment, 2 to 10 grains to the ounce (0.12-0.60 : 30.0), spread on a cloth. The salicylic acid should be used in the propor- tion of 30 to 60 grains to the ounce (2.0-4.0 : 30.0) of lard, while the tar is used in the form of the pure official tar ointment. EMISSIONS. ^47 In seborrheic eczema, where the secretion is greasy and dry, and complicated, if wrongly treated, by oozing and the pouring out of serum and the formation of cells which form crusts, the following pre- scription is of value: 1$ — Resorcin gr. x vel xx (0.60-1.3). Pulv. amyli, Unguent, zinci oxidi . . . . aa oij (8.0). Petrolati 5ss (16.0).— M. S.— To be applied after removing the scabs by the use of a lotion composed of 1 part of bay rum and 3 parts of water. The internal treatment is directed to the cure of any disordered function which is present, such as dyspepsia (see Indigestion), hepatic torpor, general debility, ansemia, scrofulosis, inanition, constipation, gouty diathesis, or renal insufficiency. The gastric disorder is to be relieved by the use of hydrochloric acid and pepsin; the hepatic tor- por by mercury, podophyllin, or, better still, by freshly prepared undiluted nitrohydrochloric acid added to water; the debility by tonics, such as cinchona, cod-liver oil, strychnine, and bitters; the amemia by iron, and, if scrofulosis exists, by the syrup of the iodide of iron. Constipation is to be cured by the use of proper foods and laxatives, and the gouty tendency counteracted by the employment of the salicylates, lithium citrate, colchicum, or potassium iodide. If the kidneys are at fault because of torpidity, the diuretic potassium salts, such as the citrate, are indicated. Arsenic is never to be used, except in those instances where the skin is very dry, and where, by improving digestion and through its alterative power, it may do good. In the chronic forms of dry eczema or those depend- ing upon an atonic state of the trophic nerves of the skin, arsenic is of great value in the form of Fowler's solution, or arsenic trioxide may be given. EMISSIONS. Seminal emissions occur as the result of sexual abuse, whereby a condition of hyperexcitation of the nerve cells in the spinal cord and the nerves of the genitalia is developed, or they are due to peripheral or centric irritations, which reflexly irritate the genitalia or their nerves, and to a number of other similar causes. These emissions also occur with some periodicity in normal males who are continent and chaste, and under these circumstances are not to be interfered with by treat- ment unless the emissions become excessive. The former types are, however, proper for medical treatment, and their cure consists in the avoidance of unchaste literature and lascivious thoughts during the waking hours, and the use of such spinal and cerebral sedatives that the centres governing the ejaculations of semen may be calmed, and so quiet a sleep produced that erotic dreams are avoided. The patient should sleep on a hard hair mattress, not be too heavily covered, and should avoid sleeping on his back, as this causes 648 DISEASES. an undue blood-supply to the spinal centres, and consequent stimula- tion and ejaculations. Sometimes hard bodies, such as spools, are tied around the loins, so that lying on the back will cause so much dis- comfort that the patient awakes and turns on his side. The drugs to be used are bromide of potassium or sodium in 20-grain (1.3) doses at bedtime, or chloral may be taken in the same amount. Hyoscine is certainly of value in the dose of T -J-g- grain (0.0006). Sometimes a warm sitz-bath or general bath before going to bed is of service. In other cases, where atony is the cause of the trouble, the physician should recommend cold sponging of the perineum and loins night and morning. In the cases in which emissions come on as the result of continence, and become excessive, the remedies just named are to be tried, but do not effect any permanent cure unless used until sexual power is seriously depressed, so that it has been the custom of many physicians to recommend "marriage," which the patient may interpret in its legitimate light or not as he pleases. It is worthy of note that all irritations of the urinary bladder and other parts of the genito-urinary system should be removed, and it is often of value to administer citrate of potassium in 20-grain (1.3) doses, in water, three times a day, to render the urine non-irritating and alkaline. Stimulating foods and drinks are to be interdicted, and condiments, such as pepper and mustard, avoided. Sometimes, when the emissions are caused by genital atony, strych- nine and arsenic are of great service if given in full dose. In many of these cases it is the duty of the physician to treat the moral state of his patient as well as to give medicines. Many per- sons, believing that emissions are always an evidence of disease, read books on such subjects which are sold by quacks, and soon find their way to the hands of these persons. A few sensibly consult a regular physician. Half the treatment in these instances consists in assuring the patient that he has nothing to worry about, and in making him feel that the physician is his friend and worthy of all confidence and complete belief. ENDOCARDITIS. Endocarditis may be acute or chronic. Acute endocarditis occurs as a result of some general infection which is usually rheumatism. In acute sthenic endocarditis tincture of aconite, 3 minims (0.20) given every hour until the physiological symptoms of its influence are present, is useful, or with equal efficacy may be employed the tincture of veratrum (10 to 15 minims [0.60-1.0]). In most cases it is better to apply an ice-bag over the heart. Aconite and other depressants are contraindicated if the heart is at all feeble, and should only be used in the earliest stages of the disease. The most important measure is absolute rest upon the back. This must be insisted upon. If the cause of the disease is acute rheumatism, a EPILEPSY. 649 number of small blisters placed on the praecordium will be of value in preventing endocardial complications. (See Acute Rheumatism.) If the disease becomes ulcerative, supporting treatment, consisting chiefly in the use of good food and the free administration of the tincture of the chloride of iron, is of great value. EPILEPSY. The disease known as epilepsy is probably the most disheartening condition as to treatment that the physician has to deal with, since it often resists the influences of all the standard remedies, and drives the practitioner from drug to drug in the hope of finding one which will be at least alleviating in its effects. For this reason the author has in this article included many of the drugs which are rarely used, as well as those generally recognized as useful in its treatment, in order that the physician may try every remedy of any possible value. In the treatment of epilepsy the fact must be borne in mind that the convulsions are the result of a lack of nervous control or balance. In idiopathic epilepsy there exists a state of impaired nervous equilibrium with the result that explosions of nervous energy take place from the motor cortex of the cerebrum. These cases almost always develop in childhood and are dependent upon a congenital defect. A careful examination of them will nearly always reveal signs of their not being perfectly balanced mentally and physically. At the same time epilepsy is not a disease of idiots by any means. Often sufferers from it are remarkably clever, at least for many years. It is evident that in cases such as these the physician cannot hope to cure the patient per- manently, although by proper feeding, hygienic measures, and suitable drugs and tonics he may diminish the attacks very greatly. So, too, by removing causes of peripheral irritation he may diminish the fre- quency of the attacks, but he cannot eradicate the underlying nervous instability. If the condition arises in adult life, it is in the great major- ity of cases due to syphilis, to brain tumor, or to injuries of the skull. Under these conditions the prognosis and therapeutic possibilities are better than in the type just described; but if the fits have lasted for any length of time, so that a state of instability of the cerebral cells has been established, the condition may be irreparable, even if the treatment be most skilful. So far as drugs are concerned, the most valuable remedy in use for the relief of epilepsy is bromide of potassium, although other bromine salts will be mentioned later. Bromide of potassium is not a specific, but many cases prove that the remedy gives relief when it is used in a suitable manner, and in a large number of instances the seizures are so decreased both in vio- lence and frequency that its use may be said to be indicated in almost every case of the disease at some period in its course. In a very small minority, however, it signally fails. 650 DISEASES. The doses to be used vary to a considerable extent with the salt employed, and depend upon the character of the disease and the tem- perament and physique of the patient. The greater the duration of the disease, the greater is the difficulty in effecting relief, and the length of time during which the patient has been epileptic should therefore be most carefully reckoned before the treatment begins. Further than this, the frequency and severity of the attacks are to be looked into, and these points are really more important than the actual duration of the ailment; since if a man has only one fit every six months for twenty years his condition is far less serious than if he has a history of three or four fits a day for one year. Again, the character of the attack, as to its violence, may be the most important fact to be regarded, for if it is violent enough to endanger life, remedies must be pushed even beyond the point of tolerance. The writer once heard a celebrated physician cause much amusement among his auditors by detailing an instance of an epileptic who was getting well, and would have recovered if he had not died. His explanation was, that the man was syphilitic, and was receiving moderate doses of iodide and bromide of potassium, which were slowly benefiting him, and would have cured him had not a single severe fit produced death in the meanwhile. Another point to be considered is the condition of the digestion, which the bromide of potassium is peculiarly liable to disorder, and which is sometimes so disturbed as to necessitate the administra- tion of the drug by the rectum in serious cases. Females generally require smaller doses than males, and children of both sexes do not require as large quantities as adults. The dose to be used in the beginning of the treatment in moderate cases is about 10 grains (0.60) thrice a day; and while this may seem a very small quantity, it will be found that it can be rapidly increased in amount without causing the gastric distress produced by the sudden use of larger doses. Each day an additional 10 grains may be added, until at the end of a week the patient is taking 80 grains (5.3) in each twenty- four hours. There are very few cases which will not become saturated with the drug if this is done, and there are very few in which a more rapid arrival at bromism is needed. If, however, the patient has become able to stand large amounts by the prolonged use of the drug, the amount given is not to be governed by grains, but by physiological effects, and it may be pushed to any amount which is borne without distress. Full doses of the bromides, particularly in epileptics of an advanced type, sometimes cause maniacal outbursts in place of the epileptic attacks. In other instances the patients become morose and homi- cidal. (See article by author in Therapeutic Gazette, June, 1897.) Cases are on record in which the persistent use of large doses of the bromides has resulted in bronchitis with profuse and dangerous exudation, causing suffocative bronchitis. EPILEPSY. 651 There is one more point to which attention must be called, and that is the fact that when the bromides are taken for any length of time they produce bromism, which in its moderate or severe forms pro- duces a mental condition closely allied to that seen in old, chronic epileptics. This condition of the mind should never be over- looked, and the ordinary mental changes of epilepsy are greatly aggravated by its constant and careless administration. (See Bromide of Potassium.) Recently European physicians have endeavored to aid the rapid saturation of patients by the bromides by depriving them of common salt, thereby causing the salt-starved system to absorb greedily the bromide of sodium. It is doubtful if this plan is justifiable. In chronic epilepsy, with regularly recurring fits, the greatest good is obtained by pushing the drug in ascending doses for one week, and then for the succeeding week only enough is given to preserve the general effects of the medicament. By doing this the stomach gets a rest and the appetite is not greatly interfered with. For obvious reasons where the attacks occur only every two weeks this is a particularly useful method. As regards the time of day when the drug is to be taken, there can be no doubt. Some writers have directed that it shall always be taken before meals, but this is entirely lacking in advantage and decidedly fruitful of harm. Drugs which are given with the object of affecting the general system should be taken after meals, not before, and it is only when a local gastric effect is desired that they should be given on an empty stomach, particularly when the substance is so depressing as a salt of potassium. If taken after meals, the appe- tite is not decreased, but there are few who can take a dose of 10 or 20 grains (0.60-1.3) of bromide of potassium before breakfast without suffering from indigestion. If the attacks have a distinct periodicity, which is rare, or can be foretold for as long as two hours beforehand, the remedy may be taken in a large dose only at this time, and but a few grains given in the intervals; and if the attacks are severe, the physician should not hesitate to use large doses by the mouth and by the rectum on the day of the attack. It has been held by some that the drug should be taken in minute doses, frequently repeated, in order to keep the patient constantly under its influence. This is an example of therapeutic ignorance, because the bromides are slowly eliminated, and this frequent admin- istration possesses the disadvantages of being inconvenient, annoying, and apt to disorder the stomach. A very important point to be borne in mind is that the drug often seems to have produced almost a cure, and this results in carelessness in the regularity of administration. The patient should be impressed by the fact that every day passed without a fit is a step forward, and that every fit carries him many steps backward. He should also be 652 DISEASES. directed to use the drug, in moderation, for at least three years after all fits hate ceased, and to watch after that time for the slightest sign of their return. The quantity taken each day should be gradually decreased, not suddenly stopped. Before passing on to the discussion of the employment of the other bromides, and the conditions produced by the excessive dosage of all of them, we may place our use of these compounds in epilepsy on a scientific footing. It is now generally recognized that the seizures known as epilepsy arise from the cells in the cerebral cortex, and there can be no doubt that the bromides act very powerfully upon the cerebrum in the higher animals, decreasing the irritability of the motor centres in these regions to a very great extent. Not only is this pointed to by clinical facts, but the researches of Albertoni prove beyond all doubt that such is their action. This investigator found that the administration of a single dose of the bromide of potas- sium so lessened the excitability of the motor cells in the cortex cerebri that much stronger stimulation was necessary in order to cause response in the limbs than was normal, and that it was difficult to produce epileptic attacks by means of electrical stimulation of the motor areas even when currents were used very much stronger than those which commonly produce such a result. He also found that this lessened irritability was increased still further if the drug was given for several days beforehand in such doses as thoroughly to impress the organism. It is therefore evident that the bromides act directly on the cortical areas, calming the tendency to explosions of nerve-force. The bromides of gold, iron, lithium, nickel, and ammonium have all been used in epilepsy with good results, but, except in certain in- stances, they fail to act as well as those of strontium, sodium, and potassium, unless given in larger doses. Bromide of sodium and of strontium are not by any means so apt to disorder the stomach, and are preferable in some cases on this account. They possess no other advantage. The bromide of ammonium is quite irritant and disorders the stomach very readily. It ought always to be used, when used at all, with other salts, the ammonium salt acting only as an adjuvant. Several clinicians have tried hydrobromic acid, but it is very much more apt to derange digestion and to produce vomiting than any of the salts. The dose of the dilute acid is \ to 3 drachms (2.0-12.0) in a tumblerful of sweetened water. There can be no doubt that in some instances what is known as the mixed treatment is very useful. This consists most commonly of a prescription in which the bromides of potassium, sodium, and ammonium take part. Why this combination acts better than any one of the salts alone is unknown, but it is certainly a clinical fact. Bechterew has recommended the joint use of the bromides with adonis vernalis in epilepsy as follows: EPILEPSY. 653 1$ — Potassii bromidi 3iij (12.0). Infus. adonis vernal f§iv (120.0).. Aquce destillat q. s. fgvj (180.0).— M. S. — A dessertspoonful three times a day. Sometimes codeine is combined with this prescription. Within the last few years it has been claimed by Flechsig that the use of opium for a long period of time is useful in the treatment of epilepsy. He gives the opium in ascending doses during a period of six weeks, beginning with J grain (0.015) three times a day, and going as high as 5 grains (0.30) three times a day. This method decreases the frequency and severity of the fits for several months in some cases, but does not cause a cure. It succeeds best in old cases and is not useful in recent ones. In still other cases digitalis, when used along with one of the bro- mides, seems to produce favorable results. Indeed, digitalis has for years been used alone in epilepsy with fairly good results, and should always be used in obstinate cases. In petit mat, in which bromide of potassium when used alone so often fails, it is useful, and several English writers, notably Gowers, assert that its best effects are seen in cases of nocturnal epilepsy. Why this is the case no one knows, and it would seem doubtful whether it is more beneficial in nocturnal attacks than in others. Another combination very much employed and lauded is bromide of potassium with belladonna, the mydriatic being almost useless alone, although of great antiquity in its use in epilepsy. Like the mix- ture of digitalis and bromide, it succeeds very frequently in petit mal, and, indeed, seems to be much more successful than the digitalis, but its mode of action is exceedingly doubtful. As the drug acts even more powerfully upon the nervous system than upon the circulatory apparatus, it has been thought that its influence for good depended upon this effect, but the experiments of Seppilli contradict this belief, for he found that if atropine was given to an animal the surface of the cortex cerebri responded more readily than is normal to electrical stimulation. At one time it was held that belladonna acted on the spinal cord and peripheral nerves under such circumstances, but it should be remembered that we now know that atropine is only of value in relaxing spasm when given in full dose, oftentimes hypodermieally, and that Albertoni has made a series of experiments to determine whether it irritates the motor centres of the cortex. In his hands repeated small doses or one large dose in no way retarded the con- vulsions commonly produced by stimulation of the brain. Both these investigators are therefore in accord. Under these circumstances it affects rather the motor nerve-endings than the central nervous apparatus. Nitrate of silver was brought into use long before the value of more recent drugs was known. Every one is agreed that it is without power for good. As the drug is eliminated very slowly, it rapidly 654 DISEASES. accumulates in the body, and argyria soon comes on. It may be used, after all else fails, in doses of J to J grain (0.01-0.15) thrice a day after meals, the mucous membrane of the inside of the lips and the con- junctiva being carefully watched for the early signs of chronic silver- poisoning. We certainly have no knowledge as to its influence on the nervous system; and if it acts at all, it must be by some alterative influence rather than by any other means. Nitroglycerin is to be employed in the treatment of petit mal, rather than haut mal, in the dose of 1 minim (0.05) of a 1 per cent, solution, once, twice, or three times a day. Our knowledge of its effects, so far as its curative influences are concerned, is very slight, but it seems to benefit some cases. Its action is fleeting, and it influences the brain but slightly, except it be taken just before an attack is expected or when the cardiac action is defective. The use of the nitrite of amyl is not for the purpose of directly curing the disease, but of warding off impending attacks, the warning of which is given by an aura of slow progression. It increases the severity of petit mal, but in epileptics who have a prolonged aura nitrite-of-amyl pearls, which are small glass beads containing a few drops of the drug, may be used. As the aura comes on the patient should break one of these in a handkerchief and inhale the drug, thereby putting aside the attack. The influence which the drug exerts upon the brain is secondary rather than primary, and is probably dependent on its action on the blood or circulation. Its influence on the spinal cord and nerves is much more marked and direct, and it is most certainly a very powerful spinal depressant. Nitrite of amyl puts aside an attack by a sudden shock to the nerve-centres, which diverts them, so to speak, from their intended discharge, very much as a ligature around the arm stops an aura. When we remember that the drug acts instantly and converts nearly all the oxygenating blood of the body into a non-oxygen-carrying fluid by reason of the methsemoglobin produced, the sudden change in the cerebral nutrition and state is easily understood. In the treatment of the "status epilepticus" nitrite of amyl is of great value in checking the seizures, and may be used under these circumstances in heroic amounts, applied to the nostrils at intervals. During the presence of the tonic spasm, if it be severe enough to suspend respiration, it should be remembered that if the drug is not inhaled it is worthless. It is only when respiration is being carried on that it can enter the lungs and do its work. The nitrite of ammo- nium or of sodium or nitroglycerin should be used internally to supplement the nitrite of amyl. Another valued method in treating the status epilepticus is free bloodletting. The use of anaesthetics during an attack of epilepsy is virtually useless, and in some cases dangerous, for ether is too slow in its effects, and may, by its irritant vapors, increase the tendency to laryngeal spasm or cause lung complications. Further than this, if uraemia is EPILEPSY. 655 the cause of the fit — and this fact is unknown in every case when it is seen for the first time until the individual is carefully examined — the ether may further irritate the kidneys. Chloroform, though it acts much more rapidly, may cause sudden cardiac failure, and both drugs may increase the post-convulsive coma very greatly. In status epilepticus they may be used, as in such cases the convulsions must be stopped at all hazards, but the preference should be always for amyl nitrite. The iodide of potassium is useless in epilepsy unless the disease is due to syphilis, when it is of the greatest service. Indeed, the bromide and all other drugs should be discarded while this one is pushed to the utmost. As is well known, syphilitics usually bear the drug extremely well, and the author knows of one instance where no less than 800 grains (53.0) were taken every twenty-four hours, with rapid improvement as a result. This point is strongly insisted upon by all therapeutists and syphilographers, notably Fournier. Where the convulsions are due to the presence of a gumma, how- ever, the iodide of potassium is too slow in its action, and should be associated with mercury in order to break down the growth without delay, lest a seizure cause death by glottic closure, producing asphyxia or some similar accident. Chloral possesses the disadvantage, as compared with the bromides, of being a very fatal poison, which is an important fact to be borne in mind by the physician when giving it to a patient whose mind is already weakened by the disease or who is naturally stupid, and who may forget the dose and take too much. Its physiological action indi- cates much more fully that it may be of .value than does that of many other more lauded remedies, since it exerts its chief influence on the motor pathways of the spinal cord and quiets the motor portion of the cerebral cortex, and so produces sleep. Seppilli has proved this by direct experimentation after the method employed by Albertoni. Its use, combined with one of the bromides, is often followed by the most desirable results, and it should be tried at all times unless some cardiac complication forbids it. It may disorder the stomach, and should, like the bromides, always be given well diluted and after meals. Of the more recent remedies, acetanilid stands in the foremost rank, and bids fair in some instances to rival the bromides. Ger- main-See, the author, and some others have reported cases which obtained marked relief from it, and more recent investigators have done likewise. The drug will be found to exert its beneficial effect chiefly in chronic epilepsy. Antipyrin has been recommended by Lemoine in certain forms of epilepsy, but it has been condemned by other clinicians. He found it very useful in cases associated with migraine. In these cases the results were better than with the bromides, but in the idiopathic simple 656 DISEASES. varieties it was useless. Mairet and Combemale have used the drug in epileptiform mania with satisfactory results. In the epilepsy of childhood Solanum Carolinense in the form of the fluid extract, in the dose of 2 to 15 minims (0.1-1.0 c.c.), is some- times a useful drug. The value of the treatment of epilepsy by borax has not received very wide recognition. Perhaps the most thorough studies of its effects have been those of Gowers in England and Folsom in America. It would seem that some cases which are obstinate under ordinary treat- ment are benefited by borax, but it is certainly not to be commonly employed. The dose generally given is about 15 grains (1.0). (See Borax.) In children who have single convulsive attacks the presence of worms should always be looked for, and when found they should be expelled as rapidly as possible. If they are oxyuris vermicular is (seat- worms), the best remedy by far is the injection of an infusion of quassia of such a strength that there are 2 ounces (60.0) of quassia in each pint (480 c.c.) of water. In girls, where the removal of the worms from the rectum is not followed by relief, a careful examination of the vagina should be made, and quassia employed in somewhat weaker solution, as very commonly intense inflammation is there present, produced by migra- tion of rectal parasites. If the quassia is unobtainable in any case, a saturated solution of chloride of sodium may be employed. A very important point, which is constantly brought before the physician who is treating epilepsy, is that of diet. Nearly every patient who suffers from this disease inquires what he shall eat. Few researches of a thorough character have been carried out on a large scale to determine what may or may not be ingested. Curiously enough, the influence of diet in one research covering a number of cases of chronic epilepsy seemed to be of little moment. Thus, Merson examined 24 such cases, putting 12 of them on a purely vegetable, and 12 on a purely nitrogenous, diet. The result, after this study had been continued for two months, was that the vege- tarians had had a few less fits than the others, but the difference was so slight as to be of almost no weight in determining the question. The view that meats are harmful is erroneous. EPISCLERITIS. Episcleritis, or inflammation of the episcleral tissue, manifests itself in the form of dusky-red, subconjunctival swellings, over which the conjunctival vessels are coarsely injected and the surrounding con- junctiva cedematous, and which usually appear in the ciliary region on the temporal side of the cornea. Occasionally the inflammation is diffuse and the injection bluish red in color. This disease may be due to rheumatism, gout, scrofula, and menstrual derangements, is EPISTAXIS. 657 very prone to relapse, and sometimes stubbornly resists treatment. This, in addition to atropine locally and mild antiseptic collyria, should include the internal administration of remedies indicated by the under- lying constitutional cause, particularly the salicylates, iodide of potas- sium, jaborandi-diaphoresis, etc. Naturally, menstrual and uterine disorders must be rectified. A peculiar variety of episcleritis, known abroad as periodic fugacious episcleritis, and in England as " hot eye," but in this country as vasomotor dilatation of the vessels, appears in the form of patches of episcleral injection or oedema of violaceous hue, lasting from two to eight days and reappearing at intervals of several weeks, or even months. Almost always gout and rheumatism are the associated dyscrasias, and suitable constitutional remedies must be exhibited. EPISTAXIS. Nose-bleed depends upon many causes, the chief of which are traumatisms, plethora, and the presence of ulcerations in the nasal chambers. It also occurs as one of the prodromata of typhoid fever and in some cases of cardiac valvular disease. The measures to be adopted for its control are both medicinal and non-medicinal. If the individual is full-blooded and strong, full doses of tincture of aconite or veratrum are useful, say 5 to 10 minims CO. 30-0.60) of one of them, followed in a half-hour by a smaller dose, if necessary. The value of these drugs depends upon their power of lowering blood-pressure, and in consequence decreasing the leakage from the break in the wall of the bloodvessel. Some physicians have recommended ipecac in full nauseating doses to relax the arterial system. Sometimes, when the oozing is slow, turpentine, oil of erigeron, or hamamelis, taken internally, does good. In the way of local treatment by far the best application, because it is efficacious and yet harmless, is adrenalin chloride in salt solution 1 : 10000, which should be placed in the nasal chambers on a piece of cotton, or if it cannot be obtained powdered alum, pure or half and half with starch, or alum in solution, may be snuffed up the nostril, or tannic acid, in powder or in solution, may be used with advantage. If this does not control the hemorrhage, an atomized spray of Monsel's solution, in the strength of 5 minims to the ounce (0.3-30.0) of water, may be of service. The non-medicinal measures to be employed if the bleeding is severe consist in plugging the anterior nares with pledgets of cotton or pieces of lint soaked in adrenalin solution or vinegar. If this does not control the hemorrhage, the posterior nares may also be closed by plugs, and compression of the facial artery of the same side as the bleeding nostril be made upon the superior maxilla near the nose, thus decreasing the blood-supply. The head must be kept raised, and the patient must not bend over a basin or wear a tight collar. A piece of bacon fat cut to fit and placed in the nostril may stop epistaxis which has resisted other measures. 42 658 DISEASES. As a household remedy diluted vinegar may be injected into the nostrils, or lemon-juice may be employed in the same way. Sometimes, if the patient raises one or both hands high above the head, the hemorrhage ceases. This is due to the fact that the easiest pathway for most of the blood is straight up the brachial arteries rather than through the tortuous vessels of the face. A hot foot-bath, by dilating the veins of the lower extremities, draws away the blood from the face and is a useful measure ; but if bleeding has been profuse, this may cause the patient to faint unless he lies down when his feet are in the water. In other cases a hot-water bag applied over the dorsal vertebra? is efficacious, and sometimes cold when so used is of service. A piece of ice pressed against the nose may prevent further hemorrhage by causing localized anaemia. Where the nasal hemorrhage results from traumatism with fracture of the bones, and great loss of blood ensues, compression of the bleeding vessel or its supplying vessel should be made if possible. ERYSIPELAS. This disease is now generally recognized as dependent for its exist- ence upon a germ. The streptococcus of erysipelas is practically identical with that of pus, and the disease is at first a distinctly local one. The changes which have taken place in its treatment are chiefly the local measures, while those methods which have been used internally for many years have undergone no alteration. In a large proportion of cases erysipelas develops because the vital resistance of the patient has been lowered by some acute illness or by a chronic malady like nephritis or diabetes. For this reason its spread in the skin and the toxaemia it causes must be controlled by the em- ployment of every measure that will enable the patient to combat the infection. Rest in bed is essential and supporting treatment is demanded. J. M. Da Costa recommended, and others have car- ried out with success, the practice of using pilocarpine in sweating dose (-§- to \ grain) hypodermically in these early stages. (See Pilo- carpus.) It is to be remembered that this use of pilocarpine is not to be resorted to if debility exists. The internal treatment of erysipelas par excellence is the plentiful use of the tincture of the chloride of iron — 20 to 30 minims (1.3-2.0), or even 40 minims (2.60), well diluted, four times a day. The diet should be regulated and the bowels kept in good order. Any excessive febrile movement is to be treated by the use of cool sponging with friction. Where the patient passes into the typhoid state supportive measures must be used and alcoholic stimulants added to the food, which should be predigested or prepared so as to be readily absorbed. During convalescence the use of tonics, both in the form of iron and of bitters, is particularly indicated if recovery of strength is slow. EYE-STRAIN. 659 The local treatment of erysipelas is very varied, but in the majority of cases resort need be had to but one method. By far the best dressing for the majority of cases of erysipelas is a modification of that of von Nussbaum, which the author has tried in a great num- ber of instances with success. The skin of the part involved is care- fully cleansed with Castile soap of the purest form, and then it is washed off with a 1:1000 solution of bichloride of mercury. The skin is dried with a soft towel, and a thick coating of ichthyol with vaselin or lanolin applied, the strength of this ointment being half and half. Over this is placed antiseptic gauze or sterilized absorbent cotton, and adhesive strips or a bandage is used to keep the dressing in place. Sometimes the ointment alone may be applied if the area is small. Under this treatment the results are often extraordinary in all stages of the malady. Where ichthyol is not obtainable, a thick coat of white-lead paint, as it is sold in cans before it is mixed with any thinning substance, will be found of service in an emergency. The iron and ichthyol method is that always followed by the author. The plan recommended by Higginbottom, of applying nitrate of silver, is sometimes successful. It consists in the use of a solution of the strength of 80 grains to 4 drachms (5.3-16.0) of distilled water, which is thoroughly applied with a earner s-hair brush over the entire inflamed area and for a little space beyond. The application must be made twice or thrice to secure a good coating. This treatment will often arrest the inflammation and prevent its spread, but has caused sloughing; the author has never used it. EYE-STRAIN. Eye-strain, in the broadest acceptation of the term, is the name applied to those symptoms which may be caused by the presence of refractive error, or imbalance of the ocular muscles. While all varie- ties of ametropia may cause eye-strain, hypermetropia and astigmatism are most potent in this respect. Fully 60 per cent, of functional head- aches are caused by refractive errors; and these headaches may vary from a moderate frontal distress to violent explosions of pain, and may be situated in any portion of the cranium. Moreover, they may be entirely unassociated with any pain in the eyes or any apparent dis- turbance of vision, and are frequently caused by low degrees of refrac- tive error; in fact, they are perhaps more frequently caused by them than by the higher defects. In addition to headache, eye-strain may cause pain in the back, especially between the shoulder-blades and at the root of the neck, precordial pain, vertigo, drowsiness, insomnia, habit-chorea, choreiform movements, convulsive seizures, melancholia, neurasthenia, palpitation of the heart, night-terrors, stomachic dis- turbances, flatulent dyspepsia, and a variety of general or so-called reflex neuroses. The existence of any of these symptoms or affections 660 DISEASES. should direct the attention of the attending physician to the condition of the eyes, and refractive error and muscular imbalance should be corrected. EXHAUSTION AND DEPRESSION. While the treatment of both these conditions is almost identical in some respects, it is nevertheless important that a clear idea of the difference between the two be clearly understood, if for no other reason than that the physician may recognize that exhaustion is a far more serious state than depression. It also requires more careful treatment. The man who is depressed retains in his body all the vital forces necessary for the maintenance of life, but they are tem- porarily in abeyance from some cause. As soon as the incubus is taken away the system at once asserts itself and recovery takes place. This is not the case with a man suffering from exhaustion. In this patient every particle of his strength is sapped and lost. The man depressed is the giant lying unconscious from a blow on the head; the man exhausted is the same giant after a long attack of typhoid or other fever of a similar nature. The treatment of depression is stimulation; of exhaustion, not only stimulation, but rest, feeding, and protection from exposure. FEET SWOLLEN, TENDER, OR SWEATING. These comparatively simple yet annoying conditions are often brought before the physician for relief, and patients suffering from them will frequently be more grateful for skilful treatment than in the event of recovery from a severe illness. Swelling of the feet occurs chiefly in two classes of cases, excepting, of course, dropsy. The two classes named are old persons taking too little or too much exercise, and who may have gouty or rheumatic tendencies, and those who by constant standing or walking cause congestion of the lower extremities, chiefly by fatigue, or by wearing bad shoes, or by running over uneven ground, causing bruising. Where the swelling takes place in the first class, small doses of arsenous acid, -bV to To" g ram (0.001-0.0015), often do good, and careful examination should be made of the circulatory, renal, and respiratory apparatus to discover any weak points, such as vascular relaxation or tendencies to varicosities. The distilled or fluid extract of hamamelis is often of service in the dose of \ to 1 drachm (2.0-4.0) of the former and 10 to 20 minims (0.60-1.3) of the latter preparation. In some cases absolute rest of the feet will be necessary before a cure is reached. Where the feet are tender the most common cause is bruising from too thin soles on the shoes, too tight shoes, and from abrasions or skin disease. More commonly than all they become sore from excessive sweating and resulting maceration. The treatment of sweating and tender feet is, of course, the removal FEVER, AND ITS TREATMENT. ^\ of the cause and the use of remedies designed to toughen and harden the skin of the parts. Probably the best application for this purpose is a solution of salicylic acid and borax, half and half, in water and glycerin, rubbed over the feet night and morning. If the sweating is very profuse, clean stockings should be worn each day, the stockings being previously soaked in a strong solution of borax and dried. The following prescription affords a useful powder: ty — Pulv. acidi salicylici gr. xx.vel xl (1.3-2.60). Pulv. acidi borici 5ij (8.0). Pulv. amyli q. s. ad . gj (30.0).— M. S. — To be dusted over the feet night and morning, after washing and thor- oughly drying them. One of the most efficient applications is a solution of formaldehyde of such strength that 1 part of the commercial 37 per cent, solution is mixed with 4 parts of water. Even this may be too strong in some cases. A more agreeable application is diluted euformol. Sometimes the use of cotton instead of woollen stockings may aid in the cure. FEVER, AND ITS TREATMENT. (For the Treatment of each Fever, see its Title.) At the present time the medical profession is universally of the opinion that fever is a disorder of calorification dependent upon nervous action, said nervous action being the result of various causes, such as the presence of poisonous materials in the blood causing per- verted functional activity of the heat centres. The rule of practice should be to control all fevers by the use of cold sponging or bathing and to resort to antipyretic drugs as little as possible. Antipyretics may be divided into three great classes : first, the sub- stances which allay or prevent fever by inhibiting its production; second, the drugs which possess the power of decreasing bodily temperature by increasing the dissipation and decreasing the pro- duction of heat; and third, the compounds which allay fever, not by stopping the manufacture of heat-units, but by so increasing the dissi- pation of heat that the loss is greater than the manufacture. The first and last of these classes are directly opposed to one another. The second class is half-way between, and it is to this class that most of our antipyretic drugs belong. The objection to the use of all antipyretic drugs is that they depress the patient and decrease his power of resisting disease. The presence of a high temperature alone does not constitute the sole indication for treatment. The physician should be governed by the state of the patient who is laboring under the malady. A temper- ature of 106° F. in a young healthy man suffering from an attack of some disease of short duration does not mean very great danger, but a temperature of 103° F. day in and day out in typhoid fever does mean 662 DISEASES. danger, chiefly because it is a gauge of the toxaemia, and must be care- fully attended to. The question is one not of actual degrees of Fahren- heit, but rather as to whether the state of the patient is toxic. We have only two measures for the relief of fever which are reliable. These are the employment of antipyretic drugs and the use of cold water. As already stated, drugs are to be used very rarely, but the beneficent effects of the use of cold water are extraordinary, and it should be freely employed if the fever is high. (For the mode of using acetanilid and antipyrin see pp. 53 and 90, and for the use of cold see p. 471.) The friends of the patient, if they are intelligent, can easily be taught how to use cold sponging with friction, and good results, far superior to those produced by antipyretic drugs, are thus obtained. The reasons for this are discussed farther on. The water should be as cold as is necessary to reduce the fever satisfactorily in twenty min- utes of sponging, and reaction must be produced by friction applied to the skin. This reaction is more important than the reduction of the fever. (See Cold in Fevers, Part III.) (For the use of guaiacol externally in fever, see article on Guaiacol.) Sthenic Fevers. The application of antipyretic drugs to the febrile temperatures occurring in sthenic cases is not so irrational as their employment in a prolonged low fever of the adynamic type, but the wise physician will always endeavor to avoid their use if possible. Fever is not, as a rule, a very harmful process unless it is continued for a long period or is exceptionally high. Indeed it may even be beneficial. Anti- pyretic drugs decrease oxidation, probably interfere with ordinary protective natural efforts against disease, and place upon the eliminat- ing organs the task of excretion. In acute illnesses, if the use of cold is impossible, these remedies may be given, but usually it is unnecessary to employ them, for unless the fever is long continued it is not harmful in itself. In scarlet fever the use of such drugs should be avoided, because the kidneys are in danger. If in any case it is decided to give antipyretic drugs, they should never be pushed to the point at which even moderate cyanosis develops ; and if they do not control the fever in moderate dose, they should be discarded and cold bathing insisted upon. The use of antipyretic drugs and cold sponging simultaneously is absolutely harmful. Personally the writer never under any circumstances employs anti- pyretic drugs for the reduction of fever. In thermic fever, or sunstroke, the employment of antipyretics is often useless. The excessively rapid upward rise of the temperature responds in no way to drugs, and there are many cases on record in which the use of antipyrin has utterly failed of good result. FRECKLES AND CHLOASMA. ^63 Asthenic Fevers. {Fevers of a Typhoid Type.) In the opinion of the author antipyretics should not be employed in the reduction of the pyrexia of the typhoid state, our main reliance being upon cold applications. They ought never to be combined with the cold bath, as they prevent the one thing we seek in the use of the cold, namely, reaction. Aside from the fact that he has found such an opinion well founded in a large number of cases, logical reason- ing endorses its correctness. Even if antipyretics were perfectly innocuous, their constant use in fever would but give the already overstrained kidneys the task of their excretion, while the stomach, already disturbed by necessary medicines and illness, has enough to do without the addition of another load. Further than this, we know that these drugs are not perfectly harmless, and we also know that they decrease oxidation, which is not the case with the cold bath, which increases it. The writer reiterates that in typhoid and other low fevers of the continued type antipyretics should not be given. (For Brand's treatment, see Cold, Part III.) Fever will sometimes resist all doses of antipyretics we can give or all that it is safe to give, but no fever can completely resist the cold sponge when properly used, for by its use we produce beneficial results by reaction even if an actual fall of temperature does not take place. In septic fever and in tuberculosis antipyretics are harmful owing to the depression and the increased sweating which is apt to be produced. FRECKLES AND CHLOASMA. The removal of freckles is readily accomplished, but their return is inevitable if any exposure to the sun or wind occurs. One of the best applications for their removal is a solution of corrosive sublimate, in water, varying in strength from 1 to 4 grains to the ounce (0.06-0.25: 30.0), and applied night and morning until the skin shows that it is irritated, when the lotion must be stopped for some days, after which its use may be begun again. A very efficient and much less poison- ous remedy to leave about the room is a saturated solution of boric acid in water, applied in the same manner as is the solution of bichloride of mercury. Another remedy is lactic acid, 10 grains to a drachm (0.60 : 4.0) of water, used in the same manner as the solution of the bichloride of mercury. The following prescription is recommended by Unna: 1$ — Bismuth, oxidi, Pulv. amyli aa gr. xxx (2.0). Kaolini oj (4.0). Glycerini fo'ij (8.0). Aquae rosse q. s. ad f§ij (60.0). — M. S. — Paint on spots and allow to dry, washing the drug off before each new application. 664 DISEASES. Or the following may be used: Jt£ — Zinci oxidi Hydrarg. ammoniati Ol. theobromat. . 01. ri cirri .... Essent. rosae . S. — Apply night and morning GASTRALGIA gr. iij (0.2). gr. iss (0.08). f5ijss(10.0). f3ijss(10.0). gtt, x (0.60).— M. Before undertaking to treat a case of severe gastric pain, as one of gastralgia, the physician must determine the possible presence of gastric ulcer, gastric cancer, and the gastric crisis of locomotor ataxia. The treatment of gastralgia may be divided into two parts — that directed to the relief of the attack when it is present, and that devoted to the prevention of other attacks. During the acute stage hot appli- cations and drinks, aromatic and locally stimulating warm infusions, a few drops of chloroform, or brandy or whiskey with a little hot water, or 30 to 40 minims (2.0-2.60) of laudanum may be used. Counterirritation often does good, and in some cases, particularly if a suspicion of an hysterical element exists, a vigorous revulsive may act with surprising success. Emesis and purgation are sometimes indi- cated, since in the early attacks the cause of the pain may be suspected to be the presence of indigestible food. The treatment required in the intervals between the attacks must vary with the cause and with the general condition of health. A careful search must be made for the real cause of the trouble, and when found it must be removed or palliated by appropriate measures. The diet should be carefully regulated, and all the hygienic details of the patient's life be critically studied and directed. The avoidance of improper food, the abandonment of tea, coffee, and tobacco, the prescription of proper dress, exercise, or change of residence, may be followed by marked improvement in general health and by a cessation of the attacks of gastralgia. Any marked disturbance of digestion should be corrected; and this may require the use of pepsin or of some tonic remedies, such as are suggested in the article on Indigestion. The chief reliance, if anaemia is present, is to be placed upon the administration of arsenic and iron im- mediately after meals, in proper form and doses. Thus, we may direct: R — Liquor potassii arsenitis f^j (4.0). Vini ferri amari . . . . q. s. ad f Jiv (120.0). — M. S. — From 1 to 2 drachms (4.0-8.0) in water after meals, three times daily. Or, K — Tincturae ferri chloridi f^j (30.0). Acidi hydrochlorici diluti, Liquor acidi arsenosi aa. f^ss (16.0). — M. S. — From 4 to 15 minims (0.25-1.0) in water after meals, three times daily. Occasionally even better results are secured by the use of cod-l.ver oil in emulsion with the hypophosphites. GASTRIC CATARRH {ACUTE). 665 When the pain in the epigastrium is due to an excessive secretion of hydrochloric acid the various bromides are of value, and should be given long enough before meals to permit them to produce their effects before the food enters the stomach. In other cases a pill of nitrate' of silver and hyoscyamus should be employed. (See Gastric Ulcer.) Chloretone is also useful in the dose of 5 to 10 grains (0.30-0.60) in capsule. It is well, in cases where the pain is very severe, to combine with the above a powder of bismuth subnitrate and pepsin, given after meals. Constipation must be overcome by proper diet, massage, enemata, or by suppositories of gluten or glycerin or soap. If the use of bismuth favors the continuance of constipation too decidedly, small doses of cyanide of potassium, dilute hydrocyanic acid, or chloroform may be substituted at the same hours. In cases where a highly neurotic state exists, it may be necessary to alternate all other treatment with the bromides or with the preparations of valerian, or the following pre- scription may be used: $— x<\cid. hydrocyanic, dil f gj (4.0). Fluidextract. cannab. indicae . . . . f gj (4.0). Tr. hyoscyami f'3iss(6.0). Spt. chloroformi f 3 i j (8.0). — M. S. — 30 minims (2.0) t. i. d. in water for an adult. GASTRIC CATARRH (ACUTE). By far the most important point in the treatment of acute gastric catarrh is the regulation of the diet. The dietetics may be divided into two parts — first, the regulation of the food during convalescence or during the attack; and, secondly, the character of the food to be used during the interval following one attack and preceding the next. Total abstinence from food in the acute stages of the attack, and absolute bodily and mental quietude, are advisable. There are several reasons for this. In the first place, the juices of the stomach are in an abnormal state and unfit to act properly if the stomach re- ceives more food. Secondly, the mucous membrane of the stomach is already hyperoemic from the inflammation, and, as the normal viscus becomes physiologically hyperaemic on the ingestion of food, we would add to the congestion of the bloodvessels did we allow more nourishment to enter the stomach. Last of all, the excess of the mucus and lactic and butyric acids present renders any new food impure before it can be assimilated, and so prolongs the trouble. As the attack passes off small amounts of food may be given, which should be of a kind readily digested and not likely to become easily decomposed or rendered acrid by the mucus in the stomach. Milk with a large percentage of lime-water is to be used, since the alkali not only prevents a too firm coagulation, but also decreases the secre- tion and acid reaction of the mucus. The thirst is often excessive, although anorexia is complete, and small pieces of ice may be admin- 66Q DISEASES. istered for its relief. Small doses of bismuth subnitrate (grains 2 [0.12]) and of cerium oxalate (grain 1 [0.06]) every two hours are advisable. Commonly it will be found that the patient rapidly improves up to a certain point, then stops improving or relapses. This is sometimes due to an accumulation of mucus, which when mixed with food causes it to undergo fermentation. If marked evidences of the presence of this secretion are given, a mild and gently acting purge, such as calcined magnesia, followed by a little orange juice, may be employed to dislodge the fermenting mass. In other instances the relapses depend upon a tendency to a condition of atony, which can only be overcome by prolonged and careful treatment adapted to the improvement of the general health. Sodium bicarbonate with com- pound infusion or compound tincture of gentian may be used during convalescence, and small sips of effervescing draughts are useful. If constipation exists and vomiting forbids the use of the ordinary purga- tives, a Seidlitz powder divided into fourths or fifths, and taken in this way every fifteen minutes or half-hour, will settle the stomach, move the bowels, and often carry away mucus. If there is much epigastric distress, a spice or mustard poultice is often of service. Sweets and starches are to be rigidly denied the patient. If anae- mia exists, iron may be used, but this is rarely needed. The abdomen should be carefully protected with flannel, and draughts and unsanitary surroundings avoided. GASTRIC CATARRH (CHRONIC). Chronic gastric catarrh is a condition of the stomach commonly seen in a more or less well-developed form. It is often associated with much indigestion and the eructation of sour liquids, or even with active vomiting. The secretions of the stomach are nearly always abnormal, and fermentative changes are constantly present in the gastric contents. Lavage is almost always to be resorted to for its relief. (See Lavage, Part III.) By far the best treatment for this condition is the use of counter- irritation over the epigastrium by means of tincture of iodine, the strict regulation of the diet, and the use, internally, of nitrate of silver and extract of hyoscyamus, and, if great hyperacidity exists, the admin- istration of the subnitrate of bismuth. Often, however, the better remedy is bicarbonate of sodium in the dose of 5 to 20 grains (0.30- 1.3). In many instances the patient will be greatly benefited by the use of a Seidlitz powder or Carlsbad salt 1 or Hunyadi or Apenta water before breakfast each morning, as this washes out the stomach, dis- 1 Artificial Carlsbad salt may be ordered, composed of 8 ounces of sodium sulphate, X A ounce of sodium chloride, and 1 ounce of sodium carbonate. The dose varies from 2 drachms to Yi ounce (8.0-16.0). GASTRIC DILATATION. QQ*j solves the mucus, and unloads the mucous membrane of its congestion, at the same time overcoming any engorgement of the liver. The efficiency of these purgatives may be increased by using hot water. Constipation is nearly always present, and should be relieved by appro- priate drugs, such as the waters just named or cascara sagrada, of which the best preparation is the fluid extract, rendered free from bitter taste, as in "Cascara Aromatic." All fats, rich foods, strong meats, ham, bacon, and fried foods are to be avoided, and only light broths, koumyss, or matzoon resorted to if the case be an obstinate or severe one. A nitrate-of-silver pill should be used half an hour before each meal, and be prescribed as follows : R — Argenti nitratis . . gr. iv (0.25). Extract, hyoscyami gr. x (0.60). — M. Ft. in pil. No. xx. S. — One pill half to one hour before each meal. In cases in which the chronic inflammatory process has gone on to atrophy of the tubules the use of hydrochloric acid is often of great value. (For formula, see Hydrochloric Acid.) GASTRIC DILATATION. Gastric dilatation is to be treated with two objects in view, namely, the relief of the symptoms and the correction of the gastric condition as far as possible. The relief of the symptoms depends upon the suit- able regulation of the diet, the proper use of washing out the stomach (lavage), and the use of other remedial measures. All these efforts also tend to relieve or modify the underlying gastric state in that they remove certain influences which, if continued, would necessarily make the condition of the patient worse. The actual state of dilatation when once developed cannot be materially improved. In the way of diet, all articles bulky in character, such as cabbage, and those foods which are slow of digestion and capable of rapid fermentation should be excluded. Particularly is this true of rich or fatty foods, and of drinks such as beer and ale. When food is given, it is to be admin- istered in small amounts and often, rather than in large, full meals, and it should consist chiefly of roasted and broiled meats, easily digested starches, such as "Zweibach" bread or "pulled bread," and the green vegetables, like lettuce, asparagus, string beans, and moderate amounts of spinach. To aid in the digestion of vegetable foods 2 to 4 grains (0.12-0.25) of taka-diastase should be taken with each meal, and to this may be added a little powdered capsicum to stimulate the stomach. Where gastric digestion is very faulty, predigested food and rectal alimentation should be employed for a time. In the way of direct treatment, the stomach of the patient should be washed out with the stomach-tube at least once a day; and if fermentation is active and food is apt to be retained in this organ, it should be thor- QQS DISEASES. oughly cleansed before each meal, and some mild antiseptic, like boric acid, used in the washing fluid. Lavage not only removes decomposing food and mucus, but also exercises a beneficial effect on the gastric walls. The water used should not be cold nor tepid, but hot, and may contain 1 drachm (4.0) of boric acid to the pint (480 c.c). Faradic electricity applied to the epigastrium or to the stomach direct by a swallowed electrode is useful. In the way of direct treatment by drugs, the physician should use full doses of dilute hydrochloric acid to aid digestion, say, 20 to 30 minims (1.3-2.0), and give strychnine in full doses to aid this function, and also to increase the motor power of the stomach, so that it will urge the food on into the bowel. Often the lavage, electricity, and strychnine combined will produce great improvement. General hydrotherapy in the form of cold douches to the entire body, and exercise on horseback or on foot, are valuable in many cases. If fermentation is marked, antiseptic substances, like beta-naphtol, may be employed internally. GASTRIC ULCER. In the treatment of gastric ulcer three points must be borne in mind as being essential. These are, rest for the stomach as far as possible, rest for the patient, and the maintenance of the general health. The first of these points involves a consideration of diet. If in any case the stomach is very irritable, it is best to place the patient in bed and nourish her for from two to eight days by means of enemata. Probably the best form of nourishment for this purpose is a mixture recommended by Dreschfeld, and consisting of 2 raw eggs with 2 ounces (60.0) of beef-tea and a little brandy, which may amount to 1 ounce (30.0) if the patient really needs stimulants. It may be well to place a little pancreatin in this injection to peptonize the proteids, but if this is done the alcohol must be left out, as it will interfere with the activity of the pancreatin. Ewald of Berlin suggests the following nutrient enema: Beat up 2 eggs with a tablespoonful of cold water; to this add a little starch boiled in half a cupful of a 20 per cent, solution of grape-sugar, and a wineglassful of red wine. The solution is to be well mixed at a temperature not high enough to coagulate the albumin, and injected as high up into the bowel as possible. For a child this mixture should be somewhat less in quantity than that given for an adult, particularly as to the wine. For the relief of thirst, which may be excessive if rectal alimentation is resorted to, the patient may hold in the mouth small pieces of ice or drink moderate quantities of cool barley- or rice-water; but much thirst can be prevented by resorting to hypodermoclysis, whereby the body is supplied with plenty of fluid. (See Part III.) After this treatment has been used for some days, small quantities of food may be given by the mouth, such as a little peptonized milk or a little warm milk with lime-water in the proportion of half and half, or 1 part of lime- GASTRIC ULCER. QQ$ water to 2 of milk. After this, thin arrow-root or gruel may be given in moderate quantity, with taka-diastase to aid its digestion. It is better to give the food in small amount every two hours than in larger quantity three times a day. The increase in rations, both as to variety and amount, should be most gradual, the physician extending the dieting over at least six weeks, of which the first two had best be spent in bed. It is well to use massage and electricity under these circum- stances to preserve nutrition, as in the rest cure. (See Rest Cure.) Beef-tea and soups had better be avoided during the early stages of the treatment, as they will irritate the stomach. Soft-boiled eggs, tender chicken or game, and minced lamb may be finally given. Cheese, coffee, tea, beer, and ale are to be avoided, as are all very hot drinks. Fresh green vegetables may be used in moderation, but fresh bread and unripe fruit must be carefully avoided. When milk is taken it should be warmed. The presence of gastric pain indicates that the diet must be cut down in quantity and the nutrition maintained solely by rectal injection. The drug treatment of these cases is palliative as to pain, and curative. For the pain counterirritation of a more or less severe and constant type should be applied to the epigastrium, either as a spice or mustard plaster or by means of a hot-water bag. The counter- irritation should be as continuous as possible. Sodium bicarbonate and the subnitrate and subcarbonate of bismuth are also of service in the dose of 20 grains (1.3) each, and to these may be added from 2V to J grain (0.003-0.015) of morphine hydrochlorate or 1 grain (0.08) of codeine. These may be given thrice daily if necessary. Only the smallest dose of morphine necessary to relieve the pain should be employed. A valuable treatment for the pain and for the ulcer itself is the following pill: 1^ — Argenti nitratis gr. iv. (0.25). Extracti hyoscyami gr. x velxx (0.60-1.3). — M. Ft. in pil. No. xx. S. — One pill half to one hour before meals. Another useful drug in such cases is chloretone in 5-grain (0.30) doses given in capsule. When great gastric acidity is present which is not controlled by the pill named above or by the use of chloretone, the following formula may be employed : 1$ — Sodii bicarbonatis, Magnesii oxidi ponderosi, Calcii carbonatis . . . . . . aa ^j (30.0). 01. menthse piperita Ulx (0.60).— M. S. — A saltspoonful every two hours in a little water. For the constipation which is frequently present the patient may receive a dose of Carlsbad salt or phosphate of sodium, or even the sulphate of magnesium, although it is best, as a rule, to rely upon the 670 DISEASES. enema which is used to wash out the bowel each day and to produce a movement. For the relief of vomiting and of hsematemesis absolute abstinence from food, so far as its administration by the mouth is concerned, is to be insisted upon. Nutrition must be maintained under such circum- stances by feeding by the rectum with predigested food. (See Part III.) If the vomiting is persistent, small doses of cocaine, \ grain (0.015), may be given, or cocaine and bismuth subnitrate combined. Sometimes drop doses of creosote are useful, or phenol may be given in the same dose with 20 grains (1.3) of subnitrate of bismuth. One of the best remedies for hsematemesis is oil of turpentine in the dose of 5 to 10 minims (0.30-0.60) four times a day. In other cases good results will often follow the use of adrenalin chloride or of the solution of the subsulphate of iron (Monsel's solution) in the dose of 3 minims (0.20) in a little water every half-hour or by the employ- ment of 3 grains (0.15) of the salt itself in pill. Cold compresses or an ice-bag may also be applied to the epigastrium for the same purpose. Should perforation of the stomach occur, operative interference is to be promptly resorted to. Shock is to be treated by supportive treatment in the way of heat to the limbs and the hypodermic use of ether, brandy, or ammonia. Morphine should also be given freely unless collapse is too pronounced, as it tends to diminish abdominal pain and inflammation. GASTRITIS (ACUTE). This is generally due to the ingestion of irritant foods or drinks, rarely arising in its true acute form from other causes. The treatment is to be directed entirely to the prevention of the spread of the inflammation and to the relief of that already developed. If the patient is seen soon after the onset of the trouble, the stomach is to be emptied of all irritant substances by means of vomiting induced by large draughts of warm water, or, better still, by the use of the stomach-tube, as the retching may increase the irritation. Mucilaginous drinks are to be given freely, and albuminous materials seem especially useful. Oils and similar protective liquids aid in preventing further damage. Opium, to allay pain and the local and systemic irritation, is invaluable. This drug should always be given in liquid form, and the deodorized tincture is the best in this respect, owing to its freedom from narcotine. Paregoric contains too little opium to be of value. If the stomach will not retain drugs, they should be given by the rectum. If evidences of collapse appear, hot applications, atropine, or belladonna should be exhibited. It is important that the heat should be applied over the epigastrium and chest, and a flaxseed poultice is the best method of doing this. Practically, the same rules hold good in regard to diet in both acute gastritis and in gastro-enteritis. GLAUCOMA. 671 GASTRO-ENTERITIS. Gastroenteritis is a condition of inflammation affecting the entire alimentary canal in some instances, and commonly produced by the ingestion of some irritant substance, either in the form of bad food, poisons, or mechanical irritants, such as grape-seeds or cherry-stones. The symptoms accompanying it are exceedingly various, but consist chiefly in pain of a griping character, with watery or mucous stools, or, if the inflammation be very severe, absolute and unyielding con- stipation may be present. The nervous symptoms depend upon the degree of irritation and the general nervous tendency of the patient; and if the trouble is very severe, a condition of shock or collapse may result. If the irritation is very intense, exfoliation of the mucous membrane may take place, the epithelium coming away in shreds. The treatment of gastro-enteritis depends upon its severity and cause. Almost always we first allay the pain and tendency to inflam- mation by the hypodermic use of morphine, and immediately follow this or precede it by an emetic of a non-irritating and rapidly acting type, such as apomorphine, provided there is reason to believe that the poison or food still remains in whole or in part in the stomach. If the irritant has been taken some time before the physician is called to see the case, emetics are contraindicated, as by disturbing the abdominal contents they increase the inflammation. If the irritant has passed the pylorus, castor oil in the dose of 2 to 3 table- spoonfuls (30.0-45.0) to an adult may be given to sweep out the offending materials and lubricate the intestinal walls. In other cases sulphate of magnesium is to be used in preference to sulphate of sodium or Rochelle salt, as they are both slightly irritant. The sulphate of magnesium is of value, because, in addition to its purgative effect, it also depletes the inflamed bowel. Having got rid of all offend- ing materials, opium is to be freely used to allay irritation and control diarrhoea (see Diarrhoea), and hot compresses are to be applied to the belly, or a spice or mustard plaster used instead. Vomiting when excessive is to be treated in the manner described under that head. The after-treatment of acute gastro-enteritis is very important, both in respect to food and drugs. Predigested foods are therefore in many cases indispensable, and a carefully regulated diet is a sine qua non. The abdomen should be protected from cold by a flannel binder. GLAUCOMA. Glaucoma, a disease dependent upon an increase of intraocular pressure, appears in an acute or a chronic form. The affection in general terms is characterized by halos appearing about gasflame; periods of obscuration of sight; shrinking of the nasal half of the field of vision; narrowing of the anterior chamber of the eye; anaesthesia 672 DISEASES. of the cornea; and increased tension of the eyeball. In the "glauco- matous attack," or acute glaucoma, the injection of the eyeball is intense; the lids swell, there is photophobia, the cornea is steamy, the pupil dilated and motionless, and the vision rapidly destroyed. The case may be mistaken for iritis or acute ophthalmia — a fatal blunder. Iridectomy or an equivalent measure is the best treatment for acute glaucoma. If for any reason this is delayed, a solution of the sulphate of eserine, 1 to 2 grains to the ounce (0.06-0.12 : 30.0), or pilocarpine hydrochlorate in twice this strength, should be dropped into the eye every two or three hours until relief follows. Atropine must not be employed. Hot compresses are also useful to alleviate the pain if for any reason operation is delayed, and full doses of salicylate of sodium should be administered. In chronic, non-congestive glaucoma the myotics are useful; if these fail, iridectomy may be employed, and in recent times excision of the superior cervical sympathetic ganglion has been recommended. GONORRHOEA. The therapeutics of urethritis varies in accordance with whether the disease is acute or chronic, and is very greatly modified by the seat of inflammation — a posterior urethritis, for anatomical and mechanical reasons, not being amenable to the same treatment which will prove successful when the disease is limited to the penile portion of the urethra. The membranous and prostatic portions of the urethra constitute its posterior part. They are surrounded by layers of powerful muscles which keep the canal constantly occluded and which play the part of vesical sphincters. Hence hand injections forced into the urethra pass to, but not beyond, its membranous part, and are worse than useless if administered with the intention of combating inflammation of the posterior urethra. It is the rare exception for gonorrhoea to be confined to the anterior urethra. Usually it extends back, and a common cause of gleet is failure to recognize this fact, and consequently the omission of measures calculated to cure the deep inflammation. Since the general acceptance of the gonococcus as a specific cause of gonorrhoea the treatment of acute anterior urethritis has been mainly antiseptic, those drugs being chosen which are found to act most powerfully upon the specific germ, and at the same time produce the least irritant action upon the mucous membrane. Bichloride of mercury, as representing the most powerful germicide known to medicine, has been used extensively. The main objection to its action lies in the fact that when employed in efficient strength it is exceed- ingly irritating. Potassium permanganate, though of less antiseptic power, is therefore preferred. A fairly satisfactory treatment consists in thoroughly and repeatedly flushing the urethra with permanganate lotion, 1 : 6000. This may be accomplished by means of a fountain- syringe and a blunt, flattened, conical nozzle of such size that when GONOBRHCEA. 673 its extremity is passed into the meatus its sides will be grasped so tightly that gentle pressure upon the nozzle will prevent regurgitation of fluid. The bag is filled with hot permanganate solution, 1 : 6000, and is elevated six feet above the level of the bladder. After first thoroughly washing the glans and lips of the meatus the nozzle should be inserted and held firmly in place until the entire anterior urethra is distended, when the nozzle should be slightly withdrawn and the urethral contents allowed to escape. After this has been repeated several times the nozzle is held firmly in place till 3 or 4 ounces of solution have passed into the bladder. This treatment should be repeated night and morning for at least a week, the strength of the permanganate solution being gradually increased up to 1 : 2000, if undue irritation is not caused by such increase. If at the end of a week no gonococci can be found, the irrigations should be continued once daily for four days, supplemented by astringent injections. When gonococci persist, the irrigations should be continued for two or three weeks. When this method of irrigation cannot be practised, a syringe with a conical nozzle and with a capacity of at least 1 ounce may be employed: this should be used two to six times a day, two syringefuls of the dilute lotion being injected immediately after urination. The liquid should be forced in very gently, being allowed to flow out by slightly lessening the pressure of the nozzle upon the meatus when the anterior urethra is full. When large injections are attempted by the ordinary small urethral syringe, the frequent application of the latter to the meatus occasions much irritation. It is desirable that the injections should pass back into the posterior urethra, since this portion of the canal is usually involved in acute inflammation. Copious irrigations inaugurated in the earliest stages of gonorrhoea are frequently successful in producing a complete cure in a few days. The following prescriptions used as hand-injections are among the most efficacious in checking persistent discharge: R — Nargol, argyrol, or protargol . . . . gr. iij (0.20). Aquae destil g iij (90.0).— M. H— Fluidext. hydrast. (colorless) . . . f giv (16.0). Bismuth, sublact ^vj (24.0). Glycerin f.^iv (16.0). Aq. destil. ....... q.s. fgvj (180.0).— M. 1$ — Zinc, sulphatis, Phenolis, Alum. crud. . . . . . ■ . aa gr. xij (0.80). Aq. destil. ... fgvj (180.0).— M. S. — Locally. Dilute if painful. When the gonorrhoea has already assumed a markedly inflamma- tory type, with swelling and oedema of the penis, redness and ever- sion of the meatus, and great sensitiveness of the urethra, and seems to be aggravated by mild irrigations, the penis should be wrapped in cloths kept wet with alcohol and water or lead-water and laudanum. 43 074 DISEASES. With the subsidence of acute inflammatory symptoms and the appear- ance of copious discharge the injection treatment may be inaugurated. It must be remembered that injections may in themselves prevent the discharge from entirely disappearing. Hence, as the symptoms ameliorate the injection should be made less frequently, finally being entirely omitted for some days if the discharge seems to continue longer than usual. Internal medication and constitutional treatment are most important in all forms and stages of gonorrhoea. It is almost universally accepted that certain drugs, such as copaiba, cubebs, and oil of sandal-wood, when eliminated through the kidneys, possess the power of inhibiting the growth of the gonococci or of destroying their vitality. Bacterio- logical research has shown that of this class of remedies copaiba partic- ularly possesses such power. To this drug may be added phenyl salicylate, which has been proved by laboratory and clinical tests to exert a powerful germicidal action upon the gonococcus. Clinical experience has shown that oil of sandal-wood is of great value in the treatment of chronic gonorrhoea. An excellent formula for the administration of balsams is the following: If— 01. santal gr. v (0.3). Balsam copaibse rriv (0.3). 01. cinnamom TTlj (0.05). — M. Encapsulate. S. — These capsules should be taken one hour after meals, from six to twelve being administered a day. Obstinate chordee may require bromide of potassium and chloral. Of these a drachm of the former must be given at bedtime, and 10 grains (0.60) of the latter; this may be repeated in the night if painful erections persist. Lupulin in 30-grain (2.0) doses is also endorsed. When practicable, opium or belladonna suppositories, or hypodermic injections of morphine gr. \ (0.015) and atropine gr. -^ (0.001), will prove very satisfactory. In all cases the patient should be instructed to take a prolonged hot bath before going to bed, and to rise once during the night to pass water. Ardor urinye is usually relieved by the use of demulcent drinks and by the employment of bicarbonate of sodium or citrate of potassium in sufficient doses to render the urine but slightly acid. Either of these drugs is conveniently administered in the form of compressed tablets, taken one or two hours after meals in 10-grain (0.60) doses, the quantity being increased, if necessary, until the desired effect is produced on the urine. The instillation into the urethra, by means of an eye-dropper, of a 4 per cent, solution of cocaine a few minutes before urination markedly diminishes the burning. Finally, this symptom may often be relieved by instructing the patient to pass water with the penis submerged in a vessel containing water as hot as can be borne. Where the inflammation is of a high grade and attended by fever GONORRHCEA. 675 and general malaise, rest in bed, milk diet, and the administration of 6 minims (0.40) of tincture of aconite, repeated every two or three hours, is followed by marked relief. In regard to the general treatment of a patient suffering from gonor- rhoeal urethritis rest in bed is particularly desirable. This, however, is rarely possible, and the surgeon must be content with enforcing the avoidance of all active exertion and the observance of as much rest of mind and body as is compatible with the continuance of the daily routine of business life. While skimmed milk or buttermilk diet is theoretically desirable, the advantages to be gained by it are scarcely sufficient to justify insistence upon such a regimen, especially as it would excite suspicion as to the presence of venereal disease; hence a light diet, consisting mainly of vegetables and fruits, and in quantity about half that usually taken, with a minimum amount of meat, should be advised. In addition the patient should be induced to drink lib- erally of plain water or any of the sparkling mineral waters, as by this means the urine is not only rendered bland, but also greatly increased in quantity, thus enabling the urethra to be fully flushed from behind many times a day. Flooding of the stomach with such large quantities of liquids as to produce dyspepsia is to be carefully avoided. It is scarcely necessary to state that copulation or any form of venereal excitement must be strictly interdicted. Finally, prolonged warm baths lasting from half an hour to two hours seem to exert a favorable influence upon local inflammation. The distressing symptoms of acute posterior urethritis do not usually develop until the disease of the penile portion of the urethra has run a course of two or three weeks. During the very acute symptoms local treatment applied to any portion of the urethral canal probably aggra- vates the condition, and even the internal administration of balsams and antiseptics must be employed with very great caution, their use being suspended at once if the inflammation seems to be aggravated. Hence, when in the third week of gonorrhoea there is a violent out- break of inflammation in the membranous and prostatic portions of the urethra, suspension of all active treatment is indicated. The bowels are kept open; the diet is carefully regulated; the urine is rendered bland, unirritating, and antiseptic; repeated warm baths are ordered; the painful symptoms being controlled by opium and belladonna, administered either hypodermically or in the form of a suppository. When the acute symptoms subside, the quantity of antiseptics taken by the mouth may be increased, balsams may be added, and local treatment may be directed first to the posterior urethra, after the cure of which the anterior urethritis should receive attention. It has been stated already that injections forced into the meatus rarely penetrate beyond the bulbous portion of the urethra; hence to influence the deeper portions of this canal some other method of applying drugs must be devised. This end is best accomplished by means of the gravity-bag and meatus nozzle or by the instillator. 676 DISEASES. The patient is first instructed to empty the bladder of a portion of its contents; by this means the urethra is flushed out. The catheter is then introduced into the membranous portion of the canal, and by means of a syringe 10 minims (0.60) of the injection are forced into the membranous and prostatic portions of the urethra. This fluid enters the bladder, and is passed with the urine at the next act of micturition. The injection most employed is a 1 to 10 per cent, solution of nargol, argyrol, or protargol. Any of the injections used in anterior urethritis may also be now employed. These instillations should be made every second or third day. Chronic Gonorrhoea. Chronic gonorrhoea differs from the acute form in the fact that the inflammation is distinctly localized in certain portions of the urethra, and does not invade the whole canal with uniform intensity; hence, efficient treatment must be directed not to the whole urethra, but to the diseased areas. Foci of chronic urethritis are usually found either in the bulbous portion of the urethra or in the membranous or pros- tatic portion. If the disease is located in the anterior urethra, it will commonly be found to depend upon the existence of a stricture of large calibre. The passage of sounds of full size — cutting the meatus if this is necessary for their introduction — will be followed by prompt relief in such cases. The sounds should be used not more frequently than twice a week, and should be followed by copious urethral antiseptic flushings, best effected by the gravity-bag and short urethral nozzle, irrigating daily with nargol, argyrol, or protargol (1: 3000 to 1: 500), silver nitrate (1: 1000), mercurol (1 : 2000), or potassium permanganate (1:2000 to 1:500). When the general catarrhal condition is materially modified, by means of an ordinary urethroscope the focus of inflammation may be exposed, and may be treated directly by strong astringent solutions carried in by means of a brush or by absorbent cotton secured to the extremity of a long applicator. Nitrate of silver or sulphate of copper, 20 grains to the ounce (1.3-30.0), may be employed. Unna has devised a most successful treatment for obstinate cases of gonorrhoea. He advises coating the sounds with the following mixture: I$— 01. cocse giij (90.0). Cerse flav . ;. . 5ss (2.0). Argent, nitratis gr. xv (1.0). Balsam. Peruvianum 5ss (2.0). — M. This is liquefied in a water-bath; the sounds are dipped in it and are then hung up to dry. On being passed the heat of the body melts the coating. The objection to their use lies in the fact that the appli- cation is made to the entire urethra. Practically, however, their employment is often followed by brilliant results. Chronic posterior urethritis must be treated by remedies applied directly to the diseased area. The silver salts are more commonly GONORRHCEA. ^77 successful than any other medication. By means of Ultzmann's instillator 5 to 10 minims (0.3-0.60) of a solution varying in strength from 0.1 per cent, to 5 per cent, may be employed. Irrigations are also serviceable; but previous to their employment the prostatic follicles should be emptied of their purulent contents by massage through the rectum. Finger recommends the following ointment: 1$ — Argent, nit rat is vel cupri sulph. . . . gr. xv (1.0). Lanolin 5iij (90.0). 01. olivae ojss (6.0).— M. By means of an ordinary catheter — which is first filled, then intro- duced until its eye reaches the prostatic portion of the urethra — a definite quantity of the ointment can be forced into the canal by a graduated rod. In many cases pressure will exert a curative action, causing prompt absorption of inflammatory effusion. To accomplish this result large sounds may be passed into the bladder. Frequently the thera- peutic influences of cold, together with pressure, are found beneficial. The best means of combining these two remedies is found in the psychrophore, an instrument in the shape of a sound, but so arranged that a stream of water flows through its interior. It must be borne in mind that chronic gonorrhoea is commonly due to unskilful or not sufficiently prolonged treatment of the acute stages. Not only should the treatment of acute gonorrhoea be continued until the gonococci have entirely vanished, but for fully two weeks after the disappearance of all symptoms of inflammation. The same rule holds good in regard to the chronic manifestations of the disease. Only after careful examination of the urine fails to show any sign of inflammatory trouble for at least two weeks should the treatment be suspended; and this should not take place suddenly, but the intervals between the applications be gradually increased in length, the patient being carefully watched in the mean time. Per contra, it must not be forgotten that long-continued irritant treatment may in itself indefinitely prolong a urethral discharge. Hence it is wise to suspend all injections in certain cases, and to exam- ine the discharge carefully, as found in the urine, to determine whether or not the continuance of symptoms is dependent upon this cause. There is a mucous secretion which quite frequently follows gonor- rhoea, but which is in no way dependent upon the persistence of this disease. Microscopic examination will at once determine its nature. It is probably most rapidly cured by attention to general hygiene and by tonic and supporting treatment. Complications of Gonorrhoea. Among the many local and general complications which may occur in the course of an acute or subacute gonorrhoea are balanitis, balano- posthitis, prostatitis, and epididymitis. 678 DISEASES. Balanitis and balanoposthitis are treated by perfect cleanliness, The discharge must be thoroughly washed out, and the surface must be dried and isolated. The thorough cleansing of the parts is best accomplished by weak astringent solutions, such as the chloride of zinc, 4 grains to the ounce (0.25-30.0), 1 per cent, boric acid, or 1.5 per cent, phenol; nitrate of silver is particularly valuable, and in the proportion of 1 grain to the ounce (0.06-30.0) will be found sufficiently strong for use as a wash or injection. The superficial ulcerations may be further touched with the solid stick of the nitrate of silver. The prepuce having been retracted and the parts having been thoroughly washed, dusting-powder, such as tannin or oxide of zinc, is distributed over the surface of the inflamed parts; the glans is then covered with a thin layer of absorbent cotton and the prepuce drawn forward. This dressing is to be repeated three times daily. If the phimosis is so tight that the prepuce cannot be retracted, cleansing, astringent injections, and wrapping the penis in one or two thicknesses of gauze or other thin fabric, constantly kept wet with dilute lead-water, will be the treatment indicated. If, in spite of this treatment, inflammatory symptoms become more marked, splitting the foreskin or circumcision is indicated. Prostatitis is a rare complication, and in its early course presents the symptoms of posterior urethritis. Where the acute symptoms are fairly developed direct local treatment is of little avail. Rest in bed, light diet, careful regulation of the bowels, medication to render the urine bland and unirritating, elevation of the pelvis, local depletion by means of leeches applied to the perineum, rectal ice-bags, and the administration of morphine and belladonna, either by means of sup- pository or by hypodermic injection, represent the general treatment of all inflammatory conditions at or about the neck of the bladder. In the great majority of cases prostatitis undergoes prompt resolution, and this is more powerfully influenced by rectal injections than by any other method of treatment. For this purpose a two-way rectal tube must be employed, the nozzle of which is directed against the pro- jection of the prostate into the bowel. From 2 to 4 quarts (2 to 4 litres) of normal saline solution, either very cold or as hot as can be borne, are allowed to flow into the rectum by gravity, this arrange- ment of the tubes allowing the injection to flow out as rapidly as it flows in. This treatment should be repeated three or four times a day. When, in spite of careful treatment and the free use of anodynes and antispasmodics, there is retention of urine, a soft catheter should be passed into the bladder and allowed to remain there. If general and local symptoms denote abscess-formation, the pus should be evacuated by perineal incision as soon as its' presence is positively determined. It is true that the pus collection usually is spontaneously discharged into the urethra, but this result cannot cer- tainly be depended upon, and, at best, is an unsatisfactory termina- tion of the trouble. GONORRHCEA. 679 When the inflammation runs into a chronic type, the treatment suitable for chronic posterior urethritis is indicated — namely, the use of large cold steel sounds, massage, and local applications to the pros- tatic urethra. In addition rectal injections, by means of the two- way tube, are very efficient in producing a cure. Epididymitis requires rest in bed, cessation of all irritating local treatment directed against the gonorrhoea, elevation of the pelvis and testicles, and the systemic treatment applicable to acute inflamma- tion. The general tendency of this complication of gonorrhoea is toward spontaneous resolution. The testicles may be supported by a handkerchief bandage, the base of which is passed beneath the scro- tum, while the ends and apex are secured in front to a circular band passing about the waist. To combat the agonizing pain and hasten cure punctures have been advised. These, by relieving tension, promptly alleviate the suffering. Ice-bags may also be applied, though it is claimed that as a result of this treatment there remains an obstinate induration of the epididymis. Local applications of nitrate of silver, guaiacol (5 per cent, ointment), and of tincture of iodine are also said to act beneficially. Since it is usually impossible for a patient suffering from gonorrhoeal epididymitis to keep to his bed, a treatment must be devised which will allow him to attend to his business, and at the same time will prevent the inflammation from becoming aggravated. The part must be splinted; if at the same time uniform pressure can be applied, the cause of the trouble will be still further favorably modified. These indications are complied with, partially at least, by strapping the injured testicle. For this purpose a number of adhesive resin strips, each half an inch wide and long enough to pass three-fourths around the swelled testicle, are cut. The first strip encircles the scrotum between the affected testicle and the body, tightly imprisoning the former in a pouch of skin. The succeeding strips are then placed, each overlapping the other in such a manner that the entire pouch is covered in, and a handkerchief bandage, applied as described above, may then be used to elevate the testicle. A better means of securing rest and pressure, and at the same time exerting the resolvent influ- ences of heat and moisture, is offered in the dressing proposed by Horand-Langlebert. The entire scrotum is first enveloped in a thick layer of cotton; over this is placed a piece of rubber-dam sufficiently large to cover in the cotton, and the dressing is completed by a jock strap, gored at the sides and provided with tapes to allow of close fitting. Unless there be decided swelling of the spermatic cord, this dressing usually allows the patient to attend to his business, and is followed by as prompt resolution as though confinement to bed had been insisted upon. When the acute symptoms have disappeared attention must be directed to the removal of infiltration, which if it persists may be a cause of sterility. This is accomplished by the continuance of heat, 680 DISEASES. moisture, and pressure; by local applications, such as iodine gr. iv (0.25) in lanolin §j (30.0), or of equal parts of mercury ointment and belladonna ointment, or by ichthyol, with lard half and half, and by the internal administration of iodide of potassium, 3 to 5 grains (0.20-0.30) three times daily. Gonorrhoea in the Female. The symptoms of acute gonorrhoea in the female are usually so mild that the attention of the physician is rarely called to the disease until it has reached its chronic form and has invaded the uterus and its appendages. When, however, acute urethritis is found, the treat- ment, both local and general, is conducted on the same principles as when the disease attacks the male urethra. During the most acute stage no local treatment is advisable, but subsequently injections can be made with the ordinary hard-rubber syringe, not more than a drachm and a half of the liquid being employed at a time. If the urethral discharge persists, the seats of the suppuration are readily found by the endoscope tubes, and treated directly by applications of strong solutions of nitrate of silver or sulphate of copper. The results of treatment are commonly satisfactory. Acute vaginitis is not very frequently observed, excepting in chil- dren and young girls. In addition to the general treatment of inflam- mation, local treatment directed to cleansing thoroughly the inflamed surfaces of discharge and acting upon them by a strong antiseptic lotion will be followed by a rapid cure. The patient is instructed to irrigate the vagina three times daily with 2 pints (960 c.c.) of bichlo- ride-of -mercury solution, 1 : 4000, thrown in by means of a fountain syringe. For this fluid to reach every portion of the diseased mucous membrane it is necessary that the patient should lie upon her back with the hips elevated. Before rising a pledget of absorbent cotton is placed between the labia. During the most acute stage of vaginitis hot-water injections and prolonged hot sitz-baths are indicated, In addition to the antiseptic irrigations which the patient is directed to make, the physician should every second day insert a speculum and paint every portion of the diseased mucous membrane with nitrate- of-silver solution varying in strength from 4 to 40 grains to the ounce (0.25-2.60: 30.0). The vagina should then be packed with tampons of absorbent cotton, which may be dusted with astringent medicaments. Vulvitis corresponds to balanitis in the male, and is treated in a similar manner. Cleanliness is the most essential point in securing a cure. The parts are thoroughly washed with weak antiseptic lotions, and the abraded mucous surfaces are kept from coming in contact by means of a layer of absorbent cotton or a piece of lint soaked in dilute lead-water or other mild astringent solution. GOUT. 681 GOUT. Gout is a word used to signify a series of manifestations occurring chiefly in those who have led an inactive life devoid of exercise, have lived on the fat of the land, and partaken more frequently of alcoholic beverages than of water; or it occurs in persons who do not live in this way, but whose ancestors have done so, and have transmitted to them the gouty taint or diathesis; or, once more, in those who have had poor food for a long time. In other words, it is a disorder of nutrition and metabolism. Very few Americans have gout in its marked and characteristic forms, owing to the active life they pur- sue, and to the fact that the inhabitants of the Western hemisphere drink large amounts of water, thereby continually dissolving effete matters in the system and washing them away. Nevertheless many Americans suffer from w T hat may be called lithaemic symptoms, which are due to lack of exercise, overeating, and perverted metabolism. The therapeutic importance of pure water in this state is remark- able, but the so-called lithia waters depend for their value more upon their freedom from lithium salts than upon their presence. When a patient goes to medicinal springs, by continually drinking water he washes out the kidneys and prevents deposits of effete matters throughout the body. In a gouty individual the liquids of the body may be said to be so overladen with salts that they deposit them wherever a spot is found which is easy of access, just as water laden with lime forms a deposit on the sides of its bed in times of drought and dissolves and removes these formations w T hen a freshet takes place. Very often, when such waters are not attainable, satisfactory results will be obtained from ordinary distilled water, the insipid taste of which can be overcome by charging it with carbonic acid gas. When an acute attack of gout comes on, it is generally situated, as is well known, in the joint of the big toe, but it may involve any part of the body, even to the heart and the abdominal viscera. By far the best remedy for the relief of the pain, if it is unbearable, is morphine, which should be given hypodermically. At the same time the best remedy for gout that we have, colchicum, should be freely given until the patient shows the full effect of the drug, as evidenced by gastrointestinal discomfort or pain and slight laxity of the bowels. The drug should be used in the form of the wine of the seed, in the dose of 40 minims (2.6) at first, and increased by 2 minims (0.10) every four hours until relief is obtained or symptoms of overdose appear as noted above. In other instances the method of ad- ministration suggested in the article on Colchicum may be resorted to. Many physicians at the present time prefer the somewhat more agreeable method of using colchicum in the form of colchicine sali- cylate, which is a mixture of colchicine and oil of gaultheria, about Y^ grain (0.0006) of colchicine being present in each capsule and 3 to 6 being given each day, at intervals of a few hours. 