Columbia ^nibersJitp \^^^ mtf)eCitj)of^etu|9orfe '•^f-v ^cfjool of Bcntal anb (Z^ral ^iirgerp i^efereme ILihvaxp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons (for the Medical Heritage Library project) http://www.archive.org/details/dentalmateriamedOOIong ■ '^^ny ^' "Cl;,,, DENTAL MATERIA MEDICA THERAPEUTICS J n PRESCRIPTION WRITINC BY ELI H. LONG, M.D. PROFESSOR OF DENTAL MATERIA MEDICA AND THERAPEUTICS IN THE DENTAL DEPART- MENT, EMERITUS PROFESSOR OP MATERIA MEDICA AND THERAPEUTICS IN THE MEDICAL DEPARTMENT, PROFESSOR OF TOXICOLOGY IN THE PHARMACY DEPARTMENT, UNIVERSITY OF BUFFALO; CONSULTING PHYSICIAN TO THE BUFFALO GENERAL HOSPITAL FOURTH EDITION, THOROUGHLY REVISED LLUSTRATED WITH FOURTEEN ENGRAVINGS AND EIGHTEEN COLORED DIAGRAMS LEA & FEBIGER PHILADELPHIA AND NEW YORK Copyright LEA & FEBIGER 1920 TO THE MEMORY OF WILLIAM T. G. MORTON, M.D. WHO FIRST MADE KNOWN SURGICAL ANESTHESIA BY ETHER AND TO WHOM THE PROFESSIONS OF MEDICINE AND DENTISTRY, AND THE WORLD, OWE A DEBT OF PERPETUAL GRATITUDE, THIS VOLUME IS DEDICATED PREFACE TO FOURTH EDITION. While progress in medical science as applied to dentistry has required a thorough revision of the text, the original aim of the author to adapt the book particularly to the needs of the dental student, has been adhered to. The chapters on Analgesia and Anesthesia have been largely rewritten, also the article on Syphilis, and a new chapter on Animal Drugs has been added, all of which necessitated enlargement by twenty-five pages. Doses have been generally included in the text, the average U. S, P. dose being employed for official substances, while the range of permissible dosage for all internal drugs is given in the Index of Drugs. The author expresses his appreciation of the great assistance rendered by his friend, the late William H. Lane, B.S., M.D., D.D.S., who care- fully revised the chapters on Local Remedies. The courtesy and patience of the publishers is likewise acknowledged, since much delay on the author's part in completing the revision was occasioned by a period of ill-health. E. H. L. Buffalo, N. Y., 1920. ^' CONTENTS. PART I. INTRODUCTION 17 CHAPTER I. Drugs and Medicines: Their Constituents and Preparations ... 21 CHAPTER II. Remedies: Their Classification and Definitions 36 CHAPTER III. Administration of Medicines 41 CHAPTER IV. Modes of Action of Medicines 50 PART 11. LOCAL REMEDIES. CHAPTER V. Depletives 55 CHAPTER VI. Counterirritants 59 CHAPTER VII. Escharotics 70 (vii) viii CONTENTS CHAPTER VIII. Demulcents and Emollients 90 CHAPTER IX. Astringents and Hemostatics 94 CHAPTER X. Detergents, Antacids and Alkalies 115 CHAPTER XI. Antiseptics ' . . . 124 CHAPTER XII. Bleaching Agents 159 CHAPTER XIII. Anesthetics. Local Analgesics 164 PART III. GENERAL REMEDIES. CHAPTER XIV. Anesthetics 185 CHAPTER XV. Stimulants and Tonics 217 CHAPTER XVI. Alteratives 2.32 CHAPTER XVII. Sedatives . 238 CONTENTS ix CHAPTER XVIII. Eliminatives 249 CHAPTER XIX. Animal Drugs 253 CHAPTER XX. Dextistrt during Pregnancy 256 PAET IV. CHAPTER XXI. Prescription Writing 261 CHAPTER XXII. Poisons 289 Table of Poisons and Antidotes 291 Index of Drugs 297 General Index 327 DENTAL MATERIA MEDICA, THERAPEUTICS AND PRESCRIPTION WRITING. PART I. INTRODUCTION. The need of a book on Materia Medica and Therapeutics, prepared especially for the specialist in dentistry, indicates a certain distinctness of practice that does not apply to other specialties. The general text- book on this branch is all that is wanted by the general surgeon, the ophthalmologist, the gynecologist, and in fact by all specialists whose preparation includes a complete medical course of study. Whether we regard the condition as normal or not, the fact is apparent that the prac- tice of dentistry today has too little in common with general medicine. This is likely to be true to a degree for the future also, even though the tendency now is to broaden the curriculum of dental colleges. The relation of mouth conditions to the health of the whole body has in recent years assumed an importance that calls for a broader training of the dental specialist, so that he may be able to stand upon common ground with the physician in solving the problems that present them- selves. The preparation for special practice cannot be too broad as to principles, but, at the same time, there is a practical limit to the detail of general medicine that can profitably enter into the dental student's undergraduate work. The matter entering into these chapters is written from a standpoint that recognizes the need of a special text-book, but that also realizes the narrowing tendency that inevitably attends the supplying of that need. The author, therefore, makes no apology for attempting to illustrate by diagrams, with explanatory text, the action of the most important internal drugs upon the general system, nor for the somewhat extensive treatment of classes of remedies and preparation of drugs. 2 18 INTRODUCTION Certain general terms require definition or comment at the outset. The term remedy inchides any agent, of whatever character, employed in the treatment of disease. A remedy is not necessarily a substance; it may be some external force or simply an influence. A medicine is any substance administered or applied in the treatment of disease. The term drug is inclusive, meaning any substance used in the com- position of medicines or entering into chemical processes, or any poison. Materia medica, in a restricted sense, means the materials or substances used in medicine. In a broad sense, the term means the science of drugs in their varied relations, i. e., their sources, properties, prepara- tions and uses. Pharmacy is the science of preparing medicines for use. It includes not only the making of drug preparations, but also the art of compound- ing and dispensing medicines. Pharmacology has had much the same meaning as materia medica in its broad sense, but it has more recently come to be applied to a distinct part of the science of drugs, that which treats of the action of drugs upon the tissues, organs and functions of the body. Therapeutics is the science and art of employing remedies in the treatment of disease. While therapeutics should have a scientific basis in the knowledge of the action and effects of remedies, practical treat- ment of disease will alwaj^s remain an art, because of the many modifying factors that render scientific precision impos^^ible. Toxicology is that part of medical science which treats of poisons. It includes the nature and effects of poisons, their doses, their detection, and the treatment of the conditions resulting from poisoning. As a standard for the purity and uniformity of drugs and prepara- tions, we have the volume known as the United States Pharmacopoeia,* which is the recognized authority for this country. Other countries have similar standards. The book does not treat of the action or uses of medicines, but it furnishes a list of recogn ized drugs, with descriptions, tests of purity, etc., and of preparations, with their formulas. The drugs and preparations so recognized are called "official." An average dose is given of each drug and preparation used internally. This book, * The IT. S. Pharmacopa ia was first issued in 1820. It is sul)je('ted to revision every ten years. It is not issued by the Government, as is the case with the phar- macopa'ias of most countries, but it is authorized by the professions of medicine and pharmacy. A convention, representing medical and pharmaceutical colleges and associations, meets once in ten years in the city of Washington, for the purpose of directing its revision, wliich is accomplished through a committee of revision. INTRODUCTION . 19 being our authority upon drugs and their preparations, forms the basis of our text-books on materia medica, pharmacy and therapeutics. It is revised every ten years under direction of the professions of medicine and pharmacy. The abbreviation (U. S. P.) always indicates this work. A Dispensatory is a comprehensive text-book on materia medica. It has been called a commentary upon the Pharmacopoeia ; but it is more than this, in that it treats of a vast number of substances that are not official, and discusses also the uses of drugs. But it is not an authorized work as is the Pharmacopoeia. The National Formulary (X. F.) is a very important collection of formulas that are not official, but which are in common use. It is pre- pared under the direction of the American Pharmaceutical Association, and is, therefore, in a sense authoritative. In the study of the practical values and uses of remedies we employ several related terms which are too often confused. Physiologic action, physiologic effect and therayeutic effect are terms distinct in meaning, and they should be properly understood. The action and effect of a drug cannot always be the same. The action may be obscure; the effect must be apparent. To illustrate: Tincture of iodine applied in a case of pericementitis has its action upon the mucous membrane where applied, but the jjhysiologic effect that we desire is alteration of the disturbed circulation in the pericementum. Again, we may have physiologic action and physiologic effect without therapeutic effect, the latter depending upon a relief of symptoms. In the above condition the therapeutic effect would be relief of the pain; but the inflammation might be so severe that our therapeutic effect would not follow. The actio?! of a drug, then, consists of a change of conditions, chemic, thermic, electric or structural, which determines an alteration of func- tion. This alteration, when apparent, is known as the effect of the drug. Within the limits of normal function this effect is physiologic, while a disturbance, or depression beyond the normal, is a toxic effect. When the action is in the direction of restoring normal conditions, the effect is usually a relief of symptoms of disease, and is called the thera- peutic effect. We may have the action and the physiologic effect of a drug in a normal, healthy individual, but never the therapeutic effect. Some drugs may cause unpleasant or undesirable effects aside from their main action. These are called untoivard effects, and their avoid- ance calls for discrimination in administration and dosage. Closely related is the matter of susceptibility to drug action, some individuals 20 INTRODUCTION being very sensitive to the influence of a certain drug and readily showing untoward effects of the same. On the other hand, tolerance to certain drugs may be acquired by continued use, so that very large quantities may be taken without dangerous results. The habit drugs, particularly morphine and cocaine, exhibit this fact; victims of habitual use of either often being able to take many times the poisonous dose. A cumulative effect is sometimes seen with slowly acting drugs, par- ticularly when elimination is faulty. The successive doses given accu- mulate and their full action is likely to be excessive, disturbing or poison- ous. Digitalis is a drug which needs care in its use to avoid cumulative effect. As related to the emplo^Tnent of remedies, the term indication means the symptom or condition that calls for a particular remedy or course of treatment, while contra-indication means the condition or symptom that forbids the use of a certain remedy or method. A symptom is an evident disturbance or alteration of function or structure, which is the expression of disease. A sign is a symptom or phenomenon that is positive evidence of some particular disease. Diagnosis means the determination, by means of s^Tnptoms or signs, of the character or name of the disease, while prognosis is the prediction of the course or termina- tion of the same. The term resolution indicates the changes in diseased tissues toward the normal, and means structural recovery. Dissolution, on the con- trary, means death. The term specific has tw^o meanings. Applied to a remedy, it means that the remedy can be invariably relied upon to produce a therapeutic effect in a certain disease, as quinine in malarial fever or antitoxin in diphtheria; but when we speak of specific disease we mean syphilis. The term is thus used among physicians to desig- nate, in a way that cannot give offence, that disease that in its true name has the stigma of vice attached to it. CHAPTER I. DRUGS AND MEDICINES: THEIR CONSTITUENTS AND PREPARATIONS. The terms dnig and medicine are not strictly sjoion^Tnous, although popularly so regarded. Both mean material substances, therefore they exclude such agents as heat, light and electricity. The term medicine implies use in the treatment of disease, while the classes of drugs include many substances that are known usually as chemicals and that are never used directly in treatment. Therefore: A medicine is any substance administered or applied in the treatment of disease. A drug is any substance used in the composition of medicines or in chemical processes. A yoisonous drug is one which is capable of causing a disturbance of function, or disease, or death. Poisons must be included among drugs, but in their poisonous quantities they cannot be medicines, although a substance that in a large dose is a poison may in a smaller dose be a medicine. Poisons are discussed in greater detail in a separate chapter. The term remedy is more inclusive than the term medicine, meaning any agent (whether a substance, a force, or any influence whatever) employed in the treatment of disease. In another chapter occurs the classification and discussion of remedies. Drugs are classified variously: in respect of their sources, as vegetable drugs, mineral drugs and animal drugs; regarding their constitution, as organic and inorganic; and respecting their uses, as medicinal and chemical drugs. In the development of the science of drugs, the beginning had to be with two quite distinct groups of substances — the simple chemicals, or chemical elements as we now know them, such as zinc, mercury and iron, and the more complex organic vegetable drugs, such as opium, cinnamon and ipecacuanha. The chemical elements, as a rule, were found to possess comparatively slight medicinal value while in their simple form, and except for their power of chemical combination would have remained of little use. Their great value, therefore, depends upon 22 DRUGS AND MEDICINES the large number of useful combinations which they form. To illus- trate: ]\Iercury or quicksilver in its pure form is insoluble and non- medicinal, but combined with chlorine in a certain proportion it yields calomel (HgCl), a valuable cathartic; and in another proportion it yields corrosive sublimate (HgCl2), a powerful antiseptic; again, it may be combined with sulphur to produce a ^-aluable red coloring agent known as vermilion (HgS). An almost endless \'ariety of combinations among the eighty-three chemical elements now known, provides a field from which we draw many agents used in dentistry, with a limitless future as to new compounds. ]\Iuch of both scientific and commercial energy is being expended in the synthesis, or putting together, of chemicals in order to secure new valuable compounds. The products are often referred to as synthetics. Phenacetin and saccharin are examples of this class. Remarkable also it is, that, besides new products, many of the active principles originally obtained from organic drugs are now produced s^^lthetically in the laboratory. Salicylic acid, artificial oil of wintergreen, and even phenol, furnish examples of such. In strong contrast to the above, the other group, the organic drugs, besides being of use in their crude form, lend themselves to division and analysis rather than to combination. They are complex in their composition, therefore one organic drug may contain from one to a dozen or more distinct substances of medicinal value. These are called crmstituents , active imnciples or proximate principles of the drug. For example, opium, the juice of the unripe seed-capsule of the opium poppy, contains gum, albumin, sugar, wax, pectin, salts, caoutchouc, acids and at least twenty alkaloids, among which are morphine and codeine. The most important work being now done upon these complex drugs is that of isolating their active principles or constituents in a state of purity and stability; and when a single principle is found to represent the drug fully it is commonly used in its stead. We have, therefore, in the rational grouping of drugs : 1. The chemical substances and their elaborated compounds. 2. The organic crude substances (of vegetable and animal origin) and their isolated active principles. PREPARATIONS OF DRUGS. Nearly all of the organic and many chemical drugs are not in proper form for administration without further preparation, hence the elabo- PREPARATIONS OF DRUGS 23 ration of our materia medica to include a large number of preparations which represent more or less completely, in medicinal value, the simple or crude substances. It would be interesting to trace the development of pharmacy in bringing forth the different kinds of preparations, in response always to definite needs, and to note individual characteristics in each class; but it must suffice to state in general that they fulfil needs in prepa- ration, such as solubility and permanency, and likewise needs in administration, such as pleasant form and taste, definiteness of strength, external uses, etc. These preparations are obtained by simple solution of a drug, by extraction of its active principles, or by incorporation of it with a vehicle, the objects of such preparations being to secure the medicine in a suit- able form, in definite strength, and in a permanent or stable condition. Occasionally chemical action is employed, but the larger number are produced without any chemical change occurring in the ingredients. The preparations produced without chemical action are known as galenical preparations, being so named after the ancient physician Galen. With so many drugs, furnishing so large a number of preparations, the need of standards of identity, purity, strength, etc., is very appar- ent. Such standards are provided in the United States Pharmacopceia.* As regards strength of organic drugs the amount of active principle present seemed to be the best basis for standardization, and much progress has been made in recent years in establishing processes of assay to which the substances must conform. Several that do not admit of a determinative chemical assay are now tested biologically. Tests of various salts and chemicals have been also added, so that now the Pharmacopceia gives about 300 assays of drugs and preparations. This contributes ^'ery much to definiteness and insures greater reliability and accuracy in the use of our most important medicines. Among all of the classes, the fluidextracts deserve emphasis as the most representative preparations of the crude organic drugs. They are so prepared as to contain all of the active principles, to be of a uni- form definite strength, and to keep indefinitely. The tinctures may be regarded as equal in importance, being permanent alcoholic solutions of drugs, though weaker than fluidextracts. Syrups present the drugs in form for pleasant administration, as also do pills and troches. * See page 18 and footnote. 24 DRUGS AND MEDICINES Plasters, linimciits and ointments illustrate the adaptation of drugs to external uses. The A'arious preparations are presented in the folio ^ving list, arranged in classes alphabetically, with each class defined, and the names given of the most important ones, or those of interest to the dental specialist. The names given, both for each class and each individual preparation, are those employed in the official volume, the U. S. Pharmacopoeia. CLASSES OF OFFICIAL PREPARATIONS. Acetum. — A Vinegar.^ — A solution of a medicinal substance in diluted acetic acid. Vinegars have an acid reaction. Acetum S'cillse. Aqua. — A Medicated Water. — A solution of a volatile substance in water. *Aqua ammonise (10 per cent.). *Aqua chloroformi (about 0.5 per cent. ) *Aqua ammonia? fortior (28 per cent.). Aqua cinnamomi. *Aqua amj'gdalse amarff. Aqua creosoti. Aqua anisi. Aqua menthie piperita?. A(iua aurantii florum. Aqua ros£e. Aqua camphorae. Those marked thus (*) may be either irritating or poisonous when used freely. All others are harmless, being used mostly as flavoring agents. Ceratum. — A Cerate. — A preparation having a fatty base with a melting point above the temperature of the body. Ceratum. Ceratum cantharidis (35 per cent.). Cerates are used only for local medication or protection. Collodium.- — A Collodion.^ — A liquid preparation for external use, having as a basis a solution of guncotton in a mixture of ether and alcohol. Collodium. Collodium flexile. Collodium cantharidatum. CoUodia are employed to protect or to constrict tissue, or to apply an irritant drug to the skin. Having the nature of a varnish, they cannot be applied unless the surface is perfectly dry. They dry quickly by evaporation of the ether and alcohol. Decoctum.— A Decoctiox.^ — A liquid preparation made by boiling a vegetable drug in water. Not used where active principle is volatile. CLASSES OF OFFICIAL PREPARATIONS 25 The U. S. Pharmacopoeia gives a general formula for decoctions of 5 per cent, strength. Unless some preservative is added, they do not keep well; so they must be freshly prepared. Elixir. — An Elixir. — A sweetened, aromatic, spirituous preparation of one or more drugs, designed for pleasant administration. Elixir aromaticum. Elixir glyc>Trliiz£e. Some elixirs are used only as vehicles, their alcoholic character permitting the addition of fluidextracts without precipitation. The National Formulary contains the formulas of a large number of elixirs for the administration of drugs of unpleasant taste. Emplastrum. — A Plaster. — A solid preparation for external use, adhesive at the temperature of the body. Emplastrum belladonnge. Emplastrum elasticum. Emplastrum capsici. *Emplastrum ichthyocollse. Emplastrum cantharidis. Emplastrum sinapis. These are usually spread upon muslin and are intended for protection to the skin, or for the application of either irritating or sedative drugs. Emulsum. — ^An Emulsion. — A liquid preparation, in which oil or resinous matter is held in suspension in water. They require a viscid or mucilaginous- substance in order to effect and maintain the suspension of the insoluble particles. Emulsum amygdate. Emulsum olei morrhuse (cod-liver oil). Emulsum asafcetidae (4 per cent.). Emvdsum olei terebinthinse. Emulsions are in no sense solutions, their object being to carry sub- stances that are not soluble in water. In case of asafoetida, a gum- resin, there is sufficient gum in the drug to carry the resin, so that the emulsion is formed hy rubbing up the drug with water only. Extractum.— An Extract. — ^A solid or semisolid concentrated prep- aration of the soluble constituents of a drug. Extractum aconiti. Extractum glycyrrliizae. Extractum beUadonnse foUorum. Extractiun malti. Extractum colocynthidis. Extractum nucis vomicae. Extractum ergotse. Extractum opii. The object of this class is chiefly concentration of the drug, but the keeping qualities are usually also improved. The form permits of their being made readily into pills, or of ready solution. Fluidextr actum. — A FLriDEXTRACT. — An alcoholic or hydro-alcoholic solution, one milliliter f of which represents one gram of the crude * Courtplaster, an exception to the rule, is applied with moisture. (Not official.) t Formerly called cubic centimeter. 26 DRUGS AXD MEDICINES drug. [Acids or alkalies are sometimes used to aid in the extraction of the principles.] Fhudextractum aconiti. Fliiidextraetum glycyrrhizae. Fluidextractum aurantii amari. Fluidextractum guaranae. Fluidextractum belladonna:^ radicis. Fluidextractum hj-drastis. Fluidextractum digitalis. Fluidextractum ipecacuanhse. Fluidextractum ergotae. Fluidextractum nucis vomicae. Fhiidextracts constitute the most representative class of preparations, there })ein.s 49 official. Their drug strength is uniformly 100 per cent. Glyceritum. — A Glycerite. — A solution of a medicinal substance in glycerin. Glyceritum acidi tannici (20 per cent.). Glyceritum hydrastis (100 per cent.). Glyceritum boroglycerini (31 per cent. *Glyceritum phenolis (20 per cent.), of boric acid). Infusum. — Ax Infusion. — A liquid preparation made by macerating a vegetable drug in hot or cold water. Infasum digitalis. Infasum sennge compositum. There is also a general formula for infusions of 5 per cent, strength. These preparations do not keep well. Either they must be freshly- made or some preservative added. Linimentum. — A Liniment. — A liquid preparation for external use, usually possessing a stimulating or sedative property. Liniments vary much in character, but most of them contain some oil or soap. Linimentum ammoniae. Linimentum chloroformi (.30 per cent.). Linimentum belladonnae. Linimentum saponis. Linimentum calcis. Carron oil. Linimentum saponis mollis. Linimentum camphorae. Camphor- fLinimentum terebinthinae (35 per cent.). ated oil. Liquor. — A Solution. — An aqueous solution of one or more non- volatile substances, [in some a chemical reaction is employed to obtain the desired product.] Liquor arseni et hydrargyri iodidi. Liquor iodi compositus (5 per cent. Liquor arseni arsenosi (1 per cent.). iodine). Lugol's solutioii. Liquor calcis. Lime-water. Liquor plumbi subacetatis. Liquor cresolis compositus. Liquor potassii arsenitis. Liquor ferri chloridi. Liq. potassii hydroxidi (4.5 per cent.). Liquor ferri subsulphatis. MonseVs Liquor sodae chlorinatae (2.5 per cent. solution. chlorine). Liquor ferri tersulphatis. Liquor sodii arsenatis. Liquor formaldehjdi. Liquor sodii hydroxidi (4.5 per cent.). Liquor hydrogenii dioxidi (3 per cent.). Liquor zinci chloridi (50 per cent.). * Formerly glyceritum acidi carbolici. t Linimentum terebintliina' (tiu-pentine liniment) may be .semisolid. CLASSES OF OFFICIAL PREPARATIONS , ''*' ''/.FT Massa. — A Mass. — A mixture of substances of the proper consistence to be made into pills. Massa ferri carbonatis. Massa hydrargj-ri. Blue -pill (33 per cent. m:rcur3'). Mistura. — A ]Mixture. — An aqueous liquid preparation usualh' hold- ing some insoluble matter in suspension. Mistura cretge. Mistura glyc}Trhiza^ comp. Broirn mix- ture. Mucilago. — A IMucilage. — A solution of a gum or vegetable mucilage in water. ^Mucilages are used as demulcents, or as excipients in various preparations. ]Mucilago acacise (35 per cent.). Mucilago tragacanthse. Oleatum. — Ax Oleate. — A solution of a medicinal substance in oleic acid. Oleic acid here contributes a superior penetrating quality. *01eatum cocainse (5 per cent.). *01eatum veratrinse (2 per cent.). Oleatum hydrargjTi (25 per cent. ye\- low oxide). Oleoresina. — Ax Oleoresix. — X liquid or semiliquid mixture, chiefly of oil and resin, extracted from the drug by percolation with ether. [They are really ethereal extracts.] Oleoresina aspidii. Oleoresina cubebse. Oleoresina capsici. Oleoresina zingiberis. The term also applies to certain natural products, consisting of mixtures of oil and resin, which occur as exudates from the trees con- taining them. These may be liquid or solid. Examples are: Copaiba (Uquidj. * Terebinthina (solid). Oleum. — Ax Oil. — A natural compound of one or more of the fatty acids with glycerin. True oils and fats must be capable of saponifica- tioQ, /. e., forming a soap when treated with an alkali. They vary in consistence and in melting point, chiefly on account of the varying proportions of olein, palmitin and stearin which they contain. They are not volatile. They occur naturally in animal tissues and in the seeds of many plants and trees. Oleum amygdalae expressum. Oleum olivse {olive oil). Oleum gossypii seminis. Oleum ricini (castor oil). Oleum lini {linseed oil). Oleum tiglii (croton oil). Oleum morrhuse {cod-liver oil). * Not official. 2S DRUGS AND MEDICINES The solid fats are: Adeps (lard). Oleum theobromatis (cacao butter). Adeps lana? (lanolin). Sevum pra^paratum (suet). Spermaceti and wax are similar to these in that they are saponifiable, but they contain no glycerin. Petrolatum (vaselin) is not a fat, although it may be used as a basis in ointments. Oleum Destillatum. — A Distilled Oil. [Volatile Oil. Essential Oil.] — A volatile, oily principle usually obtained from the crude drug b}^ distillation. They are not saponifiable, therefore they are not true oils. The volatile oils are usually the essential principles of the plants yielding them. It will be noticed that many of them are obtained from spices. *01eum amygdalae amara> (bitter almond) . Oleum limonis (leino7i). Oleum aurantii (orange). Oleum mentha; piperita? (pepperminl). Oleum cajuputi. *01eum sinapis volatile (mustard). Oleum caryophylli (cloies). Oleum terebinthinse (turpentine). Oleum cassiae (oi7 of ci?i?iamon). Oleum thymi. Oleum eucalypti (contains eucalj-ptol). Oleum gaultherise (methyl salicylate; oil of irintergreen) . Pilula. — A Pill. — A spherical or oval mass, containing one or more medicinal ingredients, intended to be swallowed whole. Pilulse (plur.) aloes (gr. 2 in each). Pilulse ferri carbonatis. Pilulae asafoetida; (gr. 3 in each). Pilulse ferri iodidi. Pilulse catharticEC compositse (gr. 1 of Pilulse phosphori (gr. j^-^ in each), calomel included in each pill). Pilulse rhei compositse. The chief object in the use of pills is to avoid the unpleasant taste of medicines. Sometimes, however, they may be used in order to secure a slow or delayed absorption of the medicine. Resina. — A Resin. — A solid preparation consisting chiefly of resin- ous substances. They are insoluble in water, and are usually obtained by precipitation from tinctures by the addition of water. As a class resins are soluble in alcohol, ether, chloroform and oils. They soften with the aid of heat. Resina (rosin). Resina podophylli. Resina jalapse. * Resina scammonise. * These do not exist ready formed in the drug, but are developed when the drug is moistened with water, in the presence of which a reaction' between certain con- stituents occurs, with the formation of the volatile oil. This process must precede distillation in case of these. With the exception of these two, which are poisonous and should never be given in larger dose than TTlJ (0.03 gm.), the dose of. the volatile oils is mi-5 (0.06-0.30 gm.). CLASSES OF OFFICIAL PREPARATIONS 29 GuM-RESixs are related to the above, but differ from them in compo- sition and solubility. They contain a gimi associated u^ith the resin; therefore they are only partly soluble in ahohol and are partly soluble also in water. The two most important ones are: Asafoetida. MjTrh. Balsamic Resins and Balsams also belong to the group of resinous substances. They are characterized by the presence of benzoic or cinnamic acid. They include : Benzoinum. Balsamum peru\'ianuin. Styrax. Balsamum tolutanum. Sapo. — ^A Soap.- — An alkaline product of the reaction between a fatty acid and either soda or potassa.* Soaps are prepared by heating a fat or oil with an alkali — potassa yielding a soft soap and soda a hard soap. Sapo {white castile soap). Sapo mollis (soft soap). Spiritus. — ^A Spirit. — An alcoholic solution of a volatile substance. Many of the spirits are prepared from the volatile oils. Spiritus getheris (32.5 per cent.). Spiritus glycerylis nitratis (1 per cent. Spiritus aetheris nitrosi. nitroglycerin). Spiritus ammonise aromaticus. Spiritus lavandulae (5 per cent. oil). Spiritus anisi (10 per cent. oil). Spiritus menthse piperitse (10 per cent. Spiritus camphorse (10 per cent.). oil). Spiritus chloroformi (6 per cent.). Spiritus myrcise (bay rum — not official). SpiritiLS cinnarnomi (10 per cent. oil). Suppositorium.- — A Suppository. — A solid, conical mass, containing one or more medicinal substances, intended for introduction into some passage or cavity of the body. A suppository should melt readily at the temperature of the body, to ensure which a base of either cacao butter or glycerinated gelatin is commonly employed. The size may vary from 15 to 60 grains (grams 1 to 4). The U. S. P. gives general directions for their preparation with either base. They are made of different shapes, according to the particular use for which they are intended. Those for introduction into the urethra, often called bougies, are pencil shaped, while for rectal and vaginal use they are conical or oval. The following is exceptional in being prepared with sodiiun stearate as a base, and in being used simply as laxative, acting by local irritation. Suppositoria (plur.) glycerini. (These contain about 80 per cent, of glycerin with a soap for a base.) * This definition is a restricted one, intended to define the official soaps. Chemi- cally speaking, the salt of a fat acid with any inorganic base is a soap. 30 DRUGS AND MEDICINES Syrupus. — A Syrup. — An aqueous medicinal solution containing sugar nearly to saturation. [A few syrups are without decided medicinal value, being used chiefly as vehicles.] Being rather thick in consistence, they may hold solid particles in suspension, thus possessing added value as excipients, and their con- sistence also gives them something of the quality of demulcents. As a rule, they are weaker than tinctures. Two objects are secured in this class of preparations — preservation and pleasant taste — both of which are due to the large amount of sugar present. Syrupus (85 per cent, sugar). Syrupus pruni virginianse. Syrupus acaciiE. Syrupus rhei. Syrupus acidi citrici. Syrupus rhei aromaticus. Syrupus aurantii. Syrupus scillse. Syrupus ferri iodidi. Syrupus scillse compositus. Syrupus hypophosphitum. Syrupus tolutanus. Syrupus ipecacuanhae. Syrupus zingil^eris. Syrupus lactucarii. Tinctura. — A Tincture. — An alcoholic or hydroalcoholic solution of the active principles of a crude drug or of a non-volatile substance. Tinctures are weaker than fluidextracts and have no uniform strength as a class, except that tinctures of potent drugs are of 10 per cent. strength. Tinctura aconiti. *Tinctura iodi (7 per cent.). Tinctura lielladonna' foliorum. Tinctura kino. Tinctura benzoini. Tinctura lavandula? composita. Tinctura benzcini composita. Tinctura niyrrha^. Tinctura cantharidis. Tinctura nucis vomica^. Tinctura capsici. Tinctura opii (10 per cent.). Tinctura cinchonge. *Tinctura opii camphorata (0.4 per cent. Tinctura cinchona? composita. opium). Tinctura cinnamomi. Tinctura opii deodorati (10 per cent.). Tinctura digitalis. Tinctura tolutana. Tinctura ferri chloridi. Tinctura veratri. Tinctura gambir composita. Tinctura zingiberis. Tinctura gentiana; composita. In point of number the tinctures hold first place, there being 54 official. Trituratio. — A Trituration. — A powder consisting of a potent drug diluted and finely divided by means of sugar of milk. The IT. S. P. gives a general formula for the preparation of 10 per cent, triturations. The following is the only official one named separately : Trituratio e'aterini. (See Tablet Triturates following.) * In these some of the medicinal constituents are quite volatile. CLASSES OF OFFICIAL PREPARATIONS 31 Trochiscus. — Tabella. — A Troche or Tablet. — A solid preparation in tablet form, consisting of one or more medicinal substances combined with sugar and mucilage. Trochisci (plur.) acidi tannici (gr. 1 Trochisci sodii bicarbonatis (nearly gr. in each). 3 in each). Trochisci ammonii chloridi (gr. 1| in Toxitabellse hydrargyri chloridi corro- each). sivi (gr. 7i in each). Trochisci cubebse (Tn, § of oleoresin in each). Several subdivisions of the class of troches must now be recognized, some of which do not conform exactly to the definition given above. Tablet Triturates combine the characters of the trituration and the troche, having the medicine in a finely divided state and in a form pleasant to take. A great variety of combinations are now prepared in this form, presenting a convenience of handling and of administra- tion that does not obtain with the liquid forms of medicine. With some drugs, however, the fresh liquid preparations are more reliable and greatly to be preferred. Hypodermic Tablets. — For h^'podermic use it is desirable to have the medicine readily soluble, therefore the tablet should contain little or nothing besides the active substance. With some drugs a little mucilage may be required to secure adhesion of the particles, but the least possible amount should be used. Compressed Tablets. — ^Many substances are sufficiently cohesive to admit of being compressed into tablet form without the addition of any adhesive material. Some that take the tablet form readily do not maintain it indefinitely. They may be deliquescent and become soft or even liquid ; or they may be efflorescent and become dry and crumble. Such will require to be kept in tightly-corked bottles. The compressed tablets, however, are very convenient and usually present the drug in its pure form. Unguentum. — An Ointment. — A semisolid fatty preparation for ex- ternal use, having a melting-point near the temperature of the bod}'. Unguentum acidi borici (10 per cent.). Unguentum hydrargyri dilutum (30 per Unguentum acidi tannici (20 per cent.). cent.). Unguentum aquae rosfe. Unguentum iodi (4 per cent.). Unguentum belladonnse (10 per cent. Unguentum phenolis (2 J per cent, of extract). Uquefied phenol). Unguentum gallse (20 per cent.). Unguentum sulphur is (15 per cent.). Unguentum hydrargyri (50 per cent.). Unguentum zinci oxidi (20 per cent.). Unguentum hydrargyri ammoniati (10 per cent.). 32 DRUGS AND MEDICINES Ointments are intended to protect, soften or medicate the skin. A few, such as unguentum hydrargyri, are used for the purpose of sys- temic medication by being rubbed into the skin. CONSTITUENTS OF DRUGS. In the foregoing hst of preparations there are some that are, as well, simple constituents. This is true of the oils, the distilled oils and the resins, these being obtainable by simple means in a fairly pure state, but there are other constituents that are less easily separated from the drug, but which are usually the most active and important of its principles. As we study the value of an organic drug in its desirable medicinal effects, it is evident that the latter must be dependent, not upon the whole drug, but upon the action of one or more of its constituents or proximate principles;* for every crude drug contains inert matter, while some have constituents of undesirable action. It is important to know just which of the principles are medicinally valuable; and where such are capable of isolation there is evident advantage in their employment instead of the preparations of the whole drug. Their recognition depends upon their possessing a definite chemical character which is not essentially altered in the process of extraction.* Since the recognition of morphine in opium by Setiirner, in 1817, much effort has been expended in securing the active principles of the various drugs in a state of purity and solubility for practical use. So successful has the effort been with many of our leading drugs that their quality is now gaged by the amount of active principles present, e. g., opium cannot be official unless it contains 9.5 per cent, of morphine. Of all classes of active constituents the alkaloids and the glucosides are most important and distinct. . Alkaloids. — These are defined to be nitrogenous compounds of organic origin, having the reaction and basic property of alkalies. The following are some of the most prominent alkaloids : Aconitine, from aconite. Mori)hine, from opium. Atropine, from belladonna. Narcotine, from opium. Caffeine, from tea, coffee and guarana. Nicotine, from tobacco. Cinchonine, from cinchona. Pilocarpine, from pilocarpus. Cocaine, from coca leaves. Quinine, from cinchona. Codeine, from opium. Scopolamine or hyoscine, chiefly from Emetine, from ipecacuanha. hyoscyamus and stramoniimi. Hydrastine, from hydrastis. Strychnine, from nux vomiciE. Hyoscyamine, from hyoscyamus. Veratrine, from asagra;a officinalis. * The term proximate principle is defined to be any substance, either simple or compound, which is present in its own form in the drug, as proven by its being capable of extraction without change of its chemical properties. CONSTITUENTS OF DRUGS , 33 Alkaloids have a definite chemical composition. Most of them are crystallizable, although a few are liquid, e. g., nicotine. Most of them are bitter to the taste, some intensely so. The pure alkaloids, as a rule, are nearly insoluble in water, but their basic character permits the formation of salts that are freely soluble. For example, while cocaine requires 600 parts of water to dissolve it, cocaine hydrochloride is soluble in 0.4 part of water, or 1500 times more soluble than simple cocaine. Therefore, almost without exception, soluble salts of alkaloids are used instead of the simple substances. Double salts also are sometimes employed. Alkaloids usually represent much or all of the activity of the drugs containing them, and it is believed that they exist in the drugs only in combination with acids. This has been proven to be true of many of them, e. g., morphine exists in opium in combination with either sul- phuric or meconic acid, i. e., as sulphate or as meconate of morphine; strychnine is combined in nux vomica with igasuric or "strychnic" acid, etc. As a class, we accord alkaloids the preeminence among medicines. Their action is chiefly upon the nervous system, through which they may exert an indirect influence upon other kinds of tissue. They have almost no influence upon elimination, none of them being classed among the cathartics. They are very active agents in comparatively small medicinal doses, and many of them are poisonous to the nervous system when given in large doses. Because of smallness of dose, ready solu- bility, and the fact that they are not irritating to tissues, as a rule, most of their salts may be used hypodermically. They furnish our most powerful narcotics and anodynes. Two especially, morphine and cocaine, present the danger of drug habit through unguarded or continued use. In some drugs these principles are very numerous. Opium and cinchona, for instance, each yield twenty or more alkaloids. Artificial Alkaloids.- — Besides the large number of alkaloids existing naturally, a number of others have been produced artificially, usually by subjecting a natural one to chemical change. Some of these arti- ficial bodies are valuable additions to the list, as they are found in some instances to have an action quite distinct from that of the original alkaloid. The principal artificial alkaloids are : Apomorphine, from morphine. Ethylmorphine (dionin), from morphine. Betaeucaine (eucaine), from piperidine. Homatropine, similar to atropine. Cotarnine (stypticin), from narcotine. Hydrastinine, from hydrastine. Diacetyhnorphine (heroine), from Novocaine, a synthetic product, morphine. 3 34 DRUGS AND MEDICINES Incompatibility of Alkaloids. — Drugs are said to be incompatible with each other when their mixture results in an undesired physical or chemical change. In using either natural or artificial alkaloids we must have in mind their incompatibility with certain other substances, as given below: 1. JJlth Alkalies. — The basic power of the alkaloids is exceeded by that of the ordinary alkalies, therefore the latter easily decompose the salts of the former. Hence, it may be stated that alkaloidal salts in solution are incomjjatible 7cith alkalies and alkaline carbonates, the mixture leading to precipitation of the alkaloid. The danger here is from the deposited drug, which might be taken in poisonous quantity in the last one or two doses of the mixture. 2. With Tannic Acid.- — Alkaloids unite with tannic acid to form tan- nates, which are insoluble; therefore, alkaloids and their salts in solution are incompatible with tannic acid or ^^ ith any preparation containing it, the mixture resulting in a deposit of the tannate of the alkaloid.* 3. ]\ith Metallic Salt^. — Certain metallic salts, especially double salts or double iodides, cause precipitation when mixed \A"ith alkaloidal solutions. Lugol's solution also will precipitate the salts from solu- tion. Ptomaines and Leukomaines. — Two other classes of bodies belonging to the group of organic bases, but which are in no sense medicines, should be mentioned here because of their similarity to the vegetable alkaloids. They are ytomaiiies, or putrefactive alkaloids, which are basic substances produced by the action of bacteria upon organic matter, and leukomaines, which are basic substances resulting from normal tissue metabolism. The former are of special interest as contributing to the toxicity of many bacterial diseases, and from the resemblance of certain of them in their action to the vegetable alkaloids. Thus, tetanine, present in the disease tetanus, or lockjaw, produces the char- acteristic spasms of this disease, which resemble closely those pro- duced by strychnine. Others are narcotic in action, bearing some resemblance to morphine or atropine. Glucoides. — This class comprises those vegetable proximate prin- ciples which, when decomposed by boiling with acids or alkalies, or by *There seein.s to be a contradiction to the above in the fact that a number of vegetable drugs contain both tannic acid and alkaloids, without any 'precipitation occurring in their liquid preparations. The explanation of this is that the alkaloid is present in a natural combination, which is not broken up by the peculiar tannic acid that is its natural associate in the particular drug; or the alkaloid may be in natural combination with the tannic acid. CONSTITUENTS OF DRUGS 35 the action of ferments, yield glucose, with some other product peculiar to the substance tested. Some have the chemical behavior of acids, while some resemble resins in nature. Neutral principles are somewhat similar, but ha\'e neither alkaline nor acid properties. These two classes form a group, some members of which are of great value in medicine. Santonin, aloin, glycATrhizin, amygdalin, digitalin, and elaterin furnish examples. While their uses are varied, the activity of many of them is addressed to the eliminative functions. Especially do we find them in the cathartic drugs. As a class they influence the nervous system less than do the alkaloids, and they are less poisonous. CHAPTER II. REMEDIES: THEIR CLASSIFICATION AND DEFIXITIOXS. The term remedy includes any agent, of whatever character, employed in the treatment of disease. It may be a medicine or an external force or influence. It may be intended for internal administration, for external application, or for less direct mental influence. Remedies are usually grouped as follows: Preventive remedies, those that are employed to prevent the acqui- sition, development, or propagation of disease, e. g., vaccination to prevent smallpox, and disinfection to pre^'ent the spread of any infec- tious disease. Since it has become known that all infectious diseases are preventable, this group has attained a rank of first importance. Hygienic remedies, those that conduce to the maintenance of health and of good resistive power against the causes of disease. They include proper food, ventilation, exercise, bathing, etc. This group is closely related to the preceding and, on the whole, stands next to it in importance, it being a sound principle that such natural means of preventing or correcting diseased conditions, when efficient, should be held as preferable to artificial medicinal or mechani- cal means. Mechanical remedies, those that involve the application of mechanical principles or appliances, e. g., restraint, the use of splints, bandages and surgical instruments. Imponderable remedies include forces or influences that are not material in nature, e. g., heat, electricity, sunlight. Medicinal or pharmacologic remedies, the substances administered or applied in the treatment of disease. They are known as medicines. They are intended to directly modify functions, or to antagonize the process of disease, or remove its results. Being material in nature, they form the basis of pharmacology, or the study of the action of medicines. Our classification will concern this group chiefly, and will be based upon action and uses, rather than the sources of the various substances. CLASSIFICATION OF REMEDIES 37 REMEDIES . Classification of Remedies. Local. General. Local Remedies Depletives. Rubefacients. Vesicants. Escharotics. Demulcents. Emollients. Astringents. Hemostatics. Detergents. Antacids (alkalies). Antiseptics. Bleaching agents. Analgesics. Stimulants (tonics) Alteratives. Arterial stimulants Nerve stimulants [ Digestive stimulants. Diffusible. Cardiac. Vascular. Cerebral. Spinal. Vasomotor. Sedatives General Remedies > Antispasmodics. f Cardiac. [Arterial sedatives | Vascular. IAnodjmes. Hypnotics. Narcotics. I Anesthetics. I Antipyretics. Eliminatives Antiseptics. Antitoxins. Vaccines. Digestants. Anthelmintics. [ Nerve sedatives Errhines. Sialagogues. Emetics. <* Expectorants. Diaphoretics. Diuretics. . Cathartics. 38 REMEDIES: THEIR CLASSIFICATION AND DEFINITIONS DEFINITIONS. Local Remedies. Depletive. — The class of local depletives includes the various means employed to abstract blood or serum from an inflamed or hy])eremic area. Scarification, leeching and cupping are the common means. Rubefacient. — An agent that produces redness of the skin. Vesicant or Epispastic. — An agent that produces a blister. Escharotic or Caustic. — An agent that destroys tissue. The terms rubefacient, vesicant and escharotic may represent the different degrees of action of the same agent in some instances. Demulcent. — An agent that protects or soothes a raw, irritated or inflamed surface. It is usually an oily, mucilaginous or albuminous substance that directly coats over the surface, but it may be an agent that, upon a mucous surface, stimulates the natural secretion, which itself acts as a demulcent. Emollient. — An agent that softens and soothes an inflamed part. Poultices and ointments are the typical emollients. Astringent. — An agent that causes contraction of tissue. Hemostatic. — An agent employed to arrest hemorrhage. Besides the astringents, thermal and mechanical agencies are included. Detergent. — An agent used to cleanse surfaces, wounds and ulcers. Antacid. — An agent capable of neutralizing acids, by reason of either its alkaline or basic property. Antiseptic (Local). — An agent that prevents the growth and propaga- tion of septic bacteria. Antiseptics, germicides and disinfectants form a related group which will be differentiated in connection with their detailed discussion. Bleaching agents include the agents and means employed to remove discoloration of tooth structures. Analgesic. — An agent that destroys sensibility to pain. General Remedies. Stimulant. — An agent that increases the activity of an organic function or process. The action of stimulants is temporary and tends to exhaustion of reserve energy. DEFINITIONS 39 Tonic. — An agent that restores one or more lacking elements to the tissues, or promotes their nutrition, or conserves their reserve energy. Alterative. — ^An agent that counteracts a morbid state of tissue by altering in a favorable manner the processes of nutrition. The action is usually obscure. Alteratives become intimately associated with the tissue elements during their stay in the system; they act slowly and influence the ^dtal processes. Sedative. — ^An agent that diminishes the activity of an organic func- tion or process. Anodyne. — An agent that relieves pain. An anodjTie may depress sensory nerve endings, or lessen conductivity of nerve fibers, or diminish the receptivity of brain centers. Hypnotic. — An agent that induces sleep. Narcotic. — ^An agent that produces stupor. The same agent may be anodyne or h}'pnotic in moderate dose and narcotic in large dose. Anesthetic. — ^An agent that abolishes all sensation. Antipyretic. — An agent that causes reduction of temperature in fever. Antispasmodic. — An agent that relieves spasm or convulsion. The term simply describes one effect of medicines that may be stimu- lating or sedative in their general action. Errhine or Sternutatory. — An agent that increases the secretion of the nasal mucous membrane. The latter term refers especially to agents that cause sneezing. Sialagogue or Ptyalagogue. — An agent that increases the secretion of saliva. Emetic. — An agent that causes evacuation of the stomach. Expectorant. — ^An agent that increases the secretion of the air passages. Diaphoretic or Sudorific. — An agent that induces sweating. Diuretic. — An agent that increases the excretion of urine. Diuretics may act through the circulation by increasing arterial pressure or modifying the composition of the blood, or by directly stimulating the activity of the kidneys. Cathartic. — ^An agent that causes evacuation of the intestinal tract. Antiseptic (General). — An agent that, being absorbed, renders fluids or tissues of the body destructive of, or resistant to the growth of, bacteria or other parasitic bodies. Antitoxin. — ^A serum that possesses the power to neutralize the toxic product of the bacteria of some particular disease. 