i$S5S«*§S$RS ■MnaHaBtanMHi LIBRARY OF CONGRESS. Shelf ,Iil_ UNITED STATES OF AMERICA. NOTES H&TEBU HEDIGA AND TBEBAPEDTICS TAKEN FROM LECTURES DELIVERED Prof. WILLIAM H. THOMSON, M.D , LL.D. MEDICAL DEPARTMENT UNIVERSITY OF THE CITY OF NEW YORK. EDITED BY W. M. IL, McEKROE, M.D., ASSISTANT TO THE CHAIR OF MATERIA MEDICA, UNIVERSITY OF THE CITY OF NEW YORK. FOURTH EDITION, COMPLETELY REVISED AND ENLARGED. NEW YORK : Press of STETTLNER, LAMBERT & CO., 22, 24 & 26 Reade Street. ^ V Copyright, 1889. w. m. h. McEnroe. PREFACE In preparing the fourth edition of these notes, the editor has been thoroughly mindful of the introduction of several valuable drugs since the publication of the last edition, and the prominence given in recent lectures by Prof. Thomson to some of these, and the desirability of having fuller notes on some of the older remedies, have rendered necessary the issue of the present edition. Advantage has been taken of the occasion to make what is practically a new work, for the present notes are based upon stenographic .reports of the lectures delivered dur- ing the winter session of 1888-89, the material in the older editions for obvious reasons having been drawn upon to a slight extent only. To render the work as complete as possible, several mono- graphs by Prof. Thomson, bearing directly upon the uses and administration of drugs, have been introduced. Other new fea- tures are the frequent use of cross-references and a summary at the end of each of the principal drugs. Owing to the nature of the work, the appearance of a few errors, typographical and otherwise, is almost unavoidable, but none of them, I trust, will be found misleading. IV PREFACE. To Mr. Edward Merrins I am indebted for the full and careful notes of Prof. Thomson's lectures, and for invaluable aid in the preparation of the material for the press. If these notes are found helpful by the student, the object of their publication will have been attained. W. M. H. McEnroe, M.D. 55 East 11th Street, October, 1889. TABLE OF CONTENTS. PAGE Classification of Medicines, 1 PART I.— DISINFECTANT REMEDIES. Introductory to Disinfectants, 11 General Disinfectants, 19 Special Disinfectants, Lime, ' 20 Charcoal, 22 Carbolic Acid and allied Compounds, 24 Chlorine, . . 31 Bromine, 32 Sulphur, 34 Iodine, 34 Boracic Acid, 35 Permanganate of Potash, 35 Uses of Disinfectants in the treatment of Special Diseases, ... 36 PART IL— MEDICINAL REMEDIES. Introductory to Medicinal Remedies, 45 CLASS I.— ORGANIC OR DISEASE MEDICINES. 1. Restoratives: Cod-liver Oil, 52 Iron, 62 Phosphorus, 73 Quinine 76 Vegetable Bitters, 87 Mineral Acids, 90 Alkalies, 95 Mineral Waters, 97 VI TABLE OF CONTEXTS. PAGE 2. Alteratives : Mercury, ... 104 Iodine and Compounds, Ill Bromides, 117 Arsenic, 127 Silver, 133 Zinc, 135 Copper, 136 Bismuth, 136 Colcliicum, 136 CLASS II.— FUNCTIONAL OR SYMPTOM MEDICINES. Neurotics ; Introductory, . 141 Narcotics, Opium, 144 Alcohol, . 168 Ethers, 176 Belladonna, . 179 Hyoscyamus, . 183 Stramonium, 183 Cannabis Indica, 185 Stimulant Neurotics, Digitalis, 190 Strophanthus, .... 192 Nitroglycerin, ...... 194 Caffeine, 196 Ammonia, .... 198 Ergot, 200 Stiychnine, .... 203 Camphor, .... 204 Asafcetida, .... . . . . .204 Valeriana, - 205 Depressant Neurotics, Aconite Veratrum Yiride, .... 212 Tartar Emetic, 212 Hydrocyanic Acid, .... 213 Conium, 214 Gelsemium, ... . 215 TABLE OF CONTENTS. Vll PAGE Anaesthetics, 219 Cocaine, 219 Chloral 220 Paraldehyd, 222 Sulfonal, . 223 Phenacetin, 223 2. Eliminatives or Glandular Medicines: a. Cathartics, Calomel, ' . 232 Castor Oil, 233 Aloes, 235 Rhubarb, 235 Cascara Sagrada, ......... 237 Colocynth, 238 Scammony, 239 Jalap, 239 Podophyllum, 239 Elaterium, 240 Camboge, ". 240 Senna, 241 Compound Cathartic Pills, 241 Croton Oil, 241 Sulphate of Magnesium (Epsom Salts), 243 Sulphate of Sodium (Glauber's Salts), 243 Cream Tartar, 243 Tartrate of Potassium and Sodium, 244 Phosphate of Sodium, 244 b. Emetics, Apomorphine, 245 Ipecacuanha, 246 Sulphate of Zinc, 248 Sulphate of Copper, 248 c. Diuretics, Digitalis, ' . . . .250 Mercury, 250 Squill, 251 Turpentine, 251 Buchu, 252 Juniper, . . . 253 Cream Tartar, 253 Vlll TABLE OF CONTENTS. PAGE d. J)iap7ioretics, Dry Heat, . . . ■ 255 Moist Heat, 255 Dover's Powder, 256 Ammonia, ........... 256 Sweet Spirit of Nitre, . 256 Jaborandi, 257 e. Expectorants, 258 3. Astringents . Plumbi acetatis, 265 Liquor Ferri Subsulphatis, 268 Liquor Ferri Pernitratis, . . ... . . . 268 Nitrate of Silver, 268 Sulphate of Copper, 269 Alum, 269 Tannin— Tannic Acid, . 269 PART III.— NON-MEDICINAL MEDICINES. Cold, 278 Dry Heat, , 285 Moist Heat, . 287 CLASSIFICATION OF MEDICINES. All Kemedies may be divided into three classes: Medicinal, Non-Medicinal, and Disinfectant. A Medicine is a remedy which cannot act until it enters the Circulation in a state of solution. The circulation includes not only the blood, but also the interstitial fluid outside the capillaries, and which is the real nutritive fluid of the tissues. That it is in nearly as rapid movement as the blood itself, is shown by the quick diffusion of hypodermatic injections. Non-medicinal Kemedies are those which act without entering the Circulation, as Counter-irritants, Blisters, Caustics, Elec- tricity, Heat, Cold, Baths, Change of Scene or of Air, Massage, etc. Disinfectants either destroy the agents which cause the de- composition of organic textures and fluids, or else neutralize the poisons generated by the growth or activity of those agents. MEDICINES. Medicines are divided into two classes: 1. Organic or Disease Medicines. 2. Functional or Symptom Medicines. The Organic Medicines are those which act upon and modify the tissues or fluids of the body, so that after their action the system is not in the same state that it was in before their ad- ministration. Examples : Cod-Liver Oil in nutritive disorders, Iron in Anaemia, Mercury in Syphilis, etc. The Functional Medicines produce no recognizable effect upon the various bodily organs, but affect their functions instead. The function of an organ is its work, as Respiration the function of the Lungs ; Circulation the function of the Heart and Blood Vessels ; Secretion NOTES ON MATERIA MEDICA. the function of the Glands, etc. Thus Ammonia may stimulate the heart's work and Aconite depress it, so as to accelerate or slow the circulation ac- cordingly, but neither of these agents affects the structure of the heart itself. Opium or Tobacco leaves no traces on the Nerve Tissues, though taken for years for their effects on Nerve Functions. The two Classes of Medicines present the following contrasts in their char- acters : ORGANIC OR DISEASE MEDICINES. They are given for Diseases or Morbid Conditions, not for Symptoms. Thus Potassium Iodide is given not to relieve the pain of a syphilitic node, but to remove the node itself. They relieve symptoms, therefore, only indirectly, by removing their cause. They show the properties which lead to their use as medi- cines only in disease. Iron or Cod-Liver Oil does not strengthen persons in health. Mer- cury is a great restorer, provided there be Syphilis, etc. By a Morbid Condition, in distinc- tion from a Disease, is meant a state like Ansemia or like Dropsy, which, though definite, yet is the result of quite different causes in different FUNCTIONAL OR SYMPTOM MEDI- CINES. They are given for Symp- toms, not for Diseases. _ Thus Opium is given in inflamma- tion, fractures, cancer, neuralgia, etc., only for what these have in common — the symptom pain. Symptom Medicines act in health as well as in disease. Emetics or Cathartics, or Neuro- tics, will act the same whether taken by the well or by the sick. Hence their actions are often studied by ex- periments on animals. Their action is never secured by one dose, but only by re- peated doses. They, therefore, require time for their opera- tion, because they are cumula- tive, and hence their effect is more permanent. Their whole action is se- cured by one dose, and no dif- ferent effect follows upon re- peated doses. Hence they are not cumulative, and their effect is transient. Thus half a dose of a Cathartic or of an Emetic fails to produce any characteristic effect. Repeated doses of a Neurotic, also, only repeat the symptoms of the first dose without adding any further effect on the dis- ease or on the symptom. Thus Stramonium may relieve the symp- tom of spasm in asthma for a life- time, but the last dose has no more helped to cure the asthma than the first one. CLASSIFICATION OF MEDICINES. They should not produce symptoms. The patient should not know that he is taking any- thing except by noticing an improvement in his disease. Whenever they produce symp- toms of their own, they are either given in excess or else they are not suited to the case. Thus iron disagrees when it pro- duces headache. Quinine should not be pushed beyond the symptoms of cinch onism. Mercury ceases to be remedial after salivation begins, and iodine after the symptoms of iodism develop, etc. Disease Medicines are most commonly employed in the treatment of Chronic Diseases. Thus Cod-Liver Oil, while valu- able in Chronic Pulmonary Diseases, is useless in Acute Pneumonia. Iron is not given for the debility of fever, etc. Chronic Diseases are due to faults of the constitution, either inherited or acquired, and hence only organic medicines can permanently benefit them. The term Chronic shows that they have no tendency to spontane- ous recovery. In some cases a Disease Medicine can be made to act as a Symptom ^»Iedieine, by giving it in the symp- tom way, viz., in one large dose. Thus Mercury in a large dose of calomel becomes a cathartic, but if so it ceases at once to act against any syphilis present in the system, for it cannot be both a Disease Medicine and a Symptom Medicine at the same time. They do not act unless they do produce symptoms. The dose of all Symptom Medicines is the quantity which will pro- duce the symptoms character- istic of the medicine, and no- thing less. Thus, while the ordinary dose oi opium for an adult is one grain, it may require in peritonitis twenty grains before a symptom of opium is obtained; if so, the dose then is twenty grains. Symptom Medicines are most commonly employed in the management of Acute Diseases. Acute Diseases, as inflammations, fevers, etc., are of the nature of acci- dents and may occur in the young and healthy. If uncomplicated, Acute Diseases are self -limited and terminate, with rare exceptions, within six weeks. Symptom Medi- cines are called for in them to relieve suffering and to prevent complica- tions, but not to cure the disease, which rather must be watched while it runs its course. 4 NOTES ON MATERIA MEDICA. CLASS I.— ORGANIC OR DISEASE MEDICINES. Division I. — Restoratives. Characters: I. They are medicines which, are natural to the system, either because they are themselves ingre- dients thereof, or else analogous to what is so. II. They act by making up a deficiency in the system, by being themselves the thing deficient, or else similar to it. They are, therefore, of the nature of foods, and hence are beneficial only when the system is starved of the ingredient to which they correspond. Examples: Iron in anae- mia, Cod-Liver Oil when blood fat is wanting, etc. Restoratives and Disinfectants are the only prophylac- tics. Division II. — Alteratives. Characters: I. They are Organic or Disease Medicines un- natural to the system. They are, therefore, more or less poisonous, and this fact is to be remembered, because, though all Symptom Medi- cines are also unnatural to the system, yet complete recov- ery from the most active of them, like Opium or Aconite, is a question of hours only, while recovery from the injury of organic poisons may be very slow. II. They act in an unknown way only against certain special diseases or morbid conditions. The range of their remedial applications is there- fore more limited than with restoratives. CLASSIFICATION OF MEDICINES. Potassium Iodide acts promptly against syphilitic periosti- tis, but not to the same degree in other forms of periostitis. Colchicum is the remedy for gouty arthritis, but not for rheumatic arthritis, etc. III. When they act as poisons they produce characteristic symptoms, such as salivation by mercury, or iodism, bromism, etc. When they do so, they cease to act as remedies, and the dose should be lessened to that which does not cause symptoms, or else they must be abandoned. As their poisonous effects are both different from their remedial effects and inconsistent with them, an important rule in their lengthened administra- tion is to conjoin restoratives with them to post- pone their poisonous effects as long as possible. CLASS II.— FUNCTIONAL OR SYMPTOM MEDICINES. Division I. — Neurotics. Characters: I. They are medicines which produce their symptoms by affecting some nerve functions. Neurotics never act upon the whole nervous sys- tem, and hence the use of such terms as "gen- eral nervous stimulants or sedatives " is incorrect. The most widely operative neurotics, such as opium, are yet quite selective, and affect the functions of only a few out of the many nerve centres. II. As they are purely functional remedies, neu" rotics cannot cure real nervous diseases like epi- lepsy, asthma, etc., as these diseases are generally the most constitutional of all diseases. b NOTES ON MATERIA MEDICA. The effect of neurotics is usually weakened by repetition, so that the doses have to be increased. Yet they promote the action of organic medicines when they relieve special symptoms of the disease. Thus opium and conium ma- terially increase the efficacy of potassium iodide in syphili- tic periostitis when there is much pain, and on the same principle chloral, by lessening reflex excitability, assists the bromides in epilepsy. Neurotics may be divided into: a. Those which are both Stimulants and Sedatives (commonly called Narcotics). These agents generally stimulate some nerve functions, while they simultaneously depress others. Thus opium stimulates some of the higher cerebral functions and also stimulates the heart, and at the same time blunts sensation and paralyzes the alimentary canal. Or else these agents first stimulate certain functions and after- wards depress the same, but secondarily from exhaustion. ft. Those which are Stimulants only of certain nerve func- tions. Examples: Ammonia on the heart, Valerian and Asafce- tida on the abdominal ganglia, etc. c. Those which are Sedatives only of certain nerve functions, as Hydrocyanic Acid of the respiratory function. , Division II. — Eliminatives or Glandular Medicines. Characters: I. These medicines increase gland secretion. They are given more against complications occur- ring in the course of acute or of chronic diseases than against mere symptoms. Thus fever arrests secretion, and therefore, if long con- tinued, endangers life by the complication of starvation from deficiency of digestive secretions in the alimentary canal, and by the complication of self -poisoning from re- tained excretions. Eliminatives here are useful, not to eliminate the disease, but to modify these complications. CLASSIFICATION OF MEDICINES. 7 II. By them also the different gland secretions are sometimes made to act vicariously for some one deficient gland function, as when Cathartics and Diaphoretics are used in kidney disease. These medicines are divided into: a. Cathartics, which increase the secretion of the intestines. h. Emetics, which act upon the secretions of the pharynx, stomach, liver, and duodenum in the act of emesis. c. Diuretics, which act on the kidneys. d. Diaphoretics, which act on the skm. e. Expectorants, which act on the bronchial secretion. Division III. — Astringents. Characters: These medicines constringe muscular and fibrous tissues and diminish secretion. They are also em- ployed for arresting haemorrhage by coagulating the blood. They are divisible into: a. Mineral Astringents. I. Vegetable Astringents. PART I. DISINFECTANT REMEDIES. DISINFECTANT REMEDIES. GENERAL INTRODUCTORY. Disinfectants are remedies which are used for the prevention of those diseases which come to us from without, and are not directly due to anything which is in the system itself. These diseases are accidents, and have nothing of the nature of consti- tutional diseases. The causes of these diseases are external, and the patient is not directly responsible for an attack unless he wilfully places himself in those surroundings where he knows the disease exists. Thus, two persons may he attacked by small-pox, one haying unwittingly come in contact with a person suffering from the disease; to this man the disease is an accident. The other per- son wilfully, and with full knowledge of the fact, incurred the risk of infection ; this cannot be called an accident. Never- theless, to both persons the cause of the disease came from with- out their own bodies. It was an external cause. It is now almost the unanimous opinion of the medical pro- fession that these extraneous, accidental diseases — of which smallpox may be taken as a type — are caused by living organ- isms, not by any physical or chemical agency. Disinfection means simply the endeavor to destroy these organisms, either directly by the disinfectant employed, or indirectly by the pro- duction of an agent inimical to their vitality; and hence any disease against which disinfectants can be successfully employed must be produced by these organisms. To speak, therefore, of eliminating the " poison " in these diseases shows an erroneous conception of the nature of their cause, for, irrespective of the dentification of the organisms by the microscope, the various 12 NOTES ON MATERIA MEDICA. processes occurring in the course of these accidental or "com- municable " diseases differ in all their essential features from those produced by poisons. The word "poison " in its strict sense means a definite chemical substance, devoid of life, that produces disease or death after having entered the circulation; but the meaning of the term has been extended to embrace also those substances — e.g., caustics — which cause death or serious bodily harm by their chemical action upon the tissues with which they come in contact. That these diseases are due to living or- ganisms and not to poisons is conclusively shown by the follow- ing facts: (1) In poisons, quantity is an essential element: a cer- tain amount will prove fatal, a lesser amount will not be fatal, and a minute amount may act medicinally. On the other hand, in these diseases quantity is unimportant, the small amount of virus introduced into a person's system by inoculation infecting him to as great an extent as though a much larger quantity had been used. (2) In the case of poisons, time is an unimportant element, for, though there may be delay in absorption, as soon as a poison enters the circulation its characteristic effects are immediately produced; but where diseases are dependent upon living organisms, there must be a certain period before the symp- toms of disease are manifested. This latent period, called "incu- bation " (an unfortunate term, as it implies animal origin, and should be replaced by that of "germination"), is followed by the period of development, which is characterized by certain changes which are never reversed. (3) Following this period of de- velopment we have the most positive proof of the character of these morbid agents in the great feature of reproduction, as there is nothing in chemistry or physics that can reproduce itself. Thus, for example, the organisms in the minute quan- tity of variola -lymph introduced into the system by inocula- tion reproduce themselves to such an extent as to enable us to obtain from the person so infected a quantity sufficient to in- fect multitudes. This element of reproduction is the cause, and the only cause, of these diseases being dangerous. Immunity from the effects of any one of them depends on the virus being unable to reproduce itself in the system of the person exposed to its influence, and, conversely, the severity of the disease will be DISINFECTANTS. 13 in proportion to the receptivity of the soil on which these or- ganisms — or, as they might be termed, seeds — will fall. Thus, of five persons exposed to the influence of one of these communica- ble diseases, two may be violently affected by it and die, two may be totally unaffected by it, and one may be affected slightly. "With poisons, however, the results are invariable; a dose of strychnine, for instance, producing precisely the same effects in one person as in another. (4) The variations in type and sever- ity of these diseases from year to year also show that they are de- pendent upon living organisms; for these variations never hap- pen with poisons, but growths are constantly having fluctua- tions in their reproduction. (5) The transportation of poisons from one country to another does not affect their peculiar prop- erties, but growths are very much affected by soil, climate, alti- tude, etc., and so we find that many of these diseases are endemic; for instance, cholera cannot ascend a mountain, and yellow fever is checked by frost. It is thus shown that we have to deal with agents that live and grow, and which never originate spontaneously; and the microscope, which confirms these deductions, reveals to us the fact that we are living in an immense ocean of minute forms of organic life, compared with which the world of life we see around us with the naked eye is quite small. Eeasoning from analogy, and from the fact that no form of li'fe can live for it- self, we should expect that this kingdom of microscopic life, by far the largest and most universal, must have very important re- lations to other departments of life, and this we find to be the case. Without the aid of these minute organisms there would be no vegetable growth, as the fermentation they produce is es- sential to the fertility of the soil; for it has been found that soil which has been sterilized will not support vegetable life. To a very large extent they furnish the microscopic nuclei to the at- mosphere which serve for the precipitation of watery particles, and thus they assist in the formation of clouds; for in air which has been filtered through cotton, and thus rid of all solid matter, the introduction of steam is not followed by a ' ' cloud " or "mist," but it immediately condenses as water. If, therefore, we were living in a perfectly pure atmosphere, there would be 14 NOTES ON MATEEIA MEDICA. no clouds and consequently no ram; the whole earth would be a desert, for as fast as water was evaporated from the ocean it would return, unable to find a resting place for its particles. What is still more important, however, is the fact that if it were not for these organisms nature would very soon be choked with her own dead. Decomposition of either animal or vegetable substances never occurs spontaneously, but is brought about by the agency of these organisms in a complex series of processes. In the putrefaction of ordinary butcher's meat, no less than eight kinds of organic life, differing in form, activity, and chemi- cal results, succeed each other, in an order which is rarely re- versed, before decomposition is complete, the processes being analogous to those in the decomposition of vegetable matter — e.g., alcoholic fermentation, where the alcoholic plant is succeeded by the acetic acid plant. These facts have an important and significant bearing on the subject of the growth of the organisms by which communicable diseases are produced, and they direct attention to a stage (the post-latent) of these diseases to which heretofore there has not been attached sufficient importance, but to which these facts give a very decided clue as to its actual ex- istence. Communicable diseases are characterized by a " latent stage," or, as it might now more correctly be termed, a "pre-latent stage " — the period of incubation or germination. This is fol- lowed by the period of development, after which comes the pe- riod of reproduction, to be succeeded by the apparent recovery of the patient. But the disease has not yet been conquered; the recovery is only apparent, for there now succeeds another latent stage, which may be termed the " post-latent." For instance, at the end of a certain time the kidneys may be affected after an attack of scarlet fever, and paralytic troubles may follow diph- theria; measles may end in chronic asthma, and measles and scarlet fever may both be succeeded by nasal catarrh and otor- rhea. These manifestations of the post-latent stage are not the sequelae of the original complaint, but are indications of a new disease due to the development of other bacterial growths, because every one of these diseases due to an organism of its own pre- pares the way for another disease which but for it would not DISINFECTANTS. 15 appear. We are thus living in a world of life which is ever ready to seize upon and destroy anything that shows a weakened vitality — a vitality insufficient to repel or overcome them. This subject should be thoroughly studied, not so much to discover this or that disease, as to enable us to grasp the general laws of this microscopic world, and to infer from them facts which would be obscure if we studied the specific forms "by themselves. For instance, in phthisis, a bacterial disease — the microscope here affording us a means of diagnosis superior to that of physical exploration, as we can by its use determine with certainty the presence of the disease where otherwise we would be in doubt — there is the suggestive fact that it does not prevail anywhere in the world where the soil is permeable to water to the depth of about thirty feet; but in proportion as we come to soil which holds water two or three feet below the sur- face of the earth, there phthisis most extensively prevails. This disease, therefore, is due to the introduction into the system of germs which are dependent upon a certain condition of the soil, not to atmospheric bacteria; hence to get rid of the disease the soil must be dealt with. In regard to the probable action of these germs ' in producing disease, there is no doubt but that the blood, in a large pro- portion of cases, is the medium of infection; for instance, in anthrax the bacilli seem to originate and multiply in the red blood-corpuscles, rendering them unfit to carry on their func- tions and thus causing death. More commonly, however, 1 Bacteria are simple, microscopic, vegetable cells, usually very minute, composed of protoplasm with perhaps an enveloping membrane. They multiply often with great rapidity by transverse division or by the formation of spores, the latter being vastly more resistant to destructive influences than the bacteria themselves. According to shape, they are divided into (1) micrococci, round or sphsero bacteria : (2) bacilli, or desmo-bacteria, rod- shaped bacteria ; (3) spirilla?, or spirochcstc? , spiral-shaped bacteria. The mi- crococci of pus occur singly or in irregular clusters called staphylococci, or in chains called streptococci. The forms most frequently found in the pus of acute abscesses are the staphylococcus pyogenes aureus and the streptococcos pyogenes albus. There are a great many other varieties of micrococci, but these are the principal. 16 NOTES OK MATERIA MEDICA. their action is by the generation of a poison, 1 as in septicae- mia. 2 Since the identification of the bacillus of Asiatic cholera, attention has been directed to the alimentary canal as the seat of generation of morbid bacteria. This disease and those of com- mon cholera, yellow fever, dysentery, cholera infantum, etc., are now supposed to be due to the development of bacteria in ,the intestines. The extraneous or accidental diseases due to the presence in the system of some form of organic life may be divided into two classes, each with its special distinctive marks : (1) the " com- municable"; (2) the "non-communicable/' I. Communicable Diseases. — In this class it is necessary that the disease shall have previously existed as such in an animal body, and its reproduction in the newly infected person be merely a succession of kind. Usually, infected animals communicate the disease to members of the same species, as man to man, but sometimes the disease is conveyed from man to animals and vice versa. The term "communicable " is used advisedly to desig- nate this class of diseases, in preference to the word "conta- gious/' for the derivation of the latter term conveys the errone- ous impression that contact is necessary to the spread of the disease. In former days, this impression was the cause of very dangerous confusion; for if a disease actually spread from one person to another, and yet did not affect those who touched the patient, it was not considered to be contagious, but 1 The word is here used in its stricter meaning. For definition, see ante, p. 12. 2 Septicaemia is a condition of the body produced by the presence of an ex- tremely virulent poison, the product of the growth of certain forms of bac- teria, which has a tendency to precipitate the fibrin-producing elements of the blood and to cause the formation of minute emboli. The poison is a definite chemical substance, devoid of life, and consequently producing effects corresponding to the amount absorbed. Septicaemia may be pro- duced by pyaemia. Pycemia is a condition of the body caused by the presence of morbific bacteria, which are capable of multiplying themselves to such an unlimited extent as to cause death, either physically by interference with the vital functions, or chemically by the production of a virulent poison. Pyaemia is never the result of septicaemia, but may cause it. DISINFECTANTS. 17 due to something in the air, and hence no precautions were taken. On this account, Asiatic cholera, a very communicable but not a contagious disease, carried off thousands upon thou- sands; but when this disease last appeared in New York, all houses were thoroughly disinfected, and the disease was stamped out with the same directness that firemen stop a conflagration. The virus of this disease (as well as of some others of this class), when it leaves one body, is not immediately ready to enter an- other, but seems to pass through an intermediate stage upon the surface of the ground or in the air; but it is just as communi- cable as that of small-pox, and no case of cholera occurs with- out the infection coming from one who has the disease. The word Geyser, and Hathorn waters of Saratoga, and the foreign waters of Kissingen. The disorders most benefited by saline waters are: 1. Piles : This complaint is an indication of an extremely slow portal circulation, the hsemorrhoidal veins being the ter- minal ones of the portal system. Saline waters, by stimulating the portal circulation, remove the cause, and thereupon the effect disappears. 2. Enlarged prostate gland: Whatever causes piles will eventually cause enlarged prostate (and when this occurs in a pa- tient over sixty years of age it is always dependent upon a slow 100 XOTES OX MATERIA MEDIC A. portal circulation), as a slow venous circulation always causes hypertrophy of connective tissue, owing to the inactive return current of the interstitial circulation. Hence saline waters are indicated to stimulate this circulation. They are also indicated for chronic cystitis and iveakness of the Madder. 3. Gynecological ailments, where these are dependent upon slow portal circulation, such as chronic congestion of the uterus, prolapse of the uterus, leucorrhoea, etc., and many of the troubles at the time of the menopause. If there is no wasting disease, saline waters may be given to enfeebled women. 4. Chronic Bright's disease : This structural degeneration of the kidneys comes on slowly, and nearhr always is the result of constant irritation of the kidneys for months or years by im- perfect intestinal digestion, especially of the nitrogenous ele- ments of food. In the nephritis produced by gout, we have distinct evidence of the genesis of Bright's disease; but this dis- ease is also caused by retrograde materials other than uric acid, many poisons being added to the circulation through imperfect intestinal digestion and other causes. 1 For instance, the coloring matter of the urine comes from the intestines, and one of the first evidences of this disease is not so much the appearance of al- bumin in the urine — for this is not always present — but the ab- sence of color, with persistent low specific gravity. If taken in its early stages before nutrition begins to suffer^ the further progress of this disease can often be prevented by a judicious course of mineral waters. 5. Chronic endarteritis: This general vascular disease, when coincident, as it almost invariably is, with Bright's dis- ease, is caused by chronic toxaemia, partly due to the imperfect action of the kidneys, partly to imperfect intestinal digestion, 2 the latter being caused in its turn by sluggish portal circula- tion. There can be no better preventive of this disease than a good course of saline waters, once or twice a year, in some cases every four months. 6. Chronic shin ailments, when dependent upon imperfect 1 See article on Intestinal Fermentation, p. 27. 2 Hence the importance of giving proper diet in this disease, fermented milk being the best form of food. MEDICINAL REMEDIES. 101 assimilation in the intestines. One very common, typical form, extremely annoying to those suffering from it, is redness of the nose, most marked after meals, and due to the formation of va- rious acids in the intestines from the absence or diminution of the digestive secretions. Local treatment will only benefit tem- porarily, a course of mineral waters being indicated to perma- nently cure this affection. This condition also occurs in some women at the time of the menopause. All forms of chronic ec- zema dependent upon a gouty condition of the system are bene- fited in the same way. 7. Chronic bronchitis, when the result of a lithasmic condi- tion of the blood. This form of bronchitis is often due to a family peculiarity, the gouty condition of the system manifest- ing itself in this form instead of chronic rheumatism or gout. At the beginning, there will be a cough, lasting only through the winter months, but it gradually encroaches on the remaining months of the year, until finally the patient has it all the time, resulting in chronic degeneration of the lung tissue, and ulti- mately general emphysema. Mineral waters should be given, not for the bronchitis itself, but for the bronchial irritation caused by the presence in the blood of poisonous substances. 8. Chronic gastritis, dependent upon interference with the return circulation from the stomach to the liver, and chronic sore throat, with chronic catarrh of the larynx or pharynx, are also benefited by saline waters made hot and sipped slowly, as this not only stimulates the portal circulation, but also stimulates the affected mucous membranes. If the complaint is tuber- cular, however, no benefit will be obtained. As ehminatives, alkaline waters enter the intestine, and, owing to their affinity for the water in the intestinal secretions, they arrest the osmotic circulation between the intestines and the blood-vessels, and therefore are sure to be sent out of the system, as they do not enter the circulation, and thus act as in- ternal enemata. ' On this account, alkaline waters are the least prostrating of all cathartics, as they abstract nothing from the blood, produce no nausea, and so are particularly recommended 1 See also article on Saline Cathartics, p. 242. 102 NOTES OX MATERIA MEDICA. for the removal of faecal accumulations and for chronic consti- pation. II. Alkaline or Purgative Waters. — These contain, besides chloride of sodium, a considerable amount of the carbonates of sodium and magnesium and other salts. They are more prompt and energetic in their action than the saline waters, but also more debilitating to the digestive functions. The most important domestic mineral waters of this class are the Bladon Springs, California Seltzer, Perry Springs, Alkaline Springs of Wisconsin, etc. ; Friedrichshalle and Hunyadi Janos being the most important foreign waters of this class. These waters are useful in the treatment of chronic rheumatism ; and in cases of diabetes where patients are not losing weight, alka- line mineral waters, such as Carlsbad, sometimes do good. As eliminatives they produce considerable purgation, particularly if taken warm, the movements being painless, unaccompanied by griping, and rapidly induced. III. Sulphurous Waters. — These usually contain, besides chlo- ride of sodium, a considerable quantity of the sulphates of sodium, calcium, and magnesium; and some waters of this class also hold sulphuretted hydrogen or metallic sulphides in solu- tion. The most important springs in this country are the hot springs of Kentucky, Michigan, and Virginia; Sharon, of New York; in England, the sulphurous waters of Harrowgate. This class is very useful in the treatment of that form of chronic rheu- matism which attacks the joints very slowly, ultimately, however, producing permanent distortion. These and the strong alkaline waters may be combined to counteract a tendency to chronic gout, the patient deriving benefit in proportion as he loses weight; but if the patient is already wasting, their exhibition must be moderate. These waters must be used with a good deal of dis- crimination, as they produce muscular prostration which may amount to paralysis, and accordingly are contra-indicated in fatty degeneration of the heart and where the arteries are atheromatous. IV. Chalybeate Waters. — These waters contain more or less salts of iron, principally the carbonate and sulphate. They a:e useful in those diseases for which iron is usually administered, but must be used with caution, as they very soon produce dis- MEDICINAL REMEDIES. 103 turbances of digestion and circulation, indicative of the system being overdosed with iron. There are several domestic fer- ruginous springs in Pennsylvania and elsewhere, the principal ones abroad being those of Tunbridge Wells, England, and the Spa, Belgium. V. Bathing Waters. — The remedial properties of baths, mineral or otherwise, have nothing whatever to do with the substances they contain. The effect of baths is to produce alkalinity of urine and other acid secretions, and to counteract the hyper- acidity of the blood, and this result will follow even if the bath be of vinegar; hence warm baths are of use in the treatment of chronic rheumatism. Warm- water baths are always prostrat- ing to the patient; but if salt is added, their depressing effect is to a large extent overcome. 1 Di vision II. — A Iteratives. Alterative medicines, or, as they are sometimes termed, specific medicines, are disease medicines which are unnatural to the system. Symptom medicines are also unnatural to the system, but they are not disease medicines. Restoratives are disease medicines, but they are not unnatural to the system. Alteratives are termed specifics, not that they have the property of acting specifically against any one disease, but because their range of operation is limited. They act in an unknown way, only against certain special diseases or morbid conditions. Thus potassium iodide acts promptly against syphilitic periostitis, but not to the same degree in other forms of periostitis; colchi- cum is the remedy for gouty arthritis, but not for rheumatic arthritis; and so with the other remedies of this class. These medicines are not given for the symptoms of disease, but for the disease itself; for they do not relieve symptoms except by re- moving the disease. Being unnatural to the system, they are therefore more or Jess poisonous , and this fact is to be re- membered, because, though all symptom medicines are also 1 See also article on Moist Heat, p. 287. 104 NOTES ON MATERIA MEDICA. unnatural to the system, yet complete recovery from the most active of them, like opium or aconite, is a quest. on of hours only, while recovery from the injury of organic poisons may be very slow. When the latter act as poisons they produce charac- teristic symptoms, such as salivation by mercury, or iodism, bromism, etc. The great rule to be observed in the administra- tion of these medicines is that they should never produce symp- toms. When they do so they cease to act as remedies, and the dose should therefore be lessened to that which does not cause symptoms, or else their use must be abandoned. Give these medicines up to the point of producing symptoms, to ascertain the dose, as, owing to personal idiosyncrasies, this may vary considerably in different patients. As their poisonous effects are both different from their remedial effects and inconsistent with them, if they are given for any length of time the danger confronts us of producing an artificial disease. An important rule, therefore, to be observed in their lengthened administra- tion, is to conjoin restoratives with them to postpone their poi- sonous effects as long as possible. The most important medicines of this class are: 1. Mercury. 5. Silver, 2. Iodine and compounds. 6. Zinc. 3. Bromides. 7. Copper. 4. Arsenic. 8. Bismuth. 9. Colchicum. I. Mercury (Hydrargyrum). Mercury is the most t} T pical of the specifics. Its precise action is unknown, but its use is sustained by clinical facts. Small doses have been found to increase the number of red blood corpuscles. Mercury appears to act by preventing their destruction. Uses of Mercury. As an Antisyphilitic. — Mercury is the only antidote against constitutional syphilis in all its stages, and the only medicine that will eradicate it from the system. The various prepara- MEDICINAL REMEDIES. 105 tions of mercury have been employed in the treatment of syphilis, calomel especially, as it is less likely to interfere with digestion. It is given in the form of powders containing one- twentieth of a grain each; two powders are taken three times per day for three days. On the third day, and every day there- after, increase one powder until the symptoms of mercurialization occur, which, in the case of calomel, are a metallic taste in the mouth and a disagreeable fetor to the breath; this will be fol- lowed by tenderness of the gums, the teeth becoming tender and apparently longer, and, if still continued, the mouth secretes saliva, which commences to run very profusely. Salivation should never be sought for, as it produces great constitutional depression and in some cases becomes almost incurable. There- fore in giving calomel it should never be pushed beyond the metallic taste in the mouth, and as soon as this symptom makes its appearance the close should be decreased one powder or more. This gradual testing of the susceptibility of the patient is very important in administering calomel. When given in this manner, the patient loses the unpleasant symptoms, gains in flesh and strength, and does not show that cachectic appearance so characteristic of syphilis when fully developed. He should only be conscious of the action of the medicine by the daily improvement which he experiences. In nocturnal syphilitic hemicrama, one-thirtieth of a grain of calomel every fifteen minutes often gives relief when the iodide of potassium has failed. When very rapid mercurialization is desired, inunction w T ith mercurial ointment should be tried. The skin should be thor- oughly washed with soap and water for at least ten minutes be- fore each application. The ointment should not be allowed to remain on the skin more than twenty- four hours, and after its removal the skin should be thoroughly washed again. The amount usually employed for each application is one half a drachm to a drachm. It should be applied, by preference, on the inside of the arms, on the thighs, and on the fore part of the body, rather than the back. The profession generally prefers the bichloride or the binipdide 106 NOTES ON MATERIA MEDICA. of mercury, as they are very reliable in their action and the least to be affected by personal idiosyncrasy. One-thirty- second of a grain of the bichloride or the biniodide is adminis- tered three times per day after meals, and the dose gradually increased to one-twenty-fourth, one-twentieth, one-sixteenth, etc., until symptoms of mercurialization appear, "which, in the case of the bichloride or the biniodide, are a disagreeable odor to the breath; more commonly there is a sense of pain and con- striction in the throat, and, coincident with this, in many cases there will be pain and griping in the bowels, cough accom- panied w 7 ith bloody expectoration, bronchitis with a tendency to bronchial haemorrhage, and, lastly, irritation of the kidneys with blood in the urine. Mercurial salivation produces profound constitutional pros- tration; this will not happen if proper treatment is adopted. In some cases of salivation, the teeth come out and necrosis of the jaw is produced. The best treatment by far is to have the mouth washed incessantly with chlorate of potash in camomile water ( 5 i. of camomile flowers to a pint of cold water, and three teaspoonfuls of chlorate of potash added to it). The patient should keep washing his mouth with this, and at times swallow a small quantity of it. Along with the bad taste in the mouth, and before salivation, some persons have griping of the bowels. If they do, salivation is arretted, but the constitutional effects of mercury are lost. This is quite noticeable in chronic poisoning by corrosive sublimate, and on that account it does not always produce salivation. The dose should never be carried beyond the production of a slight fetor to the breath. The mercurial treatment should be kept up for eighteen months to two years. When mercury is used for any length of time, it is necessary to give restoratives in order to prevent the development of any of the poisonous effects of the specific. The best for this purpose is quinine, which seems to make up the deficiency which mercury causes when given alone. Two grains of quinine should be administered in solution t. 1. d. either with the mercury or after it. Cod-liver oil may also be given if there is much anaemia, but it usually interferes with digestion in syph- ilitic subjects. Iron is sometimes required. Alcohol is always MEDICINAL REMEDIES. 107 contra-indicated in syphilis, and should only be given when necessary. Inflammation ivithout Suppuration. — Inflammation without suppuration may take place in any part of the body, and begins with hyperemia, followed by an increase in the number of proper cells of the affected part and fatty degeneration, and finally by a marked increase in the connective tissue, producing cirrhosis if the affected part is glandular in structure, or sclerosis in the nervous system. Coincident with the cirrhotic process in the organs and tissues of the body, the walls of the arteries and cap- illary blood-vessels become the seat of characteristic changes, consisting of chronic endarteritis, with an exudation of hyaline material on the outside of the blood-vessels. The coats of the affected vessels become very much thickened and their calibre diminished, and, in the case of the smaller arteries, the cavity is completely obliterated . This increase of connective tissue in the various organs of the body never occurs without injury to the proper cells of the part pressed upon, and as this shrinks the process goes on, and uses up what is left of the proper cells of the part inflamed, until there is ultimately nothing but a mass of fibrous tissue left. This condition of arterio-capillary fibrosis is a constant com- panion of chronic Bright* s disease, especially of the cirrhotic variety. This gives the hard, incompressible pulse of Bright's disease, and causes more or less derangement in the blood supply of the different organs. The diseased condition of the arteries is the commonest cause of apoplexy in Bright's disease, and interference with the circulation of the brain gives rise to certain cerebral symptoms which are the earliest indications of chron- ic Bright's disease and of threatening apoplexy: 1st. Impair- ment of memory, due to ansemia and malnutrition of the brain. 2d. Vertigo, especially in the morning just after rising. 3d. A persistent tendency to wake too early in the morning, sometimes with headache, which passes off soon after rising; the patient also suffers from cramps in the legs, especially in the calves, just after or before getting out of bed. 4th. A vague sense of fear, as of some impending danger. The intellect is dull and more or less impaired. 108 NOTES OX MATERIA MEDICA. Against this very frequent cause of declining health in middle life, producing premature old age, mercury is a constitutional medicine of the highest value. This is illustrated by examina- tion of the urine in cases of chronic nephritis. Albumin and casts are usually found, and also, a much more serious symptom, want of normal specific gravity, always low, 1.010-1 012, in this condition; the urine will also be of very light color. The first effect of the bichloride is to bring back the natural color of the urine. Urea is not the cause of uraemia, but it is the poison connected with the coloring matter. The color not only improves, but the specific gravity rises; it may rise to 1.018.. If these changes happen, the prognosis is generally good. Therefore, in all cases of chronic Bright' s dis- ease, cirrhosis of the liver, chronic affections of the lungs and pleura, chronic nervous diseases, chronic endarteritis, chronic meningitis the result of pachymeningitis or sunstroke, mercury is the remedy to be given; also in epilepsy traced to injuries about the head and characterized by muscular twitchings about the face and in the extremities at night. In locomotor ataxia and diseases of the spinal cord, mercury in constitutional doses should be given for a long time, one to three years if necessary. The following is useful in chronic interstitial nephritis: $ Hydrargyri Bichloridi, gr. i. Pulv. Digitalis, gr. xxiv. Pulv. Scillse gr- xxiv. Quininae Sulph., gr. xxiv. Misce et fiant pilulse No. xxiv. Sig. One pill three times per day. As a Symptom Medicine. — Certain preparations of mercury act as symptom or functional medicines, i.e., calomel, blue pill, and mercury with chalk (for their uses and actions, vide Cathar- tics and Diuretics). As an External Remedy, mercury is used in two classes of mor- bid conditions. 1. In diseases of the shin, due to animal or vegetable para- sites : scabies, favus, and inflammation of the follicles of the eye- lashes. The citrine ointment and that of the white and red precipi- MEDICINAL REMEDIES. 109 tate are very useful in these and other allied affections. Other forms of skin disease, though not of primary parasitic origin, are very much aggravated by the development of fungus spores, which cause decomposition of albuminoid substances with the production of acrid, irritating discharges. Thus herpes, psori-- asis, and rheumatic eczema may become very troublesome and obstinate from this cause. The oleate of mercury can be used to advantage in rheumatic eczema. The citrine ointment is, for skin diseases, diluted with equal parts of zinc ointment, and five grains of salicylic acid added to the half ounce. The oint- ment of the white precipitate may be used in full strength. When fibrous induration of a part results from chronic in- flammation, the local use of mercurials is often efficacious in promoting resolution. It seems to stimulate the interstitial cir- culation. If there is only passive engorgement remaining after the sub- sidence of inflammation, a mild preparation, such as the simple mercurial ointment, is best. But if the arteries are paralyzed, and there is a hard and shrinking exudation, the oleate of mer- cury is better, being a stimulant and acting as a counter-irritant. It is especially useful in orchitis and epididymitis, in rheumatic stiffening of the joints, and in chronic pleurisy ; the pleurisy in phthisis causes an exudation on the visceral surface of the pleura, and this soon communicates inflammation to the costal surface, and the two surfaces of the pleura adhere. Mercury by inunction should be employed in all cases of phthisis where pleuritic adhesions exist. As the bases of the lungs never get well after an exudation of chronic pleurisy, so in disturbance of the intestines, after chronic peritonitis, patients will never be well for the rest of their lives. There will always be a tendency to constipation, colic, frequent loss of appetite, notably in inflammations about the uterus, the result of cellulitis, with pain on either side about the ovaries. In these cases, mercury should be used externally in the form of the oleates. In pericarditis, the whole surface of the skin over the heart should be rubbed with the blue ointment, which is better for this purpose than the oleate. 110 NOTES ON MATERIA MEDICA. 2. The ointment of the red iodide of mercury is highly effica- cious in the treatment of pachymeningitis of the brain and spinal cord, and thus holds an important place in therapeutics, because there are very few remedial measures against this most serious trouble, which very often causes epilepsy, tonic spasms, paralysis, etc. In epilepsy with twitching of the face and ex- tremities during sleep, which indicate a cranial cause, viz., chronic meningitis, the ointment of the red iodide should be rubbed into the skull and nape of the neck. In cases of sun- stroke, meningitis following typhoid fever, pressure from in- flammatory exudation, and adhesions upon the train and spinal cord, apply the ointment of the biniodide to the skull, the nape of the neck, and down the spine. On account of its irritating properties, it should be applied during the daytime, so as to avoid disturbing sleep. It is also a good counter-irritant. It is also used in the treatment of enlarged thyroid gland, or goitre. This disease is endemic where the water is highly charged with magnesium salts. The ointment of the red iodide should be rubbed over the surface of the tumor and the patient exposed to the direct rays of the sun. One or two applications, al: hough sometimes leading to vesication, have been sufficient in many cases to cause disappearance of the enlargement. The metallic preparations of mercury are: Pilulse Hydrargyri, or blue pill; Unguentum Hydrargyri, or blue ointment; Hydrar- gyrum cum Creta, or mercury with chalk. The chlorides of mercury are two in number: The bichloride, or corrosive sublimate (dose, gr. 3V-2V) \ ^ s uses nave already been enumerated The subchloride, or calomel (dose, as an al- terative, gr. 3L— i.; as a cathartic, gr. v.-x.). Black wash (calomel, 3i.; lime-water, Oi.) is a very useful application to syphilitic skin eruptions. It can also be used to great advantage in many cases of skin disease of an indolent character with scaly surfaces; also in pruritus pudendal, and in affections generally of the skin and mucous membranes accom- panied by pruritus. Yellow wash (corrosive sublimate, gr. xxx. ; lime-water, Oi.). This lotion is very much more stimulating than the black wash, and has been used successfully in the treatment of syphilitic MEDICIXAL REMEDIES. Ill eruptions, condylomata, etc.; it can also be tried in pruritic affections of the skin that do not yield to other treatment. The iodides of mercury are two in number : The biniodide or the red iodide (dose, gr. fa-fa). The green iodide or the pro- toiodide (dose, gr. i~}). This preparation is inferior to calomel in the treatment of syphilis. The ointments of mercury are as follows: Unguentum hydrargyri iodidi rubri, or the ointment of the red iodide of mercury. Unguentum hydrargyri nitratis, or citrine ointment. Unguentum hydrargyri, simple mercurial or blue ointment. Unguentum hydrargyri ammoniati, or ointment of the white precipitate. The oleates of mercury are made by a solution of the yellow oxide of mercury in oleic acid. According to the strength of this solution will be its activity. A twenty-per-cent oleate is very irritating. The five-per-cent oleate is usually employed at first, and if no irritation occurs, then the ten-per-cent can be tried. Summary of the Uses oe Mercury. 1. As an antisyphilitic. 2. Against non-suppurative inflammations. 3. As a functional medicine. Certain preparations of mer- cury act as symptom medicines when given in one large dose. 4. As an external remedy, wiien fibrous induration of a part results from chronic inflammation; in diseases of the skin due to animal or vegetable parasites. II. Iodine (Iodum). Iodine is an elementary body obtained chiefly from sea weed. Its use as an elementary body in medicine is extremely limited, it being used more often in the form of a salt, i.e., iodide of potassium, etc. It is a specific, and although the least injurious of all the spe- cifics, j^et when taken in excess acts as a poison, and gives rise 112 NOTES ON MATERIA MEDIC A. to a train of symptoms known as "iodism." These phenomena are coryza with frontal headache, more or less suffusion of the eyes, constriction in the throat, and sometimes salivation, gastric uneasiness, and consequent loss of appetite. If its use is con- tinued still further, there will appear an eruption about the eyes and face, nervousness, debility, and even atrophy of mammae and testes. If the exhibition of iodide of potassium is continued too long and in excessive doses, gangrenous sores are apt to be formed. They first appear generally upon the legs as blisters on a red- dish base; when the vesicle ruptures, it reveals a gangrenous floor, which has a tendency to extend very rapidly. As soon as this is noticed, the use of the iodide must be stopped and quinine and opium given; if no fever is present, the muriate tincture of iron may also be given. Some persons are unable to use iodine in any form, small doses affecting them very dis- agreeably. When such idiosyncrasy exists, the exhibition of iodine is likely to do more harm than good. Uses of Iodine. 1. In scrofula : Iodine was early used in the treatment of scrofula in the form of Lugol's solution (iodine, 3 vi. ; iodide of potassium, § iss. ; water, Oi.). This is the best way of ad- ministering iodine in all scrofulous conditions. The patient should be kept under treatment for a longtime. The dose should not exceed six drops four times a day, given immediately after meals, as it is quite irritant when taken on an empty stomach; it should be well diluted with water. Its chief power lies in arresting mucous catarrhs, inflammation and ulceration of cartilaginous structures, and in hastening the resolution of adenitis and enlargement of lymphatics which follow disorders of mucous membranes in advanced stages of scrofula. These enlarged glands are usually in the neck, but in strumous girls it is not uncommon to find buboes in the groin, due to vaginitis and leucorrhceal discharges. MEDICLNAL REMEDIES. 