682 DISEASES. The local treatment of gout, when it is active, consists in the appli- cation of a number of remedies. For hospital practice a very useful mixture is made by adding 1 part of bicarbonate of sodium to 9 parts of linseed oil. The joint is then wrapped in a piece of lint soaked with this concoction. In other cases collodion may be applied in one or two good coats, not more, with relief, and in still others oil of pep- permint has been recommended. It is to be remembered, however, that the inflamed joints are not to be treated by depletion through leeches or bleeding, as by this means they ultimately become worse; or, in other words, the treatment of gouty inflamed joints is not iden- tical with that of inflamed joints from other causes. When the pains of acute gout are very severe at night, potassium iodide, in the dose of 15 grains (1.0) at four or five o'clock in the afternoon, will sometimes give relief; this drug should always be combined with colchicum if the disease is subacute or chronic. In chronic gout, except during the acute exacerbations of the dis- ease, colchicum is almost useless, but potassium iodide should be pushed to the point of iodism if the trouble be painful. Here diet forms an important part of the treatment, and should consist of foods which are not fatty nor rich, but plain and nourishing. Milk and eggs, the white meat of chicken and fruits, cooked without sugar being added, are allowed, tea and coffee being used only in modera- tion. If any wine is taken, it must be followed by copious draughts of pure water, and this last article should be used ad libitum. On the other hand, pastries, and, more than all, sweet wines, are the worst things that such a patient can take, and must be absolutely prohibited. The insomnia of chronic or subacute gout is best overcome by potassium bromide and chloral, the former drug being the safest and best. Nothing should be done in the neighborhood of gouty joints which will injure the skin, as it is easily disorganized and its injury may lead to erysipelas. Where the deposit around a joint is very great and the normal movements are impossible, relief is often obtained by the application of a solution of citrate or carbonate of lithium, 5 to 10 grains to the ounce (0.30-0.60: 30.0) of water, on lint wound around the parts. Where the skin is broken and will not heal, this treatment often permits healing by dissolving the crystals in the wound which prevent approximation of the edges and so cause local irritation. Iodine ointment or the tincture of iodine is often placed around chronic gouty joints with advantageous results. A standard remedy in subacute or chronic gout is arsenic, and its administration in the form of 3 minims (0.20) of Fowler's solution, with either perfectly pure or lithiated water, is always to be resorted to when the iodides and colchicum are temporarily abandoned. If anaemia is present, arsenic is particularly indicated, and cod-liver oil and syrup of the iodide of iron are also of value in this state. Gouty HEADACHE. (583 patients should take as much exercise and be in the fresh air and sun- shine as much as possible. We find, therefore, in conclusion, that the use of large amounts of pure water free from salts, and the administration of colchicum, potassium iodide, and arsenic are the greater points about which treatment should centre. In those cases where retrocedent gout occurs the heart must be supported by stimulants, particularly by hypodermic injections of ether, until the slower drugs can act, by heat over the belly, by the use of opium to allay irritation, except when the brain and kidneys are seriously affected, by the use of diuretics and alkaline drinks, and finally by counterirritation in the shape of a mustard plaster placed over the abdomen or chest as the case may require. HEADACHE. (For Neuralgic Headaches, see Neuralgia; for Bilious Headache, see Biliousness.) Probably no single source of pain compares in its frequency to headache, chiefly because it is essentially a symptom of many dis- ease processes or functional disturbances. It may arise from con- stipation or eye-strain, from brain disease, from anaemia, from uraemia, from plethora, from nervous breakdown, and from a multitude of causes which, if they were all recounted, would cover many pages of this book. 1 In many instances the employment of a mild laxative, which will cause the bowel to empty itself thoroughly, is a necessity. In others a careful measurement of the amount of urine passed in the twenty-four hours will show that the urinary secretion is deficient in liquids and solids, so that effete and poisonous materials are retained in the blood, which produce headache. For such cases, if the urine is acid, the frequent use of Vichy water (Celestins Spring), to which is added a little bicarbonate of potassium as a diuretic, will prove of great service. If the urine is alkaline, 10 grains (0.60) of ammonium benzoate are often useful. Congestive headaches, dependent upon engorgement of the cere- bral vessels with blood, are to be treated in a number of ways. If any direct cause of congestion can be discovered, this must, of course, be removed. So far as the direct application of drugs is con- cerned, we find two methods of promoting a cure, according to the cause. Thus if the patient be neurasthenic and feeble the use of ergot and strychnine, which will cause contraction of the dilated vessels, is useful; whereas if the congestion is due to high arterial tension and excessive cardiac action, the bromides and the employment of vascular sedatives, which will produce arterial depression and so remove con- gestion, are indicated. It is to be remembered that when the con- 1 See chapter on Headache in the author's Practical Diagnosis, Lea Brothers & Co. 684 BTSEASES. gestion is due to vascular relaxation and weakness vascular sedatives are contraindicated. The use of a hot mustard foot-bath is of great value, and a mus- tard plaster or dry cup applied to the nape of the neck is often of service in congestive headaches, while in severe cases an ice-bag applied to the head or leeching behind the ears or on the temples may be resorted to. Bleeding often gives relief at once in severe congestive headache. In nervous women who suffer from headache much comfort and relief will often ensue if the top of the head be wet with one of the following formulae : 1^ — Spt. camphorae fgj (30.0). Spt. lavandulse, Alcoholis . . . . . . . . aa f gij (60.0).— M. S. — Apply locally. Or, 1$ — Camphorae, • 01. menth. piperit. aa 3] (4.0). Chloroformi f§ss (16.0). Alcoholis q. s. ad f §iij (90.0). — M. S. — Shake the bottle and apply a little of the liquid to the head. In other instances bathing the head with cologne water to which have been added 5 grains (0.3) of menthol to the ounce is useful. Where headache depends upon fatigue, either general or local, stimulating treatment is necessary. If eye-strain be the cause, full doses of strychnine or nux vomica are of service, but these remedies cannot be used if there is much retinal irritability. Proper eyeglasses are, of course, indicated in such a case. In many instances a combi- nation of caffeine, bromide of potassium, and antipyrin is very successful, as follows: I$— Caffeinae citratis gr. xl (2.60). Potassii bromidi giv (16.0). Antipyrini £ij (8.0), — M. Ft. in chart. No. xx. S. — One powder in water as needed. Sometimes the caffeine makes the headache more acute, and if this occurs only the antipyrin and bromide can be used. (See articles on Antipyrin, Acetanilid, and Phenacetin.) Another useful prescription is: 1$ — Extract, guaranae gr. x vel xx (0.60-1.3). Ext. apii graveol gr. x (0.60). — M. Ft. in capsul. vel chart, vel pil. No. x. S.— One every half -hour till relieved or three are taken. Sleep is generally a more useful prescription than any drug, and if city life creates so much mental anxiety during the day as to be wearing upon the nervous system or make the patient wakeful at night, business must be put aside and health and recreation sought HEART DISEASE. 685 at a watering-place. Horseback exercise is very useful indeed, and should be resorted to by all who can afford it if they are sufferers from nervous headaches. Walking is also useful. A form of headache which is often very severe, sometimes fleeting, sometimes persistent, is that due to gout, and it is to be treated by means quite distinct from those named so far. Some practitioners of wide experience employ salicylic acid in doses of from 5 to 15 grains (0.3-1.0), while others rely on the iodide or acetate of potassium. (See Migraine.) Other cases of a gouty headache require colchicum, particularly if the gout be widely distributed in its manifestations, and to these Hamilton gives: R — Vini colchici seminis f 5ss (16.0). Potassii acetatis, Potassii iodidi, Tr. cimicifugae racemosae ... aa f5v(20.0). Aquse destil q. s. ad f giv (120.0). — M. S. — Teaspoonful (4.0) every four hours. In cases in which anaemia is associated with the gouty tendency Peabody uses the following prescription, the ingredients of which are compatible, whereas most of the preparations of iron and salicylic acid are incompatible: Py — Acid, salicylic gr. xx (1.3). Ferri pyrophosphat gr. v. (0.3). Sodii phosphatis gr. j (0.06). Aquae dest. f^ss (16.0).— M. S. — To be taken every three hours. Cohen has used the following, which is more pleasant to the taste: Py — Sodii salicylatis Glycerini 01. gaultherise . Tr. ferri chloridi Acid, citrici . . 5iv (16.0). . fgij (60.0). . nvxx(1.3). . f5iv (16.0). . gr. x (0.60). Liq. ammonii citratis, B. P. 1 . q. s. ad f§iv (120.0). — M. S — Dessertspoonful (8.0) in water twice, thrice, or four times a day. (For the treatment of migraine, see Migraine.) HEART DISEASE. (For Treatment of Angina Pectoris, see p. 571.) The writer classifies all forms of heart disease under this heading advisedly. In valvular disease the profession understands more and more that the mere destruction or laming of this valve or that has 1 Liquor ammonii citratis, B. P., is made by adding 5 fluidounces (imperial meas.) of strong solution of citrate of ammonium to 15 fluidounces (imperial meas.) of distilled water. The stronger solution of citrate of ammonium is made by taking 12 ounces (avoirdupois) of citric acid, strong solution of ammonia 1 1 fluidounces, and adding enough distilled water to make 24 fluidounces (imperial meas.). 686 DISEASES. little to do with the treatment, although the ultimate result of the case is somewhat dependent upon these conditions. It matters not whether the leak in a valve be minute or great, provided the heart can still do its work; the condition of the cardiac muscle is the impor- tant factor to be considered. If an irreparable leak exists in a pump which cannot be stopped for repairs, the question is not, Can we cure that leak? but rather whether we can work the pump with enough force and rapidity to obtain all the water needed for the maintenance of life. Some physicians use heart tonics, such as digitalis, whenever they find a valve diseased, as if to mend the broken valve. Nothing can be more erroneous, for a valve once injured is never regenerated. It is only in those cases which have relaxation of the muscular fibres around the mitral orifice that digitalis can cure a murmur of regurgi- tation. It should be an invariable rule with every physician in examining a patient with heart disease to determine whether or not the tissues of the body receive their normal blood-supply. If they do not, even though the leak is so small as almost to escape notice, treatment is to be instituted; but, on the other hand, if the murmur heard on auscul- tation is as loud as that of a machine-shop and the tissues are not starved, no remedy is needed. Indeed, it not rarely occurs that no murmur can be heard in the presence of signs of circulatory feebleness, because the heart may be too feeble to drive the blood past the leaking valve with sufficient force to produce any sound. Another very important point in regard to the treatment of cardiac disease in children is the remembrance that the stunting of the body and the slowness of growth are not merely the result of heart trouble, whereby the tissues do not increase in size from lack of nourishment, but occur for a special purpose. Let us suppose that a child of eight or nine years has scarlet fever or rheumatism, which leaves the cardiac valves impaired in function, the question must arise: "Can the heart properly fill the bloodvessels?" If the heart can supply the vessels, the child lives, but is stunted, because Nature is wise enough to understand that the struggling heart has all it can do to supply even a stunted frame, and realizes that a rapidly increasing area of bloodvessel surface in a growing child would exhaust the cardiac muscle. The physician should not permit the parents to worry over this lack of growth, but by the use of gentle gymnastics or tonics, and attention to the general health, he is often enabled to improve the cardiac condition. As soon as this organ is strong enough to permit of growth, growth will take place. In the general treatment of heart disease in persons who have until recently had no signs of heart-failure the most important thing for the physician to prescribe is rest. A tired heart cannot supply an active body. Having made these preliminary remarks, let us turn to the direct application of drugs to heart disease, the chief drug in the list being, of course, digitalis. HEART DISEASE. 687 The value of digitalis may be said to rest upon a number of influ- ences possessed by it. In the first place, evidence is constantly accu- mulating to show that digitalis increases the nutrition of the heart muscle by the stimulating influence which it exerts on the pneumo- gastric nerve, this nerve having been partly proved to be a trophic nerve of the heart. Aside from any such nervous influence, the heart muscle receives a greater blood-supply under the use of digitalis, since both diastole and systole are influenced by the drug, the systole being more complete and the diastole being prolonged and more extensive. Two theories concerning the nutrition of the heart muscle through its blood-supply have been promulgated. One is, that the coronary arteries are filled with arterial blood as the heart drives its contents out of the left ventricle into the aorta, or, in other words, during systole. The other hypothesis rests upon the belief that the contracting muscle prevents a free circulation of blood through the cardiac bloodvessels, and that the blood is driven into the coronary arteries during diastole by the pressure in the aorta, the aortic valves being closed. The latter view is incorrect so far as the coronary arteries are concerned, for they are filled during ventricular systole, and this systolic contraction of the muscular fibres urges onward the blood already in the intramural vessels. Nevertheless the complete passage of the blood through the smaller vessels of the cardiac muscle only takes place as relaxation or diastole occurs. The ground for this belief consists in the observation that a muscle when firmly contracted always presses upon its supplying bloodvessels, and particularly interferes with capillary flow. The heart of one of the lower animals, if carefully watched after the chest- wall is removed, will always be found to become paler during systole and redder during diastole. As the blood everywhere in the body nourishes the tissues, not when in the arteries, but while passing through the capillaries, it would seem self-evident that, while the coronary arteries are filled by the systole or contraction of the heart, the nutritive changes and perfect capillary circulation go on during diastole. If these premises are true, the increase in cardiac nutrition and growth under the action of digitalis is only what one would expect, for we have learned when studying this drug that it prolongs diastole and increases the force and volume of the systolic wave of blood. In other words, digitalis fills the coronary arteries almost to bursting, and so, when diastole occurs, not only floods the cardiac capillaries with blood, but prolongs the period during which the interchange between the blood-stream and tissues takes place. 1 There is still another way in which digitalis does good in cardiac disease by reason of its peculiar powers. Normally, the heart beats fast or slow according to the demands for blood made upon it by the system, and its action is varied by the calls which it receives from the 1 See article on Digitalis in Part II. of this book. Q88 DISEASES. tissues. In heart disease, with failure of compensation owing to leaky valves, the tissues are starved, and continually send messages for more nourishment to the cardiac muscle, which finally becomes exhausted by its endeavors to supply their wants, and beats now fast and now slow, uncertain what to do. If digitalis is given, the vagi render the cardiac action regular and effective, acting as a regulator and director of its energies, thereby supplying the tissues and using the remaining power of the heart to the greatest advantage, in addition to improving its blood-supply by the methods already describedc The starving tissues of the body having been satisfied, as Wood has eloquently expressed it, "the angry messengers from the periphery cease their callings, and the heart is at peace and in comfort. " From what has been said it becomes evident that this drug (digitalis) generally does good when the heart is weak, and we find for this reason that cardiac dilatation, simple cardiac failure, or heart-failure depend- ent upon the presence of poisons, all indicate its use. The mechanism of the action of digitalis in the different cardiac valvular lesions still remains to be described, and before doing so the author desires to remind the reader that a patient under the full influ- ence of digitalis ought to maintain the recumbent posture. (See article on Digitalis.) Further, the drug tends to accumulate, and therefore it should be stopped for several days at the end of each week of its use. Digitalis should be begun in small doses, which can be gradually increased in size if need be, except in cases in which great cardiac feebleness demands immediate and powerful stimulation, when large doses may be given and smaller doses used later to maintain the effect. Taking up the most common condition, that of mitral regurgitation, we find that in this disease the blood passes, in its normal flow, from the auricle into the ventricle, and, .when the ventricle is filled, that the cardiac muscle contracts on all sides equally. Normally, the mitral valves close the auriculoventricular opening and prevent any of the blood from regurgitating into the auricle, and the greater the pressure the tighter they become. Abnormally, the blood is still pressed upon on all sides as before, and, trying to escape, as do all liquids, from pressure, finds that, owing to disease of these valves, it can, in part at least, slip back into the auricle from which it came, rather than pass out into the high pressure of the arterial system. The ventricle, therefore, propels blood in two directions — in the wrong way and in the right way. If the leak is large enough to permit of the regurgitation of a large part of the blood, then death occurs. Digitalis does good in mitral regurgitation because, by increasing the force of the ventricle, it increases the friction at both the mitral leak and the aortic opening; but, as the aortic opening is a large one and the mitral leak a small one, the greater quantity of blood passes out into the cir- culation. It also does good because it strengthens the heart muscle and contracts the muscular ring which surrounds the auriculoven- HEART DISEASE. 689 tricular orifice, therefore rendering it easier for the valves to close the mitral opening. The same fact arises for consideration as before — namely, that it is not the amount of leak, but the amount of supply to take its place, which is the vital question in the case. Rarely relief does not occur, and the patient is made worse by digitalis, because the leak is increased as much as the normal flow. In mitral obstruction the difficulty is that the blood cannot enter the ventricle with sufficient rapidity, and this part of the heart con- tracts bejore it is well filled. By the prolongation of diastole, the blood is given sufficient time to enter and the ventricle is filled, send- ing out into the system a large wave of blood when it contracts. Fur- ther than this, the stimulation of the right ventricle by the digitalis enables this part of the heart to overcome the tendency to congestion which arises from the obstruction on the left side of the heart. Often the right side of the heart must be relieved by venesection and active purgation. In aortic stenosis there is obstruction to the normal flow of blood out of the heart, and the digitalis is needed to increase the ventricular force, so that it may overcome the difficulty. In aortic regurgitation digitalis, by its stimulation of the heart, may cause a sufficient output of blood to clear itself of the regurgitant flow, but in many cases the drug fails because the prolongation of diastole gives so much more time for the blood to flow backward into the dilating ventricle. The cardiac remedies to be used in such cases are strophanthus, in the form of the tincture, dose 5 to 10 drops (0.30- 0.60); adonidin, dose \ to \ grain (0.015-0.03), and sparteine, h grain (0.03). These remedies may also be used in the other forms of cardiac disease where digitalis fails. It is important to remember, however, that some cases of aortic regurgitation do improve, at least temporarily, under digitalis. Murmurs associated with evidences of cardiac failure do not always indicate the presence of valvular disease, for dilatation of the mitral orifice may prevent the proper approximation of the valves. In such a case digitalis, by relieving the relaxation, may produce cure of an apparent valvular defect. Physicians often meet with cases of severe cardiac disease in which there are present a laboring heart, distended jugulars, and cyanosis, indicating engorgement of the right ventricle. This is to be relieved by free venesection from the arm, and, after the engorgement is removed, by the use of digitalis. In many cases of cardiac disease there are associated with the heart lesion general debility and anaemia. These cases should be treated not only by the use of heart tonics, but also by iron, arsenic, simple bitters, and, if constipation is present, by mild purgatives. In cardiac dropsy digitalis and the other heart stimulants do good by raising blood-pressure and pulse force, and in some instances by stimulating the kidneys to increased efforts at elimination. (See 44 690 DISEASES. Dropsy.) In these cases, too, the patient will often be greatly bene- fited if he receive every few days a full dose of blue mass or of one of the hydragogue cathartics, which will relieve the dropsy and unload the portal circulation. A useful formula under these circumstances is as follows: R — Ext. sambuci folii gr. ij (0.12). Ext. oxj'dendron arborei . . . . gr. ij (0.12). Ext. scillae gr. £ (0.016).— M. Ft. in pil. No. 1. S. — Take one pill three or four times a day. On the other hand, if the heart is feeble and the arterial tension is high, not only must nitroglycerin be given to relax the spasm, but in addition a cardiac tonic must be employed which at the same time that it stimulates the heart will not raise arterial pressure, as, for example, strophanthus, in preference to digitalis, which stimulates the arterial system and increases the tension. As digitalis is prolonged in its effect and nitroglycerin is fleeting, the digitalis should be given every eight or twelve hours, and the nitroglycerin every three or four hours. In sudden cardiac failure from weakness or poisons the use of ether and ammonia is to be resorted to at once, and these are to be followed by alcohol and digitalis if necessary. Ammonia is a direct heart stimulant, as are also alcohol and ether. In cardiac palpitation dependent upon indigestion, this condition must be relieved by appropriate digestive remedies; but in that form of palpitation due to overexertion or heart strain digitalis is useful. Iron is to be used if the irritability is due to anaemia. Tea, coffee, tobacco, and excessive venery are to be forbidden. Sometimes nux vomica does good by stimulating the heart and nervous system, and belladonna seems of great value where arhythmia is present. In other cases of arhythmia the patient will be more benefited by the use of cactus grandiflorus and sparteine, and sometimes a prescription of aconite and digitalis, as suggested in the article on Aconite. In cardiac dilatation and asthenia digitalis is often very useful; but should the patient be advanced in years and have a tendency to arteriosclerosis we should, simultaneously with its use, give nitroglyc- erin to relieve any arterial spasm which resists the action of the heart. Very often such patients will suffer from scanty secretion of urine and albuminuria, and will develop congestion of the kidneys. This may be controlled and greatly relieved by the use of full doses of digitalis, say 5 drops of the tincture every four hours, with 20 grains of bitartrate or citrate of potassium every four hours. The addition of the alkaline diuretic very greatly aids in the diuretic effect of the digitalis in these cases. Sometimes diuresis can only be established after free purgation. In some cases it is best to substitute for the digitalis either strophanthus or caffeine. Both should be given freely, say 3 grains (0.20) of caffeine or 10 minims (0.60) of the tincture of strophanthus every four hours. (See Nephritis.) HEAR T DISEASE. 691 Cardiac hypertrophy is rarely seen without some other lesion accom- panying it, but it may occur from prolonged and excessive exercise or other cause. It is to be treated by absolute rest and avoidance of excessive exercise, and by moderate amounts of food of a non-stimu- lating character. Wines and coffee should be forbidden, and a bella- donna plaster may be placed over the praecordium if the action of the heart is very excessive. Both palpitation of the heart and cardiac hypertrophy are favorably influenced in many cases by aconite or veratrum. Physicians who are in the habit of examining young men professionally will constantly have their attention called to a condition of shortness of breath on exertion, palpitation, or violent pulsation of the heart, and in some instances the development of severe symptoms which, at first glance, may seem to be those of true angina pectoris. In many of these youths there will be a history of the excessive use of tobacco, or that they have left college, where they indulged in severe ath- letic exercise, such as running or bicycle racing, and have entered business, where they lead a most sedentary life. In these cases the condition which exists is comparable to that which exists in a steamship whose engines are too strong for her hull. The heart, which has heretofore been supplying the body of an athlete with blood, now finds itself too strong for the sedentary individual. There is prob- ably no remedy which will give such good results under these cir- cumstances as aconite, in the dose of 1 minim (0.05) of the fluid extract or 5 to 10 minims (0.30-0.60) of the tincture three times a day, particularly if at the same time a good belladonna plaster about four inches square is applied over the praecordium. Many cases of tobacco heart, in which there is arhythmia, with an excessive cardiac impulse over the praecordium, with palpitation on exertion, will be benefited by aconite used in this way; but where the heart seems much depressed, so that the apex beat is feeble and the first and second sounds are not clearly heard, aconite will seldom, if ever, do good. In that form of functional cardiac disorder due to indigestion aconite is not capable of producing the results which are obtained in the cases which have just been mentioned. It may, however, be used as a remedy of value at the same time that the physician is directing his attention to the cause of the trouble — namely, the gastro-intestinal disorder, the treatment of which is foreign to this article. Here, again, a con- dition of cardiac feebleness contraindicates the employment of this drug. Passing to the employment of aconite in cases of true cardiac dis- ease, we find that a careful study of a certain number of cases will soon show the physician that this drug is capable of doing more good in some instances than is digitalis. The history of the following case illustrates this point: A man, aged nineteen, was brought to the hospital suffering from aortic obstruction, and as a result of this was attacked with dyspnoea on the 692 DISEASES. slightest exertion, marked cardiac arhythmia, with palpitation, some giddiness, and a tendency to nose-bleed. He stated that in the early part of the year, and for several years preceding it, he had been a deck-hand on a coastwise vessel, where he performed hard manual labor, notwithstanding the condition of cardiac disease which was present, and of which he knew nothing. During this time he suffered from no symptoms indicating cardiac disorder. In other words, compensatory hypertrophy was complete. Because of the exposure incident to his work he was forced, under the advice of a physician, to earn his living on shore. He was not successful in obtaining em- ployment, and a prolonged period of muscular inactivity followed. As a consequence the cardiac hypertrophy, which had hitherto been compensatory, became excessive, and he suffered from marked cardiac palpitation, with disordered circulation in the extremities, and from a distressing cough. Early in the study of the case it was recognized that these disorders were due to the excess of cardiac hypertrophy, and not to failure in compensation, and, as a consequence, that a cardiac depressant was indicated rather than a cardiac stimulant in the shape of digitalis. He was given from 1 to 2 minims (0.05-0.1) of the fluid extract of aconite three times a day, and during the con- tinuance of this treatment was purposely confined to bed. At the end of a week so much improvement had taken place in his condition that he was allowed to rise and go about the ward as he wished, and after four weeks, the medicine being continued during this period, he was so improved that he was discharged from the hospital, with no other evidence of cardiac disorder than physical examination would show. When aconite is used, rest in bed is essential, in order that the heart may not be excited to great activity by exercise of the limbs, and also because the recumbent posture permits larger doses of the drug. An exceedingly useful treatment of valvular disease with or without excessive cardiac hypertrophy is rest in bed without medication. The results in some cases are often remarkable. Fatty heart occurs in two forms — that in which true fatty degenera- tion has taken place in the muscular fibre, and that in which there is a deposit of fat about the heart and between the fibres. Nothing of any importance can be done for the first state, except by the use of nitroglycerin or by the iodides to relieve arterial tension if it be too high. Strophanthus with or without nux vomica may be useful to relieve symptoms of cardiac distress. Much can be done for the second form. In neither form is digitalis of much value. If given, it should be combined with nux vomica, or nux vomica may be given alone in full doses. The patient suffering from the second form of heart trouble is nearly always obese, and should abstain from fats and rich foods, from all sweet wines and malt liquors, from sugars and milk, and at the same time take exercise. At first this treatment may HEART DISEASE. 693 cause dyspnoea, but by gradually increasing the severity of the exer- cise much can generally be effected in the end, with marked improve- ment in the cardiac action. (See Obesity.) Heart disease associated with failure of the muscle may not only be treated with drugs, but with other remedial measures, such as gentle, active exercise, passive exercise, and baths, the latter being given with care to avoid too great shock and for the purpose of improving the general circulation. Within a few years a method has been brought forward by Schott, of Nauheim, Germany, which consists in treating patients with feeble hearts by means of movements and baths of water derived from the springs at Nauheim. The movements are so-called resist- ance movements, the patient slowly flexing and straightening his limbs and neck against gentle resistance on the part of an attendant. By this means the circulation of blood and lymph in the tissues is aided without tiring the heart. These resistance exercises do not, however, agree with all cases. In persons with very feeble hearts gentle massage is far better. The rule should be never to give enough exercise or massage to cause acceleration of the respiration or marked increase in the action of the heart. Very feeble cases should have the massage first, the exercise next, and the baths last. Before considering the use of the Nauheim bath it is necessary to have a clear conception of what it is and the methods by which it does good. There are six springs at Nauheim, of which three are used for bathing and three for drinking purposes. The latter are not of great importance and do not form part of the "cure" in the strict sense of the word, although the water from the "Kur" and "Karls- brunnen" springs are sometimes sipped in the morning before break- fast for their laxative effect. The bathing waters are derived from three sources: No. 12, or Friedreich Wilhelms Quelle; No. 7, or Der Grosse Sprudel; and a new one, called No. 14. The water of all these is very heavily charged with carbonic acid by nature. So great is the pressure that the water is forced upward as high as fifty feet from a vertical pipe-nozzle. In the case of springs 7 and 12 the delivery pipe permits the water to shoot upward, and it then falls back into adjacent tanks, so that dur- ing its rise and fall a large amount of gas is lost, and much of the lime and iron held in solution is precipitated in the tanks. This water is led to bath-tubs, and if the patient is feeble and the "cure" is just beginning, it is often diluted with plain water and sometimes heated This forms the Thermal Sool-bad. Other baths are supplied by pipes which carry the water directly from the earth without the gas being allowed to escape in any quantity. This water sparkles as does soda-water, and is called the Sprudel-bad. Still another bath is provided in which there is an outflow opening as well as an inflow opening, and in which the patient sits in a tub into which freshly charged water is rushing as fast as it runs out. 694 DISEASES. This is called the Strom-bad. These baths are all therapeutically powerful, but, naturally, the first is not so active as the last. The therapeutic value of these baths depends upon their ability to cause dilatation of the peripheral capillaries, which thereby relieves internal congestions and enables the heart to pump blood more easily through the capillaries. They also stimulate the heart by reflex nervous action. When a patient is suffering from grave cardiac failure depending upon valvular disease, with grayness of the face and cyanosis of the lips, the baths should be begun very cautiously, using the Thermal Sool-bad. Even then, for the first minute after the patient enters the bath, he may seem more oppressed than before. But in the next few minutes his apprehension passes away, and a feeling of warmth and comfort develops, so that after ten or fifteen minutes it will be found that his skin is uniformly reddened wherever it has been in contact with the gas and water. The time which the patient spends in the bath should be prescribed by a local physician. After the bath the patient is carefully dried by an attendant, and must rest absolutely in a reclining position for at least one hour. At first the bath is used only every two or three days. As the patient gains strength the baths are gradually increased in length and fre- quency, and finally additional mother-salt obtained by the evaporation of the water is added to the natural water in the tub. Later, when still stronger, the patient takes the foam, or "strom" bath, in which the gas is present in such quantities that the water foams. This is, of course, very stimulating and dangerous for a weak patient with poor reaction. When the patient recovers enough to use gentle walking exercise this is permitted, the resistance exercise being employed on days between the baths as a rule. These baths may be prepared artificially and are resorted to in this country, being now installed in several watering-places. The formulae for making the baths are as follows in each 40 gallons of water at 95° F.: Bath No. 1: sodium chloride, 4 pounds; calcium chloride, 6 ounces. Bath No. 2: sodium chloride, 5 pounds; calcium chloride, 8 ounces. Bath No. 3: sodium chloride, 6 pounds; calcium chloride, 10 ounces. Bath No. 4: sodium chloride: 7 pounds, calcium chloride, 10 ounces; sodium bicarbonate, \ pound; hydrochloric acid (25 per cent.), 12 ounces. Bath No. 5: sodium chloride, 9 pounds; calcium chloride, 11 ounces; sodium bicarbonate, 1 pound; hydrochloric acid, \\ pounds. Bath No. 6: sodium chloride, 11 pounds; calcium chloride, 12 ounces; sodium bicarbonate, 2 pounds; hydrochloric acid, 3 pounds. The alkali should always be slightly in excess unless a porcelain or papier-mache tub is used. A small bottle containing the hydrochloric acid is submerged at the bottom of the tub, uncorked, and its contents allowed to escape into the water, in which effervescence at once occurs, the patient entering HEMORRHAGE. 695 the bath at that time. The numbers of the baths simply indicate different strengths. Patients may never use them stronger than that represented by the second or third formula. Toward the close of the treatment the temperature may be lowered to 85° F. Recently Tyson has used a series of perforated iron tubes placed upon the bottom of the tub under a wooden rack. These tubes are connected to a large cylinder containing carbonic acid gas, which is allowed to bubble through the water, thus supplanting the crude method of producing the gas by the acid just named. The tub should be of wood. These baths are indicated chiefly for feeble hearts, as already stated. Thus, if there be cardiac dilatation resulting from such depressing causes as epidemic influenza, they often prove useful. So, too, in cardiac neuroses and functional disorders dependent upon lack of vaso- motor tone they are serviceable. In valvular disease with perfect compensation they are not needed, and when compensation is ruptured they are dangerous, owing to the production of syncope. If the bath acts favorably, the pulse becomes stronger and fuller, the heart action slower, and the physical signs of cardiac dilatation disappear. En- gorgement of the liver also is relieved. As with all other methods of treatment, the cases submitted to this treatment should be care- fully selected, as it has its therapeutic limitations. This treatment does not necessarily exclude the use of drugs. A liberal vegetable diet, with small amounts of meats, is given. HEMORRHAGE. {Including Menorrhagia, Metrorrhagia, Haemoptysis, H&matemesis, Intestinal Hemorrhage, Hematuria, and Post-partum Hemorrhage.) Under this heading will be considered all forms of hemorrhage which we may endeavor to control by drugs or measures not directly surgical in their scope, with the exception of epistaxis, which has already been spoken of. Whenever a hemorrhage can be arrested by the application of a ligature or by compression, as in a cut of the finger or some similar wound, no styptic should be used. Styptics are employed for the double purpose of constringing the tissues and coagulating the blood, and, in consequence, form coagula which tend to make a septic mass about the wound. In their place the physician should resort to a compress soaked in some antiseptic liquid or filled with some disin- fectant powder, and if this fails to control the bleeding, then ligation of the bleeding vessel becomes necessary. Where the bleeding point cannot be reached by direct compression or for ligation, the use of packing and of astringents is advisable, and drugs which are antihemorrhagic may be used by the mouth. In all forms of hemorrhage in which the flow has been sufficiently great to endanger the patient's life, resort should be had to hypoder- 696 DISEASES. moelysis or to transfusion. (See Hypodermoclysis and Transfusion, Part III.) Recently gelatin has been employed externally to control hemor- rhage, and has been given hypodermically to aid in the coagulation of blood in bleeding parts which cannot be reached directly. Lancer- eaux and Paulesco use the following formula: 1^ — Gelatini, Sodii chloridi aa gr. cl. (10.0). Aquae destillat Oij (1000 c.c). This mixture is sterilized by heat and 2 ounces (60 c.c.) are injected into the tissues of the thigh or buttock. 1 This is increased to 5 ounces (150.0) in later injections if they are needed. Usually one or two doses are sufficient. A like solution may be used locally to check oozing. Menorrhagia is an excessive flow of menstrual blood, either excessive in quantity during two or three days or continuing an unusual number of days; while metrorrhagia is a state in which bleeding takes place from the uterus independently of menstruation and at any period of the month, or even after the menopause has occurred. Menorrhagia is not to be determined by the amount of the flow, but by whether the loss is sufficient to cause ill health or to indicate disease. In some cases it is a means of relieving plethora. When the physician decides that something should be done to improve the condition of the patient, when suffering from either menorrhagia or metrorrhagia, it is necessary for him to find out whether a polypus, fibroid growth, endometritis, or other form of uterine disease is directly responsible for the trouble, and in the mean time to employ drugs known to act favorably upon uterine hemor- rhage. The most prominent of these drugs are ergot and oil of erigeron, the first being the more active and the best remedy for active bleeding, the second better for oozing and for cases where there is a continual "show." The fluid extract of ergot may be given in varying dose, from 10 to 60 minims (0.60-4.0), according to the necessities of the case, and the oil of erigeron in capsule in the dose of from 3 to 5 minims (0.20-0.3), or, if capsules cannot be had, the physician may employ the oil in an emulsion made by using syrup of acacia or other similar substanc?. Locally, sterile cotton wet with a sterile solution of adre- nalin chloride (1 : 5000) may be employed. Where menstruation is irregular and the menorrhagia is almost a metrorrhagia, bromide of potassium or sodium in the dose of 10 grains (0.60) several times a day is often very serviceable. The water of hamamelis in the dose of 1 drachm (4.0) three times a day is almost as useful. Cannabis indica, if an active sample is obtainable, is also said to be of service, but the writer has never used 1 The gelatin should be boiled at least an hour, as tetanus spores are often present and are not killed by being exposed to heat for a short time. HEMORRHAGE. 697 it to any extent. Oil of cinnamon in the dose of J drachm (2.0) is very efficacious in the slow oozing of some cases where erigeron cannot be used or obtained. Sometimes, where congestion of the pelvic viscera is the cause of the trouble, dry cups over the sacrum give relief. Haemoptysis,. or hemorrhage from the lung, is usually due to tuber- cular ulceration of a small or large bloodvessel, and the life of the patient depends more upon the rapidity with which a clot naturally forms than upon the skill of the physician. Though text- books order atomized solutions to be inhaled and other remedies to be taken by way of the lung, in most cases these measures will be found impracticable, because the nervousness of the patient and the constant cough will not permit of inhalations to any extent, and even if a full breath is taken, it generally increases the bleeding and cough- ing. The only occasions in which inhalations of styptics are of service are those in which the hemorrhage is just beginning or is so slight as to streak the sputum or to be at least thoroughly mixed with it. Even in these cases little if any of the drug reaches the bleeding spot. The solutions to be so employed must be used in a vaporizer which will throw a fine vapor — sufficiently fine to enter the smallest air-tubes with the inspiratory wave of air. A very good fluid is one made from Monad's solution, as follows: 1$ — Liquor ferri subsulphat gtt. xx to xxx (1.3-2.0). Aquae dest f§iv (120.0).— M. S. — Use in an atomizer every few minutes. Or the following: 1 1$ — Acid, tannic gr. xx (1.3). Glycerini f5ij (8.0). Aquae dest q. s. ad f§iij (90.0). — M. S. — Use in a vaporizer. Or, ty — Aluminis ■ . . . gr. vj (0.4). Aquae dest fgiij (90.0).— M S. — Use in an atomizer. Some clinicians advise that the patient should swallow, whether the hemorrhage be acute or not, not less than 1 to H drachms (4.0-6.0) of the fluid extract of ergot, or a solution made by adding 20 grains of gallic acid to 1 ounce (1.3-30.0) of water; but it is difficult to under- stand how they can be of service, and when bleeding ceases after their use the arrest is probably a coincidence and not due to the drug. Tannic acid given by the stomach is not so good as gallic acid, because it must be absorbed and changed into gallic acid before it can reach the bleeding point through the circulation. On the other hand, 1 If the Monsel solution does not stop the hemorrhage, tannic acid will probably fail; but, more important, the two should not be used together, as they are incompatible and the tannate of iron will be formed, which is as black as ink. 698 DISEASES. tannic acid, if locally used, is the better, for it constringes the tissues and forms a clot, whereas gallic acid does not coagulate the blood. Hemorrhage from the lung must be regarded as any other hemorrhage. The object of the physician is not to stimulate the heart and vasomotor system, thereby increasing the leakage from the bleeding vessel, but to lower the arterial pressure to as low a point as is safe. The rule to follow is best stated as follows, if the hemorrhage has been severe and the patient is feeble: place his head lower than the feet and apply Esmarch bandages to the limbs to keep the blood in the vital parts as much as possible. The use of stimulants can only increase the hemor- rhage by increasing the pumping power of the heart and by dislodging the clot from the eroded bloodvessel. Daremburg and Yeo have employed ice or ice-cold compresses to the scrotum or vulva in cases of haemoptysis, and claim good results from this use of cold. To allay nervous excitement many writers advise that a hypodermic injection of morphine should be used. Chloral and the bromides are often better remedies for this purpose, and should be given by the mouth, or, if vomiting is present, they should be given by the rectum, dissolved in starch- water. (See Chloral and Bromides.) Sometimes the patient can point directly to the spot where he thinks the hemorrhage exists, and under these circumstances a dry cup or a piece of ice placed over this point may perhaps prove useful by causing a reflex contraction of the deeper bloodvessels. After an attack of haemoptysis there is great danger in many cases of a traumatic pneumonia being set up by the presence of the extrava- sated blood. This should be combated by the use of a carefully regu- lated diet, and the reduction of any arterial excitement by small doses of aconite in persons not weakened by advanced disease* or bleeding. Complete rest in bed is to be insisted on, and no stimulants allowed in food or drink unless the weakness of the patient requires them. Haematemesis. — This depends either upon some injury to the stom- ach, or, much more commonly, upon gastric ulcer, cancer, or cirrhosis of the liver, and is one of the easier of the so-called "internal hemor- rhages" to treat, because by ordering the patient to swallow styptic drugs we can act directly upon the bleeding surface. 1 Adrenalin in the dose of a drachm (4.0) of 1 : 1000 solution may be given, and ice should be swallowed frequently, or 3 minims (0.20) of Monsel's solution in half a tumblerful of water may be used every fifteen minutes till four doses are taken. Tannic acid may be given instead in the dose of 20 grains to a drachm (1.3-4.0), but the two should never be given at the same time. (See foot-note to p. 697.) Monsel's salt may be given in pill in the dose of 2 to 3 grains (0.12-0.20). The acetate of 1 Haematemesis also ensues as a result of swallowing blood which has escaped into the mouth or nasopharynx, and this symptom is sometimes induced by malingerers in order to further their ends. These forms of haematemesis should, of course, be separated from those dependent upon some lesion in the stomach itself. HEMORRHAGE. 699 lead is also of value in pill form in the dose of 2 to 3 grains (0.12-0.20) with morphine or opium. Tincture of the chloride of iron, the sul- phate of iron, turpentine, ipecac, ergot and hamamelis may all be used, the last three particularly in slow or passive hemorrhages. Sometimes nitrate of silver in the dose of \ grain (0.015) in pill form is of service if the hemorrhage is a slow one. Bandages to the extremities and external heat should be applied. Hemorrhage from the bowel is to be treated according to its point of origin. If in the small intestine, as from ulceration of Peyer's patches or other glands, the medicines must be used by the mouth; if it be from the colon or rectum or from hemorrhoids, medication must be by way of the anus. In any case rest in bed is essential. Hemorrhage of the first class is best combated by the application of a small ice-bag to the belly and by the use of Monsel' s salt (ferri subsulphas): 3 grains (0.20), made into a pill, should be given every half-hour or oftener, the pill being coated with salol so that it may reach the intestine without being dissolved in the stomach. Ergot has been resorted to, but is of doubtful value even if used hypoder- mically (see Ergot); but tannic acid may be given with advantage in large amount in solution if the Monsel salt is not obtainable. The other remedies which are of service are sulphuric acid in the dose of 5 to 10 minims (0.3-0.60) in water in acute or passive bleeding, or turpentine given in capsule, or, better still, in emulsion with acacia in the dose of 10 minims (0.60) every half-hour, particularly when the hemorrhage is not active. Chloride of calcium is useful (which see). Acetate of lead and camphor in the following pill may be of service in some cases : 1^ — Plumbi acetatis gr. v (0.3). Camphorse gr. x (0.60). — M. Ft. in pil. No. v. S. — One pill every hour. Where the hemorrhage is dependent upon ulceration of the colon or rectum injections are to be resorted to. These are both styptic and curative, the styptic injections being particularly useful when the bleeding is to be stopped at once, the others where it is sought to remove the condition producing the trouble. To the first class belong alum, sulphate of copper, MonsePs solution, sulphate of iron, tannic acid, and cold water. In the second, we find nitrate of silver, the sulphates of copper and iron, and the chlorate of potassium. The alum solution used should be fairly strong, 10 grains to the ounce (0.60-30.0) ; the copper, 5 grains to the ounce (0.3-30.0) ; the Monsel salt, 10 grains to the ounce (0.60-30.0) ; or J to 1 drachm of Monsel's solution to each 2 ounces (2.0-4.0 : 60.0) of water. The tannic acid should be used in the strength of 20 grains to the ounce (1.3-30.0) of water and glycerin. When chlorate of potassium is used, it should be employed in saturated solution in small injections (25 grains to the 700 DISEASES. ounce [1.60-30.0]), or in weaker solution if the injection be a large one (10 grains to the ounce [0.60-30.0]). Another useful drug, if the site of the hemorrhage can be reached, is adrenalin chloride in the proportion of 2 drachms of the ordinary 1 : 1000 solution in a half-pint of normal saline solution. These injections should be carefully given, and the success or failure attending the treatment of these states depends as much upon the technique of the operation as upon the particular medicinal substance employed. It should never be forgotten that an injection designed for local medication should be as small in bulk as circumstances will per- mit. Thus, in inflammation of the rectum the amount of the injected liquid should not be above 4 ounces (120.0) at the utmost, and prefer- ably 2 ounces (60.0) unless the diseased area is high up. An enema is given in bulk so as to cause distention and excite the bowel to move- ment, whereas by a medicinal injection no movement is desired. Again, the apparatus for sending in the fluid ought not to be a "fam- ily" or ordinary syringe, but a fountain syringe, the pressure being hydrostatic. This may be dispensed with if the injection be small and intended only for the lower part of the rectum, but it is indispen- sable if the injection is designed to reach the upper part of the colon. The entrance of the liquid should always be gradual and easy. If resistance is met with, the pressure must be overcome, not by force, but by waiting a moment until it passes off. When the entire colon is to be flooded, at least a gallon of warm liquid will be needed. In these cases those drugs which are readily absorbed and liable to pro- duce poisonous symptoms are not to be used except in small amounts. (See Enteroclysis, Part III.) Where the injection is to reach high up into the bowel the patient should be put in the lithotomy position with the buttocks elevated. Sometimes in dysentery the injection of a pint to a quart of ice-cold water has a most favorable effect upon the bloody purging. Whenever a medicated injection is to be used for the cure of ulcers which cause hemorrhage, the entire tract which is to be treated should be washed out with pure water or with a saline or soapy liquid, in order to dislodge mucus and feces, which prevent the medicament acting on the bowel wall. Hosmaturia is a condition in which blood appears in the urine, and may be divided into two classes — that in which the blood comes from the kidney or bladder, and that in which it comes from the urethra. In the first class the blood is always well mixed with the urine, which is changed in color from its decomposition, and the blood is present either during the entire act of urination or just at the end of the act. In those instances in which the blood is in the first part of the stream it arises in the urethra, is nearly pure, and not well mixed with the urine. If the blood is due to the presence of an acute nephritis, the kidneys need treatment, and for directions as to this point the article on Acute HEMORRHAGE. 701 Nephritis should be read; while, if the hemorrhage is due to the pres- ence of a lesion in the bladder, the directions governing the use of turpentine, erigeron, or ergot, as given for Menorrhagia and Metror- rhagia, should be followed, or if any morbid growth be present it should be removed. Sometimes 5 to 10 grains (0.30-0.60) of camphor in divided doses are of service, given in pill form, while in others can- nabis indica is efficacious. Gallic acid in 20-grain (1.3) doses is valuable. If the hemorrhage is alarming, injections of adrenalin chloride (1: 5000) may be used; or astringent washes, such as 2 or 3 grains of alum to the ounce of water, may be injected into the bladder. It must be remembered, however, that alum fills the bladder with clots, which are not readily passed and are liable to become septic. A useful prescription for internal use is: If— Acid, gallic oj (4.0). Acid, sulphuric, dil f5jj (8.0). Aquae destillat q. s. ad f§iij (90.0). — M. S. — Teaspoonful (4.0) in water every four hours. Malarial infection is sometimes accompanied by hematuria or hemoglobinuria. The cause is obscure, and an immense amount of discussion has taken place as to its proper treatment. Many physicians assert that the use of quinine in these cases produces disastrous results; others claim that the drug is most valuable. The value of quinine consists, undoubtedly, in its ability to prevent other attacks, rather than to relieve that already present or its result — the hematuria. If an examination of the blood shows the presence of the estivo-autumnal parasite, quinine is to be freely used; but if not, it is to be avoided. Personally the author believes that malarial hematuria and hemoglo- binuria will ultimately be found to depend upon very different causes. In some cases it will be found that the malarial parasite is the cause of the disease. In other instances it will probably be discovered that an entirely different organism belonging to the same general type of parasites is responsible for the development of this dangerous and much dreaded complication. (See Cinchona, Part II.) Thio- sulphate of sodium is a most useful remedy in malarial hematuria in the dose of 5 to 15 grains (0.3-1.0) every five hours. Many prac- titioners use as much as a drachm of thiosulphate of sodium every two hours till purgation takes place, give morphine and atropine hypodermically to relieve pain and quiet the stomach, apply cups over the kidneys, and give water to drink so as freely to flush the kidneys. Post-partum hemorrhage is to be controlled by the use of abdominal friction and kneading or grasping the dilated uterus through the relaxed abdominal wall; by the use of drachm doses of the fluid extract of ergot or a wineglassful of the wine of ergot, or by the hypodermic use of ergot aseptics ; and by irritation of the uterine wall by passing the hand, which must be absolutely aseptic, up through 702 DISEASES. the vagina into the uterine cavity. In other cases injections of sterile water as hot as can be borne may be resorted to. In all forms of local hemorrhage from small vessels adrenalin chloride is to be thought of as a local application or as a remedy suited for use by hypodermoclysis. (See Suprarenal Gland, Part II.) HEMORRHOIDS. Hemorrhoids are vascular dilatations of capillaries, arteries, or venules situated outside or inside of the sphincter ani, or are com- posed, in the case of what are called external piles, of tags of skin which are more or less vascular and become troublesome when inflamed. The internal pile if large, is apt to prolapse and to become strangu- lated by the sphincter muscle. It is covered with mucous membrane, and is sometimes very small or like a mulberry in shape, consisting of a tuft of capillaries, a loop of an arteriole, or of a venule. The capillary or arterial hemorrhoid is apt to be bright red, and to bleed profusely when touched or when scraped by hard feces. The venous tuft also bleeds, but not so freely, and the blood is not so bright in color. In cases in which the hemorrhoids "come down" — that is, pass out through the anus, so being in danger of becoming strangu- lated — the protruding mass should be washed with cold water, thereby at once cleansing it and reducing its congestion, and then gently pushed back with the fingers, which should be well oiled. In some cases it is advantageous to push gently into the rectum a cold rectal speculum, which will not only replace the piles, but also contract their walls and displace the blood with which they are filled. Care should be taken that an external hemorrhoid is not mistaken for an internal pile, since if an external growth is pushed through the sphincter, it also becomes strangulated. The treatment of internal hemorrhoids is to a great extent identical with that of the external variety. A suppository may be used, made up as follows, if there is a tendency to slight hemorrhage: & — Acid, gallic . gr. xx (1.3). Extract, opii ......... gr. j (0.06). Extract, belladonnse gr. ij (0.12). 01. theobromse q. s. — M. Ft. in suppos. No. x. S. — Use one every night. In place of this, water of witch-hazel extract may be injected into the rectum in the quantity of 1 or 2 ounces (30.0-60.0). If the hemorrhage is profuse, the physician should use a speculum, find the bleeding point, and touch it with strong nitric acid, followed by the suppository named above. If this is done, the bowels should be confined for some days until the spot under the slough made by the acid can heal. If the prolapsed hemorrhoid is inflamed and difficult of reduction, the following ointment of Mathews may be ordered : HEMORRHOIDS. 703 ly — Coc&iaae gr. xij (0.8). Iodoformi oj (4.0). Extract, opii sjr. xxx (2.0). Petrolati oj (30.0).— M. S. — Use as a salve. Note that this prescription calls for cocaine, not cocaine hydro- chlorate. The reason for this is that the salt of cocaine does not act well when mixed in an ointment. If the pile still refuses to be reduced, place the patient in bed and apply a hot compress wet with adrenalin chloride solution (1:2000). If this fails, operation is demanded. The treatment of external piles themselves consists in the main- tenance of the most rigid cleanliness. Immediately after each move- ment the parts should be thoroughly washed by means of a sponge dipped in cold water, or, better still, by the use of the bidet or a nozzle attached to a fountain syringe or to the general water-supply. (See Cold, Part III.) After they are thoroughly cleansed, it is well to bathe them with distilled extract of hamamelis. Often it is advisable to precede the regular daily evacuation by a rectal injection of cold water to soften the feces, and, more important still, to decrease con- gestion. If the inflammation of the external piles is very acute, the patient should be placed in bed and the cold injections frequently repeated or hot compresses applied to the anus. After this a lotion of lead-water and laudanum — laudanum foss (16.0) to dilute lead- water fSij (60.0) may be used. The injection of phenol into hemorrhoids is a dangerous practice, and, if employed, only 1 drop is to be used. In addition to these applications there are important general rules to be observed. The patient's habits should be so arranged that the daily act of defecation is at night before going to bed, rather than in the morning, as under these circumstances the rest in bed relieves congestion and soreness, which the maintenance of the erect posture might aggra- vate. Plethoric individuals should not use upholstered chairs, as the heat of the body relaxes the rectal tissues. A cane-seated chair is best, or an air-cushion with a hollow centre. The liver plays a most important part in relation to hemorrhoids, and, if it is congested, congestion of the hemorrhoidal veins is very apt to ensue. The con- nection between the liver and the hemorrhoidal plexus is most inti- mate, since this plexus is formed by the superior hemorrhoidal veins, which are branches of the inferior mesenteric, and the middle and inferior hemorrhoidal veins, which terminate in the internal iliac. The portal venous system is composed in part of the inferior mesen- teric vein, and any obstruction to venous flow in the liver at once results in engorgement of the hemorrhoidal plexus. (For the surgical treatment of piles reference must be made to surgical works.) 704 DISEASES. HEPATITIS. (Acute and Chronic Hepatitis and Hepatic Abscess.) Inflammation of the liver may be produced by many causes, such as injuries, cold, exposure to high temperatures (as in the tropics), syphilis, and the presence of any infectious disease or of parasites. It may also arise from alcoholism. The acute form is rarely directly produced by syphilis, although it may arise indirectly from this disease, being due to the absorption of septic materials into the circulation from wounds or sores. The hepatitis of hot climates is generally subacute or chronic. The pain, swelling, and general symptoms of the acute form of inflammation of the liver are described thoroughly in the text-books on the practice of medicine. The measures commonly adopted for the relief of the symptoms and the disease itself are of two kinds: the first, medicinal; the second, dietetic. The patient, if the attack be acute or severe, will commonly be found in bed, owing to the pain and fever, but if not he must be placed in bed and kept in a recumbent posture. Over the surface of the right hypochondrium may be placed a number of small cantharidal blisters; or, if this is not possible, a large mustard plaster is to be used. Sometimes hot cloths applied over this area are equally efficient. At the same time, if the bowels are confined, a saline purgative, such as magnesium sulphate, should be given, and it is often wise to precede it several hours by small doses of calomel given in fractional doses. The kidneys must be kept active by spirit of nitrous ether and citrate of potassium, or by any one of the diuretic waters, such as Vichy, in moderate quantities. If a single hepatic abscess develops, 1 the best thing to be done is to expose the liver and open it. Very frequently the inflamed organ will form so strong an attachment with the peritoneal coat of the abdominal cavity that a bistoury must be used to free the pus. Any constitutional evidence of the presence of pus, as by night-sweats, hectic, or rigors, is a sign for immediate interference with the purulent collection. If amoebic dysentery exists, it must be cured as rapidly as possible by the measures generally employed for this purpose. (See Dysentery.) Multiple hepatic abscess is beyond our measures of relief. The diet during the early and later stages of acute hepatitis should be limited to those articles of food which are easily digested and assim- ilated, and rich or greasy dishes are to be excluded. "Strong foods," as meats of all kinds, particularly beef, pork, and mutton, are to be sedulously avoided. All spices in the food must be forbidden, and alcohol utterly tabooed. If koumyss cannot be had, the patient may be fed on peptonized milk or pancreatized oysters. (See Part III.) After the abscess develops the same recommendations are to be fol- 1 It is well to recall that many cases of hepatic abscess are now known to be due to dysentery, and that the diseased state of the lower bowel may result in infection of the liver. HICCOUGH. 705 lowed, and the diet is to be as supportive as possible, small doses of quinine and iron being used. In the treatment of the subacute or chronic hepatitis of hot climates no remedy compares to freshly prepared strong nitromuriatic acid, used both externally and internally. The acid should be a deep lemon color, and be mixed with water only when about to be taken in the dose of 3 or 4 minims (0.20-0.25) three times a day. This rem- edy is contraindicated in acute hepatitis, because it acts by stimulating the organ, and would only increase the severity of the acute form of the disease if administered at this time. Externally, it is to be used by mixing it with water and applying it by means of a flannel wrung out in the mixture, or by placing it on spongiopiline in the proportion of from 1 to 3 fluidrachms to the pint (4.0-12.0:480 c.c.) of warm water and applying it over the liver. If 3 fluidrachms (12.0) irritate the skin too greatly, the smaller quantity should be employed. This applica- tion causes a tingling of the skin and a localized sweat. The hepatitis due to syphilis generally shows itself as a cirrhosis, and is to be treated by antisyphilitic measures. (See Syphilis.) If ascites develops from cirrhosis, the liquid is to be withdrawn, and frequent aspirations, as often as the liquid returns, have been known to result in apparent cure or arrest of the disease. In all forms of chronic hepatitis iodide of potassium is a useful remedy in the dose of from 5 to 10 grains (0.3-0.60) three times a day, and larger amounts should be used if the condition be due to syphilis. HICCOUGH. Hiccough is an affection arising from many causes, depending upon irritability of the nerves supplying the diaphragm as a result of gastric irritation, nervousness, uraemia, and as a complication of several exhausting diseases, such, for example, as typhoid fever. The mechanism of its production rests upon the sudden contraction or descent of the diaphragm, whereby a vacuum is formed in the chest into which the outside air attempts to rush, but is prevented from doing so by a sudden closure of the glottis, the peculiar sound of the hiccough being thus developed. Generally the symptom stops of itself, but it may become continuous and excessive. The remedies to be employed are used according to the cause of the disorder. If there be gastric or intestinal irritation, the irritating matter must be removed by emetics or purges, and nervous and local sedatives used. A drachm (4.0) of spirit of chloroform does good in many cases, and tincture of capsicum may be employed in other instances, say 5 or 10 minims (0.30-0.60) well diluted. Children should have only \ to 1 minim (0.025-0.05) of the tincture, well diluted. Spirit of camphor, or the tincture of valerian, in the dose of 1 drachm (4.0), may be serviceable, and Hoffmann's anodyne is peculiarly efficacious in the dose of 1 drachm (4.0) in ice-water. In the hiccough 45 706 DISEASES. of typhoid fever nothing compares to musk, 10 grains (0.60) by the rectum, and, if this cannot be used, oil of amber may be given by the mouth in the dose of 5 to 10 minims (0.3-0.60) in capsule or emulsion, and followed by a drink of milk to prevent irritation of the stomach. Nitrite of amyl may also be inhaled. When hiccough is so persistent as to endanger life it must be controlled by the use of bromide of sodium and deodorized laudanum given by the bowel. (See article on Vomiting, for directions.) Where external remedies are resorted to, ether thrown in a fine spray on the epigastrium may check an attack. In cases where the affection comes on after meals and is due to indigestion, a course of tonic treatment will often give relief. Thus nux vomica in pill or tincture, accompanied by some dilute mineral acid, such as hydrochloric or nitric, may be employed, or, if the stomach is acid, T^ — Sodii bicarb 5j (4.0). Tinct. nucis vom f 5j (4.0). Tinct. cardamomi . . . . q. s. ad f Siij (90.0). — M. S. — Teaspoonful (4.0) before each meal. If the symptoms are due to uraemia, a hot pack may be found of service, unless contraindicated by advanced depression and systemic weakness. Even in the presence of these symptoms it may be advis- able to resort to this measure, protecting the patient against depression by a hypodermic injection of strychnine. INCONTINENCE OF URINE. Incontinence of urine may be classified either according to its forms or the methods of its treatment. Four varieties may be recognized as occurring separately, although all of them may occur in one case. There are cases where the bladder fails to hold the urine day or night, those in which the incontinence is only nocturnal, and those in which it occurs only upon some nervous start or in which the sphincter becomes relaxed from general atony. The first of these occur in children, the last in adult females. A fourth form of incontinence depends upon paralysis arising from centric nervous disorder or from paralysis due to retention and con- sequent paralytic distention. Taking up the consideration of the first forms — namely, those occurring in children, in which the trouble is generally nocturnal— the complete history and the present condition of the case must be discovered. Many of the most obstinate cases will yield when the urine is made constantly clear and mild by the use of alkalies, and others will recover upon the removal of worms from the vagina, which have crawled there from the rectum, or upon circumcision of a redun- dant prepuce, particularly if this be tight and smegma and urine be found back of it in large or small quantity. The cause of the incon- INCONTINENCE OF UBINE. 707 tinence in both these conditions is reflex irritation of the bladder-walls, by irritation at the end of the penis or in the vagina, and the reason that alkalies do good is that they render the urine, which is concen- trated and irritating, dilute, alkaline, and mild. Belladonna in these cases is rarely, if ever, curative, and is at most only palliative, the condition returning as soon as the passing off of the effects of the drug permits the irritation to be felt by the nerves of the bladder. After alkaline diuretics have been used belladonna is, however, very valuable. Where the urine is concentrated and dark in color the following pre- scription is always useful: ]$— Potassii citratis 5ij (8.0). Spt. setheris nitrosi ...... foij (8.0). Aquae dest q. s. ad f §iij (90.0). — M. S. — Dessertspoonful (8.0) every four hours in a tablespoonful (15.0) of water. As the urine becomes clear after several days a few drops of tincture of belladonna may be added to the mixture; but if a moderate amount is not sufficient, it must not be increased, as belladonna will not cure the condition, and may make the urine concentrated — a condition directly opposed to that which is wanted. In other instances — and these are by no means rare — the urine is concentrated and ammoniacal in odor. Under these circumstances one of three drugs may be used with advantage, namely, hexamethyl- enamine (urotropin or uritone) in the dose of 4 grains (0.25) in half a glass of water three times a day; or benzoate of ammonium, given in the same quantity in capsule after meals. Both of these drugs acidify the urine and render it antiseptic, and for obvious reasons are harmful if the urine is already acid. Sometimes these cases are dependent not so much upon vesical irritability as upon weakness of the spinal centres governing the bladder. If this be the case, the urine should first be rendered mild, and then remedies should be directed to the improvement of these parts. The following pill or the succeeding solution should be admin- istered : 1$ — Arseni trioxid . gr. J (0.02). Extract, nucis vomicae gr. ij (0.12). — M. Ft. in pil No. xx. S. — One three times daily after meals for a child of eight or ten years. Or, 1^ — Liquor potassii arsenitis Til xxiv (1.5). Tinct. nucis vomicae TTL xxiv (1.5). Aquae dest q. s. ad f giij (90.0). — M. -Teaspoonful (4.0) three times daily after meals for a child of eight or ten This mixture is so bitter as to be disagreeable, and Fowler's solution may often be used alone in the dose of \ to 1 minim (0.025-0.05), and at the same time strychnine in gelatin- or sugar-coated pill or granule may be given. 708 DISEASES. It must be remembered that this last treatment is only to be employed in chronic cases devoid of all irritation and dependent upon atony. It will not do good if the urine is not previously made clear. Nothing can be more unfortunate in the treatment of these cases than punishment by severe scolding or whipping the child, as it never does good, and, the fault being beyond the child's control, the unjust punishment makes him sullen, or through nervousness, augmented by such treatment, his trouble becomes worse. In some cases it may be necessary, in order to cure the habit, to let the child drink diuretic waters for years. The patient should always be taken from bed when the parents retire for the night and made to evacuate the bladder. For the incontinence of adult females or males due to atony of the vesical sphincter, and which occurs on laughing or sudden movement, nothing compares, from a curative point of view, to drop doses of tincture of cantharides three or four times a day, the urine being kept flowing freely from the kidneys by means of alkaline diuretics. Atten- tion to the reaction of the urine in these cases is also of value. If it is acid, alkalies must be given; and if alkaline, urotropin or uritone is indicated. The treatment of the fourth form of incontinence of urine comes into the province of surgery. The bladder must be relieved by the catheter if the trouble be from retention with distention. If the dis- order is due to paralysis, nothing can be done except to carry out those general measures valuable in such cases — to maintain the urine in as normal a state as possible by urinary antiseptics, to catheterize fre- quently with an aseptic catheter, and to wash out the bladder every few days or hours, as the case may be, with some weak antiseptic fluid, such as the 1 : 10,000 solution of bichloride of mercury, or 1 : 200 of carbolic acid, or 1 : 100 of boric acid. INDIGESTION (GASTRIC AND INTESTINAL). Under the heading "Biliousness" the writer has described many of the conditions arising out of indigestion, and, this being the case, the consideration of that state known as dyspepsia or indigestion will only receive attention at this point in so far as its cure is concerned, without the relief of the symptoms produced. Lack of gastric digestion depends for its existence upon a great number of causes, and is always a symptom, not a disease. It occurs during the course of short or prolonged fevers from atony of the gastric walls and glands, from lack of secretion of the proper character, from hypersecretion of mucus by the mucous glands, or as the result of any one or all of these conditions, and, lastly, because the food is unsuitable to the case, or is of a kind difficult of assimilation, or is readily split up into effete products by fermentation, and these in turn, being absorbed, produce toxic symptoms. Sometimes it is due to organic changes in the abdominal viscera, as carcinoma or ulcer, and sometimes to acute INDIGESTION {GASTRIC AND INTESTINAL). 709 or chronic gastritis. In each of these states the treatment is, of course, different, because widely separated causative factors must be relieved. The indigestion attendant upon the course of fevers can nearly always be avoided by a proper diet and the use of predigested food, such as pancreatized beef-tea, milk, or broths. The necessity of this artificial digestion is the more readily recognized when we recall the investigations of Hoppe-Seyler upon the quality of the gastric juice of a patient suffering from typhus fever, for he found that no hydro- chloric acid was present. Uffelmann has also found in a similar study that the peptone-forming secretion of the stomach ceases entirely during fever. Where indigestion results from the presence of gastric catarrh the remedies applicable to such a state must be resorted to. (See Gastric Catarrh.) The studies made within recent years upon the chemical conditions of the gastric contents have changed the methods of treatment from being empirical to being rational, for it is now known that disorders of digestion depend on deficient or excessive acidity of the gastric juice, deficient formation of pepsin, deficient motility of the gastric walls, gastroptosis and enteroptosis, and other less important causes. Before carrying out any line of treatment the physician must therefore decide, if possible, as to the underlying cause of the dyspepsia present in each case, and his decision may be based on well-described subjective symptoms by the patient, or upon this description aided, or it may be replaced, by examination of the stomach-contents after a "test- meal." In those cases in which the dyspeptic symptoms result from imper- fect mastication and insalivation of food it is evident that careful rules about eating are to be given the patient, with the additional advice, which is equally good in all cases, that exact meal-hours shall be adhered to, since irregularity in meal-hours results in imperfect digestion as commonly as irregularity of habit in regard to defecation results in constipation. If the dyspeptic symptoms are due to deficient secretion of gastric juice, particularly if it is found that hydrochloric acid is the chief deficient element, one of two plans presents itself for employ- ment. In many cases it will be found that the administration of small doses of bicarbonate of sodium, 5 to 10 grains (0.3-0.60), before each meal will cause a free secretion of gastric juice, particularly if it be given simultaneously with bitter substances which act as stimu- lants to the gastric mucosa. These facts are not based solely on the apparent improvement in the patient, but also upon careful chemical studies of the acidity of the gastric juice by means of the stomach- tube. In mild cases the taking of a glass of imported Celestin Vichy water before each meal serves to provide sufficient sodium to produce good effects. The bitter substances which it is best to employ in cases of deficient acidity of the gastric juice are among the simple bitters, such drugs as quassia, cascarilla, calumba, and gentian. Among 710 DISEASES. the peculiar bitters we have nux vomica, quinine, rhubarb, and con- durango. These may be employed in the following form: 1$ — Sodii bicarbonatis 3j (4.0). Tinct. nucis vomicae f 3j vel fgij (4.0 vel 8.0). Tinct. gentian, comp. . . q. s. ad f §iij (90.0). — M. S. — Teaspoonful to a dessertspoonful (4.0-8.0) before meals. When there is deficient gastric secretion through atrophy of the gastric tubules or carcinoma of the stomach, the use of hydrochloric acid is the better plan. Under these circumstances the following prescription may be ordered: I$— Acid, hydrochloric, dil f 5j j vel f5iv (4.0-15.0). Fluidext. condurango f §j (30.0). Tinct. cardamomi comp. . q. s. ad f 5iij (90.0). — M. S. — Dessertspoonful (8.0) with or after each meal in water The symptoms manifested by persons needing the treatment just named are variable, but generally of sufficient constancy in type to be fairly pathognomonic. There are generally loss of appetite, some impairment in general health and nutrition, and marked difficulty in digesting food, particularly if it be in solid form. Complaint is usually made of a sensation of weight after eating, without any real pain, but indigestion is not complete, owing to the food being finally disposed of in the duodenum. Often because of the delay in gastric digestion there is some belching of gas due to fermentation of the food in the presence of warmth and moisture, and without the antiseptic influ- ence of the gastric juice. If any food is brought up with the belching, it is unaltered or changed only by fermentation. Examination of the stomach-contents for hydrochloric acid by the phloroglucin-vanillin test will speedily confirm the diagnosis of absence of hydrochloric acid, and this confirmation should be sought for in every case. In the cases of gastric indigestion depending upon hypersecretion of the acid of the juice a line of treatment quite at variance with that just discussed must be instituted. This may be divided into the direct and indirect forms, including the remedies which distinctly decrease gastric secretion and those which antagonize or overcome its acidity after it is poured out from the glands. In the first class we find both general and local nervous and glandular sedatives, and in the second alkaline drugs. Of the first class we have hyoscyamus, belladonna, and opium from the vegetable kingdom, and the bromides, bismuth, and nitrate of silver from the mineral. Of the second class we have massive doses of sodium bicarbonate taken during or after meals, ammonia, generally in the form of the aromatic spirit, and magnesia and chalk. As many, if not all, of the cases suffering from hyperacidity are of a nervous temperament, these drugs do good by quieting reflex activity throughout the nervous system connected with digestion, and by a local action on peripheral nerves, or on the glands themselves, diminish INDIGESTION {GASTRIC AND INTESTINAL). 7H secretion. Of particular value for this purpose is hyoscyamus, which very markedly decreases gastric secretion directly and indirectly, and at the same time relieves gastric pain by its local sedative influence. Taking gastric ulcer as a typical instance of a condition of excessive secretion of hydrochloric acid, it will be found that the following pill, combined with an absolute milk diet or, for the first few days, allowing only rectal alimentation by peptonized food, will be most useful : R — Argenti nitratis gr. v (0.3). Extract, hyoscyami gr. x (0.60). — M. Ft. in pil. No. xx. S. — One pill one hour before taking food. Sometimes in place of this pill it is wise, particularly if no ulcer exists, to give 10 to 20 grains (0.60-1.3) of bromide of strontium one hour before meals, and in any case where this fails to control excessive secretion of acid full doses of sodium bicarbonate may be given, 20 or 30 grains (1.3 or 2.0) or more, after each meal. The following formula may be used: R — Magnesise (hydrated) Siijss (14.0). Bismuthi subnitrat 5ijss (10.5). Cretse preparatse 3hjss (14.0). Sodii bicarbonat. ........ 5iijss (14 0). — M. Ft. in chart. No. xx. S. — One powder three hours after meals. When the bromides are given, it is best to give them in solution. If the stomach is very irritable and there is a tendency to vomiting, a powder composed as follows is often useful: R — Phenolis (cryst.) gr. xx (1.3). Bismuthi subnitrat gr. cc (13.2). — M. Ft. in chart. No. xx. S. — One t. i. d. with or before food. The symptoms manifested by the patients requiring this treatment are as follows: There is often a constant sense of gnawing or hollow- ness in the stomach, which is sometimes temporarily allayed by the taking of food. The patient is, as a rule, of a nervous temperament and often in a condition of nervous depression due to some exhausting cause. Tenderness and even pain in the epigastrium may be pro- duced by superficial or deep palpation, or the patient may complain that the pressure of her clothes is distressing. If ulcer of the stomach is present, all the characteristic symptoms of that lesion may be found. When belching occurs, there is often vomiting of sour masses or acid eructations or heartburn. Gastralgia more or less severe may also occur. Sometimes such patients are neurasthenic and need a rest- cure. In cases where testing the stomach-contents shows that the excessive acidity is not due to hydrochloric acid, but to the acids of fermentation, the use of the sedative drugs named is of no avail for obvious rea- 712 DISEASES. sons, and in their place sodium bicarbonate should be employed as a palliative, and antiseptic or antifermentative drugs, such as thymol, beta-naphtol, creosote, chloral, and sodium hyposulphite, as direct remedial agents. Lavage of the stomach should also be resorted to. In still other cases a mixture containing chloral and hyposulphite of sodium is useful because of its antiseptic influence. (See Chloral.) Often these cases are relieved if all fats, and butter in particular, are excluded from their diet-list. If much gas is developed and a sensation of weight in the stomach is felt after eating, so that the patient feels as if the food lay undigested in that organ, the following prescription may be used, but is contra- indicated if the stomach is tender on deep palpation, or, in other words, if acute irritation or inflammation of the stomach is present. It is useful in atonic states of the stomach, and it is surprising how much relief may be afforded by the use in such cases of these pre- scriptions : R — Oleoresin. capsici . . ... . . TTLij (0.1). Pepsin, vel pancreatin. . . . . . gr. xx (1.30). Carbo ligni gr. xl (2.60). Creosoti Tu_x (0.60).— M. Ft. in pil. No. xx. S. — One after eating. Another useful formula is: 1^ — Pulv. capsici . gr. x (0.60). Extract, nucis vomicae gr. v (0.3). Taka diastase gr. xl (2.60).— M> Pone in capsul. No. xx. S. — One with meals. Intestinal indigestion depends upon almost the same causes as does gastric dyspepsia, and is to be treated in much the same manner, chiefly by a careful study and regulation of the patient's diet, and by the use of a number of remedies calculated to aid to some extent the normal juices by some digestive ferment. These ferments should be given with the meals, or the food be " predigested " before it is taken. The pancreatin should be given in full dose (5 to 10 grains [0.3- 0.60]), with bicarbonate of sodium, and alkaline mineral waters used if the urine is concentrated and acid. (See Biliousness.) Sometimes where intestinal indigestion is present great flatulence comes on, and is an annoying symptom. Very commonly in these cases it will be found that the patients think they have heart disease because of the pain they suffer under the prsecordium. This pain is due to the accumulation of flatus in the small intestine, or more com- monly to its pressing upward at the angle where the transverse colon turns to go down to form the descending colon and sigmoid flexure. Under these circumstances the prescriptions named above will be found of service, or the following may be used: INFLUENZA. 713 ^— Acid, nitric, dil fgijvel 3 iij (8.0-12.0). Tinct. cardamom, comp f§vj (180.0). — M. S. — Dessertspoonful (8.0) in water four times a day. In some persons flatulence of the large bowel is met with, and is often associated with atony of the muscular coats of the gut. Under these circumstances the following prescriptions will be found of service : I$— Asafcetidae gr. xl (2.6). Extract, nucis vomicae . . . . . gr. iv (0.25). Extract, physostigmatis gr. iij (0.20). Oleoresin. capsici TTlx (0.60). — M. Ft. in pil. No. xx. S. — One pill three times a day, two hours after meals. Or, Py— Tinct. belladonnas f 3 iij (12.0). Tinct. physostigmatis f ^iss (6.0) Spt. camphorae . . . . q. s. ad f ^5 iij (90.0). — M. S. — Teaspoonful (4.0) two hours after meals or whenever needed. Abdominal massage is a valuable aid in treating this class of cases. Sometimes it can be well done by directing the patient to roll slowly and gently a three-pound cannon-ball over the course of the colon, to urge on the intestinal contents and cause secretion. In other instances the application of a roller electrode with the rapidly interrupted cur- rent from a faradic apparatus is useful. Where intestinal indigestion results in lientery the treatment becomes entirely changed, except in regard to the use of a predigested milk diet, and efforts must be made to increase the secretion of the glands of the intestinal wall. Often minute doses of mercury bichlo- ride or podophyllin may do this, -g 1 ^- to fa grain (0.001-0.0015) of the first or second, respectively. More commonly, however, the mixture of nitric acid, given above, will be the proper treatment or perhaps the following if the liver is found to be torpid: 1^— Acid, nitrohydrochlor. (not dil.) . . f 5ss vel f 3j (2.0-4.0). Tinct. gentianae comp. . . q. s. ad fgvj (180.0). — M. S. — Dessertspoonful (8.0) every four hours or after meals, in water. Chloroform spirit is often valuable in some of these cases in the dose of 30 minims (2.0). (See Chloroform.) INFLUENZA. The disease known as influenza affects individuals so differently, and presents so many symptoms associated with functional disorder of various organs in the body, that it is almost impossible to do more than consider the remedies which are to be employed in the treatment of the more frequent or more immediate manifestations or complications. Of far greater importance than the employment of drugs must be regarded continuous rest in bed, and stimulants are in many cases absolutely essential. 714 DISEASES. In those cases in which the disease is ushered in by a severe chill, accompanied by violent pains in the back, if the patient is seen early enough it may be necessary to employ remedies for the relief of the rigor, with the double purpose of improving the patient's general con- dition and preventing internal congestion of vital organs. In the majority of instances, however, the patient is not seen during this period of the disease, but during the febrile stage, which succeeds that just mentioned. Under these circumstances the author does not believe that it is well for the physician to resort to any of the remedies which have been so largely used during the last few years, and which are known as the "antipyretics" or the derivatives of coal-tar. Although originally introduced for the purpose of reducing febrile tempera- tures, practical experience has taught that their value is very limited under these circumstances, and the author almost never gives antipyrin, phenacetin, or acetanilid with the object of reducing fever. Although he does not believe that these remedies are to be used for the reduction of temperature, he has certainly seen very marked relief follow their employment with the object of subduing the severe pain which occurs in the back, limbs, or head. Small doses are usually sufficient at least to reduce the suffering, if not to remove it entirely, but, as cardiac complications are by no means unusual, large doses are contraindi- cated in most persons. The author prefers to allow the patient to suffer from a moderate degree of pain rather than from the dangers incident to the administration of doses large enough to relieve it entirely, because in his experience these doses have to be very large if they are to be entirely competent as analgesics in influenza. If any of the coal-tar products are used either for the relief of fever or of pain, phenacetin and acetanilid should be chosen. Experi- ments made in America and in Germany on animals have proved that phenacetin is far less toxic in its relations to the heart than is antipyrin or acetanilid, and while it has in a number of instances seemed more apt to produce cyanosis in man than other drugs, this cyanosis rarely, if ever, has been associated with any other dangerous symptoms. Indeed, it is quite extraordinary the amount of cyanosis which phenacetin may produce without the respiration becoming greatly disordered, very much less cyanosis when caused by acetanilid or antipyrin being accompanied by much more alarming symptoms. A very favorite combination with practitioners who have had a large experience is one of phenyl salicylate and phenacetin. The action of the phenacetin in relieving the pain and in reducing the fever seems to point to it as a rational remedy, but the exact influence of phenyl sali- cylate under these circumstances is not so clear. Composed, as it is, of 60 per cent, of salicylic acid and 40 per cent, of phenol, it seems to possess a therapeutical power different from that possessed by either of these two constituents alone, for neither phenol nor salicylic acid has much power in the relief of pain when used alone, unless, as in the case of phenol, it is applied directly to the part affected. Per- INFLUENZA. 