40 REMEDIES: THEIR CLASSIFICATION AND DEFINITIONS Vaccine. — A substance used by inoculation or injection for the pur- pose of securing immunity to some disease. Digestant. — An agent that aids the sohition and preparation of foods for absorption. Anthelmintic. — An agent that destroys intestinal parasites. The same agent may be a vermifuge, the latter term referring to expulsion of the parasites. CHAPTER III. ADMINISTRATION OF MEDICINES. It is a sound principle in medicine that the more nearly a remedial substance can be applied to the point of disease, the more effectual and the safer is its use. In accordance with this, our remedies should be applied locally as far as possible. The site of the disease, therefore, will determine in very many cases the selection of the site, avenue or method of application of a medicine. The urgency of a condition also will demand a choice of method, as an emergency often calls for the most rapid administration that is possible. We recognize various avenues and methods by which medicines are introduced to the system, and these require separate discussion. By the Stomach. — Stomach or mouth administration is the original and common method employed for the great majority of medicines. As the stomach and intestine constitute the natural avenue of absorp- tion of food substances, it is the one that most easily provides for solu- tion and absorption of a medicine, and the one that is most tolerant of the introduction of an unusual substance. It should be noted that absorption is more active from the small intestine than from the stomach; also that fluids begin to pass from the stomach into the intestine very soon after being swallowed. A very soluble drug that requires only a small dose may be placed under the tongue, and absorption follows quickly. Nitroglycerin given in this way will produce its general effect within three minutes. It is, however, a very diffusible drug. Form of Medicine. — The substance employed should be in a soluble condition, or in solution, if intended for absorption into the blood. For local effect in the stomach insoluble medicines are frequently used, e. g., bismuth subnitrate. The reaction of the gastric juice is acid; that of the intestinal juices is alkaline; thus, the solution of any substance soluble in either an acid or alkaline fluid is aided. We find that practically any substance that is even slightly soluble, whatever its form when swallowed, will in time find its way into the fluids of the body; Solution and absorp- .42 ADMINISTRATION OF MEDICINES tion are sometimes aided by chemical change, as in the case of iron, which is changed to chloride of iron by union with the hydrochloric acid of the gastric juice. Some substances that require an alkaline liquid to dissolve them may pass through the stomach unchanged. This is true of salol, which is insoluble either in water or in an acid liquid. It reaches the small intestine unchanged, where it is soon decomposed and absorbed. Rapidity of effect depends upon soluhiliti/ and rate of ahsorytum. Quinine sulphate given in powder form will require considerable time for solution, on account of its slight solubility except in the presence of a free acid. . It will probably require the secretion of considerable gastric juice to dissolve a full dose of this drug; therefore, when given in powder, an hour or two will elapse before the effect is appreciated. The same drug given in solution will produce its effect much sooner, particularly if it be given when the stomach is empty. The rate of absorption depends somewhat upon the diffusibility of the medicine used, but all of the conditions that modify osmosis have their influence; the activity of the circulation, the state of blood-pressure, difference in specific gravity or degree of salinity between the stomach contents and the blood, and the physical character of the substance to be absorbed, must all have their influence. Fats and oils before they can be absorbed require to be saponified, which change occurs after they pass into the duodenum. Therefore, they are not absorbed at all from the stomach. Among all of the above-named, the one condition modifying the rate of absorption, that is best appreciated and most easily controlled, is the degree of dilution of the drug by the stomach contents which must be absorbed with it. Thus, if the dose be given upon an empty stomach, with only sufficient fluid to ensure its solution and proper dilution, absorption should occur quickly, say in half an hour; while the same dose given after a full meal would require three to four hours for com- plete absorption, because of its dift'usion through a quart or more of stomach contents which need that length of time for absorption. In the latter case only a part of the dose would be taken up from the stomach, as the contents with which, it is mixed pass gradually into the duodenum, from which absorption continues. It follows that, in order to produce a certain degree of effect, a larger dose will be needed when given ivith a full stomach than if given before a meal, for the degree of effect depends usually upon the amount of the drug circulating in the blood at one time. This amount will be determined by the quantity absorbed within a certain period, minus BY THE BOWEL 43 the quantity eliminated during the same period. With absorption slow and elimination active (the elimination of some drugs begins very quickly), the amount present in the blood at one time may be much less than the amount administered. As a rule, then, medicines will produce their effects with a minimum dose and in the shortest time (one-half to one hour) when given with the stomach empty. But some drugs are too irritating to be placed in an empty stomach. These will require great dilution. This is true of many of the salts, which diffuse easily, as a rule, and may be given with considerable water. Salts as irritating as the bromides and iodides should never be given without first being dissolved and well diluted. When rapidity of action is unimportant, as with tonics and altera- tives, we may as well give them after meals; except that bitter tonics, whose action is a local one upon the gastric mucous membrane, should be given ten or fifteen minutes before meals, in order to obtain their best effect. Cathartics are commonly given at bedtime so as to pro- duce their effect at about the time of the usual m.orning evacuation. Saline cathartics form a distinct class of medicines in relation to stomach administration, in that absorption is not necessary to their action. If given in concentrated solution upon an empty stomach their high degree of salinity (high osmotic pressure) will determine a flow of fluid from the blood into the digestive tract with prompt and copious watery evacuations. They are best ^iven in the morning upon arising, as a prompt effect from a smafler dose may be thus obtained than when given at evening after a meal. By the Bowel (Rectum and Colon). — Whenever, on account of inability to swallow or persistent vomiting, stomach administration is impossible, medicines or food may be introduced into 'ths lower bowel. Also for local medication of the rectum or other organs located in the pelvis, as in cases of dysentery or of hemorrhoids, this method may be our first choice. Form of Medicine. — The rectum does not provide for solution of sub- stances to any degree. Therefore, if our object be general medication we must ensure solution of our drug. But if we desire local medication only, then absorption into the general circulation is unnecessary, and, indeed, may be undesirable; so we may have our drug in a condition to be taken up slowly by the tissues, the action being correspondingly prolonged. For general effect a non-irritating solution should be used in moderate or small quantity, so that it may not be expelled. In order to favor retention and absorption, it is advantageous to place the dose 44 ADMIXISTRATIOX OF MEDICINES high up in the colon. This can be done with a patient in the recum- bent posture, by raising the hips above the level of the head. For local effect a solution or suppository may be employed. Rapidity of Effect.^ — For general effect the action of a medicine by rectal administration is slower than by the stomach; but with condi- tions unequal — i. e., comparing absorption from a full stomach with absorption from an empty rectimi we may have a more rapid effect from the rectmn. It is usually held to be true that the drugs which act upon the nervous system, e. g., narcotics, may be given in a much larger dose by the rectum with safety.* This may be due partly to slow absorption and partly to the distance from vital centers of the site of absorption. A safe rule for most substances seems to be that the dose iwr rectum may be twice the dose yer orem. In addition to medication it is common practice, after severe surgical operations, to supply water to the system by rectum. An approved method is the INIurphy method, by which fluid is introduced drop by drop, no more rapidly than the system absorbs it, and continued for hours or even days. By the Skin. — ^^Ve distinguish several methods, as follows: Epidermic, uhere a substance is applied to the surface of the skin for the purpose of local medication or of counterirritation. When a s^'s- temic effect is desired a similar application may be made, with friction added, to secure penetration into the skin. Thus mercurial ointment is very commonly employed in the treatment of s^-philis. The term inunction is applied to the use of ointments in this way. Endermic, an obsolete method, which consisted in first raising a blister, then, after removal of the epidermis, in sprinkling a medicine intended for absorption upon the raw surface. Hypodermic. — This method has assumed an importance which places it next to stomach administration. For promptness of action and definiteness of dose it is superior to all other methods, in the use of those drugs which admit of its emplo}7nent. Also, on account of rapidity of absorption, the dose may usually be about one-half of the dose by the stomach. The method consists of the introduction of the medicine into the subcutaneous tissue bv means of a small s^sTinge * Contrary to this, it is sometimes stated that strychnine is more poisonous when injected into the rectum than when swallowed. (Potter's Materia Medica, 1901, p. 391.) It is true that adrug absorbed from the lower part of the rectum will pass directly into the internal iliac vein and reach the heart and general circulation without passing through the hver, where its toxicity might be lessened. BY THE SKIN 45 armed with a hollow needle, through which the injection occurs. The pain of insertion of the needle deters from the use of this method for ordinary medication, and the dangers attending the injection, though slight, should require the greatest care in employing it. As a rule, this method "u ill find its place in meeting the following conditions : 1. Inability to swallow, as when unconscious, or after local injury. 2. Anj^ condition requiring the immediate action of a medicine, or absolute certainty of dosage. 3. Inability of the stomach to receive or retain the required medicine. 4. Conditions needing local medication, as in the emplo^mient of cocaine. In dental practice the injection method is well adapted to the need of securing local analgesia in many cases of extraction. A very short needle is here employed and the injection is submucous. The hypodermic and submucous injection methods are limited to the use of soluble, non-irritating drugs. Stimulation, the relief of severe pain and the production of local analgesia comprise the common indi- cations. The freely soluble alkaloidal salts in aqueous solution are well adapted, but alcoholic solutions are irritating. Tinctures are inferior on this account, but they may be used in emergency. The dangers attending hypodermic or submucous injection are: 1. Septic infection. 2. Injection of air into a vein. 3. Injection of medicine into a vein, which might mean an overdose. Septic infection may be due to lack of sterilization of the needle or of the solution employed. The result is usually formation of abscess. To avoid this danger the needle and syringe should be sterilized (by boiling if possible), and the solution be in boiled or distilled water and freshly made. The injection of air into a vein would cause interference ^ith the circulation through the lungs. The air, being carried to the right side of the heart, would be beaten up with the blood into a foam, by the action of the tricuspid valve. The air bubbles thus formed would not pass through the pulmonary capillaries; hence, the occurrence of embar- rassment which might be serious, the condition being known as air embolism. An animal may easily be killed by injecting a moderate quantity of air into one of its veins. To avoid this danger the syringe should always, before injecting, be held with the needle upward, gently tapped so as to dislodge any air bubbles within and cause them to rise toward the needle, and the plunger then gently forced onward until all air has escaped through 46 ADMINISTRATION OF MEDICINES the needle. The presence of a Httle air in the subcutaneous tissue would usually be harmless, the danger being in the possibility of puncturing a small vein and forcing air therein. With this possibility is connected the next danger, that of overdose caused by thro\\ing the whole quantity of the drug directly into the venous system. Our dose is intended for gradual absorption into the blood during a period of from five to fifteen minutes. If, instead, the whole dose is thrown immediately into the blood current and carried to the central nervous system, with- out the possibility of free dilution, poisoning may quickly occur. To avoid this accident, it is commonly recommended to insert the needle deeply enough so that it may be withdrawn a short distance, so as to escape any vein that might have been punctured in its course.. Another precaution and, in the writer's opinion, one of greater certainty is to inject slowly and note, at the end of the needle, the accumulation of the injected fluid, which should be easily felt by the finger. If the fluid disappears about as rapidly as it is injected, puncture of a vein should be feared, but if the fluid accumulates with the injection, so that a dis- tinct swelling is felt at the point of the needle, nothing need be feared. With the injection of cocaine into the gums for local effect, the imme- diate blanching of the tissue about the point of the needle may assure one that the solution has diffused into the tissues. In fact, the danger of forcing the drug into a vein is much less with the usual submucous injection than with the hypodermic, because of the small size of the veins in the mucous membrane of the alveolar region. The Hypodermic Sjrringe. — Many kinds of syringes are on the market. The older style of glass barrel and leather plunger syringe has the advantage of permitting a view of the liquid or bubbles of air within the barrel, but the disadvantage of being less easily sterilized. It also dries out easily unless in daily use. The newer style of all-metal syringe has the disadvantage of allowing no view of the interior, but it has the very great advantage of being easily sterilized by boiling the whole syringe. Glass syringes are now also used, but they require much care in handling. W^ith any kind the needles may be sterilized by boiling, while a thorough cleansing of the syringe with boiled water after each use and frequent washing with 5 per cent, carbolic acid, followed by alcohol, will be sufficient care of the syringe. The needle should be thoroughly sterilized before each injection. How to Give a Hypodermic Injection.— Having syringe, needle and solution sterile, the skin is best cleansed by first scrubbing \Aith soft soap and water, then sterilizing by the application of 50 to 70 per cent. BY THE SKIN 47 alcoholj 5 per cent: solution of carbolic acid, oil of turpentine, 1:1000 solution of bichloride of mercurj^ or some other equally efficient disin- fectant. The hands of the operator should be similarly treated. ]Mak- ing sure of the absence of air from the syringe, the latter is held firmly with the right hand while the thumb and first finger of the left hand grasp the skin and raise it slightly at the point selected. Into the promi- nence thus occasioned the needle should be quickly pushed in a direc- tion nearly horizontal to the surface, and should penetrate to the depth of from one-third to one-half an inch or even more. It may be with- drawn slightly, so as to disengage the point, after which the injection is made slowly so as to avoid too great violence to the tissues by rapid distention, which may be painful. Diffusion and absorption may then be aided by gentle rubbing over the injected area. The site of injection for general systemic efi^ect may be upon any accessible portion of the body, care being taken to avoid any visible vein or the proximity of an artery or nerve trunk; but in case of col- lapse, when the circulation and activity of absorption are greatly reduced, the injection should be made upon the trunk rather than upon the extremities — i. e., nearer the center of the circulation, so as to secure more rapid absorption. For local effect the site of injection admits of little choice, except to avoid important structures. ^^Tien, however, the injection is for local analgesia the medicine is injected more superficially, directly into and beneath the skin or mucous mem- brane, the object here being to paralyze the sensory nerve endings, which are more abundant superficial!}'. It is unnecessary to penetrate deeply into the tissue unless a deep operation requires it. A word of caution must here be given regarding the danger of form- ing the habit of the hj-podermic use of narcotics, especially morphine and cocaine. This particular method of drug addiction is more com- mon than is usually known. The seductive effect of the drug is so quickly induced that the victim readily endures the slight pain of the injection for the sake of the agreeable result. It becomes the dut}' of every practitioner to guard his patient and emphatically himself against this danger. Self-administration of a narcotic in this way is an exceed- ingly dangerous practice and must never be encouraged. Cataphoresis.- — By this term is meant the introduction of drugs in molecular form into living tissue, by means of the galvanic current. Analgesics and alteratives may be employed for application to a limited area by this method. The positive pole applicator is saturated with a strong solution of the drug and placed directly over the part to be medi- 48 ADMINISTRATION OF MEDICINES cated, the negative pole being placed indifferently upon the cutaneous surface, but avoiding the more sensitive tissue of the face. The drug is carried from the positive pole into the tissue. This method, with cocaine as the drug, has been used to allay sensi- tiveness of dentine. Care must, however, be taken not to disturb the pulp by the employment of a strong current — 5 to 10 volts should be the maximum strength for this purpose. It is also employed to anes- thetize pulps previous to immediate extraction. Further uses of cata- phoresis in dentistry are to carry bleaching agents into the tubuli of discolored teeth and iodine into soft tissues. A current of 25 to 40 volts can be used for bleaching purposes, and also to destroy the pulp of a tooth. It has been recommended to cocainize the tissues about the roots of teeth in order to obtain painless extraction, but such employment of the method meets with little practical success. Intravenous Injection. — In case of emergency it sometimes becomes necessary to inject a stimulating or restorative agent directly into a vein. The agent most used for this purpose is the physiologic or normal saline solution at blood temperature. This is a solution of 8.5 parts of sodium chloride in 1000 of sterile water. It corresponds to the blood serum in salinity, and is used to replace the latter when deficient, after severe hemorrhage or in collapse. The intravenous method has come to be employed rather extensively also for the administration of salvarsan in syphilis and antitoxins in diphtheria and tetanus. The effect of the remedy is much more prompt and efficient when thus injected directly into the circulation. Hypodermoclysis.- — The introduction of a large amount of normal saline solution is most commonly accomplished by hypodermoclysis, or injection into the subcutaneous cellular tissue. From 1 to 2 pints are often employed once or twice daily for a number of days in succes- sion. The indications for its use are great depression from acute disease, hemorrhage and loss of fluid from the system by severe diarrhea. The apparatus employed consists of a gravity- or fountain-syringe armed with a large-sized hypodermic needle. The latter is introduced through the skin of the selected site, usually the lumbar region or underneath the breast, and the fluid is allowed to flow slowly by the force of gravity into the loose subcutaneous tissue. The temperature of the solution should be somewhat higher than that of the blood so as to allow for cooling during the slow injection. BY THE LUNGS 49 By the Lungs (Inhalation). — Only gases, vapors and finely atomized liquids may be employed by inhalation. The method is limited to the use of anesthetics, stimulants, antiseptics and a few volatile antidotes. Although thus limited, it is the most rapid of all methods of medica- tion. The great extent of surface, especially adapted for the absorption of gases, presented in the expansion of the pulmonary tract (estimated at 1000 to 1400 square feet) explains why the action of an inhaled gas or vapor is felt almost immediately. The method is adapted especially to general anesthesia where a rapid and profound effect is needed. For practical use by inhalation a vapor must be non-irritating, except when stimulation is desired. Ammonia is frequently applied by inhala- tion in case of fainting, in order to stimulate the heart and respiration. It is irritating to the mucous membrane, and by this action it produces reflex stimulation. For the purpose of local medication of the air passages, antiseptics and sedatives are frequently vaporized in connection with steam. Either the steam atomizer may be used, or the drug may be placed upon boiling water, from which the steam is inhaled. The most irri- tating cough may frequently be relieved by proper medication with this method, while even in pulmonary tuberculosis the local treatment by inhalation is now given an important place. CHAPTER IV. MODES OF ACTION OF MEDICINES. The precise modes of action of all drugs upon the human system will probably never be understood. In the laboratory many medicines exhibit certain exact physical and chemical properties that are constant; and, while a knowledge of these will aid us very much in studying drug actions, their combination with biologic factors in the vital structures of the body brings about results that are \'ariable, often indefinable, and peculiar as to individuals. This topic will not be discussed in theoretic detail; but the simpler and better understood modes of action can be profitably illustrated by examples, if we are careful to remember that any explanation can only be partial in most cases, because the contributory vital factors so commonly defy our scrutiny. Physical Action. — The sunplest kind of medicinal action is that where 2)hysical properties alone are concerned. Glycerin applied to a denuded surface or to a sensitive mucous membrane furnishes an example of such, its primary action being simply the abstraction of water from the tissues, with slight irritation which the loss of ^^■ater occasions. Alcohol has a similar action, although more irritating because of its stronger affinity for water accompanied by coagulation of albuminous matter. The irritation in each case continues until the abstracted fluids have been replaced by fluid from the adjacent tissues or from the blood. This local alteration in the fluid component of the tissues exemplifies a principle of wide application throughout the body; for as glycerin and alcohol abstract small amounts of water locally, so physical factors are also employed in the withdrawal of large quantities of fluid through the channels of elimination. In turn the fluid of the blood is restored by absorption of ingested liquids from the digestive tract or by taking up a certain amount from the tissues. In this way also waste products are removed from the cells of the tissues and in turn they receive fresh nutritive fluid from the blood. Much of this action we must attribute to osmosis, defined to be the property by which liquids and crystalline substances pass through animal meuibranes. This process takes place ELECTRIC ACTION 51 between the cells and their surrounding fluid, as well as between the capillaries and surrounding media, and is essential to the course of medicines as they pass through the body. In emergency, as after a severe hemorrhage, the same principle calls for the hypodermic use of physiologic salt solution in quantity, in order that it may be taken up by the circulation. In the treatment of nearly every disease, this same principle finds some application. Any extensive interchange of fluids is brought about chiefly through the influence of what is termed salt action — i. e., the behavior of saline solutions of different degrees of concentration in relation to the salinity of the serum of the blood, by which a flow of fluid to or from the blood is determined. The process of osmosis, as seen in the passage of fluicfs of different composition tlirough a separating animal membrane, is the most important factor of salt action. Having the blood serum of a cer- tain concentration within the vessels and a saline solution more concen- trated without, the osmotic flow will be from the blood to the stronger solution, because of the higher osmotic pressure of the latter; on the contrary, a weaker solution outside of the bloodvessels, because of its lower osmotic pressure, will readily pass into the blood. Thus the administration by niouth of a concentrated solution of a saline cathartic will promptly cause a flow of serum from the blood current into the digestive tract (exosmosis), while pure water taken into the digestive tract would pass into the bloodvessels (endosmosis) . A single drug, potassium bitartrate, may illustrate both exosmosis and endosmosis: For if it be given in form of the salt with very little water it will attract a large quantity of water from the blood and so induce a cathartic effect; but if it be given in dilute solution, it will pass into the blood and be carried to the kidneys to be eliminated, where its action will be diuretic. Any solution that is indifferent in osmotic action — i. e., having the same osmotic pressure as the blood serum — is called isotonic, one of higher osmotic pressure being hypertonic and one of lower osmotic pressure being hypotonic. The salinity of the blood is imitated in the physiologic saline solution containing 0.85 per cent, of sodium chloride, which is used hypodermically, intravenously, or by the bowel, as a restorative. Electric Action. — Passing from purely physical influences, we recog- nize also electric relations in the action of many substances. It has been ascertained that most acids, bases and salts, when in dilute solution, as in the blood and tissues, are dissociated into ions of their elements or radicals, that these are charged with positive and negative electricity, 52 MODES OF ACTION OF MEDICINES and that the solutions are capable of conducting electrical currents. The ions do not usually act as the pure elements; in fact, they often exhibit entirely different properties; e. g., in the dissociation of sodium chloride, the chlorine, which in its free state is a poisonous gas, does not act as such, but as the electronegative chlorine ion, while the sodium, which in its free state is an irritant base, in the ionized form is non-irritating and provides one of the most abundant con- stituents of the body. The practical relation of ionization to the use of drugs is important, as may be illustrated by the use of iodide of sodium or of potassium. Here the element iodine, which in a free state could be given only in small quantity because of its irritating quality, may be given in a 35-times larger dose without unpleasant effects. The combination w ith the base renders the iodine less irritating and the subsequent ionization in dilute solution, as administered, permits its wide diffusion through the body in form of the iodine ion, which is comparatively non-irritating. Little can be said of definite electric reactions as a part of drug action within the tissues. In fact, with most drugs it is impossible to fully separate the physical, the electrical and the chemical factors, blended as they are in the life action of the cells. Chemical Acticn. — The chemical features of drug action can be very clearly demonstrated for certain substances of local use. In the tooth structure especially, where the vital factors are slight, about as definite chemical reactions can be obtained as in the laboratory. The science of bleaching teeth rests upon this fact, and thorough disinfection by chemical means is made possible. But also in the softer structures that possess greater vitality, the chemical reactions of drugs locally applied are often very evident, e. g., the coagulant action of phenol and the corrosive action of strong acids and alkalies. These reactions and their chemical basis are more fully discussed in the chapter on Escharotics. A special line of medication where the action is purely chemical is the application of chemical antidotes in cases of poisoning. Secondary Effects. — With many drugs we observe both primary and secondary efl'ects. The secondary is more likely to be the desired or therapeutic effect, or to lead to it. To illustrate: The application of an irritant (tincture of iodine or mustard paper) to the gum to relieve toothache, will first cause irritation (primary effect), then alteration of circulation in the region will follow (secondary effect) and, pressure being thereby equalized, we have relief of pain (therapeutic effect). UNTOWARD EFFECTS 53 However, this order does not always obtain in drug action, for with some drugs the first action is the desirable one and later effects are undesirable. In the use of simple irritants and astringents we observe some of the reactionary effects of drugs. When we speak of irritation we mean a disturbance of tissue, or a reaction to a disturbance, inflammation is a reaction of higher grade having, as a prominent feature, a local increase in the number of leukocytes (leukocytosis), which becomes general in an inflammation of any severity. This condition really represents a reactive increase in the protective and reparative resources of the blood and tissues, which may be an important factor in securing relief. The action of an irritant drug in the vicinity of an inflammation (counter- irritation) is believed to stimulate absorption by the lymphatics as well as a local increase of leukocytes. Thus the vital factor within the tissues aids in securing the therapeutic efl^ect, and it may even influence the primary action of the drug. This factor is so variable that for most medicines the sum of the effects can only be learned by experience, and even then individual peculiarity (idiosjoicrasy) may determine unex- pected results. Medicines intended for general systemic effects have a more obscure action, which can usually be judged only by the clinical results observed. In general, we may say that stimulants and sedatives m^wervce functions chiefly and their action is temporary; while alteratives and restorative tonics influence the structure of tissues by entering into the composition of the cells, their effects being accordingly more permanent. Stimulants may irritate tissue primarily, inducing stimulation reflexly, or they may cause more rapid or more powerful discharges of energy in func- tional activity of the organ stimulated. Sedatives depress functional activity, usually by direct influence upon nerve tissue, and they easily cause poisoning in very susceptible persons. A more detailed discussion of the action of stimulants, sedatives and alteratives is given in the separate chapters devoted to them. Untoward Effects. — All undesired results of drug action, whether simply unpleasant or positively dangerous, are known as untoicard effects. For example, the pain incident to a blister, the nausea caused by some drugs given for other purposes, the constipation and headache following a full dose of opium and the depression caused by many pain-relieving agents, are all classed under this term. No small part of the prescriber's art lies in securing the desired, and avoiding the untoward, effects of his remedies. 54 MODES OF ACTION OF MEDICINES Protective Reactions. — It is well kno^ii that the blood possesses, in some degree, protective properties against certain toxic substances; and one of the important developments in therapeutics has been the dis- covery that the protective resources may be increased by medication of a peculiar kind, or added to artificially. This involves the question of securing immunity or the production ^^■ithin the body of antibodies that are antagonistic to the germs of particular diseases. The means •of securing this end differ somewhat with different diseases. Thus, immunity against smallpox is positively attained by inoculation with the living virus of the cowpox; while immimity against t\73hoid fever is secured by the injection of a hacterial vaccine or baderin, which is a preparation of killed bacteria of the kind which causes the disease. Vaccines are also employed in prevention and treatment of other bacterial diseases, the principle being that of stimulating within the body the formation of bodies that are antagonistic to the cause of the disease. We are dealing here with a protective reaction on the part of the tissues of the body, the process being a. natural one under the conditions induced. Antitoxins.- — In some of the infectious diseases the blood reacts to the toxic products of the disease and develops an antitoxic body, which directly neutralizes the poison and determines recovery in favorable cases. This fact is made use of in the treatment of diphtheria and tetanus particularly. A strong antitoxin, which can be specific for the one disease only, is developed in the blood of a domestic animal, the serum of which is then kept in a preserved state for use when needed. When a diagnosis of diphtheria is made, this antidiphtheric serum is in- jected hypodermically or intravenously as early as possible, with the result commonly that the poison of the disease is perfectly neutralized. Anti- toxins, being natural products of the blood, are harmless and may be used in strong dosage. Phagocytosis. — The protective resources of the body include also the white blood cells, or leukocytes, which increase in number greatly in most fe^'ers and infections. Aside from their function of repairing tis- sues, they have the power to destroy bacteria in the blood (phagocytosis) and thus they form a very important part of the body defenses. In this relation they are called phagocytes. PART II. LOCAL REMEDIES. CHAPTER V. DEPLETIVES. Depletive measures are those employed to abstract blood or serum from an inflamed or hjqDeremic area, usually with the purpose of reliev- ing pain or pressure. The indications for their use are: 1. Inflammation that is painful or that threatens extension or destruc- tion of tissue. 2. Passive congestion of a part that interferes with its function or with resolution of disease. .3. Simple hj'peremia, when its continuance is likely to produce serious disturbance of tissue or function. 4. In local poisoning of tissues, as from the bite of an animal, or from local absorption of arsenic. i^ ^^ 4 ^ A depletive measm-e need not always remove blood or serum from the body. It may draw it from the point of disease into another part. Fig. 1. — Dry cups applied to the chest, as in a case of puhnonar}' edema, the early stages of pneumonia, or diffuse bronchitis. (Hare.) Dry Cupping consists in the application, to the surface of the skin, of glass cups from which the air has been exhausted. An alcohol flame 56 DEPLETIVES passed quickly into the cup immediately before applying, is the means commonly employed to exhaust the air. The vaciuun permits the skin and underlying tissue to bulge into the glass and to become congested with blood. In this way, with each cup nearly or quite a tablespoonful of fluid may be drawn from deeper tissues to the skin and just beneath it. With the emplo\-ment of a number of cups a very decided influence upon a deeper-lying inflammation is noticed, but no fluid is removed from the body. This method is of great value in conditions of pulmonary congestion or pneimionia, and a number of cups may be applied, and repeatedly, to the surface of the chest. The cups cannot be applied upon an irregular surface. Wet cupping is accomplished by applying the same principle after first scarifying a limited surface with an ordinary lancet, or with the especially adapted spring lancet. The cup can then be a])plied as in dry cupping, or a special cup with an exhaust s\Tinge attached may be used. The latter permits of a more constant vacuum being main- tained. The vacuum allows a free flow of blood into the cup. By this method a considerable quantity of blood may be abstracted from any part of the body. Scarification with a lancet is the method of depletion most commonly used in dental practice. The indications are hyperemia, inflammation, passive congestion, and local poisoning, as by arsenic. After scarifica- tion, bleeding may be encouraged by holding warm water in the mouth, while cold water will tend to lessen the flow. The precautions to be observed in scarification are: Strict asepsis, guarding against too extensive a wound by a sudden movement on the part of the patient, and avoiding the proximity of vessels, nerves, or of Stensen's duct opposite the first superior molar. Lancing of the gums over advancing teeth is called for when unusual hyperemia or swelling is present, or where general irritability, fever, or convulsions point to a local irritation which is found in an abnormal eruption of the teeth. It must be borne in mind, however, that sources of irritation may exist in other parts of the digestive tract, and that in a dentition which is progressing normally there is seldom any need of scarifying the gums. When employed, the incision should be directly over the advancing margins of the teeth. Leeching, — The application of a leech {Hirudo medicinalis) is a con- venient and efficient means of abstracting blood from a local point VENESECTION OR PHLEBOTOMY 57 for the relief of acute inflammation or congestion. For use in the mouth it is not generahy applicable, on account of the aversion, on the part of some people, to having a leech in the mouth. Nevertheless, it is to be considered among the best means, and if employed with a leech tube so that it does not touch the tissue except by its sucker extremity, the objection is minimized. The leech tube is of glass, of a proper size to admit the leech and allow its distention by blood. It is dravMi to a narrow opening at one end. This smaller opening should be large enough to permit the passage of the smaller end of the leech by which it makes suction. Swedish leeches are mostly employed on account of their large size, their capacity for abstracting blood vary- ing from one-half to two fluidrachms (2 to 8 mils). If the leech does not bite readily it may be advisable to make a puncture with a fine point at the selected place, in order to obtain a small drop of blood upon the surface. This will usually induce the leech to bite. (T D Fig. 2. — Leech glass. The suction may be interrupted at any time by sprinkling a little salt upon the leech, when it will drop off. The leech bite is V-shaped and clean cut. Bleeding may continue for some time, and may even require the use of strong styptics or pressure in order to check it. When applied to the skin a small triangular scar invariably remains from the leech's bite, therefore, when used upon the face or neck, the point of application of a leech should be where the scar will not be noticeable, as under the chin, behind the ear, at the angle of the eye or nose, within the hairy region, or at the site of a natural wrinkle. As related to all means of local bleeding it must be borne in mind that the hemorrhagic diathesis {hemophilia) is an absolute contra- indication to their emplo}Tnent. Venesection or Phlebotomy .^ — General bloodletting is accomplished by opening a vein (usually the cephalic, just at, or above the bend of the elbow). This therapeutic measure was much abused in earlier years, and the natural reaction resulted in its almost complete abandonment. At the present time, however, it is often employed as an emergency procedure, in cases of severe toxemia or physical embarrassment of the circulation. A pint or more of blood may be drawn. The flow is easily stopped by the simple pressure of the dressing applied. 58 DEPLETIVES In order to find the A^ein readily and to secure its distention and consequent free flow of blood, a bandage is first placed around the arm just below the shoulder and drawn tightly enough to obstruct the venous return, but not to interfere with the arterial flow. This causes a fulness of the vessels of the arm and great distention of the veins. The median cephalic is then exposed with aseptic care and the opening made with the ordinary sterile lancet. General depletion is also secured by means of sweating or by free catharsis. In either case it is possible to withdraw from one to three pints of serum from the circulation within a short time, which result may be a considerable factor in lessening a local hyperemia or inflam- mation. Sweating is most readil}^ induced by the hot-air bath, taken either sitting (cabinet bath) or lying down (hot-air bed bath). The hot mustard foot bath also is efficient, adding to the sweating the derivative rubefacient effect upon the lower limbs. A depleting catharsis is secured by the action of a quickly acting hydragogue, such as jalap, croton oil, and the saline cathartics. The salines are most commonly used. When given in concentrated solution (hypertonic, see p. 51) upon an empty stomach, they act promptly by causing a copious flow of serum from the bloodvessels into the diges- tive tract, followed by evacuation without much irritation. The state of blood-pressure modifies their activity somewhat, a fulness of the circulation favoring an outward flow of serum. A low blood-pressure would require salines to be given in larger quantity for the same desired result. The vegetable hydragogues are, as a rule, more violent and drastic in action, because they irritate the bowel and greatly stimulate peri- staltic action. Jalap is milder than others, and very efficient when simple depletion is desired, and it may be used daily for some time; but when a revulsive action is wanted the more irritating croton oil is used. General depletion, as above, is indicated where there is accumula- tion of serum in a serous cavity, as the pleural or peritoneal, or where cardiac or hepatic disease is attended with marked venous congestion. CHAPTER VI. COUNTERIRRITANTS. CouNTERiRRiTATiON means the production of an irritation in a normal part of the system in order to influence a diseased part favor- ably. The irritant is usually applied to the skin, but it may be applied to the mucous membrane of the mouth or to other accessible mucous surfaces. The action varies in degree from a simple reddening of the skin, by increase of the circulation locally, to a destruction of the super- ficial layer of tissue. According to the degree of irritation following their application, the agents are divided into: 1. Rubefacients, agents that produce redness of the surface. 2. Vesicants or epispastics, agents that irritate sufficiently to cause an exudate of serum beneath the epidermis (a blister) . 3. Escharotics, caustics or coirosives, agents that destroy tissue. The same agent may be a rubefacient, a vesicant or a caustic, as determined by the strength and duration of its application. This may be illustrated by the application of heat to the skin. Moderate heat will cause a dilatation of the cutaneous bloodvessels, with a decided hyperemia (rubefacient effect); a higher degree of heat will determine the escape of serum from the engorged vessels to the extent of lifting up the non- vascular epidermis (vesicant effect); and a degree of heat that will burn will cause destruction of the skin (escharotic effect). Agents will be selected, therefore, for the degree of effect desired. While some of them will produce any of the above effects, others are more limited and fall naturally into only one class. Thus, arsenic acts slowly, and it cannot be said to produce any typical effect other than escharotic; capsicimi usually produces only a rubefacient effect. It must be noted, however, that the thickness and texture of the skin will cause a difference in effect, from the same application, in different individuals, and in the same person upon different parts of the body. A thin, tender skin will blister much more easily than a thick, tough one. It must also be noted that the same irritant will have a much severer effect upon the mucous membrane than upon the skin, on account of the softer and looser texture of the former; e. g., tinctme of iodine by a single application will only irritate the skin slightly, but it will quickly corrode and destroy the superficial layer of a mucous membrane. 60 COUNTERIRRITANTS The severer degree of counterirritation (i. e., blistering) should be avoided both in childhood and in old age, because of the greater sus- ceptibility to irritation and the lower vital resistance at the extremes of life. Several rules may be wisely o})served as to the site of application of a counterirritant in typical conditions: 1. If an inflammation is quite superficial, the counterirritant should be applied at a short distance. If applied immediately at the i)oint of inflammation, the latter may be aggravated. 2. If deep inflammation is to be treated, the irritant is applied directly over, so as to induce a flow of blood to the surface and away from the deeper point of disease. 3. In case of neuralgia or neuritis, the irritant may be applied with best effect directly over the origin of the affected nerve, or at the point of its emergence. 4. In treating affections about the face and head, the irritant may be applied back of the ear, beneath the chin or upon the back of the neck. Modes of Actio7i of Counterirritants. — The remedial effect of a coun- terirritant is probably brought about by a threefold action. They influence: (1) The circulation; by causing a hyperemia through vaso- dilation at the point of irritation the tendency of the blood supply will be in that direction. (2) They turn the attention of the system toward the new point of irritation and a\\'ay from the disease, partly a mental effect. (3) They influence the innervation of the diseased part by the reflex influence of the irritation. In the sum of their effects they stimulate the movement of fluids within the tissues; hence, they are regarded as l\inphatic stimulants and are often employed to stimulate the absorption of serous or inflammatory exudate. The terms derivative and revuhive are often applied to the action of counterirritants, the latter of the t"v\o referring especially to a very decided action, as in the prompt and violent effect of croton oil as a cathartic, \\hen given to relieve a cerebral condition. Heat.