113 In all these conditions the solution of iodine should be given in conjunction with cod-liver oil. The syrup of the iodide of iron and pills of the iodide of iron (Blancard's pills) can also be given; the latter are very good in conditions of anaemia. 2. In syphilis, secondary and tertiary, when the disease begins to attack the fibrous tissue, bones, and neuroglia and mem- branes of the brain and spinal cord, iodide of potassium should be given; and if the patient has not had a thorough course of mercurials, small doses of corrosive sublimate should be given with it. For the cure of syphilitic periostitis and the removal of nodes, no remedy is so reliable as the iodide of potassium, but it should be given in combination with an opiate, in order to relieve the pain, and, although the action of the neurotic is transient and purely functional, to assist and hasten the opera- tion of the specific, by relieving the symptoms, against the cause of which the disease medicine is directed. It is the iodide of potassium which removes a node, but when the pain caused by that node is removed by the opiate, the specific will act quicker and more certainly. In the use of iodide of potassium in syphilis, the rule is that the more chronic the disease the larger the dose, and the more acute the attack the smaller the dose, as such patients are apt to be intolerant of the drug. In the treatment of syphilitic periostitis, ten grains of potassium iodide, in combination with ten drops of the tincture of opium and ten to fourteen drops of the fluid extract of conium, should be given every four hours. Syphilitic periostitis may occur in the latter stages of syphilis, and then the original doses of potassium iodide will not be enough, the absorption of inflammatory exudation being slower from interference with the collateral circulation. Still more serious in every respect is the exudation when it oc- curs deeper yet, viz., within the cerebro-spinal canal. Upon the development of syphilitic meningitis, syphilitic gummat 'a with- in the cranium or spinal cord, and in all cases of syphilitic nervous disease, together with syphilitic endarteritis, ten-grain doses of potassium iodide have little or no effect. 8 ■114 KOTES OX MATERIA MEDIC A. The drug should be carried up to the point of toleration as quickly as in the treatment by mercury. Patients in this con- dition can take sixty to eighty grains at a dose where formerly ten to fifteen were sufficient. In all of those cases of chronic syphilitic disease threatening the patient with serious results on account of its location, use potassium iodide in heroic doses. Hence begin with twenty grains, then thirty, and rapidly increase the dose, watching its effects meanwhile. It should be always remembered that as it is a disease or organic medicine, and therefore unnatural to the system, its prolonged use in these doses will produce its poisonous effects,; always, therefore, give cod-liver oil and iron; if this is not well borne, quinine should be given, together with as much food as the patient can possibly take. 3. In chronic asthma and bronchitis, and in that form of spas- modic asthma which alternates with skin disease, or which, occurring in an adult, takes the place, as it were, of what would have been strumous complaints during childhood, iodide of potassium is very useful. The potassium iodide does not relieve an attack, but it dimin- ishes steadily the tendency to asthma in a very large proportion of cases not only of acquired but of hereditary asthma. The patient should be kept under the influence of the drug for a long time. Four grains of the iodide of potassium, and small doses of Fowler's solution (from two to four drops), and ten drops of the tincture of belladonna, with a teaspoonful of Hoff- mann's anodyne cr the compound spirits of ether, should be given four times per clay, largely diluted with water. In those cases where asthma is very pronounced and allied with bronchitis, the treatment should sometimes be varied by giving some other preparation of iodine, and the best for this purpose is the syrup of hydnodic acid, one teas]30onfuI corre- sponding to four or five grains of the iodide of potassium. It is not known how the iodide of potassium acts in curing asthma, except that in a very large proportion of cases it is found that patients when young have had symptoms of scrofula, sore throat, running from the nose and ears. A discharge from MEDICINAL REMEDIES. 115 the nose leads to nasal catarrh, and this leads to thickening and hypertrophy of mucous membranes and submucous tissue in this part of the respiratory tract. Now, it is an important rule that derangement of any exit of canal or tube always reacts upon the nervous supply of that tract, and frequently back of it. This persistent obstruction in the respiratory tract very often leads to disorders of the mechanism of respiration, and hence asthma is acquired. Specialists have demonstrated this in many cases. As we have said, asthmatic patients in childhood were scrofulous, and hence the nasal catarrh may have developed the asthma, so that the manner in which potassium iodide acts in asthma is. probably that it finds an old scrofulous tendency to deal with. The great danger in chronic bronchitis is that the air vesi- cles become very much enlarged, lose their elasticity, and ulti- mately become nothing but passive bladders; the blood-vessels become atrophied, and therefore the right side of the heart en- larged, with consequent congestion of the liver, kidneys, etc. Emphysema can be prevented, and, when moderate in degree, can be recovered from, by withdrawing the obstacle in the bron- chial tubes. The only remedy that is a true one, and not a mere palliative, is the iodide of potassium and the syrup of hydriodic acid, to be given in the same way as in the treatment of asthma, the two diseases being almost inseparable. 4. Iodine is useful in promoting the resolution of exudative inflammation, particularly in fibrous tissue. Unfortunately it is not so efficacious in periosteal and fibrous tissue due to other than syphilitic origin. It should be tried, however, in rheu- matic periostitis, but the results are not always certain. On the other hand, there are a few conditions where iodine can be used, as in tumor of the brain, where there is violent and continued headache and other indications of intercranial pressure, notably where symptoms are not febrile but due to a neoplasm. The administration of large doses of potassium iodide seems to moderate the symptoms. It is a question whether the preparations of iodine have any power over diseases of the arteries. Endarteritis is one of the commonest causes of decline of health, and finally of chronic disease of the system, indicated by high arterial ten- 116 NOTES ON MATERIA MEDICA. sion and an increase of connective tissue at the expense of higher tissues Mention has already been made of the use of corrosive sublimate in this condition, but in some cases the tincture of iodine (not potassium iodide) seems to act equally as well, and markedly so in those cases of chronic BrigM's disease with transient albuminuria, low specific gravity of the urine, absence of color, etc. The tincture of iodine, in five to ten drop doses, well diluted in water, after meals, should be given, and many cases respond well to it. 5. The iodide of potassium is the only medicine that has any kind of testimony in its favor in the treatment of thoracic aneu- rism, or in the treatment of all internal aneurisms that cannot be reached by surgical means. The only recoveries (not surgi- cal) have been when large doses of the potassium iodide have been given. Internal aneurisms of this class produce certain symptoms, due to their pressure upon adjoining nervous tissues, causing aphonia and disturbance of the larynx, characterized by cough and a peculiar croupy breathing. In all cases of this kind the iodide of potassium should be given, and frequently after a time the cough declines and the croupy breathing slowly disappears, though much later than the cough. In some cases, the aneurism stops dilating and shrinks in bulk, and in a few instances disappears altogether. In chronic mercurial and lead poisoning, the potassium iodide should be given in order to facilitate the elimination of the metal. Lead forms a compound with the muscular tissues, from which it is with difficulty removed, unless by the aid of potassium iodide, which is decomposed in the body to form the soluble iodide of lead. Electricity should be used in order to restore the contractility of the muscles. In acute tubercular meningitis, the only medicine which has ever done any good is the iodide of potassium. Externally, iodine is used as a caustic and counter-irritant. Preparations.— Potassii Iodidum; Liquor Iodi Compositus (Lugol's solution); Tinctura Iodi. medicinal remedies. . 117 Summary of the Uses of Iodine. 1. In scrofula. 2. In syphilis, secondary and tertiary. 3. In chronic asthma and bronchitis. 4. In exudative inflammations occurring in the fibrous tis- sue; in rheumatic periostitis; in cerebral tumors, with violent and continued headache and no fever; in endarteritis with high arterial tension. 5. In aneurisms of the thoracic or abdominal aorta. 6. Finally, in chronic mercurial and lead poisoning, also in tubercular meningitis. III. The Bromides. The bromides are recent medicines of this generation, and a very important addition to the materia medica, and, excepting quinine and opium, are used more largely than any other medi- cine. The action of the different bromides is so similar that they can be described under one, viz., bromide of potassium. Its medicinal power is due to its one action, that of diminishing reflex irritability by blunting the sensibility of the afferent nerves to all such impressions as would give rise to reflex action, which results in a motor phenomenon. If taken in large quantities, the bromide of potassium may arrest those reflex actions which are necessary to life. The one indication for the use of the bromides is exaggerated reflex action, whether it be due to abnor- mal irritability of the nervous centres or to the over-sensitive- ness of the afferent fibres. In its action it is not as rapid as the neurotics, but its effects are much more permanent. There are certain diseases which seem to depend on perversion of function or loss of equilibrium of nerve centres, aggravated and often caused by the persistent impressions conveyed by the abnormally sensitive joeripheral afferent nerves, inducing parox- ysms of convulsive character taking the form of tonic or clonic muscular spasms, with or without emotional disturbance. Epilepsy is the most noted example of this form of nervous dis- orders, and for the better understanding of the action of potas- 118 NOTES ON MATERIA MEDICA. sium bromide, which is the particular remedy to be used in this malady, a description of the disease will now be given. Epilepsy is a disease which assumes a variety of forms,, many of them unaccompanied by any severe outward systemic dis- turbance. But whether the external manifestations be pro- nounced or slight, it is always a serious disease, and many of the so-called slight attacks are ultimately as damaging in their effects as the more violent convulsive forms. The most common form of epilepsy, characterized by severe convulsions, is that termed epilepsia gravior, or le grand mal. The attack often comes on so suddenly as to render the patient incapable of having recourse to the most rapid of all the actions of the body, viz., the instinctive movements for self -protection. Other diseases may be rapid in their development, buD in none of them is the suddenness of an attack of epilepsy paralleled, and it may safely be said that, with the exception of diseases of an accidental nature, such as apoplexy, all diseases very sudden in their onset are epileptic. In many cases, there are pre- monitions varying in duration from five minutes to several hours. The most common of these preliminary sensations are termed aurse. They are varied in their nature and occur in all parts of the body. Sometimes there will be a peculiar sensation in the epigastrium, proceeding towards the brain, vaguely described by the patient as a breath of cold air; or there may be a modifi- cation of some one of the special senses or of some function connected with them. The patient sees curious sights — visual aura; or hears unusual sounds — aural aura; or the aura may consist of a peculiar taste or smell; or there may be aphasia; or, more strangely yet, the aura may be purely intellectual, curious ideas passing, through the mind. All of these aurse are a part of the epilepsy itself, and not simply the precursors of it. It is well to bear this in mind, for in many cases, after the continu- ance of the convulsive attacks has been broken by the use of the bromides, the occasional visitation of one of these aurae is some- times looked upon as an insignificant symptom — an erroneous idea, for this is an indication that the disease is still present, although in a latent form, and, unless appropriate remedies are used, the severe convulsions of the disease will reappear. MEDICINAL KEMEDIES. 119 Patients, therefore, should not be led to expect entire freedom from attacks of epilepsy until there have been no manifesta- tions of aurae for two years. A large number of these attacks commence by the patient emitting a dreadful, unearthly cry (caused by a sudden cramp of the diaphragm and of the muscles of the larynx), so pecu- liarly disagreeable in its nature as to frequently affect the domestic animals. This cry, whenever it occurs, is of itself an unmistakable sign of the disease. Along with this it is very common to have the jaws suddenly clenched, and, owing to its getting between the teeth, the tongue is not infrequently bitten. This is a valuable diagnostic sign, especially in those cases where the patient has attacks during the night of which he is uncon- scious, or where he imagines that he has only had a fainting fit; for whenever the tongue has been bitten, there has been severe convulsive epilepsy. A form of this disease, called the Jacksonian, always begins in a certain group of muscles, from whence the convulsions develop. There is generally pallor of countenance, but on account of the muscles of the neck, from their violent contraction, pressing upon the great veins of the neck, this is rapidly followed by turgescence. Eespiration for the same reason sometimes becomes of a gasping character, giving the appearance of strangulation; and the eyes, when they are not performing irregular movements, are turned upward. Occasionally, in these cases, the sphincter muscles are in a state of relaxation — not on account of the violent muscular movements, for it sometimes happens in slight attacks — and the patient passes urine and faeces, If, therefore, from the time he was a child, a patient had not, till recently, suffered from nocturnal incontinence of urine, it is quite probable he has epi- leptic attacks during the night. Gradually, during the course of an attack, the convulsions cease, the patient passes into a state of coma with stertorous breathing, and finally returns to consciousness with a feeling of exhaustion and usually with some expression of surprise. So much for the convulsive form, regarded by many as the only true form of epilepsy; but unfortunately this malady may occur without any convulsions whatever, and, therefore, it is not correct 120 NOTES ON MATERIA MEDIC A. to define it as a convulsive disease. Thus a very common form is where there is only a slight pallor of the countenance, the pa- tient rarely falls, never suddenly, the other symptoms are all slight, and he soon recovers from the attack, a little depressed and often with a tendency to excessive micturition. This is called epilepsia mitior, or le petit mal; but it is not mild or slight, as its name suggests, as, on the whole, it has a more destructive effect upon the mental powers than the violently convulsive form. In another form of the disease the patient does not lose conscious- ness; again in others, instead of falling, he performs many actions which seem to imply that he is in command of voluntary move- ments. This is so only in a limited sense, for his actions re- semble those of a somnambulist. This form is called co-ordinate epilepsy. The attacks are very sudden in their onset, and are truly epileptic; for attacks of le petit mal and of co-ordinate epilepsy frequently alternate with convulsive attacks. Another variety is where the patient, after the attack, which may or may not have been violently convulsive, is seized with a furious ho- micidal mania of which he subsequently remembers nothing. The definition of epilepsy may now be considered. It cannot be defined as a convulsive disease, for many patients with this malady have no convulsions ; nor as a disease in which the pa- tients fall, for in some forms they walk about during the seizure; nor as a disease characterized by total loss of consciousness, for this does not always happen, the patients sometimes going through very complicated intellectual processes; nor as a disease which abolishes either the motor or sensory powers of the body. What, then, is the definition ? Epilepsy is a disease characterized by sudden, transient, recurrent loss of function on the part of one or more cerebral centres, which loss of function deranges other nerve functions dependent upon it or them. Some writers, from observing the manner in which the con- vulsions of epilepsy radiate, say they are due to over-stimulation or over-excitation of the motor centres in the cortex of the brain. But they may be explained on quite another principle important to understand, for upon its thorough comprehension depends the correct treatment of the disease. In these convul- sions, we have an illustration of the fact that no nerve centres MEDICINAL REMEDIES. 121 ever act independently. For the beautiful co-ordination of the various movements of the body, all the nerve centres are related, to each other and made mutually dependent. Normally, all move- ments are proofs of regulated discipline, no centre acting before the others are ready. The sudden arrest or derangement of the function of any one of them disturbs the ordinary interaction and suspends or deranges the functions of the others. For il- lustration, what happens when a steamship is violently shaken from stem to stern on account of the screw having been lifted out of the water by a large wave? Has the screw been over- stimulated? No. The shaking was caused by the screw being withdrawn from the force against which it usually acted. In like manner, if the motor impulses are removed from the control of the inhibitory centres of the brain, convulsions follow. Or, to take another illustration, upon the mutual pressure of the stones of an arch depends the integrity of the arch itself. Suddenly remove one of the stones upon which the others depend, and the whole comes down with a crash. Have these stones been stimulated or over-excited? No. So with convulsions. They are due, not to over-stimulation of the centres, but, as already stated, to disturbance of their ordinary mutual interaction. Nervous action, unless originated, by the will, never occurs spontaneously, but always depends on some afferent impression which elicits it. Epilepsy is consequently invariably due to derangement of the nerve centres caused by unaccustomed af- ferent impressions being transmitted to them which lead them to act irregularly. If the derangement occurs in the motor centres, there will be convulsions ; if in the intellectual centres, there will be intellectual disturbance but no convulsions; if the automatic centres are affected, they will be withdrawn from the control of the intellect, and the actions of the patient will then resemble those of a somnambulist. It is very dangerous, there- fore, to create new impressions in any part of the body, for they may occasion epilepsy. For instance, the washing of the thora- cic cavity in cases of suppurative pleuritic effusion has given rise to epileptic convulsions, in some cases so uncontrollable, even by chloroform, as to terminate fatally. The most careful autopsies have failed to discover any lesion in the brain, or 122 XOTES OX MATERIA MEDIC A. spinal cord, so these curious cases of epilepsy must be due to unaccustomed surface impressions' deranging the nerve centres. From what has been said it necessarily follows that in the treat- ment of epilepsy careful search should always be made for abnor- mal surface impressions, and every effort be made to remove them. Often this afferent irritation is from within the cranium itself, e.g., meningeal irritation, occasioning twitching of the facial muscles, especially during the night, and the attacks invariably commencing in the same way. Eemove the cause of the irri- tation by trephining. Or the same symptoms may be due to malformation of the skull causing adhesions, which should be removed by corrosive sublimate. Intestinal or stomachic irri- tations are also frequent causes of epilepsy, and so is the rapid swallowing of food, the incessant action of the epiglottis irri- tating the nerve centres. Wherever the irritation is situated, in the nose, eyes, bowels, genito-urinary tract, or elsewhere, it must be removed before the disease can be effectually dealt with. Treatment of Ejjilepsy. — The greater proportion of the ordi- nary movements of the body are excellent illustrations of the excito-motor function of the nerve centres. As an example we may take the act of winking, which usually is purely reflex. This action can be prevented in three ways: (1) by severing the branches of the fifth nerve which convey the sensory stimulus calling for the act of winking to the nerve centres; (2) by para- lyzing or blunting the sensibility of the nerve centres by a neu- rotic; (3) by severing the branches of the seventh nerve govern- ing the muscles which move the eyelids up and down. Now, the bromides have the remarkable property of paralyzing periph- eral sensations. A patient, therefore, under the influence of these drugs, of which potassium bromide is by far the most im- portant, has a peculiarly dull, meaningless stare, because those peripheral impressions which lead to reflex action have been paralyzed, and therefore the patient does not wink, because no stimulus to do so reaches the nerve centres. It is doubtless to 1 The pleural nerves in a closed cavity never felt the sensation of wash- ing. Similar fatal attacks of epileptic convulsions have followed washing out the stomach. MEDICINAL REMEDIES. 123 this property that potassium bromide owes its efficacy in the treatment of epilepsy, for it paralyzes those peripheral irritations leading to the convulsions and other manifestations of this dis- ease. But it is as if we were watering a small garden-bed by turning a whole river upon it; for, in giving potassium bromide to prevent epilepsy, necessarily the greater part of the normal reflex excitability of the body is also lessened. If given in excess, the patient has no vivacity, he is slow and staggering in gait, and his movements generally are sluggish because the brain is not receiving the proper stimuli; the memory also is im- paired, though the mind is never permanently affected by the use of the bromides; the blood is impoverished, and there is a tendency to oedema and to hemorrhagic extravasation under the skin; an acne-like eruption of very disfiguring pimples appears on the forehead and elsewhere. There will also be sali- vation. If these symptoms are allowed to continue, the epilepsy returns in a more incurable and obstinate form than originally. But this need not happen, for if given carefully the bromides may be continuously administered for three or four years to stave off the attacks of epilepsy, without causing any permanent injury to the patient's health. As concentrated solutions of potassium bromide are very irritating to the stomach and apt to cause gastritis, with consequent disturbance of appetite, which is by all means to be avoided in this disease, the drug should always be freely diluted with water, and the stomach should contain sufficient food to cause a flow of the secretions. A little milk may therefore be given with the bromide. Cod-liver oil should always be given, as it is the great preventive of the injurious effects of the bromide, and with it some p eparation of phosphorus, e.g., syrup of hypophosphites acidulated with phosphoric acid. This is an excellent adjuvant, especially for preventing the acne. (Where this last symptom is severe, give at the same time small doses of Fowler's solution, and, to free the secretions of the sebaceous glands, have the skin well washed with tar soap and warm water. ) Moreover, as the action of every constitutional medicine is assisted by combining with it a symp- tom medicine, neurotics which deal exclusively with symptoms of disease may be administered, as for a short time they also are 121 notes ox materia medica. paralyzersof reflex action. The best for this purpose is chloral, which has much the same action as the bromides. Another adjuvant which may be given is alcohol. As a rule it is not very desirable to give this to epileptics, but in certain cases it does a great deal of good, especially where, as in nocturnal cases, the attack comes on at a particular time in the twenty-four hours, If the attacks are always nocturnal, Hoffmann's anodyne may also be added. If the attacks occur in the early morning, they are caused by the emptiness of the stomach. Give the patient food just before the expected attack, and with it administer the medicine. This treatment will break up the systemic habit engendered by a long continuance of the disease. ]$Kal. Bromidi, 3 iv. Chloral, 3 iss. Spts. Frumenti, | iv. Aqua?, ad § vi. M. Dose, tablespoonful t. i. d., in half -tumblerful of water. If the patient has nocturnal attacks, give half-dose in forenoon, half-dose in afternoon, and double the dose at night; and if the attacks are always nocturnal, add 3 i. of Hoffmann's anodyne. Potassium bromide is more successful in those cases subject to severe convulsive attacks than where this is not the case. The great majority of the former class of cases can be cured by this remedy properly administered with its adjuvants, but it is not so efficacious where the external manifestations of the dis- ease are not so pronounced. However, in all cases of epilepsy give the bromides in one form or another, and remember that the disturbing afferent impression is to be remedied. At the same time with the use of bromide of potassium in epilepsy, at- tention must be paid to the diet. The pyloric sphincter of the stomach is relaxed or semi-paralyzed, and food rapidly passes into the small intestines, which are also in a relaxed condition; this condition causes the ravenous appetite of the patient, and the tendency to "bolt" his food without properly masticating it. Animal food aggravates this condition, and should be pro- hibited; but if any is taken, it should be in the morning and not at night. Fish, milk, and eggs may be allowed. MEDICIXAL REMEDIES. 125 The Bromides in oilier Diseases. — Nervous irritation proceed- ing from the pelvic viscera, particularly from the genito-urinary tract, produces an extremely depressing effect upon the system, the patients having an impression of impending evil. A clean, incised wound in the perineum, of only an inch in length, often seems to cause more shock to the system than the amputation of a limb. Not infrequently, from the extreme depression of the heart, there will be cardiac vomiting and uncontrollable nausea — a grave sign of speedy dissolution. If any disturbance occurs in the pelvic viscera, the abdominal viscera sympathize, as shown by the normal function of pregnancy causing nausea and vomiting. For all troubles due to pelvic irritation the bro- mides are to be given as sedatives, and hence are to be used for any nervous condition caused by irritation of the Madder, ute- rus, or ovaries, for spermatorrhea, etc., and, as a stimulant ad- juvant, alcohol or ammonia should be combined with them. In hysteria, hypochondriasis, etc., the bromides may also be given, not steadily, but simply to lessen the nervousness. Bromide of sodium (dose, gr. xxx.) often answers as well as the bromide of potassium (dose, gr. xv. ) for this purpose. Occasionally pel- vic disturbances give rise to what gynaecologists term a ute- rine cough — a loud, barking, non-expectorant cough, occurring whenever the patient is excited. For this trouble bromide of ammonium answers very well indeed, as it has an effect on the bronchial nerves peculiar to itself, and on this account it is also useful in icliooping -cough. In tetanus, the spinal cord is in such an irritable condition that the smallest irritation, as a puff of cool air or touch to the skin, will induce generalized and violent muscular spasm out of all proportion to the exciting cause. Bromide of potassium has been used in this disease with good results, but its exact value has not been determined. During the first dentition the irritation which is set up by the tooth which is coming through gives rise to reflex pain in the ear and to suppression of gastric and intestinal secretions, and secondarily to acid vomiting and diarrhoea (due to fermenta- tion), and sometimes convulsions. In a majority of cases this reflex action is due to the pressure of the tooth on the jawbone,. 126 NOTES ON MATERIA MEDICA. and consequently the lancing of the gums should not be resorted to unless there is unusual swelling and tension. Bromide of potassium should be given, not to relieve the pain of the tooth, but to overcome the reflex irritability, and, by removing the cause of the suppression of gastro-intestinal secretions, arrest the vomiting and diarrhoea (dose in these cases, gr. v.-vii.). In health, there is a physiological association between the movements of the stomach and rectum, due to reflex action of the muscular coats of one upon the other. Thus, when food is taken into the stomach, there is a tendency for the rectum to discharge its contents, and, at the same time with the discharge of its contents, for the partially digested food to pass through the pyloric end of the stomach. In chronic dysentery, this reflex action is abnormal. The mere taking of a small quantity of food into the stomach causes the rectum to act, and the undigested food passes through the pyloric end of the stomach and rapidly through the small intes- tines, and in the stools there is present the odor of the food. This interferes greatly with nutrition, and causes emaciation, especially in children. The indication in dysentery is to blunt the sensibility of the afferent nerves of the rectum, and so pre- vent paralysis of the pyloric end of the stomach. If the stomach will not bear the necessarily large doses, it may be given in enema per rectum, combined with laudanum. It may be given by the mouth, if it does not derange the stomach. It is often difficult to make a laryngoscopic examination on account of the persistent gagging of the throat, and sometimes vomiting, which ensues whenever the uvula or the walls of the throat are touched. This reflex action can be overcome by administering thirty grains of the bromide half an hour before the examination. The bromides, by blunting the sensory impressions and thus allaying nervous irritability, act indirectly as soporifics; for many cases of insomnia are due to irritability of the surface nerves from over-fatigue, mental or physical, as in women after parturition. Alcohol, ether, and Hoffmann's anodyne greatly assist the soporific effect of the bromides. Dysmenorrhcea, attended with headache and other disturb- MEDICINAL REMEDIES. 127 ances, is often relieved by the use of the bromides, and by placing the feet in hot water. Preparations. — The bromides commonly used are those of potassium, sodium, ammonium, and lithium. The bromide of potassium is the most effective as a reflex paralyzer; next, the bromide of lithium; and lastly, that of ammonium. Fifteen grains of the bromide of potassium will produce the same effect as thirty grains of the bromide of sodium or ammo- nium. The disadvantages of bromide of potassium are that it pro- duces bromism much sooner than the other salts; it is more depressing on the heart than the bromide of sodium, which can be taken for a longer time. The bromide of potassium, being taken up by the red blood- corpuscles, is apt to cause anaemia when given in excess or for too long a time. The bromide of sodium is found only in the liquor sanguinis, and is to be preferred in the treatment of deli- cate women. In epilepsy, the bromide of potassium acts much better than the other salts, and is the only one that should be given. It should be given in large doses until symptoms of bromism appear, and the amount which just falls short of producing these symptoms is to be taken as the dose and given three times a day. Some patients require forty grains, others sixty, others ninety. The last quantity is usually well borne in severe cases. Small doses are of no account. IT. Arsenic (Arsenium). Arsenic ranks among the most virulent of all poisons, being very similar in its local and constitutional action to corrosive sublimate, and characterized, like the latter, by producing fatty degeneration, beginning with the glandular and extending to the muscular tissues of the body. Particularly will there be fatty degeneration of the liver and kidneys where there is chronic arsenical poisoning. These two organs show their degenera- tive processes together. It also attacks, by the same morbid 128 XOTES OTs MATERIA MEDICA. process, the peripheral nerves, producing arsenical paralysis. The central nervous system, as a rule, is not involved, although in many cases the symptoms closely resemble those of central paralysis. Mercury and phosphorus also produce fatty degen- eration. Phosphorus should not be administered without some caution. Its continued administration leads to a form of jaun- dice which may become serious, the disease not only being functional but textural. Phosphorus should be given with more caution than any other of the restoratives. The latter are natural to the system, and an excess is merely overfeeding the patient; but with phosphorus its natural form is not the same as when taken into the system in the food, and it acts in the same way as mercury, arsenic, and antimony. All of these medicines, in small doses, have a singular effect upon the blood, appar- ently increasing the red blood-corpuscles. It is not believed that they increase their formation, but prevent their destruc- tion and elimination. 1. As anAntiperiodic. — In pernicious ancemia. there is a steady decrease of the red blood-corpuscles. This disease is peculiar in its character, and not to be confounded with anaemia of other diseases. It has lately been shown that in this disease there is a great accumulation of iron in the liver, due to the destruction of the red blood-corpuscles, which leave behind them their iron. This destruction occurs in the portal circulation, and there- fore is not due to changes throughout the system. In perni- cious ansamia, no medicine that increases the formation of red blood-globules has any effect. Arsenic delays their destruction and is effective. It can also be given to prevent the destruction of the red blood-corpuscles in malarial disease of the liver, and where the. liver is deranged owing to the poisonous effects of sewer gas. This resembles malaria, except that there is no de- cided periodicity, although there are all the other symptoms of malaria. Arsenic has long been employed in the treatment of malaria, and where quinine fails it ought to be used. It operates in an entirely different manner from quinine. The latter is generally employed during interfebrile times. Arsenic can be administered at all times without reference to when the MEDICINAL EEMEDIES. 129 disease comes and goes, and can be given three or four times a day. In the treatment of intermittent fever, it should be given up to the point of producing a slight nausea, but should not be given too long. Fowler's solution (the most definite way of administering arsenic) can be given in doses of from six to twelve drops three times a day, and in some cases more, with this result: if the pa- tient improves, he remains well for a longer time than when treated by quinine. No case, however, of ague gets well under twenty-eight days; but it can be eradicated apparently better by arsenic than by quinine, owing probably to the former being a better germicide than the carbolic-acid class. Eelapses in ma- larial fever are the exception after having been treated by arse- nic. The French army have adopted this treatment for inter- mittent fever in certain parts of the sea coast of Algiers. One drop of Fowler's solution is given every fifteen minutes, and w r hen this produces nausea it is given per rectum. It is claimed that this is more successful than the treatment by qui- nine. This is probable, as the fever interferes with absorption of quinine, the portal circulation being so slow that it has very slight absorptive powers, and, as a result, a large quantity of the quinine is lost. Arsenic is also used in cases of chronic mala- ria, where quinine has been tried without success; notably suc- cessful in cases of neuralgia and headaches of malarial origin. To be successful it must be given for a long time (three to six weeks). When it breaks up the paroxysms of ague, it does not do so at once; the patient will keep on having chills, but each time they will be less severe, much shorter, no sweating, and so gradually decline until there is no fever at all. Quinine, on the other hand, to succeed, must totally abolish the paroxysms. If they recur, no good can be expected from quinine. 2. Arsenic is also a great remedy for irritative conditions of the stomach, when there is vomiting due to gastritis of a chronic kind, as of drunkards, and vomiting due to any obstinate cause except a cerebral one. Arsenic may be given in small doses, one-half to one drop of Fowler's solution, no more. This works like a charm. Also in the vomiting of pregnancy the same doses should be used. Sometimes one drop doses of the tincture of 9 130 NOTES ON MATERIA MEDICA. iodine are equally successful in the treatment of vomiting when due to the stomach itself or in pregnancy. Arsenic, though difficult to explain how, acts as a specific in cjastralgia. Many forms of this complaint are characterized by sudden violent attacks of pain, producing deathly faintness, without signs of inflammation, gastric ulcer, or peritonitis, and will recur periodically once or twice a year. It is due to some derangement of the sympathetic system of nerves, similar to enteralgia, which attacks the flanks on either side, and evi- dently is located in the abdominal plexus. Sometimes there are also pains in other parts of the body that raise suspicion of loco- motor ataxia, and sometimes they are the premonitory symptoms of that disease. For these attacks, arsenic is the remedy. It is best given in the form of arsenious acid (dose, gr. ^), in pill form with the extract of gentian, repeated every hour. 3. In Chronic Diseases of the Skin. — Organic or disease medi- cines are not beneficial in acute diseases, so arsenic is not to be used, as it almost invariably aggravates skin diseases of an acute character. The case must have lasted at least six weeks before beginning the treatment by arsenic. It must not be given in an acute disease, nor in acute exacerbation of a chronic disease. Arsenic is the remedy for scaly skin diseases, psoriasis, lepra, etc., which are very serious skin diseases and are often hereditary. They are relieved by arsenic and one other medicine which should always be combined with it — liquor potassaB. It ranks about equal to arsenic in chronic skin diseases, particularly scaly ones. In the treatment of those diseases, arsenic can be given for weeks and weeks, carefully looking out for symptoms, and along with it liquor potassas should be given ; sometimes the arsenic can be dropped, and reliance wholly placed upon the liquor po- tassaB. In these cases, large doses of the liquor potassaB can be given, though patients vary remarkably as to the dose they can take — as a rule one-half drachm of the liquor potassse and an equal amount of the elixir cinchonaB to be taken one hour after each meal ; then increase to one drachm, then to a drachm and a half and up to two drachms, and some authorities recommend six or seven drachms at a dose. It should be diluted with a consider- able amount of water. This is a great adjuvant to arsenic, and MEDICINAL REMEDIES. 13 L particularly good in many forms of skin diseases where arsenic does not do good alone, as in eczematous cases. 4. Along with scaly skin diseases, there will be trouble with mucous membranes, as might naturally be expected. In these cases, there will be a tendency to asthma and alternate bronchi- tis, chronic bronchitis, and chronic emphysema. There are only two remedies for this trouble, iodine and arsenic, so that in every case of asthma the treatment should be with arsenic and iodide of potassium, and give belladonna as an adjuvant. The following will be found useful in hay asthma, and should be given for two months before the expected attack, which usually takes place, in New York City, on August 20th: 'Sf Liquoris Potassii Arsenitis, 3 vi. Tincturae Belladonna, q. s. ad § iij. M. Sig. Begin with nine drops in water one hour after meals; after a week increase to twelve, after another week to six- teen, and after another to twenty, provided there are no symp- toms of poisoning by arsenic developing. This course of treatment should be commenced about June 1st and continue to August and up to the time for development of the disease. In the first year there will be less of the asthma, in the second year very little if any, and the third year is sufficient to break up the constitutional tendency to this trouble. Arsenic should be given in chronic bronchitis and in cases of ordinary asthma in the same way as recommended for slow diseases, with the help of a certain class of restoratives to be mentioned later ou. Another condition with a tendency to asthma often occurs in women, viz., dysmenorrhea, particularly in families subject to these scaly skin affections. Arsenic is of great service in dys- menorrhcea, inducing a more healthy condition of the mucous membrane of the cervix uteri, and in preventing spasmodic action and closure of the canal by the mucous membrane. Other forms of dysmenorrhcea are not benefited by arsenic. 5. Chorea is a disease dependent upon the rheumatic poison acting in that form in early life, and, like rheumatism, gets well of its own accord. This is a serious complaint, having a tendency to produce heart disease, and leaving behind it weak- 132 NOTES ON" MATERIA MEDICA. ness of the nervous system. Arsenic should be given i:i full doses, children being able to bear it better than adults. In eczematous diseases of the shin, arsenic is good, but not so markedly as in scaly affections. In papillary diseases, as acne, arsenic is quite inferior in its effects to those produced in the other two classes of skin diseases already named. Nevertheless it is still used in the common form of acne, where the small papules are not much inflamed, but should not be used where there is inflammation and a tendency to the formation of small boils, local treatment being better here. This disease, in some cases, is very disfiguring. There is a very close relation between acne and irritation of the genito-urinary tract, there- fore hot-water vaginal injections, with a little borax and pepper- mint or menthol, should be used. This acne may also occur in young men, not dependent at all upon anything immoral. These cases should be treated by passing a cold sound through the urethra into the bladder. The sound should be thoroughly dis- infected, and passed twice a week. Toxicology. — The medicinal and the poisonous doses of arsenic differ widely. The first symptom noticed is a sense of weight and discomfort in the epigastrium, very much resembling gas- tritis, then pronounced nausea; intestinal disturbances, with griping, which may or may not be accompanied by slight loose- ness of the bowels. After this commence the constitutional symptoms, first manifested about the eyelids, which become swollen and puffy, and are more or less stiff when closed or opened. Then a sense of numbness and tingling, most pro- nounced at the tips of the fingers, owing to the beginning of fatty degeneration in the peripheral nerves. This may also involve the tongue and the lips. Lastly, a sense of faintness. The heart begins to beat feebly, and in some cases there are attacks of syncope. The medicine must be stopped or the dose diminished at the first symptom of gastritis and nausea. When numbness and tingling, with swelling of the face, are present, the medicine should be given up altogether or the dose greatly diminished. Where no symptoms are present, it is quite cer- tain that no harm is being done, although continued for several weeks or months together. MEDICINAL REMEDIES. 133 The chemical antidotes to arsenic are freshly prepared hy- drated sesquioxide of iron and magnesia freshly calcined. Preparations. — Acidum Arseniosi (dose, gr. -^""fj)- Liquor Potassii Arsenitis, or Fowler's solution (dose, usually about gtt. iv.). Liquor Arsenici Hydrochlorici (or the Liquor Acidi Arse- niosi); this preparation is very well borne by the stomach (dose, gtt.iij.-vi.). Clement's Solution of the Bromide of Arsenic (dose, gtt. iij.). This last preparation is very powerful, and is recommended in the treatment of diabetes. It answers admirably in dimin- ishing the sugar, and also gives muscular strength to the patient, great weakness being one of the chief symptoms of this disease. Summary of the Uses of Arsenic. 1. As an antiperiodic. 2. In chronic gastritis and gastralgia. 3. In chronic skin diseases of a scaly nature, combined with liquor potassse. 4. In asthma, chronic bronchitis, chronic emphysema, and hay asthma. 5. In chorea. 6. For dysmenorrhea occurring in women who are subject to scaly skin diseases, also in acne where there is no tendency to inflammation. Y. Silver. This substance is used in medicine principally in the form of the nitrate, the most convenient and best preparation. As it is an organic medicine, any disease benefited by it is a serious one. It is particularly effective in those nervous disorders dependent upon organic disease of some part of the nervous tract, giving rise to violent neuralgic pains, which are sooner or later followed by local anaesthesia. A typical disease of this kind is locomotor ataxia, the most protean of all nervous disorders in its manifes- tations. In some cases, it begins in disturbance of the bladder, or with violent pains in the bowels or side, more commonly in the left side, and referred, perhaps, to the region of the heart; • 134 NOTES ON MATERIA MEDIC A. other patients lose their voices and have a peculiar sensation about the larynx from involvement of the laryngeal nerves, while others may have nothing else for years but intermittent attacks of vomiting and prostration, with perhaps palpitation of the heart. The vomitiug induced by this disease may be known by the absence of the local symptoms of tenderness, tumefaction, sense of heaviness and pain, and by the diminished or absent tendon reflex and permanent contraction of the pu- pils of the eye. Fulminating pains are also characteristic of this disease, indicating that it is organic and leading to sclerotic change. Nitrate of silver relieves these pains better than the anodynes, and for the time apparently cures the disease. It should be given intermittently, as the long-continued use of this drug produces a ghastly discoloration of the skin. The pains of angina pectoris, probably due to degenerative changes in the intercardiac ganglia, are also occasionally relieved by the nitrate of silver. Before the introduction of the bromides, it was the favorite remedy with many physicians for epilepsy; and where this is dependent upon constant organic irritation, it may still be given with some benefit, notably in epilepsy accompanied by severe headache. A dose of one-quarter grain an hour after each meal may safely be given for six weeks, when its use should be discontinued for a similar period, or even longer, and then given again. This substance is also a very powerful astringent, and hence is one of the best remedies in the treatment of chronic dysentery. It should be combined for this purpose with a sub- stance that does not dissolve readily. I£ Argenti Nitratis, gr. \. Pulveris Opii, . gr. J. Terebinthinae Resinae, gr. ix. Bismuthi Carbonatis, gr. ij. M. et ft. pil. No. iii. (If nitrate of silver cannot be taken, sulphate of copper may be substituted.) Its use has also been recommended in pachy- meningitis, myelitis, paralysis agitans, and those forms of vaso- motor depressions characterized by violent palpitations, frequent flushings, and perhaps permanent dilatation of the arteries of certain parts, in consequence of derangement of the cardio- MEDICINAL REMEDIES. 135 inhibitory mechanism, and of the centres which control the calibre of the arteries. This condition is met with in some forms of Graves' disease or exophthalmic goitre,' though it may exist independent of thyroid hypertrophy. (For the uses of nitrate of silver as a caustic, see p. 268.) YI. Zinc. This substance, when given as a medicine, is generally admin- istered in the form of the oxide. Its use is restricted to nervous disorders, particularly to two, chorea and muscular tremors. In chorea, the larger the dose the more quick and effective will be the result. Small doses are useless. Commence with two- grain doses of the oxide in pill form, three times a day, and gradually increase until the dose is five grains. If the patient can take the latter amount, the chorea will be relieved in a week. If no effects are shown, its use may as well be discon- tinued. It may be given until there are symptoms of dyspepsia, nausea, and the patient has a metallic taste in the mouth. The oxide is to be preferred to the sulphate of zinc, as the latter gives rise to nausea in doses larger than three grains, while the former does not. Tremors are of two kinds: (1) those caused by muscular ex- haustion, as from carrying loads that are too heavy; (2) those due to positive organic mischief in the peripheral nerves or in the nerve centres. If the cause is in the nerve centres, as in paralysis agitans, exertion of the will can temporarily stop the tremors; if the cause is peripheral, exertion of the will increases the tremors. Zinc oxide very decidedly diminishes peripheral tremors, which most commonly are dependent upon alcoholismus or caused by mercurial or arsenical poisoning. It may be given, therefore, to counteract the effects of a drunken debauch, as shown in tremor of hands, etc. On account of its soporific properties it is also a good remedy for the insomnia of delirium tremens, and in those cases bordering on it from inability to sleep (dose, gr. iij. t. i. d.). It may also be given to relieve 1 For the palpitation of the heart in this disease, strophanthus should be given. 136 NOTES ON MATERIA MEDICA. the depression caused by the withdrawal of alcohol from the patient. For this purpose combine with it one-fourth grain of extract of belladonna. Lastly, zinc is of use to check excessive secretion from bronchial mucous membrane, as in bronchorrhcea, chronic bronchitis, phthisis, etc. It should not be given if the secretion is purulent, a3 zinc seems to enter into chemical com- bination with the pus, giving an excessively foetid odor to the breath. It also diminishes the coughing by lessening the sus- ceptibility to irritation which causes the cough. Full doses should be given three or four times a day. It is not to be recommended for whooping-cough. YII. Copper. Sulphate of copper has been given for the relief of epilepsy, but it is doubtful if it has any beneficial effect when so used. Occasionally it may be substituted for nitrate of silver in the treatment of chronic dysentery, its principal use being as a local astringent. ? Till. Bismuth. 2 This substance is not an ingredient of the system, is very in- soluble, and its action may be only local, though in its effects it appears to be a specific. It is an excellent remedy for intestinal fermentation, and is, in this way, a preventive of gastrodynia, sick headache, dyspepsia, borborygmus, etc. It controls the diar- rhoea of typhoid fever and chronic phthisis (dose, five to thirty grains). IX. Colchicum (Meadow Saffron). Colchicum is the only vegetable substance known which acts as an alterative or specific medicine. Its effects are analogous to those of mercury, iron, arsenic, and the bromides, and in over- doses it causes very disastrous and permanent changes in the tissues and nutritive processes of the body; the blood is im- poverished and very difficult to restore to its normal condition; 1 For the astringent uses of copper, see p. 269. 2 See also Disinfectants, p. 39, and Constipation, p. 225. MEDICINAL REMEDIES. 137 there is fatty degeneration of the liver, ruinous alteration of the gastric mucous membranes, and loss of hair, nails, and teeth. Hence colchicum may be termed a constitutional poison. Colchicum is the specific medicine for gout in all its varied manifestations. "Why it is so cannot be explained any more than we can tell why mercury is the specific for syphilis, except from clinical experience. Gout is a disease dependent upon the presence in the blood of uric acid and combinations of this sub- stance with different alkalies, such as sodium, etc. The excess of urates in the system is probably due to the lack of oxidizing power on the part of the liver to convert the whole of the retro- grade substances of the body into urea, part being formed instead into uric acid, which in excess enters into combination with other substances to form urates. It is difficult for the system to elimi- nate these insoluble substances, so they circulate in the blood, and finally are deposited in those places where the circulation is poorest — e.g., around the joints — and cause local irritation. As the treatment of this disease is essentially different from that of rheumatism, with which gout is sometimes confounded, it is neces- sary to thoroughly understand its nature, for the detection of a gouty diathesis will throw a flood of light on a multitude of be- wildering symptoms otherwise inexplicable. A gouty condition does not always show itself in inflammation of the joints. In women especially, it may appear in the form of sore eyes, or as bronchitis characterized by violent coughing with a non-purulent expectoration, or there may be severe attacks of dyspepsia, diar- rhoea, or dysentery, or, what is very commonly the case, the pa- tient may have violent neuralgic pains about the head and face. Moreover, if one manifestation of the disease be made to disap- pear, it will frequently show itself in another form. If the patient does not suffer from B right's disease, an incompressible pulse will generally furnish the clue for the detection of gout. One in- fallible sign of a gouty constitution, when found, is the presence of little, bead-like deposits in the cartilages of the ears. The principal points for the differential diagnosis of acute gout and acute rheumatism are as follows: 138 XOTES OK MATERIA MEDICA. Acute gout. 1. History of high living or in- herited tendency. 2. The smaller arteries, irritated by the circulation in the blood of the insoluble poisons causing the disease, contract, obstructing the course of the blood through the larger arteries, and thus give a full, incom- pressible pulse. 3. At the beginning of the disease, gout is monoarthritic, usually com- mencing in some small joint, as the great toe. 4. Gout does not leave one joint when it attacks another. 5. An inflamed joint is more sen- sitive in the transverse diameter than elsewhere. (In the elbow joint, the olecranon process is also very sensi- tive.) 6. Veins surrounding inflamed joint are dilated. 7. Pressure with finger, pits or de- presses the swollen part. 8. There will frequently be de- squamation of the skin after the in- flammation has subsided. 9. There will be tophi in the joint for the rest of the patient's life. Acute rheumatism. 1. History of exposure to wet or cold. 2. The poison circulating in the system is soluble, causes no irrita- tion, and the pulse is therefore com- pressible. 3. Rheumatism is polyarthritic. 4. Rheumatism usually shifts from joint to joint. 5. The inflammation and sensitive- ness extend uniformly over the af- fected joint. 6. Veins surrounding inflamed joint are not dilated. 7. Pressure with finger does not pit or depress the swollen part. 8. There is never any desquama- tion of the skin after inflammation has subsided (of course excluding that due to the application of iodine, etc.). 9. A joint may wholly recover from a rheumatic attack. The treatment of acute gout is by the administration of col- chicum (dose, Tr. Oolchici Kadicis, gtt. xv. S. To be taken every three hours). As soon as symptoms of nausea appear, or the bowels act as if there was to be a movement, the dose for that particular case has been reached. Some persons who are very susceptible to the influence of the drug cannot bear more than gtt. x.; but usually where the suffering of gout is severe the full dose may be given. In those cases where the bowels are already loose, laudanum may be combined with a x.-gtt. dose of colchi- MEDICINAL REMEDIES. 