715 haps the condition of pain in the lumbar and other muscles during the attack of influenza is in some unknown way associated with the condition which has been called "rheumatism," and in which salicylic acid does good in an unknown manner. Salicylic acid alone might be equally useful if it were dissolved in the intestine and did not irritate the stomach. On seeing a case of influenza during the first few hours of the attack the author resorts to those remedies which have been in use by the profession for many years, and, so far as he can learn, it is the custom of other members of the profession to give a mixture composed of spirit of nitrous ether and a solution of citrate of potassium in pref- erence to any other medicine at this time. This mixture possesses the advantage of increasing the action of the skin and kidneys, and of reducing the temperature, of quieting the circulation, and of being readily taken by the patient without danger of disordering the stomach at this time or later, which is important, as this organ is apt to become irritable. As a general rule, citrate of potassium is given in too small doses, and, unless there are reasons to the contrary, it should be given in the dose of 10 to 15 grains (0.60-1.0) three times a day to an adult. If the fever becomes excessive, so that there is danger of the patient suffering from a true hyperpyrexia, it is better to resort to cool sponging instead of the antipyretics just spoken of. It is a very important portion of this treatment to use frictions designed to bring the heated blood to the surface. (See Cold and Fever.) Hyperpyrexia in influenza does not seem to possess the same dangers that it does in the course of some other diseases. In the first place, as a general rule, the course of hyperpyrexia is very brief, and, although it may leave the patient weak and exhausted, the duration of the febrile portion of the malady does not extend beyond a few days. Clinical experience and physiological study have proved that it is not the tem- perature of 105° or 106° F. w T hich is distinctly dangerous, but the continuation of this temperature for many hours which is harmful. Similarly, a patient ill from typhoid fever, having a temperature of 103° for many days, is injured very much more than is a patient w T ho is suffering from pneumonia, and who may have for forty-eight hours a temperature of 104.5° or 105° F. For these reasons a temperature of 104.5° or 105° F. is not particularly alarming in the condition w T hich we are considering, unless there are symptoms pointing to the fact that the patient is being injured by an excessive temperature, as may be indicated by somnolence and an exceedingly dry skin as well as cerebral symptoms. The point to be strongly emphasized is that the mere existence of high temperature is not to be regarded as a condition to be overcome by the use of drugs. It seems to be the general consensus of opinion, both in America and in England, that any measures of a depleting character are dis- tinctly harmful in influenza, even at its earliest stages, and we would 716 DISEASES. naturally expect that this would be the conclusion arrived at by phy- sicians who treat their patients rationally. Although influenza is a short-lived disease, there is probably no malady in which the patient goes so quickly into a condition of profound depression, or even exhaustion, as in this one, The abstraction of blood from a vein or by the use of wet cups for the relief of pulmonary congestion should not be resorted to, as it will increase the exhaustion. Before the sys- tem has a chance to recover from the onset of the attack it will be still further depressed by the therapeutic measures of the physician if he is unwise enough to bleed. As the case of influenza progresses a condition of marked depression, or even collapse, very frequently develops. The expression of anxiety on the patient's face is, to a physician who is accustomed to see it in other diseases, a most alarming symptom, and it is not until one has seen it repeatedly in influenza that he is able to give it its exact value. Associated with this condition, the skin is frequently covered with a profuse perspiration, and the pulse is apt to be very rapid, running, feeble, and easily compressed. At first glance the old saying, that "we treat the symptoms as they arise," would seem to cover to a very large extent the indications which are present at this period; yet the author's experience, which may differ from that of some of his readers, is that the cardiac stimulant which we are most frequently accustomed to use — namely, digitalis — does not seem to take hold of the circulatory apparatus and to act upon it in the manner which is desired. It may be that the pressing symptoms make us more anxious and impatient as to the use of any medicament, and that we do not have the patience to wait and allow such a slowly acting remedy as digitalis to take effect. Be this as it may, the author regards strychnine as infinitely preferable to foxglove when these symptoms appear; and he has been able to prevent their appearance, or at any rate to modify them to a very great extent, by using strychnine in full doses from the first portion of the stage of depression. As a general rule, strychnine is given in very much smaller doses than safety requires, and in many instances it fails to act because the doses are too small to combat the profound condition of exhaustion which is present. In an adult there is no reason why ^o" grain (0.003) may not be given three or four times in twenty-four hours, and in some cases it may be given every four hours without producing any of the symptoms of an overdose. Divided doses are better than a few very large ones. In the employment of strychnine in influenza, the author knows of no better illustration of the fact that in some conditions drugs should be given for effect rather than in customary dose, and the physician who is timorous in the presence of this frequent complication, de- pression, certainly does not lessen the patient's danger. As with all powerful medicaments, the action of the drug should be carefully watched, and at the first manifestations of muscular twitching or stiff- INFLUENZA. 717 ness at the back of the neck its administration should be cut down or discontinued. In many instances where the collapse comes on suddenly the strychnine should be administered hypodermically and followed by full doses by the mouth, in order to keep up the full effect upon the nervous and circulatory systems. In some cases it will be found that the bloodvessels seem to be so atonic that the strych- nine is unable to produce a sufficient vascular effect to bring the patient out of his difficulties, and under these circumstances very good results follow the combination of belladonna with strychnine, the belladonna being a useful vasomotor stimulant under such circum- stances. It also should be given in full doses for effect. As the acute stage of depression passes off the belladonna should be stopped and the strychnine continued alone through convalescence. It is proper to point out, however, that strychnine is not suitable for the purpose of producing constant stimulation. It is a whip to the nervous system, and if used in too large a dose for too long a time the overwhipped system fags out. Under these circumstances it may cause an active delirium. Alcohol has not seemed to be of much value during the active period of the disease. In milk-punches and egg-nog it is, of course, useful during convalescence. When delirium comes on, it does not seem to be a symptom of very serious character either for immediate results or in influencing the prognosis as to the ultimate recovery of the case, and in cases of pneu- monia complicating la grippe, in which delirium is the prominent symptom, it is not to be regarded in the same light as similar mani- festations complicating ordinary pneumonia or other diseases. The delirium may be either talkative or muttering, but does not in the majority of cases require treatment, passing away with the fever and rarely extending into the stage of exhaustion. For the irritative cough steam inhalations, laden in the first stage with benzoin or other innocuous and sedative substances, seem par- ticularly useful. For the bronchitis which is often present it is gen- erally sufficient to administer the ordinary mixtures, containing ipecac and potassium citrate, in the earliest stages, and to follow them by chloride of ammonium and cubebs in the later stages. The author does not think that the compound liquorice mixture containing anti- mony should be given in the second stage of influenza. A complication too apt to occur at this time is oedema of the lung or a widespread bronchitis, with a profuse exudation which bids fair to drown the patient in his own secretions. Antimony is not only depressing to the circulatory and respiratory systems, but also aids verv materially in causing the peculiar excess of secretion which has just been spoken of. Atropine is in reality the drug of choice. It may be necessary to use bromides if the cough is excessive, or to replace them by codeine or very small doses of morphine. In many cases still better results will be obtained by a good preparation of 718 DISEASES. cannabis indica, which may be pushed until it relieves the cough with- out in any way endangering the patient's life — a safety which cannot be obtained by the employment of any other of the drugs named. If sleeplessness is so pressing a symptom as to require attention, the bromides may be given, but it will be generally found that the insomnia comes after the attack rather than during it, or in any event it will not require attention until the patient is convalescent. Under these cir- cumstances chloral or chloralamide, or even sulphonal, may be admin- istered, care being taken, of course, in the case of chloral that the cardiac apparatus is in good condition, and in the case of sul- phonal that it is administered in a powdered form or dissolved in hot water and given four or five hours before the time at which sleep is desired. For the vertigo and dizziness which are sometimes bitterly com- plained of by the patient either during or after the attack, moderate doses of bromide of sodium with ergot or cannabis indica have seemed particularly valuable, probably because they exercise some effect upon the bloodvessels of the brain or its membranes or perhaps upon the bloodvessels of the ear. Certain it is that in those cases of tinnitus not associated with organic change in the aural canals bromides and ergot do more toward relieving them than any other medication. In the constipation which is sometimes present in the early stages of influenza it is generally advisable to administer either castor oil or in other cases \ ounce (16.0) of the sulphate of magnesium, or for more fastidious patients the citrate of magnesium. A full purgative effect of any of these salines seems to lessen the fever when the bowels are unloaded. Care should be taken that the dose of the purgative is not excessively large, as it will weaken the patient. For the con- stipation following the attack probably no drug is so efficient as cascara sagrada, combined perhaps with aloin. (See Constipation.) If diarrhoea supplants the constipation, the ordinary astringents, such as aromatic sulphuric acid or hematoxylin, will be found suffi- ciently active. (See Diarrhoea.) INSOMNIA. Insomnia is a condition complicating many diseases, and arises from such a host of causes that the physician may not be able to dis- cover them for some days after the patient is first seen. As a general rule, a patient consulting a physician with this symptom expects a prescription to be given at once and the cause of the insomnia found out afterward. Under these circumstances the physician may employ several drugs according to the information that he has concerning the patient's state. One of the most common remedies is chloral given in the following manner: INSOMNIA. 719 R— Chlorali hydrati 5iij (12.0). Syrupi f oiv (16.0). A quae cinnamomi . . . . q. s. ad i'oiij (90.0). — M. S — Dessertspoonful (8.0) at night. Or, Bf. — Butyl chloral hydrat 5j (4.0). Ft. in pil. No. xii. S. — One, two, or three pills at night, as needed. Where, for any reason, as the presence of a weak heart, chloral is contraindicated, resort may be had to the bromide of potassium or sodium, and if the patient is a woman these drugs should always be accompanied by a small dose of arsenic, generally in the form of Fowler's solution, 1 to 3 minims (0.05-0.20) three times a day in order to avoid the possibility of the production of acne. The fol- lowing prescription is useful: I$— Potassii bromid £ ij vel ^ss (8.0-16.0). Liq. potassii arsenit t' t ^ss (2.0). Aquae cinnamomi . . . q. s. ad f^vj (180.0). — M. S. — One or two dessertspoonfuls (8.0-15.0) at night. In many cases larger amounts of the bromide will be needed. Where the sleeplessness is due to pain, chloral is of little value and bromides are worthless. Under these circumstances by resorting to what is known as the "crossed action of drugs," we can often obtain a very good effect. Thus morphine and chloral both act on the brain to produce sleep, or, in other words, their action is here crossed, for one relieves pain and the other does not; one kills by failure of the heart in overdose, the other by respiratory failure; as a consequence large doses of neither can be given alone. The following is therefore a useful combination, either where one drug fails or when danger- ously large doses of either alone have to be used to obtain the desired result. ty — Morphinae sulphatis . . . . . gr. ij vel iv (0.12-0.25). Chlorali hydrati ...... 3ij (8.0). Syrupi fgij (60.0). Aquas q. s. ad fgiv (120.0) —M. S. — Dessertspoonful (8.0) at night. In cases where insomnia is due to mania hyoscine is said to be very useful, given in the dose of y^- to -^ grain (0.0007) by the mouth or yy-Q- or y-jj-Q- grain (0.0006) by the hypodermic needle. Owing to its tastelessness the powder may be put on the tongue, and it is best to order a little sugar of milk or white sugar (1 grain) to be added to each dose of hyoscine, in order to give it bulk. Where insomnia follows mental effort, avoidance of all cerebral activity should be insisted upon during the evening, and if the feet are cold on going to bed sleep should be induced by relieving the cerebral congestion by a hot foot-bath or the use of a hot-water bag at the feet while cold is applied to the head. In other instances a general hot bath, during which an ice-bag is applied to the head, will produce 720 DISEASES. sleep when drugs fail ; and it is to be remembered that in the insomnia of convalescence and neurasthenia hydrotherapeutic measures are to be used to the exclusion of drugs (see Cold and Heat), for the former cure the condition, while the latter only palliate, and may produce a drug-habit. Not infrequently patients convalescing from prolonged illness suffer from drowsiness during the day and wakefulness at night because the circulation is feeble and fails to supply the brain with blood while the body is erect, but does so very well when recumbent. Hydrotherapy to improve vascular tone and the use of a pill of nux vomica and arsenic, or nux vomica and phosphorus, is useful in these cases. During the last few years a large number of remedies have been introduced as hypnotics, such as chloretone, somnal, paraldehyde, chloralamide, sulphonal, trional, amylene hydrate, hypnal, and others. Of these the best, from every point of view, are sulphonal, trional, and chloretone. The dose of sulphonal and trional is 10 to 20 grains (0.60-1.3) in powder, but, as they are large in bulk and not easily swallowed, they should be used in a prescription made up as follows: 1$ — Sulphonal. (sulphonmethani) . . . gr. xxx (2.0). Sympi . . . . ■ fgij (8.0). Mucilaginis acacise f 3 i j (8.0). Aquse destillat q. s. ad f oj (30.0).— M. S. — From half to all of this at one dose, as may be needed. In other instances sulphonal may be dissolved in very hot water or milk, and the solution swallowed before it cools sufficiently to permit precipitation. In ordinary nervous insomnia or that due to heart disease chloretone often acts very efficaciously in the dose of 10 to 20 grains (0.60-1.3) in tablets or capsules of 3 to 5 grains (0.20-0.30) each. Chloralamide (Chloralformamide.XJ.S.'Y.) maybe used in the dose of 15 to 60 grains (1.0-4.0), dissolved in wine or given in capsule. Paraldehyde is given in the dose of 20 to 60 minims (1.3-4.0). As it is disagreeable in odor and taste, it must be given in capsule, and it is very apt to disorder the stomach. Somnal is used in the dose of 10 to 40 minims (0.60-2.60) with liquorice and water, and possesses considerable power. In the treatment of insomnia it should be remembered that if pos- sible those drugs should be used which will quiet the part of the brain which is most active. Thus if the patient is restless, bromides and chloral should be used as motor depressants. If sensation is acute, bromides and the hot pack may be used as sensory quietants. In some cases horseback exercise taken late in the afternoon does good, particularly if the patient follows a sedentary life. Many per- sons who are usually sleepless will obtain a refreshing slumber by taking a very light and easily digested meal just before retiring for the night or by eating a cracker or drinking a glass of milk when they awake during the night. INTERMITTENT FEVER. 721 In some instances sleeplessness arises from acidity of the stomach, and is put aside by the use of bicarbonate of sodium. INTERMITTENT FEVER. It having been proved that malarial fever is practically always the result of the bite of a mosquito, Anopheles quadrimaculatus, the disease is to be prevented by destroying mosquito-breeding pools and by protecting the skin. It is also important to prevent mosquitoes from biting a patient with malaria, as by this means the infection is spread. Such patients should sleep under a netting. In all forms of intermittent fever, whether the attacks are quotidian, tertian, or quartan, the best remedy for their prevention is quinine, which should under these circumstances be given about two or three hours before the attack is expected, so as to be absorbed and be physio- logically active when the paroxysm is due. This precaution is often overlooked, and the dose ordered at the time of the expected attack, with failure as a result. Not only should sufficient time elapse for absorption, but the fact should be remembered that the chill often begins an hour earlier each day, and will be in full sway before the quinine can stop it if the drug be not administered at the proper time. There are two methods of giving quinine in malaria. In one it is given just before an expected paroxysm, to prevent it by destroying the parasite at the time of maturity. In the other plan the drug is administered in the sweating stage, not because it will have any valu- able influence on that particular paroxysm — which is nearly over — but in order that it may destroy the young spores which are floating free in the blood-stream and about to attack corpuscles, in which they will mature. Undoubtedly if the quinine is given at the proper time before an attack it tends not only to prevent the oncoming paroxysm, but also future ones by its influence upon the mature and immature parasites. If, therefore, the patient is seen before the attack, he should receive quinine to prevent or modify it. If seen after an attack is well advanced, he should receive a dose to prevent the next attack by destroying the crop of parasites set free in the blood during the paroxysm just passed. When the patient is seen during an intermission, the following plan of quinine medication is wise: If the infection be due to the tertian organism, which causes an attack every forty-eight hours, the quinine should be given every alternate day in full dose, as already described. If there be a double infection with this organism, so that the attacks occur daily, then the full dose must be given daily. If the quartan parasite, or that which matures every seventy-two hours, is the cause of the attack, then the full dose of quinine should be given on the day of the expected attack long enough before to be absorbed, and smaller doses between the attacks to maintain a quinine influence. If, however, there be a double quartan infection, then the attack occurs on two consecutive days with a third day free. Here the quinine 46 722 DISEASES. is needed on the two severe days and only in small doses on the inter- vening day; or if there be a triple quartan infection, it is used every day in full amount to antagonize each brood of parasites as they mature. Very much smaller doses of the quinine will be needed if the patient rests in bed than if he is up and about. Experience has proved that quinine never acts as favorably if con- stipation is present as when the bowels are lax, and hepatic activity seems particularly necessary for its full effect. To obtain the full influence of the drug, it should be preceded, by some four or five hours, by J to J grain (0.010-0.015) of calomel every fifteen minutes until a grain (0.06) is taken, or by a dose of podophyllin amounting to yV to i grain (0.006-0.008). If the podophyllin is used, a longer time should be allowed, because of the slow action of this purgative, and if the patient has been rendered unusually insensitive to purgatives^ larger doses of both the remedies named must be used; particularly is this true in the South, where 5 to 20 grains (0.3-L3) of calomel are often used and really needed. The dose of quinine varies with the exigencies of the case which in turn generally depend upon the region in which the patient lives or has lived. If the patient remains in bed, smaller doses are needed than if he remains up and about; 10 to 15 grains (0.60-1.0) in one dose are generally sufficient in the eastern and northern States, but as much as 20 to 45 (1.3-3.0), or even 60 grains (4.0) may be required in the southern and southwestern parts of the United States and else- where. When still larger doses are employed, the drug should be given partly hypodermically and partly by the rectum in suppository or in solution, as well as by the stomach, as this viscus will rarely withstand 60 grains (4.0) without irritation. (For the best salts of quinine for hypodermic use, see article on Cinchona.) If the stomach is irritable, resort to these means of entrance into the body are abso- lutely necessary and must be wholly relied on. Having considered the prophylaxis of a chili, let us turn to the treatment of the attack itself. It must be remembered that the greater part of the harmful effect of the malarial poison is exerted at this time by the internal congestions and engorgement of the abdominal and thoracic organs. The physician should therefore try to prevent as far as possible, too great a rigor; and if stasis results from the chill overcome it, not by depletants, unless the case is very sthenic, but by stimulants, such as strychnine or digitalis, which will drive out the blood from the congested area. If a full meal has just been eaten, the stomach should be emptied by an emetic dose of ipecac, 2 drachms (8.0) of the powdered drug to an adult, or by 20 grains (1.3) of sulphate of zinc. It is almost useless to give quinine at this time, as absorption from the stomach and sub- cutaneous tissues is almost entirely absent. Alcoholic stimulants are not to be employed, as clinical experience seems to indicate that they act unfavorably. IRITIS. 723 If the chill is severe enough to endanger the patient's life, measures must be used to control it. Chloroform may be inhaled, and immedi- ately preceded by laudanum by the bowel or mouth. If the laudanum is given by the mouth, a little ether or chloroform may be added to the dose of the opiate. The opium may be used hypodermically in the form of morphine in the dose of \ grain (0.01) combined with -g- 1 -^ grain (0.001) of atropine. In the fevered stage little can be done except to give the patient comfort by cool drinks and cool sponging, or, if the fever becomes excessive, by the use of ice-cold sponging with active friction. These measures have seldom to be used, as the fever is generally too fugitive to need such treatment. The sweating stage needs no particular treatment unless exhaustion is caused by it when stimulants may be cautiously used as needed, and large draughts of water at ordinary temperatures swallowed. Many measures have been resorted to to abort a malarial attack, the chief of which is the use of ether or chloroform anesthetization at the time of the expected paroxysm, of nitrite of amyl or of the nitrite of potassium or sodium in 10-grain (0.60) dose for the same purpose. Where the " chill habit" exists and depends largely upon nervousness, it has been broken by misplacing the hands of the clock, and so getting the patient past the time for his attacks without his knowledge. It should be remembered that the use of quinine in malarial fevers is no longer based on empiricism, but upon the fact that the drug exerts a peculiarly lethal influence over the cause of the disease, the Plasmodium malaria of Marchiafava and Celli, or, as it is sometimes called, the malarial germ of Laveran or the hsematozoon of malaria. It is worth remembering that methylene blue possesses antimalarial proDerties in the dose of 1 to 4 grains (0.06-0.25) . (See Methylene Blue.) IRITIS. Iritis* or inflammation of the iris, as usually encountered is caused either by syphilis rheumatism, or gout. It may also be traumatic: less frequent causes are gonorrhoea, diabetes, malaria, and tuberculo- sis. Metastatic iritis occurs in pyaemia, relapsing fever, etc. The most marked symptoms are severe brow pain; fine ciliary injection; discoloration of the iris and immobility of the pupil, due to the forma- tion of adhesions between the iris and the capsule of the lens. The most important local remedy is atropine, to be used every two hours according to circumstances. If for any reason this is not tolerated, duboisine, scopolamine, or daturine may be substituted. Cocaine increases the mydriatic power of atropine. Pain may be relieved by leeches to the temple and the use of dry heat externally (cotton batting heated over a register will suffice) or hot fomentations — water, chamomile infusion, or laurel-water (1: 15). In traumatic iritis iced compresses are suitable in the early stages, 724 DISEASES. but not in the later periods and not in any other form of iritis. Great care must be taken not to mistake iritis for conjunctivitis on the one hand, and glaucoma for iritis on the other; delayed use of atropine and the employment of astringents on account of the former error, or the instillation of atropine because of the latter, would constitute a serious therapeutical blunder. In serous iritis, or that variety in which there is a hypersecretion of the aqueous humor, which becomes turbid, and a precipitate of dark spots occurs upon the membrane of Descemet, atropine must be cautiously instilled, owing to the tendency to increased tension. If this occurs, paracentesis of the cornea may be needed, and pilocarpine should be given internally if the vitreous becomes opaque. Instead of the subconjunctival injections of sublimate at one time highly recommended, Darien advocates cyanide of mercury (1 : 5000 to 1 : 1000), a few drops of a 1 per cent, solution of acoin being added to mitigate the pain. From 1.0 to 15 minims of the cyanide solution may be injected subconjunctivally. Similar injections of physio- logical salt solution are equally efficacious, and preferable because they cause less pain. In true syphilitic iritis mercury should be pushed to the point of tolerance, but it is not necessary to salivate the patient. Any form of mercury usually employed in secondary syphilis may be used — calomel, blue mass, or protiodide of mercury; but the most efficacious method is by inunction: this is preferable even to hypodermic medica- tion in the opinion of many authors. After the mercurial impression has been made and the pupil is well dilated, potassium iodide, either alone or in combination with bichloride of mercury, is indicated. In plastic iritis, appearing six to eight months after the disappear- ance of the secondary symptoms, this latter treatment without the previous use of mercury has been recommended. Rheumatic iritis calls for salicylic acid v oil of gaultheria, and, later, potassium iodide; in the chronic types of the affection Zollicoffer's mixture is an excellent remedy. Potassium iodide should be admin- istered in gonorrhceal iritis, and relief occasionally follows a pilocar- pine sweat. In all forms of iritis the treatment of the constitutional disorder which has occasioned the local inflammation is necessary, and if the iritis becomes purulent surgical interference is usually required. In any variety of iritis the intense pain should be alleviated with morphine or other anodyne sufficiently active to secure sleep. Hyoscine at night is a valuable remedy. Locally dionin (1 per cent, solution) is specially recommended by Darier; it causes a somewhat prolonged local anaesthesia. It may be combined with atropine and cocaine. During the course of the disease saline laxatives may be administered, and after subsidence of the inflammation and cessa- tion of the specific treatment a course of iron tonics is an excellent routine practice. In chronic iritis, and in some forms of relapsing iritis, iridectomy is required in order to reopen the angle of the anterior KERATITIS. 725 chamber which has been closed by inflammatory exudates, and thus prevent secondary glaucoma. KERATITIS. Keratitis is the name applied to the various types of inflammation of the cornea. If this inflammation is associated with a breach in the continuity of the corneal surface 4 it is termed corneal ulcer, and four characteristic symptoms supply the indications for local treat- ment: (1) photophobia, or dread of ight; (2) blepharospasm, or spas- modic contraction of the orbicularis muscle; (3) congestion of the bloodvessels, (4) pain; while any existing dyscrasia or constitutional condition upon which the local disease may depend requires general medication. Interstitial Keratitis. Interstitial keratitis is that form of chronic diffuse inflammation of the cornea characterized by ciliary congestion and a ground-glass appearance of this membrane most common between the ages of five and fifteen years, and in the majority of cases the result of inherited syphilis. No local measure is sufficient, antisyphilitic treatment being of paramount importance. During the height of the ciliary congestion warm antiseptic lotions and atropine are indicated, the latter especially to prevent the tendency to iritis. Severe pain may be alleviated by the use of a leech to the temple if the subject be of suf- ficient age to justify the employment of local bleeding. Exactly simi- lar forms of keratitis are caused by rhachitis, scrofula, rheumatism, tuberculosis, and depressed nutrition. In addition to the local meas- ures already described, the appropriate constitutional remedies are required, particularly iron, arsenic, cod-iiver oil, and Jhe iodides. Suitable dietetic and general hygienic measures are important. Various other types of keratitis are described as the result of con- stitutional disturbances, such as gout (Hutchinson), malaria (Kipp, van Milligen), or any condition of the system associated with great exhaustion, such as irregularities in the menstrual function, certain forms of pulmonary disorders (true herpes of the cornea, Horner). The local management of these cases does not differ from that which has been described. The coexisting constitutional disturbances must be combated with suitable remedies. Phlyctenular Keratitis. Phlyctenular keratitis appears in the form of small, blister-like bodies, sometimes single, sometimes multiple, frequently situated directly at the corneoscleral margin, which become yellow, break down, and leave an open ulcer (phlyctenular ulcer), to which runs a leash of injected bloodvessels. The disease is common in children, often follows in the wake of the exanthemata, and is so frequently associated with a strumous diathesis that it was formerly called stru- 726 DISEASES. mous ophthalmia. In the majority of cases there is coexisting nasal disease, especially adenoid vegetations, which is responsible for the frequent relapses of the disorder, even if it does hot cause it. Con- gestion may be* relieved by frequent irrigation with a warm boric-acid solution. Pain and irritation call for the use of atropine drops (4 grains to the ounce [0.25-30.0JJ, which should be continued until the ulcer is covered with regenerated epithelium, when the process of cicatrization may be hastened by the insertion daily into the conjunctival sac of a small quantity of yellow oxide of mercury salve or dusting it with finely powdered calomel, providing the patient is not taking at the same time any form of iodine. During the whole treatment the eyes should be protected by dark glasses and the subject permitted to go out into the open air. All local treatment will prove unsatisfactory unless associated with strict hygiene, carefully regulated diet, and con- stitutional measures — tonics and alteratives — and treatment of the nasopharyngeal lesions. If the photophobia becomes distressing in spite of the other treat- ment, it has been suggested that this may be relieved by the use of cocaine, a practice that by no means commends itself in corneal ulcera- tion, in spite of the temporary relief from the local anaesthesia. Relief of this symptom in many instances follows the use of a douche of cold water on the closed eyelids, or by touching with blue-stone the ulcer- ated fissure at the external commissural angle, which is commonly an exciting cause of the spasmodic closure of the lids. Ulcerative Keratitis. Ulcerative keratitis, or ulcers of the cornea, may be primary in origin — that is, the disease begins in the cornea — and may be caused by phlyctenular disease, injury, abscess, depressed nutrition, etc. ; or may be secondary, and result as the sequel of severe inflammations of the conjunctiva: for example, purulent, diphtheritic, or granular con- junctivitis. There are numerous varieties of corneal ulcers, but three groups only will be mentioned: simple ulcers, which form a small, superficial gray lesion, and are not accompanied by much vascularity or dread of light; purulent or deep ulcers, in which the open lesion is of yellowish color and is surrounded by hazy cornea; and infecting or sloughing ulcers (purulent keratitis), in which the ulcer assumes a serpiginous or creeping form, and there is usually a deposition of pus in the bottom of the anterior chamber (hypopyon-keratitis). Recent investigations indicate that typical serpiginous ulcer of the cornea with hypopyon is frequently caused by the Frankel-Weichselbaum capsulated diplococcus; that ulcers not typically serpiginous may originate from a staphylococcus, streptococcus, or mixed infection; and that a small percentage of sloughing keratitis is due to a schizo- mycetal infection — the aspergillus fumigatus. The various micro- organisms come from the conjunctiva, the ciliary borders, the nares, KERATITIS. 727 and the lachrymal passage, and infect some slight abrasion on the corneal epithelium and thus start a dangerous form of suppurative keratitis. An abscess of the cornea may also occur as the result of an inoculation of the infected area with pathogenic micro-organisms, typical forms sometimes appearing during scarlet fever, measles, typhoid and typhus fevers, and especially during the convalescent stage of smallpox. Simple corneal ulcers are treated in precisely the same maimer as phlyctenular ulcers. The treatment of severe ulcera- tion of the cornea, no matter what its etiology, may be summarized as follows: (1) Search should be made for the cause of the ulcer, includ- ing careful examination for the presence of a foreign body, a misplaced cilium, conjunctival inflammation, lachrymonasal disease, affections of the rhinopharynx, carious teeth, and constitutional disorders of all types. (2) At frequent intervals moist heat should be applied by means of lint or flannel compresses dipped in water at a temperature of 120° F. (3) Unhealthy conjunctival discharge should be removed by frequent irrigations with mercuric chloride (1 : 8000), or a saturated solution of boric acid. (4) Sterile atropine drops (4 grains to the ounce [0.25-30.0]) should be instilled with sufficient frequency to main- tain mydriasis if there is any tendency to iritis. In the opinion of some surgeons, eserine {\ to \ grain to the fluidounce) is a useful drug in the treatment of peripheral ulcers with a tendency to perforate the cornea, provided there is no iritis. Recent experiences of the writer indicate that the value of eserine in the treatment of corneal ulcers is problematical. (5) The eyes should be protected with smoked glasses; but in severe cases and in the absence of purulent conjunctival discharge a dry anti- septic dressing, held in place by a light but firmly applied bandage, promotes healing and prevents perforation. It may be worn until the floor of the ulcer is covered with epithelium, and removed whenever the applications are required. A little iodoform may be dusted upon the surface of the ulcer before the bandage is applied, or the ulcer may be covered with an iodoform wafer. (6) If the ulcer shows a tendency to spread rapidly, it should be curetted and immediately afterward gently touched with a probe which has been dipped in pure carbolic acid, or with a wisp of cotton which has been dipped in a solution of nitrate of silver (10 grains to the ounce), tincture of iodine, or formal- dehyde (1:60). Of these remedies, nitrate of silver and tincture of iodine yield the best results in ulcers of the non-infective type; but in ulcers of the infective variety pure carbolic acid or nitric acid should be employed. (7) If the ulcer continues to spread, the actual cautery may be used, the glowing point of the cautery-needle being applied to every portion of the ulcer, the area of which is outlined by means of fluorescine (2.5 per cent, solution), which will color green any portion of the cornea deprived of its epithelium, and there- fore furnish a reliable guide to the extent of the destructive process. Before these severe applications are made the cornea should be rendered insensitive by a few drops of a holocain solution, and the 728 DISEASES. ulcer itself painted with a cotton wisp dipped in holocain. Indeed, there is much evidence to show that the application alone of this drug has a distinct curative influence on corneal ulcers, in this respect differing very distinctly from cocaine, which rather retards the cica- trizing process. Subconjunctival injections of cyanide of mercury (1 : 5000) or of physiological salt solution at times yield satisfactory results. If an abscess forms in the cornea, the pus should be evacuated by an incision; and hypopyon, or pus in the anterior chamber may be drained by an operation after the manner of Saemisch — that is, by division of the corneal layers — or by a simple para- centesis of the cornea. Sequelae of Corneal Ulceration. After healing of a corneal ulcer the cicatrix consists of a more or less dense white spot in the cornea (macula). If these scars are thick and white, they are irremediable by local medication and require surgical interference for relief. If, however, they are diffuse, much good will follow systematic massage of the cornea, aided by the introduction of a small particle of yellow oxide of mercury salve. The massage is performed as follows: A piece of the salve the size of a split pea is introduced beneath the upper lid; upon the closed lid a finger is placed, and regular motions made through the lid over the surface of the cornea — namely, vertical, lateral, and radial motions, the seance being completed by circular movements. The whole should last from one to three minutes. Alleman claims excellent results in dissipating corneal opacities by the use of electricity by connecting a suitably prepared electrode with a battery, the cathode being placed directly on the previously anaesthetized cornea and the anode on the cheek. Subconjunctival injections of physiological salt solution, placed near the corneal margin, have some power in causing absorp- tion of corneal nebula. The internal administration of thiosinamin has been recommended; the author has never observed encouraging results from the use of this remedy. LACHRYMAL ABSCESS. Lachrymal abscess results from suppuration in a chronically dis- tended lachrymal sac owing to the presence of obstruction in the nasal duct, and exists as a swelling under the skin at the inner can- thus, pressure upon the surface causing an escape of pus through the canaliculi. The treatment is practically confined to surgical inter- ference^ — that is, division of the canaliculi and washing out the dis- tended sac with antiseptic fluids, and restoring the patulency of the nasal duct by the use of probes as soon as the inflammatory symptoms have subsided; or, if the skin over the seat of the abscess is thinned and rupture is threatened, by free puncture downward and outward. In purulent discharge from the lachrymonasal duct solutions of formal- LARYNGITIS (ACUTE). 729 dehyde (1:6000), nitrate of silver (1:500), or protargol or argyrol (2 to 5:100), injected through the passage, favorably modify the unhealthy secretion. Much comfort will ensue from the use of hot compresses over the inflamed area. These may be made in the ordi- nary way, but are more efficacious if composed of a lead lotion, the ordinary lead-water and laudanum answering the purpose very well. Excision of the lachrymal sac is the best surgical procedure for chronic dacrocystitis. LARYNGITIS (ACUTE). The treatment of acute laryngitis is identical in many respects with that directed against acute inflammatory processes elsewhere. It may be divided into local, external, and internal methods. The con- dition of the larynx when acutely inflamed is that of intense hyper- emia and irritation, and the object of the physician must be to allay this irritability. This is best accomplished by the use of compound tincture of benzoin, which is placed in boiling-hot water (1 ounce to the pint [30.0: 480 c.c.]), and the steam inhaled as it rises from a pitcher or as it passes out of the nozzle of a deep coffee-pot. Another method consists in the use of a can or wide-mouthed bottle arranged with one long and one short tube like a Wolff bottle, the air being drawn into the larynx through the short tube, after bubbling through the medicated water. (See Inhalations, Part III.) This inhalation should be resorted to six or eight times a day, but the patient must not go out of doors or into a cold room, as the steam relaxes the parts involved and renders them more susceptible to cold. Sometimes advantage is gained by adding to this inhalation 1 grain (0.06) of menthol. If the patient is unable to remain in an equable temperature, then the steam inhaler should be supplanted by a nebulizer, in which should be placed the following mixture: 1^— Menthol gr. iij (0.20). Albolene . fgj (30.0).— M. S. — Use as a spray. The patient is directed to inhale this vapor gently, which because of its lightness readily passes deeply into the air-passages, and has the effect of soothing rather than irritating them as does the spray from an atomizer. Rarely in the very acute stages of laryngitis should a watery spray be employed to wash the laryngeal mucous membrane, as it is apt to increase the irritation. If any aqueous spray is used, as may be nec- essary when the irritation has resulted from the inhalation of dust, it may be made up as follows: 1$ — Sodii chlorid gr. xv (1.0). Acid, boric gr. x (0.60). Sodii borat . . gr. x (0.60). Aquae rosae fgiij (90.0). — M. S. — Use as a spray. 730 DISEASES. The external treatment, if the inflammation is exceedingly severe and the patient can be confined to bed, consists in the application of a mustard plaster over the larynx, or instead a cold compress should be applied and kept in place with a long stocking tied around the neck. This soon becomes a warm compress by the heat of the body and may be kept in place all night. The cold followed by heat pro- duces excellent results. A mustard foot-bath and a warm drink on going to bed are useful. The internal treatment should consist in. opening the bowels with calomel and a saline purgative if constipation is present, and in the administration of full doses of aconite and bromide of sodium or potas- sium, as follows: 1^— Tine, aconiti m xl vel lxxx (2.6-5.3). Sodii bromidi ^ij (8.0). Syr. lactucarii (Aubergier) . . . f oj (30.0). Aquae dest q. s. ad fgiij (90.0). — M. S. — Dessertspoonful (8.0) every hour until six or eight doses have been taken. This prescription may in many cases be continued until convalescence, as it checks cough, soothes the inflamed area, and allays arterial excite- ment. Often it is best to omit the aconite after the first few doses. In other cases good results follow the use of 2 or 3 minims of dilute nitric acid in water every half -hour or hour for 6 doses. This is useful in the early stages only. By the second day the patient should be directed to make a heavy application of tincture of iodine over the trachea and episternal notch, as high as is possible without the stain showing above the collar. In children and in some adults this is well substituted by oil of amber and sweet oil in the proportion of 1 to 3 parts rubbed on the skin. For the laryngeal stiffness following the inflammation preparations of coca are very useful given internally, and tonics to the general sys- tem are needed. In many cases the prescription calling for ammonium chloride in the article on Bronchitis is useful. Abrams asserts that freezing the skin over the insertion of the inter- nal laryngeal nerve, near the thyrohyoid space, where it enters the larynx, is a very useful curative measure. This may be repeated several times if necessary. The writer has never used this measure. LEUCORRHCEA. This is a condition — vulgarly known as the " whites" — consisting in a hypersecretion from those glands which pour out their contents into the vagina or the cervical canal of the uterus, or even into the cavity of this organ. It is a state dependent upon many causes for its existence, the chief of which is a condition of the system when it is "run down" from any cause, with perverted functions of the glands or their surroundings. The character of the discharge varies with almost every case. In some instances it is thick and tenacious, and LEUCORRHCEA. 731 in others so liquid as to trickle down the limbs and soil the clothing. In most of the latter cases catarrh of the Fallopian tubes or ovarian irritation and tenderness are present. When the secretion is very thick and tenacious it generally arises from the cervical canal, while that from disorder of the vaginal wall alone, independent of other morbid conditions, may be either thick or thin. The treatment of these forms of leucorrhcea may be divided into two parts — one, that directed to the remedying of the morbid process through the use of drugs by the mouth; the other, by their employ- ment locally. In obstinate cases the repair of a lacerated cervix or the curettement of the uterus may be necessary. It is needless to state that in that form dependent upon excessive lactation or other exhausting manner of life tonics of an active character are needed. As a general rule, anaemia will be present, and the follow- ing pill will be found of service : 1$ — Arseni trioxidi gr. \ (0.015). Ferri reducti gr. v (0.30). Quininse sulph gr. xx (1.3). — M. Ft. in pil. No. xx. S. — One pill three times a day, after meals, for an adult. 1 Or, 1$ — Tr. cinchonse comp f oij (60.0). Tr. gentian, comp q. s. ad. f §iv (120.0). — M. S. — Dessertspoonful (8.0) three times a day, after meals. When any preparation of iron is used care must be taken that the bowels are kept active and that the stomach is not disordered. Asso- ciated with the use of these internal remedies should be a moderate amount of exercise and the avoidance of late hours and rich foods. The local applications which are of value in these states consist in counterirritation and vaginal injections or painting with proper fluids the mucous membrane of the parts from which the discharge comes. In the leucorrhcea dependent upon irritation of the ovaries associated with catarrh of the Fallopian tubes the use of small blisters formed by the employment of cantharidal collodion or a cantharidal plaster over the groin on either side is often accompanied by good results. At the same time the vaginal surfaces surrounding the cervix uteri may be painted with a mixture of iodine, carbolic acid, and chloral, such as was used by Goodell, as follows: 1^ — Iodi resublimat. . ^iv (16.0)., Phenolis, Chlorali hydrati . . . . . . aa gj (30.0). Rub the iodine and chloral in a glass mortar into a powder and add the carbolic acid. S. — Formula. To be used by the physician only. 1 In this prescription the small amount of iron given will probably be noted, but this is done advisedly, as iron does as much good to the blood in small as in large amounts under most circumstances. (See Iron.) 732 DISEASES. The following pill may also be employed: 1$ — Hydrarg. chlor. corros. . . • . . . . gr. \ (0.03). Ft. in pil. No. xx. S. — One pill three times a day after meals, or a tablet triturate may be used instead of a pill The remaining treatment of watery leucorrhoea consists in the use of astringent injections. A cheap astringent injection is made by adding 1 ounce (30.0) of powdered white-oak bark to each pint (480 c.c.) of hot water, or tannic acid and glycerin in the proportion of 1 ounce to 2 quarts (30.0: 1920) of warm water, Ringer recommends the following: 1$ — Sodii bicarbonatis 3J (4.0). Tincturae belladonna? f^ij (8.0). Aquse Oj (480 c.c.).— M. S. — Use as a vaginal wash. Where the discharge is fetid a solution of permanganate of potas- sium should be used as an injection in the strength of \ drachm to 1 pint (2.0: 480 c.c.) of water. In purulent vaginitis, specific or otherwise, the following injection is serviceable: 3— Creolin f^ss vel fgij (2.0-8.0). Fluidext. hvdrast. canaden. . . t'zijss (10.0). Aqu« fgviij (240.0).— M. S. — Add 2 tablespoonfuls to a pint (30.0 : 480 c.c.) of hot water, shake thoroughly and use as an injection. A very useful astringent injection is: 1$ — Zinc, sulphat. . . ..... 3j (4.0). Alumin. sulph 3i (4.0). Glycerini . . . fgvj (180.0).— M. S. — A tablespoonful (16.0) to each quart (1 litre) of water. The injected fluid should always be as hot as the patient can bear, as tepid injections are harmful. Sometimes a tampon thoroughly saturated with a powder of iodo- form and tannic acid, equal parts, and packed around a discharging uterine cervix, is of service. When using vaginal injections in females it is important to remem- ber that they should be in large quantities. Nothing is more antago- nistic to true asepsis than the usual manner in which these applications are made. Often a pint of the solution is placed in a basin over which the woman squats, and by means of a syringe forces the liquid into the vagina as fast as it runs out, thereby filling the syringe joints with the dissolved secretions, and returning to the vagina as soon as they flow away the impurities which have left it. The only proper way to give such an injection is to use a fountain syringe or to have the solution in one basin, to the extent of 1 gallon (4 litres), while the patient squats over a second basin, into which the impure liquid may run. MANIA (ACUTE). 733 LID ABSCESSES. Lid abscesses are seen more frequently in children than adults, as the result of injury, the sequel of acute illness (epidemic influenza, pulmonary catarrhs, fever, etc.), or from local infection; under the latter circumstance they may assume a gangrenous type. The treat- ment is that for any form of abscess—poultices, preferably in the form of hot compresses, early incisions, antiseptic solutions, and tonics. LUMBAGO. This is a form of myalgia or muscular rheumatism of the muscles of the loins and small of the back, and is frequently the result of lifting heavy weights or it is due to other strains. In many cases acu- puncture is very useful, particularly if the trouble is bilateral. (See Part III.) Sometimes after the employment of this measure the patient can straighten the back at once and retain that position. In other instances of antipyrin or acetanilid, in 5- to 10-grain (0.30-0.60) doses of the former and 4- to 8-grain (0.25-0.5) doses of the latter are of service, and iodide of potassium and salicylic acid are not to be forgotten if the condition of the patient does not rapidly improve. Phenacetin and phenyl salicylate are also useful, combined or alone. A large hot poultice applied to the back is often efficacious in obstinate cases. Sometimes the use of a hot foot-bath and a Dover's powder on going to bed will produce a cure, and ironing the back with an ordinary hot laundry iron at a proper heat, a piece of newspaper or cloth being placed over the skin under the iron, is very efficient. Counterirritation in the shape of a blister, a mustard plaster, or capsicum draft will often give relief. Where these measures fail, an ether or chloride of ethyl spray may be played on the centre of the painful area until the skin is greatly blanched. MALARIAL FEVER. (See Intermittent and Remittent Fevers and Pernicious Malarial Fever.) MANIA (ACUTE). Space is wanting to consider the thorough and complete treatment of mania as it comes to the neurologist. All that can be mentioned here are temporary measures suitable for cases which are brief in their course. In those cases which occur after confinement and are not supposed to be based upon permanent trouble, cimicifuga racemosa is said to be very useful in the dose of 20 to 30 minims (1.3-2.0) of the fluid extract three times a day. For the rapid quieting of the patient hyoscine hydrobromide may 734 DISEASES. be used hypodermically in the dose of T ^ 7 grain (0.0006). In other instances, if the kidneys and heart are healthy, full doses of chloral may be used; and if an active preparation of cannabis indica can be had, at least 1 grain (0.06) of the solid extract or \ to 1 drachm (2.0-4.0) of the tincture should be employed. Cannabis indica will be found much more serviceable if 60 grains (4.0) of one of the bromides be combined with it. Where a patient suffering from mania is so violent that nothing can be done with him, he should be held, and an emetic dose of -^ grain (0.005) of apomorphine be given hypodermically to produce vomiting and so relax the muscular system; or he maybe tied or anaesthetized sufficiently to enable the physician to administer proper remedies. Sometimes full doses of morphine are needful or a cold douche to the head while the body is in a tub of hot water is of service. In still others a hot steam bath or Russian bath is a valuable sedative. MELANCHOLIA. This is not the place for the discussion of melancholia of so severe a form as to amount to insanity, since the treatment of this latter state is very various and largely depends upon the skill of alienists. There is one form of melancholia, however which may often be quickly relieved by a simple measure. It is that dependent upon the condition of the system in which oxaluria is present. Whenever an individual complains of melancholia the urine should be examined, and if oxalate crystals are found, the undiluted, freshly made nitro- muriatic acid should be given in the dose of 5 minims (0.3) after each meal in a half-tumblerful or more of water. In order to guard against errors in diagnosis it is well to remember that pears, tomatoes, rhubarb, and cabbage all cause oxalates to appear in the urine for a short period after their ingestion. MENINGITIS (ACUTE). In a large proportion of cases the development of meningitis is secondary to some other state of disease, as, for example, typhoid fever or croupous pneumonia. Under these conditions the treatment must be governed by the exciting cause. In meningitis following injury to the head or arising primarily, the treatment is that of any other form of acute inflammation occurring in a sthenic or dynamic individual, and particularly does its treatment correspond to that of the other inflammations of large serous membranes, such as peritonitis or pleurisy. In the early stages, if the pulse is full and bounding, the patient should receive sufficiently large doses of aconite or veratrum to impress the circulatory system strongly. These drugs have the power of producing such dilatation of the bloodvessels throughout the body that the congested or inflamed area is relieved of its excess of blood, MENINGITIS {ACUTE). 735 because, the pressure being low elsewhere, the blood obeys the law that liquids always seek escape from pressure, and so leaves the meninges of the brain for the vessels of the limbs and trunk. The proper dose of veratrum in the form of the tincture is 10 minims (0.60) every hour until the skin becomes moist or nausea is developed. 1 The tincture of aconite is also useful in full dose. If great arterial excitement is present, venesection may be practised (see Bleeding), but veratrum and aconite are better remedies if they are at hand. They are, of course, contraindicated if the circulation is feeble. Associated with these two drugs mercury and opium should be employed, the first for its antiphlogistic influence, the second for its power in allaying irritation. \ grain (0.015) of powdered opium and i grain (0.03) of calomel may be given every hour until the full effect of the opium or mercury is manifested. In some instances the tincture of deodorized opium ( Tinctura opii deodorati) is better than the crude drug, in the dose of 2 to 5 minims (0.1-0.30) every one or two hours. Sometimes belladonna is of great service, and this is particularly the case where the drugs already named are contraindicated because of a condition of weakness or asthenia. A good-sized blister may be placed at the nape of the neck as a counterirritant with the hope that it will prevent effusion. During the first acute stage an ice-bag should be applied to the head both for its local influence and its antipyretic effect, and leeches may be put at the nape of the neck with advantage. As the disease advances and the nervous disorders of the affection become marked, sedatives are required to allay the twitchings, muscular spasms, or convulsions, and for this purpose no drugs excel chloral and the bromides. The doses to be used vary with the violence of the symp- toms, but it may be stated that the chloral should rarely, if ever, be used in doses above 10 grains (0.60), and the bromides given in the dose of from 5 to 40 grains (0.3-2.60). If coma comes on, a large blister should be applied to the nape of the neck. Quinine has been recommended in meningitis, but it is absolutely contraindicated, as it predisposes to meningeal congestion. It may be employed only in convalescence, and then used most carefully. The treatment of the advanced stage of meningitis must be neces- sarily supportive. Alcohol should be given with the food if weakness is present, and a very simple or milk diet insisted upon. If symptoms of cerebral pressure are marked, lumbar puncture should be performed, the technique of which is described under Cocaine. Of course, no cocaine is injected. In many cases the relief is only temporary, but in a few it is permanent. 1 It is to be remembered that veratrum often causes nausea, and even vomiting, in sus;e o Dtible persons, and in consequence it should be carefully given in meningitis, lest if vomiting come on the condition be made worse, 736 DISEASES. MIGRAINE. Migraine is a form of head pain usually limited to one side of the head — hemicrania. It is often characterized by the presence of severe boring pain in the eyeball or over the brow on one side. Asso- ciated with or preceding this pain there may be some dimness of vision or even a true transient amblyopia. The exact pathology is not clear, and so our treatment of it is perforce largely empirical. Before the introduction of the coal-tar products as pain-relievers, the best treat- ment of the attack of pain consisted in ordering the patient to bed and giving him 15 to 30 drops (1.0-2.0) of tincture of gelseminum, with j to \ grain (0.015-0.03) of extract of cannabis indica every two hours. If the heart is feeble, the fact that gelseminum is a cardiac depressant must not be forgotten. So far as the other measures for relief of the individual attack of pain are concerned, reference should be made to the article on Neuralgia. For the cure of the condition which results in the attack, the endeavor should be to keep the liver active, since the failure of this organ to destroy the poisons which cause an attack, and its failure to prevent fermentation in the bowel by the proper secretion of bile, is supposed to be the chief cause of the disorder. The use of a mild cholagogue like sodium phosphate, taken in hot water every morning on first rising, does good in many cases, particu- larly if the patient also takes some one of the salicylates several times a day. Rachford has recommended the use of the following prescrip- tion in such cases: & — Sodii sulphatis Sodii salicylatis 1 Magnesii sulphatis Lithii benzoatis Tinct nucis vomicae Aqua? destillat . gr xxx (2.0). gr. x (0.60). gr. 1 (3.3). gr. v (0.3) miij (0.2). fgiv (120.0).— M. This mixture should be made up in large quantity and placed in a siphon by one of the concerns which charge soda-water, and from one- quarter to one-half glass of this water at ordinary temperature is to be taken every morning at least half an hour before breakfast, enough being used to insure an adequate bowel movement during the forenoon. The ingredients meet several indications, for the sulphates of sodium and magnesium act as laxatives, the salicylate of sodium acts as a gastrointestinal antiseptic and cholagogue, and the lithium benzoate presumably aids in the elimination of uric acid, or, to speak probably more correctly, aids in the elimination of effete materials representing perverted metabolism. The small dose of nux vomica is introduced to mask the soapy taste of the mixture. Associated with this treat- ment additional doses of salicylates may be used if needed, or benzoate of sodium may be given. The author prefers 10- to 20-grain doses of ammonium benzoate given in capsule. When evidences of intestinal 1 The salicylate should be derived from natural sources and not be the synthetic variety. MYALGIA. 737 fermentation are marked, the following pill may be used, devised by M. Allen Starr; it should be coated with phenyl salicylate to insure its entrance into the bowel before it is dissolved : 1^ — Sodii phenolsuiphonat gr. v (0.3). Potassii permanganatis gr. j (0.06). Beta-naphtol gr. j (0.06).— M. S. — One after meals and at night. An occasional free catharsis with blue mass is advisable in many of these cases. Usually 5 to 10 grains (0.3-0.60) once a week and fol- lowed by a saline is sufficient. It is essential that all causes of sys- temic and nervous worry be removed in these cases. Excessive sexual indulgence is often a cause of the attacks, and it must be inter- dicted. (See also articles on Headache and Neuralgia.) MUSCJE VOLITANTES. Muscat volitantes is the name applied to the dark specks which patients frequently see floating across their fields of vision, especially if the eyes are directed toward a bright sky or a white page. Usually they indicate no disease of the vitreous humor, and the ophthalmo- scope fails to detect abnormal changes. They are attributed to tor- pidity of the liver by the laity. Muscat volitantes may indicate eye- strain, and if the refraction is abnormal this should be corrected; a mild course of alteratives is often a useful adjuvant. MYALGIA. Soreness of the muscles either on pressure or on movement may be dependent upon a number of causes, such as strains, bruises, toxaemia, or inflammation due to cold. Here, as in many other states, the treat- ment should be divided into the external and the internal methods. Of the internal remedies, the best are the salicylates or the iodide of potassium if rheumatism be the cause of the trouble. On the other hand, if a bruise or cold be the cause, the chloride of ammonium will be of service in 10- or 20-grain (0.60-1.3) doses given in a solution with fluid extract of liquorice. (For prescription see Bronchitis.) Other remedies which may be tried with a good chance of success are full doses of an active fluid extract of cimicifuga (20 minims to 1 drachm [1.3-4.0]) or the citrate or acetate of potassium in 20-grain (1.3) doses. The local medications are numerous, but only a few can be consid- ered as worthy of routine employment. The chief one is iodine, in the form of the pure ointment or the ointment diluted one-half with lard if the skin is easily irritated. Another method is to employ a liniment, well rubbed into the skin, made up as follows: I$— Tr. belladonna? f^iss (6.0). Tr. aconiti fgvi (24.0). Tr. opii f3ij (8.0). Liniment, saponis . . . . q. s. ad f §vj (180.0). — M. S. — Poison. To be used externally and only as a liniment 47 738 DISEASES. Sometimes chloroform liniment is singularly successful, and poul- tices applied as hot as can be borne and covered by oiled silk and cotton to retain the heat are often of great value. Massage or good rubbing is also a sine qua non for the successful treatment of this state. NASAL CATARRH (ATROPHIC). In atrophic nasal catarrh the nostrils are roomy and the mucous membrane red and shiny. The, formation of connective tissue has to a great degree obliterated the delicate serous glands, and the dis- charge of mucus, no longer diluted, forms inspissated crusts, which adhere to the mucous membrane of the septum and turbinated bones. Areas of ulcerated or abraded membrane are disclosed upon removal of these adherent crusts. The turbinated bones are gradually absorbed and the secreting surface thereby much reduced. Sometimes the wasting is so great that the posterior wall of the pharynx is clearly visible through the anterior nares. The inspissated secretion may form a cast of the nostril, and as fresh layers form underneath, the oldest part is raised until the whole interior of the nostril becomes a mass of decomposition, giving rise to an overpowering stench. This form of catarrh causes loss of the sense of smell, and the odor is not recognized by the patient himself. Ulceration or caries of the bony structure produces an odor even worse than the so-called ozama. The pharynx suffers from the general wasting, and presents a dry, varnished appearance called pharyngitis sicca, which is rather a symptom of nasal atrophy than a separate disease of the pharynx. The indications are the removal of all accumulations in the nose and nasopharynx and the healing of abraded or ulcerated surfaces. The early removal of dead bone is imperative, and what secreting surface remains must be stimulated as far as possible, to compensate, in a measure, for the glands that are hopelessly destroyed. In other words, efforts are directed toward producing a compensatory hyper- trophy of the glandular tissue that remains. Therefore with the use of antisepsis alteratives and local stimulation are combined. The nose should be thoroughly cleansed with an alkaline wash — Dobell's solution — warmed to increase its solvent power. To relieve the odor, we may increase the amount of phenol or substitute for it eucalyptol and thymol in the wash. Euthymol contains both of these and may be added to the wash. Its own pungent odor masks some- what the offensive odor. Permanganate of potassium may be used in weak solutions, but it is painful except when sensation is entirely lost. Peroxide of hydrogen is valuable used in an atomizer in the strength of 1 part to 10 or 1 to 20. After this has softened the crusts they should be dislodged by the further use of a warm alkaline spray, and after the cleansing is complete ichthyol, pure or diluted one-half with water or albolene, is applied by means of an applicator. Often a much NASAL CATARRH {CHRONIC). 739 weaker solution of ichthyol will do equally well. The patient may be given a salve of: fy— Ichthyol . . . gr. xl (2.6). Menthol gr. v (0.3). Petrolat. alb . . . oj (30.0).— M. A piece of this is to be inserted into the nostril, after using a douche, each night. The solutions are best applied by means of an atomizer, or post- nasal syringe in the hands of the physician, or by snuffing from the hand or cup. The odor, if due to decomposition, is much decreased as soon as the passages are clear. The discharge must never be allowed to reaccumulate or much gain will be lost. Ulcerations require local stimulation by a strong solution of nitrate of silver or a superficial application of the flat surface of the galvano- cautery heated to dull redness. Necrosed bone should be removed, and it is often found detached in the nostril. Local stimulants should be judiciously combined with alteratives. Powders of nitrate of silver in starch, varying in strength from 1 to 10 grains to 2$ drachms (0.06-0.60: 10.0) of the latter, may be blown into the nostrils by means of an insufflator. Cover gently the whole surface with a thin layer, and use it only of sufficient strength to be slightly felt. Nitrate of silver in solution, 1 to 10 grains to 1 fluidounce (0.06-0.60 : 30.0) gives better results at other times when applied to the mucous membrane. The physician must avoid overstimulating, and so exhausting, the glands which it is wished to strengthen. The use of alteratives may alternate with the silver salt and iodide of potas- sium, and this may be done by using solutions of iodine and glycerin, as recommended for hypertrophic nasal catarrh. Internally, we may employ iodide of potassium, to increase nasal secretions, and mucous- membrane stimulants and tonics. Attention should also be paid to the activity of the skin. NASAL CATARRH (CHRONIC). Chronic nasal catarrh is essentially a disease of civilization, which may occur at any period of life, but more commonly develops from youth to early adult life. Although very prevalent among the upper classes, it is in the lower ranks that it most frequently reaches its later stages and its worst forms. This does not result from lack of opportunity for treatment, but from the ignorance or indifference which this class show to dis- eases while there is no suffering and no interference with business. Hypertrophic nasal catarrh commonly has its origin in a neglected cold in the head or in a series of colds occurring in rapid succession, keeping the nose in a congested state until the erectile tissue covering the turbinated bones loses in a measure its power of contracting, and, 740 DISEASES. decreasing the calibre of the nostrils, becomes a source of permanent obstruction to breathing. As the disease advances there is increased susceptibility to cold. Slight exposure produces a stuffy feeling in the nose. The nostrils may become completely occluded; usually, however, only one side at a time is obstructed at first, the obstruction showing a tendency to change sides. This change is most noticeable on turning in bed, the lower side usually stopping, and on changing the posture the obstruction is reversed, the clearing being accompanied by a crackling sensation. A slight tickling cough and tendency to clear the throat in the mornings may result from irritation of the pharynx or larynx. The first indications for treatment are the reduction of inflammation and restoration of the breathing-space. As the chief function of the nose is respiratory, the re-establishment of free nasal respiration, combined with the liberal use of antiseptic washes, will lessen the inflammation and irritation and produce a healthier state of the secretions. The writer places cleanliness at the head of the list of remedial measures. The alkaline wash recommended on page 620, sprayed into the nose by a hand atomizer or gently snuffed from the palm of the hand or from a small cup, gives good results. The hand warms the solution slightly, but when snuffed from a cup the solution should be artificially warmed. This wash may be used two or more times a day. The nasal douche should never be used where there is nasal obstruc- tion, on account of the risk of forcing the solution into the Eustachian tube and causing catarrh of the middle ear. In addition to the antiseptic wash where the mucous membrane is congested and irritable, the treatment recommended ■ for coryza may be instituted for a few days with good results. A solution com- posed of equal parts of water of hamamelis and water or a dilute solution of hydras tis may be sprayed into the nose during the acute stage. A little latter a spray of ferric alum, 5 grains to the ounce (0.3-30.0), may be applied carefully in an atomizer by the physician. It is not advisable to use alum in any considerable strength in the nose, as its continued use is liable to impair the sense of smell. The alterative and absorbent action of iodine makes it a valuable remedy for local application in very chronic nasal catarrh. It should be combined with glycerin in the strength of 6 or 8 grains to the ounce (0.40-0.50 : 30.0), with enough potassium iodide to make a solution. Apply this by means of a piece of absorbent cotton on the end of an applicator, along the floor of the nose, until it reaches the pharynx. It is needless to say that such an application as this should be made with the utmost gentleness. The cotton should project beyond the probe, and care should be taken to avoid bruising the tissues. After the irritation has subsided, as shown by the disappearance NEPHRITIS {ACUTE). 741 of the livid color and lessened sensibility, any remaining hypertrophied tissue should be removed by a snare or the galvanocautery. NEPHRITIS (ACUTE). In the early stage of onset, for the reduction of inflammation cir- culatory depressants are to be resorted to, and aconite is generally most serviceable. The patient should be kept quietly in bed and given a milk diet, and hot compresses, cups or leeches used over the loins if the urine is scanty. Blisters are not advisable, as the irritant substances producing them may be absorbed and cause in- creased renal irritation. The resdessness will generally be quieted by the aconite; but if this fails, resort must be had to bromides or small doses of opium, which must be given cautiously, as these drugs are not readily eliminated when the kidneys are diseased. Cannabis indica is thought to be of great service if blo'ody urine is present, but chloral is generally too irritating to the kidney to justify its employ- ment. The appearance of large amounts of blood in the urine at about the fifth day of the illness is an indication, according to Sydney Ringer, for the use of drop doses of tincture of cantharides, given every few hours. Personally the author would be afraid to use this method of treatment. Should the urine be scanty and of high specific gravity, and con- stipation be present, some calomel, followed by a purgative dose (J an ounce [16.0]) of sulphate of magnesium should be used to aid in the elimination of impurities by the bowel. Warm mucilaginous drinks, as flaxseed tea, are of service, and the use of the citrate of potassium and the sweet spirit of nitre with copious draughts of pure water should be resorted to to increase urinary flow and promote the action of the skin. If dropsy or symptoms of uraemia (see Uraemia, Part IV.) come on, they may be relieved by the use of hydragogue purges, such as elate- ritim, which is particularly useful in that it is supposed to aid in the elimination of urea by the bowel. If vomiting is present, elaterium ought not to be used, as it irritates the stomach. Jaborandi or pilo- carpine may be used to sweat the patient at this time or in the earlier stages with advantage; \ grain (0.008) of the hydrochloride should be given hypodermically, and repeated in fifteen minutes if no sweat appears; but it should never be forgotten that when the heart is feeble or the patient very susceptible pilocarpine may produce serious col- lapse. This can sometimes be guarded against by the simultaneous use of strychnine in -^ grain (0.003) doses. Hot-air baths are often useful to provoke sweat and are much safer than pilocarpine. (See Heat, Part III.) The treatment of the later stages consists in the use of stimulants to the kidneys to arouse them from the atony consequent upon the excitement of inflammation. To this end digitalis and squill, or digi- 742 DISEASES. talis and calomel, or caffeine citrate, may be used in small amounts, or in their place the compound spirit of juniper or gin may be used as the case progresses. If the renal structure is persistently atonic, \ to 1 minim (0.025-0.05) of the tincture of cantharides at each dose may be used, and, as ansemia is often a prominent symptom, tincture of the chloride of iron, which is both a diuretic and a tonic, should be resorted to. If renal hemorrhage is excessive, gallic acid and ergot are indicated to control the bleeding. A milk diet should be rigidly enforced. NEPHRITIS (CHRONIC). The treatment of chronic nephritis is a very different matter from that devoted to the cure of the acute form. It is almost, if not quite, impossible to cure the condition present, and we can only strive to improve the state of the kidneys and other organs by care and the use of proper drugs. As Tyson has aptly put it, we must try to arrest the development of the renal lesions and improve the general health, treat the symptoms which are not dependent upon the nephritis, except indirectly, and, last, treat those signs which are due to the nephritis itself. To arrest the disease all alcoholic drinks should be avoided as far as possible, and business cares and worries be cast aside. Great care should be taken to avoid cold v and a warm climate is generally to be recommended to the patient, since sudden changes of temperature tend to produce congestion of the kidneys by the chilling of the skin. The diet and drink are important considerations, and should con- sist largely of milk. Many physicians direct that skimmed milk be used. The author believes that this advice is not wise, as it deprives the patient of the nutritive fats, which he needs and which are not contraindicated, whereas the proteids of skimmed milk, while they are the best form of albuminoid food we can give, are not so advantageous, but have to be used to maintain nutrition. If the cream in the milk disagrees with the patient, it may be removed or the milk may be diluted with some effervescent water like Vichy. The treatment suggested so far is applicable to all forms of chronic nephritis, but there are symptoms and complications of both the inter- stitial and parenchymatous forms of the disease which require special treatment. If the urine be scanty in the parenchymatous form, and the heart is feeble, digitalis and caffeine are useful to improve the renal circulation and act directly on the kidney. In other cases we may prescribe the well-known pill of digitalis, squill, and calomel. These drugs not only increase urinary flow, but also decrease albumi- nuria in many cases. In still other instances we may give the acetate and bitartrate of potassium as diuretics, which are particularly valuable if combined with digitalis in those cases of albuminuria dependent upon failure of the heart muscle. These remedies are also of value to relieve the dropsy, and one of the most efficacious forms of treat- NEURALGIA. 743 ment is a combination of the hitartrate of potassium and juniper- berries, so that 1 ounce (30.0) of the former is dissolved in 1 pint (480 c.c.) of an infusion (1 ounce (30.0) to the pint) of the latter and taken in twenty-four hours. A most valuable aid in decreasing the ... * - ... " albuminuria is the use of 1 minim of tincture of cantharides in water three times a day, particularly if the kidneys seem torpid and are secret- ing too little urine. If dropsy develops (see Dropsy), hydragogue purges are useful, such as jalap and elaterium. Very great benefit can often be obtained from the use of nitroglycerin when the arterial tension is high, giving it in ascending doses beginning with y-jjQ- grain (0.0006) three times a day. This decreases the albu- minuria, if it is present, lowers arterial tension, and benefits the heart. Copious draughts of pure water should be given, if the urine be scanty and dropsy is not present, to flush the kidneys if possible and aid sweating, although copious urination may in many cases be present and troublesome. Another drug of value in those cases of chronic contracted kidney which have their origin in gout or syphilis is iodine in the form of iodide of sodium. This may be given in 10-grain ( 0.60) doses three times a day with great advantage to old persons with well- advanced atheromatous changes. The treatment of uraemia, should it be mild or severe, is important, and the reader is referred to the article on that subject (see Uraemia). The various forms of hot baths should also be employed to aid the skin in eliminating poisons and so relieve the kidney. The anaemia in parenchymatous nephritis is to be combated by the use of the tincture of the chloride of iron, or Basham's Mixture (see Iron), and oxygen inhalations. It is, however, a mistake to use large doses of Basham's Mixture. Chronic parenchymatous nephritis is an incurable disease, and the most that Basham's Mixture can do is to combat the anaemia and act as a diuretic. Small doses of iron will do as much for the anaemia as large ones, and will not disorder digestion, and the diuretic effect can be obtained by using liquor ammoniae acetatis if it is desired. In the interstitial form of the disease iron must be used with caution, or not at all, as it is apt to produce headache and perhaps conduces to the development of uraemia. It is in this form of renal disease that nitroglycerin does the most good by lowering arterial tension and so saving the heart from excessive labor. In cases in which the kidney is suspected of being inadequate by reason of disease, we may give 1 grain (0.06) of methylene blue in water, hypodermically. If the color appears in the urine in an hour, the kidney is probably fairly active. NEURALGIA. Like headache, neuralgia gives rise to much of the suffering expe- rienced by active persons who are not sick enough for bed. It affects people in every walk of life, and may be so severe as entirely to inca- pacitate the most powerful men. 744 DISEASES. The causes of neuralgia are very various, but they may be briefly stated to depend chiefly upon malnutrition and anaemia, overwork, nervous excitement with consequent reaction, and upon reflex irrita- tion from diseased organs, as in the case of supraorbital neuralgia from eye-strain or pelvic neuralgia from ovarian irritation or uterine inflam- mation. Nerves functionally diseased are always more or less active than normal; that is, hyper-excited, or depressed, above or below par. In both cases they must be brought back to their normal tone by appropriate remedies, and these consist in nervous excitants and nervous sedatives. To give a nerve already depressed the additional depression of a bromide, or a nerve excited the additional excitement of strychnine, is harmful. From what has just been said, it becomes evident that the physician must always determine the condition of the system of his patient and the causes of the neuralgia before administering remedies. The treatment of neuralgia, from its curative standpoint, may be divided into the use of tonics, nutritives, and palliatives. Where neuralgia is associated with anaemia no hope of permanent relief can be looked for unless iron and arsenic are used until the ansemia is cured, and it is often necessary to combine with these drugs the use of cod-liver oil and bitter tonics. These are the cases, too, in which nux vomica and strychnine raise the depressed nerves to increased activity, and so bring relief. How they do this is not known, but we know enough to recognize one or two important facts. Strych- nine is certainly a nervous stimulant, and is also a stimulant to the anterior columns of the spinal cord. It probably also acts upon the trophic centres in the anterior cornua of the spinal cord, and by stimu- lating these centres increases the nutrition of the tributary nerve-fibres. It is needless to state that the neuralgias of syphilis and tuberculosis are to be treated by the remedies usually directed to the relief of these affections, while at the same time the pain itself is carefully controlled by appropriate palliatives. When nervous exhaustion causes neuralgia, phosphorus is a useful remedy, particularly in those cases which are convalescing from acute fevers. Sometimes malarial poisoning produces a violent form of supra- orbital pain known as "brow ague," which is to be relieved, not by ordinary remedies, but by large doses of quinine. The relief of the states producing neuralgia having been spoken of, it yet remains to consider the measures' to be adopted for the cure of an attack. Fortunately, the recent advances of therapeutic study have placed in our hands a large list of drugs not apt to produce a habit after prolonged use, comparatively safe though active* and not of disagreeable taste or evil general effect. By these terms the writer refers to antipyrin, acetanilid, citrophen, and phenacetin, all of which possess wonderful power in the alleviation of pain dependent upon true nervous involvement. In order to avoid failure in the use of these , NEURALGIA. 745 drugs in the relief of headache, we must always remember that their field of service is that of neuralgic pain, not other pains. Antipyrin is to be used in the dose of 5 to 10 grains (0.30-0.60) for ordinary neuralgia and more for the pain arising from the crisis of locomotor ataxia, acetanilid in the dose of 3 to 8 grains (0.20-0.5) for the same purposes, and citrophen and phenacetin in the same amount as acetani- lid. Upon these remedies, combined with caffeine and the bromides according to circumstances, we now depend, and the following pre- scriptions will be found of service: Jy — Antipyrinae gr. xxx vel 3j (2.0-4.0). Caffeinae citratae . . . . ■. . gr. xx (1.3). — M. Ft. in chart. No. x. S. — One every thirty minutes till relieved. The following may be of use also : Py— Antipyrinae gr. xxx vel 3 j (2.0-4.0). Potassii bromidi oiij (12.0). — M. Ft. in chart. No; x. S. — One every thirty minutes till relieved, or until six doses have been taken. Or, when the caffeine in the first prescription causes nervousness, Py — Antipyrinae gr. xxx vel 3 j (2.0-4.0). Caffeinae citratae . . . . . . gr. x (0.60). Potassii bromidi 3iij (12.0). — M. Ft. in chart. No. x. S. — One as above. In any one of these prescriptions acetanilid or phenacetin may be substituted for the antipyrin, and they should be used in preference to it if the heart is weak. A very effective remedy in some cases of neuralgia of the fifth nerve is croton chloral in from 5- to 20-grain (0.3-1.3) doses in pills or capsules of 5 grains (0.3) each. In some cases of anaemic neuralgia of the head nitrite of amyl inhalations have proved useful, probably by reason of the cephalic flushing produced by this drug. A very large number of local applications have been used with success . in obstinate neuralgias and other cases not so difficult of cure. Cocaine cannot be applied, as it does not penetrate the skin, but relief can sometimes be obtained by the local use of the oleate of aconitine painted over the spot if it be limited in area. Much of this alkaloid should not be applied, lest poisoning by absorption occur. Where the nerve is very superficial it can often be treated by cold with great success. This is accomplished by freezing the parts with an ether, chloride of methyl, or rhigolene spray, or by the application of a small package of finely-chopped ice and salt to the part. Within the last few years the treatment of neuralgia by kataphoresis (see Part III.) has come into prominence, and consists in the use of 746 DISEASES. some anaesthetic such as chloroform, which is applied over the part on a small piece of lint, and a galvanic current used through the pledget which is attached to the positive pole. Under these circumstances the anaesthetic passes through the skin and affects the nerve. A very useful injection in neuralgia is ^ to \ grain (0.012-0.015) of morphine, but the danger of beginning the morphine habit is to be remembered when treating chronic cases. Sometimes acupuncture (see Part III.) is of service, and the surgeon may be called upon to stretch the nerve or to do a neurectomy. In some cases repeated doses of castor oil, 1 to 2 ounces (30.0-60.0) a day, seem to exercise a very extraordinary influence in relieving neu- ralgic pain. Such cases probably depend upon deficient activity of the bowel with retained toxic material which gains access to the blood. (For Migraine, see article on that subject.) NIPPLES (SORE). Whenever the nipples become sore, so that it is impossible for the mother to allow the child to nurse, a solution of cocaine of the strength of 4 grains to the ounce (0.25-30.0) should be applied to the part and washed off carefully just before the child sucks. Following the nurs- ing, a solution of boric acid, of the strength of 20 grains to the ounce (1.3-30.0) of water or mucilage of acacia, may be used over the part, the nipple being first thoroughly dried. Where the fissures are deep and slow to heal the tip of a stick of silver nitrate may be applied to them with advantage. Some practitioners employ tincture of benzoin over the inflamed part, and glycerite of tannin is often of value. Clean- liness, dryness, and care of the breast previous to parturition do much toward preventing the condition. Sometimes it is necessary to use a breast-pump or nipple-shield before a cure can be effected. OBESITY. Whenever an excess of fat accumulates in the body, various dis- comforts, both mental and physical, arise, and in addition the normal functions of all the parts are so disturbed or interfered with that the continuance of health is often impossible. In many cases the deposi- tion of fat about the heart or between its fibres results in serious symp- toms; and breathlessness on exertion is produced by the obstruction which is offered to the free movements of the diaphragm by masses of omental fat, aided by the fact that the great weight and bulk of the body require severe muscular effort. It is worthy of note, also, that a layer of fat over the body increases the vascular surface very greatly, and in consequence gives the heart the labor of supplying a larger number of bloodvessels. In many families there is an inherited tendency to obesity, while in OBESITY. 747 others only certain individuals are affected. These persons are fat because their systems naturally tend to the deposit of obese materials, in the same way that the members of one family have large bones, while those of another have a small frame. The etiological causes of obesity, outside of those just named, are numerous, but the chief one is overindulgence in food. It is not out of place to state exactly what overindulgence in food means. Every individual is a law unto himself in regard to the amount of food which is ingested and consumed. One often sees large, powerful, wiry men, who eat little, stand beside others, not so powerful or large, who eat excessively, and who apparently do not suffer from indigestion in consequence. Neither of these groups becomes excessively fat, because one represents a grate which burns its fuel so that there is no waste, while the other resembles a grate in which there is always a residue of unburnt coal which is cast out with the ashes as effete matter. As different engines of the same build require varying amounts of coal, so do different men assimilate different amounts of food. No stated amount of food can be set down as a man's daily portion until his case is carefully studied, but it is important to remember that the quantity of food is generally in direct ratio to the ' severity of the toil, and that a man who loiters about a club or "takes life easily" often eats more than a day-laborer — of far richer foods, too^and wonders why he gets stout. In nearly every case of obesity not dependent upon gross disorder of nutrition overindulgence in food is the cause. To some this may seem absurd, and the patient will say that he eats just enough to keep him from feeling empty between meals; but this does not alter the case in the least. The proper amount of food for a man is not what his appetite or gastric viscus calls for, but what his system needs. To this further reference will be made when considering the diet for obesity, found below. The very presence of fat aids in the deposition of it, for, by acting as a non-conducting pad all over the body, it prevents the dissipation of heat, and so decreases the combustion of those substances which, when not used for the manufacture of heat, are deposited as fat. Again, we often find that obese persons take alcohol with their food, thereby increasing the fat in their bodies; for, finding that they cannot digest all the substances which greediness makes them swallow, they take alcohol to stimulate their digestive apparatus to increased efforts and assimilation. Further than this, alcohol adds force to the body, and preserves the tissues by substituting itself for food in the oxidizing processes. We find, therefore, that three great causes are active in producing corpulence in many cases — namely, heredity, overindulgence in food, and lack of exercise, which is one of the means by which overindul- gence is produced; i. e., less exercise, less food needed, but often more eaten. 748 DISEASES, The treatment of corpulence rests solely upon the conditions named. In all instances the diet is the important point for the bestowal of care. Reference has already been made to the fact that the needs of the system are the criterion by which should be determined the amount of food necessary to each case, not the sensations in the stomach. The use of coca by the natives of South America enables them to withstand hunger and privation, not because it gives tissue to the body, but because it paralyzes the sensory nerves in the stomach and relieves the sensation of hollowness or weakness which we are accustomed to overcome in this country, in the absence of food, by tightening our belts. Every one who has undergone severe mental or physical labor and missed a regular meal will remember that about the usual hour for the meal his sensation of emptiness may amount to nausea and distress, but the hour once passed he feels as strong as before until by prolonged toil he so exhausts his powers that the system forces him to eat, not so much from hunger as from exhaustion. To under- stand this clearly, we must recollect that the system keeps its shares of force in the same way as a careful speculator keeps his shares of stock — namely, one part in active use for speculation, the other half for reserve in case of need. In health the stomach begins to "feel hungry" as soon as the speculative shares of force are nearly used, in order to cause the ingestion of more food and to preserve the " sink- ing fund" intact. It becomes evident, therefore, that the mere pres- ence of hunger is purely a symptom, not an indication of the absolute necessity of food, for, if it were, the consumptive would be notorious for his appetite, instead of being noteworthy for his anorexia. The food of the patient suffering from obesity is to be cut down gradually, and the character of it arranged so that, though its bulk be great, its nutritive properties are small. Beef and other meats are concentrated foods containing much nourishment in a small bulk, while lettuce, spinach, cabbage, and nearly all vegetables, except roots or tubers, contain a large amount of fibre useless to the body. By the use of a carefully arranged vegetable diet in obesity we cut down the actual amount of food absorbed, and by its bulk keep the stomach so busy at sifting the nutritious from the non-nutritious materials that hunger is not felt, because another meal-time is reached almost before the food of the first is assimilated. We find, therefore, that the diet for the reduction of corpulence should consist chiefly of bulky vegetables, but not too exclusively of any one article or set of articles. Heretofore it has been thought that proteids (meats, eggs, etc.) should be used to take the place of all hydrocarbons or carbohy- drates (fats, starches, and sugars), but this is not physiologically cor- rect, as both forms of food are always needed for health, and it has been found that proteids may be converted into fats in the body. The following bill of fare will be found of service in the treatment of obesity. Breakfast : One or two cups of coffee or tea, without milk or sugar, OBESITY. 