^ — This agent has an important place as a counterirritant, because of the readiness and variety of forms in which it can be applied. The hot-water bag, dry and moist poultices, hot foot and sitz baths, the hot iron, the thermocautery and the galvanocautery indicate the range of methods and effects that attach to the use of heat. The irritant drugs, other than escharotics, are here discussed in the order of their severity, beginning with the mildest. Escharotics are considered in a separate chapter. SI NAP IS NIGRA 61 Capsicum. — Cayenne Pepper. — The fruit of Capsicum frutescens. Preparations and doses: Oleoresina capsici, gr. | (0.03 gm.). Emplastrum capsici — external use. Tinctura capsici, lU 8 (0.5 mil.). The most irritating preparation of capsicum is the oleoresin, which is seldom employed undiluted. The tincture may be applied to the mucous membrane in sluggish or atonic conditions. It acts by irri- tating, and thereby inducing a more active local circulation. Diluted with water, it may be used as a wash or gargle. The official plaster is prepared by spreading the oleoresin upon resin plaster. It is used as a counterirritant to the skin or, in a limited area, to the gums, as in the beginning of pericementitis. The powdered driig is likewise recom- mended as a dental counterirritant. To limit and concentrate its action it must be enclosed in a small sack, and in this way it may be combined with other drugs if desired. The drug and its preparations are capable of causing irritant poison- ing if taken internally in large doses. Sinapis Alba. — White Mustard. — The seed of Sinapis alha. Sinapis Nigra. — Black Mustard. — The seed of Brassica nigra. Preparations and doses of black mustard: Emplastrum sinapis {mustard paper) — external use. Oleum sinapis volatile, TH, | (0.008 mil.). Powdered mustard (as emetic), 32| (10 gm.). These two drugs are similar as to constituents and uses, although the black is the more powerful and claims our chief attention. Mus- tard in a dry state is not irritating, but the black mustard seed contains a glucoside, sinigrin and an enzyme, myrosin, which, in the presence of water, react to form the very irritating volatile oil {oleum sinapis volatile). Myrosin in aqueous solution coagulates at 140° F. (60° C); therefore, a temperature of that degree or higher will prevent the development of the volatile oil. Alcohol and acids also interfere with its production. Water at ordinary temperature is the agent to use to develop the valuable constituent of the drug. Taken internally mustard is an excellent emetic, the effect being due tc its irritation of the stomach. In case of poisoning by opium or arsenic, or, in fact, by any except the most irritant poisons, if the case is seen early while the poison is still in the stomach, a tablespoonful of mustard stirred up in a glass of water and taken at oime is a most efficient emetic. Mixed with enough water to form a paste, mustard 62 COUNTERIRRITANTS is applied between two layers of muslin to produce quick and moderate counterirritation, which, if prolonged, may proceed to vesication. For a continued rubefacient effect, the mustard may be diluted by mixing with from one-fourth to half as much flour before adding water. A mustard plaster or poultice thus prepared is called a sinapism. The irritant power of this drug makes it a valuable addition to the hot foot bath. Here the mustard is to be stirred up in cold water, and the mixture allowed to stand for several minutes, then added to the hot water for the bath. In the treatment of pericementitis or other active inflammation in the upper part of the body, the hot mustard foot bath, carried to the point of thorough relaxation and sweating, is a valuable general measure. In similar conditions of inflammation about the face or mouth a mustard plaster may be applied to the back of the neck. A preparation of some value to the dentist is mustard paper (Emplastrum' sinapis) , in which powdered black mustard, freed from fixed oil, is mixed with a solution of india-rubber, and spread upon paper or upon cloth. Protected from moisture, mustard paper will keep indefinitely, and it may be found at any time ready prepared in the stores. For local blistering of the mucous membrane in the treatment of pericementitis, it is cut into small squares or other suitable shapes and applied directly to the gum over an offending tooth. The moisture of the mouth will cause the volatile oil to develop ciuickly. It is very convenient also for more extensive irritation upon the surface of the body, but when used upon the skin the plaster must be moistened with water before application, so as to secure the reaction which develops the oil. Volatile oil of mustard may be used as an irritant, by being applied pure for limited effect, or diluted with alcohol for extensive effect; but it has a very rank odor which is objectionable. Oleum Terebinthinae. — Oil of Tirpextine. — The volatile oil distilled from turpentine. Dose of the rectified oil, TTlo (0.30 mil.). Crude turpentine is the solid oleoresin, or pitch, which exudes from the pine tree when the bark is cut. By distillation it is separated into the volatile oil of turpentine and a solid residue called resin or rosin. The oil is colorless, with a characteristic odor and taste, which become stronger and less pleasant with age and exposure to air. It is soluble in 5 parts of alcohol and in 1 part of glacial acetic acid. For internal use the rectified oil is preferred. It is neutral, while the commercial oil may be slightly acid. Oil of turpentine is used mostly as a rubefacient over a large surface, as upon the abdomen or front or back of the chest. It may blister lODUM 63 if used full strength. The ofRcial liniment (35 per cent.) may be used, or a turpentine stupe employed. The latter is prepared by wringing a piece of flannel, about twelve inches square, out of very hot water, then distributing from ten to thirty drops of oil of turpentine upon it. It is then quickly spread out, while still hot, upon the surface to be treated, and covered with several layers of fabric. This may be renewed frequently so as to keep up a constant rubefacient action. This drug is a useful general antiseptic, and it may be used to cleanse instruments or disinfect the skin, but the odor is objectionable to some. It has been employed as a local antiseptic, but is not used in dentistry to any extent; the old oxidized oil may be used as deodorant in moist gangrene of the pulp, to destroy the extremely unpleasant odor. It does not coagulate albumin, so that except for its unpleasant odor it might be an excellent penetrating antiseptic. In poisoning by phosphorus this drug has long been regarded as a valuable chemical antidote, if administered while the poison is still within the digestive tract ; but this is true only of an old, highly oxidized oil, tne old, French oil being most valuable. Fresh oil of turpentine will dissolve phosphorus and must, therefore, be avoided. Incompatibility. — It reacts violently with bromine or powdered iodine, and in contact with a mixture of nitric and sulphuric acids it will ignite. lodum. — Iodine [I]. — ^A solid non-metallic element, found in sea-weeds and in natural mineral compounds, its chief commercial source being sodium iodate, obtained in Chili. The drug is seldom used internally except in form of iodides. Preparations and doses: Liquor lodi compositus, Lugol's solution, (5 per cent.), TU 3 (0.2 mil.). Tinctura lodi (7 per cent.), m H (0.1 miJ.). Unguentum lodi (4 per cent.), external use. See also Iodides. All of these preparations contain potassium iodide. Pure iodine occurs in bluish-black, rhombic plates, having a penetrat- ing odor and sharp taste. It is slowly volatile, soluble in 12.5 parts of alcohol, in 80 parts of glycerin and freely in ether; also soluble in an aqueous solution of potassium iodide, although nearly insoluble in water.* These solutions are brown in color, while chloroform and carbon disulphide each dissolve it with a violet color. * Iodine is soluble in about 3000 parts of water. According to the U. S. Dispen- satory, eighteenth edition, its solubility in water may be increased, not only by potassium iodide, but by sodium chloride, ammonium nitrate and, to some degree, by tannic acid. The official tincture now contains 5 per cent, of potassium iodide, which renders the solution miscible with water in any proportion without precipitation. 64 COUNTERIRRITANTS Iodine in the form of the tincture is an irritant of great vahie, as appHed either to the skin or mucous membrane. Upon the latter it should be used only to a limited extent, as it will quickly corrode the superficial layer. As a counterirritant to the gum in pericementitis, or irritated or inflamed pulp, it is invaluable. Iodine is a penetrating agent, although the alcohol in the tincture will coagulate albumin slightly. In common with other irritants it has the power to stimu- late absorption by the Ijinphatics, ^^"hich is regarded as a valuable part of its local action. The great advantages possessed by the tincture are promptness and limitation of its action. The alcohol ciagulaies the tissue, thus limiting action, and the excess evaporates quickly, leaving a dry surface. Where coagulation is a disadvantage, or where the action of alcohol is not desired, the compound solution may be used, but it is slightly weaker than the ordinary tincture. Churchill's tincture (X. F.)* is much stronger than the official tincture, and is too irritating for application to the mucous membrane. The favorite combination of equal parts of tincture of iodine and tincture of aconite may be used more freely, as in it the iodine becomes diluted and its irritant action counteracted somewhat by the aconite, which is a local sedative, t The brown stain produced by iodine makes it objectionable to use upon a visible surface, and it should never be used within a tooth, for fear of permanent staining of the dentine. Stains upon the hands or upon fabrics are easily removed by water of ammonia. As an antiseptic and disinfectant, iodine is very efficient. The tincture diluted with an equal part of alcohol is used to sterilize regions to be operated upon in the mouth as well as elsewhere. The use of strong solutions in the mouth, except as a counterirritant, is to be * I65 %. This differs from Churchill's iodine caustic {Liquor iodi causticus, N. F.), which is stronger still, containing about 25 per cent, iodine, t A very useful formula is : I^ — Tinctura^ iodi, Tinctura; aconiti aa f5ij (60 mil.) Chloroformi 3j ( 4 mil.) — M. Note. — Boulton's solution (Liquor iodi cirbolatus, N. F.) is a time-honored and generally useful combination of iodine and phenol, much weaker than the official preparations of iodine. Its formula is: Gm. or mil. I^ — Tincturse iodi compositae 15 1 Phenolis (liquefied by heat) 5l5 Glycerini 165 Aqua? q. s. ad 1000 — M. Expose to sunlight until it has become colorless. lODUM 65 condemned, on account of its destructive action on the tissues. Upon the skin the tincture may be used in full strength. It may be applied in strong solution to ulcers, but is quite painful. For cleansing abscess cavities the tincture or the compound solution may be used somewhat diluted, either applied upon cotton or injected carefully. It may also be carried into the tissues by cataphoresis, by which method it is very useful in treating pericementitis, pericemental abscess, and especially the affections of the pericementum that follow influenza (Hofheinz). In selecting an iodine solution for use we should have in mind the distinctive qualities of each, as given below, for the three preparations most commonly employed: 1. Tincture of iodine, 7 per cent. 2. Compound solution of iodine, 5 per cent. (Lugol's solution).* 3. Ecjual parts of tincture of iodine and tincture of aconite. Comparative action upon mucous membrane. Mixed with albumin. Most severe irritant; cor- | Immediate coagulation due rodes mucous mem- ; chiefly to the alcohol brane superficially and present, promptly. Moderate irritant; does Coagulation sHght, and not corrode. slowly produced. Moderate irritant ; cor- rodes more slowly than tincture of iodine alone, and sometimes only after several appUcations. Immediate coagulation due chiefly to the alcohol present. The tincture may be combined with carbolic acid, which, with full strength of each, increases the corrosive and coagulating action. Equal parts, or any desired variation from this, may be used. Such mixture diluted with alcohol or glycerin is a proper application to abscess cavities, ulcers, unhealthy gums in stomatitis, etc., as it will combine disinfectant, irritant and indirectly stimulant properties. ^Yhen prop- erly diluted the carbolic acid may contribute a local sedative effect. Water can be used to dilute the official tinctm*e, as the formula now includes 5 per cent, of potassium iodide, w'hich will hold the iodine in * The formula of Lugol's solution (Liquor iodi compositus) is : I^- -lodi . . . , Potassii iodidi Aquae destillatae Gm. or mil. . . . 51 . . . 10 1 q. s. ad 100 j — M. The potassium iodide is needed to hold the iodine in solution. 5 66 COUNTERIRRITANTS solution. Such dilution is a very great advantage in some of the uses of the tincture. Iodine has a reputation as a stimulant to absorption by the hinphatics, in common with almost all counterirritants and alteratives, with the advantage that it belongs to both of these classes. To influence the absorption of indolent swellings or to reduce enlarged l}Tnph nodes, either the tinctiue or Lugol's solution may be applied (the tincture possessing the very great advantage of drying quickly), although after a number of applications the skin becomes blister^ or broken, when their use becomes very painful. A better preparation for continued use is the ointment (containing 4 per cent, iodine and 4 per cent, potassium iodide), which may be applied daily, with friction to aid absorption. Decolorized tincture of iodine,* so called, is less irritating and less efficient than the other solutions, but it may be applied where the color of the latter would forbid their use. It does not dry readily upon the skin, which is an objection to its employment. In poisoning by iodine the proper chemical antidote is starch, preferably in the form of starch paste. This should be given freel}'. IncomimtihiUty . — Free iodine is incompatible with starch, forming the blue iodized starch; with oil of turijentine, mixture with which may be followed by violent reaction. Internally the drug is used mostly in the form of iodides, for the reason that these salts are much less irritating and therefore permit a much larger quantity of iodine to be taken. As an alterative it will be further discussed in the chapter devoted to that class of remedies. Oleum Tiglii. — Ceoton Oil.^A fixed oil expressed from the seed of Croton tiglium, a small tree indigenous in India. A brownish-yellow oil, soluble in 60 parts of alcohol, becoming darker and more soluble with age. It has an unpleasant, fatty odor and an acrid taste. Average dose, TTl 1 (0.05 mil.). Croton oil is an irritant, whether applied to the skin or taken inter- nally. When rubbed into the skin it acts slowly, producing in from twelve to twenty-four hours a crop of small vesicles, which are distinct and separated from each other. If undisturbed, these dry without breaking. The counterirritant effect is pronounced, with much less discomfort than from cantharides. The drug may be applied back * Tinctura iodi decoJorata (N. F.) is prepared with the aid of sodium thiosulphate and stronger water of ammonia. Because of the chemical change attending the decolorization, it contains no free iodine, but is a variable mixture containing chiefly ammonium iodide. CANTHARIS 67 of the ear in treatment of severe or chronic inflammations about the face or mouth. It should be rubbed well into the skin. It may be mixed with equal parts of tincture of iodine for combined effect, but about the head it will generally be used alone. Internally the oil is a drastic cathartic, poisonous in very moderate quantity, thirty minims (2 mils.) ha^'ing caused death. In the usual dose of one-half to two minims (0.03-0.12 mil.) it irritates the intestinal tract, producing purging in from one-haK to two hours. On account of its prompt action it is often given for revulsive effect in cases of cerebral hemorrhage or inflammation, and in uremic poisoning. Care must be taken in handling croton oil, and it should never be tasted. Cantharis. — Caxthaeides (Spanish Flies).— The dried insect, Can- tharis vesicatoria. Obtained in various European countries, the large Russian flies being preferred. Average dose of tincture, mil (0.10 mil.) As a counterirritant, cantharis is used in the form of the cerate applied as a plaster to the skin (Emplastrum cantharidi.s) , or the cantharidal collodion, which is applied as a varnish. The cerate produces in about twelve hours a single blister, the full size of the application, painful, and gi"ving a maximum of counter- irritant effect. Seldom should a space larger than one by three inches be covered. Either the surface of the plaster or the skui should be oiled before applying, to ensure acti^'ity of the irritant principle can- tharidin, which is soluble in oils. The cantharidal collodion may be used instead of the cerate for ordi- nary application. It is believed to be safer, and it is much more con- venient. It is applied as any other collodion, dries quickly and requires no dressing until the blister is formed. There is some danger of absorption of the active principle, can- tharidin, to avoid which the application should be as limited as pos- sible. Irritation of the genito-urinary tract will be the first symptom of its poisonous general effect. The drug is reputed to be aphrodisiac in effect, but any sexual stimulation is due to irritation and is only one symptom of general poisoning, for cantharis is an irritant poison if taken internally in excessive dose. The tincture is the preparation for internal use, but it is seldom employed. In case of poisoning by the drug in bulk, or by the cerate, no oil should be used as a demulcent, because of the solubility of the active principle in oils. Chloroformum. — Chloroform. — This drug is discussed fully in the chapter on Anesthetics, but it is mentioned here on account of its irri- 68 COUNTERIRRITANTS tant local action. This action is secured best when the vapor is con- fined. The " thimble blister" is a convenient form of counterirritation when it is to be limited to a single point. It is produced by placing a bit of cotton saturated with chloroform in an ordinary thimble and apjilying it closeh' to the skin for five to ten minutes. Treatment of Blisters. — Bearing in mind that the healing of injured tissues is always a natural process, and that any application is to be regarded only as an aid, the simpler we make the treatment of blisters the better. This involves the simple principles of the treatment applied to burns, which may be stated as follows: 1. Cleanliness. 2. Protection from air. 3. Stimulation of repair. The first is self-evident and requires only the simple statement that, as simple cleansing applications, any but the mildest antiseptics should be avoided. Boiled water, normal salt solution, and sterilized oils or fats answer the purpose of cleansing a blister in most cases. In the absence of infection it is unnecessary to disturb the blister often, if proper protection is employed, as the natural process of healing may be disturbed by the daily removal of dressings, particularly when they adhere. Usually, when we are sure that the blistered surface is clean and aseptic, we can assume that healing will progress without interfer- ence. It is only in case of septic or unhealthy conditions that frequent treatment or strong applications may be needed. The second is accomplished by the use of a demulcent such as a sterile oil or fat, or by any non-irritating protective agent, and the api)lication of a dressing that will exclude the air. The contact of air is usually painful from its drying effect, and it presents also the danger of infection of the open sore. Carron oil* is a time-honored application to burns and blisters, but an objection to its use is the fact that the drying of the linseed oil contained in it makes the dressing hard and often difficult to remove without disturbing the sore. The third applies chiefly to large blisters that heal slowly, and includes such measures as the application of poultices of brewers' yeast, which is a most excellent cleansing and stimulating agent, f * lAnimenlum cnlcis, composed of equal parts of linseed oil and lime-water, t The great value of brewers' yeast in cleansing and stimulating repair of indolent and foul ulcers is believed to be due to the nuclein developed by the yeast plant. TREATMENT OF BLISTERS 69 When healing is much prolonged and hindered by the development of excessive granulations (proud flesh), the latter may be removed by a mild caustic, such as burnt alum, or scraped away. Such removal will often be followed by more rapid healing. The last resort is skin- grafting, which consists in transplanting pieces of normal skin from some other part of the body upon the denuded surface, after proper preparation. This will usually be successful in securing a satisfactory epithelial growth, with the usual cicatricial healing of the surface. CHAPTER VII. ESCHAROTICS. Escharotics or caustics are agents that destroy tissue upon contact. Many attack the tissue immediately and are, therefore, called corrosives. . It will be noticed that nearly all agents of this class are strong chemi- cals; that is to say, they are known and characterized by j^owerful chemical affinities. And this fact serves to explain why they are nearly all corrosives. They have so great affinity for one or more constituents of the tissues that they destroy the organic structure in order to satisfy it. It is further noted that they all differ somewhat in their effects upon tissue. This is explained by their difference in chemical affinity.* Thus carbolic acid has a strong affinity for albuminous matter; it cannot corrode deeply because the firm coagulum immediately formed prevents its penetration. Caustic potash, on the contrary, has no affinity for albumin, forms no coagulum, but penetrates deeply into the tissue, displacing weaker bases from their combinations. It also possesses an affinity for water. These affinities suggest the antidotes in case of poisoning by each. The antidote to carbolic acid will be albumin, that to caustic potash a dilute acid. In the practical application of caustics we prefer those that combine efficiency and safety, with action self-limited or easily controlled. The strong acids and alkalies are prominent, forming groups that are typical as to the nature and action of corrosives, but they are not usually the agents of choice because of the severity of their effects. In the grouping that follows, chemical similarity, rather than simi- larity of action, is made the basis. This facilitates the study of chemical antidotes, which apply as well to groups as to individual substances. Some agents that cannot be thus grouped are considered in an unclassi- fied list and their chemical relations studied separately. * Experiment. — To compare the coagulant and non-coagulant action of caustics: Spread the white of an egg upon a pane of glass lying upon a dark surface. Place at intervals upon the albumen a drop of each of the mineral acids, of phenol, and of caustic soda or potash. Note that the alkali does not coagulate; the acids and the phenol do, but the coagula formed differ in firmness. MINERAL ACIDS 71 Mineral Acids. Acidum Hydrochloricum. — ^Hydrochloric Acid (Muriatic Acid). — Contains 32 per cent., by weight, of absolute hydrochloric acid [HCl]. Acidum Nitricum. — Nitric Acid (Aqua Fortis).^ — Contains 68 per cent., by weight, of absolute nitric acid [HNO3]. Acidum Nitrohydrochloricum, — Nitrohydrochloric Acid (Nitro- muriatic Acid, Aqua Regia) . — Consists of 82 parts of hydrochloric acid and 18 parts of nitric acid. Acidum Sulphuricum. — Sulphuric Acid (Oil of Vitriol). — Contains not less than 94 per cent., by weight, of absolute sulphuric acid [H2SO4]. Applied t-o living tissue mineral acids all coagulate alhumin, but nitric acid more firmly than the others.* Sulphuric acid has also a marked affinity for water, and is accordingly the most powerfully corrosive, producing an effect very similar to an ordinary burn. They all have so great an affinity for bases that they disorganize the tissues in order to combine with them, hence their extremely poisonous effects. The strong mineral acids are seldom applied to the mucous mem- brane because of the severity of their action. Upon the skin they may be applied directly to warts, for the removal of which a few daily applications usually suffice. For this purpose nitric acid is preferable, because slightly less severe in action than the others. These acids are caustic to bone as well as to soft tissues, on account of their power to dissolve the earthy salts of bone. Accordingly, nitric acid has sometimes been applied to small foci of carious bone which were not accessible for removal. Its action may be checked at any time by the use of a weak alkali, such as sodium bicarbonate solution or lime water, which should be injected forcibly, so as to ensure the anti- dotal reaction at the point of the corrosive action of the acid, which may be at some depth. Employing in dental practice the solvent power of these acids upon mineral salts, they are sometimes applied, slightly diluted, within a small root canal to aid in enlarging the same. They act more rapidly upon partly decomposed than upon sound den- tine. In fact the normal tooth structure seems to be little affected during the ordinary time of application; however, when the action has proceeded as far as is desired the acid should be completely neutralized. The range of strength of sulphuric acid, as mostly employed, is 20 to 50 per cent., depending upon extent of action required. Caution should be used to prevent its passage into the periapical region, for there * See Experiment, previous page. 72 ESCHAROTICS is no doubt that such strong agents predispose to the formation of abscesses by lessening the resistance to infection. Internally mineral acids are employed only in diluted form. They are further discussed under the heading of Restorative Tonics. Poisoning by Mineral Acids. — When a strong mineral acid is used for any purpose, it must be borne in mind that it is a dangerous substance, and great care must be exercised to guard against poisoning. The bottle should be labeled with a poison-label, such as pharmacists are required to place upon all powerful poisons. The dentist also should have a ready knowledge of first treatment in case of poisoning; for any treatment, to be of use, must be employed very promptly, or a fatal result may be expected. In the presence of a case of poisoning by a strong mineral acid, it is not essential to know just which acid has been swallowed. The important facts upon which to proceed are: (1) that the corrosive action depends chiefly upon the concentration of the acid ; and (2) that the affinities of the whole group are so nearly identical that the same antidotal treatment will apply to all. The first and most important thing to do is to dihite the poison freely by large draughts of water. This will remove the danger of further corrosion, and, as water is always at hand, it can be employed immediately. The use of a chemical antidote must be secondary, because of the time usually neces- sary for its preparation, during which serious damage is being done by the corrosive poison if undiluted. But after free dilution the chemical antidote should be given, so as to completely neutralize the poison. An alkali \^ill be selected, diluted if at all irritating, and given freely. Lime-water and magnesia are preferred to a carbonate, because the latter will, in reaction with the acid, give off a large quantity of carbon dioxide gas, which may cause painful distention of the stomach and even endanger its corroded wall. In emergency, soap, or plaster scraped from the wall, may be given. Vomiting generally occurs, and washing out of the stomach is facilitated by the early dilution with water as recommended above. The use of emetics or the stomach tube is open to question in these cases. Since the neutralization of the acids with simple alkalies results usually in harmless products it seems unneces- sary to further irritate the stomach. Later treatment will comprise the use of demulcents, anodynes and stimulants. (See Table of Poisons and Antidotes.) The fact that poisoning by strong mineral acids is usually fatal, demands that emphasis be placed ui)()n immediate treat- ment, as outlined. CAUSTIC ALKALIES 73 Organic Acids. Acidum Acetum Glaciale. — Glacial Acetic Acid [C2H4O2]. — Nearly or quite absolute acetic acid, being not less than 99 per cent. It is liquid or crystalline, according to the external temperature, its melting- point being a little below 60° F. It is colorless and has a strong vine- gar-like odor and a sharp acid taste. It is not a coagulant, but, on the contrary, is a solvent of albuminous and fibrous tissue. It is employed only as a caustic and to soften callous tissue. It is not used internally. Acidum Trichloraceticrm. — Tkichloeacetic Acid [C1HO2CI3]. — It should be not less than 99 per cent. Obtained by oxidation of chloral hydrate with fuming nitric acid and subsequent distillation, it occurs in colorless crystals that are very deliquescent. It is soluble in 0.1 part of water and very soluble in alcohol and ether. Either in crystals or strong solution it is used as a caustic to remove redundant tissue, as overhanging gums, warts, etc. It coagulates albumin, and may be employed as a test for that substance. A 20 per cent, solution is recom- mended as an application to chronic inflammations of mucous mem- branes. In full strength it may be applied to the gum tissue to prevent exudation of moisture, the so-called "weeping gums," during filling or setting of a crown. In the treatment of pyorrhea alveolaris this drug may be applied in from 90 per cent, down to 5 per cent, strength — the strongest solution first, as a powerful escharotic, and the strength then gradually reduced to that which is astringent and antiseptic, having the added advantage in any strength of its solvent power upon the calcareous deposits. It is also used to obtund sensitive dentine. . Acidum Lacticum. — Lactic Acid. — A colorless, syrupy liquid contain- ing 85 to 90 per cent, of absolute lactic acid [CsHeOs]. It is obtained by lactic fermentation of milk-sugar or grape-sugar. It is strongly acid in reaction, freely miscible with water, alcohol, or ether; insoluble in chloroform. It does not coagulate albumin, but may be employed as a solvent to fibrinous exudates, as in diphtheria, a 20 per cent, solution being applied. A solution of 20 to 50 per cent, may be used in the treatment of pyorrhea alveolaris to soften remnants of calcular}^ deposit in the tooth socket. Caustic Alkalies. Aqua Ammoniae Fortior. — Stronger Water of Ammonia. — A 28 per cent, solution, by weight, of ammonia gas [NH3] in water. This solu- 74 ESCHAROTICS tion is not used medicinally to any extent, but it is the basis for the preparation of spirit of ammonia. It is a volatile caustic, the vapor being extremely irritating to the air passages. The United States Pharmacopoeia directs that it should be kept in strong, glass-stoppered bottles, not completely filled, in a cool place. The bottle should be opened cautiously ^vith its mouth directed away from the face; and if the temperature is warm, the bottle had better be cooled before opening, as otherwise the gas may be under considerable pressure. In case of accidental swallowing of this caustic, sjinptoms of irritation of the respiratory tract, with dyspnea, will be prominent. This will call for a volatile antidote in addition to the free dilution of the poison by water. The proper antidote will be the vapor of strong acetic acid, in the absence of which strong vinegar may be swallowed and its vapor inhaled. Stronger water of ammonia is a powerful saponifying agent. It does not coagulate albumin. The ordinary water of ammonia (10 per cent.) may be prepared from this stronger solution by diluting with twice its volume of water. Potassii Hydroxidum. — Caustic Potash. — Potassa. — Potassium Hy- drate [KOH]. — 85 per cent, at least. Sodii Hydroxidum. — Caustic Soda. — Soda. — Sodium Hydrate [NaOH]. — 90 per cent, at least. Potassa and soda are the only caustic alkalies used in dental practice, and these very seldom. They are prepared in form of sticks, which deli- quesce readily and must, therefore, be kept in tightly-corked bottles and must not be handled without protection of the fingers. Their affinities are for water and acids. They do not coagulate albumin, there- fore their penetration is unhindered. They corrode deeply, causing severe pain. They are in no respect superior to iodine and carbolic acid as superficial caustics, and accordingly have little to recommend them at the present time. Their action is more easily controlled than that of arsenic, as they can be completely neutralized by weak acids. They may be useful in the place of arsenic for the removal of small tumors. In poisoning by one of the caustic alkalies the usual rule of giving water freely to dilute the poison applies, with the additional advantage that water satisfies one of the affinities of either soda or potassa. The chemical antidote to follow dilution is any dilute acid, giving prefer- ence to the less irritating vegetable acids, such as vinegar and lemon juice. (See Table of Poisons and Antidotes.) While only the strong alkalies are classed as escharotics, even the dilute solutions known as UNCLASSIFIED ESCHAROTICS 75 liquor potassii hydroxidi and liquor sodii hydroxidi (not less than 4.5 per cent.) are decidedly caustic and irritating to mucous membranes. As an alkali soda is slightly stronger than potassa. Both are powerful saponijQers. Unclassified Escharotics. Phenol. — Carbolic Acid [CeHaOH]. — Hydroxybenzene obtained from coal-tar or made synthetically, being of not less than 97 per cent, strength. The average internal dose is 1 grain (0.06 gm.) well diluted. Phenol Liquef actum. — Liquefied Phenol. — 87 per cent. [Crude jjhenol is a liquid consisting of various constituents of coal- tar, having an odor resembling that of creosote. It is used only as a general disinfectant, never internally as a medicine.] Phenol was discovered in 1834 by Runge, who gave it the name of carbolic acid. In chemical nature this substance is not an acid, but an alcohol, the term "acid" having been given to it probably on account of its corrosive action. It is only slightly acid to test-paper, and while it combines with a few bases, the resulting salts are so unstable as to be decomposed by carbonic acid. It is not capable of neutralizing alkalies. It is a definite, crystalline compound, with a distinct, sweetish odor, soluble in about 15 parts of water, very soluble in alcohol, glycerin, ether, chloroform and oils. The crystals liquefy easily in a warm temperature, and reform when the liquid is cooled; but a permanent liquid form may be secured by the addition of 5 to 10 per cent, of water or glycerin. By exposure the liquefied drug gradually acquires a pinkish and later a reddish or brownish color, which does not lessen its value. According to Demant,* the color of phenol may be removed, and perfectly white crystals again obtained, by adding 11 parts of alcohol to 89 parts of the phenol, subjecting the mixture to freezing, and then draining off the portion remaining liquid. As a caustic this drug differs from all others in having a local analgesic effect following a momentary irritation. Its most decided affinity is for albumin, which it coagulates quicliy and firmly, thus limiting pene- tration beyond the superficial layer of tissue, f Its analgesic effect, * United States Dispensatory, eighteenth edition, p. .37. t Experiment. — To show the effect of phenol upon mucous membrane and the restorative effect of alcohol : Evert the lower hp and, after drying, touch two sepa- rate points each with the quantity of phenol that will adhere to the head of a pin. See the white coagulum form at each point. After half a minute dry the surface and apply a few drops of alcohol to one coagulum. Xote the difference in the two points after a few minutes. Also observe the results next day. 76 ESCHAROTICS combined uitli a superficial but decided corrosive action, makes it an ideal caustic for limited ai)plication to a mucous membrane. Extensi\'e application might, indeed, cause inflammation and symptoms of poison- ing, and must be avoided. Upon the skin the action is less energetic, although still quite caustic where the skin is soft or thin. In case of accidental contact uith tissues, the effect may be mitigated by the immediate application of alcohol, as explained later in the discussion of poisoning. The drug may be applied pure to ulcerated or denuded points, whether painful or not, ^ ith the result that any septic process present will be antagonized, and the coagulum formed will protect exposed nerve endings. Thus applied to canker sores, it will relieve the pain for a considerable time and check the bacterial activity. The sore should first l>e dried and just sufficient of the pure drug applied to cover well the ulcer. Several daily applications may be needed for complete relief. Carbolic acid is not an efficient devitalizing agent, because it does not penetrate, and its superficial effect is not sufficiently irritating to induce engorgement of the deeper tissues. Only in deciduous teeth is carbolic acid made use of as a pulp devitalizer. Here a slovver effect occurs from repeated ajiplications, without the pain that may attend the use of arsenic and without any danger of systemic disturbance. For disinfecting alveolar abscess and stimulating repair, a small quantity of pure phenol upon a pledget of cotton may be introduced after the abscess has been evacuated; or, in suitable cases, it may be pumped through the apex of the root into a pus tract and through a fistulous opening. It is frequently used as a pulp dressing in case of toothache from exposure of pulp, but never \\ hen the pulp is to be conserved, on account of its destructive action upon it. It may also be applied to obtund sensitive dentine. It has been used to lessen the sensitiveness of the gums in order to apply a rubber-dam ligature far beyond the gum margin. But for this, as for nearly ever}' purpose as an analgesic, it is inferior to cocaine, and has the further disadvantage of always destroying some tissue when applied strong. The uses discussed thus far apply to the pure carbolic acid or a slight dilution of it. But the most important place of this substance in medi- cine is as an antiseptic, under which heading will be discussed its more general uses in diluted solutions. Poisoning by Phenol. — The poisonous poA\er of this drug is very great, as the recently immerous deaths by suicide show. The s^Tnptoms UNCLASSIFIED ESCHAROTICS 77 of poisoning combine those of local injury to the lining of the digestive tract, with shock and great depression of the nervous system, the latter often leading to death within an hour. The antidotes are albumin in the form of raw egg, or milk or flour paste as substitutes for it, and alcohol. Albumin furnishes material for the poison to act upon and expend its corrosive po^er in coagulation. It must be given early to be of use. It is a true chemical antidote. Alcohol is employed in phenol poisoning but it is not a chemical antidote. It seems to act upon the corroded tissue, lessening the destruction that would follow, its action being physiological rather than chemical. It has been found that the hands may be immersed in pure liquid carbolic acid, and, if washed immediately afterward in strong alcohol, no harm to the tissues will result. Also, if carbolic acid be applied to the mucous membrane with the production of the white, superficial coagulum, and strong alcohol be then applied, the white spot will partly disappear and the corrosive action be much diminished.* An explanation of this antidotal influence of alcohol is found in its affinity for water, which it draws toward the surface, thereby furnishing more fluid for redissolving the coagulum and diluting any uncombined car- bolic acid that may be present in the tissue. (See Table of Poisons and Antidotes.) The poisonous effects of phenol are not limited to its local action upon tissue, t When it is absorbed in considerable quantity it gives rise to irritating products which may seriously damage the kidneys, liver and other organs. Fatty degeneration of various tissues has often been found postmortem. Corresponding to this action the urine in phenol poisoning often shows an olive-green or dark color. To counter- act the systemic poisonous action it is advised that a soluble sulphate be given for some time, so that harmless combinations may be formed and eliminated; but the value of this treatment has been questioned, and by some authorities believed to have been disproved. * See Experiment, p. 75 (note). t In the Philadelphia Medical Times, vol. xi, p. 284, Taylor records a case in which a man, who was supposed to have swallowed about 1 ounce of carbohc acid, became comatose within three minutes and died within four minutes from the time of taking the poison. In the New York Medical Journal, November 30, 1889, Richardson reports a case in which equal parts of carbolic acid and sweet oil, apphed to a burn on the arm of a child seven months old, caused stupor in two hours, and death occurred, with convulsions, thirty hours after the appUcation. Death has followed the application to the skin of half an ounce of carbohc acid in watery solution, for the purpose of destroying parasites. — Wood's Therapeutics, eleventh edition, p. 563. 78 ESCHAROTICS Several combinations of phenol deserve mention because of their modified action, which is at times desirable: Camphorated phenol, or campho-phenique, consists of about equal parts of camphor and phenol, which liquefy when heated together. It is less soluble than phenol, and it does not corrode tissue. Used chiefly as a disinfectant canal dressing and as an obtundent. JAquor sodii carholatis contains 50 per cent, phenol (see formula, p. 128). It is somewhat caustic if used in full strength. It provides a strongly alkaline application for limited use as a disinfectant. Chloral-phenol, prepared by triturating together with heat, 1 part chloral hydrate and 3 parts phenol. The product is an oily liquid which may be used as counterirritant and local analgesic. Iodized phenol, consisting of a mixture of iodine and phenol in vary- ing proportions, whereby the irritant property is increased. Equal parts of tincture of iodine and phenol is sometimes used as a counter- irritant. Argenti Nitras.^ — Nitrate of Silver [AgXOs]. — Dose, gr. | (0.01 gm.). Argenti Nitras Fusus. — Moulded Nitrate of Silver. — Lunar Caus- tic. — ]\Ioulded sticks containing about 95 per cent, of silver nitrate. Argenti Nitras Mitigatus. — Diluted Nitil^te of Silver. — Mitigated Caustic. — IMoulded sticks consisting of 1 part silver nitrate and 2 parts potassium nitrate. (Not official.) Nitrate of silver occurs primarily in colorless crystals, having a bitter, metallic, and somewhat caustic taste. Its aqueous solutions are neutral. From the crystals are prepared the moulded and diluted forms, which are in pencils or sticks convenient for application. All forms are freely soluble in water, the pure salt being soluble in 0.4 })art and in 30 parts of alcohol. This drug in any form or strength of solution turns dark upon exposure to sunlight. This is a standing objection to its use about the face, and especially about a carious tooth, the structure of which it may stain permanently if allowed to penetrate the dentinal tubuli. A stain upon the skin remains until the stained epithelium is Avorn away. It cannot be removed sooner except by paring or scraping away the superficial layer, but the stain upon a fabric may be easily removed by a weak solution of potassium cyanide. The prolonged internal use of silver in any form may cause a permanent blueness of the skin called argyria. As a caustic its action depends upon its affinity for albumin, it being a decided coagulant. Its application causes an irritation that continues UNCLASSIFIED ESCHAROTICS 79 for some time, but the effect is quite superficial because of the coaguhim formed, which hinders penetration. It has long been used to cauterize wounds that are probably infected, such as dog bites and dissection wounds, but it must be regarded as poorly adapted to this use. It does not penetrate deeply, therefore cannot be relied upon to destroy the infected tissue, and it, moreover, by coagulating the surface, checks hemorrhage that might be useful in washing away the infectious matter, and it seals in, as it were, the point of infection. Its use, therefore, as a cauterant for deep, infected wounds must be condemned. It is one of the most irritating caustics to the mucous membrane, on account of the added effect of a small amount of nitric acid liberated by the coagulant reaction. The field of usefulness of this drug is for superficial effect upon invis- ible surfaces, where it is desired to have the irritation pronounced or productive of a secondary stimulation of the local circulation. Accord- ing to the degree of action desired it may be applied in the pure stick of lunar caustic, the stick of mitigated caustic, or in aqueous solution of 1 to 10 per cent, strength, the weaker solutions being astringent rather than caustic. It is frequently applied to abort acute inflamma- tions and as a stimulating caustic to indolent ulcers. In dental practice silver nitrate is used to check caries in temporary teeth, where fifling is impracticable. It was fir-st recommended for this purpose by S. Stebbins, in 1891. Szabo, of Budapest, has made the most extensive scientific study of this action. He found by experi- ments that: 1. It penetrates one-half milluneter (5V oi an inch) into the dentine. 2. The albumin unites with the metallic salt in form of a precip- itate. 3. Granular albuminate is formed which the action of light darkens. 4. It finally becomes black and insoluble. For the purpose stated it is applied either in pure form, or in satur- ated aqueous solution, at the point of decay. The fused stick may be employed, or some of the crystal may be melted upon a heated plati- 'num point and carried to the tooth, as recommended by Craven; or a silver wire dipped in nitric acid may be used. Holmes* advises, for approximal cavities, to carry the powdered crystal adhering to a piece of gutta-percha, which has been softened by heat, of proper size to remain in the cavity. The silver nitrate is thus retained for a long time. * Dental Cosmos, 1892, p. 982. 80 ESCHAROTICS Because of its coagulant power it may also be used to obtund sensitive dentine in cavities that are not visible, where the staining would be less objectionable. Its distinctive antiseptic value is discussed inider Antiseptics, Incompatihility. — With alhumhums matter coagulation occurs; with hydrochloric acid, soluble chlorides, or chlorine solutions, a precipitate of chloride of silver occurs; in contact with most metals it is reduced to metallic silver; an aqueous solution acidulated with nitric acid and heated with alcohol will form the explosive "fulminating silver." In poisoning by silver nitrate the chemical antidotes are albumin and sodium chloride. The latter forms ^^'ith it the insoluble chloride of silver. In case of the use of the drug locally any excess may be at once removed by sodium chloride solution. (See Table of Poisons and Antidotes.) Hydrogen dioxide [H2O2], in very strong ethereal solution (25 per cent.), is a caustic, but its uses as such have not been very definitely developed as yet. It is used chiefly as a bleaching agent. Care must be taken in handling this strong solution to avoid its action upon the hands. Oiling will protect the skin from its action. Alumen Exsiccatum. — Dried Alum. — Burnt Alum [i\lK(S04)2]. Alum, by being deprived of its water of crystallization, is changed from an astringent to a mild caustic. It has little influence upon firmly organized tissue. It is used chiefly to destroy excessive granulations in wounds or ulcers, the so-called "proud flesh." The powder is applied directly. Cupri Sulphas. — Sulphate of Copper. — Blue Vitriol [CUSO4+5H2O]. Ks, a mild caustic the pure crystal may be api)lied to mucous mem- branes, the typical condition for its use being found in granular eyelids. It is acid in reaction. In strong aqueous solution it has been applied to pyorrheal pockets, but here it is an inferior agent because of the danger of discoloring the root and tooth. It is likewise astringent, and is more fully considered in that relation. (See under Astringents, also Table of Poisons and Antidotes.) Chromii Trioxidum. — Chromic Anhydride. — Chromic Acid [CrO,i]. It occurs in purplish-red crystals, which are soluble and deliquescent, forming chromic acid. Alcohol decomposes it sometimes with explosive violence. It is an energetic caustic, but rarely used. Zinci Chloridum. — Chloride of Zinc [ZnCl2]. This substance occurs in white powder, or in irregular masses or fused sticks, all of ^^'hich are intensely caustic and dangerous to taste, UNCLASSIFIED ESCHAROTICS 81 and acid in reaction. The salt is very deliquescent, therefore the drug may commonly be in either solid or liquid form. It is soluble in 0.3 part of water and very soluble in alcohol. Used pure it is a very energetic caustic. Its affinities are for water and albumin, therefore its action is prompt, producing a firm, white eschar. It is held to be the most penetrating of all coagulants. The official liquor zinci chloridi (50 per cent.) may be employed, or a stronger solution prepared, as a pene- trating coagulant anient within the structure of the tooth. After removal of the pulp it will efficiently disinfect and coagulate the contents of the tubuli. Indeed, in the stronger solutions, it is used more in treating tooth structure than soft tissues, on account of the pain attending its action upon the latter. It has long been used in full strength to lessen the sensitiveness of dentine. Its action is not a simple one, but is based upon its affiaity for water, and its coagulant power, to which is added the irritant influ- ence of a small quantity of hydrochloric acid liberated in the coagulant reaction. Care must be taken not to apply it so near the pulp as to produce irritation; and repeated applications may be needed as exca- vation proceeds. When irritation of the pulp is feared from its use, the cavity should be at once irrigated with tepid water. It is one of the agents used to cauterize and stimulate the closure of alveolar pockets about the roots of teeth in cases of recession or pyorrhea. In" addition to its other dental uses, it is very effective in the treat- ment of chronic aiveolar abscess. It should be applied directly to the abscess cavity thrbugh the root canal or through an external opening. It is very painful for a short time when first applied. In addition to its escharotic action it produces considerable irritation, thereby setting up an active inflammatory process which hastens resolution. For this purpose it may be used in a solution varying in strength from 10 to 50 per cent. The following is recommended when the aqueous solution proves very painful:* Gm. or mil. I^ — Zinci chloridi 2 Alcoholis, Chloroformi aa 15 60 (gr. xl). (fgss).— M. (Hofheinz.) In the weaker solutions (1 to 20 per cent.) it is astringent and anti- septic, and further discussion of its uses will occur in the chapters devoted to those classes of agents. * Dental Cosmos, 1903, p. 31. 82 ESCHAROTICS It must be ranked as a corrosive poison. The preparations likely to cause poisoning are the full strength liquid, the 50 per cent, solution, and the popular "Burnett's disinfecting fluid," which contains 200 grains to the fluidounce (about 42 per cent.)- The chemical antidotes are albumin and dilute solution of sodium or j)otassium carbonate. (See Table of Poisons and Antidotes.) Incompatibility. — The drug is incompatible with the antidotes men- tioned above and with nitraie of silver. Chloride of zinc in its liquid form enters into the formation of the oxychloride of zinc filling cement. Arseni Trioxidum. — ^White Arsenic. — Arsenous Acid [AS2O3] . Average dose, gr. ^V (0-002 gm.). Following the U. S. P. description, arsenic is a heavy solid, occurring " either as an opaque white powder, or in irregular masses of two varie- ties: one amorphous, transparent and colorless, like glass; the other crystalline, opaque and white, resembling porcelain. Contact with moist air gradually changes the glassy into the white, opaque variety. Both are odorless and tasteless."* "In cold water both varieties dissolve very slowly, the glassy variety requiring about 30, the porcelain-like about 100 parts of water at 25° C. (77° F.). Both are slowly but completely soluble in 15 parts of boiling water. In alcohol, arsenic trioxide is sparingly soluble, but it is soluble in about 5 parts of glycerin." An aqueous solution is only faintly acid in reaction. Wherever the term "arsenic" is used in the following pages it stands for the official arsenic trioxide. The characteristic action of the drug is due to the ion of arsenous acid and not to the element arsenic, which is insoluble in water. (The relations of the drug as a caustic only will be treated at this place. For its internal uses, see under Alteratives.) Arsenic stands alone in its characteristics as an escharotic. The dry powder may be placed on the tongue and allowed to remain for one minute without causing the slightest irritation and, if then thoroughly removed, without producing any effect upon the tissues. On the contrary, if it is allowed to remain until it becomes dissolved and pene- trates the tissues, extensive sloughing will result. It cannot be called an irritant. It is not a corrosive. It has no decided chemical affinities; therefore, it is not escharotic b}^ reason of any apparent chemical action. * United States Pharmacopcria, eighth revision. UNCLASSIFIED ESCHAROTICS 83 It stands by itself as a vital or alterative eschar otic, in that it acts only after being absorbed by the tissue elements, altering or destroying their vital processes in an obscure manner. Because of this action it is difficult, if not impossible, to limit or antagonize its influence upon the tissues which it has penetrated; and its penetration is not lunited by any action of its own. The fact of its being tasteless and non-irritating at first, renders its use about the mouth the more dangerous, for by careless handling it may become lodged about the teeth or beneath the edges of the gum,' and its presence be not appreciated for hours, until devitalization of the tissue has begun. It does not coagulate albumin. The drug acts slowly, penetrates deeply, and destroys tissue exten- sively. It seems to affect abnormal or unorganized tissue elements, as in cancer, more readily than normal tissue; hence its use in the removal of abnormal growths. As an escharotic it is always used in its pure form, although often mixed with other agents for convenience of appli- cation or to mitigate its action. The medicinal solutions officially prepared from it are all for inter- nal use, to secure the general tonic and alterative effects of the drug. Therfore, when we speak of applying arsenic locally we mean always arsenic trioxide in powder form or in mixture. (See Alteratives.) Dental Use. — It is rare that arsenic is used in the mouth for any other purpose than devitalizing pulps of teeth; and it may be ^aid today, after more than half a century of experience with it and with other less dangerous but less efficient devitalizants, that it is the substance of first choice for this purpose. It is only with deciduous teeth that a less powerful agent must be chosen. Here the danger would be penetration of the arsenic through and beyond the apex of the root, with a corresponding extension of its destructive action. With the exception noted, it is true generally that nothing need be feared, in the way of extension of its action, when the drug is care- fully used upon the tooth pulp. The natural confines of the pulp cavity and root canal prevent its penetration to other tissues, so that only careless handling and inappropriate or excessive use need be followed by bad results. While we must admit the possibility of irritation extending beyond the pulp chamber in case of a good-sized apical fora- men, a septic inflammation could not be expected from the action of the arsenic, itself being a strong antiseptic. Careful use of the drug implies (1) isolation of the tooth to be treated, by applying the rubber dam; (2) the use of a small amount of the drug; 84 ESCHAROTICS (3) careful sealing-in during the period of its action; and (4) its thorough removal after de^•italization is complete. Hofheinz formulates the following rules for the application of arsenic to a pulp : 1. Do not combine it with an escharotic. 