139 cum. Some physicians give this combination after nausea has been produced by the action of colchicum, but the practice is reprehensible; for the heart may be so depressed as to cause cardiac vomiting, and considerable gastro-intestinal enteritis may result. The only other medicine that can control the pain of gout is a nostrum called Laville's Extract. Its formula is well known. Often this medicine promptly gives relief where colchicum fails. In large doses it acts as a purgative, and its good effects are lost (dose, 3 i. t. i. d. once in the forenoon, once in the after- noon; or equal parts of Laville's Extract and elixir of cinchona may be given, dose 3 iss., divided up into three doses for the day). What has been said of acute gout is also applicable to the clironic form. Colchicum or Laville's Extract should be given and the diet carefully attended to. Kigidly exclude all wines containing a considerable quantity of carbonic acid, such as champagne, moselle, etc., and all beers and ales, as these cause gout more than anything else. If the patient insists on hav- ing alcohol, spirits such as brandy or whiskey may be given, but not rum. as this also has a tendency to produce gout. As an excess of animal food should not be taken, meat three times a day should not be allowed. Most patients are benefited by blue pill once a week. For the lithsemic condition, the best remedy is benzoate of soda, gr. x t. i. d., taken after meals. If there is dyspepsia, a small dose of salol may be added (dose, Salol, gr. ij.; Benzoate of Soda, gr. viij.; made up into two capsules, to be taken one hour after each meal). When there is irritation of the kidneys, the patient should take a small quantity of potash salts— citrate of potash or bitartrate of potash — changed once in a while to phosphate of soda (dose, 3 i. in course of the day in considerable quantity of drinking water). Colchicum, however, is the remedy to give in all these cases. Whenever symptoms of the disease are aggravated, the patient gets depressed in spirits. He may be put for a week upon treatment by colchicum with its adjutant, quinine. These drugs always go well together; quinine is a great adjuvant in chronic cases (gr. J— J of solid ext. of colch. put up with 140 NOTES ON MATERIA MEDICA. gr. ij. of quinine, t. i. d. an hour or two after eating). In some chronic cases, it is good to add powdered guaiacum (make up into capsule gr. i. quinine, gr. J of ext. colch., andgr. v. of pow- dered guaiacum, t. i. d.). No gouty patient ought to lead a sedentary life, as they are always better according to the activity of respiratory processes. Colchicum is also good for chorea with gouty origin. Treat with large doses. As soon as nausea is produced, chorea subsides. Preparations. — Extractum Colchici Radicis, gr. i.— ij. Extraction Colchici Radicis fluidum, . . gtt. ij.-viij. Vinum Colchici Radicis, . . . . gtt. x- 3 i. Extractum Colchici Seminis fluidum, . . gtt. ij.-viij. Tinctura Colchici, . 3 ss.-ij. Vinum Colchici Seminis, .... 3 ss.-ij. MEDICINAL REMEDIES. 141 CLASS II.— FUNCTIONAL OE SYMPTOM MEDICINES. Functional or symptom medicines are those medicines which are given for the relief of the symptoms of a disease, or to stimu- late or depress some one or more of the bodily functions. In dealing with medicines of the restorative class, we have seen that the constant repair or nutrition of the body is a slow and not immediately perceptible process, and that consequently the action of medicines which affect nutrition must also be slow and not immediately perceptible. On the other hand, the functions of the various organs of the body are either in inces- sant activity — e.g., respiration, the function of the lungs; the circulation, the function of the heart and blood-vessels — or else they respond immediately to appropriate stimuli, e.g., secretion, the function of the glands. In precise relation to the rapid and perceptible activity of these functions is the rapid and per- ceptible action of medicines which affect them. Hence, the features that distinguish these two classes of medicines are based on indisputable physiological facts, and they are so funda- mental that a thorough understanding of them is absolutely essential. Functional medicines should, therefore, produce immediate and perceptible effects, and if they do not it is because the functions of the organ cannot be aroused, or the dose is incor- rect. Their whole action is secured by one dose — half a dose of a cathartic, for instance, fails to produce any characteristic effect, and no different effect follows upon repeated doses. Hence they are not cumulative (with the possible exception of digitalis, which occasionally, for some inexplicable reason, is apparently cumulative) and their effect is transient. Thus stramonium may invariably relieve the symptom of spasm in asthma for a lifetime, but the last dose has no more helped to cure the dis- ease than the first one; repeated doses of these medicines only repeating the symptoms of the first dose, without adding any further effect on the disease or on the symptom. 142 NOTES ON MATERIA MEDICA. These medicines, which, unlike the restoratives, operate in health as well as in disease, produce no recognizable structural effect upon the various bodily organs, but affect only their functions. Ammonia may stimulate the heart's action, and aconite depress it, so as to accelerate or slow the circulation accordingly, but neither of these agents affects the structure of the heart itself. Opium and tobacco leave no traces on the nerve tissues, though taken for years for their effects on the nerve functions. Even where functional medicines operate with such severity as to cause death, as by the suspension of respiration by hydrocyanic acid, except the actual presence of the drug itself or of some combination into which it has entered, no traces whatever are left by them on the tissues of the body. As functional or symptom medicines do not operate against any disorders of nutrition, they cannot be expected to cure dis- ease, for disease is a morbid process almost invariably dependent upon disturbed or perverted nutrition of the body. The use of these medicines is to lessen distress by acting against some form of suffering requiring immediate relief, or to deal with some complication, in the course of a disease, requiring immediate attendance. They are very important on this account in the majority of acute diseases, such as inflammations, fevers, etc. These diseases, which may occur in the young and healthy, are of the nature of accidents, for we have no means of modifying them, and expect nature to recover by her own powers of repair. We can, however, by the administration of these medi- cines, so manage a case of acute disease as to enable the patient to go through it with as little pain and distress as possible, and to relieve any complications which may arise. If uncomplicated, acute diseases are self-limited and terminate, with rare excep- tions, within six weeks. The dose of all symptom medicines is the quantity which will produce the symptoms characteristic of the medicine, and nothing less. Thus, while the ordinary dose of opium for an adult is one grain, it may require in peritonitis twenty grains before a symptom of opium is obtained; if so, the dose is twenty grains. MEDICINAL REMEDIES. 143 Functional or symptom medicines are divided into three classes: I. Neurotics; II. Eliminatives; III. Astringents. Division I. — Neurotics. Neurotics are medicines which produce their symptoms by affecting one or more of the functions of the nervous system. These functions are so numerous, and differ from each other so widely/ that no one neurotic ever acts upon the whole nervous system. For instance, sensation is divided into many different forms ; there are the nerves of special senses, of temperature, of muscular sense, and the indefinable sensation of well-being. These different sensations of the body — and the same is true of the motor system, whose manifestations may be either automatic or voluntary — do not resemble each other, and in their disorders they are equally distinct. Hence the use of such terms as <{ general nervous stimulants " or "general nervous sedatives" is incorrect; for if there was a general nervous stimulant, its administration would affect every nerve and muscle of the body, producing tonic spasm on account of opposing muscles being equally affected. The most widely operative neurotics, such as opium, are yet quite selective, and affect the functions of only a few out of the many nerve centres. As they are purely functional remedies, neurotics cannot cure real nervous diseases like epilepsy, asthma, etc., as these are generally the most constitutional of all diseases. The effect of neurotics is usually weakened by repetition, so that the doses have to be increased. Yet they promote the ac- tion of organic medicines when they relieve special symptoms of the disease. Thus opium and conium materially increase the efficacy of potassium iodide in syphilitic periostitis when there is much pain, and, on the same principle, chloral, by lessening reflex excitability, assists the bromides in epilepsy. Owing to the variety of the functions of the nervous system which they affect, it is difficult to make a definite classification of neurotics, but for general purposes they may be divided into : 144 ;n"otes o:n" materia medica. (a) Those which are both stimulants and sedatives, commonly called narcotics. (b) Those which are stimulants only of certain nerve functions. (c) Those which are sedatives only of certain nerve functions. (a) Narcotics. Narcotics, or those neurotics which are both stimulant and se- dative, are agents which generally stimulate some nerve func- tions, while they simultaneously depress others — for example, opium stimulates some of the higher cerebral functions, and also the heart, but at the same time blunts sensation and paralyzes the alimentary canal — or else these agents first stimulate certain nerve functions and afterwards depress the same, but second- arily from exhaustion. The principal neurotics of this class are : 1. Opium. 3. Ethers. 2. Alcohol. 4. Belladonna and its allies. 5. Cannabis Indica. I. Opium. Opium is the inspissated juice of the poppy (Papaver somni- ferum), which grows in Asia Minor, Western Asia, and India. It is the most ancient of all our great medicines, being well known from a very early period. The opium we receive here comes from Asia Minor, and is the best. The Indian opium is inferior to it. The value of opium depends largely on the cli- mate, soil, etc., of the country where it grows. In Asia Minor, the poppy is cultivated until its capsule grows to about the size of an orange. When the petals have fallen, incisions are made, and from these exudes a juice which upon drying masses together and is then called gum opium. It has all the disadvantages of a vegetable product; it cannot be depended upon for uniformity in strength. One year the gum opium is very strong ; another, the yield is equally good, but the opium is not so strong. We judge its quality by the percentage of alkaloids it MEDICINAL REMEDIES. 145 contains. A good variety should contain twelve per cent morphine. A great number, however, contain but four per cent. Opium as a Stimulant. — Opium stimulates the brain in those functions related to thought, more particularly those which have to deal with the imagination. This is powerfully stimulated by opium, and men spend their lives enjoying the pictures pre- sented under stimulation. When this takes place, there is con- siderable hyperemia, dilatation of the blood-vessels of the head, throbbing of the arteries, etc. The eye will be brilliant, the pupils contracted, and at the same time the functions of the alimentary canal will be held in abeyance. Prolonged thinking and digestion do not go well together. Hence the frequency of constipation in those who perform much mental work imme- diately after eating. As a cardiac stimulant : Opium produces a powerful stimulat- ing effect upon the heart. If a full dose of opium be taken by a strong, healthy man, its action upon the heart may be appreciated by careful examination of the pulse, which is characteristic. The cardiac elements of an opium pulse are : 1st, strength; 2d, slowness; 3d, perfect regularity of rhythm. The arterial ele- ments are : 1st, fulness; 2d, compressibility; 3d, moderate length. Now, this is precisely the pulse of a strong man in per- fect health. Its most distinctive features are its equability and its steadiness, both as regards strength of beat and rhythm. It is not affected by those circumstances which ordinarily disturb the heart's action, as change of position, exercise, and mental agitation ; this constitutes the important difference between the action of opium and the other cardiac stimulants. Alcohol increases the frequency of the beats, and, for a time, their power also; digitalis increases the force of the cardiac systole, but it in- terferes with the diastole and causes marked irregularity in the pulse. Opium has not so much a stimulating as a truly strength- ening and sustaining effect upon the heart, which is toned up, so to speak, under the influence of the medicine, so as to empty itself forcibly and completely at each stroke. Opium as a cardiac stimulant is, therefore, indicated in a con- dition of shock. 10 146 NOTES OIS" MATERIA MEDICA. Shock is a sedative impression per se, but differs from other sedative impressions in that it is followed by reaction, which reaction it produces itself. Every one is familiar with the sudden shock produced by a dash of cold water on the face or head. The face turns pale because the arteries contract; the heart jumps because it has to force the blood through the sudden ob- struction caused by the contracted arteries. The death of expert swimmers, supposed to be from cramps, is now demonstrated to be due to the sudden stoppage of the heart from its inability to drive the blood through the arteries, contracted from the uni- versal peripheral cold. Those with strong muscles, but not strong hearts, usually suc- cumb to such impressions, dying instantly. When the heart begins to throb on going into the water, great care should be exercised, and nobody under the circumstances should go beyond his depth. Opium is the remedy for shock, provided collapse is not threatened. Shock is a positive nervous impression, and its effect is always recovered from, when it is recovered from, by in- creased action; that which was suspended comes back again with redoubled force, so that it is always felt, viz. , the reaction, pro- vided the shock is not enough to exhaust the powers. The cir- culation is increased, the arteries are dilated, and the blood is driven all over the body with greater rapidity and force than before. Hence shock is a positive nervous impression; in itself it is very depressing and always sedative, but when recovered from there is always a reaction, by which is meant that all the vital phenomena first depressed manifest themselves in an in- creased degree. Hence we repeatedly use shock as a therapeutic measure — cold shower baths, hip baths, etc. — to arouse the sys- tem. Occasionally the reaction from shock is injurious, and we are more afraid of it than of the original shock, e.g., surgical shock, when measures are taken against the reaction to counter- act the violent inflammation produced by it. Shock may be so severe that it cannot be recovered from and passes into collapse. Shock can induce collapse, but collapse can never produce shock. The terms are not interchangeable, for the reason that collapse is a negative state of exhaustion. Death may take place in this state. If the patient recovers, it will be without reaction. MEDICINAL REMEDIES. 147 Collapse, therefore, resembles pure sedative impressions on the nervous functions which are never followed by reaction. Seda- tive impressions are of two kinds : medicinal, such as the action of hydrocyanic acid and aconite ; non-medicinal, such as a warm bath, neither of which is followed by reaction. Shock may be so severe, as in cases of surgical shock, that it passes immediately into collapse without any reaction at all. The vital powers are exhausted, and death results by collapse. The commonest of all forms of shock are those due to sudden serious traumatic injuries, and, on account of the suddenness and severity combined, are very apt to pass into fatal collapse at once. If this is likely to be the case, opium should never be given, for the reason that in condition of shock the heart is contracted and remains so, and there will be a corresponding contrac- tion of all the arteries. So long, however, as the arteries are contracted the patient will not die with symptoms of col- lapse. Collapse is characterized by relaxation of the heart, all the symptoms indicating that the heart has no power to propel the blood through the body. The portal system becomes congested; there will be difficulty of breathing, owing to the pulmonary congestion present; also suppression of the urine, due to the same cause in the kidneys. The surface of the body looks shrunken and shrivelled, so that a familiar face may be totally unrecognizable. After death, the heart will be in a state of dila- tation, and all the organs will be swollen with an accumulation of blood. Now, opium causes the heart to fully dilate before its stimulant effect can be felt upon the systole, and this very state of things is produced. No medicine should be given in this condition which relaxes the heart as opium does. In a case of surgical shock where there is danger of the patient passing into a state of collapse, medicines must be given that increase the systole of the heart, such as alcohol, brandy, and ammonia. If there is time, i.e., no immediate danger of collapse, in surgical shock, then opium is the medicine of medicines; so that in many cases it is good practice to give opium with brandy, alco- hol, etc., where there is no fear that the patient is going to sink too suddenly. Medical shock is produced by all injuries to the abdomen and the abdominal viscera, and produces the same 148 XOTES OX MATERIA MEDICA. effects as surgical shock. Thoracic inflammations do not tend to produce shock, but the reverse, there being great exaltation of spirits, etc., as in phthisis. But disturbing the abdominal vis- cera, even functionally, results in depression; the smallest sur- gical injury to the abdominal cavity will produce shock. Hence in all affections of this kind there is a small, flickering, incom- pressible pulse, and generally a weak one, all the way through from first to last. This is just the opposite of the opium pulse; hence it is that opium is the remedy for 'peritonitis, as only such functional remedies can be. Some have supposed that the object of giving opium in peritonitis is to confine the bowels; but obstinate constipation is a prominent symptom of this dis- ease, because the muscular coats of the intestines are com- pletely paralyzed for the time being, and opium would be super- fluous if there were no other indication for it. Neither is opium given merely to relieve the pain, for cases of painless peritonitis do occasionally occur which require as much opium as any others. Besides, this hypothesis will not account for the remarkable tolerance of opium which forms so charac- teristic a feature of peritonitis; for in pleurisy, which is also an inflammation of a serous membrane, and may be just as pain- ful, ordinary doses are all that can be borne, and are quite ade- quate to relieve the suffering. What does opium do in peritonitis? It does not act as a sed- ative, nor to keep the bowels quiet— the disease itself does that. Neither is it given to relieve pain. It therefore acts as a cardiac stimulant, to prevent the great danger in abdominal in- juries, viz., cardiac failure and consequent death. Lastly, opium is of use as a stimulant where, without the least pain on the part of the patient, he nevertheless is going to die quickly from poisoning by gangrene. This poison, when taken into the system, is a powerful anodyne. It suspends pain and distress almost as well as opium itself does. The patient is generally in fair spirits and dies quietly and peacefully. In this disease there is deathly pallor, the patient begins to grow cold, has a disagreeable perspiration, and, after a little time, faints away and dies. This disease tolerates opium, showing that it is being used up as a stimulant; hence in this condition large MEDICINAL REMEDIES. 149 doses should be given. There is a shin disease, lately described by Mr. Hutchinson, beginning as a blister, in which patients all died from gangrene until treated with opium, when they began to recover and in some instances were cured. The stimulant properties of opium manifest themselves in a particular form of stimulation of the intellectual functions, also of the heart, and, to speak rather vaguely, though about as near as we can express it, of the general vitality of the system. Great prostration occurs in the course of gangrene and slough- ing inflammation. When sloughing phagedena attacks a soft chancre, the patient should be brought as quickly as possible under the influence of opium; also in similar conditions not specially connected with gangrene. Opium checks the inflam- matory processes, and turns them into adhesive rather than necrotic forms of inflammation. There is one element in the intellectual stimulus which is of peculiar importance and very difficult to describe. It comes as near as possible to the con- dition of mind to which we apply the term interest. A person interested in a piece of work can do a far greater amount of actual labor and feel less fatigued than one who does not have this interest. A sportsman will walk double the number of miles in his pursuit of game that he could under ordinary circumstances ; somehow- the muscles do not tire so rapidly. We know as a fact that the brain has a great power over this vital force, often preventing the system from giving way under conditions of great physical strain; and this endurance will be proportionate to the development of the brain, as is shown by the fact that officers bear fatigue better than common soldiers. The mind can supply to the physical frame something of the nature of a stimulus antagonistic to waste, and this con- dition is remarkably present in the action of opium. A person taking a stimulant dose of opium finds himself in a state of great mental interest. He does not want to do anything but contemplate the mental pictures that in his imagination rapidly pass before him, and which he notices with a sense of delicious quiet and superiority to all the annoyances of life. He is not excited; on the contrary, calm and philosophical. This condi- tion is one of the most seductive and irresistible to overcome of 150 NOTES ON MATERIA MEDICA. all desires that can be awakened by any physical substance in our constitutions. There are certain articles which when taken into the blood produce corresponding mental and emotional conditions and changes, so much so as for a while to make new beings of us — not better beings, but new ones. Alcohol, for instance, transforms the secretive person into a communicative one, the dignified into one who shows a contemptible familiarity with all, the peaceable man into a pugnacious one, etc. There is a marked difference, however, in the action of nar- cotics. Opium is just as difficult to resist as alcohol, even more so, but the man who has taken opium prefers to be solitary; he is company enough for himself; he does not want his visions broken in upon. On the other hand, the alcoholic drinker is necessarily gregarious; he does not want to be alone, because the stimulation is not of the imagination but of the feelings. But certain disasters occur to those addicted to any one of these physical means of altering their ordinary constitutional temper- ament. Opium is more pronounced in its results and more ruinous than alcohol. The mind is not injured by opium; very few cases of opium-eating lead to insanity. But instead of that the will power, that which makes us really what we are, is ruined. Our mental and intellectual processes are mechanical; our ideas come and go from us without any other than mechan- ical origin. There is no doubt whatever that our intellects are just as much machines as our hands and feet. Our ideas are dependent upon previous impressions made upon us, and we are not responsible for them. But man possesses something else besides mind; he is something more than an intellectual machine. He possesses a high capacity, called the will, which holds him responsible for the way in which he allows his mind to work. He is not responsible for thoughts which come un- bidden to his mind, but he is responsible if he entertains them. He has the power to drive away thoughts which he does not wish to remain with him, and vice versa. This habit can be cultivated by having a governing principle or purpose control- ling life, and it is this power of the will which mainly differen- tiates man from the lower creatures. Unfortunately opium, alcohol, cocaine, chloral, chloroform, and cannabis indica have MEDICINAL REMEDIES. 151 the power, not of altering the mind (even if they do derange the mind, it is quickly recovered from), but of producing afar more serious and ruinous derangement of the power of the will over the mind. The mind is as good as ever, and so is the will, but the connection between them is broken. Nothing can be more pathetic than the confessions of powerlessness of those who have become addicted to these drugs, to free themselves, as De Quincey called it, from the accursed chains which bind them. Effort after effort maybe made, but fails, until finally the strug- gle is given up in hopeless despair, and the man lapses into a mere intellectual machine, dreaming away his whole existence, a visionary, helpless human being. In the use of alcohol, on account of its having to do more with the feeling, etc., than with purely intellectual operations, the degradation is most evident in the moral sentiments. The drinker laments his fail- ing at first and is deeply ashamed, having lost his true self; some suffer from this so acutely as to commit suicide. After a time this feeling passes away, until all sense of shame is ulti- mately gone— the worst of all results of this criminal tampering with our frame by addition of that which rums the dominance of the will. Sedative Actions of Opium. There are different sensations and modifications of sensation — the sense of temperature, tactile sensation, pressure, localiza- tion, pain, etc., each independent of the other. This is so with the anodynes. These agents, which allay the sensation of pain, are not all alike. Some will allay certain forms more than others. Opium is no exception to this rule. As an Anodyne. — The pain characteristic of inflammation lo- cal rather than radiating, excited or increased by movement or pressure on the part, is relieved more by opium than by any one medicine acting directly to relieve that pain without blunt- ing the whole nervous system, as when ether or chloroform is given. Hence the great use of this medicine in diseases with acute inflammatory pains. When these pains are in the perios- teum, they give rise to a sense of intolerable aching. This is one of the characteristics of inflammations, occurring very early 152 NOTES ON MATERIA MEDICA. in meningitis. When the pains are in fibrous tissue and serous membranes, they are of a stabbing or boring character, or both. In the pain of mucous membranes, there will be a sense of sore- ness. In all of these opium gives decided relief. The dose for simple inflammatory pain for an adult is about one grain of good opium; but when the patient bears larger doses before the pam is relieved, there are very likely other elements than mere inflammation causing the pain — that is, if the patient has not been accustomed to the use of the drug. As an Ant % neuralgic. — Neuralgic pains differ from inflamma- tory pains in that the part to which the pain is referred is not aggravated by movement or pressure, and is apt to radiate, fol- lowing the course of the affected nerve. Neuralgic pains are of different origin. Some are due to pressure on a nerve, as in cases of tumors, cancers, abscesses, etc., which, besides pressing upon it, may involve the nerve in its growth or stretch, the nerve by its growth. Others are due to the dilatation of a very nar- row duct, owing to the presence of a calculus, renal or hepatic. These have a special tendency to produce faintness, nausea, or vomiting. Lastly, there are pure neuralgic pains very difficult to account for. In many cases, they accompany a state of ane- mia; in other cases, they accompany a state of poisoning, those of malaria being characteristic. In all these different non-inflam- matory pains, opium may be used; the effect will not be at all proportionate to the dose, as in inflammatory pains, but it should be used continuously for a long time. When patients get accustomed to it, the dose must be increased, until often quite a large amount has to be given. On this account, opium should be assisted by other anodynes, on the principle that a com- bination of .two or more neurotics, in small doses of each, is more powerful than a corresponding large dose of any one of them. All neurotics can be made to work together, even when they oppose each other, paradoxical as it may seem, but no antago- nism of neurotics is of a chemical kind. No neurotic is the anti- dote of another in the same way that an acid is the antidote of an alkali. Instead of that, the antagonism is an illustration of the law that while some of them stimulate certain functions, others simultaneously depress them. There are also neurotics which, MEDICINAL REMEDIES. 153 while antagonizing each other on one function, reinforce each other on another function — e.g., atropine and morphine. Atro- pine stimulates the respiratory centre; the breathing becomes more rapid and stronger. Opium has the opposite effect upon the respiratory centre, diminishing the frequency of the respira- tions; not only this, but partially suspending them, so that there is a marked interference with the breathing, Opium destroys life very soon by paralyzing respiration. Atropine can be used for counteracting this depressing effect. Belladonna and atropine are then really antidotes to opium. Opium can also be used as an antidote to belladonna poisoning in the first stage. On the other hand, opium is a sedative to the sensory system of nerves, and so is atropine. Hence in many cases a better anodyne ef- fect is secured by combining the two; here the atropine does not antagonize the action of opium, but on the contrary assists it. Hence no class of medicines ought to be more often combined than neurotics, as thereby the injurious effect of large doses of any single one of them is avoided. In the case of severe inflammatory pain, nothing equals opium, and in these cases it answers very well alone. For neuralgic pains, however, opium should not be given alone, lest by doing so the foundation is laid for the de- velopment of the opium habit. As an Antispasmodic. — Opium will relieve spasms of a certain kind only, namely, those due to distention of ducts by calculi, etc. — the bile duct, the ureters, etc. — notably in cases of gall stones and renal calculi. Very intense spasms occur in the pas- sage of a stone, which not infrequently arrest its progress, and opium is an admirable antispasmodic for this purpose. The patient should be brought rapidly under its influence by hypo- dermatic injections of morphine, and very often the spasm will subside, the tube relax, and the stone pass through. As a Soporific. — Opium is a soporific, having a tendency to produce sleep, which may not be immediate, however, owing to personal idiosyncrasies. With a large number of persons, it has uo tendency to produce sleep, so before prescribing it for this purpose it is well to ask patients if they have taken it before for the same purpose. Some are kept wide awake all night by visions, etc. In other cases, especially in women, it sometimes 154 NOTES ON MATERIA MEDICA. produces a distressing sensation and a good deal of nausea as well. Usually it is where persons have been kept awake by pain that opium acts bast as a soporific, as well as relieving the pain. Large doses will produce somnolence, except in special cases. The sleep produced is heavy, with slow respiration. This means deficient oxygenation of the blood and the accu- mulation of carbonic acid gas, on account of the slow expi- ration, the patient waking up unrefreshed and with paii\ in his head. That this is due to C0 2 poisoning is rendered probable by the fact that when opium is given in the daytime, when the patient can respire in the open air, etc., it does not produce headache. This only occurs after sleep, and is sometimes very severe and lasts for a long time, accompanied with a greater or less amount of nausea. A remedy that prevents nausea pretty well is hydrocyanic acid. After great muscular soreness, as after parturition, a dose of hydrocyanic acid, morphine, and chloral is very good. Another sedative action of opium, and a very important one, is its power to paralyze the peristaltic movements of the intes- tines, producing a perfectly motionless condition, particularly of the upper part. Hence it is of considerable use in allaying excessive peristaltic movements occasioned by the presence of inflammatory products. Irritation of the bowels results in one of two things — first, intense pain and obstinate constipation with vomiting, which means enteritis; an inflammation involv- ing the entire mucous membrane of the inflamed part, and spreading to the other coats, being very likely to end in perito- nitis, the pain at first being localized. In this case, opium should be given, but with considerable discrimination as to whether it sliould be the first thing or not. When it is given, it is for the purpose of allaying pain, having more power in this tract for this purpose than in any other part of the body to allay inflammatory irritation. Another and more common form is inflammation leading to mucous catarrh. An abundant flow of serum takes place, and, if sufficiently diluted, there is nothing but a watery diarrhoea. Very frequently this flow simply mixes with the intestinal con- tents, producing irritation, then fermentation and excessive irri- MEDICINAL REMEDIES. 155 tation. When this happens, the peristaltic action begins to be very mnch increased, and amounts finally to irritation of the middle or muscular coats, which produces cramps, and this hurries on the offending matter until discharged from the bowels in the form of an acrid, burning, irritating discharge, indicating that such matter could not remain longer in the bowels without causing pain. There is this difference between pain dependent upon irrita- tion of the mucous membrane and localized enteritis, viz., in the former the sense of diffused soreness continues between the cramps, and there is a feeling that it is in the stomach at large. Opium should be given here for the purpose of allaying irri- tation and peristaltic movements, and by so doing check the movements of the bowels. Another condition of the bowels is that state resulting from this irritation, viz., that for some time there remains a weak irritability in which there is a great deal of per- istaltic movement without pain. Here we have an indi- cation of the same kind of weak, nervous irritability that be- longs to all mucous membranes when they have been the seat of acute inflammation. Here opium does good, because it allays the unnecessary irritability, which at first serves a good purpose by helping the offending matter to be voided; after- wards, however, and especially in children, it keeps up the diarrhoea from the remaining irritability after inflammation has subsided. In the first form — enteritis — if called to a recent case, and you find the patient has attacks dependent on some very indigestible material in the stomach, and not due to intus- susception, organic stricture, or hernia, opium should not be given. Give castor-oil, and, after that has acted, then give opium. If, on the other hand, some considerable time has elapsed and symptoms are severe, then opium should be given at once, for this very often, when the enteritis has lasted for twenty-four hours, relieves the constipation. How does it do this, since opium itself produces constipation ? By suspending the spasmodic stricture of the intestine at the seat of inflamma- tion, by causing the pain there to subside; and after the stric- ture subsides, the bowels move of their own accord. 156 :s t otes ois T materia medica. Diarrhoea is divided into two kinds • 1. The diarrhoea due to inflammation of the intestines as the result of fermentation in them. 2. Diarrhoea due to the absorption of ptomaines into the blood. This form is totally different from the first, and is the choleraic diarrhoea. Its genesis is entirely different from the first, and hence should be treated differently. The diarrhoea caused by fermentation is brought about by the alteration or suspension of the natural secretions, which fulfil the double function of being digestive and antiseptic, the latter being quite as important as the former. Many diseases are now distinctly traceable to this suspension of antiseptic secretions. One-half the cases of B right's disease in this country primarily take their origin in the intestines. It is now known that one of the great functions of the intestinal secretions is to prevent materials from being decomposed by fermentation, so that they can be properly digested; and hence whenever the secretions are absent, not only is the digestion imperfect, but fermentation occurs, which varies very much in its results in different parts of the intestines. Under certain circumstances there will be fer- mentation of starchy materials, producing enteritis and diarrhoea, until the starchy elements have been gotten rid of. Many cases of chronic diarrhoea are successfully treated by discovering what article of diet is particularly difficult for the patient to digest, which opium would have failed to cure. Worse than fermenta- tion of saccharine matters is fermentation of the oily elements of the food, which produces an extremely irritating series of acid products. This begins in the stomach itself, and is continued to the upper part of the intestines. Patients frequently vomit very acrid materials so irritating that it burns the oesophagus, the throat, and the mouth, produces tears, and causes the nose to run. It is not uncommon for patients to feel as if they had sore throat, owing to the intense irritation produced by these acrid products. Enteritis will inevitably result. But the worst of all is the fermentation of the nitrogenous principles of the food; this produces horribly foetid stools, with a special tendency to produce irritation of the lower part of the intestines, viz. ; dysen- tery. There is a putrid odor in addition to the sour odor, and MEDICINAL EEMEDIES. 157 the dysentery is an effort of nature to expel the offending mate- rial. The treatment here is to wash the intestines clear of such offending material. The discharges will frequently be mixed with mucus and pus. No mucous membrane, paradoxical as it may seem, should discharge mucus, at least not in any great quantity . The very first thing to be done is to get rid of the mucus discharged by the irritated or ulcerated mucous membrane, and the whole trouble will subside very often as promptly as in the case of inflammation of the bladder, where pus may be in the urine for months. If the bladder is washed clean twice a day, leaving a little material in the bladder to keep the two surfaces from rubbing together, rapid improvement takes place at once. The principle of this treatment is the same that should govern the treatment of chronic dysentery, viz., to wash the inflamed parts quite clear; this acts better than any medicine. Chronic dysentery is one of the most obstinate diseases, lasting sometimes from ten to twenty years. The reason is that some mucus is left decomposing over the inflamed surface, which ulcerates, and when this happens the case is extremely difficult, because the ulcer is every few hours torn open by the action of the bowels, and the ulcerated surface smeared oyer with faecal matter. The treatment consists of large injections of peppermint water, and this is often quite sufficient to cure this complaint without any medicine. The number of cases of fatal dysentery and diarrhoea would be much lessened if they were not treated with opium, because the stoppage of the bowels produces fermentation in addition to that already going on. The treatment should be to let all the fermenta- tive matter out, because it is irritating the mucous membranes down to their deepest parts, and the trouble should be corrected at its origin by restoring the natural secretions. Usually the liver is out of order; the patient is sallow and perhaps has been eating indigestible food. The indications are to clean out the bowels, then give a good agent for restoring the natural secre- tions, and follow this up promptly with antiseptics for the in- testines. Do not give opium unless the patient has many movements, due to irritability remaining after the former move- 158 NOTES OX MATERIA MEDIC A. ments, when a small dose of opium can be given to allay the pain and too frequent movements, but not by any means to lock up the secretions. Disinfect the intestines, and the diarrhoea will in a great majority of cases stop of its own accord. This treatment is to be persisted in from the beginning to the end. Opium is the adjuvant, but disinfectants are the special med- icines against every form of intestinal catarrh, whether it be diarrhoea or dysentery. This is the principle upon which opium is to be used in intestinal disturbances. Choleraic diarrhoea is quite different from that just described. It is different in its symptoms. First, instead of pain preceding the movements, with griping action of the intestines, it sets in with a painless, watery discharge, with often little odor. The patient does not mind the first movements, being, if anything, re- lieved by them. In the fermentative form of diarrhoea, the pain is for a time relieved by movements, and then comes on again. "Not so in choleraic diarrhoea. The first movement is quite painless, the second also; but with the third the patient weakens, the face turns pale, the pulse is rapid, fails in size and strength, and he begins to show the very perilous symptoms of collapse; vomiting sets in with purging, and the patient sinks more and more. These symptoms are present in cholera morbus, and are typical of Asiatic cholera; they are also present in the choleraic diarrhoea of infants. In regard to the latter, it is very unfavor- able if the child does not cry with the movements. It would be a better sign if griping pains were present. Choleraic diarrhoea is produced by a poison generated in the intestines by bacteria which differ in different countries, but are evidently of the same general species. Bacteria infect children more than adults. When they appear in adults, it is called cholera morbus. In India, they are the source of epidemics of Asiatic cholera, pro- ducing a poison which, being absorbed into the system, para- lyzes the solar plexus, producing effects similar to that produced by extirpation of the solar plexus in animals, viz., profuse serous discharge, with shedding of the epithelium of the intes- tines in flakes, causing rice-water discharges, and in infants cerebral symptoms, they generally dying in convulsions, and on post-mortem examination there will be found an effusion into MEDICINAL KEMEDIES. 159 the ventricles of the brain. In these cases never give opium; if it is of any use at all, it is to sustain the heart as a stimulant. When there is pain, as in some forms of cholera morbus, do not rely upon opium so much as upon camphor, which is the counteracting, antiseptic, and sustaining agent. It kills the bacteria, prevents the poisoning, and besides this it raises the power of the heart. In chronic disease of the intestines, use opium steadily, for the reason that no chronic trouble of the intestines occurs with- out producing a weak, irritable condition of the bowels, leading to increased peristaltic action. Small doses should be given, the object being simply to prevent peristaltic irritability. One- quarter of a grain of opium can be given as an adjuvant, a'long with other remedies, three or four times a day in choleraic diar- rhoea or dysentery; but do not rely upon opium. The difference between diarrhoea and dysentery is marked, though sometimes the symptoms are mixed, there being diar- rhoea and dysentery together; but whichever disease predomi- nates, the symptoms will be according to it. Dysentery always keeps the pylorus open, so that very little can be kept in the stomach; and on this account it is liable to produce starvation, as may be seen in little children with this disease, who look al- most like skeletons. Dysentery is very apt to come on immedi- ately after eating, so that the odor of the food taken into the stomach can be detected in the faeces; and it is also effected by moving about. It is allayed by lying down, and therefore does not occur as often at night as during the day. Besides this, there is a sense of tenesmus after an action of the bowels; so that instead of being relieved by the movement, the patient feels worse, as if he must have another movement. This symptom is a plain indication of dysentery. In addition to this, there is a discharge of blood which is bright, not dark, indicating that it has come from the lower, not the upper, part of the intestines. All of these symptoms contrast strongly with those of diarrhoea. Diarrhoea most commonly occurs early in the morn- ing before the patient's usual time for getting out of bed, commencing when he is lying down; during the day there are but one or two movements. If it is chronic diarrhoea, 160 NOTES OK MATERIA MEDICA. there are generally pretty profuse movements in the morning. Eating does not especially start the diarrhoea, nor does walking. The odor of the food cannot be detected in the faeces, as the contents of the stomach have been there for a number of hours, and so have been changed. It is of great importance to find out at what time the movements occur. If early in the morning, it is diarrhoea; if during the day, after walking, it is dysentery. There is one kind of dysentery, however, that is different, viz., malarial dysentery, dependent upon an infection of the system by malarial poison — a disease that carries off multitudes of Europeans visiting the tropics, and is also common in New York City. The symptoms differ on account of this fact, viz., that they are constitutional. It is usually ushered in with a chill, followed by high fever and intense headache, aching in all the bones of the body, and this is followed by profuse discharges from the bowels, uniformly mixed with blood. A case beginning in this way is one of constitutional infection, of which dysentery is one, but only one, of the elements. Large doses of quinine should be given immediately, before the dysentery is dealt with at all. In neither of these cases should opium be given at the beginning. Opium Poisoning. This is the commonest form of accidental or intentional poisoning that physicians are called upon to deal with. Its symptoms are very pronounced, and afford a test for distin- guishing the unconsciousness of opium poisoning from that due to other causes. And this brings up the different kinds of coma. Coma is not infrequently defined as a state of insensibility. This is not as clear as it should be, as such a definition would include sleep, the syncope of a fainting fit, etc. Coma may be defined as a state of insensibility with symptoms of brain pres- sure. No form of real coma can exist unless some portion of the cerebrum is compressed either directly or indirectly, e.g., the venous exudation of serum into the ventricles from a blow on the head. The same part or the same nerve centre will not be affected in all comas, but nevertheless some part, if not the whole, of the contents of the cranium will be in an|unnatural state, owing to the altered circulation of the blood. MEDICINAL REMEDIES. 1G1 Syncope is a condition of simple failure of the arterial circula- tion of the brain. It may be due to sudden stoppage of the propulsion of blood from the heart, leading to immediate insen- sibility. This condition may be distinguished by the character of the pulse and the state of the Jieart itself; it is a condition of profound anaemia. It differs from collapse insomuch that in syncope the consciousness is lost, in collapse it is retained. The circulation is very much affected in coma, but not in the same way as in syncope; therefore syncope cannot answer at all to a condition of coma. Opium Coma. — In the first stage, the face is swollen, due to a stasis of the venous blood of the face, and this gives/ along with the heavy, swollen aspect, a dark flush. Along with this there will be a symmetrical contraction of the pupils of the eyes, so much so as to be likened to a pin's head in many instances; this condition of the pupils should at once lead to a strong suspicion of opium poisoning. Next the state of the skin should be noticed. In opium poisoning, as opium is a powerful diapho- retic, the skin will be wet with perspiration, and, owing to opium being also a cardiac stimulant, it will not be a cold, clammy sweat in the majority of instances, but similar to that produced by exercise. The respirations should be carefully noticed; they are characteristically affected by opium. They are slowed, sometimes falling even to five per minute. An- other characteristic of the respirations is that they are very deep and stertorous, as if the whole lung was being inflated, and a marked pause intervenes before expiration. In the first stage, the pulse will be slow, strong, regular, large, and quite compressible, and therefore short. Having noticed these things, which, if taken together, are quite pathognomonic, en- deavor to arouse the patient. In a great majority of cases, this can be done, the patient coming back to consciousness for a brief period. At once put some question and notice the answer. The articulation is good, what he says he pronounces distinctly, and the answer is rational, although, from returning uncon- sciousness, he may not be able to complete it; all of these symptoms together leave very little doubt of opium poison- ing. 11 162 NOTES OX MATERIA MEDICA. Alcoholic Coma. — This is the commonest form of coma. The face is flushed, but it is an arterial flush; the pupils are not contracted ; the skin may be covered with perspiration as in opium poisoning. There is a marked difference in the respira- tions in the two cases. In alcoholic coma, instead of being slow and deep, they are regular and hurried, and there is quick expiration following inspiration. The pulse is very different, and by this it can be determined whether this coma is com- bined with the preceding one, viz., whether the coma is due to both opium and alcohol. The pulse should always be quick and strong, unless the patient has been in alcoholic coma for some time, when it will be quick but weak. If any attempt is made to arouse the patient, he returns to a drunken consciousness. His answers are not rational, and the words are not well articu- lated, the first effect of drunkenness being to produce thickness in utterance; not only that, but he is irritated by interference and probably uses profane language. Individuals under the influence of opium never swear. Urcemic Coma. — This is very characteristic in one particular: the pupils are insusceptible to light; they may be contracted, but not symmetrically so, or one may be contracted and the other dilated, or, as is not uncommon, both may be dilated. The respirations are very irregular, sometimes rapid, sometimes slow, but, as a rule, there is not the deep inspiration of opium poisoning, though occasionally there is stertorous breathing. The pulse is very changeable, sometimes being quite rapid, in other cases slow, and has a tendency to irregularity and incom- pressibility in the majority of cases. If, in addition to the incompressible pulse, rigid arteries are present, it is highly pre- sumptive that the coma is urasmic in character. As a rule the face is pale, but, if not, the hands will be very white. In ursemic poisoning, the skin is of a dead white, chalky color. Apoplectic Coma. — This sometimes resembles closely the coma of opium poisoning. The respirations may be very slow; usually, however, they are very irregular, sometimes slow, sometimes rapid. The pulse may be very hard or very full, as in opium poisoning. The hands should be noticed. In many cases, one iand is moving, the other lying motionless at the side of the MEDICINAL EEMEDIES. 163 body. On taking ivp the hand, it will be found that the arm behaves in a like manner ; in other words, there is more or less paralysis of one or more of the extremities. On examining the eye, not infrequently there will be found strabismus. If this is the case (when strabismus did not exist before), the diagnosis is settled. The pupils may be either contracted or dilated, very commonly the latter. Finally, there is coma due to concussion of the brain from blows on the head, etc. (It is very important to distinguish this form, as it is often due to criminal assault.) There is something very characteristic in this form of coma, viz., the control of the brain over the spinal cord is withdrawn, and con- sequently the reflexes of the spinal cord are set free, and hence every external impression leads to twitching of the muscles, some- times sufficient to produce a movement of the whole limb. Hence, wherever there is jactitation it points to some injury of this kind to the head, and is very characteristic. Lastly, in the coma of apoplexy and concussion of the brain the patient cannot be aroused. In the coma of alcohol and opium, he can be. In urasmic coma, except in a few cases, the patient cannot be aroused. If he does come to consciousness, he does so spontaneously, and not because of any efforts made to bring him to. The second stage of opium poisoning is quite opposite to the first. It occurs during the condition of collapse that shortly precedes death, and as a rule nothing can be done for it except to greatly stimulate with alcohol or, better still, nitro- glycerin. This stage has all the symptoms of profound exhaus- tion of the respiratory centre and of the heart. Instead of a turgid and livid countenance, it is pale; instead of contracted pupils, they may be widely dilated; and there will be rapid and shallow breathing, extremely feeble and perhaps rapid and very compressible pulse. The patient cannot be aroused; but if any answer can be elicited, proceed at once to the treatment of the second stage. Treatment of Opium Poisoning. — The measures applicable to the first stage are not at all applicable to the second stage. In the first stage, the stomach should be thoroughly washed out, 164 NOTES ON MATERIA MEDICA. either by means of the stomach pump or by the stomach tube; this is very important, and many lives can be saved by so doing. If it is certain that opium has been taken in the liquid form, as laudanum or the solution of morphine, or that the opium has . been in the stomach for some time, the patient having been in cooia for a number of hours, it is useless to wash out the stomach; it is only wasting time. Eecourse must now be had to the two great .antidotes. The first by all odds is the tincture of belladonna. It should be given in xx.-gtt. doses, repeated every twenty minutes, watching carefully meanwhile the respirations of the patient. As soon as they are increased to about sixteen, cease the administration until the respirations begin to fall again. Also watch the pupils of the eyes; as soon as they dilate, even if the respirations have not increased, the dose should be given less often. Belladonna has been given in these cases in doses that would have been poisonous if opium had not been taken, but the opium counteracts the belladonna, and conversely. Twenty minutes between the doses is long enough to wait, if the symp- toms of opium poisoning have not disappeared. Along with belladonna, and in no way interfering with its action, is caffeine, preferably in the form of strong coffee. This may be adminis- tered at the same time that belladonna is given, and all possible means should be used to arouse the patient; he should be pre- vented from lying down, as this has a tendency to diminish the respirations; keep him moving about, and do not give alcoholic stimulants, as they are injurious in this stage. Finally, elec- tricity should be used; this is of greater value in the second stage, but can be given in both, the object being to stimulate the dia- phragm, which, with the heart, has a tendency to stop. Place one of the poles of a faradic battery at the nape of the neck, waiting until the patient has had expiration. As soon as through, apply the other pole to the epigastrium, pressing upwards to bring it forward upon the chest. The action of electricity can sometimes be increased by dashing cold water suddenly upon the chest (not upon the face), as stimulation of the surface nerves of the chest causes inspiration. Do not apply electricity to the nostrils, as this stops inspiration. Also place the poles suddenly on different parts of the chest and MEDICINAL REMEDIES. 165 over the region of the heart; a continuous application in one place is injurious. Occasionally the patient should be laid down flat and artifi- cial respiration resorted to. In this case, keep the battery to the nape of the neck when the face is turned downwards, and when the patient is turned on his back apply again to the epigastrium, and so on. In the second stage, or stage of collapse, do not use any of the remedies above mentioned except electricity. The condition is now one of great exhaustion. As it is impossible to keep him walking in this stage, he should be laid down. Use cardiac stimulants; brandy and water should be given ad libitum, there being no necessity to take into account the effect of large doses of alcohol, because cardiac failure is imminent owing to the excessive weakness. The following prescription should be used : ]J Tincturse Nucis Vomicae, 3 i. Tincturae Strophanthi, 3 ss. Caffeinge Citratis, gr. xxx. Spiritus Ammonii aromatici, § iss. Aquce, . q. s. ad § iij. M. Dose, two teaspoonfuls every half or every hour, to be given in 3 i. of brandy. Hypodermatic injections of nitroglycerin should also be given at the same time, gr. y-J-g- at each dose. Meat juice extracted from beef steak should be given every fifteen minutes; it can also be given freely by the rectum, as it is a strong stimulant. The only hope is to tide the patient over this deathly collapse. Dry heat can also be applied to the feet and epigastrium. Preparations. — Gum opium contains two alkaloids that are of sufficient importance to mention specially, viz , morphine and codeine. It contains other alkaloids and principles of the glucoside class, so that opium has therapeutic properties not possessed by morphine. In the first place, opium is more of a cardiac stimulant than morphine. For a case, therefore, of peritonitis, opium is preferable to morphine. The following rule is a good one : Where there is a small, irregular, hard pulse 166 NOTES ON MATERIA MEDICA. (as in something of the nature of peritonitis, abdominal inflam- mations, gangrene, or in certain skin diseases that end in death by producing gangrene), opium as a stimulant should be used rather than morphine, which has slight stimulating properties only. Morphine, however, has all the other actions of opium, viz., anodyne, diuretic, diaphoretic, etc. Very often mistakes are made in regard to the administration of this powerful poison. Little children should not have opium given them, unless with extreme care. Infants scarcely bear opium at all. Death has resulted by the administration of one drop of lauda- num to a child six months old. One drop of laudanum to a child one year of age is a large dose, for the reason that the dis- proportionate development of the brain to the rest of the body in children renders them peculiarly susceptible to the influence of this drug. Alkaloids : Morphinae Sulphas (dose, gr. \). Codeina (dose, gr. ss.