749 but sweetened with a fraction of a grain of saccharin. Three ounces of toasted or ordinary white bread or 6 ounces of bran bread. Enough butter may be used to make the bread palatable — not more than 1 ounce. Sliced raw tomatoes with vinegar or cooked tomatoes without any sugar or fats. This diet may be varied by the use of salted or fresh fish either at breakfast or at dinner. This fish must not be rich like salmon or sword-fish, but rather like perch or other small fish. Noon meal (dinner): One soup-plate of bouillon, consomme, Julienne, or other thin soup, or Mosquera's beef-jelly, followed by one piece of the white meat of any form of fowl or a small bird. Some- times a small piece, the size of one's hand, of rare beef or mutton, but no fat, may be allowed, and this should be accompanied by string- beans, celery (stewed or raw) , spinach, kale, cabbage, beans, asparagus, leeks, and young onions. Following this, lettuce with vinegar and a little olive oil (to make a French dressing), a cup of black coffee or one of tea, and a little acid fruit, such as some sour grapes, tamarinds, and sour oranges or lemons, may be taken, and followed by a cigar or cigarette. Supper should consist of one or two soft-boiled eggs, which may also be poached, but not fried, a few ounces of bran bread, some salad and fruit, and perhaps a glass or two of light, dry (not sweet) wine, if the patient is accustomed to its use. Before going to bed, to avoid discomfort from a sensation of hunger during the night, the patient may take a meal of panada, or he may soak Graham or bran crackers or biscuits in water and flavor the mass with salt and pepper. The reduction of diet is generally best accomplished slowly, and should be accompanied by measures devoted to the utilization of the fat present for the support of the body. Thus the patient should not be too heavily clad, either day or night, should resort to exercise, daily becoming more severe, and should not drink freely of water, unless sweating is established sufficiently freely to prevent the accumu- lation of liquid in vessels and tissues. Very often a cold bath will, by its dissipation of heat, cause destruc- tion of fat, which will be burnt up in the body in the manufacture of heat-units to maintain the temperature ; and if the patient is not too anaemic and stands this exposure to cold well, the bath should be repeated each day or a Turkish bath used instead. The bowels should be kept active by laxative fruits or purges, but if liquids taken in drink are not eliminated rapidly, saline purges are useful, since, if the bloodvessels are engorged, the circulation in the capillaries is slow and a deposit of fat is apt to result. Where proper exercise is impossible the rest cure, with massage, electricity, passive exertion, and an absolute skimmed-milk diet, may be resorted to, particularly in those persons known as "fat amemics," who have not enough red corpuscles in their blood to carry sufficient oxygen to the tissues to complete oxidation. 750 DISEASES. So far as medication is concerned, the value of thyroid gland in some cases is not to be forgotten. (See Thyroid Gland, Part II.) PERICARDITIS. Inflammation of the pericardial sac requires prompt treatment. If the case be sthenic and is seen early, and the heart is overacting, five to ten leeches or several small fly blisters should be placed over the prsecordium, and at the same time sufficiently large doses of veratrum viride or aconite given to depress the circulation, and by dilatation of the bloodvessels elsewhere to draw off the blood from the inflamed area. An ice-bag placed over the prsecordium not only relieves the pain, quiets the circulation, and reduces the temperature, but also acts favorably in modifying the severity of the inflammation. Where the case passes from the acute stage of inflammation to that in which effusion takes place, or if the patient is already depressed by illness, the treatment changes at once, and becomes supportive if the system shows signs of failure. The friction-sounds of the first stage are now lost, and the heart-sounds may be feeble or muffled by reason of the effusion present. Digitalis, alcohol, or caffeine may be used if the heart shows signs of failure; but when digitalis is used its influence should be carefully watched, since the employment of this drug pro- duces a very full diastole or dilatation of the ventricles, and these are already cramped for space in which to dilate by reason of the exudate which has entered the pericardial sac. If the effusion is sufficient to endanger life, it should be tapped and aspirated very gradually. Often it is best to explore with a long needle attached to a hypodermic syringe in order to be sure that there is fluid, but the greatest care must be taken that the heart is not wounded. After the skin is punctured a dull canula should be pushed into the sac, as a sharp one may wound the heart. Some authorities hold that the danger of wounding the heart is so great that it is best to make an incision. The best place for making the puncture is the fourth or fifth intercostal space, very close to the left edge of the sternum. Often a blister over the prse- cordium is of service in aiding absorption. Should pus be present, free drainage must be established by means of an incision, and it may be necessary to excise the sternal end of the fifth rib on the left side. PERITONITIS (ACUTE) The views of the best minds in the medical profession concerning the treatment of peritonitis have changed radically in the last ten years, chiefly through the advances made in abdominal surgery and bacteriological research. These opportunities for study have shown that peritonitis never arises as a strictly primary condition, but is due in every case to the infection of the peritoneum by micro-organ- isms, benign or malign, which originally are found in the intestines PERITONITIS {ACUTE). 751 or other portions of the abdominal viscera. Even when peritonitis follows directly upon injury, the actual cause of the pathological process is the escape of micro-organisms through the devitalized wall of the intestine, and the severity of the attacks depends in turn upon the vital resistance of the patient, the virulence of infection, and the rapidity with which a plastic exudate is thrown out to encapsulate the inflamed area. It is not possible in this article to discuss the facts now known in regard to the etiology and pathology of acute peritonitis. Suffice it to state that the bacillus coli communis found normally as a benign inhabitant of the intestine becomes at once, on entrance into the peritoneal cavity, malignant and capable of producing rapidly fatal peritonitis. Nor is actual rupture of the bowel or appendix vermi- formis necessary for this infection, since it has been shown that this germ rapidly migrates through the bowel-wall as soon as it becomes inflamed or congested in all its coats. Streptococci and staphylo- cocci, finding access to this cavity, also produce violent inflammation. It has been found that the peritoneum will destroy many infecting germs if its vitality is not impaired, but if it is impaired, even a mild infection gives rise to severe inflammation. Having learned, then, that acute peritonitis is always secondary to some local cause or to some general infection, the first thing for the therapeutist to do is to determine what the provoking agent is, in order that his treatment may be directed against the cause rather than the effect. This cause is now known, in the great majority of cases, to be Appendicitis (which see), the inflammatory process being spread by infection from this source. In women it is not uncommonly due to more or less obscure pelvic disease; or, again, it may arise from abscess and other severe diseases of the liver, spleen, pancreas, or stomach. Finally, it should never be forgotten that intestinal obstruc- tion and perforation are causes of peritonitis. The physician may rest assured that if he cannot find the provoking cause, it is his own fault, and not decide that the case is purely idiopathic. Having found the cause, treatment is of course to be at once insti- tuted, and is medical or surgical — more commonly the latter than the former, since nearly all the exciting causes of this disease are at most only palliated by medicinal treatment, while they can sometimes be removed by surgical interference. Fortunately for those who can only obtain medicinal treatment, nature does much to aid in producing a cure in many cases by limiting the disease through its localization by walls of lymph, so that many cases of peritonitis recover without active medicinal or surgical care. In the pelvis this localization of the process is very apt to take place unless the infection follow child- birth, when septic diffuse peritonitis may arise, which is always fatal unless surgical assistance is obtainable. If the trouble arise in the appendix vermiformis, this condition may be treated in its early stages by the means suggested in the article 752 DISEASES. on Appendicitis, but at the very first sign of the spread of the inflamma- tion, or of its becoming locally very severe, or of general systemic dis- turbance, the surgeon must be called in. In many cases requiring operation it is performed too late through the hesitancy of the patient, his friends, the physician, or even of the operator himself. If the local trouble does not seem to be spreading and the patient's general condition is favorable, operation should be postponed until a state of quiescence is reached, when the prospects of recovery from operative interference are better. If there is reason to believe that an abscess has ruptured into the peritoneal cavity, or if perforation of the bowel is suspected or shown to be present by severe general symptoms of widespread peritoneal involvement, operation should be resorted to at once. In deciding the question, however, as to whether a case of peritonitis requires surgical interference, the physician at the present time is in an unfortunate position. There can be no doubt that there are many records in medicine which prove most conclusively that lives have been saved through operative interference which would have been undoubt- edly lost had the surgeon not come to the rescue. On the other hand, there are cases in which a fatal result has followed an operation, and in which the physician has bitterly reproached himself that he consented to surgical interference, for as he looked back over the case he per- ceived that the operation distinctly aided in causing the loss of life. At the present time each case must be decided upon its individual merits, and the physician or surgeon in giving advice to the family in regard to a well-developed case of peritonitis should always be careful to let them understand distinctly that the condition of the patient is most alarming, and the chances of life poor whether the treatment be medi- cal or surgical, since in many instances neither form of remedial measure can possibly produce good results. In other words, the relatives should clearly be made to understand that whether medicinal measures or surgical procedures are resorted to, the patient has only a fighting chance. The following case illustrates the value of surgical interference in peritonitis : M was taken ill at twelve midnight, with violent pain in the belly, and was seen by the writer the following evening at eight o'clock. At this time all the physical signs of a widely diffused peritonitis were present. The belly was hard and board-like, the pulse was exceed- ingly rapid, the respirations 56, and there was great pain. Care- ful physical examination of the belly and a study of the patient's history failed to reveal any cause near or remote for the attack, he having been in perfect health up to the time at which the pain began. After consultation with an eminent surgeon it was decided that his condition was so pressing that death under medicinal treatment was assured, and that, while operative interference offered but a faint chance of success, it was the only measure which could be resorted to. PERITONITIS {ACUTE). 753 Accordingly, at twelve o'clock that night, just twenty-four hours after the pain began, the patient was operated upon, the incision being made in the median line for the purpose of exploring the belly, with the hope that an exciting cause for the attack might be found. On opening the belly it was found that acute intestinal obstruction had taken place through the bowel being twisted over an old inflammatory band. After this obstruction had been reduced the appendix was examined, and found to be in a condition of acute inflammation, and for this reason it was removed. It was noted that the peritoneal surfaces of the intestines and of the abdominal wall were intensely hyperaemic and red, and lacking in their normal appearance. The operation lasted an hour and a half, and the patient recovered after a desperate struggle for life which lasted for weeks, during which time his attendants several times gave up all hope of his recovery. Had no operation been permitted, death would certainly have resulted from the intestinal obstruction if not from the appendicitis, and had the median incision not been made, but the appendix alone sought for by a lateral incision, the obstruction would have been overlooked, and the death recorded as one due to general peritonitis following appendi- citis for which an operation had been performed unsuccessfully. This work is not the place for the consideration of the surgical procedures to be followed, but it may be stated that in septic peritonitis in all cases it is a question of operation with probable death, or no operation with certain death. In obscure cases of general peritonitis, where the cause of the disease cannot be detected by ordinary methods of diagnosis, the writer believes that exploratory incision should be done, and after the cause is removed the belly-cavity should be well washed out with hot normal saline solution, and a drainage-tube or gauze left in for at least twenty-four hours. Aside from the surgical treatment, which is an absolute essential in many cases of peritonitis, we have at hand medicinal methods which are of some value early in the attack and where operation is refused or considered inadvisable. The first of these is the use of opium, given until the pain is partly decreased and the respirations decreased to 12 or 14 per minute. The patient should never be so narco- tized as to have no pain on abdominal palpation or be unable to answer questions. On the other hand, it should be remembered that cases of peritonitis bear large doses of opium without effect. The dose should be pushed till the desired effect is obtained, and not be measured in grains. Cases are on record in which many hundred grains of opium have been given in a few days, with recovery as a result. (For the proper use of opium see Appendicitis.) An ice-bag or a turpentine stupe may be put over the area originat- ing the trouble. If the case is very sthenic, leeches may be used on the belly, but this is not advisable in most cases, as the patient may later need the blood to preserve his strength. Should vomiting be a press- ing symptom, it is best controlled by the use of 2 grains of acetanilid 48 756 DISEASES, very uncomfortable. They have been supplanted almost entirely by the cotton jacket, which is much better. It consists of one or two thicknesses of carded cotton basted inside a thin undershirt, as fur is placed in a fur-lined coat. On the outside of the shirt oiled silk should be basted. By using this we envelop the chest in a warm poultice, because the heat of the body keeps the cotton at the proper tempera- ture, while the oiled silk, by preventing evaporation of the moisture exhaled from the skin, soon causes the cotton to become moist as well Fig. 112. 1\ #c I Showing the overlapping of the adhesive strips in strapping the chest for painful pleurisy. The strips extend too far to the patient's right. as warm. Even the cotton jacket is losing its popularity, as the fever of the patient makes a hot jacket almost unbearable and it does little real good. Further, its removal is very apt to result in exposure to cold. The author never uses either of these dressings. When the pleurisy has fully developed, other lines of treatment are needed. The cardiac sedatives should be stopped as soon as the quiet- ing of the circulation has been accomplished. If the pulse becomes weak and the system is depressed, stimulants in the form of alcohol or digitalis are needed, and special care must be devoted to the condition of the exudate in the pleural space. PLEURITIS, OR PLEURISY. 757 The physical signs at this time consist in flatness on percussion over the lower portions of the chest, which area of flatness generally varies with the change in the position of the patient from the erect to the recumbent position, unless the effusion is sacculated. Blow- ing or bronchial breathing at the apex of the lung, when this organ is compressed upward by the fluid beneath it, is often heard. If the effusion is on the right side, the apex beat of the heart is apt to be displaced to the left. If it is on the left side, there is obliteration of Traube's semilunar space, which is a spot at about the level of the sixth and seventh ribs anteriorly below the nipple, where there is usually a tympanitic note on percussion. If the effusion is sufficiently large to cause marked dyspnoea or reaches to the third interspace anteriorly, it should be removed by aspiration. When the effusion is not causing dyspnoea, or other evil symptoms by reason of pressure, the physician should allow sufficient time for recovery to occur; as, for example, a week or ten Fig. 113. Arrangement of bottles for promoting lung expansion. days, during which interval the system will in many cases remove the fluid by natural processes of absorption. If after this time has elapsed the quantity of fluid remains unchanged, it is wise to give salicylic acid in the dose of 1 to 2 drachms (4.0-8.0) a day, or saline purges given in the early morning in concentrated form; and finally, if the fluid is not taken up by the vessels after a dose of jalap or elaterium is used, resort must be had to aspiration of the liquid. These purges ought never to be employed so freely as to weaken the patient, but in most cases this cannot be avoided if the purgative is active enough to be effective in withdrawing liquid from the body- cavities. In his own practice the author rarely uses these drugs, but resorts at once to aspiration. In cases in which it is desired to attempt the removal of a pleural effusion by the use of .purgatives and diuretics, and it is doubtful if absorption can go on through the pleura, we may inject 5 grains (0.3) 758 DISEASES. of methylene blue into the affected pleural cavity, give the purgative, and examine the urine for the blue. If it is eliminated, absorption is possible; if not, the removal of the fluid by the aid of purgatives is probably impossible. In order to cause proper expansion of the lung after convalescence is begun, chest exercises should be used (see Part III.) and wash- bottles may be employed, as are shown in Fig. 113. There is no danger in aspiration if it is properly performed. The best place to insert the needle is the sixth or seventh interspace in the middle axillary line. Care should be taken that the needle is aseptic; that the skin at the point of puncture is well cleansed; and that the exhaust-pump is working well. All the liquid should not be withdrawn at one sitting. Often the withdrawal of a portion of it will result in the natural absorption of the quantity which is allowed to remain in the chest. During this stage of effusion blisters have been largely used to aid absorption of the fluid which is present, but they are not of great service. When used they should be applied in the form known as fly- ing blisters. (See Cantharides, Part II.) It is to be remembered that blisters are, as a rule, contraindicated in the case of children, because of the pain and irritation they produce. If a pleural effusion in the chest of a child is not absorbed by natural processes, it is best to aspirate it. If the fluid is purulent, it must be removed by making an intercostal incision and draining the abscess cavity, although if the displacement of the heart is great we should first aspirate to relieve pressure and operate afterward. PLEURODYNIA. This condition, being one of intercostal neuralgia, should be treated according to the directions given under the headings of Neuralgia and Counterirritation. PNEUMONIA. Pneumonia is a term loosely applied to two very different forms of disease — namely, that acute infectious process due to an infection by micrococcus lanceolatus and called croupous pneumonia; and that form following, as a rule, some other disease which has exhausted the patient's strength and due in some cases to various forms of infection, namely, catarrhal pneumonia. These two distinct diseases have been confused by the common term pneumonia, and yet are very different conditions as to their pathology and treatment. Croupous Pneumonia. The treatment can be divided into that devoted to the stage of onset, the stage of consolidation, and the stage of absorption of the exudate and convalescence; and it will be governed by the state of the patient's pulse, the sounds of his heart, and his general PNEUMONIA. 759 condition as to strength, as well as the degree of respiratory embar- rassment which is present. There can be no routine treatment of croupous pneumonia; each case must be a law unto itself, and there is no such thing as the depletant treatment to be advocated on the one hand, nor the stimulant treatment to be lauded on the other. Further than this, it must be remembered that as croupous pneumonia is an acute infectious disease the patient may die not from pulmonary con- solidation nor cardiac distention, but from the malignancy of the infec- tion. One man with an entire lung consolidated may have slight evidences of general infection or toxaemia; another with a small area of lung involved may be overwhelmed by toxaemia within a few hours. For this and other reasons all cases of croupous pneumonia may be divided into three groups — those that are doomed to death by the malignancy of the infection, those that are but slightly ill by reason of mild infection, and those which are between these two extremes of severity and need careful medical aid to accomplish recovery. The first class die do what we will, the second class get well almost without help, the third need all the help possible to survive. It is to this last class that our treatment must be chiefly directed. The fact must not be lost sight of that croupous pneumonia is often a terminal infection superimposed upon nephritis or some other malady. The primary disease must, therefore, be considered in all plans of treatment. In the very earliest stages of the disease occurring in a healthy, sthenic individual who has been seized with a chill followed by fever and a bounding pulse, with marked anxiety and nervous excitement, it is often proper to bleed freely from a vein in the arm to the extent of a pint (see Part III.), or in its stead to use veratrum or aconite to relax the systemic bloodvessels and " bleed him into his own vessels " by making it easier for the blood to pass into the general arterial system than into the lung which is inflamed. These sedative drugs also quiet the excited heart and prevent it from pumping so much blood into the engorged lung. A hot foot-bath at this time will also tend to relieve thoracic congestion. If veratrum or aconite is used, it should be given in 5 minim doses of the tincture every half-hour till five or ten doses have been used or until the patient's pulse becomes quiet and his skin moist. Veratrum is the best drug of the two for adults If severe pain in the chest is present, it is to be relieved by moderate doses of morphine or Dover's powder. This treatment is devoted to an attempt to limit the degree of inflammatory action as far as possible. It may be aided, if it is thought wise, by wet cups over the engorged lung. The depressant treatment of croupous pneumonia is, however, lim- ited in its application to the very beginning of the malady and to those persons who have a bounding circulation. It is absolutely contraindi- cated after consolidation has taken place or if the patient is feeble. Because of the fact that its usefulness is confined to this early stage, it cannot be employed in many cases because the physician is not called 760 DISEASES. till after this stage has passed by. I repeat, that its use in a case with a feeble pulse or in one who is adynamic or feeble is absolutely contra- indicated. Furthermore, it is not to be used if any primary malady, such as nephritis, is present, as this renders the case asthenic from the onset. In the majority of cases the physician is called after consolidation has occurred, and he must now be a watchman all the time and a therapeutist only when treatment is actually needed. Every patient who is suffering from pneumonia does not need active treatment. A certain number of cases get well without treatment, and do so sooner than if meddlesome therapeutics hinders them. The treatment usually necessary is to combat fever if it becomes excessive, to support the heart if it seems feeble or engorged, to keep the kidneys in a state of active secretion, and to see that constipation is relieved. In the treatment of the fever the physician should remember that it is not to be regarded as a dangerous symptom unless it rises to 103° F. and remains at this point for some hours, for in a febrile disease running a short course fever is not only not harmful, but there is also reason to believe that when present to a moderate degree it is actually beneficial. 1 When the fever does rise to a point above 103° F. it should be reduced by sponging with cool water, active friction being used at the same time. (See Cold, in Part III.) There is absolutely no danger of the patient "taking cold," although this is generally doubted by the laity. If the fever has a tendency to be excessive and if the heart's action is tumultuous, an ice-bag may be placed over the heart, and this will be particularly useful if, as is often the case, there is a tendency to pericar- ditis. If it is desired to apply cold over a greater area of the chest than the pryecordium, cold compresses may be employed, but they pos- sess the disadvantage of being wet applications, do what we will to protect the bedding. The cold plunge bath is always badly borne in croupous pneumonia. (See Cold, in Part III.) The use of antipyretic drugs is not good practice. They tend to depress the heart, to relax the bloodvessels, and apparently render the patient more susceptible to his infection. For the support of the heart several circulatory stimulants may be employed. If the patient is feeble with lack of vitality and relaxa- tion of his vessels, then alcohol in the form of a good whiskey or brandy given in water after food every three or four hours in the dose of from half an ounce to an ounce is useful. Sometimes more than this must be given, particularly if the patient has been accustomed to the use of the stimulant. In other cases none is needed. For the laboring heart with almost empty arteries no drug com- pares with digitalis; and if the skin is moist or the bloodvessels relaxed, so that the pulse is gaseous, then belladonna should be combined with it. The writer usually gives 8 minims (0.50) of a 1 See article on " The Role of Fever in the Modification of Disease," in the Therapeutic Gazette for February, 1896. PNEUMONIA. 761 physiologically tested tincture of digitalis every eight hours, with 8 minims (0.5) of the tincture of belladonna every four hours. (See Digitalis and Belladonna.) If necessary, both of these drugs may be given in larger dose, but usually these doses are sufficient. If the fever is very high, the digitalis will often have to be supplanted by alcoholic stimulants or strychnine for a few doses. The question as to whether the patient's pulse is of the proper strength is one of impor- tance : very often the quiet pulse of a patient lying in bed will be taken by the anxious attendant as an evidence of true cardiac feebleness, when if the physician feels his own pulse he will be surprised to find it no stronger than that of his patient. A feeble apex beat, a feeble second sound at the second right costal cartilage (aortic valve), and an accent- uated second sound at the second left costal cartilage (pulmonary valve) will reveal the fact that active stimulation is needed, for the weak apex beat and the soft second (aortic) sound show that the heart is feeble and the arterial walls relaxed, and this means a low arterial pressure. Further, the accentuated second sound on the right side indicates pulmonary congestion and a tendency to failure of the right side of the heart from obstruction to the flow of blood in the lungs. Should the action of the heart become labored, the jugular veins distended and pulsating, and the radial pulse weak, while the face is cyanotic, then free venesection (Part III.) is to be practised. It will often save an apparently desperate case. Digitalis in the presence of this condition is not rapid enough in its effects. Strychnine should be given in full dose hypodermically, ■£$ to ■£$ of a grain (0.003-0.006), and with it, if the skin is moist or sweating, y^-g of a grain of atropine (0.0004), and both these drugs should be repeated in an hour if needed. At the same time it is well to give \ drachm (2.0) of aromatic spirit of ammonia every two hours in cold water or 1 drachm (4.0) of Hoffmann's anodyne in cold water every hour. Oxygen inhalations may be used at this time with benefit, particularly if cyanosis is marked. (See Oxygen.) If the patient be one advanced in years, with thickened arteries and a high arterial tension which causes the heart's action to be labored, nitroglycerin is to be employed. Should crisis come on at this time, active supportant treatment, such as that just described, will be needed. Many patients die in crisis for the want of active stimulation. Nervous excitement with insomnia, if excessive, should be combated by small doses, \ to \ grain (0.008-0.015), of morphine, given in the early evening by hypodermic injection. The secretion of the kidneys is best maintained by the use of some alkaline diuretic, such as sweet spirit of nitre and citrate of potassium, and if necessary a little gin may be given to support the heart and aid in maintaining renal activity. Having detailed this treatment of the second stage, that for the third stage is to be considered. — 760 DISEASES. till after this stage has passed by. I repeat, that its use in a case with a feeble pulse or in one who is adynamic or feeble is absolutely contra- indicated. Furthermore, it is not to be used if any primary malady, such as nephritis, is present, as this renders the case asthenic from the onset. In the majority of cases the physician is called after consolidation has occurred, and he must now be a watchman all the time and a therapeutist only when treatment is actually needed. Every patient who is suffering from pneumonia does not need active treatment. A certain number of cases get well without treatment, and do so sooner than if meddlesome therapeutics hinders them. The treatment usually necessary is to combat fever if it becomes excessive, to support the heart if it seems feeble or engorged, to keep the kidneys in a state of active secretion, and to see that constipation is relieved. In the treatment of the fever the physician should remember that it is not to be regarded as a dangerous symptom unless it rises to 103° F. and remains at this point for some hours, for in a febrile disease running a short course fever is not only not harmful, but there is also reason to believe that when present to a moderate degree it is actually beneficial. 1 When the fever does rise to a point above 103° F. it should be reduced by sponging with cool water, active friction being used at the same time. (See Cold, in Part III.) There is absolutely no danger of the patient "taking cold," although this is generally doubted by the laity. If the fever has a tendency to be excessive and if the heart's action is tumultuous, an ice-bag may be placed over the heart, and this will be particularly useful if, as is often the case, there is a tendency to pericar- ditis. If it is desired to apply cold over a greater area of the chest than the pnecordium, cold compresses may be employed, but they pos- sess the disadvantage of being wet applications, do what we will to protect the bedding. The cold plunge bath is always badly borne in croupous pneumonia. (See Cold, in Part III.) The use of antipyretic drugs is not good practice. They tend to depress the heart, to relax the bloodvessels, and apparently render the patient more susceptible to his infection. For the support of the heart several circulatory stimulants may be employed. If the patient is feeble with lack of vitality and relaxa- tion of his vessels, then alcohol in the form of a good whiskey or brandy given in water after food every three or four hours in the dose of from half an ounce to an ounce is useful. Sometimes more than this must be given, particularly if the patient has been accustomed to the use of the stimulant. In other cases none is needed. For the laboring heart with almost empty arteries no drug com- pares with digitalis; and if the skin is moist or the bloodvessels relaxed, so that the pulse is gaseous, then belladonna should be combined with it. The writer usually gives 8 minims (0.50) of a 1 See article on " The Role of Fever in the Modification of Disease," in the Therapeutic Gazette for February, 1896. PNEUMONIA. 761 physiologically tested tincture of digitalis every eight hours, with 8 minims (0.5) of the tincture of belladonna every four hours. (See Digitalis and Belladonna.) If necessary, both of these drugs may be given in larger dose, but usually these doses are sufficient. If the fever is very high, the digitalis will often have to be supplanted by alcoholic stimulants or strychnine for a few doses. The question as to whether the patient's pulse is of the proper strength is one of impor- tance : very often the quiet pulse of a patient lying in bed will be taken by the anxious attendant as an evidence of true cardiac feebleness, when if the physician feels his own pulse he will be surprised to find it no stronger than that of his patient. A feeble apex beat, a feeble second sound at the second right costal cartilage (aortic valve), and an accent- uated second sound at the second left costal cartilage (pulmonary valve) will reveal the fact that active stimulation is needed, for the weak apex beat and the soft second (aortic) sound show that the heart is feeble and the arterial walls relaxed, and this means a low arterial pressure. Further, the accentuated second sound on the right side indicates pulmonary congestion and a tendency to failure of the right side of the heart from obstruction to the flow of blood in the lungs. Should the action of the heart become labored, the jugular veins distended and pulsating, and the radial pulse weak, while the face is cyanotic, then free venesection (Part III.) is to be practised. It will often save an apparently desperate case. Digitalis in the presence of this condition is not rapid enough in its effects. Strychnine should be given in full dose hypodermically, -£-$ to T ^ of a grain (0.003-0.006), and with it, if the skin is moist or sweating, t i=-q- of a grain of atropine (0.0004), and both these drugs should be repeated in an hour if needed. At the same time it is well to give \ drachm (2.0) of aromatic spirit of ammonia every two hours in cold water or 1 drachm (4.0) of Hoffmann's anodyne in cold water every hour. Oxygen inhalations may be used at this time with benefit, particularly if cyanosis is marked. (See Oxygen.) If the patient be one advanced in years, with thickened arteries and a high arterial tension which causes the heart's action to be labored, nitroglycerin is to be employed. Should crisis come on at this time, active supportant treatment, such as that just described, will be needed. Many patients die in crisis for the want of active stimulation. Nervous excitement with insomnia, if excessive, should be combated by small doses, \ to \ grain (0.008-0.015), of morphine, given in the early evening by hypodermic injection. The secretion of the kidneys is best maintained by the use of some alkaline diuretic, such as sweet spirit of nitre and citrate of potassium, and if necessary a little gin may be given to support the heart and aid in maintaining renal activity. Having detailed this treatment of the second stage, that for the third stage is to be considered. 762 DISEASES. It must be remembered that in most individuals the process of repair is carried out best if the efforts of nature are not meddled with. When resolution is delayed, there is always a possibility of the condi- tion being tubercular, and this should make the physician cautious in the use of alteratives, such as the iodides, for if tuberculosis be the cause of the condition such treatment may cause rapid breaking down of the lung. First and foremost for the relief of any associated bronchitis stands the chloride of ammonium, a drug whose elimination takes place largely through the lungs, and which acts most happily in aiding in the loosen- ing of the cough and secretions. Its only disadvantage is its salty taste, which in many cases renders it disagreeable to the patient, while its irritant properties may disorder the action of the stomach, although if this organ is depressed and atonic this drug often improves its condition. This drug may be given in compressed pills, or, what is far better, in such a mixture as here follows: 1$ — Ammonii chloridi ,^ij (8.0). Fluidext. glvcyrrhizae f.^ij (8.0). Aquae dest fgiij (90.0).— M. S. — Teaspoonful (4.0) in water every four hours during the day. If the cough be in excess of the expectoration — that is, if the cough often fails to bring up phlegm and is due to tickling or irritation — it may be relieved by the addition of a little morphine to this mixture, as follows: 1$ — Morphinae sulph gr. j vel gr. ij (0.06-0.12). Ammonii chloridi gij (8.0). Fluidext. glycyrrhizse f giv (16.0). Aquae dest. . ...... . f^vj (180.0).— M. S. — Dessertspoonful (8.0) every four hours in water If much more morphine than this is used, it will tend to stop secretion. When the chloride of ammonium fails to act favorably, the car- bonate may be called into use for its local and circulatory action, and, in addition, the bromide of ammonium may be employed to allay the cough if morphine cannot be used. The following prescription is valuable : ^ — Ammonii chloridi . . .. . . . • 5j (4:0). Ammonii bromidi ....... 5j (4.0). Ammonii carbonat 5j (4.0). Fluidext. glycyrrhizse f^iij (12.0). Aquae dest fgvj (180.0).— M. S.— Dessertspoonful (8.0) every four hours in water. In other cases heroin may be given in the dose of ^ grain (0.005) every eight hours to control excessive cough. (For other remedies for this stage see Bronchitis.) It must be borne in mind that the effect of expectorant drugs upon the pneumonic process itself is very slight, and that they are not to be given unless bronchial secretion is present in excess. PRURITUS. 763 Nutritious broths, milk, and, if necessary, predigested foods, should be given with even greater regularity than medicine would be given, from the beginning to the end of the attack. Catarrhal Pneumonia. The main difference in the treatment of Catarrhal Pneumonia in distinction from the treatment of croupous pneumonia lies in the fact that first, last, and all the time the treatment is to be stimulant in its character if any treatment other than rest in bed is resorted to. Catar- rhal pneumonia usually arises out of a severe bronchitis or is superim- posed upon some exhausting disease which has sapped the vitality. Toward its close expectorants are even more useful than in croupous pneumonia, and every care should be taken that the catarrhal process does not pass by insidious degrees into a hidden tuberculosis. Tubercular infection should be suspected in all cases in which recovery is abnormally slow. PRURITUS. Itching of the skin or mucous membranes about the openings of the body is a very common state, and while it may be dependent upon local causes, such as hemorrhoids in the case of pruritus ani, it more commonly is due to some systemic condition, such as debility, diabetes, gout, or renal disease, or other similar causes. The treatment con- sists, first, in the removal of the cause, and, next, in the local treatment of the condition. There is generally no redness or eruption, except that due to scratching. Internally, arsenic, quinine, bitter tonics, cod-liver oil, alkaline diuretics, or mineral waters are useful in debilitated cases, and an avoidance of condiments, such as mustard or pepper, is needful if the disease affects the orifice of the urethra or vagina. The local treatment of pruritus consists in the use of lotions, salves, or ointments made up of various constituents, a number of which are capable of acting as local anaesthetics. Very often bathing the parts with 1 drachm of bicarbonate of sodium or of borax to a pint of cold water gives relief temporarily, or the following formulae will be of service : 3— Phenolis f gj velf 3 ij (4.0-8.0). Aquse dest q. s. ad Oj (480 c.c). — M. S. — Apply as a lotion several times a day. Or, 1$ — Liquor, carbon, detergen. 1 . . . f ^ij (8.0). Aquae dest q. s. ad Oj (480 c.c.).— M. S. — Apply as a lotion. Or an ointment made as follows is serviceable: If- Phenolis gtt.vvelxx (0.3-1.3). Adipis benzoinati §j (30.0). Petrolati 3J (4.0).— M. S. — Apply as an ointment. 1 For method of preparing this liquor see article on Eczema. 764 DISEASES. In other cases 10 to 20 minims (0.60-1.3) of chloroform may be used in place of the phenol. Cocaine may be painted over the parts, but it should rarely be used in ointment, as fats prevent its acting effectively. It should also be remembered that the anal and vaginal mucous membranes are so thick that strong solutions of cocaine are necessary to produce anaesthe- sia, and that the effects of cocaine are only temporary. Cocaine is useless when applied to the skin. Where the itching is very obstinate the parts may be painted with a solution of nitrate of silver of the strength of 20 grains to the ounce (1.3-30.0) of water, cocaine having been previously applied to relieve the pain of the application. (See article on Cold.) My colleague, Brinton, has highly recommended powdered teucrium scordium in the dose of 20 grains (1.3) three times a day for itching hemorrhoids. Allingham has used with advantage a piece of ivory shaped like a rubber nipple and provided with a circular shield. This is slipped into the bowel at night and serves to keep the surfaces apart. In cases of general pruritus baths are often of great service. They may consist in plain hot-water baths or Turkish baths. In other instances, to each bath of 30 gallons may be added \ pound of bicar- bonate of sodium, or 1 to 4 ounces (30.0-120.0) of borax may be used. When the skin is very irritated starch, 1 pound (480), or bran, 2 pounds (960), may be added to the bath. Sometimes linseed-meal baths may be used. The meal is placed in hot water until the gluti- nous matter is set free, when it is added to the bath. One or two pounds (480-960) are used. In very persistent cases the patient may actually eat and sleep in the bath with advantage. PUERPERAL DISEASES. The diseases of the puerperium may be divided into two broad classes — infectious and non-infectious. The first class should be further subdivided into (1) those infectious diseases in which the point of infection has been somewhere along the parturient tract, and (2) those in which the infecting poison has entered the body by some other channel. Under subheading 1 come all those disease con- ditions grouped together under the very inadequate generic terms "puerperal fever," "puerperal septicaemia/' "puerperal infection," and the like, none of which truly expresses the condition. If it is neces- sary in medical nomenclature to have a single term which shall denote infection of the genitalia after delivery, a word should be coined strictly limited in sense to mean the pathological conditions which result from the activity of pathogenic microbes along the whole genital tract. This classification is necessary for a clear and systematic description of the treatment of diseases in the puerperal state. The Treatment of Infection along the Genital Tract after Labor. — A common form of infection along the genital tract after labor is a tox- PUERPERAL DISEASES. 765 semia from the infection and decomposition of membranes, fragments of placenta, or blood within the uterus. Therefore, in any case after labor in which there is fever that cannot be explained by some evident cause independent of the genitalia, it is safe to assume that the uterine cavity is the seat of pathogenic micro-organisms. The indications are plain: to destroy the microbes, to stop the manufacture of their toxin, to remove putrescible material, and to prevent an invasion of the system. The writer's routine application of this principle in practice is as follows: If the temperature after delivery remains over 101° F. for twenty-four hours without evident cause independent of the genitalia, he washes out the uterine cavity with at least 1 quart (960) either of bichloride of mercury solution, 1 : 2000, or a mixture of alcohol, 8 ounces, water 8 ounces, and tincture of iodine 1 drachm. The former is more convenient in private practice, because the tablets of corrosive sublimate can be easily carried about in one's instrument-bag. To insure the entrance of the antiseptic fluid to the fundus and its free exit from the cervical canal an intra-uterine catheter is desirable. Of all those upon the market, the best is that known as Fritsch's modifica- tion of Bozeman's catheter. If, however, the cervical canal is patu- lous, as it usually is after labor, a hard-rubber catheter attached to a Davidson or fountain syringe answers the purpose perfectly. In many cases this treatment brings the temperature down to normal within twenty-four hours. If fever does not appear within this time or perhaps rises even higher, the second indication must be met. The infected albuminous substances within the uterine cavity, usually necrotic endometrium, must be removed in order to deprive the micro- organisms of their feeding-ground. This is best accomplished by the use of the curette and the placental forceps, care being taken in the employment of the former instrument to guard the uterine wall itself from the slightest injury; for not only can the uterine muscle be per- forated by a curette in clumsy hands, but slight wounds of the uterine wall with this instrument may be enough to inoculate the general sys- tem with the germs whose activity has been before confined to the uterine cavity, by penetrating the layer of granulation cells under the endometrium. The writer's manner of employing this plan of treatment after labor is as follows: The anterior lip of the cervix is seized with a double tenaculum and pulled gently downward; a cleansing uterine douche is then given in order to disinfect the field of operation; next a broad, dull curette is inserted to the fundus, and the whole interior of the uterus is carefully gone over with the instrument, first the fundus and then each of the four sides ; then the curette is turned with the scraping surface upward and withdrawn from the cervical canal, a finger in the vagina meeting its tip as it emerges in order to help extract any sub- stances which may be caught by and entangled in it. 766 DISEASES. Next the placental forceps is inserted, and an effort made to grasp any material lying loose within the cavity or still attached to the uterine walls. It is usually best to repeat each of these manoeuvres several times until nothing more can be brought away except a little clear blood. Then the uterine cavity is again thoroughly washed out. Occasion- ally it is necessary to repeat the irrigation, but rarely the curetting, for several successive days. If this treatment should prove unsuccess- ful and the temperature remain elevated in spite of irrigation and the use of the curette and placental forceps, one must assume either that general systemic infection has occurred, or at least that an inflam- matory action has begun in the uterine walls or within the tubes. One of the signs of systemic invasion is the appearance of peritonitis. In such a case the only treatment is to support the body-cells in the combat which they must wage with the invading micro-organisms. This is best accomplished by the administration of as large a quantity of nutriment as the patient can stand without rebellion of the stomach or bowels, and the exhibition of a large quantity of alcoholic stimulant. Cases of this sort not infrequently require more than a pint of whiskey or brandy in the twenty-four hours. Occasionally measures are required to reduce an excessive elevation of the temperature, but this is best avoided as long as possible, for antipyretic treatment is usually depressing and ill suited to the patient's adynamic condi- tion. The use of antistreptococcic serum, nuclein, and injections of normal salt solution are important adjuvants to the treatment which should not be neglected in a serious case. With this plan of treatment about three-fourths of the cases of general septic infection after labor will recover. There may be some in which metastasis to important organs occurs so early as to render all treatment of no avail. There will be others in which the peritoneum is early infected, and in which the septic peritonitis develops rapidly and to an extensive degree. It is in such cases that coeliotomy and evacuation of the septic matter, usually pus, within the peritoneum will occasionally save life. The physician must guard himself, however, from operating too early and unnecessarily. After operation, drainage of the peritoneal cavity is an essential feature of the treatment, even although the evidence of sup- puration within the cavity is slight. The writer has in mind a case in which an operation was performed ten days post-partum for septic peritonitis: a very small quantity of purulent lymph was found upon one ovary, which was greatly enlarged and contained a small quantity of seropus. The ovary was removed and the abdomen closed with- out drainage, as there was no other evidence of suppuration within it. Thirty-six hours later the patient died, and the peritoneal cavity was found filled with pus which had accumulated in that short space of time. In the early stages of the peritoneal infection, if the subject is vigorous, not exhausted by a prolonged labor or other depressing PUERPERAL DISEASES. 767 causes, the administration of saline purgatives in concentrated solution often effects brilliant results. The writer's custom is to give a dessertspoonful of a concentrated solution of Epsom salt every fifteen minutes until free evacuation of the bowels is secured. He has seen the temperature reduced by this plan of treatment from 104° F. to normal in the course of twelve hours, and with the reduction of temperature all the symptoms of peritonitis, which were well marked, entirely disappeared. In the treatment of microbic activity along the parturient tract after labor it should never be forgotten that the point by which the microbes invade the system may be anywhere from the fundus of the uterus to the parturient outlet; therefore the practitioner should never neglect to examine carefully all the lower parturient tract, in order to detect, if possible, an ulcerated surface covered by diphtheritic membrane, which if overlooked might be the entrance-point for a fatal infection. These unhealthy surfaces are best detected by the use of a cylindrical speculum of clouded glass introduced so that the cervix appears within its inner end, and then withdrawn, so that the vaginal mucous mem- brane as it prolapses into the end of the speculum may be examined, and treated if necessary throughout its whole extent. If an unhealthy, ulcerated wound is thus discovered, the writer's practice is to apply to it a solution of nitrate of silver 40 or 60 grains to the ounce (2.60-4.0 : 30). In the vast majority of cases this application will promote an exfoliation of the unhealthy membrane and the appearance of healthy granulation tissue within a few days. It may, in some cases, be necessary to employ a stronger applica- tion, as the solution of chloride of zinc, but the writer has not been driven to its use. The most common point of infection outside the parturient tract after labor is some portion of the urinary apparatus, almost invariably the bladder. The process of parturition necessarily diminishes the vitality of the vesical mucous membrane cells by the pressure and stretching to which they are subjected. After labor, therefore, they are not in a condition to resist the attacks of micro- organisms, should these in any way gain access to the vesical cavity. Most commonly microbes are introduced into the bladder by a catheter. This, however, is not necessary, as it has been plainly demonstrated that they can wander from the vaginal canal through the urethra into the bladder without the intervention of an instrument which would directly carry them into the vesical cavity and deposit them in that situation. Once arrived within the bladder, the microbes attack the depressed bladder-cells, and very often gain a lodgement in the vesical mucous membrane. This is manifested by the usual symptoms of septic cystitis — fever, pus in the urine, pain on pressure over the hypo- gastrium, and pain and difficulty in micturition. The duration of these symptoms is, as a rule, not very long. The fever subsides and the symptoms of cystitis disappear. After an interval of some days, however, there is again a sharp outbreak of fever, with pain in the 768 DISEASES. region of the kidneys, the reappearance of pus, or at least of numerous microbes, in the urine, and a marked leucocytosis. This indicates a septic infection of the pelves of the kidneys after the micro-organisms have migrated along the ureters. During their migration their pres- ence has not been manifested by any symptoms. In the majority of cases even the symptoms of pyelitis will disappear after a time, and the patient will make a good recovery; but in a certain proportion there is a systemic infection by the direct passage of microbes or their products from the kidneys into the blood. There may be an extensive suppuration of the kidneys and surrounding tissue, with fatal results, or, as the writer has seen in several cases, the symptoms of general systemic infection become so grave as for a long time to threaten the patient's life. In the worst cases of bladder infection the mucous lining sloughs, peritonitis develops, and the patient dies before the disease has time to infect the kidneys. The practitioner, bearing in mind the serious consequences of septic cystitis after labor, should always be on the watch for it, and should adopt an energetic treatment immediately upon its detection. A thor- ough disinfection of the bladder will remove all present symptoms, and prevent the occurrence of grave and possibly fatal after-complica- tions. To accomplish this purpose the writer employs a saturated solution of boric acid. One injection of a quart of this solution through a two-way catheter is usually sufficient. Occasionally it is necessary to repeat it or to follow it by several injections of boric acid solution. A 1 : 8000 bichloride of mercury solution may be employed if the first boric acid injection fails to improve the local symptoms. If, in spite of all precautions, infection of the kidneys should ensue, a vigorously stimulating and supportive plan of treatment affords the only hope of success. If extensive suppuration occurs in the kidneys, all treatment will of course be useless. Perhaps the most uncommon point of septic infection after labor is the rectum. The writer has, however, seen one fatal case of this sort — from the use, no doubt, of a dirty syringe-nozzle in the hands of a care- less nurse. It would be difficult, or perhaps impossible, to diagnosti- cate such a case until after death, and therefore treatment directed toward this form of infection will usually not be adopted. Next in frequency to the parturient tract and the urinary system as a region of infection after labor come the breasts. Infection of the nipples, and a consequent mammary inflammation or suppuration, is one of the most troublesome minor complications that the obstetrician is called upon to treat. By careful preparation of the nipple during the last month of pregnancy, by extreme care to secure perfect cleanliness during the period of lactation, by emptying the breast and supporting it with a mammary binder, infection of the breast can almost surely be avoided. If it occurs, the first effort should be to limit its extent and degree, and to prevent, if possible, suppuration. The best means to accomplish this end are derivation of the blood from the mammary PUERPERAL DISEASES. 769 glands by an active purge, compression of the gland-substance, and support of the breasts by a suitable mammary binder. To these should be added, in the acute stage of inflammation, fomentations of very hot water, or the ice-bag, and, later, the applica- tion of cloths wrung out in lead-water and laudanum, renewed every three hours. Unless the infection has been of a virulent nature and the amount of infective material large, this plan of treatment will almost surely dissipate the inflammation and prevent suppuration. The other infectious fevers of the puerperal state include the infec- tious diseases which can, under any circumstances, attack the adult female, and their treatment differs in no respect during the puerperium from that adopted under ordinary circumstances unless there should be developed some local complications. Non-infectious Diseases of the Puerperium. Anomalies of Involution. — Superinvolution, an exaggeration of that process by which the uterus is reduced to its normal size after labor, manifests itself, as a rule, only after the puerperal state is completed, and therefore its treatment need not be considered. Subinvolution, an arrested or retarded return of the uterus to its normal condition and dimensions after labor, is one of the commonest complications with which the obstetrician has to deal in the manage- ment of the puerperium. The cause of subinvolution is always a local one. General conditions, as acute fevers, have no influence what- ever upon the process of involution unless they are accompanied by some local complication. There are two causes which prevent the involution of the uterus which must be borne in mind when one is called upon to treat this condition. The involution may be prevented, on the one hand, by anything which brings an excessive amount of blood to the uterine body, as, for instance, small fibroids within its walls or hypertrophied deciduous membrane remaining adherent to its inner surface. On the other hand, subinvolution may be the result of mechanical obstruction to the contraction of the uterine walls and the reduction of the cavity of the uterus to the normal size. An example of this is a retained placenta or a submucous fibroid or adhesions dragging the uterus out of place and preventing its contraction, or, most commonly perhaps, an overdistended bladder and rectum. In those conditions which result in a hyperemia of the uterus the cause of an excessive blood-supply must be sought out and removed before the subinvolution can be remedied. If small fibroids can be detected, the administration of ergotin 1 grain, hydrastinin \ grain, and stypticin 1 grain, in pill form, has been found most useful. If practical, a faradic current may be employed in addition to medication. If there is an hypertrophied endometrium retained within the uterus, a curette will most quickly and effectually 49 770 DISEASES. hasten involution. In cases of heart disease in which the blood-cur rent is sluggish and dammed back into the large veins of the trunk digitalis will be the most effective remedy to overcome the subinvolu- tion. There may be an active hyperemia associated with inflamma- tory action, either in the uterine wall or upon its peritoneal covering or in its adnexa; in this case the inflammation must be overcome by disinfection, the use of purgatives, the local application of hot water, or possibly operative treatment, before involution can be secured. When there is mechanical obstruction to the return of the womb to its normal dimensions, the hindrance must, of course, be removed before one can expect a good result from treatment. In the case of retained adherent placenta every effort must be made to remove the placental tissue. In the case of submucous fibroids their removal must be attempted if there is any hope of safely accomplishing it. There is no case of labor which does not leave behind, in the par- turient tract, some injury of the maternal structures. Usually these are slight in degree, manifesting no symptoms and healing spontane- ously. Occasionally the injury done results in fistula communicating with the bladder or rectum, in deep granulating wounds in the vagina, or in ulcerated sores. In the case of fistula a cure can sometimes be effected without operative interference by touching up the edges of the fistulous tract with nitric acid, in order to excite an outpouring of granulation-tissue in the hope that it may plug the opening. In deep tears, which have not been primarily united, application of a solution of nitrate of silver will hasten the cure and prevent infection of the wounded surface. If ulceration occurs, the ulcerated spots are to be carefully watched and treated in the same manner. All the injuries of the birth-canal should be repaired by primary, intermediate, or secondary operation. Hemorrhages from the birth-canal after labor depend upon a num- ber of well-known causes, which must be sought out and corrected before the bleeding will cease. Most frequently the cause of a hemor- rhage will be found in retained placental fragments, which must be removed. Frequently displacements of the uterus will be found as a cause, and correction of the displacement will check the bleeding. In interstitial bleeding after labor, resulting in hematoma, care must be taken to preserve the parts in as aseptic a condition as pos- sible, while an attempt is made to limit the bleeding by the application of direct cold, preferably by means of a colpeurynter dilated with ice- water, which must be removed from time to time in order to allow the lochia to escape. After rupture or incision of these blood-tumors the cavity left behind must be carefully disinfected with bichloride of mercury solution, and, if necessary to control further bleeding, well packed with iodoform gauze. Of all forms of bleeding, that which occurs directly after labor in consequence of inertia uteri, known as post-partum hemorrhage, is PUERPERAL DISEASES. 771 the most frequent, the most alarming and dangerous in its manifesta- tions and consequences. No one should attend a case of obstetrics without having in mind a clearly defined programme to be put in immediate execution when called upon to deal with this frequent and dangerous complication. There are two indications to be met: first, to control the hemorrhage, and, second, to treat the after-condition. The first indication is met by the following plan of treatment : External stimulation of the uterus by kneading and rubbing through abdominal walls, as is practised in Crede's method of expressing the placenta. If this fails carry the hand into the uterus and remove any blood- clots, pieces of placenta or membrane that may be found there, and manipulate the parts so that the internal surface of the uterine walls is irritated by the movements of the operator's fingers, which are covered by a sterile glove. Next apply a small piece of ice upon the abdomen externally. The use of cold must not be persisted in for more than a minute at most, for its ultimate action is depressing and relaxing. If all these measures fail the physician should resort to the use of sterile water at a temperature of 116° or 120° F., which should be injected into the uterine cavity. If one happens to have the necessary appliances at hand (a small Gaiffe battery, which can be carried in an ordinary instrument-bag), a strong faradic current can be applied to the uterine muscle. Finally, as a last resort, the uterine cavity may be packed with long strips of iodoform or sterile gauze in the manner suggested by Diihrssen and carried out by a number of observers with gratifying success. The physician should give ergot in full dose by the mouth and, if need be, hypodermically. (Ergone or ergot aseptic.) Drugs, as the styptic salts of iron, and especially Monsel's solution, have been recommended from time to time as intra-uterine applica- tions in the case of post-partum hemorrhage, but they are dangerous, for the coagulation produced by them may extend far into the uterine vessels, and the clots can only be broken up by putrefaction, exposing the patient to the danger of septic poisoning. This programme is to be carried out in the order given: if the milder measures suffice, of course the more radical plans of treatment need not be employed. Excessive hemorrhage (post-partum) from lacerations along the genital canal can be controlled by well -placed sutures. Bearing in mind this plan of treatment, it is almost inconceivable that an intelligent and skilful practitioner should lose a case of post- partum hemorrhage. Treatment of the After-condition. — While the physician is busy controlling the hemorrhage the nurse should administer a hypodermic injection of ether if symptoms of shock or collapse are manifested. After the bleeding has ceased it is well to administer an enema of a 772 DISEASES. pint of hot normal salt solution, which maintains the patient's tem- perature, relieves the shock, and by its irritation promotes contraction of the uterine muscle. The submammary or intravenous injection of normal salt solution is more efficient than the enteroclysis, but more difficult for the ordinary physician to administer. This should be succeeded by small doses of hot, strong brandy-and-water, and a little warm milk if the stomach will retain it. As soon as reaction is well established a half -pint (240 c.c.) of hot beef -tea should be administered, and a hypodermic of J- grain (0.008) of morphine given in order to secure quiet and rest and to get the stimulant qualities which this drug undoubtedly possesses. Occasionally measures must be adopted to retain enough blood within the large vessels and in the heart to prevent excessive cerebral aii£emia or cardiac failure. This is best done by auto-transfusion; that is, by bandaging the extremities from below upward, in order to secure as large a quantity of blood as possible within the vessels of the trunk and brain. Actual transfusion of a 0.6 per cent, solution of common salt into the bloodvessels is required when there are profound exhaustion and depression after hemorrhage. It has been demonstrated that it is not necessary to throw this solution directly into the bloodvessels, as interstitial injection seems to answer the purpose equally well. The most convenient place for such injections in females is under the breasts. (See Hypo- dermoclysis, Part III.) The milk secretion during the puerperal state presents abnormalities which call for treatment. One may have to deal with anomalies of quantity or quality. The most frequent anomaly of quantity in milk secretion is unfortunately one of deficiency. Insufficient milk-supply depends on a number of causes. Perhaps the most frequent is a lack of development of the glandular tissue, and in this form of insufficient milk secretion no treatment can be of avail. When the lack of milk is due to some intercurrent affection in the puerperal state the treat- ment must be directed toward this complication before the milk-supply can be re-established in normal quantity. It may be the consequence of hemorrhages or of diarrhoea, or the result of an acute febrile attack during lactation, or of inflammation within the gland itself. Serious organic disease may also be a cause, and insufficient nourishment must be held accountable in some cases. Profound emotions exert an extraordinary influence upon lactation in altering both the quantity and the quality of the milk. It has long been supposed that the return of menstruation has a disastrous influence upon milk secretion. This, however, has been definitely disproved by careful observations. The return of normal menstruation without complications has no apparent influence, as a rule, upon the quantity or quality of the woman's milk. In all the temporary diseases interfering with milk secretion described above it should be borne in mind that on the disappearance of the abnormal general or local condition milk secretion can be successfully re-established even though it be absent for days or weeks. Electricity PUERPERAL DISEASES. 773 has been much vaunted as a remedy for insufficient lactation. It may be applicable in cases of torpidity of the mammary gland or in those cases where lactation has been suppressed on the birth of a first child, and where the mammary gland, therefore, does not respond readily to the stimulus of subsequent births. This remedy will, however, often prove ineffective and disappointing. Instances of excessive milk secretion are not infrequently met with. The milder and simpler forms can be managed by regulation of the diet and free purgation. Galactorrhcea, a constant flow of milk from the breasts, is one of the most stubborn forms of excessive milk secretion. Two measures can usually be relied on to give relief: firm compression of the mammary gland with the application of bella- donna ointment, and the administration internally of iodide of potas- sium. In some cases of this character milk secretion stops spon- taneously with the return of menstruation, and in a certain proportion of cases a treatment to secure a discharge of blood from the uterus has been successful in stopping the flow of milk. Success has been obtained with Simpson's plan of introducing a piece of caustic within the uterus in order to bring back the menstrual flow, but this local treatment has been superseded by the safer plan of applying the negative pole of a galvanic current (15 milliamperes) in utero. Warm douches have been used successfully. Electricity to the mammary glands has been recommended to secure the proper contraction of the sphincter muscles of the lactiferous ducts, but as this is usually a result, and not a cause, of the galactorrhcea, the use of electricity must prove in the vast majority of cases ineffective. The long-continued admin- istration of ergot has been warmly recommended. The remedy should be tried, for its use is rational. Chloral has been shown to be very effective in diminishing the quantity of milk. This drug, therefore, is worthy of trial. It has been declared that antipyrine, in 2^-grain (0.15) doses three times a day, will diminish milk secretion. The drug, however, has not been tested often enough to demonstrate its power. Quantitative anomalies in the milk secretion must often depend upon an ill-regulated diet. A fatty diet will diminish the quantity of milk; a vegetable diet will diminish the casein, and fat will increase the sugar; a diet rich in meat, especially if reinforced with alcoholic stimulants, will increase the fat and casein, but will diminish the sugar. If the mother's milk is evidently disagreeing with the nursing infant, a chemical analysis of it should be made, and on the result rules regulating the diet should be adopted. The most common mistake in practice is to overfeed a nursing woman, espe- cially with a milk diet, with the idea which prevails extensively among the laity that the cows' milk poured into the stomach appears again in the mammary gland. It is usually sufficient for a nursing woman to observe the ordinary diet which agrees with her under all circum- stances, with the addition perhaps of a half-pint of milk midway between the morning and mid-day and mid-day and evening meals. 774 DISEASES. Occasionally a wineglassful of malt at the mid-day and evening meals is a useful addition to the diet, and in anaemic patients the addition to the malt of 5 grains (0.3) of pyrophosphate of iron will be an advan- tage. There is found in every pregnant woman some alteration in the constitution of the blood, which consists, roughly speaking, of a dimi- nution of the red blood-corpuscles and of the albumin and the iron in the blood, with an increase in the white blood-corpuscles and the serum. In some cases this change is much exaggerated, so that an intense degree of anaemia appears in the puerperal state which, in its severity, will stimulate pernicious anaemia or some fatal form of blood disease. The anaemia of puerperal women, however, even in severe cases, usually yields to treatment in a most gratifying man- ner. After the prolonged use of Blaud's pills the writer has seen the blood-corpuscles rise from less than three to nearly four and a half millions, and the haemoglobin increase from 40 to 75 per cent, in a few weeks. In some cases arsenic alone succeeds where iron fails com- pletely. Eclampsia. To treat eclampsia intelligently and successfully it is necessary to understand its etiology as fully as modern knowledge permits. Although the subject needs more light from future investigations, enough is now known to justify the following statement: 1. The cell-activity of mother and foetus produces excrementitious substances which are poisonous to the whole organism unless they are voided or made harmless by the excretory organs. 1 2. The organs in the childbearing woman are often inadequate to the disposal of effete material from the maternal and foetal bodies. 3. Consequently, poisons, of a nature not yet demonstrated, are stored up in the maternal blood until, by cumulative action, their presence is manifested in the eclamptic seizure and other symptoms. 4. The convulsions are probably the result of an acute cerebral anaemia brought about by violent contraction of the arterioles, possibly by direct irritation of the brain-substance or perhaps by the emboli of giant cells from the placenta, described by Echinard. As a result of intense muscular action the circulation is interfered with, and blood is determined into non-muscular regions, as the brain, lungs, kidneys, etc., to such a degree that the congestion of these parts becomes dan- gerous, leading to apoplexy in the brain, oedema in the lungs, and often a complete abrogation of renal function. The indications for treatment in convulsive seizures of this nature are plain : First, to eliminate the poisons from the blood as quickly and in as large quantities as possible. Second, to diminish nervous sensibility 1 Harold C. Ernst, American System of Obstetrics, vol. ii. p. 431. PUERPERAL DISEASES. 775 and lessen muscular power, in order to reduce the convulsions in vehemence, duration, and frequency. Third, if convulsions occur during labor, to save the infant without adding to the risk of the mother. Fourth, to guard the woman from injury during the attack. The first indication is met by venesection, diaphoresis, and catharsis. By the first, one eliminates a certain quantity of poison along with the blood and relaxes the muscles. If there is sharp post-partum hemor- rhage, or if the patient is from any cause weak and anaemic, blood- letting is not called for. In the ordinary case, however, with full pulse, congested head, the veins standing out upon the neck and face, venesection is an undoubted advantage. While the median basilic of one or both arms is being opened some croton oil should be sent for, and 2 minims (0.1) mixed with sweet oil may be placed upon the tongue. Directions should at the same time be given to wring out three or, better, four old blankets in boiling water; these are wrapped around the legs, trunk, and arms, and well covered over with one or more dry blankets. A hot-air bath, or immersion of the patient's body in a bath-tub full of hot water, is equally efficient. A submam- mary injection of a pint of normal salt solution is an extremely valuable aid in producing free diaphoresis. The sweating thus induced is profuse. An ice-bag must be put to the head to prevent overcon- gestion of the brain. In this way, directly and indirectly through the skin and bowels, one eliminates the cause of eclamptic convulsions as quickly and thoroughly as possible from the blood. The latter may be acted upon by \ grain of elaterium rubbed up in butter, or by compound jalap powder and calomel, instead of the croton oil. Pilocarpine seemed at one time an ideal remedy to secure diaphor- esis in eclamptic cases, but it has fallen into well-deserved disre- pute. It much increases the danger of pulmonary oedema, and is too profound a depressant. It is no longer employed by experienced obstetricians. The second indication is best met by an anaesthetic. Usually the convulsion first shows its approach in the eyes: these should be closely watched, so that on the first symptom of the oncom- ing attack chloroform may be at once administered and pushed as rapidly as possible. Ether is inadmissible in these cases, for it is slow of action, congests the brain, and irritates the kidneys. Just before the woman is wrapped in blankets 1 drachm (4.0) each of chloral and bromide of potassium in starch-water should be injected into the rectum. This may be repeated in an hour if necessary. Morphine, veratrum, and inhalations of nitrite of amyl have their enthusiastic advocates in this connection. They may be held in reserve in case the plan of treatment described needs reinforcement. If convulsions come on during labor, the child should be rapidly extracted as soon as the os is well dilated, but not before, because efforts to dilate the os increase the convulsions, and attract the phy- sician's attention from the woman's most threatening danger. More- over, the os dilates with unusual rapidity during eclampsia. 776 DISEASES. The only injury to be feared during eclamptic attacks is wounds of the tongue from the teeth. They can be prevented by inserting between the teeth a brush-handle wrapped in a handkerchief or by drawing a towel into the mouth like a bit. Well-meaning but igno- rant bystanders sometimes throw themselves upon an eclamptic patient to restrain her convulsions by force. This should be forbidden. REMITTENT FEVER. This is sometimes called bilious fever by reason of the violent bilious vomiting and jaundice which often accompany it. It separates itself from intermittent fever by the fact that the patient's condition, chiefly as regards temperature, does not have normal intervals, but has periods of only temporary improvement, or, in other words, the disease remits. Not only is this true, but it is also to be remembered that the sestivo- autumnal parasite which produces remittent fever is more difficult to destroy than the tertian or quartan forms, and that larger doses of quinine are needed for this reason. For the proper treatment of this fever, three facts must be borne in mind: 1. It is more dangerous than intermittent fever. 2. It is dangerous in the hot stage, not in the cold stage. 3. The patient, not having periods for complete or partial recovery, rapidly loses strength. The safety of the patient depends upon the use of large doses of quinine to cut short the pyrexial stage, the doses used being from 20 to 30 grains (1.3-2.0) a day or 5 grains (0.30) every four hours, preceded by a good-sized purgative dose of calomel, say 3 or 4 grains (0.20-0.25). If vomiting is too violent to permit of the retention of the quinine, it must be used by the rectum and hypodermically, the stomach and intestines being first swept out by the use of divided doses of Seidlitz powder or citrate or sulphate of magnesium. If purgatives are used, they should precede the quinine by twenty minutes, as other- wise the latter drug is swept out in the bowels, where it is rendered useless by reason of its precipitation by the alkaline juices there pres- ent. Many clinicians claim that remittent fever is chiefly benefited by quinine during the remission, and cinchonism during the pyrexial stage undoubtedly increases the discomfort of the patient. If pyrexia is excessive, relief must be sought in the use of cool sponging with frictions. Cure is much facilitated by absolute rest in bed. The best treatment of the vomiting is the use of small doses of morphine, or 3- to 5-minim (0.20-0.3) doses of chloroform in from 30 drops to 1 drachm (2.0-4.0) of cherry-laurel water. Aconite may also be used if the patient is strong enough. (See Vomiting.) If the belly is tender, a turpentine stupe should be applied. (See Turpentine.) If intestinal hemorrhages occur, gallic and tannic acids or Monsel's salt, in the dose of 3 grains (0.20) in hard pills, may be used, and cold cloths be placed over the belly. (See Hemorrhage.) RHEUMATISM {ACUTE ARTICULAR). 777 If hematuria appears and the malarial parasite is found in the blood, quinine must be used, but it must be remembered that quinine in some cases increases the hematuria. (See Cinchona and Collective Investigation by author in Therapeutic Gazette, July, 1892.) The treatment of convalescence consists in the use of tonics, such as quassia, calumba, gentian, Huxham's tincture, arsenic, and purgatives when needed, with attention to the kidneys, the potassium salts being employed to keep these organs active. (See Intermittent Fever.) RETINITIS. Retinitis, or inflammation of the retina, often associated with cho- roiditis, is commonly the result of several constitutional diseases: Bright's disease, diabetes, syphilis, etc. In some cases no cause can be found. The general remedies must be directed according to the supposed cause, and the eyes must be protected from light and all close work avoided. Very distinct retinal irritation may be caused by eye-strain, which is to be relieved by the prolonged use of atropine and dark glasses, and later suitable lenses for the correction of any existing error in refraction. RHEUMATISM (ACUTE ARTICULAR). No better example of the fact that therapeutics is in advance of pathology can be adduced than the disease known as acute rheu- matism. The therapeutist cannot tell how he cures the condition designated by this name, simply because the pathologist cannot tell what the cause of the disease is, and when this information is forth- coming from the one side, an explanation will probably be given by the other. This being the case, we must devote ourselves to the study of pure empiricism, and not to rational pharmacology. The treatment of acute articular rheumatism is divided into that portion devoted to the cure of the disease-process, and that directed to the relief of the pain and of the other local manifestations of the dis- ease. When an acute attack of rheumatism comes on, it is nearly always accompanied by a high temperature, a bounding pulse, and all the evi- dences of the active systemic disturbance accompanying inflammatory outbreaks, which, in this particular instance, involve the joints. We may therefore use at such times the remedies which we have learned are best able to combat inflammation — namely, aconite and veratrum So powerful are these drugs in the early stages of acute rheumatism that some persons have believed them to be possessed of a specific antirheumatic power. This is, however, highly unlikely, as they act no better here than in inflammatory conditions elsewhere. The proper manner in which to use the tincture of aconite under these circumstances, in a strong, healthy individual, is to administer 778 DISEASES. 10 minims (0.60) at once in a little water, and follow it by a teaspoon- ful of a mixture containing 15 minims (1.0) of tincture of aconite and 2 ounces (60.0) of water, every half-hour until perspiration on the skin betokens circulatory depression through the action of the drug. If this is not used, veratrum in the same proportions may be given. The advantages of this treatment are numerous: first, it allays the fever; second, it quiets nervous excitability; and, last of all, it aids in the production of a sweat. Whenever these drugs are employed the patient must be strong and hearty, not debilitated or weak. Finally, care is to be taken that the symptoms of depression from the drug and the disease combined do not become too severe. Where great exhaus- tion is primarily present or ensues upon the use of depressant drugs, carbonate of ammonium and aromatic spirit of ammonia are valuable. Simultaneously with these internal measures a solution of bicar- bonate of sodium, 20 grains to the ounce (1.3-30.0), may be applied to the joints involved, by means of lint wet with this solution, with dimi- nution of the sense of heat or burning, or ice-cold compresses may be tried. In other cases relief may be obtained by applying hot cloths saturated with the so-called Fuller's lotion — namely, carbonate of sodium 6 drachms (24.0), laudanum 10 ounces (300.0), glycerin 2 ounces (60.0), and water 9 ounces (270.0). Sometimes much benefit can be obtained by fixation of the joints by means of splints. A most valuable application to the inflamed joints of rheumatism, and the one the author always employs, both during the acute stage and afterward when they remain swollen and enlarged, is: I$— Ichthyol . • gij (60.0). Adipis lanae hydros Bij (60.0). — M. S. — Rub in well and apply about the inflamed part on lint. In other cases the acute stages of the inflammation may be combated with advantage, particularly where there is gastric disorder, by the local application of salicylic acid made into an ointment with an animal fat, not vaseline or glycerin, as it is not absorbed when so mixed. According to Bourget, this treatment is best suited to blondes and young persons, as absorption is more rapid in this class of patients. The following salve may be prescribed : 1$ — Acid, salicylic oj (4.0). 01. terebinthin. rnxxx (2.0). Adipis lanae hydros oj (30.0). — M. High fever is to be controlled by the same measures as the high fever of any other disease — by cool sponging, or sponging with tepid water, and sometimes by the use of antipyretic drugs, the use of which is more justifiable in this case than in ordinary fevers in that they tend to relieve the pain. Immediately after the system has been thoroughly impressed by cardiac sedatives — or at once and in their place if the case is not seen at first or is weak — the physician should resort to salicylic acid RHEUMATISM {ACUTE ARTICULAR). 779 or its salts. It is worthy of note that good results generally follow rapidly; that is, the salicylates give relief in from three to four days, or fail altogether. It is most important to remember that salicylic acid protects the cardiac valves and the entire endocardium from the ravages of the disease only by shortening the attack, and not by any direct influence; and in addition that this acid, by reason of the profuse sweats often produced by it and its tendency to cause cardiac depression, must be watched lest it act unfavorably on the general systemic state. The proper use of salicylic acid is often misunderstood, and it fails to produce good results sometimes because of this fact. When- ever acute articular rheumatism appears the salicylic acid should be pushed in the same way that we use quinine on the advent of a malarial paroxysm — namely, in full dose. It is useless to give salicylates in 5- or 10-grain (0.3-0.60) doses three times a day; they must be given in 20- to 30-grain (1.3-2.0) doses, morning, noon, and night, or oftener, or not at all. If the sweats are too severe or the stomach rebels, they may be stopped, but not decreased in amount unless for good reason. Further than this, if salicylic acid is used for three or four days in this way, and produces evidences of cinchonism, yet fails to alter materially the course or severity of the trouble, it should be withdrawn, as it will rarely if ever do any good after this time. (See article on Salicylic Acid.) Lees also asserts that the salicylates often fail in acute rheumatism because the dose is not large enough. He advocates as much as 300 grains a day to a child, and insists that large doses of bicarbonate of sodium are necessary to prevent evil effects from these doses. The chief of these is "air hunger" or dyspnoea. The author would be afraid to use such large amounts, but this view of Lees emphasizes the fact that the doses used are often too small. In the author's experience the salicylate of strontium is a very useful substitute for the acid, as it is less apt to irritate the stomach. Clinical experience seems to show that if sodium bicarbonate is given in full doses with the salicylates, better results are obtained than if the salicylate is used alone. • The dose of the bicarbonate of sodium should be about 20 or 30 grains (1.3-2) three or four times a day. It is also thought that this mixture protects the heart, whereas the salicylate when given alone fails to do so. Acetanilid does good by benumbing the sensibility of the patient to the excruciating pain consequent upon movement, and so putting aside the nervous wear and tear of sleeplessness and suffering.. Further than this, it would seem probable that acetanilid possesses a direct antirheumatic influence. The author has found that acetanilid in such cases will often relieve the pain, and so permit a refreshing sleep, in doses of from 4 to 8 grains (0.25-0.50) three times a day, and that these amounts do not cause the excessive sweating which the necessarily large doses of salicylate are sure to produce — sweats which leave the 780 DISEASES. patient oftentimes almost dyspnoeic from very weakness. Whether this temporary relief produces such changes in the system as to permit of a better battle against the disease, or whether it actually counteracts the rheumatic poison, we do not know. The following prescription, which is of additional value because the caffeine supports recommended : the heart and increases urinary secretion, is Py— Acetanilid gr. xl (2.6). Caffein gr. xx (1.3). Camphor, monobromat gr. xx (1.3). — M. Ft. in capsul. vel pil. No. xx. S. — One every three hours or three times a day. Phenacetin is often very useful when used in rheumatism for the relief of pain, particularly if combined with phenyl salicylate. Passing from what may be appropriately called the coal-tar treat- ment of rheumatism, because all the drugs so far named for internal use have such a source, we come to a list of remedies heretofore largely used in rheumatism in place of the newer compounds, but which are not so commonly employed to-day. These remedies act, as a rule, in the subacute forms of rheumatism or in the cases where the first group fail because the disease is obsti- nate. Of these the chief is the iodide of potassium, followed by the acetate, bicarbonate, and citrate of potassium. If the iodide is used, the following prescription is of service : Py— Potassii iodidi . §j (30.0). Syr. sarsaparillse comp f 5vj (180.0). —Dessertspoonful (8.0) three times a day, after meals. -M. In other cases it is best, because of the disagreeable taste of the iodide, to give it in sugar-coated pill or in tablet form, but care should be taken that milk or water is taken at the same time to prevent gastric irritation. Or, if preferred, 20 to 30 grains (1.3-2.0) of the bicarbonate of potassium may be taken every four or five hours in water flavored with cinnamon for the sake of the taste, or the citrate of potassium, which is more agreeable, may be taken in equal amount. If the case is very obstinate, sometimes a little colchicum added to the prescription given above may be useful, as follows: I£— Potassii iodidi gj vel gij (30.0-60.0). Vini colchici seminis .... f^ss vel f % j (16.0-30.0). Syr. sarsaparillae comp. q. s. ad f^vj vel f Jxij (180.0-360.0). S. — Dessertspoonful (8.0) three times a day, after meals. -M. Haig claims that in rheumatism there is retention of uric acid, and that the use of alkalies and the salicylates at once causes this substance to be changed into a soluble form ready for elimination. The other drugs used in acute rheumatism are numerous, but only RHEUMATISM [ACUTE ARTICULAR). 781 a few of them deserve attention here. There is abundant evidence on record that full doses (10 to 30 minims [0.60-2.0]) of the fluid extract of cimicifuga if given every five hours will decrease the redness and pain of the joints and shorten the attack in some cases. Again, certain species of rhus, as rhus toxicodendron, are said to be useful if fresh preparations are at hand. The dose of rhus toxicodendron is T ^ to 1 minim (0.005-0.05) of a tincture made by adding 1 part of the fresh leaves of poison-ivy to 2 parts of alcohol, this dose being taken three times a day. Where the pain seems particularly severe at night this drug is said to be valuable, but the writer has had no experience with it. Nearly every case of acute rheumatism will do better if a strong mixture of lemon- or lime-juice and water be taken daily in large quantities. The local remedies in the later stages of acute rheumatism are chiefly counterirritants and sedatives. Thus, small or large blisters applied around a stiffened joint after the general systemic excitement has passed may be of great value in restoring the suppleness of the joint and in aiding in the absorption of the effusion. The remaining local treatment consists in thoroughly painting the stiffened joints with tincture of iodine if blisters are not used, or in the application of veratrine ointment or iodine ointment around the joint. (See Vera- trina.) Sometimes the application of ichthyol and lanolin in equal parts, also rubbing this ointment into the tissues thoroughly, will aid in the absorption of inflammatory exudates. In this connection we must not forget the great value of morphine in endocarditis, myocarditis, and pericarditis; for not only does this drug give relief from the pain, but it also diminishes the patient's anxiety, quiets his restlessness, and slows the pulse by this means and by direct action upon the circulatory system. This question of slowing the heart does not receive sufficient attention. When we consider that a difference of ten beats a minute amounts to 600 beats per hour, and to nearly 15,000 beats a day, we can see how comparatively slight variations in pulse rate may mean very great variations in the amount of work done by the heart in twenty-four hours. For the pre- vention or relief of endocarditis the application of a number of small blisters over the prsecordium seems to be a very valuable measure; or, in their place, 8 to 12 leeches may be placed over the heart and followed by the application of an ice-bag. (See article on Peri- carditis.) No drugs can serve to protect the heart so well as complete physical rest. Not only is this necessary during the attack, but for several weeks afterward; and if the patient gets up too soon, a latent, unsus- pected valvulitis may gradually develop into a fatal lesion. The lame valve must be given time to recover before it is given more work to do. This is perhaps the most important therapeutic fact in regard to the therapy of this disease. 782 DISEASES. EHEUMATISM (CHRONIC). Chronic rheumatism is one of the most obstinate diseases with which we have to deal. In some cases the acute form just con- sidered merges slowly into the chronic form, or, in other instances, the disease develops gradually, increasing, it may be, by exacerba- tions or by gradual progression. The treatment of chronic rheuma- tism is somewhat different from that of the more acute forms, and approaches that of gout in some of its therapeutical indications. In other words, the salicylates are not so useful in these cases as are the iodides and colchicum, so that in the majority of instances the pre- scription of iodide, sarsaparilla, and colchicum given in the article on Acute Rheumatism is indicated. When anaemia or weakness is pres- ent, cod-liver oil is often of great service, and it is worthy of note that this useful nutritive remedy was first brought into therapeutics by the fishwives of Holland, who found it useful in the attacks of rheumatism to which their husbands were subjected through ex- posure. When the oil is thoroughly rubbed into chronically inflamed joints it is almost as useful as when taken internally. The same forms of severe counterirritation are not so useful in chronic rheumatism as in the acute form, but a very valuable therapeutic measure in these cases is the use of the Russian or Turkish bath or an improvised hot bath by means of a lamp and a blanket. (See Heat and Cold.) Liniments are always called for, for two reasons: first, they relieve pain and do good to the parts, if not from their medicinal prop- erties at least by the rubbing which accompanies their application: second, because they give the patient something to do or to have done, and therefore impress him with the object-lesson that his attendants are attentive and alive to his suffering and need of sympathy and care. Among the lower classes the belief in liniments is widespread, and their use will often instil into the minds of the friends a far greater confidence than the most rational of treatments with the liniment left out of the list of remedial measures. The following liniments wiU be found very useful under these circum- stances : Py— Tr. aconiti f^vj (24.0). Tr. opii fgj (30.0). Olei terebinth inse ..... fgj vel_f 5 ij (30.0-60.0). Linimenti saponis . . q. s. ad Bviij (240.0). — M. S. — Poison. Use as a liniment three times a davr Or, Py — Aquae ammonise fortior . . . f3iv(16.0). Olei cajuputi f 3j (4.0). Tr belladonna f |j yelf§ij (30.0-60 0). Linimenti camphorae . q. s. ad f §viij (240.0). — M. S. — Poison. Use as a liniment. RICKETS. 783 Or, R— Tr. acphiti f^j (30.0). Tr. opii, Aquae amnion, fort aa f giv (16.0). Linimenti chloroformi f £vj (180.0.) — M, S. — Poison. Use as a liniment to chronically inflamed muscles or joints. In other instances the greatest relief is obtained by employing the following ointment : Py — Veratrinae . . gr. xxx (2.0). Hvdrargvri iodidi nav oj (4.0). Petrolati" • . . Bij (60.0).— M. S. — Use as an ointment over the joints. This ointment ought not to be widely distributed, and the pulse and respiration should be watched, as the veratrine may be absorbed and depression of a severe character set in. For the reduction of enlargements of the joints due to the disease, and accompanied in some cases by pain, the following ointment is serviceable : Pr- Unguent, iodi Bj (30.0). Adipis 5iv vel §j (16.0-30.0).