2. Never use it in deciduous teeth. 3. Do not place it over an aching pulp. 4. Place it directly on the pulp. o. Exert no pressure upon the pulp. ' 6. Never crowd it into root canals. 7. Take special care of the gum tissues if the cavity is near the gingival line. 8. Let it remain twenty-four hours at least. With the small amount necessary to destroy a pulp, systemic effects will never occur. The ordinary medicinal dose of arsenic is from ^q to tV of a grain, which need never be exceeded for this use; according to jMiller from y'Wo to 2^5 is sufficient. It should be impressed upon the mind of the practitioner that any untoward effects that may follow his emplo^inent of arsenic in a tooth \\ ill be purely local and the result of either ^ant of care in its application or lack of judgment as to its appropriateness . The precise mode of action of this drug as an escharotic cannot be stated ^^"ith positiveness. The several views advanced merit our atten- tion, but discussion of them to a definite conclusion is hardly possible. Sollmann* regards paralysis of the capillaries as the beginning of its action, ^^■hich, with increased permeability of their walls, is followed by exudation into the connective tissue. These changes, it is observed, are very similar to those of inflammation. Fatty degeneration of cells results and the destruction of tissue is accomplished without evident chemical reactions. This author finds support to the theory of capil- lary paralysis in the fact that intravenous hijections of large quantities of salt solution will cause edema in animals poisoned with arsenic, but not in normal. He suggests further that the distention of capillaries may lead to their rupture and the formation of ecchymoses. (It would seem that such changes must take place in the walls of the digestive tract in arsenical poisoning, for the symptoms and the appearance of the discharges are almost identical with those of cholera, and the destruction of tissue found after death is regarded as due to degeneration * SoUmaun's Pharmacology, 1901. UNCLASSIFIED ESCHAROTICS 85 and not to any direct action of the poison.) Regarding changes in the blood opinions differ, but Silberman* asserts that arsenic tends to cause intravascular coagulation, and the experiments of Heinz t indicate that this is not ordinary coagulation, but formation of thrombi of blood plates, and he attributes the hemorrhages to such thrombosis. A theory of the action of arsenic advanced by Binz and Schultzi is to the effect that arsenous a( id is oxidized to arsenic acid by living tissue and the arsenic acid is again reduced to arsenous. This alternate withdrawal and supply of oxygen, in its influence upon the protoplasm, is supposed by them to be the essential feature of the action of arsenic. Arsenic will attack any soft tissue to which it is applied, so that, when explaining its action, we must recognize its influence upon the vitality of tissue apart from kind or location; but within the pulp cavity and upon so vascular and highly sensitive an organ, enclosed as it is by bony walls with very small unyielding openings for vessels and nerves, the factors of increased pressure, due to the intense hj'per- emia, and leading to stoppage of the circulation by strangulation of vessels or by thrombosis, is believed to contribute largely to the destruc- tive action. The occurrence of pain in connection with pulp devitalization depends somewhat upon the condition of the pulp. A healthy pulp, that has not become irritated, may be destroyed without any pain; but in the average case where irritation has occurred, it must be expected that within a varying period of time after the application, usually several hours, the patient will experience pain, first gnawing, later throbbing in character, which will continue until the pulp is destro}'ed, which is accomplished in from six to forty-eight hours, as a rule. Combinations. — In its use as a devitalizer, arsenic is combined with other substances to meet two objects — to obtain a convenient form for application and to lessen the pain of its action. The form mostly pre- ferred is that of a paste, which is prepared by rubbing up the powdered arsenic with a sufficient quantity of a volatile oil, creosote, glycerin or carbolic acid. The antiseptic character of these drugs may be held by some to give added value, but arsenic itself is a sufficient antiseptic as to really need no addition on that score. § It should be noted that any * Cushny's Pharmacology, tliird edition, p. 615. t Ibid. t Ibid., p. 619. § According to Koch's experiments (Brunton's Pharmacology', 1885, p. 98), arsenic is one-tenth as strong as bichloride of mercury in antiseptic power. Cushny (Phar- macology, third edition, p. 619) states that it is less poisonous to fungi than to higher forms of life, and that it seems to have no effect upon the action of pepsin and similar ferments. 86 ESCHAROTICS strong coagulant, such as carbolic acid, by coagulating the surface of the pulp where the application is made, -vvill tend to hinder penetration of the arsenic, on which account it is inferior to a volatile oil. Some- tunes cotton fiber is incorporated with the paste, and being then dried, is known as "devitalizing fiber."* To lessen the pain of de^'italization a number of drugs have been recommended and used, but the list can now be narrowed down practi- cally to one, or substitutes for it. Cocaine hydrochloride possesses every quality that is essential, with no serious disadvantage. It is soluble, it mixes with the substances usually combined in the paste, and it is more efficient than any other known agent. The danger of absorption into the general circulation, with the small quantity employed and the barrier presented to its penetration, is so slight that it may usually be disregarded. Any quantity not exceeding one-quarter of a grain may be regarded as safe to use. Proper substitutes for this drug are eucaine, novocaine and orthoform, any one of which may be employed, but they are not more efficient than cocaine. Their chief advantage is in being less toxic, although it may be found by experi- ence with orthoform that its influence is more prolonged because of its insolubility. In considering this part of the subject it should be remembered that pain in a tooth pulp can be practically relieved at two points — either at the pulp, by agent;^ that paralyze the terminals of the sensory nerve, or at the centers of appreciation of painful sensation in the brain, by agents that depress or benumb those centers. Corresponding in their site of action to these two points, we have two classes of anodynes — those that act locally upon the periphery of nerves, and those that act * The following formulas of arsenical pastes are typical and useful: Gm. I^ — Arseni trioxidi 2 1 (gr. 30). Novocaine I'SO (gr. 22). Olei carophylli q. s., to make a paste. Coloring matter may be added, if desired to make it contrast to the tooth substance. Gm. I^ — Arseni trioxidi, ('ocaina3 hydrochloridi . . . . aa 1 ' 30 (gr. 22). Mentholis 'sO (gr. 5). Glyc-erini (}. s., to make a jiaste. (Kirk). Gm. I^ — Arseni trioxidi, (yocaina; hydrochloridi . . . . aa 1 1 30 (gr. 22) Olei caryophylli q. s., to make a paste. (Miller). UNCLASSIFIED ESCHAROTICS 87 centrally upon the centers for painful sensation. Agents that act locally as anodjaies have little or no central effect in ordinary doses^ and, con- versely, agents that relieve pain by depressing brain centers may have no effect of this kind when applied locally. This line of discussion is prompted by the fact that morphine is so commonly recommended as a local anodyne combined with arsenic. This is entirely opposed to our knowledge of the action of morphine. This drug has almost no local action when applied to sensory nerve endings, but is anodyne only through its central action, after being absorbed into the blood in suffi- cient quantity. Morphine locally applied, therefore, can be of little use for the purpose of mitigating the pain or irritation caused by arsenic. This fact was recognized many years ago* and is fully supported by the most recent authorities.! The volatile oils, thymol, iodoform and carbolic acid are all feebly analgesic, but inferior to cocaine, while iodo- form has the disadvantage of disagreeable odor, and carbolic acid is a coagulant. Local Poisoning by Arsenic. — The lodgment of arsenic between the teeth or beneath the edge of the gum will cause, after some hours, local irritation leading to engorgement of the gum, which will be fol- lowed by sloughing if the poisoning is severe. Pain may be absent. These symptoms will correspond in extent to the depth of penetration of the arsenic, sometimes including pericementum and alveolus. All tissues whose vitality has been seriously disturbed must be expected to slough away. Treatment of this condition will include the removal, by cutting or scraping, of all tissue that has been destroyed, the scarification of engorged tissue to secure free bleeding, and washing away of any parti- cles of the drug that may remain undissolved, by injecting a stream of water between tooth and gum. Following this, gentle massage of the gums of the whole region will be useful. As a rule, when the patient * Harris's Principles and Practice of Dentistry, tenth edition, 1876, page 371. "Morphine was formerly supposed to modify the irritating action of arsenous acid, but since this has been discovered not to be the case, its use has been dispensed with by many." t Cushny, Pharmacology and Therapeutics, 1901, page 208. "It is often stated that the sensory terminations are paralyzed by morphine, and solutions are therefore injected into the seat of pain, or hniments are rubbed into the skin over it, but as a matter of fact, morphine seems entirely devoid of any such local action." SoUmann, Pharmacology, 1901, page 204. "Particular stress must be laid on the fact that the sensory endings are in no way affected, so that the local application of morphine or opium is entirely iiTational." 88 ESCHAROTICS presents with these s\7nptoms the damage will have been done, and local medication is of doubtful value. But if any arsenic still remains about the tissues, the freshly prepared ferric hydroxide will neutralize it wherever accessible. The latter may be packed about the teeth and beneath the gum margin. Dialyzed iron has been recommended, but it is inferior to fresh ferric hydroxide (see below). Tincture of iodine is beheved by some to be a useful application, and the same may be said of tincture of chloride of iron, but neither of these exert any antidotal action except as they stimulate the tissues to better resistance. Scari- fication will usually precede the use of any of these agents. General Poisoning by Arsenic* — Acute general poisoning occurs as the result of an overdose being taken into the stomach. Usually the symp- toms develop slowly, beginning with gastrointestinal irritation. There is in most cases sufficient tune to administer an antidote and empty the stomach if the mistake of dosage is discovered at once. An ordi- nary emetic is to be given at once (one to three teaspoonfuls of mustard flour in a glass of lukewarm or cold water, or the same quantity of either powdered alimi or common salt with a little water, or one-third of a teaspoonful of sulphate of zinc); meantime the antidote should be prepared and given. The best antidote to arsenic is ferric hydroxide, which is prepared by adding an alkali to a solution of a ferric salt, which precipitates the brown ferric hydroxide. It must be freshly prepared. This is easily done by mixing 7)iilk of magnesia (Magma Magnesiae, U.S. P.) with tincture of chloride of iron or with MonseVs solution, both agents to be diluted somewhat before mixing. It should be taken freely immediately after being mixed, as it gelatinizes upon standing. The official dose is f§4 (120 mils). (See also Table of Poisons and Anti- dotes.) Cobalt (not official). — While pure cobalt [Co] is a distinct chemical element, in the commercial form arsenic is associated with it. It is employed to devitalize pulps, and in this use it acts very much like diluted arsenic, being slower in action and less irritating than pure arsenic, and, in some cases, even painless. * The fact may be stated that in some parts of the world, especially in Styria, the peasants take arsenic habitually and acquire a tolerance to the drug, so that they take quantities which would ordinarily be poisonous. It is claimed that it secures a ruddy complexion and plumpness of form, as its action favors the deposit of fat in the tissues, and that mountain climbing is easier under its use, requiring less effort and producing less respiratory discomfort. UNCLASSIFIED ESCHAROTICS 89 Actual Cautery. — This term applies to the use of heat of sufficient degree to burn the tissue. Formerly an iron or silver wire was employed, heated to a white heat. Pulps were destroyed by plunging the heated wire directly into the pulp canal. Fortimately both the means and its use have become obsolete. Nevertheless heated metallic points and wire loops are frequently employed in general and special surgery today. The approved methods of applying the actual cautery are the following : Thermocautery. — Under this term there is arranged an apparatus, by means of w^hich a platinum point, previously heated up in a gas or spirit flame, is maintained continuously at a white or red heat by the com- bustion of gasoline vapor forced through it. Paquelin's thermocautery is the one mostly used. Platiniun points of various sizes and shapes permit an extensive use of this method for removal of small tumors, checking hemorrhage, etc. It is seldom used about the mouth, prefer- ence being given to the galvanocautery. Galvanocautery. — This consists of a galvanic battery, arranged in simple circuit — i. e., with all positive elements connected together and likewise all negative, so as to equal in effect one large cell. A battery so arranged presents a large surface of elements with the resistance of only one cell. It furnishes a large quantity of electricity capable of producing a high degree of heat when it meets with external resistance. Platinum loops in various shapes and sizes, adapted to cutting, searing or snaring tissue, are employed. One of these mounted upon a suitable hand-piece and included in the current furnishes a sufficient resistance to convert the electricity into heat, the degree of which can be easily regulated by mauipulation of the battery. A great advantage attaching to this method, for use about the face and mouth, is that the patient need not see the heated loop. It may be placed right in proximity to the diseased or bleeding tissue before the current is turned on; and if the application of cocaine precedes its use the pain is not severe. CHAPTER VIII. DEMULCENTS AND EMOLLIENTS. DEMULCENTS. Demulcents are agents that protect or soothe raw, irritated or inflamed surfaces. They consist chiefly of oily, mucilaginous or albumi- nous substances, of which the ones here named are the most important: Oleum olivse {olive oil). Acacia {gum arabic). Oleum lini {linseed oil). __ Limim {flaxseed). Oleum gossypii seminis {cottonseed oil). llmus {slippery elm bark). Petrolatum liquidum (albolene). Albumin. The oils are used in their ordinary form, as a rule; sometimes, how- ever, the addition of an alkali is ad\isable, and such a combination is found in the time-honored 'carron oil," known officially as linimen- tirai calcis.* This has long been a favorite application to burns and scalds. A disadvantage in its use lies in the fact that linseed oil dries upon exposure, and the stiffening of the dressing which results may make it more difficult to remove. This may be obviated by substituting cottonseed oil for linseed oil in the combination. In poisoning by corrosives and irritants, demulcents are valuable to protect the injured surfaces. Any of the above are applicable, except that in poisoning by phosphorus or cantharides oils shoukl not be used, as they are solvents for these drugs. In any case where albumin is the proper antidote it may be the demulcent of choice so as to serve a double purpose, raw egg being the best form. The mucilaginous drugs are employed in aqueous solution, either infusion, mucilage or syrup, and are for internal use, being seldom applied externally except in poultices. When flaxseed tea is to be prepared, the whole seed, not ground, should be treated with hot water. The mucilage is present in the shell and is thus easily dissolved out. The ground seed is used only in poultices. Gm. or mil. *I^— Oleilini 60| (fgij) Liquoris calcis 60 (fBij) — M. Sig. — Apply freely and cover with dressing. EMOLLIENTS 91 Certain sialagogues and expectorants may exert a secondary demul- cent effect through stimulating secretion in the irritated or inflamed part. Irritation of the air passages, and particularly an irritative cough, is often due to dryness of the mucous membrane. Sialagogues or expectorants may be the very best agents to relieve this irritation by increasing secretion, which moistens the irritated surface, and at the same time the engorgement of the tissue is lessened. The drugs mostly used in this way are: Cubeba (cubeb berries). Ipecacuanha. Glycyrrhiza {licorice root). Ammonii chloridum. EMOLLIENTS. Emollients are agents that soften and soothe an inflamed part. Fatty preparations, in the form of ointments, are used to soften the skin and at the same time protect denuded or ulcerated surfaces from dust and from the drying effect of the air. Among the fats, lanolin (adeps lanse), the fat of sheep's wool, deserves special mention as a valuable emollient. Its penetrating and softening power, it is claimed, exceeds that possessed by any other fat; and it has the unique property of mixing with at least 30 per cent, of its own weight of water without losing its ointment-like character. The latter quahty permits the use of solutions of salts or alkaloids in an ointment, which is often desirable, as in case of a pain- ful sore. Here a crj'stalline substance like cocaine should be more active when in solution and mixed with lanolin, than when the particles are simply rubbed up with a fat that has feeble penetrating power. Where protection by a fat is the chief purpose, lard (adeps) and vaseline (petrolatimi) are the most commonly employed bases for oint- ments, but in softening and penetrating power they seem to be inferior to lanolin. Lard, being an animal fat, is better in this respect than vaseline, which is not a true fat, but a product obtained in the distilla- tion of petroleum. The poultice (cataplasm) is another form of emollient application. Various substances may enter into the composition of poultices, but the possibilities of their use are most typically combined in ground flaxseed. The shell of this seed contains 15 per cent, of mucilage and the interior contains 25 to 40 per cent, of oil. By treating the ground seeds with hot water we obtain a poultice having the emollient qualities of both oil and mucilage. Applied hot the relaxing effect of the heat contributes to the softening process, and altogether we have in the poultice a great aid in either resolving an inflammation, or hastening suppuration when it cannot be prevented. 92 DEMULCENTS AND EMOLLIENTS Glycerinum. — Glycerin. — Glycerol. This substance is obtained by decomposition of oils and fats, being a by-product in the manufacture of soaps, and it should contain not less than 95 per cent, of absolute glycerol [C3H5(OH)3], a trihydric alcohol. It is a thick, heavy, colorless liquid, neutral, freely soluble in water, in alcohol and in a mixture of 1 part ether and 3 parts alcohol, but insoluble in ether, chloroform and oils. Its specific gravity is about 1.250. It has a sweet taste, and when applied to a mucous surface produces a warm or burning sensation. It does not coagulate albumin. The chief quality that determines its action upon tissue is its marked affinity for water, it being capable of absorbing 50 per cent, of its own weight; therefore, when applied to a raw surface glycerin may irritate by its energetic abstraction of water, but it does not irritate the unbroken skin or mucous membrane. Its eftect upon tissue is to soften and protect. As an emollient, glycerin is used extensively in hand lotions and either in full strength or diluted with an equal quantity of water, as a simple application to chapped hands. Here its action is typically seen. The smarting at first experienced is due to its abstraction of water from the tissues wherever the skin is cracked or broken. This is suc- ceeded by a softness of the skin, due to the increased amount of moisture which is attracted into the superficial layers of epithelium by the action of the glycerin. When we observe that chapping of the hands occurs mostly in cold weather, when the absolute moisture of the atmosphere is greatly reduced by precipitation, we can appreciate the importance, as a causative factor, of excessive drying of the skin by the surrounding air; and we are helped to an understanding of the value of glycerin as a retainer of moisture wherever applied to soft tissues. The maintenance of a normal degree of moisture is, of com-se, essential to the healing of wounds of the skin. Roughness of the hands, or of the skin of other parts, is effectually treated by a lotion of glycerin and water, or glycerin, water and alcohol. If there is a tendency to scaling of the epithelium, or increase of seba- ceous secretion, as in "dandruff" of the scalp, the addition of salicylic acid is very useful. The following formula is suggested: Gtn. or mil. I^ — Acidi salicylici 1 Alcoholis 30 Glycerini 30 Olei amygdalae amarse Aquffi q. s. ad 90 Sig. — Hand lotion. (gr. xv) (fSj) (f5j) 30 (mv) ad (f5iij).— M. EMOLLIENTS 93 Glycerin keeps indefinitely and is even classed among the antiseptics. It is an excellent preservative. It is used also as a solvent and vehicle for other drugs, and is often incorporated in small amount with extracts in order to keep them from becoming dry. Its combination with tannic acid, known as glycerite of tannic acid,* is a powerful astringent. In dentistry it is used in case of hyperemia of the pulp previous to capping; also after the application of arsenic to a pulp, it may be employed to harden or tan the pulp tissue in order to facilitate its removal. It is a generally useful astringent to mucous membranes. Incompatibility. — With borax a solution is formed which becomes acid in reaction, but whose value is not otherwise lessened. Glycerin should never be combined with nitric and sulphuric acids, nor with chromic acid, chlorinated lime or potassium permanganate, for fear of explosive results. * The official Glycerituni acidi tannici has the following formula : Gm. or C.c. I^ — Acidi tannici * 201 Glycerini 80 1 M. — Heat mixture until complete solution occurs. CHAPTER IX. ASTRINGENTS AND HEMOSTATICS. Astringents are agents that cause contraction of tissue. In a general view of the use of ajStringents, we include the checking of hem- orrhage and of diarrhea and the lessening of inflammation, particularly of the mucous surfaces. The several modes of action of astringents may be stated to be: 1. Simple contraction of the tissues of the part, as by cold appli- cations. 2. Coagulation of the surface, as by tannic acid. 3. Constriction of arterioles, thus lessening the blood supi)l}^ to the tissues, as by application of suprarenal gland protlucts.* 4. Abstraction of water from the tissues, as by alcohol locally applied. The terms hemostatic and styptic apply to agents that arrest hemor- rhage. Most of these act by securing coagulation of the blood, but some act mechanically, such as ligatures and bandages, and others lessen the blood supply to the bleeding part, as cold and arterial seda- tives. Other styptics induce contraction of the arterioles; ergot, antipyrine, suprarenal gland and the local application of hot water, all act in this way, ergot acting through the system, while the others act by local application. Collodion exerts pressure through contraction of its volume while drying. It must be borne in mind that the one object of employing any hemo- static is to secure coagulation of blood at the point of hemorrhage; and the employment of the various agents can only facilitate this process; so that the use of coagulating agents, the lessening of the amount of blood in the part, the contraction of arterioles, and the employment of pressure, all have precisely the same object, but secure it in different ways. The choice of agent depends upon locality and size of the vessels that are injured. A capillary hemorrhage can usually be controlled by coagulants, or by cold, or by agents like antipyrine, which causes the arterioles to contract. If the hemorrhage is from a larger vessel, or from a tooth socket, where the muscular control of the capillary circulation is dt^ficient, pressure upon the bleeding points, or, in extreme cases, ligation of the * The U. S. Pharmacopoeia gives epinephrine as the active principle of the .sujira- renal glands. This, or similar body, is known conunercially as adrenalin, adnephrin and suprarenin. ASTRINGENTS AND HEMOSTATICS 95 vessel, may be required. Again, in case of hemorrhage from the bowel or lung, perfect rest of body and mind, the ice-water coil and arterial sedatives will be employed. But with all our art we are only aiding nature to secure coagulation. The following classification will aid our consideration of these agents : Classification of Hemostatics. Coagulant Astringents. 1. Vegetable. Tannic acid. Drugs containing tannic acid : Nutgall. Hematoxylon. Gambir (catechu). Hamamelis. Kino. Tea. Krameria. Coffee. Alcohol. 2. Mineral. Iron preparations : Tincture of ferric chloride. Solution of ferric chloride. Ferrous sulphate. Ferric subsulphas (Monsel's salt). Solution of ferric subsulphate. Alum. Copper sulphate. Lead acetate. Silver nitrate.* Zinc chloride.* Zinc sulphate. Vascular Astringents. 1. Those that act locally: Antipyrine. Epinephrine. Heat. 2. Those that act after absorption into the general circulation: Ergot. Gallic acid. Remedies that Favor Coagulation of the Blood. 1. By reducing blood-pressure: Cold. Arterial sedatives : Aconite. Veratrum viride. 2. By acting in the blood to increase its coagulant property: Calcium salts. Thyroid preparations. Blood serum. 3. By causing direct pressure or occlusion of vessels: Collodion. Bandages, Hgatures and other surgical measures. * Caustic in full strength. 96 ASTRINGENTS AND HEMOSTATICS Application of Cold. — By this is meant not only the abstraction of heat, which may be desirable, but also the contact of a substance having a low temperature with the skin, in order to cause a reflex contraction of the muscularis of the skin and of the arterioles. The ice-bag, ice- water, or ice directly applied, are the usual means. If considerablf surface is to be treated, a very convenient method of applying ice-water continuously is by means of the Leiter coil, which consists of soft-rubber tubing coiled concentrically to fit upon the part (as in form of skullcap for the head), or wound about an affected joint; through the tubing ice-water is run by siphonage as constantly as may be desired. Cold applications will be found useful to lessen the hyperemia of acute inflammation and to lessen the amount of blood in the locality of a hemorrhage. The twofold action induced is reduction of blood supply and condensation of tissue. In employing cold locally to relieve toothache we secure its astringent action upon the local cir- culation, and we also have the sedative effect of the cold upon the nerve endings. A pulpitis may sometimes be relieved by the contact of ice with the tooth and contiguous tissues. Application of Heat. — Practically the only uses of heat as a hemostatic are two — (1) as hot water applied to a surface where there is oozing from small vessels, the heat causing vascular constriction through irritation; and (2) as some form of actual cautery, by which the bleeding point is seared. Coagulant Astringents (Vegetable). Tannic acid is the astringent principle in each drug of the vegetable group, therefore a discussion of its action and uses will suffice for all. Acidum Tannicum. — Tannic Acid. — Tannin [HC14H9O9]. — An organic acid obtained usually from nutgall. Average dose gr. 8 (0.5 gm.). It is a yellowish powder, becoming darker upon exposure; soluble in less than 1 part of either water or alcohol, and in about 1 part glycerin with the aid of moderate heat. These solutions have an acid reaction. Its chief action is that of a coagulant. It has a bitterish and astringent taste, but is non-irritating to the tissues. It is useful only when applied locally to tissues, as it has no effect through the circulation; in fact, tannic acid is never absorbed into the circulation. When taken into the stomach it unites with any albuminous matter present, it interferes with the activity of pepsin, and, if in excess, some may be converted into gallic acid, which can be taken up into the system. COAGULANT ASTRINGENTS 97 The drug may be applied in powder to a bleeding-point, or packed with cotton into a tooth socket. In any strength of solution it may be applied to inflamed, raw or ulcerated mucous surfaces, or used as a gargle. In catarrhal and relaxed states of the mucous membrane it is a useful application, especially when combined with glycerin. Being incom- patible with alkaloids, it is used as a chemical antidote to them. In hemorrhage from the stomach it is taken in strong solution or powder form, but for internal hemorrhages outside of the digestive tract it is of no value, except as it is changed into gallic acid, which may be absorbed and possibly exert some general influence. Tannic Acid Group or Vegetable Astringents. — All vegetable astringents owe their activity to the tannic acid which they contain, so it is a matter of personal choice whether the pure acid or a drug containing it be used. For hemostatic purposes preparations of astringent drugs are rather weak, but for a mouth wash or gargle they are useful. Incompatibility. — ^Tannic acid drugs are incompatible with albumin, alkaloids, ferric salts, lime-water, mineral acids and most metallic salts. Galla. — XuTGALL. — ^An excrescence occurring on certain species of oak, caused by the puncture and deposit of ova of an insect This is the source of the official tannic acid. Average dose gr. 8 (0.5 gm.), but the drug is seldom used except externally in the form of tincture or ointment. Gambir. — Catechu. — An extract prepared from leaves and twigs of Ourouparia gambir. The compound tincture and troches are used. Kino. — The dried juice of Pterocarpus marsupium, average dose gr. 8 (0.5 gm.). The tincture is the only official preparation, aA^erage dose m 60 (4 mils). Krameria. — Rhat.ixy (not official). — The root of several species of Krameria. This drug has a number of preparations. Hematoxylon. — Logwood (not official). — The heart-wood of Hcema- toxylon campechianum. Besides tannin, this drug contains hematoxylin, which is used to stain microscopic specimens. The extract may be used. Hamamelis. — Witch-hazel (not official). — The leaves and bark of Hamamelis virginiana collected in autumn. The fluidextract is used. Tea and Coffee. — Although not official, tea leaves and coffee seeds contain a variable amount of tannic acid, tea yielding about 15 per cent, and coffee somewhat less. WTiile all tannins are similar, some may be distinguished by their 7 98 ASTRINGENTS AND HEMOSTATICS reaction with ferric salts, e. g., gallotannic acid will yield a bluish-black and kinotannic acid a greenish-black ink. Drugs of this group are non-poisonous. Their preparations may be used freely as astringents either in full strength or diluted with water. [^ Alcohol. — Rectified Spirit. — Ethyl AIcoJwl [C2H6OH]. A liquid composed of about 95 per cent, by volume (92.3 per cent, by weight) of ethyl alcohol and about 5 per cent, by volume (7.7 per cent, by weight) of water. Sp. gr. about 0.816 at 60° F. It is obtained by fermentation of grain or the juices of fruits, and subsequent distillation. It is a clear, colorless, volatile liquidji, with a burning taste and a distinc- tive odor. Alcohol boils at 172.4° F. This agent is nentraJ. It has a great affinity foi* water, even absorb- ing it from the atmosphere, and it coagitlofes albumin. It burns with a blue, smokeless flame, yielding a high degree of heat, which renders it very useful in the spirit lamp. In addition it is extensively used as solvent, preservative and drying agent. The following strengths of alcohol also are official, but whisky and brandy (about 50 per cent.) and wines (8 to 20 per cent.) have been dismissed from the Phormacojjoeia. Alcohol Dehydratum (not less than 99 per cent, by weight) is the purest spirit obtainable. Owing to the strong affinity which alcohol has for water, it is impossible to separate them absolutely; but, by treating strong alcohol with potassium carbonate and fused calcium chloride, w^hich have a stronger affinity for water, and redistilling, all except a fraction of 1 per cent, of water can be remo^'ed. Absolute alcohol is equally difficult to keep in full strength on account of absorp- tion of moisture from the air. It must be kept in well-stoppered bottles and exposure to air avoided. It is highly inflammable. It is seldom that so strong a spirit is needed, but it may be required for special uses as a sohent and as a chemical. Alcohol Dilutum (about 49 per cent, by volume). This, composed approximately of equal parts of alcohol and water, corresponds nearly to "proof spirit" (50 per cent.), which is the United States standard for measuring unrectified spirit. Spiritus Frumenti (whisky) contains from 44 to 55 per cent, b}' vol- ume of alcohol. It is distilled from fermented grain and should be at least four years old. (Not official.) Spiritus Vini Gallici (brandy) contains from 46 to 55 per cent, by volume of alcohol. It is distilled from the fermented juice of grapes and should be at least four years old. (Not official.) COAGULANT ASTRINGENTS 99 Whisky and brandy do not gain in alcoholic strength by age, but they develop flavor; and, in whisky particularly, the fusel oil, which is a natural impurity of raw spirit, is destroyed during the ripening process. Local Action and Uses of Alcohol. — ^This drug is astringent by virtue of its power to coagulate albumin and to abstract water from the tissues. The coagulum is not so firm as that produced by most mineral astrin- gents, and it may be gradually redissolved by the alkaline fluids of the tissues. When applied in the full strength to the mucous membrane, alcohol induces first a burning sensation, which becomes painful as the fuH action upon the tissue is attained. With its evaporation a cooling sensation may then be experienced. The irritation soon passes away, and there remains a sense of fulness in the part, with corrugation of the surface, which at the same time has acquired a whitish appearance in the superficial layer. GraduaUy the mucous membrane will be restored to its normal condition with very slight surface exfoliation. The action is very superficial and of only moderate duration. Alcohol, therefore, cannot rank as more than a mild astringent, but the posses- sion of the power to abstract water, with its volatility, makes it a valuable drying agent wherever applied. Added its antiseptic quality, we have in alcohol an agent that is cooling to an inflamed surface, slightly astringent and antiseptic — the very qualities that make it (whether used pure, diluted, or as a vehicle for other substances) a very useful wash or application in stomatitis or any unhealthy state of the gum or mucous membrane. The strength as a mouth wash should not exceed 1 part alcohol to 2 parts water. It is also useful as a drying agent in cavities and root canals; and if its application be followed by that of chloroform or ether a mos perfect and rapid removal of moisture will be effected; the alcohol first taking up the moisture, evaporation is then hastened by the alcohol being taken up by the more rapidly volatile chloroform or ether. The only precaution necessary regarding this use is the avoidance of the proximity of a flame, because of the inflammability of alcohol and of ether. Alcohol is also a useful lotion when applied, somewhat diluted, to a bruised or inflamed surface; and if capillary oozing be present, its action will faA'or coagulation of blood and contraction of arterioles. It must be said that alcohol contributes much to the local action of certain tinctures, of which tinctm-e of myrrh is an example; indeed, in this preparation the alcohol is much more important and active than is the myrrh. (See under Antiseptics.) 100 ASTRINGENTS AND HEMOSTATICS Applied to the skin, the action of alcohol is less marked than upon mucous membranes, because of the firmer texture of the former and the better protection it affords to the sensitive structures beneath. Rubbing or bathing the skin with alcohol produces, first, cooling of the surface, Avhich is soon followed by a reaction that is delightful. The power of attracting moisture gives alcohol a place as a remedy in carbolic acid poisoning. Its action here is more upon the injured tissue than upon the poison. (See Phenol Poisoning.) The same property, plus antiseptic power, makes alcohol a detergent of some value. In addition to remedial uses, alcohol is employed largely as a solvent for drugs, being the chief menstruinn in fluidextracts, thictures, spirits and elixirs, besides being used to extract many vegetable active prin- ciples. When selecting an astringent drug for use, it follows that the thwture of that dk-ug (if its solution in alcohol is possible) will be espe- cially efficient by reason of the added action of alcohol. Alcohol is also used as the general solvent for resins, as in the prepa- ration of sandarach varnish. The internal action of alcohol is considered under Stimulants. Iruvmimtibility. — Alcohol is incompatible with albuminous substances, all of which are coagulated by strong alcohol. It precipitates gums from their aqueous solutions. On account of their insolubility in alcohol many salts of the alkalies and metals ma}' be precipitated by it from their aqueous solutions. Both chromic acid and potassium per- manganate are decomposed by alcohol. Methyl Alcohol (not official). — Wood Spirit [CH4O]. A thin color- less liquid obtained in the destructive distillation of wood. It has a peculiar odor and burning taste, sp. gr. about 0.800, and boils at about 151° F. It burns with a pale, smokeless flame, giving less heat than ethyl alcohol. By partial oxidation it yields formaldehyde gas. A purified product is called Columbian Spirit. Wood spirit is used as a substitute for ethyl alcohol as solvent and for external uses. Its use as a solvent may be proper, but on account of its poisonous action it should never be used in medicine. Aside from deaths caused by methyl alcohol, many cases ha\'e been rej)orted within recent years where blindness, more or less ])ermanent, followed contact with the fumes of this drug. Coagulant Astringents (Mineral). This grouj) of drugs stands in contrast with the tannic acid group, as we might expect from their compound chemical nature. They are COAGULANT ASTRINGENTS 101 compounds of acids with metallic bases, so that, by their dissociation in contact with tissues, we have two distinct agents concerned in the action of each mineral astringent. This fact is given prominence by some of the later authorities in pharmacology* and its recognition removes much of the difficulty in understanding the action of these salts upon living tissues. The essentials of their action may be stated as follows: Mineral astringents have the property of precipitating albuminous or proteid substances. ■ This must be understood to be a definite chemical reaction, whereby a metallic albuminate is formed and the acid of the salt is liberated. There is, therefore, added to the coagulation or precipitation process the action of whatever acid is liberated. As they differ in coagulant power, the sum of the action of such astringent will depend, as Cushny states,! upon "Two factors — the character of the precipitate and activity of the acid formed. The latter again varying with the extent to wdiich it is dissociated into ions; it, therefore, exercises the same astringent or corrosive efi'ects as if it had been applied uncombined. But its action may be modified by the presence of metallic albuminate protecting the surface." The firmer the coagulum the less will the liberated acid irritate the tissues, and, on the other hand, the stronger the acid liberated the greater will be the possibility of irritation by it. We would, therefore, expect the mineral acid salts to be more irritating than organic acid salts. This we find to be the case in comparing the action of chloride of zinc with that of acetate of lead. Again, among the mineral acid salts those that are most easily dissociated, such as the soluble chlorides and nitrates, are found to be most irritating. A comparison of the chloride and sulphate of zinc gives evidence of this, the chloride being much more irritating. The variety of these mineral compounds permits of the selection of an agent for any grade of action desired. The group of astringent iron salts in common use comprise the following, all of which are acid in reaction: Ferri Chloridum. — Ferric Chloride [FeCls + 6H2O]. An orange- yellow, crystalline salt, with a strongly astringent taste. Very deli- quescent in moist air and freely soluble in water and in alcohol. It contains not less than 20 per cent, of iron. Used chiefly in the two following preparations: Tinctura Ferri. Chloridi.— Tincture of Ferric Chloride. — This con- tains about 5 per cent, of metallic iron. Average dose, TTL 8 (0.5 mil.). It has a very astringent taste and acid reaction. * See Cushny, Pharmacology and Therapeutics, fifth edition, 628. f Ibid., p. 628. 102 ASTRINGENTS AND HEMOSTATICS Liquor Ferri Chloridi. — Solution of Ferric Chloride. — This con- tains about 10 per cent, of metallic iron. Average dose,Tn, 1§ (0.1 mil.). It has a very astringent taste and acid reaction. Ferri Subsulphas (not official). — Basic Ferric Sulphate. — MonseVs Salt. — The chemical composition of this salt is variable. Liquor Ferri Subsulphatis. — Solution of Basic Ferric Sulphate. MonseVs Solution. — This contains 13.5 per cent, of metallic iron. This preparation is often improperly called persulphate of iron. The true persulphate is a normal salt, official in form of its solution {Liquor Ferri TersuJphatis) but very seldom used. Of all of the above, the liquor ferri subsulphatis or Monsel's solution is used more than all others as a hemostatic. It is objectionable on account of the copious, dirty, black coagulum which it produces; and it also stains any fabric that it touches. It is not an agent of first choice, but is used rather as a later resort when the milder astringents have failed. It is very efficient even when largely diluted. As astrin- gents for use in the mouth, the whole group here named are objec- tionable because of their strongly acid reaction, which renders them deleterious to the teeth. If employed at all, strict precaution should be taken to prevent their contact with the teeth, and neutralization of their acidity should follow their use. A solution of sodium bicar- bonate is a useful alkali for the latter purpose. Hemostatic cotton is prepared by satiu'ating absorbent cotton with either Monsel's solution or solution of ferric chloride and drying. It should be remembered that not all iron preparations affect the teeth. They all may form iron sulphide in a foul mouth or in a carious cavity, with a resulting stain, but only those that have an acid reaction are destructive to the tooth structure. All astringent iron salts are acid, but for internal administration there are a number of neutral preparations that are harmless. (See under Restorative Tonics.) Incompatibility. — Ferric salts in solution, with alkalies or alkaline carbonates in excess, produce a brown precipitate of ferric hydrate. With tannic acid, tannate of iron (black ink) is formed. Verroas salts with oxidizing agents are con\'erted into ferric salts. With alkalies and alkaline carbonates, solutions of ferrous salts yield precipitates. Tannic acid produces no change in ferrous salts in the absence of oxygen. Alumen. — ^Alum. — Aluminium and Potassium Sulphate [A1K(S04)2 + I2H2O], or Alumirmim and Ammonium Sulphate [A1NH4(S04)2 + I2H2O]. Either potassium alum or ammoniiun alum is official under this title. COAGULAXT ASTRIXGEXTS 103 It occurs ixL colorless crystals having a s\veetish and strongly astringent taste and acid reaction. Potassium alum is soluble in 7.2 parts of cold water, 0.3 part of boiling water, freely soluble in glycerin, but insol- uble in alcohol. Ammonia alum is somewhat less soluble in water. Alum coagulates albumin, acting superficially as an astringent and hemostatic. Average dose, gr. 8 (0.5 gm.). In larger dose the drug is emetic. To check slight hemorrhages the pure crystal or strong solution may be applied. For nosebleed a nasal irrigation or injection of the solution as hot as can be borne is useful. The aqueous solution may be used in any strength as a gargle or wash, but, being acid in reaction, it is not admissible as a mouth wash for continuous use. AYhen alum is subjected to a high degree of heat it loses its water of crystallization and becomes opaque and amorphous. It is then known as dried alum (aliunen exsiccatumj or ''biunt" alum, and is more energetic in its action upon tissue, being even escharotic to loosely organized tissue. Incompatihility. — Alumen is incompatible with alkalies and their carbonates. With metals soluble m dilute sulphuric acid the aqueous solution of alum will liberate hydi'ogen. Argenti Nitras. — Xitrate of Silat^r [AgXOs]. AA-erage dose, gr. | (0.01 gm.). This drug is described and discussed qtiite fully in the chapter upon Escharotics. As an astringent it is used upon mucous membranes in conditions of relaxation or of clironic catarrh, such as chronic pharyngitis, where the dilated capillaries give evidence of a decided loss of tone in the mucous membrane. The indications here are for a drug that will cause condensation of the relaxed tissue ^dth contraction of the dilated vessels. Xitrate of silver is one of our best agents to accomplish this when applied in solution of from 1 to 5 per cent., the stronger solutions being commonly used with an atomizer. It is irritatmg, but superficial m its action. It coagulates albumin. Its irritant action is explamed m part by the liberation of nitric acid at the time of its coagulant action, albumin taking the place of the acid in the combination. In connection with the application of this drug it may be remarked that a catarrhal condition does not need a constant irritant. The restoration of the ^-ascular tone will occiu* slowly under the influence of a decided local stimulant applied not too frequently. For the best effect, therefore, nitrate of silver should not be applied oftener than once a day or once in two days. In general, any strength of solution may be used up to 5 per cent., although this strength is decidedly irritating. Any excessive action may be prevented by 104 ASTRINGENTS AND HEMOSTATICS promptly neutralizing with a solution of sodium chloride. This drug cannot be used in a mouth wash nor upon visible surfaces, because it blackens tissues and fabrics wherever it touches and may stain tooth structure. The solutions of siher nitrate are neutral. As a rule it is not prescribed in combination with other substances. Cupri Sulphas. — Sulphate of Copper. — Blue Vitriol [CUSO4 + 5H2O]. This substance occurs in blue crystals with a metallic, nauseous taste, soluble in 2.5 parts of water, 2.8 parts of glycerin and in 500 parts of alcohol. The solution is acid in reaction. It coagulates albumin. It ranks with silver nitrate as an irritating astringent, being even a mild caustic when used in the form of crystal or strong solution. The acid liberated in connection with its coagulant action is suljjhuric, one of the most irritating of acids. Its value in dental practice is limited, being useful for limited application where a decided, though irritating, astringent efi'ect is desired. If it is allowed to enter a carious tooth staining is likely to result. Internally the drug is emetic in ftill dose, the average dose being gr. 4 (0.25 gm.). In case of poisoning by it albumin is the best chemical antidote. Plumbi Acetas. — ^Acetate of Lead. — Sugar of Lead [Pb(C2H302)2 + 3H2O]. Average dose, gr. 1 (0.06 gm.). (For preparations, see Index of Drugs.) It occurs in colorless or whitish crj'stals or masses, having a slight odor and sweetish, astringent taste. It is somewhat efflorescent, absorbing carbon dioxide from the air; soluble in 1.4 parts of water and in 38 parts of alcohol, freely in glycerin. It is slighth/ alkcdine in reaction. It coagulates albumin, being one of the active mineral astrin- gents. It is classed as a sedative astringent because of the absence of any marked irritation from its application. This fact agrees with the explanation that the acid of an astringent salt is liberated at the time of the coagulant action, being displaced by the albumin. In case of this substance acetic acid is liberated, which in its dilute form is not irritating. When used internally this drug presents the danger of lead poisoning. Therefore, its use is somewhat restricted as to quantity and length of time employed. In conditions of denuded surfaces, irritable ulcers, and acute local hiflammations of the gums, the solution may be employed, but swallowing the drug must be avoided. On account of this danger the lead preparations are seldom used internally, and even their external application to large surfaces may induce poisoning. For local use a simple solution of the salt in water or alcohol, or the COAGULANT ASTRINGENTS 105 official solutions of the subacetate may be employed. The latter contain a considerable amount of oxide of lead, which is soluble in a solution of the acetate with a change of the latter to the subacetate. The official diluted solution, known as lead^water, is of proper strength for ordinary use; or a stronger application may be obtained by diluting the stronger solution, which is known as Goulard's extract. A favorite application with some is the lead and opium wash* but the addition of the tincture of opium can contribute very little to the local action of the combination, except the astringent action of the alcohol it contains, as it is well known that opium has no appreciable local action. Among the evidences of saturation of the system by lead, there is noticed, especially in foul mouths, a blue line within the gum close to the margin. This is believed to be a deposit of lead sulphide within the tissue, and it is indicative of chronic lead poisoning only. (For symptoms, etc., of acute poisoning, see Table of Poisons and Antidotes.) Incompatibility. — Acetate of lead is incompatible with most acids which displace the acetic acid, with iodide of potassium and with liquor iodi compositus. The solution of the subacetate will precipitate solu- tions of acacia. Zinci Chloridum. — Chloride of Zinc [ZnCl2]. This substance is used more as an escharotic and antiseptic, but in the weaker solutions (1 to 10 per cent.) it is astringent. It coagulates albumin, but on account of the hydrochloric acid liberated the application of a strong solution is painful, and it is also quite penetrating. It is acid in reaction. Zinci Sulphas. — Sulphate of Zinc. — White Vitriol [ZnS04 + 7H2O]. Average dose, as emetic, gr. 15 (1 gm.). It occurs in colorless crystals or crystalline powder, having an astringent, metallic taste, soluble in 0.6 part of water and in 2.5 parts of glycerin; insoluble in alcohol. It is acid in reaction and it coagulates albumin. It is one of the feebler astringents, well adapted to the more sensitive mucous membranes, as the conjunctiva of the eye. In acute conjunctivitis and in acute disease of the antrum, it is a useful astringent in 1 per cent, solution. About the mouth it may be used stronger, as it is not irritating to the oral mucous membrane. It is a reliable emetic frequently employed to empty the stomach in cases of poisoning. In such emergency a dose of 30 grains (2 gm.) may be given. * Lotio plumbi et opii (N. F.): Gm. or mil. I^ — Plumbi acetatis 17 1 5 Tincturae opii 35 Aquse q. s. ad 1000 ! — M. 106 ASTRINGENTS AND HEMOSTATICS IncomjxiiihUiiy. — vSiilphate of zinc is incompatible witli aUcalies' and their carbonates and with ammonium sulphide. Zinci lodidum. — Iodide of Zinc [Znl2] (not official). — This salt occurs as a white powder, having a sharp taste, very deliquescent, and becom- ing brown upon exposure frorri the liberation of iodine. It is freely soluble in water and alcohol, and is acid in reaction. Its action is chiefly alterative combined with the characteristic action of the zinc ion. Dr. E. S. Talbot, after considerable experience with it, advises its use in interstitial gingivitis in the following combination with iodine, to which he gives the names of lodo-glycerole : Cim. or mil. I^ — Zinci iodidi 15 j (3iv) Aquse 10 1 (fSijss) lodi 25J (3vj) Glycerini 50 i (fSxijss) — M. Sig. — Apply to gums every second day. His purpose in using the zinc iodide is to increase the strength of the preparation and to make it more astringent. Zinci Oxidum.