-i.). Liquid Preparations of Morphine : Liquor Morphinae Sulphatis (U. S.) [Morphinae, gr. i.; Aquae, | i.] (dose, a teaspoonful). Liquor Morphinae Sulphatis, Magendii [Morphinae, gr. xvi.; Aquae, § i.] (dose, tfj, v., equal to one-sixth grain of mor- phine). Neither of these two solutions of morphine is officinal. Preparations of the Crude Drug : Pulvis Opii (dose, gr. i.-ij.). Pulvis Ipecacuanhae et Opii, or Dover's powder, or the compound powder of Ipecac. Ten grains contain Opium, gr. i.; Ipecac, gr, i. ; Sugar of Milk, gr. viij. Liquid Preparations of the Crude Drug : Tinctura Opii, or Laudanum [Opii, gr. xlviij.; Alcohol, § i.]. Ten minims are equal to one grain of opium; there are two drops to one minim, consequently twenty drops are equal to one grain of opium. Tinctura Opii Camphorata, or Paregoric (gr. ij - § i). In addi- tion to the alcohol, it contains camphor, benzoic acid, oil of anise, and glycerin. This preparation is very pleasant to the taste, and has the advantage of acting upon the bronchial mucous membrane in bronchitis with soreness. It is well adapted for children. Ten drops should be the outside dose for an infant. MEDICINAL REMEDIES. 167 Opium can be combined with a number of different medicines, so as to have actions that opium by itself cannot produce. It can be made to act admirably as a diuretic or to promote the action of diuretics, notably when the kidneys are irritated or inflamed, e.g., as in stone or gravel. In these cases, the camphorated tincture should be given with buchu. This will also act well in cases of irritability of the urethra and bladder, increasing the good effects of buchu and allaying pain and soreness. Opium by itself is a diaphoretic. This diaphoretic action is strikingly shown by combining it with ipecac to form Dover's powder. It is an excellent diaphoretic in many conditions of dry skin with considerable pain, e.g., as in inflammations with fever. Dover's powder acts very well here, also in conditions where there is a hard pulse, dry skin, and restlessness; and if the tincture of aconite root be added in doses of from four to five drops, the diaphoretic action is promoted, and there is less cardiac disturb- ance than when the Dover's powder is given alone. Another very good combination in some cases is the extract of colchicum, Dover's powder, and aconite. This combination is very good for articular pains. Magendie's solution is principally used for hypodermatic injec- tions, and five drops are equal to one-sixth of a grain of morphine. This should be remembered, as many deaths result from the careless use of the hypodermatic syringe, frequently fifteen min- ims being given. With a patient unaccustomed to morphine, begin with five drops, and increase as necessity demands. Summary of the Uses of Opium. 1. As a stimulant, opium acts as a stimulant to the brain, the heart, the intellectual functions, and general vitality of the system. 2. As a sedative, opium acts as an anodyne to relieve pain. 3. It also acts upon the intestines to arrest excessive peristal- tic action, and for certain forms of diarrhoea. 4. As a soporific. 5. As a diuretic, especially the camphorated tincture com- bined with buchu. 6. As a diaphoretic. 168 NOTES ON MATEEIA MEDICA. II. Alcohol. As a medicine, alcohol is a sedative as well as a stimulant, and quite as much one as the other. Alcohol, as such, is the most complex of all medicines, in the sense of having so many preparations. As a Cardiac Stimulant. — Its action upon the heart is simi- lar to that produced by violent muscular exercise. The pulse is rapid, strong, regular, full, compressible, and very short; con- sequently the arterial system is dilated, respirations are in- creased, and the heart beats with a force and steadiness of rhythm resembling that produced by opium, but differing in frequency. This is the main medicinal action of alcohol; but as, when violent muscular exercise is prolonged, exhaustion results, so this rapid action of the heart, produced by constant doses of alcohol, finally ends in cardiac weakness. Alcohol requires a great deal of discrimination in its administration. The following rules should be closely followed: As a cardiac stimulant, it should be given where heart failure is impending and there is danger of the patient dying from this. The radial pulse is not always a good indication of the strength of the heart. An incompressible pulse, due to obstruction of contracted arter'es, may give the impression of a full, strong pulse, whereas the heart may be very weak. The impulse of the heart against the chest walls should be carefully watched. If it is very perceptible, do not give alcohol; for as the cardiac weakness progresses, the impulse diminishes and becomes quite feeble. On auscultation, however, it can be determined exactly when alcohol should be given. In many cases of fever, only one sound can be heard, and the heart is beating 100-120 per minute. This is the second sound. The first sound is so weak that it cannot be heard; and it is the rule that where only one sound is heard, it is the second, the first having diminished or almost disappeared. This is always a dangerous condition, there being great danger of collapse; for the first sound coin- cides with the systole, and in proportion to its feebleness there will be weakness in the systolic contraction of the heart. At the first it may sound muffled, but as the contractions become MEDICINAL KEMEDIES. 169 more feeble it can only be hoard by a practised ear. On the other hand, the second sound is due to relaxation of the heart. If it relaxes quickly, the sound is more clear than if gradual, and this clearness of the second sound clearly indicates the begin- ning of heart failure. Disappearance of the first sound always calls for alcohol, and it should be given until the first sound returns clear. Cardiac failure in acute diseases may come on suddenly, pro- ducing syncope; unlimited quantities of brandy and ammonia should be given. It may also come on rapidly in high fever, as in typhus fever, small-pox, severe cases of measles, and occasion- ally in typhoid fever; in these cases, do not begin the administra- tion of alcohol too early. It is impossible to forestall the weak- ness of the heart. The stimulants must be reserved for the time of actual heart failure. Cardiac failure is more likely to occur at certain hours than at others, generally after midnight, from that period till early morning. It rarely happens between 8 and 12 a.m., for usually this is the time of highest vitality. It is lowest between 2 and 6 a.m. In many cases, therefore, order stimulants to be given during the latter part of the night. After midnight, it may be necessary to stimulate till 7 a.m. The period of access of the fever is about 3 p.m. At first, the pa- tient is stimulated by the access, and this, in turn, is followed by restlessness and delirium toward the evening, followed by exhaustion between 2 and 6 a.m. As feebleness increases, begin stimulation before midnight, then in the evening, and back through the afternoon. Alcohol should not be given right through the twenty-four hours, neither should it be given in small doses frequently repeated; this should only be done in cases of hemorrhage. It is much better to give § i. of whiskey once every three hours than f ij. in three hours dis- tributed over the whole time, one good stimulation being better to tide the patient over the depression than repeated small doses. Alcohol is of great value for its stimulating effect upon the spirits in conditions of profound nervous prostration. It should not be giver unless there are signs of muscular weakness pres- ent, trembling, great depression, etc. ; here it will do good. 170 NOTES OH" MATERIA MEDICA. As a Sedative. — Alcohol is one of the most valuable sedatives, in the sense that it is a brake upon the too rapid exhaustion and waste of the nervous system particularly, and here it does not act at all as a stimulant; when it does so, it produces injury. The sedative action of alcohol is simultaneous with the stimu- lative, and both are felt from the moment it is taken, affecting both the sensory and motor nerves, and particularly the nerves that are concerned with the muscular balance of the body. All the automatic and the quasi-automatic operations of the body are carried on and kept in play by a continuous series of un- recognized sensations regulating these motor acts of the bod} T , e.g., the sensation of the need of breathing, by the pneumogas- tric nerve, etc. This sensory mechanism is very much blunted by alcohol from the very commencement. In proportion to the amount of alcohol taken, the delicacy of the sense of touch is lost. The appreciation of form is next lost, and when actually drunk it is difficult to perform any of the ordinary operations of the body, not because paralysis is present, but on account of the muscles not receiving their proper sensory impressions, and therefore not being directed with precision; consequently the un- steady gait, double vision, etc., very much resembling the symp- toms of locomotor ataxia. The sedative action of alcohol in blunting the sense of pain is also considerable, so that it is an anodyne, and may, on this account, be given with opium to increase its effects, and in former days this was done to prepare the patient for surgical operations. The sedative action of alcohol is of great use in those conditions in which the nervous system is wearing out from excessive irritability. It is a universal rule that nervous debility is accompanied by excessive reflex irritability. Very slight external impressions lead to motor disturbances, and this is exaggerated in disease, so that in certain conditions it amounts to the cause of death, r.s in tetanus, hydrophobia, strychnine poisoning, etc., when a slight touch or breath of air will throw the patient into terrible convulsions. In conditions of nervous exhaustion, when the patient is worn out with nervous and mus- cular irritability, alcohol taken in a proper manner has a re- markably quieting effect; also in conditions of insomnia follow- MEDICIKAL REMEDIES. 171 ing great muscular exertion, e.g., women after parturition, who, in trying to sleep, suddenly start all over; also in women who have had the care of large families for years and who are suffering from overstrain; and to men who are subjected to overstrain alcohol should be given for its sedative effect. This enables the patient to endure fatigue, sleep well, and gain strength — not be- cause alcohol adds anything to the system, but because it pre- vents waste from continual exhaustion. Administration. — The urine can be taken as a guide as a stated fact in chronic disease; when the urine is of high specific gravity, alcohol is always contra-indicated. . There is not a sin- gle condition, in health or disease, with urine of high specific gravity, in which alcohol does good; it invariably does harm. This is difficult to explain, but nevertheless it is an infallible rule. Thus, in diabetes mellitus, where the specific gravity of the urine runs from 1.025 to 1.050, and a great deal of nervous ex- haustion and muscular weakness is present, there is apparently every reason why alcohol should be administered. Instead of doing good, however, it always does more or less harm, and seems to aggravate the disease. So also in all cases of acute dis- ease where the specific gravity of the urine is high with high color. In cases of rheumatism where there is great depression, also in disturbed conditions of the liver, all of these, being ac- companied with high specific gravity of the urine, contra-indi- cate the use of alcohol. But, on the contrary, when the urine is of low specific gravity, every case is benefited by alcohol, even in Bright' 's disease when it is taken so as not to irritate the kidneys. Therefore in all conditions in which the urine is of low specific gravity and of alkaline reaction — these conditions indicating the waste of the body being in excess of its nutritive power, especially nervous waste, characteristic of persons with a great deal of worry and anxiety, or who have subjected them- selves to some heavy strain, venereal excesses, or, in fact, any heavy drain on the nervous system — alcohol should be given. Unfortunately there is no remedy equal to alcohol for this pur- pose. Generally, in these cases, the pulse is very compressible. If it is incompressible, it indicates Bright's disease. Alcohol should always be taken with food, there being then 172 XOTES OX MATERIA MEDICA. no danger of the alcohol habit being acquired. No drunkard is a good eater. Food and alcohol are mutually antagonistic, there being hardly a case of delirium tremens in which the patient had taken a full meal for twelve to fourteen days beforehand. Many of the symptoms are really symptoms of the body demand- ing food. Every case of delirium tremens should be fed from the very beginning with milk, lime water, beef tea, or whatever can be taken into the disordered stomach. Every time the patient asks for drink, food should be given. Alcohol taken upon an empty stomach stops the desire for food and creates the desire for drink. The only effect that alcohol ever has in promoting digestion is that, when taken with food in moderate quantities, it stimu- lates the emotions and feelings pleasurably, causing the food to digest better. This is to be explained on the principle of asso- ciation. For we find that a good spirit and a cheerful frame of mind always accompany a good appetite and a healthy digestion, while dyspepsia is almost invariably associated with despondency and loss of appetite. It is for this reason that pleasant associations and surround- ings are so conducive to hearty eating and good digestion, while a gloomy atmosphere, disagreeable society, or solitude has the very opposite effect. Further, upon the principle of this asso- ciation between food and the action of alcohol, we can explain the fact that craving for spirituous drinks may always be tempo- rarily checked by taking food, and so, also, we find that persons accustomed to take alcoholic- liquors only with their meals rarely become intemperate. Alcohol, as such, should never be given, but in the different preparations, of which there are a great variet}^ in degrees of concentration, and hence divided into the mild and strong — the mild being the wines, the strong the spirits. "Wines include beers, which are virtually wines. They are all fermentative liquors, and on that account form a complex pre- scription, as there are other drugs besides alcohol in fermentative liquors. Wines contain tartaric acid, phosphates, ethers, and in some wines tannin, in others iron, etc. A good bottle of claret contains a large dose of the tartrate of iron. MEDICINAL REMEDIES. 173 In beers there is a quantity of nutritive albumen, so that in reality there is more nourishment in a pint of porter than in a pint of beef tea. There is a vast difference in the strength of the different preparations, wines, beers, spirits. Beer, for ex- ample, contains scarcely more than 4 per cent, whiskey 58-62 percent. It is, therefore, impossible for these two drinks to act in the same manner. Before the alcohol in lager beer can affect the head, the drinker has to imbibe large quantities, which should rapidly pass through the system. Whiskey, on the other hand, very soon produces intoxication. Alcohol being not only a neurotic, but also a chemical, it produces coagulation of albumen and fibrin, and therefore concentrated alcohol produces changes in the stomach, liver, kidneys, and finally all over the body. This could not be done unless concentrated. There is a marked difference in diseases resulting from beer and those produced by spirits, dependent upon this chemical action interfering with the functions of the liver and leading to diseases elsewhere. Different Preparations of Spirits. — Spirits are of different kinds: brandy, whiskey, rum, gin. Brandy is an alcoholic preparation, strength 56$-58$ if properly made. A tablespoon- ful is equivalent to a little over two teaspoonfuls of pure spi- rits of wine or alcohol. It contains a large amount of tannin, and on this account brandy is constipative. Brandy is there- fore often given as an astringent. It also acts better than any other alcoholic preparation in increasing the appetite. Hence it is a favorite addition to prescriptions containing bark or any- thing for arousing the appetite. It is preferable to the tinctures for this purpose. Brandy has a large variety of ethers, old brandy particularly, some of them closely approaching oil of wine itself. These give the particular flavor of each brand, de- pendent upon the reaction between vegetable products and alco- hol in the process of fermentation. In the case of brandy, an ether is generated that is particularly good to arrest nausea, and it should therefore be given when there is vomiting with hsemate- mesis. The smell of the ether sometimes is sufficient to prevent the nausea, as vomiting is more often excited through the sense of smell than by any other channel. In the vomiting attending labor, brandy should be given, and for this purpose it is prefer- 174 NOTES ON MATERIA MEDICA. able to whiskey, gin, or rum. California brandy is about the best. Wliishey is the most trustworthy of liquors as to strength. It is a diuretic, and this action can be counted on pretty well. It has all the advantages of alcohol as such, except that against nausea, and it is not constipative. Gin is still more of a diuretic, from the juniper berries. It is also an antispasmodic, on account of the ethers it contains. It is much used to relieve spasmodic pains of the genito-urinary system, but it increases the pain when due to gravel. Rums are made from fermented molasses. Grin, whiskey, or brandy can be used with milk as stimulants. Wines. — Wines differ in amount of alcohol and saccharine principle. When the ferment and saccharine elements are equal, the wine is said to be " dry," while when one or the other is in excess a sour or sweet wine results. Wines are divided into strong and light wines. Strong wines are those which are so concentrated as to range from 18^-22$ of alcohol. The sweet wines are produced from very saccharine juices of grapes, and hence are from the warmer climates. Sherry (Spain) and port (Portugal) are types of this class. The malt liquors are fermented liquids produced from grains; they are wines. Their strength varies: lager beer, 2$-6$ alcohol; English ales, porter, and brown stout, 6f -12fo. The light or sour wines are the weakest, as clarets, hocks, etc. In these, the percentage of alcohol is from six to twelve. The clarets ought to be made from black grapes, and the juice of these includes the coloring matter and a portion of the extractives from the skins, so that they are red. Light hocks are derived from white grapes or black ones without the skins. Now, as to the choice of the different preparations, when we wish to use alcohol as a sedative, there is no rule but one — that is, the patient's own experience. With a great many, spirits will be much the best; with others, wines; with others, beers. If any of these affects the head, alcohol is not indicated at all, or not in that particular form. The effect upon the head should be the guide. Women, as a rule, cannot take alcohol unless in combination. It goes to the head, causing a sensation of heavi- MEDICINAL REMEDIES. 175 ness, etc. This indicates that even a teaspoonful is too much. Wines, as found in this country, are very rarely the juice of the grape alone and the product of its fermentation. They all con- tain brandies or free alcohol, in order to preserve them from further fermentation. As has already been said, any free alco- hol is very certain to affect the beads of most women and of some men, and hence wines containing free alcohol act more as drugs than as wines. The royal tokay California wine is to be preferred; it can also be given to children. ~No kind of drink whatever, whether it be wine, tea, or coffee, should ever repeat, i.e., be tasted again, and this should be the answer to questions as to whether any particular drink may be taken. So with articles of food. The difficulty with beers is that when they do not agree they irritate the skin, and both wines and beers, w T hen taken for a long time, are prone to produce gout. If there is any tendency to kidney trouble, as gravel, etc., anything in the form of beers or wines should not be prescribed; nor if there is any tendency to eczematous troubles, which are frequently dependent upon fermentation iri the stomach. Acute alcoliolismus occurs generally in those who go on a pro- longed spree after a period of abstinence from intoxicating liquors. It is a real paroxysmal disease, like epilepsy; the at- tacks become more and more frequent, the interval between them decreasing. Hereditary tendency has a great deal to do with the etiology, children of drunkards have a tendency to insanity. The parox- ysms occur especially in those who are highly gifted and tal- ented. They will drink in secret, and cannot be restrained by any influence. When the desire for drink comes on, the appe- tite is lost; no remedy can control the craving except veratrum viride, which should be given in five-drop doses of the tincture until nausea is produced. There is generally great tolerance of the drug in these cases. The nausea supplants the thirst better than anything else except food, but these patients refuse to take the latter. The symptoms of an impending attack are an in- creased pulse and high arterial tension. When a large amount of alcohol has been taken in a short 176 NOTES OX MATERIA MEDICA. time, acute alcoholic poisoning may result. The symptoms of this condition are: coma, relaxation of the entire muscular sys- tem; pulse is hard, rapid, and strong. This may develop into convulsion, epileptic in character, resembling puerperal eclamp- sia. The face becomes blue, the heart very rapid. To save the patient, either bleed until the pulse becomes soft and patient shows signs of consciousness, or administer tr. veratrum viride in drachm doses until the same effect is produced. There is no danger of veratrum poisoning. Chronic Alcoholic Poisoning. — 1st. Delirium tremens always follows prolonged drinking without taking food. It is pro- duced by alcohol following starvation, and will not occur unless the patient has been without food for ten days or two weeks. He should be forced to take food. 2d. Alcohol Habit : Patients suffering from this habit com- plain of gastric troubles. There is loss of appetite, especially in the morning; animal food is distasteful; there is pain on pressure over the stomach The bowels are constipated, and movements are scanty and dry. Tongue is brown at the back and dry, with red tip; the red line continues on the fauces. There is also chronic pharyn- gitis. The hands are fat, flabby, and soft. Sleep is disturbed char- acteristically; the patients sleep well the first part of the night, but wake about 3 A.M., and are unable to sleep again, or, if they do, are troubled by unpleasant dreams. Constant and excessive use of alcoholic stimulants ages the drinker in all respects. He becomes an old man before his time; the skin becomes dry, with soft, unhealthy, waxy feeling. The mind becomes sluggish and weak. These changes are due to a sedative action of a paralytic character. III. Ethers. Ethers are agents generated by the action of an acid upon alcohol. There are a great variety, but those used in medicine are few. Used as medicines, they have properties similar to those of alcohol, only more rapid and evanescent, but they also MEDICINAL REMEDIES. 177 possess properties distinct from alcohol. Thus sulphuric ether, when taken into the stomach, produces a sensation of warmth, as alcohol does; along with this, the heart begins to beat rapidly and strongly, and its action is still further characterized by dilatation of the arterioles all over the body. Hence every one of the ethers, taken in sufficient doses, is a decided diuretic, pro- ducing warm perspiration. Some of them act upon other secretions, notably sulphuric ether, which is a good cholagogue; and all of them, but particularly sulphuric ether, are very efficient in arresting the spasms of ducts in the intestine, the gall bladder, etc. They are the most valuable medicines of the neurotic class for this purpose. Spirit of Nitrous Ether. Sweet spirit of nitre has a special effect upon the kidneys. It is more of a diuretic than sulphuric ether; it is also a very good agent to relieve spasm of the uneter, and, to a less degree, of the bladder and. urethra. Hence it is often given to relieve the pain caused by renal irritation, and is of service in condi- tions of congestion of the kidneys; besides this, it is an admir- able diaphoretic. It can also be used in bronchitis with pain and soreness m the chest, especially in children. Chloric Ether. Chloric ether, or spirit of chloroform, is not used very much at the present time. It is very good for allaying irritability of a sensory kind producing nausea, and so can be given in the vomiting of pregnancy, also in intestinal colic; a few drops given with glycerin have the same effects as Hoffmann's ano- dyne. Spiritus ^Etheris Comp. The compound spirit of sulphuric ether, or Hoffmann's ano- dyne, is a combination of sulphuric ether with alcohol and the heavy oil of wine. All ethers are of very low specific gravity 12 178 NOTES ON MATERIA MEDICA. and very volatile when pure. Alcohol, when added to them, lessens their pungency and develops their power. The oil of wine is an extremely valuable antispasmodic. This preparation is the best of all the ethers for the relief of pain that is paroxys- mal in character, due to the spasms of ducts. It can also be given for the relief of asthma. The oil of wine is very expensive, and on that account in some cases is not added; so, also, with the sweet spirit of nitre and compound spirit of sulphuric ether. SquibVs preparations can be depended upon, however. Ethers are of some importance in the treatment of Bright 's disease. The nitrates are a class of medicines that have very decided effects in relieving or in preventing spasm of the un- striped muscular fibres. Arterial spasm is caused by certain poisonous products in the blood, and, as a result of this chronic contraction, enlargement of the heart takes place, and in the kidneys themselves this persistent tonic contraction leads to low specific gravity of the urine, clearly indicating that materials that ought to be excreted are retained in the blood. In spas- modic or irritable stricture of the urethra, great difficulty is sometimes experienced in the introduction of a sound; in which case, placing the feet in hot water, the administration of a full dose of chloric ether, and the injection per rectum of ten drops of tincture of aconite in an ounce of warm water, will often relax the spasm, so as to admit of the passage of the instru- ment or to render the operation unnecessary. The muriated tincture of iron contains chloric ether, and may be used in urethral spasm. Ammonia and ethers combined are used for the relief of trigeminal neuralgia, occurring in angemic persons and due to feeble circulation. The Mydriatics. The mydriatics are a class of medicines bearing close resem- blance to each other, and take their name from the fact that their most characteristic effect is marked dilatation of the pupil. The most important members of this class are belladonna, hy- MEDICINAL REMEDIES. 179 oscyamus, and stramonium. These drugs come from one par- ticular family of plants called the solanaceae. IT. Belladonna. Belladonna is the best type of this class. The action of these medicines can be explained by their innervation of the rhythm of involuntary muscles (voluntary muscles do not act rhythmi- cally). The action of involuntary muscles consists in a wave beginning at one end, and proceeding in a wave through the whole length of the muscle. There is one peculiarity about the arrangement of rhythmical muscles — if in a state of spasm, in- stead of the whole muscle being affected, one half sometimes will be contracted and the other half paralyzed or relaxed. In studying their arrangement, when they surround tubes we find that some of their fibres run lengthwise and some trans- versely; hence when a tube — e.g., the intestine — is in a state of spasm, one part will often be contracted, and next to it there will be a dilated or relaxed part. Cramps are often present, due to the fact that the air passes first into a constricted part a,nd then into a dilated part. This alternate contraction and relaxation produce various rumbling sounds in the intestines. What belladonna and the other members of this class do is to act in restoring the normal, vermicular, steady rhythmical ac- tion of these muscles. Unstriped muscular fibres are always found in the tubular or involuntary muscles, never in the volun- tary or skeletal muscles. The tubular structures, as the arteries, etc., in large divi- sions if not in small ones, have a muscular coat; besides, there are a number of hollow viscera which are really dilatations of tubular structures, e.g., the stomach, the bladder, and the heart. Hence many diseases of the heart we now know to be due to the fact that the blood-vessels are affected, which re- act upon the heart and hence involve the whole mechanism. Therefore, in heart disease it should be remembered that the arteries are a part of the same apparatus, and that many affec- tions of the heart are dependent on their action. This explains the good effect of belladonna in heart disease. Rhythmical 180 XOTES OX MATERIA MEDICA. muscles are to be found lining all the tubes and viscera; bella- donna and its allies restore the natural action of the muscular layers. The bronchial tubes are sometimes affected in their rhythm by a purely nervous disease. In asthma, there is a cramp of the finer bronchial tubes in the same way as already described — not the entire tube, but certain portions of it: one part is contracted and the other is dilated or relaxed; hence the air, in passing through, gives rise to a musical, sibilant, or whistling sound. Belladonna arrests the spasm by restoring the natural rhythm, and as soon as this is done the contracted parts relax and the dyspnoea disappears. Asthmatic breathing is very different from other kinds of dyspnoea which are very often confounded with it. There is one unmistakable sign which, if not present, shows that the disease is not asthma: that is, difficulty in expiration. The air goes into the lungs with comparative ease, but the pa- tient cannot drive it out again so readily, in marked distinction to normal breathing, in which inspiration is three times as long as expiration. In asthma, the conditions are reversed. Bella- donna and its allies, for the time being, relieve the spasm ; but as they are neurotics, whose functions are to relieve symptoms only, they cannot cure the disease. The symptoms are relieved, but the asthma itself is not in any way benefited. It not infrequently happens that persons of a nervous temper- ament are troubled with a choking sensation, as if some foreign body were lodged in the oesophagus. This is a real " globus hystericus," even when occurring in males, and indicates that there is a spasm of the oesophagus. A large quantity of saliva collects in the dilated portion during the night, and is raised in the morning. Belladonna will relieve this condition, if it is not due to serious structural disease. This condition usually ends in irregular contraction or cramp of the stomach. In all cases of dyspepsia, nervous, irregular action of the he art, palpitation, severe stomach-ache, it is an indication that whatever is given must contain belladonna. In gastrodynia, it should always be tried, not only with tonics, but with bismuth, pepsin, and re- sorcin. In chronic constipation of women, there is a peculiar tendency,. MEDICINAL REMEDIES. 181 when the ovarian plexus is irritated, to paralyze the peristaltic movements of the intestines. In dysmenorrhea or a tendency to amenorrhcea, there will be obstinate constipation, due, in a great part, to the irregular contraction and spasm of the intes- tines. If this condition lasts for any great length of time, dur- ing a paroxysm borborygmi will be developed; this is due to a running sort of contraction and relaxation of the intestines. This reflex nervous disturbance is one of the commonest causes of constipation in women, and hence belladonna should always be added when a laxative is to be given. B Extracti Belladonnse, gr. v. Extracti Nucis Vomicae, gr. x. Extracti Colocynthidis Comp., . . . . 3 i. Liquoris Potassae, gtt. 1. M. et ft. pil. No. xx. Sig. One at night. On the same principle, belladonna and its allies are of great value in the treatment of cystitis. The bladder, when irritated or inflamed, acts in a spasmodic way, expelling its contents. The principle is to give rest to the part, as every movement aggra- vates the inflammation. Belladonna here relieves the spasmodic action very markedly, and should therefore be given. If the muscular fibres of the bladder have lost their tone, the bladder is of course weakened, and belladonna should not be given. This is the case with old men, who are often troubled with obstruction due to an enlarged prostate gland ; the bladder, retaining its contents, loses its power of expulsion, and hence must be emptied very frequently, because it is virtually a very much smaller one, only the upper part being capable of ex- pelling its contents. In this case, if belladonna should be given the patient could not empty the bladder at all. Belladonna sim- ply allays the spasmodic irritation, and is not a stimulant to the bladder itself. Overdistention frequently happens during the process of parturition, and is always a serious matter, for it is a rule that unstriped muscles, if overdistended or stretched, never recover their normal condition again. The patient should not go for more than three or four hours after parturition with- out micturition. Four women out of five' who have borne ch.il- 182 XOTES OX MATERIA MEDICA. dren have difficulty in emptying the bladder, due to this one cause. In these cases, belladonna should not be given, but in- stead of it give mix vomica and perhaps add ergot. Nocturnal incontinence of urine in children is generally due to irritation of the bladder, causing it to expel its contents as soon as it has become filled to a certain degree, provided this is not prevented by a direct act of the will. Belladonna will often effect a perfect cure in these cases, but it must be given in suffi- cient quantities to secure its full physiological effect at night. It should cause flushing of the child's face while he is awake. Combining it with chloral and ergot may be beneficial. The Vascular System. — It is of special use in certain affec- tions of the heart in young persons who have had rheumatic en- docarditis. Very often, in a year or two, there will be dilatation of the left chamber of the heart, with severe pain on exertion; this is due to want of balance in the rhythm of the two sides of the heart. In cases of cardiac pain, confined to the heart itself, with rheumatic history, etc., a belladonna plaster can be ap- plied and belladonna itself given internally; it can be combined with iron and given in pill form. The pain of angina pectoris is not confined to the region of the heart, but radiates down the left arm ; the latter pain is not relieved by belladonna, but by nitroglycerin and other cardiac stimulants. Glandular Secretions. — Belladonna arrests certain normal se- cretions of the body. It is the most reliable drug to check the secretion of milk, and should be given for one or two weeks con- tinuously. If, therefore, a woman expects to be confined, and knows that she cannot nurse her child, belladonna should be administered, before parturition. By some it is claimed to be a good remedy for the tediousness of the first stage of labor. Be this as it may, it will certainly cause milk to dry up without forming abscesses. The internal administration of the drug is to be preferred in these cases. However, if promptness is essen- tial, apply locally; but poisoning sometimes results from its ap- plication to the breast, where the skin is very thin and absorbs readily, the constitutional effects of the drug being sometimes produced. The officinal ointment is to be preferred. Exces- sive sweating in the armpits and the feet may be checked by the MEDICINAL REMEDIES. 183 application of the ointment of belladonna. If, however, it is general, as in phthisis, belladonna should be given internally in the form of the tincture or the solid extract. Preparations. — Tinctura Belladonnae (dose, t\[ x.); Extrac- tum Belladonnae (dose, gr. i). The alkaloid atropia is very powerful, and is used almost ex- clusively for making solutions to dilate the pupil for examina- tion of the eye, being superior to belladonna itself for this purpose. Summary of the Uses of Belladonna. 1. In bronchial spasm and asthma. 2. In spasm of the oesophagus, dyspepsia, cardiac palpitation, and gastrodynia. 3. In chronic constipation of women. 4. In cystitis. 5. In cardiac pain. 6. For arresting glandular secretions. 7. For nocturnal incontinence of urine in children. Hyoscyamus. Hyoscyamus has the properties of belladonna and no other. There is no difference between them except in activity. The extract of hyoscyamus is a very uncertain preparation, and can- not be depended on in all cases, compared to the true and well- known dose of belladonna. Its alkaloid, hyoscyamine, how- ever, is very powerful, more so than atropine. There is virtually no difference in action between the two. Stramonium. Stramonium is the leaf of a weed found all over the United States. These leaves are dried and broken up in the same way as tobacco, and used in the same manner, viz., by inhaling the smoke. This smoke inhaled into the bronchial tubes produces an immediate effect upon asthmatic paroxysms, more than when atropine or belladonna is taken internally, and hence it is used almost entirely for this purpose. All of this class are good ano- 184 NOTES ON MATERIA MEDICA. dynes for the relief of pain in fibrous tissue, and notably where the pain is due to overstretching. Against a sprain belladonna or stramonium is more effective than opium; hence when there is inflammation or injury involving fibrous tissue, the addition of either of these two medicines markedly increases the action of opium, and opium helps them also. On account of this ano- dyne action, atropine and morphine should be given in sciatica, and also in sprains in the back from lifting. In sprains about the ankle, etc., an ointment of atropine and morphine should be used. V. Cannabis Indica. The flowering tops of the female plant of Cannabis sativa, which grows in the East Indies. Indian hemp does not affect all persons similarly, and race and climate are supposed to modify its influence. Its effects are most marked on the brain, whose functions it more or less perverts in various ways. It generally produces a pleasurable intoxication. The patient is possessed with a feeling of happi- ness and contentment, and ideas of a pleasing kind pass rapidly through the mind, sometimes unconnected and immediately forgotten, but in some instances recollected on the return to the normal state. Sometimes there is furious delirium. The eyes are bright and shiny. Pressure on the skin may excite a sensa- tion of burning. After a time, complete anaesthesia sets in to such an extent that while standing there may be no consciousness of touching the ground. If indulged in for a long time, as is common in the East, it produces loss of appetite and strength, trembling, and much mental weakness. Dilatation of the pupil and disorders of vision, which con- tribute to the hallucinations by the distortion of external objects, are produced by Cannabis Indica. It has been employed to re- lieve pain, and as a substitute for opium in neuralgia and as a hypnotic. It is a valuable remedy for migraine, or sick head- ache. It appears to act upon the nervous system, from whence this headache is derived. It is useful in those cases accom- panied with little or no nausea, or in cases with severe vomit- ing; it is also useful in those attacks accompanied with spectra. It is well established that hemp has the power to promote uterine .MEDICINAL REMEDIES. 185 contractions. It does not cause them, but it increases their energy when action has begun. Cannabis Indica is useful in Menorrhagia, and especially in that form which occurs at the menopause. It is also useful in cases of functional impotence, and may in this disease be combined with ergot and nux vom- ica. In some cases, it acts well as a diuretic, and hematuria is a special indication for its use. It can also be employed in dys- uria and strangury, and is useful in retention of urine depen- dent on paralysis of spinal origin. Preparations — Extractum Cannabis Indicse (dose, gr. i-ij.)? Extraction Cannabis Indices fluidum (dose, TT[ ij.-iv.); Tinctura Cannabis Indicse (dose, tt[ vi -xxx.). (o) Those Medicines which are Stimulants only. 1. 2. 3. 4. Digitalis. Strophanthus. Nitroglycerin. Caffeine. 6. 7. 8. 9. Ergot. Strychnine. Camphor. Asafcetida. 5. Ammonia. 10. Valeriana. I. Digitalis (Foxglove). The leaves of Digitalis purpurea, from plants of the second year's growth. Digitalis is a biennial plant, indigenous to southern and central Europe, particularly in the western sec- tion, and grows wild as far north as Norway, likewise in Ma- deira and the Azores. It is a cardiac stimulant, and is given for the purpose of increasing the contractile power of the heart and to cause it to recover as far as possible, even in organic changes, its natural size. Digitalis is a very old remedy comparatively, and in former days it was noted that its action was to slow the heart if given continuously, and also to make the heart beat intermittently, and so it was classed as a pure heart sedative. This was previ- ous to the careful studies of physiologists in their experimenta- tion on animals. When we have a living heart exposed, to watch the effects of digitalis, we find that it produces a pecu- liar tonic contraction of the heart, particularly of the walls of 186 XOTES OX MATERIA MEDIC A. the ventricles. The contraction is not uniform, but cramp- like, not all of the fibres of the heart equally participating; and so the heart presents a streaked or nutmeg appearance, as it is called, owing to the contracted fibres turning pale, those not contracted remaining relatively redder. This contraction is mainly due to the prolongation of the systole at the expense of the diastole. Digitalis increases the systole at the expense of the diastole, and if given continually, even where there is a normal heart, causes death by increasing the systole without any subsequent diastole or relaxation, the heart cavities growing smaller and smaller. This demonstrates the uses and dangers of digitalis, and explains, when acting as a poison, one symptom particularly, namely, the inter mittency of the pulse, because the heart does not relax and skips a beat. With this condition there is persistent and dangerous nausea and vomiting. The cumulative effects of digitalis are sometimes produced where, after the drug has been taken for a number of days, there will be persistent nausea and vomiting, often lasting for several days. In some cases, it will appear almost impossible to discover the cause of the vomiting until the intermitten- cy of the pulse leads to the suspicion of digitalis poisoning. Hypodermatic injections of morphine should be given. The vomiting is caused by cerebral anaemia, and should be counter- acted by morphine, because it produces relaxation of the heart. Digitalis is therefore the medicine for dilatation of the heart due to the relaxation of its muscular walls beyond their normal capacity. It is not a loud murmur that indicates great danger, as heart disease of a valvular kind never gives any trouble until the heart is not able to empty itself at each stroke. When this happens, then commences the general systemic disturbance of the circulation. When unable to wholly expel its contents, the heart becomes much dilated, and here a remedy is needed that shall contract the heart enough to bring it back to its natural size. Digitalis does not increase the contractile power of the heart in the way that alcohol and ammonia do, but the heart remains permanently smaller so long as it is under the effects of digitalis. This explains its whole action. It is not a car- diac stimulant in the sense that ammonia, alcohol, and brandy MEDICINAL KEMEDIES. 187 are, yet it is often given by physicians in the most routine way in pneumonia or typhoid fever where the danger is not of a dilated heart, but of a weak heart. Where the heart is only weak and not dilated, digitalis does no good. Apparently, therefore, digitalis is a typical medicine for dilatation of the heart; but, unfortunately, it has another effect, namely, it con- tracts not only the heart, but also the muscular coats of the arteries: not the aorta — for there the coat is elastic — but the small arteries, and the smaller they are the more they feel the effect of the drug. How does it do this ? On the coats of the arteries the vaso-motor nerves are distributed, and wherever there is a division of the artery, there we find a little ganglion, and at the next division another little ganglion of the vaso- motor system, and so on. These ganglia, instead of being acted upon all at once, are sometimes acted upon from the periphery, as in Bright's disease, or, as when digitalis is administered, from larger ganglia downwards. So in the latter case we find that when the heart is through with the action of digitalis, the little arteries are not, and so there is an obstruction which undoes all the good obtained from digitalis in strengthening the heart. The addition of nitroglycerin, however, overcomes this arterial obstruction, and we lose nothing of the action of digi- talis on the heart in combining these two drugs with strophan- tus, as nitroglycerin itself is a cardiac stimulant^ The com- bination of these drugs is very gratifying in its effects in all cases of heart failure due to obstruction of the circulation. It can be given also in angina pectoris, many of these cases being due to chronic obstruction in the arterioles, the heart being simply tired out from endeavoring to overcome this obstruction. Another of the actions of digitalis equally beneficial is in treat- ment of chronic Bright* s disease, where there is serious disturb- ance in the circulation over the whole body, due to toxmmic poisoning irritating and contracting the arteries. This disease, with sometimes one exception, namely, amyloid degeneration, gives a characteristically small, incompressible pulse. Here digitalis may be given to enable the heart to overcome its great tax of contracted arteries and the dilatation going on from con- stant obstruction. Digitalis should be given for the heart and 188 :n"otes ox materia medica. nitro-glycerin for the arteries. Under this treatment Bright^ disease shows decided symptoms of improvement, there being less albumin in the urine, with higher specific gravity. The following can be used for chronic Bright's disease: $ Hydrargyri Bichloridi, gr. i. Pulveris Digitalis, ...... gr. xxiv. Quininse Sulphatis, . . . . . gr. xxiv. ' Massse Ferri Carbonatis, 3 ij. Misce et fiant pilulae No. xlviii. Sig. Two pills t. i. d. after eating. Digitalis is also a diuretic of a kind which can be given with- out fear where there is engorgement or congestion of the kid- neys from acute nephritis. It is the remedy, therefore, in the nephritis of scarlatina, where a saline diuretic cannot be given, nor an irritant diuretic like ether or turpentine. The reason why digitalis can be given is that it produces the same kind of change in the circulation of the kidneys that occurs whenever there is a shock given to the whole arterial system. It operates on the kidneys, therefore, in the same way that fear does. When a man is frightened, the heart contracts, also intermits; he is nervous, cold, turns pale — all indications of vaso-motor spasm, producing a diuretic effect, as is frequently shown by incontinence of urine. Digitalis acts much in the same way in certain conditions of hysteria, and in spermatorrhoea due to weakness and debility. A stimulant of this kind produces a contraction of the arteries of the part. In epilepsy, there is one curious condition where digitalis does good, namely, where there is more or less intestinal disturbance and the patient has a bad breath, either before or during the convulsions. Anything like this should always be inquired for, also if there is diarrhoea or obstinate constipation accompanying, preceding, or following the convulsion. These peculiarities are often due to intestinal fer- mentation and the resultant poisoning. Digitalis always does good here, of course combined with other things. Finally, as to its action in pneumonia. In typhoid fever, it is of no use at all. Never give it in diphtheria, worse results pos- sibly following from its administration than from the disease it- self, because it interferes with the peripheral circulation, which MEDICINAL REMEDIES. 189 is the first thing that fails in prostrate conditions of heart fail- ure. Nor should it be given in fatty degeneration of the heart, where it does no good. But in certain conditions of pneumonia it does a great deal of good, namely, where the right side of the heart is embarrassed and there is danger of death from its being unable to drive the blood through the lungs ; this rarely hap- pens until the temperature falls, and hence this is the indication for giving digitalis, and at the same time iron in large doses. Therefore, when the patient has a low temperature coming on instead of high ; if he turns blue, particularly if the lips turn blue when the patient is turned over from side to side, or if foolishly raised when the pulse is weak, these are very grave symptoms of prostration, because the right side of the heart is dilated and exhausted with its futile efforts to drive the blood through the lungs. Then it is that digitalis with oxygen gas and iron may be given with great success. Cases of alcoholic pneu- monia are most likely to produce this condition. In acute pneu- monia with high temperature, it should not be given, because here the heart is not dilated. Digitalis should not be given for weak heart simply, not being a tonic in that sense, but only in cases where the heart is dilated either temporarily or permanently. In fevers, on the other hand, where the danger is of the patient dying from heart exhaus- tion, in the fatty state produced by the febrile process (fever is now considered to be a trouble of the muscles, heat being gene- rated there in excessive amount), digitalis is not only useless but positively mischievous. To overcome the arterial obstruction caused by digitalis, combine it with nitroglycerin and strophan- tus, which forms practically a new medicine. (We now know that hypertrophied muscles have a greater tendency to fatty de- generation than natural muscles; this is to be borne in mind, for, consequently, when the heart hypertrophies there is a greater ten- dency to fatty degeneration. In one of the English manufac- turing towns, where there is a large class of artisans engaged in hammering brasswork, there is found in many of them hy- pertrophy of the biceps muscle owing to their occupation, and a large number of cases have total atrophy. Apparently the hy- pertrophied biceps becomes more prone to fatty degeneration.) 190 K"OTE8 OK" MATERIA MEDICA. Preparations.— Pulvis Digitalis (dose, gr. i.); Extractum Digitalis (dose, gr. £); Infusum Digitalis, 3 i.-Oss. (dose, 3 i.- 3 iv.); Tinctura Digitalis, I ij.-Oi. (dose, tt[v.-xx.; Extractum Digitalis fluidum (dose, TT|i.-ij.). The tincture is not always reliable. The best preparations are the infusion freshly made from the English leaves, and SquibVs fluid extract. II. Strophantus. Strophanthus hispidus is an African plant found both on the western coast of the continent of Africa, in Senegambia and Guinea, and on the eastern coast along the Zambesi River; its alkaloid is one of the most virulent poisons known, and is used by savages on the coast of Africa for poisoning their arrows. A dose of one two-hundredths of a grain is sufficient to kill a strong dog. It is given only in the form of a tincture. Its operation is more definite than that of digitalis, if it is a good preparation. Un- fortunately, however, it is difficult to obtain a good preparation of uniform strength, but when its alkaloid becomes cheaper we may be able to use that. At present, we have to rely upon the tincture, and of a good preparation of this medicine the dose for an adult ought to be four drops, from that up to ten, but not beyond. The action of strophanthus has been very thoroughly studied. It has the following excellent properties: it is a stimulant of the same nature as digitalis, so far as the heart systole is concerned, producing a strong, steady, uniform systole, and it also interferes with the diastole, but not to the same extent, as it does not produce intermittency except when given in large doses. Its chief value is that it does not contract the arteries and raise the blood-pressure to the same extent, or so soon, as digitalis. Strophanthus is, therefore, one of the best medicines for use in heart failure, and, on the whole, is to be preferred to digitalis for this purpose. There are two forms of heart failure: one from muscular overexertion, the other from inherent inability. Of the former, we have failure from valvular or chronic arterial disease; of the latter, we have many cases where there is no hypertrophy and no dilatation, and so MEDICINAL REMEDIES. 191 we ascribe the heart failure to simple deficient innervation (this trouble has increased very much in the past ten years). One of the signs of heart failure is palpitation. In many cases, the heart, instead of failing at once, commences with weakness, indicated by irritability, causing palpitation. There are some diseases in which palpitation, as such, is very distressing; for instance, in Basedow's or Graves' disease, where commonly we have enlargement of the thyroid gland, and with this excessive nervousness, excessive rapid action of the heart causing a visible throbbing of the arteries all over the body. Its exact cause is not known, but it is thought to be due to poisoning from fer- mentation in the intestines. In hysterical, nervous persons with dyspepsia, there is frequently palpitation without murmurs or valvular disease, and this is evidently due to deficient power of the heart, caused by paralysis of its inhibitory mechanism. The strength of the heart is shown, not by its rapid beat, but, on the contrary, by the ability to restrain it from beating too fast in conditions of nervous disturbance or in great emotion. Where the palpitation is due to great sensibility to nervous emotion and nervous irritability, and to vaso- motor disease, strophanthus is the best remedy by far that is known. Strophanthus increases the power of the heart's action, and does not have the same effect in raising the tension of the pulse by interfering with the calibre of the small arteries, and is of special use where the heart is weakened from nervous causes, as in functional palpitation (the majority of these cases, however, are due to intestinal fermenta- tion, and should be treated dietetically and by intestinal anti- septics). In strophanthus, we have the best remedy for func- tional palpitation of the heart, and it is a great adjuvant to digitalis, and is frequently combined with it in the treatment of heart failure in pneumonia and in the treatment of cardiac dropsy. We have other agents that have the same power to assist a failing heart, and one is nux vomica. This added to' strophanthus works in the same way that a small dose of ipeca- cuanha added to opium acts as a diaphoretic. Nux vomica by itself is not a pronounced cardiac stimulant, but added to stro- phanthus it increases the power of the latter, and conversely. In dropsical disease of the liver due to weak heart, a form that 192 NOTES ON MATERIA MEDICA. occurs whenever there is regurgitation on the right side, the person becomes jaundiced, has gastritis, this combination is use- ful. III. Nitroglycerin. The action of nitroglycerin as a medicine is extremely rapid. Given in proper medicinal doses, it operates as quickly as ether, the first effect being a rapid dilatation of all the arteries, pro- ducing an uncomfortable sensation about the head, similar to that produced by alcohol or by some great mental emotion. Pain is a prominent symptom; the eyes are suffused, there is ringing in the ears, etc. The heart begins to beat quickly with powerful contractions, similar to those produced by alcohol or ether. Nitroglycerin is an extremely valuable medicine in pneu- monia, for in this disease the great danger is from arrest of the circulation in the lungs, where the circulation suddenly ceases in one part of the lung; the remaining portion, being unable to adapt itself to the sudden change, becomes highly embarrassed, congestion and pulmonary oedema take place, and this condition affects the heart, embarrassing that also in its action, and, as the result, the patient sinks from great prostration. The stimulating treatment of pneumonia by large doses of the carbonate of ammonia and alcohol is often discouraging. The treatment of the present time consists in giving digitalis and strophanthus in small doses to increase the systolic power of the heart. Unfortunately, with both of these agents, and especially with digitalis, nothing is gained ultimately, for, al- though the heart is strengthened, the arteries are contracted and the extra strength of the heart is expended in overcoming the increased arterial resistance, the one balancing the other. In all these cases, nitroglycerin should be combined with digitalis and strophanthus. In cases of pneumonia with high fever and no indication of heart failure, aconite should be given; five drops of the tincture of aconite with 3 i. doses of the sweet spirit of nitre every two or three hours, according to the urgency of the symptoms. As soon, however, as the respira- tions begin to increase and the pulse becomes weak and irregu- MEDICINAL REMEDIES. 