— M. S. — Apply locally. Or, still better, Py— Ichthyol 3iv to gj (16.0-30.0). Adipis §j (30.0).— M S. — Rub into the joints thoroughly. In many cases ichthyol is certainly the most efficient remedy for the enlarged and painful joints. The employment of red flannel over inflamed joints is no better than the use of white flannel, and it is never beneficially "medicated," as claimed in the stores. The only advantage of red flannel is that, as it is dyed, the wool is often better for not being thoroughly bleached, and is in larger amount. The disadvantages of red flannel are that if the patient sweats the dye stains the clothing, and the possibility of its producing irritation of the skin or even systemic effects of an evil character. RICKETS. Rickets may be defined as a state of the body of an infant or child in which there is a deficiency of the normal salts of the bones and tissues, with corresponding enlargement of the organic portion of the bone, or, in other words, the cartilaginous parts. Generally the term is applied solely to designate bony troubles, but every practising physician sees cases where the manifestations of rickets are emphasized in gastrointestinal disorders rather than in bony deformities. The chief cause of rickets in children, aside from the presence of any dis- 784 DISEASES. ease, such as scrofulosis, is inanition; that is, malnutrition of a specialized form, or, in other words, bone-salts starvation. This may occur after or before birth, and it is quite common to see children, born of mothers ill-fed or whose assimilation of salts is defective, with soft bones or a distinct tendency to rickety development. In other cases the condition is chiefly one of failure of assimilation more than of starvation of bone salts. The treatment of rickets is therefore largely dietetic and devoted to the improvement of the food and digestion. In the presence of this disease no part of the body fails in force more than the diges- tive apparatus, probably because the alkalinity of the blood is altered, and partly because the stomach cannot secrete properly formed juices from imperfectly nourished glands. The medicines to be used in rickets are general tonics, digestives, and stimulants, and bone tonics, such as salts of lime and phosphorus. The general tonics are quinine, and cod-liver oil, mix vomica, and iron, while the digestive tonics are the simple bitters, physostigma, and mineral acids. Tonic treatment is best carried out in young children by the admin- istration of quinine in the form of quinine chocolates or by the use of strychnine in the dose of t ^-q- to t ^q- grain (0.0003-0.0006) in sugar- coated pink granules. Arsenite of copper in the dose of t ^-q grain (0.0006) in tablet triturate three times a day is also useful, A very useful preparation is the following: I$— Olei morrhuae f5vj (24.0). Syr. calcis lactophosphat., Liquor calcis aa fgiij (90.0). — M. S. — \ to 1 teaspoonful (2.0-4.0) two or three times a day. Shake thoroughly. Nux vomica is so bitter as to be difficult of administration to young children, and when given only \ to \ minim (0.008-0.015) of the tincture should be used, three times a day. Where a distinct scrofulous tendency exists and anaemia is present, small doses of the syrup of the iodide of iron are of service, and \ to 1 minim (0.025-0.05) may be given three or four times a day to a child of six months or a year, thus: 1$ — Svrupi ferri iodidi gtt. xij vel xxiv (0.8-1.5). Aquae dest q. s. ad fgiij (90.0). — M. S. — Teaspoonful (4.0) every four or five hours during the day. • Or, ly — Svrupi ferri iodidi gtt. xij vel xx (0.8-1.3). Syrupi q. s. ad f B ii j (90.0).— M. S. — Teaspoonful (4.0) three times a day, after meals. Here, again, arsenite of copper is a particularly valuable remedy. The salts of lime and sodium are of direct benefit to the bones, forming by their presence in health a large proportion of the osseous system, and therefore they may be considered as foods rather than SCARLET FEVER. 735 drugs. Very often their administration to nursing mothers or preg- nant women saves the maternal teeth from caries and preserves the general health of the mother and child. The following prescription may be used: 1$ — Syrupi calcii lactophosphatis . . . f §iv (120.0). S. — J to 1 teaspoonful (2 0-4.0) three times a day, after meals. The reasons for the use of phosphorus are clear, from what has been said of that drug when speaking of it elsewhere in this book, as it acts as a direct and powerful stimulant of bone-growth. Phosphorus is best given to children in the form of very small sugar- coated pills (y-J-q grain [0.0003]), such as are put up in the form known as "pink granules. " The ventilation of the rooms where a child prone to rickets is kept should be excellent, not too hot or cold and free from draughts. A cool sponge-bath is useful at night if the patient is strong enough, or a good rubbing with salt and whiskey, 1 drachm (4.0) of salt to a pint (480 c.c.) of whiskey, is of still greater service. Special attention should be paid to the development of the muscles by massage and passive movements, as these parts are always weak. Walking must not be allowed too early, as it may cause bony deformi- ties. RINGWORM. Many methods of treating this affection are employed and are more or less efficacious. Jackson recommends as the best the rubbing into the part of 1 drachm (4.0) of iodine crystals in 1 ounce (30.0) of real goose-grease. This grease has greater penetrating power than ordi- nary fats and usually is effective by the end of three weeks, the ointment being applied night and morning till some redness of the skin appears, when it is used once a day. Depilation is not necessary, for the hair soon falls out, but is supplanted by a new growth. This application may burn slightly, but is not really painfuL SCARLET FEVER. This disease, the most fatal of all the exanthematous diseases of childhood, requires the greatest care in its treatment. Complications often arise requiring skill on the part of the attendant, and it is upon his success in treating these outbreaks, as well as in the general direc- tion of the case, that the life of the patient may depend. It has been claimed by certain practitioners that one or two remedies, which they have used, act as abortifacients of the attack, decreasing its severity, its duration, and the probability of complications. Thus, one Euro- pean physician has used the salicylates with wonderful results, if his claims are true, for he found them to prevent all complications and even to remove them when present. He gives, throughout the entire 50 786 DISEASES. attack and for some days after defervescence has ensued, the fol- lowing : 1^ — Sodii salicylat gr. xlviij (3.2). Aquae destillat f 3ij (8.0). Syr. aurantii . ,. . . . q. s. ad fgiij (90.0). — M. S. — Teaspoonful (4.0) every hour during the day and every two or three hours at night, in a little water. In the United States some practitioners have employed chloral throughout the entire attack, with asserted good results; but in the opinion of the author this method is not the best for most cases, unless the nervous manifestations are very marked, when the chloral treatment may be of value. As a rule, the drug is easy of administration and well borne by the stomach. Its acrid after-taste is best masked by its administration in Aubergier's syrup of lactucarium, thus : I£— Chlorali hydrati gr. xxx (2.0). Svrup. lactucarii (Aubergier), Aquae dest aa fgss vel fgj (16.0-30.0).— M. S. — A teaspoonful (4.0) in iced water every two, three, or four hours, if pos- sible after food. The convulsions which sometimes usher in an attack are to be treated by 5-grain (0.3) doses of chloral and 10 to 20 grains (0.60-1.3) of bromide of sodium for a child of five to eight years. The convul- sions of the advanced stages are often ursemic, and must be treated accordingly. (See Uraemia.) From the very beginning of an attack to its end the child should always be supplied with plenty of pure water, and, if possible, this water should be obtained from a spring containing a low percentage of solids, as Poland water, which is widely sold throughout the United States. If this is impossible, then Celestin's Vichy water may be em- ployed, or an effect produced by obtaining the granulated Vichy salts sold by most large drug firms, and adding this in small amounts to pure filtered or distilled water. This makes an effervescing draught which may be taken while bubbling or not, as the child desires. The object of this treatment is to flush out the kidneys, and so to dilute the effete matters generated in the body by the fever and the germs of the disease that they lose, to a great extent at least, their poisonous and irritating powers. If the child is so young that it takes food from a nursing bottle, Poland water may be placed in the bottle. In other cases a prescription containing sweet spirit of nitre and citrate of potassium proves useful, as follows : ^—Spt. aether, nitros. . ^ f 5j. (30.0). Potassii citratis . x 5ij (8.0). Aquae dest q. s. ad f §vj (180.0).— M. S. — Teaspoonful (4.0) every two hours if the urine is high-colored. The further treatment of the disease rests upon the symptoms alone. We cannot cure the patient by the use of remedies, but we can do SCARLET FEVER. • 737 much toward making the pathway to health smooth and free from pit- falls and obstructions. Probably the most common complications calling for treatment, when the kidneys have been treated in the way just spoken of, are high temperature or fever, and sore throat or angina. The fever is to be controlled in these cases in precisely the same way that it is in all other conditions in which it is present. It is best to attempt to keep it below 101°, or at least below 102° F., by tepid sponging, which also allays the itching of the skin, or, if the temperature continues to rise, by the use of colder water. Generally the popular fear that the application of cold to the surface will drive the eruption "inward" is so strong as to make the cold sponging objectionable to the friends; but if the temperature reaches 105° F., the physician must assert the fallacy of this belief and insist on its use. (See Cold, Part III.) When the patient is overcome by toxaemia, the skin marbled and mottled, and the brain stuporous, he should be placed in a bath at 100° F., and water at 60° or 70° F. poured on his head and shoulders with some force. In very young children the same effect may be obtained by dipping the patient alternately in hot and cool water. The object is to cause reaction and equalize the circulation. If sup- pression of the rash occurs, the wet pack must be used. (See Heat, Part III.) Antipyrin and acetanilid may both be used, but it is worthy of note that each of these may produce collapse or other complication if large doses are necessitated by an obstinately high temperature. If these complications ensue, alcohol will be indi- cated. Quinine has been highly recommended as an antipyretic in scarlet fever; but it is of little value in the majority of cases, simply disordering the stomach and irritating the kidneys if used in doses large enough to be effective. Where the head seems to be particularly hot and the fever is high an ice-bag or a head-coil of rubber tubing is to be employed, and through the latter water may be circulated at whatever temperature is thought best. (See Cold, Part III.) The treatment of the sore throat of scarlet fever is an important part of the care of the child in many cases. Small pellets of ice may be held in the mouth and an ice-bag applied to the outside of the throat. This is done by finely breaking some ice and placing it in a thin India-rubber bag about the neck, the surface of the bag being covered by a cloth to prevent too rapid melting of the ice and the wettir g of the clothes by the condensation of moisture on the surface of the bag. This treatment should be used during the entire attack if needed, and the contents of the bag renewed as often as the water becomes at all warm from the heat of the body. By this means the redness of the fauces and the swelling of the glands of the neck are relieved. Chlorate of potassium may be used in a spray or on a swab, but never internally owing to its irritant effects upon the kidneys and stomach and its general influence on the blood. When a false membrane forms, antidiphtheritic serum is to be given until a bacteriological examina- 788 DISEASES. tion shows that it is not due to the Klebs-Loeffler bacillus. This membrane should be treated by applying peroxide of hydrogen. In cases where the eruption suddenly fades or is never well developed it is of the greatest importance that it be made active. Under these circumstances the child may be placed in the warm wet pack, and, if the head is very hot, cold applied to the vertex and throat while the body is enveloped in the blanket. (See Heat.) This often brings out in an hour or two a bright scarlet rash, and the child falls asleep and wakes up free from delirium and high fever. The itching and burning of the skin in many cases of scarlet fever are annoying symptoms, and they may become really dangerous. The author has carried out a series of experiments showing that fever of high degree can be brought on solely through nervous irrita- tion, thus explaining a fact long well known to clinicians — namely, that the relief of this dermal irritation in scarlet fever may be followed by a fall of temperature. To relieve this symptom it will often be found advisable to cover the entire skin with a thin layer of vaseline or cosmoline or benzoated lard; or, in other cases, as an antiseptic and local anaesthetic, phenolized oil may be applied (2 minims of phenol to each 2 ounces [0.1-60.0] of olive oil). In other cases almond oil should be used. If nephritis comes on and in a severe form, the greatest care is necessary, and the object of the physician must be to make the skin, disabled as it is, carry out sufficiently active eliminative function to relieve the kidneys of any strain, to remove dropsy, and to aid in the removal of effete matter by producing catharsis. Sweating may also be produced by the employment of heat obtained by the use of bottles of hot water or hot bricks placed about the patient, who is first wrapped in blankets, care being taken that the bottles do not burn the skin. The thermometer must be placed in the mouth to foretell any dan- ger from heat-stroke if the sweat should fail to appear. In such cases the hot pack is also of great value. (See Heat.) The after-treatment of scarlet fever during convalescence consists in the use of Basham's mixture or the tincture of the chloride of iron, and in the employment of simple bitters, strychnine, or quinine. Tresh air, sea-air or mountain-air is useful, while cold or exposure to cold air or draughts is to be carefully guarded against. SCIATICA. Sciatica is an exceedingly obstinate affection, in the many cases resisting the best treatment for weeks. It seems to be due to rheu- matic taint in the majority of instances, and may sometimes be cured by the remedies used and described under the headings of Acute or Chronic Rheumatism. In other instances it is due to injury or jarring of the nerve, as by heavy persons stepping off from a high step to the hard ground. Thus the most obstinate case ever seen by SCLERITIS. 739 the writer was one in which a man weighing about two hundred and fifty pounds acted as " coupler " on a switching engine, and, though wonderfully agile for his weight, provoked the disease in the leg on which he always first struck the ground when jumping from the platform of the moving locomotive. The treatment for all cases is both internal and external. The internal treatment may be the same as that already described under Acute or Chronic Rheumatism, or in other instances consists in the use of large doses of bitartrate or citrate of potassium, 40 grains (2.6) three times a day, in plenty of water to aid in the maintenance of free kidney action. At the same time the amount of coffee and tea should be cut down as much as possible, and lemonade, with little sugar, be taken freely during the day. If the pain is excessive, morphine should be given, or antipyrin, citrophen, or acetanilid may be used. In some instances methylene blue in 5-grain (0.3) doses twice or thrice a day has seemed to relieve pain. (See Methylene Blue.) The local treatment of sciatica is quite various. One of the favorite methods is to inject deeply into the flesh, just over or about the exit of the nerve from the pelvis, 10 to 20 minims (0.60-1.3) of chloro- form, or instead of the chloroform \ to \ grain (0.01-0.015) of mor- phine, in 30 minims (2.0) of water which has first been distilled and sterilized, may be used with equally good results and less danger of sloughing. The pure chloroform is apt to cause an abscess. Other physicians prefer acupuncture, the needle being driven down until the sheath of the nerve is punctured. Still another useful method is to take a strong glass rod with a round, smooth end, and, after anointing the skin over the course of the nerve with a little ichthyol ointment or lard, to pass the end of the rod back and forth over the tender area, using as much pressure as can be borne. By this means massage or pressure on the nerve is accomplished. In other cases the daily use of an ether or rhigolene spray over the part is effective, or kataphoresis may be resorted to. In still others, from three to five large wet or dry cups, preferably the wet, may be placed along the course of the sciatic nerve with great advantage. In many cases absolute rest of the limb, obtained by placing it in splints, has to be adhered to before cure is possible. Hot-water bags should be placed continually about the exit of the sciatic nerve from the pelvis. The liniments recommended in chronic rheumatism may be tried, and cod-liver oil is of service in obstinate cases. Sometimes nerve- stretching must be performed before a cure is effected. SCLERITIS. Scleritis, or inflammation of the sclera, consists in a bluish-red, somewhat elevated patch, with implication of the overlying episcleral tissue (episcleritis). In the earlier stages pain and photophobia, if present, require atropine and boric acid and compresses of hot water; 790 DISEASES. later, the infiltration may be subdued with yellow oxide of mercury ointment, associated with massage. If the disease spread and impli- cate the cornea and iris, the treatment useful in ordinary iritis is indi- cated. In stubborn episcleritis, without iritis, which does not yield to these measures, eserine, usually accompanied by pilocarpine sweats, should be tried, and even the actual cautery has been recommended. The disease in many instances is associated with rheumatism, syphilis, scrofula, anaemia, and menstrual disorders: these must always receive the needed constitutional treatment, especially if iritis or keratitis ensue. Scleritis is a disease difficult to eradicate and subject to frequent relapses. SCROFULOSIS. It is now universally recognized that scrofulosis is really a form of tuberculosis, yet, as its manifestations are often quite distinct, it is separately considered. Scrofulosis is to be treated by hygienic measures rather than drugs — fresh air, residence by the seaside, proper out-door exercise, massage, and dietetics, all of which take precedence of medicines. If these necessary adjuncts to a cure are obtainable, the prognosis is fair, to say the least, and the following drugs may be used, all of them being devoted to the improvement of the general health, and not to any direct influence over the scrofulous tendency in itself. It is hardly necessary to state that cod-liver oil is perhaps the best remedy of all. The oil should be given in emulsion, being first pan- creatized and so prepared as to be somewhat palatable by the addition of flavoring substances if the child is old enough to appreciate such flavors. In young children, while distaste of the oil is often shown at first, a liking for it rapidly develops, so that the writer has seen children cry for it when the oil was discontinued. In these cases it is nearly always best to combine the lactophosphates or the hypophosphites with the oil. When anaemia is present, syrup of the iodide of iron is useful in from 1- to 10-minim (0.05-0.60) doses, according to the age of the child, as follows : I$— Syrupi ferri iodidi f 5 ss velfSij (2.0-8.0). Aquae dest q. s. ad f §iij (90.0). — M. S. — Teaspoonful (4.0) in water three times a day, after meals, to a child of one year. In place of iodide of iron, yj-g- grain (0.0006) of arsenous trioxide or yutt grain (0.0006) of corrosive sublimate may be given to a child of three or four years, in the form of tablet triturates, or the follow- ing prescriptions may be used : 1^ — Liquor potassii arsenitis TUxvj (1.0). Aquae destillat f gij (60.0).— M. S. — Teaspoonful (4.0) three times a day, after food for a child of five years. SCURVY. 791 Or, I$— Hvdrarg. chlor. corros. . . gr. T V vel gr. £ (0.006-0.012). Aqua? desiillat f Sij (60.0) — M. S. — Teaspoont'ul (4.0) ever}' five hours, after food. The use of the iodides is generally contraindicated in those cases in which softening and breaking down of the glands are going on rap- idly. In their place calx sulphurata may be employed, given by placing 1 grain (0.06) of it in half a tumblerful of water and giving a teaspoon- ful hourly. The mixture should be freshly made every day, to prevent its becoming oxidized. When enlargement of the cervical glands takes place, iodine oint- ment, diluted, one-half of lard, should be well rubbed into the part twice daily, but it should be stopped at once if signs of softening or fluctuation appear or if the skin becomes reddened. In cases in which these enlargements are persistent, ichthyol ointment is to be rubbed in, using the following formula : 1^— Ichthyol 3ij vel 5iij (8.0-12.0). Adipis gj (30.0).— M. S. — Apply locally. If this is not followed by cure, the glands should be excised and the cavity packed with iodoform, as in the majority of cases these enlarge- ments will be found to be distinctly tuberculous. (See Adenitis.) SCURVY. The cure is so completely dependent upon the use of proper foods that almost no drugs are to be employed in the treatment of scurvy. The only remedies particularly indicated are orange- or lemon-juice or lime-juice or citric acid, the latter being far less valuable in all cases than the juice of the fresh fruit. Arsenic and iron are of service in most cases, and rest and quiet are to be insisted upon. By far the more common form of scurvy is seen in bottle-fed babies. The child may or may not have rhachitic manifestations. Generally it loses animation, becomes listless and peevish, evidently suffers pain in its body and limbs when it is lifted from the bed, and looks feeble and wan. The gums become spongy and swollen, and have an ecchy- motic appearance, and light blows produce bruises out of proportion to the severity of the injury. The treatment of infantile scurvy is a complete rearrangement of the child's diet-list,, and varying its food. No one baby food should be used to the exclusion of another, and sterilized milk is to be supplanted, if possible, by fresh new milk. It is important to remember that a large proportion of these cases occur in the children of the rich, who have subsisted largely on prepared "Infant Foods." Beef-juice squeezed from a half-cooked steak is useful. 792 DISEASES. SHOCK. The medical treatment of shock is very important, and the life of the patient may depend upon the care exercised by the attendant; but before describing the treatment it is in place to consider the causes of the condition and the state of the injured person, so that we may understand the methods indicated. Every physiologist recognizes the fact that the body, particularly in its most vital parts, is controlled by inhibitory and accelerator nerves or nerve-cells, which govern the functions of all organs. Normally these two forces of inhibition and acceleration act in such a way as to be perfectly balanced, but abnor- mally they may either of them become excessive and overcome the other. Further than this, we must remember that all conditions of great functional activity are ultimately followed by a reaction which amounts to depression or exhaustion. Shock consists primarily in an overstimulation of the inhibitory apparatus which governs the heart and respiration, immediately fol- lowed by exhaustion of inhibition, so that the pulse and breathing become rapid and shallow instead of slow, and depression of the vaso- motor centre, so that a serious fall of arterial pressure ensues. Various degrees of shock can be readily recognized, and the severity of the condition depends upon the constitution of the individual and the character of the injury. Every one has heard a nervous woman say "You frightened me so that my heart stood still/' and again, a moment later, "Just feel how fast my heart is beating;" and we all of us know how any severe and sudden shock causes these changes to appear in the pulse to some degree. The same mechanism is the cause of great shock in railway or other injuries, only it is much more severe, owing to the actual injury received and its accompanying terrors. Many of the readers of this book probably know that a violent blow upon the belly-wall just over the solar plexus will cause death even in so large an animal as the ox, and every boy has had the "breath knocked out of him" by a blow in this region. This period of inhibitory excitement speedily gives place to inhib- itory exhaustion, and we have a rapid pulse not only from inhibitory palsy, but because the palsy of the vasomotor system relaxes the blood- vessels so that the normal resistance to the heart is removed. This vasomotor paralysis is the most important factor in the case. The heart beats wildly and fast for the same reason that a locomotive's wheels fly round when the track is slippery — or, in other words, nor- mal resistance is lost. The capillaries in this second stage of shock are dilated, and the patient may actually bleed to death into his own bloodvessels. The skin is relaxed, moist, and cold from excessive dissipation of heat. This is the more prolonged stage of the two, but they both need active treatment. The patient will rarely be seen in the first stage of shock, simply SMALLPOX. 793 because by the time the physician reaches him the second stage will have come on. In either event the principal things to be done are the administration of -^ to 7 V grain (0.001-0.0012) of sulphate of atropine hypodermically, the injection of half a drachm of adrenalin chloride solution (1 : 1000) in 1 pint of hot salt solution into a vein, and the application of external heat to maintain the bodily temperature, the fall of which is a factor of great importance, but generally over- looked in attending to an operation or other measures of relief. The use of atropine and adrenalin are peculiarly triumphs of experimental therapeutics and rests upon logical deduction. It will be remem- bered that atropine in full dose acts as a depressant to the vagus nerve, and, as this nerve is overactive in the first stage, the drug acts as a sedative to it. This is, however, a comparatively unimportant fact, for it is another action of atropine which makes it valuable. If the vagus be greatly stimulated, a safe dose of atropine cannot quiet it; but in the second stage, which we most commonly have to treat, a safe dose does not act so much upon the vagus as upon the vasomotor centre, and it and the adrenalin, by preventing the dilatation of the blood- vessels of the body, thereby provide bloodvessels of normal tone and tenseness, which do not hold all the blood in stagnant pools where it is not needed, but carry it to the brain and vital parts. Digitalis is a useful adjuvant to atropine in the second stage of shock because of its powerful vasomotor and cardiac influence. Thirty drops (2.0) of digitalone should be given hypodermically, and repeated in an hour if the pulse does not show the influence of the drug at the end of that time. The application of heat in the form of hot-water cans, hot bricks or bottles, must not be forgotten, care being taken that the patient is not burned. (See Heat, Part III.) In many cases of surgical shock hypodermoclysis of hot saline solutions is of the greatest value, particularly if much blood has been lost. Its efficacy will be greatly increased if a drachm of a 1 : 1000 solution of adrenalin chloride be added to it to stimulate the muscular coats of the bloodvessels, because the vasomotor centre may be so paralyzed as to have lost all control, for the time being, over the vessels. (See Hypodermoclysis, Part III.) SMALLPOX. The treatment of smallpox is not specific, simply because it is one of those diseases which run a given course and which cannot be aborted. We can only treat the various symptoms which present themselves, and by the modification of these manifestations prevent complications and sequelse to some extent. The fever is to be treated as is any fever of this class. Often it can be allayed by a mixture containing tincture of aconite, spirit of nitre, and spirit of Mindererus (liquor ammonii acetatis), while the headache or backache may be controlled by small 794 DISEASES. doses of antipyrin or acetanilid. Mustard plasters are not to be used for the backache, as the dermal irritation will increase the eruption. Insomnia and restlessness, if excessive, are to be quieted by the bro- mides or chloral, care being taken that the doses of the latter are not large enough to depress the heart. It must be remembered that the time of onset of the secondary fever, the eighth day, is one of grave import to the patient. Before its arrival the treatment of the case must be so managed that strength is saved for this strain, and tincture of the chloride of iron, in 5- to 10- (0.3-0.60) or even 20-minim (1.3) doses, may be resorted to to give strength to the patient and to affect specifically the pysemic fever. The pulse should be watched, and if it flags brandy and whiskey should be freely but wisely used. At the same time nourishment in the shape of eggnog, milk punch, or beef tea should be given as freely as the digestion will allow. The peripheral irritation and itching of the eruption are a cause of the fever in part, and produce much unrest and nervous irritability. The condition of the skin is therefore to be looked after and pit- ting prevented, if possible, by every means in our power, particular care being taken to prevent its development on the face. One of the means which has been recommended to prevent pitting is the use of flexible collodion, and another application is glycerite of starch or simple cerate applied in a heavy coating. Some physicians recom- mend inserting the tip of a nitrate of silver stick into each vesicle as it ruptures, to prevent pitting. All of these measures are futile in most cases, and the use of collodion is probably harmful in some instances. The best application to use is made of 4 parts of salicylic acid to 100 parts of vaseline or cold cream. Sometimes, anointing the entire body with sweet oil slightly phenolized (1 : 100) is useful to check irritation. If the mouth is sore, a mouth-wash of chlorate of potassium and water may be used, flavored with a little tincture of myrrh. (See Chlorate of Potassium.) Disinfection, good ventilation, and the avoidance of much light are necessary. STINGS AND BITES. The stings of nearly all small insects depend for their activity upon formic acid, and are to be relieved by the use of dilute alkaline liquids, or, better still, by the application of ammonia, or, instead, an applica- tion of ordinary or flexible collodion may be made, or water of witch-hazel, which is improved in its action by the addition of 1 part of mercury bichloride to 1000 of the collodion, or, if preferred, salicylic acid may be added in the proportion of 5 grains to the ounce (0.3-30.0). Sometimes a solution of phenol, 1:100 or 1:50, when sponged over the parts exposed, not only relieves the itching of mosquito-bites, but also repels the mosquitoes. In other instances the stings are relieved and cooled by the use of dilute or pure vinegar. STOMATITIS. 795 A useful application to prevent mosquitoes from biting is : I$— Olei citronellse . . . . . . ■ . . f'5j (4.0). Alcohol 1'oj (4.0).— M. S. — Apply freely to the skin exposed. In snake-bite the best treatment consists in sucking the wound, as snake-venom, even if swallowed, is not very poisonous. The part should then be freely incised, so as to cause the blood to flow freely, and immediately the wound should be filled with permanganate of potassium, and full doses of this drug given hypodermically about the wound, the salt being diluted three-fourths with water, and followed by full doses of alcohol or ammonia by the mouth. The secret of success- ful treatment consists, however, in the use of a ligature above the bitten spot and the opening of the wound as soon after its reception as pos- sible, thereby preventing absorption of the poison. Antivenine and other antitoxins promise much for treatment in the future. STOMATITIS. This annoying affection is most commonly seen in children, and is characterized by the appearance on the tip and sides of the tongue, lips, and lining membrane of the mouth of small spots which some- times have a reddened zone around them, and which result in minute or large ulcers. The best treatment, if the kidneys are not acutely inflamed, is the use of the following prescription, which largely depends for its value upon the potassium salt used : !£y — Potassii chlorat 5j (4.0). Tinct. myrrh. gtt. xx (1.3). Elixir calisayse fgiij (90.0).— M. S. — Teaspoonful in water every four hours. As the chlorate of potassium is eliminated with the saliva, it not only does good when taken into the mouth, but is also active all the time that it is being eliminated. If the stomach is disordered, the same preparation may be used as a mouth-wash. Often constipation is present, and it should be relieved by salines or by rhubarb in the form of the aromatic syrup. Another remedy which is very efficient in stomatitis is borax, used as a mouth-wash, in the strength of 10 to 15 grains to 1 ounce (0.60-1.0: 30.0) of water and honey, as follows: 1^ — Sodii boratis gr. xxx (2.0). Mel. depurati f 3 iij (12.0). Aquse destil q. s. ad f 5iij (90.0). — M. S. — To be used on a swab or as a mouth-wash every four hours. This also may be given internally to adults in the dose of a teaspoonful (4.0) every three hours. In many cases peroxide of hydrogen in the proportion of 1 ounce (30.0) to 8 ounces (240.0) of water proves a valuable mouth-wash. 796 DISEASES. If the liver is at fault and is torpid, nitromuriatic acid is useful; and when the spots do not readily yield to treatment they may be touched with the tip of a stick of silver nitrate, which treatment, while it is momentarily painful, is very efficacious. Nearly always with this disease in childhood there is considerable fever, vomiting, and wakefulness at night, with fretfulness and crying during the day, and total refusal of food, not because hunger is absent, but because the food hurts the mouth and is rejected with a cry of pain as soon as it touches the lips. The food should be very soft milk- toast for older children, or milk with lime-water in it in large amount for infants fed by the bottle. If a child at the breast be attacked, the mother's nipple should be carefully washed with boric-acid solution after each nursing. A warm foot-bath at night is often necessary to produce rest, and 10 minims (0.60) of sweet spirit of nitre thoroughly diluted may be given with advantage to a child of one or two years. If the irritability of the nervous system is excessive, bromide of sodium or potassium in the dose of from 1 to 10 grains (0.06-0.60), according to age, three times a day, is of service, and may be added to the mixtures already named, or, better still, given alone, well diluted with syrup and water. After the attack tonics and a carefully selected diet are generally necessary. STYES. Styes consist in a localized inflammation of one of the glands in the margin of the lid or the surrounding connective tissue. Before suppuration is established, abortive treatment may be practised by inunction with a salve of the red or yellow oxide of mercury (2 grains to 1 ounce [0.12-30.0]), by painting the surface with an ethereal solu- tion of collodion, or, according to Abadie, by the application of a satu- rated solution of boric acid. Pain may be alleviated with hot com- presses (water 110° F.), frequently changed; but as soon as pus appears incision is necessary. Associated conjunctivitis requires a boric-acid solution for its relief. It should be remembered that styes indicate ill health, that tonics are indicated, and that they most frequently appear in subjects with refractive error. When they tend to recur in crops the internal use of sulphurate of calcium has been recommended. SUNSTROKE. Sunstroke — or, more correctly speaking, heat-stroke — is an affec- tion produced by exposure of the body to any form of high temperature, whether the source of heat be the sun, a furnace, or the radiation of heat from the earth. For this reason the condition may occur as readily at midnight as at mid-day. Heat-stroke is to be divided into two classes, in one of which excessive exposure to heat upsets the balance of the thermal mechanism of the SUNSTROKE. 797 body, so that fever (thermic fever) comes on ; in the other the tempera- ture is lowered and forms the condition known as heat-exhaustion. The condition of thermic fever is very frequently seen, while heat- exhaustion is rare. The treatment of these two states is, of course, radically different. When a patient has thermic fever and comes under the care of the physician, the first thing to be done is to loosen the clothing — if possible, remove it — and if the pulse be bounding, the face cyanotic, and the heart laboring, to bleed him freely. At the same time intra- venous injection of normal salt solution should be freely resorted to, and this is particularly needful if the blood flows slowly and is very dark in hue. (See Intravenous Injection.) At the same time cold should be applied to the body, and particularly to the head, abdomen, back, and chest. The man should be stripped, laid upon a bed, which must be covered with a rubber blanket, and ice-water applied to the body by means of a sponge, or a piece of ice may be laid on the head, while another piece is rubbed over the rest of the body. While this is being done the surface of the patient's body must be thoroughly and briskly rubbed in order to bring the hot blood to the cooled skin. Care should be taken that the temperature, when it once begins to fall, does not drop suddenly below the normal and cause collapse. If the clinical thermometer in the mouth or rectum shows that the temperature has fallen to 101.5° or 100° F., the cold application should be stopped, and the patient allowed to lie on a bed, covered only with a thin sheet. The bodily temperature must be constantly watched, as it will probably bound up again in a few minutes, and require the application of more cold, used with the same care. This second rise is due either to the disorder of the nervous mechanism of heat-production and dissipation, or to the fact that, while the surface of the body is cooled by the ice, the innermost viscera are still in high fever and rapidly heat the surface as soon as the ice is taken away. Antipyretics have been found to be almost useless in the hyperpyrexia of sunstroke, and are not to be relied upon. After the fever has been reduced permanently the danger is not all passed, and it is the greatest mistake to discharge a patient as cured at this time. After two or three days it is very common for a menin- gitis to develop, accompanied, it may be, by little or no fever, but characterized by violent darting headache, which is made worse on lying down or on sudden movement. The treatment of this state must be bold, and venesection is the only safe method of obtaining relief, although vascular sedatives, such as veratrum, may be employed. The bleeding should be copious enough to impress the circulatory system to some degree, and may be done by opening any of the prominent veins in the arm. (See Venesection.) Sometimes a vio- lent attack of epistaxis saves the man's life when it would have been lost through the ignorance of his attendant. If life is preserved without vascular depletion, secondary changes in the brain may ensue 798 DISEASES. and produce hemianopsia, optic atrophy, imbecility, or insanity. Quinine, salicylic acid, and similar substances are all contraindicated under these circumstances, because of the congestion of the meninges to which they predispose by their physiological effects. The treatment of heat-exhaustion consists in the use of heat instead of cold, in order to restore the bodily temperature. Just here, how- ever, must be uttered a word of warning — namely, that the mere fact that the skin is cold does not prove the case to be one of heat-exhaus- tion, since a rectal thermometer may show the central or real tem- perature of the body to be that of hyperpyrexia. Of course, such a case should not receive hot, but cold, rectal injections if the symptoms require it. The bodily heat in heat-exhaustion is to be raised by placing the patient in a bath at 105° to 110° F., or by the use of hot bricks or bottles, care being taken that they do not burn the patient. The bodily tem- perature should also be watched, lest the other extreme of heat be reached. Cases of heat-exhaustion are not so apt to have meningitis as are cases of sunstroke, but they are generally slow to convalesce, and require tonics and careful watching for a long time. Indeed, in many instances the system seems to receive a shock from which it takes several weeks or months to recover. SYPHILIS. In so far as the choice of drugs is concerned, the treatment of syphilis is exceedingly simple: iodine, iodide of potassium, and mercury practically represent the only remedial agents which are well proved to possess the power of distinctly counteracting the effects of the dis- ease. In regard to the method of administration and the period of the disease in which any or all of these drugs can be given to the best advantage there is a wide diversity of opinion. Following the teach- ing of Fournier, in the United States the practice generally obtains of administering mercury on the appearance of the first symptoms of the secondary stage of syphilis; this drug is continued for from twelve to eighteen months, and is then followed by a course of iodide of potassium continued for from six to twelve months. If after the sus- pension of this treatment for six months no manifestations of disease appear, the patient is regarded as cured. Should the disease again break out, the iodides are administered in increasing doses, supple- mented by the addition of mercury if necessary. Against this treatment, however, there have been many and vigor- ous protests. Every syphilographer knows that the disease is fre- quently self-limited. Zeissl states that a large number of cases progress to spontaneous cure, and that the secondary eruption in such cases disappears in from two to eight months, after which time the patient SYPHILIS. 799 is perfectly well, recidivity being far less common than when mercury has been employed in the early stages of the disease. The treatment by iodides, he thinks, should be commended chiefly after the expectant plan: their effect is not so rapid as is that of mercury; they are suitable, however, to all stages of the disease. When the symptoms become so urgent that it is no longer safe to depend upon iodides, mercurial inunctions should be employed, the dosage of the drug being regulated by its effect upon the symptoms, in all cases the minimum quantity necessary to accomplish the result being administered. We have, then, three methods of treatment proposed, each advo- cated by a formidable array of authorities: 1. The expectant treatment. 2. The treatment by iodides, followed, if necessary, by mercury. 3. The continued treatment, beginning with mercury and ending with iodides or the combination of the two drugs. By the expectant treatment is implied abstinence from all medication intended to counteract directly the syphilitic virus: if possible the patient should lead an active, out-of-door life, the diet should be most carefully regulated, and the treatment should be purely symptomatic, tonics being administered when required, the sore throat being com- bated by astringent gargles, particularly those containing chlorate of potassium or malic acid, together with direct local applications, while the eruption on the exposed parts of the body is controlled by the application of heat. Even in the mildest cases there is nothing to be said in favor of this treatment. W T here the primary lesion is large and persistent; where the period of secondary incubation is less than seven weeks; where the papular eruption is universal, is confluent, and is accompanied by the simultaneous appearance of mucous patches; where the lymphatic enlargement is marked and persistent; and where the disease attacks a subject with depraved constitu- tion, the expectant plan offers little hope of accomplishing a cure. Here the second and third methods of treatment are absolutely indi- cated. By the second plan of treatment the iodides are administered, not immediately on the appearance of the secondary eruption, but after this has run a course of several weeks and is steadily increasing in severity. The iodide of potassium is chosen by preference, beginning with the administration of 5 grains (0.3) three times a day, and increas- ing steadily 5 grains (0.3) a day until either the constitutional effects of the drug are manifested or the symptoms are favorably influenced. Should iodism appear, the dose is cut down one-half and continued for one or two weeks, after which time, if the syphilitic lesions are not favorably modified, inunctions of mercury are employed, a drachm (4.0) of mercurial ointment being rubbed in every other day. The iodide should be continued for from six to twelve months after the disappear- ance of all symptoms, relapses being combated by temporarily increas- ing the dose and by a course of mercurial inunctions. If after the 800 DISEASES. suspension of the treatment the patient remains free from all mani- festations of syphilis for two years, he can be fairly considered as cured. By the third method of treatment — and this is the method most commonly accepted in practice — the patient is placed upon mercury the moment the early secondary symptoms denote that the primary sore was surely syphilitic. Many surgeons begin this treatment from the time that the inguinal glands on both sides become characteristic in shape and size. Others wait until there is general lymphatic involvement, while others believe that the mercury should not be administered until roseola appears. In regard to the particular preparations of mercury to be employed, the protiodide, blue mass, bichloride, and mercury with chalk repre- sent the forms usually employed when the drug is administered by the stomach. Of these the protiodide is to be preferred, and the effort of the surgeon is directed first toward determining what is termed the "tonic" dose. With this end in view, \ grain (0.015) of the protiodide of mercury is given, in pill form, three times a day, and every second day this quantity is increased by one pill, the patient being mean- while carefully watched. The drug usually manifests its physiological effects by griping pains accompanied by two or more watery passages from the bowels, or by fetid breath and slight tenderness of the gums. The quantity taken to produce this effect represents the extreme limit to which it is safe to push the drug. If this dose is continued or increased, the characteristic symptoms of mercuric saturation appear. When the surgeon has determined the limit to which the drug can be safely pushed, this dose is cut down one-half, and in the absence of further complications the patient is directed to continue with this dose for eighteen months. If during this time local symptoms appear which show that the disease is not thoroughly under control, the mercury must again be pushed to the full dose, being reduced to the tonic dose as soon as the disappearance of specific lesions permits. Where comparatively small doses of the protiodide produce pain and purging, opium may be added; in this case the breath and the mouth will show when the full effect of the medicine is obtained. Manifesta- tions of the disease occurring during mercuric treatment must receive local treatment. The surface eruption is combated by mercuric ointments and washes and by the application of heat. (See Heat.) Mucous patches in the mouth are quickly healed by applications of solid nitrate of silver or sulphate of copper, 20 per cent, chromic acid solution, or the acid nitrate of mercury. When these patches occur about the genitals, washing with 1 : 2000 bichloride solution and dust- ing with calomel and bismuth will be found satisfactory. Alopecia is combated by shampooing and by the application of strong stimulating lotions containing croton oil or tincture of cantharides. The intense cephalalgia is combated by J-grain (0.010) doses of calomel, repeated every two hours. The periostitis yields most readily SYPHILIS. 801 to gentle, long-continued mercuric inunction, supplemented by the application of pressure bandages. When the integrity of any vital organ is threatened there should be no hesitation in pushing the mercury treatment, and in supplementing it, if favorable results do not follow promptly, by large doses of iodide of potassium. After the first eighteen months iodide of potassium is generally indi- cated. This is commonly given together with the mercury, consti- tuting the mixed treatment. The following formula, or one similar to it, may be employed: I>— Potassii iodidi oij vel 5iv (8.0-16.0). Hydrarg. chlor. corros. ... gr. ss (0.03). Syrup, aurant. cort foj (30.0). Aquae destil. . . . q. s ad f §ij (60.0).— M. S. — Teaspoonful (4.0) three times a day. When this prescription is put up a precipitate is formed and then dis- solved. This mixture, or iodide of potassium without the mercury, admin- istered in 5- to 10-grain (0.3-0.60) doses three times a day, is given for from six to twelve months longer. When the iodide is given alone it is most conveniently administered in the form of a saturated solution. Of this a drop contains a grain of the salt. Milk seems to have the power of completely disguising the disagreeable taste of the drug. Thereafter, specific treatment is stopped, unless symptoms arise, in which case it should be renewed and should be continued for many months. The protiodide is usually preferred, because the symptoms of its constitutional effect are manifest at first by looseness of the bowels, and because in practice it has been found one of the most satisfactory of all preparations. Where this form of mercury is not well borne the physician should at once employ some other salt; the bichloride, in T V-grain (0.005) doses three times a day, is efficacious. Blue mass will often act favorably when other preparations cannot be tolerated. Its combination with iron is desirable, and the following formula repre- sents one of the most valuable of the antisyphilitic pills: R — Mass. hydrargyri gr. xxx (2.0). Pulv. ferri chloridi gr. xv (1.0). — M. Ft. in pil. Xo. xii. S. — One three times a day. Where mercury cannot be administered by the mouth it may be given by means of vapor-baths, by inunctions, and by hypodermic injections. The vapor-baths are useful when it is desired to cure promptly erup- tions on the surface of the body or when it is most important to bring the disease quickly under the influence of mercury. They are readily administered, the only apparatus required being an alcohol lamp and a plate on which the mercury preparation can be volatilized. The 51 802 DISEASES. patient is seated in a chair entirely naked ; several blankets are wrapped around his neck, and beneath the tent thus formed a large vessel of steaming water is placed. When the skin is thoroughly softened J drachm (2.0) of calomel is sublimed by means of the lamp. These baths may be repeated every night until fetor of the breath is observed or until the specific symptoms disappear. (See articles on Mercury and on Heat.) Inunction represents the most efficient way of administering the mercury treatment. When the stomach is intolerant of drugs, or when, administered by the mouth in full doses, they do not favorably modify the symptoms, inunctions are indicated. The patient is instructed to take a warm bath, and the mercury is then well rubbed in over the inner surface of the forearm and arm and along the side of the chest for fifteen minutes. Either the oleate of mercury, 10 per cent., or the ordinary mercury ointment is commonly employed; the former is more cleanly, but less efficient. The rubbings should be done by the patient, should be made over a large surface of the body, and should be performed thoroughly; 1 drachm (4.0) of blue oint- ment is rubbed in daily. A shirt kept for this purpose is then put on next the skin and the ordinary clothing is worn over this. The next night the opposite arm and side of the body are utilized as the seat of inunction; the following night the right groin and the inner surface of the right thigh and leg; next, the same regions of the opposite side of the body; finally, the anterior surface of the chest and abdomen. In this way irritation of the skin is avoided. Where it is impossible to employ the inunctions in this way, another means of causing absorp- tion of mercury through the skin, suggested by Sturgis, will be found satisfactory: After a thorough soaking of the patient's feet in hot water, from J to 1 drachm (2.0-4.0) of a 20 per cent, oleate of mercury is rubbed vigorously into the sole of one foot; the next night the sole of the other foot is treated in the same way. The patient is directed to wear, night and day, a pair of woollen socks; these are not changed for one week. Mercury may be taken by the mouth at the same time inunctions are employed when it is desired to influence the system quickly. In the late periods of the disease very striking effects are often obtained by supplementing the iodide treatment by a course of twelve to eighteen inunctions. In the United States the hypodermic administration of mercury is limited to those few cases which do not seem to respond to the drug when given by the month or by inunction. Although many prepara- tions of mercury have been lauded as most efficacious when used hypo- dermically, the best formula seems to be that recommended by Hebra. This consists of a solution of 1 per cent, of bichloride of mercury in a 6 per cent, sodium chloride solution; the resulting mixture is per- fectly clear and is readily prepared. If it becomes turbid, it should be thrown away. Most rigid antiseptic precautions must be observed, as abscess-formation is not uncommon. One injection is given daily, TONSILLITIS. 803 J to J grain (0.01-0.02) of the sublimate being administered. The nates are selected as the seat of the injection, the solution being driven well into the muscles of each side every other day. Twenty injections are usually sufficient to cause the disappearance of all symp- toms. The employment of the insoluble preparations of mercury, particularly of calomel, gives much pain, frequently causes abscess, and is at times attended by a continuous absorption which may pro- duce severe and even fatal ptyalism. The ulcerations often found as tertiary manifestations of syphilis are treated according to general surgical principles. The local appli- cation of mercury preparations is of less service than during the existence of the secondary lesions. Iodoform is peculiarly serviceable. The tonic and general treatment of syphilitic cases must not be for- gotten; fresh air, exercise, bathing, careful diet, regular living, all must be enjoined. Moreover, in certain cases where there is marked anaemia or physical weakness cod-liver oil, stimulants in moderation, compound syrup of the hypophosphites, and other tonic and nutritive courses of treatment must be carefully administered. Although the treatment of an ordinary case of syphilis is simple and satisfactory in its results, it must be remembered that there are malig- nant forms of the disease, attacking by preference feeble and cachectic individuals, running a rapid and virulent course, unchecked, nay aggravated, by specific treatment, and responding feebly, if at all, to the most careful hygienic and tonic regimen. In such cases a strong extract of sarsaparilla is sometimes of service. TETANUS. The treatment of tetanus after the symptoms have developed is quite independent of its causation, so far at least as drugs are concerned, and is virtually identical with that of strychnine-poisoning, to which the reader is referred. (See Nux Vomica.) It is stated that Fowler's solution acts almost as a specific in some cases. The value of the anti- toxin for tetanus depends very largely upon how early it is given. When the disease has once developed, it cannot be of much use, but it should always be tried. (See Antitoxin, Part III.) The diet should be most nourishing. Continuous immersion in hot water may be tried. TONSILLITIS. Inflammation of the tonsils occurs in three forms: superficial ton- sillitis, in which the mucous membrane covering the tonsils becomes inflamed through extension of a pharyngitis; follicular tonsillitis, in which the follicles are chiefly involved and pour out an excessive secretion; and, finally, true tonsillitis, in which the gland itself suffers from severe, widespread inflammation phlegmonous in type. In all these forms the treatment to be instituted at the beginning is prac- 804 DISEASES. tically identical. The bowels should be opened by a saline purgative, which in some cases should be preceded by small doses of calomel, the diet should be liquid and nutritious, and a fever and diuretic mix- ture should be given freely as follows: I$— Tinct. aconiti n\xl vel lxxx (2.0-5.3). Spt. setheris nitros foj (30.0). Liq. potassii citratis . . q. s. ad f Biij (90.0). — M. S. — Dessertspoonful every three hours to a child of ten years; or a tablespoon- ful (2.0) to an adult. The best local treatment is to paint the tonsil with pure guaiacol on a cotton applicator, or a solution of nitrate of silver may be used, 60 grains to the ounce (4.0-30.0), applied with a camel's-hair brush. Externally, an ice-bag should be applied about the throat, and as soon as the purgative has acted and the fever is reduced by the mixture just given, full doses of the tincture of the chloride of iron should be administered (20 minims [1.3] every three or four hours), in plenty of water, which preferably should be Vichy or one of the good lithia waters. Small doses of biniodide of mercury are sometimes useful to abort an attack of acute tonsillitis, -jto - grain (0.0003) every hour in water for four or five hours being the amount usually employed. In some instances hot fomentations about the neck and hot gargles seem to be more beneficial than the use of ice. Often a mild antiseptic gargle of phenol (1: 100 of water will relieve the pain and the fetor of the breath. Finally, it should be remembered that rheumatic persons suffer severely at times from tonsillitis, and the best remedies for this form of tonsillitis are the salicylates or guaiac. TUBERCULOSIS. Tuberculosis affecting any part of the body is a manifestation of the fact that vital resistance has been decreased, for if not infection could not have taken place. The whole point at issue in cases of tubercular infection is the building up of vital resistance to such a level that the battle between the invading bacillus and the cells of the body can be waged with victory for the cells, and as soon as they are able to cope with the infecting agent there is at once formed a protecting wall of inflammatory lymph which surrounds the area infected and protects the rest of the body from the bacilli that it contains. The means by which the greatest degree of vital resistance are obtainable is an out- door life with exposure to as many hours of sunshine as possible and an abundance of fresh air. No drugs can equal the value of these out- door agencies. (See Climate, Part III.) The second point to be borne in mind is that no drugs in tuberculosis equal good food if it is well digested and , taken in full amount, and he who disorders the digestion by drugs is doing his patient more harm TUBERCULOSIS. 805 than good. A good cook is a better friend to a tuberculous patient than a good druggist. (See Diet, Part III.) Cases of pulmonary consumption follow, rudely speaking, four well-defined lines. A very early stage sometimes comes to the care of the physician, and it is that in which the following history is given or a similar story is elicited. A patient, previously strong and well or of poor health, as the case may be, begins to lose vivacity. Life becomes a burden and exercise is distasteful. A slight daily chill and fever develop in morning or evening, and the physician who is careless treats the case as one of mild malarial poisoning. Careful examina- tion, however, will show an area in the lung, generally near the apex on one or both sides, where slight prolongation of expiration with a harsh inspiratory sound is heard, and where percussion will give impaired resonance or dulness. In other words, the first stage of phthisis is present, and the physician must resort at once to those active measures for the patient's relief which will be considered shortly. In another form a chill, a sweat, a loss of flesh and vigor, with, more prominent than all, a hard cough, sudden in its onset and rap- idly becoming excessive with profuse expectoration, are the dominant symptoms. The wasting is extreme, the sweats are constant, and death may come in a few weeks. This is the form known as " galloping consumption." The third variety is ushered in by a gradual loss of vigor or a sensa- tion of being a little unwell, or this form is brought before the patient's mind by a sudden acute hemorrhage, or several hemorrhages rapidly succeeding one another. This variety passes along its course with varying rapidity. Death now is due directly to the hemorrhage, although a secondary pneumonia may bring the end. In most cases the disease keeps on for months and the case dies from exhaustion. Last of all, the fourth class is made up of persons who gradually pass from bad to worse: First, they "catch a cold," which hangs on longer than it ought, and, as soon as they are well, this is followed by another one, which is found more difficult to cure, until finally there is always a cough. Soon wasting comes on, strength is lost, and a long period of months ensues during which the progress of the case is now slow, now fast, the condition now better, now worse, until death ensues from wasting, pneumonia, or some other complication. These forms and stages have been roughly outlined so that a dis- cussion of their treatment might be taken up with a clear idea of what is to be done. When a patient exhibits those physical signs which have been given as evidences of the early beginnings of phthisis, the physician should institute certain hygienic and medicinal measures. If the individual be earning a livelihood by following some confining occu- pation, this occupation must be given up and one undertaken which is carried on in the open air and yet not accompanied by too great 806 DISEASES. exposure. Even if exposure is incurred, it is often better than the occupation previously followed : thus, if the patient be a bookkeeper, a printer, or a bookbinder, or a clerk kept much at a desk in an ill- ventilated room, a few wettings in the rain will do little or no harm if the patient is properly protected by the wearing of flannel shirts, which, when wet, are changed as soon as labor ceases, as under these circumstances the danger of catching cold is at a minimum. (See Climate, Part III.) The medicinal measures to be carried out in all cases of phthisis, except that known as the galloping form, are not numerous if we con- tine ourselves to the modes possessing any real value. For many years cod-liver oil has been sadly abused in the management of these cases, and has been given at all stages, owing to ignorance of its proper use. The writer believes that the following rules are never to be departed from: 1. Never use cod-liver oil if it disturbs digestion. 2. Never use it if fever is active. 3. The use of cod-liver oil when rapid degenerative changes are occurring in the lung may be distinctly harmful, as it is not of any service, disorders the digestion, and destroys the appetite. 4. Its best employment is in the earliest stages of the disease and in chronic fibroid phthisis. When the oil is used, it should be given as directed in the article on Cod-liver Oil. A remedy of some value as a palliative is creosote. Many cures have been claimed from its use in the early stages of phthisis, and it has been highly lauded by a number of European clinicians. In the author's experience it is of value only when the presence of bronchitis requires the use of an expectorant. If it disorders digestion, it is harmful. The opinion declared by Striimpell expresses so well the thought which the author was about to write when he read Strumpell's article that his words are here given: " Taking it all in all, we find that creosote, even in large doses, has no injurious effect on tuberculosis. At times we notice an apparently favorable symptomatic effect. We failed, however, to observe any real influence exerted by creosote on the progress of the disease." (See Creosote.) When creosote is used internally it may be given in the following formula : I£ — Creosoti (beechwood) gtt. xxxij vel foj (2.0-4.0). Tr gentian f 3j (4.0). Alcoholis foj (30.0). Vin. albi q. s. ad f§iv (120.0).— M. S. — Teaspoonful (4.0), in water or wine, three times a day. Better still, it may be given in ascending doses (1 minim extra each dose) in milk or wine. Often a 1-minim (0.05) dose three times a day may be increased to 5 minims (0.3) in the same period with advantage. Sometimes 1 or 2 TUBERCULOSIS. 807 minims (0.05-0.1) in capsule are as useful as the formula just named. (For methods of administration see Creosote; also, see Guaiacol and Creosote Carbonate.) Creosote may also be inhaled in the spray from a steam atomizer or by means of an inspirator fitted over the nose and mouth and made of perforated zinc with a sponge at the edge to hold the drug. A very good method is to wet the sponge with creosote, alcohol, and water, equal parts, or to use the creosote alone if coughing is not too severe. Another useful mixture consists of equal parts of terebene, iodide of ethyl, and chloroform. This last mixture is most useful when the secretion is tough and tenacious, and should not be used in the pres- ence of acute irritation due to inflammation. Such inhalers are very cheap, not easily broken, and readily worn. (See Inhalations.) If the cough is excessive, a little spirit of chloroform placed on the sponge of the inhaler will often relieve it, or a mixture of mor- phine and wild-cherry bark may be given as follows : 1$ — Morphinae sulph gr. j vel ij (0.06-0.12). Syr. pruni Virginianae f oiij (90.0). — M. S. — Teaspoonful (4.0) every- three hours Or the following: I$_Spt. chloroformi f|ss(16.0). Morphinae sulph gr. j vel ij (0.06-0.12). Syr. pruni Virginianse f^iij (90.0). — M. S. — Teaspoonful (4.0) even- four hours. In still other cases 2 to 10 minims (0.1-0.60) of a good fluid extract of cannabis indica, or \ to \ grain (0.008-0.015) of the solid extract, will act with surprising benefit and stop the cough. Heroin in small doses is also useful when there is an idiosyncrasy to morphine. Very often during the course of phthisis localized spots of pleuritic inflammation develop which give rise to pain. The best treatment is to apply a small blister or to paint the spot with iodine. (For the treatment of Haemoptysis see Hemorrhage.) Laryngeal phthisis, one of the most serious complications of this disease, is best prevented by ordering the patient to inhale the steam arising from boiling water which contains corrosive sublimate in the proportion of 1 : 10,000. If a proper watch is kept for evidences of a general mercurial effect, and this measure stopped at once when tenderness of the gums appears, no danger exists. Before the inhala- tion takes place a spray of cocaine (4 per cent, solution) should be thoroughly used. The treatment of laryngeal phthisis itself is various. The best method is that in which lactic acid is used. By the aid of a laryngeal mirror and a cotton applicator a 10 per cent, solution of lactic acid is applied to the spots which are involved. As this is generally quite painful, cocaine solution should first be used. Gradually the strength of the lactic-acid solution should be increased to 60 per cent, if the 808 DISEASES. weaker solutions do not check the disease. Very valuable results have been obtained by this method. The second method in point of value is that of iodoform insuffla- tions. A powder of iodoform alone is too light for satisfactory pro- pulsion into the larynx, and powdered talc should be added to it in small amount, with yg- grain (0.004) of morphine to each drachm (4.0) of iodoform. The odor is generally disagreeable to the patient, but if a cocaine spray be first applied to the fauces and the operator is skilful,, very little coughing is produced. As iodoform is a local anaesthetic, it relieves the pain in the larynx, acts as an antiseptic and alterative, and is peculiarly obnoxious to bacillus tuberculosis. Camphoric acid in 20- to 30-grain (1.3-2.0) doses is the best internal remedy for treating night-sweats. When the night-sweats are very profuse, hypodermic injections of atropine in the dose of yfit to TM grain (0.0004-0.0006) are useful in some cases, and the efficiency of this treatment may be increased by the use of an alum sponge-bath at bedtime. A solution of alum, 10 to 20 grains to the ounce (0.60-1.3:30.0), may be sponged over the body, or sulphuric acid may be added to water in the proportion of 1 drachm to the pint (4.0-480 c.c), and used in the same way as the alum solution. Sulphuric acid is often given internally with advantage in these cases of sweating. Small doses of pilocarpine amounting to -^V grain (0.003), given from one to two hours before the sweat is expected, are some- times potent for good. The means by which this result is brought about are not far to seek. The drug in any dose causes stimulation of the peripheral ends of the nerves supplying the sweat-glands. In many instances we find excessive secretion dependent upon depression of function, as in a serous diarrhoea or a local sweating of the feet. These states pass away just as soon as the parts regain their normal tone through proper treatment. The night-sweats of phthisis are sometimes improved by pilocarpine, because this drug in all doses stimulates the sweat-glands. In large doses this stimulation amounts to free diaphoresis; but in minute doses, such as -£$■ to -fa grain (0.0015-0.003), the stimulation just balances the depression and a normal tone is acquired. While it is true that pilocarpine and atropine are physiological antagonists, it will be found practically beneficial to prescribe small doses of both in such cases as refuse to respond to either one alone, as by their antagonism they prevent overaction on other parts of the body, and both act in harmony in so influencing the sweat- glands as to be of service to the patient. TYPHOID FEVER Any attempt to review the various forms of treatment of the disease known as typhoid fever is absolutely impossible, owing to the very numerous theories and practices put forward by various clinicians. TYPHOID FEVER. 809 What is said under the general heading of Fever and under the con- sideration of Cold, Part III., and also under Antipyrin and Acetanilid, gives sufficient information as to the treatment of febrile movements, and the care of the patient beyond this point in nearly all cases depends upon the severity of the attack. Before going farther, however, the writer desires to insist very strongly upon one fact — namely, that a case of typhoid fever is not curable in any degree. No remedy yet found, except it act through the prevention of complications, can shorten the course of the disease. We can only guide the patient safely to health when the storm of dis- ease comes on, and we cannot stop the storm. Not only should the facts of the last paragraph be carefully borne in mind, but the physician must also remember that he is treating an exhausting disease — not a disease which runs a violent course for a few days and strands the patient sick and weak, but convalescent, upon the shores of health, but one in which, after sapping the strength for weeks, some sudden intercurrent malady or accident may ensue which will speedily kill him if every grain of strength is not preserved for the struggle. The physician should always put every case in which there is a suspicion of typhoid fever to bed at once, and keep the patient there till the disease has passed or fails to develop. Every muscular movement unnecessarily made is a waste of force, and, in consequence, everything should be done for the patient, and not by him. A bed-pan should always be employed, the patient not being allowed to sit erect upon a commode. Remembering, too, that a typhoid fever patient is subjected to pro- longed wasting fever and toxjemia for many days, his nutrition should be maintained by the use of a nourishing diet easy of digestion. In addition to milk he should also receive one or two very soft-boiled eggs each day, arrowroot and perhaps thin corn starch, provided they agree with his digestive powers. If diarrhoea is not present, broths may be given, but it must be recalled that Brieger has shown that typhoid bacilli do not readily reproduce themselves and their poisons in pep- tone and well-digested milk, but do so very actively in meat-broths or jelly which has not been acted upon by the digestive juices. Milk diet is therefore evidently better than a broth diet in typhoid fever, and we once more are able to explain an empirical fact by a scientific discovery. There is no reason for using liquid instead of solid foods, except the difficulty of digesting the latter. Alcohol has been used in all stages of typhoid fever as a stimulant, as a giver of force to the system, and as an aid to digestion, but its real value is found when actual depression exists. A very large part of the profession believe that the mere presence of an abnormally high temperature contraindicates the use of alcohol. Mere high tempera- ture does not do so, however. High temperature of a sthenic type, with a full, tense, bounding pulse and all the signs of a disease attack- ing one in the full vigor of life, of course precludes its use; but in the 810 DISEASES. high temperature of advanced typhoid, with the marked asthenia often present in that stage, alcohol should be given whenever the heart-sounds are feeble. Under these circumstances the tissues which the man can afford to lose are gone, and much of his vitality is greatly encroached upon: the alcohol yields force to the body, and is burnt up in great part, keeping the flagging heart pumping the blood through the lungs and systemic circulation, when otherwise the circu- latory depression would result in hypostatic congestions, if not in more widespread circulatory disorder. A no less useful and valuable result obtained by the use of alcohol in the later stages of exhaustive fevers is the part that it plays in aiding digestion. The writer has elsewhere defined the difference between the influence of alcohol in the artificial digestion of the test-tube and that occurring in the stomach. Alcohol acts rather by restoring the equilibrium of the circulation than by a direct stimulant effect. It may also increase the bacteriolytic power of the blood. Aside from experimental evidence, every-day experience has taught the gourmand that alcohol, in *a fairly concentrated form, enables him to digest an amount of food which under ordinary circumstances would remain unchanged in his stomach. In those cases in which a temporary loss of heart-power is due to hemorrhage or to some sudden severe depres- sion, alcohol is one of the remedies to be employed — in a hot and concentrated form. The physician ought not to use alcohol as a routine measure in every case without a rational idea of why he does so, nor without a clear idea as to what indication is met by its use. In many cases it is not needed at any time. That alcohol may be misused and cause great harm is, of course, known to every practitioner of medicine. So long as it reduces the temperature and lowers the rate of the pulse, causes a moist skin and tongue, and quiets nervous twitchings, it does good, and only up to this point is it to be employed. If its administration is pushed after this, the tendency to adynamia becomes, under the overuse of the drug, one of dynamia; the pulse is no longer soft, but is felt as angry, bounding beats; the nervous symptoms change from low, weak, muttering delirium to talkative delirium and restlessness; and when the influence of the alcohol begins to decrease, and even before this time, the system has put forth the strength of days in a few hours, and the man, having no reserve strength, is in a dangerously feeble state. The treatment which is used by the author in his wards at the Jefferson Medical College Hospital has given him results which the application of other methods has failed to give, and is as follows : As soon as the patient enters the house he is washed or bathed and placed in bed, and required to remain there. He is assured that the more quietly he lies the more mild and safe will be the course of his attack, and is made to use a bed-pan and urinal, and never allowed to get up. He receives several small doses of calomel, followed, if the TYPHOID FEVER. 811 bowels are not moved, by a mild saline purge, such as a Seidlitz powder. After the calomel has acted he is also given 5 drops (0.3) of dilute hydrochloric acid in a wineglass (30.0) of water every four hours, or, if the bowels are not active, nitromuriatic acid is substituted there- for, care being taken to employ 3 drops of the strong, freshly mixed acid according to the degree of coating of the tongue. The diet is largely a milk diet — namely, a quart to a quart and a half (1 to 1\ litres) a day, with a little salt to flavor it, as already described in the article on Indigestion. In some cases koumyss is an agreeable change from milk. Sometimes, if vomiting is threatened, lime-water is .added, or the milk is peptonized, or beef-tea is temporarily employed. In other instances the milk agrees with the patient if it is partly diluted with plain soda-water, Vichy or Apollinaris water. Eggs, arrowroot, -corn starch, and curds and whey are also allowed, as already indicated, and when starches are used it is the author's invariable rule to give taka-diastase in the dose of 2 grains with each meal. For the dry and sordes-covered tongue a mouth-wash of glycerin and water, half and half, to which may be added a little lemon-juice, is used, and it is important to keep the mouth constantly cleansed, as by this means swallowing is not interfered with through cracking of the lips, tongue, and buccal mucous membrane, pulmonary infection is avoided, and facial erysipelas and parotitis are prevented. If constipation is very obstinate and continues over one day, an injection is employed, and if this, after being used twice, fails to act, a dose of calomel, \ grain (0.001) every fifteen minutes till a grain has been taken, is prescribed, and, if no movement occurs in twelve hours, is followed by half a bottle of citrate of magnesium, or a tea- spoonful of liquorice powder is given. In other cases small doses of mascara sagrada are equally useful. Violent purgatives should never be used for obvious reasons. Rectal injections should be given some hours after the purgative is taken, to aid its action, since not infre- quently the laxative causes the contents of the small intestine to flow into the large bowel, which is too inactive to extrude them. When diarrhoea becomes troublesome — that is, more than three or four passages a day — the following will be of service : 1$ — Acid, sulph. aromat foij (8.0). Fluidext. haematoxyli f 5iij (12.0). Syr. zingiberis f oiij (90.0). — M. S. — Teaspoonful (4.0) in water every hour until relieved. Should the stools be excessively fetid and tympanites be marked, guaiacol carbonate may be given as an intestinal antiseptic, or, so soon as any evidence of tympanites or much meteorism comes on, turpen- tine may be given, as follows: ^—0\. terebinthinse . f 3ij (8.0). Syr. acacise q. s. ad f §iij (90.0). — M. Ft. in emulsio. S. — Teaspoonful (4.0) in milk three times a day. 812 DISEASES. At the same time it is well to employ a turpentine stupe over the abdo- men. (See Turpentine.) Where the tympanites is excessive it may be relieved by an injection made as follows: 1$ — 01. terebinthinse f5j to 3 ij (4.0-8.0). Ol. olivse fgiv (120.0). Emul. asafoetidae . . . . . . . Oj (480 c.c.).— M. S. — Use as an injection. Shake well before using. When the tympanites is severe, half an ounce (16.0) of Hoffmann's anodyne may be used in place of the turpentine. In the later stages of typhoid fever, as convalescence is approached, turpentine is often useful, as it seems to cause rapid healing of the intestinal ulcers and checks diarrhoea. Much has been said about the value of purgatives and so-called intestinal antiseptics in typhoid fever, and extravagant claims made for them. Suffice it to state that while they may be indicated in cer- tain cases they are not to be used as a routine plan of treatment, because the skill of the true physician is to give each patient what he needs — not to give all the same treatment. Typhoid fever cannot be aborted; it can only be modified in the sense that we place our patients in the best possible physical state to withstand its ravages. A point of importance in the treatment of typhoid fever is to see that the patient receives enough water in twenty-four hours. Owing to his apathy he often does not complain of thirst and the kidneys are not flushed of impurities by fluid. Some perfectly pure water, such as Londonderry Lithia, or Poland water, should be freely given to help eliminate toxic materials through the kidneys. Should toxaemia be severe, the use of cold is essential, and if in addition emaciation be marked, it is wise to employ hypodermoclysis. (See Part III.) Not infrequently cases are met with in which toxsemia with mental depression is well developed, yet in which the temperature is below 102° F., and so the use of cold sponging seems contraindi- cated. Active friction with tepid water and alcohol is now of value. If the temperature is normal or subnormal, the patient may be sponged with hot water. The value of this measure does not lie so much in the temperature of the water as in the reaction and conse- quent readjustment of the circulation. The complications of typhoid fever of the most serious import are hemorrhage from the bowel, pneumonia and pleurisy, and perforation of the bowel. The hemorrhage from the bowel may be treated as indicated under that heading (see Hemorrhage), and the pneumonia or pleurisy should be treated as are these diseases when they occur alone; but it is to be remembered that the patient is an asthenic adynamic case, and musr not be depressed, but stimulated. When perforation of the intestine occurs, sufficiently large doses of morphine should be given to relieve pain, prevent collapse, and allay irritation. Warm applications UREMIA. 813 should be used over the belly and down the limbs, and stimulants given if needed. In all cases where it is possible to find a surgeon capable of doing a skilful abdominal section a consultation should be had at once. If shock is not present, operation should be performed immediately, the perforation or perforations found, closed, and the peritoneal cavity well flushed with warm normal saline solution, to cleanse it of extravasated intestinal contents. If shock is present, operation should be delayed until it is overcome and then be per- formed. 1 (See Shock.) As stated at the beginning of this article, cold bathing is very impor- tant and should always be employed in one of its forms if the fever is high, except in the presence of hemorrhage or perforation. For a number of days after the patient begs for solid food it should not be allowed, for he will ask for it long before he should have it; but if the temperature remains normal after nine days, the soft part of stewed oysters may be used and the patient gradually brought back to an ordinary simple diet. UREMIA. The treatment of this dangerous manifestation of renal disease is often futile, but always to be resorted to with the recollection that Avonderful recoveries sometimes occur under judicious management. It matters little whether the onset of the symptoms has been gradual or instantaneous: in either event the prime endeavor must be to rid the system of the poison which is threatening life. This can only be accomplished by aiding its elimination through the bowels, skin, and kidneys. The second indication is to support the vital organs until the emunctories have had time to act. Often this second indi- cation will be more pressing than the first, and the physician will have to give stimulants at once. The third indication is to arrest any convulsive seizures. The methods to be resorted to for the elimination of the ursemic poison are external and internal, externally the hot pack being resorted to to increase the activity of the skin. (See Heat, Part III.) Inter- nally we give elaterium or elaterin in the close of ^ grain (0.01) or^g- grain (0.004), respectively, for the induction of watery purging, which at once aids elimination through the bowel and relieves dropsy if pres- ent. The elaterin should be dissolved in a few drops of alcohol or in whiskey. The medication directed to increased action of the skin should consist of small doses, hypodermically — say J grain (0.008) — of hydrochloride of pilocarpine with strychnine 2V grain (0.003), but the pilocarpine is contraindicated unless the heart is strong and acting properly. Even if the heart seems strong its use is not devoid of dan- ger. It may be used in conjunction with the hot-pack or hot-air bath. bus 1 For discussion of this condition see the author's work on the Medical Complications and Sequela^ of Typhoid Fever. Lea Brothers & Co., Philadelphia, 1899. 814 DISEASES. If dropsy is present, the drug will have to be given by the mouth, as it will not be absorbed from the dropsical subcutaneous tissues. Pilo- carpine also tends to increase the activity of the kidneys, and in addition to this influence on the renal structure we may use caffeine in the dose of 2 grains (0.12) every four hours for three doses, to stimu- late the renal epithelium still remaining healthy to greater effort; or if the arterial tension is high we may give nitroglycerin to lower it and increase urinary flow. Should pulmonary oedema threaten, atropine may be used in full dose with advantage. For the support of the heart and respiratory function we employ strychnine hypodermically or by the mouth in the dose of ■%■$ to yq- grain (0.003-0.006), and follow it by the more powerful stimulant digitalis in the dose of 30 minims (2.0) of the tincture by the mouth. Hypodermic injections of ether are also very valuable if the tissues are not too cedematous for absorption to occur. The convulsions, if present or threatened, are to be combated by the use of an enema of 20 grains of chloral (1.3) and 60 grains (4.0) of bromide of sodium in 3 ounces (90.0) of starch-water, and the hot pack will also be of value, not only to produce sweating, but for its sedative influence on the nervous system. Should the convulsive tendencies be marked, chloroform inhalations may be employed until the chloral or bromide can be absorbed. Two other remedial measures should be resorted to in cases of ursemia for the relief of all the symptoms — namely, full venesection if the pulse is bounding, and hypodermoclysis. (See Part III.) Vene- section is contraindicated in the feeble, but as much as 1 to 2 pints (480-960) of blood may be withdrawn in a sthenic case from a vein in the arm. After the bloodletting or during its progress hypodermoclysis may be performed or a saline solution transfused into a vein. (See Transfusion.) Often deep insensibility is speedily removed by vene- section, which should be regarded as the sheet-anchor of treatment in those cases which have a high blood-pressure. The author also regards hypodermoclysis and intravenous transfusion of salt-solution as most useful methods of treatment in this state. VITREOUS DISEASES Vitreous opacities may be either dust-like, flaky, or dense and mem- branous. They impair vision in proportion to their number and density, and are to be detected with the ophthalmoscope. Patients detect them as floating dark spots in their field of vision, because the opacities cast a shadow upon the retina. If vitreous disease is syphil- itic, the usual remedies are indicated. Hypodermic injections of pilo- carpine act favorably, and in the earlier stages of the inflammations of the retina, choroid, iris, and ciliary body, upon which the opacities depend, leeches should be applied to the temple. Galvanism has been recommended. VOMITING. 815 VOMITING. Vomiting is a symptom, not a disease, and arises from a large number of causes, some of which are very unimportant, others very serious. The most common cause is probably lack of proper diges- tion, with all that this implies; that is, gastro-intestinal irritation and perversion of normal function. Additional causes are cerebral hemorrhage, tubercular meningitis, cerebritis, uraemia, or diseases of the middle lobe of the cerebellum, all of which conditions cause irrita- tion of the vomiting centre. 1 All these states may be considered as lesions of a centric character which directly or indirectly cause the vomiting centre to send out impulses. On the other hand, it is worthy of note that under certain circumstances vomiting may be reflex and dependent upon irritation of the nerves of the stomach or elsewhere which convey impulses to the muscles whose activity results in vomiting. These conditions are well represented by the vomiting which comes on in incarcerated hernia, or in pregnancy, or in that occurring during the passage of renal or hepatic calculi, or in indigestion. It is important to bear in mind that peripheral vomiting due to dis- order of the gastric walls may be dependent upon two conditions. The mucous membrane and its nerves may be overexcitable or they may be depressed. For this reason we shall find that two modes of treatment are necessary when this subject is considered below. The mechanism of vomiting consists in the closure of the pyloric sphincter, the contraction of the gastric muscles from the pylorus to the cardia, and at the same time, and more important than these movements, the contraction of the supplementary respiratory and abdominal muscles, which so compress the stomach as to drive its contents through the open oesophagus. The violence of the muscular contractions in the abdominal walls is greatest when the stomach is partly empty, and gives rise to the pain and exhaustion accompanying the condition known as retching. The practical point to be learned from this is that vomiting is always easier when the stomach is not empty; so if an emetic is given on an empty stomach-, as the popular expression runs, a large amount of liquid should precede or accom- pany it if possible. Dogs vomit easily because of the development of the gastric muscles, but they render the effort easier by filling the stomach with air, and so completely fill the viscus that its walls can contract on a resisting mass. Having described the mode and causes of vomiting, it remains to consider its treatment. It is needless to remark that the vomiting of cerebral disease is very intractable, and that very active agents must be used to check it. Probably the vomiting following etherization is centric, and should 1 See Practical Diagnosis, by the author. Lea Brothers & Co., Philadelphia. 316 DISEASES. be treated, as should all forms of obstinate emesis, by the injection into the rectum of 40 grains (2.60) of sodium or potassium bromide and 20 minims of deodorized laudanum in 4 to 8 ounces (120.0-240.0) of water. If this does not check the vomiting, a second injection may be given two hours after the first. A very valuable remedy in this state is acetanilid given in 1-grain (0.06) doses every half-hour in a drachm of brandy with cracked ice (see Acetanilid), and it is well to remember that inhalation of the fumes of vinegar from a cloth wetted with it will often be of service. When vomiting seems to be due to hyperexcitability of the gastric mucous membrane, so that very small amounts of food when swallowed are at once rejected, local anaesthetics and depressants are needed, the chief of these being chloretone, cocaine, and aconite. The last two drugs, however, have disadvantages, because in effective dose their general physiological action may be very severe and almost poison the patient. When given as antiemetics, these drugs act as local anaes- thetics, or, in other words, by paralyzing the peripheral sensory nerves of the stomach. Cocaine should be given in the dose of 2 to 3 minims (0.1-0.20) of a 4 per cent, watery solution every fifteen minutes until 10 minims (0.60) are taken. And it is best given in capsule so as to exert all its effects on the stomach rather than on the mouth and oesophagus. The aconite should be used in the form of the tincture, the patient being placed flat on the back, so as to withstand the ensuing cardiac depression with the least inconvenience, and 6 to 10 minims (0.40-0.60) of the tincture given in a little water every thirty minutes until the rapidly weakening pulse forbids its further use. This drug may be resorted to in all forms of vomiting due to irritability of the stomach, but it is contraindicated in cases of debility or weakness. Two grains of chloretone given in capsule or dissolved in a little brandy, and repeated every hour for 5 doses, are very efficient. Sometimes a prescription of the following character is of service, the bismuth acting as a coating to the walls of the stomach, protecting and soothing them : 1$ — Bismuthi subnitrat. .... ^iij (12.0). Fhndext. aconiti ..... niiij vel vj (0.20-0.40).— M. Ft. chart, No. x. S. — One powder every half-hour. In other cases of the same type the following is useful, and is to be preferred if, owing to active fermentation, the vomiting is excessive (the creosote or phenol being a local anaesthetic and antiseptic) : J\ — Phenolis vel creosoti (beechwood) . gtt. x vel xx (0.60-1.3). Bismuthi subnitratis ..... ^iij (12.0). — M. Ft. in chart. No. x. S. — One powder every hour. In other cases 1 drop of tincture of iodine and 1 drop of phenol in a couple of drachms of water will act very well. VOMITING. 