^ — Zinc Oxide [ZnO]. A very fine white or yellowish- w^hite powder, without any gritty quality. It is odorless, tasteless and insoluble in water or alcohol. It is a feeble astringent, very mild and even soothing in effect, so that it may be applied to any irritated or denuded surface. Either in simple powder or in the official 20 per cent. ointment it is largely used in diseases of the skin. It is not used internally. Vascular Astringents. An important group of hemostatics comprises those whose chief action is upon the bloodvessels. The term styptic is often used to designate these. Either by local action when directly applied, or by stimulating the vasomotor nerve supply, they induce contraction of the mus- cular coat of the smaller arterial vessels, thus favoring coagulation by lessening the capillary circulation. They do not coagulate albumin. They are applicable only in hemorrhages of the smallest vessels, and particularly those in which unstriped muscle tissue is sufficiently abundant to be a factor in controlling the blood supply; for these agents act only through direct or indirect stimulation of the layer of unstriped muscle in the wall of the vessel. Where this is deficient, as in bone, they are likely to be inferior to coagulant agents. Those that act locally are of greatest importance to the dental practitioner and will accordingly be first considered. VASCULAR ASTRINGENTS 107 Antipyrina. — Phenazone [C11H12OX2]. Average dose, gr. 5 (0.3 gm.). This substance is obtained, by a series of chemical reactions, from pyrrol, a base found in coal-tar. Chemically it is phenyldimethyl- pyrazolon, which term shows the impracticability of using the chemical names of many of the newer drugs. Classed generally as an antipyretic and analgesic it was among the first of the coal-tar derivatives intro- duced to medicine. It occurs in colorless crystals, having a bitter taste, neutral, soluble in less than 1 part of water and in 1.3 parts of alcohol, also soluble in 1 part of chloroform and in 43 parts of ether. It is not a coagulant. Its hemostatic value is purely local. If applied or sprayed upon a bleeding surface, in the strength of 10 per cent, solution, it has the power to cause contraction of the arterioles, and in this way will effi- ciently control any ordinary capillary hemorrhage. It will be less efficient than a coagulant hemostatic in checking hemorrhage from a tooth socket, because of the deficiency of muscle in the vessel walls in bone. It is a harmless drug when applied as above, for one-half of a fluidounce (15 mil.) of a 10 per cent, solution may be used without exceeding the maximum internal adult dose. It is useful in stopping epistaxis (nosebleed), the solution being sprayed into the nostril. Its uses as anodyne and sedative are discussed in another place. Incomfaiihility . — ^The aqueous solution is incompatible with a dilute solution of carbolic acid; also with spirit of nitrous ether when the latter is acid^ as it is likely to be ordinarily; also with solution of tannic acid. Suprarenalum Siccum. — Dried Suprarenal Glands. — ^Average dose, gr. 4 (0.25 gm.). Unofficial preparations: Epinephrine, adi'enalin, adnephrin, suprarenin (synthetic) and adrenin. A preparation much used is a solution of adrenalin chloride in 1000 parts of physiological salt solution. The active principle of the suprarenal glands was first isolated by Abel (Cushny) and has been named epinephrine. It is found only in the medullary portion of the gland. Takamine later isolated another substance, adrenalin, which is claimed to have all the properties of the gland substance. \\hen an extract of the gland is injected into a vein, there occurs an immediate rise of blood-pressure which is more or less proportional to the strength of the extract. The rise in blood-pressure is accompanied by a slowing of the heart due to reflex stimulation of the cardio-inliibi- tory center excited by the rise of blood-pressure; when this reflex slow- 108 ASTRINGENTS AND HEMOSTATICS ing is rendered impossible by cuttino; the yr^i the rise in blood-pressure may reach an extraordinary height. (Howell.) The chemical nature of the extract has been worked out and has made it possible for the chemist to prepare a synthetic substitute together with a series of related substances having a similar nature. By careful studies it has been found that the extract of the gland and related substances cause the rise in blood-pressure by stimulating the nerve jfibers of the sympathetic nervous system distributed to the muscular coats of the bloodvessels. It is on this account that a weak solution of the extract is used to stop hemorrhage. While this substance will stop hemorrhage by constricting the arterioles, it reduces the coagulability of the blood and secondary hemorrhage may follow. It shoukl be applied locally and is especially useful in capillary hemorrhage. On account of its vasoconstrictor action it is a useful adjunct to the local analgesic solutions, making them more efficient by localizing the action and lessening absorption into the circulation. The synthetic preparations are claimed to be more stable in com- position and can be boiled in solutions wdiich are for immediate use. For dental uses the usual dose is 1 drop of the 1 to 1000 solution of adrenalin, or of the synthetic preparations, to each cubic centimeter of the anesthetic solution with a maximum of 5 drops at any one time (Prinz). Acidum Gallicum. — Gallic Acid [CvHeOs + H2O]. Average dose, gr. 15 (1 gm.). An organic acid, prepared from tannic acid, having a rather uncertain reputation as a general styptic — i. e., acting through- out the system after absorption into the circulation. It occurs in whitish crystals, having an astringent taste, soluble in 87 parts of water, in about 5 parts of alcohol, and in 10 parts of glycerin. It is acid in reaction. It does not coagulate albumin, therefore it has no appreciable local action. It may be given internally in a dose of from 5 to 20 grains (0.3-1.3 gm.). It is not much to be relied upon, still it is recommended by some in the hemorrhagic diathesis and to control internal hemor- rhages that cannot be reached by local medication. Ergota. — Ergot of Rye. — This fungus, which replaces individual seeds of the grain, is sometimes called "spurred rye." The pieces are one-half to one inch long, fusiform, slightly curved, purplish-black, hard, and breaking transversely. Preparations : ExTRACTUM Ergot.^. Average dose, gr. 4 (0.25 gm.). VASCULAR ASTRINGENTS 109 Fluidextractum Ergots. Average dose, TU 30 (2 mils.). While this drug contains several alkaloids, none is regarded as representing its full action, therefore the preparations of the whole drug are preferred. Fig. 3. — Ergotized rye. Uses as a Hemostatic. — Ergot is really useful only as it induces contraction of unstriped muscle in the arterioles. Capillary hemor- rhages that cannot be treated locally call for its administration by stomach or, in emergency, hypodermically. The fluidextract is the preparation most commonly employed, in doses of J-l fluidram (1-4 mils.). In hemophilia (hemorrhagic diathesis) it is one of the drugs recommended. It should never be used in case of hemorrhage from a 110 ASTRINGENTS AND HEMOSTATICS good-sized vessel, for fear of increasing the flow through the rise of arterial pressure which the drug produces. (Plate I.) It is one of the drugs used to control postpartum hemorrhage. This dangerous complication after labor is due to relaxation of the unstriped muscle which is so abundant in the parturient uterus. Ergot stimulates this to powerful contraction, thereby closing up the uterine sinuses from which the bleeding has occurred. Cotarninse Hydrochloridum. — Cotarnine Hydrochloride. — Stypticin. — [C12H14O3NCI]. Average dose, gr. 1 (0.06 gm.). A yellow crys- talline, odorless powder, derived from narcotin, an opium alkaloid. It is very soluble in water and in alcohol, and is neidral. It causes contraction of the unstriped muscular tissue of arterioles and of the uterus and is, therefore, used in hemorrhages from small vessels and from the uterus. It may be applied locally or given internally. Hydrastininae Hydrochloridum. ^ — Hydrastinine Hydrochloride [Cn H11O2X.HCI]. Average dose, gr. \ (0.01 gm.). Hydrastinine is an artificial alkaloid obtained by oxidizing hydrastine, an alkaloid of hydrastis. It is an odorless white powder, very soluble in water and in alcohol, and is neidral or slightly acid. It is used internally to secure constriction of arterioles both in hemorrhages and in catarrhal conditions. Remedies that Favor Coagulation of the Blood by Reducing Blood-pressure. Besides the application of cold, which has been considered in the earlier part of the chapter, there are several agents which comprise the group of arterial sedatives. The most prominent of these are: ^ Aconitum. — The root of Aconitwn naiJeUvs. The tincture is the preparation commonly used, the average dose of which isTU 5 (0.3 mil.). For its precise action, see Plate XIV, under Sedatives. Veratmm. — The root of Veratrum mride. This drug is so similar in action and uses to aconite as to require no special discussion here. Average dose of the tincture, lU 8 (0.5 mil.). Remedies that Increase the Coagulant Property of the Blood. Within recent years there has been a decided gain in our resources for treating cases of persistent hemorrhage due to various causes, including those that present deficient coagulation of the blood. The remedies employed may not all act in the same way, but each has been PLATE I. ERGOT. A fungus replacing the grain of rye. Classified as : Oxytocic. Vasoconstrictor. Hemostatic. Physiologic action : Nervous System. Brain. Not affected. Medulla. Not affected therapeutic doses. Spinal cord. Stimulates center for uterine contrac- tion in lower part of cord. Muscular System. Stimulates unstriped muscle, — noted especially in the ar- terioles and gravid uterus. The vasoconstrictor effect, and the consequent inter- ference with the capillary circulation, are so decided, that gangrene may result from its prolonged use. Circulation. Arterial pressure may be increased, but not constantly. Heart. May be slowed, but influence not definite. Capillary area. Arterioles contracted chiefly by local vasomotor stimulation. Uterus. Stimulates uterine con- tractions, mainly by local action upon the uterus. Pelvic Plexus Eed color indicates stimulation. REMEDIES THAT INCREASE COAGULANT PROPERTY OF BLOOD 111 sufficiently successful to entitle it to trial in any severe hemorrhage and particularly in cases of hemophilia. Since it is generally held that calcium salts are essential to the blood reactions that precede coagula- tion, these have come to be used with confidence in persistent hemor- rhages. The chloride and lactate are efficient. Calcii Chloridum. — Calcioi Chloride [CaClo]. — [Do not confuse with chloride of lime, a chlorine disinfectant and bleaching agent.] Average dose, gr. 8 (0.5 gm.). Chemically pure calcium chloride occurs usually in hard white frag- ments, which are very deliquescent, odorless and have a sharp, saline taste. It is neutral, soluble in 1.2 parts of water and in 10 parts of alcohol. When given internally it is believed to increase the coagula- bility of the blood. Good reports have been made of its value in hemo- philia, used both locally and internally. A dose of 5-10 grains (0.3-0.6 gm.) may be given every four or six hours. For local application a 5 or 6 per cent, solution in water has been employed. Parry* reports a case of hemophilia in which a persistent and alarming hemorrhage from the gums was checked by the local application of a 6.25 per cent, solution (30 grains to the fluid ounce). This drug certainly deserves a trial in any case of persistent hemorrhage. Calcii Lactas.— Calcium Lactate [Ca(C3H503)2 + SHoO].— Average dose, gr. 8 (0.5 gm.). This is the hydrated form of the salt. It occurs in white, granular form or in powder, odorless and nearly tasteless. It is soluble in 20 parts of water, almost insoluble in alcohol. Usually neutral. Though less soluble than the chloride, it is better tolerated by the stomach in case of prolonged use and seems to be equally efficient. Gm. or mil. I^ — Calcii lactatis - 6 (5iss) Aqua; 120 (f§iv)— M. Sig. — One to two teaspoonfiils every four hours. Gelatinum. — Gelatin. — Gelatin is soluble in hot water, acetic acid or glycerin. It is insoluble in cold water, but absorbs from five to ten times its own weight, forming a jelly. Obtained from the skins and bones of animals, gelatin may be contaminated with the bacillus of tetanus, the spores of which resist ordinary sterilization by boiling. Because of this, Woodf states that "the hA^Dodermic use of commercial gelatm is not to * Lancet, February 21, 1903. t Pharmacology and Therapeutics, 2d ed.. 1916, p. 325. 112 ASTRINGENTS AND HEMOSTATICS be thouglit of." The same danger of tetanus would obtain with intra- venous use, with the added danger of thrombosis. Therefore none but a specially prepared gelatin* should be used. By mouth the dose is 5 |-1 (15-30 gm.) of the gelatin, in form of a 10 per cent, jelly, every three or four hours. Thyroideum Siccum. — Dried Thyroid GL.\:^rt)S. — Average dose, gr. 1| (0.1 gm.). Both the extract of the th\Toid gland of the sheep or of other domestic animals, and the dried gland substance itself, have given such striking results in the treatment of myxedema, that its administration has been resorted to experimentally in many conditions. Especially in disorders of nutrition and in diseases of the circulating fluids, where absence of the thyroid secretion might be a causative factor, this substance has been tried. Regarding its value in hemo- philia, a very satisfactory result is reported of a case by Fuller. f The patient was a boy, aged fifteen years. Four maternal uncles and two elder brothers had bled to death. The patient had frequent copious hemorrhages from the nose and also bled se\'erely with the loss of tem- porary teeth. For a year he had been in a very weak condition caused by spontaneous attacks of hemorrhage from the kidneys. After failure with the usual remedies, 5 grains (0.3 gm.) of thyroid extract were given three times daily. After the second dose the bleeding ceased. The case was reported nine months after, during which time there had been no recurrence of hemorrhage. While this remedy may be useful in an occasional case only, it merits a trial in any condition attended by persistent hemorrhage. Blood Serum. — Precipitated Blood Serum (not official). — An anhydrous, sterile powder, readily soluble in water. The usual dose is 8 grains (0.5 gm.) dissolved in sterile water and given subcutaneously, which is equivalent to 10 mils, of whole serum, and this may be repeated frequently. Human blood serum and also serum from the blood of the horse and the rabbit have been used with marked success in persistent hemorrhages where coagulation is deficient. The results reported by Welch J in cases of hemorrhages in newborn children, * "Under the name of Gelatina slerilizate pro injectione, Merck has marketed a 10 per cent, solution manufactured from specially selected material and sterilized by heating to 11.5° C. Of this preparation 5f 2—4, representing I5 to 3 drams of gelatin, may be injected subcutaneously, preferably after dilution with hot physio- logical salt solution." Ibid. t Medical News, February 28, 190.3. t Am. Jour. Medical Sciences, 1910, p. 800. REMEDIES THAT CAUSE DIRECT PRESSURE 113 and by Clowes and Busch* in a variety of cases, with reports by other observers, have given blood serum an important place among* our remedies. The precipitated serum is preferred to fresh serum, and that of the horse is most satisfactory. The conclusions of Clowes and Busch in regard to this remedy are as follows if 1. Blood serum is found to be of considerable value in the treatment of all forms of hemorrhage due to low blood coagulability. 2. Human serum is in no wise superior to that of a variety of animals. 3. Blood serum precipitated by means of a suitable mixture of ace- tone and ether is fully as effective as fresh serum, if not superior to it. Precipitated serum is freely soluble and possesses the advantages of being sterile, always available, and retaining indefinitely its capacity to stimulate coagulation of the blood. 4. The product obtained from horse serum appears to yield more uniformly satisfactory results than that obtainable from the sera of other animals, and very seldom exerts any deleterious influence. Remedies that Cause Direct Pressure or Occlusion of Vessels. Mechanical Hemostatics. — Under this heading are included surgical measures, such as pressure, ligatures and torsion. Pressure may be made directly upon the bleeding-point, or upon the artery of supply at some near point where it may be more effectually applied. Ligatures are intended to completely occlude the bleeding vessel, leading to its obliteration beyond. Torsion means twisting of a vessel. Small vessels that are not easily ligated may be treated in this way. In case of persistent bleeding after extraction of a tooth, the most effectual remedy is pressure, for the application of which the tooth socket and the occluding jaw opposite are well arranged. A cork may be shaped with the knife and file to conform to the root of the extracted tooth, and, after sterilization by boiling, inserted into the bleeding socket. It is also recommended that warm wax or modeling compound be first inserted and the cork pressed into it. A rather simpler method will be to roll hemostatic cotton firmly into a cone of proper size to fit the socket tightly. Its fibrous nature aids coagulation, though the cotton plug will be less solid than a cork. After insertion, a cork or firm pad of gauze is placed between the plug occupying the socket and the opposing jaw, or the teeth contained in it, so as to have * New York Medical .Journal, January 4, 1913. t Ibid. .114 ASTRINGENTS AND HEMOSTATICS pressure of the necessary degree exerted by closure of the jaws. The pressure is usually maintained by a bandage passing under the lower jaw and about the head. The collodion gronp act by exerting pressure. They are all inflam- mable, and must not be handled in the vicinity of a flame. Collodium. — Collodion. — ^A varnish that consists of a solution of 4 parts of p;\Toxylin in 75 parts of ether and 25 parts of alcohol. It is applied by means of a camel's hair brush upon a thoroughly dried surface. By rapid evaporation of the liquids its volume contracts, and considerable pressure is exerted upon the underlying tissue. It is applicable only to slight superficial hemorrhages. IncompotihiJify. — Collodion is precipitated by carbolic acid. Collodium Flexile. — Flexible Collodion. — In this preparation 2 parts of camphor and 3 parts of castor oil are added to 95 parts of collodion. Its flexible character adapts it to use over movable parts, such as the lips, or about a joint. Collodium Stypticum. — Styptic Collodion (not official). — In this the formula is modified so as to contain 20 per cent, of tannic acid, which adds coagulant power and furnishes a more powerfully styptic combination. The class of hemostatics would not be sufficiently discussed without mention of a drug not usually included in the class, but one that is nevertheless valued highly in its distinct application to cases of hemor- rhage. Opium.— (For description and detailed action, see under Sedatives.) This drug, of general systemic action, is mentioned here only for its value in aiding to restrain certain kinds of hemorrhage. It cannot be classed with any of the preceding drugs, for it has neither coagulant nor vasoconstrictor action; but it is by its power to put the system at rest that it becomes so valuable in the treatment of internal hemorrhages. Bleeding from the lungs requires that cough be restrained and respira- tory excitement allayed; intestinal hemorrhage requires that the bowel be held quiet; and in either case mental excitement and apprehension must be removed. Opium, or its alkaloid, morphine, will accomplish all of this. In fact, the element of nervous excitement may aggravate almost any kind of bleeding and call for the use of opium or morphine for its removal. Morphine in moderate dose is usually employed, by stomach or, if the case is urgent, hypodermically. CHAPTER X. DETERGENTS, ANTACIDS AND ALKALIES. DETERGENTS. The term detergent, meaning a cleansing agent, applies rather to one of several uses to which certain agents are put. These, in their more important designation, are usually alkalies or antiseptics; therefore, it seems unnecessary to make a separate class of detergents. ]Many of the alkalies and milder antiseptics are well adapted to the cleansing of the mouth, teeth, throat and nasal chambers, while the stronger disinfectants and even corrosive agents are adapted to the cleansing of foul ulcers, putrescent pulp canals, etc. For the former uses, agents that do not coagulate albumin will be most useful, for a certain degree of penetration, especially into the recesses between the teeth, is desir- able, which might be hindered by coagulation. For the latter uses, destruction of diseased tissue, bacteria and decayed matter is necessary, calling at times for the strongest chemical drugs. Again, in dentifrices one kind of detergent contributes the scouring quality, as prepared chalk; another kind will thoroughly cleanse all surfaces and remove fatty matter, as soap; and still another may be desired to exert a solvent or a penetrating influence. Hydrogen peroxide is a very important detergent besides being an antiseptic. Its action is a double one: (1) Lpon coming into contact with blood, pus or loosely organized tissue, it is decomposed, yielding nascent oxygen, by which it acts as an oxi- dizing agent and antiseptic. (2) The freeing of ox^'gen causes gaseous expansion, by which foul materials may be loosened and carried away from the tissues mechanically. ANTACroS (ALKALIES). Antacids are agents that are capable of neutralizing acids by reason of either their alkaline or basic properties. Alkalies are known by their power of changing the color of red litmus to blue. The action of antacids is always chemical, for the acid character of a substance is lost only through combination or decomposition. In 116 DETERGEXTS, AXTACIDS AND ALKALIES some instances, where a simple alkali is used, such as lime-water or magnesia, the chemical change is a simple one, while with the use of sodium bicarbonate or prepared chalk, there is decomposition with evolution of carbon dioxide, and new combinations result in which the acid quality is lost. The importance in dentistry of the various substances belonging to this class is readily appreciated. With the tendency toward acidity of the fluids of some mouths; with the vitiation of the same in disease; and with the very common presence of fermentation in food particles which are allowed to remain between the teeth, we have factors of prime importance in the causation of caries; and in the recognition of these factors we have also the basis upon which to found our prophylaxis. The judicious use of antacids becomes a necessity, at least for the purpose of meeting temporary conditions, recognizing, however, that proper care of the teeth requires also proper care of the mdividual as to general health and all nutritive processes. As a rule that scarcely admits of exception, all mouth washes for continued use, and all dentifrices, should be alkaline or antacid; but in the prevention of caries we recognize that antacids per se do but one thing — ^they neutralize acids. The prevention of acid formation is equally important, and involves, besides strict local cleanliness, the use of an antiseptic to arrest fermentation, which is the very common source of the acid, or the use of an agent that is both antacid and anti- septic. Furthermore, when acidity of the oral secretions persists in spite of local treatment, the condition of the general system must be considered, particularly as to disorders of digestion or errors of diet, which ma>" be the cause of the condition. The difference in solubility of the several antacids in ordinary use gives them a wide range of adaptability in dental practice. To illustrate: For the purposes of a mouth wash a soluble alkali is needed; here sodium bicarbonate, lime-water or borax are applicable. For use in the mouth of a young child, where rinsing the mouth is impracticable, the gelatinous hydrated magnesia may be applied quite thoroughly by means of a cotton swab, or injected between the teeth and the cheeks, where, because of its thick consistence, it will adhere and remain in contact for some time; and, again, in case of erosion, where a soluble substance would be rapidly washed away, the insoluble prepared chalk may be packed between and about the teeth, and its neutralizing action will continue for hours, or through the night if applied at bed- time. ANTACIDS 117 The excessive or continuous use of antacids may disturb gastric digestion to just the extent that they are allowed to reach the stomach during the first two or three hours after meals. During this time the natural acidity of the gastric juice is needed and the entrance of much alkali mto the stomach might hinder digestion by neutralizing the acid. Otherwise no harm is likely to arise from their use. Soaps. — Soaps are compounds of the ordinary fat acids (oleic, palmitic; and stearic) with bases. In the process of saponification, by boilmg a fat with a base, the fat is decomposed, glycerin is set free, and the fat acids combine with the base. Strictly speaking, all metallic salts of oleic, palmitic and stearic acids are soaps; but only those of potassium, sodium and ammonium are soluble. Whatever the consistence of the oil or fat emplo}'ed, its reaction with sodium will produce a hard soap and with potassium a soft soap. Lead plaster is a familiar example of an insoluble soap. Sapo. — Soap. — Wkiie Castile Soap. — It occurs as a white or whitish solid prepared from sodium hydroxide and olive oil. It should be hard, but easily cut M^hen fresh, and free from rancid odor. It has an unpleasant alkaline taste and an alkaline reaction. It is soluble in water and in alcohol. It contains about 21 per cent, of water, which may be largely removed by drying at an elevated temperature, when the soap may be more readily pulverized. It is capable of dissolving fats, which property gives it its great value. ^Medicinally it is alkaline and somewhat antiseptic, possessing detergent qualities in marked degree. Its chief dental use is in dentifrices, where, in powdered form, it may be mixed with any other agent in common use. As soap is irritating to the mucous membrane, unless well diluted, the mixture should not contain more than 25 or 30 per cent. Colored or marhled castile soap is less pure, as it contains ferruginous coloring matter. It is more strongly alkaline, harder, containmg only about 14 per cent, of water, and is, therefore, more economical for ordinary uses. Sapo Mollis. — Soft Soap. — ^A soft, yellowish or brownish mass, pre- pared from potassium hydroxide and cotton-seed oil, and containing an excess of the alkali. It is freely soluble in water and in alcohol. It has a slight odor and alkaline taste and is irritating to mucous mem- branes because of the free alkali contained. It is used preparatory to surgical operations as a cleansing agent for the hands of the operator and the site of operation. For this use it is diluted with alcohol and the parts are thoroughly scrubbed with lis DETERGENTS, ANTACIDS AND ALKALIES sterile brush, the sohition of soft soap and water. The tincture of soft soap {linimentum sapunis mollis) contains 65 per cent, of the soap. IjicoinjMtibility. — Sokible soaps are incompatible with all acids and with earthy and metaUic salts; they are precipitated in hard water, or in a solution of corrosive suhlimate, as an insoluble soap. Sodii Bicarbonas. — Bicarbonate of Sodium [XaHCOs]. — A white, opaque powder, having a mildly alkaline taste, soluble in 10 parts of water, insoluble in alcohol. It is alkaline in reaction. Average dose, gr. 15 (1 gm.). Although the carbonates of the alkalies are more soluble and more strongly alkaline than the bicarbonates, the latter are preferred for dental uses because they are milder and less unpleasant to the taste. For similar reasons the sodium salts are preferred to the potassium. Sodium bicarbonate is the one usually selected for internal use, as it answers every purpose of an alkali without being at all irritating. In stomatitis due to fermentative conditions and in constitutional disorders that cause vitiated oral secretions, this drug is useful used alone or in combination with an antiseptic. As a mouth wash or gargle it may be used freely in saturated solution (10 per cent.). It may enter into dentifrices simply as an alkaline ingredient, as it is not antiseptic nor does it contribute any scouring quality. It is useful to neutralize the mouth after any acid or acid iron preparation has been taken or used locally. It is used also, by direct application, to lessen the sensitiveness of dentine when this is due to acidity. Internally the drug is used to neutralize hyperacidity in the stomach, and in the various acid intoxi-- cations of the system, such as rheumatism. The internal dose is 5-30 grains (0.3-2 gm.). In connection with sterilization of instruments by boiling, sodium bicarbonate is oftentimes added to the water in order to lessen the liability of rusting. Incoinyatihility. — This salt is incompatible with all acids, producing effervescence with liberation of carbon dioxide. In solution it is changed by boric acid into sodium carbonate and borax, with liberation of carbon dioxide. (If carbonate of sodium be present, reaction may occur with either magnesium sulphate or mercuric chloride in solution,- a brown-red precipitate being thrown down.) Sodii Boras. — Borate of Sodium. — Borax [Na2B407 + lOIIoO]. A^■erage dose, gr. 12 (0.75 gm.). It occurs in colorless crystals or white powder, having an alkaline taste, soluble in 15 parts of water and in about 1 part of glycerin, insoluble in alcohol. It is aJkaJine in reaction. ANTACIDS 119 non-u'ritating to tissues, and its taste is bland and sweetish. The solution in glycerin is acid in reaction. (See below, under Incompati- bility.) This salt is also known as sodium biborate, tetraborate and pyro- borate. It occurs naturally in many volcanic regions, our American supply coming chiefly from Nevada and California. It is also prepared artificially upon a commercial scale. In borax we have an agent that is both alkaline and antiseptic, and that may be used freely in satm-ated solution (6.6 per cent.). It is, therefore, admirably adapted to all uses that call for a mouth wash possessing the above qualities. In stomatitis and in thrush especially it is a superior agent. The latter disease occurs mostly in young infants where a mouth wash cannot be so well employed. Here, before the eruption of any teeth, we may use a saturated solution in glycerin, made by dissolving the powdered borax in hot glycerin, which will insure saturation when it has cooled. Glycerin itself is a preservative, and the resulting thick, sweet solution may be applied by means of a swab to all parts of the infant's mouth. In dentifrices borax will contribute antacid and antiseptic properties. This drug is seldom given internally. Incompatibility. — Borax in saturated aqueous solution is decom- posed by mineral acids, with the precipitation of boric acid, which is slightly less soluble. A white precipitate is also thrown down by corrosive sublimate. Special interest attaches to borax because of its peculiar behavior with certain other substances. Thus,* "It is incompatible with muci- lage of acacia, causing gelatinization, which can, however, be prevented by the presence of sugar; it precipitates many alkaloids from their solution, such as cocaine, morphine, atropine, quinine, etc., except in the presence of glycerin; it forms a damp, almost moist, mixture when triturated with alum; in the presence of glycerin it decomposes alkali carbonates with effervescence; and, lastly, while an aqueous solution of borax shows an alkaline reaction toward litmus, a solution in glycerm has a decided acid reaction, which is changed to alkalme upon large dilution with water," Liquor Calcis. — Solution of Calcium Hydroxide. — Lime-water. — Average dose f5 4 (15 mils.) or a tablespoonful. An aqueous solution containing not less than 0.14 per cent, of calcium hydroxide [Ca(0H)2]. * The National Standard Dispensatory, third edition, 1916, pp. 1487-8. 120 DETERGENTS, ANTACIDS AND ALKALIES It is readily prepared by treating freshly slaked lime with water. It is strongly alkaline in reaction, almost tasteless and very agreeable to the stomach. It may be used freely as a mouth wash and to correct undue aciflity of the stomach. For the latter purpose it is very com- monly added to the food of infants, especially in the digestive disorders occurring during the summer, when the milk so easily loses its normal alkaline quality. Incomixiiihility. — Carbon dio.ride gas produces in lime-water a cloudi- ness, due to calcium carbonate. Oxalic acid produces a white precipi- tate of calcium oxalate. With corrosive sidiUmaie a yellowish precipitate occurs, and with calomel a black deposit. Magnesii Oxidum. — Light Magnesia. — Magnesia [MgO]. — x\verage dose, gr. 30 (2 gm.). The light magnesium oxide is prepared by expos- ing light magnesium carbonate to a dull-red heat. It is a white, very light powder, having a slight earthy taste and alkaline reaction. It is insoluble in alcohol, almost insoluble in water, but when mixed with 15 parts of water and allowed to stand for half an hour it gelatinizes, forming magnesium hydroxide or "milk of magnesia." (See Magma Magnesise, below.) This drug is an agreeable antacid for stomach administration, and is at the same time laxative. This combination of properties makes it a useful agent for the treatment of intestinal dis- orders of childhood, the alkaline quality serving to neutralize any undue acidity, and the laxative action ridding the bowel of offensive contents. When used thus internally it should be given in not less than 20 parts of water to prevent the formation of a gelatinous mass. Magnesia should be kept from exposure to air, as it slowly absorbs moisture and carbon dioxide, forming a carbonate. Magma Magnesise. — Milk of Magnesia. — ^Average dose f5 2^ (10 mils.). A thick, white liquid containing about 7 per cent, of magnesium hydroxide [Mg(0H)2] in suspension in water; alkaline in reaction. Milk of magnesia is one of the most useful agents to neutralize acids in the mouth, being ranked first by some practitioners. This prepara- tion is easily made in the way mentioned above and it keeps well. Its gelatinous consistence causes it to adhere to the teeth and remain about them for a considerable time, which is a decided advantage. In infants it may be applied by means of a cotton swab to the inside of the cheeks and throughout the mouth. It may be used freely in any mouth and at any age. Gi^'en internally, it has the antacid and laxative action of magnesia, the latter being aided by following the dose with lemon juice or other mild acid. Inconipatibilify. — Magnesia is neutralized by acids. DILUENTS— WATER— MINERAL WATERS 121 Creta Piaeparata. — Prepared Chalk [CaCOs]. Average dose, gr. 15 (1 gm.). This substance is one kind of calcium carbonate. It occurs in form of a whitish powder, which is often moulded into the shape of small cones. It is odorless and nearly tasteless, almost insoluble in water, insoluble in alcohol, soluble in acids with effervescence and chemical change. It is not properly an alkaline substance, but an antacid, i. e., it neutralizes acids, but does not turn red litmus blue. Its action consists of a chemical union with any free acid, which displaces the carbonic acid of the chalk. It may be used freely internally, as an antacid in gastric and intestinal disorders. While solubility of a drug is usually desirable in order to have rapid action, the insolubility of pre- pared chalk gives it a special place in dentistry. Having a mild scour- ing quality, and being antacid, it holds first place as a basis for tooth powders. Its insolubility also gives it a prolonged action as an antacid so that in a mouth with a marked tendency to acidity it may be packed between and about the teeth upon retiring, and its action will continue during the night. This use is regarded as very important in progressive cases of erosion, where the damage occurs mostly at night, when there is less saliva secreted and, accordingly, the secretions of the mouth do not become so well mixed, the mucus remaining upon the surfaces of the teeth and about the gum margin. The extreme sensitiveness of the dentine, which is present in these cases, may also be lessened by the continuous use of this agent within the cavities of erosion and decay and about the teeth. The accepted belief that sensitiveness of dentine is often due to irritation by acids, points to the use of prepared chalk during the preparation of any cavity where sensitiveness is marked. It is well to continue its use during several days preceding the final preparation for filling. (See Index of Drugs for preparations for internal use.) Incompaiibility. — In contact with acids chalk decomposes with effer- vescence, caused by the liberation of carbon dioxide. DILUENTS. WATER. MINERAL WATERS. The increasing recognition of various autointoxications of the human system as the most disturbing factors in many diseases, brings into prominence the use of diluents, especially water, in the aid of normal cell function thi'ough free elimination. Particularly after full develop- ment of the body, in other words after the play period of life has passed, the tendency to less active and a lessened amount of exercise, favors 122 DETERGENTS, ANTACIDS AND ALKALIES deficient oxidation of food substances and waste tissue materials, with resulting accumulations of partially elaborated products, which are more or less deleterious. A distinct group of diseases related to such causes, including gout, so-called lithemia, fermentative digestive dis- orders, chronic rheumatism, etc., give evidence of the extreme impor- tance of aiding cell elimination throughout the body. If with lessened exercise the usual amount of food is still taken, the conditions are aggravated, a superabundance of nutriment being furnished to the tissues whose oxidation processes are below normal. Moreover, as age advances, with development completed,* many of the capillary blood- vessels disappear because no longer needed. The capillary circulation is accordingly less active and, with the factors of excessive food material and deficient oxidation cooperating, the tissues easily become clogged, so to speak, laying the foundation for the diseases mentioned. The presence of arteriosclerosis, which means hardening of the walls of the arteries, adds another contributing factor by lessening the uniform- ity of blood supply to the capillaries. The relation of these conditions to oral pathology is being emphasized today in classification and treat- ment of pericemental and alveolar diseases. Uric acid is recognized as a product of partial oxidation of nitrog- enous waste, and has been regarded as a prominent factor in gouty disorders. At the present time, however, doubt is being thrown upon its importance as a poison to the system. Nevertheless it stands with a group of substances arising in the body through faulty cell activity, some of which are acid in nature. For the double purpose of washing these substances out of the tissues into channels of elimination and of diluting them, it is advisable to use water freely, with or without alkaline salts for antacid efli'ect. Various alkaline mineral waters are taken with good results, and the salts of lithium have had a recent extensive use; but many physicians now g'we preference to pure water. Distilled water, because of its greater solvent power, being de^•oid of salts, is preferred in some conditions. In whatever kind, the taking of water in the quantity of one or two quarts daily is an important part of the constitutional treatment of these conditions. Pure water is a diuretic and the addition of certain salts will uicrease this action, while others will induce a cathartic action. While the natural mineral waters are useful according to their saline and alkaline constituents, they are not necessarily superior to simple * Balfour, The Senile Heart, MacMillan & Co., 1894, p. 14. DILUEXTS—WATER^MIXERAL J]^ ATERS 123 solutions of the cathartic and diuretic salts, while the latter permit of modification which places the kind and degree of the saHne action under our control. (See Cathartics and Diuretics.) Certain artificial combinations, in imitation of the formulas of popu- lar mineral waters, are upon the market, e. g., artificial Carlsbad salts. These seem to meet the demand, but their employment, as well as that of any mineral water, should be based upon proper discrimination as to indications for their use. CHAPTER XI. ANTISEPTICS. The term antiseptic in a general sense applies to the antagonism of sepsis- — i. e., to whatever measures are employed to prevent the growth and propagation of disease-producing bacteria, also to counter- act their influence and to remove their noxious products. If, however, we anal}'ze modern antiseptic treatment, we find that the agents and means employed vary as to the precise part they play in bringing about the result. One agent will kill the bacteria; it is, therefore, a germicide. Another will not only destroy bacteria, but will remove the noxious properties of putrefaction and fermentation; this is a true disinfectanf. Another will inhibit the growth and propagation of bacteria without destroying them or removing their noxious products; this cannot be designated otherwise than as a simjih aniiseptic — preventing sepsis, but not removing it when present. A deodorant is an agent that removes or corrects an offensive odor. It is impossible, however, to make a distinct classification in accord- ance with these terms, for the reason that many agents belong to one or another class, according to the strength in which they are employed, being in strong solution germicidal or disinfectant, and in weak solution simply antiseptic. Other conditions, such as character of solvent, temperature of solution and character of bacteria, also modify our designation of the several agents.* An antiseptic may be germicidal to one kind of bacterium and only inhibitory to the growth of another. To the writer it seems better to employ the term aniisepiic in its general inclusive sense, to cover all agents employed to prevent, counteract and remove the influence of disease germs, and to further designate differences of action by using the adjective terms germicidal and dis- infectant. * The efficiency of antiseptics can be stated only in a relative manner, since, as yet, there are no generally accepted standards. Rideal and Walker have ijroposed the "phenol coefficient" but the results have not justified its general acceptance. Briefly stated it means the result arrived at l)y dividing the figure indicating the degree of dilution of the disinfectant that kills an organism in a given time by that expressing the degree of dilution of phenol that kills the same organism in the .'ame time under exactly similar conditions. ANTISEPTICS 125 The intelligent use of antiseptics has been a matter of development during the past forty years, following closely the progress made in the science of bacteriology. When Pasteur in 1857 proved that the processes of fermentation and putrefaction were caused by the presence and growth of organisms, the way was prepared for investigation of septic conditions and special diseases. In 1875 Lister set forth the germ theory as applied to the infection of wounds. His work and methods were a great step toward realizing the aseptic surgical methods of today and are referred to by an eminent surgical writer* as having "brought about an entire revolution in surgery and surgical technic, and an entire reversal of the statistics of operations; where thousands formerly died, thousands now live, their lives being indirectly due to the labors of this one man and his following." Since then the specific organisms of many diseases have been dis- covered and the application of antiseptic agents has become more precise and the results more definite. In dental practice antiseptics must be regarded in relation to widely differing structures, as presented by the teeth, in their very hard min- eral character, by the softer tissues of the mouth, and by the extremely delicate and sensitive tooth pulp. Indeed, two quite distinct fields are before the dental specialist in his study of antiseptic therapeutics. He has now to select his agents for mouth disinfection and again for tooth disinfection. For mouth treatment his antiseptics must be selected with regard to safety of the soft tissues; for tooth disinfection the application is of such limited extent, and the soft structures are so well excluded, that the main question is that of efficiency, the very strongest escharotics being eligible for use; then also treatment of the tooth pulp will require the selection of agents especially adapted to its condition. These considerations will lead to the use of the terms " mouth disin- fection" and "tooth disinfection" in the discussion of antiseptics. The ideal condition to be aimed at in all surgical work is that of asepsis, or absence of disease germs. The operator seeks to begin his operation with perfect asepsis. To this end his instruments are steri- lized by boiling, and the dressings by dry heat at a temperature of 230° or over, while his hands and the site of operation are treated with suitable disinfectants. Asepsis of the mouth is difficult of attainment, but the site of operation may be made relatively aseptic after exclusion of the fluids by a sterile rubber dam, and the condition then maintained * Park's History of Medicine, second edition, p. 261. 126 AXTISEPTICS through the use of sterile instruments by sterile hands. The appli- cation of tincture of iodine to the site of operation is most relied upon today to secure asepsis. The importance of thoroughly sterilizing all instruments that have been used in the mouth, after each dental operation, must be insisted upon. There can be no doubt that one must frequently operate in a syphilitic mouth without being aware of it, because the lesions may be slight or invisible. In secondary syphilis the danger of carrying the disease to another mouth or of infecting a chance lesion upon the hand is very great, and preventable with certainty only by sterilization of instruments and appliances. Alcohol has been regarded as a disin- fectant for this piu-pose, but its value is questionable. Absolute certainty should require sterilization by heat. Acidum Boricum. — Boric Acid. — Boracic Acid [H3BO3]. — Average dose, gr. 8 (0.5 gm.). This occurs in transparent, colorless scales or crystals, nearly tasteless, soluble in 18 parts of water, 18 parts of alcohol, and 4 parts of glycerin. It is sligJitly acid in reaction. This substance is found in various parts of the globe chiefly in the form of natural borates, the American market being supplied from the borax regions of California. The saturated aqueous solution of this drug {0.0 per cent.) is largely used as a mild antiseptic wash. It is non-irritating, therefore may be applied to the most delicate tissue. As an eye wash it is much used. It may be employed freely as a mouth wash, the only objection being its slight acidity. However, it must be said that it possesses no real advantage over its sodium salt. In powdered form it is used in tooth powders or dusted upon ulcers or wounds. Incompatibility. — In aqueous solution boric acid is decomposed by carbonates, with the formation of borates. Glyceritum Boroglycerini. — Glycerite of Boroglycerix. — Whenever a stronger preparation of boric acid than the saturated solution is desired, it may be had in the official glycerite of boroglycerin, which contains 31 per cent, of boric acid incorporated by chemical union with glycerin. This may be used in full strength or diluted. It is neutral in reaction. Sodii Boras. — Borax. — Average dose, gr. 12 (0.75 gm.). This salt has been discussed under Antacids. As an antiseptic it may be used freely in saturated solution (0.6 per cent.) as a mouth wash, or the crystal may be allowed to dissolve in the mouth. Borax deserves a large use as a mild antiseptic since it possesses every essential quality PHENOL LIQUEFACTUM 127 of a mouth antiseptic, though one of the class of weaker agents. It is alkaline, non-irritating, almost tasteless and non-toxic. Dobell's solu- tion* is a very useful combination. A saturated solution in glycerin (equal parts of each) is very efficient in the removal of the thrush fimgus (oidium albicans), which is so often seen in the mouths of bottle-fed infants. The thick consistence of this solution is advantageous in that it thereby adheres to the mucous membrane for some time. It should be applied several times daily. Sodii Perboras. — Sodioi Perborate [XaBOs + 4H2O]. — ^Average dose, gr. 1 (0.06 gm.). It occurs as white granules or powder, odor- less, with a saline taste, stable in cool dry air, but losing oxygen in warm or moist air; soluble ui water; alkaline in reaction. It should contain not less than 9 per cent, of available oxygen. Sodium Perborate makes an efficient antiseptic mouth wash in ulcer- ative conditions of the mouth. It is important that it be prepared fresh each time, as the solution does not keep well. A teaspoonful in one-half glass of water is a proper strength. It produces its action by the liberation of nascent oxygen. Phenol. — Carbolic Acid. — ^Average dose, gr. 1 (0.06 gm.). This substance has been considered in its action upon the tissues, under Escharotics. In dilute solutions it is one of the most generally useful antiseptics. Although slightly acid in reaction, this substance is not an acid, chemically speaking. It is a coagulant when used in strong solution, and while this property may be a factor in its antiseptic action, its germicidal power may be thereby lessened b}' interference with penetration. Phenol Liquefactum. — Liquefied Phenol, containmg not less than 87 per cent, of absolute phenol, is convenient for ready use and for diluting. Phenol is soluble in about 15 parts of water, giving a saturated solution of about 6 per cent. This is too strong for use upon mucous membranes, * The formula of Dol^ell's solution, as given in the National Formulary under the title Liquor Sodii Boratis Co?npositus is: Gm. or mil I^ — Sodii boratis 15 Sodii bicarbonatis . 