193 lar, commence with cardiac stimulants, strophanthus, digitalis, and nitroglycerin, to be administered together, and, if occasion demands, these remedies should be pushed. As has been already said, nitroglycerin has a special power of relaxing the arteries, which property it has in common with the nitrite of amyl, but the former is more permanent. Hence it is the medicine for high arterial tension, which indicates that the calibre of the arteries is diminished, and we infer from this that the trouble is in the small arteries throughout the body, producing a tendency to dropsy, due to the venous current not receiving proper impulse, and hence the serum of the blood exudes into the surrounding tissues. This will be most appa- rent where the veins are not pressed upon to any extent by muscles and not provided with valves; hence in Bright' 's disease the face becomes puffy, etc. This condition will lead to heart disease, first hypertrophy, then dilatation, owing to the in- creased amount of work imposed upon the heart in driving the blood forward. Hence in Bright's disease, and in all diseases of the heart due to hypertrophy first and dilatation afterwards, nitroglycerin should be used for the purpose of dilating the arterioles, and thus relieving the heart of much of its burden of work; consequently it is a great adjuvant in the treatment of anasarca, and also of great benefit in increasing the power of the kidneys to excrete urea and diminish the amount of albumin in the urine, notably in the chronic interstitial form of Bright's disease with a hard, incompressible pulse. Nitroglycerin is a medicine which, like all powerful neurotics, acts differently upon different persons, there being many so- called idiosyncrasies to take into account in administering it, some persons being unable to take even extremely minute doses, while others can take comparatively large ones with impunity. The dose to begin with should not exceed gr. jfo, and if dis- agreeable symptoms are produced the dose, should be reduced to S r ' Fo"o* Usually, however, gr. y^ is well borne, and after a time the dose may be increased to gr. ^-g or gr. -£$. In some cases of chronic Bright's disease, it maybe necessary to increase to g r - 3W0- or even to gr. T \. The pain of angina pectoris is greatly relieved by the admin- 13 194 XOTES O^ MATERIA MEDICA. istration of nitroglycerin. If it is the first attack (this disease is dangerous from the very first, death resulting in some cases from the first attack), the nitrite of amyl should be given by inhalation; five drops can be inhaled, the nitrite of amyl being more rapid in its action than nitroglycerin. Angina pectoris is a severe neuralgic pain in the heart, and very frequently muscular spasm of the heart due to overwork. Any muscle when cramped gives rise to a severe pain, owing to the pressure upon the nerves caused by the muscular contraction. In angina pectoris, the patient feels as if he was going to die; the pains radiate to the left arm. This symptom should always excite suspicion. Pain over the region of the heart is not comparatively of much account unless it radiates to the arm, and then the cause of pain is in the heart itself. In some instances the pain radiates to the right arm and also into the neck, but generally it is felt in the left arm. Therefore any cardiac pain caused by valvular disease radiating into the left arm will be relieved promptly by the nitrites, nitroglycerin and nitrite of amyl. The arteries should be carefully examined; if high tension with rigid arteries be present, give nitroglycerin t. i. d. with iron as a cardiac tonic, and prohibit the use of ni- trogenous food; meat, when taken largely, having a tendency to aggravate the rigidity of the arterioles. The patient should be placed in the open air as much as pos- sible. In headache combined with coldness of the surface of the body, pale face, pulse small and sometimes incompressible, nitroglycerin often does good. Tinnitus aurium, which sometimes is an extremely obstinate and distressing complaint, in a few cases is relieved by nitro- glycerin. IV. Caffeine. Coffee is indigenous to tropical Africa, more particularly to Abyssinia. It grows wild in Central Africa and on the coast of Mozambique, and was introduced into Java near the close of the seventeenth century, and into the West Indies and South America during the eighteenth century. Caffeine is an alkaloid which is at the base of tea, coffee, cocoa, etc. It is very widely MEDICINAL REMEDIES. 195 dispersed and possesses curious effects, both chemically and phy- siologically. Coffee is allied to uric acid so closely that it can be made from it; hence it seems as if man has been using materials allied to those found in the body due to the retrograde metamorphosis of the system; for uric acid is an irritant, pro- ducing gout where there is an excessive quantity of it. Large quantities of tea, coffee, etc., will also aggravate a gouty condi- tion. Caffeine markedly increases the stroke of the heart by increasing its contractile power. Hence it is good practice to keep up the effectiveness of neurotics by using them inter- changeably. Where digitalis, strophanthus, or the other remedies are losing effectiveness, one-, two-, or three-grain doses of caff eine may be used for a time instead. In some cases, it is not borne in larger doses than one grain. If not well borne, the symptoms are tremor of the muscles, similar to that produced by excessive use of tea or coffee, and the patients feel uncomfortable about the head. Generally begin with one grain of the citrate of caffeine and increase to two or three. It is also very good in asthma, particularly where there is a good deal of bronchial congestion, in which patients raise a considerable amount of watery expec- toration after the asthmatic attack. Not uncommonly these are cases of chronic asthma where there is some emphysema and weakness on one side of the heart. Lastly, there is a mineral, proved to have an action on the heart similar to that of digitalis, viz., chloride of barium. It is quite a powerful poison in large doses. Not more than one-fourth of a grain should be given. . Some cases of heart failure are quite susceptible to the action of barium. Therefore, to sum up, there are six great medicines for palpi- tation of the heart, both with and without dropsy, producing effects upon the portal circulation, heart weakness, and heart failure, which are shown by a tendency to palpitation; these rem- edies are, digitalis to lead, strophanthus, nitroglycerin, nux vomica, caffeine ; and to these vegetable remedies should be added the mineral chloride of barium. All these remedies sooner or later disturb the stomach by interfering with the pa- tient's appetite. There is repugnance of food, and later on nausea and vomiting, and when this sets in it is very difficult to 196 NOTES ON MATERIA MEDICA. control. As soon as the patient becomes nauseated, their use should be intermitted for a good while, as the stomach has strong prejudices, and it may be some weeks before they can be tolerated again. T. Ammonia. Ammonia is one of the most volatile of the alkalies, and has some special actions apart from its neurotic properties. Alkalies are usually fixed and pretty strong in their alkaline forms, but ammonia is very diffusible and operates with promptitude. Many cases of headache from acidity of the stomach have been relieved by a teaspoonful of the aromatic spirits of ammonia. It relieves this because, being an alkali, it counteracts the acidity of the stomach. It is also useful in those slight headaches caused by using tea too freely. Besides this, on account of its alkaline action when taken into the blood, it has the effect of diminish- ing the coagulation of fibrinous exudation. There is no doubt, therefore, that it is proper to rank ammonia among the expec- torants, if by that term we mean, as we should, a remedy that facilitates expectoration. "When mucus is difficult to expel on account of being viscid from excess of albuminous material, as in certain forms of bronchitis, inhalations of ammonia should be given. Until recently, evidence has been very strong in favor of the use of the carbonate of ammonia in the treatment of pneu- monia, on account of its action as a cardiac stimulant and a liquefier. In the early stage of pneumonia, when vascular ex- citement has subsided and there is coughing, it does good in helping to raise the expectoration; but it is now considered that the danger in pneumonia is not from suffocation, but from weakness of the heart. Ammonia is a direct stimulant of the heart, of the same kind as alcohol, increasing the rapidity and force of the beats, and dilating the arteries, causing a warm perspiration all over the body. Moreover, it is a stimulant which does not cause the slightest depression, as is the case when too much alcohol is given, because it is a pure stimulant and not a sedative. Am- monia is particularly indicated when rapid stimulation of the heart is required, as in syncope or hemorrhage. The ammonia MEDICINAL REMEDIES. 197 may be combined with brandy, this being a time-honored resource in pneumonia. Whenever there is a severe cramp, notably in the tubular struc- tures of the body, as in the ureters during the passage of gall stones, or in the intestines, the result is to produce cramps else- where. In cases of severe griping, there are cramps in the calves of the legs, as shown in choleraic diarrhoea, the patient becoming cold and the pulse small. All griping is accompanied with cold- ness of the extremities. A good dose of ammonia relieves this quite markedly. Similarly a stimulant dose gives great relief in those neuralgias where the patient has coldness of the surface of the body and extremities. Ammonia is a decided diaphoretic. Five-grain doses, given every hour or two, cause the patient to perspire very freely. Some preparations are more powerful than others in this respect, but all are classed under the head of diaphoretics. The carbo- nate is the best cardiac stimulant. As the salts have a sharp taste, they should be given in mucilage, syrup, or licorice. The carbonate should be only given in lobar pneumonia. Five grains should be given every hour or two during the entire course of the disease, but care should be taken that the patient is not chilled after sweating from this treatment. Its action is still more rapid against syncope. A comparatively pleasant preparation to take is the aromatic spirits of ammonia in doses of one tea- spoonful at a time, to be repeated every ten or fifteen minutes, for its expectorant action. In broncho-pneumonia, the chloride of ammonia should be given in doses of from ten to twenty grains every two or three hours. In certain forms of neuralgia, notably that of the face known as tic douloureux, good results have been obtained by giving thirty-grain doses of muriate of am- monia every two hours. It works better with quinine or ginger. An old German prescription, that is very successful in some cases of severe neuralgias of this kind, consists of thirty grains of the chloride of ammonia in . two-thirds of a tumblerful of a strong infusion of horse radish, the whole amount to be taken in one dose. It is claimed that the chloride of ammonia is a good chola- gogue in jaundice. It is the favorite treatment of British sur- 198 STOTES ON MATERIA MEDICA. geons in India for chronic hepatic congestion. Thirty grains of the muriate of ammonia are given every two hours to a patient with an enlarged and tender liver from malarial disease. It is said that after three doses have been taken the patients cry out with pain, describing it as a feeling as of the breaking of the attachments of the liver, and shortly after the liver rapidly di- minishes in size and the patient recovers. VI. Ergot (Secale Oornutum). Ergot is a fungus, the sclerotium of Claviceps purpurea replac- ing the grain of Secale cereale; chemically it is a compound sub- stance, and none of its elements have been obtained in a crys- talline form. Ergot is a stimulant to the vaso-motor nerves, causing tonic contractions of the unstriped muscular fibres in the different parts of the body. Vascular System. — Its action upon the circulatory system is almost entirely confined to the muscular coats of the arteries. In large doses, it produces tonic cramps or spasms of these fibres, and along with this, feeble heart beat and a fall of tem- perature all over the body, while in moderate doses it only pro- longs their natural contraction. When its use is continued, it produces anaemia of the surface of the body, and especially of the brain. Dependent on this action is its use in subacute and chronic meningitis (cerebral and spinal). In this disease, the blood-vessels are enlarged, and there is hyperemia of the brain. Ergot should be given until its effects are seen. The tolerance of ergot in these cases is remarkable, the dose being about ten times as large as in other conditions. It should always be administered without regard to the size of the dose. As a rule, those forms of meningeal trouble that contra-indicate strychnia are benefited by ergot, and vice versa. It is especially useful against the chronic dilatation of the arteries of the brain after sunstroke. In this condition, its action should be aided by cold douches to the nape of the neck. It is also useful in epi- lepsy following exposure to great heat and characterized by flushed face, photophobia, apprehension or fear of responsibili- ties, vertigo on stooping over and when exposed to the sun, MEDICINAL REMEDIES. 199 bright specks before the eyes, and headache of a confused kind, attended with insomnia and slow, rapid, and irregular pulse. These are all symptoms of chronic cerebral irritation, and may be cleared up by ergot and corrosive sublimate. Genito- Urinary Tract. — In spermatorrhoea due to great weak- ness and irritability^, ergot is one of the best remedies. The fluid extract can be combined with the elixir of cinchona, two teaspoonfuls to be taken at night. Ergot is also given for the purpose of exciting uterine contractions when deficient in them- selves, or to procure contractions of the uterus in the last stage of labor; hence the common practice is to prevent relaxation likely to occasion post-partum hemorrhage. A teaspoonful of the fluid extract should be given as soon as the child is born. It should not be given if the birth is likely to be delayed, be- cause there is great danger of the child being suffocated by arrest of the placental circulation due to the action of ergot upon the uterus, producing tonic contraction without relax- ation. In chronic subinvolution of the uterus, ergot should be used persistently. Ergot may also be used in the treatment of tumors of the fibroid variety. Injections into them some- times cause them to diminish in size. It can also be used in the same way for enlarged spleen, viz., injections being made directly into the structure of the spleen itself. Acne occurring in young women and aggravated at the men- strual period is sometimes relieved by ergot; but as this is very difficult to treat, and as it depends so much upon the stage of digestion and disturbance of the genital organs, particular atten- tion should be paid to this, especially to digestion; sugars and all fats being eliminated from the diet, and the benzoate of sodium administered internally, with charcoal and salol, in small Hemicrania is not infrequently dependent on paralysis of the vaso-motor nerves of one side of the head, as indicated by throbbing of the arteries of the side affected and dilatation of the pupil, with photophobia and suffusion of one eye, and ring- ing in the ears. Ergot will often relieve these symptoms, if taken in full doses until no more can be borne. It may be advantageously combined with antipyrine. The ergot may be 200 KOTES 0!tf MATERIA MEDICA. administered internally, or injected nypodermatically into the nape of the neck. It should only be given at the beginning of the attack. The dose is a drachm of the fluid extract every hour, if necessary, until three have been given. Ergot is a great adjuvant of quinine in brow ague or true periodic headaches attended with photophobia. Quinine alone will not cure this condition. What is true of the photophobia of ague is true of all photophobias not dependent upon inflam- mation of the eye. Give a drachm every half-hour until re- lieved. To control haemoptysis, ergot should be injected hypoder- . matically at the nape of the neck. It is also given in dysentery to check the profuse hemorrhages which are apt to occur Preparations. — Extractum Ergotse fluidum [Squibb's] (dose, 3ss.-ij.); one drop is equal to one grain of the crude drug. Extractum Ergotae (dose, gr. v.-xx.); one grain of this equals five grains of the crude drug. VII. Strychnine. Kux vomica is the seed of the Strychnos nux vomica, a mid- dle-sized tree common in many parts of Hindostan, Farther India, and some of the East India islands. It is an excessively bitter powder, and owes its activity to two alkaloids, strychnine and brucine, the leading one, however, being strychnine. This is a powerful poison; its actions are peculiar and very definite. It produces death by severing the connection of the spinal cord with the cerebrum. The muscles are liberated from all control, the body is thrown into violent cramps and spasms, and death results from tonic contraction of the diaphragm and other respiratory muscles. Owing to the severity of the spasms, the muscles are frequently torn and the body is arched backwards by the contraction of the powerful muscles of the back. These symptoms resemble rather closely those of tetanus, and in some cases of poisoning by strychnine the defence is raised in courts of law that tetanus was the cause of death. The points of dif- ference between the two are as follows: In strychnine poison- ing, the symptoms develop suddenly; in tetanus, the develop- MEDICINAL REMEDIES. 201 ment of symptoms is always gradual In strychnine poisoning, the convulsions appear immediately after the absorption of the poison into the blood, the first convulsion being usually the most severe. Tetanus comes on with gradual stiffness of the mus- cles of the neck; after a time the muscles of the jaw become affected, and, after a period varying from several hours to two or three days, this stiffness ends in permanent lockjaw. Except in rare cases, tetanus takes time to run its course. In tetanus, the symptoms make their first appearance in the upper extremity — the muscles of the neck and jaw. In strychnine poisoning, the symptoms are first manifested in the lower ex- tremity, usually in the legs. They both resemble each other in this: that the slightest touch, or breath of air, or flash of light will throw the body into violent convulsions, owing to excessive reflex irritability. As soon as the convulsion is over, in strych- nine poisoning, complete muscular relaxation takes place, the jaw is open, and for the time being the muscles are quite nor- mal. In tetanus, there is never complete muscular relaxation, and the jaw cannot be opened. Strychnine is of no use as an agent to increase the power of the voluntary muscles, and therefore in all cases of true volun- tary muscular paralysis, where the region is under the control directly of the cerebrum, not of the spinal cord, strychnine should not be given. Not so in cases of paralysis of spinal origin, as in paraplegia. Here it is of some value, particularly in restoring the tone of mixed muscular structures rather than the purely voluntary ones — viz., all structures relating to the sphincters of the body which are mixed — for, although they be- long to the unstriped muscles, every one of them is so arranged that the will has a certain power to call into play and arrest their action. In cases, therefore, of ivealc bladder, strychnine should be given, and is the main neurotic for this purpose. Where there is incontinence of urine from loss of the propul- sive power or weakness of the sphincter, strychnine is indicated. It is the best remedy in treatment of prolapsus of the rectum, to which children and aged persons are extremely prone, the aged also suffering from piles or congestion of the mucous mem- brane about the rectum. In old people, this infirmity has an 202 NOTES ON MATERIA MEDICA. extremely depressing effect on the mind, amounting in some cases to insanity of the melancholic variety. In these cases, strychnine should be given in solution by submucous injection directly into the substance of the tissue itself, this being the most effective way to produce good results, and then retain the parts in their proper position by bandaging. This injection should be given t. i. d., if possible. Strychnine in solution is not irritating when given hypoder- matically. Care should be taken that the liquid is a good one and that the water is distilled. One-fortieth of a grain should be given to begin with, and rapidly increased until the desired effects are produced. If tolerated, it is possible to give one-tenth or even one-fifth of a grain after a time. Strychnine has a good effect in all conditions of exhaustion of the lower part of the spinal cord; therefore it is contra-indicated where there is an inflam- matory condition. Aside from these actions, and in a few cases of paraplegia where it may be used cautiously, strychnine has a marked effect in increasing the peristaltic movements of the alimentary canal, and notably of the intestines, more than of the oesophagus. It may also be given in cases of water brash, a difficulty in which the patient raises a large amount of clear mucus on getting up in the morning. During the night, a large amount of mucus is secreted to keep the throat moist, and in certain conditions of the oesophagus this accumulates at the cardiac end, and in the morning is raised. Strychnine should be given. It is also specially indicated in chronic constipation, and on this account forms one of the ingredients in a great variety of laxative medicines. It is also indicated in conditions of vaso-motor weakness, where persons blush without any reason whatever, as in the case of women, particularly at the time of the menopause. Five drops of the tincture of nux vomica can be given in these cases t. i. d. Preparations. — Extractum Nucis Vomicae (dose, gr. £); Tinctura Nucis Vomicae [ 3 iv. to OL] (dose, tt^x.-xv.); Strych- nines Sulphas (dose, gr. jVgV)* MEDICINAL REMEDIES. 203 VIII. Camphor. A stearopten or concrete volatile oil obtained from the wood of Cinnamomum camphora. It is indigenous to Eastern and Southeastern Asia, China, Japan, and the Sunda Islands. Camphor is the most diffused of all the substances of the vege- table kingdom; it is found in pennj^royal, hemp tops, and a large number of plants of this class. The eucalyptus tree seems to be destructive to malarial poison on account of the cam- phoraceous exudation from its roots, which permeates the upper layers of the surrounding soil. Camphor is a member of the carbolic-acid series of disinfectants. 1 Locally, camphor is an anesthetic; it can be used for tooth- ache, and notably against inflammatory pains. In the form of camphorated oil, it is a good counter-irritant. In order to act, evaporation should be prevented by covering it with oiled silk; it should not be applied too long, as it will produce a blister. Its stimulant action is almost entirely confined to the solar plexus of the sympathetic nervous system. It is especially use- ful in choleraic diarrhma. 2 In Asiatic cholera, camphor should be given in combination with capsicum every hour. In cholera morbus, teaspoonful doses of camphor water shouM be given every ten minutes and after vomiting; if an astringent is necessary, acetate of lead can be added to it. In moderate doses, camphor stimulates the circulation by increasing the rapidity and force of the heart's action. It in- creases the secretions of the bronchial mucous membrane, and is often found in expectorant mixtures, but it has no special action in allaying the cough. Combined with soporifics, campnor helps to induce sleep. Preparations. — Spiritus Camphorae [ 3 ij.— Oi.] (dose, 1U x.- 3i.); Aqua Camphorae [ 3 i.— Oi.] (dose, 3 i.- 3 ij.); Oleum Camphorae (dose, fit i.-vi.). For external use, the Linimentum Camphorae (Camphor, one 1 For the uses of camphor as a disinfectant, see page 29. 2 See under Opium, page 159. 204 NOTES ON MATERIA MED1CA. part; Olive Oil, six parts) and the Linimentum Saponis, or soap liniment, are very popular by themselves, or as the basis of more stimulating preparations. IX. Asafoetida. A gum resin obtained, by incision, from the living root of Ferula narthrex. It is indigenous to Central Asia, Turkestan, Western Afghanistan, and Bokhara. It grows wild in the barren regions between the sea of Aral and the Persian Gulf south to Laristan. It is found in the market in the form of irregular masses with a strong odor of garlic. Asafoetida is a neurotic which stimulates the abdominal sympathetic ganglia, and is used to correct functional disturbances only. It is a valuable medicine in flatulency accompanying hysteria of an emotional character, with cold liands and feet, with paralysis of the intestines where some parts are contracted and others dilated. It is also capable of removing many of the strange complications of hysteria. Asafoetida can be used to relieve spasms of the genito-urinary tract, also in painful affections of the pelvic organs, as dysme?i- orrhcea, amenorrhoea, etc. It can be given for all reflex mani- festations due to irritation of the pelvic viscera. Aphonia, coming on suddenly without any disease of the throat, is often the first symptom of chlorosis, or is due to some menstrual irregularity. In all these cases, asafoetida can be given with good results. It should be given in capsules containing two to five grains of asafoetida combined with two grains of ginger and two grains of the bicarbonate of soda. It is very apt to disturb the stomach, and its action is only obtained after it has reached the small intestine. An injection of half an ounce of the tinc- ture of asafoetida in mucilage or milk will very often cut short a hysterical convulsion. X. Valeriana. Valerian is a native of Europe from the Mediterranean Sea northward, and of Northern Asia, and is cultivated to some MEDICINAL REMEDIES. 205 extent in Holland and England, and, in this country, in New England and New York. Valerian resembles asafcetida in its antispasmodic action. It can be given in hysteria followed by low spirits. In facial neu- ralgia and hem (crania with photophobia, occurring in hysterical or nervous women, gr. v.-x. valerianate of ammonium, com- bined with gr. xxx. of the chloride of ammonium, should be given. The valerianate of quinine does not differ therapeutically in its effects from a mere mixture of the two ingredients. The valerianate of zinc is a good antispasmodic; it should be given in pill form. (c) Those Medicines ivhich are Sedatives only. On the application of cold as a remedy, there is primarily ner- vous depression of the nature of shock, followed by a reaction of the nerve centres impressed, so that ultimately stimulation results. On the other hand, if a person be immersed for any length of time in warm water of the temperature of 98.5° F., there is sedation, bat this is not followed by any reaction, and consequently there is great exhaustion, the whole muscular sys- tem being relaxed. Sedative neurotics are drugs which resem- ble moist heat in their action, as the nerve centres which they affect are depressed and no reaction follows. The principal sedative neurotics are the following . 1. Aconite. 5. Conium. 2. Veratrum viride. 6. G-elsemium. 3. Tartar emetic. 7. Anaesthetics. 4. Hydrocyanic acid. 8. Cocaine. 9. The Hypnotics. I. Aconite (Aconitum). Aconite is the tuberous root of the Aconitum napellus, or monkshood, an ornamental garden plant indigenous to Europe. In appearance, it closely resembles the root of horse radish, and this has led to many cases of poisoning. Its most active principle is an alkaloid called aconitia or aconitina. Aconite is 206 NOTES ON MATERIA MEDICA. a universal sedative, paralyzing particularly the nerves of com- mon sensation. Applied externally in such manner as to reach the cutaneous nerves, it first produces tingling, and this is fol- lowed by numbness and loss of sensation. (When, in the course of pathological changes, the patient complains of tingling and numbness of the tongue and tips of fingers, it is an unfavorable symptom, indicating not only a loss of power, but that this loss is paralytic. ) Hence aconite is an anodyne, relieving pain, when lo- cally applied, by paralyzing the nerves. When taken internally in fall doses, it produces the same symptoms, the patients complain- ing of numbness all over the body, but particularly in those parts most freely supplied with sensory nerves, viz., the tongue and fingers. As aconite is a powerful cardiac paralyzer, there is also great depression of the heart, indicated by a slow and feeble pulse. If the dose be very large, the symptoms of suspension of the heart's action are extremely pronounced ; there is deathly prostration, and the patient is in a state of great anxiety and moans continu- ously; the whole body is bathed in a cold perspiration, there is frequent passing of the arms and hands, and, if death, ensues, the patient not uncommonly dies in convulsions. These are the chief actions of aconite, and from them, there- fore, follow its different remedial operations as a medicine. In the first place, it is one of the most powerful reducers of tem- perature in fevers caused by inflammation. There are two en- tirely distinct stages in all inflammations, the acute and the subacute, and the treatment of one should be exactly opposite to that of the other. In the first stages of acute inflammation, there is a very excited action of the heart from the irritation of the inflammation; it beats strongly and rapidly, and usually there is dilatation of the arteries leading to the inflamed part, causing a mistimed and very injurious local hyperemia. This is followed by stasis of the capillary circulation of the inflamed area, and the blood con- tinuing to come in a powerful stream from the arteries, the ca- pillaries become clogged, and this increases the trouble and sets up oedema with violent pain from the stretching of the nerves of the inflamed part. The great indication in the treatment of MEDICINAL REMEDIES. 207 the acute stage is to diminish arterial hyperemia. For local in- flammation, as of inflamed knee joint, the best thing to do is to apply cold, so as to cause contraction of the arteries and thus sus- pend the determination of blood to the part. Where cold, as in internal inflammations like pneumonia, peritonitis, etc., cannot safely be applied, then the old practice — and not a bad one — was to reduce the activity of the heart and of the arterial circula- tion by phlebotomy. If this is not done, then give arterial sed- atives — medicines that reduce the action of the heart and cause less vascular excitement — and for this particular purpose aconite answers very well, as it suspends the excitement of the arterial circulation, and has a sedative action upon the heart, the very thing desired in acute inflammations. It should be commonly prescribed, therefore, in all of the acute inflammations that come within the province of the physician. Its action is illus- trated particularly in the treatment of pneumonia in its first stages. Here digitalis, strophanthus, and nitroglycerin should not be given, because this is not the time for the administration of these remedies; rather than that, we should moderate the ar- terial excitement, and for this purpose aconite is very good. So also for pleurisy and other inflammatory conditions. After a varying period, all these inflammations begin to enter upon the subacute stage. The treatment here is just the oppo- site to that in the other stage. Instead of sedatives, stimulants should now be given, for the purpose of increasing the blood cur- rent of the part to clear obstruction. ' Aconite is not to be given in pneumonia when the patient's pulse shows that he is weak. Heart stimulants should be given instead. Nor should it be given in any inflammations when the symptoms of the acute stage are subsiding. The purposes, therefore, that aconite sub- serves are, to allay arterial excitement and to diminish pain; hence it may be given in pneumonia, .pleurisy , and in the severe pains of peritonitis, as an adjuvant to opium to relieve the pain as well as to allay the arterial excitement. Occasionally aconite lias been very beneficial in the treatment of certain forms of neuralgia, notably tic douloureux, a very chronic and difficult 1 See pp. 189, 192. 208 KOTES 0^" MATERIA MEDICA. form to treat. In a certain proportion of cases, we can some- times cure these neuralgias by lowering the pulse sufficiently to produce a feeling of numbness throughout the body; and this may be done by giving aconite in the form of its alkaloid, aconitia. In giving aconite regularly, watch its effects on the pulse; when it reaches fifty-five beats per minute, discontinue the use of aco- nite. Prescription for acute neuralgic affections: R Extracti Colchici, gr. J Extracti Aconiti, .... . gr. | Pulvis Ipecacuanha? et Opii, gr. ij. Eepeat every three hours. Colchicum is here given because that condition of the system which manifests itself in men by gout frequently shows itself in women by neuralgias. Another of the properties of aconite is its specific action upon the circulation of the pharynx. When an overdose has been taken, besides the numbness and tingling of the tongue and lips there is a peculiar sensation about the throat as if it were con- stricted, and there is also considerable soreness. Aconite is very valuable in the treatment of pharyngiti 's, tonsillitis, quinsy, ab- scess in tonsils, and bad sore throat. For quinsy, first give an emetic (ipecacuanha), as this causes a profuse flow of mucus from the back of the throat, which relieves the intense congestion of the part; then give internally fifteen grains of salicylate of sodium every three hours; and, if greater certainty is desired, ten drops of the tincture of aconite root, which is double the ordi- nary dose — five to eight drops — may also be given. A bad sore throat is often benefited by giving ten drops of the tincture at night. Another of the uses of aconite is against irritable stric- ture of the urethra, where, though desirable, it is sometimes very difficult to pass a catheter. Inject into the rectum a dose of from eight to ten drops of the tincture of aconite. This has a paralyzing effect upon the rectum, sometimes causing a slight degree of prolapsus, but its action upon the contiguous organ, produced in about fifteen minutes, is very marked. Aconite acts as a diaphoretic when in combination with MEDICIKAL REMEDIES. 209 Dover's powder. This combination has the advantage of requir- ing smaller doses of Dover's powder than when the latter is given alone, and the disadvantages of the aconite are counter- acted. Aconite is also valuable as an antipyretic, as it depresses the heart's action and thus slows the arterial current. The follow- ing formula will be found useful as an antipyretic: B Tincturae Aconiti Radicis, .... gtt. iij. Tincturae Veratri Viridis, .... gtt. i. Extracti Gelsemii fl., gtt. i. M. Sig. Take at one dose. This is also good for chronic rheumatism where the tempera- ture has been above the normal for two weeks. Preparations. — Tinctura Aconiti [Aconite Root § vi., Alcohol Oi.] (dose, TT[ i.-v.); Extractum Aconiti (dose, gr. J-J). The Crystalline Alkaloid Aconitia [an extremely powerful poison] (dose, gr. ¥ ^). II. Yeratrum Yiride (American Hellebore). This drug is made from the dried rhizome and rootlets of the Veratrum viride, an American herb growing in the swampy regions of the Southern and Middle States. It is more definite in its effects than the veratrum album of Europe, so that the latter is now rarely used. Veratrum viride is a pure cardiac sedative, and it acts in a peculiar way, as it slows the force and frequency of the heart without disturbing the rhythm, which aconite does. The amount demanded to produce a definite result can be estimated by the frequency of the pulse, as it slows the heart in a very con- stant proportion to the quantity taken. If, for instance, five drops reduce the pulse from one hundred to eighty per minute, five drops more will bring it down to seventy, fifteen to sixty, etc. In this way, the pulse maybe brought down to fifty-five per minute: below this it is not safe to go. As soon as there are any symptoms of nausea, the use of the drug should not be persisted 14 210 NOTES OX MATERIA MEDICA. in, as it shows that the safety limit has been reached, the nausea being due to cerebral anaemia. The action of veratrum viride is almost exactly the action of the lancet in general blood-letting, as it causes the heart to beat more slowly and feebly, and the pulse becomes more compress- ible. Hence it is the medicine for a rapid and strong pulse; but where the rapidity of the pulse is occasioned by weakness, vera- trum viride should not be given, and consequently it must not be indiscriminately administered in fevers. When the pulse is rapid and strong, it may be used in any disorder, as these are signs of too much excitement in the circulation, which becomes extremely dangerous if the third element of incompressibility is added, as then the patient is on the verge of the most dangerous of all convulsions These convulsions are purely epileptic in character, very severe, followed by unconsciousness, then by a return to consciousness. This will be repeated two or three times, the periods of consciousness gradually becoming shorter, until finally the patient remains in a state of coma, with one convulsion following another, until the coma ends in death. In the convulsions of puerperal eclampsia, the heart starts off beating very rapidly (120 to 140). In a fever, this high pulse is not necessarily fatal, but it is so in eclampsia, for not only is the pulse both strong and rapid, but it is also incompressible. The old practice was to open a vein, and this is always indicated; but as the patient is in a dangerous condition, many physicians hesitate to do this for fear the patient's death might be ascribed by the friends to this method of treatment. If this is not done, by all means give veratrum viride, as in this disease it is exactly indicated; for, first, it slows the pulse by making the heart beat less quickly; secondly, it makes the heart beat less strongly; and thirdly, it opens all the arteries and makes the pulse compress- ible. When veratrum viride does this, the convulsions stop and the patient's life is saved. For this condition give different doses than those previously mentioned. Commence with gtt. xx., and when convulsions begin give twenty more. It may be ne- cessary to give gtt. xx. every twenty minutes. This treatment shows the correctness of the rule that the dose of sedative medi- cines has not been readied until their symptoms are produced. MEDICINAL REMEDIES. 211 The symptoms of veratrum viride are slow pulse, etc., and until these are shown enough has not be. n given. A similar condition exists m acute alcoholic poisoning. A man sometimes drinks large quantities of whiskey or brandy, and falls down in convulsions of the same kind as those previously described; the heart is excited, the pulse strong and incompress- ible, and the patient has a peculiar form of cyanosis, occasion- ally strikingly illustrated in the convulsions of children with scarlet fever. Veratrum viride should be exhibited. Veratrum viride is sometimes given in delirium tremens, but it is only to be recommended in certain conditions of this dis- ease. If there is a considerable quantity of albumin in the urine, it is not safe to give this remedy; but if the pulse is strong, and the patient's system has not been very much weak- ened, as the majority of these cases are very unmanageable, ve- ratrum viride may be given to keep them quiet. It may be given in the drink for which they will be constantly asking (dose, gtt. v., repeated, if there is a strong pulse, until vomit- ing is induced). Under this treatment, from being very uproar- ious and violent they become very quiet, as there is nothing like nausea to calm excitement, this being frequently induced, by other methods, to quiet hysterical females. Veratrum viride is also very effective in acute rheumatism where the patient has a rapid rise in temperature (107° to 114°), and, if he dies, with heat increasing after death. These cases have been successfully treated by the persistent immersion of the patient in cold water. ' The immersion may have to be fre- quently performed before the temperature is broken, the patient often returning to the state of coma between the baths. In former days, no case recovered; but now, by giving free doses of veratrum viride in addition to the cold baths, many patients recover. Preparations. — Tinctura Veratri Viridi (dose, TTUij.-viij.); Extractum Veratri Viridi nuidum (dose, fT[i.-iij.). 1 See "Antipyretic Uses of Cold," p. 283. 212 NOTES ON MATERIA MEDICA. III. Tartar Emetic (Antimonii et Potassii Tartras). Taken in small doses, this substance produces nausea; in larger doses, it acts as a cardiac emetic, i.e., an emetic which induces vomiting by depressing the heart's action, thus causing cerebral anaemia and general prostration of the system. It is due to this fact that tartar emetic is such an extremely power- ful paralyzer of the sensory system of nerves, and to a certain extent of the motor system. It could be used as an anaesthetic, as animals under its influence exhibit no signs of pain when their limbs are amputated. Its action upon the blood when long continued is disastrous, as it produces an anaemia difficult to recover from. As an emetic this drug is not to be recom- mended, nor should it be used for any purpose except as a tem- porary expedient in the early stages of acute ironc7iitis. The beginning of this disease is frequently accompanied by intense dyspnoea, the mucous membranes of the smaller tubes being dry and tumefied. This is the period of engorgement; the patient feels as if a load was upon his chest; he is blue or dusky in the face, and has a little, squeaky cough. In this condition, the in- dications are to start the bronchial secretions, and for this one purpose tartar emetic acts splendidly. Add one grain of tartar emetic to a teacupful of water, and give a teaspoonful every ten minutes until the patient feels nauseated. As soon as this hap- pens, the asthmatic condition of the bronchial tubes relaxes, the secretions pour out, and sometimes the whole disorder is aborted. Subsequently, when secretions are present, do not give tartar emetic. IT. Hydrocyanic Acid — Prussic Acid (Acidum Hydrocy- anicum DiL). This drug, when concentrated, is the most rapid in its action of all the liquid poisons, one drop injected into the eye of a dog killing it instantly. Many fatal accidents have happened from its use in experimental chemistry and in the process of its manu- facture. Apparently it kills by the instantaneous stoppage of respiration, from its action upon the respiratory centre situated MEDICINAL REMEDIES. 213 near the calamus scriptorius. It acts so suddenly that often a terrible scream is given by the patient from the air being forced out at once from the lungs, and he falls in convulsions of the same nature as those produced by sudden loss of blood. It therefore acts upon the source of the pneumogastric nerve, and consequently it is in affections of this nerve that it is to be used as a medicine. Hydrocyanic acid may therefore be added to a cough mixture to allay irritant or useless coughs, due to irrita- tion of some one or more of the branches of the pneumogastric nerve, upon which it acts as a sedative. ' Y. Conium. Spotted hemlock is indigenous to the temperate countries of Asia, Europe, and North America, and has been naturalized in some portions of New England, New York, and in South America. It grows in waste places and along streams. Conium is a paralyzing poison of the muscular system, some muscles being more affected than others; its most characteris- tic action being on the muscles of the eye, producing ptosis. "When a person is fully under its influence, there is not only general muscular relaxation, but giddiness, difficulty of sight, and, where a poisonous dose has been taken, death from paraly- sis of the heart itself, if not of the muscles of respiration. It was used in ancient times in the execution of those sentenced to death, as affording one of the most painless modes of extinction of life. This medicine has a marked value in relieving pains due to inflammation of fibrous tissue, as of the periosteum in syphilis. Here conium combined with potassium iodide and opium re- lieves the pain very much. In pachymeningitis, the addition of conium very often relieves that aching of the head so charac- teristic of organic mischief in the cranium. It has also been given in some forms of epilepsy in addition to other medicines, but only in those cases that give meningeal symptoms, notably those that occur after syphilis, blow on the head, sunstroke, etc., or where there is twitching of the muscles during sleep. Conium 1 See Coughs, p. 260. 214 XOTES OK MATERIA MEDICA. will promote the operation of the bromides along with chloral. It is of particular value in that class of cases where, from very early life, there is a lithsemic diathesis, the formation of stone sometimes occurring in the second or third year of life — an ex- ceedingly dangerous condition if stone is lodged in the urethra. After this period, stone is not apt to be formed again until after thirty, but all the while there is often vesical irritation, with pain referred to the neck of the bladder, so continuous as often to undermine the health. These may be termed cases of hyper- esthesia of the neck of the bladder, a trouble which sometimes, though rarely, affects women; these persons are wonderfully relieved by conium (dose, of fluid ext. V\ x. in § i. of water, injected into rectum and allowed to remain there). It can also be used in cystitis where there is a great deal of pain. Owing to the leaves rapidly losing power, ordinary preparations are very uncertain, and conium should be given in the form of Squibb's fluid extract (dose, vi x.-xv.). The latter will some- times produce the symptoms of an overdose — headache, vertigo, disorder in movements of the eyes, feeling of numbness, etc. — so begin with TT], x., and increase to xv. as the patient can bear it. VI. Grelsenaium (the root of G-elsemium sempervirens). The yellow jessamine is indigenous to the southern United States, growing in moist woods from Virginia to Florida and Alabama, and flowering early in spring, beginning to bloom in Florida in January, and further north in March or April. G-elsemium lessens the frequency of the pulse, but not with the same certainty as aconite and veratrum viride. It produces vertigo with a tendency to fall forward. It can be tried in sick headache where the pain begins in the eyes and radiates to the back of the head, with nausea, sallow complexion, and high-colored urine; when the urine is pale in color, it does not do much good. Preparations. — Extractum Grelsemii fluidum [Squibb's] (dose,, m iij.-x.), MEDICINAL KEMEDIES. 215 VII. Anaesthetics. Ether was discovered in 1846 by Dr. Morton, of Boston, pre- vious to the discovery of the anaesthetic properties of chloroform by Sir James Simpson. Ethers produce their effects by entering the blood through the lungs; and this is almost an isolated fact, as the lungs ordinarily will not take up any medicines, as they are constructed in such a manner as not to allow the introduction into the blood of gases and vapors, with the exception of oxygen. In the case of ethers, however, and their allied class of turpen- tines, absorption takes place rapidly by the pulmonary air vesi- cles, and, when inhaled rapidly after a short period of excite- ment similar to that produced by alcohol, the patient becomes completely stupefied. This is a true alcoholic stimulation, and produces insensibility to pain, although the patient may be con- scious that something is being done. Many details connected with its administration should be borne in mind. No anaes- thetic can be regarded as perfectly safe; for it is incredible, rea- soning a priori,thsit the most conservative function of the body, the sense of pain, can be interfered with without danger. All of them are dangerous, even nitrous oxide. But there is a marked difference in the manner in which these different anaesthetics pro- duce death. In some cases, this is easily prevented; in others, with great difficulty, for reasons that we do not understand. Ethers produce anaesthesia by affecting the respiratory centre more than that of the heart, and consequently the patient may die in a state of asphyxia because he cannot, or does not, breathe. Ether is not at all likely to produce its destruction of life to the degree that chloroform does, from the fact that it gives us warning, and usually the patient can be restored by artificial respiration, efforts at resuscitation being more successful than when chloroform has been given. It was for a long time claimed that no deaths whatever re- sulted from the administration of ether. This is not so; but, fortunately, the conditions, aside from suffocation, in which ether is dangerous are well determined, and are as follows. 1. In acute inflammation of the kidneys, calculus irritation, 216 NOTES ON" MATERIA MEDICA. etc., because this may suddenly increase and suspend the excre- tion of urea, and uraemic poisoning result. 2. In general bron- chitis, where there is dilatation of the right side of the heart. In emphysema with bronchitis, the administration of ether has sometimes proved fatal, not from suffocation, but from the system being poisoned with ether vapor. But disastrous re- sults happen very rarely. In the great majority of cases, ether is as safe as an anaesthetic can be expected to be. Some deaths have resulted from operations, while under the influence of ether, in which these conditions did not exist; but as to this it can be said that deaths had taken place during operations before ever anaesthetics were used. With these few exceptions, there- fore, ether can be recommended in all cases. Chloroform, on the other hand, is extremely treacherous, and, when it produces death, does it very suddenly and by an ex- tremely minute quantity — in one case, only one drachm, al- though in this case the chloroform had probably been inhaled directly. This indicates without question that deatn is caused by cardiac, not respiratory, paralysis, though even here there is a difficulty, as sometimes the respirations cease while the heart continues to beat; but, as a rule, death results from stoppage of the heart. A surgeon of Baltimore, from an experience of ten thousand cases in which he administered chloroform, and from experi- mentation on animals, claims that cases which apparently termi- nated fatally while under the influence of chloroform have been restored to life by inverting them, as he maintains that death from chloroform is due to anaemia of the brain. If this is so, of course it renders chloroform a far superior agent to ether in every respect. . Chloroform is the much more convenient of the two. The state of excitement is shorter than in the case of ether, or, in other words, it is easier to bring them into the state of anaesthesia; moreover, it passes off a great deal more quickly. There is not the violent struggle and sense of choking as in ether, where the patient sometimes appears as if he was being strangled. On the contrary, by chloroform, in the case of MEDICINAL REMEDIES. 217 children and during parturition, the patients pass at once into a gentle sleep. Another element which shows that at all times we are deal- ing with something beyond our depth, is that there are certain conditions of the nervous system which make the administra- tion of chloroform perfectly safe, in the state of parturition very few deaths resulting from its use, this state seeming to counteract the effects of chloroform upon the heart. Also, in military surgery, chloroform is a particularly successful anaes- thetic, the excitement of war having the same counteracting effect. The danger in chloroform comes from giving it before pain is actually present, when the patient has not yet submitted to the operation, and probably is depressed with the thought of its approach. At first introduction, the greatest number of deaths resulted from patients in the dentist's chair. Hence there is proof that the condition of the nervous system has a great deal to do with the safety of chloroform, and when death is caused it is due to a nervous condition beyond our knowledge. The drawback to the use of both, but especially of ether, is that they produce vomiting; mauy things have been tried to pre- vent this, but so far without success, because vomiting itself is one of the disturbed nervous functions. It is the same with sea-sickness. No remedy has yet been found for this, and it almost exactly resembles the sickness pro- duced by the anaesthetics. There is the same deathly nausea, the same temporary relief on vomiting, followed again by in- tense nausea and great depression, which, as in sea-sickness, may last for many hours. Nothing will relieve it, but about the best thing to be done is to give brandy and water, and nothing more. The vomiting in ether is not only annoying to the surgeon, but is very dangerous, as, occurring while the patient is profoundly unconscious, it allows of the regurgitation of vomited matter into the trachea, in some cases this being the cause of secondary pneumonia, besides the immediate danger from suffocation; and it is particularly dangerous in operations about the head and face. The patient should be allowed no solid food for twenty- four hours before the operation, and particularly no oatmeal. He may take milk or beef tea, anything dilute that is sure of 218 NOTES OX MATERIA MEDICA. being digested. The solid food would not be digested, because, owing to the dread of the coming operation, the digestion is suspended. In administering ether, the patient very soon begins to strug- gle, cough, etc., and one is tempted to let air in to relieve him, but this would only prolong the agony. The character of the respirations should be carefully noticed. The patient should be encouraged, so long as he is conscious, to inhale the ether as deeply as possible. He should be restrained so as to go through the state of excitement without injury to himself. As he gets well under the influence of the ether, he begins to snore, which is a good sign, so long as it is pharyngeal — the ordinary snoring of deep sleep, caused by relaxation of the soft palate and uvula. If instead of this it is laryngeal, stertorous, high- pitched, squeaky, croupous breathing caused by paralysis of the vocal cords, then the administration of ether should be sus- pended and air admitted, because now there is danger of asphyxia in two ways: First, by the ether paralyzing the vocal cords, epiglottis, etc., in which case the diaphragm ceases to act. When this happens, turn the patient over on the right side, and the breathing mechanism will resume its action. The other danger is that, when anaesthesia is complete, the sensation of the tongue is lost and it is consequently relaxed, and if the head is thrown back the tongue is crowded into the pharynx, and asphyxia produced by stopping up the air passages. The mouth should be open, the tongue brought forward, the patient turned on the right side, and breathing will be resumed. The sign by which to judge whether the patient is fully under the influence of ether is when sensitiveness of the conjunctivae is lost. With chloroform, all of these statements are equally applicable about respiration, but the pulse and countenance should be care- fully watched as well. The admission of air during the admin- istration of chloroform should never be completely shut off. When, from being flushed, the face becomes suddenly pale, it is a dangerous symptom, and notably when it occurs in the mucous membrane of the lips. Irregularity of the pulse indicates cardiac weakness, and the chloroform must be suspended. MEDICINAL REMEDIES. 