817 Sometimes pure chloroform in 1- or 2-drop (0.05-0.1) doses, in a little water, does good; and dilute hydrocyanic acid, in the dose of 2 to 5 minims (0.1-0.3) is also of value in like instances, given in a tablespoonful (16.0) of water. In other instances small repeated doses of nitroglycerin do good. Particularly is nitroglycerin useful in the nausea which often follows the use of opium, although this symptom is best prevented by its pre- liminary use. The dose used should be about -g-J-g- grain (0.0002) every half-hour. The treatment of a case of vomiting dependent rather upon depres- sion and debility of the stomach than upon irritation is directed to the administration of gastric and, it may be, systemic stimulants. The chief of the gastric stimulants is ipecac in small doses, and it is this employment of a drug generally resorted to for the production of emesis by physicians which has caused homoeopaths to claim that the regular school obey the rule of similia similibus curantur and infinitesi- mal doses. The claim only holds good on its face, for we do not use an infinitesimal dose, and obey no law, but use common sense. Ipecac is an irritant, even to the skin, and it is partly by its irritant effects that it causes vomiting by exciting the stomach to a point over and above its normal condition. In the vomiting depending upon gastric debility and depression small doses of ipecac do good because they irritate the stomach sufficiently to restore its normal tone without going to the other extreme of hyperexcitation. Under these circum- stances a drop dose of the wine of ipecac, or \ grain (0.015) of the powdered ipecac, every hour, is of the greatest value, often succeeding after all other remedies have failed. In other instances tincture of nux vomica, given in J- to 1 -minim (0.025-0.05) doses, is useful as follows: 1^ — Tinct. nu cis vomicae .... gtt. iv vel viij (0.25-0.5). Aquae cinnamomi i%] (30.0). — M. S. — Teaspoonful (4.0) every half-hour or later. In the nausea and vomiting following an alcoholic debauch \ to 1 minim (0.025-0.05) of Fowler's solution every two hours, or before food, often gives relief, and it may be used in some cases in place of the nux vomica and ipecac. Another useful measure for the cure of alcoholic nausea is the use of full doses of hydrochloric acid, 5, 10, or 15 minims (0.3-0.60-1.0) of the dilute acid in half a tumblerful of water, repeated every two hours. In all cases of persistent vomiting counterirritation should be applied over the stomach in the form of a mustard plaster, or, if preferred, an ice-bag may be applied to the nape of the neck, the lumbar spine, or the epigastrium. Sometimes the application of the positive electrode of the rapidly interrupted induced or faradic current between the sternoclavicular muscles while the negative electrode is placed on the epigastrium will give relief. In still other cases the skin over the 52 818 DISEASES. vagus nerves in the neck may be frozen by the use of a chloride of ethyl spray, or blisters may be applied in its stead. The food given in cases of vomiting should be especially prepared. It is always best to use peptonized milk, made by using the pepton- izing materials sold by all reliable drug firms (See Diet, Part III.) Lime-water should always be put in the milk if it is not peptonized; the small amount usually employed is perfectly useless at least 2 to 3 tablespoonfuls (30.0-45.0) should be placed in each glass of milk. Another point of importance is the quantity of liquid taken. As fast as the patient vomits he is often fed with glasses full of liquid by well-meaning friends. Instead of this, he should have only 1 or 2 teaspoonfuls (4.0-8.0) of milk every hour, half-hour, or fifteen min- utes, for it is better for him to retain a drachm than to take a quart and vomit it. Often milk will disagree with the patient, and then he may be given with excellent result barley gruel, which has been strained, and follow it by 3 grains (0.20) of taka-diastase. In its place strained gruel made from wheaten grits, oatmeal, or rice may also be used. Where vomiting is persistent enemata previously partly or entirely digested must be resorted to to sustain strength. WHOOPING-COUGH. The remedies recommended for this disease are almost as numerous as the members of the medical profession, and every one of them is worthless so far as a cure is concerned. Probably the very best drug of all in the majority of cases is antipyrin. Given in the dose of J to 3 grains (0.03-0.20) every five hours according to the age of the child it will nearly always decrease the number of paroxysms, but not the severity of each individual attack. Where the child will submit to it there is little doubt that a solution of quinine applied to the pharynx by means of a very fine spray will be of service in many cases, and it is very useful when so used, as a prophylactic in other children of the family who it is feared will be attacked by the same disease. The strength of the solution to be employed should be about 1 grain (0.06) to the ounce of water. There is no doubt that carburetted hydrogen as inhaled in the air at gas-works is useful as a curative measure in some cases of whooping- cough. A very useful remedy in some cases is belladonna in the form of the tincture, in the dose of 2 minims (0.10) twice a day to a child of one or two years. Where paroxysms come on so rapidly as to interfere seriously with respiration, the child should inhale a whiff of chloroform poured over the parent's hand, and so relax the spasm, while in other instances nitrite of amyl is equally serviceable. Only 2 or 3 minims of the WOBMS. 81^ nitrite of amyl should be used at a time, and this fact must be impressed upon the parents. Benzine has been found useful in certain cases of whooping-cough. It should be lightly sprinkled about the room or on the bed-clothing, care being taken that no fire or light is present. In France it has been used internally in the dose of 10 to 15 minims (0.6-1.0) for this affection. This is scarcely to be recommended. Bromoform renders good service in some cases. (See article on Bromoform for prescription.) The vomiting following the cough may be overcome by using such minute amounts of milk as to enable nutrition to go on without at any time overloading the stomach, as, for example, a teaspoonful (4.0) after each paroxysm of cough. Usually it will be found advisable to modify the severity and fre- quency of the attacks by keeping the patient under a bronchitis-tent or by keeping the air of the room moistened by steam. (See Bronchitis.) WORMS. Intestinal parasites may be said to be represented by Ascaris lumbricoides or round-worm; Taenia solium, Taenia saginata, and Bothriocephalus latus, or tape-worms; and, finally, by Oxyuris ver- micularis sometimes called seat-, pin-, or thread-worm. A very much rarer form of intestinal parasite, but one which is quite frequently found in some parts of the world, is Anchylostoma duodenale. The round-worm, tape-worm, and anchylostoma are to be attacked by way of the patient's mouth, the seat-worm by way of the anal open- ing; but before mentioning the drugs to be employed it is necessary to insist upon one or two important points, disregard of which will result in failure in treatment. Whenever a round- or tape-worm is to be attacked, the patient must be starved for at least twelve to twenty-four hours, in order that no food in the intestinal tract may protect the worm from the action of the drug. During this time a little milk may be taken, and after a night of fasting, before breakfast, the anthelmintic must be swal- lowed. In addition, nearly all of these drugs must be followed by- purges in order to dislodge the intruder while he is paralyzed and has lost his hold; and in many instances it is well to have a basin of salt and water ready, so that when a passage occurs a rectal injection may be given to wash out any segments of the worm which remain in the rectum. In the treatment of thread-worms it is necessary to fill the bowel thoroughly with soap and water to dislodge the fecal matter and expose the worms in the folds of the mucous membrane. The drugs which are used against the round-worm are: spigelia in the form of the fluid extract, dose 1 drachm (4.0) to a child of two or three years, or 2 drachms (8.0) to an adult, or, better still, the fluid 820 DISEASES. extract of spigelia and senna, dose 2 to 3 drachms (8.0-12.0) given in divided doses, to a child; santonin, dose J to \ grain (0.015-0.03) to a child in the form of troche, made by using the crystals, or as much as 2 to 4 grains (0.12-0.25) to an adult. (See Santonin.) Unless the spigelia is used with senna, it should always be followed after from two to four hours by a full dose of castor oil or a saline purgative to sweep out the worm, and the same rule applies to all the drugs mentioned above. Brayera, or kooso, is given for the removal of the tape-worm in the form of an infusion, which is made by adding \ ounce (16.0) of the powdered leaves to 1 pint (480 c.c.) of water and mucilage of acacia, one-half of each. This may be taken at one dose, or the fluid extract may be given in the dose of J ounce (16.0) to an adult. Koosin may be given in 40-grain (2.60) doses in capsule to adults, but it should not be used against worms in pregnant women, as it may cause abortion. The most efficient remedy against the tape-worm is pelletierine, the active principle of pomegranate, dose 3 to 5 grains (0.20-0,30) in capsule; or pepo, or pumpkin-seeds (2 ounces [60.0]), may be resorted to when deprived of their outer coating and rubbed into a paste with sugar. Almost, if not quite, as valuable a remedy is male fern, or Filix mas, or, as it is officially called, Aspidium. Used in the form of the oleoresin (Oleoresina Aspidii), in the dose of \ to 1 drachm (2.0-4.0) to an adult, it should be followed in three or four hours by a calomel purge, aided by a saline. Either the calomel or the increased amount of bile which is present is apparently peculiarly abhorrent to the tape- worm, and its free flow should be made to follow the use of all the drugs just named. Aspidium should not be followed by castor or other oils, as they increase the absorbability of the drug, and so tend to develop symptoms of poisoning. For the removal of Anchylostoma duodenale thymol in the dose of 2 to 4 grains (0.12-0.25) or more may be given in capsule once a day and followed by a purge. By far the most useful remedy for seat-worms is quassia used by injection. One to 2 ounces (30.0-60.0) of powdered quassia or quassia chips may be made into a decoction with a pint (480 c.c.) of water, and half of this injected into the rectum after it has been well cleansed with soap and water. The quassia injection should be retained in the bowel for some minutes, and in children this may be accomplished by pressing upon the anal opening the ball of the thumb covered by a pad formed from a small folded towel. If this treatment fails to bring away all the worms in three or four trials, either there are none present or the bowel was not thoroughly invaded by the injection. In some cases the worms infest the colon, and large injections sent high up into the bowel are necessary. DOSES OF MEDICINES. The doses in this table are commonly employed. They are not always equivalent to those given in the text, which are used by the author as a rule. dr.= drachm; ft. dr. = fluidrachm ; /. oz. =fluidonnce; gr.= grain; fpn. = gramme ; cc. cubic centimetre ; min. = minim ; oz. = ounce. *• Acetanilid Acetophenone Acetphenetidin Acetum lobelia) opii . . sanguinarise scillie . Acid, acetic, diluted . . . arsenous solution of (Ph. U. S. benzoic boric carbolic chrysophanic citric fluoric, dilute gallic hydriodic, dilute . . . hydrobromic, dilute . . hydrochloric dilute hydrocyanic, dilute . . lactic nitric dilute nitrohydrochloric . . . phosphoric, dilute . . . picric polygalic salicylic . sulphuric aromatic dilute sulphurous ...... tannic tartaric valerianic Aconite, abstract of . . . leaves, extract of . . . fluid extract of . . . tincture of root, extract of . . . . fluid extract of . . . tincture of Aconitine * Adonidin ^Ether. See Ether. Dose. Apothecaries' Weights and Measures. 1-8 gr. 5-20 min. 2-5 gr. 15-30 min. 5-10 min. 15-30 min. 10-30 min. 1-2 fl. dr. eWff g r - 2-8 min. 5-15 gr. 5-10 gr. i-1 g r - i-5gr. 5-20 gr. 10-20 min. 3-15 gr. l fl. dr. f-2fl.dr. 2-5 min. 10-20 min. 2-5 min. 1-3 dr. 2-5 min. 10-25 min. 2-5 rain. 5-25 min. 1-5 gr. i-lgr. 5-15 gr. 2-5 min. 5-20 min. 5-20 min. i-1 fl. dr. 2-10 gr. 10-30 gr. 3-4 min. i-igr- i-^gr- 1-5 min. 10-30 min. i-i gr : |— 1 min. 5-10 min. ■thsvs g r - tW gr- Metric System. 0.06-0.5 gm. 0.3-1.3 cc. 0.12-0.3 gm. 1.0-2.0 cc. 0.3-0.6 cc. 1.0-2.0 cc. 0.6-2.0 cc. 4.0-8.0 cc. 0.001-0.003 gm. 0.10-0.5 cc. 0.3-1.0 gm. 0.3-0.6 gm. 0.03-0.06 gm. 0.008-0.3 gm. 0.3-1.30 gm. 0.6-1.30 cc. 0.2-1.0 gm. 2.0 cc. 2.0-8.0 cc. 0.10-0.3 cc. 0.6-1.3 cc. 0.10-0.3 cc. 4.0-12.0 gm. 0.10-0.3 cc. 0.6-1.5 cc. 0.10-0.3 cc. 0.3-1.5 cc. 0.06-0.3 gm. 0.015-0.06 gm. 0.3-1.0 gm. 0.10-0.3 cc. 0.3-L3 cc. 0.3-1.3 cc. 2.0-4.0 cc. 0.12-0.6 gm. 0.6-2.0 gm. 0.2-0.25" cc. 0.015-0.03 gm. 0.015-0.03 gm. 0.06-0.3 cc. 0.6-2.0 cc. 0.01-0.015 gm. 0.025-0.05 cc. 0.30-0.60 cc. 0.00015-0.0002 gm. 0.005-0.01 gm. (821) 822 DOSES OF MEDICINES. Remedy. Agaricin Aloes extract of and myrrh, tincture of tincture of watery extract wine of Aloin Alumen (as emetic) Aluminium hydrate Ammonia, aromatic spirit solution of acetate of . spirit of water of Ammoniacum mixture Ammonium benzoate bromide carbonate chloride iodide ... phosphate picrate salicylate sulphate valerate Amygdala amara, water of Amyl nitrite by inhalation Amylene hydrate Amylum iodatum Angelica- root, fluid extract Angustura-bark Anise, oil of spirit of . . Anthemis extract fluid extract Antimonial powder Antimony oxide oxysulphuret - and potassium tartrate, as diaphoretic as emetic sulphide sulphurated sulphuret wine of frTrtipyrine A ntitoxine (for diphtheria) Apiol Apocynin ... Apocynum cannabinum fluid extract of Apomorphine hydrochloride Aralia hispida, fluid extract of ... . nudicaulis, fluid extract of racemosa, fluid extract of spinosa, fluid extract of Arbutin Areca, fluid extract of . . • .... Argentum and compounds. See Silver. Arnica-flowers, extract of Dose. Apotheoaries' Weights and Measures. T2-? gr- 2-6 gr. 2-6 gr. • 1-2 fl. dr. 1-2 fl. dr. i-2 gr. 1-2 fl. dr. Hgr- 5-10 gr. 30 gr.-l dr. 5-15 gr. 30 min.-l fl. dr. 1-2 fl. dr. 5-15 min. 5-15 min. 10-30 gr. J-l oz. 10-20 gr. 10-30 gr. 3-10 gr. 5-10 gr. 3-5 gr. 10-20 gr. i-igr. 5-20 gr. 3-10 gr. 2-8 gr. 1-2 fl. dr. 2-3 min. 3-5 min. 10-30 min. 5-30 gr. 30-60 min. 10-30 gr. 1-5 min. 1-2 fl. dr. i-l dr. 2-10 gr. 30-60 min. 1-3 gr. 2-3 gr. 1-2 gr. TV? gr- *-l gr. 1-2 gr. 1-2 gr. 1-2 gr. 10 min.-l fl. dr. 5-15 gr. 2000-5000 units. 2-5 min. |-2 gr. 10-20 gr. 10-30 min. tWo g r - 30-60 min. 30-10 min. 30-60 min. 30 -60 min. 1-10 gr. 30-60 min. Metric System. 0.005-0.015 gm. 0.12-0.40 gm. 0.12-0.40 gm. 4.0-8.0 cc. 4.0-8.0 cc. 0.03-0.12 gm. 4.0-8.0 cc. 0.015-0.03 gm. 0.3-0.6 gm. 2.0-4 gm. 0.3-1.0 gm. 2.0-4.0 cc. 4.0-8.0 cc. 0.3-1.0 cc. 0.3-1.0 cc. 0.6-2.0 gm. 16.0-30.0 cc. 0.6-1.3 gm. 0.6-2.0 gm. 0.20-0.6 gm. 0.3-0.6 gm. 0.20-0.3 gm. 0.6-1.3 gm. 0.015-0.03 gm. 0.3-1.3 gm. 0.20-0.6 gm. 0.12-0.50 gm. 4.0-8.0 gm. 0.10-0.20 cc. 0.20-0.3 cc. 0.6-2.0 gm. 0.3-2.0 gm. 2.0-4.0 gm. 0.6-2.0 gm. 0.05-0.3 cc. 4.0-8.0 cc. 2.0-4.0 cc. 0.12-0.6 gm. 2.0-4.0 cc. 0.06-0.20 gm. 0.12-0.20 gm. 0.03-0.12 gm. 0.004-0.03 gm. 0.03-0.06 gm. 0.03-0.12 gm. 0.06-0.12 gm. 0.03-0.12 gm. 0.6-4.0 cc. 0.3-1.0 gm. 0.10-0 0.03-0 0.6-1 0.6-2 0.004-0 2.0-4 2.0-4 2,0-4 2.0-4 0.06-0 2.0-4 .30 cc. .12 gm. .3 gm. Oca .006 gm, .Occ. .Occ. .Occ. .0 cc. .6 gm. .Occ. 2-5 gr. 0.12-0.3 gm. DOSES OF MEDICINES. 823 Remedy. Arnica-flowers, fluid extract of root, extract of fluid extract of - . . tincture of Aromatic powder Arsenate of sodium, solution of Arsenic. See Acid, arsenous. bromide iodide and mercury iodide, solution of (Dono- van's solution) . Arsenite of potassium, solution of (Fowler's solution) Asafoetida mixture of tincture Asclepias incarnata, fluid extract of . . . Syriaca, fluid extract of tuberosa Aspidium. fluid extract of oleo-resin of Aspidosperma, abstract of fluid extract of Atropine sulphate Aurantii cortex, fluid extract of Azedarach, fluid extract of Balsam of Gurjun of Tolu Eaptisia, extract of fluid extract of Baptisine Belladonna, abstract of alcoholic extract of leaves, fluid extract of tincture of root, extract of fluid extract of Benzanilide Benzoin, compound tincture of tincture of Benzol Berberina sulphate Berberis aquifolium, fluid extract of . . . vulgaris, fluid extract of Beta-naphthol . Bismuth and ammonium, citrate of . . . . citrate salicylate . subcarbonate . subgallate . . subnitrate subsalicylate tannate valerate ' Boldo, fluid extract of oil of tincture of Brayera fluid extract of infusion of Dose. Apothecaries' Metric Weights and Measures. System. 5-15 min. 0.3-1.0 cc. 2-5 gr. 0.12-0.3 gm. 5-15 min. 0.3-1.0 cc. 10-20 min. 0.6-1.3 cc. 10-30 gr. 0.6-2.0 gm. 3-5 min. 0.20-0.3 cc. sWV g r - 0.001-0.003 gm. tW g r - 0.004-0.008 gm. 2-4 min. 0.1-0.25 cc. 2-5 min. 0.1-0.3 cc. 5-20 gr. 0.3-1.3 gm. \-l fl. oz. 16.0-30.0 cc. 30 min.-l fl. dr. 2.0-4.0 cc. 15-30 min. 1.0-2.0 cc. 15-30 min. 1.0-2.0 cc. 15-30 min. 1.0-2.0 gm. 1-2 fl. dr. 4.0-8.0 cc. 30 min.-l fl. dr. 2.0-4.0 cc. 5-20 gr. 0.3-1.3 gm. 15-30 min. 1.0-2.0 cc. tIWo g r - 0.0005-0.0015 gm. 15 min.-2 fl. dr. 1.0-8.0 cc. 15-60 min. 1.0-4.0 cc. 20-30 min. 1.3-2.0 cc. 10-30 min. 0.6-2.0 cc. 2-10 gr. 0.12-0.6 gm. 10-30 min. 0.6-2.0 cc. 2-5 gr. 0.12-0.3 gm. i-H gr- 0.03-0.1 gm. i-?g r - 0.015-0.03 gm. 3-6 min. 0.20-0.40 cc. 5-30 min. 0.3-2.0 cc. Hgr. 1-2 min. 0.008-0.015 gm. 0.05-0.10 cc 1-5 gr. 0.06-0.3 gm. i-1 fl. dr. 2.0-4.0 cc. \-\ fl. dr. 2.0-4.0 cc. 5-1 min. 0.3-0.6 cc. 3-10 gr. 0.20-0.6 gm. 3-10 gr. 0.20-0.6 gm. 15-30 min. 1.0-2.0 cc. 15-30 min. 1.0-2.0 cc. £-5 gr. 0.03-0.3 gm. 1-10 gr. 0.06-0.6 gm. 3-15 gr. 0.20-1.0 gm. 5-15 gr. 0.3-1.0 gm. 5-20 gr. 0.3-1.2 gm. 3-10 gr. 0.2-0.6 gm. 5-20 gr. 0.3-1.2 gm. 5-10 gr. 0.3-0.6 gm. 5-30 gr. 0.3-2.0 gm. 1-3 gr. 0.06-0.18 gm. 5-15 min. 0.3-1.0 cc. 5 min. 0.3 cc. 8 min. 0.5 cc. 2-4 dr. 8.0-16.0 gm. 2-4 fl. dr. 8.0-16.0 gm. 4-8 oz. 120.0-240.0 cc. 824 DOSES OF MEDICINES. Remedy. Bromal Bromoform Brucina Bryonia, fluid extract of tincture of Buchu, fluid extract of Buckthorn, fluid extract of Cactus grandiflora, fluid extract of . . Caffeine citrated Cajuput, oil of Calamus, fluid extract of Calcium benzoate - . bromide carbonate chloride hypophosphite iodide lactophosphate, syrup of phosphate sulphide Calendula, fluid extract of tincture of Calomel. See Mercury, mild chloride of. Calumba, extract of fluid extract of tincture of .-...'. Calx chlorinata sulphurata Camphor bromide monobromated . spirit of. water Camphoric acid Cannabin tannate Cannabis Americana, fluid extract of . Indica, abstract of extract of fluid extract of tincture of Cantharides tincture of Capsicum fluid extract of oleoresin of tincture of Caraway, oil of . Carbon bisulphide . . . Cardamom, compound tincture of . . fluid extract of tincture of Caryophyllus, oil of Cascara sagrada extract of fluid extract of Cascarilla fluid extract of Cassia fistula, pulp of Castanea vesca, fluid extract of . . . . Castor Dose. Apothecaries' Metric Weights and Measures. System. 2-3 gr. 0.12-0.2 gm. 5-10 min. 0.3-0.6 cc. 1 _ 1 (TV 3 2 16 s 1 - 0.002-0.004 gm. 15-60 min. 1.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. i-1 fl. dr. 2.0-4.0 cc. 15-30 min. 1.0-2.0 cc. 5-10 min. 0.3-0.6 cc. 2-5 gr. 0.12-0.3 gm. 2-5 gr. 0.12-0.3 gm. 5-20 min. 0.3-1.3 cc. 15-60 min. 1.0-4.0 cc. 10 gr. 0.6 gm. 10-20 gr. 0.6-1.3 gm. 15-30 gr. 1.0-2.0 gm. 5-10 gr. 0.3-0.6 gm. 10-30 gr. 0.6-2.0 gm. 1-3 gr. 0.06-0.20 gm. 1-2 fl. dr. 4.0-8.0 cc. 15-30 gr. 1.0-2.0 gm. Hr g r - 0.012-0.03 gm. 10-30 min. 0.60-2.0 cc. 20-60 min. 1.3-4.0 cc. 3-10 gr. 0.20-0.6 gm. 15-60 min. 1.0-4.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 2-5 gr. 0.12-0.3 gm. 1-1 gr. 0.015-0.06 gm. 2-10 gr. 0.12-0.6 gm. 2-5 gr. 0.12-0.3 gm. 2-5 gr. 0.12-0.3 gm. 5-30 min. 0.3-2.0 cc. f-2 fl. oz. 16.0-60.0 cc. 15-30 gr. 1.0-2.0 gm. 5-10 gr. 0.3-0.6 gm. 3-15 min. 0.20-1.0 cc. 1-3 gr. 0.06-0.20 gm. H g r - 0.015-0.06 gm. 3-6 min. 0.20-0.40 cc. 10-30 min. 0.6-2.0 cc, 1-1 gr- 0.03-0.06 gm. 2-10 min. 0.10-0.6 cc. i-2 gr. 0.03-0.12 gm. i-2 min. 0.025-0.10 cc ^-1 min. 0.015-0.05 cc. 3-10 min. 0.20-0.60 cc. 1-5 min. 0.05-0.3 cc. l-l min. 0.025-0.05 cc. 1-2 fl. dr. 4.0-8.0 cc. 15-45 min. 1.0-3.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 1-5 min. 0.05-0.3 cc. 10-30 gr. 0.60-2.0 gm. 2-8 gr. 0.12-0.5 gm. 10-30 min. 0.6-2.0 cc. 20-30 gr. 1.3-2.0 gm. 20-30 min. 1.3-2.0 cc. 1-2 dr. 4.0-8.0 gm. 1-1 fl. dr. 2.0-4.0 cc. 1 10-30 gr. 0.6-2.0 gm. DOSES OF MEDICINES. 825 Remedy. Castor, tincture of Cataria, fluid extract of Catechu compound tincture of fluid extract of Caulophyllin Caulophyllum, infusion of Cava-cava . . . . . Cerium nitrate . oxalate Chalk, compound powder of mixture prepared Chamomile, oil of Charcoal, animal, purified Chelidonium majus extract of fluid extract of Chenopodium, oil of Cherry- laurel water Chimaphila, fluid extract of Chinoidin Chionanthus, fluid extract of ... . Chiretta, fluid extract of tincture of Chloral, hydrated Chloralformamide Chlorine-water Chloroform, mixture of purified spirit of Chrysarobin Cimicifuga, fluid extract of tincture of Cinchona-bark aromatic fluid extract of compound tincture of extract of fluid extract of tincture of Cinchonia sulphate Cinchonidia or Cinchonidine sulphate Cinchonine sulphate Cinnamon oil of spirit of tincture of Cloves. See Caryophyllus. Coca, fluid extract of leaves of . Cocaine Cocculus, fluid extract of tincture of Codeine or Codeia Colchicine Colchicum, acetic extract of corm extract of fluid extract of wine of seed Dose. Apothecaries' Metric Weights and Measures. System. 2-4 fl. dr. 8.0-16.0 cc. 15 min.-l fl. dr. 1.0-4.0 cc. 10-30 gr. 0.6-2.0 gm. £-2 fl. dr. 2.0-8.0 cc. 10-30 min. 0.6-2.0 cc. Wg*. 0.015-0.03 gm. 1-2 oz. 16.0-60.0 cc. 10-30 gr. 0.6-2.0 gm. 1-2 gr. 0.06-0.12 gm. 2-5 gr. 0.12-0.3 gm. 10-30 gr. 0.6-2.0 gm. 1-2 fl. oz. 30.0-60.0 cc. 15-30 gr. 1.0-2 gm. 5-15 min. 0.3-1.0 cc. 10-30 gr. 0.6-2.0 gm. l-l dr. 2.0-4.0 gm. 5-10 gr. 0.3-0.6 gm. 30-60 min. 2.0-4.0 cc. 4-8 min. 0.25-0.5 cc. 5-30 min. 0.3-2.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 10-30 gr. 0.6-2.0 gm. 30-60 min. 2.0-4.0 cc. 10-30 fl. dr. 0.6-2.0 cc. 15-60 min. 1.0-4.0 cc. 5-20 gr. 0.3-1.3 gm. 15-30 gr. 1.0-2.0 gm. 1-4 fl. dr. 4.0-10.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 5-10 min. 0.3-0.6 cc. 10 min.-l fl. dr. 0.6-4.0 cc. 5-20 gr. 0.3-1.3 gm. 10-30 min. 0.6-2.0 cc. |-1 fl. dr. 2.0-4.0 cc. 10 gr.-l dr. 0.6-4.0 gm. 30-60 min. 2.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 5-15 gr. 0.3-1.0 gm. 10-30 min. 0.6-2.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 10-20 gr. 0.6-1.3 gm. 10-30 gr. 0.6-2.0 gm. 10-30 gr. 0.6-2.0 gm. 5-20 gr. 0.3-1.3 gm. 1-5 min. 0.05-0.3 cc. 5-20 min. 0.3-1.3 cc. i-2 fl. dr. 2.0-8.0 cc. 20 min.-l fl. dr. 1.3-4.0 cc. l-l dr. 2.0-4.0 gm. i-1 g^ 0.03-0.06 gm. 1-3 min. 0.05-0.2 cc. 2-10 min. 0.10-0.6 cc. 1-2 gr. 0.06-0.12 gm. 0.0006-0.0012 gm. \~\ g r - 0.015-0.03 g:n. 2-5 gr. 0.12-0.3 gm. 1 1 orr 0.015-0.0:; gm. 2-5 min. 0.10-0.3 cc. 10-20 min. 0.6-1.3 cc. 2-10 gr. 0.12-0.6 gm. 826 DOSES OF MEDICINES. Remedy. Colchicum, seed, fluid extract of . tincture of wine of Colocynth compound extract of extract of Colocynthidine Colocynthin Condurango, fluid extract of . . . Coniine hydrochloride Conium, abstract of fluid extract of fruit, alcoholic extract of . . . fluid extract of tincture of leaves, extract of fluid extract of Convallamarin Convallaria, extract of fluid extract of Copaiba oil of Copper, acetate ammoniated sulphate, astringent, tonic . . . emetic Coptis, fluid extract of Corrosive sublimate. See Mercury. Corydalis, fluid extract of ... . Coto fluid extract of tincture of Cotoin Cotton-root bark. See Gossypium. Creasote water Creolin Croton-chloral hydrate Croton oil Cubebs fluid extract of oil of oleoresin of tincture of Curare Curarin Cypripedium fluid extract of Damiana, fluid extract of ... . tincture Daturine Delphinium, fluid extract of . . . Digitaline Digitalis, abstract of extract of fluid extract of infusion of powder of leaves of tincture of Apothecaries' Metric Weights and Measures. System. 2-10 min. 0.10-0.60 cc. 10-40 min. 0.6-2.6 cc. 10-40 min. 0.6-2.6 cc. 2-10 gr. 0.12-0.6 gm. 5-10 gr. 0.3-0.6 gm. 1-5 gr. 0.06-0.3 gm. irl gi". 0.005-0.01 gm. i-1 gr- 0.015-0.06 gm. 10-30 min. 0.6-2.0 cc. eW* gr- 0.001-0.002 gm. ■h-h gr- 0.001-0.002 gm. 1-2 gr. 0.06-0.12 gm. 5 min. 0.3 cc. 5-1 gr- 0.03-0.06 gm. 1-2 min. 0.05-0.10 cc. 10-20 min. 0.6-1.3 cc. 1-2 gr. 0.06-0.12 gm. 1-5 min. 0.05-0.3 cc. i-2 gr. 0.03-0.12 gm. 2-10 gr. 0.12-0.6 gm. 15-30 min. 1.0-2.0 cc. 20 min.-l fl. dr. 1.3-4.0 cc. 10-20 min. 0.6-1.3 cc. i-i gr. 0.015-0.03 gm. i~l gr- 0.01-0.06 gm. i-5 gr. 0.015-0.03 gm. 5gr. 0.3 gm. 30-60 min. • 2.0-4.0 cc. 15-30 min. 1.0-2.0 cc. 5-15 gr. 0.30-1.0 gm. 5-15 min. 0.3-1.0 cc. 10-40 min. 0.60-2.6 cc. tW gr- 0.005-0.008 gm. 1-3 min. 0.05-0.20 cc. 1-4 fl. dr. 4.0-16.0 cc. % min. 0.025 cc. 2-10 gr. 0.12-0.6 gm. ^-1 min. 0.025-0.05 cc. 10 gr.-l dr. 0.6-4.0 gm. 10-60 min. 0.6-4.0 cc. 10-20 min. 0.6-1.3 cc. 5-20 min. 0.3-1.3 cc. 1-2 fl. dr. 4.0-8.0 cc. j\-i gr. 0.002-0.008 gm. 1 1 -y,. 64~S2 g 1 - 0.001-0.002 gm. 15-30 gr. 1.0-2.0 gm. 15-30 min. 1.0-2.0 cc. 30 min.-2 fl. dr. 2.0-8.0 cc. 1-3 fl. dr. 4.0-12.0 cc. t^Wo gr- 0.0006-0.0012 gm 1-3 min. 0.05-0.2 cc. ■5o~z\ gr- 0.0012-0.002 gm. 1-2 gr. 0.06-0.12 gm. i-5 gr- 0.01-0.03 gm. 1-6 min. 0.05-0.40 cc. 2-4 fl. dr. 8.0-16.0 cc. 5-2 gr. 0.03-0.12 gm. 5-30 min. 0.3-2.0 cc. DOSES OF MEDICINES. 827 Remedy. Dioscorea, fluid extract of Dita, fluid extract of Dogwood, bark of root fluid extract of Donovan's solution. See Arsenic. Dover's powder Dracontium fluid extract of Drosera, fluid extract of Duboisine Dulcamara, extract of fluid extract of Elaterin Elaterium Emetin, diaphoretic emetic Ergot extract of fluid extract of tincture of wine of Ergotin, Bonjean's (purified extract of ergot) Erigeron, oil of Eriodictyon, extract of fluid extract of ........... . Ervthrophlcein Erythroxylon. See Coca. Eserine Ether, acetic compound spirit of (Hoffman's anodyne) nitrous, spirit of (sweet spirit of nitre) . sulphuric Ethyl bromide Eucalyptol Eucalyptus, fluid extract of oil of Euonymin Euonymus, extract of fluid extract of Eupatorium, fluid extract of .Euphorbia pilulifera, fluid extract of . . . Fel bovis purificatum Ferrum. See Iron. Frangula, fluid extract of Galls, aromatic syrup of fluid extract of tincture of . . -Gambir compound tincture of fluid extract of Gamboge . . Gaultheria, oil of Gelsemium, abstract of extract of fluid extract of . . . tincture of Gentian, compound infusion of extract of fluid extract of tincture of -Geranium, fluid extract of Dose. Apothecaries' Metric Weights and Measures. System. 15-30 min. 1.0-2.0 cc. 1-4 min. 0.5-0.25 cc. 20-60 gv. 1.3-4.0 gm. 30-60 min. 2.0-4.0 cc. 5-20 gr. 0.3-1.3 gm. 10-30 gr. 0.6-2.0 gm. 10-30 min. 0.6-2.0 cc. 5-10 min. 0.3-0.6 cc. ro-o gr- 0.0006 gm. 30-60 gr. 2.0-4.0 gm. £-1 fl. dr. 2.0-4.0 cc. WG-T5 gi'- 0.001-0.004 gm. 1 1 ~ r n? g r - 0.006-0.015 gm. T2'?5~'3 0" g r# 0.0005-0.002 gm. i-i gr- 0.008-0.015 gm. 15-60 gr. 1.0-4.0 gm. 2-10 gr. 0.12-0.6 gm. 15 min.-l fl. dr. 1.0-4.0 cc. £-2 fl. dr. 2.0-8.0 cc. 1-3 fl. dr. 4.0-12.0 cc. 2-8 gr. 0.12-0.5 gm. 5-15 min. 0.3-1.0 cc. 2-5 gr. 0.12-0.3 gm. 15-30 min. 1.0-2.0 cc. tW gr- 0.004-0.008 gm. tWxr gr- 0.001-0.003 gm. 10-20 min. 0.6-1.3 cc. 30 min. 2.0 cc. |-1 fl. dr. 2.0-4.0 cc. 15-40 min. 1.0-2.6 cc. 15-60 min. 1.0-4.0 cc. 10-15 min. 0.6-1.0 cc. 15-30 min. 1.0-2.0 cc. 5-10 min. 0.3-0.6 cc. 2-5 gr. 0.12-0.3 gm. 1-3 gr. 0.06-0.20 gm. i-1 fl. dr. 2.0-4.0 cc. £-1 fl. dr. 2.0-4.0 cc. 5-30 min. 0.3-2.0 cc. 3-6 gr. 0.20-0.40 gm. 15-30 min. 1.0-2.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 5-20 min. 0.30-1.3 cc. £-2 fl. dr. 2.0-8.0 cc. 10-30 gr. 0.6-2.0 gm. £-2 fl. dr. 2.0-8.0 cc. 10-30 min. 0.6-2.0 cc. i-4gr. 0.03-0.25 gm. 2-10 min. 0.10-0.6 cc. 1-2 gr. 1-1 gr- 0.06-0.12 gm. 0.03-0.06 gm. 2-5 min. 0.10-0.3 cc. 5-20 min. 0.3-1.3 cc. 1-4 fl. dr. 4.0-8.0 cc. 2-5 gr. 0.12-0.30 gm. i-1 fl. dr. 2.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 20-30 min. | 1.3-2.0 cc. 828 DOSES OF MEDICINES. Remedy. Ginger, fluid extract of oleo-resin of . . . . tincture of Gland, suprarenal, dried thyroid, dried Glycyrrhiza. See Licorice. Goa powder Gold bromide Gold and sodium chloride Gossypium-root, fluid extract of bark of . Granati radicis cortex, fluid extract . . . Grindelia, fluid extract of ...... . Guaiac, ammoniated tincture of ... . resin of tincture of Guaiacol Guarana fluid extract of Gurjun. See Balsam. Hsematoxylon extract of fluid extract of Hamamelis, fluid extract of Hedeoma, oil of Helleborein Helleborus niger, extract of fluid extract of tincture of Hepatica. fluid extract ol ...... . Hexamethylenamine Hops, extract of fluid extract of tincture of . . . . . Hydrangea, fluid extract of Hydrastine . Hydrastis, extract of fluid extract of tincture of Hyoscine hydrobromide . Hyoscyamine sulphate Hyoscyamus, abstract of alcoholic extract of extract of fluid extract of flowers ........ of seeds tincture of flowers of seedf; of leaves Hypnal Hypnone Hypophosphites, syrup of with iron, syrup of Ichthyol Ignatia, abstract of extract of fluid extract of . tincture of Iodine, compound solution of tincture of Iodoform lodol Dose. Apothecaries' Metric Weights and Measures. System. 10-30 min. 0.6-2 cc. 1-3 min. 0.06-0.20 jc. 15-60 min. 1.0-4.0 cc. 2-5 gr. 0.12-0.3 gm. £-5 gr. 0.03-0.3 gm. 5-20 gr. 0.3-1.3 gm. M gr. 0.008-0.03 gm. 0.0015-0.003 gm. i-l fl. dr. 2.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. |-1 fl. dr. 2.0-4.0 cc. 30-60 min. 2.0-4.0 cc. 10-20 gr. 0.6-1.3 gm. 30-60 min. 2.0-4.0 cc. ^-3 min. 0.025-0.2 cc. 10-30 gr. 0.6-2.0 gm. 10-30 min. 0.6-2.0 cc. 30-60 gr. 2.0-4.0 gm. 10-20 gr. 0.6-1.3 gm. 30-60 min. 2.0-4.0 cc. 30 min.-2 fl. dr. 2.0-8.0 cc. 2-5 min. 0.10-0.3 cc. iHgr- 0.006-0.015 gm. 4-2 gr. 0.03-0.12 gm. 5-15 min. 0.3-1.0 cc. 10-30 min. 0.6-2.0 cc. 30-60 min. 2.0-4.0 cc. 5-20 gr. 0.3-1.3 gm. 3-15 gr. 0.2-1.0 gm. 30-60 min. 2.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 30-60 min. 2.0-4.0 cc. i~ig r - 0.015-0.03 gm. 3-10 gr. 0.2-0.6 gm. 10-30 min. 0.6-2 cc. 30-60 min. 2.0-4.0 cc. TiyWo g r - 0.0006-0.001 gm. T27~6 g r> 0.0005-0.001 cm. 2-3 gr. 0.12-0 2 gm. 1-2 gr. 0.06-0.12 gm. 2-3 gr. 0.12-0.2 gm. 5-15 min. 0.3-1.0 cc. 5 min. 0.3 cc. 15-30 min. 1.0-2.0 cc. 15-30 min. 1.0-2.0 cc. 10-30 min. 0.6-2.0 cc. 5-20 gr. 0.3-1. gm. 1-5 gr. 0.06-0.3 gm. 1 fl. dr. 4.0 cc. 1 fl. dr. 4.0 cc. 2-4 gr. 0.12-0.25 gm. 1-3 gr. 0.06-0.2 gm. i-1 gr- 0.015-0.06 gm. 1-6 min. 0.05-0.40 cc. 5-15 min. 0.3-1.0 cc. 5 min. 0.3 cc. 2-4 min. 0.1-0.25 cc 1-3 gr. 0.06-0.2 gm. i-* g^ 0.03-0.12 gm. DOSES OF MEDICINES. 829 Remedy. Ipecacuanha, emetic . . . expectorant abstract of, emetic . . . fluid extract of, emetic . syrup of wine of, emetic . . . . expectorant I rid in or Irisin Iris, extract of fluid extract of . . . . Iron acetate, tincture of . . and ammonium citrate - sulphate tartrate arsenate benzoate bitter wine of bromide syrup of carbonate, saccharated . chloride tincture of and cinchonidia citrate . citrate compound mixture of . dialyzed solution of hydroxide of hypo phosphite syrup of* iodide syrup of lactate magnetic oxide of . . . inalate nitrate, solution . . . . phosphate pomate and potassium tartrate . pyrophosphate and quinia citrate . . . reduced saccharated carbonate of. and strychnine citrate . subcarbonate subsulphate sulphate . . dried valerianate wine of the citrate of. . Jaborandi, extract of . . . fluid extract of Dose. Apothecaries' Weights and Measures. Metric System. 15-30 gr. 4-1 gr. 5-15 gr. 15-30 min. i-1 fl. dr. 3-6 fl. dr. 5-15 min. 1-5 gr. 1-3 gr. 5-15 min. 15-30 min. 5-10 gr. 5-10 gr. 5-15 gr. -5 gr. 1-2 fl. dr. 1-5 gr. _ 15-60 min. 5-15 gr. 1-3 gr. 10-30 min. 5-10 gr. 5-10 gr. 1-2 fl. oz. i _ ¥o • 1- " alap abstract of compound powder of extract of alcoholic extract of . fluid extract of . . . resin of tincture of ... . Juglans, extract of . . 10-30 min. Tablespoonful doses in 5-10 gr. 1 fl. dr. 1-5 gr. _ 10-30 min. 1-5 gr. 5-10 gr. 5-15 gr. 8-15 min. 1-5 gr. 5-15 gr. 10-30 gr. 2-5 gr. 5-10 gr. 3-6 gr. 5-15 gr. 1-3 gr. 5-30 gr. 1-3 gr. 1-3 gr. i-2 gr. 1-3 gr. i-l fl. dr. 2-5 gr. 10-60 min. 5-30 gr. 5-15 gr. I dr. 5-10 gr. 3-6 gr. 5-30 min. 4-8 gr. f-2 fl. dr. 5-20 gr. 1.0-2.0 gm. 0.01-0.06 gm. 0.3-1.0 gm. 1.0-2.0 cc. 2.0-4.0 cc. 12.0-24.0 cc. 0.3-1.0 cc. 0.06-0.3 gm. 0.06-0.2 gm. 0.3-1.0 cc. 1.0-2.0 cc. 0.3-0.6 gm. 0.3-0.6 gm. 0.3-1.0 gm. 0.0015-0.003 gm. 0.06-0.3 gm. 4.0-8.0 cc. 0.06-0.3 gm; 1.0-4.0 cc. 0.3-1.0 gm. 0.06-0.20 gm. 0.6-2.0 cc. 0.3-0.6 gm. 0.3-0.6 gm. 30.0-60.0 cc. 0.3-1.0 cc. 0.6-2.0 cc. arsenical poisoning. 0.3-0.6 gm. 4.0 cc. 0.06-0.3 gm. 0.6-2.0 cc. 0.06-0.3 gm. 0.3-0.6 gm. 0.3-1.0 gm. 0.5-1.0 cc. 0.06 -0.3 gm. 0.3-1 .Ogm. 0.6-2.0 gm. 0.12-0.3 gm. 0.3-0.6 gm. 0.2-0.4 gm. 0.3-1.0 gm. 0.06-0.20 gm. 0.3-2.0 gm. 0.06-0.20 gm. 0.06-0.20 gm. 0.03-0.12 gm. 0.06-0.20 gm. 2.0-4.0 cc. 0.12-0.3 gm. 0.6-4.0 cc. 0.3-2.0 gm. 0.3-1.0 gm. 2.0 gm. 0.3-0.6 gm. 0.20-0.40 gm. 0.3-2.0 cc. 0.25-0.5 gm. 2.0-8.0 cc. 0.3-1.3 gm. 830 DOSES OF MEDICINES. Remedy. Juglans, fluid extract of ........ Juniperus, fluid extract of Kairin Kamala fluid extract of Kino fluid extract of tincture of ... Kola, fluid extract of Koosso. See Brayera. Krameria extract of fluid extract of syrup of tincture of Lactucarium fluid extract of syrup of Lappa, fluid extract of Lead acetate iodide Leptandra extract of fluid extract of Leptandriu . Lime, solution of syrup of • Liquor potassae, soda?, etc. See Potassa, Soda, etc. Liquorice, compound mixture of powder of .• Lithium benzoate . . . bromide carbonate citrate . • • salicylate Lobelia, fluid extract of tincture of Lupulin fluid extract of oleoresin of . . tincture of . Magnesia Magnesium carbonate oxide . sulphate • ■ effervescent ............ sulphite Male fern, oleoresin of Malt, extract of . Manganese dioxide, precipitated hypophosphite sulphate Manna Matico fluid extract of tincture of . . . ' Matricaria, fluid extract of . Menispermum, fluid extract of Menthol Mercury with chalk Dose. Apothecaries' Metric Weights and Measures. System. 1-2 fl. dr. 4.0-8.0 cc. 30-60 min. 2.0-4.0 cc. 2-10 gr. 0.12-0.6 gm. i-1 dr. 2.0-4.0 gm. 30-60 min. 2.0-4.0 cc. 10-30 gr. 0.6-2.0 gm. 10-30 min. 0.6-2.0 cc. i-2 fl. dr. 2.0-8.0 cc. 10-30 min. 0.6-2.0 cc. 10-30 gr. 0.6-2.0 gm. 5-15 gr. 0.3-1.0 gm. 20-30 min. 1.3-2.0 cc. 1-4 fl. dr. 4.0-16.0 cc. |-2 fl. dr. 2.0-8.0 cc. 10-30 gr. 0.6-2.0 gm. 10-30 min. 0.6-2.0 cc. 1-3 fl. dr. 4.0-12.0 cc. 30-60 min. 2.0-4.0 cc. i-3 gr. 0.03-0.20 gm. 4-3 gr. 0.03-0.20 gm. 20-40 gr. 1.3-2.6 gm. 3-10 gr. 0.20-0.6 gm. 20-40 min. 1.3-2.6 cc. 2-4 gr. 0.12-0.25 gm.. 1-4 dr. 4.0-16.0 cc. 15-30 min. 1.0-2.0 cc. 1-4 fl. dr. 4.0-16.0 cc. i-1 dr. 2.0-4.0 gm. 5-10 gr. 0.3-0.6 gm. 2-10 gr. 0.12-0.6 gm. 2-10 gr. 0.12-0.6 gm. 2-10 gr. 0.12-0.6 gra- 2-10 gr. ft 12-0. 6 gm. 1-5 min. 0.05-0.3 cc. 10-30 min. 0.6-2.0 cc. 5-15 gr. 0.3-1.0 gm. 5-15 min. 0.3-1.0 cc. 2-5 gr. 0.12-0.3 gm. \-2 fl. dr. 2.0-8.0 cc. 10-30 gr. 0.6-2.0 gm. 10 gr.-l dr. 0.6-4.0 gm. 10-30 gr. 0.6-2.0 gm. 2 dr.-l oz. 8.0-30.0 gm.. £-1 oz. 16.0-30.0 gm.. 10-30 gr. 0.6-2.0 gm. 30 min.-l fl. dr. 2.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 2-4 gr. 0.12-0.25 gm.. 2-5 gr. 0.12-0.3 gm. 2-10 gr. 0.12-0.6 gm. 1-2 oz. 30.0-60.0 gm.. 1-2 dr. 2.0-8.0 gm. 1-1 fl. dr. 2.0-4.0 cc. |-2 fl. dr. 2.0-8.0 cc. 10-30 min. 0.6-2.0 cc. 30-60 min. 2.0-4.0 cc. 2 gr. 0.12 gm. 2-10 gr. 0.12-0.6 gm. DOSES OF MEDICINES. 831 Remedy. Mercury, corrosive chloride of cyanide formamidate (1 per cent, solution) . . . green iodide of . . mass of (bine pill) mild chloride of red iodide of. . < salicylate tannate yellow subsulphate of Mezereum, extract of fluid extract of Morphine and its salts Morrhuol Musk tincture of Myrrh . tincture of Myrtol Naphthalene Naphthol m Narceine Narcotine Nectandra, fluid extract of Nitroglycerin (1 per cent, solution) . . . . Nux vomica, abstract of extract of fluid extract of tincture of Opium, camphorated tincture of (paregoric) confection of . . extract of powder tincture of (laudanum) wine of Pancreatin Papaver, extract of fluid extract of Papayotin Paracotoin Paraldehyde Pareira extract of fluid extract of tincture of Pelletierine sulphate tannate Peppermint, oil of spirit of Pepsin, pure liquor of saccharated Petroselinum, fluid extract of Phenacetin Phenol Phenyl, salicylate of Phosphorated oil . Phosphorus Physostigma, extract of fluid extract of tincture of Dose. Apothecaries' Metric Weights and Measures. System. sWe gr- 0.002-0.004 gm. tW gr. 0.004-0.008 gm. 5-15 min. 0.3-1.0 cc. hi £r- 0.01-0.03 cc. 3-10 gr. 0.2-0.6 gm. I- 5 g r - 0.008-0.3 gm. sWe gr- 0.002-0.004 gm. H gr- 0.03-0.06 gm. 2-1 gr- 0.03-0.06 gm. J-l gr- 0.015-0.06 gm. 1-1 gr- 0.03-0.06 gm. 3-10 min. 0.2-0.6 cc. tW gr- 0.004-0.03 gm. 1-5 min. 0.05-0.3 cc. 2-15 gr. 0.12-1.0 gm. 15-60 min. 1.0-4.0 cc. 3-10 gr. 0.2-0.6 gm. 15-30 min. 1.0-2.0 cc. 2-3 gr. 0.12-0.20 gm. 2-10 gr. 0.12-0.6 gm. 2-10 gr. 0.12-0.6 gm. h\ gr- 0.01-0.03 gm. 3 gr. 0.2 gm. 1-4 fl. dr. 4.0-16.0 cc. 1 min. 0.05 cc. i-1 gr. 0.015-0.06 gm. i-a- gr- 0.008-0.03 gm. 1-5 min. 0.06-0.3 cc. 10-20 min. 0.6-1.3 cc. i-2 fl. dr. 2.0-8.0 cc. 10-40 gr. 0.6-2.6 gm. i i ™ r 6 2 gr- 0.01-0.03 gm. i~2 gr. 0.015-0.3 gm. 5-20 min. 0.3-1.3 cc. 5-20 min. 0.3-1.3 cc. 10-20 gr. 0.6-1.3 gm. 1-2 gr. 0.03-0.12 gm. 15-30 min. 1.0-2.0 cc. 1-5 gr. 0.06-0.3 gm. 1-3 gr. 0.06-0.2 gm. 20-60 min. 1.3-4.0 cc. 10-30 gr. 0.6-2.0 gm. 5-15 gr. 0.3-1.0 gm. 10-30 min. 0.6-2.0 cc. 1 fl. dr. 4.0 cc. 2-5 gr. 0.12-0.3 gm. 1-5 gr. 0.6-0.3 gm. 2-5 min. 0.10-0.3 cc. 30-60 min. 2.0-4.0 cc. 15 gr.-l dr. 1.0-4.0 gm. 2-4 fl. dr. 8.0-16.0 cc. 30 gr.-| oz. 2.0-16.0 gm. 1-2 fl. dr. 4.0-8.0 cc. 2-5 gr. 0.12-0.3 gm. 4-1 gr- 0.03-0.06 gm. 5-20 gr. 0.3-1.3 gm. 3-5 min. 0.2-0.3 cc. Th~i\ gr- 0.0006-0.0008 gm. iW gr. 0.004-0.01 gm. 1-3 min. 0.05-0.2 cc. 10-20 min. 0.6-1.3 cc. 832 DOSES OF MEDICINES. Remedy. Physostigmine salicylate sulphate Phytolacca, abstract of berries, fluid extract of root, extract of fluid extract of tincture of . . . . Phytolaccin Picrotoxin . Pilocarpine and its salts Pilocarpus, abstract of fluid extract of Pimenta, fluid extract of , Piper methysticum, fluid extract of. . nigrum, fluid extract of Piper nigrum, oleoresin of Piperine Piscidia erythrina, extract of ... . fluid extract of . . . . powder of Podophyllum, abstract of resin of • • • Pomegranate, bark of Poppy. See Papaver. Potassa, solution of (liquor potassse) . Potassium acetate bicarbonate bitartrate bromide carbonate chlorate ■ citrate . . solution of cyanide ferrocyanide hydroxide, solution of hypophosphite • iodide mixture of the citrate of ... . nitrate permanganate . . and sodium tartrate sulphate sulphide sulphite tartrate Prinos fluid extract Pulsatilla, fluid extract of Pyrethrum, tincture of Pyridine Pyrodine Quassia, extract of fluid extract of tincture of Quebracho, fluid extract of ... . Quercus, fluid extract of Quinidine Quinine and salts arsenate Quinoidin Dose. Apothecaries' Metric Weights and Measures. System. tIo- h g r - 0.0005-0.0008 gm. TZO~~JO g r - 0.0005-0.0008 gm. 5-15 gr. 0.3-1.0 gm. 5-30 min. 0.3-2.0 cc. 1-3 gr. 0.06-0.2 gm. 5-30 min. 0.3-2.0 cc. 10-60 min. 0.6-4.0 gm. 2-3 gr. 0.12-0.2 gm. TsWs g r - 0.001-0.002 gm. *W g r - 0.001-0.03 gm. 5-20 gr. 0.3-1.3 gm. 15-60 min. 1.0-4.0 cc. 15-45 min. 1.0-3.0 cc. 15 min.-l fl. dr. 1.0-4.0 cc. 15-45 min. 1.0-3.0 cc. 1-3 min. 0.05-0.2 cc. 1-8 gr. 0.00-0.5 gm. 1-2 gr. 0.06-0.12 gm. 10-30 min. 0.6-2.0 cc. 10-30 gr. 0.6-2.0 gm. 1-5 gr. 0.6-0.3 gm. i-i gr- 0.008-0.03 gm. 20-30 gr. 1.3-2.0 gm. 5-20 min. 0.3-1.3 cc. 15 gr.-l dr. 1.0-4.0 gm. 10-40 gr. 0.6-2.6 gm. 10-60 gr. 0.6-4.0 gm. 10 gr.-l dr. 0.6-4.0 gm. 5-30 gr. 0-3-2.0 gm. 5-15 gr. 0.3-1.0 gm. 15-60 gr. 1.0-4.0 gm. 2-4 fl. dr. 8.0-16.0 cc. tW gr- 0.004-0.008 gm. 10-15 gr. 0.6-1.0 gm. 5-20 min. 0.3-1.3 cc. 5-15 gr. 0.3-1.0 gm. 2-15 gr. 0.12-1.0 gm. \ fl. oz. 16.0 cc. 5-15 gr. 0.3-1.0 gm. 1-2 gr. 0.06-0.12 gm. i-1 oz. 16.0-30.0 gm 30 gr.-2 dr. 2.0-8.0 gm. 1-10 gr. 0.06-0.6 gm. 15-30 gr. 1.0-2.0 gm. 1 dr.-l oz. 4.0-30.0 gm. 30 gr.-l dr. 2.0-4.0 gm. 30-60 min. 2.0-4.0 cc. 2-5 min. 0.10-0. 3 >cc. 10-30 min. 0.6-2.0 cc. 1-3 gr. 0.06-0.2 gm. 1-3 gr. 0.06-0.2 gm. 1-5 gr. 0.06-0.3 gm. 30-60 min. 2.0-4.0 cc. i-1 fl. dr. 1.0-4.0 cc. 20-60 min. 1.3-4.0 cc. 30-60 min. 2.0-4.0 cc. 1-30 gr. 0.06-2.0 gm. 1-30 gr. 0.06-2.0 gm. i-1 gr- 0.01-0.06 gm. 10-30 gr. 0.6-2.0 gm. DOSES OF MEDICINES. 833 Resorcinol . Rhamnus catharticus, fluid extract of . . Rhubarb aromatic syrup of tincture of . . . . compound powder of extract of fluid extract of and soda, mixture of sweet tincture of syrup of tincture of wine of Rhus, aromatic fluid extract of glabra (cortex), fluid extract of . . . (fructus), fluid extract of Rhus toxicodendron Roses, fluid extract of syrup of Rubus, fluid extract of Ruraex, fluid extract of . Ruta, fluid extract of Sabina, fluid extract of Saccharin Salicin Salix, fluid extract of Salol (phenyl salicylate) Salvia, fluid extract of - . . Sambucus, fluid extract of Sandal-wood, oil of Sanguinaria fluid extract of tincture of Santonica fluid extract of Santonin Sarsaparilla, compound fluid extract Of . compound syrup of fluid extract of Sassafras, fluid extract of ...... . Savine, oil of Saw palmetto fluid extract of ......... . Scammony resin of Scoparius, fluid extract of Scutellaria, fluid extract of Scutellarine Senega, abstract of fluid extract of syrup of Senna compound infusion of confection of fluid extract of infusion of syrup of tincture of Serpentaria, fluid extract of tincture of , Silver iodide Dose. Apothecaries' Metric Weights and Measures. System. 5-10 gr. 0.3-0.6 gm. 30-60 min. 2.0-4.0 cc. 5-40 gr. 0.3-2.6 gm. 1-4 fl. dr. 4.0-16.0 cc 4-1 fl. dr. 2.0^.0 cc. 4-1 dr. 2.0-4.0 gm. 5-15 gr. 0.3-1.0 gm. 15-40 min. 1.0-2.6 cc. 1-2 fl. dr. 2.0-8.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 15-60 min. 1.0-4.0 cc. 30-60 min. 2.0-4.0 cc. - 30-60 min. 2.0-4.0 cc. 1-6 min. 0.05-0.4 gm. i-2 fl. dr. 2.0-8.0 cc. 1-2 fl. dr. 4.0-8.0 cc. i-2 fl. dr. 2.0-8.0 cc. 30-60 min. 2.0-4.0 cc. 15-30 min. 1.0-2.0 cc. 5-15 min. 0.3-1.0 cc. J-4 gr. 0.03-0.25 gm. 10-30 gr. 0.6-2.0 gm. i-2 fl. dr. 2.0-8.0 cc. 5-20 gr. 0.3-1.3 gm. 4-2 fl. dr. 2.0-8.0 cc. 4-2 fl. dr. 2.0-8.0 cc. 10-20 min. 0.6-1.3 cc. 5-10 gr. 0.3-0.6 gm. 5-10 min. 0.3-0.6 cc. 10-40 min. 0.6-2.6 cc. 10-30 gr. 0.6-2.0 gm. 10-30 min. 0.6-2.0 cc. 1-4 gr. 0.06-0.25 gm. 4-2 fl. dr. 2.0-8.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 4-2 fl. dr. 2.0-8.0 cc. 4-2 fl. dr. 2.0-8.0 cc. 2-5 min. 0.10-0.3-cc. 15-30 gr. 1.0-2.0 gm. 15-30 min. 1.0-2.0 cc. 5-15 gr. 0.3-1.0 gm. 2-10 gr. 0.12-0.6 gm. • 4-1 fl. dr. 2.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 1-3 gr. 0.06-0.20 gm. 4-10 gr. 0.25-0.6 gm. 8-15 min. 0.5-1.0 cc. 4-2 fl. dr. 2.0-8.0 cc. 1-2 dr. 4.0-8.0 gm. 1-2 oz. 30.0-60.0 gm. 1-2 dr. 4.0-8.0 gm. l-2fl.dr. 4.0-8.0 cc. 4 fl. oz. 120.0 cc. 1-4 fl. dr. 4.0-16.0 cc. 2 fl. dr.-l fl. oz. 8.0-30.0 cc. 30 min.-l fl. dr. 2.0-4.0 cc. 4-2 fl. dr. 2.0-8.0 cc. 4-2 gr. 0.03-0.12 gm. 53 834 DOSES OF MEDICINES. Remedy. Silver nitrate oxide Simaruba, fluid extract of . Soda, solution of (liquor sodii hydroxidi) Sodium acetate arsenate . . exsiccated benzoate bicarbonate bisulphite borate bromide carbonate chlorate citrate hydroxide, solution of hypophosphite hyposulphite (thiosulphate) iodide nitrite phenolsulphonate (sulphocarbolate) . phosphate compound solution of exsiccated salicylate sulphate sulphite Sparteine sulphate Spigelia, fluid extract of and senna, fluid extract of Squill, compound fluid extract of . . . syrup of fluid extract of syrup of tincture of Stillingia, fluid extract of Stramonium, extract of fluid extract of leaves, alcoholic extract of .... . tincture of seeds, extract of . tincture of . Strontium bromide iodide . lactate phosphate salicylate Strophanthus, tincture of Strophantin Strychnine and its salts Sulphonal Sulphur Sumbul, fluid extract of tincture of Taraxacum, extract of fluid extract of Terebene Terpine hydrate Terpinol .... Thallin, sulphate of tartrate of Dose. Apothecaries' Weights and Measures. . M gr. i-1 gr. 15-30 min. 5-20 min. 15 gr.-l dr. 1-1 or 6 0~To 5 1 - 5-30 gr. 10-30 gr. 10-30 gr. 10-30 gr. 10-30 gr. 10-30 gr. 5-30 gr. 1-10 dr. 5-20 min. 5-15 gr. 10-30 gr. 5-20 gr. 1-4 gr. £-5 g r - i-2 dr. i-2 fl. dr. 15-60 gr. 10-20 gr. 1-4 dr. 10-30 gr. hi gr. 15-60 min. i-2 fl. dr. 5-15 min. 15-30 min. 5-15 min. i-l fl. dr. 10-60 min. 15-60 min. igr : 1-4 min. 1-1 err ¥ 2 g r ' . 8-15 min. H g^ 6-15 min. 20-30 gr. 10-20 gr. 20-30 gr. 20-30 gr. 5-20 gr. 3-8 min. T2o"~"A g r - eWe gr. 15-30 gr. 1-3 dr. 10-30 min. 20-60 min. 5-15 gr. l-l fl. dr. 5-10 min. 2-5 gr. tb gr- 1-5 gr. 1-5 gr. Metric System. 0.015-0.03 gm. 0.03-0.06 gm. 1.0-2.0 cc. 0.3-1.3 cc. 1.0-4.0 gm. 0.001-0.006 gm. 0.0006-0.002 gm. 0.3-2.0 gm. 0.6-2.0 gm. 0.6-2.0 gm. 0.6-2.0 gm. 0.6-2.0 gm. 0.6-2.0 gm. 0.3-2.0 gm. 4.0-40.0 gm. 0.3-1.3 cc. 0.3-1.0 gm. 0.6-2.0 gm. 0.3-1.3 gm. 0.06-0.25 gm. 0.03-0.30 gm. 2.0-8.0 gm. 2.0-8.0 cc. 1.0-4.0 gm. 0.6-1.3 gm. 4.0-16.0 gm. 0.6-2.0 gm. 0.008-0.002 gm. 1.0-4.0 cc. 2.0-8.0 cc. 0.3-1.0 cc. 1.0-2.0 cc. 0.3-1.0 cc. 2.0-4.0 cc. 0.6-4.0 cc. 1.0-4.0 cc. 0.03 gm. 0.05-0.25 cc. 0.015-0.03 gm. 0.5-1.0 cc. 0.015-0.03 gm. 0.4-1.0 cc. 1.3-2.0 gm. 0.6-1.3 gm. 1.3-2.0 gm. 1.3-2.0 gm. 0.3-1.3 gm. 0.2-0.5 cc. 0.0005-0.001 gm. 0.001-0.004 gm. 1.0-2.0 gm. 4.0-12.0 gm. 0.6-2.0 cc. 1.0-4.0 cc. 0.3-1.0 gm. 2.0-4.0 gm. 0.3-0.6 cc. 0.12-0.3 gm. 0.003 gm. 0.06-0.3 gm. 0.06-0.3 gm. DOSES OF MEDICINES. 835 Remedy. Theine . . . Thuja, fluid extract of Thymol Toxicodendron, fluid extract of . . Triticum, fluid extract of Turpentine, oil of Urethane Ustilago maidis, fluid extract of . . Uva ursi, fluid extract of Valerian, abstract of ammoniated tincture of extract of fluid extract of oil of tincture of Veratrine Veratrum abstract of fluid extract of tincture of. Verbena, fluid extract of Viburnum, fluid extract of ... . Vinegar. See Acetum. Wahoo. See Euonymus. Wild-cherry bark Wild-cherry bark, fluid extract of . infusion of syrup of Wintergreen, oil of Wormseed, oil of . . . . • . . . . Xanthoxylum bark, fluid extract of. fruit, fluid extract of Zinc acetate bromide iodide oxide • phenolsulphonate phosphide sulphate (alterative) (emetic) syrup of iodide of valerianate Zingiber. See Ginger. Dose. Apothecaries' Metric Weights and Measures. System. 1-2 gr. 0.06-0.12 gm. 10-15 gr. 0.6-1.0 gm. 1-5 gr. 0.06-0.3 gm. 1-5 min. 0.05-0.3 cc. 1-2 fl. dr. 4.0-8.0 cc. 5-30 min. 0.3-2.0 cc. 10-30 gr. 0.6-2.0 gm. 15-60 min. 1.0-4.0 cc. |-1 fl. dr. 2.0-4.0 cc. 10-15 gr. 0.6-1.0 gm. i-2 fl. dr. 2.0-8.0 cc. 5-15 gr. 0.3-1.0 gm. |-1 fl. dr. 2.0-4.0 cc. 4-5 min. 0.25-0.3 cc. 1-2 fl. dr. 2.0-8.0 cc. eWo g r - 0.001-0.003 gm. 1-2 gr. 0.06-0.12 gm. 1-5 min. 0.05-0.3 cc. 10-20 min. 0.6-1.3 cc. 15-60 min. 1.0-4.0 cc. 1-2 fl. dr. 4.0-8.0 cc. 1-1 dr. 2.0-4.0 gm. 30-60 min. 2.0-4.0 cc. 1-2 fl. oz. 30.0-60.0 cc. 2-4 fl. dr. 8.0-16.0 cc. 1-20 min. 0.05-1.3 cc. 4-8 min. 0.25-0.5 cc. 15-30 min. 1.0-2.0 cc. 15-30 min. 1.0-2.0 cc. 1-2 gr. 0.06-0.12 gm. 1-2 gr. 0.03-0.12 gm. i-3 gr. 0.03-0.2 gm. 2-8 gr. 0.12-0.5 gm. i-2 gr. 0.03-0.12 gm. 2V-T0 gr- 0.003-0.006 gm. i-1 gr. 0.015-0.06 gm. 10-30 gr. 0.6-2.0 gm. 20-40 min. 1.2-2.5 cc. 1-4 gr. 0.06-0.2 gm. INDEX OF DRUGS AND REMEDIAL MEASURES. AC. E. mixture, 186, 244 Billroth's, 186 Abdominal transfusion, 539 Abortifacients, 39 Abrin, 301 Abrus precatorius, 301 Absolute acetic acid, 59 alcohol, 64, 70 Absorption of drugs, 34 Abstract of aconite, 63 Abstracts, 26 Acacia, 53 mucilage of, 53 syrup of, 53 Acacise gummi, 53 Aceta, 26 Acetanilid, 53 poisoning by, 56 Acetanilidum, 53 Acetate of ammonium, 80 of lead, 306 of morphine, 366 of potassium, 58 of sodium, 421 of zinc, 458 Acetic acid, 58 Acetphenetidin (phenacetin), 378 Acetum, 58 ipecacuanhas, 292 lobelise, 312 opii, 365 sanguinarise, 411 scillse, 425 Acid, cathartic, 417 cinnamic, 198 citric, 198 ecbolic, 233 ergotic, 233 ergotinic, 234 gallic, 254 gelseminic, 256 gentisic, 257 hydrobromic, 270 hydrochloride of quinine, 195 infusion of cinchona, 197 of roses, 402 ipecacuanhic, 290 lobelic, 311 lupulinic, 268 nitrate of mercury, 331 nucleinic, 351 phenic, 151 phosphoric, 382 picric, 386 Acid, polygalic, 417 ricinoleic, 157 santominic, 412 sclerotinic, 233 sphacelinic, 234 tartrate of potassium, 122 trichloracetic, 448 Acidum aceticum, 58 dilutum, 59 glaciale, 59 arseniosum, 99, 105 benzoicum, 119 boricum, 124 carbolicum, 151 liquef actum, 155 chronicum, 187 citricum, 198 galli cum, 254 hydrobromicum dilutum, 131 hydrochloricum, 270 dilutum, 271 hvdrocyanicum, 271 dilutum, 271 nitricum, 344 dilutum, 345 fumans, 345 nitro-hydrochloricum, 271, 347 dilutum, 271, 347 phosphoricum concentratum, 382 dilutum, 382 salicylicum, 403 sulphuricum, 433 aromaticum, 434 dilutum, 434 tannicum, 438 tartaricum, 441 trichloraceticum, 448 valerianicum, 453 Acoine, 59 Aconine, 60 Aconite, 59 liniment, 63 ointment, 63 poisoning by, 61 Aconitina, 63 Aconitine, 59, 63 DuquesnePs crystalline, 63 oleate, 62 Aconitum napellus, 59 Action of drugs, direct, 21 duration of, 34, 35 indirect, 21 modes of, 21 Acupuncture, 461 (837) $38 INDEX OF DRUGS AND REMEDIAL MEASURES. Adeps benzoinatus, 120 lame hydrosus, 303 Administering drugs, modes of, 21 Adonidin, 63 Adonis vernalis, 63 Adrenalin, 435 ^Ether, 237 purificatus, 237 Agaric, 63 Agaricin, 63 Alcohol, 64, 70 absolutum, 64, 70 administration of, 69 amy li cum, 64 contraindications to, 70 dilutum, 64, 70 ethylicum, 64 phenylic, 151 Alcoholism, acute, 67 differentiation of, from apo- plexy, 68 from opium poisoning, 68 from paretic dementia, 69 chronic, 68 Ale, 71 Alkaloids, 26 Allis ether inhaler, 242 Allium, 71 -juice, 71 sativum, 71 syrup of, 71 Allspice, 71 Almond bread, 72, 552 milk, 552 Almonds, 72 bitter, 72 sweet, 72 Aloe, 73 Perryi, 73 purificata, 74 vera, 73 Aloes, 73 compound decoction of, 75 contraindications to, 74 Aloin, 73 Aloinum, 73 Alpha-eucaine, 247 Alteratives, 39, 45 Alum, 75 Alumen, 75 exsiccatum, 76 Amber, 76 American wormseed, 160 Ammonia, 77 liniment, 79 -water, 79 stronger, 79 Ammoniac, 79 Ammoniacum, 79 Ammoniated liniment of camphor, .143 mercury, 324 tincture of ergot, 237 of guaiac, 262 of opium, 365 Ammoniated tincture of quinine, 195 of valerian, 453 Ammonii acetas, 80 benzoas, 80 bromidum, 80 carbonas, 81 chloridum, 81 iodidum, 82 oxalas, 83 phosphas, 83 sulphas, 83 valeras, 83, 453 Ammonio-ferric alum, 293, 294 Ammonium, 80 Amygdala amara, 72 dulcis, 72 Amygdalin, 72, 396 Amyl nitris, 83 nitrite, 83 Amylic alcohol, 64 Amylopsin, 372 Amylum, 426 Ansesthesia bv infiltration, 202, 203 Anesthetics, 39, 45 Anaphrodisiacs, 39 Antacids, 39, 45 Anthelmintics, 39, 45 Anthrarobin, 85 Antiarthritics, 39 Antidotum arsenici, 108, 297, 313 Antifebrin, 53 Antihydrotics, 39 Antimalarials, 46 Antimonial powder, 85, 89 Antimonii oxidum, 85 et potassi tartras, 85, 86 sulphidum, 85 purificatum, 85 Antimonium nigrum purificatum, 85 sulphuratum, 85 tartaratum, 85, 86 Antimony, 85 compound pill of, 89 ointment of, 89 wine of, 89 Antiperiodics, 39, 46 Antiphlogistics, 39 Antipyretics, 46 Antipyrin, 90 Antipyrinum, 90 Antiseptics, 46, 462 Antispasmodics, 46 Antistrepto coccus serum, 470 Antitoxin, 467 for diphtheria, 468 Aphrodisiacs, 39 Apiol, 96 Apocynum, 96 androsimsefolium, 96 cannapinum, 96 xApomorphina? hydrochloridum, 98 Apomorphine, 97 Apothecaries' measure, 29 INDEX OF DRUGS AND REMEDIAL MEASURES. 839 Apothecaries' weight, 29 Aqua ammoniae, 79 fortior, 79 amygdalae amarae, 73 camphorae, 143 chloroform!, 182, 187 cinnamomi, 198 creosoti, 221 hamamelidis, 265 hydro genii dioxide, 273 menthae piperitae, 375 pimentae, 72 rosae, 402 Aquae, 26 Arbutin, 452 Argenti nitras, 340 fusus, 341 mitigatus, 344 Argvria, 341 Aristol, 98, 445 Aristolochin, 418 Arnica, 98 montana, 98 Arnicse flores, 99 radix, 99 rhizoma, 99 Aromatic chalk powder, 139 mixture of iron, 294 powder, 156, 199 spirit of ammonia, 79 sulphuric acid, 434 syrup of cascara, 157 of rhubarb, 401 tincture of rhubarb, 401 Arsenate of iron, 294 of sodium, 105 Arseni iodidum, 105 trioxidum, 99, 105 Arsenic, 99 trioxide, 99, 105 Arsenicum, 99 Arsenite of copper, 218 Arsenous acid, 99 Artificial milk, 553 Asafetida, 109 Asafcetida, 109 Aspidium, 110 filix-mas, 110 Aspirin, 111 Astringents, 40, 46 mineral, 46 vegetable, 46 Atomization, 24 Atropa belladonna, 112 Atropina, 113 Atropinae sulphas, 113, 118 Atropine, 113 oleate of, 118 Auranine, 334 Auri et sodii chloridum, 261 Avoirdupois weight, 30 Azedarach, 111 decoction of, 111 fluid extract of, 112 .'DALM of Gilead," 449 D Balsam of copaiba, 216 Barbadoes aloes, 73 Barium chloride, 112 Barley-water, 551 Barosma betulina, 133 Basham's mixture, 293, 294 Bath, Brand, 484 cold, 477 Russian, 508 stretcher, 485 Turkish, 505 Bearberry, 452 Beechwood creosote, 218 Beef essence, 550 peptonized, 547 -tea, 550 Beer, 71 Belladonna, 112 contraindications to, 119 folia, 112 leaves, 112 liniment, 118 ointment, 118 plaster, 118 poisoning by, 115 radix, 112 root, 112 suppositories, 119 Benzaconine, 60 Benzoate of ammonium, 80 of bismuth, 121 of lithium, 311 Benzoated lard, 120 Benzoic acid, 119 Benzoin, 119 Benzoinated lard, 120 Benzoinum, 119 Benzonaphtol, 339 Benzosulphanidum (saccharin), 403 Berberine, 140, 269 Beta-eucaine, 247 -naphtol, 339 -naphtol-bismuth, 339 Bicarbonate of potassium, 395 of sodium, 421 Bichloride of mercury, 325 as an antiseptic, 462 Bidet, the, 475 Billroth's A. C. E. mixture, 186 Bimuriate of quinine and urea, 196 Biniodide of mercury, 327 Binoxide of manganese, 316 Bismuth, 120 and ammonium citrate, 120 benzoate, 121 carbonate, 120 citrate, 120 oxide, 120 subcarbonate, 120 subgallate, 120, 121 subnitrate, 120 subsalicylate, 120, 121 Bismuthi et ammonii citras, 120 840 INDEX OF DRUGS AND REMEDIAL MEASURES. Bismuthi carbonas, 120 citras, 120 oxidum, 120 sub carbonas, 120 subgallas, 120 subnitras, 120 subsalicylas, 120, 121 Bisulphate of quinine, 195 Bitartrate of potassium, 122 Bitter almonds, 72 wine of iron, 299 Bitters, 40 Black cohosh, 189 draught, 417 drop, 365 ginger, 258 mustard, 337 oxide of manganese, 316 pepper, 374 snake-root, 189 wash, 327 Blaud's pill, 295 Bleeding, 540 Blistering collodion, 214 Blisters, 490 figures showing areas to apply, 491 Blood-root, 411 Blue-gum tree, 249 -mass, 327 ointment, 330 pill, 327 Bone-marrow, 259 Boneset, 250 Bonjean's ergotin, 236 Borate of sodium, 123 Borated lint, 124 Borax, 123 Boric acid, 123, 124, 467 Boroglycerin, 124 Bran bread, 552 Brand bath, 484 Brandy, 70 Brayera, 223 anthelmintica, 223 Brometone, 125 Bromide of ammonium, 80 of calcium, 130, 137 of ethyl, 131, 244 of gold, 130 of iron, 294 of lithium, 131, 311 of nickel, 131 of potassium, 125 of sodium, 131 of strontium, 427 Bromides, 125 contraindications to, 130 Bromine, 132 Bromoform, 132 Bronchitis, moist air inhalations in, 25 tents, 518, 592 Broom, 415 Brown mixture, 310 Brucine, 352 Bryonia, 132 alba, 132 dioica, 132 Bryony, 132 Buchu, 133 folia, 133 Burgundy pitch, 393 Butyl chloral hydras, 221 riACODYLATE of iron, 295 \J of sodium, 421 Cactus grandiflorus, 134 fluid extract of, 134 tincture of, 134 Caffea, 134 Arabica, 134 Caffeina, 134, 136 citrata, 134 effervescens, 135 Caffeinae citras, 134 effervescens, 135 Caffeine, 134, 303 Cajuput oil, 137 Calabar bean, 385 Calabarine, 385 Calamine, 458 Calcii bromidum, 130, 137 carbonas prsecipitatus, 137 chloridum, 137 hydras, 141 hypophosphis, 137 phosphas, 137 prsecipitatus, 137 sulphas, 137, 139 Calcined magnesia, 313 Calcium, 137 bromide, 130 chloride, 137 hypophosphite, 137 lactophosphate, 139 oxide, 140 California buckthorn, 156 Calomel, 327 ointment, 330 Calumba, 140 Calumbse radix, 140 Calumbine, 140 Calx, 140 chlorinata, 169 sulphurata, 141 Camphor, 141 cerate, 143 compound tincture of, 143 liniment, 143 monobromate, 143 spirit of, 143 -water, 143 Camphora, 141 monobromata, 143 Camphorated alcohol, 143 oil, 142 tincture of opium, 364 Camphoric acid, 144 INDEX OF DRUGS AND REMEDIAL MEASURES. 841 Canada pitch, 393 plaster, 393 turpentine, 449 Cannabis indica, 145 sativa, 145 Cantharidal cerate, 149 collodion, 149, 213 Cantharidin, 147 Cantharis, 147 vesicatoria, 147 Capsici fructus, 149 Capsicine, 149 Capsicum, 149, 494 fastigiatum, 149 fruit, 149 plaster, 151 Carbo ligni, 155 Carbolic acid, 151 as an antiseptic, 463 ointment, 155 poisoning by, 152 Carbon, 155 Carbonate of ammonium, 81 of bismuth, 120 of creosote, 220 of guaiacol, 264 of iron, 293, 295 of lead, 307 of lithium, 311 of magnesium, 313 of potassium, 395 of zinc, 458 Cardamom, 156 seed, 156 Cardamomi semina, 156 Cardamomum, 156 Cardiac sedatives, 40, 46 stimulants, 40, 46 Carminative powder, 198 Carminatives, 40 Carron oil, 141, 252 Caryophyllum, 199 Caryophyllus, 199 Cascara cordial, 157 evacuant, 157 sagrada, 156 Cassia fistula, 157 Cassiae pulpa, 157 Castile soap, 419 Castor oil, 157 Cataphoresis, 25 Cataplasma carbonis, 155 kaolini, 302 Cataplasms, 26 Catechu ; 159 Cathartic acid, 417 Cathartics, 40, 48 Cat's-hair, 250 Caustic potash, 159 soda, 160 Cayenne pepper, 149 Cerates, 26 Ceratum camphorae, 143 cantharidis, 149 Ceratum plumbi subacetatis, 308 resinae compositum, 398 Cerebral extracts, 259 Cerii oxalas, 160 Cerium oxalate, 160 Chalk, 139 mixture, 137, 139 Chamber inhaler, 518 Champagne, extra dry, 70 Charcoal, 155 poultice, 155 Charta potassii nitratis, 340 sinapis, 338 Chartae, 26 Chenopodium, 160 ambrosioides, 160 oil of, 160 . Chimaphila, 161 umbellata 161 Chinoidinum, 198 Chirata, 161 Chireta, 161 Chloral, 161 hydras, 162 hydrated, 161 poisoning by, 163 Chloralf ormamide ( chloralf ormamidum), 166 Chloralose, 166 Chlorate of potassium, 167 troches of, 168 Chloretone, 168 Chloride of ammonium, 81 of barium, 112 of calcium, 137 of ethyl, 245 of gold and sodium, 261 of iron, 293, 295 of mercury > corrosive, 325 mild, 327 of methyl, 334 of methylene, 335 of sodium, 422 of zinc, 459 as an antiseptic, 466 Chlorinated lime, 169, 498 Chlorine gas, 170 Chlorobrom, 166 Chlorodyne, 170 Chloroform, 170 contraindications to, 183 inhaler, Esmarch's, 180 Krohne and Seseman's modifi- cations of Lawrie's, 182 Lawrie's, 180 liniment, 187 -water, 182, 187 Chloroformum, 170 purificatum, 170 venale, 170 Cholagogues, 40 Chromic acid, 187 Chronium trioxide, 187 Chrysarobin, 188 842 INDEX OF DRUGS AND REMEDIAL MEASURES. Chrysarobin ointment, 188 Chrysarobinum, 188 Cimicifuga, 189 racemosa, 189 rhizoma, 189 Cinchona, 190 calisaya, 190 flava, 190 Ledgeriana, 190 officinalis, 190 pale, 190 pitayensis, 190 red, 190 rubra, 190 rubrae cortex, 190 succirubra, 190 yellow, 190 Cinchonicine, 190 Cinchonidinse sulphas, 196, 197 Cinchonidine, 190, 197 sulphate, 197 Cinchonine, 190 Cinnamic acid, 198 Cinnamomi cortex, 197 Cinnamomum camphora, 141 Cinnamon, 197 -water, 198 •Citrate'of bismuth, 120 and ammonium, 120 of caffeine, 134 of iron, 296 and ammonium, 296 and quinine, 296 and strychnine, 296 of lithium, 311 of magnesium, 314 of potassium, 395 Citrated caffeine, 134 Citric acid, 198 Citrine ointment, 332 Citrophen, 380 Citrullus colocynthis, 213 €larified honey, 268 Classification of drugs, 45 Claviceps purpura, 233 Climates, 533 Cloves, 198 Clyster, 23 Cobalto-nitrate of potassium, 346 Coca, 199 Cocse folia, 199 Cocaina, 199 Cocainae hydrochloridum, 199, 201 Cocaine, 199 habit, 206 hydrochloride, 199, 201 Cod-liver oil, 207 Codeina, 206 Codeinae phosphas, 206 Codeine, 206, 357 phosphate, 206 sulphate, 206 Coffee, 134, 210 Colchiceine, 210 Colchici cornus, 210 semen, 210 semina, 210 Colchicine, 210, 213 Colchicum. 210 conn, 210 seed, 210 Cold bath, 477 cream, 402 in fevers, 480 pack, 478 as a remedv, 471 Collodion, 212 cantharidal, 149, 213 flexible, 212 styptic, 212 Collodium, 212 cantharidatum, 149, 213 flexible, 212 stypticum, 212, 439 vesicans, 149, 213 Colocynth, 213 Colocynthidis pulpa, 213 Colocynthine, 213 Colocynthis, 213 Cologne-water, 70 Columba, 139 Columbic acid, 140 Columbine, 140 Columbo, 139 Combination of drugs for joint effect, 35 Commercial oxide of zinc, 368 Compound cathartic pill, 213 cerate of resin, 398 decoction of aloes, 75 effervescing powder, 416 elixir of kola, 303 extract of colocynth, 213, 414 fluid extract of sarsaparilla, 413 infusion of gentian, 258 of senna, 316, 417 liniment of mustard, 338 mixture of iron, 295 of liquorice, 310 of senna, 418 pill of antimony, 89 of calomel, 330 of colocynth, 213 of galbanum, 110 of rhubarb, 400 of scammony, 414 of soap, 365 of squill, 426 powder of almonds, 72 of catechu, 255 of chalk, 139 of cinnamon, 198 of elaterin, 233 of ipecac, 292, 365 of jalap, 300 of kino, 302 of liquorice, 310, 418 of morphine, 366 of opium, 365 INDEX OF DRUGS AND REMEDIAL MEASURES. 843 Compound powder of rhubarb, 401 of scammony, 414 solution of iodine, 287 sodium phosphate, 381 .spirit of ether, 266 of juniper, 301 suppositories of lead, 307 svrup of sarsaparilla, 413 of squill, 89, 426 tincture of benzoin, 119 of camphor, 143, 364 of cardamom, 156 of catechu, 255 of chloroform and morphine, 187, 367 of cinchona, 197, 419 of gentian, 257 of senna, 418 Condurango, 214 bianco, 214 Confectio piperis, 374 rosse, 268, 402 gallicre, 402 sennse, 157, 417, 438 sulphuris, 433 Confections, 26 Conii folia, 214 fructus, 214 •Conine, 214, 215 hydrobromide, 215 Conium, 214 maculatum, 214 Conserves, 26 Constipation, 615 Contraindications for drugs, 39 Convallamarin, 216 Convallaria, 215 majalis, 235 Convolvulin, 300 •Cool sponging, 480 Co-ordinated movements for treating locomotor ataxia and myelitis, 488 Copaiba, 216 Copaifera Langsdorffi, 216 Copper, 216 Cornutine, 234 Corrosive chloride of mercury, 325 sublimate, 325 Cosmoline, 378 Cotarnine, 218 hydro chlorate, 218 Counterirritants, 41, 46 Counterirritation, 490 Coxe's hive syrup, 89, 417, 426 Cream of tartar, 122 Creolin, 221, 466 as an antiseptic, 466 Creosotal, 220 Creosote, 218 carbonate, 220 inhaler, Yeo's, 219 mixture, 220 ointment, 220 water, 220 Creosotum, 218 Cresol, 218 Creta praeparata, 139 Croton chloral, 221 oil, 222 liniment, 222 Croup kettle, 519 Cubeba, 222 Cubebic acid, 222 Cubebin, 222 Cubebs, 222 Cumulative action of drugs, 35 Cupping, 495 Cupri sulphas, 217 Cuprum, 216 Cups, dry, 495 applied, 495 wet, 495 Curds and whev, 377 Cusso, 223 Cyanide of potassium, 223 DANDELION, 440 Datura stramonium, 427 Daturine, 427 Deadly nightshade, 112 Decoction of azedarach, 111 of chimaphila, 161 of condurango, 214 Decoctions, 26 Decoctum aloes compositum, 75 granati corticis, 395 haematoxyli, 264 scoparii, 416 Definition of drugs, 39 of therapeutics, 17 Demulcents, 41 Denison's resistance inhaler, 517 Deodorized opium, 364 tincture of opium, 365 Dermatol, 121, 223 Deshler's salve, 398 Diabetin, 309 Diachylon, 308 Dialyzed iron, 296 Diaphoretics, 41, 47 Diastase, 224 Diet for child one year old, 550 seven years old, 549 six to twelve months old, 550 two years old, 549 importance of, in disease, 19 lists, 549 Dietetic treatment, importance of, 45 Diethyl-sulphon-dimethyl-methane, 430 Digestants, 47 Digested gruel, 548 Digitalein, 224 Digitalin, 224 Digitalis, 224 contraindications to, 230 folia, 224, 230 844 INDEX OF DRUGS AND REMEDIAL MEASURES. Digitalis, poisoning by, 228 purpurea, 224 Digitalone, 232 Digitin, 224 Digitonin, 224 Digitoxin, 224 Dilute acetic acid, 59 alcohol, 64, 70 hydrobromic acid, 131 hydrochloric acid, 271 hydrocyanic acid, 271 nitrate of silver, 344 nitric acid, 345 nitro-hydro chloric acid, 271, 347 phosphoric acid, 382 solution of subacetate of lead, 308 sulphuric acid, 434 Diphtheria antitoxin, 468 Direct action of drugs, 21 Disease, elimination in, 19 food in, 19 relief of symptoms in, 20 sleep in, 20 treatment of, factors in, 19 Disinfectants, 47 Disinfection, 495 Distilled extract of hamamelis, 265 Diuretics, 41, 47 Diuretin, 420 DobelPs solution, 123 Donovan's solution, 105 Dorema ammoniacum, 79 Dormiol, 232 Dosage, 27 hypodermic, 28 by the rectum, 28 rules of, 28 Young's rule of, 28 Dover's powder, 292, 365 Dried alum, 76 sulphate of iron, 299 Drip-sheet, 478 Drop, size of a, 28, 29 Drugs, absorption of, 34 classification of, 45 combination of, for joint effect, 35 cumulative action of, 35 duration of action, 35 indications and contraindications for, 39 modes of action of, 21 of administering, 21 strength and reliability of, 36 Dry cups, 495 applied, 495 heat, 510 Dryopteris filix-mas, 110 Duboisia myoporoides, 232 Duboisine, 232 sulphate, 232 Duquesnel's crystalline aconitine, 63 Duration of action of drugs, 35 ECBALLIUM elaterium, 233 Ecbolic acid, 233 Ecgonine, 199 Effervescing citrate of caffeine, 135 of lithium, 311 of magnesium, 315 of potassium, 396 draught, 396 powder, 416 sulphate of sodium, 423 Egg-flip, 71 -nog, 69 Elaterin, 233 Elaterinum, 233 Elaterium, 233 Electuaries, 26 Elettaria repens, 156 Elimination in disease, 19 Eliminators, 41, 47 Elixir adjuvans, 310 ferri, quininae et strvchninae phos- phatum, 298 kolae composita, 303 phosphori, 385 proprietatis, 75 roborans, 197 Elixirs, 26 Emetics, 41, 47 contraindications to, 41 direct, 41, 47 peripheral, 41, 47 Emetine, 290, 292 Emmenagogues, 42, 47 direct, 42, 47 indirect, 42, 47 Emplastra, 26 Emplastrum arnicae, 99 asafoetidae, 110 belladonnas, 118 cantharidis, 149 capsici, 151 ferri, 299 hydrargyri, 331 menthol, 376 opii, 365 picis, 393 burgundicae, 393 canadensis, 393 cantharidatum, 149, 393 plumbi, 308 iodidi, 307 resinae, 308, 398 saponis, 419 Emulsin, 72, 397 Emulsion of asafcetida, 110 of bitter almonds, 72 of cod-liver oil, 210 with hypophosphites, 210 of sweet almonds, 72 Emulsions, 26 Emulsum amygdalae, 72 asafoetidae, 110 INDEX OF DBUGS AND BE ME DIAL MEASURES. 845 Emulsum chloroformi, 187 olei morrhua?, 210 cum hypophositibus, 210 terebinthina?, 451 E.idermic medication, 25 Enema, 23 nutrient, 23 peptonized, 547 Euteroclysis, 499 Epispastics, 46, 490 Ergot, 233 Ergotic acid, 233 Ergotin, 233, 236 Bonjean's, 236 Ergotinic acid, 234 Ergotinum, 233, 236 Erigeron, 236 canadense, 236 Erythrol tetranitrate, 237, 347 Erythroxylon, 199 coca, 199 Escharotics, 46 Eserine, 385, 386 Esmarch's chloroform inhaler, 180 Ether, 237 contraindications to, 244 inhaler, Allis, 242 Ethyl alcohol, 64 bromide, 244 chloride, 245 inhaler, 246 iodide, 247 Ethylate of sodium, 422 Eucaine hvdrochlorate, 247 lactate, 247 Eucalyptol, 248 Eucalyptus, 248 globulus, 248 Eudoxine, 249 Euformol, 253 Eugenia aromatica, 199 Eugenol, 199 Euonymi cortex, 249 Euonymin, 249 Euonymus, 249 atropurpureus, 249 Eupatorium, 250 perfoliatum, 250 Euphorbia pilulifera, 250 Euphthalmin, 250 Europhen 251 Evans' pocket inhaler, 521 Exalgine, 251 Exercises for treating locomotor ataxia and myelitis, 458 Expectorants, 42, 47 sedative, 42, 47 stimulating, 42, 47 Exsiccated sodium phosphate, 381 Extracts, 26 Extractum aconiti, 63 liquidum, 63 aloes, 75 barbadensis, 75 Extractum belladonna alcoholicum 119 foliorum, 118 liquidum, 118 radicis liquidum, 118 viride, 119 buchu liquidum, 134 calumba* liquidum, 140 cannabis indicse, 147 liquidum, 147 capsici liquidum, 151 cascara? sagradse, 157 liquidum, 157 chirata? liquidum, 161 cimicifugs\ 189 liquidum, 189 cinchona?, 197 liquidum, 197 coca?, 205 liquidum, 205 colchici cormi, 211 colocynthidis, 213 compositum, 213. 414 conii, 215 digitalis, 230 ergotse, 236 liquidum, 236 euonymi, 250 siccum, 250 eupatorii liquidum, 250 filicis liquidum, 111 gentiana?, 258 glycyrrhiza?, 310 liquidum, 310 purum, 310 ha?matoxyli, 264 hamamelidis liquidum, 265 hydrastis liquidum, 270 Iryoscyami, 275 ipecacuanha^ liquidum, 292 jaborandi liquidum, 391 jalapae, 300 leptandrae, 308 nucis vomicae, 354 liquidum, 354 opii, 364 liquidum, 365 pareira? liquidum, 373 physostigmatis, 386 pilocarpi liquidum, 391 podophylli, 394 quassise, 398 rhei, 400 sarca? liquidum, 413 stramonii, 427 strophanthi, 429 taraxaci, 440 liquidum, 441 uva ursi, 452 FEEDING the sick, 542 Fel bovinum purificatum, 368 bovis, 367 purificatum, 368 846 INDEX OF DRUGS AND REMEDIAL MEASURES. Ferri et ammonii citras, 296 sulphas, 293, 294 tartras, 296 arsenas, 294 bromidum, 294 cacodylas, 295 carbonas saccharatus, 293, 295 chloridum, 293, 295 citras, 296 hydroxidum, 297 cum magnesia, 108, 297 iodidum saccharatum, 297 lactas, 299 oxalas, 298 phosphas, 298 solubilis, 298 et potassii tartras, 296 pyrophosphas solubilis, 298 et quininas citras, 296 solubilis, 296 et strychninse citras, 296 reductum, 298 subsulphas, 293, 298 sulphas, 293, 299 exsiccatus, 299 granulatus, 299 valeras, 299, 453 Ferrum, 292 dialysatum, 296 reductum, 293, 298 tartaratum, 296, Ferula fcetida, 109 Fevers, cold in, 480 Filix-mas, 110 Flaxseed meal, 252 oil, 252 poultice, 252 tea, 252 Fleabane, 236 Fleming's tincture of aconite, 63 Flexible collodion, 212 Flowers of sulphur, 431 Fluid extract of azedarach, 112 of cactus grandiflorus, 134 of condurango, 214 of hsematoxylon, 265 of rhus aromatica, 401 of solanum carolinense, 423 of piscidia erythrina, 392 extracts, 26 Fluidextractum aconiti, 63 belladonnas radicis, 118 buchu, 134 calumbas, 140 cannabis indicas, 147 capsici, 151 chimaphilas, 161 chiratas, 161 cimicifugas, 189 cinchonae, 198 cocas, 205 colchici seminis, 211 conii, 215 convallarise, 216 Fluidextractum cubebas, 223 cusso, 223 digitalis, 230 ergotas, 236 eucalypti, 249 eupatorii, 250 gelsemii, 257 gentianap, 258 geranii, 258 glycyrrhizas, 310 granati, 395 grindelise, 261 hamamelidis foliorum, 265 hydrastis, 270 hyoscyami, 275 ipecacuanhas, 292 kolas, 303 leptandras, 308 lobelias, 312 lupulini, 269 nucis vomicas, 354 pareiras, 373 pilocarpi, 391 podophylli, 394 pruni virginian as, 397 quassias, 398 querci, 398 rhamni purshianas, 157 rhei, 401 rhois glabra?, 401 rosas, 402 sabinas, 414 sanguinarias, 411 sarsaparillas, 413 compositum, 413 scillas, 425 scopalas, 414 senegas, 416 sennas, 417 serpentarias, 418 spigelias, 424 et sennas, 425 stillingias, 427 stramonii, 427 strophanthi, 429 taraxaci, 440 uva ursi, 452 Valeriana?, 453 veratri, 456 zingiberis, 258 Flying blister, 490 Food in disease, 19 -materials, 544 Foods for the sick, 542 Formaldehyde, 252, 464 generator, Novy's, 497 Formaldehydum, 252 Formic aldehyde, 252 Fowler's solution, 104, 105 Foxglove, 224 Frazier-Lentz hot-air apparatus, 510 Fumigation, 24 lamp for mercurial, 319 Fusel oil, 64 INDEX OF DRUGS AND REMEDIAL MEASURES. 847 GALLA, 254 Gallic acid, 254 ointment, 254 Gambir, 159 Garlic, 71 Gaultheria, 255 Gavage, 503 method of employing, 503 Gelsemii radix, 256 Gelsemine, 256, 257 Gelseminic acid, 256 Gelsemium, 256 poisoning by, 257 General therapeutical considerations, 17 Generator, Novy's formaldehyde, 497 Gentian, 257 Gentiana, 257 lutea, 257 Gentianae. radix, 257 Gentianine, 257 Gentisic acid, 257 Geranium, 258 German chamomile, 316 soft soap, 419 Germicides, 462 Germs, mode of destroying, 462 Gin, 70 Ginger, 258 _ Glacial acetic acid, 59 Glandulae suprarenales siccae, 436 thyroidae siccae, 446, 448 Glandular treatment, 259 Glauber's salt, 422 Glonoin, 346 Glusidum, 403 Glutol, 253 Glycerin, 260 Glycerins, 26 Glycerinum, 260 acidi borici, 124, 261 carbolici, 155, 261 tannici, 261, 439 aluminis, 76, 261 amyli, 260, 261 boracis, 261 pepsini, 261, 377 plumbi subacetatis, 261, 308 tragacanthae, 261 Glycerita, 26 Glycerites, 26 Glyceritum acidi carbolici, 155 tannici, 439 amyli, 260 boroglycerini, 124 hydra stis, 270 phenolis, 155 vitelli, 260 Glvcerole of aloes, 74 Glyceryl nitrate, 347 Glycyrrhiza, 310 Glycyrrhizae radix, 310 Glycyrrhizinum ammoniatum, 310 Goa powder, 188 Gold, 261 Gold, bromide of, 130 Golden seal, 269 Gonolobus condurango, 214 Goodell's pill of the threevalerianates,453 sumbul pill, 434 Goulard's extract, 307 Graduated medicine glasses, 29 Granati cortex, 394 Granatum, 394 Granulated citrate of magnesium, 314 opium, 364 sulphate of iron, 299 Gray oil, 321, 330 powder, 330 Green extract of belladonna, 119 soap, 419 Griffith's mixture, 295 pills, 295 Grindelia, 261 robusta, 261 Gruel, digested, 548 Guaiac, 262 resin, 262 Guaiaci resina, 262 Guaiacol, 262 carbonate, 264 Guaiacum, 262 officinale, 262 Gum acacia, 53 arabic, 53 HvEMATOXYLI lignum, 264 Haematoxylin, 264 Haematoxylon, 264 Hamamelidis cortex, 265 folia 265 Hamamelis, 265 virginiana, 265 Heat, 504 dry, 508 Heavy magnesia, 313 Hemlock fruit, 214 juice, 214 leaves, 214 Henbane, 275 Heroin, 265 hydrochloride, 266 Hexamethylenamine (urotropin, uri- tone), 452 Hoffmann's anodyne, 266 Holocaine, 266 hydrochloride, 266 Homatropinae hydrobromidum, 267 Homatropine, 267 Home modification of Turkish bath, 507 Honey, 267 of borax, 124, 268 of rose, 268, 402 of squill, 426 Hop poultice, 269 Hope's camphor mixture, 268 Hops, 268 Horse-nettle, 423 848 INDEX OF DRUGS AND REMEDIAL MEASURES. Hot-air apparatus, Frazier-Lentz, 510 Kelley's, 511 pack, 509 springs, 531 House mixture, 519 Humulus, 268 Husband's magnesia, 313 Huxham's tincture, 197, 418 Hydragogue cathartics, 48 Hydrargyri chloridum corrosivum, 325 mite, 327 iodidum navum, 332 rubrum, 327 oleas, 331 oxidum flavum, 332 rubrurn, 332 perchloridum, 325 subchloridum, 327 subsulphas flavus, 333 Hydrargyrum, 317 ammoniatum, 324 cum creta, 330 Hydrastine, 269, 270 Hydrastinine hydrochloride, 270 Hydrastis, 269 canadensis, 269 rhizome, 269 Hydrate of chloral, 161 of lime, 141 Hydrated sesquioxide of iron, 108, 297 Hydriodide of scopolamine, 415 Hydrobromic acid, 131, 270 Hydrobromide of conine, 215 of homatropine, 267 of hyoscine, 276 of hyoscyamine, 275 of pelletierine, 394 of quinine, 195 of scopolamine, 414 Hydrochlorate of eucaine, 247 Hydrochloric acid, 270 Hydrochloride of apomorphine, 98 of cocaine, 199 of cotarnine, 218 of heroin, 266 of holocaine, 266 of hydrastinine, 270 of methylthionine (methylene blue), 335 of morphine, 366 of pelletierine, 394 of phenocoll, 380 of pilocarpine, 391 of quinine, 195 acid, 195 of scopolamine, 414 of strychnine, 355 Hydrocyanic acid, 271 Hydrogen peroxide, 273, 369 as an antiseptic, 466 Hydroxide of iron, 297 with magnesia, 108 of potassium, 159 of sodium, 160 Hvoscinae hydrobromidum, 276 Hyoscine, 275, 276 hydrobromide, 276 Hyoscyami folia, 275 Hyoscyaminae hydrobromidum, 275 sulphas, 275 Hyoscyamine, 275 Hyoscyamus, 275 leaves, 275 Hypnal, 277 Hypnotics, 42, 48 Hypodermic injection of apomorphine, 98 of cocaine, 206 of ergot, 236 of morphine. 367 medication, 22, 28 Hypodermoclysis, 511 apparatus for, and method of per- forming, 512 Hypophosphite of calcium, 137 of manganese, 316 Hyposulphite of sodium, 422 TCE-BAG, 474 1 -coil, 474 -jacket, 472 -poultice, 472 -rub, 481 Ichthyol, 277 Idiosyncrasy, 28, 37 Imperial measure, 30 Incompatibility, 43 Indian hemp, 145 poke, 454 Indications for drugs, 39 Indirect action of drugs, 21 Infiltration anaesthesia, 202 method of producing, 202, 203 Infusion of juniper, 302 of matricaria, 316 Infusions, 26 Infusum brayerae, 223 buchu, 134 calumbae, 140 caryophylii, 199 chiratae, 161 cinchonae, 197 acidum, 197 columbae, 140 digitalis, 230 ergotae, 236 gentianae compositum, 258 lupuli, 269 pruni virginianae, 397 quassias, 398 rhei, 401 rosaa acidum, 402 scoparii, 416 senegae r 417 sennae, 418 compositum, 316, 417 serpentariae, 418 uvae ursi, 452 INDEX OF DRUGS AND REMEDIAL MEASURES. 849 Inhalations, 24, 513 exercises to be used in, 514, 515 Inhaler, Allis ether, 242 chamber, 518 Denison's resistance, 517 Esmarch's chloroform, 180 ethyl chloride, 247 Evans' pocket, 521 menthol, 521 Yeo's creosote, 219, 521 Injectio cocainse hypodermica, 206 ergotae hypodermica, 236 morphinse hypodermica, 367 opomorphinae hypodermica, 98 Inspissated ox-gall, 367 Intravenous injection, 524 Inunctions, 25 Iodide of ammonium, 82 of arsenic, 105 of ethvl, 247 of iron, 297 of lead, 307 of potassium, 279 of sodium, 282 of strontium, 427 of thymol, 445 Iodine, 282 contraindications to, 281 ointment, 287 poisoning by, 283 Iodoform, 287 as an antiseptic, 464 ointment, 289 poisoning by, 287 Iodoformum, 287 Iodol, 289 Iodothyrine, 448 Iodum, 282 Ipecac, 290 Ipecacuanha, 290 Ipecacuanhae radix, 290 Ipecacuanhic acid, 290 Ipomcea purga, 300 Iron, 292 aromatic mixture of, 294 arsenate of, 294 bromide of, 294 cacodylate of, 295 carbonate of, 295 chloride of, 295 citrates of, 296 dialyzed, 296 by hydrogen, 293 hydroxide with magnesia, 108 iodide of, 297 lactate of, 299 oxalate of, 298 phosphates of. 298 plaster, 299 reduced, 298 subsulphate of, 297 sulphate of, 299 tartrates of, 296 valerate of, 299 Iron, wines of, 299 Isopilocarpine, 387 TABORANDI folia 387 t) Jaborine, 387 Jalap, 300 Jalapa, 300 Jalapin, 300, 414 Jamaica dogwood, 392 James' powder, 89 Jamestown weed, 427 Jequirity, 301 Jervine, 454 Joint effects of drugs, 35 Juniper, 301 Juniperin, 301 Juniperus, 301 Junket, 553 KAMALA, 302 Kaolin, 302 cataplasm of, 302 Kaolimim, 302 Kataphoresis, 25, 524 Kelene, 247 Kelley's hot-air apparatus, 511 Kermes mineral, 85 Kinic acid, 190 Kino, 302 Kinotannic acid, 302 Kinovic acid, 191 Kola, 302 Kolatannic acid, 303 Koosin, 223 Koumyss, 549 Kousso, 223 Kreolin, 221, 466 LACTATE of eucaine, 247 of iron, 299 of strontium, 427 Lactophenin, 380 Lactophosphate of calcium, 139 Lactose, 429 Lady Webster dinner pills, 75 Lamellae atropine, 118 cocainae, 205 homatropinae, 267 physostigminae, 386 Lanolin 303 Lard, benzoated, 120 Laudanine, 357 Laudanum, 365 Laughing gas, 349 Lavage, 524 methods of performing, 526 Lavements, 23 Laxatives, 48 Lead, 303 acetate, 306 carbonate, 307 54 850 INDEX OF DRUGS AND REMEDIAL MEASURES. Lead, iodide, 307 nitrate, 308 oxide, 308 plaster, 308 -water and laudanum, 307 Ledoyen's disinfectant solution, 308 Leeches, 527 application of, 528 Leeching, 527 therapeutics of, 528 Lemon-juice, 198 Leptandra, 308 Leptandrin, 309 Leptandrine, 309 Levant wormseed, 411 Levulose, 309 Light magnesia, 313 Lignum vitse, 262 Lime, 140 chlorinated, 169 sulphurated, 141 -water, 140 Lingual traction, 241 Lini farina, 252 semina, 252 Liniments, 26 Linimentum aconiti, 63 ammoniae, 79 belladonnae, 118 calcis, 141, 252 camphorae, 143 ammoniatum, 143 chloroformi, 187 crotonis, 222 hydrargyri, 331 mollis, 419 opii, 365 plumbi subacetatis, 308 potassii iodidi cum sapone, 282 saponis, 143, 419 sinapis, 338 compositum, 338 terebinthinae, 451 aceticum, 452 Linseed, 252 oil, 252 poultice, 252 Linum, 252 Lipanin, 309 Liquid petrolatum, 378 Liquor acidi arsenosi, 104, 105 chromici, 188 ammoniae, 79 fortis, 79 ammonii acetatis, 80 citratis, 83 arseni et hydrargyri iodidi, 105 arseni calis, 104, 105 arseni ci hydro chloricus, 105 atropinae sulphatis, 118 bismuthi et ammonii citratis, 120 calcis, 140, 141 chlorinatse, 170 saccharatus, 141 Liquor calumbae concentratus, 140 carbonis detergens, 646 chiratae concentratus, 161 cresolis compositus, 313 epispasticus, 149 ferri acetatis, 299 et ammonii acetatis, 293, 294 chloridi, 296 citratis, 296 perchloridi, 296 fortis, 296 persulphatis, 297 subsulphatis, 297 tersulphatis, 108 formaldehydi, 253 hamamelidis, 265 hydrargyri nitratis, 331 acidus, 331 perchloridi, 326 hydrogenii peroxidi, 273 iodi compositus, 287 fortis, 287 magnesii carbonatis, 314 citratis, 314 morphinae acetas, 367 hydro chloridi, 367 sulphatis, 366 tartratis, 367 pancreatis, 372 pepsini, 377 plumbi subacetatis, 307 dilutus, 308 fortis, 307 potassae, 310 potassii arsenitis, 104, 105 citratis, 395, 396 permanganatis, 378 potassii hydroxidi, 310 quassiae concentratus, 398 rhei concentratus, 401 sarsae compositus concentratus, 413 sennae concentratus, 418 sodii arsenatis, 105 ethylatis, 422 hydroxidi, 160 phosphatis compositus, 381 strychninae hydro chloridi, 355 thyroidei, 448 trinitrini, 347 zinci chloridi, 459 Liquorice, 310 root, 310 Liquors, 27 Litharge, 308 Lithia-water, 311 Lithii benzoas, 311 bromidum, 130, 311 carbonas, 311 citras, 311 effervescens, 311 salicylas, 311 Lithium, 311 bromide, 130 Liver, 259 INDEX OF DRUGS AND REMEDIAL MEASURES. 851 Lobelia, 311 Lobelic acid, 311 Lobeline, 311 Lofoten cod-liver oil, 207 Logwood, 264 Lotio hydrargyri flava, 333 nigra, 327 Lozenges, 27 Lugol's solution, 287 Lunar caustic, 341 Lung expansion, arrangement of bottles for promoting, 517 Lupulin, 268, 269 Lupuline, 268 Lupulinic acid, 268 Lupulinum, 269 Lupulus, 268 Lycetol, 312, 392 Lycopodium, 312 Lysol, 313 MAGEN DIE'S solution, 366 Magnesia, 313 levis, 313 ponderosa, 313 Magnesii carbonas, 313 ponderosa vel levis, 313 citras, 314 effervescens, 314 oxidum ponderosum, 313 sulphas, 314 effervescens, 315 Magnesium, 313 Male fern, 110 Mammary gland, 315 Mandrake, 393 Manganese, 316 Mangani dioxidum praecipitatum, 31 hypophosphis, 316 sulphas, 316 Manganum, 316 Manna, 316 Marsden paste, 104 Massa copaibse, 216 ferri carbonatis, 295 hydrargyri, 327 Matricaria, 316 infusion of, 316 May apple, 393 Meadow saffron, 210 Measures, weights and, 30 Meconic acid, 357 Meconine, 357 Medication by cataphoresis, 25 endermic method, 25 fumigation, 21 hypodermic injection, 22 inhalation, 24 inunction, 25 mouth, 21 rectum, 23 Medicine glasses, graduated, 29 Mel, 267 Mel boracis, 124, 268 depuratum, 268 rosae, 268, 402 Melaleuca leucodendron, 136 Melia azedarach, 111 Mentha piperita, 374 Menthol, 317, 375 inhaler, 521 Mercurial fumigator, 319 ointment, 330 diluted, 331 oleate, 331, 332 pills, 327 plaster, 331 Mercurol, 317 Mercurv, 317 bichloride, 325 biniodide, 327 with chalk, 330 ointment, 330 protiodide, 332 salicylate, 332 Metadioxybenzol, 398 Methyl acetanilid, 251 blue, 333 chloride, 334 salicylas, 255 violet, 333 Methylene blue (methylthionine hydro- chloride), 335 chloride, 336 mixture, 187 Methylenum cceruleum, 335 Methylthionine hydrochloride (methyl- ene blue), 335 Metric equivalents, 31, 32 system of weights and measures, 31, 32 Mild chloride of mercury, 327 Milk, almond, 552 artificial, 553 of asafoetida, 110 peptonized, 546 -punch, 69 peptonized, 547 -sugar, 429 of sulphur, 432 Mineral astringents, 46 cathartics, 48 springs, 530 Mint camphor, 375 stearopten, 375 Mistura ammoniaci, 79 amygdala, 72 creosoti, 220 cretse, 137, 139 ferri aromatica, 294 composita, 295 glycyrrhizse composita, 310 guaiaci, 262 olei ricini, 159 potassii citratis, 396 rhei et sodas, 401 sennae composita, 418 852 INDEX OF DRUGS AND REMEDIAL MEASURES. Mistura spiritus vini gallici, 71 Mitigated caustic, 344 Mixtures, 27 Modes of action of drugs, 21 of administering drugs, 21 Monkshood, 59 Monobromated camphor, 143 Monochloral-antipvrin, 277 Monsel's salt, 293," 297 solution, 297 Morphina, 366 Morphinae acetas, 366 hydro chloridum, 366 sulphas, 366 tartras, 366 Morphine, 357, 366 Moschus, 336 Mouth, administration of drugs by the. 21 Mucilage of acacia, 53 Mucilago acaciae, 53 Mulled wine, 70, 553 Muriate of ammonium, 81 of morphine, 366 Musk, 336 Mustard, 337 papers, 338 plaster, 337, 494 Mydriatics, 42 Myotics, 42 Myristica, 351 Myrrh, 338 Myrrha, 338 Myrrhin, 338 NAPHTHALENE, 338 Naphthalin, 338 Naphthalinum, 338 Naphthol, 339 Naphtol, 339 Narceine, 357 Narcotine, 357 Nargol, 339, 467 Nebulizer, Oliver's, 523 Robertson's, 522 Nebulizers, 375, 522 Nervous sedatives, 42, 48 stimulants, 42, 48 Neutral mixture, 395, 396 Nickel, bromide of, 131 Nitrate of lead, 308 of mercury, 331 of pilocarpine, 391 of potassium, 340 of silver, 340, 467 Nitre, 340 Nitric acid, 344 Nitrite of amyl, 83 of potassium, 345 of sodium, 346 Nitrogen monoxide, 349 Nitroglycerin, 346 Nitro-hydrocnioric acid, 271, 347 Nitrous oxide, 349 contraindications to, 350 Normal saline solution, 537 Norwood's tincture of veratrum viride, 456 Nosophen, 351 Novy's formaldehyde generator, 497 Nuclein, 351 contraindications to, 351 Nucleinic acid, 351 Nut-gall, 254, 438 Nutmeg, 351 Nutrient enema, 23 Nux vomica, 352 AATMEAL- WATER, 551 U Oil of amber, 76 of garlic, 71 of rue, 402 of tar, 439 of vitriol, 433 Ointment of aconitine, 63 of ammoniated mercury, 324 of ntimony, 89 of atropine, 119 of belladonna, 118 of boracic acid, 124 of calomel, 330 of cantharides, 149 of capsicum, 151 of carbolic acid, 155 of chrysarobin, 188 of cocaine, 206 of conium, 215 of creosote, 220 of eucalyptus, 249 of gallic acid, 254 of galls, 254 with opium, 254 of hamamelis, 265 of iodide of lead, 307 of potassium, 282 of iodine, 287 of iodoform, 289 of lead acetate, 307 carbonate, 307 of mercurv, 330 diluted, 331 of nitrate of mercury, 332 of oxide of zinc, 368 phenol, 155 of red iodide of mercury, 327 oxide of mercury, 332 of resin, 398 of rose-water, 402 of salicylic acid, 408 of stramonium, 427 of sulphur, 432 of tannic acid, 439 of tar, 440 of tartrate of antimony, 89 of turpentine, 451 of veratrine, 454 INDEX OF DRUGS AND REMEDIAL MEASURES. 853 Ointment of yellow oxide of mercury, 332 Ointments, 27 Oleate of aconitine, 62 of atropine, 118 of cocaine, 201 Oleatum atropine, 118 cocainae, 201 hydrargyri, 331, 332 veratrinae, 454 Oleoresina aspidii, 111 capsici, 151 cubebae, 223 lupulini, 269 piperis, 374 zingiberis, 258 Oleum am} T gdal3?, 72 amarse, 72 expressum, 72 eajuputi, 136 caryophilli, 199 chenopodii, 160 cinereum, 321, 330 cinnamomi, 198 copaibae, 216 crotonis, 222 cubebae, 223 erigerontis, 236 eucalypti, 248 gaultheriae, 256 jecoris aselli, 207 juniperi, 302 lini, 252 menthae piperita?, 375 morrhuae, 207 myristicae, 351 pimentae, 71 piscis liquidae, 439 phosphoratum, 385 ricini, 157 sabinae, 413 santali, 410 sinapis volatile, 337 succini, 76 tanaceti, 439 terebinthinae, 449 rectiflcatum, 450 tiglii, 222 Valerianae, 452 Oliver's nebulizer, 523 Opium, 356 deodoratum 364 granulatum, 364 poisoning, acute, differentiation of, from acute alcoholism, 68 Opodeldoc, 419 Orphol, 339 Orthoform, 367 Ouronparia gambier, 255 Ovarian extract, 259, 367 Oxalate of ammonium, 83 of cerium, 160 of iron, 298 Ox-gall, 367 Oxide of antimony, 85 of bismuth, 120 of calcium, 140 of lead, 308 of magnesium, 313 heavy, 313 of mercurv, 332 of zinc, 368 Oxygen, 369 apparatus, 370 -water, 369 Oxymel, 268 scillae, 426 Oxytoxics, 42, 48 Oysters, peptonized, 547 PACK, hot, 509 Pale cinchona, 191 rose, 402 Pancreas, 259 Pancreatin, 371 Pancreatinum, 371 Papain, 372 Papaverine, 357 Papayotin, 372 Papers, 25 Papoid, 372 Paraldehyde, 373 Paraldehydum, 373 Paregoric, 364 Pareira, 373 Pareirae radix, 373 Parsley, 96 Pearson's solution, 105 Pelletierine, 394 tannate, 395 Pepo, 373 Pepper, 374 Peppermint, 374 -water, 375 Pepsin, 376 cordial, 377 Pepsinum, 376 saccharatum, 377 Peptonized beef, 547 enema, 547 milk, 546 -punch, 547 oysters, 547 Permanganate of potassium, 377 Peroxide of hydrogen, 273, 369, 466 Persulphate of iron, 297 Petrolatum, 378 album, 378 liquidum, 378 molle, 378 spissum, 378 Petroselinum, 96 Phenacetin (acetphenetidin), 378 Phenacetinum (acetphenetidinum), 378 Phenazone, 90 Phenazonum, 90 Phenic acid, 151 854 INDEX OF DRUGS AND REMEDIAL MEASURES. Phenocoll, 380 hydrochloride, 380 Phenol, 151 glycerite of, 155 ointment of, 155 Phenolis, glyceritum, 155 unguentum, 155 Phenolsulphonate (sulphocarbolate) sodium, 381 of zinc, 381 Phenyl-acetamide, 54 -dimethyl-pyrazolon, 90 -salicylate (salol), 409. Phenylic alcohol, 151 Phlebotomy, 540 Physostigma, 385 Physostigmatis semina, 385 Physostigmine salicylas, 386 sulphas, 386 Physostigmine, 385 Phosphate of ammonium, 83 of codeine, 206 of iron, 298 of sodium, 381 of strontium, 427 Phosphorated oil, 385 Phosphoric acid, 382 Phosphorus, 382 Picea, 393 Picric acid, 387 Pill of three valerianates, 453 Pills, 27 Pilocarpine hydro chloridum, 391 nitras, 391 Pilocarpine, 387 Pilocarpus, 387 Pilula colocynthidis composita, 213 et hyoscyami, 213 galbani composita, 110 hydrargyri, 327 subchloridi composita, 330 ipecacuanhe cum scilla, 292 plumbi cum opio, 307 quininse sulphatis. 195 saponis composita, 365 scammonii composita, 414 Pilule aloes, 74 et ferri, 75 et mastiches, 75 et myrrhe, 74, 338 antimonii composite, 89 asafcetide, 110 cathartice composite, 213 vegetabiles, 213 ferri, 295 carbonatis, 295 iodidi, 297 laxative composite, 75 opii, 364 phosphori, 385 quinine sulphatis, 195 rhei, 400 composita, 400 compositus, 400 of Pilule scille composita, 426 Pimenta, 71 Pinkroot, 424 Piper, 374 cubeba, 222 nigrum, 374 Piperazine, 391 Piperin, 374 Piperinum, 374 Pipsissewa, 161 Piscidia erythrina, 392 Piscidine, 392 Pitch, 392 Pix, 392 burgundica, 393 canadensis, 393 liquida, 439 Piaster of arnica, 99 of asafcetida, 110 of belladonna, 118 of Burgundy pitch, 393 of Canada pitch, 393 of cantharides, 149 of capsicum, 151 of iodide of lead, 307 of iron, 299 of lead, 308 of menthol, 376 of mercury, 331 of opium, 365 of pitch, 393 of resin, 308, 398 of soap, 419 Plasters, 26 Plumbi acetas, 304 carbonas, 307 iodidum, 307 nitras, 308 oxidum, 308 Plumbum, 303 Plummer's pills, 89 Podophyllin, 393 Podophyllum, 393 Poke-root, 454 Polygalic acid, 417 Pomegranate, 394 Port wine, 71 Porter, 71 Potash papers, 340 Potassa caustica, 160 cum calce, 140, 160, 457 Potassii acetas, 58 bicarbonas, 395 bitartras, 122 bromidum, 125 carbonas, 395 chloras, 167 citras, 395 effervescens, 396 cyanidum, 223 hydroxidum, 159 iodidum, 279 nitras, 340 permanganas, 377 INDEX OF DRUGS AND REMEDIAL MEASURES. 8b5 Potassii et sodii tartras, 401 tartras acidus, 122 Potassium acetate, 58 bicarbonate, 395 bitartrate, 122 bromide, 125 carbonate, 395 chlorate, 167 citrate, 395 cobalto-nitrite, 346 cyanide, 223 hydroxide, 159 iodide, 279 nitrate, 340 nitrite, 345 permanganate, 377 silicate, 418 Poultice of charcoal, 155 Precipitated carbonate of calcium, 137 of zinc, 458 dioxide of manganese, 316 phosphate of calcium, 137 sulphur, 401 Prepared chalk, 139 Prescription, parts of a, 51 writing, 49 Pride of China, 111 Protargol, 396, 467 Protiodide of mercury, 332 Protoxide of nitrogen, 349 Pruni virginianae cortex, 396 Prunus virginiana, 396 Prussic acid, 271 Pseudomorphine, 357 Psychotria ipecacuanha?, 290 Pulvis acetanilidi compositus, 58 amygdalae compositus, 72 antimonialis, 85, 89 aromaticus, 156, 198 catechu compositus, 255 cinnamomi compositus, 198 cretae aromaticus, 139 cum opio, 139 compositus, 139 effervescens compositus, 416 elaterini compositus, 233 glycyrrhizae compositus, 310, 418 ipecacuanha? compositus, 292, 365 et opii, 292, 365 jalapae compositus, 300 kino compositus, 302 morphinae compositus, 366 opii, 356, 364 compositus, 365 rhei compositus, 401 scammonii compositus, 414 soda? tartaratae effervescens, 416 Pumpkin-seed, 373 Punch, milk-, 70 Punk, 63 Purgatives, 48 Purging cassia, 157 Purified aloes, 74 chloroform, 170 Purified ox-gall, 368 sulphide of antimony, 85 Pyoktanin, 333, 397 Pyrogallic acid, 397 Pyrogallol, 397 Pyrophosphate of iron, 298 QUASSIA. 397 infusion of, 398 Quassiae lignum, 397 Quassin, 397 Queen's root, 426 Quercus, 398 Lusitanica, 254 tinctoria, 398 Quevenne's iron, 293, 298 Quicksilver, 317 Quinicine, 190 Quinidinae sulphas, 197 Quinidine, 190 sulphate, 197 Quinina, 190 Quininae bimuriatica carbamas, 196 bisulphas, 195 hydrobromidum, 195 hydro chloridum, 195 acidum, 195 sulphas, 195 valeras, 195, 453 Quinine, 190 acid hydrochloride of, 195 bisulphate, 195 chocolates, 195 hydrobromide, 195 hydrochloride, 195 tannate, 195 sulphate, 195 and urea, bimuriate of, 196 valerianate. 195 RASPBERRY, 402 Rectal medication, 23, 28 Rectified spirit, 71 Red cinchona, 190 iodide of mercury, 327 oxide of mercury, 332 precipitate, 332 ointment, 332 rose, 402 wine, 70 Reduced iron, 293, 298 Reliability and strength of drugs, 36 Remedial measures other than drugs, 461 Remedv, cold as a, 471 Resin, 398 cerate, 398 compound of, 398 of guaiac, 262 ointment, 398 plaster, 308 Resina, 398 jalapae, 300 856 INDEX OF DRUGS AND REMEDIAL MEASURES. Resina podophylli, 394 scammonii, 414 Resistance inhaler, Denison's, 517 Resorcinol, 398 Respiration-indicator, Krohne and Sese- mann's, 371 Rest cure, 528 in the treatment of disease, 20 Restorative beef-essence, 550 Revulsives, 42 Rhamnus purshiana, 156 Rhei radix, 400 Rheum, 400 Rhigolene, 400 Rhubarb, 400 Rhus aromatica, 401 glabra, 401 Rice-water, 551 Ricinoleic acid, 157 Ricinus communis, 157 Robertson's nebulizer, 522 Roborants, 42 Rochelle salt, 401 Rosa gallica, 402 gallicse petala, 402 Rose-water, 402 Rosin, 398 Rottlera, 302 Rottlerin, 302 Rubefacients, 46, 493 Rubus idseus, 402 Rue, 402 Rules for dosage, 27 Rum, 70 Russian bath, 508 OABINA, 413 k3 Saccharated carbonate of iron, 295 iodide of iron, 297 pepsin, 377 solution of lime, 141 Saccharin (benzo-sulphanidum), 403 Saccharum, 429 lactis, 429 purificatum, 429 Sal prunella, 340 Salicin, 403 . Salicinum, 403 Salicylate of bismuth, 121 of lithium, 311 of mercury, 332 of methyl, 255, 409 of phenyl (salol), 409 of physostigmine, 386 of sodium, 409 of strontium, 427 Salicylic acid, 403 poisoning by, 404 ointment, 408 Salol (phenyl salicylate), 409 Salophen, 410 Salophenum, 410 Salt, 422 Saltpetre, 340 Salts, 314 Sandalwood oil, 410 Sanguinaria, 411 Sanguinarine, 411 Santonica, 411 Santonin, 411 poisoning by, 412 Santoninate of sodium, 412 Santoninic acid, 412 Santoninum, 411 Sapo, 419 durus, 419 mollis, 419 Sarsae radix, 413 Sarsaparilla, 413 Savine, 413 Scammonia radix, 414 Scammonise resinee, 414 Scammonium, 414 Scammony, 414 Schleich's anaesthetic mixture, fluid, 202 Scilla, 425 Scillin, 425 Scillipicrin, 425 Scillitoxin, 425 Sclerotinic acid, 233 Scoparii cacumina, 415 Scoparin, 415 Scoparius, 415 Scopola, 414 Scopolamine, 414 hydriodide, 414 hydrobromide, 414 hydrochloride, 414 Sedatives, cardiac, 40, 46 nervous, 42, 48 vasomotor, 43, 49 Seidlitz powder, 416 Senega, 416 Senegse radix, 416 Senegin, 416 Senna, 417 Alexandrina, 417 confection of, 157 Indica, 417 Serpentaria, 418 Serpentaria? rhizoma, 418 Serum antidiphtheritic, 468 antistreptococcus, 470 Sherry, 71 Sick, feeding the, 542 Silicate of potassium, 418 of sodium, 418 Silver nitrate, 340, 467 Sinapis alba, 337 albse semina, 337 nigra, 337 nigrse semina, 337 Sinapisma, 338 Slaked lime, 141 Sleep in disease, 20 Smilax, 413 187 INDEX OF DRUGS AND REMEDIAL MEASURES. 857 Smooth sumach, 401 Snake- weed, 250 Soap, 419 liniment, 143, 419 plaster, 419 Socotrine aloes, 73 Soda caustica, 160 tartarata. 401 Sodii acetas, 421 arsenas, 105 bicarbonas, 421 boras, 122 bromidum, 131 chloridum, 422 hydroxidum, 160 hyposulphis (thiosulphas), 423 iodidum, 282 nitris, 346 phenolsulphonas, 381 phosphas, 381 effervescens, 381 exsiccatus, 381 et potassii tartras, 401 salicylas, 409 santoninas, 412 sulphas, 422 effervescens, 423 sulphoearbolas, 381 tartarata, 401 thiosulphas (hyposulphis), 423 Sodio-theobromine salicylate, 420 Sodium, 421 arsenate, 105 bicarbonate, 421 borate, 123 bromide, 131 cacodylate, 421 chloride, 422 ethylate, 422 hydroxide, 160 hyposulphite (thiosulphate), 423 iodide, 282 nitrite, 346 phenolsulphonate, 381 phosphate, 381 effervescing, 381 exsiccated, 381 salicylate, 409 santoninate, 412 silicate, 418 sulphate, 422 sulpho-carbonate, 381, 430 thiosulphate (hyposulphite), 423 Soft petrolatum, 378 Solanum Carolinense, 423 Soluble citrate of iron and quinine, 290 glass, 418 phosphate of iron, 298 Solution of acetate of ammonium, 80 of iron, 299 of morphine, 367 of ammonia, 79 of arsenate of sodium, 105 of arsenic and mercuric iodide, 105 Solution of arsenite of potassium, 105 of arsenous acid, 104, 105 of carbonate of magnesium, 314 of chloride of iron, 296 of zinc, 459 of chlorinated lime, 170 of chromic acid, 188 of citrate of ammonium, 83 of bismuth and ammonium, 120 of iron, 296 of magnesium, 314 of potassium, 395 of hydrochloride of morphine, 367 of strychnine, 355 of iodide of arsenic and mercury, 105 of iodine, 287 of iron and ammonium acetate, 293, 294 of lime, 140, 141 of nitrate of mercury, 331 of pancreas, 372 of pepsin, 377 of perchloride of iron 296 of mercury, 326 of permanganate of potassium, 378 of potassa, 310 of potassium hydroxide, 310 of silicate of sodium, 419 of sodium hydroxide, 160 of subacetate of lead, 307 of sulphate of atropine, 118 of iron, 297 of morphine, 366 of tartrate of morphine, 367 of tersulphate of iron, 108 Somnal, 423 Sozoidol, 424 Spanish fly, 147 Sparteine sulphas, 415 Sparteine, 415 Sphacelinic acid, 234 Spice plaster, 494 Spigelia, 424 Spinal anaesthesia, mode of introducing the needle in, 192 extracts, 259 Spirit of Mindererus, 80 of nitrous ether, 436 of turpentine, 450 Spirits, 27 Spiritus setheris, 244 compositus, 266 nitrosi, 436 ammoniae, 79 aromaticus, 79 fcetidus, 79 cajuputi, 137 camphorse, 143 chloroformi, 182, 187 einnamomi, 198 frumenti, 70 gaultherise, 256 glycerylis nitratis, 347 juniperi, 302 858 INDEX OF DRUGS AND REMEDIAL MEASURES. Spiritus juniperi compositus, 70, 301 menthse piperita?, 375 myristicse, 351 odoratus, 70 phosphori, 385 restificatus, 71 vini gallici, 70 Sponging, cool, 480 Sprays, atomized, 24, 25 Springs, mineral, 530 Squill, 425 Squirting cucumber, 233 Starch, 426 glycerite of, 260 poultice, 426 -water, 426 Steam vaporizer, 520 Steapsin, 372 Stillingia, 426 Stillingin, 426 Stimulants, cardiac, 40, 46 nervous, 42, 48 vasomotor, 43, 49 Stomach-pump, 527 Stout, 70 Stramonii, 427 Stramonium, 427 Strength, relative, of drugs, 36 Stretcher, bath, 484 Strong gray ointment, 330 Stronger water of ammonia, 79 Strontium, 427 bromide, 131, 427 iodide, 427 lactate, 427 phosphate, 427 salicylate, 427 Strophanthi semina, 428 Strophanthin, 428, 429 Strophanthus, 428 Strychninse sulphas, 355 Strychnine, 352 hydrochloride, 355 sulphate, 355 Strychnos nux vomica, 352 Styptic collodion, 212, 439 Stypticin, 218 Styrax benzoin, 119 Subcarbonate of bismuth, 120 Subgallate of bismuth, 121 Sublimed sulphur, 431 Subnitrate of bismuth, 120 Subsulphate of iron, 293, 298 Succinum, 76 Succus belladonnse, 119 conii, 215 hyoscyami, 275 limonis, 198 scoparii, 416 taraxaci, 440 Sugar, 429 -beet, 429 -cane, 429 of lead, 306 Sugar of milk, 429 Sulphate of aluminum and potassium, 75 of ammonium, 83 of atropine, 113, 118 of calcium, 137, 139 of cinchonidine, 196 of cinchonine, 197 of codeine, 206 of copper, 216 of duboisine, 232 of hyoscyamine, 275 of iron, 293, 299 and ammonium, 293, 294 of magnesium, 314 of manganese, 316 of morphine, 366 of pelletierine, 394 of physostigmine, 386 of quinidine, 197 of quinine, 195 of sodium, 422 of sparteine, 415 of strychnine, 355 of zinc, 459 Sulphide of antimony, 85 of calcium, 433 Sulphocarbolate (phenolsulphonate) of sodium, 381 of zinc, 381, 467 Sulphonal (sulphonmethane), 430 Sulphonalum, 430 Sulphonethylmethanum (trional), 449 Sulphonmethanum (sulp'ional), 430 Sulphur, 431 lotum, 431 ointment, 433 praecipitatum, 431 sublimatum, 431 Sulphurated antimony, 85 lime, 141 Sulphuric acid, 433 ether, 237 "Sulphuric acid lemonade," 434 Sumach, smooth, 401 sweet, 401 Sumbul, 434 pill, Goodell's, 434 radix, 434 Suppositoria acidi tannici, 439 asafcetidee, 110 belladonnse, 119 glycerini, 260 iodoformi, 289 morphinae, 367 plumb i composita, 307 Suppositories, 24, 27 Suppositorium acidi carbolici, 155 Suprarenal gland, 259, 435 Suspension, 536 Swamp hellebore, 454 Sweet almonds, 72 spirit of nitre, 436 sumach, 401 Swertia chirate, 161 INDEX OF DRUGS AND REMEDIAL MEASURES. 