15 PhenoUs (crystals) 3 Glycerini 35 (3iv) (5iv) (gr. xlv) (fSi) Aquas q. s. ad 1000 (Oij) Dissolve the salts in one-half of the total quantity of water, then add the glycerin and the phenol, previously liquefied by warming, and, lastly, enough water to make up the total quantity. 128 ANTISEPTICS but may be used upon the skin with care.* It is the proper strength for occasional disinfection of the hands, but its frequent use will make the skin rough, because of its coagulant action. As a mouth-wash or gargle it has the advantage of being slightly analgesic, but it should not be used stronger than 1 per cent. The slight acidity may be counter- acted by combining a solution of sodium bicarbonate with it. For the purpose of tooth disinfection the pure phenol may be used in small quantity with due care. It is remarkable that the continuous application of a solution as wxak as 5 per cent, has been followed by gangrene, the result probably of thrombosis. This is especially liable to occur in a finger or toe wdiere all ^'essels of supply are equally affected. The local analgesic action undoubtedly aids in lowering the vitality of the part and prevents painful sensation, which otherwise might give warning of the danger. It may be said of this agent that, having been one of the first sub- stances proposed as an antiseptic and disinfectant, it has held its place for more than forty years as one of the best drugs of the class. A solution of 1 in 250 will quickly destroy lower forms of vegetable life and check fermentation, a 1 per cent, solution may be relied upon as a general antiseptic, while a 5 per cent, .solution is an efficient disinfectant. As to its germicidal power, Harrington found that a 5 per cent, solu- tion destroyed the Staphyhcoccus pyogenes mireus, the most common and most resistant pus organism, in two minutes; a 2.5 per cent, solu- tion requu'ed four minutes, f In saturated solution it is useful to keep instruments in sterile con- dition during an operation. It has no action upon metals; therefore instruments may be disinfected by its use in full strength, bearing in mind always that any albuminous matter will be coagulated by it instead of being removed. The combination known as liquor sodii carbolatisj contains 50 per cent, of carbolic acid. * A wet dressing of not stronger than 5 per cent, phenol has caused gangrene of a finger, after a twenty-four hour apphcation. See Hare's Therapeutics, thirteenth edition, 1909, p. 400. t Annals of Surgery, October, 1904. % Liquor sodii carbolnii.s (N.F.) corresponds very closely to the proprietary prepara- tion known as i)hcnol sodique. It has the following formula: Gm. or mil. I^— Phenolis (crystals) 50 Sodii hydroxidi 3 5 Aquaj 46 5 Dissolve the soda in the water, add the j)lienol, and warm gently \mtil it is dis- solved. This i)reparati()n should lie freshly made. Used in fvdl strength this combination would be caustic. TRICHLORPHENOL 129 Internally phenol is a valuable antiseptic. In doses of ^-2 minims (gm. 0.03-0.12), well diluted, it is used to arrest fermentation in the stomach and intestines, an advantage of its use being that it does not disturb digestion. When employing this drug, it must always be borne in mmd that it is a poison — corroswe when applied in full strength to tissue; and also a systemic poison when absorbed in quantity, producing irritation of the kidneys which may result in nephritis; therefore, caution should always attend its use, and in view of the frequency of poisoning by carbolic acid every practitioner should be prepared to treat the same in emergency. Albumin is a true antidote, while alcohol has some restorative action upon tissues; soluble sulphates have been employed. (See under Escharotics.) Incompatibility. — Phenol will coagulate albumin and collodion. In aqueous solution a white precipitate occurs with bromine water, with ferric chloride a violet color is produced, and with solution of antipyrin a white precipitate occurs. When the saturated aqueous solution is mixed with a solution of cocaine hydrochloride a white precipitate may occur. Cresol ~ Tricresol. — Cresylic Acid [CyHgO].— Average dose, lU 1 (0.05 mil.). A mixture of isomeric cresols obtained from coal-tar. It is a nearly colorless liquid, becoming yellowish or brownish upon prolonged exposure to light. Its odor is similar to that of phenol. It is soluble in 50 parts of water and in alcohol and glycerin. The uses of this substance are the same as those of phenol. It is believed to be a more powerful disinfectant. A 5 per cent, solution has been found to destroy Staphylococcus pyogenes aureus in two minutes.* Liquor Cresolis Compositus. — Lysol. — This solution contains 50 per cent, of cresol, with linseed oil and potassium hydroxide. It is liquid cresol soap. It mixes with water readily and in solution of from 1 to 5 per cent., it is largely used as a general antiseptic wash and disin- fectant. It is a good hand disinfectant, although its odor may be objectionable. Trichlorphenol [CeHaClsOH] (not official).— The action of chlorine upon phenol produces a series of bodies whose antiseptic power exceeds that of phenol. Of these trichlorphenol is a definite crystalline sub- stance, soluble in alcohol and ether. According to Nenckif a 2 per cent, solution was found to be more active than a 5 per cent, solution * Harrington, Annals of Surgery, October, 1904. t U. S. Dispensatory, eighteenth edition, p. 1615. 130 ANTISEPTICS of phenol and only a little weaker than 1 to 1000 solution of bichloride of mercury. Creosotum. — Creosote. — Oil of Smoke. — ^Average dose,Tn, 4 (0.25 mil.) . A mixture of phenols, chiefly guaiacol and creosol, obtained by distilla- tion of wood-tar. In addition to the discussion of this substance in the class of irritants, its use as an antiseptic claims consideration at this place. Obtained usually from beechwood-tar by distillation, creosote is always liquid, nearly colorless when fresh, but becoming yellowish. The U. S. P. states that it should not readily become brown on exposure to light. It is neutral or only faintly acid to litmus paper. It is soluble in about 140 parts of water, and more freely in absolute alcohol, ether, chloroform and oils. In some respects it resembles liquefied phenol, but the latter acquires a pink or reddish color with exposure ; in odor it is somewhat similar, although decidedly smoky and unpleasant. It is less useful in dental practice, because of its odor and also the fact that it discolors teeth by continuous treatment. The chief points of differ- ence between the two substances are given below^: Phenol. Creosote. Crystallizable. Always liquid. A definite chemical compound. A mixture of phenols. Coagulates collodion. Does not coagulate collodion. Soluble in glycerin. Insoluble in glycerin. Soluble in about 15 parts of water. Soluble in about 140 parts of water. In antiseptic power creosote surpasses phenol,* and its internal use is safer. In recent years it has been used extensively as an mternal remedy in the treatment of pulmonary tuberculosis, tolerance to quite large doses being readily acquired. It has a local analgesic and sedative effect, which makes it a valuable inhalant. In full strength creosote is an excellent tooth disinfectant, being preferred to carbolic acid by some, because it has little or no coagulant action, f It penetrates more deepty, but is less corrosive. As it is apt to discolor tooth structure it is not to be used in teeth that are visible. As a mouth wash it may be used freely in saturated aqueous solution (0.66 per cent.), but its unpleasant odor and taste are objectionable. * See table on p. 137. t It is stated by some authorities that creosote contains some carbolic acid and that it coagulates albumin. This was formerly true, when pure creosote was difficult to obtain and adulteration with carbolic acid was common; but at the present time pure creosote is easily obtainable and it has little coagulant action. However, creosote being a*mixture of substances, its properties may vary slightly. ALCOHOL 131 The official aqua creosoti is prepared with 1 per cent, of creosote, in order to insure saturation. Although there has been a tendency toward eliminating creosote from dental uses, there is good reason to believe that it is a valuable antiseptic agent in the treatment of putrescent root canals. On the whole, it may be said that in dental practice creosote is used little compared with phenol, though a stronger antiseptic. Poisoning by this drug would occur by SM^allowing a quantity of it pure. The symptoms would be those of irritant poisoning. It has no definite chemical antidote. Emetics would be indicated, followed by demulcents. Creosoti Carbonas. — Creosote Carbonate. — A liquid mixture of car- bonates of several constituents of creosote, chiefly guaiacol and creosol. Average dose, TTl 15 (1 mil.). This agent, being a mixture of sub- stances, varies as to color, odor and taste. It may be colorless, odor- less and tasteless, or it may be yellowish and have a slight odor and taste of creosote. It is insoluble in water, but soluble in alcohol and in fixed oils. It is less irritating for internal use than is creosote and, with similar uses in pulmonary diseases, it can be given in larger doses. Guaiacol [C7H8O2].— Average dose, gr. 8 (0.5 gm.).— A crystalline solid obtained from creosote and constituting from 60 to 90 per cent. of the latter. It melts at 82.4° F. It is soluble in 53 parts of water, 0.8 part of glycerin, but separating upon addition of water, and also soluble in alcohol and ether. Being a definite compound, it forms a number of combinations, some of which, as well as itself, are used as substitutes for creosote for internal administration. Guaiacol has been used as a vehicle for cocaine in its application by cataplioresis. Guaiacolis Carbonas.— Guaiacol Carbonate [(C7H70)2C03]. — Aver- age dose, gr. 15 (1 gm.). A white crystalline powder, insoluble in water, soluble in 60 parts of alcohol, neutral and almost tasteless. Alcohol. — This drug, fully considered iti other places as astringent and stimulant, has a well-founded reputation as an antiseptic. Its action upon bacteria is probably due to its power of abstracting water and of coagulating albumin. It is less valuable as a disinfectant than as a simple antiseptic and as a vehicle for stronger agents of this class. It must be used in strength of 40 per cent, or more to have any decided antiseptic value; however, upon the dry skin the very strong alcohol (absolute and 95 per cent.) has been found less efficient than if it is diluted somewhat. This is due to the hardening effect of the undiluted alcohol which hinders penetration. 132 ANTISEPTICS The experiments of Harrington and Harris* as to the germicidal power of alcohol in different strengths led to the following results: 1. Against dry bacteria, absolute alcohol and ordinary commercial alcohol are wholly devoid of bactericidal power, even with twenty-four hours' direct contact; and other preparations of alcohol containing more than 70 per cent., by volume, are weak in this regard, according to their content of alcohol ; the stronger in alcohol, the weaker in action. '2. Against the commoner, non-sporing, pathogenic bacteria in a moist condition, any strength of alcohol above 40 per cent., by volume, is effective within five minutes, and certain preparations within one minute. 3. x\lcohol of less than 40 per cent, strength is too slow in action or too uncertain in results against pathogenic bacteria, whether moist or dry. "4. The most effective dilutions of alcohol against the strongly, resisting (non-sporing) bacteria, such as the pus organisms, in the dry state, are those containing from (K) per cent, to 70 per cent, by volume, which strengths are equally efficient against the same organisms in the moist condition. "5. Unless the bacterial envelope contains a certain amount of moisture, it is impervious to strong alcohol; but dried bacteria, when brought into contact with dilute alcohol containing from 30 per cent. . to 60 per cent, of water by volume, will absorb the necessary amount of water therefrom very quickly, and then the alcohol itself can reach the cell protoplasm and destroy it. '6. The stronger preparations of alcohol possess no advantage over the 60 per cent, to 70 per cent, preparations, even when the bacteria are moist; therefore, and since they are inert against dry bacteria, they should not be employed at all as a means of securing an aseptic condi- tion of the skin." Certain of the vegetable tinctures have a reputation as antiseptics, which with a few is well-founded. When we consider the value of the contained alcohol, it appears that any addition of a drug that has antiseptic power should produce a valuable preparation. Tinctura Myrrhae. — Tincture of Myrrh. — Average doscTH. 15 (1 mil.). — This has long been used as an application to the gums, and as an ingredient in mouth washes. To irritated, lacerated or spongy gums, ulcers, etc., it may be applied freely. It cannot be diluted with water, * Boston Medical and Surgical Journal, May 21, 1903. TINCTURA BENZOINI COMPOSITA 133 for the latter precipitates the resinous portion of myrrh. It can only be mixed with water or aqueous solutions in the presence of a large per- centage of alcohol. A dilution of alcohol with more than one-third water will not mix with tincture of myrrh without precipitation occurring. Tinctura Benzoini. — Tincture of Benzoin (20 per cent.). — ^Average dose, m 15 (1 mil.) Tinctura Benzoini Composita.* — Compoixnd Tincture of Benzoin (10 per cent, benzoin). Average dose, TU 30 (2 mils.). Benzoin contains resin, benzoic acid (about 14 per cent.) and traces of a volatile oil. Benzoic acid has been found, by a number of observers, to rank among our very best non-irritating antiseptics, and it is freely soluble in alcohol; therefore, these tinctures should be valuable anti- septics, as they contain 1 to 4 per cent, of benzoic and cinnamic acids, the latter being also valuable. The compound tincture is a time-honored preparation, and one of the best antiseptic and stimulant applications to mucous membranes. An unhealthy or ulcerated condition of the gums calls for its use. It must be applied upon cotton. It cannot be used in a mouth wash because of the precipitation of the resin when mixed with water. Except the resinous portion, it may be vaporized with steam by being poured upon boiling water, and it thus forms a useful inhalant in irritable or infected conditions of the upper air passages. A useful prescription for this purpose is the following: Gm. or mil. I^ — Phenolis liquefacti 10 (fSijss Spiritus camphorae 10 (fSijss) Tincturse benzoini compositse .... 30 (f§j) Glycerini q. s. ad 60 (fgij)— M. Sig. — A teaspoonful to a pint of boiling water. Inhale the steam. For the correction of foul breath, when due to an unhealthy con- dition of tonsils or upper air passages, the same inhalation is useful; in addition the compound tincture may be applied in full strength to the surface of the tonsil and within all of its crypts that are visible. Foul breath may be due to the collection of solid offensive secretion within these crypts. This should be removed before making the application. * The formula of compound tincture of benzoin contains: Benzoin 100 parts Purified aloes 20 " Storax 80 " Balsam of tolu 40 " Alcohol, to make 1000 " 134 ANTISEPTICS Balsamum Peruvianum. — Balsam of Peru. — ^A balsam obtained from Toluifcra Percircp. — It is a thick, dark brown liquid, having an agree- able odor resembling that of vanilla. It is soluble in alcohol and in chloroform, partly soluble in ether and almost insoluble in water. Its value as an antiseptic depends upon benzoic and cinnamic acids and aromatics which it contains. It is rarely used internally, but is an agreeable and valuable application to ulcers and in parasitic diseases of the skin. Acidum Benzoicum. — Benzoic Acid [C7H6O2]. — Average dose, gr. 8 (0.5 gm.). An organic acid obtained from benzoin, or prepared arti- ficially. This drug occurs in whitish crystals, with or without the odor of benzoin,* has a pungent taste and is somewhat volatile. It is soluble in 275 parts of water, but with an equal quantity of borax it is soluble in 100 parts of water; soluble also in 2.3 parts of alcohol and in 10 parts of glycerin. It has an acid reaction. A solution of 1 to 400 has been found to destroy developed bacteria; and according to Miller, a 1 per cent, solution will accomplish ordinary disinfection of the mouth in one-quarter of a minute. With its solubility in water increased by borax, the two may be combined in aqueous solution to make a very efficient mouth wash. It is found that a saturated solu- tion of borax will dissolve 1 per cent, or more of benzoic acid and still be alkaline. Incompatihiliiy. — When a solution of benzoic acid has been neutral- ized by an alkali, as with borax, a precipitate will occur when mixed with hydrochloric or dilute nitric acid, or with dilute solutions oi ferric salts or with lead acetate, mercuric chloride or silver nitrate. Acidum Salicylicum. — Salicylic Acid [CyHeOs]. — Average dose, gr. 12 (0.75 gm.). An organic acid obtained from vegetable sources or pre- pared from carbolic acid. It occurs in very fine, white needles or crys- talline powder, having a sweetish taste. It is soluble in 4G0 parts of water and in 2.7 parts of alcohol, 2 parts of olive oil and 00 parts of glycerin. It is acid in reaction. According to Miller, f a 1 per cent, solution will accomplish ordinary disinfection of the mouth in one- quarter of a minute. It must be ranked among our best antiseptics, but it is objectionable for continued use because of its acid reaction. The saturated aqueous solution is rather weak to be of much value as * Benzoic acid prepared artificially does not have the odor of l)enzoin. t Microorganisms of the Human Mouth. PHENYLIS SALICYLAS 135 a disinfectant; but a saturated solution of borax in water will dissolve 1 per cent, or more of salicylic acid and still be alkaline in reaction. Such a solution really makes an ideal mouth wash. The drug may also be used as a mouth wash either in combination with other antiseptics or in alcoholic solution diluted. Incompatibility. — ^^Vith 'potassium chlorate, hydrochloric acid, nitric acid, chlorine or a solution of ferric chloride, it undergoes chemical change. It causes gradual decolorization of a solution of potassium permanganate. With carbonates it effervesces, with the formation of salicylates. Sodii Salicylas. — Salicylate of Soditoi [XaC7H503]. — ^Average dose, gr. 15 (1 gm.). This salt is much more soluble in water than is the acid, being soluble in 0.9 part, also in 9.2 parts of alcohol and in glycerin. For internal use it is less disturbing to the stomach than salicylic acid, and it is used largely in the acute stage of rheumatism to control the fever and pain. It is not a very efficient antiseptic. Phenylis S-alicylas. — Salol [C13H10O3]. — Average dose, gr. 5 (0.3 gm.) It occurs in form of a white, crystalline powder, having a sweetish taste, almost msoluble in water, soluble in 6 parts of alcohol, and in ether, chloroform and oils. It melts at 42° C. (107.6° F.). Its use in dentistry depends upon the ease with which it can be fused, and the fact that, when fused at a tetnperature considerably above its melting-pomt, recrystallization is retarded. Mascort* in 1894 advocated its use in melted form as a root-canal filling. Being a feeble antiseptic unless decomposed, its ready adaptability and non-hritating character must be its chief recommendations. It is used either alone or in connection with a cone of gutta-percha. This substance is not often employed as a local antiseptic, because of its insolubility in water. It may, however, be used in alcoholic solution. Its chief use is as an intestinal antiseptic. Its adaptability to this use lies in the fact that, passing through the stomach unchanged, it is first decomposed into carbolic and salicylic acids by contact with the alkaline juices in the small intestine, where the effect of these tw^o antiseptic substances is then obtained. It is valuable in diarrheas and intestinal fermentation, but with large doses toxic effects of phenol are possible. * Dental Cosmos, 1894, p. 352. 136 ANTISEPTICS VOLATILE OIL GROUP. Volatile oils are odorous, volatile principles, not possessing the chemi- cal qualities of true oils. Since they are mostly obtained by distillation they are also called distilled oils; and, as they are usually the most essential constituent of the drug yielding them, they are also known as essential oils. While usually of vegetable origin, several are now made synthetically. ^"olatile oils are colorless or nearly so when freshly distilled, becom- ing, as a class, somewhat colored wdth age and exposure, without losing any of their valuable properties. They are insoluble in water, soluble in alcohol, ether, chloroform and fixed oils. The volatile oils as a class are antiseptics. Some have an analgesic effect when applied to sensitive tissue, while others are irritating and a few are poisonous. Some are not applicable to uses about the mouth because of unpleasant taste or odor. Most of them are used in full strength as disinfectants in root canals and in carious cavities, but by prolonged use they may discolor the tooth structure. Even with pulp exposure the non-irritating oils may be used. They do not destroy tissue, they do not coagulate albumin, hence they pene- trate well, and any irritation from brief application is but slight and momentary. Exception to the last statement is found with oils of turpentine and mustard, but these are seldom used in the mouth because of their rank odor. Dr. A. H. Peck* has contributed some excellent experimental work with the volatile oils and a few other antiseptics, in which he studied their antiseptic power, their action upon soft tissues, their influence upon the healing of sores and their germicidal action upon infected sores. He very properly holds that . the volatile oils and other agents have been used "without reference to their relative merits as anti- septics, or to their therapeutic effects upon the tissues to which they are applied." From these observations, a summary of which is given in the table following, he concludes that the oils of cinnamon (including oil of cassia), while high in antiseptic value, are too irritating to be used in root canals. Also that oil of cloves and creosote are superior agents, both being efficient antiseptics, while non-irritating to soft tissues. In fact, he found oil of cloves to possess local analgesic properties to a * The Dental Review, August, 1898, p. 593. VOLATILE OIL GROUP 13/ marked degree. He regards oil of gaultheria as useless. Formalin he discards in the treatment of conditions about the mouth. Attention is asked to the comparative table below, following which the several volatile oils are described separately: Antiseptic Power and Local Action of Certain Volatile Oils and Other Substances (Dr. A. H. Peck).* Antiseptic Power. Action on Soft Tissues. 10 c.c. of sterile mutton bouil- lon as culture medium. Growth TVTien confined to When sprayed of mouth bacteria prevented by skin by rubber cap. upon artificial sore amounts given below in drops. (guinea-pig). (Ratio varies as size of drop.) Ratio. Oil of cassia 0.3 drop, or 1:2233 24 hrs. Blister; in- Healing prevented. tense inflammation Oil of cinnamon with slow heaHng. (Ceylon) 0.3 " 1:2100 24 hrs. Blister; less Healing prevented. Oil of cinnamon severe than above. (synthetic) 0.3 " 1:2133 15 hrs. Blister; but Creosote (beech- no inflammation. wood) 0.5 " 1 : 1280 36 hrs. No irritation. Sore healed. Oil of cloves 0.6 " 1:1150 36 hrs. No irritation. Rapid healing. Oil of bay 0.7 " 1 : 1028 36 hrs. No irritation. Inflammation sub- sided gradually. Oil of sassafras.. . .0.7 " 1:1000 36 hrs. No irritation. Inflammation sub- sided. Oil of peppermint .0.8 " 1 : 875 36 hrs. No irritation. Inflammation sub- sided. Black's "1-2-3" f. .1.4 drops, or 1:454 36 hrs. No irritation. Inflammation sub- sided. Phenol (959^).... 1.8 " l:338t Oil of cajuput .... 6 " 1 : 120 36 hrs. No irritation. No irritation. Eucalyptol (San- der's and Merck's 6 " 1:116 36 hrs. No irritation. Inflammation sub- Eucalyptol sided. (ordinary) Saturated solution required. „., . ixi_ ■ f No action even in Oil of gaultheria. • , i i . T^ , i saturated solution ^^S^°°^ I (8 drops). Formalin 0.4 drop, or 1 : 1400 4 hrs. Severe pain. 20 hrs. Severe inflammation, followed by sloughing and toxic symptoms. Germicidal Action. Apphed to infected sores, ]pus germs were destroyed by the cinnamon oils, creosote, oil of cloves, oil of bay, oil of peppermint and Black's "1-2-3." Oil of sassafras was less efficient, while the action of oil of cajuput and eucalyptol was not very positive. * For article forming basis of this summary, see Dental Review, August, 1898. t Black's "1-2-3" mixture (mild) consists of 1 part oil of cassia, 2 parts phenol (crystals), and 3 parts oil of gaultheria. X The influence of phenol was transient, growth occurring after three days. 13S ANTISEPTICS Oleum Cassias. — Oil of Cinxamox. — Oil of Cassia. — ^Average dose, TU 3 (0.2 mil.). A volatile oil distilled from Cassia cimiamoii (young twigs), containing not less than 80 per cent, of cinnamic aldehyde, and ha^■ing the odor and taste of cinnamon. It is yellowish or brownish in color, becoming darker and thicker by age and exposure; sp. gr. about 1.055; soluble in about 3 parts of 70 per cent, alcohol. The changes by age are due to the oxidation of cinnamic aldehyde to cin- namic acid and resins; therefore, the oil should be kept from exposure to light and air m well-stoppered, amber-colored bottles, in a cool place. The oil is frequently adulterated.* Oil of cinnamon is non-coaguknit to tissues, it is penetrating, it is agreeable in odor and the discomfort of its application to soft tissues is momentar}^, unless it is confined for some time, when it may cause severe irritation. It is doubtless the most powerful antiseptic of all the volatile oils used hi dentistry (see preceding table). It is used for tooth dismfection, but is less applicable to front teeth than to posterior ones, because of its discoloring effect with continued use, this being due to its tendency to become darker with exposure. It may be used in full strength in pyorrhea with deep pockets. Aquae Cinnamomi. — Cixxamox Water. — Average dose, f5 4 (15 mils.). Cinnamon water is officially prepared as follows : Gm. or mils. I^ — Olei cassiae 2 Talci purificati 15 Aquse destillatse q. s. ad 1000 Triturate the oil with the purified talc, add the recentlj^ boiled distilled water gradually with continued trituration, filter, and pass the filtrate through the filter repeatedly until the cinnamon water is perfectly clear. (It is estimated that one- half of the oil is dissolved by the water.) Spirihfs Cinnamomi (10 per cent.) is also official. Average dose, TU 30 (2 mils.). The official cinnamon water is useful as a mouth wash and to irrigate fistulous tracts, as, according to Dr. Peck's report, it should be able to prevent the growth of mouth bacteria. It is very pleasant to the taste and can well be used in preference to proprietary liquids of complex composition and imcertain value. It may be used in full strength freely. Oil of cinnamon is an important ingredient in the formula of Dr. * Oil of cassia has often been found adulterated with a mixture of petroleum and rosin. The U. S. P. test for detection is as follows: Shake 2 mils, of the oil in a test- tube with from 5 to 10 mils, of purified benzin, and decant the latter; this hquid is colorless and does not assume a green color upon shaking it with an equal volume of y\f per cent, copper acetate solution. VOLATILE OIL GROUP 139 Black, known as Black's 1-2-3, which is widely used as a dressing in pulp canals where antiseptic and anodyne action is needed. The formula is as follows : Gm. or mils. 'Bf. — Olei cassise 4 Phenolis fcrv'stals) 81 Olei gaultherise 12) Mix the oils and add the melted crj^staLs of phenol. Cixxa:mic Aldehyde [CgHjO] (not official;. — An aldehyde obtained from oil of cinnamon or prepared synthetically. It should be 95 per cent, in strength. It is nearly identical with the official oil of cinna- mon, having the same qualities in general, but being more definite in composition. At a low temperature it becomes solid, melting again at 18.5° F. It is sparingly soluble in water, but soluble in alcohol, ether and oils. It uses are the same as those of oil of cinnamon. Oleum Caryophylli.— Oil of Cloves. — ^Ai-erage dose, TU 3 (0.2 mil.j. A volatile oil distilled from cloves (the flower-buds of Eugenia Aromatica) , varying in color from pale yellow to brown, age and exposure producing the change. It has the odor and taste of cloves, is soluble in 2 parts of 70 per cent, alcohol, the resulting solution ha\dng a slightly acid reaction. Sp. gr. about 1.050. Its chief constittient of value is eiigenol, of which it should contain 82 per cent. While the change m color does not impair its value, it should be kept protected from light and air, so as to retard the same. Oil of cloves has a high antiseptic value (1 to 1150 for mouth bac- teria), while Dr. Peck's experiments have proved positively that it is not only non-irritating locally, but that, when applied to inflamed or infected tissues, it is decidedly soothing, and healing progresses rapidly under its application. It is iwn-coagidant to tissue. It can be used freely as a tooth and root canal disinfectant, though its tendency to discolor prohibits its use in front teeth. It is entitled to a larger use as an application to irritated and infected tissues. In addi- tion to its dental uses, oil of clo\'es is employed in the preparation of microscopic specimens. Eugenol [C10H12O2]. — ^Average dose TU 3 fO.2 mil.). An aromatic phenol, the chief constituent of oil of cloves, but obtainable also from other sources. Sp. gr. about 1.067. It is similar to oil of cloves in all of its qualities. It may be mixed with alcohol in any proportion and it is soluble in 2 parts of 70 per cent, alcohol. In Peck's observa- tions it was found to be much inferior to oil of cloves {vide ante). 140 ANTISEPTICS The two following agents are ^'ery similar, both owing their ^•alue chiefly to cineol (identical with cajuputol and eucalyptol) . Oleum Cajuputi.— Oil of Cajuput. — Average dose, TTl 8 (0.5 mil.). A volatile oil obtained from the fresh leaves and twigs of Melaleuca leuca- dendron. Its chief constituent is cineol (eiicalyptol) , of which there should be at least 55 per cent. It is a light, thin, colorless liquid, with an aromatic odor and taste. It is soluble in 1 part of 80 per cent, alcohol, the solution being neutral. Sp. gr. about 0.920. Oleum Eucalypti. — Oil of Eucalyptus. — Average dose, TTl 8 (0.5 mil.). Distilled from the fresh leaves of Eucalyjitiis globulus, this vola- tile oil owes its value to cineol (eucalyptol), of which it should contain 70 per cent. It is soluble in 4 parts of 70 per cent, alcohol, the solution being neutral. Sp. gr. about 0.915. It is similar to oil of cajuput because of the presence of cineol. It has no distinct value in comparison with other volatile oils, and preference is usually given to the following chief constituent, which is more definite than the oil. Eucalyptol. — Cineol. — Cajuputol [CioHigO]. — Average dose TTl 5 (0.3 mil.). An organic compound obtained from oil of eucalyptus and other sources. It is a colorless liquid with an aromatic, camphoraceous odor and a spicy, cooling taste. It is soluble in alcohol in any propor- tion, the solution being neutral. Sp. gr. 0.922. It should be kept protected from air and light. Eucalyptol has no special advantage over the stronger volatile oils, though regarded by some as especially detergent in root canals. It is non-irritating and non-coagulant. Its antiseptic value is shown in the table on p. 137. Oleum Gaultherise. — Oil of Wintergreen. — [Known now officially as Methylis Salicylas. — Methyl Salicylate] [CH3C7H5O3]. — Average dose, TTl 12 (0.75 mil.). This volatile oil is produced synthetically or distilled from Gautheria procumbens. From either source, it has the odor and taste of wintergreen. It is used chiefly as a flavoring agent Its antiseptic value is low. Thymol [C10II14O]. — A phenol, present m the volatile oil of Thymus vulgaris and some other volatile oils. Dose, gr. 1-30 (0.06-2 gm.). It occurs in large, colorless crystals, having a penetrating odor of thyme and an aromatic taste, soluble in 1010 parts of water, in about 1 part of alcohol, also soluble in chloroform, ether and oils. It is used as a general antiseptic, having a germicidal power similar to that of phenol, as a VOLATILE OIL GROUP 141 substitute for which it was introduced into medicine. It is less toxic than phenol. It is used also as an anthelmintic, being regarded almost a specific in hook-worm disease (uncinariasis) where it is given in the large dosage of from 1 to 2 gms. per day. Thymolis lodidum. — Thymol Iodide [C2rjH2402l2] ■ — This substance, known also as Aristol, contains 43 per cent, of iodine. It is a reddish- yellow or brownish powder, insoluble in water and glycerin, very slightly soluble in alcohol, freely soluble in ether and in oils. It does not keep well unless protected from light. It is used as an antiseptic powder, and is applicable as a pulp-canal dressing. Oleum Menthse Piperitse.— Oil of Peppermint. — ^Average dose, TH 3 (0.2 mil. J. A volatile oil distilled from the flowering plant of Mentha piperita, yielding 50 per cent, of total menthol (5 per cent, as esters). It is colorless, neutral and soluble in 4 parts of 70 per cent, alcohol. It should be kept in a cool place and protected from light. It possesses a strong odor of peppermint. Its contact with tissue is followed by a sensation of cold. In form of the spirit (10 per cent.) it is given inter- nally as a carminative. Locally it is analgesic and antiseptic, and is, therefore, useful to relieve itching of skin or mucous membrane, a 5 to 10 per cent, ointment or solution in alcohol being used. Menthol [C10H19OH]. — ^Average dose, gr. 1 (0.06 gm.). A secondary alcohol obtained from oil of peppermint or other mint oils. It occurs in colorless crystals having the characteristic odor of peppermint. It is only slightly soluble in water, freely soluble in alcohol, ether, chloroform and oils. When rubbed upon the skin there follows a decided sensation of cold to the part. This effect classes it as an analgesic and makes it a valuable application in itching (pruritus) of various parts. It may be applied in solution or in ointment. It is a useful antiseptic for internal administration and for local dental uses. As an analgesic antiseptic for use in pulp treatment it may be dissolved in chloroform or in a volatile oil. In neuralgias and headaches the solid crystal is rubbed upon the skin of the painful area. Oleum Terebinthinee Rectificatum.— Rectified Oil of TrRPEXTiXE. — ■ Average dose, TU 5 (0.3 mil.). This agent has been discussed in its more important use as an irritant. As an antiseptic it is chiefly used exter- nally to disinfect the skin or the hands of the operator in preparation for surgical operations. Terebenum. — Terebene. — Average dose, 1TL 4 (0.25 mil.). The reac- tion between oil of turpentine and sulphuric acid yields a colorless liquid, known as terebene. It has an agreeable odor and aromatic 142 ANTISEPTICS taste, and it should rank among the vahiable antiseptics for local use. It is almost insoluble in water, but is soluble in 3 parts of alcohol. With exposure to light and air it gradually becomes resinified and acquires an acid reaction. It is used internally in bronchitis. HALOGEN GROUP. Bromum, — ^Bromine [Br]. — Besides its use as an escharotic, bromine in aqueous solution (soluble in 90 parts) is a good general disinfectant, but its irritating vapor precludes its use about the mouth or air passages. Chlorine [CI]. — (For internal doses, see Index of Drugs.) Pure chlo- rine in gaseous form is too irritating and poisonous to be employed except to disinfect rooms. One part in 100 of the atmosphere, with moisture present, is an efficient germicide for disinfection of dwellings. In either of the official preparations it is available for tooth disinfection or bleachmg. It is also a deodorant by its power of decomposing sul- phuretted hydrogen compounds. Its disagreeable odor is an objection to its use as a mouth-wash, but it is a very efficient antiseptic. Even 1 part in 22,000 has been found capable of killing developed bacteria.* The value of chlorine as a water disinfectant has led to the method of "chlorination" upon a large scale in order to insure a safe water supply to cities. In the experience of the city of London it has been found that 1 part of chlorine to 2,000,000 parts of water is efficient, while 1 part in even 3,000,000 has given considerable success. f Following are the commonly used chlorine disinfectants: Liquor Sodce ChlorinatcB (Labarraque's solution) contains at least 2.5 per cent, of available chlorine. Calx Chlorinata (Chlorinated lime, Bleaching powder) contains at least 30 per cent, of available chlorine. Incompatibility. — Chlorine gas with a solution of ammonium chloride forms chloride of nitrogen, which is explosive. Chlorine water decom- poses potassium iodide in solution, liberating iodine, and mked with a solution of silver nitrate it precipitates chloride of silver. In contact with silver cyanide it liberates hydrocyanic acid. It oxidizes organic substances and destroys vegetable colors. Liquor sodse chlorinatse is decomposed by hydrochloric acid with evolution of chlorine gas and carbon dioxide. * Brunton's Pharmacology, 1885, p. 96. t Houston: Water and Gas Review, NeW York, May, 1919. HALOGEN GROUP 143 lodum. — Iodine [I]. — This substance ranks with the other halogens as a powerful antiseptic. The tincture can be added to water to secure any desired strength, a weak solution being suitable as an irrigation to pus cavities. As an inhalant in pulroonary diseases, when a powerful antiseptic vapor is needed, the tincture may be vaporized with steam in a strength not to exceed 10 minims (0.6 gm.) to a pint of boiling water, usually combined with carbolic acid, eucalyptol or similar drugs. In its uses it has been considered under Irritants. lodoformum. — Iodoform [CIII3]. — Obtained by the action of iodine upon alcohol in the presence of an alkali, it is in form of a lemon-yellow crystalline powder, with a xexy penetrating odor resembling that of iodine. It is practically insoluble in water, soluble in 60 parts of alco- hol and in 7.5 parts of ether. It contains 96.7 per cent, of iodine, to which its antiseptic power has been supposed to be due. However, Heile* found that the value of iodoform does not depend upon nascent iodine, but upon a much more active substance, diiodacetylidin, which is set free from iodoform in contact with organic substances when air is excluded Iodoform differs from iodine in being non-irritant. As an antiseptic dressing it is applied in powder, or upon gauze, to wounds and ulcers. Its disagreeable odor precludes its use in dentistry; but a number of odorless or less unpleasant substitutes have been introduced, examples of which are here named, the first only being official. They are all nearly insoluble in water. Thymol Iodide (Aristol), containmg 43 per cent, of iodine. lodol containing 89 per cent, of iodine. Antiseptol, containing 50 per cent, of iodine. Losophane, containing 78 per cent, of iodine. Sozoiodol (Sozoiodolic acid), containing 54 per cent, of iodine, 20 per cent, carbolic acid, and 7 per cent, sulphur. This substance has acid combining properties and forms a number of salts. Sodium sozo- iodolate is preferred on account of its ready solubility in water and' in glycerin. In addition to the above group, the following substance, derived from coal-tar, holds a place as an antiseptic powder: Acetanilidum [CsHgNO]. — ^Acetanilid, a white crystalline substance, obtained by the interaction of glacial acetic acid and aniline, is employed in very fine powder, as an antiseptic, by being dusted upon wounds * See Gould's Year-Book of Medicine, 1905, p. 498. 144 ANTISEPTICS after surgical operations. Being only slightly soluble, it is an excellent substitute for iodoform. It is soluble in 190 parts of water and in 3.4 parts of alcohol. MISCELLANEOUS ANTISEPTICS. Among the following agents will be found none of the ready-made proprietary solutions or mixtures that are advertised so largely as antiseptics. Such are entitled to no place in a book that aims to treat subjects in a scientific way, for the basis of their exploitation is com- mercial, and their use should be regarded as unethical. But, aside from these considerations, there is evidence that they are inferior to some of our well-known simple agents. The only reason for a reference to such preparations here is in order to discourage their use, and this can be done upon the ground of their inefficiency, as shown below. In a very important series of observations in the field of mouth dis- infection, Wadsworth,* working in connection with the Health Depart- ment of New York City, presents a comparison of the antiseptic power of several of the most popular of the proprietary solutions with that of alcohol. His observations were made with the pneumococcus, which is so frequently found in the mouth. He found that this bacterium can be readily destroyed in a broth culture, but that in sputum its destruction by harmless solutions is extremely difficult, for the reason that, with many antiseptics, diffusion into sputum or into an exudate is hindered by the albuminous matter. Alcohol proved to be very dift'usive and this property was greatly aided by the addition* of glycerin. The observer's conclusions include the following statement: "Of all the commercial solutions studied — listerine, borine, borolyptol, glycothymoline, odol and Seller's solution — none proved efficient when tested on pneumococci under the conditions most favorable for their action. Formalin, lysol and hydrogen peroxide failed to act upon the pneumococci in exudates. In short, alcohol alone, of all antiseptics studied, proved efficient when tested on the pneumococci inidcr all the conditions of the experiments." Alcohol was used in the strength of 20 to 40 per cent. Preference is given to a mixture of water, glycerin and 30 per cent, of alcohol, as being readily dift'usible, efficient and harmless. * Journal of Infectious Diseases, October, 190G. MISCELLANEOUS ANTISEPTICS 145 Betanaphthol. — Naphthol [C10H7OH]. — A phenol occurring in coal-tar but usually prepared from naphthalin. It occurs in colorless or buff- colored crystals, having slight odor and sharp taste, soluble in 1000 parts of water and in 0.8 part of alcohol; soluble also in glycerin and in olive oil. It is neutral. Average dose, gr. 4 (0.25 gm.). Betanaphthol in solution is useful to keep instruments sterile during an operation, as it does not corrode metals. It is applied as an anti- septic to tissues, from the 1 : 1000 saturated aqueous solution, which may be used to irrigate wounds and as a mouth wash freely, to the full- strength alcoholic solution (1 : 0.8) in the disinfection of root canals. Upon soft tissues, and as a cleansing and disinfecting agent in pyorrhea alveolaris, a 1 : 200 or 1 : 300 solution may be used, prepared either with alcohol or hot water, for it is soluble in 75 parts of boiling water. A saturated solution in hot water, allowed to cool to the desired point, is very useful; while some of the drug precipitates with cooling, the solution will be saturated at whatever temperature used. Incompatibility. — With chlorine water or bromine water betanaphthol will produce a white turbidity. ResorcinoL — Resorcin [C6II6O2]. — ^A phenol from various sources. It occurs in colorless or pinkish crystals, having a sweetish taste, solu- ble in 0.9 part of either water or alcohol, also soluble in glycerin or ether. It is neutral or slightly acid. Average dose, gr. 2 (0.125 gm.). This drug is useful as a mouth antiseptic, a 2 per cent, solution in water being a proper strength for mouth wash or gargle. It is frequently employed in whooping-cough to cleanse the throat and posterior nares by instilling the 2 per cent, solution directly into the nostrils several times daily. Although similar to phenol in action and uses, it is not corrosive and is less dangerous. The internal dose being double that of phenol, it can be used in stronger solution (2 to 5 per cent.) for general antiseptic purposes. Incompatibility. — The aqueous solution of resorcin will react with chlorinated lime, ferric chloride or bromine water. Potassii Chloras. — Chlorate of Potassium [KCIO3]. — It occurs in colorless crystals or white powder, odorless, and having a salty taste. It is neutral, soluble in 11.5 parts of water, soluble also in glycerin, but almost insoluble in alcohol. Average dose, gr. 4 (0.25 gm.). The U. S. P. advises caution with this salt, as explosion may occur when it is mixed with organic matter (tannic acid, sugar, etc.), or with sulphur, sulphides, hypophosphites or other easily oxidizable substances. It is not a strong antiseptic, a 3 per cent, solution failing to prevent 10 146 ANTISEPTICS the development of bacteria. In mercurial or other forms of stomatitis it is used in saturated solution as a mouth-wash, or in tablet form it is allowed to dissolve slowly in the mouth. It is also valued highly by some as an internal remedy in aphthous stomatitis. It has become a popular remedy in sore-throat, undeservedly so, and is bought and used too freely. Great care must be exercised in the internal use of this drug and its indiscriminate sale should be discouraged, because of its poisonous effects in the blood. It can change hemoglobin into methemo- globin, and in large doses it may also irritate the kidneys.* On the whole, it must be said that the usefulness of potassium chlorate has been overrated and its dangers not sufficiently recognized. Incompatibility.- — Besides the dangers mentioned above, the drug is incompatible with strong snlphvric and hydrochloric ocids. (A drop of sidyhuric acid will ignite a mixture of equal parts of potassium chlorate and sugar.) An aqueous solution mixed with silver nitrate will precipi- tate silver chloride. Potassii Permanganas. — Permanganate of Potassium [KMnOJ. — It occurs in dark purple crystals, having a characteristic, unpleasant taste: neutral; soluble in 13.5 parts of water. Its aqueous solution is rose-colored when dilute and deep purple when concentrated. It decomposes in contact with alcohol. Being a powerful oxidizing agent the U. S. P. directs that it should be kept in glass-stoppered bottles, protected from light, and should not be brought in contact with organic or readily oxidizable substances. Average dose, gr. 1 (0.06' gm.). Its oxidizing power makes it a valuable disinfectant and deodorant. Applied to the mucous membrane of the mouth in proper dilution it is non-irritant, but it produces a dirty brown stain, which is an objection to its use. However, the stain is easily removed from accessible sur- faces by a solution of oxalic acid. It may be applied locally in any strength up to, or even above, 5 per cent. Its action is quite super- ficial and is to be explained by the fact of the liberation of oxygen, which unites with the albumin of the tissues. Very strong solutions, therefore, may be irritating and even somewhat caustic to mucous * As examples of fatal poisoning by potassium chlorate note the following: (1) A woman, aged seventy years, took 1 ounce by mistake for Epsom salt. Four hours later she fainted, became cyanosed and died fifteen hours after taking. (2) An infant of three weeks died in three days from about 1 gm. (gr. 15), which had been dusted into its mouth. Of 89 cases recorded, 76 were fatal. Witthaus and Becker, Med. Jurisprudence, 1896, vol. iv. MISCELLANEOUS ANTISEPTICS ■ 147 membranes. It has been found efficient, and has been extensively used by surgeons, as a hand disinfectant in preparation for operating. After preliminary scrubbing of the hands and nails with soap and water, they are immersed in a saturated aqueous solution of the permanganate. This is followed by a solution of oxalic acid which removes the stain of the permanganate. When used as a mouth wash, 1 : 1000 is a proper dilution. Its use within a carious cavity is always to be avoided; other agents are just as efficient, without the objectionable staining quality. As an appli- cation to the throat in diphtheria or tonsillar infection, and to foul ulcers, it possesses considerable value. In 1 per cent, solution it has been found to destroy developed bacteria and in 1 : 1000 it prevents their development.* It is an efficient chemical antidote to morphine if given while the latter is still in the stomach, and, since morphine is partly eliminated into the stomach, in prolonged cases of poisoning the stomach may be washed out at hourly intervals with a weak solution (1 : 2000). Incompatibility. — ^With organic substances, or triturated with sulphur or other inflammable substances, explosion may occur. For this reason it should not be mixed in a closed vessel with syrup or glycerin. With carbolic acid oxidation occurs. Alcohol, oxalic acid or solution of hydrogen dioxide will decompose it. This drug should be used alone in a simple aqueous solution. Sodii Thiosulphas. — Thiosulphate of Sodium. — H yposidphite of Sodium [Na2S203 + 5H2O]. — This salt is soluble in 0.5 part of water and the solution is neutral; insoluble in alcohol. Its antiseptic powder makes it a useful mouth wash. It is also a useful internal antiseptic. Average dose, gr. 15 (1 gm.). Zinci Chloridum. — Chloride of Zinc. — (For general properties, see under Escharotics.) This substance, on account of its germicidal and penetrating power, must be ranked among our best antiseptics. The disadvantages in its use are the irritation it causes and its coagulant action. For tooth disinfection, especially in pulpless teeth, these dis- advantages do not obtain, and strong solutions (above 20 per cent.) may be used; while for mouth disinfection a 1 per cejit. solution may be employed. It must be remembered that its coagulation of albu- minous matter liberates hydrochlorrc acid, which should not remain * Brunton's Pharmacology, 1885, p. 96. 148 ANTISEPTICS about the teeth, but must be neutraHzed at once. The following formula is typical: Gm. or mil. I^ — Zinci chloridi 2 4 (gr. xxxvij) Glycerini 30 (fgj) Aquae rosse q. s. ad 240 (fSviij) M. et Sig. — Use as a mouth wash. Argenti Nitras. — Nitrate of Silver [AgNOs]. — (For solubility and properties, see under Escharotics.) Although generally inadmissible as a mouth or tooth antiseptic because of its staining quality, this drug is valuable in severe local infections of the mucous membrane. It is destructive to the gonococcus wherever found, and in that severe form of conjunctivitis known as ophthalmia neonatorum, which is usually a gonorrheal infection of the eyes occurring during birth, nitrate of silver is most relied upon as the germicide. Also, in order to prevent this serious malady, the advice of C'rede* should be supported and followed, which is, that the eyes of all babes born in charitable institu- tions should invariably have a 2 per cent.f solution of silver nitrate instilled into them immediately after birth, so as to disinfect every part of the conjunctival membrane. As evidence of the efficacy of such preventive treatment, it may be noted that the statistics of large lying- in institutions where it has been employed, show that the Crede method has reduced the disease to less than one-fifteenth of its former pre- valence in the same institutions. Whenever nitrate of silver is locally applied, any excess may be completely neutralized by a solution of sodium chloride. Stains of sih-er nitrate may be removed by a solution of potassium cyanide (not applicable within the mouth as the cyanide is very poisonous), or by moistening with a solution of iodine followed by sodium thiosulphate. Certain other preparations of silver have been foimd to be highly antiseptic and have come into use in general surgery. Of these the most remarkable is an allotropic form of metallic silver that is solnhle in water and in albuminous fluids. The aqueous solution of this (usually 1 per cent.) may be injected into infected tissues, and has * The justification for tliis advice is found in the large percentage of cases of blind- ness that are due to this severe inflammation, occurring as a result of infection of the eyes at birth. In 1897 an investigation of the causes of blindness of the 306 inmates of the schools for the blind in New York State showed that 21 per cent, of cases were due to ophthalmia neonatorum. Howe, Transactions of the Medical Society of the State of New York, 1897. t A 1 per cent, solution is now commonly used. MISCELLANEOUS ANTISEPTICS 149 even been used intravenously in cases of septicemia. It is also used in form of ointment rubbed into the skin. The following non-ofBcial preparations are also now employed in general surgery: Silver Lactate. — Actol [AgCsHaOs + H2O].