219 Irregular respirations of a shallow character are dangerous if repeated often, and should be treated in the same way. With these precautions, chloroform may be safely administered, es- pecially if taken well at the beginning; there is not much fear afterwards, death most often occurring at the beginning of its administration. Nitrous oxide is used quite extensively in dental practice and is very serviceable as an anaesthetic, provided the operation can be performed as quickly as the extraction of a tooth, the anaes- thesia being very brief and so not answering for any prolonged operation. VIII. Cocaine. This alkaloid is obtained from the leaves of the Coca erythroxy- lon. This medicine has obtained a wide range of popularity within a comparatively short period of time. Cocaine produces a localized anaesthesia when applied to the mucous membranes or the skin, and its action is decidedly marked in this respect, and extends more deeply when a hypo- dermatic injection is made into the submucous tissue. When painted over the skin, a sensation of warmth is at first experi- enced, to be followed in a few minutes by complete loss of sen- sation, the part becoming pale and anaemic. Cocaine acts upon the circulation in two ways: by constrict- ing the blood-vessels, and so increasing arterial pressure, while at the same time it stimulates the heart. The stimulating action upon the heart passes away, however, before the arterial contraction disappears. Cocaine possesses a marked mydriatic effect. This effect is perceived in from ten to twenty minutes after dropping the solution on the conjunctiva, and it reaches the maximum effect in half an hour, lasting for another half hour, and then slowly disappearing. The employment of the muriate of cocaine as an anaesthetic in ophthalmic practice is highly spoken of. A four-per-cent solution is dropped on the conjunctiva three or four times, at intervals of five minutes, when complete anaes- thesia follows. In examinations and operations about the larynx, cocaine is 220 NOTES OX MATERIA MEDIC A. employed and with good results. A twenty-per-cent solution should be used in those cases. Tonsillitis is sometimes relieved by the use of a four-percent solution of the hydrochlorate of cocaine painted over the tonsils. It may be necessary to repeat the application every hour or so. Hay fever is sometimes greatly relieved and its paroxysms prevented by painting the mucous membrane of the nose with a twenty-per-cent solution. Epi- staxis is usually a trivial complaint, but may become dangerous when due to toxaemia and malarial diseases of the spleen and liver. In these cases, it cannot be arrested, from the fact that the veins in the turbinated bones lie in long cavities, and no pressure can be applied to them; the haemorrhage is best con- trolled by applying a two-per-cent solution of cocaine. It can he used to relieve the pain of fissure in ano, when the patient suffers for several hours after a movement of the bowels. Ifc is useful also in the treatment of haemorrhoids and ulcers about the anus. It has been used to relieve the pains of parturition, but must be injected into the submucous tissue. Upon the genito-urinary tract cocaine acts well. The injection of a few drops of a two-per-cent solution into the urethra relieves the pain and irritation of acute gonorrhoea. Sometimes it is extremely difficult to pass a sound into the urethra, owing to great sensi- tiveness, as in the case of stricture; the injection of a few drops of the four-per-cent solution can be tried. In irritable condi- tions of the bladder, an injection of the four-per-cent solution is useful. In neuralgia, the hypodermatic injection of one- third of a grain may be employed, and the injection should be made in the course of the affected nerve. IX. The Hypnotics. Chloral. Chloral itself is an oily liquid discovered in 1832. The addi- tion of water forms the hydrate, a salt with sharp taste and pos- sessed of very peculiar sedative properties. On addition of an alkali, the salt is decomposed and gives off chloroform ; hence the mistaken surmise that the action of chloral in the system was due to the chloroform elaborated from it. But the actions MEDICINAL EEMEDIES. 221 of chloral, and those of chloroform administered internally, are not identical; chloral having no stimulant action, as the ethers and chloroform, but is a pure sedative. Chloral hydrate is one of the best hypnotics known, as the sleep which it causes resembles in all particulars that of nature. The patient, under its influence, drops quietly to sleep ; the respirations are rhythmical, the blood is perfectly oxygenized, and it is not followed by headache and nausea from slowness of the respirations and the accumulation in the blood of carbonic acid gas. The brain is perfectly rested by the sleep, as there is not hyperemia of the brain and a comatose state, as in the sleep by opium. On this account, chloral hydrate is a valuable remedy in cases of insomnia, a symptom which demands close attention; for if it is allowed to go on it may lead to grave results. It is indicated in cases of sleeplessness from anxiety and men- tal fatigue, and can, therefore, be used in mania and in patients with worn-out or anxious brain. Insomnia is one of the earliest and most persistent symptoms of insanity, and can often be traced back to care, grief, some sudden impression, as terror, or to other forms of mental shock. In this kind of insomnia, the mind is occupied with some train of thought which makes it difficult to fall asleep; and when asleep the dreams are on one subject. The brain, remaining active, has no rest and will wear itself out. As a result, there is destruction of the red blood- corpuscles, loss of bodily weight, hallucinations with a tendency to suicide, homicide, or epilepsy ; and on autopsy, meningeal inflammation from excess of circulation will be found. Sleep- lessness of this variety becomes dangerous when accompanied by depression of spirits, despondency, and melancholia, for these are symptoms of approaching insanity. With the depression of spirits there may be fixedness of the eye. There may be an effort on the part of the patient to throw friends off their guard by feigning cheerfulness. In this form of insomnia, chloral is the great remedy. The hypnotic must be persevered in till the pa- tient has had five or six nights of uninterrupted artificial sleep. There will be less likelihood of the chloral habit or dependence on hypnotics when given in this way than with the usual irregu- 222 ^"otes o:n" materia medica. lar and occasional administration. After a week of artificial sleep, the patient will probably sleep naturally. The dose is from gr. x.-xv. for producing sleep. To reduce reflex excitability producing insomnia, use it as an adjuvant to potassium bromide; add gr. viij. to each dose of the bromide in case of epilepsy. Also add small dose of the chloral in irrita- tive coughs, as it promotes the action of medicines that allay the irritation producing cough. So far so good. But every now and then, for reasons beyond our knowledge, chloral is fatal. When dangerous symptoms appear, it is extremely difficult to save the patient's life. The use of stimulants, electricity, etc. , will rouse him out of the dan- gerous state, but he will relapse into it again continually. Never, on that account, begin with more than gr. x., for a number of deaths have been recorded from gr. xv., and two deaths from gr. x. doses; but usually the latter is a safe dose to begin with, and then, if symptoms are not produced, it may be increased to gr. xv. or xx., but the peculiarity of its persistent action indi- cates that there should be some considerable time between the doses. The dose should not be repeated under two hours' inter- val. Some patients can take gr. xxx. very well indeed; but do not begin with that. As an anaesthetic, its properties are not very well marked until added to other remedies. Paraldehyd. Paraldehyd is a medicine used only for producing sleep. It has a vile taste and is difficult to give on this account, and, more- over, it has to be given in large doses, from fit xxx.-xl. The taste may be covered by syrup of ginger. It is a moderate hypnotic and' a good one, particularly useful in insomnia from mental causes, not so useful in insomnia due to peptic causes — fermentation in stomach and intestines. The difference between these two forms of insomnia is that in nervous insomnia the difficulty is in getting to sleep; in the other form, in remaining asleep. MEDICINAL REMEDIES. 223 Sulfonal. This is a medicine not found in nature, but made artificially by the chemist. Chemically it belongs to the group disul- phones. Sulfonal is a whitish, crystalline substance, without odor or taste, very slightly soluble in cold water, more so in warm water, and still more in alcohol, ether, etc. It is a pure hypnotic, neither anaesthetic nor depressing in character, and it does not affect the heart or circulation, and the sleep it produces is per- fect. Being quite insoluble, it requires about three hours to be- come thoroughly dissolved in the stomach, and should be given about two hours before bedtime. As it is not affected by the di- gestive secretions, it may be given shortly after the evening meaL Sulfonal is of great value in the insomnia of the insane, and the dose should be repeated once during the night if the sleep is too short. It is specially recommended in cases of nervous in- somnia, also in the sleeplessness of delirium tremens. In the latter case, gr. xx. should be given every two hours until sixty or eighty grains have been taken, but it should be remembered that every case of delirium tremens is also a case of starvation, and to produce good sleep the patient must be fed. The usual dose of sulfonal as a hypnotic is gr. xv.-xx., and should be given in capsules. Phenacetin. 1 The number of remedial agents drawn from the carbolic-acid series seems to increase day by day. From this source we have not only obtained powerful antiseptics and active antipyretics, but more recently anodynes which, in some conditions, rival those furnished by the vegetable alkaloids. To the carbolic- and salicylic-acid classes are added antipyrine and acetanilid, and these are now increased by the addition of the phenacetins. Phenacetin is a white, glossy, crystalline powder, being per- fectly tasteless. It is freely soluble in alcohol, but only slightly so in water. It has a double action: it lowers the temperature 1 Phenacetin is not a hypnotic. It is derived from the carbolic-add series, And has actions similar to antipyrine, acetanilid, etc. — Ed. 224 NOTES ON MATERIA MEDIC A. and relieves pain. As an anodyne, it is superior to antipyrine and antifebrin. It can be used in neuralgia, migraine, muscular rheumatism, acute articular rheumatism, and the lightning pains of locomotor ataxia. In some cases of hysteria and of hysterical or neurotic pains, phenacetin seems to act as well as the bromides; it quiets irritable conditions of the nervous system, and in some cases in- duces sleep. As an anodyne, the dose should not exceed gr. vij., and, if necessary, this dose may be repeated after three hours. The dose necessary to produce a decided reduction of the tempera- ture m fevers is, on the average, gr. xx., and this can be divided into two parts, and each dose given in the interval of one or two hours. For the reduction of the temperature in fevers, however, the external application of cold is to be preferred to any one of the internal antipyretics. Division II. — Eliminatives or Glandular Medicines. These medicines increase gland secretion, and are given more against complications occurring in the course of acute or of chronic diseases than against mere symptoms. Thus the high temperature of febrile conditions arrests secretion generally, and where this is long continued, life will be further endangered in these diseases by the complication of starvation, from the de- ficiency of the digestive secretions in the alimentary caual, and by the complication of self poisoning from retained excretions. If the fever be lowered and the glands supplied with blood at the normal temperature, they will at once resume their func- tions; but, until this is done, eliminatives are meanwhile useful, not to eliminate the disease, but to modify the complications. In those non-febrile conditions of the system where the arrest of secretions is not general, as in fevers, but local, the elimina- tive class of medicines is also useful, as by them the different gland secretions are sometimes made to act vicariously for some one deficient gland function, as when cathartics and diaphoretics are used in kidnev disease. MEDICINAL REMEDIES. 225 The eliminatives are divided into: 1. Cathartics, which increase the secretions of the intestines. 2. Emetics, which act upon the secretions of the pharynx, stomach, liver, and duodenum in the act of emesis. 3. Diuretics, which act on the kidneys. 4. Diaphoretics, which act on the skin. 5. Expectorants, which act on the bronchial secretion. 1. Cathartics. Cathartics are those remedies which increase the secretion of the intestines. The use of cathartics is indicated by two en- tirely different conditions: (1) in diarrhoea due to local intesti- nal inflammation; (2) in constipation. Constipation. — This condition, when not dependent on some gynecological ailment, is generally due either to deficient action of the small intestine or to deficient action of some part of the large intestine. Deficient action on the part of the small intestine is due to two causes: 1. Deficient secretion. 2. Want of innervation, or want of muscular action. Constipation dependent upon deficient secretion is quite distinct from that caused by want of muscular action, but in many cases both causes will be operating. Deficient secretion in the small intestine may be caused by some disturb- ance of the liver. Constipation, therefore, may date from the time when the patient suffered from some severe form of fever in which the liver was prominently involved, such as the bilious remittent ; or it may follow an attack of tropical diarrhoea, which is almost invariably accompanied by marked hepatic disturbance. In such cases, the patient does not have an extraordinary fecal accumula- tion and impaction, but there is, instead, a sluggish action of the bowels, and he is usually obliged to take medicine to bring about a movement once in four or five days ; and when it does occur, the evacuation is moderate in amount and quite dry. This kind of constipation is quite common in the Southern States as a sequence of the diarrhoea which prevails in that latitude ; and it is also fre- quently seen in the Northern States as the result of malarial poisoning. The symptoms are extremely negative, except the constipation. The one which perhaps gives the patient most discomfort is a tendency to a dull, indefinite headache. In a majority of cases, this is located in the posterior part of the head, is rather an uncomfortable sensation than a real pain, and is best relieved by something which promotes a free discharge of bile. The !5 226 NOTES OX MATERIA MEDICA. tongue usually is small, not large and flabby, generally a little reddened along the edges and tip, and the secretions of the mouth are commonly vis- cid. The condition of the mouth is an indication of the condition present along the entire alimentary canal. We have, therefore, evidence of the presence of only a moderate amount of secretion in the intestinal tube, and our treatment should be regulated accordingly. If, for the relief of this condition, mild cathartics be administered, the condition of the case will be aggravated, because the temporary stimulus afforded by them, however mild, is immediately overcome by the tendency to deficient secretion. Active purgation produces a much more injurious effect than mild laxatives. If resort be had to the use of medicines which have been recommended to stimulate nerve action, not much benefit will be obtained. What should be present in the intestine is a small increase of lubricating substances, as it were, and to that end altogether the best results have been obtained by causing the patient to take a great deal more water than is his usual custom. Let him take, on rising in the morning, two tum- blerfuls of drinking-water. As a rule, those who drink considerable water are not troubled with constipation. The laxative action of the water can be insured by the addition of some mild saline, like the carbonate of soda, or even common salt, and the reason why such an effect is produced is this : the mixture formed by the union of some saline with water does not readily pass through the mucous membrane, and so into the general system. The theory now generally accepted with regard to the action of salines is that they are not absorbed, and that they prevent the water with which they are combined from being absorbed ; hence the water, by exciting the peristaltic action of the bowel, brings about a movement to discharge it, and with that the other contents of the intestinal tube. There is considerable to lend sup- port to this view. It is not necessary to give large doses of saline cathartics, as a half-drachm of the sulphate of magnesia, dissolved in a pint of water, commonly operates very nicely. There is another fact which may here be mentioned, namely, the addition of small doses of quinine to salines increases their power of acting upon the intestine. For example : ^ Magnesii Sulphatis, . . . . . 3 i. Quininse Sulphatis, .... . gr. i. mixed and taken in a tumbler of water every morning, rarely fails to pro- duce all the laxative effect required in every form of deficient secretion from the bowels ; for instance, in the constipation following fever, when you desire to obtain a free alvine evacuation. It is well to tell the patients that they will not, perhaps, see much effect for one or two weeks ; but if they can be induced to persist in the daily use of large quantities of water, a great deal of benefit will almost certainly follow. There is a supposition on the part of the laity that certain fruits are laxative, and that is probably true to a limited extent. Oranges may be eaten with ben. MEDICINAL REMEDIES. 22? efit, but it usually requires ten or twelve to overcome an obstinate constipa- tion, a fact which renders the remedy quite impracticable in this climate. In the warmer climates, however, the worst forms of constipation which appear can be overcome by oranges alone; and the more juicy they are the better, from the fact that the citric acid which they contain has a tendency to pro- duce a catarrh of the intestine if taken in excess. Figs are a rather danger- ous laxative, for they may obstruct the intestines ; there is not much danger, however, in this direction, if taken with a large quantity of water. It will be found necessary to use about double the amount of water with figs that will be required with any other laxative fruit. The fruits of this climate are very uncertain in their action ; the action of apples is very good, but very many persons are unable to take them in sufficient quantity to produce any effect upon the bowels, although they may at the same time take a large quantity of water. All along it will be found that water is one of the most important agents to be employed for overcoming deficient secretion in the intestine attending constipation. If flatulence, resulting from decomposi- tion of the intestinal secretion, accompanies the constipation, recourse may be had to the following pill : R Asafoetidse, gr. iv. Saponis, gr. ix. M. To this may be added nux vomica, if there is evidence of deficient innerva- tion in the intestine. How are we to judge that the leading element in the case is deficient in- nervation, especially with reference to the small intestine ? As a rule, deficient innervation is an accompaniment of the constipation that troubles persons with sedentary habits of life. As a rule, it attends the constipation present in elderly persons and such constipation also occurs among those whose occupation causes them to main- tain positions in which the abdominal muscles are to a very great extent motionless, such as shoemakers, tailors, etc. There is also a tendency to headache, and there is a great deficiency in the excretion of the coloring matters of the bile, as might be expected ; for the secretory action of the intestines is as much interfered with as is the muscular action. Hence this class of patients are usually of dull, sallow color ; there is a tendency to greasy accumulations upon the surface ; the entire movements are sluggish, and there is usually. a lack of frequency in the pulse. Now, with regard to the treatment for this class of cases, in the first place the habits of the patient have a tendency to keep up the constipation, but the means to be employed for overcoming it are quite different from those resorted to in the other class. As a rule, these patients do not bear much water, because it weakens their digestive powers, and they will very soon complain of loss of appetite, heaviness in the head, etc., and it does 228 NOTES ON MATERIA MEDICA. not excite much peristaltic action in the bowels. At all events, it is not. nearly so apt to increase the peristaltic action as in the class of cases in which deficiency of secretion in the intestinal canal is the leading element. What should be done here is to arouse the peristaltic action of the bowels, and at the same time increase the general innervation of the secretory appa- ratus. To do this, the best means that can be employed, if the patient is permitted to remain at his occupation, is water applied externally. The only way in which they can derive benefit from the internal use of water is to send them away from their business to a mineral spring. Then, having a change of occupation, the water taken internally will give them much benefit. But most patients will be unable to make this change, and for these water may be used externally with great advantage. Direct that a sitz bath be taken every night in water as cold as the patient can bear, and have a good reaction afterwards. In a great many cases, this simple measure will work wonders, just as it will do in certain cases of deficient innervation of the large intestine. Another method of using water externally is, on rising in the morning, to sponge the spine and bowels with cold salt water, made about as irritant as possible. In other cases, great benefit will be derived by giving the bowels a local shower-bath, and that can be done by dashing the water against the abdomen while the patient is in the standing position. This brings about an action in the bowels, the same as a cold hand upon the abdomen causes contraction of the uterus ; that is, it is through the sympathy of the nerves of the surface with the viscera underlying them. In this class of cases, nux vomica has proved itself a very efficient remedy, and it may be administered in combination with any other drug. It will increase the efficacy of small doses of the resinous cathartics, which are irritant and stimulant ; hence small doses of rhubarb with nux vomica and soap may be given in the form of a pill with much more benefit than when administered separately. The application of the faradic current, one pole of the battery placed over the spine, and the other passed up and down over the abdominal walls, will, in many cases, be found beneficial. What is known as the health-lift will prove advantageous in certain cases, and the reason is that it brings into action all the abdominal muscles, espe- cially the recti, and that action is brought to bear directly upon the sluggish intestines. When any lesion of the bowels is present, the health-lift cannot be employed. In the constipation dependent upon diabetes, due to total deficiency of secre- tion into the intestinal tube, death may result in consequence of the consti- pation which occurs in connection with this disease. Constipation Dependent upon Certain Conditions Present in the Large Intestine. — In the large intestine, we find that constipation depends upon nearly the same conditions as were found present in the small intestine. That is, we have constipation dependent upon deficiency of action, and that MEDICINAL REMEDIES. 229 it in turn may depend upon deficient secretion or deficient innervation, but it is far more commonly dependent upon the latter. Here the patient may be troubled with large faecal accumulations, and that condition may depend upon deficient nerve power on the part of the colon, or the deficient inner- vation may be confined to the rectum. One of the worst forms of constipation may occur, dependent upon no other condition than that which is present in the rectum alone, and, unless the physician is upon the alert, the result may be the development of a rectal abscess. When this condition is present, the patients have but little knowledge that they should have a movement from the bowels, and whenever the sensation is developed they have little or no power to expel the faecal accumulation. When such symptoms are present, it is a pretty certain indication that they depend upon deficient innervation of the rectum, and, unless that condition is overcome, serious consequences may follow. One of the most common causes of this condition is a chronic inflammation set up about haemorrhoids. Prolonged inflammation of any part, especially, however, about the mucous membrane, produces deficient innervation, and then follows a relaxed con- dition, and with this deficient innervation we are, therefore, very liable to have prolapsus of the rectum. These patients are peculiar in one respect, namely, they are generally very low-spirited. It sometimes happens that insanity is developed by such a diseased condition of the rectum, and is relieved when the rectal trouble is removed. With regard to treatment, the first indication is to keep the rectum empty. When faecal accumulations are present, the most efficient and convenient method of removing them is by means of enemata, but caution must be used in resorting to this measure. Never prescribe* enemata as a regular treatment, for if the patient gets into the way of emptying the bowels daily in health by enemata, he can never dispense with their use. If the patient should use the syringe every morning for the purpose of evacuating the bowels, and it is continued regularly for six weeks, he has gone considerably far towards making it a necessity during the remainder of his life. This measure should not be used unless absolutely necessary. Within recent years, glycerin has been largely used as an enema, and in a certain proportion of cases it answers admirably; a retained injection ( 3 i - ij.) producing very free movements in from five to twenty minutes, gen- erally unaccompanied by any pain. Glycerin suppositories are now made, and are claimed to be superior to an enema. Glycerin seems to act best when the rectum is loaded from faecal accumulations in the descending colon. It has been used extensively in Europe for the constipation of infants (gtt. xx.). Occasionally it has produced some irritation of the rectum, but in the great majority of cases the constipation has been re- lieved promptly. In cases where the intestine is obstructed in adults, an 230 NOTES OX MATERIA MEDICA. enema should be tried (dose, 1 ss.) It will probably be necessary to use enemata for removing accumulations which happen to be present, but when they are thoroughly cleared out resort should at once be had to other mea- sures for restoring lost innervation to the bowel, and one of the very best of these is the local use of strychnia It is an exceedingly valuable specific in these cases. It will frequently succeed in curing the worst forms of pro- lapsus of the rectum, as well as that condition in which there is simple debility with hypertrophy of the mucous membrane. The manner in which you can cure long-standing cases of prolapsus of the rectum by means of injections of strychnia into the submucous tissue itself is sometimes wonder- ful. If necessary, a fold of the mucous membrane can be drawn down and the injection then inserted. This agent may be relied upon almost exclusively in the treatment of this class of cases, whether the real cause was hypertrophy of the mucous mem- brane from long-standing haemorrhoids, or there was a simple deficiency of power in the rectum to expel its contents. There is another class of cases in which this agent will prove beneficial, and that is cases of prolonged cystitis from any cause. As is well known, elderly men who suffer from enlarged prostate, suffer more or less from cystitis, and they are always apt to have accumulation of faecal matter in the lower part of the bowel, and it is for the reason to which reference has just been made, namely, deficient innervation. Hence in the treatment of any form of cystitis, especially that accompanying enlarged prostate, if the patient complains that the evacua- tion from the bowels is small and that the movement does not seem to com- pletely empty them, clear them out effectually by means of enemata, and then use injections of strychnia, and you will find that, in very many cases both conditions will be materially relieved. With the other form of consti- pation there is a tendency to the formation of scybalous masses. The most common situation of such accumulations is at the upper part of the rectum, and next in the transverse colon. It is only when they are dislodged that they come down into the sigmoid flexure. It is in these cases that the mineral waters will be found most beneficial of anything that can be employed. In the first place, the mineral water will loosen the scybalous masses without depressing the patient in the least, and it will also prevent new accumula- tions. Of these, the Congress or Kissingen may be used, or both may be used at the same time. In this class of cases, considerable benefit will be derived from the use of belladonna or stramonium in the form of a suppos- itory. The patient may take his Kissingen water in the morning, and use a suppository of belladonna or stramonium at night. If the belladonna is employed, it should be given in such quantity as will produce a little dry- ness of the throat and slight dilatation of the pupil the following morning. Faradization along the track of the colon is equally beneficial as in the treatment of constipation of the small intestine; and the hip bath may also be of service, but it does not answer so good a purpose as when the small MEDICINAL KEAIEDIES. 231 intestine is chiefly involved. If possible, the use of enemata should be avoided except for the purpose of removing faecal accumulation near the anus, for the effect produced by much overdistention of the intestine is bad. A single overdistention of the bladder may be followed by a perma- nent weakness for the remainder of the patient's life, and that distention may not last more than eighteen hours. So a single overdistention of the intestine may greatly weaken the normal rhythm of that tube. Constipation and Fcecal Accumulations following Febrile Diseases. — The effect of fever is to dry up all the secretions present in the intestine; conse- quently a very common complication when a patient is making a recovery from pneumonia or any other disease in which fever has been a leading ele- ment, is an accumulation of faeces at different parts of the intestinal tube. In former days, when fevers were treated upon the plan of administering medicines which were to eliminate the poison from the system by way of the bowels, scybalous accumulation did not occur very frequently; but nowadays, when the treatment is conducted upon an entirely different plan, the fever may be continued and retained as the direct result of faecal accu- mulation. This is especially true of the latter stages of a fever; but such accumulation can be prevented from forming, and be removed by the use of a proper kind of cathartic. For this purpose there is no combination more serviceable than the compound jalap powder, and it is the one which by all means should be employed. It promotes the discharge of the serous elements into the intestine, assists in the absorption of the deposits which have taken place in the lung, if the case be one of pneumonia, acts upon the kidneys as well as upon the bowels, and is one of the mildest cathartics that can be employed, which so fully meets the indications in this class of cases. Constipation Due to Great Deficiency of Biliary Secretions. — In this form of constipation, there are sallownessand greasiness of the skin. Compound Licorice Powder, formed of Senna, 18 parts; Licorice, 16 parts; Fennel Seeds, 8 parts; Washed Sulphur, 8 parts; Refined Sugar, 50 parts, should be given as a laxative (dose 3 i.— Ij .)- This powder is also very beneficial where there is irritation of the rectum, and should be the laxative wherever there is a tendency to hcemorrhoids. Nervous Constipation of Women. — In the female sex, constipation is some- times due to suppression of the peristaltic movements of the intestine by reflex irritation of the ovarian plexus, which will also cause cold feet, the irritation contracting the arteries of the legs, and there will be aching in the back. Warming the feet artificially, and giving belladonna, with a small dose of extract of colocynth, ' will often relieve the whole trouble. In administering cathartics, the following facts are to be remembered: 1 For prescription, see page 181. 232 2ST0TES OX MATERIA MEDIC A. 1st. All cathartics operate better when in combination with each other, or with some other medicine, than when given alone. By combining small doses of several cathartics, the par- ticular action of each can be secured without the undesirable qualities of any, and this combination is therefore practically a new medicine. 2d. Quinine and the mydriatics assist them in their action; quinine especially increasing the power of the sulphate of mag- nesium. 3d. All saline cathartics must be taken very cold or very hot, as their action depends on their affecting the stomach. Cathartics may be divided into the following classes: (a) Cathartics which stimulate natural secretions. (b) Irritant or drastic cathartics. (c) Saline cathartics. (a) Cathartics that Increase the Natural Secretions. Calomel. Calomel is the cathartic for fevers when the constipation is due to the arrest of the normal secretions by the high tempe- rature, so that the stomach is wholly unable to digest solid food from the absence of the digestive secretions, and there is the serious danger, in all fevers lasting more than four- teen days, of the patient being virtually starved. A dry skin and intense thirst are present, and, owing to the scanty flow of urine, materials which ought to be excreted are retained, and there is the further danger of self-poisoning. Calomel, there- fore, should be given as a cathartic at the commencement of every fever, as it stimulates in a natural way the secretions of the intestines,' and thus diminishes the danger of starvation; and, being also a diuretic, it increases the flow of urine and diminishes the danger of self-poisoning from retained excre- tions. In addition to this, it will be found that in every fever, after the calomel has operated, the temperature is lowered, the skin becomes moist, and the intense thirst which invariably accompanies a dry skin is relieved. It has been demonstrated that typhoid fever runs a much better course if a calomel purge MEDICINAL REMEDIES. 233 is given at its commencement. It is supposed that the retained excretions early vitiate the blood and afford a fruitful soil for the reproduction of the morbific germs of the disease. Calomel as a cathartic should always be given in large doses, as the effect does not vary much with the dose. When given alone, it acts in about twelve hours, but its action is hastened when combined with other cathartics, especially jalap and cream of tartar. Calomel is also valuable as a cathartic where the secretion of bile is deficient from congestion of the liver or other functional causes. A good formula for biliousness is: 5 Pil. Hydrargyri, gr. iv. Sodii Bicarbonatis, Pulv. Rhei, aa gr. viij. Pulv. Aloes, gr. ij. Quimnae Sulphatis, gr. iij. M. Fiant capsul. No. iii. Sig. Take at one dose. In cases of lumbago and other forms of muscular rheumatism, with acid urine of high specific gravity, a cathartic of blue pill (gr. v.) with ipecac and soda is the best mode of treat- ment. Scrofulous children are often troubled with loss or per- version of the appetite, associated with constipation, with light or clay-colored stools, showing a deficiency of bile. These cases are greatly benefited by the use of some mild mercurial cathar- tic, as two or three grains of the hydrargyrum cum creta, com- bined with rhubarb and soda. This should be given three times a week for two or three weeks. Castor Oil (Oleum Eicini). This oil is expressed from the seeds of the Ricinus communis, a plant the best varieties of which grow in warm climates free from frost. The " cold drawn M castor oil is to be preferred, as this method of preparation eliminates an acrid principle, very irritating and poisonous, contained in the outer coat of the seed. The effect of oils in general, when applied to mucous mem- branes, is to produce a non-albuminous, watery flow until every particle of the oil has been washed away; and it is probably due to this action, and to its stimulation of the peristaltic .move- 234 IKTOTES ON MATERIA MEDIC A. ments of the intestines, that castor oil owes its cathartic prop- erties. It has not, however, a local action upon the intestines alone, for, after it has been absorbed into the blood, it produces the same effects elsewhere. This has its advantages and disad- vantages, for castor oil given to a nursing woman will some- times purge the infant, but at the same time it stimulates the secretion of milk. (A fomentation of the leaves of the plant, or castor oil itself, applied to the breast, is often used for this purpose.) Castor oil, therefore, should not be given where these effects are not desired, nor should it be given to children with capillary bronchitis ; for, acting upon the same principle, it stimulates the secretion of mucus in the bronchial tubes — the very thing to be avoided, as, owing to the feeble expectorant powers of children, this disease is very dangerous, and one of the commonest causes of death among them. (These cases may often be successfully treated by giving 3 ss. doses of hot milk and lime water, which strengthens the heart and assists expecto- ration by taking advantage of the vaso-motor nervous associa- tion existing between the oesophagus on the one hand and the trachea and bronchial tubes on the other.) Castor oil is a very good cathartic for the faecal accumula- tions, or constipation with dry, hard faeces, occurring in many febrile diseases of short duration. Where the fever is prolonged, calomel is the best cathartic; but where, as in malarial fever, it lasts only for a day or two, castor oil, besides its beneficial cathartic action, is also effective in rapidly lowering the tem- perature. It is the remedy to begin with in the treatment of the dysen- tery of temperate climates, 1 a disorder not uncommonly due to the retention of hard faecal matter. After the bowels have been cleared, the treatment should be castor oil 3 i., and laudanum gtt. x., given every three hours. This combination has a bene- ficial soporific effect not produced by the laudanum given alone. Castor oil is indicated in all cases where there are stringy mucus, blood, etc., in the faeces. As a rule, it is a prompt cathartic, 1 For the treatment of the dysenteries prevalent in hot climates, see page 247. MEDICINAL REMEDIES. 235 producing movements within half an hour after administration; but in some cases they will not take place for four hours, or even longer (dose, 3SS.-L). Aloes and Rhubarb. These are excitants of the natural secretions, par excellence, and the only ones to be recommended for this purpose. There- fore, in all cases where, from absence of the digestive secretions, there is intestinal catarrh or imperfect action of the liver, with sallowness of skin, loss of appetite, and sluggish, irregular action of the bowels, or mal-digestion with consequent disor- ders, the first and foremost of which is summer diarrhoea, these cathartics are the ones indicated, as they restore the digestive powers, improve the appetite, etc., and may be given for months together without any harmful results; whereas other cathartics, if their use was so long continued, would certainly cause a great deal of weakness if not serious intestinal derange- ment. Many of the symptoms of chronic dysentery will also be relieved by the daily administration, week after week, of rhu- barb or aloes. Aloes. — This substance is the inspissated juice of the leaves of the Aloe Socotrina and other species of aloes growing in warm climates. The best varieties come from Mozambique. It is a greenish -black substance, breaks with a smooth, glassy fracture, and has an aromatic odor. It contains a crystalline principle called aloin (dose, gr. T V-i )• Aloes is a slow cathartic, requiring from twelve to eighteen hours before it operates, and, if given alone, causes considerable griping. Hence it is often necessary to combine it with other cathartics, and it acts best when in combination with rhubarb in the compound rhu- barb pill (Pulv. Ehei, gr. ij.; Pulv. Aloe, gr. iss. ; dose, two to five pills). The movement produced by it is not watery, showing that it relieves the system of faecal accumulations. Many ailments, especially those of young women, are due to such accumulations, the patients sometimes not having a move- ment for several days. For this condition, and for offensive breath dependent on intestinal disorders, aloes and rhubarb in 236 NOTES OX MATERIA 3IEDICA. the form of pills, with the administration of nitro-muriatic acid, is the most successful treatment. An old prescription, and a very good one, for stimulating the sluggish digestion of chlorotic women, was tincture of aloes and myrrh. (This mix- ture is intensely bitter, and is now put up in pill form.) Given with iron in chlorosis, this mixture answers admirably, as it improves the appetite, overcomes the constipation, and pro- motes the assimilation of the iron. Aloes also stimulates the circulation of the pelvic viscera, and acts upon the uterus as an ^mmenagogue. It is, therefore, indicated in amenorrhea, dys- menorrhea, also in chronic constipation, in piles which are not inflamed, in prolapsus of the rectum not due to recent inflam- mation, and in enlarged prostate from sluggish circulation. It is contra-indicated when inflamed hemorrhoids are present; also in pregnancy, cystitis, and in inflammatory conditions of the pelvic organs. The dose of the powdered aloes is ten grains, but if given twice a day, five grains. As it accumulates in the system, the doses should be smaller still if its use is to be continued for any length of time. A saline drink should be given six hours after its administration, or in the morning when the aloes is given at night on retiring. Rhubarb (Rheum). — This resinous cathartic is prepared from the root of several species of Eheum growing in elevated regions of Central Asia. By virtue of a kind of tannic acid contained in the root, rhubarb possesses astringent as well as purgative properties. Rhubarb, as a cathartic, stimulates the intestinal movements and produces a slow, griping movement in from six to eight hours. This is followed by increased appe- tite and a tendency to constipation, the tannic acid operating after the cathartic action has ceased. Combined with an alkali, rhubarb makes a sort of emulsion which, in its constituents and properties, closely resembles human bile, less some of its salts. Besides its other properties, it is, therefore, both antiseptic and restorative. Hence rhubarb is the typical cathartic for the common summer diarrhea due to intestinal fermentation, es- pecially when it occurs in children. For the purpose of pre- MEDICINAL REMEDIES. 237 venting the griping action of both rhubarb and aloes, we combine other substances with them. The alkalies are the best for this purpose, as they do not cause constipation and promote the action of the cathartics. The bicarbonate of soda and mag- nesium sulphate are the substances generally used. Soap has the same effect as the alkalies, but not to the same degree. All spices will counteract griping, but they cause constipation. As, however, we want this effect in treating diarrhoea, the aromatic tincture of rhubarb is commonly prescribed for this disorder. For the treatment of summer diarrhcea of adults, the follow- ing is a good prescription: 3 Magnesii Sulphatis, 3 iv. Tr. Rhei, 3 vi. Syr, Zingiberis § iss. Aquae Menthae Piperitae, ad % vi. M. Sig. Tablespoonful every three hours. For a child one year old or under: $ Tr. Rhei 3 ij. Magnesii Sulphatis, 3 i. Syr Zingiberis, 3 iv. Aquae Menthae Piperitae, ad § iss. M. Sig. Teaspoonful every two or three hours until the diarrhcea is stopped. Opium should not be used, as it aggravates the original cause by suspending the natural secretions, but it may be necessary to give it where there is inflammat'on, and in violent peristaltic movements it may be necessary to use it. Cascara Sagrada. This drug is the dried bark of the Rhamnus Purshiana, a tree growing on the North Pacific coast. A very bitter fluid extract is made from it. In small doses it acts as a tonic, im- proving the appetite, etc.; in larger doses it is a mild cathartic. For offensive breath caused by intestinal disorders, this sub- stance is an excellent remedy if the patient is not troubled 238 NOTES ON MATERIA MEDICA. with hemorrhoids. Give five drops of the fluid extract three times a day, as it operates better in this way than if given in one dose. (b) Irritant Cathartics, or Drastics. The drugs which form this class are all vegetable cathartics, and contain resinous and acrid principles in such a degree that in large doses they produce severe if not fatal gastric irritation and inflammation. Their operation is accompanied by more griping than that of other cathartics, and the violent purgation often produces faintness; but where prompt and free action is desired, recourse must be had to them. If small doses of several of these cathartics are combined, it prevents the too great activity of any one of them acting singly. Colocynth Is the dried pulp of the Citrullus colocynthis, a bitter cucumber growing on the southern and eastern shores of the Mediterranean Sea. When fully developed, it is a gourd about the size of a large orange. The part used in medicine is the pulp surround- ing the seeds, and is intensely bitter and irritating to the eyes. It contains an active principle called colocynthm. When given alone, even in small doses, it produces intense inflammation of the duodenum and of the biliary and pancreatic ducts, with a profuse flow of serum. Its action may be so violent as to produce fatal g astro-enteritis. It is never used alone, but as an addition to the laxatives where it is desired to unload the bowels or to deplete the portal circulation. It should never be used where there is dropsical effusion. It is an active constituent of Brandreth's pills, and the chief ingredient of most quack pills. The administration of three of the compound cathartic pills of the TJ. S. Pharmacopoeia (which contain colocynth) is an excellent preparatory step to the ex- hibition of quinine in malaria. For chronic constipation of women, this drug, with belladonna, etc., is superior to calomel. MEDICINAL REMEDIES. 239 Scammony. This substance is the resinous exudation from the root of the Convolvulus Scammonia, a vine growing in Arabia and Syria. It is an extremely powerful cathartic, resembling colocynth in its physiological action. It is generally used in combination with other drugs. Jalap. Jalap is the tuberous root of the Exogonium purga, and is named from the town of Xalapa, in Mexico, of which country the plant is indigenous. It is the mildest in its action and the least irritating of all the resinous vegetable cathartics, producing a prompt watery flow from the small intestines. On this ac- count it is especially useful for unloading the portal circulation. A very good combination for this purpose is jalap ten grains, and calomel ten grains, as each drug assists the action of the other, and there is no nausea. Its action may be made still more beneficial by adding about sixty grains of bitartrate of potassium. Jalap is the cathartic to be used when the blood is charged with poisonous substances, as in Bright' s disease. It may also be given to remove the ascites and dropsy of this disease, especially when the dropsioal effusion begins to threaten the lungs; and to relieve the cerebral congestion which is some- times an accompaniment of certain forms of this disease. In those cases of congestive bronchitis where the patients have a short cough, great hyperemia in the chest without much secre- tion, shortness of breath, etc., and which may go on to danger- ous suffocative bronchitis, a prompt cathartic will often cut short the attack, and, as one is indicated which produces a watery flow, jalap should be given. Purgative dose of jalap is 3i.-3i., combined, if desired, with a small dose of calomel. The compound powder of jalap (Pulvis jalapce compositus) is formed of jalap thirty-five parts, bitartrate of potassium sixty-five parts. Podophyllum Is the outer root of the Podophyllum peltatum, or may-apple of North America, growing in the Northern and Middle States, 240 NOTES ON" MATERIA MEDICA. and is best when obtained just after frost has set in. In its ac- tion it is as irritating and acrid as colocynth, producing bloody vomiting and discharges > with inflammation of the intestines. It is the most certain cholagogue of all the vegetable cathartics, but its action is very slow, and, unless combined with other drug.-*, cannot be hurried. On account of its action upon the liver, it is of considerable use as a cathartic in cases where constipated patients have been malarious. It should be combined with a small dose of compound extract of colocynth. The dose of the resin, which is the only trustworthy preparation, varies from one-sixth to one-half of a grain. Elaterium. A substance deposited by the juice of the fruit of Momordica Elaterium, a small trailing vine growing on the shores of the Mediterranean Sea. It is very uncertain in its strength, and on this account has been omitted from the official list, and its active constituent, Elaterin, substituted. The latter consists of small, colorless shining scales or prisms, without odor, which are not altered on exposure to the air, and have a somewhat acrid and extremely bitter taste. When civen in full therapeutic doses, it produces a copious serous discharge, which may contain albumin and even blood, with great prostration of the nervous system which may be fatal. Elaterin operates by paralyzing the solar plexus, and, when given in toxic doses, its symptoms resemble those of cholera. It is the most efficient of this class of medicines in producing absorption of dropsical effusions in renal disease. It has been claimed that it has the power of causing the elimination of urea by vicarious action of the bowels. It should always be combined with other cathartics (dose, gr. -gVrV)- Camboge (Oambogia). A gum resin obtained from the root of the G-arcinia Hanbu- rii, an East Indian tree. As a cathartic it produces a copious watery flow, but, owing to the violence of its action, it is not to be used in chronic constipation except of the most obstinate MEDICINAL REMEDIES. 241 kind, as it leaves the bowels in a state of torpor, due to the re- action of overstimulation and secretion. Dose is from two to five grains with soap, but it is seldom given alone. Senna. The leaflets of several species of Cassia growing in Central Asia, India, etc. It is usually administered in the form of an infusion which has a very bitter and nauseous taste. This infu- sion combined with epsom salts and an aromatic makes the noted "black draught." Senna operates very beneficially in cases of intestinal atony following malarial disease, and where constipation is accompanied with biliousness. It is now put up in many elegant forms, which must be used interchangeably. It is also combined with sulphate of magnesium in capsules. Compound Cathartic Pills (U. S.) These pills have long been noted for the relief of portal con- gestion, and should always precede the administration of quinine. Each pill contains the following ingredients: Calomel, gr. i.; Abstract Jalap, gr. i.; Ext. Colocynth. Comp., gr. 1-J; Cam- boge, gr. £. The full dose is three pills. Croton Oil (Oleum Tiglii). This is a fixed oil obtained from the seed of the Croton Tig- lium, a plant growing in the southern part of Asia. It is vio- lently irritating both to the skin and gastro-intestinal tract, producing to the greatest degree the catarrhal effects of oil. It mixes readily with any other oil, and one part croton oil to nine parts sweet almond oil is very effective as a counter-irritant in catarrhal bronchitis, congestive 'bronchitis, and in certain stages of phthisis, as, applied to the chest, it gives rise to a very extensive eruption. The strength will have to be increased as the skin becomes habituated to its use, until finally the pure oil itself may have to be applied, which then produces no greater effect than its original application of one part in ten. In the spinal irri- tation occurring most frequently in women and young. girls, 16 242 NOTES OX MATERIA MEDICA. partly nervous, but mainly dependent on weak muscular power- where there are several tender places along the spine, especially over the sacrum, counter-irritation works very well, and croton oil may be applied in the manner above described. Given internally, croton oil is an intense hydragogue cathartic, acting more powerfully than any other, and producing profuse discharges with griping pain. It should be used when a speedy and complete evacuation of the bowels and a diminution of the arterial pressure are demanded; and the smallness of the dose (gtt. i.-ij.), and the fact that it acts if simply placed on the tongue, indicate that it is to be used in those cases where con- sciousness or deglutition is suspended and a cathartic is needed. It is, therefore, to be given in coma, especially if it be apoplec- tic, but not if the patient is in a state of syncope; in other words, if the pulse is full and strong, give a cathartic to prevent fur- ther cerebral inflammation; if weak and irregular, do not give it. Croton oil is also to be recommended as a purgative in the early treatment of cerebrospinal meningitis when the symp- toms are high fever, stiffness of the muscles of the neck, etc. It should also be used to remove an impaction of fasces in the intestines when other remedies fail. (c) Saline Cathartics. l This class of purgatives have a peculiar mechanical action, which depends on their saline properties. They are extremely difficult of absorption, but remain in the intestines, and by their presence act on the mucous membrane, causing an increase of secretion. But this is only a part of their action. As the nat- ural secretions are poured out, this class of purgatives, through their affinity. for water, prevent their reabsorption, and thus in- crease the liquid part of the faeces. Their action is analogous to that of an enema. As they do not increase the secretion of the intestinal juices, they are not followed by constipation. These are true hydragogues, as they produce a flow of water. They act rapidly, producing little or no griping, and are not followed by prostration. They are very useful where the de- 1 See also Mineral Waters, p. 101. MEDICISTAL REMEDIES. 243 jecta are scanty in quantity and dry, as in the case of drunkards; also to remove accumulated faeces and irritating matters from the intestines, except when they have produced inflammation. Their prolonged use is to be avoided, for by preventing reab- sorption of the intestinal juices they impoverish the blood. On account of their refrigerant action, they should not be given in chlorosis, jaundice, Brighfs, or any exhausting or depressing disease. Their effect is increased by adding small doses of qui- nine. When given in small doses (one-eighth of a purgative dose), they act as diuretics. The saline cathartics are contra- indicated in fevers and when iron is administered, as they pre- vent its absorption. Sulphate of Magnesium (Epsom Salts). This is an intensely bitter, crystalline salt, causing free watery discharges. It seems to act especially on the mucous membrane of the duodenum. Its cathartic action is increased by dilution with water, and it appears to be more active when dissolved, in hot water. The addition of quinine also increases its power of acting upon the intestine, a grain of quinine to a drachm of sulphate of magnesium in a tumbler of water rarely failing to produce all the laxative effect required. Sulphate of magnesium causes less depression than any of the other saline cathartics, but if given too often it produces intestinal debility and a tendency to ancemia. Combined with senna and an aro- matic, it forms the well-known " black draught" (dose of Sul- phate of Magnesium: laxative, 3 i. ; purgative, fss.). Sulphate of Sodium (Glauber's Salts). In some respects, this salt is superior to the sulphate of mag- nesium, but, on account of its extreme bitterness, it is rarely taken, except in the mineral waters of Friedrichshall, Carlsbad, etc. (see Mineral Waters, p. 102). Cream Tartar (Potassii Bitartras). This salt has a pleasant, acid flavor, and is well borne by the stomach. G-iven in doses of half an ounce, it will act as a'hydra- 244 KOTES ON MATERIA MEDIC A. gogue cathartic without any griping or other bad symptoms. In sixty-grain doses, it operates as a diuretic, and is to be given in fevers when the secretion of urine is deficient. Combined with lemonade, it makes a cooling drink, and its diuretic prop- erties may be increased, if desired ? by adding some other diu- retic. It is especially useful in the hot stage of chills and fever, in all eruptive fevers, and for children in scarlet fever. Tartrate of Potassium and Sodium (Eochelle Salts). This is the most palatable of any of the salts, and it acts with- out griping. When given just short of the purgative dose, it acts as a diuretic and increases the alkalinity of the blood. Phosphate of Sodium (Sodii Phosphas). This operates as a mild cathartic, and is very useful for chil- dren, since, tasting like common salt, it may be put in milk or gruel (dose, § ss.). Being an antacid, it is a good prophylactic for some of the attendant troubles of rheumatism — skin disease, bronchitis, slight rheumatic pains, etc. — and may also be given in cases of malnutrition that occur in rheumatic families with scrofulous tendency. In acute articular rheumatism, the blood should be made alkaline as soon as possible, and more powerful drugs than phosphate of sodium are required for this purpose. As this salt is a constituent of the blood, poisoning need not be feared. 2. Emetics. Emetics are drugs given for the purpose of producing vomit- ing. They are unpopular medicines, cathartics generally tak- ing their place, but in certain conditions they do a great deal of good. Thus an emetic given at the very commencement of an attack of tonsillitis will very often abort the disease at once, as it causes a free flow of mucus from the pharynx, which acts as a local depletive. Emetics are of two kinds: (a) cardiac, (b) ir- ritant. (a) Cardiac Emetics. Cardiac emetics produce nausea and vomiting by their action upon the heart, reducing its action, and causing in this manner MEDICINAL REMEDIES. 