859 Sydenham's laudanum, 365 Symptoms, relief of, in disease, 20 Syrups, 27 Syrupus acaciae, 53 acidi citrici, 198 allii, 71 amygdalae, 72 calcii lactophosphatis, 139 cascarae aromaticus, 157 chloral, 165 codeinae, 207 ferri bromidi, 295 iodidi, 297 phosphatis, 298 cum quininaetstrvchnina, 298 quininae et strychninae phos- phatum, 298 hypophosphitum, 139 compo situs, 139 ipecacuanhas, 292 limonis, 198 piscis liquidae, 440 pruni virginianae, 397 rhei, 401 aromaticus, 401 rosae, 402 rubi idaei, 402 sarsaparillae compositum, 413 scillae, 426 compositus, 89, 426 senegae, 416 sennae, 418 zingiberis, 258 TABELL./E trinitrini, 347 Tables of relative weights and measures in the metric and apoth- ecaries' systems, 33 Tablet triturates, 27 Tablets, 27 of nitroglycerin, 347 Taeniin, 223 Taka-cLiastase, 224 Tamarinds, 438 Tamarindus, 438 Tanacetum, 439 Tannate of pelletierine 395 of quinine, 195 Tannic acid, 438 Tansy, 439 tea, 439 Tar, 439 ointment, 440 -water, 440 Taraxaci radix, 440 Taraxacum, 440 Tartar emetic, 85, 86 Tartaric acid, 441 Tartrate of antimony and potassium, 85 86 of iron and ammonium, 296 and potassium, 296 Tartrate of morphine, 366 of potassium and sodium, 401 Tea, beef, 550 Terebene, 441 Terebenum, 441 Terebinthina, 449 canadensis, 449 Terminal infections, 19 Terpine hydrate, 441 Terpini hydras, 441 Terpinol, 442 Testicular juice, 259 Thapsia, 442 Thebaine, 357 Theine, 134 Theobromine, 303 sodio-salicylate, 420 Therapeutical considerations, general, 17 nihilism, 17 Therapeutics, definition of, 17 Thiocol, 442 Thiol, 443 Thiolum liquidum, 443 siccum, 443 Thiosinamine, 443 Thiosulphate of sodium, 422 Thoroughwort, 250 Thymol, 444 iodide, 445 Thymus glands, 445 Thyreoidine, 448 Thyroid gland, 259, 446 Thyroideum siccum, 448 Tinctura aconiti, 63 aloes, 75 et myrrhae, 75, 338 arnicae, 99 radicis, 99 asafcetidae, 110 belladonnas, 118 folio rum, 118 benzoini, 119 composita, 119 bryoniae, 132, 133 buchu, 134 calumbae, 140 camphorae composita, 143, 365 cannabis indicae, 147 cantharidis, 148 capsici, 151 cardamomi, 156 composita, 156 catechu, 255 chiratae, 161 chloroformi et morphinae composita, 187, 367 cimicifugae, 189 cinchonae, 197 composita, 197, 419 cinnamomi, 198 colchici seminis, 212 conii, 215 convallariap, 216 cubebae, 223 860 INDEX OF DRUGS AND REMEDIAL MEASURES. Tinctura digitalis, 230 ergotae ammoniata, 236 ferri ehloridi, 295 perchloridi, 295, 296 galte, 254 gambir composita, 255 gelsemii, 257 • gentianae composita, 257 guaiaci, 262 ammoniata, 262 hamamelidis, 265 humuli, 269 hydrastis, 270 hyoscyami, 275 iodi, 286 ipecacuanhae et opii, 365 jaborandi, 391 jalapse, 300 kino, 302 lobeliae, 312 aetherea, 312 lupuli, 269 moschi, 337 myrrhae, 338 nucis vomicae, 354 opii, 365 ammoniata, 365 camphorata, 364 deodorata, 365 phvsostigmatis, 386 podophylli, 394 pruni virginianae, 397 quassiae, 398 quininae, 195 ammoniata, 195 rhei, 401 aromatica, 401 composita, 401 dulcis, 401 sanguinariae, 411 scillae, 425 senegae, 417 sennae composita, 418 serpentariae, 418 stramonii, 427 strophanthi, 429 sumbul, 434 Valerianae, 453 ammoniata, 453 veratri, 456 zingiberis, 258 Tincture of cactus grandiflorus, 134 of muriate of iron, 295 Tinctures, 27 changes in strength of, 52 Toast, watered, 553 Tonics, 43, 48 Touchwood, 63 Transfusion, 536 abdominal, 539 apparatus, 539 Tribromomethane, 132 Tribrom-phenol-bismuth, 458 Trichloracetic acid, 448 Trikresol, 448 Trinitrin, 346 Trinitrophenol, 386 Trional (sulphonethylmethane), 449 Trionalum, 449 Triturates, 27 Trituratio elaterini, 233 Troches, 27 Trochisci acidi benzoici, 120 tannici, 439 catechu, 255 cretae, 139 cubebae, 223 eucalypti gummi, 249 ferri reducti, 299 gambir, 255 glycyrrhizae et opii, 310 guaiaci, 262 ipecacuanhae, 292 magnesiae, 313 menthae piperitae, 375 morphinae et ipecacuanhae, 366 potassii chloratis, 168 santonini, 412 sodii santoninatis, 412 sulphuris, 433 zingiberis, 258 Trochiscus acidi carbolici, 155 bismuthi compositus, 120 morphinae, 367 et ipecacuanhae, 292, 367 Tropic acid, 267 Tropine, 267 Trypsin, 372 Tully's powder, 366 Turkish bath, 505 home modification of, 507 Turpentine, 449 liniment, 452 ointment, 452 stupe, 450, 494 Turpeth mineral, 333 U NGUENTS, 27 Unguentum acidi carbolici, 155 gallici, 254 salicylici, 408 tannici, 439 aconitinae, 63 antimonii tartarati, 89 aquae rosae, 402 atropinae, 119 belladonnae, 118 cantharidis, 149 capsici, 151 cetacei, 120 chrysarobini, 188 cocainae, 206 conii, 215 creosoti, 220 eucalypti, 249 gallae, 254 cum opii, 254 INDEX OF DRUGS AND REMEDIAL MEASURES. 861 Unguentum glycerini plumbi subacetatis, 261 hamamelidis, 265 hydrargyri, 330 ammoniati; 324 iodidi rubri, 327 nitratis, 332 dilutum, 332 oleatis, 331 oxidi flavi, 332 rubri, 332 subchloridi, 330 iodi, 287 iodoformi, 289 petrolei, 378 phenolis, 155 picis liquidae, 440 plumbi acetatis, 307 carbonatis, 307 iodidi, 307 potassii iodidi, 282 resinse, 398 stramonii, 427 sulphuris, 432 terebinthinae, 451 veratrinse, 454 zinci oxidi, 368 Unna's dressing, 368 Uritone, 452 Urotropin (hexamethylenamine), 452 Ursin, 452 Uva ursi, 452 Uvse ursi folia, 452 T7 ALE RATE of ammonium, 83, 453 T of iron, 299, 453 of quinine, 195, 453 of zinc, 453 Valerian, 452 Valeriana, 452 Valeriana rhizoma, 452 Valerianic acid, 453 Vallet's mass, 295 Vapor acidi hydrocyanici, 273 chlori, 170 conii, 215 Vaporization, 24 Vaporizer, steam, 520 Vaseline, 378 Vasomotor depressants, 43, 49 stimulants, 43, 49 Vegetable astringents, 46 cathartic pills, 213 cathartics, 48 Venesection, 540 Veratri viridis rhizoma, 454 Veratrina, 453 Veratrine ointment, 454 Veratroidine, 455 Veratrum, 454 Veronal, 456 Vienna mixture, 186 paste, 159, 457 Vinegar, 58 of ipecac, 292 of lobelia, 312 of opium, 365 of sanguinaria, 411 of squill, 426 Vinegars, 26 Vinum album, 70 antimoniale, 89 antimonii, 89 colchici, 211 seminis, 211 ergotse, 236 ferri am arum, 299 citratis, 299 ipecacuanha?, 292 opii, 365 picis, 440 portense, 71 quininse, 195 rubrum, 70 xericum, 71 Virginia snake-root, 418 Volatile oil of mustard, 336 WAHOO, 249 Warburg's tincture, 457 Warming plaster, 149, 393 Wash, black, 327 yellow, 333 Washed sulphur, 431 Water of ammonia, 79 stronger, 79 of chloroform, 182, 187 Watered toast, 553 Waters, 25 Weights and measures, 30 tables of relative, 33 apothecary, 30 avoirdupois, 30 metric, 31, 32 Wet cups, 495 pack, 509 Whiskey, 70 White ginger, 258 lead, 307 mustard, 337 oak, 398 petrolatum, 378 precipitate, 324 ointment, 324 wine, 70 Whytt's tincture, 197 Wild cherry, 396 Wine, 70 of antimony, 89 of citrate of iron, 299 of colchicum, 212 of colchicum-seed, 211 of ergot, 236 of ipecac, 292 of iron, 299 bitter, 299 862 INDEX OF DRUGS AND REMEDIAL MEASURES. Wine measure, 30 mulled, 553 of opium, 365 port, 71 of quinine, 195 red, 70 of tar, 440 whey, 70, 551 white, 70 Wines, 27 Wintergreen, 255 Witch-hazel, 265 Wormseed, American, 160 XANTHOPUCCIN, 269 Xeroform, 458 YELLOW cinchona, 177 1 gentian, 257 iodide of mercury, 332 jasmine, 256 Yellow oxide of mercury, 332 prussiate of potassium, 217 pyoktanin, 334 sulphate of mercury, 333 wash, 333 Yeo's creosote inhaler, 219, 521 Yolk of egg, glycerite of, 260 Young's rule for dosage 28 ZINCI acetas, 458 carbonas. 458 prsecipitatus, 458 chloridum, 459, 466 oxidum, 368 venale, 368 phenolsulphonas, 381 sulphas, 459 sulphocarbolas, 381 as an antiseptic, 467 valeras, 453 Zingiber, 258 INDEX OF DISEASES AND REMEDIES. ABORTION, 555 Cascara sagrada, or compound liquorice powder, as a laxative for associated con- stipation; if these fail, rhubarb or castor oil, 555 Creolin (2 per cent, solution), should be in- jected after removal of the membranes, or if fever should follow, 557 Curette me nt, 557 Diet and hygiene, 555 Elaterium, jalap, scammony, strychnine, erigeron, cantharides, contraindicated, unless very necessary, 555 Ergot and quinine, in small doses with perfect rest for one or two weeks, and antiseptic irrigation as an after-treat- ment, 556 Iodine, applied to the inner surface of uterus, after removal of membranes, as a haemostatic and antiseptic, 557 Opium or morphine, best agents to quiet uterus if abortion threatens, 556 Podophyllin, senna, salines in active doses, and aloes, not to be used if they can be avoided, 555 Quinine, useful in malarial poisoning, as a preventive; in other cases contraindi- cated, 557 Saline purges contraindicated, except in plethoric women, 555 Sponges should not be used as tampons, 556 Tampons of absorbent cotton, dusted with iodoform, foUowed later by ergot, if abortion is inevitable, 556 Venesection useful in plethoric women to prevent, 556 Viburnum prunifolium, fluid extract, drachm £ to 1 (2.0-4.0), taken during pregnancy as a prophylactic, 556 ABSCESS, 557 Aconite or veratrum in full dose may abort, 557 Alcohol, given with milk, in cold abscess, 558 Belladonna ointment, locally applied to abort; or tincture, internally, if aconite is not at hand, 559 Calx sulphurata, gr. T \ (0.006), every hour or two, useful to abort or cause absorp- tion, 558 Carbolic acid, minims 5 to 10 (0.3-0.60) of 2 per cent, solution, injected into gland threatening suppuration, 557 Cod-liver oil with hypophosphites, quinine, and iron, useful in cold abscess, 558 Hydrogen peroxide, 3 per cent, solution, to wash out cavity of tubercular or slow abscess, 274, 558 Incision, if pus forms, followed by irrigation with phenol (1 :20) or bichloride solution (1:5000) and antiseptic dressing, 558 Iodine, locally applied, may abort, 559 Iodoform gauze, packed into cavity, or ethereal solution injected after aspira- tion, and antiseptic dressing, useful in tubercular abscess, 558 Lead-water, applied on bread-crumb poul- tice or lint, in early stage, to abort, 557 Nitrate of silver, gr. 20 to 40 (1.3-2.6) to the ounce (30.0), locally applied, may abort, 558 Poultices to assist maturation, 557, 558 Prescriptions for tonics, in cold abscess, 558 ACIDITY. Ammonia, the most active remedy in gas- tric acidity, contraindicated if acute irritation exists, 79 Bicarbonate of sodium, in form of efferves- cing powder, valuable in gastric acidity, 421 Bismuth a slow and feeble antacid, 120 Carbonate of calcium, precipitated, best antacid in intestinal acidity, 137 Cerium oxalate, used in some cases of gas- tric acidity instead of bismuth, 160 Charcoal useful in some cases of "sour stomach," 155 Lime-water, 140 Liquor potassii hydroxidi useful both for gastric and urinary acidity, 310 Magnesium a useful antacid, 314 ACNE, 559 Calx sulphurata, gr. ^ to £ (0.006-0.008), in pill, thrice daily, in pustular acne, 141, 559 Carbolic acid touched to pustules, after incision, 560 Cod-liver oil, if scrofulosis exists, 559 Fowler's solution often cures and prevents relapse, dose gtt. 1 to 3 (0.05-0.20), thrice daily, for a month or two, 559 Green or Castile soap used in face-bath night and morning, followed by brisk rubbing; if irritation ensues, simple, cerate or emulsion of bitter almonds will relieve, 559 Ichthyol, 20 to 100 parts of lard, well rubbed in, when induration is great, 278, 560 ( 863 ) 864 INDEX OF DISEASES AND REMEDIES. Mercurial ointment, to relieve induration, several days intervening between its use and that of sulphur, 560 Phosphorus especiallv useful in acne indu- rata, 384 Resorcinol, gr. 10 to 20 to the ounce (0.60- 1.3:30.0) of lard, when induration is great, 560 Saline purges, followed by cascara sagrada or similar remedy, to regulate bowels, if dependent upon obstinate constipa- tion, 559 Sulphur internally and as a wash or oint- ment for women with disordered men- struation, prescription for, 433, 559 ADDISON'S DISEASE. Suprarenal gland, 436 ADENITIS, 560 Ichthyol, prescription for, 560 Iodine ointment and lard, equal parts, ap- plied by inunction night and morning, or tincture, as a paint, stopping applica- tion on appearance of redness or fluc- tuation, 560 Iron, svrup of the iodide, TT[10 to 40 (0.60- 2.60) in children, 560 Lancing preferable to allowing abscess to break, 560 Poultice, when redness or fluctuation ap- pears, 560 Removal of gland by dissection, if enlarge- ment is scrofulous. 560 Tonics, to improve systemic condition, 560 ALBUMINURIA. (See Bright 's Disease.) Cacodylate of iron in albuminuria of tuber- culosis, 295 Gallic acid, if due to atony of kidneys, 254 Juniper in albuminuria due to congestion, 301 Strontium lactate, if due to renal atony, 428 ALCOHOLISM. (See Poisoning from Alcohol.) ALOPECIA, 561 Chrysarobin, drachm \ to 1 (2.0-4.0) to lanolin, 1 ounce (30.0), 561 Corrosive sublimate, gr. 2 (0.12) to rectified spirit 1 drachm (4.0) and oil of turpen- tine 7 drachms (28.0), 561 Liquor epispasticus painted over bald spot after loose hairs have been depilated, 561 Pilocarpine, locally applied, often stimu- lates new growth; too much causes small pustules around follicles; prescription for, 390 AMBLYOPIA AND AMAUROSIS, 561 Antipyrin, 563 Bromide of potassium, 562 Cauterization of nape of neck, 562 Correction of optical errors, when arising from congenital trouble or non-use, 561 Cups, wet and dry, 562 Digitalis in toxic cases, 562 Electricity, constant current, 562 Emmenagogues, if due to menstrual dis- orders, 562 Fly-blister to temple in, some cases, 562 Iodide of potassium, 562 Lactate of zinc, 563 Mercury, when due to syphilis, 562 Metallo-therapy, may be tried in hysterical cases, 562 Nitrate of silver, 563 Nitrite of amyl, inhalations, 562 Nitroglycerin, 562 Nux vomica in ascending doses in tobacco or alcoholic cases, 353 Phosphorus, 563 Pilocarpine, in ursemic, tobacco, or alcohol amaurosis, 389, 562 Salicylates, 562 Stretching the optic nerve, 563 Strychnine, hypodermically, after irritation has subsided, 562 Suspension, and injections of testicular juice, 563 X-rays of no value after optic atrophy is established, 563 AMENORRHEA, 563 Aloes, as a specific, when dependent upon constipation, atony of sexual system, or anaemia, 74, 563 Apiol, TT\ 2 to 8 (0.1-0.5), in capsule, thrice daily for a week before date of men- struation, 96, 564 Arnica, 99 Binoxide of manganese, gr. 1 to 3 (0.06- 0.20), taken for two weeks before time of menstruation, 316, 563 Cantharides, as a stimulant, if due to atony or depression, 148 Cimicifuga, fluid extract, Til 30 (2.0), at the proper time for a flow, 189, 563 Dewees's emmenagogue mixture, 564 Eupatorium, in hot infusion, if due to cold, 250 GoodelPs prescription for, 563 Griffith's' pills, largely used when depend- ent upon anaemia, 295 Hot sitz-bath, for several nights before period; mustard added often increases its efficacy, 564 Iron and myrrh, a standard remedy if due to atony or anaemia, 338, 563 Oil of rue, TT\ 5 (0.3), in capsule, thrice daily, 564 Potassium permanganate, useful, but infe- rior to binoxide of manganese, 377, 564 Salines inferior to aloes if due to constipa- tion, 563 Savine, Vf[ 5 (0.3), in capsule, thrice daily, to stimulate uterus, 414, 564 Tansy, TTl 5 (0.3), in capsule, thrice daily, or in form of tansy tea, 439, 564 ANffiMIA, 564 Aromatic mixture of iron, 294 Arsenate of iron in anaemia of chronic diarrhoea, 294 INDEX OF DISEASES AND REMEDIES. 865 Arsenic, not to exceed gr. -fa (0.006) daily, alone or combined with iron, valuable, 567; very valuable in pernicious and malarial anaemia, 101 Arsenite of copper, 219, 220, 568 Beta-naphthol, when due to intestinal in- digestion, 567 Bitters, simple or aromatic, in conjunction with iron, when stomach and intestines are atonic, 566 Blaud's pill, 567 Bromide of iron, gr. 5 to 20 (0.3-1.3), in syrup, useful when there is chorea, 294 Cacodylate of iron, when haemoglobin and corpuscles are lacking, 295 Carbonate of iron, 295, 567 Cerebral and spinal extracts useless in pernicious anaemia, 259 Chloride of iron, useful because of its tonic properties, 296 Dialyzed iron, 296 Diet and hygiene, 568 Hypophosphites and phosphate of lime, with cod-liver oil, iron, and quinine, when anaemia is due to childbearing and lactation, 139, 567 Iodide of iron, syrup of, largely used in strumous and scrofulous anaemia, 297 Iron, 293, 565 Mercury, bichloride or calomel, especially valuable in syphilitic cases. Inunctions of mercurial ointment, once a day or every other day, of service in all forms of anaemia, 326, 567 Ovarian extract in chlorotic type, 259 Oxygen inhalations of value, 370 Phenyl salicylate, when due to decomposi- tion-products, 410 Quevenne's iron, 299, 567 Quinine in malarial cases, and in tonic doses in all other anaemias, 567 Reduced iron, with laxatives and mineral acids for their effects on intestines and liver, in uncomplicated cases, 299, 566 Sodium cacodylate in anaemia of tubercu- losis, 421 Sulphate of iron or some other astringent preparation in conjunction with mild purges, when tongue is broad, flabby, and white, 299, 567 ANAL FISSURE, 568 Belladonna ointment or suppository in spasm of the sphincter, due to fissure, 116 Castor oil, to relieve bowels if sulphur cannot be used, 569 Flexible collodion, painted over spot, may relieve, 569 Ichthyol, pure, applied locally, 569 Iodoform suppositories, gr. 2 to 10 (0.12- 0.60), relieve pain of defecation; bella- donna, gr. I (0.015), to be added when there is spasm of sphincter, 289, 568 Phenol, 1 drop (0.05), applied to fissure to effect cure; in addition, when hemor- rhoids are present, a lotion of tannic acid, glycerin, and water, 568 Potassium bromide, drachms H to the ounce (6.0:30.0) of glycerin, locally applied to fissure by means of a brush, highlv recommended, 569 Sulphur, gr. 20 to 40 (1.3-2.6), combined with powdered cinnamon or aromatic powder, at night to render passages soft, 569 ANEURISM 569 Aconite, inferior to veratum as a cardiac sedative, 569 Chloroform inhalation if dvspncea is great, 570 Digitalis, contraindicated, 569 Electrolysis, 570 Gelatin injected into the subcutaneous tissues, 570 Iodide of potassium, in large doses, asso- ciated with restricted diet and rest in bed; more valuable in syphilitic than in other forms of the disease, 280, 569 Morphine, gr. -J (0.008), combined with chloral or, better, with croton chloral, gr. 10 (0.60), in sleeplessness due to pain, 569 Veratrum, m 4 to 8 (0.25-0.50), twice or thrice daily if heart is excitable and vascular tension high, 456, 569 ANGINA PECTORIS, 570 Aconite, useful between attacks, 572 Alcohol, instead of nitrites, when there is vascular relaxation, 571 Antipyrin, gr. 20 (1.3), valuable in some cases, 571 Arsenic, in full doses long continued, and elimination of causes of nerve-storm, 571 Cactus grandiflorus, in some cases, 134 Digitalis, when heart is weak, 571 Ether, in 1-drachm (4.0), doses in ice-water or capsule, to nervous females, often aborts, 571 Hoffmann's anodvne, often the best remedv, 266, 571 Morphine, gr. J to \ (0.015-0.03), hypoder- mically, when nitrate of amyl fails to relieve, 571 Nitrite of amyl, inhalation of a few drops from handkerchief during attack, 84, 570 Nitrite of sodium or potassium, gr. 3 (0.20), thrice daily, useless unless arterial ten- sion is high and heart throbbing, 345, 571 Nitroglycerin, TTL 1 (0.05) of a 1 per cent. solution during attack, 346, 571 Phosphorus, gr. ^-^ (0.0006), after meals, often of value, 571 Prescription for use between attacks, 571 Stomach-pump may be required when due to overloaded stomach, 572 Tonics, combined with careful diet and hygiene necessary to a cure, 571 ANOREXIA, 572 Calomel, useful when following acute dis- ease; nitro-muriatic acid, however, gen- erally preferable, 329 55 866 INDEX OF DISEASES AND REMEDIES. Capsicum, in convalescence, acts most favorably, 150 Chimaphilia, in dropsical patients, as a tonic and diuretic, 160 Eupatorium useful in, 250 Gentian, 257 Prescriptions for tonics, 572 Quassia, especially valuable when follow- ing malarial fever, 397 APOPLEXY, 572 Belladonna, hypodermically, if respiration fail, 573 Calomel, gr. \ (0.015) every four hours, if symptoms of meningitis arise, 573 Croton oil, TT\ 1 (0.05), with sweet oil, V(\ 5 (0.3), as a depletant cathartic, 572 Diet, 573 Elaterium, gr. £ (0.01), as a depletant cathartic, 573 Ice to the head, 572 Iodine of potassium, in large doses several days after attack, when clot has firmly formed, to promote absorption, 573 Massage and electricity, applied to muscles to prevent atrophy; contraindicated if inflammation exist, 573 Mercury, 573 Mustard plaster to feet, or mustard foot- bath and ice to head, keeping head high and feet low, 572 Opium and calomel, gr. \ (0.015) of each every four hours, if meningitis arise, 573 Stimulants contraindicated, 574 Strychnine, hypodermically, if respiration fail; is also useful to stimulate trophic centres in cord, 573 Venesection, if patient is full-blooded, to prevent inflammation and further leak- age, 540, 572 APPENDICITIS, 574 Absolute rest necessary, 574 Gastric lavage in nausea, vomiting, or gas- eous distention, 575 Ice-bag or leeches, applied to appendicular region, 574 Magnesium sulphate or citrate, 574 Opium or morphine (after the bowels have moved), to relieve pain and act as an antiphlogistic, 574 Rules for treating, 575 Surgical treatment, 575 ARTHRITIS. Bicarbonate of sodium, applied to part on lint, to allay pain, 421 Lithium carbonate and citrate, prevent deposit in joints from rheumatoid ar- thritis, 311 Mustard plaster, as a counterirritant, 337 Veratrine ointment, 454 ASCARIS LUMBRICOIDES. (See Worms.) ASCITES. (See Dropsy.) ASPHYXIA, 576 Ammonia, injected intravenously into leg to stimulate heart and respiration, 78 Artificial respiration, Sylvester's method, 576 Electricity, only to be used as a peripheral irritant to restore respiration, 579 Laborde's lingual traction of great value, 579 Oxygen inhalations, 370 Rules regarding position of patient, 578 ASTHENOPIA, 579 Cannabis indica, in retinal asthenopia, pre- scriptions for, 146 Eserine or pilocarpine, weak solution, as a stimulant to ciliary muscles, 580 Glasses, combined with prisms if necessary, to correct optical defects, 580 Hot compresses, 580 Massage, rest, salt baths, strychnine, and iron, if due to neurasthenia, 580 Strychnine or tincture of nux vomica in large doses, to stimulate ciliary muscles, 580 ASTHMA, 580 Aconite, in early stages, 62 Amyl nitrite, 3 to 6 minims (0.20-0.4) on handkerchief, inhaled with care, relieves spasm, 84, 581, .582 Arsenic, internally or smoked in cigarettes, best remedy when mucous membrane is at fault, 103, 583 Belladonna, combined with morphine, very useful, 116, 581 Bromide of potassium or sodium, gr. 30 (2.0), half an hour before retiring, 583 Bronchitis-tent, 583 Chloral, rarely useful ; if pushed, dangerous, 165 Chloroform, inhaled, relaxes spasm; also useful in form of liniment applied to chest, to abort, 183 Cocaine, applied to nasal cavities, if due to nasal disorders, 583 Coffee, a cup of strong black, during par- oxysms, 136, 582 Compressed and rarefied air, 583 Diet and hygiene, 583 Ethyl iodide, to increase secretions and prevent thickening, 247 Euphorbia pilulifera, i to 1 drachm (2.0- 4.0) of the fluid extract, 250, 582 Gelsemium, 257 Grindelia, fluid extract of, TT1 10 to 30 (0.60-2.0), or leaves soaked in nitre smoked as cigarettes, or fumes of burn- ing leaves inhaled, exceedingly useful, 261, 583 Iodide of potassium, useful in bronchial, harmful in gastric, type, 281, 583 Lobelia, tincture, TT\ 10 (0.60) every four hours, if attack threaten; in emetic dose if heart be strong, when spasm is present, 312, 581, 583 Morphine, hypodermically, gr. \ to \ (0.01- 0.015), alone or combined with atropine, 581 Nitrate of potassium alone or combined with belladonna, in form of cigarettes or inhalation of fumes, often relieves, 340, 581, 582 INDEX OF DISEASES AND REMEDIES. 867 Nitroglycerin, serviceable if bronchial mucous membranes are engorged, 347, 582 Oil of amber, 77 Oxygen inhalations when cyanosis is extreme, 583 Physostigma, in bronchial asthma, to aid in expelling mucus, 386 Sandalwood oil, useful in catarrhal cases, 411 Tobacco-smoking often efficacious in pa- tients not accustomed to it, 582, 583 Zinc oxide, prescription for, 369 ATONY. Arsenic, in gastric and intestinal atony, 101, 103 Calumba, valuable in gastro-intestinal atony, following fevers, 140 Capsicum, one of the best remedies in gas- tric atonv due to debility and alcoholism, 69, 149 Cardamom, with bitter tonics and mineral acid, in gastro-intestinal atony, 156 Chimaphilia, useful as a stimulating diuretic in atonic renal conditions, 160 Hydrastis, indicated in atony of mucous membranes, 269 Leptandra, in duodenal atony, 309 Mustard, in gastric atony of drunkards, 338 Pepper, in atony of genito-urinary mucous membranes, 374 Physostigma, in intestinal and vesical atony, 386 Strychnine, in intestinal atony, 353, 354 AURAL VERTIGO. Pilocarpine, 390 BALANITIS AND BALANOPOSTHITIS, 678 Astringent solutions, to cleanse parts, zinc chloride (gr. 4 to the ounce [0.25-30.0]), boric acid (1 percent.), phenol (1.5 per cent.) ; silver nitrate (gr. 1 to the ounce [0.06:30.0]) especially valuable, 678 Lead-water, dilute, as a wet dressing, pre- ceded by astringent washes, in phimo- sis; if inflammation increases, circum- cise, 678 Silver-nitrate stick, touched to ulcerations, 678 Tannin or zinc oxide, as a dusting-powder, after retracting prepuce and cleansing over absorbent cotton, 678 BALDNESS. (See Alopecia.) BED-SORES, 584 Aloes, glycerole of, as a local application, 74 Alum, with spirit of camphor and white of egg, locally applied, to prevent, 584 Gambir, with lead subacetate, locally applied, to harden skin, 584 Glycerin application daily, after washing and rubbing part, to prevent, 260 Incision, followed by irrigation, if sores tend to burrow, 585 Iron, tincture of chloride, W\ 20 (1.3) every four hours, as a tonic, 585 Nitrate of silver (gr. 20 to the ounce [1.3: 30.0]), painted over threatening part, to abort. If ulcers form and are sluggish, same solution may be used, 343, 584, 585 Salt and whiskey, rubbed over skin to harden it (drachms 2 to the pint [8.0: 480.0]), 584 Soap plaster, applied to sore after washing with bichloride solution (1 :5000) and dusting with iodoform, 419, 584 Supportive measures and increased amount of food, if sloughs are large, 585 Zinc ointment, on squares of lint, some- times used in lieu of soap plaster, 584 BILIOUSNESS, 585 Aconite, antagonizes the poisoning alka- loids which cause slow pulse, high arte- rial tension, etc, 588 Ammonium chloride, gr. 5 (0.3) thrice daily, if associated with catarrh, 588 Bromides and chloral, if nervousness and irritation are present, 588 Calomel, gr. -£- (0.01) in powder every fifteen minutes until six are taken, followed in four hours by a saline, if stools be light, 323, 329, 587 Chirata, extract of, gr. 5 (0.30), in hepatic torpor, prescription for, 587 Diet, 587 Euonymus, extract of, gr. 3 (0.20), 587 Horseback riding combined with gymnastic movements especially valuable, 587 Ipecac, powdered, gr. 30 to 60 (2.0-4.0), or apomorphine, gr.'-^ (0.004) hypodermic- ally, may relieve in first stage, 586 Leptandra, where liver is torpid, 309 Mustard plaster or cup to nape of neck, if face flushed ; foot-bath also of service, 588 Nitro-muriatic acid, TT1 3 (0.20), thrice daily in water, of great service, 348, 567 Podophyllin, gr. £ (0.01), if stools be dark, 587 Protiodide of mercury, gr. *$ to ^ (0.001- 0.0015), in trituration, thrice daily, if due to catarrh, 588 Salines, if attack is sudden, to sweep out poisonous matter, 587 Salol (phenyl salicylate) or salophen, in 10 gr. (0.60) doses, useful as an intestinal antiseptic, 588 Stillingia, fluid extract of, dose, 20 drops (1.3), 585 BLEPHARITIS, 588 Boric-acid lotion when there is accompany- ing conjunctivitis, 588 Chloral, 5 per cent, solution, to remove scabs and crusts, 588 Creolin, 1 to 2 per cent, solution, use as a wash, 221 Methyl blue, 333 Ointments, dilute citrine, Pagenstecher's ointment (yellow oxide of mercury, 1 gr. [0.06]), vaseline, 1 drachm (4.0), pyrogallic acid, milk of sulphur (3 percent.), locally applied after removal of crusts, 588 868 INDEX OF DISEASES AND REMEDIES. Silver nitrate, touched to crater-like ab- scesses, gives good results, 588 Sodium bicarbonate or biborate solution, gr. 8 to ounce (0.5:30.0), to remove scabs and crusts, 588 BOILS, 589 Belladonna, locally applied to relieve pain and inflammation, 589 Calcium sulphurate hastens pointing and prevents formation of new ones; useless in boils of diabetes, 141, 589 Camphorated alcohol, applied over boils in formative stage, then wiped dry, fol- lowed by camphorated oil to abort, 143, 589 Chloride of calcium, added to poultice, hastens maturation, 138 Collodion painted over inflamed spot, to abort; 212; if pus form, it may be ab- sorbed, if not, evacuate by incision, 589 Egg-shells baked and eaten, for successive crops, 141 Opium, locally applied to relieve pain and inflammation, 589 Phenol, 5 per cent, strength, injected into apex of boil when formation is assured, to abort, 154, 589 Phosphorus, 384 Poultices, containing sweet oil and lauda- num, to assist maturation, 589 Prescription for ointment, 589 Silver nitrate (gr. 20 to the ounce [1.3: 30.0]), painted over part, may abort, 343, 589 BONE DISEASE. Iodide of iron, syrup of, if anaemia exist, 284 Iodine ointment, diluted one-half, or tinc- ture, locally applied, 284 BREASTS (INFLAMED), 590 Aconite of veratrum, to depress circulation, 590 Belladonna, internally or as an ointment, before and after inflammation, with cold compresses to breast, 116, 118, 590 Breast-pump, if milk continues to form, 590 Incise as soon as pus forms, 590 Pressure bandage with ice-bag, 590 Purges, mild saline, 590 BREATH, FETID. Camphor, as a mouth- wash, 142 BROMIDROSIS. Belladonna, 115 Borax of great value, 123 Carbonate of calcium, precipitated, a useful application, 137 Formaldehyde useful, 253 Lead plaster and linseed oil, equal parts, applied every third day, 308 Salicylic acid, used as a dusting-powder, prescription for, 407 BRONCHITIS, 590 Aconite, alone or combined with sweet spirit of nitre, in initial stage, 62, 591 Amber, oil of, and olive oil (1 :3), applied to back and front of chest, in infantile bronchitis, 77 Ammoniac, useful in old forms devoid of inflammation, 79 Ammonium carbonate, alone or with the chloride, especially useful in children; gr. 2 to 10 (0.12-0.60) in svrup of acacia, 81 Ammonium chloride, in second stage to stimulate bronchial tubes, prescription for, 82, 518, 593 Apomorphine, 98 Asafoetida, as a stimulating expectorant, 110 Belladonna, to check excessive secretion and stimulate respiration, 595 Benzoic acid, 119 Bronchitis tent, 510, 592 Caffeine, or strong coffee, to stimulate respiration if suffocation threatens, 595 Camphor, in old or atonic cases, 142; liniment rubbed on chest, 591 Cimicifuga in chronic bronchitis, 189 Codeine, recommended when cough is ex- cessive, 207, 594 Creosote, recommended in chronic bron- chitis, 218 Croton oil and sweet oil (half and half), sometimes applied to chest, 222 Cubebs or copaiba, as expectorants, liable to derange stomach, 216, 222, 594 Digitalis, if heart be feeble, 595 Dover's powder, gr. 5 to 10 (0.30-0.60), with a hot drink, useful in early stage, 591 Dry cups, if secretion is excessive, 595 Ethyl iodide, 5 to 10 minims (0.3-0.60), inhaled from a handkerchief every few hours in the later stages to loosen secre- tions, 247, 594 Eucalyptus oil, valuable in later stages; dose, gtt. 1 to 5 (0.05-0.30), in capsule, every three hours, 249, 594 Euphorbia pilulifera, ^ to 1 drachm (2.0- 4.0) of fluid extract, in chronic bron- chitis, 250 Flaxseed tea, a useful demulcent, 252 Gallic acid for profuse expectoration, 254 Grindelia, very useful in later stages, 261 Guaiacol vapor inhalations very valuable, 263 Hot foot-bath, with drinks of hot lemon- ade, in early stages, 591 Hypnal for cough, 277 Inhalations of steam from boiling water, to relieve bronchial soreness when counterirritation fails, 518, 520 Iodide of potassium, often useful when ammonium salts fail, contraindicated if secretion is excessive, 281 Iodine externally, 285 Iodoform, to lessen cough and fetid dis- charge, 289 Ipecac, to unload stomach, 291 ; as a seda- tive expectorant, 291 Mustard plasters, 591, 595 INDEX OF DISEASES AND REMEDIES. 869 Myrrh with expectorant mixtures, useful in later stages, 338 Oro-nasal respirator with terebene, iodide of ethyl, and chloroform, 594 Oxygen inhalations, when dyspnoea is great, 370, 595 Potassium citrate with ipecac, to aid forma- tion of secretion, prescriptions, 395, 591 Potassium cyanide for excessive cough, 223 Resin, inhalation of fumes, 398 Sandalwood oil, in later stages, dose 5 to 10 minims, 411, 594 Sanguinaria, 411 Senega, a stimulating expectorant in sub- acute and chronic stages, 416 Squill, inferior to other drugs as an expec- torant, 425 Steam inhalations, 520, 591 Strychnine, to stimulate respiration, if suffocation threatens, 595 Tar, 440 Tartar emetic, as an expectorant, gr. ^ (0.001) hourly, or 1 drachm (4.0) of solu- tion (gr. i (0".03) to 4 ounces [120 c.c.]), or as an emetic in sthenic cases, 88 Terebene, if ammonium chloride fails; dose, 5 to 10 minims (0.3-0.60), in cap- sule or emulsion; must be stopped if kidneys or stomach are irritated; or used in an inhaler with equal parts of iodide of ethyl and chloroform, 441, 594 Terpine hydrate or terpinol useful, 442, 954 Thiocol in chronic bronchitis, 443 Turpentine, inhalations or applied to chest, for children diluted one-half with sweet oil, 451 Turpentine stupes, as counterirritants, 595 Water, hot and cold dashes, if death is imminent from suffocation, 595 BRONCHOCELE. Ointment of biniodide of mercury, useful in, 327 Potassium iodide internally, and tincture of iodine externally, 281 Thymus gland in, 446 BRONCHORRH(EA. Alum, solution, gr. 20 to the ounce (1.3: 30 0), applied in fine spray, 76 Gallic acid, 254 BRUISES. Alcohol, as a lotion, very useful, 67 Arnica, 99 Liquor plumbi subacetatis, locally applied; strength 1 to 4 ounces to the pint (30.0- 120.0:480.0); contraindicated, if skin is broken; also useful as lead-water and laudanum (water 16, lead-water 4, laudanum 1), 307, 363 Warming plaster, 393 BUBO. Incision, at first sign of suppuration, fol- lowed by washing with either bichloride solution' (1 : 1000), hydrogen peroxide (£ strength), or zinc chloride (gr. 40 to the ounce [2.6:30.0]), 599 Iodine, painted around spot, with compress and spica bandage, or hot bag over swelling, 599 Phenol, solution (gr. 8 to the ounce [0.5:30.0]), 10-minim injections, pre- ceded by ether spray, 154 BURNS AND SCALDS, 596 Adrenalin chloride, drachm 1 (4.0) of a 1 :1000 solution, in a pint of normal salt solution intravenouslv as a stimulant, 596 Anaesthesia, chloroform in, 597 Bath in the treatment of, 596 * Boric-acid solution, a useful dressing, 123, 596 Calcium carbonate, precipitated, as a dress- ing, 137 Cantharides, tincture of (1:40), locally applied on lint if burn is not diffuse, 597 Carbolized sweet oil, cosmoline, or simple cerate, useful application to counter- irritation burns, 154, 596 Carron oil in, 141 Chloretone in 10 per cent, ointment, 169; as a dusting powder, 596 Cold cream, as a dressing, 402 Digitalis, in shock, if circulation fails to respond to less powerful stimulants, 596 Glutol, as a dressing, 253 Hypodermoclysis useful, 513 Ichthyol ointment, 278 Lead carbonate, as an ointment, or, with linseed or other oils, as a dressing, 307 Lime-water and linseed oil, equal parts, the best dressing, 252; carbolic acid is of service, added in proportion of 1 to 20, 596 Morphine and atropine, gr. \ to h (0.015- 0.03) of former to gr. ^ (0.0006) of latter, to allay pain, 596 Nargol ointment, 5 to 10 per cent., 340 Orthoform, as an antiseptic and anaesthetic, 367 Picric acid the best dressing, 387, 596 Potassium citrate with sweet spirit of nitre, if urine is high-colored, 597 Poultice, applied to counterirritation blis- ter, relieves pain; when blister forms, puncture if large, allow to break if small, and dress with absorbent cotton, 494 Salicylic acid, prescription for, 407 Sodium carbonate solution often relieves pain, 597 Stimulants, if shock is severe, 596 Zinc oxide, 368 CANCER (GASTRIC). Arsenic, small doses often repeated, to relieve vomiting and pain in gastric cancer, 103 Condurango, in the dose of 1 drachm (4.0) of the fluid extract, 214 Chloretone, to relieve pain, 168 Hydrochloric acid, 271 Lavage in, 524 870 INDEX OF DISEASES AND REMEDIES. CANCRUM ORIS. Arsenic internally, 103 Boric acid, as a mouth-wash, 123 CARBUNCLE. Phenol solution (gr. 8 to the ounce [0.5:30.0]), hypodermic injections, to abort, 154 Phosphorus, 384 CARIES. Lime salts, especially valuable in dental caries of nursing women, 139 CATARRH OF AIR-PASSAGES. (See Nasal Catarrh.) Alum solution (gr. 20 to the ounce [ 1 .3 : 30.0]), applied in fine spray, 76 Arsenic, internally, 103 Camphor, of service in old and atonic cases, 142 Ethyl iodide, by inhalation in subacute or chronic catarrh, 247 Sozoiodol, applied locally in 5 per cent. solution, 424 CATARRH OF BLADDER. Ammonium benzoate, to render urine acid, 80 Juniper, a valuable stimulant in chronic cases, 301 CATARRH OF UTERUS. Hydrastis, 269 Sozoiodol, in powder, applied by tampon, in catarrh of cervix uteri, 424 CEREBRAL DISEASES. Blisters, to nape of neck in cerebritis, 492 Croton oil, in cerebral congestion, 222 Elaterium, in cerebral congestion, 233 Phosphorus, often of service in cerebral softening, 384 Veratrum, of greatest value in cerebritis during stage of hypersemia, after that period harmful, 456 CHANCRE. Nitric acid, used as a caustic, surrounding tissues being protected by oil, 344 CHANCROID, 597 Acetanilid, used in a dry powder, 57 Actual cautery, the most destructive caustic, 598, 599 Benzoate of bismuth, 121 Bismuth and zinc oxide, or calomel and bismuth, are substitutes for iodoform, 598 Cocaine, 20 per cent, solution, to relieve pain of cauterization, 598 Hot sitz-bath or general warm bath, 599 Iodoform, the best dusting-powder _ after cauterizing, also useful as a palliative treatment, preceded by nitric-acid wash (3j to water Oj [4.0:480.0]), in erosive chancroid, 598 Iodol or aristol, as a substitute for iodo- form, 598 Nitric acid, a good caustic, surrounding tissues being protected by oil, 344, 598 Phenol, as a wet dressing (gr. 5 to water oz. 1 [0.30:30.0]), 590 Salicylic acid in powder or ointment, 407 Sulphuric acid with charcoal, a good caustic and after-dressing, 598 Tannin, combined with dusting-powder (1 :4), if discharge is profuse, 599 CHAPPING. Calcium carbonate, precipitated, as a local protective in intertrigo of infants, 137 Camphor, added to precipitated calcium carbonate, useful in intertrigo, 143 Carbonate of zinc, in infantile forms, pre- scription for, 458 Cold cream, a useful application, 402 Light magnesia, as a dusting-powder in intertrigo, 313 Lycopodium, as a dusting-powder, 313 Starch, as a dusting-powder in intertrigo, 426 Zinc oxide, in powder form, useful in intertrigo, 369 CHILBLAINS. Alum, as a wash, 76 Capsicum, tincture, painted over parts or applied as a paper, prescription for, 150 Ceratum resinae, 398 Ichthyol ointment, 278 Iodine ointment and lard, equal parts, give great relief, 285 CHLOROSIS. (See Anaemia.) CHOLERA (ASIATIC), 600 Camphor, in the form of camphorated wine of the greatest service in controlling cramps, 600 Enemata of warm salt solution (5j) to Oj [4.0 to 480.0]), highly recommended by Italian observers, 601 Enteroclysis, associated with hot baths, very valuable, 499, 601 Ether, subcutaneously, as a diffusible stim- ulant, 601 Hypodermoclysis, very useful, 513, 602 Opium, 600 Phenyl salicylate and salophen, 410, 601 Purgatives, contraindicated unless bad food has been taken, 600 Quarantine and strict hygiene, as pro- phylactics, 600 Sulphuric acid with camphor, to control diarrhoea, 434, 600 Tannic acid, by enemata (3j" vn j to Oj [4.0-30.0 :480'.0]), 602 CHOLERA INFANTUM, 602 Arsenic, to check vomiting, prescription for, 604 Beef-juice, as a food, especially valuable, 604 INDEX OF DISEASES AND REMEDIES. 871 Brandy, if vomiting is active and collapse threatens, a few drops to drachm (4.0) of nourishment, 603 Castor oil, with paregoric, to empty bowels and allay irritation, 603 Cold drinks, cracked ice, and antipyretics, if rectal temperature is above normal, 602 Diet, 603 Enteroctysis, very valuable, 605 Hot drinks, applications, and baths if rectal temperature is subnormal, temper- ature being watched, 602 Iodoform and oil injections to relieve tenes- mus, 289 Irrigation of bowels, 605 Laudanum, ffl 10 (0.60), and starch-water, oz. 2 (60.0), by enema, and calomel, gr. ^ (0.005), or gray powder, gr. \ (0.01), by mouth, to control vomiting and purg- ing, if severe, 604 Mustard or spice plaster, over belly, always useful, 605 Podophyllin, if stools are of peculiar pasty- white color, 603 Prescriptions for, 604, 605 CHOLERA MORBUS, 605 Camphor, 142 Castor oil, with laudanum, to sweep out intestines, before diarrhoea mixture is used, 605 Ipecac, gr. 3 (0.20) every two hours, often of service, 291 Morphine and atropine, if pain is severe, 606 Mustard or capsicum plaster, over abdo- men, 605 Prescription for, 605 Salol (phenyl salicylate), prescription for, 410 CHORDEE, 674 Aconite, often relieves, 62 Belladonna internally, and ointment ap- plied to under surface of penis, 116 Bromide of potassium, drachm 1 (4.0), with chloral, gr. x (0.6), at bedtime, repeated during night if necessary, 674 Camphor with bromides, very useful in some cases, 142 Cantharides, XT[ 1 (0.05), thrice daily, 148 Hot sitz-bath and steeping penis in hot water before retiring, relieves, 504 Lupulin, gr. 30 (2.0), 674 Morphine, gr. ^ (0.015), with atropine, gr. g 1 ^ (0.001), hypodermically near peri- neum, to relieve, 674 Opium or belladonna suppositories, to re- lieve, 674 CHOREA, 606 Arsenic, in ascending doses ; discontinued if symptoms of poisoning ensue, 101, 606 Bromides with chloral, when there is in- somnia, prescription for, 607 Chloral, 160 Chloroform inhalations when excessive, 179 Cimicifuga alone, or with arsenic, very useful, 189, 606 Hot pack, at bedtime, if muscular jerkings are severe, 509, 606 Monobromated camphor, 144 Nitroglycerin, 346 Quinine in full doses, 194 Salicylates or iodides of value, if associated with rheumatism, 606 Silver nitrate, occasionally used, not re- liable, 342 CINCHONISM. Potassium bromide, as a preventive, 129 CIRRHOSIS OF LIVER. (See Hepatic Cirrhosis.) COLDS. (See Coryza.) COLIC. Asafcetida, useful in children, 110 Chloral and bromide, when severe in chil- dren; prescription for, 164 Ether internally, very useful, 243 Hoffmann's anodyne, 266 Hyoscyamus, 275 Matricaria, infusion, to prevent, in teeth- ing children, 316 Mustard plaster, \ to % strength, if skin is tender, 337 Peppermint in infantile colic, 374 Rue, as a carminative, 402 COLIC (HEPATIC), 607 Belladonna, in full doses, to relax spasm, 116 Benzoate of sodium, 609 Calomel, if liver be very torpid, 609 Chloroform or ether inhalations, to relieve pain during spasm, 182, 609 Diet, 609 Hot applications over liver, as a relaxant, 607, 609 Horseback riding, 608 Morphine, gr. \ to \ (0.015-0.03), with atropine, gr. r J ff (0.0006), hypodermic- ally, to relieve pain ? 607 Olive oil or cotton-seed oil, 1^ pints (720.0), during attack; ether, drachm 1 (4.0), may be added with advantage, 607 Opium with belladonna, to relieve pain and spasm, 361 Salicylate of sodium, 609 Turpentine, useful in, 607, 609 COLIC (LEAD). Alum with morphine to allay pain, 76 COLIC (RENAL). Belladonna, in full dose, 116 Chloroform, a few inhalations often relieve, 182 Opium with belladonna relieves spasm and pain, 361 COLLAPSE. Belladonna, as a vasomotor stimulant, 115, 117 Digitalis, 229 872 INDEX OF DISEASES ASD REMEDIES. Ether, by mouth, inhalation, or hypoder- mically. of great service. 2-43 CONDYLOMATA. Calomel, as a dusting-powder, often re- moves, 330 CONGESTION. Croton oil, as a revulsive in cerebral con- gestion, 222 Digitalis, relieves stasis of congested lung in tvphoid state, and congestion of the kidneys, 229 Elaterium, in cerebral congestion, 233 Ergot of service, especiallv with digitalis. 235 Glycerin, on cotton tampon, as a depletant in uterine congestion, 260 Jalap, useful in plethora with cerebral con- gestion, 300 Juniper, often relieves congested kidnevs, 301 Mustard, to nape of neck in cerebral con- gestion, 337 CONJUNCTIVA (BURNS OF), 611 Atropine incorporated with liquid vaseline instilled into eye. to prevent iritis, 611 Cod-liver oil instilled into eye after re- moval of foreign matter. 611 Gold-beaters' skin inserted between licls and eyeball, or breaking up granula- tions, prevents corneal inflammation. 611 Neutralization of foreign matter, if acid or alkaline, 611 CONJUNCTIVA rCHEMOSIS OF , 614 Astringent washes, especially alum. 614 Xicking swollen tissue with scissors, 614 Warm, moist compresses, 614 CONJUNCTIVA (HEMORRHAGE BE- NEATH;, 614 Boric-acid or cocaine wash, when conjunc- tival irritation exists. 615 . Massage of globe through closed lids, to aid absorption of blood, 615 CONJUNCTIVITIS CHRONIC , 612 Acetate of zinc. gr. 1 to 2 (,0.06-0.12), to the ounce (30.0), 45S Boric acid, wash (gr. 10 to the ounce [0.60 : 30.0]), cocaine, gr. 2 (0.12), may be added if there is no corneal ulcer ; for this con- dition salt. gr. 4 to the ounce (0.25:30.0 . may be substituted, 612 Copper crystal, or a solution Cgr. 1 to 3 to the ounce [0.06-0.20:30.0]. applied to diseased spot, if subacute, 218 Correction of any refractive error. 612 Lapis chvinus, 612 Tannin and glvcerin (gr. 10 to the ounce [0.60:30.0]), as an application. 612 Yellow oxide or sulphate of mercury salve, or alum crvstal. useful application. 333. 612 Zinc oxide, in powder, or the sulphate in the form of a wash. 369. 613 CONJUNCTIVITIS (DIPHTHERITIC , 614 Antitoxin injections the best treatment, 614 Atropine instilled, 614 Boric-acid or bichloride solution, frequently applied in early stages, 614 Hot compresses, 614 CONJUNCTIVITIS FOLLICULAR., 613 Alum, crystal, applied locally if due to atropine instillations, 613 Astringent and antiseptic lotions, 613 Calomel, as a dusting-powder, alone or with bismuth, aristol, or iodoform, 613 Copper sulphate, as an ointment (gr. % to the drachm [0.03 :4.0]), 218, 613 CONJUNCTIVITIS GRANULAR), 613 Adrenalin locally, 436 Atropine, instillations, in acute forms, 613 Boric acid or salicylic acid, solution, as a wash in acute forms. 613 Boroglyceride (20 to 50 per cent.), applied to chronic granulations, 613 Copper sulphate, crystal, applied to chronic granulations, 218", 613 Corrosive sublimate solution (1 :300 or 1 : 500), applied every second day in chronic forms, preceded by cocaine, eyes also being irrigated thrice daily with sublimate solution (1 :7000), 613 Crushing granulations, often satisfactory, 614 Excision of granulations when isolated, 614 Glycerole of tannin, applied to chronic granulations, 613 Grattage. 614 Jequirity infusion (3 per cent.) painted on inner side of eyelids, of use. 301. 614 Leeches to temple, to reduce inflammation in acute stage, 613 Liquor potassii hydroxidi, beta-naphthol, iodoform, aristol in powder or salve, yel- low-oxide ointment, calomel, or hydras- tin may be tried. 614 Scarification, not advisable. 614 Silver nitrate, stick or solution (gr. 10 to the ounce [0.60:30.0]). applied daily, if there is discharge : neutralize excess with ^ salt solution. 343. 613 Yellow oxide of mercury ointment with lard, equal parts, in chronic types, 332 CONJUNCTIVITIS fLACRYMAL). Treatment same as for chronic type. CONJUNCTIVITIS MUCOPURULENT). Treatment same as for purulent type. CONJUNCTIVITIS fPURULENT;, 611 Atropine, if corneal ulcer appears, 611 Bichloride of mercury (1 -.8000), formalde- hyde (1:3000; . or boric acid (saturated solution), as a wash, used hourly, 611 Boroglycerin. 124 Creolin solution. 1 per cent.. 221 Hot compress, in lieu of cold, if vitality of cornea is threatened. 611 INDEX OF DISEASES AND REMEDIES. 873 Iced compress in early stage, to reduce inflammation, 611 Leeching, useful if inflammation is high, contraindicated in infants, 612 Permanganate of potassium, aqua chlorini, argentamin, protargol, sulphocarbolic acid solution, alum sulphate, zinc sul- phate, creolin (1 per cent.), or iodoform ointment may be tried, 612 Silver nitrate, stick or solution (gr. 10 to the ounce [0.60:30.0]), touched to lids after they have been cleansed of pus, excess neutralized with salt solution ; 2 per cent, solution dropped in newborn infant's eyes to prevent, 611 Sozoidol (2:30), 424 CONJUNCTIVITIS (SIMPLE), 610 Alum crystal applied when it tends to be- come chronic, 610 Argyrol, 5 to 20 per cent, solution in place of silver nitrate, 610 Atropine usually unnecessary unless cor- neal ulcer is present, 610 Boric acid, lotion (gr. 10 to the ounce [0.60:30.0]), 610 Compresses of ice to allay inflammation, 610 Mercury, bichloride solution (1 :10,000), if discharge is great, 610 Methyl blue, 334 Peroxide of hydrogen, 610 Poultices and bandages contraindicated, 610 Protargol, 5 to 20 per cent, solution, 610 Protargol and argyrol, 20 to 25 per cent, solution in place of silver nitrate, 611 Silver nitrate, solution (gr. 2 to 5 to the ounce [0.12-0.30:30.0]), if there is muco- purulent discharge. If discharge is ex- cessive, employ gr. 10 to the ounce (0.60: 30.0), and neutralize excess with salt solution or wash with tepid water, 610 Smoked glasses, 601 Sodium bicarbonate, gr. 4 to 8 to the ounce (0.25 to 0.5:30.0), 610 Tannin and glycerin (gr. 10 to the ounce [0.60 :30.0]), or alum crystal if there is a chronic tendency, 610 Zinc oxide, 369 Zinc sulphate solution (gr. 1 to 2 to the ounce [0.06-0.12:30.0]), alone or with boric acid, if there is chronic tendency, 459, 610 CONSTIPATION, 615 Aloes, 73; and podophyllin, with other drugs, useful for temporary use; pre- scription for, 618 Belladonna, 116 Bryonia, when intestinal secretions are deficient, 133 Cascara sagrada, the best curative agent, dose, HI 10 to 40 (0.60-2.60) of fluid ex- tract or drachm 1 (4.0) to 6 (24.0) of cordial, 156, 157, 617 Castor oil ultimatelv harmful in all cases, 158, 617 Colocynth, jalap, or senna, not to be used constantly, 617 Compound cathartic pill, sometimes neces- sary, 618 Diet, of extreme importance, 616 Enemata, as a routine treatment, harmful, 619 Glycerin, suppositories or enemata, often used, 260, 619 Gymnastic movements, horseback riding or massage, with regulated diet, 616 Hunyadi, Carlsbad, or Friedrichshall wa- ters, rarely of value in chronic forms, 617 Leptandra, fluid extract of, in intestinal atony, 309 Lobelia, in combination with cascara sagrada, useful in atonic forms, 312 Magnesium sulphate by the mouth or by enema, 315, 617 Manna, as a laxative fruit for adults, or drachms 1 to 2 (4.0-8.0) to bottle of milk, for infants, 316, 618 Mercury, as an habitual purgative harmful, 321, 617 Opium in reflex constipation, 362, 618 Phosphate of sodium, useful in rickety children, gr. 5 to 10 (0.30-0.60); or adults, 381, 618 Pilula cathartica vegetabilis, may be re- quired, 618 Rhubarb, usually harmful, in some cases in children, useful, 400, 617 Salines, simply to unload bowels, 617 Seidlitz powder, 416 Senna, said to be useful in constipation of pregnancy, particularly if combined with cascara sagrada, 417 Soap suppositories, useful in children, 419 Stillingia, recommended when habitual; prescriptions for, 427 Sulphur, especially valuable if hemorrhoids are present, 432 Tobacco, sometimes used, 619 CONVULSIONS. Allium, as a poultice, over spine or feet in infantile spinal or cerebral convulsions, 71 Amyl nitrite, 84 Chloral with bromide, in infants; also useful alone in uremic and puerperal convul- sions, if no acute renal trouble exists, 127 164 Chloroform, 179 CORNS, 619 Fowler's solution, locally applied, 104 Salicylic acid, the best application, formula for, 406, .619 Silver nitrate solution (gr. 60 to the ounce [4.0:30.0]), applied to soft corns every four or five days, 619 CORYZA, 619 Aconite, useful in early stages, 62 Adrenalin locally to relieve engorgement, 436, 619 Allium, as a poultice to breast, or in emul- sion or boiled in milk, for children, 71 874 INDEX OF DISEASES AND REMEDIES. Antipyrin, in gr. 2 to 4 to the ounce (0.12 to 0.25:30.0), as a spray, preceded by a cocaine spray, 94, 620 Arsenic, taken for months, often cures per- sistent colds, 103 Belladonna in, 118, 620 Bromides useful in headache, 620 Camphor, as a snuff, or inhalation of spirit, or fumes, when sneezing and lachryma- tion are excessive, 142, 143 Cocaine, a few minims of a 4 per cent, solu- tion dropped into nostril, followed by lotion (see prescription) with atomizer, 202, 619 Cubebs, as a snuff during stage of secre- tion, 222 Glycerin, applied alone by brush or spray, often of service, 260 Hamamelis, useful after acute stage is past, 265 Hot mustard foot-bath with hot draught or Dover's powder, followed by rest in bed, may relieve, 620 Inhalation of tincture of iodine, 286 Iodide of potassium, at beginning will often abort, 280 Menthol, very useful, 375 Prescription for wash, 620 Quinine, internally, combined with chlo- ride of ammonium, useful after secre- tion is established, 620; also useful as a spray, 194 Sodium bicarbonate, gr. 30 (2.0) every two hours for three doses, of much benefit, 620 Sweet spirit of nitre, 438, 620 Tartar emetic, 88 COUGH. Acacia, as a mucilaginous drink with flax- seed and liquorice, to loosen hacking cough, 53 Almond, essential oil of, in emulsion, as a demulcent in cough of phthisis, 72 Belladonna, the best remedy in nervous cough, 116 Cannabis indica, a useful adjunct to cough mixtures, 145 Chloroform, useful, added to cough mix- tures for irritant cough, 182 Codeine, useful in nervous cough, 207 Flaxseed tea, alone or with paregoric, a useful demulcent in excessive cough, 252 Gelsemium in nervous cough, 257 Heroin, 265 Honey, 267 Hydrocyanic acid, highly recommended, prescription for, 272 Hyoscyamus in nervous cough, 275 Hypnal, 277 Iodine, as a paint over supraclavicular spaces, in irritative cough, 285 Ipecac, in spray, useful in chronic winter cough, 291 Morphine in wild-cherry syrup useful in, irri- tative cough and when cough is greater than necessary to expel mucus, 362 Paregoric (1 drachm [4.0]) in hot water, from which the steam is inhaled, useful in irritative form of cough, 362 Sandalwood oil for excessive cough follow- ing influenza, 411 Syrup of wild cherry, as a vehicle for cough mixtures, 397 CRAMPS. Belladonna, internally or locally, as a lini- ment, 116 Chlorodyne, for stomach cramp, 170 Ginger, especially useful in menstrual cramp due to cold, 258. (See Dysmenor- rhoea.) CRETINISM. Thyroid gland very useful, 447 CROUP (MEMBRANOUS). Diphtheria.) (See CROUP (SPASMODIC), 621 Aconite useful, 62 Amyl nitrite, inhalations, if paroxysm is severe, 84, 621 Belladonna, bromides, chloral, or opium in small doses at bedtime, as a preventive, 621 Bromides and lactucarium, 621 Bronchitis tent, 621 Cold cloth around neck, and child placed at once in hot bath, air of room being moistened by steam, 621 Hot compress is very useful, 504 Menthol, useful, 376, 518, 621 Prophylactic measures, 621 Sanguinaria, as an emetic, unfavorable, 41 1 CYSTITIS (ACUTE), 621 Aconite in full dose, with sweet spirit of nitre and potassium citrate if there is fever; prescription for, 621 Belladonna, alone or with aconite, espe- cially useful if due to cold; dose, 111 5 to 10 (0.3-0.60) thrice daily, 622 Boric acid, to render urine acid, 124 Cannabis indica, preferable to opium for relieving pain, 146, 622 Copaiba, 216 Creolin, as a vesical wash (1 to 2 per cent, solution) in cystitis of women, 221 Flaxseed tea, as a demulcent, 252 Hot compress over bladder, should not contain irritants, 622 Hot sitz-bath and enemata, to relieve bearing-down pain, 622 Hygienic measures, 622 Laudanum, V\ 30 (2.0), to starch-water oz. 2 (60.0), in enema, to relieve bearing- down pain, 622 Leeches to perineum or cups to sacrum, 622 Liquor potassii hydroxidi, TTX 5 (0.3) every four hours if urine is acid, 622 Opium belladonna, or iodoform supposi- tory, to allay bearing-down pain, 362, 622 Quinine, contraindicated, 622 Salines, in earlv stage to evacuate bowel, 622 Salol (phenyl salicylate), gr. 10 (0.60) thrice daily if inflammation becomes purulent, 622 INDEX OF DISEASES AND REMEDIES. 875 Urotropin (hexamethylenamine) in ammo- niacal cystitis, 452, 622 CYSTITIS (CHRONIC), 622 Arbutin, gr. 3 to 5 (0.20-0.3), or fluid ex- tract of buchu or uva ursi, \ to \\ drachms (2.0-^6.0), to improve vesical mucous membrane when inflammation is of subacute type, 452, 623 Benzoate of ammonium, urotropin, or boric acid, gr. 5 to 10 (0.3-0.60) in pill, to render urine alkaline, 80, 623 Benzoic acid useful when urine is alkaline and loaded with phosphates, 119 Buchu, 133, 623 Cantharides, 148, 623 Chloretone solution useful, 623 Creolin solution (1 to 2 per cent.), as a vesical douche, 624 Grindelia, as a vesical stimulant, 260 Juniper of value, 301 Mercurol solution, 623 Mercury bichloride solution (1 :10,000), as an injection to cleanse bladder, 623 Myrrh often of service, 338 Opium suppositories, gr. \ to \ (0.015-0.03) very useful, 362 Pareira, 373 Potassium salts, except bitartrate, to render urine alkaline when mucus is excessive, 623 Salol (phenyl salicylate), 623 Sandalwood oil, 411 Silver-nitrate solution (gr. 1 to oz. 4 [0.06 : 120.0] increased gradually to gr. 2 to oz. 1 [0.12:30.0]), as an injection when dis- charge is mucopurulent, followed by salt solution if pain is severe, 623 Strychnine and cantharides, when vesical atony is great, 623 Turpentine, oil of sandalwood, cubeb, or copaiba, useful when vesical atony is great, 623 Urotropin or uritone, 623 DEBILITY. Arsenic, with bitter tonics, very useful, 101 Calomel, in debility of children, often re- lieves, 328 Capsicum for gastric atony, 149 Eupatorium, a good tonic, 250 Lime salts, 139 Phosphorus, of service in sexual debility, 384 Sodium cacodylate in debility of tubercu- losis, 421 DELIRIUM TREMENS. Apomorphine to produce nervous quiet, 98 Chloral, of great service used cautiously, 164 Croton oil, 222 Hops, 269 Hyoscine, in insomnia, 276 Monobromated camphor, when nervous twitching is troublesome, 144 Valerian with morphine, frequently used, 453 DERMATITIS. Chloride of ammonium lotion, when duo to ivy-poisoning, 82 Grindelia robusta in solution one of the best lotions in ivy-poisoning, 261 Lead acetate useful in ivy-poisoning, 307 Lead-water and laudanum in ivy-poison- ing, 307 Lobelia infusion as a lotion in ivv-poison- ing, 312 DIABETES INSIPIDUS, 624 Arsenic, 103 Belladonna or opium, if due to nervous irritability, 624 Carbonate or citrate of lithium, gr. 10 (0.60), with sodium arsenite, gr. ^ , (0.002), valuable in gouty types, 311 Ergot, in combination with bromide of sodium, 236, 624 Gallic acid, alone or with opium, one of the best remedies, 254, 624 Opium, 363 Rhus aromatica, highly recommended. 401 Strychnine and sulphate of iron, as tonics, 624 Suprarenal gland useful in, 624 DIABETES MELLITUS, 624 Acidulated water or non-purgative alka- line water, to allay thirst, 626 Almond bread, bran bread, or artificial milk, as a food for diabetics, 72, 552 Alum, 76 Antipyrin, 93, and arsenate of sodium and carbonate of lithium when of gouty origin, 93, 625 Carbonate of sodium, by intravenous in- jection in diabetic coma, 627 Chloride of gold and sodium, gr. ^ (0.006), recommended, 625 Codeine, in ascending doses, beginning gr. 1 to 5 (0.06-0.30), thrice daily, 207 Colchicum and iodides, in gouty types, 625 Diet, 624, 625 Ether hypodermically, to support heart in diabetic coma, 627 Gallic acid, with opium, one of the best remedies, 254 Glycerin or saccharin, as sweetening agents to replace sugar, 260, 403, 626 Iodol, gr. 2 to 6 (0.12-0.40), thrice daily, recommended, 289 Iron, lacto-phosphates of lime and sodium, strychnine and astringents, if cachexia comes on, 626 Jambul, gr. 5 to 30 (0.3-2.0), once to thrice daily, said to be very useful in some cases, 626 Levulose, 309 Lime-water, 140 Lithium carbonate or citrate, with arsenic, very useful, if due to gout, 311, 625 Morphine, very useful in ascending doses, 625 Opium, gr. i to ^ (0.015-0.03), thrice dailv, largely used, 363, 625 Pancreas of doubtful value in pancreatic diabetes, 259 76 INDEX OF DISEASES AND REMEDIES. Panoreatin, when the disease is due to a lesion of the pancreas, 372 Purgatives, restricted diet, and exercise, if due to high living and sedentary habits, 625 Salicylates and iodide of potassium, if due to rheumatic or gouty taint, 625 Sodium bicarbonate, oz. £ to 1 (16.0-30.0) daily when coma is feared, because of increase in acetone in urine, 627 Transfusion, in diabetic coma, 538, 627 DIARRHCEA. Allspice, 72 Arsenic, 103 Belladonna, may be used in serous types, 116 Beta-naphthol-bismuth, in serous and fer- mentative types, 339 Bichloride of merciny, gr. -^iv (0.0003), hourly, if stools be slimy and bloody, 326, 630 Bismuth, with phenol, gtt. 1 to 2 (0.05-0.1), highly recommended in serous and slim- mer diarrhoeas, 120, 629 Cajuput, TTl 10 to 20 (0.60-1.3), in serous forms, 137 Calomel, followed by a saline, useful in sthenic cases of summer diarrhoea, 629 Calumba, in summer and serous diarrhoeas, prescription for, 140 Camphor, useful in serous but never in mucous types, 142, 629 Castor oil, with laudanum and sodium bicarbonate, to unload bowel and render it alkaline, 158, 628 Chalk mixture, with kino and gambir, in serous diarrhoeas, prescription for, 137 Charcoal, useful in acid and fermentative types, 158 Chirata, nitro-muriatic acid, or, better still, nitric acid and cardamons, in mucous type, prescription for, 628 Chlorate of potassium for acute rectal catarrh with mucous diarrhoea, 168 Chlorodyne, largely used in serous types, 170. Chloroform, with astringents and opium, verjr useful after removal of irritant cause, 182, 629 Cinnamon, as a stimulant in serous types, 197 Cloves, to prevent griping, 199 Copper sulphate, gr. •£ (0.015) with opium, gr. 1 (0.06) in pill, or in enema, gr. 5 to 20 to the ounce [0.3-1.3:30.0]), if due to ulceration, 217 Creolin in entero-colitis, 5:1000 of water, 221 Diet, for summer diarrhoea, 628 Enteroclvsis, when mucous form becomes chronic, 499, 631 Ergot, sometimes useful in serous types, 235 Eudoxine, as an intestinal antiseptic in children, 249, 629 Gallic acid, 254 Gambir, alone or with opium, in serous types, prescription for, 255 Geranium, 1 to 2 roots, boiled in pint of milk, of great service in infantile types, and in serous diarrhoea, 258 Ginger, a good addition to diarrhoea mix- tures, 258 Guaiacol carbonate, in fermentative forms, of, 264 Ha^matoxylon, useful in children, because of agreeable taste, 264 Hope's camphor mixture, in serous and choleraic types, 268 Ipecac, gr. i to i (0.015-0.03) thrice daily, useful in summer diarrhoea of childien, 291, 630 Kino, formula for, 302, 629 Lead acetate, with opium and camphor in serous types, prescription for, 306, 628 Mercury, with chalk or calomel, in hepatic disorder, 330, 629 Morphine, gr. ^ to^ (0.0008-0.0012) hypo- dermically, often checks summer diar- rhoea in children, 363 Mustard plaster, or other counterirritants, to abdomen, 628 Naphthalene or naphthol, in fetid and sum- mer diarrhoea, 339, 629 Nitrate of silver and hyoscyamus, or lead acetate and opium, in mucous diarrhoea, prescription for, 628, 631 Nitro-muriatic acid, or podophvllin, gr. ik to ?V (0.0012-0.0015), in 'summer diarrhoea, if duodenum is at fault, 348, 630 Nutmeg, useful in serous types, 351 Opium, 363, 628 Pancreatin in lienteric diarrhoea, 372 Pepsin with hydrochloric acid in summer diarrhoea, if gastric digestion is deficient, 630 Phenol, especially useful as an intestinal antiseptic, 153 Phenolsulphonate of zinc, 2 grains (0.12) every three hours; of service in summer diarrhoea, 629 Phenolsulphonates, 381 Phosphate of sodium, lime salts, and com- mon salt in summer types, if rickets is present, 381, 630 Podophyllin, 393, 630 Precipitated carbonate of calcium, in serous diarrhoea, 137 Raspberry-leaves, used in domestic medi- cine, 402 Rhubarb, often useful, preceding direct treatment in summer diarrhoea, 400 Salol (phenyl salicylate) combined with chalk mixture, 410, 629 Sulphate of iron in chronic forms, 299 Sulphuric acid, especially valuable in serous types, prescription for, 434, 629 Tannic acid, in atonic or serous tvpes, 439, 631 Tar mixture, highly recommended in ob- stinate types, formula for, 440 Thymol, naphthalene, and especially sali- cylic acid, useful in intestinal antisep- tics, in summer diarrhoea, 629 Zinc oxide, in summer types, prescription for, 369 INDEX OF DISEASES AND REMEDIES. 877 Zinc sulphate, 2-grain (0.12) pills, especially useful with opium, or podophyllin, gr. ek (0.001), in serous types, 459 DIARRHOEA (CHRONIC), 631 Ammonium chloride, gr. 5 (0.3) every four hours, best remedy in persistent catarrhal states, 632 Arsenic, 103 Bismutlai et ammonii citras, in chronic serous types, 120 Diet, 631 Ipecac, gr. 3 (0.20) every two hours, of service, 291 Iron sulphate, gr. 5 (0.3) in pill, in chronic types, 299 Nitric acid, with a bitter tonic, useful in green diarrhoea of children, combined with pepsin, 345 Operative procedures when due to lesions of the rectum, 632 Potassium iodide, gr. 3 to 5 (0.20-0.3) if catarrhal state is obstinate, 632 Rockbridge alum water, useful when anae- mia is present, 632 Silver nitrate in pill form, or in other cases rectal injections of this drug, gr. 2 to oz. 1 (0.12-30.0), foUowed by iodoform suppository, of greatest benefit, 632 DILATATION (GASTRIC AND INTES- TINAL). Physostigma with nux vomica, 386 DIPHTHERIA, 632 Aconite, in earh T stages, 62 Alum, 76 Antistreptococcic serum, 470 Antitoxin, of great value; 2000 to 5000 units should be thrown into the connec- tive tissues of the back. A special syringe is used for this purpose, and should be perfectly aseptic, 46S, 633 Borax solution as a gargle in, 123 Bronchitis tent, 636 Calomel by sublimation, of great good in some cases, 636 Carbolic acid (1 :100) in the form of spray or gargle, 154 Chlorate of potassium, contraindicated for internal use, because of danger to the kidneys. It may be applied upon a swab, 167, 637 Corrosive sublimate to prevent fibrinous exudation, 326 Hypodermoclysis, 636 Ice-bags to the neck, ice in the mouth and the tincture of the chloride of iron inter- nally, if glandular suppuration threatens, 636' Irrigation of the nasal chambers useful in, 633 lime-water as spray or application very useful in, 141 Loeffier's application (menthol, dr. 2h [10.0], dissolved in dr. 9 [34.0] of toluol; add dr. 1 [4.0] of liquor ferri chloridi and absolute alcohol, fl. oz. 2 [60.0]), 635 Milk diet. 636 MonsePs solution, as a topical application, 298 Oxygen inhalations, strychnine, and atro- pine if suffocation is imminent. Intu- bation or tracheotomy may be necessary, 637 Peroxide of hydrogen is the best local ap- plication. May be applied on a swab or as a sprav (1 :4), to remove false mem- brane, 274, 632 Potassium permanganate, solution (gr. 20 to the pint [1.3 480.0]), applied as a swab or gargle, 377 Salt solution (7:1000), as a sprav in nasal diphtheria, 633 Tincture of the chloride of iron, 296, 636 Tonics, such as quinine, strychnine, and the chloride of iron, as supportive meas- ures, 636 Turpentine, bv inhalation, prescription for, 636 DROPSY, 637 Acupuncture, less favorable than incisions, only to be resorted to after other reme- dies fail, 461 Adonidin useful in cardiac dropsy, 63 Apocynum, in cardiac or renal dropsy of the subacute or chronic type, 96, 640 Caffeine, in cardiac or renal drops}', 136; in torpidity of kidneys, 640 Calomel and digitalis, in renal and cardiac types, 328, 640 Colocynth, compound extract of, gr. 2 to 6 (0.12-0.40), 213, 639 Copaiba, of service in slow renal tvpes, 216 Digitalis, TTl 5 to 15 (0.30-1.0), with can- tharides, TT[ 1 (0.05), thrice daily, in renal torpidity due to heart trouble, 640 Elaterium, especially useful in renal dropsy, 233, 639 Jalap, compound powder of, gr. 20 to 30 (1.3-2.0), with potassium bitartrate, gr. 10 (0.60), added, especially serviceable in renal dropsy, 300, 619 Magnesium sulphate, in concentrated solu- tion, before breakfast, 315, 639 Milk diet, very useful, 640 Paracentesis abdominis, very useful in ascites, 640 Pilocarpine, useful in localized and renal dropsv, contraindicated in cardiac tvpes, 389, 640 Potassium bitartrate with gin in dropsy due to chronic nephritis, 122 Potassium iodide, in hepatic cirrhosis and localized effusions, to remove liquid, 641 Scoparius, infusion, may be used, 416 Senega, rarely of value, 417 Squill with digitalis, prescription for, 425, 640 Strophanthus in cardiac dropsy, 429 Sugar of milk, useful as a diuretic, 430, 640 Tapping in ascites, the best method, 640 DYSENTERY, 630 Alum, internally, 76 Arsenic, 103 Bichloride of mercury, gr. ^h (0.0003), if passages are slimy and bloody, 326, 630 878 INDEX OF DISEASES AND REMEDIES. Bichloride of mercury, injections (1:5000), followed by solution (1:30,000) to pre- vent toxic effect by absorption, 631 Boric acid, 3j to Oj (4.0:480.0), or phenoJ- sulphonate of zinc, gr. 15 to 1 quart (1.0 : 960.0), very useful as rectal injection, 631 Calomel, in purgative dose, contraindicated if weakness exists, 328, 630 Continuous irrigation with two-way tube, of great value, 631 Copaiba, 216 Creolin enemata, 221 Ergot, useful in bloody stools, 235 Hamamelis, injections, if much blood is present, 530 Ice-water injections, if due to inflamma- tion, used only in strong persons, 475, 630 Ipecac, best remedy in acute dysentery, 291, 630 Irrigation of colon, 500 Lead acetate, with opium and camphor, prescription for, 307 Nitro-hydrochloric acid, if due to defective action of secretory glands, 348 Prescription for enema, 630 Quinine injections useful in amoebic dysen- tery, 195, 631 Silver nitrate, rectal injections (gr. 10 to 20 to the pint [0.6-1.3:480.0]), if ulcers are chronic; followed by salt solution if action is too severe, 342, 631 Sulphate of magnesium, 315, 630 Tannic acid (5j [4.0] to water Oj [480.0]), in the form of intestinal irrigation, 631 Taraxacum in dyspepsia due to hepatic torpor, 441 DYSMENORRHEA, 641 Amyl nitrite, often relieves, 84 Antipyrin or acetanilid, in neuralgic at- tacks; in other cases of doubtful value, 93, 642 Belladonna, suppository, gr. £ (0.03), of extract of ointment applied to os; tinc- ture, internally, useful to relax spasm, 116, 641 Camphor with acetanilid, in pill, useful in nervous cases, 142 Cannabis indica and gelsemium, often of service, 146, 642 Epsom salts or aloes, if constipation is present, 641 Ether or bromide of ethyl, 642 Gelsemium in spasmodic forms, 257, 642 Hot sitz-bath, followed by turpentine stupe, and Dover's powder, gr. 10 (0.60), often relieves, 505, 641 Iron, strychnine, and quinine, as tonics, with rest and horseback riding for anaemic and run-down patients, 642 Opium, to relieve spasm and pain, 361, 641 Piscidia erythrina, extract, in the dose of from I- to 2 fluidrachms (2.0-8.0), 392 Potassium bromide, 128 Water, cold and hot, alternately dashed over loins in atonic cases, 642 DYSPEPSIA. (See Indigestion.) Ammonium chloride in painful dyspepsia due to hyperacidity, 82 Arsenic, useful in atonic types associated with chronic diarrhoea, 103 Benzo-naphthol, in fermentative dyspepsia 339 Bismuth subgallate in fermentative dys- pepsia, 122 Bismuth, when due to acid fermentation 121 Bryonia, when due to gastric and intestinal atony, 132 Gentian, 257 Hydrastis, as an antisepsic and curative agent in chronic types, 269 Hydrochloric acid, if gastric secretion is deficient, 271 Lavage in fermentative dyspepsia, 524, 712 Nitric acid with bitter tonics often relieves intestinal types, 345 Permanganate of potassium, 377 Quassia, useful, if not due to gastritis, 397 Serpentaria, as a tonic in atonic types, 418 Strontium bromide, in painful dyspepsia, 428 Terebene, useful as an antiseptic in fer- mentative dyspepsia, 441 DYSPNEA, 642 Ammonium carbonate, as a respiratory and cardiac stimulant, 643 Arsenic, continuously employed, useful in emphysema and chronic pulmonary in- flammation, 643 Dry cupping over back, when diie to car- diac or pulmonary trouble, 643 Heroin said to be of value in uraemic dysp- noea, 266 Hyoscine, contraindicated, 643 Morphine, gr. i to \ (0.008-0.015), night and morning, often cures when due to nervous or cardiac disorders, 364, 643 Opium, if due to nervous disorders, 643 Strychnine, in idiopathic types and when due to bronchorrhoea in old people, 354, 643 Thoracentesis if there is pleural effusion, 643 EAR (DISEASES OF). Bismuth subgallate, useful in purulent otitis media, 122 Glycerin, useful to soften impacted ceru- men, 260 Potassium permanganate, solution, useful in purulent otitis media, 377 EARACHE, 643 Cardiac sedatives, 643 Chloroform, on swab, behind and in front of ear in otalgia, 645 Cocaine, Til 1 to 3 (0.5-0.20) of a 4 per cent, solution or adrenalin chloride (1 :5000 solution), dropped into nostril, followed by spray if mucous membrane is en- gorged, 644 Heat, dry, applied to head on affected side, 644 INDEX OF DISEASES AND REMEDIES. 879 Inflation of Eustachian tube with Politzer's air-bag, 644 Irrigation with normal salt solution hot as can be borne, gives great relief, 644 Leeching behind ear, to relieve pain, 643 Menthol and alboiene spray, following cocaine, 644 Poultices, oil, and laudanum, contraindi- cated, 644 Puncture of tympanum, if it bulge, fol- lowed by careful cleansing and insuffla- tion of boric acid, 644 Tincture of belladonna and of opium dropped into the ear, 644 ECLAMPSIA, 774 Amyl nitrite, dangerous, 84 Chloral and bromide, each 1 drachm (4.0), by rectum, before applving hot pack, 775 Chloroform, pushed rapidly as possible, at onset of attack, 775 Elaterium, gr. \ (0.015), rubbed up with butter, or compound jalap powder and calomel, may be substituted for croton oil, 775 Ether, as an anaesthetic, contraindicated, 775 Extraction of child rapidly as possible, if attack comes on during labor, 775 Ice-bag to head while in warm pack, 775 Morphine, veratrum and amyl nitrite, may be held in reserve, to be used if necessary, 775 Pilocarpine contraindicated, 775 Transfusion, 538 Venesection, hot wet pack, and croton oil, TT1 2 (0.1), with sweet oil on tongue, to eliminate poison, 775 Veratrum in full doses, 456, 775 ECZEMA, 645 Ammoniated mercury in chronic dry form, 324 Arsenic, only when skin is very dry, 102 Bismuth subgallate in weeping eczema, 122 Black wash of value in, 327, 645 Calamine in moist eczema, 458 Cantharis, internally in small doses, 148 Dermatol in weeping eczema, 122 Green soap, 419, 646 Hygienic measures and diet, 645 Ichthyol ointment, highly recommended, 278 Internal treatment, 647 Iron, syrup of iodide, in young children with anaemia and debility, 297 Kaolin as a dusting-powder, 302 Lead, dilute solution of subacetate, a useful lotion, 308 Liquor carbonis detergens, in acute cases, 466 McCall Anderson's ointment, 645 Methyl blue in eczema of the eyelids, 333 Ointments, prescriptions for, 368, 646 Phenol ointment (minims 10 [0.60] to cerate 1 ounce [30.0]), to prevent itch- ing, 154, 646 Poultices, or olive oil with phenol (TT\ 1 to 2 to the ounce [0.05-0.1 :30.0]), followed by soap and water, necessary in some cases to soften scales, before use of oint- ment, 646 Prescription of iodol, as an ointment, about nose and lip, 290 Resorcinol ointment (gr. 2 to 30 to the ounce [0.12-2.0:30.0]), locally applied in sub- acute types; in chronic form ointment (gr. 2 to 10 to the ounce [0.12-0.60 :30.0]), 375, 607; solution, gr. x to xv C0.6-1.0) to f o j (30.0), in itching of erythematous form, 399, 646 Salicylic acid ointment (gr. 30 to 60 [2.0- 4.0] to lard 1 ounce [30.0]), in chronic or weeping types, 407, 646 Starch poultice, in crusty eczema, 426 Tar ointment, in chronic forms, 440, 646 Thiol, as a dusting-powder, preceded by an antiseptic wash, especially suited to moist eczema, 443 Unna's dressing, 368 Zinc carbonate, as a protective powder in weeping eczema, 458 Zinc oxide, as a dusting-powder or oint- ment in early stages, applied directly or on lint, generally preceded by black wash, 368, 645 EMISSIONS, 647 Bromide of sodium or potassium, gr. 20 (1.3), at bedtime, valuable in spinal irritability, 127, 648 Chloral, gr. 20 (1.3), at bedtime, 648 Cold sponging of perineum and scrotum, 474, 648 Gold and sodium chloride in nocturnal emissions, 261 Hygienic measures, 647 Hyoscine, gr. ^ (0.0006), of great value, 276, 648 Monobromated camphor very useful in spermatorrhoea, 144 Potassium citrate, gr. 20 (1.3), thrice daily, to render urine non-irritating, 648 Strychnine and arsenic, in full dose, of great service in genital atony, 648 Warm bath before retiring, often useful, 648 EMPHYSEMA OF LUNGS. Cod-liver oil, useful, 209 Ethyl iodide, 248 Euphorbia pilulifera, \ to 1 drachm (2.0- 4.0) of the fluid extract, 251 Iodide of potassium, 281 Physostigma, aids in expelling mucus, 380 Strychnine, 354 EMPYEMA. Iodine, gr. 6 (0.4) ; potassium iodide, gr. 6 (0.4); water, 1 pint (500.0), as an irri- gating fluid, used daily, 286 ENDOCARDITIS, 648 Aconite, tincture of, TTl 6 to 10 (0.4-0.6), hourly, in early stages of acute sthenic types* 648 880 INDEX OF DISEASES AND REMEDIES. Antistreptococcic serum in ulcerative endo- carditis, 470 Blisters on praecordium, to prevent endo- cardial complications, 649 Ice-bag over prsecordium, 473, 648 Iron, tincture of chloride, associated with supportive treatment, in purulent types, 649 Veratrum, used for same purposes as aconite, 648 ENTERIC FEVER. (See Typhoid Fever.) ENTERITIS. (See Dysentery and Diar- rhoea.) EPIDIDYMITIS, 679 Guaiacol used locally highly recommended, 264 Heat, moisture, and pressure, in later stages, to relieve induration, 679 Horand-Langlebert's dressing, 679 Ice-bags, 679 Iodide of potassium, gr. 3 to 5 (0.20-0.30), thrice daily, to remove induration, 680 Iodine, painted over scrotum, said to be beneficial, 493, 679 Mercury and belladonna ointments, equal parts, or iodine, gr. 4 (0.25), with lanolin, ounce 1 (30.0), locally applied, to relieve induration, 680 Punctures, useful to relieve tension and alleviate pain, 679 Rest in bed, elevation of pelvis and testi- cles, cessation of local gonorrhceal treat- ment, and administering treatment for acute inflammation, 679 Silver nitrate, solution, painted over scro- tum, in early stage, mav relieve, 343, 493. 679 Strapping and suspending testicle, to re- duce inflammation, 493, 679 EPILEPSY, 649 Acetanilid, 57, 655 Adonis vernalis with bromides have been found useful, 63, 652 Ammonium or sodium nitrite, used to supplement amyl nitrite, 654 Amyl nitrite, inhalations, when aura is perceived and also in status epilepticus to relax spasm, 84, 654 Anaesthetics contraindicated in all cases except status epilepticus, when chloro- form may be used to control attack, 654, 655 Antifebrin and antipyrin especially useful in some cases, 93, 655 Belladonna, with bromides, recommended, 653 Bleeding for the status epilepticus, 654 Borax may be used, 123, 656 Bromide of ammonium, should be used with other drugs, 81, 652 Bromide of calcium, 130 Bromide of gold, 130 Bromide of iron, when anaemia is present, 652 Bromide of lithium, highly recommended in some cases, 130, 652 Bromide of nickel, 131 Bromide of potassium, the most reliable, in ascending dose, 126, 649 Bromide of sodium, not so apt to disorder stomach, 652 Chloral, alone or with bromides, well diluted, after meals, used with care, 166 655 Diet, 656 Digitalis, with bromides, useful in some cases, 653 Duboisine, especially in psychic forms, 233 Hydrobromic acid, liable to derange diges- tion, 652 Iodide of potassium, useless except in syphilitics, 655 Mercury, associated with potassium iodide, when due to gumma, 655 Mixed treatment, 652 Monobromated camphor, 144 Nitroglycerin, useful in some cases of petit mal, 346, 654 Opium with gelsemium, only to be used when other remedies fail; also a pro- longed course of, in ascending doses, useful in old cases, 653 Potassium nitrite, 345 Quassia injections, when due to worms; if not obtainable, sodium chloride solu- tion may be used, 656 Silver nitrate, may be tried when other remedies fail, 342, 653 Solanum carolinense, fluid extract of, 2 to 15 minims (0.1-1.0), thrice daily, in the epilepsy of childhood, 423, 656 Strontium bromide, 428 Tartar emetic ointment, as a counter- irritant at back of neck, 88 EPISCLERITIS, 656 Antiseptic collyria, 657 Atropine locally, 657 Iodide of potassium and salicylates, 657 EPISTAXIS, 657 Acetanilid, used locally, has been recom- mended, 57 Acetic acid, locally applied, to arrest, 59 Aconite or veratrum, tincture, tt[ 6 to 12 (0.4-0.8) in sthenic cases, followed in thirty minutes by smaller doses, if necessary, 62, 657 Adrenalin locally, 436, 657 Alum powder, pure or half-and-half with starch, as a snuff, 657 Bacon fat, inserted as a plug in nostril, may arrest, 657 Compression of facial artery may be neces- sary, 658 Cotarnine, locally, 218 Ergot, turpentine, hamamelis, or oil of erigeron, internally, in slow oozing, 235 657 Hot foot-bath, or hot- or cold-water bags applied to dorsal vertebrae, may arrest, 658 Ice applied to nose, may arrest, 658 INDEX OF DISEASES AND REMEDIES. 881 Ipecac, in nauseating doses, recommended, 657 Monsel's solution, in spray ( TT\ 30 to 4 ounces [2.0:120.0]), only to be tried when other remedies fail ; very dis- agreeable, 298, 657 Oil of erigeron, 237, 657 Plugging anterior and posterior nares, if necessary, with cotton or lint soaked in vinegar, 657 Tannic acid, in powder or solution, snuffed up nostril, 657 Vinegar or lemon-juice injected into nos- tril, 658 EPITHELIOMA. Acid nitrate of mercury, applied to part with glass rod, 332 Arsenous anioxide and gum acacia (of each 1 ounce [30.0] to water 5 fluidrachms [20.0]), locally applied, 104 Resorcinol, in epithelioma of the face, 399 ERYSIPELAS, 658 Alcoholic stimulants if patient passes into typhoid state, 658 Antistreptococcic serum, 470 Bitters and iron, during convalescence, as tonics, 658 Boric acid, as a lotion, 123 Cold bathing to control excessive fever. 658 Ichthyol ointment and vaseline, half-and- half, locally applied, preceded by wash- ing with Castile soap, followed by bi- chloride solution (1:1000), 278, 659 Iodine, tincture, painted around inflamed edges, to arrest, 285 Iron, tincture of chloride, TT] 20 to 40 (1.3-2.6), thrice dailv, best internal treatment, 295, 658 Pilocarpine, gr. £ to £ (0.008-0.01), hypo- dermically, contraindicated in debility ; also injected around borders of inflam- mation in some cases, to arrest, 390, 658 Silver nitrate, solution (gr. 80 to the \ oimce [5.3:16.0]), applied twice or thrice, to arrest, 343, 659 White-lead paint, locally applied, when ichthyol is not at hand, 659 EXHAUSTION AND DEPRESSION, 660 Stimulants, 660 EXOPHTHALMIC GOITRE. Belladonna relieves some cases, 118 Sparteine, 416 EYE-STRAIN 659 Correct error of refraction, 660 FAINTING. Alcohol, 66 FEET ( SWOLLEN, TENDER, OR SWEAT- ING), 660 Arsenous anioxide, gr. 6 ^ to ^ (0.001- 0.0015), in swelling of old persons, 104, 660 Borax, stockings soaked in saturated solu- tion and dried, each day, when sweat- ing is excessive, 661 Carbonate of calcium, precipitated, locally applied to sweating feet, 137 Cotton instead of woollen stockings may aid cure, 661 Formaldehyde, 661 Hamamelis, distilled or fluid extract, drachm \ to 1 (2.0-4.0) of former, or HI 10 to 20 (0.60-1.3) of latter, 660 Lead plaster and linseed oil, equal parts, applied on linen to feet, every third day, for sweating, 308 Prescription for dusting-powder, 661 Rest, absolute, of feet, may be necessary in swollen feet, 660 Salicylic acid and borax, equal parts, in water and glycerin, best application to sweating and tender feet, 661 FELON. Bread-crumbs saturated with liquor plumbi subacetatis, as a poultice, to abort, 308 Silver nitrate, solution, applied early, to abort, 343 FEVER, 661 Acetanilid, 56, 662 Aconite, the best depressant for sthenic types in children, 62 Alcohol, as a systemic support and stimu- lant in low fevers, 66, 67 Ammonia for sudden cardiac failure in, 78 Antimonial powders as an intipyretic, 89 Antipyretics, useful in most sthenic fevers, often fail in thermic fever, 662 Antipyrin, 92 Brand's method, 484 Camphor a diffusible stimulant in ady- namic fevers, 142 Capsicum as a stimulant in low fevers, 150 Coca a supportive and stimulant in low fevers, 204 Cold applications and baths, 480, 662, 663 Cold packs and baths in asthenic types to be relied on first; if impracticable, then antipyretics, 663 Digitalis, in small doses, valuable in ex- hausting fevers, 229 Guaiacol, useful in, 263 Hydrochloric acid an adjuvant to diges- tion, 271 Musk, by rectal injections, valuable in low stages, 337 Neutral mixture, useful as a febrifuge, especially in children, 395, 396 Phenacetin, 379 FIBROIDS. Ergot, used as an expulsive and curative remedy, 236 Mammary gland, for effect on bleeding and growth, 316 FLATULENCE. Aromatic powder, 198 Asafoetida, 110 Camphor, 142 56 882 INDEX OF DISEASES AND REMEDIES. Capsicum, prevents formation of gas, 150 Charcoal, 155 Chloroform, TT1 1 to 2 (0.05-0.1), or spirit, TTl 10 to 20 (0.60-1.3), will relieve, 182 Cloves, a useful tonic and stimulant, 199 Ginger, 258 Hoffmann's anodyne, the best carminative, 266 Naphthol in gastric fermentation and flatulence, 339 Pepper, 374 Peppermint, 374 Podophyllin with euonymin, leptandra, chirata, and creosote, 393 Potassium permanganate, 377 Turpentine, prescriptions for, 450 FRECKLES AND CHLOASMA, 663 Almonds, emulsion of, supposed to be of value, 72 Boric acid, saturated solution, applied same as corrosive sublimate wash, 124, 663 Corrosive sublimate (gr. 1 to 4 to the ounce [0.06-0.25:30.0]), applied night and morning until irritation appears, then stop for some days and again renew, 663 Lactic acid (gr. 10 to the drachm [0.60: 4.0]), applied same as corrosive subli- mate, 663 Prescription for chloasma of pregnancv. 368 Prescriptions for, 663 FURUNCLES. (See Boils.) GALACTORRHEA, 773 Antipyrin, gr. 2\ (0.123), thrice daily, said to decrease secretion, 773 Caustic, introduced into uterus, successful in some cases by inducing menstrual flow, 773 Chloral should be tried, 773 Compression of gland with applications of belladonna ointment and potassium iodide internallv, usuallv relieves, 773 Diet, 773 Electricity, generally ineffective, 773 Ergot, long continued, highly recom- mended, 773 Malt, wineglassful at midday and evening meals, useful addition to diet: pyro- phosphate of iron, gr. 4 (0. 25), in addi- tion, if anaemia is present, 774 Warm douches, 773 GANGRENE. Bromine, as an escharotic in hospital gan- grene, 131 Carbolic acid or creosote, spray (TTl 5 to 15 to the ounce [0.3-1.0:30.0]), useful in pulmonary gangrene, 153 Nitric acid, to destroy tissue, 344 GASTRALGIA, 664 Acetanilid, 57 Alum, 76 Arsenic with iron, the most reliable remedy, prescription for, 664 Bismuth and pepsin, after meals, to pre- vent pain, 121, 665 Bromide of strontium, a valuable remedy, 427 Bromides or valerian, alternated with other treatment if case is neurotic, 665 Cannabis indica, prescription for, 146 Chloretone, gr. 5 to 10 (0.30-0.60), is useful, 168, 665 Cod-liver oil in emulsion with hypophos- phites, occasionally better than arsenic and iron, 664 Counterirritation and a vigorous revulsive, especially useful in hysteria, 493, 664 Cyanide of potassium, dilute hydrocyanic acid or chloroform as a substitute for bismuth, if it favors constipation, 665 Diet and hygiene, 664 Emesis and purgation, when due to indi- gestible food. 664 Hot applications, stimulating infusions, chloroform, hot brandy or whiskey or laudanum, TT] 30 to 40 (2.0-2.60), during acute stage, 664 Hydrocyanic acid, useful in nervous types, 272 Massage, enemata, diet, or suppositories of gluten, glycerin, or soap, to overcome constipation, 665 Menthol, 375 Nitroglycerin, 346 Potassium nitrate, gr. 4 to 5 (0.25-0.3), 345 GASTRIC ATONY. Arsenic, prescription for, in, 104 Prescription for, in drunkards, 69 GASTRIC CATARRH (ACUTE), 665 Ammonium muriate, useful in subacute forms in children, prescription for, 82 Bismuth subnitrate, gr. 2 (0.12) and cerium oxalate, gr. 1 (0.06) every two hours, 666 Calcined magnesia, as a mild purge to dis- lodge fermenting mass, 666 Diet, principal point in treatment, 665 Effervescing draughts, useful in convales- cence, 666 Flannel to protect abdomen,, 666 Ice, to quench thirst, if anorexia is great, 665 Iron, if anremia exists, 666 Milk, with large percentage of lime-water, 665 Salicylic acid, valuable in vomiting, 407 Seidlitz powder, one-fourth of one powder every fifteen minutes, to settle stomach and remove fermenting mucus, 666 Sodium bicarbonate with gentian, useful, 257, 666 Spice poultice to relieve epigastric distress, 666 Tartar emetic, given early, in acute attack of children, may abort, 88 GASTRIC CATARRH (CHRONIC), 666 Apomorphine, as an emetic, to throw off muciis, 98 Arsenic for the vomiting, in hand-fed babies, 103 INDEX OF DISEASES AND REMEDIES. 883 Bicarbonate of sodium for hyperacidity, 666 Bismuth subnitrate, added to prescription, if hyperacidity exists, 666 Carlsbad salt, Saratoga-Carlsbad water, or Seidlitz powder of great benefit, 668 Cascara sagrada, if constipation exists, 667 Charcoal, prescription for, 155 Diet, such as koumyss, light broths, and matzoon, 667 Hydrochloric acid, if due to atrophy of the gastric tubules, 271, 667 Lavage almost alwaj's to be used, 666 Silver nitrate and hyoscyamus, with coun- terirritation and regulated diet, 275, 342, 666, 667 GASTRIC DILATATION, 667 Beta-naphthol if fermentation is marked, 668 Cold douches, 668 Diet, 667 Enemas, nutrient, often useful, especially in older children, 667 Exercise, 668 Faradization of gastric walls recently in- troduced, 668 Hydrochloric acid, to aid digestion, 668 Lavage, 524, 667 Physostigma useful, combined with mix vomica, 386 Salicylic acid as an antiseptic when vomit- ing occurs and when the vomited matter contains sarcinaa, 407 Taka-diastase taken with meals, 667 GASTRIC ULCER, 668 Arsenic, 103 Bismuth and sodium bicarbonate, as an astringent and sedative, and to these may be added morphine or codeine for pain, 121, 669 Carlsbad salts, magnesium sulphate, or sodium phosphate, for relief of constipa- tion, 669 Chloretone of value to relieve pain, 168, 669 Cocaine, gr. \ (0.015), alone or combined with bismuth, to control vomiting, 670 Cold compresses or an ice-bag applied to epigastrium in hsematemesis, 670 Counterirritation, continuous over belly, to relieve pain, 669 Creosote or carbolic acid, for vomiting, 669 Diet and hygiene, 668 Hypodermoclysis, 668 Massage and electricity, 669 Monsel's solution, cold compresses, adrena- lin chloride, or turpentine, may be given to check hsematemesis, 670 Morphine for pain or collapse following perforation, 670 Oil of turpentine one of the best remedies, for hsematemesis, 670 Rectal alimentation, of great service, 668 Resorcinol useful in some cases, 399 Rest for the patient and rest for the stom- ach essential, 668 Silver nitrate with hyoscyamus in pill, half to one hour before meals, 275, 342, 669 Spice plaster, useful as a continuous coun- terirritant, 669 Stimulants, cardiac, guardedly adminis- tered, external heat and rubbing, in col- lapse, following hemorrhage or perfora- tion, 670 GASTRITIS (ACUTE), 670 Belladonna or atropine, internally, and flaxseed poultice over epigastrium and chest, if collapse threatens, 670 Bismuth, as an astringent and sedative, 121 Flaxseed tea, a useful demulcent, 252 Mucilaginous drinks and albuminous sub- stances freely given, 670 Oils, to prevent spread of inflammation, 670 Opium, in fluid form, to relieve pain and irritation. 670 Paregoric contraindicated, 670 Warm water, internally, or stomach-pump, to unload stomach at onset, 670 GASTRO-ENTERITIS, 671 Castor oil or magnesium sulphate, to sweep out poison, 671 Morphine, hypodermic ally, to allay pain, followed or preceded by mild, rapidly acting emetic, if irritating substance re- mains, 671 Opium, with hot applications or plasters to belly, to control irritation and diar- rhoea, 671 Predigested food, 671 GASTRO-INTESTINAL CATARRH. Ammonium chloride useful in subacute types in children, 82 Carlsbad, Vichy, or other alkaline mineral water of purgative powers, often useful, 531 Diet for seven-year-old child, 549 Garlic, as a poultice to belly almost equal to spice poultice, 71 Gentian with bicarbonate of sodium useful in children, 257 Hydrastis, especially useful if due to alco- holism, 269 Salicylate of bismuth in the presence of fermentation or putrefaction, 121 Sanguinaria, of service if jaundice is present, 411 Sodium bicarbonate, 10 to 20 grains, 421 Tar, in 2-gr. (0.12) pills, 440 Tartar emetic in acute forms, 88 GIDDINESS. Cod-liver oil with quinine, valuable in old age, 209 Ergot and bromides useful, 236 GLANDS (DISEASED). Ammoniac plaster, as a stimulant to en- larged gland, 79 Ammonium iodide and glycerin (gr. 30 to the ounce [2.0:30.0]), locally applied to enlarged tonsils, 82 884 INDEX OF DISEASES AND REMEDIES. Cod-liver oil, in lymphatic enlargements, 208 Ichthyol ointment, valuable as an inunc- tion in lymphatic enlargements, 278 Iodine, the best remedy for enlargements, 284 Mercury ointment as an inunction in en- larged glands, 331 Phenol (2 per cent, solution), injected into glands threatening suppuration, 154 Potassium iodide for enlargements of the cervical glands, 281 GLAUCOMA, 671 Atropine, contraindicated, 672 Eserine (gr. 1 to 2 to the ounce [0.06-0.12 : 30.0]), or pilocarpine nitrate (gr. 2 to 4 to the ounce [0.12-0.25:30.0]), dropped into eye if operation is delayed, 386, 672 Hot compresses, leeches, and opiates to relieve pain, 672 Iridectomy, the only curative treatment, 672 Pilocarpine in, 389, 672 GLEET. Bichloride of mercury, injection (gr. ^ to water 6 ounces [0.03 :180.0]), every three or four hours, 326 Cantharidal collodion, applied to under surface of penis or perineum, 492 Cantharis, 148 Sandalwood oil, 411 Turpentine, internally, 451 Uva ursi, 452 GOITRE. (See Bronchocele.) GONORRHOEA (ACUTE). 672 Aconite, TT\ 6 (0.4), every two or three hours, if inflammation is high, 62, 675 Almond emulsion, diminishes burning on urination, 72 Argvrol, 1 to 10 per cent., as injection, 676 Benzoic acid, with cannabis indica, useful in later stages, 119 Bicarbonate of sodium or potassium citrate, gr. 10 (0.60), after meals, increasing, if necessary; relieves ardor urinse, 674 Cannabis indica, often used in later stages instead of copaiba and cubebs, 146 Cinnamon oil, by injection or spray, 197 Cocaine, solution (4 per cent.), instilled into urethra before urination, dimin- ishes ardor urinse, 674 Copaiba and cubebs, useful, 216, 222, 674 Diet and hygiene, 675 Erigeron oil, occasionally used instead of copaiba and cubebs, 237 Eucalyptus, valuable in subacute stages, 249 Hot bath, prolonged, before going to bed, 674 Hydrastis, one of the best remedies, locally and internally, in later stages; also as a vaginal wash for females, 270, 673 Lead acetate, injection, gr. 1 to 8 to the ounce (0.06-0.5:30.0), 307 Lead-water and laudanum, or alcohol and water, applied on a cloth to penis, dur- ing inflammation, 673 Mercurol, 317 Mercury bichloride (1 :20,000 or 1 :40,000), in large quantities to flush urethra; in females, 2 pints of solution (1:4000), thrice daily, to irrigate vagina, 672, 680 Nargol, argyrol, or protargol injections, 1 to 10 per cent., 340, 676 Opium or belladonna, hypodermically or in suppository, to control pain in posterior urethritis, at same time discontinuing active treatment, and observing strict hygiene and diet, 675 Permanganate of potassium solution (1 : 6000), as an antiseptic, 672 Prescription for administration of balsams, 673 Prescriptions for checking the discharge, 673 Protargol, 396, 676 Quercus, injections, useful in females, 398 Salol (phenyl salicylate), 410, 674 Sandalwood oil, 674 Silver nitrate, injections (gr. -h to 3 ounces [0.03-90.0]), useful in subacute stage; in females, gr. 4 to 40 to the ounce (0.25- 2.6:30.0), painted over vagina, followed by astringent cotton tampon, 343, 680 Urinating with penis in hot water, to re- lieve ardor urinee, 674 Warm baths, lasting one-half to two hours, useful in early stage, 675 Zinc acetate, injection, gr. 1 to 20 to the ounce (0.06-1.3:30.0) of rose-water, 458 Zinc chloride, injection, gr. 1 to 2 to the ounce (0.06-0.12:30.0), occasionally used in second stage, 459 Zinc sozoiodol, 2 per cent, solution, 424 Zinc sulphate, weak solution, as an astrin- gent, 459 GONORRHOEA (CHRONIC), 676 Bichloride of mercury useful in, 326 Copper sulphate or silver nitrate, solution, as an application, after dilatation, to focus of inflammation, 676 Dilatation, if stricture exists, 676 Irrigations daily with nargol, argyrol or protargol (1:3000-1:500), silver nivrate (1 : 1000), mercurol (1 : 2000) or potassium permanganate (1 : 2000-1 : 500), 676 Prescriptions for, 676, 677 Pressure and use of cold, often valuable, 677 Sandalwood oil, to stimulate depraved mucous membrane, 411 Silver nitrate, solution, if discharge per- sists after dilatation; also in posterior urethritis, 677 Unna's treatment with coated sounds, pre- scription for. 676 Uva ursi, 452 GOUT, 681 Antipyrin, said to have a specific effect, 93 Chloral, in insomnia, 682 Chloroform liniment, applied over affected part, 183 INDEX OF DISEASES AND REMEDIES. 