— This occurs in colorless crystals, easily affected by light, soluble in 15 parts of water. An aqueous solution of 1 : 1000 may be used, as 1 : 300 to 1 : 500 solution is said to be equivalent to 1 : 1000 mercuric chloride solution in dis- infectant power.* Silver Citrate. — Itrol [CeHjOvAgs]. — A white powder, soluble in 3800 parts of water, said to be destructive to all ordinary germs when used in a solution of 1 : 4000. The solution should be freshly prepared. It is also used in ointment of 1 to 2 per cent, strength. Protargol {Protein Silver) .—This substance is a silver albumose, con- taining 8 per cent, of metallic silver. It is a yellowish powder, readily soluble in water, and is less irritating than nitrate of silver. The reason for this probably is that, being an albumin compound, its application to tissues is not followed by the liberation of an acid, as is the case with the nitrate. It destroys various bacteria, and it has, therefore, come to be used much as a substitute for the nitrate in purulent inflammations of mucous membranes, particularly when they are gonorrheal in nature. One to 5 per cent, is the strength of solution in which it is employed. As to germicidal power, Post and Nicoll found a 10 per cent, solution about equivalent to 1 : 5000 solution of silver nitrate, f Argyrol {Silver vitellin). — A proteid salt of silver occurring in black scales, containing 30 per cent, of metallic silver. It is freely solu- ble in water and the solutions do not readily deteriorate. It does not coagulate albumin nor precipitate chlorides. It is comparatively non-irritating an)d non- toxic, therefore, it may be used freely even in strong solution, e. g., in simple conjunctivitis 5 to 20 per cent, may be applied several times daily and in the gonorrheal form 25 to 50 per cent. As an irrigating fluid 1 : 1000 may be freely used and internally 5 to 10 grains may be given. Its antiseptic power is small as compared with silver nitrate. Post and Xicoll found a 50 per cent, solution inferior to a 1 : 10,000 solution of silver nitrate in germicidal power. | Stains of argjTol may be removed by a 1 : 500 solution of mercuric chloride. Preparations of silver have been used internally, especially the nitrate and oxide, for alterative effect. It must be noted that the prolonged internal use of this metal should be discouraged. It is * National Dispensatory, 1916. t Wood's Pharmacology and Therapeutics, 1916, 2d ed. t Ibid. 150 ANTISEPTICS capable of producing a permanent staining of tissues, which is outwardty shown by a slight blueness of the skui. This condition is known as argyria and is due to the deposit of silver in the papillary layer of the skin. The same condition may be produced in a smaller area by the local use of silver preparations, where they are allowed to enter the tissues. Hydrargyri Chloridum Corrosivum. — Mercuric Chloride. — Bichloride of Mercury, — Corrosive Sublimate. — Perchloride of Mercury [HgCy. — Average dose, gr. ^ (0.003 gm.) This substance occurs in colorless, odorless crystals, having a disagreeable metallic taste, soluble in 13.5 parts of Avater, in 3.8 parts of alcohol, and in about 12 parts of glycerin. It is acid in reaction, although the addition of chloride of sodium to its aqueous solution will render it neutral. Because of its corrosive proper- ties, for general antiseptic purposes it is used only in dilute solution of 1 : 2000 to 1 : 10,000. However, for limited use as a powerful disinfect- ant, it may be used as strong as 1 : 1000 or even 1 : 500 in the mouth, as in plantation cases. This drug may cause poisoning in two ways, either as a corrosive by local destruction of tissues, or, after absorption, as a systemic poison. In the former case a strong solution or the pure salt is necessary to cause poisoning, while in the latter case small doses continued, or careless use of ordinary solutions or of any preparation of mercury, is likely to cause systemic mercurial poisoning, with the production of salivation. For example, a single cathartic dose of calomel, or the daily use of the compound cathartic pills, which contain 1 grain of calomel each, has caused salivation. This powerful drug will seldom be the antiseptic of first choice in dental practice. Its unpleasant, metallic taste prevents its use as a mouth-wash. As a tooth disinfectant it is seldom used because of the danger of staining the tooth through the formation of sulphide of mercury.* It corrodes instruments, therefore cannot be used to steri- lize them, although glassware may be easily sterilized by the solution of 1 : 1000. In spite of all disadvantages mercuric chloride remains as one of the most efficient germicides. In general medicine and surgery the weaker solutions (1 : 3000 to 1 : 10,000) are u.sed cautiously and for a short time, to irrigate wounds and abscess cavities, to disinfect ulcers, and as douches mto the several passages of the body. Whenever used, a * See remarks on metallic stains in Kirk's article on "Discolored Teeth and their Treatment," American Text-book of Operative Dentistry, second edition, page 559. MISCELLANEOUS ANTISEPTICS 151 free escape of the solution must be insured, and its use in these ways should rather be regarded as a temporary necessity, to be supplanted by safer agents. As a rule, it should not be combined with other sub- stances. Incompatihility. — Mercuric chloride mixed with livie-water, ammonia or carbonates of the alkalies, will produce a precipitate. With a solution of soap a precipitate of mercurial soap occurs. With potassium iodide red iodide of mercury is formed. Hydrogen sulphide causes a black precipitate of mercuric sulphide. With siher nitrate a deposit of chloride of silver occurs. Metals are tarnished by it, amalgamation occurring with silver and some others. Albumin is coagulated by it. Acute Poisoning. — The symptoms of acute poisoning by this drug are those produced by any corrosive irritant — i. e., pain in the stomach, with vomiting and prostration. The chemical antidote is albumin. (See Table of Poisons and Antidotes.) Systemic Poisoning or Mercurialism. — Only the soluble salts of mercury are capable of causing local irritation, but any preparation of this metal may cause mercmialism. The symptoms of this condition may come on without any gastric disturbance; in fact, it is fortunate that the first indications of systemic saturation occur in the mouth, where they are at once noticed and easily recognized; and the dentist should be familiar with the early symptoms of this, possibly disastrous, toxic disturbance. The first symptom will be hyperemia of the more vascular structures, the pericementum and gums, causing in the former slight tenderness upon forcible closure of the jaws, and in the latter redness. If the condition progresses, the soreness of the teeth becomes decided and an increased flow of saliva occurs, with decided fetor of the breath. This gives the picture of salivation in a positive degree; fortunately the superlative degree, with ulceration and loss of teeth, is almost never seen today because of smaller quantities of the drug now given, with the decline of the antiphlogistic methods of treatment which were formerly in vogue. The elimination of mercury in the saliva, from a system saturated with it, is probably responsible for the occurrence of the ulcerative stomatitis seen in severe cases. Right here let it be stated that detection by the dentist of the early symptoms of mercuri- alism should call forth no reflection upon the physician who prescribed mercury. This for two reasons: (1) The condition may have occurred accidentally through idiosyncrasy — i. e., a special susceptibility of the patient to the action of the drug, which is sometimes seen; or, the 152 ANTISEPTICS patient may have exceeded directions and used the medicine carelessly. (2) The condition may be intentional, for, in the treatment of syphilis, the use of mercury in some form is often pushed to saturation for a time. Treatment of Mercurialisni. — The patient will complain of two symp- toms if the condition is well developed: (1) soreness of the teeth, and (2) the constant flow of saliva which may interfere with sleeping. These will need to be relieved. Relief of the pericementitis and stoma- titis must be brought about by elimination through other channels than the salivary and oral glands. The bowel being the most natural route for the elimination of mercury, saline cathartics, freely given, by then power of withdrawmg serum from the blood, will serve our purpose best. The salivation may be controlled by belladonna or its alkaloid, atropine. Of the tinctm-e give 5 minims (0.3 gm.), or of atropme gr. ^0 (0.0006 gm.) two or three times daily. This is the best drug for this purpose, as it checks the salivary secretion very decidedly and is not disturbing to the system if used properly. Opium, or morphine, also causes dryness of the mouth, but the systemic effects are unpleas- ant; and on the whole they are inferior to belladonna. A mouth wash of solution of potassium chlorate (2 to 4 per cent.) is often used in addition. Reports have also been made of the very successful use of hydrogen dioxide in this condition. One part of the official solution to 3 of water, as a mouth wash every half hour, is recom- mended. Its peculiar detergent property makes it particularly appli- cable to severe cases, where ordinary antiseptics are less useful. \Yith improvement in the condition, the saline cathartics should still be continued until the drug is believed to have been thoroughly eliminated. Potassium iodide has long been used to aid elimination of this as of other heavy metals. The dose is 10 to 30 grains (0.6-2 gm.) three times daily. It is believed to form the more soluble iodide, which then passes out through the kidneys. Carbo Ligni.- — Wood Charcoal. — Employed as deodorant. Carbo Animalis. — Anbial Charcoal (not official). — Prepared from bone; employed as a decolorizing agent in preparing organic solutions. Carbo Animalis Purificatus.^ — Purified Animal Charcoal. — Bone- black (not official). — The purification consists in decalcifying by boiling for hours in hydrochloric acid diluted with water. It is employed as an antidote to organic poisons. Charcoal of any kind is not really antiseptic, but it is deodorant and detergent and has marked absorbent jjower. Ob^•iously its applica- MISCELLANEOUS ANTISEPTICS 153 tion to mouth conditions is limited, though its general value should be appreciated. Wood charcoal, prepared from soft wood because more porous, is least powerful of the group, but it has the power of absorbing gases to a large extent — e. g., it is said to be capable of absorbing ninety times its own volume of ammonia gas. It destroys foul gases by absorbing and condensing them within its pores. This power may be increased by platinizing the charcoal. In order to be an efficient deodorant, wood charcoal must either be fresh, or have been recently heated so as to destroy organic impurities that may have been taken up through exposure to the air. Animal charcoal is a more powerful absorbent, being capable of extracting coloring matters from organic solutions. It may be used in decolorizing galenical preparations of drugs. Purified animal charcoal is too powerful to use in decolorizing solu- tions of drugs, for it is capable of extracting organic principles, such as tannin, alkaloids and resins,* whereby the strength of the product would be lessened. Because of this behavior toward organic principles, purified animal charcoal has a distinct V'alue as an antidote to alkaloids and other organic poisons. All charcoals should be kept in well- closed containers, so that their absorbent power may not be exhausted by absorption of gases from the atmosphere. Dental Uses. — About the only use to which charcoal could be properly put is to cleanse a foul mouth, such as is too often met with among ignorant people. Its practical application is questionable. It is not a proper ingredient of tooth powders, because of the sharpness of its particles. Hydrogen Dioxide. — This compound, having the chemical formula of H2O2, is used in several strengths as an antiseptic. Its value depends upon the extra oxygen which it contains and which it gives up readily when brought into conditions that favor its decomposition. It is, therefore, an oxidizing agent, the oxygen liberated in nascent condi- tion giving it three distinct properties w^hich make it especially valuable in dental practice, it being a disinfectant, a detergent and a bleaching agent. A compound that yields its oxygen so readily is, of course, unstable; but it has been found that a solution containing 3 per cent, of pure * U. S. Dispensatory, eighteenth edition, page 329. 154 ANTISEPTICS hydrogen dioxide in water keeps its strength and quaUties for months at ordinary temperatures. Higher strength sohitions require the addition of considerable acid or other preservative, and must be looked upon as unstable and dangerous to handje. A 25 per cent, ethereal solution is put up in closed glass tubes with certain precautions noted upon the label. In this strength the agent is a decided caustic and must be handled with care, its chief use being as a bleaching agent. The official solution is called : Liquor Hydrogenii Dioxidii — Solution of Hydrogen Dioxide [H2O2]. This is a colorless liquid, slightly acid in reaction, and it contains when freshly prepared, not less than 3 per cent., by weight, of the pure dioxide. It is also known as the "ten volume" solution, as it yields upon decomposition about ten times its own volume of oxygen. The acid it contains is necessary to its preservation. Average dose, f51 (4 mils.). The most characteristic property of this liquid is its foamy decom- position in contact wdth organic matter, by the activity of which its strength can be roughly estimated. It gradually loses strength by keeping, though it is stated that deterioration will be retarded if the stopper of the bottle be coated with paraffin, or if a stopper of cotton be employed instead of an ordi- nary cork stopper. It should be kept in a cool place. It decomposes when heated or exposed to sunlight, also when in contact with charcoal, oxides of manganese, potassium permanganate, alkalies, blood, pus and other loosely organized matter, besides many other chemical substances. Mixed with a solution of potassium iodide it liberates iodine. As a rule, it should be used alone, so as to avoid unexpected decomposition. When the 3 per cent, solution is applied to the tissues it decomposes with some energy, because of the rapidity and abundance of the liber- ation of oxygen. Upon a tender mucous membrane the action may be so irritating as to require dilution of the liquid. The oxygen in nas- cent condition is a powerful germicide and disinfectant, cleansing the surface of the tissue thoroughly without injury, for it does Jiot coagulate, nor constringe, nor penetrate. Its action is solely that of an oxidizing agent, and any irritation from it corresponds to the energy of oxygen liberation. As a gargle or mouth wash it may be employed in full strength of the official solution (3 per cent.) or diluted. With children it is usually diluted to one-half or one-quarter strength. It should be regarded distinctively as an antiseptic that does not MISCELLANEOUS ANTISEPTICS 155 injure healthy tissues. Its special value lies in its power to oxidize, disintegrate and destroy disorganized tissue, such as pus; and in dis- infecting abscess cavities it has the further advantage of distending the cavity by the expansion resulting from the liberation of oxygen, so that every portion of the cavity and its walls are reached by the oxygen. Distention of an abscess cavity in this way will cause momentary pain, but scarcely more than attends the use of a coagulating or penetrating antiseptic. In tooth and root-canal disinfection the dioxide is used freely. In removing pus and cleansing the pockets in pyorrhea, in the cleansing of ulcers and, in fact, in any local infectious condition, hydrogen dioxide is an ideal disinfectant. But the mistake should not be made of expect- ing of this substance properties that it does not possess. It is not antacid, it is not coagulant, it is not astringent, it does not affect healthy tissue. Its action is upon disorganized tissue, blood, pus and bacteria. The one indication for its use is the presence of infection . One exception must be made under the general statements as to its use in abscess cavities; it should not be used in the antrum with its unyielding bony wall, unless a very free opening has been made. Very severe pain might easily attend its use ordinarily in empyema of the antrum, on account of pressure from the rapid expansion of the liberated oxygen. Systemic effects never occur from the proper use of hydrogen dioxide; therefore, it is non-toxic. However, by its hypodermic use some of the unchanged dioxide may be absorbed into the circulation and cause disorganization of blood elements with the production of emboli. An animal may easily be killed by intravenous injection of dioxide of hydrogen. As a bleaching agent this substance is discussed elsewhere. Quininae Sulphas. — Quinine Sulphate [(C2oH2402N2)2.H2S04 + 7H2O]. Quinine, the chief alkaloid of cinchona bark, is used in the form of various salts, but mostly as the sulphate. This occurs in white, silky crystals or as hard, prismatic needles; soluble in 725 parts of water, 107 parts of alcohol and in 30 parts of glycerin. [Acids aid the solu- bility of quinine and of the sulphate. The bisulphate and several other salts are much more soluble than the sulphate.] Average dose, tonic, gr. 1| (0.1 gm.) three times daily; anti-malarial, at least gr. 15 (1 gm.) daily. While this drug is classed as antipyretic and anti-malarial, the latter action is most important and is really antiseptic. It is the most typical internal general antiseptic in use. Not only is its action in the diges- tive tract destructive of some of the intestinal infections, such as amebic 156 ANTISEPTICS dysentery, but, in the blood of malarial subjects it readily destroys the Plasmodium malaria, which is the specific organism of malarial or intermittent fever. In order to be absorbed into the blood in suffi- cient strength to accomplish this it must be given in large doses daily for a week or more; but even thus it is comparatively harmless to the system, the only unpleasant effects being ringing in the ears and slight temporary deafness. The term cinchonisni is applied to these symptoms of the full action of quinine. The former use of quinine in large doses, to combat inflammation (antiphlogistic), is now nearly obsolete. Incornpatibility. — (See Incompatibility of Alkaloids.) Chinosol. — Quinosol [C9H6X.KSO4 + H2O] (not official). — Chemi- cally this drug is oxy-quinoline-potassium-sulphate, occurring in yellow crj^stals having an astringent, aromatic taste and readily soluble in water, but insoluble in alcohol. It is not a coagulant, therefore not destructive to tissue. It may be used in a 1 : 1000 aqueous solution as a general antiseptic wash, but for local uses, such as application to abscess cavities, empyema of the antrum, etc., 1 to 2 per cent, solutions may be used. Incoinpatihility. — With lead acetate or mercuric chloride precipitates .will occur, while the addition oi ferric chloride will produce a bluish- green color. Steel instruments are tarnished but not corroded by the drug. Formaldehyde [CH2O]. — This valuable addition to our materia medica is a gas, usually obtained by the partial oxidation of methyl alcohol. It is one of the most powerful disinfectants known, ranking almost with corrosi\'e sublimate. It fills a place that no other agent does as a really eft'ective and practicable disinfectant gas. It is far superior to sulphurous acid gas in respect to efficiency, penetrating power and non-action upon metallic furnishings. A'arious lamps and other appa- ratus for generating the gas for extensive use have been devised, and small fumigators or candles for limited use, as in the disinfection of books, instruments and clothing in a small air space. The gas is very irritating to the eyes and to the air i)assages. As a medicinal agent formaldehyde is employed in its official aqueous solution, as below. Liquor Formaldehydi. — Solution of Formaldehyde. — Formalin. — This is an aqueous solution containing not less than 'A7 per cent, of formaldehyde gas. It has a pungent odor and caustic taste, being irri- tant to tissues. It is the commercial form of the drug and is miscible with water and with alcohol in any proportion. It should be neutral or only faintly acid in reaction. ri)on standing it may become cloudy MISCELLANEOUS ANTISEPTICS 157 from the separation of paraformaldehyde. A stronger sohition is unstable. A much weaker solution must be used for application to living tissues, for this substance is characterized by its penetrating quaUiy and irritant action. While this di'ug has the power to harden tissues to a marked degree, the action is not a coagulation in the ordinary sense. When applied to a mucous membrane, it does not coagulate appreciably. In contact with egg albumin it coagulates the latter only slightly. In fact, it seems to hinder the coagulation of albuminous liquids to which it has been added; for egg albumin and serum are not precipitated by heat, nor is casein coagulated by the rennet enzyme, after being thus treated.* Compared with carbolic acid, the local action of formalin is less corrosive and more penetrating; it is on the whole more irritating, except for the momentary pain caused by the former. The result of its action is a deeper hardening of the tissues to which it is applied. Because of the continued irritation which it occasions, it cannot be used extensively as a general antiseptic to the soft tissues, except in very dilute solution. Even for disinfection of the hands, it has been largely discarded as being too irritating for daily use. As a mouth-wash, 0.5 per cent, of formalin should never be exceeded. For disinfection of pulpless teeth 5 per cent. may be used, but many have discarded it as being undesirable in any gfiicient strength, and liable to work injury beyond the apical foramen. On the whole, it must be said that formalin is not gaining favor as a general antiseptic for application to the tissues of the body. The experiments of Hunt and Jackson f rate the 1 : 200 solution of formalin as far inferior to the same strength of benzoic acid and to 1 : 2500 solution of mercuric chloride, for mouth disinfection. Harrington found that a 1 per cent, solution of formaldehyde failed to kill the Staphylo- coccus pyogenes aureus in sixty minutes, while a 2 per cent, solution required forty-five minutes, and a 5 per cent, solution twenty minutes to destroy the same organism. J As an agent to prevent the growth of mouth bacteria. Peck found pure formaldehyde in 1 : 1000 solution hardly one-fourth as potent as the same strength of bichloride of mercury solution. § In his experi- ments formalin proved to be a dangerous escharotic when kept in contact with soft tissues. * Cushny's Pharmacology, 5th edition, p. 479. t Transactions of the Dental Society of the State of New York, 1904, p. 94. t Annals of Surgery, October, 1904. § Dental Review, August, 1898, p. 607. 158 ANTISEPTICS Formocresol, largely used in root canal work, consists of equal parts of solution of formaldehyde and cresol. An important use of formaldehyde is in the hardening and pre- servation of anatomic and pathological specimens. A 5 per cent, solution of formalin is commonly employed. The advantages of this agent over alcohol is that the color of the specimen is better retained, and the tissue does not shrink to any great degree. Paraformaldehydum. — Paraform. — Average dose gr. S (0.5 gm.) . This polymeric form of formaldehyde occurs in white masses or powder, slowly soluble in cold water, more readily in hot water, insoluble in alcohol. It has a slight odor of formaldehyde, which, given off slightly at ordinary temperature, is evolved rapidly when heat is applied. This points to its extensive use, in the form of "formaldehyde candles," in disinfecting rooms and clothing. In dentistry it is used in various combinations for root filling and pulp mummification. The following are favorite combinations: For root filHng: Chloro-percha and Formaldehyde. Guttapercha (baseplate) 10 parts Chloroform 25 " Eucalyptol 15 " Thymol 2 " Paraform ..." 1 part Dissolve the guttapercha in the chloroform. Dissolve the thymol in the eucalyptol, add the paraform, finely powdered, and shake well. Mix the two solutions, and keep the bottle open in a warm place until the chloroform has evaporated. (Prinz.) For pulp mummifying: Paraform 1 part Thymol ■. 1 " Zinc oxide 2 parts Glycerin sufficient to make a stiff paste. (Prinz.) Hexamethylenamina. — Urotropin [C6H12N4]. — This substance is a chemical compound of formaldehyde and ammonia. It occurs in color- less crystals or white powder, soluble in 1.5 parts of water and in 12.5 parts of alcohol. Average dose, gr. 4 (0.25 gm.). The aqueous solu- tion is alkaline. The chief value of urotropin is as an antiseptic to the urinary tract. The explanation of its action is, that when elimi- nated by the kidneys it is decomposed into formaldeh}'de and ammonia, the former acting then as an antiseptic. It is a very efficient agent, but the urine must be acid, in order to secure a reliable effect, and quite large doses, even up to gr. 20 (1.30 gm.), are often employed. CHAPTER XII. BLEACHING AGENTS. The art of removing discolorations of the teeth has for years engaged some of the best thought of the dental profession, with the result that today we may say that the bleaching of teeth has become a science. With causes of discoloration well known and properly classified^ the chemical reactions necessary to discharge the color may usually be secured with certainty. Moreover, the appreciation on the part of the patient is usually commensurate with the effort expended. The excellent chapter on "Discolored Teeth and their Treatment," by Dr. Ku"k, in the American Text-hook of Operative Dentistry, gives a systematic presentation of present-day knowledge of methods of bleaching discolored teeth, which must stand as the authority of today upon this special subject. The province of the chapter here presented is to deal with substances rather than detailed methods of their appli- cation. The chief agents employed to bleach teeth are discussed, there- fore, as to their properties, action and, in general, their uses. There must necessarily be a chemical basis for the action of these agents, for it is inconceivable that colors could be discharged by the action of such strong chemicals as chlorine and nascent oxygen without the occurrence of chemical reactions. The substances employed in the treatment of ordinary discolorations are conveniently grouped into (a) Agents that furnish free chlorine, or indirect oxidizers. (6) Agents that furnish nascent oxygen, or oxidizing agents, (c) Agents that have an affinity for oxygen, or reducing agents. For the removal of metallic stains, additional agents, chiefly in the nature of solvents, are required. While the use of chlorine to secure a change of the metallic deposit to a chloride, followed by thorough washing with warm distilled water, is held to be the general rule of treatment, its final success may depend upon the solubility of the chloride. Chlorides are commonly soluble in water, but silver chloride is an exception, it being entirely insoluble. Hence, in removing silver stains the chlorine treatment is followed by a saturated solution of 160 BLEACHING AGENTS sodium thiosulphate (hyposulphite), which is a sol\-ent for chloride of silver. In removing stains of manganese the final washing must be with a solution containing oxalic acid. In case of mercurial stain, Kirk advises the use of an aqueous ammoniacal solution of hydrogen dioxide after the chlorine treatment. CHLORINE GROUP. Chlorine. — The value of chlorine gas as a bleacher depends largely upon its affinity for hydrogen, by which it may either directly break up the color molecule or liberate oxygen from the water molecule. In the former case it is a direct decolorizer, and in the latter it is indirectly an oxidizer. The gas is now seldom applied directly to the tooth, although the Wright method employed it this way with good results, but the complicated apparatus needed prevented its general adoption. At the present time it is applied either in solution or in a loosely combined preparation which yields it up readily. The official preparations yielding chlorine in sufficient strength to be of any value in bleaching are the following: Liquor Sodse Chlorinatae. — Solution of Chlorinated Soda. — Labar- raqiie's Solution. — This liquid contains at least 2.5 per cent, of available chlorine. Calx Chlorinata. — Chlorinated Lime. — This is a whitish powder containing at least 30 per cent, of available chlorine. The powder deteriorates upon exposure to the air, becoming moist and losing its strong odor of chlorine. If kept in metal containers it is unfit for bleaching teeth, because of the liability of metallic contamination. It is preferably kept in paraffined card- board packages or in bottles. To be fit for use it must be dry and should exhale a strong odor of chlorine. When either chlorinated lime or Labarraque's solution of chlori- nated soda is employed, it is, after being placed in the tooth, treated with any dilute acid, usually 50 per cent, of either acetic acid or tar- taric acid, in order to free the chlorine more rapidly. The use of chlorinated lime in this way constituted the original Truman method of bleaching teeth. The incompatibilities with chlorine are stated in the chapter on Antiseptics. OXYGEN GROUP 161 OXYGEN GROUP. Hydrogen Dioxide. — This substance and its properties are discussed fully in the chapter on Antiseptics. While the official 3 per cent, solution possesses some degree of bleaching power, its use has been largely superseded by that of the "caustic pyrozone" or 25 per cent, ethereal solution. Its value depends upon the nascent oxygen which it liberates. Kirk* states that "more rapid and permanent effects are produced when the pyrozone solution is rendered alkaline," which may be done by the addition of a little of one of the solutions of the pure alkalies, either aqua ammonise fortior or solution of potassium or sodium hydroxide. Special care must be taken in handling and using the 25 per cent, solution, on account of its caustic action upon the fingers, which may be prevented by first oiling them. Sodium Dioxide. — Sodiu:h PsROxroE [Xa202] (not official). — ^This occurs as a yellowish-white powder that absorbs water readily when exposed to the air, with deterioration of its activity. It is caustic, soluble in water, and strongly alkaline. Its value as a bleacher is threefold : 1. It liberates nascent oxygen as does hydrogen peroxide, but after parting with one of its atoms of oxygen it still possesses caustic and alkaline properties. (Kirk.) 2. It possesses some solvent power upon albuminous matter. 3. It has the power of saponifying fats. Thus it not only acts as an oxidizer, but as a detergent. It is applied in saturated aqueous solution, which must be prepared at a low temperature in order to avoid loss of strength. If weaker solutions are desired in some cases, they may be prepared from the saturated solution by diluting carefully with water. Benzoyl-acetyl Peroxide. — Acetozone. — Bemozone [CeHsCOOOCOC- Hs] (not official). — In a comparative experimental study of bleachers f Dr. Hoff has obtained results that would seem to place this new agent next to hydrogen dioxide and sodium dioxide. He describes it as an organic peroxide, whose decomposition products are not destructive to the tooth structure. It acts slowly, and it may be allowed to remain for some time within the cavity. This drug is obtained in form of a whitish powder, consisting of * American Text-book of Operative Dentistry, t Dental Cosmos, February, 1902. 11 162 BLEACHING AGENTS equal parts of the pure crystal and an inert powder, which makes a cloudy solution in water. The solubility of the crystals in water varies from 1 : 1000 to 1 : 10,000. It is slightly soluble in alcohol and in ether. Nearly all solvents, including water and alcohol, decompose it gradually. It should be kept in small, well-stoppered bottles in a cool place, securely protected from moisture, and from contact with organic matter, alkalies, alcohol and other solvents. In aqueous solution this drug is claimed to be a very powerful, non- toxic germicide. Potassium Permanganate parts readily with its oxygen when brought into contact with organic matter. Its disadvantage as a bleaching agent is, that the resulting compounds are dark-colored and require to be treated with a solution of oxalic acid in order to complete the decolorization. REDUCING AGENTS. Sulphur Dioxide [SO2] (not official). — A gas. Acidum Sulphurosum. — Sulphurous Acid. — An aqueous solution con- taining not less than 6 per cent., by weight, of sulphur dioxide gas. Both are bleaching agents by reason of their affinity for oxygen. However, they do not destroy organic pigments, as the color may be largely restored by an alkali or a stronger acid, according to Witthaus. The dioxide (SO2) possesses the stronger affinity, being oxidized in the presence of water to sulphurous acid (SO3H2), and finally to sulphuric acid (SO4H2). The dioxide gas being preferable, Kirk advocates the use of a mixture of 10 parts of sodium sulphite and 7 parts of boric acid which, being packed into a tooth and moistened with water, may be quickly sealed in with a temporary filling. A reaction occurs between the two substances with liberation of sulphur dioxide. The bleaching process by this method is slower than by the use of the peroxides. The solution in water known as sulphurous acid is less efficient than the gas, but still may be employed. It must be remembered that the final product of oxidation of this class of bleachers is sulphuric acid, which must be thoroughly removed or neutralized. Incompatibility. — Sulphurous acid gas, or its solution, is incompatible with acids, with ferric, mercuric, and silver salts, with carbonates and with sohdions of iodine. Sodii Bisulphis. — Bisulphite of Sodium [NaHSOs]. Sodii Sulphis. — Sulphite of Sodium [Na2S03 -f 7H2O]. These salts are freely soluble in water, and when exposed to air lose REDUCING AGENTS 163 sulphur dioxide. They are of use as sources of sulphur dioxide gas when they are decomposed. In bleaching of teeth the sulphite chiefly is used, as in the process noted above. (See also under Antiseptics.) Sodii Thiosulphas. — Hyposulphite of Sodiuivi [Xa2S203 + 5H2O].— This salt, soluble in 0.5 part of water, is used in saturated solution to remove the silver chloride resulting from previous treatment of silver stains with chlorine. CHAPTER XIII. ANESTHETICS— LOCAL ANALGESICS. Anesthetics are agents used to abolish sensibility, for the purposes of surgical treatment, the relief of spasm, and the alleviation of severe pain. Complete general anesthesia includes unconsciousness, due to paralysis of the cerebral cortex, and loss of excitability of all centers of reflex action, except those concerned in the functions of respiration and circulation. Local anesthesia means usually the abolition of sensibility to iKtin in a certain locality. It is rather a condition of analgesia, which is defined to be the absence of sensibility to pain, as distinguished from anesthesia, which means the absence of all sensibility. When confronted by the necessity of a surgical operation, a decision must be made first as to the advisability of using an anesthetic, then, as to whether local or general anesthesia shall be employed, and finally the choice of the agent must depend upon the condition of the patient, the length of time required for the operation and the comparative safety of the drugs from which a selection is to be made. In major operations the necessity of general anesthesia appears at once, and the chief point will be the choice of the drug to be used. In minor operations, such as the extraction of a tooth or the lancing of an abscess, we should not resort too readily to general anesthesia. We should rather allow the patient to assume the responsibility of deciding to take an anesthetic. And in case of a prolonged or severe operation in dental practice, the patient's physician should, as a rule, assume the responsibility of deciding what anesthetic shall be used, and also super- vise its administration. The use of local analgesics may be more readily resorted to for any minor operation about the mouth. LOCAL ANALGESICS. These agents are employed to paralyze the sensory nerve endings to painful impressions in a limited region. They produce their effects in two ways, and are accordingly classified into: Refrigerant Analgesics, or those which cause an abstraction of heat from the part, even to the point of freezing the tissue, and REFRIGERANT ANALGESICS 165 Paralyzant Analgesics, or those which have a specific paralyzant action upon the sensory nerve terminals. REFRIGERANT ANALGESICS. Ice and salt mixture. Rhigolene spray. Ether spray. Chloride of ethyl spray. . The value of all of these depends upon the operation of the physical law that a solid in changing to a liquid, or a liquid changing to a vayor requires a certain amount of heat to effect the change. The heat so required is abstracted from the surrounding medium and becomes latent in the new form of the substance, being necessary to the maintenance of that form. When a mixture of ice and salt is applied to tissue, heat is abstracted so rapidly by the melting ice that the part may be frozen superficially. The only use of the salt in the mixture is, by its affinity for water, to make the ice melt more rapidly. It would be impossible to freeze tissue by the application of ice alone, because of the slow abstraction of heat. One danger in the application of ice and salt is freezing too intensely or too extensively, which may induce sloughing of tissue. The more salt there is added to the ice up to a certain point the more rapidly will freez- ing occur. Therefore, to a given quantity of ice, pounded fine, one-fourth to one-third as much salt should be added. They should be well mixed and applied in such manner that heat may be abstracted only from the part to be operated upon. This mixture, probably the earliest of all local analgesics, must still be accorded a place of usefulness, although it has been largely superseded by the highly volatile liquids whose effects are so easily secured and controlled. It may be used upon an accessible surface, but within the mouth it is certainly inferior to a spray. The liquids used for local analgesic purposes must be very volatile at or below the temperature of the body, so as to evaporate rapidly when sprayed upon the tissues. The following have been employed: ^ther (Ethylic).— Boils at about 95° F. It is very inflammable, the vapor forming an explosive mixture with the air. Rhigolene (not official), a distillate of petroleum, boiling at 65° F, It may be explosive under certain conditions. .ffithylis Chloridum. — Ethyl Chloride. — Boils at 55° F. As a liquid it burns with a smoky flame; and its vapor is very inflammable. 166 ANESTHETICS— LOCAL ANALGESICS The comparison of boiling-points and inflammability of the above agents indicates the superiority of ethyl chloride, Avhich is practically the only one used at present. Chemically, ethyl chloride [C2H5CI] is an ester resulting from the action of hydrochloric acid gas upon absolute alcohol. It is a colorless liquid, inflammable and extremely volatile, with a specific gravity of 0,918 at 46.4° F, The specific gravity of its vapor is 2.22, It is put up for use in sealed tubes containing | or 1 fluidounce. By means of a capillary opening through the glass stopper a very minute jet is emitted, which is directed upon the part to be frozen. Thus there is no waste, and the fine stream may be forced a distance of a foot or more, especially if the pressure within the tube be increased by enclosing it in the warm hand. The action of the drug is, therefore, easily controlled and may be secured at any point within the mouth without endangering the tissues. Fig. 4.— Chloride of ethyl spray tube. Some pain attends the freezing of tissue by whatever means induced, but this disadvantage is outweighed by the assurance the patient acquires that the pain of the operation will be much lessened. Indeed, for the extraction of a tooth, the mental effect of the harmless chloride of ethyl application may be taken advantage of to nerve a hesitating or nervous person up to a point of ready cooperation. With this agent several teeth may be extracted at one sitting with prac- tically no danger; however, by inhalation the drug has been found to be a quick and powerful general anesthetic, whose safety seems to be less than that of ether; so that, in its local use in the mouth, care should be exercised to avoid the occurrence of general anesthesia. One-half to one fluidrachm (2-4 mils) quickly inhaled may easily cause uncon- sciousness. The full effect of the local application is shown by blanching of the tissues at the point of evaporation. The action being chiefly upon the gums, the real advantage to be sought is painless application of the forceps. We cannot expect the actual pain of extraction to be entirely removed. On the whole, the use of this substance is to be highly recommended. TECHNIQUE OF LOCAL ANESTHESIA 167 Its convenience, readiness, safety and comparative efficacy give it a sum of advantages not possessed by any other local analgesic for slight opera- tions. As a general anesthetic it is considered in Chapter XIV. PARALYZANT ANALGESICS. The paralyzant class of local analgesics includes the following drugs, which are here compared as to solubility, their other properties and uses being discussed in regular order. The first three are oflficial. Cocaine Hydrochloride, soluble in 0.4 part of water, 2.3 parts of alcohol. Beta-eucaine Hydrochloride* soluble in 30 parts of water and in 35 parts of alcohol. Quinine and Urea Hydrochloride, soluble in 1 part of water and in 2| parts of alcohol. Tropacocaine Hydrochloride, readily soluble in water. Nirvanin, easily soluble in water. Stovaine, soluble in 2 parts of water and readily in alcohol. Alypin, very soluble in water and in alcohol. Novocaine, soluble in 1 part of water, freely in alcohol. Apothesine, readily soluble in water and in alcohol. Orthoform, slightly soluble in water, freely in alcohol. These all obtund or paralyze the sensory nerve terminals wherever they are applied, afi^ecting chiefly sensibility to pain. They produce very little effect upon the unbroken skin. Upon mucous membrane, whose texture is less firm, their effect is decided, but their full action is only obtained when they are applied to a denuded surface or injected hypodermically; except, that in the application to the very sensitive mucous membranes of the eye a complete effect is quickly obtained, although no abrasion be present. Three dangers are recognized as pertaining to the use of these drugs: 1. Damage to the tissues treated, leading at times to sloughing. 2. General poisoning. 3. Formation of habit. TECHNIQUE OF LOCAL ANESTHESIA. To attain success in the practice of local anesthesia it is essential that the operator should possess suitable instruments and exercise infinite care in the preparation and use of the solution selected. The syringe should be strongly constructed and should permit of * Alpha-eucaine, being more irritating, is now seldom used. 168 ANESTHETICS— LOCAL ANALGESICS sterilization by boiling. Such syringes may be of the all-metal type or the barrel may be of glass. The needles should be selected with due regard to the accessibility of the part to be operated upon. The solution should be freshly prepared for each case. It is conven- ient to use tablets containing definite amoiuits both of the drug and of s^'nthetic suprarenin. These should })e dissolved in either normal Fig. 5. — Hypodermic syringe. saline* or Ilinger's solution. f A 1 or 2 per cent, solution of the drug is suitable for all dental operations. There are on the market small graduated porcelain dishes with standard and handle, in which the solution may be prepared and, where permissible, boiled over a Bimsen burner or alcohol lamp. Fig. 6. — Boiling cup. The injections about the teeth may be made in any of the following ways according to the requirements of the case: vSnbperiosteal, intra- osseous, peridental or submucous. The area to be injected should first be painted with tincture of iodine diluted with an equal cjuantity of grain alcohol. Thorough asepsis should be practised throughout the operation. * Normal saline solution is known officially as Physiological Solutioti of Sodium Chloride and consists of 0.85 per cent, of sodium chloride in distilled water. t Ringer's solution imitates closely the salinity of the blood plasma, containing, in distilled water, sodium chloride, 0.7 per cent.; potassium chloride, 0.03 per cent.; calcium chloride?, 0.025 per cent. COCA. The leaves-of Erythroxylon Coca and its varieties. The alkaloid Cocaine fully rep- resents the druff. Classified as : Cerebral stimulant. Mydriatic. Local analgesic. General protoplasmic poison. Physiologic action The drug pro- duces fii'st a de- scending stimula- tion of the central nervous system, followed by a descending depression if a large dose has been taken. The succession may be irreg- ular, so that a case of cocaine PLATE II. Scnsoi'U nerve endings depressed when locallyj uppUcd. Vagus Center Vaso Motor Center Cervical Sym23athetic poisoning may show mixed Voluntay^y symptoms of stimulation and depression. The two diagrams presented (Plates II. and III.^ stimulant and depressant effects respectively. Stomach. The local effect is to benumb the sensory nerve endings in the stomach. Nervous System. Brain. Simuilates the cerebral cortex. Medulla. Stimulates respiratory and vasomotor centres. Spinal cord. Stimulates reflex centres. Sensory nerve endings are always depressed when the drug is applied locally. Muscular System. Increases irritability and working power of voluntary muscles. Eye. Dilates pupil by stimulating dilator nerves. Circulation. Arterial pressure is increased. Heart. Action accelerated by direct stimulation either of heart muscle or of the accelerator nerves. Capillary area. Contracts arterioles by stimulation of vasomotor centre in the medulla and by direct action upon the vessel walls. Respiration. Rate increased by stimulation of respiratory centre. Elimination. Cocaine has been detected in the urine, but its in- fluence upon the kidneys is variable and uncertain, therefore probably indirect. Solar Plexus The red color indicates the stimulant effects of Cocaine. PLATE III. Arterioles relaxed Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus COCAIXE. The poisonous effects of Coca, or the secondaiy effects of a large dose, are depressant, following quite definitely the lines of pre- vious stimulation. Nervous System. Brain. Cerebi-al functions are depressed, frequently with production of narcosis or convulsions. Medulla. Depresses respira- tory center and probably vaso-motor center. Spinal cord. Depresses re- flex centers. Circulation. Arterial pressure is lessened. Heart. Depressed by dii-ect action of the drug. Capillary area. Ai-terioles relaxed, probably through paralysis of vasomotor cen- ter. Respiration. Depresses the respi- ratory functions by lessening the irritability of the center in the medulla. In general, the depressant ac- tion is that of a general proto- plasmic poison, the commonest evidence of which is its paral- yzant influence upon nerve tissue when locally applied. For local analgesic purposes the alkaloid Cocaine is employed in from i to 4 per cent, solutions. The blue color indicates the depressant eflfects of a toxic dose of Cocaine. CONDUCTIVE OR REGIONAL ANESTHESIA 169 CONDUCTIVE OR REGIONAL ANESTHESIA. In addition to the simple local use of this group of drugs, their appli- cation has been extended to anesthetize a whole extremity or region supplied by a certain nerve. This is accomplished by injection of the drug into and about the nerva at some point in its course. If thor- oughly done, painful sensation will be abolished in all the region of dis- tribution of the nerve. While this method may be employed to secure anesthesia for a surgical operation, the same is also advocated to prevent shock from operations upon the extremities.* This method of producing regional anesthesia is coming into wide use by the dental practitioner and possesses many points of merit. But before this method is taken up the dentist should become thoroughly familiar with the technique as well as possess an exact knowledge of the anatomy of the parts. It is also quite necessary that the operator possess the necessary paraphernalia for properly carrying out the exact- ing technique of this method. Injections should be made at the point where the trunk of the nerve supplying the part may be reached, as in the following locations: zygomatic, infra-orbital, anterior palatine, pos- terior palatine, pterygomandibular or mental, according to the areas which ar€ to be anesthetized. The student is referred to the more exhaustive treatises on this subject for the minute details of technique. Cocainse Hydrochloridum [C17II21O4XHCI], average dose gr. \ (0.015 gm.). — This agent stands as the typical local analgesic. It is a neutral salt of the alkaloid cocaine, from the leaves of ErytJiroxylon coca, grown chiefly in Peru and Bolivia. ^Yhile the alkaloid was discovered about 1860, and its peculiar analgesic power observed soon after, its introduction to the medical world as a practical local analgesic was due to Karl Roller, who in 1884 reported experiments to the Congress of German Oculists. In a few weeks cocaine was being used all over the world, t Administered internally, the coca leaves and their preparations, as well as the alkaloid, are stimulating to the nervous system in small doses and depressing and poisonous in large doses. (See Plates II and III.j Locally applied to sensory nerves, cocaine is always depressing. Applied to the tongue it removes the sense of taste for bitter substances, diminishes it for sweet and acid substances, while for salt it is not appreciably lessened. When taken into the stomach it diminishes the * See footnote on page 170. t Park's History of Medicine. 170 ANESTHETICS— LOCAL ANALGESICS sensibility of the organ, thereby lessening the sense of hunger, and probably impairs the activity of digestion. The sense of touch may be lessened by it, but the most marked result of its application, and the most desirable, is the removal of the sense of pain. The temperature sense for heat and cold is not diminished. Applied locally into the eye it causes dilatation of the pupil in addition to the analgesic effect. It usually is applied as directly as possible to the terminal endings of the sensory nerve, but will produce the same effect if applied to the nerve trunk anywhere in its course.