245 anaemia of the brain and great prostration to the system, simi- lar to that caused by extreme loss of blood with its accompany- ing deathlv sickness. It is upon this action only that their emetic properties depend. The medicines which act as cardiac emetics are neurotics. They produce intense nausea, and the vomiting is persistent and often uncontrollable. Those belong- ing to this class are digitalis, colchicum, tartar emetic, lobelia, tobacco, etc. They are not medicinal emetics, but the emesis is due to their poisonous effects. Apomorphine ' (Apomorphinse Hydrochloras). This is the hydrochlorate of an alkaloid obtained by heating morphine or codeine in sealed tubes with hydrochloric acid. It forms in small, grayish-white, shining needles, which are in- odorous, faintly acid, and turn green on exposure to light and air. It is much used in Europe to produce emesis, but it produces great depression of the system, and on this account is not to be recommended. It may be given in cases where, for any reason, ordinary emetics cannot be administered, as in cases of narcotism where the patient is unable to swallow (dose, gr. ^ by the mouth, gr. -|- ^ hypodermatically). Patients usually vomit three times before the action of the drug ceases. Irritant or medicinal emetic* owe their properties to their irritative effects, producing vomiting by reflex action. Thus emesis of this kind may be produced by tickling the back of the tongue with a feather or with the finger, or by drinking warm water containing a certain proportion of mustard or salt, the irritant properties of the mixture causing a decrease in the secretion of the digestive juices, and vomiting. The vomiting produced by irritant emetics is free from nausea, and there is no depression of the system. They also act more quickly than the cardiac emetics, and so are to be given in all cases where rapidly induced vomiting is desired. 1 The other emetics of this class are treated of elsewhere, as, owing to the great depression following their administration, their use as emetics is not to be recommended. 246 NOTES ON MATERIA MEDICA. Contra-indications to the use of emetics: (1) No person over the age of fifty years should ever take emetics, as the act of vomiting produces great cerebral congestion, and the act itself increases in difficulty after the fortieth year has been passed. (2) Where poison has been taken. ' Here the stomach pump or stomach siphon should be used to empty the stomach. (3) Emaciation. Owing to the stomach getting well up behind the ribs, many thin persons cannot vomit, or can do so only with great difficulty. This, to some extent, may be obviated by giv- ing the patients liquids to distend the stomach and bring it in contact with the abdominal walls. (4) Obesity. Here there is difficulty in vomiting on account of the muscular weakness of the abdominal walls. (b) Irritant Emetics. Ipecacuanha. Ipecacuanha is the root of a Brazilian shrub, Cephaelis Ipecac- uanha. It contains an active alkaloidal principle called emetine. Locally applied, ipecacuanha acts as a direct irritant, causing a peculiar eruption which lasts from five to six days. In this way it can be used as a counter-irritant — for example, in tuber- culosis of the lungs — to raise sores on the surface of the chest. Tartar emetic was formerly used for this purpose, but the sores produced by this substance left scars, while those produced by ipecacuanha do not. (Mix gr. x.-xv. ipecac, in r ss. of lard.) As a general emetic there is nothing to be compared with ipe- cacuanha, It is not a cardiac emetic, and therefore not pros- trating to the system. When taken into the stomach, it causes, by its irritant action, a considerable flow of mucus, and, in the vomiting which ensues, the contents not only of the stomach but also of the duodenum are expelled, and the liver, by the mechanical action of the abdominal muscles, is stimulated in its circulation. Emesis, therefore, clears up a jaundiced coun- tenance more quickly than anything else, the bile pouring out rapidly under the influence of the drug. In many cases, there- fore, of hepatic congestion, and notably at the beginning of fevers, emesis gives great relief by reducing the fever and irri- MEDICINAL REMEDIES. 247 tation. Children under two years of age naturally possess weak expectorant power, and when suffering from diseases such as acute capillary bronchitis, pneumonia, croup, etc, are often in an extremely perilous condition from their inability to raise the matter to be expectorated higher than the larynx. To aid expectoration, emesis may here be induced several times during the day and night at intervals of four or five hours. Prostration need not be feared, as vomiting does not have the same effect upon children as upon adults, regurgitation occurring very easily in the former. The emetic should be given as soon as the respiration increases in frequency and the breathing becomes labored from accumulation of mucus in the trachea. Emesis should always be used for the reflex laryngeal spasm in cough- ing which occurs in croup, and for the spasmodic cough in false croup. In the dangerous dysenteries of tropical climates, ipecacuanha is much used on account of its specific topical action in the large intestine. A sinapism or blister is placed upon the epi- gastrium, and as soon as this has acted gr. xxx. of ipecacuanha should be given as a dose with gtt. xxv. laudanum, and the dose repeated every hour until gr. xc. have been taken. The first dose may induce vomiting, but not the second or third. The effect is to change the whole dysenteric process. For the milder dysenteries of this country, castor oil is to be preferred. 1 Where there is a tendency to tonsillitis, a disease which often precedes an attack of acute articular rheumatism, on the first manifestation of sore throat give ipecacuanha, which, acting as a local depletive, often aborts the disease, and apply iodine or bromine to the tonsils once or twice a day, as in the following: 5 Tincturse Iodi, 3 iv. Tincturae Aconiti, ttj, xx. M. S. For local application. This should be diluted on the second day with tinctura cin- chonas comp. See also p. 234. 248 NOTES ON" MATERIA MEDICA. Sulphate of Zinc. This is an irritant emetic, has good topical operation, pro- duces no prostration, and hence may be used as an adjuvant to ipecacuanha, the combination acting better than either emetic by itself (dose, Ipecac, gr. xx.; Sulph. of Zinc, gr. xv., for adults; for children proportionately less). To produce emesis, sulphate of zinc should not be given in small doses. Many pa- tients, dreading the nausea of an emetic, take small doses, think- ing that the smaller the dose the less there will be of sickness and nausea; but just the opposite actually occurs. A dose of gr. xx., therefore, is better than a dose of gr. xv., and still bet- ter than one of gr. x., which produces nausea but no vomiting (dose to child, gr. v.). This emetic operates in about ten min- utes. It should not be given unless it is certain that the patient will vomit. Sulphate of Copper. This drug, like all strong astringents, is also an emetic, pro- ducing emesis without any prostration of the system. It is much used by German physicians in the treatment of croup. It may be used in the early stages of this disease when there is considerable bronchitis, and before the period of excitement is followed by carbonic-acid poisoning. But when the latter stage has been reached, no emetics of any kind should be given, as the susceptibility of the stomach to these remedies is blunted by the carbonic-acid poisoning. As emetics soon become tole- rated by the system, it is well to use them interchangeably. Commence with ipecacuanha, and, after three doses have been given, change -to cupric or zinc sulphate. Sulphate of copper is far more irritating than the other emetics, and should not be repeated more than twice (dose as emetic: children, gr. i.-ij.; adults, gr. iij.-v.). 3. Diuretics. Diuretics are remedies which have the property of increasing the volume of urine excreted from the kidneys, either by MEDICINAL REMEDIES. 249 increasing the general blood pressure, or by causing local dilata- tion of the renal arterioles, or by direct irritation of the renal structure. When given for the relief of symptoms not depen- dent on any renal disease, diuretics are said to act generally ; when given for the relief of symptoms dependent on some de- rangement of the kidneys or genito-urinary tract, they are said to act locally. The following conditions of the urine are to be taken as indications for the administration of diuretics: (1) Urine of high specific gravity but of normal quantity. Saline diuretics are to be given, and, as this condition is indicative of high living and gouty diathesis, the diet is to be regulated and the use of alcohol and other stimulants prohibited. (2) Urine of high specific gravity tut deficient in quantity. This, if not due to excessive perspiration, indicates the use of saline diu- retics. (3) Urine with gravel or uric-acid deposits. This indi- cates a tendency to the formation of calculi, and therefore the prophylactic treatment is much more important than the cura- tive. Grive plenty of pure water, or water which contains an excess of carbonic acid. Liquor potassae may also be used in doses of half a drachm. If it is desired to render the urine alkaline, use the carbonate or citrate of potassium. The bitar- trate and the acetate are the most active stimulants to the kid- neys of the salts of potassium. (4) The presence of bile in the urine. When this occurs, the kidneys become irritated, and there is a tendency to/the formation of uric-acid deposits. The treatment should be to promote vicarious action of the skin and bowels, and to administer cholagogues. (5) Deficiency of urine, both in solids and quantity, due to renal congestion. This may be artificially produced by varnishing the skin, thus interfering with its excretory functions. A very similar condition to this exists in the desquamative stage of scarlet fever, it being imma- terial whether the desquamation be in large flakes or small scales. Therefore in this disease, as also in scarlatinal and acute nephritis, the object should be to re-establish the normal secre- tion of urine, and so diuretics should be given. (6) Deficiency in the quantity of urine in dropsical affections. This is due to the action of the kidneys being interfered with by the accumu- lation of fluid in the abdomen. The endeavor must be made to 250 NOTES ON" MATERIA MEDIC A. remove this mechanical obstruction before the diuretics are given, otherwise it will be very difficult for them to act. Digitalis. The leaves of the Digitalis purpurea, or purple foxglove, a plant growing wild in Europe. As a diuretic, digitalis acts by increas- ing the propulsive power of the heart and raising the general arterial pressure. It produces a free flow of pale urine of low specific gravity, and its action, when once started, often con- tinues for four or five days, resulting in considerable prostration of the system. Its diuretic power is not decreased when used as a diaphoretic. Where there are idiosyncrasies its action may be uncertain, and if the arteries are diseased there is always dan- ger from the rupture of a blood-vessel, owing to the increased arterial tension. It is especially indicated in cases of acute nephritis, as the stimulant diuretics— i.e., those which act by causing a determination of the blood to the kidneys — are not to be given, as they intensify the renal congestion produced by the disease. Mercury. This substance, in combination with some other diuretic to direct its action to the kidneys, is the most reliable remedy in chronic Bright' 's disease, as it liquefies and causes to be absorbed the hyaline material which surrounds the arteries, hardening and constricting them, and setting up a slow process of inflam- mation which destroys the glandular structure. In chronic renal disease, the specific gravity of the urine is the index of its course. At first the specific gravity falls to 1.010 or thereabout, and remains stationary for a long time, and falls again at the close of the disease. When it reaches 1.006, danger is immi- nent. Calomel increases the watery flow of the urine, but not the solids. One grain each of calomel, squill, and digitalis is a good combination, and when the pulse becomes intermittent leave out the digitalis. One-twenty-fourth of a grain of corro- sive sublimate and a grain each of quinine, squill, and digitalis is also a good formula. When the use of mercury is to be con- MEDICINAL REMEDIES. 251 tinued for a long time, the preparations with corrosive subli- mate are to be preferred. The above formulae can be used in dropsy, and especially in cardiac dropsy. 1 Squill (Scilla). This drug is obtained from the bulb of Urginea Scilla. It is very irritant to the mucous membrane of the stomach and in- testines. When given in one to three-grain doses, it stimulates the pulse and causes determination of the blood to the kidneys; afterwards it depresses the heart and becomes an expectorant. It should always be combined with other diuretics. Turpentine (Terebinthina). The turpentine class of diuretics are active stimulants of the kidneys, producing arterial hyperemia even in a healthy person, and, if their use is continued, congestion; and the urine, which at first is albuminous and then bloody, becomes deficient in quantity; and, finally, there may be strangury with irritability of the whole genito-urinary tract. For the three sets of nerves in this region — viz., those to the kidneys, to the neck of the bladder, and to the glans penis — are intimately associated, so that irritation of the neck of the bladder 2 will cause irritation of the kidneys and sensation of pain in the glans penis. There- fore, when these diuretics produce renal congestion, there will be a painful sensation, referred to the anus or penis, causing a constant desire to micturate, and producing strangury because there is no water to pass. This irritation of the urinary tract is a serious matter; death sometimes resulting, in persons over six- ty, from the passage of a sound, which causes a sensation of chil- liness and suppression of urine very difficult to treat This sup- pression is difficult to account for, unless it is an illustration of the extreme sensitiveness and intimate relation of that part of the body to general vitality. In giving this class of diuretics, 1 See also page 108. 2 An injection of gtt. xiv.-xv. of fl. ext. of conium is to be given in all cases of pain in the neck of the bladder, and this treatment may also prevent the dangers following the use of the sound. 252 NOTES ON MATERIA MEDICA. therefore, constant watch should be kept for these symptoms, many people having an idiosyncrasy against their use, so that great care has to be taken in their administration. These diuretics are useful in the treatment of chronic inflam- mation of the urinary passages, such as chronic pyelitis. This disease may be diagnosed in the following manner : Have the patient pass his urine in three different glasses. If the glass which contains that which was passed first contains the most pus, then the disease is urethritis; if pus is most abundant in the second or in all three equally, pyelitis ; and if in the third, cystitis. Hematuria may be determined in the same manner. Turpentine is valuable in the treatment of diseases of the uterus, as in painful dysmenorrhea which is spasmodic in character and shown by pain coming on before the flow. Chronic bronchitis, with offensive bieath, is benefited by its use in doses of five to ten drops. In the latter stages of typhoid fever, turpentine, which is also a valuable disinfectant in twenty- four-drop doses, is very good; but as soon as the desire to mictu- rate becomes frequent, discontinue its use. Buchu. Buchu leaves are the leaves of several species of Barosma, a shrub growing in South Africa ; the infusion has a strong aromatic odor, due to a volatile oil which readily yields to alco- hol and water. It is very safe, never producing strangury, but it may cause disturbance of the stomach. Buchu is very valu- able in the treatment of cystitis, especially when the stomach is irritable and weak, as it is borne much better than turpentine. If it is necessary to reduce the acidity of the urine, liquor potassae may be added : I£ Tincturse Belladonnas, 3 i. Extracti Buchu fluidi, . . . . § i. Liquoris Potassse, . .. « . . 3 vi. Syrupi simplicis, § ss. Aquae, ad f vi. M. Sig. Teaspoonful every three hours. (For chronic cys- titis.) MEDICINAL REMEDIES. 253 It is also used in the spasm of the urethra, being an antispas- modic of the genito-urinary tract, and the infusion or the fluid extract may be used in bronchitis and phthisis with purulent exudation and spasmodic cough. Buchu is used to assist in the differential diagnosis of kidney disease. If it is given to a person with a small, contracted kid- ney, its odor will not be noticed in the urine, otherwise it will. Buchu and paregoric should be given in all cases of injury to the spine, to prevent pyelitis and cystitis. Juniper. Juniper is the fruit of the Juniperus communis. It contains an officinal volatile oil which forms the basis of the preparations representing the drug and upon which depend their medici- nal properties. In cases of irritable stricture of the urethra, in atony of the bladder (a condition which interferes very decidedly with the action of the kidneys), and in dysmenorrhea when there is a constant desire to micturate, juniper combined with gin is an effective diuretic. It is also very useful as a diuretic in dropsy not dependent on acute renal disease, e.g., cardiac or hepatic dropsy. In large doses, juniper causes strangury and renal inflammation, and its use should not be continued if the first dose is unsuccessful. It is, however, better borne by the stomach than either buchu or turpentine (dose, gtt. x. in tablespoonful of gin). Saline Dittketics. 1 These, in addition to their action as diuretics, are also useful by being powerful oxidizers, and are to be used in febrile con- ditions. In pneumonia, it is well to add to the saline diuretics an ether, to direct their action both to the kidneys and to the sudoriparous glands. Of the saline diuretics, those of the pot- ash series are the best. Potassium acetate is the most diuretic (dose, 3 ss.). 1 See also Mineral Waters, p. 101. 254 NOTES ON MATERIA. MEDICA. The citrate of potash is the most palatable. It should he diluted very freely with water (dose, gr. xx.). As diuretics the nitrate and chlorate of potash should not be used when the kidneys are inflamed or irritated. 4. Diaphoretics. Diaphoretics, or sudorifics, are medicines which increase the amount of perspiration. They are mainly used as eliminatives, but sometimes they are used for the purpose of reducing the temperature when this is above the normal. In fevers, for ex- ample, the skin is hot and dry, a condition which is invariably accompanied by thirst, and the sensory nerves are irritated by the bed clothes; there is consequently great restlessness, which aggravates the disease by preventing sleep and raising the tem- perature. If perspiration be induced, the thirst will be allayed and the temperature lowered. So also in diabetes, when the skin is dry, the patient's constant thirst will be lessened if the skin be kept moist. In using diaphoretics as eliminatives, it must be remembered that the skin is an eliminative organ only to a small extent, and only acts as such when the natural eliminative organs fail. Whenever, therefore, the skin is to be used for this purpose, it should always be prepared for this vicarious action, one of the first indications being to remove any existing tension of it; for when it has been dry for any length of time, the different epithelial layers are brought into close contact with each other, the orifices of the glands are closed, and thus the discharge of the secretions is prevented. This condition exists in fevers and generally in dropsy. In the latter disease, the dry skin is due to the subcuta- neous effusion acting as a mechanical obstacle to the capillary circulation, and thus arresting the secretions of the sebaceous glands by lessening their blood supply. An inunction of oil, therefore, is a valuable adjuvant to the diaphoretics when these conditions exist, as this opens the mouths of the glands and separates the epithelial layers of the skin. After the patient has been oiled, as another adjuvant he may be wrapped in a hot-water pack. Diaphoretics will not act when the other eliminative organs MEDICINAL REMEDIES. 255 are in abnormal activity, and for this reason diaphoretics should not be attempted while the bowels are under the influence of a cathartic. Diaphoretics may be divided into two classes: (1) External ; (2) Internal. (a) External Diaphoretics. Dry Heat. This is seldom used, as it is only effective when the skin is moist, and this condition is generally wanting. Moist Heat. Hot steam is absorbed by the skin, and should never be used as a diaphoretic. Hot water is one of the surest ways to pro- duce sweating, but is very depressing. The best method is to use it in the form of a hot pack in the following manner: The body is first oiled, and the patient is then wrapped in a woollen blanket that has been moistened in boiling water and wrung as near dry as possible; over this a dry woollen blanket is wrapped, and around the whole a linen sheet. It should be assisted by warm diaphoretics internally. (p) Internal Diaphoretics. Internal diaphoretics are divided into two classes: (1) Depres- sant; (2) Stimulant. 1. Depressant Diaphoretics. — These partially paralyze the heart and depress the arterial circulation, producing the cold sweat which is an invariable concomitant of a debilitated heart, as in fright, loss of blood, overdoses of colchicum, tartar emetic, aconite, etc. This class may be used when the skin is dry and hot, as in fevers. (For description of aconite, the principal member of this class, see p. 205.) 2. Stimulant Diaphoretics. — These give the warm perspira- tion of exercise. With the exception of jaborandi, these diaphoretics will not act if the skin is cold, some other action being produced, e.g., Dover's powder becomes expectorant or diuretic, alcohol becomes diuretic, etc.; so that in administer- 256 XOTES OX MATERIA MEDICA. ing this class it is necessary that the patient shall be kept warm. Dover's Powder (Pulvis Ipecacuanha et Opii). This is the most commonly used diaphoretic of this class. In the last Pharmacopoeia, sugar-of-milk has been substituted for sulphate of potassium. Singularly, it can be made to act better by combining it with aconite, as this allays the surface irritability of nervous hyperemia (Dover's Powder, gr. ij.-v. ; Tincture of Aconite Root, gtt. v.). Ammonia. The preparations of ammonia in free doses are all diapho- retics, some, however, being more effective than others. Liquor ammonii acetatis (or the spirits of Mindererus) was much used at one time, but liquor ammonii citratis is now generally sub- stituted for it (dose, 1 ss'.-i. every hour). The carbonate in gr. v. doses every hour is also very good. Sweet Spirit of Nitre (Spiritus ^Etheris Nitrosi). This drug with a little alcohol in a hot drink acts well as a diaphoretic. All hot drinks, and hot water itself, produce better diaphoresis if slowly sipped than if taken rapidly; the process of sipping relaxing the arteries and stimulating the heart. To abort a cold, and for the first stages of bronchitis when there is a good deal of dyspnoea, hot dry skin, etc., a hot drink of lemonade, infusion of flaxseed, and a teaspoonful of sweet spirit of nitre, sipped two or three hours before going to bed, is very effective. While taking this drink, instead of putting the feet in hot water (which will only increase the sus- ceptibility of the feet to cold, and probably cause a relapse on the following day), have the patient well wrapped up and let him sit in a warm place. The plan of giving a quantity of hot drinks during the night to induce perspiration is not to be recommended, as, although it works well for an hour or two, the patient is liable to catch another cold before morning. MEDICINAL REMEDIES. 257 Jaborandi (Pilocarpus). The dried leaflets of Pilocarpus pennatifolius, a Brazilian tree. It contains several alkaloidal principles, the most impor- tant being pilocarpine, a colorless liquid, to which the chief effects of the drug are due. Jaborandi is unquestionably the most powerful diaphoretic known, and were it not for certain drawbacks it would be used very extensively. Its power is not increased by combination, and it is not necessary to endeavor to assist or increase its action by keeping the patient warm, etc., as jaborandi operates at all times, and it is only necessary to keep the patient from getting chilled. The first effect of jaborandi is to cause flushing of the neck, which spreads quickly to the forehead, causing a sensation of dizziness; these effects appear almost immediately after it is given. Sometimes it causes salivation, and if this is excessive and in- terferes with the diaphoresis, which usually lasts for about two hours, the use of the drug should be discontinued; if not, the salivation, if moderate, may be disregarded. Jaborandi is particularly indicated whenever the skin is de- sired to act vicariously in the elimination of poisons from the blood; but on account of the very decided circulatory depression which it causes, it is contra-indicated in all conditions of fatty or weak heart. It should be used, therefore, in the anasarca of acute nephritis, scarlatinal nephritis, and in the dropsy of Bright 's disease when the heart is strong, as in these conditions the drug works surprisingly well; but it should not be given when the heart is weak and begins to dilate, as, although sweat- ing is produced, the patient is prostrated, and the dropsy is increased owing to the added weakness of the heart. It should not be given in fevers, nor should it ever be used in cases of pregnancy with albuminous urine and dropsy, as, although it is desirable to eliminate the urea which is being retained in the system and which may cause puerperal convulsions, jaborandi, by increasing the weakness of an already debilitated heart, may cause death. (Pilocarpine, gr. i.-ij., and Eau de Cologne, § i., has been recommended to stimulate the growth of the hair.) 17 258 NOTES OX MATERIA MEDICA. Dose of fluid extract of jaborandi, the most trustworthy preparation, 3 ss.-i. Dose of pilocarpine, gr. -J-J hypoder- matically (this may be given twice a day in urgent cases of Bright' } s disease, especially in the young). 5. Expectorants. Expectorants are drugs which promote the bronchial secre- tion, or modify its character so as to facilitate its expulsion, or which evacuate it with greater ease. Not infrequently the word is applied to any medicine used to relieve a cough. Expecto- rants may be divided into two classes: (1) Nauseant; (2) Stim- ulant. 1. Nauseant expectorants are really emetics in doses too small to cause actual vomiting. They increase the flow of mucus from the membrane of the bronchial tubes. In its normal con- dition, the secretions of the mucous membrane are not mani- fest, only a very small amount necessary for the moistening of the membrane being exuded. Tartar emetic and squill are the most reliable nauseating expectorants, the latter being most effective in combination. 2. Stimulant expectorants, so-called from their effect on the circulation, acting upon the veins of the mucous membrane. To this class belong the balsams and ethers, and, on account of the chloric ether it contains, perchloride of iron. (The indications for the use of both the nauseant and stim- ulant expectorants are given in the following article on Coughs.) Coughs. 1 A cough may be denned as a reflex act, whose single motor or efferent mechanism is called into play by a great variety of afferent impres- sions. Its one- proper object is expectoration, but, much oftener than any other reflex act of the body, it occurs without its object, and is consequently useless. Coughs may therefore be divided into two classes : (a) Expec- J This article is a condensation of Prof. Thomson's paper on "The Signifi- cance of Cough with Reference to Treatment," read before the New York County Medical Society, December, 1888, and given by him in his lectures as an introduction to the subject of ' ' Expectorants. " It is published in full in the New England Medical Monthly of March, 1889. MEDICINAL REMEDIES. 259 torant; (b) Non-expectorant or Useless. The distinctive character of all use- less coughs is to be found in their sound, which is specifically different from the sound of any expectorant cough whatever. A non-expectorant cough, no matter if it be so constantly or rapidly repeated as to produce prolonged paroxysms, always consists of a series of acts distinctly independent of each other, and hence may be likened to the separate blows of a hammer. An expectorant cough, on the other hand, is never single. It may consist of only one act of real coughing, but, if so, it is immediately followed by a sound which indicates the clearing of the pharynx, which is the last step in expec- toration as far as the respiratory tract is concerned. Generally, however, it consists of a number of coughs in which the sound distinctly connects each act, both with the one which precedes and with that which follows it, so that, instead of resembling the strokes of a hammer, it is more like the passing of the links of a chain over a pulley, or in some cases like the sound of a saw. (a) Expectorant Coughs. — These coughs are due to the presence of some material (which may be either a foreign body or secretion of fluid) in an air tube, causing a continuous imperative coughing until the offending material is removed. In the respiratory tract, there are certain sensitive areas, most marked at the bifurcation of the trachea and at the first and second divisions of the bronchi, and whenever a secretion collects in the bronchial tubes, so soon as it arrives at these sensitive parts the expectorant cough immediately begins, and does not stop until that place has been cleared. There may then be a lull until the secretion reaches another of these sensitive tracts, when the coughing again begins, and this process continues until the matter is finally expectorated. This continuous character of an expectorant cough is well illustrated in cases of chronic bronchitis with very viscid expectoration. The particle of mucus may be only a small globular but sticky mass, and yet, once started on its way, the patient has to devote his whole efforts in a succession of quick, powerful coughs, which it is impossible for him to check until he gets rid at last of a seemingly insignificant quantity for such a great and tumultuous effort. The indications, therefore, for the treatment of expectorant coughs are simple, and there are only three : (1) to make the phlegm so liquid that it will flow easily ; (2) to make the coughing powerful enough to be effective ; (3) to check or diminish the amount of superabundant secretion. 1 . Remedies to render secretion less viscid, and so more easy of expulsion. — The drugs ordinarily recommended for this purpose, such as mixtures of ipecacuanha, squill, senega, chloride of ammonium, chlorate of potash, bal- samic mixtures with opium, etc. , while successful in a certain numbwr of cases, are not at all satisfactory in others, especially where the coughs are more or less chronic. Now, all oils that are taken up in any quantity from the intestine will always produce a watery flow into the bronchial tract, especially if directed to that mucous surface by a local hyperemia; much of the benefit of a flaxseed infusion in acute bronchitis being due to the oil of 260 NOTES OX MATERIA MEDICA. the seeds. Accordingly, linseed oil seems to be indicated for the treatment of expectorant forms of cough, and it has been found by actual experience a most efficient remedy for this purpose. An initial difficulty was to make a stable palatable emulsion of the linseed oil, but this has now been over- come. The formula for the emulsion is : 3 Olei Lini § xv. Olei Gaultheriae, Olei Cinnamomi, aa 3 ij. Chondri (Irish moss), § ss. Aquae, ... .... § xxiv. Glycerini, . . 3 v. Syrupi simplicis. § x. Acidi Hydrocyanici dil., 3 iiss. Of this emulsion the usual prescription for acute bronchitis is ; ]J Misturae Olei Lini, ... § vi. Chloral, . 3 iss. Morphinae Sulphatis, gr. iss. M. S. Tablespoonful an hour after meals, and, if the coughing is severe at night, a fourth dose at bedtime. In order to allay the element of nervous irritability caused by the inflam- matory condition of the bronchial mucous membrane, there should be added to each tablespoonful of the emulsion six to eight grains of chloral and from To" to i of a grain of morphine. This emulsion is to be relied on, not only in acute bronchitis, but also in the most chronic forms of the disease where the expectoration is viscid and adhesive. It is an invaluable prophylactic against emphysema, and it not improbably serves as a direct nutrient of the pulmo- nary tissue. It is also of decided value in the treatment of bronchitic asthma, as well as in the asthmas which have a history of sequence to pertussis or measles. Another frequent indication for its administration is in the treatment of phthisis in patients who cannot take cod-liver oil, particularly in those who have much bronchitis. Of course, it can hardly claim to possess the nutrient properties of cod-liver oil, but it is much more easily borne by the stomach, and as a substitute for it, where such has to be found, it is much superior to cream or other proposed substitutes. In many phthisical cases also that can take cod-liver oil, but in whom the cough is very racking, the emulsion may be temporarily administered to relieve the cough by changing the character of the expectoration. It is not to be used in cases of capillary bronchitis or broncho-pneumonia, nor in those cases of bronchitis occurring during epi- demic influenzas where profuse nasal catarrhs alternate with bronchitis, as here the coughs are of infectious origin and generally have to run their course. The same may be said of intercurrent bronchitis in fevers, as those MEDICIXAL REMEDIES. 261 depend often on pure muscular weakness of the bronchial walls combined with cardiac failure from the fever ; also in secondary bronchitis of heart disease, as well as in toxic bronchitis from gout, Bright's disease, etc., and in all cases of bronchorrhcea, whether senile or from bronchial palsy in fibroid degeneration of the lungs. 2. Remedies to make the act of coughing 'powerful enough to be effective.— A. condition in which expectorant power is often imperatively needed is the ca- pillary bronchitis or pneumonia of young children or infants. Here recourse may be had to the physiological association l which exists between the oesopha- gus and respiratory tract ; for it has been shown that each act of swallowing produces a distinct stimulant effect upon the heart as well as upon the me- chanism of expiration, and hence in the severe dyspnoea of children's pneu- monia the little patients should be kept for prolonged periods swallowing half- teaspoonf ul doses of hot milk and lime water, to aid their failing power of expectoration. On the same principle, the sipping of a cup of hot coffee for phthisical patients before they rise in the morning, to facilitate their fits of morning expectoration, is to be recommended. 3. Remedies to check or diminish superabundant secretion. — The indication for these remedies occurs especially in the passive bronchorrhcea of old persons, in cardiac weakness, and in most cases of chronic bronchitis with emphysema. For many such cases of chronic bronchitis there is no better treatment than with the Tinct. Ferri Muriatis to tone the heart and weakened bronchial mus- cles. Along with this action may be found that of the adjuvants, Tr. Nucis Vomicae, Digitalis, Citrate of Caffeine, and Sweet Spirit of Nitre. In other cases, as in phthisis with profuse bronchial discharge, dilute nitric acid is indicated to check secretion, and occasionally a very good effect may be obtained in these cases from three-grain doses of zinc oxide. (b) Non-expectorant or Useless Coughs. — These coughs, of which there are no less than fourteen kinds more or less common, do not subserve any good purpose, and the aim, therefore, should be to arrest them. The nature of these coughs with their appropriate remedies will be dealt with in their order. 1. Coughs due to simple inflammatory irritation without secretion of some portion, or the whole, of the respiratory tract from the epiglottis down to the third division of the bronchi. A typical instance of this is to be found in the purely hyperaemic stage of acute bronchitis, when, with a tumefied and dry state of the bronchial mucous membrane, we find the patient much oppressed for breathing and constantly tormented with a frequent short and hacking cough, each act of coughing evidently increasing his sense of sore ness and tightness of the chest. Auscultation reveals a number of dry, whistling rales, often more pronounced on expiration. To turn the cough into the expectorant variety as soon as possible, nauseant expectorants which start secretion should be given. For this purpose one 1 For other examples of this physiological association, see pp. 277 et seq. 262 XOTES OK MATERIA MEDICA. grain of tartar emetic should be dissolved in a teacupful of water, and the patient directed to take a teaspoonf ul every ten minutes until he begins to be nauseated, when usually the dyspnoea vanishes and the cough becomes loose. A much more common example of this cough, however, occurs in the course of ordinary bronchitis, both acute and chronic, where, owing to the fact of the co-existence of secretion and more or less free expectoration, its presence may be overlooked and it be confounded with the expectorant cough. In these cases, the patients have a number of distressing and pain- ful separate hacks without bringing up anything, their cough, however, every now and then terminating in the continuous expectorating kind. In all such cases, though there may be considerable secretion, yet it is unequally distributed in patches of viscid coating with inflamed spaces between, and particularly if the dry surfaces are about the bifurcation of the bronchi. These cases of mixed expectorant and non-expectorant coughs are especially frequent in the course of phthisis, as we then have ulcerated conditions in the track of decomposed pus expelled from vomicae or from pouches of di- lated bronchi. It is necessary, therefore, to listen to the patient's coughing in order to determine the ratio between the expectorant and the non-expec- torant sounds, and, if there be a considerable number of the latter, to add the sedative neurotics to the cough mixture. Of these, a small dose of chloral with a small dose of morphine (which is better than a full dose of either separately) is to be given, with the addition of aconite in febrile cases. Eight grains of chloral and one-eighth of a grain of morphine for an adult are quite sufficient. These neurotics are to be given for the non-expectorant element in the cough exclusively. So far as expectoration itself is con- cerned, they are drawbacks and not helps. In the passive bronchorrhcea of the aged, with dilated hearts, in chronic bronchitis with bronchiectasis and emphysema, in capillary bronchitis, in pneumonia, and, lastly, in all condi- tions in which there is abundant secretion, they are not only useless, but may be quite mischievous, and they have no place in a cough mixture, un- less the sound of the cough betrays much useless irritation as a complica- tion. 2. Cough due to pure inflammatory irritation of tlie pharynx. — This is com- mon enough in ordinary colds, and not infrequently the precursor of laryngo- tracheitis by extension. It is, however, one of the most obstinate troubles of advanced phthisis, giving rise to a constant tickling sensation in the throat which has been wrongly ascribed to reflex irritation from ulcerated surfaces lower down. For this, and for the same distress in phthisis, apply a powder of one grain of morphine to five of starch, with a brush, low down in the throat, as this often enables patients to get a night's rest from the arrest of the prolonged paroxysm of coughs, which otherwise would rarely stop until vomiting changed temporarily the sensation of the throat. 3. Coughs due to irritation of the pleura. — The importance of recognizing a pleuritic origin or element in a cough can scarcely be overrated. Many cases of permanent damage to the lungs, including the induction of phthisis MEDICINAL REMEDIES. 263 itself, might often be prevented if the frequent origin of a chronic cough in a pleuritic adhesion were more commonly recognized. Post-mortem revela- tions show that of all serous inflammations, those which lead to pulmonary- adhesions are the most common, often where they had not been at all sus- pected. There is generally a prolonged tendency to short, hacking cough after the patient has recovered from an attack of severe pleurisy. (The only exceptions, and these are only apparent exceptions, are in cases of hydro- thorax with renal disease, for in them the effusion is often too watery to leave adhesions after absorption.) These patients are specially prone to have their cough return with changes of the weather, a common source of aggravation of all symptoms due to adhesions of serous membranes, as in pachymeningitis, for example; but because their cough returns, then they are apt to ascribe it to their catching a fresh cold. The treatment should be to strap the whole affected side for six months or more after every attack of general pleurisy (explaining to the patients the necessity of the procedure), to allow of as perfect rest as possible to this unresting respiratory surface, as otherwise the embers of the original inflammation will not go out and a permanent source of pulmonary mischief will remain. The immediate relief to the constant sense of uneasiness in the side, and the cessation of the useless, ominous, hacking cough which accompanies that uneasiness, very soon reconcile the patient to the trouble of wearing the straps. There are, however, many other conditions besides simple pleurisy where these con- siderations will apply. Whenever patients have the ordinary signs of phthi- sis, ask if they have been troubled with rheumatic pains about the shoul- ders. The answer will be frequently in the affirmative, the patient adding that he has often a pain behind the scapula, worse in stormy weather. These pains are sure to give rise to useless cough, the familiar, dry, hack- ing cough of early phthisis. As a means of diagnosis, laying the cold hand on the infraclavicular space over the affected part will immediately elicit several sharp hacks, when the same procedure tried first on the unaffected side will not do so. But a still more decided example of this kind of cough, and with much more injurious effects, is when a vomica has contracted extensive adhesions in front. The patients often then complain of an acute incisive pain through the lung, which constantly excites more coughing. Now, in both the early stages, and still more in vomical, this pleuritic cough cannot be otherwise than harmful and provocative of increased inflammation in the surrounding parts. When, therefore, the phthisical process is limited to one lung, invariably strap that side, and keep it so for months together. 4. The spasmodic cough of pertussis. — This cough is specific in its kind, and not due to bronchitis. It may, therefore, be wholly suppressed in less than a week and not return, though the disease remains and runs its natural course, and may remain as infectious as ever without there being any cough present. If, however, the patient contract a cold before the six weeks are over, the whooping cough at once comes back and is then quite intractable 264 XOTES ON MATERIA MEDICA. to the measures which at first arrested it, showing that the irritation of sim- ple bronchitis plays the same role in inciting the nervous irritability of pertussis that bronchitis does in exciting asthma. To arrest the cough or pertussis, bring the patient as rapidly as possible fully under the influence of belladonna. Nothing short of doses which will produce the physiologi- cal effects of the drug should be tried. In children, the dose should be enough to produce flushing of the skin, and repeated every two or three hours, night and day, for a week, after which the intervals of the doses may be gradually lengthened. Five grains of chloral may be added if, after the third day, the belladonna does not seem to have the full desired effect. 5. The tracheo-laryngeal cough in children, occurring mostly at night and due to malarial infection. — It is quite paroxysmal and strongly suggestive of whooping cough. A sign upon which a good deal of reliance may be placed as a diagnostic of a malarial infection in children is the presence of blood- corpuscles in the urine under the microscope. Children with these malarial coughs often rise in the morning tired and fretful, with no appetite, with brownish-yellow coating of the tongue and considerable pharyngeal redness; but during the day they scarcely cough at all. If a small number of blood- corpuscles are found in the urine, a few doses of quinine are sufficient to arrest the cough. 6. The nocturnal cough of children from some irritation in the alimentary canal, such as from indigestion, the presence of worms, etc. These should be treated by removing the cause. 7. The uterine cough. — If it be meant by this term that the cough is associated with disorder of the female generative functions or organs, it is correct enough; but the starting point of the irritation may not be from the uterus, but rather from some of its accessories. This cough is often the loudest of all coughs, as in some hysterical women. Like other accompani- ments of hysteria, its treatment is most successful with purgatives like cas- cara, aloes, and rhubarb, with intestinal antiseptics like benzoate of soda, salol, and camphor, with the usual adjuvants of myrrh, asafoetida, and valerian, and the bromides. On the other hand, in women more advanced in life there may be a local cause in the cervix uteri, the removal of which may be all that is necessary The cough of chlorotics, which so often ex- cites alarm as likely to be from phthisis, is doubtless of the same general character. 8. The aneurismal cough. — The diagnosis may be facilitated by listening carefully over the trachea to the persistent croupy sound of the breathing, no matter how quiet the respiration may be. This cough is best relieved by morphine, but it is surprising how often its most distressing paroxysms can be warded off by a couple of leeches to the notch of the sternum. 9. The cough produced by enlarged bronchial glands pressing upon the pneumogastric nerve. — This may be one of the earliest signs of phthisis, but, if so, it wholly differs in its nature and associations from the early pleuritic cough. It is almost invariably accompanied by excessive sensitive- MEDICINAL REMEDIES. 265 ness of the pharynx. Very often this goes along with hoarseness or even aphonia and intractable vomiting, although there may be no vomica or scarce- ly any pulmonary symptom present. At other times there is a good deal of palpitation of the heart. In these cases, the normal bronchial breathing between the scapulae is much intensified. The hoarseness and vomiting will both cease after a while, usually with softening of the implicated glands, but all the symptoms, including the cough, can meanwhile be greatly relieved by repeated dry cupping between the shoulders. Of course this kind of vomiting with hoarseness in phthisis is wholly different from the same symptoms later on. 10. Another example of purely reflex coughs is mentioned in text-books on diseases of the ear. Foreign bodies in the external auditory canal are especially prone to occasion it, and if we cannot find the reason for parox- ysms of apparently causeless coughing, we had better look for plugs of hardened wax in the ear as a possible explanation. Finally, we have the coughs of mitral insufficiency and of cardiac dilata- tion. Also the cough from irritation of the phrenic nerve in perihepatitis, and even in abscess of the liver, as well as in some cases of splenitis, each of which is to be recognized by its sound as having nothing to do with ex- pectoration of matter from the lungs, each also requiring its own and not a routine treatment. There remains one cough, however, which is always of grave import; namely, the cerebral cough. In a few cases of epilepsy, it may indicate nothing but a functional irritation, but when associated with symptoms of cerebral mischief it points to organic changes or irritative lesions affecting the cough centre in the medulla oblongata. This is parti- cularly apt to be excited by affections of the under surface of the cerebel- lum, or by effusion, abscesses, or tumors pressing the cerebellum down upon the medulla. Division III. — Astringents. Astringents are medicines which constringe muscular and fibrous tissue and diminish secretions, and are also employed for arresting haemorrhage by coagulating the blood. They act chemically upon the tissues, and, unlike the other medicines, do not assist one another by combination. They are divisible into: (1) Mineral astringents; (1) Vegetable astringents. 1. Mineral Astringents. Lead (Plumbum). Lead is the most valuable member of this numerous class. While all other astringents, mineral and vegetable, given in large 266 xotes o^r materia medica. doses, are very irritant to the mucous membranes, especially to that of the stomach, the acetate of lead (the only form of lead used for internal administration) does not have this effect. Therefore, where vomiting and purging are going on simultane- ously, as in choleraic diseases, no medicines being retained owing to the irritability of the stomach — vomiting being the exact oppo- site of absorption, not only in the act of expulsion, but in ab- stracting watery flow from the blood — an astringent must be given, and the acetate of lead is the only one that can be used: for (1) it is markedly sedative; (2) it is antiphlogistic; (3) it is an astringent. It is the most powerful astringent for diarrhoea, but should only be used as a last resort in that form of diarrhoea dependent upon intestinal fermentation where a great deal of irritation has occurred (antiseptics, with a little opium if there is pain, should be the treatment in the early stages of this dis- order). The acetate must be combined with calomel as an antiseptic, and with opium to assist in allaying the pain and irritation. In cholera infantum, when time must not be lost, gr. •^ calomel, gr. i. acetate of lead, gr. i. tannin, should be given. For choleraic diarrhoea with vomiting in an adult, the follow- ing can be given: ~ ~B, Phimbi Acetatis, gr. xij. Pulveris Camphorse, gr. xij. Pulveris Opii, gr. iij. Bismuthi Carbonatis, gr. xij. Extracti Gentianae, q. s. M. et ft. pil. No. xii. S. One pill to be given after every movement of the bowels. The following is useful for cholera infantum with vomiting : ~$ Hydrargyri Subchloridi, gr. i. Plumbi Acetatis, gr. iv. Pulveris Camphorse, gr. iv. Saccharat. Albse, gr. xij. M. et ft. pulv. No. xii. S. One powder every hour with a little water, and, if an anodyne is necessary, give one-half drop of laudanum rather than powdered opium. If vomiting and purging continue, one powder should be given after each attack. MEDICINAL REMEDIES. 267 Patients who are confined to their beds for a long time are much emaciated, or suffer from the formation of bed-sores and severe neuralgic pains due to pressure on nerves. These may be prevented by placing under them a sheepskin or bear robe, and covering with a sheet. The parts should be rubbed with: 5 Tannate of Lead, 3 i. ; Simple Cerate, 3 1. Lead and opium washes are excellent applications for erysipe- latous inflammations of the shin. They can be made in strength of gr. iij.-v. of the acetate of lead to 3 1. of the solution of morphine (U S). The mixture should be well shaken before using, as lead is incompatible with morphine, and so forms a precipitate. If continued for any length of time, this wash is apt to produce lead poisoning, a result which is to be carefully avoided. Lead Poisoning . — The sources of lead poisoning are numerous; those en- gaged in occupations requiring the use of lead, as painters, etc., are most frequently affected, but it is also common in country districts from the water being conveyed from the well to the house in leaden pipes. Lead poisoning is very insidious in its approach, and, owing to the obscurity of its symptoms, the diagnosis is difficult till neuralgias and liver troubles furnish the clue The first symptom is what the patient calls rheumatic pains, because they are worse when the weather is about to change; but that the pains are not rheumatic is shown, firstly, by the fact that they are not localized, ie.. confined to anyone joint, but travel over the course of the great nerves; and, secondly, the patient presses with his hand upon the seat of pain, thus showing that it is neuralgic, not inflammatory. After this there is a slow loss of strength and general cachexia, lasting for months, the patient continuing to suffer from neuralgias, headaches, and finally, owing to disordered liver, there will be considerable jaundice. The pulse is now of high tension, and many symptoms are developed closely resembling those of gout. The next most important symptoms from rapid absorption' of lead, as in the case of painters, are localized pain in the rectus abdominis and lead colic, the latter symptom being distinguished from hepatic and renal colic by the pains coursing only from the umbilicus to the pubes, and not extending to the back. Whenever severe abdominal pains occur without any inflammation, and it is certain they are not those of hepatic or renal colic, suspect lead poisoning. If the pain be in the rectus abdominis, the f aradic current will enable us to apply a pathognomonic test ; for the same effect will be produced upon this muscle by lead poisoning as upon the extensors of the arm, viz., the faradic excitability is reduced while the neighboring muscles are unaffected. Along with the colic, the patient is 268 NOTES ON MATERIA MEDICA. apt to be extremely constipated After a time the grasping power of the hands and fingers will be weakened, and there will be "' wrist drop " Both hands are usually affected, and this symmetrical weakness is one of the signs of the disease. Next the deltoid muscles are affected, with consequent in- ability to raise the arms to any extent, and, lastly, the interossei muscles will be paralyzed. Another symptom will be the deposit of sulphide of lead on the teeth, or mucous membrane of the mouth, in the form of a blue line but absence of this blue line does not prove that lead poisoning is not present, for the teeth, for instance, may be false or have been constantly cleansed Treatment of Lead Poisoning. — The peripheral neuritis causes degenera- tion of a fatty kind of the muscle-cells of the affected muscles, which become almost saponified. The iodide of potassium should be given, and the patient brought rapidly under its influence until symptoms of iodism appear (close, gr x.-xx , or as much as the patient can bear, t. i. d. for a week). For the first three or four days, while the lead is being dissolved and eliminated, the pain will be increased. The faradic current must early be applied to the muscles, as, if left for any length of time without treatment, they may never recover. The inter- ossei are the most difficult to restore, but, as with the rest, it can be done by the patient and persistent use of the faradic current to each muscle sepa- rately The irritability produced by the current causes an increased flow of "blood to the part, making it warmer, increasing it in bulk, and awakening susceptibility to motor influence, Liquor Ferri Subsulphatis, Or Monsel's solution, is the most astringent and the least irri- tating of any of the salts of iron. Liquor Ferri Pernitratis, In closes of six to ten drops, is often used in the diarrhoea of phthisis and in chronic dysentery. Nitrate of Silver Is a very active astringent; as a caustic, a very small amount (^J of what is applied acts, since it unites with the albumin of the tissues, forming the albuminate of silver. It is useful in checking bleeding from the alimentary canal. A good formula for chronic dysentery or chronic diarrhoea is: MEDICINAL REMEDIES. 269' 3 Argenti Nitratis, Pulveris Opii, aa gr. v. Terebinthinae Resinae, 3 iij. Sodii Bicarbonatis, 3 ss. M. et fiant pilulae No. lx. Sig. Three pills t. i. d Sulphate of Copper Kesembles the nitrate of silver in its astringent and caustic properties. When given internally in large doses, it acts as an emetic, from its irritant action. It can be substituted for the nitrate of silver in the above formula. Locally, it is the best application for chronic conjunctivitis. It should be applied in substance quickly and lightly to the granulations. Alum. Alum is largely used as a styptic, in domestic practice, to check bleeding. A paste made of alum, capsicum, and honey is very good for relaxed uvula. 2. Vegetable Astringents. Taunin— Tannic Acid. Vegetable astringents are very numerous, and many of them were much used formerly in the treatment of diarrhoea, etc., but now tannin, which is the active principle of all vegetable astringents, is generally preferred. The powerful astringent qualities of tannin depend chiefly upon its property of coagulat- ing albumin and gelatin. Taken into the system, it causes hardening and shrinking of the tissues, both nervous and mus- cular, and on this account is of great use as a medicine where there is vital relaxation showing itself, more particularly in weakness of the vascular system, which results, as in vaso-motor paralysis, in cold sweats, nervous sweats, exudations from mucous membranes, as in chronic nasal catarrh, lachrymal dis- charges, watery diarrhoea, etc. , conditions that call for astrin- gent as well as tonic treatment. Tannin, given alone, deals only with the symptoms, not with the disease itself; so that- tonics 270 notes on materia medica. are necessary to remove the cause by strengthening the heart, etc. Cold may also be used for the local treatment of these mucous discharges. Tannin is a good appetizer (dose, gr. "TJ - iij. ). Given in combination with quinine, it promotes its action and disguises its taste (quinine, gr. iij\-iv.; tannic acid, gr. i., which must be shaken, if in solution, as a precipitate is formed). It also assists the action of the mineral acids and does not pro- duce much constipation (dose of tannin, gr. iij.