885 Cod-liver oil, 209, 682 Colchicum, wine of seed, TT[ 30 (2.0), in- creasing by TT[ 1 (0.05) every four hours, until symptoms are relieved or appear toxic, in acute types, 210, 681 Collodion, not more than one or two coats ; also useful with iodine, 212, 682 Diet, 682 Fowler's solution, ttl 3 (0.20), in water, a standard remedy in subacute and chronic types, 682 Gentian, 257 Guaiac recommended as preventive, 262 Hot air, valuable, 511 Iodide of iron, syrup of, and cod-liver oil if anremia is present, 682 Iodide of potassium, to relieve night pains ; also with colchicum, in chronic gout, 682 Iodine, ointment or tincture, locally ap- plied to chronic gouty joints, 683 Leeches or venesection, contraindicated, 682 Lithium carbonate or citrate (gr. 5 to 10 to the ounce [0.30-0.60:30.0]), locally applied, to dissolve deposit around joints, 311, 682 Morphine, hypodermically, to relieve acute pain, 681 Peppermint oil, locally applied, 682 Potassium bromide, the best remedy for insomnia, 682 Potassium permanganate, 377 Salicylates in large dose may be useful in, 405 Sodium bicarbonate and linseed oil (1:9), locally applied to joints, 682 Stimulants, ether hypodermically, opium except in brain or kidney disturbances ; diuretic and alkaline drinks and counter- irritation, in retrocedent gout, 683 Water, distilled or medicinal, in large amounts, 681 GRANULAR LIDS. (See Conjunctivitis, Granular.) GRAVE S?S DISEASE. (See Exophthal- mic Goitre.) GRIPING. Allspice or ginger, to prevent griping of purgatives, 72, 258 Belladonna useful, 116 GROWTHS (PATHOLOGICAL). Acid nitrate of mercury, 332 Caustic potash, or soda, occasionally used to destroy, 159 Chromium anioxide, as a caustic, to destroy growths on skin or mucous membranes, 188 Lime as an escharotic on hairy growths, 140 Methylene blue, 335 Nitric acid, 344 Pyoktanin, 334 Sodium ethylate to remove hairy growths, 422 Thiosinamine has been used with some success in malignant growths, 444 GUMS (DISEASES OF). Burnt alum, useful if applied to swollen gums, 76 Cocaine, locally applied, in soreness and tenderness of gums, 201 Gambir, as a mouth-wash, for spongy gums, 255 Iodine, solution (gr. 1 to the ounce [0.06: 30.0]), locally applied, followed by rins- ing mouth, when gums are retracted, 285 Myrrh, tincture, locally applied, to spongy or tender gums, 338 HAY FEVER. Adrenalin, locally, to relieve engorgement, 436 Arsenic, 103 Cocaine, with bismuth and morphine, as a snuff, 202 Resorcinol, solution, 2 per cent., in spray, 399 Terpine hydrate, in full dose, 442 HEADACHE, 683 Acetanilid, 57 Belladonna, valuable in young people, 118 Bleeding, 684 Caffeine, with antipyrin or sodium bro- mide, in nervous headache, 136, 684 Camphor, with acetanilid or antipyrin, in nervous headache, 142 Cannabis indica, when at menopause ' or due to retinal asthenopia, 146 Capsicum plaster to nape of neck, 150 Castor oil, daily, in neuralgic headache, 156 Cimicifuga, if due to eye-strain, 189 Colchicum, in gouty headache, 685 Croton chloral, if due to eye-strain or asso- ciated with sick stomach, 221 Cup, to nape of neck, in congestion, 684 Ergot, if due to congestion, 236, 683 Eucalyptus, if headache be rheumatic or malarial, 249 Gelsemium, if due to nervous troubles or eye-strain, 256 Horseback exercise and sleep very useful in obtaining relief from nervous head- ache, 685 Hydrobromic acid, if due to eye-strain in nervous women, 131 Ice-bag, applied to head, or leeches behind ears, in severe cases, 684 Kola, very useful in elixir or tincture for sick and neuralgic headaches, 303 Liquor magnesii citratis, in sick headache, 314 Magnesium carbonate, gr. 5 to 60 (0.3-4.0), in sick headache due to gastric acidity, 314 Mustard foot-bath and plaster to nape of neck, in congestion, 337, 684 Nux vomica, gtt. 1 (0.05), every five or ten minutes till 10 minims (0.60) are taken, in sick headache, 354 Phenacetin, if due to eye-strain or neural- gia, 379 Potassium bromide, 127 Prescriptions for, 684, 685 886 INDEX OF DISEASES AND REMEDIES. Salicylic acid or iodide or acetate of potas- sium, if due to gout, 685 Sodium bicarbonate, as an anticid in sick headache, 421 Strychnine or mix vomica, in sick head- aches or if due to eye-strain, 354, 684 HEART DISEASE, 685 Aconite or veratrum, often useful in pal- pitation and hypertrophy, 62, 690, 691 Adonidin, often of service when digitalis fails, 63, 689 Adrenalin intravenously in cardiac and vasomotor failure, 436 Alcohol in heart failure due to shock or to poisons, 66 Ammonia and ether, followed by digitalis, and alcohol, in heart failure, 78, 690 Amyl nitrite, in single whiffs, often relieves cardiac failure, 84 Barium chloride, in heart failure, 112 Baths bv Schott's method; formula for 693, 694 Belladonna, when arhythmia is present 690; in palpitation, 115; plaster in hyper- trophy, 691 Cactus grandiflora, useful in valvular dis- ease with incompetency, cardiac weak- ness and palpitation, 134, 690 Caffeine, very useful, 136 Camphor in palpitation, 142 Cimicifuga, as a tonic in fatty and irritable heart when digitalis fails, 189 Citrate or bitartrate of potassium with digitalis when secretion of urine is scanty, 690 Convallaria majalis, in cardiac arhythmia, 215 Diet, exercise, and hygiene, 691 Digestive remedies, in palpitation due to indigestion, 690 Digitalis, to be tried in all heart troubles, except in simple or compensatory hyper- trophy, 228, 687 Hoffmann's anodyne, very useful in palpi- tation due to indigestion or tobacco, 266 Hydragogue cathartics for the dropsy and portal engorgement, 690 Iodides to relieve tension in fatty heart, 692 Iron, arsenic, and simple bitters for asso- ciated debility and anosmia, 689 Iron in palpitation due to anaemia, 690 Kola, useful in cases with debility, 303 Nitroglycerin, when arterial tension is high, 690 Nux vomica, as a stimulant, 690 Opium, if dyspnoea prevents sleep, 364 Potassium bitartrate or citrate with digi- talis for scanty secretion of urine, 690 Rest in bed essential when aconite is used, 691, 692 Sparteine, in arhythmia or palpitation, also as a substitute for digitalis, if it fails, 416, 690 Strophanthus, if digitalis fails, 429, 689, 690 Suprarenal gland, in heart failure due to lack of vascular tone, 436 Venesection followed by digitalis for over- distended right ventricle, 689 Veratrum, 456, 691 HffiMATEMESIS, 698 Adrenalin, 698 Ergot, hamamelis, or ipecac, in slow bleed- ing, 699 Hamamelis, internally, 265 Ice, cracked, swallowed frequently, accom- panied by Monsel's solution, XT[ 3 (0.20), in a half-tumblerful of water, every fif- teen minutes, 698 Iron, tincture of chloride, or turpentine, internally, 699 Lead acetate with morphine or opium, gr. 2 to 3 (0.12-0.20), in pill, 698 Monsel's salt, gr. 2 to 3 (0.12-0.20), in pill, 298, 698 Silver nitrate, gr. ^ (0.015) in pill, in slow bleeding, 699 Tannic acid, gr. 20 (1.3) to drachm (4.0); must not be given with Monsel's solu- tion, 698 HEMATURIA, 700 Adrenalin chloride (1 :5000) as injection, 701 Alum, gr. 2 to 3 (0.12-0.20) to water 1 ounce (30.0), injected into bladder, if alarming, 701 Astringent injections, should be used only when bleeding is alarming, 701 Camphor, gr. 10 to 20 (0.6-1.3), in divided doses, in pill, 701 Cannabis indica, useful in some cases, 701 Ergot, 701 Erigeron, 701 Gallic acid, gr. 20 (1.3), very valuable, 254, 701 Hamamelis, injected daily into bladder, or used internally, 265 Hyposulphite of sodium, 5 to 15 gr. (0.3- 1.0), if due to malaria, 423, 701 Morphine and atropine hypodermically and cups over kidneys in hematuria, 701 Prescriptions for, 701 Quinine, usually harmful, unless due to malaria, 701 Rhus aromatica, 401 Turpentine, 451, 701 HEMOPHILIA. Calcium chloride, 138 HEMOPTYSIS, 697 Acetanilid, has been recommended, 57 Aconite, to prevent pneumonia following, contraindicated in exhaustion, 698 Alum, solution (gr. 20 to the ounce [1.3: 30]), in fine spray, 76 Chloral and bromides, to allay nervous ex- citement, 698 Ergot, fluid extract, 1 to 1% drachms (4.0- 6.0), internally, 697 Esmarch bandages to limbs when aconite cannot be used because of exsanguina- tion, 698 INDEX OF DISEASES AND REMEDIES. 887 Gallic acid, gr. 20 to the ounce (1.3:30.0) of water, when ergot is not at hand, 254, 697 Hamamelis, 265 Ice or dry cup over bleeding spot, 698 Ice or ice-cold compresses to the scrotum or vulva in, 698 Ipecac, in small doses, very effective, 291 Morphine, hypodermically, to allay ner- vousness and cough, 362, 698 Tannic acid, Monsel's solution, or alum, used in spray, as stvptics, prescriptions for, 297, 439, 679 HEMORRHAGE, 695 Alum, a useful styptic, applied to bleeding vessel, 75 Antipyrin, 94 Arnica, 99 Cinnamon in uterine hemorrhage, 197 Compress, soaked in antiseptic liquid or filled with antiseptic powder, preferable to styptics, 695 Gelatin, locally and hypodermically, to aid in the coagulation of blood, 696 Hamamelis, useful for uterine oozing, and bleeding from the bladder, 265 Hypodermoclysis, 512, 513, 695 Ligation preferable to styptics, when appli- cable, 695 Monsel's solution, 297 Oil of erigeron, 237 Packing of astringents, if bleeding point cannot be reached by compression, or for ligation, 695 Sulphate of sodium, by the mouth or intra- venously; useless hypodermically, 423 Tannic acid, 439 Transfusion, 538, 696 HEMORRHAGE (INTESTINAL), 699. (See also Hemorrhage.) Chloride of calcium, 699 Enemas, styptic, for hemorrhage from rectum or colon; adrenalin chloride, 2 drachms of 1 :1000 solution in \ pint of normal salt solution; alum (gr. 10 to the ounce [0.60:30.0]), copper (gr. 5 to the ounce [0.3:30.0]), Monsel's solution (dr. | to 2 ounces [2.0:60.0]), Monsel's salt (gr. 10 to the ounce [0.60:30.0]), or drachm ^[2.0] to water 2 ounces [60.0]), chlorate of potassium (gr. 10 to 25 to the ounce [0.6-1.6:30.0]), tannic acid (gr. 20 to ounce [1.3:30.0]), of glycerin and water, 699, 700 Ergot, 235, 699 Ice, by mouth, and to the belly, and Mon- sel's salt, gr. 3 (0.20), in hard pill, every half-hour or oftener, 699 Ice-water injections in bloody purging of dysentery, 700 Lead acetate and camphor, in pill, of ser- vice in some cases, 699 Monsel's solution not advisable, 298 Sulphuric acid, gtt. 5 to 10 (0.3-0.60) in water, 699 Tannic acid, when Monsel's salt is not at hand, 699 Turpentine, in capsule or emulsion, when bleeding is not active, 451, 699 HEMORRHOIDS, 702 Aloes, 74 Antipyrin with cocaine in suppository, to check bleeding and relieve pain, 94 Carbolic acid injection dangerous, 703 Cocaine and iodoform ointment, prescrip- tion for, 703 Cold-water injections in the morning, re- lieve congestion and cause easy evacua- tion, 475, 703 Ergot, sometimes useful in bleeding piles, 236 Gallic acid and ointment of stramonium, equal parts, 254 Gallic acid and opium suppository, pre- scription for, 702 Hamamelis, internally or as a lotion or in- jection, 265, 702 Hot compress wet with adrenalin chloride, 1 :2000, 703 Hygiene and general rules, 703 Iodoform suppository, if ulceration is present, 289 Lead-water and laudanum lotion after acute stage is passed, 703 Linseed oil, 252 Nitric acid, lightly touched to one or two points; as a lotion, \ to 1 drachm to the pint of water in bleeding hemorrhoids, 345, 702 Potassium chlorate, with laudanum, as an injection, 168 Quercus, as an astringent wash, 398 Stillingia, prescription for, 427 Sulphur, to produce soft passages, 432 Tannic acid, suppositories in bleeding piles, 439 HEPATIC ABSCESS, 704 Active treatment for dysenterv, if present, 704 Ammonium muriate, thought to be of value, 82 Aspiration, when pus forms, 704 Diet, 704 Quinine and iron, after abscess develops, 705 HEPATIC CIRRHOSIS. Ammonium chloride, 82 Iodoform, highly recommended, 288 Liver, 3 oz. of fresh gland, in delirium of cirrhosis, and in alcoholic cirrhosis with icterus, 279 Nitro-muriatic acid, in early stages, 348 Potassium iodide, often useful in early stages, 280 Sodium phosphate very useful, 381 HEPATIC TORPOR. Ammonium chloride in, 82 Chirata, in indigestion due to torpor, 161 Citric acid in, 198 Euonymus in, 250 Nitro-hydrochloric acid when either acute or chronic, 348 Taraxacum, 441 888 INDEX OF DISEASES AND REMEDIES. HEPATITIS (ACUTE), 704 Cantharidal blister, small, over right hypo- chondrium; if impracticable, use mustard plaster, 704 Hot cloths, over counterirritant, may re- lieve pain and aid in formation of blister, 704 Saline purgatives, preceded by calomel, gr. 1 (0.06), in divided doses, if constipa- tion exists, 704 Sweet spirit of nitre with potassium citrate, or diuretic waters, to regulate kidneys, 704 Veratrum, 456 HEPATITIS (CHRONIC AND SUB- ACUTE), 705 Ammonium chloride, useful in subacute forms, 82 Antisyphilitic treatment, if due to syphilis, 705 Aspiration, frequently repeated, may effect a cure, 705 Nitro-muriatic acid, internally and exter- nally, most useful remedy, 348, 705 Potassium iodide, useful in all cases, 705 HERNIA. Chloroform or ether inhalations, to relax muscles during reduction, 179, 243 HERPES. Anthrarobin in, 85 HICCOUGH, 705 Amyl nitrite, 706 Belladonna, 116 Camphor, spirit of, dose 1 drachm (4.0), 142, 705 Capsicum, tincture, \T[ 2 to 3 (0.1-0.20), 705 Chloral, 166 Chloroform, 705 Emetics or purges when gastric or intestinal irritation is present, 705 Ether, sprayed on epigastrium, 243, 706 Hoffmann's anodyne, especially valuable, 266, 705 Hot pack when due to uraemia, 706 Musk, gr. 10 (0.60), given by rectum, valu- able in all cases, especially in typhoid fever, 337, 706 Nux vomica, accompanied by mineral acids, if due to indigestion, 706 Oil of amber, Til 5 to 10 (0.3-0.60), in cap- sule, one of the best remedies, 76, 706 Sodium bromide and laudanum by the bowel when life is threatened, 706 Valerian, tincture of, dose 1 drachm (4.0). 705 HYDROCELE. Iodine, injections, after evacuation of the sac, the best curative remedy, 285 HYDROCEPHALUS. Potassium iodide, to cause absorption of fluids, 280 HYSTERIA. Calcium bromide, 130 Hops, as a nervous sedative, 269 Monobromated camphor, to produce sleep, 144 Oil of amber, 77 Ovarian extract has been used, 259 "Pill of three valerianates," recommended, 453 Potassium bromide, 127 Valerian, 453 Valerate of ammonium, 83 Valerate of iron, if associated with anaemia, 299 IMPOTENCE. Cannabis indica, with strychnine, nux vomica, or ergot, if no organic trouble exists, prescription for, 146 Cantharis, with nux vomica and iron, may restore sexual power if loss is due to ex- cess, 148 Cold douche to perineum and testicles, in atonic types, 476 Gold, chloride of, and sodium, gr. J*- (0.003), 261 INCONTINENCE OF URINE, 706 Alkalies, 706 Ammonium benzoate or urotropin, gr. 4 (0.25), in water, three times a day, if urine is concentrated and ammoniacal in odor, 707 Antiseptic fluids, to cleanse bladder, in paralysis, 708 Arsenic, with nux vomica, in weakness of spinal centres, prescription for, 707 Belladonna, if due to vesical spasm, 116, 707 Bromides with chloral, if due to vesical spasm, 127 Buchu, with sweet spirit of nitre, valuable in some cases, 133 Cantharides, TT1 \ (0.025), with alkaline diuretics, thrice daily, in adults, 148, 708 Catheterization, in retention or paralvsis, 708 Circumcision, if prepuce is redundant, re- lieves some Cases, 706 Fowler's solution, T7] \ to 1 (0.025-0.05), in chronic types due to atony, 707 Hyoscyamus, if due to irritable bladder,275 Potassium citrate when due to acidity, 395 Rhus aromatica, in incontinence of chil- dren, due to atony, 401 Santonin, often valuable when other rem- edies fail, 412 Strychnine, 707 Sweet spirit of nitre and potassium citrate, if urine is dark and concentrated, pre- scription for, 437, 707 Worms removed from vagina often cure, 706 INDIGESTION (GASTRIC AND INTES- TINAL), 708 Alkalies, before meals in atonic states, dur- ing or after meals when the secretion of acid is excessive, 709, 710 INDEX OF DISEASES AND REMEDIES. 889 Ammonium acetate solution as an antacid in gastric indigestion, 80 Ammonium chloride, in painful forms, 82 Asafcetida, in indigestion of old age, asso- ciated with flatulence, 110, 713 Bicarbonate of sodium with bitters, 709 Bitter tonics, Useful in atony, contraindi- cated in gastric irritation, 709 Bromide of strontium, in excessive secre- tion, when not due to ulcer, 428, 711 Bryonia, when dependent upon gastric or intestinal atony, 132 Carbolic acid and bismuth, 711 Chirata, if liver is torpid or constipation is present, 161 Chloral, creosote sodium hyposulphite, or thymol, with lavage, when fermentation is excessive, 712 Chloroform spirit, TTl xx (1.3), often of great value, 713 Creosote, HI $ to 2 (0.025-0.1) after meals in fermentation, due to deficient diges- tion of meats or the use of sweets, 221 Diastase when starchy foods are not di- gested, 224 Diet, 709 Fats, excluded in fermentative types, 712 Gold, chloride of, and sodium, when epi- gastric pain is present, 261 Hydrochloric acid, combined with carda- moms, in atrophy of the gastric tubules, cancer, or intestinal dyspepsia, 270, 710 Hyoscyamus, belladonna, opium, bromides, bismuth, when there is hyperacidity, 710 Lavage, 712 Leptandra, of great value in intestinal types, prescription for, 309 Massage, 713 Nitrate of silver, especially where an ulcer is present, 711 Nitro-hydrochloric acid or nitric acid, valuable in many cases, 345, 348, 713 Ox-gall, 368 Pancreatin, with sodium bicarbonate and alkaline mineral waters, in intestinal types, 712 Papain, 372 Pepsin immediately after meals, 377 Podophyllin or mercury in lientery, 713 Prescription for flatulence of intestinal in- digestion, 712, 713 Prescription for torpid liver of indigestion, 713 Rhubarb, quinine, condurango, and nux vomica, useful tonics, 710 Salol (phenyl salicylate) in intestinal form with fermentation, 410 Serpentaria as a tonic, 418 Test-meal as a means of diagnosis, 709 Thymol, beta-naphthol, creosote, chloral, and sodium thiosulphate in acidity due to acids of fermentation, 712 Yellow oxide of mercury, gr. fa to fa (0.001-0.0012), in trituration, if there is foul belching or ill-smelling stools, 332 INFLAMMATION. Aconite, in acute, 62 Bismuth in inflammation of mucous mem- branes, 120 Cannabis indica, valuable in chronic tvpes, 146 Cocaine, in acute types, prescription for, 201 Cold applications, locally, 471 Flaxseed for inflamed mucous membranes, 252 Hop poultice, 269 liquor plumbi subacetatis, useful as a topical application, 307 Opium, 362 Silver nitrate useful in all inflammations of the pharynx, larynx, fauces, and mouth, 343 Sulphurated lime, useful to check, 141 Tartar emetic, in sthenic inflammation, 88 Turpentine stupe, 450 Veratrum, 456 INFLUENZA, 713 Aconite, sweet spirit of nitre, and citrate of potassium in combination, valuable in early stage, 715 Alcohol, 717 Antipyrin, phenacetin, and acetanilid should be used only in small doses to allay pain, 714 Belladonna, combined with strychnine, if there be vasomotor paresis, 717 Bromides, codeine or morphine, if cough be excessive, 717 Cannabis indica, often valuable, if pushed, for irritative cough, 718 Castor oil or magnesium sulphate for con- stipation, 718 Chloral, chioralformamide, or sulphonal, for insomnia, 718 Cold bath, preferable to antipyretics for reduction of temperature, 715 Cups, contraindicated, 716 Ergot, cannabis indica, with bromides, often relieve vertigo, 718 Monobromated camphor, 144 Phenacetin, 380 Remedies for bronchitis when present, 717 Salicin, 403 Salol (phenyl salicylate) and phenacetin, valuable in combination, to allay irrita- tion and pain, 714 Sandalwood oil, for excessive cough, 411 Steam inhalations, laden with vaporized drugs, for cough, 717 Strychnine preferable to digitalis, if there be tendency to collapse, 716 INSANITY. (See Mania, Acute.) INSOMNIA, 718 Amylene hydrate, useless if due to pain, 720 Bath, cold, in cerebral anaemia, hot, in nervous irritability, 474 Bromide of potassium with Fowler's solu- tion, in nervous females, prescription for, 719 Chloral, useful if not due to pain, prescrip- tion for, 164, 718 Chioralformamide, gr. 15 to 60 (1.0-4.0), in wine or capsule, in nervous insomnia, 165, 720 890 INDEX OF DISEASES AND REMEDIES. Chloralose, 2 to 8 grains (0.12-0.5), in cap- sule, 167 Chloretone, 168, 720 Chlorobrom for insomnia of melancholia and acute mania, 166 Croton chloral preferable to chloral, if due to pain, 221 Duboisine more useful than hyoscine, 232 Hop pillow, 269 Hot pack in nervous insomnia, 509 Hot-water bags to feet and cold to head, or general hot bath, 719 Hyoscine gr. T ^ to ^ (0.0006-0.0007), bv mouth, or gr. ^ to ^ (0.0004-0.0006), hypodermicallv, in mania or hysteria, 276, 719 Hypnal, useful in insomnia due to pain, 277, 720 Morphine with chloral, if due to pain, pre- scription for, 719 Opium, only to be used in pain, 361 Paraldehyde, 373, 720 Potassium bromide, in nervousness and overwork, 128 Somnal, minims 10 to 40 (0.60-2.6), in liquorice and water, 424, 720 Sulphonal, prescription for, may be given in hot water, 431, 720 Trional, in 15-grain (1.0) doses, 449, 720 Valerian, in nervousness, 453 INTERMITTENT FEVER, 721 Alcohol, contraindicated during chill, 722 Ammonium chloride in, 82 Anesthetization, has been employed to put off paroxysm, 723 Arsenic, in intervals between attacks, as an antiperiodic, 102 Calomel, gr. i to i (0.01-0.015), every fif- teen minutes until 1 grain (0.06) is taken, four or five hours before quinine, if con- stipation is present, 722 Chloroform inhalations, preceded by lauda- num, by mouth or rectum, or morphine, gr. i (0.01), with atropine, gr. 6 \ (0.001), hypodermicallv, if death threatens dur- ing chill, 723 Cool drinks and sponging, in fevered stage, cold with friction, 723 Digitalis or strychnine, to relieve internal congestion during chill, 722 Eupatorium useful in, 250 Ipecac or zinc sulphate, as an emetic, if chill follows full meal, 722 Methylene blue, 1 to 4 grains (0.06-0.25), 335, 723 Podophyllin, gr. ^ to J (0.006-0.008), pre- ceding quinine, if constipation is present, 722 Potassium or sodium nitrite, gr. 10 (0.60), has been employed to put off attack, 723 Quinine, as a prophylactic and antiperiodic, 721 INTERTRIGO. (See Chapping.) INTESTINAL CATARRH. Ammonium chloride, useful in subacute types, 82 Chlorate of potassium, injections (gr. 20 to the ounce [1.3:30.0]), in acute rectal catarrh, 168 Iodide of potassium, if ammonium chloride fails to relieve, 280 Leptandra, fluid extract, dose 20 minims to 1 drachm (1.3-4.0), 309 Salol, 410 INVOLUTION (ANOMALIES OF), 769 Applications of nitric acid and silver nitrate useful in lacerations, 770 Cannabis indica, of great value in subinvo- lution, 146 Cimicifuga in subinvolution, 189 Curette in subinvolution due to retention of hypertrophic endometrium, 769 Digitalis in subinvolution due to smggish circulation, 770 Ergotin, gr. j, hydrastinin, gr. \, and stypticin, gr. j, in pill, if due to fibroids, 235, 769 Mammary gland, 315 Purgatives, disinfectants, and possibly hot water locally applied, if due to inflam- mation, 770. Removal of placenta, if adherent, 770 IRITIS, 723 Atropine, the best local remedy, 117, 723 Daturine, scopolamine, or duboisine, when atropine cannot be used, 723 Dionin, 1 per cent, solution, locally, for pain, 724 Holocaine as a local anaesthetic, 267 Hyoscine valuable for pain, 724 Iced compress, in early stage of traumatic iritis, 723 Iodide of potassium, alone or with mercury bichloride, following mercurial impres- sion, in syphilitics, 723 Iridectomy required in some cases, 724 Leeches and dry heat or hot fomentations, to relieve pain, 723 Mercury, preferably by inunction, if due to syphilis, 724 Morphine, if pain is severe, 724 Paracentesis, 724 Pilocarpine, internally if vitreous becomes opaque, also in gonorrhceal types, 724 Salicylic acid or oil of gaultheria, followed later bv potassium iodide, in rheumatic iritis, 724 Saline laxatives, during course of disease, followed by iron, after cessation of spe- cific treatment, 724 Scopolamine in early stages of, and in plastic, 414 Subconjunctival injections of cyanide of mercury (1 :5000-l :1000), or of salt solu- tion recommended in syphilitic iritis, 724 Zollicoffer's mixture, useful in chronic types, 724 IRRITABILITY. Almonds, as a drink in irritability of in- testines and air-passages, 72 Cantharis, recommended in irritable blad- der of women and children, 148 Cimicifuga, in uterine irritability, 189 INDEX OF DISEASES AND REMEDIES. 891 Hops, in vesical irritability, 269 Hydrocyanic acid, in irritability of the stomach, 272 Hyoscyamus, for vesical irritability with incontinence, 275 Petrolatum, as a soothing agent in gastro- intestinal types, 378 Piperazine, in bladder irritation due to excess of uric acid, 391 Potassium bromide, in irritability of phar- ynx, 127 JAUNDICE. Calomel, gr. £ (0.01), every half-hour till gr. ^ (0.03) is taken, if due to cold, 328 Carbolic acid (phenol), gr. 10 (0.60), with water and gtycerin, each 2 drachms (8.0), locally applied in itching of jaundice, 154 Citric acid, in catarrhal form, 198 Hydrastis, useful in subacute types, 269 Iodoform, highly recommended, 288 Manganese sulphate, may be tried in malarial types, 316 Pilocarpine, useful unless due to malignant disease, 389 Salol, said to be of value, 410 Sodium phosphate, of value, 381 JOINTS (ENLARGED). Tartar emetic ointment as a counter- irritant in old enlargements, 88 Turpentine liniment, 452 JOINTS (INFLAMED). Alcohol, locally, as a wash, 67 Camphor liniment, locally, 143 JOINTS (RHEUMATIC). Oil of amber as a counterirritant over, 77 KELOID. Ichthyol ointment, 278 Thiosinamine, 10 per cent, solution in alcohol, injected into the growth, 444 KERATITIS (INTERSTITIAL), 725 Antiseptic lotions, in marked ciliary con- gestion, 725 Antisyphilitic treatment, if due to syphilis, 725 Atropine, in ciliary congestion, to prevent iritis, 725 Leeches, to temple to relieve pain, if patient it not too young for bleeding, 725 Thymol iodide, as a dusting-powder, 445 KERATITIS (PHLYCTENULAR), 725 Atropine, to relieve pain, 726 Boric-acid solution, to relieve congestion, 726 Cocaine, not advisable in photophobia, 726 Cold-water douche on closed eyelid, to relieve photophobia, 726 Creolin solution, 1 to 2 per cent., as a wash, 221 Dark glasses, to protect eyes, 726 Tonics and alteratives, with strict hygiene and regulated diet, associated with local treatment, 726 Yellow oxide of mercury ointment, or calomel as a dusting-powder, to hasten cicatrization, contraindicated if iodine is being given, 726 KERATITIS (ULCERATIVE), 726 Antiseptic lotions, to limit sloughing, 727 Atropine, instilled into eye, to limit slough- ing, 727 Cautery, actual, best means of preventing perforation, 727 Curetting floor of ulcer, if perforation threatens, 727 Eserine, instilled into eye, in peripheral ulcers, 727 Holocain as an anesthetic, 727 Hot compresses, 727 Massage of cornea and introduction of yellow-oxide ointment to remove scars of ulcers, 728 Pressure bandage, if perforation threatens, _727 Silver nitrate, tincture of iodine, or for- maldehyde applied to margin of ulcer does good, 727 Subconjunctival injections of cyanide of mercury (1 :5000), or of salt solution to absorb corneal nebula, 728 LACRYMAL ABSCESS, 728 Division of canaliculi and washing out sac with antiseptic fluids, and insertion of probes into ducts after inflammation subsides, to restore patulency, 728 Formaldehyde (1 :6000), silver nitrate (1:500), or protargol or argyrol (2 to 5 per 100) injected through external opening if there is purulent discharge, 729 Hot compresses, composed of lead-water and laudanum, to relieve pain, 729 Puncture of abscess, if rupture threatens, 728 LARYNGISMUS STRIDULUS. Amyl nitrite, 84 Belladonna, 116 Bromide of potassium, 127 Gelsemium, 257 LARYNGITIS (ACUTE), 729 Aconite, to control fever, 730 Antipyrin, as a spray, 94 Bromides, useful in full doses, 60 to 120 grains (4.0-8.0) a day, 127, 730 Calomel, small and repeated doses, followed by saline purges, along with hot mustard foot-baths and demulcent drinks, 730 Creosote spray in subacute laryngitis, 220 Cubebs cigarettes, useful for hoarseness of subacute forms, 222 Inhalations in, 520 Iodine, painted over throat, useful on third or fourth day, 730 Mustard plaster or hot applications over larynx, 730 892 INDEX OF DISEASES AND REMEDIES. Nitric acid, dilute, Til 2 or 3 every ^ hour or hour for six doses in early stage, 730 Oil of amber and olive oil, half and half, well rubbed into the skin of the neck and chest, 77, 730 Prescriptions for sprays, 729 Silver nitrate, 343 Steam inhalations, charged with benzoin ; often advantageous to add menthol, 119, 729 LEPRA. Arsenic, 103 LEUCOCYTILffiMIA. Arsenic, very useful in full ascending doses, 101 LEUCORRH(EA, 730 Alum, gr. 10 to 20 to the ounce (0.60-1.3: 30.0), as a vaginal wash, 76 Ammonio-ferric alum, gr. 2 to 5 (0.12-0.30), in atonic types, 294 Belladonna, gr. 1 to 2 (0.06-0.12), with tannic acid, gr. 6 to 8 (0.5), applied on cotton, in disease of uterine cervix, 116 Cantharidal collodion, applied over groins to produce blister, 731 GoodelFs prescription for, 731 Hffimatoxvlon, used internally, of service, 264 Hot sitz-bath, or vaginal injections of hot water, if due to uterine congestion, 505 Hydrastis, injections, 269, 270 Iron, with tonics, if due to excessive lacta- tion or exhausting life, 731 Myrrh, if due to uterine trouble, 338 Nitrate of silver, when there is cervical ulceration, 343 Potassium permanganate (drachm \ [2.0] to water 1 pint [480.0]), as an injection, if discharge is fetid, 732 Prescriptions for injection, 732 Ringer's prescription for wash, 732 Tampon, saturated with iodoform and tannic acid, 439, 732 White-oak bark (ounce 1 [30.0] to water 1 pint [480.0]), or tannic acid and glycerin (ounce 1 [30.0] to 2 quarts [2 litres] of water), as an injection, 398, 732 LICHEN. Arsenic, usually cures, 103 Cantharides, 148 Carbolic acid (phenol) ointment in lichen planus, 154 LID ABSCESSES, 733 Treatment same as for other abscesses, 733 LITRffiMIA. (See Gout.) LOCOMOTOR ATAXIA. Acetanilid, 57 Antipyrin, relieves lancinating pains, 93 Chloralformamide, prescription for, 166 Co-ordinated movements in, 488 Exalgine, prescription for, 251 Phenacetin, 379 Potassium bromide, to prevent laryngeal crises, 127 Suspension, 536 LUMBAGO, 733 Acupuncture, often relieves, especially if pain is bilateral, 461, 733 Antifebrin, dose gr. 2 to 4 (0.12-0.25), 733 Antipyrin, dose gr. 5 to 10 (0.30-0.60), 733 Capsicum plaster useful, 150 Chloroform liniment, 183 Cod-liver oil, 208 Foot-bath and Dover's powder, before retiring, often relieves, 733 Hot poultice to back often useful, 733 Ice-bag or ether spray to loins, if hot applications fail, 733 Ironing back with laundry iron, skin being protected by cloth or paper, very efficient, 504, 733 Monobromated camphor, with other drugs, very useful, 144 Mustard or capsicum plaster or blister over painful spot may relieve, 733 Phenacetin and salol, of each 5 grains (0.3), 733 Potassium iodide or salicylic acid, if recovery is slow, 280, 733 Salicylic acid, useful, 405, 733 Turpentine, gtt. 20 (1.3), said to be useful, 451 LUPUS. Acid nitrate of mercury, 332 Europhen, in ointment or powder, 251 Ichthyol ointment, 278 Iodine, as a paint, to retard spread, 285 Thiosinamine, useful in, 444 MALARIAL FEVER. (See Intermittent and Remittent Fevers.) Antipyrin, 94 Arsenic, as a cure and prophvlactic, 101 Calomel, 324 Eucalyptus, instead of quinine, when it cannot be borne, 249 Gelsemium, of doubtful value, 257 Gentian, in malaria associated with dys- pepsia, 257 Hydrastis, said to be antimalarial, 270 Methylene blue, 1 to 4 grains (0.05-0.2), 335 Phenocoll, useful in some cases, 380 Pilocarpine, may be used to abort, 389 Piperin, has been used with varying success, 374 Quinine, the best remedj^ as a prophylactic and a cure, 193 Warburg's tincture, said to excel quinine in pernicious malarial regions, 457 MANIA (ACUTE), 733 Anaesthetics, or apormorphine in emetic dose, to relax muscular system, if patient is very violent, so that other remedies may be administered, 734 Bromide of potassium, as a soporific. 128 Cannabis indica, with large doses of bro- mides, particularly serviceable, 734 INDEX OF DISEASES AND REMEDIES. 893 Chloral, in full doses, if kidneys are healthy, 734 Chloroform for insomnia, 179 Cimicifuga, fluid extract, TTl 20 to 30 (1.3- 2.0) thrice daily, in cases occurring after confinement not due to permanent causes, 733 Cold douche to head while body is im- mersed in hot water, often of service, 734 Duboisine, for insomnia, 232 Hot steam bath or Russian bath valuable, 734 Hyoscine hydrobromide, gr. T fo (0.0006), when necessary to quiet patient quickly, 733 Morphine, in full dose, may be required to quiet patient, 734 Sulphonal as an hypnotic, 431 Tlryroid gland, gr. 5 to 20 (0.3-1.3), 448 MARASMUS. Cod-liver oil inunctions, one of the best remedies, 208 Mercurv with chalk in svphilitic marasmus, 330 MASTITIS. (See Breast, Inflamed.) MELANCHOLIA, 734 Chloroform for insomnia, 179 Nitro-muriatic acid, YX[ 5 (0.3), in water after meals, if associated with oxaluria, 349, 734 Phosphorus, useful in some cases due to overwork, 384 Thyroid gland, gr. 5 to 20 (0.3-1.3), 448 MENINGITIS (ACUTE). 734 Aconite of veratrum, in early stages to depress circulation, 734 Alcohol, given with food in second stage, if there be asthenia, 735 Belladonna, often useful, especially when opium and calomel are contraindicated, 735 Blister to nape of neck, in early stage to prevent effusion; also in comatose state, 735 Bromides and chloral, best agents to allay nervous symptoms, 735 Calomel, gr. \ (0.03), with opium, gr. \ (0.015), every half-hour, in early stage, until effect is manifested; the deodor- ized tincture, TTl 2 to 5 (0.1-0.30), every two hours, or less, preferable to powder of opium in some cases, 735 Ice-bag to head, in early stage, 474, 735 Leeches to nape of neck, in early stage, 735 Lumbar puncture if symptoms of cerebral pressure are marked, 735 Milk diet, in second stage, 735 Opium, useful in second stage, 361, 362, 735 Quinine, contraindicated in acute stage, 735 Venesection in early stage of sthenic cases, if aconite or veratrum viride is not at hand, 540, 735 MENINGITIS (CHRONIC). Phosphorus, 384 MENOPAUSE. Bromide of potassium, in nervous dis- orders, 127 Cannabis indica, alone or with aloes and iron, if anaemia or constipation exist in headaches of the menopause, 146 Eau de Cologne, saturated with camphor, locally applied in headache or drowsi- ness, 143 Ovarian extract, for nervous and nutri- tional disturbances, 259, 367 Valerate of ammonium, in nervous dis- orders, 83 MENORRHAGIA AND METROR- RHAGIA, 696 Adrenalin chloride (1 :5000) may be em- ployed, 436, 696 Bromide of potassium or sodium, gr. 10 (0.60) once or twice dailv, if bleeding is irregular, 128, 696 Cannabis indica, recommended, 146, 696 Cinnamon oil, drachm \ (2.0), when erig- eron is not at hand, in oozing flow, 697 Cotarnine useful, 218 Dry cups, over sacrum, if due to conges- tion, 697 Ergot, fluid extract, TTl 10 to 60 (0.60-4.0), best remedy in active bleeding, 235, 696 Erigeron, oil of, minims 3 to 5 (0.20-0.3), in capsule or emulsion, the best remedy for oozing, 696 Hamamelis, water of, drachm 1 (4.0) thrice daily, in irregular bleeding, 696 Mammary gland, 315 MonsePs solution (50 por cent.) full strength locally applied, if due to polypus, 298 Rhus aromatica, highly recommended in menorrhagia, 401 Rue, in atonic menorrhagia, 402 Savine, oil of, TTl 5 to 10 (0.3-0.60), in capsule or emulsion, every three or four hours, as a tonic in menorrhagia, 414 Turpentine, often of value, 451 MENSTRUATION. Suppression of, due to cold, aconite in, 62 MIGRAINE, 736 Ammonium benzoate, gr. 10 to 20 (0.6- 1.3), 736 Amyl nitrite, 84 Bromide of potassium, with caffeine, almost a specific, if due to eve-strain, 128 Cannabis indica, extract, gr. \ to % (0.015- 0.03) with tincture of gelsemium, gtt. 10 to 20 (0.60-1.3) every two hours, 145, 736 Croton chloral, very efficient, especially if fifth nerve is involved, 221 Gelsemium, with cannabis indica, to abort, 256, 736 Methylene blue, gr. 1 to 2 (0.06-0.12), in capsule, 335 Phenacetin, 379 894 INDEX OF DISEASES AND REMEDIES. Rachford's prescription for, 736 Salicylic acid, of great service in rheumatic types, 406, 736 Sodium phosphate in hot water taken in morning, 736 Starr's prescription for, 737 MILK DEFICIENCY, 772 Electricity, 772 Treatment for intercurrent affection, if due to such cause, 772 MORPHIOMANIA. (See Poisoning from Opium, Chronic.) Bromide of potassium, 128 Phosphorus, of service in sequelae of mor- phiomania, 384 MUCOUS MEMBRANE (DISEASES OF). Acacia, as a mucilaginous drink in irrita- tion and inflammation of upper air- passages, 53 Bismuth, as an astringent, to inflamed membranes, 120 Flaxseed, as a soothing demulcent, 252 Glycerole of aloes, locally applied to fis- sures, valuable, 74 Opium, suppositories, gr. \ (0.015), useful in rectal inflammation, if not an acute catarrh, 362 Pareira, useful in chronic genito-urinary inflammation, 373 Tannic acid, useful in depressed conditions, 439 Terebene, useful in subacute and chronic genito-urinary inflammation, instead of sandalwood or copaiba, 441 Zinc sulphate, weak solution, as an astrin- gent, 459 MUSOffi VOLITANTES, 737 Alteratives and correction of anomalies of refraction, 747 MUSCULAR STIFFNESS. Hot laundry iron passed over part, skin being protected by layers of paper or cloth, often relieves, 504 MYALGIA, 737 Ammonium chloride, if due to cold or bruises, 737 Camphor liniment, 143 Chloroform liniment, 738 Cimicifuga, fluid extract, TT1 20 to 1 drachm (1.3-4.0), 737 Clove oil, added to liniment, as a counter- irritant, 199 Iodide of potassium or salicylates, if due to rheumatism, 737 Iodine ointment, pure or diluted with lard, 737 Massage or good rubbing, very necessary, 738 Potassium acetate or citrate, gr. 20 (1.3), may be tried, 737 Poultices, hot as can be borne, 738 Prescription for liniment, 737 MYXOEDEMA. Thyroid gland, or extract of, a specific for 447 NASAL CATARRH (ATROPHIC), 738 DobelFs solution, as a cleansing wash; carbolic acid may be increased, or thymol and eucalyptus substituted for it, to relieve odor, 738 Galvano-cautery, or strong silver nitrate solution, if ulcerations are present, 739 Hydrogen peroxide, 738 Ichthyol, useful, 738 Iodine and glycerin (gr. 6 to 8 to the ounce [0.4-0.5:30.0]), with potassium iodide sufficient to cause solution of the iodine, valuable locally applied, 739 Potassium iodide internally, tonics and stimulants to mucous membrane, and attention to activity of skin, 739 Potassium permanganate, useful; painful if sensation is not entirely lost, 738 Removal of necrosed bone, 739 Silver nitrate and starch (gr. 1 to 10 [0.06- 0.60] to drachms 2\ [10.0]), as an insuf- flation powder, or solution (gr. 1 to 10 to the ounce [0.06-0.60:30.0]), better in some cases, locally applied, 739 NASAL CATARRH (CHRONIC), 739 Arsenic, 103 Camphor, 142 Ferric alum (gr. 5 to the ounce [0.3:30.0]), useful, in spray, in later stage, 740 Galvano-cautery or snare, to remove hyper- trophic tissue remaining after acute stage, 741 Hydrastis, dilute solution or distilled ex- tract of hamamelis and water, equal parts, useful in spray, in acute staee, 740 Iodine and glycerin (gr. 6 to 8 to the ounce [0.4-0.6:30^0]), with potassium iodide sufficient to cause solution of the iodine, locally applied, 740 Prescription for alkaline wash, 740 NAUSEA. (See Vomiting.) Hoffmann's anodyne, when due to excessive use of tobacco, 266 Hydrocyanic acid, dilute, ttl 3 (0.20), in water, often useful, 271 Lime-water, 140 NEPHRITIS (ACUTE), 741 Aconite, to depress circulation, 741 Blisters contraindicated, 741 Bromides or opium, given cautiously if aconite fails to quiet restlessness, 741 Caffeine, in later stages, 742 Cannabis indica, if hematuria is present, also to allay pain over kidneys, 146, 741 Cantharides, £ to 1 minim (0.025-0.05), of tincture" about fifth day, when kidneys are atonic, also if hsematuria is present, 148, 741 Citrate of potassium and sweet spirit of nitre, to increase flow of urine, 741 INDEX OF DISEASES AND REMEDIES. 895 Cups or leeches over loins if urine is scanty, 741 Digitalis, with squill or calomel, gradually increased, followed by gin or compound spirit of juniper in later stages, 741 Elaterium, to relieve dropsy, 741 Flaxseed tea, as a demulcent, 252, 741 Gallic acid and ergot to control excessive hematuria, 742 Hot-air baths, useful to provoke sweat, 741 Iron, if anaemia be present, also to decrease albuminuria, 742 Juniper, to re-establish secretion, after inflammation has subsided, 301, 742 Milk diet, 742 Pilocarpine hydrochloride, gr. ^ tof (0.003- 0.008), hypodermically, if ursemia threat- ens, repeated in fifteen minutes if no sweat appears, but guarded by strych- nine, when the heart is weak, 389, 741 Potassium bitartrate, 122 Sulphate of magnesium, gss (16.0), or calomel, to aid in elimination of toxic products by bowel, 741 Turkish bath, to aid in eliminating effete products, used with care, 506 NEPHRITIS (CHRONIC), 742 Basham's mixture for anaemia, 294, 743 Bichloride and protiodide of mercury, 332 Cannabis indica, to allay pain over kidneys, also if hsematuria is present, 146 Cantharides, particularly useful if due to alcoholism, 148, 743 Capsicum, to check albuminuria, 150 Chloride of gold and sodium has been recommended in interstitial forms, 261 Chloride of iron if anaemia is present; also to decrease albuminuria, 295, 743 Digitalis and caffeine useful, 742 Elaterium or jalap, to relieve dropsy, 743 Juniper of value, 743 Methylene -blue solution hypodermically, when kidney is suspected of being in- adequate, 743 Milk diet, 742 Nitroglycerin useful in ascending doses in chronic parenchymatous nephritis, 346, 743 Oxygen inhalations, 743 Potassium acetate or bitartrate combined with digitalis, or the bitartrate combined with gin or compound infusion of juniper, 122, 742 Potassium iodide, gr. 5 (0.3), thrice daily, used with great care, 281 Sodium iodide, of great value in many cases, 743 Squill, 425, 742 Strontium lactate, for the relief of albu- minuria, 428 NEPHRITIS (INTERSTITIAL). Nitroglycerin with cardiac disturbance and high arterial tension, 346 NERVOUSNESS. Ammonium valerianate in nervous unrest of pregnancy or hysteria. 83 Asafcetida in nervous irritability of chil- dren, 110 Bromides, 127 Camphor, as a sedative, 142 Hops, as a sedative, 269 Musk, useful in nervous excitement and col- lapse; only to be used through crisis, 337 Phosphorus, in nervous debility and ex- haustion, 384 "Pill of three valerianates," highly recom- mended, 453 Rest-cure very useful where nervousness is due to exhaustion, 528 Strychnine, in functional nervous atony or depression, 353 Suprarenal gland, 436 Sumbul, prescription for, 435 Sweet spirit of nitre, in nervous excitement of fever and other nervous states of in- fancy, 438 Valerian, alone or with other drugs, 453 NEURALGIA, 743 Acetanilid, useful, especially with mono- bromated camphor, 57, 745 Aconite ointment (gr. 2 to the drachm [0.12 : 4.0]), or oleate of aconitine (gr. 2 [0.12] to sweet oil 100 minims [6.6]), useful ap- plied over painful spot, if limited in area, 62, 745 Acupuncture, nerve-stretching, or neurec- tomy, necessary in some cases, 746 Ammonium chloride, in ovarian neuralgia, 82 Amyl nitrite, inhalations, when due to anaemia, 745 Antipyrin, very useful, especially in gout, rheumatism, or nervous depression, 93, 745 Belladonna, 115, 118 Bromide of potassium with caffeine, almost a specific, 128, 745 Prescription for, 128, 745 Camphor liniment, locally applied, to re- lieve pain, 143 Castor oil, oz. 1 to 2 (30.0-60.0) a day, at times gives good results, 746 Chloralformamide, 166 Chloretone and antipyrin (3 to 6 grains [0.20-0.4]), 169 Chloroform by kataphoresis, 524 Chloroform liniment, as a local anaesthetic, 183, 746 Cimicifuga, especiallv useful in ovarian types, 189 Cod-liver oil, 208, 744 Cold applications, locally, 472 Croton chloral, gr. 5 to 20 (0.3-1.3), in 5- grain pills, often effective in brow neu- ralgia, 221, 745 Duquesnel's crystalline aconitine in obsti- nate forms, 63 Freezing parts with ether or rhigolene sprav or bv small packages of ice and salt,*243, 472, 745 Guaiacol used locally, of value, 263 Hydrocvanic acid, useful in intestinal neu- ralgia, 273 896 INDEX OF DISEASES AND REMEDIES Iodide of potassium, may be tried in rheu- matic neuralgia, 284 Iron and arsenic, in anaemia; often neces- sary to associate with them bitter tonics and cod-liver oil, 744 Kataphoresis, 524, 745 Menthol, locally, 375 Morphine, gr. \ to \ (0.012-0.015), injected into painful spot, if localized ; not ad- visable in chronic cases, 746 Muriate of ammonium, useful in ovarian types, 82 Mustard plaster, as a counterirritant, 337 Nux vomica or strychnine, if nerve is de- pressed by anaemia, 744 Peppermint oil, locally applied on cloth over painful spot, 374 Phenacetin, gr. 3 to 8 (0.20-0.5), very use- ful, prescription for, 379, 744 Phenocoll, 380 Phosphorus, if due to nervous exhaustion, 384, 744 Potassium iodide, 280 Prescriptions containing antipyrin with bromides and caffeine, 745 Quinine, if due to malaria, 193, 744 Rest-cure very useful in exhausted patients 528 Salol (phenyl salicylate), if due to expo- sure, 409 Salophen, useful when combined with phenacetin, 410 Specific remedies, if due to scrofulosis or syphilis, 744 Turkish baths, may relieve if due to rheu- matism or gout, 506 Veratrine ointment, locally applied, over neuralgic nerve, 454 NIGHT-SCREAMING. Bromide of potassium, 127 NIGHT-SWEATS. Acetic acid, as a lotion, diluted one-half, 59 Agaricin, of doubtful value, 63 Alum dissolved in water or alcohol, efficient application for sponging, 76 Belladonna, best remedy, 115 Camphoric acid, the best of all remedies, 144 Ergot, 235 Gallic acid, 254 Pilocarpine, gr. J^ (0.003), hypodermically, two hours before sweat, often useful, even when atropine fails, 390 Sulphuric acid, with belladonna or mor- phine, often useful, 434 Zinc oxide, prescription for, 369 NIPPLES (SORE), 746 Benzoin, tincture, locally applied, 746 Boric acid (gr. 20 to the ounce [1.3:30.0]), or mucilage of acacia, applied after nursing, nipple being dried beforehand, 746 Breast-pump or nipple-shield may be neces- sary to effect cure, 746 Cocaine (gr. 4 to the ounce [0.25:30.0]), applied and washed off before nursing, if breast is very painful, 201, 746 Ichthyol, when indurated, 278 Prophylaxis, 746 Silver-nitrate stick touched to fissure, if deep and slow to heal, 746 Tannin, glycerite of, locally applied, 746 NYMPHOMANIA. Bromide of potassium, of great service, 127 OBESITY, 746 Acetic acid, harmful, 59 Cold bath, 749 Diet, 748 Laxative fruits and purges, to regulate bowels, 749 Massage, passive movements, absolute skimmed-milk diet, and electricity, if exercise is impracticable, 749 Potassium permanganate, 377 Saline purges, 749 Thyroid gland, 447 Turkish bath, 749 OPHTHALMIA. (See Conjunctivitis.) OPIUM HABIT. (See Poisoning from Opium, Chronic.) ORCHITIS. (See Epididymitis.) OSTEOMALACIA. Ovarian tract in, 259 Phosphorus, 384 OTITIS MEDIA. Dermatol as a dusting-powder in purulent forms, 122 Potassium permanganate, gr. 1 to oz. 1 (0.06-30.0) as a wash, 378 0T0RRH03A. Creolin, solution (1 :500), used with syringe, 221 OXALURIA. Nitric acid, 345 Nitro-hydrochloric acid, 349 OZ-ffiNA. Ichthyol very useful in fetid ozaena, 278 Prescriptions for insufflation powder, 325 PARALYSIS AGITANS. Cannabis indica, to quiet tremors, 146 Chloral, of great service, 164 Duboisine sulphate of some use, 232 Sparteine, 416 PARASITES. Bichloride of mercury (gr. 2 [0.12] to water oz. 1 [30.0]), applied thrice daily in para- sitic skin diseases, 326 Cajuput oil, applied pure, will destroy pediculi, 136 Chrysarobin, gr. ■§■ (0.008), internally, or the ointment, with benzoated lard (1 :4 or 5), locally applied, in parasitic skin diseases; must not be used on face, 189 INDEX OF DISEASES AND REMEDIES. 897 Mercurial ointment, useful to destroy pediculus pubis or other parasites, 331 Oil of cloves, 200 Pyrogallol, 30 grains to the ounce (2.0: 30.0), for parasitic skin disease or pso- riasis, 397 Thiosulphate of sodium, 1 drachm to the ounce (4.0:30.0), for parasitic skin dis- ease, 423 Volatile or fixed oils, useful to destroy, 331 PARTURITION. Antipyrin for pains, of doubtful value, 93 Castor oil, to relieve constipation, 158 Cimicifuga, 189 Quinine, as a stimulant to uterus, 194 PEMPHIGUS. Arsenic, 103 PERICARDITIS, 750 Aconite, to allav inflammation and quiet heart, 62, 750~ Alcohol, digitalis, or caffeine, if heart shows signs of failure, 750 Aspiration, gradual, if exudation endangers life, 750 Blister, over pra?cordium, often useful, 750 Elate rium, useful in effusions, 234 Ice-bag over the preecordium, very useful, 750 Iodide of potassium, to aid in absorption of fluid, 280 Leeches, 5 to 10, over prsecordium, accom- panied by large dose of veratrum viride in early stages of sthenic cases, 750 Opium, to allay inflammation, 362 PERITONITIS (ACUTE), 750 Acetanilid, gr. 2 (0.12), every two or three hours, with brandv and ice, for vomiting, 753 Hyoscyamus, by suppository or injection, in collapse, 754 Ice, with white of egg, for thirst. Vomit- ing does not contraindicate small amounts of water, 754 Ice-bag or turpentine stupe to abdomen; leeches in sthenic cases, 753 Opium, pushed until pain is relieved, but never to the point of obtunding intelli- gence, 362, 753 Rectal tube, milk of asafcetida or turpen- tine injections, in tympanites, 754 Salines, useful in cases following surgical operations, but contraindicated by fee- bleness, perforation, or obstruction, 754 Surgical procedures, often necessary. When diagnosis is obscure or in septic general peritonitis exploratory incision is justi- fied, 752 Veratrum, 456 PERITONITIS (CHRONIC), 754 Incision, with or without drainage and iodoform, useful in tubercular peritonitis, * 754 PERNICIOUS MALARIAL FEVER, 755 Morphine and atropine to control retching and vomiting, 755 Quinine, large doses, in solution, by mouth, rectum, or hypodermically, 193, 755 Thiosulphate of sodium, grs. 60 (4.0) to move the bowels, 755 PHARYNGITIS. Antipyrin in 4 per cent, spray, 94 Cocaine, gives temporarv relief; after- effects bad, 201 Cubebs, troches of , used in chronic types, 223 Monsel's solution, pure or diluted one-half with glycerin, applied on pledgets of cotton or camel's-hair brush, 298 Peroxide of hydrogen, 274 Potassium chlorate, as a gargle, 168 Salol (phenyl salicylate), in 5-gr. (0.3) doses, 409 Silver-nitrate solution, in varying strength, locally applied, 343 Turkish bath, in acute forms, when phar- ynx feels raw, 506 PHTHISIS. (See Tuberculosis.) PITYRIASIS VERSICOLOR. Anthrarobin in, 85 PLEURITIS OR PLEURISY, 755 Aconite or veratrum, preferable to vene- section, in early stage, 755 Aspiration, when hydragogue purges fail to remove effusion, 757 Bryonia, in pleurisy with effusion, 133 Cantharidal blister, two inches below axilla, aids absorption of effusion, 492, 758 Cotton jacket, 756 Digitalis or alcohol, if pulse weakens in second stage, 756 Elaterium or jalap, useful to remove effu- sion, 233, 757 Gelsemium, 257 Ice-poultice or jacket, used with success in sthenic cases, 472 Iodide of potassium, used in chronic stage, to aid absorption, 280 Iodine, locally applied, to abort, and aid absorption of fluid, 285 Pilocarpine, 389 Salicylates, verv useful for the removal of effusion, 406," 757 Saline purges, in second stage, to remove effusion, 757 Strapping chest, if respiratory movements are very painful, 755 Veratrum, 456 PLEURODYNIA. (See Neuralgia.) PNEUMONIA, 758 Aconite, preferable to veratrum, in early stage, in children, 62, 759 Alcohol, inferior to digitalis, as a cardiac stimulant in the second stage in adults, but better than in children, 66, 67, 760 Ammonia useful for adults and children, I 78, 761 57 898 INDEX OF DISEASES AND REMEDIES. Ammonium bromide and carbonate may be used if the chloride fails, 762 Ammonium chloride, as an expectorant in third stage, 762 Antipyrin, of great value, if fever is exces- sive, 92 Asafcetida, by rectal injections, in tym- panites, 110 Belladonna, very useful, if there are evi- dences of collapse, 117, 760 Citrate of potassium, to maintain renal activity, 761 Cold compresses, locally, 760 Cold sponging for fever, 760 Counterirritation in, 491, 492 Digitalis, tincture, ffl 8 (0.5), every four hours, accompanied by belladonna, gtt. 8 (0.5), carefully watched in second stage, 229, 761 Dover's powder for pain at onset, 759 Ethyl iodide, causes resolution, 247 Gelsemium, in early stages, 257 Gin, to maintain renal activity, 761 Heroin, gr. J^ every eight hours, for exces- sive cough, 762 Hoffmann's anodyne, useful, 761 Hot foot-bath, useful at onset, 759 Ice-bag to heart if fever be high and heart tumultuous, 760 Ice-poultice or jacket, highly recommended in first stage of sthenic cases, 472 Iodide of potassium, in later stages to absorb exudates, 281 Morphine, for pain at onset, and for exces- sive cough, 761, 762 Nitroglycerin, in high arterial tension with thickened arteries, 761 Oxygen inhalations, if asphyxia threatens, 369, 761 Phosphorus, 384 Prescriptions, containing ammonium chlo- ride, to loosen cough of second stage, 762 Quinine, gr. 2 (0.12) thrice daily, in sup- pository in lobar pneumonia of children, 194 Strychnine as a respiratory and circulatory stimulant in second stage and as an adjuvant to digitalis, 353, 761 Sweet spirit of nitre to maintain renal ac- tivity, 761 Venesection, in early stage of sthenic cases, cardiac depressants, preferable and late when heart is laboring and veins dis- tended, 540, 759, 761 Veratrum, preferable to aconite, in early stage, in adults, 456, 759 POISONING FROM— Acetanilid. Supportive measures, stimulants, external . heat, belladonna to maintain blood- pressure, strychnine to counteract res- piratory failure, and oxygen inhalations to overcome cyanosis, 56 Acetate of Zinc. Treatment same as for gastro-enteritis, 671 Acetic Acid. Large amounts of milk, alkaline liquids, and general treatment for gastro-enter-' itis, 59 Aconite. Keep patient in prone position, with feet higher than head. Hot applications; emetics contraindicated; evacuate stom- ach by siphon or stomach-pump. Ether hypodermically, followed by alcohol, and this by digitalis. Artificial respiration and amyl nitrite a few whiffs, no more, if heart fails; atropine, strychnine, 61 Alcohol (Acute). External heat, digitalis and strychnine hypodermically, in coma, if heart fails. Belladonna, if the skin is relaxed and clammy, and counterirritation to nape of neck, for brain symptoms. After- treatment, ammonia, spices, spirit of mindererus; emollients in gastritis, ice, aconite, hydrochloric acid, or ipecac in minute dose, and coimterirritation for vomiting. Jalap, gr. 40 (2.6), elaterium, gr. I (0.01), or calomel and salines, as purgatives, 67 Fowler's solution for morning vomiting, 68 Alcohol (Chronic). Withdrawal of drug, at once or gradually. Highly seasoned broths, predigested food, and morphine or coca, in small dose, if weakness is marked. Capsicum prescriptions (pages 69, 150), 68, 69 Antimony. Large doses of tannic acid, external heat, alcohol, digitalis, and opium hypoder- mically, if respiration is not too feeble. If necessary to use opium, it should be accompanied by strychnine. Prone posi- tion, the patient vomiting into towels. Stomach-pump, if vomiting is absent, 89; atropine, 118 Antipyrin. Maintain bodily heat, stimulants, atropine, and oxygen inhalations, if cyanosis is alarming, 92 Arsenic (Acute and Chronic). Stomach-pump, external heat, stimulants, and the chemical antidote, hydrated sesquioxide of iron and magnesia. Mag- nesia also useful by itself. Opium should follow antidote, to allay pain, also large draughts of water to flush kidneys and dilute poison. For chronic poisoning, iodide of potassium, tonics, electricity, and out-of-door life, 107, 108 Belladonna. External heat if collapse intervene, and strychnine to support respiration. The physiological antidote, opium, may be carefully given, 115 INDEX OF DISEASES AND REMEDIES. 899 Carbolic Acid (Phenol). Soluble sulphates, as Epsom or Glauber salts, warm mucilaginous drinks, hot applications to extremities, digitalis, strychnine, and counterirritation over abdomen. Emetics and stomach-pump should be used if possible, 152 Chloral. External heat, emetics in early and stom- ach-pump in later stages. Strychnine or atropine to stimulate respiration. Digitalis, preceded by ether, ammonia, brandy, or whiskey. Prone position, feet being elevated, 163 Chloroform. Artificial respiration, ether and hot brandy hypodermic ally. Poles of battery with rapidly interrupted current swept over body, not over diaphragm or phrenic nerve. Place patient with head down- ward. Compression of the abdomen and limbs; compression and massage of the prapcordium. Atropine, strychnine, and digitalis to stimulate the heart and respiration. Laborde's lingual traction, 183 Cocaine. Ammonia, coffee, strychnine, ether, and alcohol. If convulsive in type, treat same as strychnine poisoning, 206 Colchicum. Tannic acid, emetics, and stomach-pump. Opium to relieve pain, and oils. Atro- pine and stimulants if collapse comes on, 211 Conium. Emetics or stomach-pump, strychnine as a nervous and respiratory stimulant, external heat, and cardiac stimulants, if circulation fails, 215 Copper. Yellow prussiate of potassium, sweet oil, white of egg; followed instantly by emetics or stomach-pump. If emesis or purgation is present, emetics are contra- indicated; instead, mustard plaster over abdomen and opium, internally, are to be employed, 217 Corrosive Sublimate. Large amounts of white of egg, followed by stomach-pump, external heat, stimu- lants, 325 Croton Oil. Treatment same as for gastro-enteritis, 671 Digitalis. Tannic acid as a chemical antidote, emetics or stomach-pump, external heat to ab- domen, and aconite as a physiological antidote. Maintain horizontal position, 228 Elaterium. Treatment same as for gastro-enteritis, 671 Ether. Artificial respiration, lowering head if face is pale; strychnine, atropine, and digi- talis hypodermically,.or intravenous in- jection of ammonia to stimulate heart and respiration; friction and hot ap- plications; ether dashed on chest and abdomen; Laborde's method of traction of the tongue, 240 Eucaine, Treatment like that of cocaine intoxica- tion, 206 Gelsemium. Emetics and stomach-pump, digitalis, atro- pine, and ammonia as cardiac stimu- lants; external heat, strychnine, and . atropine for respiratory centre, 257 Iodine. Emetics or stomach-pump, large amounts of starch, hot applications, and hypo- dermic injections of alcohol, ammonia, atropine, digitalis, or strychnine, 283 Iodoform. Sodium bicarbonate to combine with iodine alcohol, diuretics, and hot blankets; saline transfusion, 287 Lead (Acute). Epsom or Glauber salts, in large amounts; alum; emetics or stomach-pump. Hot applications and opium to relieve pain, 304 Lead (Chronic). Jalap and calomel with opium or alum, gr. 2 (0.12), in full dose, valuable in lead colic. Blister to back of neck, revulsives and pilocarpine in cerebral inflamma- tion. Iodide of potassium to eliminate lead. Strychnine in yjrogressive paraly- sis. Electricity and baths of sulphuret of potassium, 304 Mineral Acids. Alkalies, such as magnesium, lime, white- wash, and soap as antidotes; white of egg, external heat, oils, and opium, to relieve irritation, Monsel's Solution. Soap, 298 Nitrate of Silver (Acute). Common salt as the chemical antidote, opium and oils to allay irritation; also large amounts of milk and soap and water; maintain bodily heat, 341 Nitrate of Silver (Chronic). Iodide of potassium, to aid in eliminating poison, 341 soo INDEX OF DISEASES AND REMEDIES. Nux Vomica and its Alkaloids. Inhalations of amyl nitrite, to prevent con- vulsive tendencies; at the same time use stomach-pump. Tannic acid followed by physiological antidotes, potassium bromide, gr. 60 (2.0), with chloral, gr. 20 (1.3). If convulsions prevent swal- lowing, chloroform patient Carefully and give antidotes by rectum in starch- water. Amyl nitrite, hypodermically, if relaxation does not occur, 355 Opium (Acute). Emetics, or stomach-pump, tannic acid? black coffee, electricity, and other meas- ures to keep patient awake. Atropine or strychnine, hypodermically, if respi- ration fails. Alcohol, ammonia, and external heat. Artificial respiration may be necessary; repeated washing out of stomach. Permanganate of po- tassium, 358 Opium (Chronic). Decrease a sixth or fourth of customary amount each twenty-four hours. Co- caine not advisable as a substitute, as the cocaine-habit may be established. Digitalis and strychnine if heart fails. Hvoscine hvdrobromide in large doses verv Valuable," 359, 360 Phosphorus. Permanganate of potassium, 1 per cent, solution, or peroxide of hydrogen. Sul- phate of copper is too poisonous in itself, 384 Physostigma. Atropine as a physiological antidote, ex- ternal heat, and cardiac and respiratory stimulants, 386 Scammony. Treatment same as for gastro-enteritis, 671 Strychnine. (See Nux Vomica.) Veratrum. Prone position, head higher than feet; atropine, strychnine, external heat, and cardiac stimulants, 455, 456 POST-PARTUM HEMORRHAGE.701,770 Adrenalin chloride, 702 Auto-transfusion, or actual transfusion of weak salt solution, necessary in some cases, 772 Beef-tea. \ pint (240.0), and morphine gr. \ (0.008) hypodermically, after reaction is established, 772 Correction of displacement sometimes nec- essary, 770 Drugs have been recommended, but are dangerous as local applications, 771 Enema of hot normal salt solution, 1 pint (480.0), after cessation of bleeding, 772 Ergot, as a cure and prophylactic, 235, 701, 771 Ether, hypodermically, if symptoms of shock are manifested, followed by small doses of hot, strong brandy and water, and warm milk, 771 Faradism of uterine muscle, 771 Gauze, preferably iodoform, packed into uterine cavity, 771 Ice, used externally and internally, 771 Injections of lemon-juice, vinegar, or hot water, 702, 771 Manipulations of the uterus, 701, 771 Method to pursue when caused by hsema- toma, 770 Suture, if due to laceration, 771 Hops. 269 PRIAPISM. PROLAPSUS ANI AND RECTI. Injection of cold or hot water, often relieves, 475 Quercus, infusion, 398 PROSTATITIS, 678 Cold-water injections and perineal douches, 476, 678 Local treatment to prostatic urethra, and use of cold steel sounds in chronic tvpes, 679 Perineal incision, to evacuate pus, if abscess forms, 678 Rest in bed, regulation of bowels, leeches to perineum, medication to render urine alkaline, and morphine hypodermically or in suppository, 678 Soft catheter, allowed to remain in bladder, if retention of urine is persistent, 678 PR0STAT0RRHC3A. Cantharides, 148 PRURIGO. Cantharides, 148 PRURITUS, 763 Alum solution in pruritus vulvsp, 76 Arsenic, quinine, bitter tonics, cod-liver oil, alkaline diuretics or mineral waters, in debility, and avoidance of condiments if mouth of vagina or urethra is affected, 103, 763 Boric acid, 123 Calomel and lard (1 drachm to the ounce [4.0:30.0]), locally applied, 330 Chloride of calcium, prescription for, 138 Chloroform may be used, 764 Cocaine, relieves temporarily, 764 Cold douche and injections highly recom- mended in pruritus ani and vulva?, 476 Goulard's extract, dilute, useful in pruritus pudendi, 308 Hydrocyanic acid, locally applied, 273 Ivory plug for, 764 Phenol, 763; prescriptions for, 154 Prescriptions for lotions and ointments, 763 'Salicylic acid, prescription for, 406 INDEX OF DISEASES AND REMEDIES. 901 Silver nitrate (gr. 20 to the ounce [1.3: 30.0]), locally applied, preceded by cocaine, if itching is intense; a 4- to 6- grain (0.25-0.4) solution may relieve itching of pruritus pudendi, ani and vulvae, 343, 764 Sodium bicarbonate or borax (1 drachm to the pint [4.0:480.0]), as a wash, 763 Lead-water useful in pruritus pudendi, 308 Sodium thiosulphate, gr. 30 to the ounce (2.0-30.0), locally, 423 Teucrium scordium, highly recommended by Brinton, 764 Turkish baths, 764 P SEUDOLEUKJEMIA. Arsenic internally, and injections of Fow- ler's solution into glands, 101 PSORIASIS. Ammoniated mercury in, 324 Anthrarobin, 85 Aristol, 445 Arsenic, 103 Cantharides. 148 Chrysarobin, gr. ■& (0.008) internally, or the ointment with benzoated lard (1 to 4 or 5), locally applied, face excepted; prescription for application, 188 Gallic acid, ointment, 254 Pvrogallol, 30 grains to ounce (2.0:30.0) of lard, 397 Resorcinol, prescription for, 399 Tar, locally applied, 440 Thymol iodide, 445 Thyroid gland, 447 PTYALISM. Alum, applied on swab, in mercurial ptyalism, 76 Belladonna, in idiopathic or mercurial types, 115 PUERPERAL DISEASES, 764 (For treatment see special titles.) PUERPERAL FEVER, 764 Antipyretics, best abstained from as long as possible, 766 Antistreptococcic serum, nuclein, and injec- tions of normal salt solution important adjuvants, 766 Bichloride of mercury (1:2000), or iodine solutions, as antiseptic injections, 765 Boric acid, creolin (2 per cent.), or bichlo- ride (1:8000; , solutions, as injections into bladder, to prevent septic cystitis, 768 Curette or placental forceps, to remove membranes if fever continues after anti- septic injections, 765 Epsom salts, concentrated solution, 2 drachms (8.0) every fifteen minutes, if peritonitis develops, 767 Hot fomentations, or ice-bag, and later compresses dipped in lead-water and laudanum, 769 Laparotomy occasionally saves life, if septic peritonitis develops, 766 Nutriment in large amounts and alcoholic stimulants, if symptoms of systemic invasion arise, 766 Silver nitrate (gr. 40 to 60 to the ounce [2.60-4.0:30.0]), locally applied to un- healthy ulcerated wounds; zinc chloride solution may be necessary, 767 Veratrum, 456 PURPURA HEMORRHAGICA. Turpentine, 451 PYELITIS. Buclm in chronic types, 133 Cantharides, 148 Copaiba, 216 Juniper, as a tonic in chrome types, 301 Pareira, 373 Uva ursi, 452 QUINSY. Aconite, in early stage, 62 Salicylic acid, gr. 3 (0.20), hourly, acts as a specific, especially if due to rheuma- tism, 406 REMITTENT FEVER 776 Cool sponging with friction if fever is excessive, 776 Eupatorium, 250 Monsel's salt, gallic or tannic acid inter- nally, if intestinal hemorrhage occurs, 776' Morphine, spirit of chloroform, or aconite, in sthenic cases, to control vomiting, 776 Quinine, gr. 20 to 30 (1.3-2.0), preceded bv calomel, gr. 3 to 4 (0.20-0.25) : if not re tained, administer by rectum, or hypo- dermically, with divided doses of Seid- litz powder by mouth, 193, 776 Tonics, potassium salts, to regulate kidneys and purgatives, if necessary, during con- valescence, 777 Turpentine stupe, if belly is tender, 776 RETINITIS 777 Atropine, dark glasses, and later suitable lenses, if due to eye-strain, 777 RHEUMATISM, ACUTE (ARTICULAR), 777 Acetanilid, relieves pain and fever, 57, 779 Acetate of potassium, 58 Aconite, or veratrum, useful at onset of inflammation in sthenic cases, 777 Aspirin in acute cases. 111 Ammonium bromide and phosphate. 81 Antimonial powder as an antipyretic, 89 Antipyrin, gr. 5 to 10 (0.3-0.60), or anti- febrin, gr. 4 to 8 (0.25-0.5), often very valuable, 93, 779 Benzoic acid, drachms 2 to 3 (8.0-12.0), daily, said to be a specific, 119 Bicarbonate or citrate of potassium, gr. 20 to 30 (1.3-2.0), in water, every five hours, in obstinate cases, 780 Bicarbonate of sodium, 421, 778, 779 902 INDEX OF DISEASES AND REMEDIES Blisters over joints, useful after systemic disturbance is past, 781 Caffeine useful to support the heart, 779 Camphor liniment, 143 Capsicum plaster, 150 Cimicifuga, shortens attack and relieves pain in some cases, 189, 781 Colchicum, prescription for, 211, 780 Puller's lotion, applied on hot cloths to joints, 778 Guaiac, 262 Ice-cold compress, may relieve inflamed joints, 778 Ichthyol, ointment, valuable, applied to joints, prescription for, 277, 778, 781 Iodine, ointment or tincture, painted over parts, 781 Leeches, over prsecordium in endocarditis, during, 781 Lemon- or lime-juice, or citric acid, bene- ficial in nearly all cases, 199, 781 Oil of gaultheria, useful as a substitute for salicylic acid; also used as a local appli- cation to the joints, 256 Oleum succini, applied locallv over joints, 77 Phenacetin, alone or with salol, 379, 779 Phenocoll, 380 Potassium iodide, useful in subacute or obstinate types, prescription, 280, 780 Potassium nitrate, 340 Rhus toxicodendron, especially useful for night pains, 781 Salicylic acid, applied to joints in a salve when stomach is irritable, 406, 778 Salicylic acid, gr. 20 (1.3) thrice daily; if untoward symptoms arise, it must be stopped, 405, 779 Salol (phenyl salicylate), useful as a sub- stitute for salicylic acid; dangerous in large doses, 409 Sodium bicarbonate (gr. 20 to the ounce [1.3:30.0]), to inflamed joints, 421 Splints for fixation of limbs, may relieve greatly, 778 Veratrine ointment, used locally, applied to joints, 781 RHEUMATISM (CHRONIC), 782 Arsenic, useful in some cases, 103 Cimicifuga, sometimes relieves, 189 Citric acid, 198 Cod-liver oil, internally; also useful rubbed into joints, 208, 782 Colchicum, with iodide of potassium, pre- scription for, 210 Hot-air bath, 510, 511 Ichthyol, the best remedy for joints, 783 Iodine, locally applied, 285 Liniments, prescriptions for, 782 Ointments, prescriptions for, 783 Potassium iodide, colchicum, and sarsa- parilla, usuallv indicated; see prescrip- tions, 280, 782 Salophen, 410 Sulphur, 432 Turkish or Russian baths, very valuable, 506, 782 Veratrine ointment, gives greatest relief in some cases, prescription for, 454, 783 RHEUMATISM (MUSCULAR). Acetanilid in subacute, 57 Burgundy pitch, a mild local remedy, 393 Croton-oil liniment, 222 Dover's powder in conjunction with hot drinks and hot foot-baths, often cures, 363 Mustard, as a counterirritant, 337 Oil of cloves in liniment, locally, 199 Pitch, locally, 393 Salicin, as a substitute for salicvlic acid, 403 Salicin useful, 403 Salol useful, 409 Veratrine ointment, locally applied, 454 RHINITIS. Creolin (1:1000), as a nasal douche, 221 Fluid cosmoline, in spray, 378 Potassium permanganate, solution, in foetid rhinitis, 378 RHUS POISONING. Grindelia, 262 Infusion of lobelia, 312 Lead acetate, 307 Liquor plumbi subacetatis, 307 RICKETS, 783 Arsenite of copper, 784 Cinchona, or strychnine, 784 Cod-liver oil, prescription for, 208, 784 Cool sponging or rubbing with salt and whiskey (1 drachm to the pint [4.0: 480.0]), useful at night, 785 Hypophosphites and lactophosphates use- ful, 139 Iodide of iron, syrup of, if scrofulous tend- ency or anaemia exists, prescription for, 784 Lime salts, phosphorus, zinc phosphide, as bone tonics, 784 Massage and passive movements, 785 Mineral acids, physostigma and simple bitters, as digestive tonics, 784 Nux vomica, rarely given because of bitter- ness, 784 Phosphorus (gr. yj^ [0.0006]), in sugar- coated pill, 384, 785 Quinine, cod-liver oil, nux vomica, and iron as general tonics, 784 Sodium and lime salts, useful in. nursing and pregnant women, 784 Sodium phosphate to regulate the bowels, 381 RINGWORM. (See Tinea Circinata.) SATYRIASIS. Potassium bromide, one of the best reme- dies, 127 SCABIES. Sulphur, the best remedy, 433 SCARLET FEVER, 785 Aconite, harmful if constantly employed, 62 Alcohol, indicated in collapse, 787 INDEX OF DISEASES AND REMEDIES. 903 Antidiphtheritic serum when false mem- brane forms in throat, 787 Antipyrin or acetaiiihd, may produce col- lapse in large doses, 90, 787 Antistreptococcic serum, 470 Bromide of sodium, with chloral, useful when convulsion ushers in attack, 786 Chloral, very useful, prescription for, 786 Chlorate of potassium, locally applied by spray or swab, in sore throat, 787 Cold sponging, useful, 787 Ice applied externally and held in mouth, to prevent swelling of throat, 787 Ice-bag or rubber head-coil to head, if verv hot, 787 Juniper, in later stages, if there is renal atonv, 301 Phenol" (HI 2 [0.1] to olive oil oz. 2 [60.0]), benzoated lard, vaseline, cosmoline, or almond oil, useful, locally applied, to allay itching, 788 Potassium citrate and sweet spirit of nitre, prescription for, 786 Potassium permanganate (gr. 20 to pint 1) (1.3-480.0), as a gargle, 377 Quinine, unsuccessful in most cases, 787 Salicylic acid, highly recommended, pre- scription for, 786 Strychnine, iron, simple bitters, quinine, or Basham's mixture, in convalescence, 788 _ Sweating necessary in nephritis, 788 AYarm wet pack, useful to bring out rash, 788 Water, pure, s\ich as Vichy or Poland, in large amounts, 786 SCIATICA 788 Absolute rest of limb in splints verv needful, 789 Acetanilid and antipyrin, 57, 789 Acupuncture, recommended, 461, 789 Chloroform, deeply injected over exit of nerve, a favorable remedy, 182, 789 Cod-liver oil, of service in obstinate cases, 208, 789 Ether or rhigolene sprayed on part, often effective, 789 Hot-water bags, placed around exit of sciatic nerve, 789 Liniments for rheumatism, may be tried, 789 Massage of nerve with glass rod, 789 Methylene blue, gr. 5, twice or thrice a day to relieve pain, 789 Morphine, injected over course of nerve, 789 Nerve-stretching, 789 Opium subcutaneousry over affected part, 361 Potassium bitartrate or citrate, gr. 40 (2.6) thrice daily, in plenty of water, to I regulate kidneys, 789 Potassium iodide, 280 Remedies for rheumatism, often relieve, 789 Salicvlic acid, 405 Sulphur. 432 Wet or dry cups, highly beneficial over course of nerve, 789 SCLERITIS, 789 Atropine, boric acid and hot-water com- presses, in early stages, 789 Eserine, with pilocarpine sweats or cautery, in stubborn episcleritis without iritis, 790 Specific treatment, in syphilitic cases, 790 Yellow-oxide ointment, associated with massage to subdue infiltration, 790 SCLEROSIS. Antipyrin, 93 Nitrate of silver, 342 SCROFULOSIS, 790 Arsenic or corrosive sublimate, useful if anaemia is present, prescriptions for, 790 Calcium chloride, 138 Cod-liver oil, the best remedy, 208, 790 Diet and exercise, 790 Europhen in scrofuloderm, 251 Excision, or scraping gland, and packing with iodoform gauze if other treatment fail, 791 Hypophosphite of calcium, 139 Ichthyol ointment, useful, rubbed into per- sistent enlargements, prescription for. 791 Iodine ointment and lard, equal parts, rubbed into glands, stopping at first sign of reddening or fluctuation, 791 Iron, syrup of the iodide, in anaemia, pre- scription for, 297, 790 Lactophosphates, or hypophosphites, with cod-liver oil, useful in young children, 790 Phosphate of sodium or lime, if glands are breaking down, 139 Sulphurate of calcium, if suppuration is active, 791 Thiol, recommended in scrofulous skin dis- eases, 443 SCURVY, 791 Arsenic and iron, of service in most cases, 791 Citric acid, if lemon-juice is not attainable, 198, 791 Diet, 791 Lemon- or lime-juice, particularly indi- cated, 791 SEA-SICKNESS. Bromides, the best prophylactics, 128 Chloralformamide and potassium bromide, 166 Nitrite of amvl, 84 Kola, 303 SHOCK. 792 Adrenalin chloride solution 1 :1000, \ drachm in 1 pint of hot normal saline solution injected into a vein, 436 793 Alcohol, 66 Atropine, gr. ^ to -^ (0.001-0.0012) hypo- dermically, with hot applications, very useful in first or second stage, 117, 793 Digitalis, valuable as an adjuvant to atro- pine, 229, 793 Heat, external, very useful, 793 Hypodermoclysis, useful, 513, 793 Strychnine, very valuable, 354 904 INDEX OF DISEASES AND REMEDIES. SKIN DISEASES. Arsenate of iron, 294 Arsenic, in dry, scaly types, 102 Bismuth subgallate, when there is much secretion, 121 Boroglycerin, 124 Chrysarobin locally in parasitic diseases, 188 Cod-liver oil, in strumous types, 208 Copper sulphate, gr. J^ (0.006) thrice daily, if arsenic is not well borne, 217 Corrosive sublimate, oz. -|- (16.0), and am- monium chloride, oz. 1 (30.0), useful, added to bath, in syphiloderm, 326 Hydrocyanic acid, in itching types, pre- scription for, 273 Ichthyol in those forms associated with atony and induration of the deeper layers, 278 Ointment of biniodide and of yellow oxide and lard, in equal parts, useful applica- tion, 327, 332 Petrolatum, as an emollient dressing, 378 Sodium thiosulphate in pityriasis versi- color, 423 Tar and suet, equal parts, locally applied except on face, 440 Unguentum hydrargyri ammoniati, 324 Zinc-oxide ointment, 368 SMALLPOX, 793 Aconite, with spirits of nitre and Min- dereus, useful as a fever mixture, 793 Antipyrin or acetanilid, to control head- ache and backache, 92, 794 Brandy and whiskey, if pulse fails, 794 Bromides and chloral, in insomnia; latter must be used carefully, 794 Chlorate of potassium with tincture of myrrh, as a mouth-wash, 794 Disinfection and hygiene necessary, 794 Flexible collodion, glycerite of starch, or simple cerate, locally applied, to prevent itching, 794 Iron, tincture of the chloride, to give strength and act as a specific, 794 Mustard plasters contraindicated, 794 Opium for restlessness caused by itching, 362 Phenol and sweet oil (1 :100), as an oint- ment to check irritation, 794 Phenol, pure, touched to the vesicles to decrease pustulation, secondary fever, and pitting, 154 Salicylic acid and vaseline, or cold cream (4:100), best local application, 794 Silver nitrate, locally applied, to prevent pitting, 342, 794 SORDES. Glycerin and water, equal parts, useful as a mouth-wash, 260 SORES. Acetic acid, in old sores, 59 Black wash, useful for syphilitic sores, 327 Camphor, locally applied, as a stimulant in indolent sores, 143 Charcoal, applied to old sores, as a deodor- ant and antiseptic, 155 Cold cream, as an emollient dressing, 402 Dried alum a useful dressing, 76 Formaldehyde solution useful for cauter- izing syphilitic sores, 253 Gallic acid, 254 Iodoform, gr. 20 (1.3), with oil of eucalyp- tus, oz. ^ (16.0), or iodoform, oz. \ (16.0), camphor, gr. 75 (5.0), and essence of roses, gtt. 2 (0.1), as a dressing for syph- ilitic sores, 288 Petrolatum, as an emollient dressing, 378 Potassium permanganate (gr. 60 to the pint [4.0:480.0]), as a wash, 377 Quercus, powdered, as a poultice, to check discharge, 398 Red or yellow oxide of mercmy a good dressing for syphilitic sores, 332 Sulphuric acid, sometimes used as an escharotic in venereal sores, 434 Zinc-oxide ointment, 368 SORE-THROAT. Aconite, in early stage, 62 Alum (gr. 20 to the ounce [1.3:30.0]), locally applied on swab, 75 Arsenic, 103 Belladonna, of greatest service in some cases, 118 Capsicum, tincture of, and glycerin, 150 Copper sulphate (gr. 4 to the ounce [0.25: 30.0]), often of service in relaxed sore throat, 218 Gambir, as a gargle or in troches, 255 Guaiac. 262 Hamamelis, in relaxed sore throat, 265 Hydrogen peroxide (2 per cent, strength), in spray, in foetid types, 274 Kino, as a gargle, 302 Myrrh, tincture of, diluted one-half, as a gargle in ulcerated types, 338 Phenol (1 :100J, in spray, in ulcerated tvpes, 154 Potassium chlorate gargle in anginose form, prescription for, 167 Quercus, useful as a gargle, 398 Quinine (gr. 1 to 2 to the ounce [0.06-0.12 : 30.0]), in spray, in foetid sore throat,. 194 Rhus glabra, with glycerin and water, use- ful as a gargle, 401 SPASMS. Belladonna, useful in urethral, anal, and vesical spasm, 116 Bromides in spasmodic contractions, 127 Cannabis indica, useful in vesical spasm, 146 Conium, useful, if due to irritation of nerve-trunk, 214 Ether, inhalation, relieves local spasms, 243 Gelsemium in localized muscular spasms, 257 Hyoscyamus in local spasm or where pain is due to spasm, 275 Nitrite of amyl, of service to relax, 84 INDEX OF DISEASES AND REMEDIES. 905 SPERMATORRHOEA. (See Emissions.) SPRAINS. Arnica, 99 Camphor liniment, 143 Cold applications, useful in sprained ankle, 471 Croton-oil liniment, 222 Hot bath, very useful in sprained ankle, 504 Hot-air bath, 510 Ichthyol ointment, well rubbed in, very useful, 278 Lead- water and laudanum, 307, 363 Soap liniment, 419 Soap plaster, used as a support to sprained joints, 420 Soluble glass, 419 Turpentine liniment, 452 Warming plaster, 393 STINGS AND BITES, 794 Alcohol in snake-bite, 66 Ammonia or alkaline liquids, locally ap- plied to neutralize poison, 79, 794 Antivenine, 795 Corrosive sublimate, with flexible collodion (1:1000), painted over part; salicylic acid a useful addition, 794 Hydrogen peroxide applied locally to hornet's sting, of great value, 274 Ipecac paste for stings of bees, 292 Ligature, or cleansing of wound, at once, to prevent absorption in snake-bite, 795 Phenol (1:50 or 100), sponged over part, useful in mosquito-bites, 794 Potassium permanganate, applied and in- jected around snake-bite, followed by alcohol in full dose, 377, 795 Vinegar, dilute or pure, locally applied, often relieves insect-bites, 794 STOMATITIS, 795 Borax, as a mouth-wash, prescription for, 123, 795 Bromide of potassium or sodium, gr. 1 to 10 (0.06-0.60), thrice daily, when nervous irritability is excessive, 796 Cleansing nipples, in breast-fed babies, 796 Cocaine, before cauterization, 201 Nitrate of silver, stick touched to sore spots when thev fail to yield to other treatment, 343/796 Nitric acid, V\ 3 (0.20), in water, taken through tube, 345 Nitro-muriatic acid, indicated when hepatic torpor exists, 796 Peroxide of hydrogen, 795 Phenol, as a mouth- wash, 154 Potassium chlorate, prescription for, 168, 795 Salicylic acid (1:250), as a mouth-wash, after blisters have broken, to allay pain, 406 Salines or rhubarb, if constipation exist, 795 Sozoiodol (5 per cent, solution), locally applied, 424 Sweet spirit of nitre, 10 minims (0.60), well diluted, to a one- or two-year-old child, and a warm foot-bath, before retiring, to produce rest, 796 Thymol, prescription for, 445 Tonics and careful diet after the attack, 796 STYES, 796 Boric acid (saturated solution), collodion (ethereal solution), or red or yellow oxide of mercury salve (gr. 2 to the ounce [0.12-30.0]), locally applied to abort, 796 Calcium sulphate, if they tend to return, 796 Hot compresses, to alleviate pain, 796 Incision, as soon as pus forms, 796 Tonics, if general health is poor, 796 SUBINVOLUTION OF UTERUS. (See In- volution, Anomalies of.) SUNBURN. Almonds, in emulsion, 72 Carbonate of lead, prescription for, 307 SUNSTROKE, 796 Antipyretics, almost useless, 93, 797 Hot baths (105° to 110° F.), or hot bottles or bricks, in heat exhaustion, 798 Ice, application to chest, back, and abdo- men, as quickly as possible, in thermic fever, 487, 797 Salicylic acid, quinine, and similar drugs contraindicated, 798 Tonics, during convalescence in heat ex- haustion, 798 Venesection, best treatment, if face be cyanotic and heart laboring, and if meningitis threatens, after thermic fever, 797 Veratrum may be used if meningitis threatens, 797 SYNCOPE. Ammonia, if due to shock or indigestion, 78 SYNOVITIS. Counterirritation, 492 Iodine, 285 Phenol (2 per cent, strength), as an injec- tion in chronic types, 154 SYPHILIS, 798 Biniodide of mercury, 327 Bismuth and calomel, as a dusting-powder, or bichloride solution (1:2000), locally applied to mucous patches about geni- talia, 800 Calomel hypodermically, 328 Calomel, gr. % (0.01), every two hours for cephalalgia, 800 Cod-liver oil, useful in advanced cases, 208, 803 Europhen, gr. 1 to 3 (0.06-0.20), internally, 252 Expectant plan of treatment, 799 906 INDEX OF DISEASES AND REMEDIES. Folmaldehyde solution, useful for cauter- izing sores, 252 Guaiac not used at present, 262 Hvpodermic injections of mercury, 325, 328, 330, 802 Iodides, followed if necessary by mercury, recommended by some, 279, 799 Iodoform, gr. 1 to 5 (0.06-0.30), internally in tertiary stage, and the ointment applied to ulcers, very useful, 288, 803 Iodol, in tertiary stage, 289 Mercurial ointment, by inunction, 331, 802 Mercurv by fumigation, general and local, 319, "801 Mercurv, at beginning of secondarv stage, followed later by the iodides, 799, 800 Mercury, with chalk, chiefly employed in infantile svphilis, 330 Mixed treatment, 800, 801 Ointments and washes of mercury, and hot applications, to combat surface erup- tions, 800 Prescription for potassium iodide and mer- cury, to be used after first eighteen months, 801 Prescriptions for blue mass and iron, 801 Pressure bandage and mercurial inunctions for periostitis, 801 Protiodide of mercury, 332, 800 Salicylate of mercury hypodermically, 333 Sarsaparilla, a useful adjunct to potassium iodide, 413, 803 Shampooing and local application of croton oil, or cantharides, as a lotion, to com- bat alopecia, 800 Silver nitrate, copper sulphate, chromic- acid solution (20 per cent.) or acid nitrate of mercury, locally applied to mucous patches, in mouth, 800 Stillingia, used as an aid to other drugs, 427 Thiol, in syphilides, 443 Tonic and general treatment, 803 Vapor baths, hypodermic injections, or inunctions, useful modes of applying mercury if it cannot be taken bv mouth, 801 SYSTEMIC STRAIN. Opium, useful in prolonged physical strain, 363, 364 Quinine, gr. 2 to 4 (0.12-0.25), useful to prevent exhaustion following physical and mental strain, 192 TABES DORSALIS. (See Locomotor Ataxia.) Chloralformamide, prescription for, 166 TAPE-WORM. (See Worms.) TEETHING. Bromide of potassium, to prevent convul- sions, 127 TETANUS, 803. (See Poisoning from Strychnine.) Amyl nitrite, to relieve and prevent, 84 Antitoxin, value of, not established, 803 Chloral and bromide of potassium, by mouth or rectum, 164 Fowler's solution, said to be almost specific in some cases, 803 Hot pack may be used, 509 Physostigma, of moderate value, 386 TINEA CAPITIS. Lime-water, locally applied, 141 TINEA CIRCINATA, 785 Borax, strong solution, locally applied, 123 Iodine, applied with camel 's-hair brush, 285, 785 Turpentine, useful, applied with a brush, 452 TINEA TARSI. Copper, crystals, or weak solution, applied to diseased eyelid, 218 TINEA TONSURANS. Anthrarobin as a wash, 85 Borax, strong solution, locally applied, 123 Iodine, applied with camel's-hair brush, 285 Oil of cajuput, applied pure, 137 TOE-NAILS (IN-GROWING). Absorbent cotton, soaked in strong alum solution, and inserted under nail, 76 Liquor potassii hydroxidi, to soften nail prior to packing with cotton or partial evulsion, 310 Phenol to produce local anaesthesia in e version of, 154 TONSILLITIS, 803 Alum stick, deeply applied, 76 Ammonium iodide, for enlarged tonsils, 82 Bichloride of mercury, gr. -^ts (0.0003) every hour in water for 4 or 5 hours to abort, 327, 804 Corrosive sublimate when inflammation is severe, 326 Glycerin and tincture of capsicum, equal parts, applied by swab, 150 Guaiac, 262, 804 Guaiacol, applied locally, 263, 804 Hot fomentations and gargles useful in some cases, 804 Hydrogen peroxide (2 per cent, strength) , in spray, in ulcerative types, 274 Ice-bag to throat, 804 Iron, tincture of the chloride, 296, 804 Monsel's solution, pure, applied with cam- el's-hair brush, 298 Nitrate of silver, applied locally, 804 Phenol, solution (1 :100), as an antiseptic gargle, 804 Salicylates, are valuable in rheumatic cases, 406, 804 Saline purgatve, followed by fever mixture of aconite, sweet spirit of nitre, and potassium citrate, 804 Scarification may be of service in early stages, 804 TOOTHACHE. Chloretone dissolved in oil of cloves, ap- plied on cotton, 169 Creosote, applied on cotton, often relieves, 220 INDEX OF DISEASES AND REMEDIES. 907 Oil of cloves, inserted into cavity on cot- ton, 199 Oil of peppermint, applied on cotton, 375 TORPOR. Acetate of potassium, in hepatic torpor, 58 Ammonium chloride, in hepatic torpor, 82 Arsenic, in gastric torpor, 103 Citric acid, in hepatic torpor, ] 98 Euonymus, in mild hepatic torpor, 250 Lactophosphates and hypophosphites, use- ful in hepatic torpor, 139 Nitro-hydrochloric acid, in torpor of liver, 348 Russian and Turkish baths, useful in tor- pidity of skin and kidneys, 506 Taraxacum, in hepatic torpor, 440 TORTICOLLIS. Belladonna, injected into muscles, 116 Gelsemium, 257 Hot compresses, 505 TREMOR. Hyoscine, 276 Sparteine, 416 TUBERCULOSIS, 804 Acetanilid, generally acts unfavorably, 56 Agaricin. of doubtful value in night-sweats, 63 Almonds, essential oil of, recommended in cough, 72 Alum (gr. 10 to 20 to the ounce [0.60-1.3: 30.0]), or sulphuric acid (1 drachm to the pint [4.0:480]), useful, sponged over body in night-sweats, 808 Antipyrin harmful, 93 Arsenic, in phthisis, and in phthisical ten- dencies, 101, 103 Atropine, gr. ^ to T fo (0.0012-0.0006), hypodermic ally, in excessive night- sweats, 808 Blister, small, useful over new pleuritic spots, 807 Cacodylate of iron in albumimiria of, 295 Camphoric acid, gr. 20 to 30 (1.3-2.0), in- valuable, 144, 808 Cannabis indica. 145, 807 Chloride of calcium, 138 Chloroform, spirit of, used by inhaler, often relieves cough, 807 Cinnamic acid hypodermically and intra- muscularly, 198 Climatic treatment, 533 Codeine, recommended in excessive cough, 207 Cod-liver oil, rules for its use, 209, 806 Copper in tubercular tendencies, 217 Creosotal as an expectorant, 221 Creosote, internally, in spray or by inhaler, often relieves cough and discomfort; contraindicated if fever and haemoptysis are present; prescription for, 218, 806 •Glycerin and water equal parts, with lemon juice, useful as a mouth-wash, 260 Guaiacol carbonate more readily borne by the stomach than guaiacol, 264 Guaiacol. useful in, 262. 263 Heroin useful to stop cough, 807 Hygienic measures, 805 Inhalations of steam from corrosive subli- mate solution (1 :10,000), stopping at first sign of mercurial effects, in laryn- geal phthisis, precede inhalation with cocaine-spray (4 per cent, solution), 807 Iodine, useful, painted over new pleuritic spots, also useful in chrome cases as an inhalant, 285, 286, 807 Iodoform emulsion (10 per cent.), useful in tubercular abscess, 288 Iodoform with small amount of powdered talc and a little morphine, useful when puffed into the larynx in laryngeal tuber- culosis, 808 ; also used in spray, 288 Iodol, of use in tubercular laryngitis, 289 Lactic-acid applications (10 to 60 per cent, solution), in laryngeal tuberculosis, vising cocaine-spray first to relieve pain, 807 Lactophosphates and hypophosphites, 139 Morphine and wild-cherry bark in cough, prescription for, 807 Nuclein, 351 Oil of cloves, 199 Opium, may be given in last stage, to re- lieve pain and discomfort, 364 Oxygen, inhalations in dyspnoea, 370 Phenol (TTl 5 to 15 to the ounce [0.3- 1.0:30.0]), in spray, 153 Pilocarpine, gr. ^ (0.003), one to two hours before sweat, sometimes arrests; if it or atropine fails alone, give them together, 808 Potassium cyanide, in excessive cough, prescription for, 223 Silver nitrate (gr. -h to 2 to the ounce [0.03- 0.12:30.0]), in spray, may be tried in laryngeal types, 343 Sodium cacodylate in anaemia, 421 Strychnine in d\'spnoea, 354 Sulphuric acid, . internally, may relieve night-sweats, 808 Terebene, iodide of ethyl, and chloroform, equal parts, for inhalation, 807 Thiocol as a substitute for creosote, 443 TYPHOID FEVER, 808. (See Fever.) Acetanilid, generally acts unfavorably, 56 Alcohol, useful throughout course of dis- ease, 67, 809 Asafoetida, by rectal injections, in tympa- nites, 110 Belladonna in cases of collapse or vaso- motor relaxation, 117 Calomel, gr. ^ (0.001), every fifteen min- utes, till gr. 1 (0.06) is taken, followed by magnesium sulphate, •§- ounce (16.0), if constipation lasts two days, 379, 811 Cascara sagrada for constipation, 811 Enemas, to be tried first, if constipation lasts over two days, 811 Glycerin and water, equal parts, with a little lemon-juice, as a mouth-wash, if sores are present, 260, 811 Guaiacol carbonate, an intestinal anti- septic of value, 264, 811 Guaiacol, an antipyretic in, 263 908 INDEX OF DISEASES AND REMEDIES. Hydrochloric acid, dilute, Vf[ 5 (0.3) every few hours, or, if bowels are inactive, nitrohvdrochloric acid. TT\ 3 (0.15), 271, 811 Hvpodermoclysis, if toxaemia is marked, 812 Lime-water added to milk, if vomiting threatens, 811 liquorice powder, drachm 1 (4.0) if con- stipation lasts over two days, 811 Milk diet, 809, 811 Morphine in large dose, if perforation oc- curs, 812 Opium for insomnia, 362 Phenolsulphonate of zinc, useful, 381 Phosphorus, if nervous system is affected, 384 Prescription for diarrhoea, 811 Quinine inferior to new antipyretics, 193 Reduction of fever by cold, 485 Rest and diet, 809, 810 Silver nitrate, gr. * to £ (0.01-0.015), highly recommended, 342 Sponging with tepid water and alcohol, with friction, of value when toxaemia is marked, 812 Thymol as an intestinal antiseptic, 444 Turpentine, in the form of stupes, enemata, or by mouth, in tympanites, also useful in later stage, to relieve diarrhoea, heal ulcers, and prevent relapse, 450, 811 Urotropin (hexamethylenamine) to render the urine sterile, 452. (For remedies for complications — intestinal hemorrhage, pneumonia, and pleurisy — see their titles.) ULCERS. Aristol, 445 Benzoate of bismuth, as a dressing for in- dolent or sloughing ulcers, 121 Burnt alum, as a dressing for old ulcers, 76 Caustic potash, as an escharotic for exu- berant ulcers, 159 Chimaphilia, said to be of service in stru- mous ulcers, 160 Chloretone with equal parts of boric acid, as an antiseptic dressing, 169 Conium, used locally to relieve pain, 215 Copper, in solid or powder form, locally applied to indolent ulcers, 218 Creolin, solution (1:100), as a douche for nasal ulcers, 221 Dried alum, useful, 76 Europhen, in 10 per cent, ointment, in leg ulcers, 251 Gallic-acid ointment, in actively discharg- ing ulcers, 254 Glutol as an antiseptic powder, 254 Hamamelis, locally applied on a cloth, relieves leg ulcers, 265 Hot pack, to increase activity of skin, 509 Hydrogen peroxide, a useful application, 274 Lime, as an escharotic in old ulcers, 140 Methyl blue in corneal ulcers, 334 Nargol ointment, 5 to 10 per cent., in sup- purating ulcers, 340 Nitric acid, as a caustic for phagedenic ulcers, or a solution (n\ 5 to 30 to the ounce [0.3-2.0:30.0]), locally applied to indolent types, 344, 345 Ointment of lead carbonate as a dressing, 307 Potassium permanganate (gr. 60 to the pint [4.0:500]), as an antiseptic wash, 377 Precipitated carbonate of calcium, as a dry dressing, 137 Silver nitrate, by injection for rectal and caecal ulcers, 342 Sulphuric acid, sometimes used as an escharotic in slow ulcers, 434 Tannic acid, useful locally, in indolent ulcers, 439 Unna's dressing, 368 URiEMIA, 813 Atropine useful in pulmonary oedema, 814 Bromides for convulsions, 814 Caffeine useful to stimulate the kidneys, 814 Chloral and chloroform for convulsions, 814 Elaterium or elate rin to aid elimination of poison by the bowel, 233, 813 Ether given by the mouth or hypodermic- ally, 243, 814 Heroin for dyspnoea, 266 Hot pack, 813 Hypodermoclysis, 513, 814 Nitroglycerin to increase the urinary flow when arterial tension is high, 814 Pilocarpine, gr. &, with strychnine, gr. -£$, to increase action of the skin, 389, 813 Strychnine, followed by digitalis for heart failure, 814 Transfusion of salt solution of great value,. 538, 814 Venesection, very useful, 814 URIC- ACID DIATHESIS. Acetate of potassium, 58 Lime-water, 140 Piperazine in the dose of 15 grains (1.0) a day in 1 pint (480) of water, 391 URTICARIA. Calcium chloride, to prevent, 138 UTERINE INERTIA. Kola useful, 303 Quinine not of great value, 194 UVULA (RELAXED). Capsicum, tincture of, and glycerin, equal parts, as a gargle, 150 Kino, as a gargle, 302 VARICOCELE. Cold water, applied by bidet, highly recom- mended, 476 VARICOSE VEINS. Barium chloride, internally and locally applied, said to be of value, 112 VITREOUS DISEASES, 814 Antisyphilitic treatment, if due to syphilis, 814 Galvanism, 814 INDEX OF DISEASES AND REMEDIES. 909 Leeches, in earl}' stage, if due to inflam- mation, 814 Pilocarpine, hvpodermicallv, in opacities, 389, 814 VOMITING, 815 Acetanilid, very useful, 57, 816 Allium-juice, 17] 2 to 5 (0.10-0.3), useful in nervous vomiting, 71 Arsenic in vomiting of pregnancy, and of hand-fed babies, and of drunkards, 103, S17 Bismuth and aconite may be of service, prescription for, 120, 816 Brandy poured on cracked ice very useful, 67, 816 Bromide of potassium, effervescing, 128 Bromide of sodium, with laudanum as a rectal injection, prescription for, 129, 362, 816 Calomel, 329 Chloretone, if due to irritation, and after etherization, 168, 816 Chloroform, T7U to 2 (0.05-0.1), in water,817 Cloves, oil of, sometimes controls, 199 Cocaine or aconite, if clue to hyperexcita- bility of stomach, 205, 816 Enemas, partially digested, if vomiting is incoercible, 818 Faradism sometimes gives relief, 817 Fowler's solution, gtt. -^ to 1 (0.025-0.05), every two hours, useful in nausea follow- ing debauch, 68, 817 Hydrochloric acid, HI 5 to 15 (0.3-1.0), in water, every two hours, in alcoholic nausea, 271, 817 Hvdrocyanic acid, dilute, Vf[ 2 to 6 (0.1- 0.4), in water, 272, 817 Ice-bag to nape of neck, lumbar region, or epigastrium, 817 Iodine and phenol, TT\ 1 (0.05) of each in dr. 2 (8.0) of water, 816 Ipecac, in small doses, if due to gastric depression, 291, 817 Lime-water, added to milk, may relieve nausea, 140, 818 Mustard plaster over stomach, useful in all cases, 817 Nitroglycerin, very useful in some cases, 347, 817 Nux vomica, if due to- gastric depression, prescription for, 817 Opium when excessive, 362 Peptonized milk, best food, 818 Phenol or creosote, with bismuth, useful in acidity and fermentation, prescription for, 153, '806 Podophyllin, useful in gastric depression and hepatic torpor, 393 Seidlitz powder, often settles stomach, if due to constipation, 416 Vinegar fumes of service when inhaled, 59, 816 VOMITING OF PREGNANCY. Aconite, as a nervous sedative, 62 Arsenic, may be tried, 103 Bromide of potassium, as an effervescing draught, or with opium, by enema, pre- scriptions for, 128 Cerium oxalate, gr. 2 to 5 (0.12-0.30), in pill, every four or five hours, 160 Cocaine, useful to decrease irritability, 205 Iodine, tincture of, largely used of late with good results, 287 Ipecac wine, 171 1 (0.05), or powder, gr. 2 (0.1), useful in some cases, 291 Menthol, very useful, 375 WARTS. Acetic and salicylic acids combined, 59 Chromic acid (gr. 100 to the ounce [6.6: 30.0]), locally applied, to remove, 188 Fowler's solution, locally applied, 104 Glacial acetic acid, useful to remove, 59 Mercuric nitrate solution locally, 332 Nitric acid, as a caustic, 344 Sulphuric acid locally, 434 Trichloracetic acid, useful, 448 WHOOPING-COUGH, 818 Amber, oil of, 77 Amyl nitrite, when paroxysms interfere with respiration, 84, 818 Antipyrin, gr. + to 3 (0.03-0.20), every five hours, probably the best remedy, 94, 818 Belladonna, tincture of, Vf[ 2 (0.10), twice a dav. to child of one or two vears, 116, 818 Benzine, 819 Bromoform, prescription for, 132, 819 Bronchitis tent, to modify severity of at- tacks, 819 Carburetted hydrogen, 818 Chloral, 165 Chloride of gold and sodium has been recommended, 261 Chloroform, a few whiffs, if paroxysms in- terfere with respiration, 179, 818 Creosote, on wet cloths hung in the nursery, of value, 220 Gelsemium, 257 Hyoscyamus, probably better than bella- donna, 275 Milk, in small amounts, ma}" overcome vomiting following paroxysms, 819 Monobromated camphor, 144 Potassium bromide, in 127 Quinine (gr. 1 to the ounce [0.06:30.0]), in spray, useful, also of service in exposed children as a prophylactic, 194, 818 Resorcinol, TT1 10 (0.60), of a 2 per cent, solu- tion, internally, or, better, in spray, 399 Silver nitrate (gr. J to 1 to the ounce [0.03- 0.06 :30.0]), in spray, used when stomach is empty, 343 Zinc oxide, 369 WORMS, 819 Aspidium, very efficient against tape-worm, prescription for, 110, 820 Azedarach, a useful remedy against round- worms, 111 Brayera, as an infusion, or fluid extract, against round-worms, 820 Calomel, should follow or precede all drugs used for tape-worm, 820 910 INDEX OF DISEASES AND REMEDIES. Castor oil, or a saline purgative, should fol- low remedies for round-worms, 820 Chenopodium, oil of, 111 5 to 20 (0.3-1.3), on sugar to remove round-worms, 161, 820 Chloroform, should not be used against tape- worm, 183 Cusso in tape-worm, 223 Kamala, drachms 1 to 2 (4.0-8.0), in syrup, against tape-worms, 302 Koosin, gr. 40 (2.6), to adult, against round-worms, contraindicated in preg- nant women, 820 Matricaria, 316 Pelletierine, gr. 3 to 5 (0.20-0.30), in cap- sule, best remedy against tape-worm, 820 Pepo, ounce 2 (60.0), in confection, against tape-worm, 373, 820 Pomegranate, useful in tape-worm, 394, 820 Quassia injections, preceded by soap and water, most useful remedy against seat- worms, 397, 820 Rue, should not be used against round- worms, 403 Rules for diet preceding taeniacides,, 819 Salicylic acid; gr. 8 (0.5), hourly till gr. 40 (2.6) are taken, against round-worms, or as an injection against seat-worms, prescription for, 407 Santonin, gr. \ to \ (0.015-0.03), in troches, for child, against round-worms, 412, 820 Spigelia, alone, or, better, with senna, to remove round-worms, 424, 819 Thymol, gr. 2 to 4 (0.12-0.25) in capsule, once a day, for removal of anchylostoma duodenale, 820 Turpentine and castor oil, equal parts, effi- cient, but somewhat dangerous, against tape- worm, 451 WOUNDS. Acetanilid, as a dusting-powder, 57 Alcohol, very useful in contused wounds, 67 Chloretone, with equal parts boric acid, as- an antiseptic dressing, 169 Collodion, as an air-tight dressing for small wounds, 212 Glutol, as an antiseptic powder, 253 Oil of cinnamon, 197 Orthoform as an antiseptic, 367 Potassium permanganate (gr. 20 to 60 to the pint [1.3-4.0:480]), as an antiseptic wash, 377 Salicylic acid, 407 Sozoiodol, as an antiseptic and disinfectant in diseased wounds, 424 Thymol, locally, 445 YELLOW-FEVER. Cocaine of great value as a stimulant and anti-emetic, 204