-iv., repeated at least four times a day). The addition of water to tannin changes it from tannic acid to Gallic Acid, which has some slight differences chemically, and medicinally it is not so astringent as tannin. Both are excreted by the kidneys, giving the urine a dark, smoky color, and therefore may be used in suppurative inflammations of the kidneys, as in chronic pyelitis. They may also be given for chronic cystitis. Tannin may also be used as a local astringent to check hemorrhage, and in the form of a tampon is used by some obstetricians for this purpose, but in post-partum hcemorrhage tannin should not be used under any circumstances. When the sputum has been slightly tinged with blood for several days, tannin may be given in haemoptysis, but not if it is very free. PART III. NON-MEDICINAL REMEDIES. NON-MEDICINAL REMEDIES. Non-medicinal remedies are those which act without entering the circulation, as counter-irritants, blisters, caustics, electricity, heat, cold, baths, change of scene or of air, massage, etc. Therapeutic Measures. Cold. Physically, cold is the absence of heat. Therapeutically, it is a positive agent, and has five actions : 1. Tonic. 2. Styptic. 3. Antiphlogistic. 4. Anaesthetic. 5. Antipyretic. In the first three, cold acts upon the vaso-motor (not upon the cerebrospinal) system as a pure irritant neurotic. In the last two, it acts partly on physical principles, partly as a neurotic. 1. Cold as a Tonic. When cold acts as a tonic, it is an irritant. Every irritant produces a shock and causes an expenditure of the energy of the part irritated, which, therefore, becomes depressed; but this de- press' on differs from that produced by a simple sedative, in that it is followed — provided the shock is not so great as to cause ex- haustion — by a reaction to or beyond the condition in which the part was prior to the irritation. Thus, cold, as an irritant, affects the vaso-motor system and produces a shock which is 18 274 XOTES OX MATERIA MEDIC A. followed by a reaction. In other words, this system is exer- cised, and all moderate exercise tends to strengthen the organ called into action, and permanently to improve its nutrition. Cold, then, is a vascular tonic, and may be used generally or locally. When the circulation is feeble and there is loss of muscular power, the general use of cold will arouse the heart, restore arterial tone, and thereby improve the nutrition of the whole body. For this purpose either the dip-, shower-, or sponge- bath may be used, according to the strength of the patient, tak- ing care never to cause exhaustion by its too frequent or pro- tracted use. A thorough reaction, as indicated by a glow of the skin, should always follow the bath, and never a sensation of lassitude or fatigue. When the irritant effect produced by the cold water alone is not sufficient, salt or some mild rube- facient may be added. In all cases, reaction may be assisted by friction with a rough towel. Dip laths, sea lathing, etc. — The manner in which the gen- eral application of cold affects the system is shown by the sudden stoppage of the heart and short respiratory acts whenever the body is suddenly immersed in cold water. The arteries become suddenly contracted and the heart embarrassed, and it is to this cause, and not to cramp, that the deaths of good swimmers, when- ever they plunge into extremely cold water, are generally due. It is not safe for persons to go in bathing who cannot stand a cold bath without loss of breath, and in all cases it is well to accustom the vaso-motor nerves gradually to the severe exercise, as it may be termed, given to them by bathing. The extensive application of cold, if given as a remedy, must be of short dura- tion. Most of those who go sea bathing are injured rather than benefited by it, because it is indulged in too frequently before the system has become accustomed to it. If the patient is too feeble to bear even the sponge bath, simple exposure of the sur- face of the body to cold air will often prove beneficial. The night sweats of phthisical patients may often be greatly relieved by having the patient get up during the night and exposing the skin until it is chilled, and then applying friction and returning him to bed. This has the same effect as an application of cold water, but, of course, in a less degree. NON-MEDICIXAL REMEDIES. 275 • Hip baths. — These have an excellent action upon the circula- tion of the pelvic viscera where it is congested, as in prolapsus recti, prolapsus uteri, chronic piles, congested condition of the vagina with leucorrhcea, etc. The cold should be strictly limited to the part affected, the nerves above and below being well pro- tected; and, as many of these patients are women with feeble powers of reaction, care must betaken that the application is not too prolonged. At first the water should be tepid, and the pa- tient should not remain in it for more than five minutes, which may afterwards be increased to eight and the water made colder. Shoioer baths, cold douche, etc. — In shower baths there is another element besides the irritation of the cold water, viz., the force of the falling water, which is extremely severe, though, being dif- fused, it is not felt so much. These should never be used by any one who has not strong powers of reaction, and should cer- tainly never be given to a patient, especially one with cardiac disease. The shower bath is not so injurious, however, if con- fined to one part of the body only, as the head. Here it may be used for any sudden congestive condition of the brain with un- consciousness or convulsions, or where there is much hyperemia about the head and scalp without any renal disease (it should never be used in Bright's disease), as in puerperal convulsions, alcoholismus, and in the convulsions of scarlet fever. In the latter disease, when it occurs in children and commences suddenly, with vomiting, high fever, and convulsions, pour water on the top of the head from the height of one foot, and keep on pour- ing until the child returns to consciousness; because, if the pa- tient is allowed to remain in convulsions, the disease may ter- minate fatally. So in meningitis, when the patient is delirious or has a tendency to convulsions, cold water may be poured gently on the nape of the neck and on the head. The cold douche may also be used for any circumscribed in- nervation or malnutrition dependent on local weakness of the circulation. For example, rheumatic joints are apt to remain stiff and swollen for months or years after the attack, because the local inflammation embarrassed a normally poor local circu- lation. Cold, which stimulates the absorption of the fibrous exudation of rheumatism clogging the joint, will often restore 276 NOTES ON MATERIA MEDICA. its natural condition, even after a long period. Water should be poured on it from a height of about two feet until there is an aching pain, when friction must be used. Pouring on hot water for a moment, by increasing the contrast, will produce still more beneficial results. If the stiffness of the joint be due to gouty deposits, cold is not of much uso. The cold douche or its equivalent is also of great use in vaso- motor weakness dependent upon sunstroke or malaria. After sunstroke, the patient is never the same again either physically or mentally. An injury has been done to the cervical ganglia of the sympathetic, and nervous control of the blood supply of the face and scalp, and possibly of the brain, has accordingly been weakened. The patient suffers from dizziness, flushing of the face, insomnia, and finally there may be meningitis or epi- lepsy, or such depression of spirits as may lead to suicide. Much good may be done by preventing the progress of the dis- ease. Unfortunately, cold, ergot, and nitrate of silver are the only vaso-motor tonics we have. Therefore, as medicinal treat- ment: 3 Argenti Nitratis, gr. ± Ext. Ergotae, gr. iij. M. et fiat pil. No. i. Sig. To be given an hour after each meal t. i. d. For one week in every month add corrosive sublimate, g r - it In addition, the cold douche should be applied to the nape of the neck every morning, keeping the back of the head dry, for, if not, it may cause coryza. In two or three months there will be marked improvement under this treatment. What sunstroke does to the vaso-motor centres in the nape of the neck, malaria does to the centres in the lumbar region, causing vaso-motor weakness in the hepatic and splenic circula- tion. Any severe malarial infection will be felt for years after- wards, congestion of the liver or spleen following from slight causes, with chills, diarrhoea, jaundice, etc., and epistaxis. (If epistaxisis from the right nostril, the liver is affected; if from the left nostril, the spleen.) Quinine does no good here, as this is not a periodical disease, but the result of the weakening of the KON- MEDICINAL REMEDIES. 277 vaso-motor centres of the spleen and liver. Ergot, nitrate of silver, and corrosive sublimate should be used with cold douche to the spine, repeated at times to the abdomen, or over the liver or spleen, as the case requires. A cold douche to the nape of the neck is also useful in false croup, or the crowing respiration of children; in tinnitus aurium, when the throbbing is synchro- nous with the heart's beat, and the tympanic artery distended — in this condition, the simultaneous exhibition of hydrobromic acid is of value; in chronic nasal catarrh and in all cases of unilateral headache with corresponding dilatation of the arteries, -and suffusion of the eye on the affected side. 2. Cold as a Styptic. Cold acts as a styptic by causing contraction of the arteries through its influence on the vaso-moto r nerves. It is preferable to astringent drugs and other haemostatics, as it obviates the application of irritating substances to the bleeding part. It is not always necessary to apply it directly to the seat of the haemorrhage, for it will also affect distant parts in accordance ■with certain laws of the vaso-motor system, of which the fol- lowing are the most important. The first laic is that organs which exist in symmetrical pairs, such as the hands, the feet, the eyes, and the ears, are so closely associated in their vaso-motor relations that the same effect, so far as their circulation is concerned, is produced in both by an impression made only on one member of the pair. Thus a thermometer held in one hand will drop 14° F. if the other hand be dipped in ice-water, while a thermometer in the axilla at the same time will mark no difference. In like manner, if the tip of one of the translucent ears of a rabbit be sharply pinched, the pulsating arteries in the other ear will at once contract into invisibility. It is on this principle that injury to one eye is so dangerous to the integrity of its fellow by consecu- tive inflammation. It is tortunate that organs that are not in symmetrical pairs, as the lungs and the kidneys, do not show anything like such a close nervo-vascular association. 278 NOTES ON MATERIA MEDICA. The second law is that there is a close association between the sensory nerves of any part of the skin with the vaso-motor nerves of the organs or viscera which are immediately within that part, so that like impressions on the cutaneous nerves produce like effects on the circulation of the inner structures. Thus, if a cold hand be suddenly laid upon the praecordium, the heart will give a bound and for a moment stop ; so a cold hand laid on the abdomen will cause the uterus to contract ; a dash of ether spray on the chest is the quickest way to arrest an hcemoptysis, and a cold hand may often be used for the diagnosis of incipient phthisis. It may be tried by dipping the patient's own hand in cold water, so that he will not be so afraid of the procedure, and then laying it alternately over the right and left apex ; if done suddenly, he gives a short cough when the impression of cold is made on the affected side, but not when the application is made on the other. This principle is also illustrated in the recourse to all surface applications in internal disorders, such as rube- facients, blisters, and faradism to stimulate absorption, or poul- tices, etc., to allay irritation. No physician, in fact, should neglect cutaneous protection in all acute internal inflammations, such as pericarditis, pleuritis, etc., and in every case of phthisis or chronic bronchitis. The third law is that there are certain special vaso-motor asso- ciations of widely separated parts which have no obvious func- tional connection with each other. The first of these which we would mention is between the vaso-motor nerves of the pelvic viscera and those of the feet. Thus, females can stop menstrua- tion by putting their feet in cold water, while, on the other hand, there is no emmenagogue which at all equals persistent applica- tion of dry heat to the feet; so also we find in males with an irritable stricture of the urethra or an enlarged prostate, that nothing aggravates their infirmity so much as getting the feet wet or cold. On the same principle, if surgeons are troubled with bleeding in cutting for stone in an old case of vesical irri- tation, putting the feet in cold water will suspend the haemor- rhage. Again, irritation in the pelvis contracts the femoral artery; so that coldness and anaemia of the feet is the rule in all NO ^-MEDICINAL REMEDIES. 279 instances of ovarian irritation in women, and in cystitis or pro- lapse of the rectum, etc., in men. Another such association is between the feet and the circula- tion of the pharynx and larynx. Putting the feet in cold water is followed by an immediate paleness of the pharyngeal mucous membrane, in contrast with the rest of the mucous membrane of the mouth. This association is quite unmistakable and pecu- liar, and best shown in normal cases. Still another such association is between the nape of the neck and the circulation of the nasal cavity. While the relations of the cervical sympathetic are known to be very wide in the con- trol of the circulation of the face, head, and throat, yet the close dependenca of congestions of the nasal cavity on abnormal innervation of the cervical nerves has not been as fully recog- nized as it should in the management of some of the obstinate maladies of a region in which vascular disorders are so apt to be tedious, because there is so little muscular tissue to aid in restor- ing tone to the affected structures. As a summary, the following instances will suffice to illustrate the application of these laws in the use of cold as a styptic: (1) cold water applied directly to a bleeding surface; (2) ice bags to the epigastrium to check hcematemesis ; (3) cold applied to one hand to check haemorrhage in the other; (4) cold foot baths to arrest metrorrhagia; (5) in post-partum hcemorrliage, where the best way of applying cold is by the ether spray, for the sudden and intense impression produced causes contraction of the uterus without chilling the patient. If the ether spray is not available, cold water should be poured from the height of two or three feet. The shock of the falling water assists the action of cold. These same measures may be used to control haemoptysis. 3. Cold as an Antiphlogistic. As an antiphlogistic, cold may be used to arrest an acute inflammation, unless suppuration has occurred, or to prevent inflammation when threatened. This it does by causing a pro- tracted constriction of the arteries, thereby preventing the active congestion essential to all acute inflammation. The inflamma- 280 KOTES OK MATERIA MEDICA. tion must be local, both as to cause and manifestation, and not be dependent upon a constitutional cause with a local manifes- tation. It should be invariably applied as dry cold, directly to the part affected, in sufficient intensity to relieve pain, but not so as to produce shock and reaction, and should be continued so long as the exciting cause exists. If, before the tendency to inflammation has entirely disappeared, a neuralgic pain occurs, it is a sign that the vaso-motor nerves have become exhausted, and the use of cold must at once be discontinued, or gangrene will result; moreover, the patient will feel more comfortable without than with the cold applications. This neuralgic pain is continuous, and, if the injured part be one of the extremities, it extends from the part injured toward the trunk. Inflamma- tory pain, on the other hand, is local throbbing, accompanied by local heat, and is relieved by more thorough applications of cold. In fractures, or other severe injuries near joints, the in- jured parts should be completely surrounded with pounded ice placed in water-tight receptacles, such as pigs' bladders, rubber bags, etc., two or three layers of perfectly dry muslin being placed between the skin and bags, lest the parts be chilled too suddenly. A bottle filled with ice-water makes a good anti- phlogistic splint for injuries of the hand. Inflammation of the eyes due to some external injury may be controlled, and its spread from one eye to the other prevented, by means of cold applications. If the inflammation is due to some internal injury of the eye, such as of the retina, cold will not control it. Ice bags should be applied to the head and spine in epidemic cerebro- spinal meningitis, and kept there during the # whole period of the inflammation. Cold applications will control the spread of erysipelas, and are the best means for relieving febrile headache. Headache from uterine trouble is best relieved by moist warmth. Cold should not be used antiphlogistically in any acute inflam- mation of internal organs, except peritonitis with vomiting, and meningitis. 4. Cold as an Ancesthetic. The use of cold as an anaesthetic depends upon its physical property of freezing tissue and deadening sensation without NOX-MKDICIXAL REMEDIES. 281 destroying vitality. It is most useful in operations where no great thickness of tissue is involved, as in opening abscesses, amputation of fingers, etc. In all cases, the effect of the cold should be secured as rapidly as possible. Apply ether spray to that part alone which is to be operated upon, the other parts being protected with some covering, such as chamois leather. Anaesthesia is complete as soon as the skin becomes white and glistening. Ehigolene may also be used for this purpose. 5. Cold as an Antipyretic. It is only within recent years that we have been enabled to answer the exceedingly complex questions, what is the source of the heat when the bodily temperature is raised above the nor- mal, and how far will its direct abstraction be beneficial? A rise in the temperature of the body may be caused in three different ways, each of which has been considered as the genesis of fever: (1) increased oxidation in the system; (2) insufficient radiation; (3) derangement of the thermic centres and nerves. It may now be accepted as proven, that while the first two may give rise to the symptoms of fever, or be its accompaniments, they are not its direct cause, and it is to the third, therefore, that we must look for the explanation of the pyrexia. Experiments upon animals have demonstrated the existence of a heat centre ' in the corpus striatum which regulates the heat-producing function of the muscular system — a function which is entirely independent of muscular contraction, heat being evolved when the muscles are in a complete state of relaxation. Both heat genesis and heat lysis are under the control of the thermic centres and nerves, just as the circulation of the blood is under the control of the vaso-motor centres and nerves. Hence fever is due to a derangement of this thermic system, and neurotics such as aconite, and neurotic drugs of the carbolic-acid class 1 There may be another centre in the spinal cord opposite the third cer- vical vertebra, as injury to the cord above this point will sometimes raise the temperature to 125° F , and injury below it will sometimes reduce the temperature below that of the dead body. The existence of this centre may be assumed to exist, though it has not yet been conclusively proven. , 282 NOTES ON MATERIA MEDICA. such as antipyrine. are real antifebrile agents. Cold, therefore, which is an excellent neurotic, can be used as an antipyretic measure; for it not only directly abstracts heat, but also acts as a stimulant to the thermic centres, arousing them from the para- lysis or derangement of the fever. This derangement is due to a variety of causes, mainly toxic — the poison of septicaemia, for instance, producing the most violent fever known; and probably all fevers, with the exception of that in sunstroke (see infra, p. 283), are due to some form of poisoning. In every fever there is a certain point beyond which if the temperature rises certain structural changes will take place. The glands become affected with cloudy swelling, their secretions are arrested and fatty degeneration ensues, and the muscles become remarkably brittle. The point at which these changes occur differs in each fever. In scarlet fever, it is 105° F. ; in typhoid fever, 10G° F. ; in re- lapsing fever, from 107° to 108° F ; and in erysipelas still higher. Beyond this dangerous point in each fever the temperature should not be allowed to rise, but must be lowered by the use of cold. This may be effected by immersing the patient in a bath at 70° F., and gradually cooling the water down to 65° or 60° F. — never lower — at the same time using cold affusions to the head continuously. At first the temperature will rise slightly, owing to the blood being driven from the surface of the body into the viscera, which are always a little warmer than the skin; but the bath should be continued until the temperature is reduced to 100° F., provided the fall is gradual — that is, one degree in six, five, four, or three minutes Never allow the temperature to fall below 100°, and if the immersion has to be prolonged for more than twenty minutes before the temperature breaks, do not wait until the temperature reaches 100°, but take the patient out when it is 101°. If it falls one degree in two and a half minutes, stop the bath whe-i the temperature has reached 101° F. ; for in most cases a further reduction of one degree will occur after the bath has been discontinued. If the fall in tem- perature during the bath be one degree in two minutes or less, the patient should be t iken out at once, whatever the actual temperature may be; for in such cases there is danger of the NON-MEDICIXAL REMEDIES. 283 subsequent fall becoming uncontrollable, perhaps reaching 97° and causing the patient to pass into a state of colhipse. Should this at any time occur, wr.ip the patient in warm blankets, apply hot water to the epigastrium, and give brandy or other stimulants. When for any reason the bath is imprac- ticable, the cold pack 1 may be used, always observing, however, the same precautions as in the use of the bath. The cold pack or bath should be repeated often enough to keep the tempera- ture below the dangerous p >int of the disease. If necessary, use one every hour; but if only two or three a day are neede 1, one should be given when the highest diurnal rise in temperature may be expected, i.e., about two or three o'clock in the after- noon. Antipyretic Uses of Cold. In Acute Articular Rheumatism. — The application of cold is the only measure that will save life in the pyrexia of the severer forms of this disease. When this occurs, the patient becomes apathetic, ceases to complain of the pain in his joints, his face becomes dusky red in color, delirium sets in (an extremely bad sign in rheumatism), and this becomes intensified with every hour. Meanwhile the temperature has been steadily rising, and, if the disease terminates fatally, continues to do so even after death. When the temperature reaches 108°, the patient becomes comatose, and now death is inevitable unless cold is used, medi- cinal antipyretics being useless in this condition. Immerse the patient in cold water until the temperature of the body is reduced to 100°. When it is at 104°, the patient returns from coma to delirium, and when it is at 102° he is quite rational and will remain so for an hour or two, after which the temperature will begin to rise again, and the same process must be repeated. One- third of such cases will inevitably die, but with the remain- ing two-thirds the fever is broken by this treatment, the artic- ular rheumatism resumes its ordinary course, and the patient finally recovers. This disease shows that heat alone is sometimes the direct cause of death. In Sunstroke. — The same rapid elevation of temperature con- 284 notes ox materia medica. tinuing after death, which occurs in the pyrexia of a r ;ute artic- ular rheumatism, occurs also in about two-thirds of nil the fatal cases of sunstroke. This condition is not due to any form of poisoning, as in the case of other fevers, but to the direct action of the sun upon the nape of the neck, deranging one of the thermic centres. Cold baths must be given in the manner al- ready described. It must be borne in mind, however, that there are two entirely distinct conditions of sunstroke: in the condi- tion for which cold is indicated, there will be coma, with elevated temperature, high tension of pulse, and the face will be suffused; in the other condition, for which stimulants and not cold are indicated, the face will be pale, the pulse weak and flickering, and the patient will be in a condition bordering on syncope. In Typhoid Fever. — The application of cold in combination with the administration of intestinal antiseptics takes the lead of all therapeutic measures in the treatment of typhoid fever, as, in the great prostration and muscular weakness of this dis- ease, cold directly abstracts heat from the affected muscles and keeps up their tone. AYhen the patient is delirious, with dry skin, rapid pulse, etc., immerse him in a bath at 75 p , and grad- ually make the water colder by the addition of ice, so that the initial shock shall not be too great, and the rise in temperature following immersion avoided. The temperature of the bath should not be lowered below 70°, or at most in severe cases 68°. After being taken out of the bath and placed in bed, the patient may shiver; if so, a slight dose of some stimulant may be given." His pulse is now stronger, the tongue is moist, he is able to take more nourishment, and perhaps perspires — a good symptom. If within two hours the temperature rises again, allow it to last for one hour, and then immerse the patient in the bath again; for the danger to be feared is heart failure from exhaustion, and experience proves that cold increases the muscular strength of the heart, tones up the nervous system, stimulates the secretory glands, and allows of perspiration. Medicinal antipyretics, as alcohol, ultimately only still further fatigue the heart, and the antipyretics of the carbolic-acid class, as antipyrine, antifebrin, and quinine, should not be given, as they are cardiac depressants. Other Uses. — The application of cold to the chest in pneu- NON-MEDICINAL REMEDIES. 285 monia is not to be recommended, as it increases the congestion, and experience does not justify its use. Nor should it be used in peritonitis, except where the inflammation is localized. In those cases of perityphlitis caused by perforation of the appendix, where there is only local inflammation and no abscess threaten- ing general peritonitis, the ice bag may be used, and in many cases the inflammation will be reduced without the necessity of any surgical operation; though, if treatment by cold is not suc- cessful, recourse must be had to laparotomy. In some fevers, such as measles, for example, cold need not be used, and very rarely if ever in small-pox. In scarlet fever, which does not last for so long a period as typhoid fever, and where, consequently, the muscular exhaustion is not so great, a temperature of 104° t may be allowed for two or three days ; but if it lasts for a longer time or reaches 105°, cold should certainly be used. Heat. The actions of heat differ essentially, according as it is dry or moist ; the effect of one being directly opposed to that of the other. Dry Heat. Dry heat gives the simple action of heat. It is primarily a cardiac and vascular stimulant. It causes both stronger and more frequent contractions of the heart, and its use is of special value in all cases of failure or exhaustion of that organ. Car- diac failure is liable to occur in malignant, intermittent, and remittent fevers, cholera, the exanthemata, and notably in typhus fever, and sometimes in typhoid and in congestive mala- rial chills. The symptoms of cardiac exhaustion, with a ten- dency to stop in diastole, are: a terribly distressing sensation of sinking in the epigastrium; dyspnoea due to congestion of the lungs, producing shallow or gasping respirations; loss or alteration of the voice; insatiate thirst, due to congestion of the viscera; suppression of urine; pallor of the surface and coldness of extremities, with cramps in the flexor muscles, shrivelled skin, and anxious, drawn expression, with sharp, pinched fea- tures and sunken eyes. The surface of the body is generally 286 NOTES ON MATERIA MEDIC A. covered with a cold, "clammy" sweat, and in exanthemata the eruption disappears, as no blood reaches the surface. In such cases, the heart must be aroused, both by the internal adminis- tration of brandy and ammonium, or by injection, and by the external use of dry heat. Wrap the patient in warm flannel blankets, then apply to the epigastric and pericardiac regions saucers heated by being dipped in boiling water, bottles of hot water, or bags filled with hot salt, ashes, etc. Dry heat should also be applied to the feet and calves of the legs, care being taken that these do not scorch the skin. If these means fail, then place the patient in a bath with a temperature of 102°-103° F. Mustard or capsicum may be used #to increase the stimulant action of the bath (ten grains of the powder to ten gallons of water) . Another remedy is the use of the f aradic current, one pole being placed at the nape of the neck, the other directly over the heart. The first indication of recovery is disappearance of the distress in the epigastrium, accompanied by a deep sigh and normal respiration; the voice returns to its natural sound; the cramps are relieved; the pallor, shrunken and " Hippocratic " expression of the countenance disappear, and if an eruption has previously existed it returns. As an Emmenagogue. — In most cases of amenorrhea, and especially in chlorosis, the patient suffers from cold feet, on ac- count of the relation which exists between the pedal circulation and that of the pelvic viscera, irritation of the ovarian plexus con- tracting the femoral artery and its branches. In these cases, it will be found that the long-continued use of the foot-stove during the day, and a hot soapstone at the feet in bed, will do more toward establishing the menstrual and other disordered func- tions than any other one line of treatment; for by this means the radiated ovarian irritations, which are at the bottom of all the trouble, are suspended, and the intestines are left free to perform their work. In order to encourage the patients to per- severe in keeping their feet warm, it is well to inform them that by so doing they will be relieved of the backache from which they all suffer. In sudden suppression of the menses, a hot pediluvium or other hot applications to the feet are among the best means of restoring the flow. NON-MEDICrSTAL REMEDIES. 287 As a Diaphoretic. — To induce diaphoresis, strip the patient and roll him up in a hot blanket. The hot-air bath is given by placing the patient on a chair under which has been placed a lighted alcohol lamp; a blanket pinned closely around the neck and reaching to the floor confines the heated air. If the patient is too weak to sit up, the heated air may be introduced under the bedclothes, which have been elevated so as to form a kind of tent. The sudoriparous glands are stimulated both by the presence of heat and also by the large amount of blood which has been determined to the surface. Diaphoresis is assisted by thoroughly anointing the body with olive oil. As a Styptic. — Under certain conditions, hot water has the ef- fect of dry heat, and acts as a styptic. In order to obtain this effect, it is necessary that the water, through its high tempera- ture, should produce a shock to the nerves and so constringethe blood-vessels. Post-partum hemorrhage may sometimes be con- trolled by douching the spine with very hot water. A more certain way is by hot- water injections, 110°-112°F., thrown into the vagina, or into the uterus itself. Moist Heat. Moist heat is an anodyne and antispasmodic, being a pure sedative, the action not being that of the heat but of the water itself. If of low temperature, water is not felt by the nerves, the impression of .cold only being conveyed, because the con- traction of the unstriped muscular fibres has withdrawn the cu- taneous nerves, and the skin has accumulated over the papillae, producing the appearance known as goose flesh. If the water is of high temperature, there will be the stimulation of heat. Water, however, of the temperature of the body, 98.5°, gives us the full effect of moist heat, which is invariably depressing, as it abstracts nervous vitality; the hand, for instance, if immersed in warm water for half an hour, loses the sense of feeling and muscular power, and it is some time before this is fully re- covered from. So after immersion for the same length of time in a bath of this temperature, a person feels faint, the muscular 288 stotes ox materia medica. system does not respond to motor impulses, and sensory impres- sions are deadened. Hence, for the purposes of stimulation, a hot bath should always be of short duration, two minutes at the outside; for, as soon as the temperature of the water is lowered, the patient will be subject to the depressing effect of moist heat. In the form of poultices, moist heat may be used in acute in- flammation to relieve the pain and to reduce the irritability. The drawback to its use for this purpose is that the vitality of the part is lowered; parts which had hitherto resisted the sup- purative process now yield, and it is necessary to use caustics to restore the weakened reparative power. In all inflammations of the internal organs, such as pleurisy, pericarditis, pneumonia, peritonitis, etc., the application of a large, warm poultice or fomentation over the whole region of the affected organs, by tak- ing advantage of the laws of vaso-motor nervous association (supra, p. 277), will often give decided relief. The soothing ef- fect will be increased by adding neurotics to the application. In acute articular rheumatism, the profuse perspiration may do harm by drenching the linen, thus chilling the patient and weakening the heart's action. The patient should be stripped and wrapped in flannel blankets, which absorb the perspiration and are poor conductors of heat. During the entire course of the disease, a warm poultice or a pad of cotton batting, covered with oil-silk, should be kept over the precordial space. The antispasmodic action of the warm bath is well illustrated by its power to relax the tissues around a strangulated hernia, and by its efficacy in renal and biliary colic, urethral spasms, and in the convulsions of children. As soon as the breathing of a child becomes rap:d, and there is paleness about the mouth, place it in a bath at once, for by this means the convulsion may be prevented, or, if it has already occurred, its duration will be shortened and the liability to repetition diminished. In all forms of laryngitis, croup, diphtheria, etc., the inhala- tion of steam is very useful; for in all of these diseases there is danger of asphyxia, resulting from spasm of the glottis, and para- lysis of the vocal cords due to the irritation. Mix four parts of water with one of molasses, and introduce steam through a tube into a tent which envelops the head and NON-MEDICl^AL KEMEDIES. 289 shoulders of the patient, keeping the temperature of the air moderately high. The tent may be made of newspapers pinned together, a sheet, or anything which confines the vapor. It must not be made too small, or the patient will imagine that it interferes with his breathing. Care must be taken not to boil too long, as the vapor of molasses then becomes irritating. 19 GENERAL INDEX. Acid, boracic, 35 carbolic, 24 gailic, 270 hydrochloric, 91 hydrocyanic, 212 nitric, 92 nitro-muriatic, 93 phosphoric, 94 prussic, 212 salicylic, 26 sulphuric, 92 tannic, 269 Aconite, 205 Alcohol, 168 Alkalies, 95 Alkaline waters, 102 Alkaloid, definition of, 46 n. Aloes, 235 Alterative medicines, 103 Alum, 269 Ammonia, 196, 256 Anaesthetics, 215 Antifebrin, 30 Antipyrine, 30 Apomorphine, 245 Arsenic, 127 Asafo3tida, 204 Astringents, 265 Barium, chloride of, 195 Bathing waters, 103 Belladonna, 179 Benzoin, 28 /J-Naphthol, 29 Bismuth, 136 Blancard's pills, 113 Boracic acid, 35 Bromide of potassium, 117 Bromine, 32 Buchu, 252 Caffeine, 194 Calomel, 282 Calumba, 88 Camboge, 240 Camphor, 29, 203 Cannabis Indica, 184 Carbolic acid, 24 Cascara sagrada, 237 Castor oil, 233 Cathartics, 225 Chalybeate waters, 102 Charcoal, 22 Chinoline, 30 Chloral, 220 Chloric ether, 177 Chloride of barium, 195 Chlorine, 31 Chloroform, 215 Classification of Medicines, 1 Clelland's solution, 96 Clement's solution, 133 Cocaine, 219 Cod-liver oil, 52 administration of, 61 Colchicum, 136 Cold, as an anaesthetic, 280 as an antipyretic, 281 as a styptic, 277 as a tonic, 273 Colocynth, 238 Columbo, 88 Compound cathartic pills, 241 Conium, 213 Copper, 136 sulphate of, 248, 269 Cream tartar, 243 Creosote, 38 Croton oil, 241 Diaphoretics, 254 292 GENEEAL INDEX. Digitalis, 185, 250 Disinfectants, introductory to use of, 10 classification of, 10 general, 19 special, 20 uses in treatment of special dis- eases, 36 Diuretics, 248 Dover's powder, 167, 256 Dry heat, 255, 285 Elaterium, 240 Eliminatives, 224 Emetics, 244 Epsom salts, 243 Ergot, 198 Ether, chloric, 177 nitrous, spirit of, 177 spiritus aetheris comp., 177 sulphuric, 177 Ethers, 176, 215 Expectorants, 258 Fowler's solution, 129, 133 Functional medicines, 141 Gallic acid, 270 Gelsemium, 214 Gentian, 88 Glandular medicines, 224 Glauber's salts, 243 Laville's extract, 139 Lead, 265 Lime, 20 Lime water, 22 Linseed oil emulsion, 260 Liquor ferri pernitratis, 268 Liquor ferri subsulphatis, 268 Lugol's solution, 112 Magendie's solution, 167 Magnesium, sulphate of, 243 Medicinal remedies, introductory, 45 Medicines, classification of, 1 Mercury, 104, 250 Mineral acids, 90 waters, 97 Moist heat, 255, 287 Monsel's solution, 268 Mydriatics, 178 Naphthaline, 29 Narcotics, 1.44 Neurotics, 143 Nitrate of silver, 133, 268 Nitre, sweet spirit of, 256 Nitric acid, 92 Nitroglycerin, 192 Nitro-muriatic acid, 93 Nitrous ether, spirit of, 177 Nitrous oxide, 219 Non-medicinal remedies, 273 Nux vomica, 191 Heat, dry, 255, 285 moist, 255, 287 Hoffmann's anodyne, 177 Hydrochloric acid, 91 Hydrocyanic acid, 212 Hyoscyamus, 183 Hypnotics, 220 Iodide of potassium, 113 Iodine, 34, 111 Iodoform, 35 Ipecacuanha, 246 Iron, 62 administration of, 71 Jaborandi, 257 Jalap, 239 Juniper, 253 Labarraque's solution, 32 Oil, castor, 233 croton, 241 of peppermint, 28 of wintergreen, 28 Opium, 144 Oxide of zinc, 135 Paraldehyd, 222 Peppermint, oil of, 28 Permanganate of potash, 36 Phenacetin, 223 Phosphate of sodium, 244 Phosphoric acid, 94 Phosphorus. 73 Podophyllum, 239 Poison, definition of, 12 Potassium, iodide of, 113 Prescriptions. See Clinical index, Prussic acid, 212 Quassia, 88 Quinine, 76 GENERAL INDEX. ^93 Restorative medicines, 52 Rhubarb, 235 Rochelle salts, 244 Salicin, 26 Salicylate of soda, 26 Salicylic acid, 26 Saline cathartics, 242 diuretics, 253 waters, 99 Salol, 27 Salts Epsom, 243 Glauber's, 243 Rochelle, 244 Scammony, 239 Senna, 241 Silver, 133 nitrate of, 268 Smith's solution, 33 Soda, salicylate of, 26 sulphite of, 34 Sodium, phosphate of, 244 sulphate of, 243 Solution, Clement's, 133 Fowler's, 129, 133 Lugol's, 112 Magendie's, 167 Smith's, 33 Spiritus aetheris comp., 177 Squill, 251 Stramonium, 183 Strophanthus, 190 Strychnine, 200 Sulfonal, 223 Sulphate of copper, 136, 248, 269 of magnesium, 243 of sodium, 243 of zinc, 248 Sulphite of soda, 34 Sulphur, 34 Sulphuric acid, 92 ether, 177 Sulphurous waters, 102 Sweet spirit of nitre, 256 Tannic acid, 269 Tannin, 269 Tartar emetic, 212 Tartrate of potassium and sodium 244 Thymol, 30 Turpentine, 251 Valeriana, 204 Vallet's mass, 69 Vegetable bitters, 87 Veratrum viride, 209 "Warburg's tincture. 82 Waters, alkaline, 102 bathing, 103 chalybeate, 102 mineral, 97 saline, 99 sulphurous, 102 Wintergreen, oil of, 28 Wood smoke, 34 Zinc, 135 sulphate of, 248 CLINICAL INDEX. Abscess in tonsils aconite, 208 Accidental diseases, classification of, 18 Acne arsenic, 132 ergot,- 199 of bromism Fowler's solution, 123 Adenitis cod-liver oil. 57 Lugol's solution, 112 Alcohol ism us oxide of zinc, 135 veratrum viride, 175 Amenorrhcea aloes, 236 asafcetida, 204 sulphate of iron, 70 dry heat, 286 Ansemia Blancard's pills, 113 gentian, 88 iron, 64. For prescription, see p. 71 pernicious arsenic, 128 Aneurism iodide of potassium, 116 Aneurismal cough treatment of, 264 Angina pectoris digitalis, 187 nitrate of silver, 134 nitrite of amyl, 194 nitroglycerin, 193 Anorexia vegetable bitters, 87 Ascarides quassia, 88 Asiatic cholera camphor, 203. See also p. 17 Asthma arsenic, 131 belladonna, 114, 180 caffeine, 195 Fowler's solution. 114 Hoffmann's anodyne, 114, 178 iodide of potassium, 114 linseed oil emulsion, 260 stramonium, 183. For prescrip- tions, see pp. 131, 260 Atony, intestinal senna, 241 of bladder juniper, 253 Bed-sores tannate of lead, 267 Biliousness. For prescription, see p. 233 Bladder, weakness of strychnine, 201 Boils disinfection, 37 Borborygmus bismuth, 136 Bright's disease alcohol. 171 cod-liver oil, 59 ethers, 178 iron, 64 jaborandi, 257 jalap, 239 nitroglycerin, 193 pilocarpine, 258 quinine, 78. For prescription, see p. 188 Bright's disease, chronic digitalis, 187 mercury, 108, 250 saline waters, 100 tincture of iodine, 116 Bronchitis ammonia, 196 CLINICAL INDEX. 295 Bronchitis arsenic, 131 balsams, 29 buchu, 253 hydriodic acid, 114 iodide of potassium, 114 sweet spirit of nitre, 177, 256 acute linseed oil emulsion, 260 tartar emetic, 212. For pre- scription, see p. 260 capillary hot milk and lime water, 234 ipecacuanha, 247 catarrhal croton oil, 241 chronic iron, 67 nitric acid, 93 saline waters, 101 tinct. ferri muriatis, 261 turpentine, 252 zinc, 136 congestive y croton oil, 241 jalap, 239 Broncho-pneumonia chloride of ammoDium, 197 Bronchorrhcea nitric acid, 93 zinc, 136 Brow ague ergot, 200. See also under "Neuralgia.*' Burns lime water and olive oil, 97 oil of peppermint, 28 Calculi alkalies, 96 Cancer permanganate of potash, 36 of stomach sulphite of soda, 34 Carbuncles disinfection, 37 Cardiac dilatation digitalis, 186 dropsy juniper, 253 strophanthus, 191. For pre- scription, see pp. 108, 251 exhaustion syrup of hypophosphite of sodium, 74 Cardiac failure alcohol, 169 irregularity belladonna, 180 pain belladonna, 182 Catarrh, mucous Lugol's solution, 112 Cerebro-spinal meningitis application of cold, 280 Chancroid iron, 69 Chlorosis administration of, medicines in, 48 asafcetida, 204 dry heat, 286 iron, 64, 65. For prescrip- tions, see pp. 66, 236 Cholera, asiatic camphor, 29, 203. See also p. 17 infantum camphor, 29. For prescrip- tion, see p. 266 morbus camphor, 159, 203 Choleraic diarrhoea with vomiting For prescription, see p. 266 Chorea arsenic, 131 colchicum, 140 oxide of zinc, 135 Cirrhosis of liver mercury, 108 Classification of accidental diseases, 18 Colic, biliary moist heat, 288 intestinal chloric ether, 177 renal, moist heat, 288 Coma croton oil, 242 alcoholic, 162 apoplectic, 162 from coucussion of brain, 163 of opium poisoning, 161 ursemic, 161 Communicable diseases, 16 specific, 17 septic, 17 Condylomata yellow wash, 111 296 CLINICAL INDEX. Congestion, hepatic ipecacuanha, 246 muriate of ammonia, 198 Conjunctivitis, chronic sulphate of copper, 269 Constipation aloes, 235 belladonna, 180 calomel, 231 camboge, 240 castor oil, 233 colocynth, 238 croton oil, 242 rhubarb, 236 saline waters, 101 strychnine, 202 sulphate of iron, 71. For article on constipation, see p. 225. For prescriptions, see pp. 181, 226 Convulsions moist heat, 288 of scarlet fever application of cold, 275 puerperal application of cold, 275 Coughs, for article on, see p. 258 irritant chloral, 222 hydrocyanic acid, 213 uterine bromide of ammonium, 125 Croup ipecacuanha, 247 moist heat, 288 sulphate of copper, 248 false cold douche, 277 ipecacuanha, 247 Cystitis administration of medicines in, 49 belladonna in, 181 buchu, 252 conium, 214 disinfection, 36 strychnine, 230 chronic quinine, 83 saline waters, 100. For pre- scription, see p. 252 tannin, 270 Delirium hyposulphite of sodium, 75 Delirium oxide of zinc, 135 veratrum viride, 211 tremens, insomnia of, , sulfonal, 223 Diabetes alkaline waters, 102 Clement's solution, 133 diaphoretics, 254 iron, 68 mellitus cod-liver oil Diarrhoea acetate of lead, 266 camphor, 29 chalk mixture, 97 charcoal, 24 Labarraque's solution, 32 nitric acid, 93 oil of wintergreen, 28 opium, 157 sulphuric acid, 92. For prescription, see p. 269; for description for diar- rhoea with gout, see p. :9 choleraic ammonia, 197 of phthisis liquor ferri pernitratis, 268 summer aloes and rhubarb, 235. For prescription, see p. 237 Diphtheria bromine, 33 iron, 69 lime, 22 moist heat, 288 Dropsy administrations of medicines in, 47 elaterium, 240 juniper, 253 strophanthus, 191. For pre- scriptions, see pp. 108, 251 Dysentery castor oil, 234 charcoal, 24 ergot, 200 ipecacuanha, 247 peppermint water, 156 chronic aloes and rhubarb, 235 bromide of potassium, 126 CL1XICAL IXDEX. 297 Dysentery, chronic liquor ferri pernitratis, 268 naphthaline, 29 nitrate of silver, 134 oil of peppermint, 28 oil of wintergreen, 28 sulphate of copper, 136 For prescriptions, see pp. 134, 269 malignant Labarraque's solution, 32 Dysmenorrhea administration of medicines in, 49 aloes, 236 arsenic, 131 asafcetida, 204 bromides, 126 juniper, 253 turpentine, 252 Dyspepsia belladonna, 180 bismuth, 136 charcoal, 24 mineral acids, 91. For pre- scription, see p. 67 Dysuria cannabis iodica, 185 Eczema alkalies, 96 arsenic, 132 boracic acid, 35 cod-liver oil, 60 saline waters, 101. See also under Skin diseases, rheumatic mercury, 109 Emphysema arsenic, 131 hydriodic acid, 115 iodide of potassium, 115. For prescription, see p. 260 Endarteritis tincture of iodine, 116 chronic mercury, 108 saline waters, 100 syphilitic iodide of potassium, 113 Enteritis opium, 154 Epididymitis mercury, 109 Epilepsy, definition of, 120 Epilepsy alcohol, 124 bromide of potassium, 117, 122 chloral, 124 cod-liver oil. 59, 123 conium, 213 digitalis, 188 ergot, 198 Hoffmann's anodyne, 124 iron, 66 mercury, 108 nitrate of silver, 134 phosphorus, 74 red iodide of mercury, 110 sulphate of copper, 136 syrup of hypophosphites, 123. For article on epilepsy, see p. 118. Epistaxis cocaine, 220 Erysipelas application of cold, 280 lead and opium wash, 267 lime, 22 Expectorant coughs treatment of, 259 Exudation, inflammatory red iodide of mercury, 110 Favus mercury, 108 Fevers aconite, 206 application of cold, 282 calomel, 232 cream tartar, 244 diaphoretics, 254, 255 dry heat, 286 ipecacuanha, 246 iron, 66 phenacetin, 224 phosphoric acid, 94 quinine, 84 vegetable bitters, 89 For antipyretic prescription, see p. 209 intermittent, see Intermittent fever remittent, see Remittent fever Fibroid tumors ergot, 199 Flatulency asafoetida, 204. For prescrip- tion, see p. 227 298 CLINICAL INDEX. Fractures application of cold, 280 Gangrene bromine, 33 Labarraque's solution, 32 lime, 22 opium, 148 Gastralgia arsenic, 130 Gastritis administration of medicines in,47 arsenic, 129 chronic calumba and bismuth, 89 saline waters, 101 Gastrodynia belladonna, 180 bismuth, 136 Globus hystericus belladonna, 180 Goitre nitrate of silver, 135 red iodide of mercury, 110 strophanthus, 135 n Gonorrhoea cocaine, 220 Gout colchicum, 137 Laville's extract, 139 quinine, 87, 139 ripe fruit, 96. For prescrip- tion for gout with diar- rhoea, see p. 29 chronic sulphurous waters, 102 Gummata, syphilitic iodide of potassium, 113 Hematuria cannabis indica, 185 Haemoptysis ergot, 200 ether spray, 278 tannin, 270 . Haemorrhage ammonia, 196 post-partum ergot, 199 Haemorrhoids cocaine, 220 Hay asthma arsenic, 131 For prescription, see p. 131 Hay fever cocaine, 220 Headache ammonia, 196 antifebrin, 30 antipyrine, 30 ergot, 200 nitroglycerin, 194 febrile application of cold, 280 malarial arsenic, 129 sick gelsemium, 214 Heart disease iron, 67 Hemicrania cold douche, 277 ergot, 199 valerianate of ammonium and chloride of ammo- mium, 205 nocturnal syphilitic calomel, 105 Hepatic congestion ipecacuanha, 246 muriate of ammonia, 198 dropsy juniper, 253 Herpes mercury, 109 Hyperidrosis belladonna, 182 sulphuric acid, 92 Hypochondriasis bromides, 125 Hysteria asafoetida, 204 /?-naphthol, 29 benzoate of soda, 29 bromides, 125 phenacetin, 224 rhubarb, 29 valerian, 205 Impotence cannabis indica, 185 Incontinence of urine in children, nocturnal belladonna, 182 Inflammation, exudative iodine, 115 Insanity, insomnia of sulfonal, 223 Insomnia alcohol, 170 bromides, 126 CLINICAL INDEX. 299 Insomnia chloral hydrate, 220 paraldehyd, 222 sulfonal, 223 of delirium tremens oxide of zinc, 135 Intermittent fever arsenic, 129 Intestinal colic chloric ether, 177 fermentation alkalies, 96 henzoate of soda, 29 /3-naphthol, 29 bismuth, 136 charcoal, 24 lime water, 22 rhubarb, 29 salicylate of soda, 28 salol", 28 Iodism muriate tincture of iron, 112 opium, 112 quinine, 112 Jaundice chloride of ammonia, 197 ipecacuanha, 246 iron, 64 nitro-muriatic acid, 94 Laryngitis moist heat, 288 general treatment of, 268 Lead poisoning iodide of potassium, 116 Lepra alkalies, 96 arsenic, 130 liquor potassas, 130 Leucorrhooa application of cold, 275 permanganate of potash, 36 saline waters, 100 Lithsemia benzoate of soda, 139 conium, 214 Locomotor ataxia antifebrin. 30 antipyrine, 30 mercury, 108 nitrate of silver, 133 phenacetin, 224 Lumbago cathartics, 233 Lumbago salicylic acid, 27 Malaria arsenic, 128 castor oil, 234 cold, 276 compound cathartic pills, 238 iron, 64 podophyllum, 240 quinine, 77, 264 For prescription for the vaso- motor weakness of malaria, see pp. 276, 277 Meningitis cold, 275 red iodide of mercury, 110 acute tubercular iodide of potassium, 116 cerebro-spinal application of cold, 280 croton oil, 242 chronic ergot, 198 mercury, 108 phosphorus, 74 subacute ergot, 198 syphilitic iodide of potassium, 113 Menorrhagia cannabis indica. 185 Menses, suppression of application of dry heat, 286 Mercurial poisoning iodide of potassium, 116 Migraine cannabis indica, 184 phenacetin. 224 Muscular debility. For prescription, see p. 67 tremors oxide of zinc, 135 Myelitis nitrate of silver, 134 Nasal catarrh, chronic cold douche, 277 Nephritis, acute digitalis. 188, 250 jaborandi, 257 chronic interstitial mercury, 108 scarlatinal jaborandi, 257 300 CLINICAL INDEX. Nervous debility alcohol, 170. For prescription, seep. 67 Neuralgia aconite, 207 ammonia, 197 antifebrin, 84 antipyrine, 84 cannabis indica, 184 cocaine, 220 iron, 65 'opium. 152 phenacetin, 224 phosphorus, 74 quinine, 84 valerian, 205 For prescriptions, see pp. 197, 208 malarial arsenic, 129 trigeminal ammonia and ethers, 178 Neurasthenia mineral acids, 91 phosphorus, 74 Neuroses cod-liver oil, 59 syphilitic iodide of potassium, 113 Nodes, syphilitic iodide of potassium, 113 Non-communicable diseases, 17 Non-expectorant coughs treatment of, 261 Offensive breath aloes and rhubarb, 235 cascara sagrada, 137 Opium poisoning, treatment of, 163 For prescription, see p. 165 Orchitis mercury, 109 Otorrhcea boracic acid, 35 bromine, 33 Oxaluria nitro-muriatic acid, 94 Ozsena permanganate of potash, 36 Pachymeningitis conium, 213 nitrate of silver, 134 red iodide of mercury, 110 Pain, inflammatory opium, 151 Pain, camphor, 203 Paralysis phosphorus. 74 agitans nitrate of silver, 134 Paraplegia strychnine, 201 Pelvic irritation bromides, 125 Pericarditis mercury, 109 moist heat, 288 Periostitis, rheumatic iodine, 115 syphilitic conium, 113, 213 iodide of potassium, 113 tincture of opium, 113 Peritonitis aconite, 207 moist heat, 288 opium, 148 chronic mercury, 109 Perityphlitis application of cold, 285 Pertussis belladonna, 264 Pharyngitis aconite, 20S Phthisis belladonna. 183 bismuth. 136 buchu, 253 cod-liver oil, 60 coffee, 261 creosote, 39 croton oil, 241 disinfection, 15, 20, 38 linseed oil emulsion, 260 mercury, 109 nitric acid, 93 sulphite of soda, 34 sulphuric acid, 92 syrup of hypophosphite of sodium, 75 zinc, 136 cough of morphine, 262 diarrhoea of liquor ferri pernitratis, 268 night sweats of application of cold, 274 Piles aloes, 236 CLINICAL INDEX. 301 Piles saline waters, 99 chronic application of cold, 275 Pleurisy- aconite, 207 moist heat, 288 chronic mercury, 109 cough of treatment of, 263 Pneumonia aconite, 192, 207 carbonate of ammonia, 196 digitalis, 189 ipecacuanha, 247 iron, 69 moist heat, 288 nitroglycerin, 192 saline diuretics, 253 strophanthus, 191 Portal congestion compound cathartic pills, 241. For prescription, see p. 81 Post-part um haemorrhage application of heat, 287 ergot, 199 Pregnancy, vomiting of arsenic, 129 Prescriptions anaemia, 71 antipyretic, 209 asthma, 260 biliousness, 233 Bright's disease, 188 bronchitis, acute, 260 cardiac dropsy, 108, 251 chlorosis, 66, 236 cholera infantum, 266 choleraic diarrhoea with vomit- ing, 266 constipation, 181, 226 cystitis, chronic, 252 diarrhoea with gout, 20 chronic, 269 summer, 237 dropsy, 108, 251 dysentery, chronic, 134, 269 dyspepsia, 67 emphysema, 260 flatulency, 227 gout with diarrhoea, 29 hay asthma, 131 malaria, vaso-motor weakness of 276, 277 Prescriptions muscular debility, 67 nephritis, chronic interstitial, 108 nervous debility, 67 neuralgia, 197, 208 opium poisoning, 165 portal congestion, 81 rheumatism, 95 chronic, 209 scabies, 97 summer diarrhoea, 237 sunstroke, vaso-motor weakness of, 276 typhoid fever, 39 Prolapsus recti aloes, 236 application of cold, 275 strychnine, 201 uteri application of cold, 275 saline waters, 100 Prostate gland, enlarged aloes, 236 saline waters, 99 Pruritus pudendae black wash, 110 Psoriasis alkalies, 96 arsenic, 130 liquor potassae, 130 mercury, 109 Puerperal eclampsia veratrum viride, 210 Pyaemia, definition of, 16 n Pyelitis, chronic tannin, 270 turpentine, 252 Quinsy aconite, 208 Remittent fever administration of medicines in, 47 Rheumatic eczema mercury, 109 Rheumatism alkalies, 95 antifebrin, 30 antipyrine, 30 application of cold, 275 mercury, 109 phosphate of sodium, 244. For prescription, see p. 95 302 CLINICAL INDEX. Rheumatism acute veratrum viride, 211 acute articular application of cold, 283 moist heat, 288 phenacetin, 224 salicylic acid, 26 chronic alkaline waters, 102 cod-liver oil, 58 sulphurous waters, 102 warm water baths, 103. For prescription, see p. 209 muscular cathartics, 233 phenacetin, 224 Scabies mercury, 108. For prescription see p. 97 Scarlatinal nephritis digitalis. 188 jaborandi, 257 Scarlet fever application of cold, 285 cream tartar, 244 lime water and olive oil, 97 Sciatica atropine, 184 morphine, 184 Scrofula Blancard's pills, 113 cathartics, 233 cod-liver oil, 56 Lugol's solution. 112 Secretions, glandular, arrest of belladonna, 182 Septicaemia, definition of, 16 n quinine as a remedy in, 83 Shock opium, 145 Sick headache gelsemium, 214 Skin diseases arsenic, 130 black wash, 110 cod-liver oil, 60 disinfection, 37 liquor potassre, 130 mercury, 108 phosphorus, 75 saline waters, 100 Sore throat aconite, 208 Sore throat saline waters, 101 Small-pox lime water and olive oil, 97 Spasms opium, 153 Spermatorrhoea bromides, 125 ergot, 199 Spinal cord, diseases of mercury, 108 Spinal irritation croton oil, 241 Spleen, enlarged ergot, 199 Sprains belladonna, 184 stramonium, 184 Strangury cannabis indica, 185 Stricture of urethra aconite, 49, 208 Summer diarrhoea aloes and rhubarb, 235, 236 nitric acid, 93. For prescrip- tion, see p. 237 Sunstroke application of cold, 276, 283 corrosive sublimate, 199 ergot, 198 red iodide of mercury, 110 For prescription for the vaso- motor weakness of sunstroke, see p, 276 Suppuration, prolonged quinine, 83 Syncope, definition of, 161 ammonia as a remedy in, 196 Syphilis black wash, 110 iodide of potassium, 113 mercury, 104 yellow wash, 111 Syphilitic hemicrania, nocturnal calomel, 105 Teething of children bromide of potassium, 126 Tetanus bromide of potassium, 125 Tic douloureux aconite, 207 muriate of ammonia, 197 phosphorus, 74 CLINICAL INDEX. 303 Tinnitus aurium cold douche, 277 nitroglycerin, 194 Tonsillitis aconite, 208 emetics, 244 hydrochlorate of cocaine, 220 ipecacuanha, 247 Toothache camphor, 203 oil of wintergreen, 28 Toxicology alcoholic poisoning, 176, 211 arsenical poisoning, 132 digitalis poisoning, 186 lead poisoning, 135. 267, 268 mercurial poisoning. 106, 135 opium poisoning, 160 strychnine poisoning, 200 Tubercular inflammation of lungs pure air, 20 meningitis, acute iodide of potassium, 116 Tuberculosis of lungs ipecacuanha, 246 Tumors, fibroid ergot, 199 Typhoid fever application of cold, 284 bismuth, 136 calomel, 232 chlorine, 31 disinfectants, 39 hydrochloric acid, 92 milk, 40 turpentine, 252. For prescrip- tion, see p. 39 Typhus fever lime, 22 Ulcers iron, 69 Lugol's solution, 112 Urethra, irritable stricture of aconite, 208 juniper, 253 spasm of buchu, 253 moist heat, 288 Urine, incontinence of strychnine, 201 nocturnal incontinence of, in children belladonna, 182 Uterine cough treatment of. 264 Uterus, chronic subinvolution of ergot. 199 Uvula, relaxed alum, 269 Vaginitis Lugol's solution, 112 Vaso-motor association, laws of, 277 weakness strychnine, 202 "Vomiting of pregnancy arsenic, 129 chloric ether, 177 Water brash strychnine, 202 Whooping cough bromide of ammonium, 125 nitric acid, 93 Wounds, disinfection of, 40 Yellow fever, see p. 18 LIBRARY OF CONGRESS DDQEbO'miD