* It should be noted that cocaine has a deleterious effect upon all kinds of tissue when applied in any but very small quantities; therefore it is classed as a general protoplasmic poison. The reason for the prominence of its effect upon nerve tissue is, that we are here dealing with the tissue that is a medium of sensation and expres- sion, and its impairment is, therefore, more easily appreciated. Being one of the drugs that combines a stimulant (early) effect with a depres- sant (later) effect, the greatest degree of caution must be exercised to avoid the habitual use of the drug by patients. It is one of the most seductive of the drugs that are taken habitually, and its effects are most disastrous. Particularly is it unwise to order this drug for the patient to use at home, whether as gargle, mouth wash or nasal spray. Observation has shown that the system acquires a tolerance of large doses of cocaine when it is taken habitually, as is the case with morphine, the quantity taken daily in some cases reaching as high as 30 grains. The drug is often taken as a substitute for morphine, or as an antagonist to it. The effects of cocaine taken habitually seem to be more rapidly disastrous than those of morphine. In the practical use of the drug the hydrochloride of cocaine is preferred to the simple alkaloid, because of its greater solubility. Alkaloids, as a rule, are only sparingly soluble in water, hence their salts are commonly employed. Cocaine illustrates this rule, being soluble only in 600 parts of water, while the hydrochloride is soluble in 0.4 part of water. It is also soluble in 2.3 parts of alcohol. * We are indebted to Dr. G. W. Crile for some facts concerning the value of cocaine in blocking nerve trunks to the transmission of sensory impressions from an injured part of the body. By very careful experiments he has come to the conclusion that one prominent factor in surgical shock is the depression of the vasomotor system by exhaustion of the centers. This occurs through their excessive stimulation by sensory impressions coming from the site of injury or operation. In operations upon the extremities, he prevents shock by "nerve-blocking" with cocaine, i. e., by inject- ing the drug about the nerve trunk so as to abohsh its power of carrying sensory impressions. COSDUCTIVE OR REGIONAL AXESTHESIA 171 It is obtained in form of crystals or a crystalline powder, permanent in the air and bitter to the taste, leaving a sensation of nmnbness on the tongue. Solutions of cocaine hydrochloride do not keep well beyond a few days, neither can they be sterilized by boiling without impairing their value. The practitioner must either make up his solution when needed, renew it frequently, or else add some antiseptic to preserve it. If it is desired to keep the solution more than a few days a very little phenol (I to 1 per cent.) may be added to prevent the growth of organisms, and in this strength the coagulant action of the latter drug is scarcely noticed. Boric acid likewise is used as a preservative in the proportion of 2h per cent, in the aqueous solution of cocaine. Salicylic acid is also recom- mended m the strength of 0.1 per cent. 1 : 1000;. Chloretone is used by somie in the strength of i to ^ per cent. Local Action of Cocaine. — The chief interest of the dental surgeon m this drug centers about its use as applied locally to. or injected beneath, the mucous membrane. ^A hen applied to the membrane of the mouth the bitterness of the drug is marked. The pure crystal or a strong solution, .5 to 10 per cent., will cause some anemia of the surface, which is probably due to a constrictor action upon the arterioles, and at the same time sensitiveness of the tissues to pain will be abolished to the depth of penetration by the drug. For surface treatment, or upon so sensitive a mucous membrane as that of the eye, direct application of cocaine in 1 to 4 per cent, solution is sufficient: but for extraction of teeth such application is of no use. The drug must be injected into the tissues about the socket of the tooth. When this is done there occius immediately a blanching of the tissues at the site of injection, which is due partly to forcible distention by the fluid injected, and probably partly to vascular constriction, .^ome pain attends the use of the drug in this way, but it occurs only at the moment of injection, and is quickly succeeded by complete analgesia of the locality. The vasoconstriction is often foUowed by a relaxation that permits liA^peremia of the tissues, which may be more or less painful. This, however, must be regarded as a secondary and later effect, occurring rather after than during the operation. Dosage. — The strength of cocaine solutions employed varies from I to -4 per cent., according to the rapidity and degree of effect desired, the total quantity' used being limited by considerations of safety. The maximumi quantity allowed to gain entrance into the circulation at one time should not exceed one-quarter of a grain. This ought to be the 172 ANESTHETICS— LOCAL ANALGESICS limit in the ordinary nse of the drng by hypodermic injection. However, the free bleeding of the tissues following extraction will remove some of the drug, and may modify our estimate of the quantity that may be safely injected in a given case. A 1 per cent, solution will usually suffice, and of this twenty-five minims contain one-quarter of a grain. When application is made to the surface of the mucous membrane of the mouth, or when the drug is used by cataphoresis, stronger solutions may be required; and when the drug is so applied that absorption occurs only through the unbroken mucous membrane, a larger quantity may be used, but should never exceed one-half of a grain, which is the maximum dose for stomach administration. For direct application to the pulp of a tooth, a small quantity of a stronger solution or a little of the pure crystal may be employed. An excellent rule in the interest of exactness of dose and ease of calculation is given by Burchard.* It is "to make the solution upon the basis of 8 grains of the cocaine salt to 1 ounce of the. menstruum which will give 1 grain in each drachm and ^-^ of a grain in each minim." This solution would be a little less than 2 per cent, in strength. Ten minims would ec^ual | of a grain, which would be within the safe hypo- dermic dose for an adult. That this drug is one of the most dangerous of those in daily use is attested by the many cases of cocaine poisoning that are upon record. Among those well authenticated is the case of a girl, eleven years of age, whose death resulted in forty seconds from the hypodermic injection of 12 drops of a 4 per cent, solution, or about | grain. f In another case death is said to have been caused by the application of 20 drops of a 5 per cent, solution (1 grain) to the gum. J Among other cases of severe poisoning by cocaine, without a fatal result, the following are noted :§ T. H. Burchard reports a case in which 10 drops of a 4 per cent, solution hypodermically caused unconsciousness and apparent death in four minutes; Meyerhausen, a case in which 8 drops of a 2 per cent, solution upon the conjuncti^'a of a girl of twelve years produced ^•iolent symptoms; Stevens, one in which 4 minims of a 3^ per cent, solution caused, in a man, violent convulsions followed by mania; Frost, a case of a child of fourteen in which 1 drop of a 1 per cent, solution in the eye caused marked poisoning. Idiosyncrasy must probably account for * American Text-l)ook of Operative Dentistry, second edition, page 641. t Wood's Therapeutics, eleventh edition, page 201. X ll)id. § Ibid. CONDUCTIVE OR REGIONAL ANESTHESIA 173 the occurrence of such cases, but the fact that they are not rare should lead to great care and discrimination in the employment of cocaine. Schleich Infiltratian Method. This consists of infiltration of the tissues with a very weak solution of cocaine by a series of contiguous injections, which produce really a local edema. Three different strengths of cocaine, approximately 1 : 500; 1 : 1000 and 1 : 10,000, are employed as the case demands.* To the solution is added 0.2 per cent, of sodium chloride and small quantities of morphine hydrochloride and phenol. The 1 : 1000 is the strength commonly used. Undoubtedly the pressure of distention by the larger bulk of solution injected contributes to the analgesia, for it has been found that forcible distention of tissues by sterile water often sufEces for slight operations. This method has the advantage of permitting a large quantity of solution to be used, and a longer operation to be performed with much less danger of cocaine poisoning. A number of ready-made solutions for local analgesia are upon the market. They are primarily commercial articles, and it is safe to say that cocaine or some substitute forms the basis of their formulas. There is no reason why a qualified practitioner should select a commercial formula instead of making up his own solution, when using so powerful a drug. There is absolutely no guarantee of the composition and uniformity of the proprietary analgesic preparations, even though the names of ingredients are given; while if the practitioner orders by his own formula of official drugs, his pharmacist can guarantee acciu-acy. The advantages claimed for special formulas are: first, that they contain substances that aid the desired action and permit a lessening of the quantity of cocaine used; second, that they contain one or more physiologic antagonists to cocaine, which will counteract any possible toxic action; or, third, that they keep better than a simple solution of cocaine. All of these objects are desirable, but it is better for the dentist himself to intelligently and scientifically select his own aids and antag- * The precise formulae of the three solutions are as follows: I. II. III. parts. parts. parts. Cocaine hydrochloride, 0.2 0.1 0.01 Morphine hydrochloride, 0.025 0.025 0.005 Sodium chloride, 0.2 0.2 0.2 Phenol (5 per cent.), 0.30 0.30 0.30 Distilled water (sterilized), 100.00 100.00 100.00 174 ANESTHETICS— LOCAL AXALGESICS onists to the drug. This impHes a knowledge, on his part, of the physio- logic action of the various drugs proposed, and the ability to note the indications for the selection of one or another in a given case. And this is not too much to expect of the trained practitioner of today. As a type of combination that will be found generally applicable, the following is suggested: I^. — Cocaine hj-drochloridi Atropinae sulpha tis Stn'chninae sulphatis . Phenolis .... Gm. or mil. 16 008 03 12 (gr. iiss) (gr.l) (gr. ss) (1Uij) Aquse destillatse q. s. ad 15 (fSss)— M. The cocaine strength of this solution wall be 1 per cent., and each 15 minims will contain I grain, with yYo grain of atropine, and g-^ grain of strychnine. One or two drops of adrenalin solution (1 : 1000) may be added, if desired, to each quantity of injection. The carbolic acid present is for preservation. Even less will suffice to keep the solu- tion for some time. Prinz* suggests that the solution should be made isotonic with the blood, so as to preserve normal cell osmosis, which is doubtless an advan- tage in the matter of lessening the irritation caused by the solution. He states that to make a 1 per cent, solution of cocaine isotonic requires the addition of 0.8 per cent, of sodium chloride, making the following proportions : Cocaine hydrochloride, 5 grains Sodium chloride, 4 Sterile water, 1 fluidounce. To each syringeful (30 minims) he adds 2 drops of adrenalin choride solution when used. General Action of Cocaine. — Plates II and III are intended to illus- trate the action of the drug upon the different parts of the system. General Uses.— Cocaine has come to be relied upon for the relief of pain and irritation wherever it can be locally applied. Its local anal- gesic action renders it of great value in minor surgery, and, properly adapted, it is useful for operations of considerable extent. A t^-pical occasion for its use would be the removal of a foreign body from the eye. Here the instillation of a few drops of a 2 per cent, solution will quickly abolish painful sensation and lessen reflex sensibility to such a degree as to permit of easy removal of a foreign body even from the cornea. * Dental Cosmos, September, 1908, p. 931. COXDUCTIVE OR REGIOXAL AXESTHESIA 11 o ■ Itching in various parts of body may require its application, either in aqueous solution or in form of the oleate. Painful conditions in the lower part of the bowel, as in dysentery, call for its use in form of suppository. In coryza it is useful in form of solution sprayed or dropped into the nostrils, but such use prolonged, or that of a cocaine snujff, presents great danger of habit formation. Internally it may be of use in persistent vomiting when this is depend- ent upon irritation in the stomach. Its use as a substitute for morphine in habitual use of the latter should be advised against, as it proves no aid in overcoming the habit, while the result is likely to be the con- tinuance of both drugs or substitution of cocaine habit for morphine habit, which is no improvement. Earache, when not relieved by warm irrigation, calls for the appli- cation of cocaine; three drops of a 3 or 4 per cent, solution dropped into the ear wiU usually suffice. [A | grain tablet (0.015 gm.) dissolved in eight drops of water, one-half used and repeated if needed.] Incompatibility. — Cocaine hydrochloride is incompatible with alkalies and alkaline carbonates, with tannic acid, with potassium iodide, and with some metallic salts. It is decomposed by 2^0/0.5.5^^;/^ jpermanganate. With solution of silver nitrate a white precipitate of chloride of silver occurs. A white precipitate occurs with a solution of borax or with a strong solution of phenol. Aids to the Action of Cocaine. — Other agents of the same class, that are less poisonous and sufficiently soluble, may supplant cocaine or be combined with it. It is preferable, in the interest of accuracy, to use the drugs separately; so that mixtures of cocaine with its substitutes need not be considered. For prolonged effect, as in nerve blocking, quinine and urea hydrochloride is a useful addition, but it is injected separately. If there is an open wound or denuded siu-face, as in case of a burn, cjrthoform powder is useful. Agents that lessen the blood supply to the part, as cold applications, will aid slightly. The use of adrenalin or other suprarenal products as an aid to the action of cocaine has become established. The claim that less cocaine is needed when so combined is borne out in the experience of surgeons. Two factors in its action serve to explain its value: first, it contracts the arterioles locally, thus lessening the amount of blood in the injected area; and, second, it lessens the activity of absorption into the circu- lation beyond the locality. It is evident that, with the local circulation lessened by vasocon- striction, less cocaine is likely to pass into the circulation in a given time, 176 ANESTHETICS— LOCAL ANALGESICS which means that more remains just where its effect is wanted, and the danger of systemic poisoning is lessened. The combination is easily made by adding, to the solution of cocaine hydrochloride for each injection, several drops of the 1 : 1000 adrenalin chloride solution. Reports indicate that the cocaine strength of the solution can be considerably reduced. One series of 100 operations,* which included resection of the superior maxilla, removal of a goitre and complete removal of the larynx, were performed under the use of a solution consisting of 9 parts of a | per cent, solution of cocaine and 1 part of adrenalin (1 : 1000). If the part to be operated upon admits of a ligature being placed about it, the entrance of cocaine into the general circulation may thus be limited and its local effect prolonged. ■Morphine has no local analgesic action, t therefore it is without value as an aid to cocaine. Poisonous Effects. — Antagonists. — Poisoning by cocaine may be due to a weakened condition of certain organs whereby they are rendered more susceptible of depression, or to an overdose (see Plate III), or to idio- syncrasy. The symptoms are variable, hence cocaine poisoning presents no distinct picture. ^Yhile the drug has the power to first stimulate and later depress the central nervous system, depression in some part may occur suddenly with irregularity of symptoms. The toxic effects may include : (a) Depression of the brain, manifested by narcosis or spasm, (6) Depression of the medulla and spinal cord, as shown by failure of respiration and depression of vasomotor and reflex activity. (c) Direct depression of the heart, which, with lessened vasomotor control, causes a marked fall of arterial pressure. The most serious conditions, then, are depression of heart, ^'aso- motors and respiratory center. The combined result of these is to lessen the arterial pressure very decidedly, with a certain degree of asphyxia added. These are the conditions to be antagonized. Therefore, it appears at once that any agent that does not either stimulate the vasomotor system, the heart, or the respiratory center, is of no value. Nitrite of amyl and nitroglycerin dilate the arterioles by depressing the vasomotor system; they do not stimulate respiration and their direct action upon the heart is doubtful. Therefore, they should never be used to antagonize cocaine, chiefly because they will still further * See Gould's Year Book of Medicine and Surgery, 1905 (Medical vol.), p. 472. t See note on page 87. a s o a « s. •a >o --i s « a g 6 Ss Si § 5i o a a p ■= ^ CONDUCTIVE OR REGIONAL ANESTHESIA 177 reduce the arterial pressure.* Our best antagonists will be those that increase arterial pressure by stimulation of both vasomotor centers and heart, and which at the same time stimulate the respiratory center. Three agents that act in all three ways are caffeine, strychnine and atropine (see Plate IV). Caffeine has a dose of 1 to 5 grains (0.06-0.30 gm.) and is soluble in not less than 25 parts of water ;t therefore it would be an impracticable substance to include in a cocaine solution. The proper salt of caffeine for hypodermic use is the official caffeine sodio-benzoate, soluble in 1.1 parts of water, dose 3 to 5 grains (0.20- 0.30 gm.). The dose of strychnine sulphate is -^q- to y^ of ^ grain (0.001-0.006 gm.) and of atropine sulphate y^Q- to -^-^ of a grain (0.005- 0.001 gm.), and both are sufficiently soluble so that they may be com- bined in the same solution with cocaine. The dose for injection at one sitting should not exceed | grain of cocaine hydrochloride, y^o" of atropine sulphate, and -^q^ of strychnine sulphate; then in case of danger symp- toms from the cocaine the other drugs may be repeated in the same dose, but the atropine sulphate not more than once. It is well to have at hand separate hypodermic tablets of these drugs in the doses mentioned, not for routine administration in every case, but for use according to the operator's judgment. It would be unwise to depend upon these in order to exceed the safe dose of cocaine, but in persons known to be susceptible to its depressant action, or where such susceptibility is feared, it is proper to employ these antagonists in advance of the injection of cocaine. When poisoning occurs unexpectedly we may use the remedies mentioned above for the purpose of stimulating the whole central nervous system, in order to induce activity of cerebral functions, of respiration, and of circulation. Plate IV illustrates the action of these and of digitalis, which also is indicated if the circulatory failure is at all persistent. In this emergency fSi"! (1-4 mils) of tincture of digitalis may be given hypodermically. But it must be remembered that digi- * Nitroglycerin has been mentioned as an antagonist to cocaine, but it is contra- indicated when blood-pressure is low. If there is much depression of the circulation it may do harm by further reducing blood-pressure. It is doubtful whether nitro- glycerin has any direct stimulant action upon the heart. (See Plate XIII.) t Caffeine in its simple form is soluble in 46 parts of water and 66 parts of alcohol at 25° C. (77° F.), but the addition of benzoate or saUcylate of sodium renders it very soluble in water. Thus Caffeine-sodium salicylate is soluble in 2 parts of water and caffeine-sodium benzoate in 1.1 parts. Either may be used hypodermically in dose of 3 to 5 grains (0.20-0.30 Gm.). Citrated caffeine forms a clear, syrupy liquid with about 4 parts of hot water. Upon dilution with water, this yields a white precipitate (caffeine), which redissolves when about 25 parts of water have been added. 12 178 ANESTHETICS— LOCAL ANALGESICS talis is a slowly acting drug and cannot be relied upon alone for sudden emergencies. Adrenalin is among the most useful of agents for stimulating a depressed circulation. It acts both by direct stimulation of the heart and by constriction of arterioles, causing a decided rise of arterial blood- pressure. The disadvantage of uncertainty of action, unless employed intravenously, lessens its practical value in emergency cases. It gives no result when administered by the stomach and very little when injected h^-podermically in ordinary quantities; but its use by the latter method may be resorted to in emergency, 1 to 5 mils of the 1 : 1000 solution, diluted with ten times as much normal saline solution, being employed. Another of our most efficient circulatory stimulants is cam- phor, dissolved in oil, given hypodermically. The dose is gr. 1 to 5 (0.06-0.30 gm.). Immediate stimulation of both respiration and circulation should be secured also by administering, and applying to the air passages, some of the irritant agents that stimulate reflex activity by irritating sensory nerve endings. The chief preparations that act in this way are water of ammonia and spirit of camphor by inhalation; and for administration by the stomach, aromatic spirit of ammonia or alcohol, each in dose of 15 to 60 minims diluted with as much water. If necessary, repeat the dose of any in ten or fifteen minutes. The fact holds that these agents are useful mainly by reason of their irritant action. They should, therefore, be given without much dilution, so that their effect upon sensory nerve-endings in the mouth, throat, esophagus and stomach may be decided, and the consequent reflex stimulation of heart and respiratory center be efficient. Irritation of the skin by friction, slapping or faradism will act in the same way. If there be considerable depression of the respiration, as shown by slow or weak movements of the chest or by cyanosis, artificial respiration should be resorted to in order to secure proper oxygenation of the blood. (See Artificial Respiration.) In connection therewith massage of the heart by an assistant, by pressure between diaphragm and chest wall particularly with the movement of expiration, has come to be employed as an important aid in reestablishing the heart's efficiency. It is most effectual in cases where the irritability of the heart muscle is not much impaired. Substitutes for Cocaine. — The following list comprises the chief drugs that have been substituted for cocaine from time to time, some of which have been found wanting in essential qualities, some are still under CONDUCTIVE OR REGIONAL ANESTHESIA 179 trial, while others answer the purpose in varying degree. It is evident that any agent, in order to be entitled to consideration, must compare favorably with cocaine not only as to efficiency, but in addition must be less toxic, or its solutions must keep better, or it must possess some other decided advantage. Alypin. Beta-eucaine. Novocaine. Tropacocaine. Apothesin. Nirvanin. Stovaine. The two following are used for a slower and more prolonged effect: Orthoform. Quinine and Urea Hydrochloride. These drugs are mostly alkaloidal in nature and, therefore, used largely in form of a soluble salt. Their properties will be noted briefly and comparisons of their efficiency and adaptability given in tabular form. Alypin (not official). — This name is usually applied to ah-pin hydro- chloride, though the nitrate also is upon the market. As experiments have shown alypin to be fully as poisonous as cocaine (see pp. 182-183), it is destined to be discarded as a substitute. Its only place would seem to be in form of the nitrate when it is desirable to use a local analgesic in combination with silver nitrate, with which any soluble chloride would be incompatible. Alypin is freely soluble in water and in alcohol. Apothesin (not official) . — This is one of the newer synthetics for which important advantages are claimed, but the experiments of Sollmann seem to place it low in the scale of efficiency. (See pp. 182-183.) How- ever, many practitioners have found it valuable. Beta-eucaine Hydrochloride is a white, crystalline, odorless powder, soluble in 30 parts of water and in 35 parts of alcohol. It is about one- half as efficient as cocaine and about two-fifths as toxic. Its solutions keep well. It is more irritating than cocaine and it combines less effi- ciently with suprarenal preparations, as it does not constrict arterioles, but rather causes h^-peremia. It ranks as a fair substitute for cocaine in from 2 to 5 per cent, solutions, either for direct application to mucous membranes or for hj^Dodermic use. In 1 per cent, strength it may be substituted for cocaine in the solutions for infiltration anesthesia. Nirvanin (not official). — This occurs in crystalline or powder form, soluble in water and in alcohol, the aqueous solution being neutral and claimed to be germicidal in 1 per cent, strength. It is used in from 1 to 5 per cent, solutions, though it should be used with care, as it is reported to be seven-tenths as toxic as cocaine. 180 ANESTHETICS— LOCAL ANALGESICS Novocaine (U.S. P., Part II [C13H20O2X2.HCI]). — This drug has proved to be of such vakie as a local analgesic and substitute for cocaine as to merit a more extended description. It was discovered by Einhorn in 1905. It is a white powder, soluble in 1 part of water, the solution being neutral in reaction; soluble also in 30 parts of alcohol. A 10 per cent, aqueous solution is neidral to litmus. The aqueous solution, as usually employed, may be heated to the boiling-point without decom- position. It has the advantage of being non-irritating, since a solution of any strength, or even the powder, may be applied to the conjunctiva. It acts efficiently with suprarenal preparations, the effect being increased by the combination. Novocaine possesses the same action upon the peripheral sensory nerves as does cocaine, when directly applied to the nerve. The same is true of its use by injection and infiltration. However, by surface application, as to the cornea, its action is very much weaker than that of cocaine, but may be increased somewhat by the addition of sodium bocarbonate, according to Gros.* Since novocaine is only one-half as toxic as cocaine, it may be used more freely, although the systemic effects of large doses are essentially the same as those of cocaine; but when used in the ordinary dosage there are no systemic effects. Five thousand injections in the extraction clinic of the Dental School of the University of Buffalo, using a 2 per cent, solution in normal saline, with small adrenalin dosage, have shown no systemic reaction in a single case, the ages ranging from childhood to old age. Prinzf regards novocaine as the only one of these substances that meets the demands of substitution for cocaine. He cites evidence that its combination with adrenalin increases the efficiency of both drugs in their local action. He prefers a 2 per cent, solution and suggests the following : Novocaine, 10 grains Sodium chloride, 4 ' " Distilled water, 1 fluidounce. Boil. To each syringeful (30 minims) add 2 drops of adrenalin chloride solution when used. Incompatibility. — Novocain in solution is incompatible with solution of mercuric chloride and with solution of iodine, a precipitate occurring with each. Mixed with calomel in equal parts, the mixture blackens when moistened with diluted alcohol. [It is not precipitated by borax * Jour. Am. Med. Assn., January 26, 1918, p. 218. t Dental Cosmos, September, 1908, p. 932. CONDUCTIVE OR REGIONAL ANESTHESIA 181 nor by potassium iodide, as are cocaine hydrochloride, alypin and stovaine.] Stovaine (not official) .—Occui-s in small scales, soluble in 2 parts of water and readily in alcohol. It is two-thirds as toxic as cocaine, but much more irritating. In recent years it has been brou^^ht into promi- nence through its use in spinal anesthesia. Tropacocaine (not official) .^An alkaloid from the leaves of Java coca, prepared also synthetically. It occurs in colorless crystals, soluble in water. It ranks well in efficiency, is one-half as toxic as cocaine, but is more irritating. It has the disadvantage of not acting efficiently with suprarenal preparations, since it destroys the vasoconstrictor action of the latter. Orthoform (U.S.P., Part II [CgHgOaN]).— A white, tasteless powder, sparingly soluble in water, but soluble in about 5 parts of alcohol and in 50 parts of ether; also soluble in sodium hydroxide solution. This drug is non-toxic in usual dosage, and, on account of its slight solubility in water, it has practically no penetrating power, therefore is useful only for surface action. It is not a substitute for cocaine in the usual use of the latter by injection, but it holds an important place for prolonged surface action, as in painful ulcers and, in dentistry, applied to a painful tooth socket after extraction. After operations upon the mouth or throat its application in powder form will greatly lessen the pain of movement or friction. It has been used internally to relieve the pain of gastric ulcer, the internal dose being from 2 to 15 grains (0.12-1 Gm.). Used in tablet form to be slowly dissolved in the mouth, it will often give much relief in cases of sore-throat. The hydrochloride of orthoforvi* is said to be soluble in 10 parts of water, the solution being acid in reaction, and having the same action, dosage and uses as orthoform. Incompatibility. — Orthoform is generally used alone. It is incom- patible with silver nitrate, potassium permanganate and with zinc chloride. Quinine and Urea Hydrochloride occurs in colorless crystals or as a white granular powder, odorless and bitter to the taste. It is soluble in 0.9 part of water and in 2.4 parts of alcohol. The aqueous solution is acid in reaction. This agent is comparatively non-toxic, the internal dose being 15 grains (1 Gm.). It is about one-fourth as efficient as cocaine when injected into the tissues; however, it has the unique advantage of producing a more lasting effect — from several hours to several days. Accordingly, it is often used for continued effect, in con- * National Dispensatory, 3d ed., p. 1020. 182 ANESTHETICS— LOCAL ANALGESICS nection with a more powerful analgesic, in order that the pain after operation may be lessened and the use of opiates averted. A 1 per cent, solution is commonly employed. Comparisons of Cocaine and its Substitutes. — The essential requirements of a satisfactory substitute for cocaine are as follows: 1. It should be less toxic than cocaine. 2. It should be soluble in water. 3. It should not be irritating to the tissues. 4. It should be compatible with suprarenal preparations. 5. It should admit of sterilization by boiling. 1-2. — Four of the drugs described fulfil conditions one and ttvo, viz.: Stovaine. Xovocaine. Tropococaine. Beta-eucaine. 3. A comparison in regard to the third condition shows the following results when injected subcutaneously into the abdomen of the rabbit.* Cocaine. — Swelling and hyperemia soon after injection, with complete return of the area to normal. Stovaine. — Intense hyperemia, dilatation of bloodvessels followed by sloughing. Beta-eucaine. — Swelling about the site followed by sloughing. Tropococaine. — wSwelling followed by sloughing. Xovocaine. — Xo swelling, no hyperemia, part normal after injection and remained so. 4-5. — Xovocaine also fulfills conditions four and five and thus is the only one of the substitutes which fulfills all of the essential require- ments for a local anesthetic. Indeed it may be said that this drug is an ideal local anesthetic for use in dentistry. Toxicity. — The following comparative table of toxicity of cocaine and its substitutes is of interest. It is based upon the minimum quanti- ties causing death in frogs, mice and rabbits, the drugs being named in the order of their toxic effects. f Frogs. Mice. Rabbits. Alypin. Alypin. Alypin. Cocaine. Cocaine. Cocaine. Stovaine. Nirvanin. Stovaine. Nirvanin. Stovaine. Tropococaine. Beta-eucaine Lactate. Novocaine. Novocaine. Tropococaine. Tropococaine. Beta-eucaine Lactate. Novocaine. Beta-eucaine Lactate. * Le Brocq, British Med. Jour., March 27, 1909, p. 783. t Ibid. COXDUCTIVE OR REGIOXAL AXESTHESIA 1S3 Taking the action on mammals into consideration, i. e., paralysis of nerve centers (including respiratory; the following results have been shown : Toxicity of cocaine is 1 00 ah-pin is 1 . 25 nirvanin is 714 stovaine is 625 tropococaine is 500 novocaine is 490 beta-eucaine is 414 Efficiexcy. — Solhnami* has investigated local analgesics in reference to their efficiency both by surface application and by injection into the tissues. The practical results of his observations may be thus tabu- lated, sho-^-ing the ratio of efficiency with cocaine as the unit : Analgesic Effect upon Sensory Serves Compared. By surface application (to cornea) . By intracutaneous use finfiltration and Ratio. injection) . Ratio. Cocaine hydro cKLoride ... 1 Cocaine hydrochloride 1 Beta-eucaine hydrochloride . | Xovocaine hydrochloride ' j Tropococaine ] Tropococaine hydrochloride . . | Al\"pin } i Al}.-pin hydrochloride ' Quinine and urea hycbochloride Beta-eucaine hydrochloride . . | Apothesin hydrochloride . . f Quinine and urea hydrochloride . | Xovocaine hydrochloride . . it Apothesin i A fact worthy of note in the above comparison is the very low effi- ciency of novocaine when applied upon the siu^ace to the cornea), as compared with its high efficiency when injected. It was found, how- ever, that the addition of sodium bicarbonate increased the efficiency of novocaine, as also of the other agents, for siu-face effect. To state the matter definitely: If the anesthetic is made up "in double concen- tration, and diluted, just before use, with an equal volume of .5 per cent, sodium bicarbonate solution, this increases the efficiency (for the cornea) as follows: Cocaine, from one to two times; beta-eucaine. two times; novocaine, from two to foiu* times; tropococaine or ah"pLn, four times." It must he emphasized that this result does not obtain with injec- tion or infiltration uses of the drugs, but only with surface application. Another point arrived at by SoUmannf is that the suprarenal prepara- tions, combined with the local anesthetic, while very valuable to pro- long the period of anesthesia when the mixtiue is injected into the tis- * Jour. Am. Med. Assn., .January- 28, 1918, p. 216. t Ibid. 184 ANESTHETICS— LOCAL ANALGESICS sues, is useless for surface application — in fact, " it rather diminishes the penetration and therefore the efficiency of the anesthetics on mucous membranes (cornea) . ' ' Spinal Cocainization. — Among the methods of inducing analgesia, that of injecting a solution of cocaine (0.2 to 0.5 per cent, strength) into the spinal canal has been employed, having been first advocated by Dr. Corning, of New York. By this means all parts of the body below the point of injection may have sensation to pain abolished, so that it is possible to do even an extensive surgical operation by aid of this method. There are dangers attending this procedure, and its limitations have become recognized. When employed, the injection should be made as low down as possible, so as to avoid the efi"ect of the drug upon the medulla. The method for the present should be used only in those cases where a general anesthetic is contra-indicated, and where the site of injection may be at a point some distance from the medulla. PAET III. GENERAL REMEDIES. CHAPTER XIV. ANESTHETICS. A TOPIC of so great importance as that of general anesthesia merits brief historical references as to agents employed and their discoverers.* Ethylic ether, formerly called "sulphuric ether," and, still earlier, "sweet oil of vitriol," was known as early as the thuteenth century, but the name of its discoverer is unknown. While it was used for some medicinal purposes in the eighteenth century and probably earlier, and although its intoxicating and narcotic properties had been discovered, it was not employed for practical anesthesia until 1842. During several years it was put to successful practical tests by Crawford Long, of Georgia, by Horace Wells, of Vermont, and by W'illiam T. G. Morton, of Boston, the last-named having demonstrated its use in a public way in Dr. Warren's clinic at the Massachusetts General Hospital, October 16, 1846. With the discovery of chloroform four names must be associated: Guthrie, of Sackett's Harbor, N. Y., who is credited with its first dis- covery (1831); Liebig, of Germany, and Soubeiran, of France, who were close contemporaries with Guthrie in its recognition, and Dumas, who made known its composition in 1835 and gave it its present name. In 1847 it was introduced as an anesthetic by Simpson, of Great Britain, a physician of great prominence, who at once began to use it extensively in his practice. Nitrous oxide also was known for many years before it came to be practically applied as an anesthetic. It was first obtained by Priestly in 1772. In 1799 Humphry Davy, of England, observed the exhilarating and intoxicating effects caused by inhaling this gas, and published his * For a fuller discussion of the history of anesthesia, see Park's Epitome of the History of Medicine. 186 AXESTHETICS investigations in ISOO. The credit for its first use as a surgical anesthetic belongs to Horace Wells, who employed it in 1844 for the extraction of a tooth. The condition of general anesthesia must include more than the abolition of consciousness to pain, the removal of unconscious muscular activity being only secondary in importance. In many cases a compara- ti\-ely small amount of an anesthetic will suffice to abolish consciousness of pain, but muscular rigidity or activity will prevent the performance of a surgical operation. The term partial anesthesia is sometimes applied to a grade of effect where the cerebrum is paralyzed, with loss of conscious sensation, but where the reflex centers of the spinal cord are still sensitive, as shown by muscular activity whenever sensory nerves are irritated. In studying these agents we also recognize the possibility of securing a purely analgesic effect from smaller quantities than are required for anesthesia. This is particularly true of nitrous oxide, as will be shown later. As a class the t>i)ical anesthetics are peculiar in respect to the order in which the\' paralyze the different parts of the nervous system. At first thought the production of complete paralysis of all parts of the body capable of responding to external stimuli, by the administration of a substance foreign to the body, would seem to be an extremely dangerous procedure; and so it appeared until it was ascertained that the paralysis was induced in such order that the centers of consciousness were affected first and those whose activity is absolutely essential to life last. Any agent, therefore, to rank safely among this class of drugs must conform in action strictly to the lines of safety which have now become well established. Plate V. presents a division of the central nervous system into sections, which are nmnbered in the order in which they are paralyzed by anesthetics. It will be seen that the most highly developed, or differentiated, nerve tissue (brain) is first affected, while the simpler and more vital structures that are common to all forms of animal existence (those connected with the functions of respiration and circu- lation) a^e affected later, being apparently more resistant to the influence of the drugs of this class. It is remarkable that these century-old agents have never been sup- planted by newer anesthetics. The past few decades, that ha\e yielded so much in the way of synthetic drugs, have not given us new general anesthetics, but have been devoted to a closer study of the old, as to their precise action, their dangers, and better methods of administration. That this has been a fruitful study is evidenced, among other things, PLATE V. Danger area Anesthesia area Consciousness abolished 3, Mespiration paralyzed 4, Circulation paralyzed The several sections are numbered in the order in which they are paralyzed by anes- thetics. The paralysis of 1 and 2 constitutes surgical anesthesia, paralysis of 3 introduces an element of great danger, and that of 4 is usually fatal. [The heart is included in this diagram of the several parts of the central nervous sys- tem, for the reason that it contains nerve- ganglia, which, with their highly ii'ritable muscular structure, provides for its auto- matic, rhythmic action. This provision is quite independent of the cerebrospinal sys- tem.] 2. Keflex activity abolished MODE OF ACTION OF ANESTHETICS 187 by the adaptation of nitrous oxide to the field of general surgery, where it is now used so largely with satisfaction and safety. Another result is that the science of anesthetics has been so developed that now very few cases occur that cannot be safely anesthetized by an expert using the proper agent. It may be added also that the judicious use of other narcotics with the anesthetic, in order to render the narcosis more pro- found and to lessen shock, has become more and more a routine practice. This is particularly true of the hypodermic use of morphine (sometimes with scopolamine) preliminary to prolonged nitrous-oxide-oxygen anes- thesia. Mode of Action of Anesthetics. — ^\'arious theories have from time to time been proposed to explain the mode of action of anesthetics, by ascribing their effects to action upon the blood, to alteration of the circulation within the brain, and to asphyxia; but the present belief is that these substances produce their effects chiefly by a direct action upon the nerve centers. As to the precise action of the anesthetic upon nerve cells, it has been observed that the volatile liquid anesthetics are fat solvents; and the investigations of Meyer and Overton led them, independently, to the conclusion that anesthesia is caused by the solution of the lipoid constituents of the cells by the absorbed anesthetic vapor. The fact of the transient influence accords with a belief in some such simple physical change as solution, which would obtain only while the vapor was present in sufficient quantity. This theory could hardly explain the action of nitrous oxide, a gas whose nature and properties differ so greatly from those of the other anesthetics. If a common action is to be found it must rest upon other facts. Blood Changes Induced by Anesthetics. — A number of observers have studied the blood in reference to anesthesia and some positive conclusions have been set forth as to changes in the blood caused by anesthetics. Ui^on Hemoglobin. — It is now generally recognized that the hemo- globin of the blood is diminished in varying degrees by these agents (by ether markedly and rapidly, by nitrous oxide slightly and transiently) and that any case having less than 60 per cent, of hemoglobin would be hazardous under ether, and probably under chloroform, which increases hemolysis as well. Upon Blood Cells. — Casto,* in observations upon eight human sub- jects, found that: "The general tendency of the erythrocytes was to * Am. Year Book of Anesthesia and Analgesia, 1915. 188 ANESTHETICS decrease during anesthesia, an average loss of IG per cent, resulting from the cases studied." These results were confirmed in the main by experi- ments upon animals. Upon Alkalinity of the Blood. — Acid products are increased in the tissues and blood during anesthesia, chiefly because of diminished oxida- tion. In prolonged anesthesia this may reduce the alkalinity of the blood to a serious degree. When there is muscular activity during par- tial anesthesia the natural production of acid is increased, and if cyanosis is present, indicating a great diminution of oxygen intake, the acidosis may be a factor of great danger, not simply during anesthesia, but afterward. Hemorrhage increases this danger, because a diminished circulation brings less oxygen to burn up the accumulated acid products. Thus, acidosis (or high concentration of hydrogen ions*) probably is the important factor in auto-intoxication that often follows surgical anesthesia, and which must be distinguished from surgical shock. Upon Blood-pressure. — The tendency is for blood-pressure to diminish during anesthesia that is at all prolonged, but the effect varies according to the agent employed; with chloroform the fall usually begins by the end of fifteen minutes and rapidly reaches its minimum within a few minutes; with ether the fall does not usually begin under twenty minutes and is then very gradual, often continuing and reaching its minimum after the operation has been completed and the anesthetic removed; with nitrous-oxide-oxygen no change in blood-pressure attributable to the anesthetic is seen within two hours, and any fall occurring after longer administration has been found to disappear promptly upon removing the anesthetic, f Since nitrous oxide is reputed to raise blood- pressure, which may be true of the gas given undiluted because of the attendant asph^-xia, the fact is worthy of emphasis that the mixture with oxygen does not show clinically any rise of blood-pressure. Asphyxia. — The condition of asphyxia (which, in this relation, may be defined to be lack of a sufficient ox^'gen supply to the cells of the tis- sues), is, without question, a factor in anesthesia in cases where an agent is administered with a limited supply of air. It was formerly held by high authority that nitrous oxide anesthesia was due simply to asphyxia, but this has been disproved by the fact, now daily observed, that anes- thesia is induced by nitrous oxide when mixed with sufficient oxygen to prevent asphyxia. It is simply a question of dep^i^^ation of oxygen, without which the cells cannot function; and it is only with the use of * Casto, Am. Year Book of Anesthesia, 1915; Henderson, Ibid, p. 96. t McKesson, Am. Year Book of Anesthesia, 1915, pp 90-91. ACTION OF ANESTHETICS UPON NERVE CELLS 189 nitrous oxide alone and of ether by the old, closed inhaler method, that we encounter asphyxia in any important degree. However, asphyxia is of primary importance in its causative relation to auto-intoxication, under which topic it will be further discussed. Action of Anesthetics upon Nerve Cells. — While the precise action that determines the paralysis of function of nerve cells in the state of anes- thesia has not been demonstrated, much light is thrown upon the ques- tion by Lillie in his comprehensive article on "The Physico-chemical Theory of Anesthesia,"* which details the researches of himself and others. Lillie defines anesthesia, in reference to all responsive tissues, as "the ijhenomenon oj reversible decrease of activity of responsiveness." He argues from the proposition that the response of cells to stimulation probably begins at the surface of the cell, i. e., that surface changes, where the cell-wall (or "plasma membrane") must first meet the stimu- lating agent in the surrounding medium, are responsible for the activity that follows in the cell as whole. It is evident that anesthetics decrease temporarily the responsiveness of nerve cells, and it is reasonable to assume that the action begins at the sm*face where the anesthetic first reaches the cell. But whether the action consists of physical change of the fat-like (lipoid) constituents (Meyer and Overton), whether, by this or other change, oxidation is restrained, or whether the protein constitu- ents are affected either physically or chemically, remains to be proved. Lillie believes that the action begins at the surface. To quote from his earlier-expressed view, "anesthetic action is due primarily to a modifi-' cation of the plasma-membrane of the cells or irritable elements, of such a kind as to render these membranes more resistant toward agencies which under the usual conditions rapidly increase their permeability; cytolysis and stimulation, both of which depend on such increase of permeability, are hence checked or prevented .... this effect is produced by various salts, e. g., of magnesium, and by ether and other lipoid-solvent anesthetics in certain, not too high, concentrations. .... It seems clear that for irritable tissues the state of the lipoids in the plasma-membrane largely determines the readiness with which changes of permeability — and of the dependent electrical polarization — are induced by external agencies." The essence of this theory seems to be that the anesthetic in some way lessens the permeability or the electrical conductivity of the cell surface, so that response to the usual stimuli is prevented. * Am. Year Book of Anesthesia, 1915, pp. 1-30. 190 ANESTHETICS We may state, therefore, that present theories are \ariously char- acterized by (a) behef in physical change of the Hpoids, (h) in decreased oxidation, and (c) in alteration of electric polarization upon the cell surface; also, that these theories deal more with the mechanism of induc- tion than with the essential state of the narcotized cell. Whatever theory is fa^'o^ed, it is evident that the phenomenon of anesthesia involves selective action, i. e., certain nerve centers are affected before others. The usual order is for the cerebral areas to be affected first, the spinal cord second, while the medullary centers are affected last. In fact, any agent whose action does not exhibit this selective order cannot rank as a safe anesthetic, for the respiratory centers in the medulla must remain active during anesthesia of brain and spinal cord. A recognition of this order also furnishes an index as to danger or safety in the course of its inhalation. Plate V. will aid us in appreciating the stages tlirough which the action of anesthetics may extend, the numbers 1 and 2 pertaining to essential and safe anesthesia, and 3 and 4 to the dangers of profound anesthesia. Stages of Anesthesia. — Descriptions of the stages of anesthesia are sometimes so elaborate as to be confusing. The simple division of Cushny into three stages seems sufficient for ether and chloroform at least. A. Imperfect Conscionsness* — At the beginning the inhalation may be accompanied by a sense of suffocation, which is greater with ether than with chloroform and is seldom present with nitrous oxide. The cerebrum is very quickly affected, with the production of ^•arious manifestations of disturbed or uncontrolled nerve function, such as incoherent talking, laughing or crying, indefinite muscular movements and holding of the breath. The pulse is not much influenced as a rule. Respiration is quite normal except for the influence of the early choking sensation when the anesthetic vapor is too concentrated. The pupils are responsive to light and are apt to be dilated. The specJal senses may be disturbed. Coughing is occasionally present. B. Excitement. — With consciousness completely abolished, the control of the lower part of the cerebrospinal system by the cerebrum is removed, and we see accordingly various manifestations of uncontrolled reflex activity. The centers here concerned are mostly situated in the spinal * This stage is described by some authorities as the stimulant stage, but the stimu- lant effects noted are mainly reflex, while the real concUtion is one of depressed consciousness. There is frequently noticed quite early a very brief period of com- plete relaxation, during wliich a slight operation might be performed. IMPORTANT THINGS TO WATCH 191 cord, which is the second division of the nervous system to be influenced by anesthetics. (See Plate V.) Being not yet depressed to any marked degree, the impulses that it originates without cerebral control may produce the most violent muscular action, which is likely to be most marked shortly before complete relaxation occurs. This stage of excitement is more decided with ether than with chloro- form, whose general depressant effect is early evident, or with nitrous oxide, whose action in every stage is transient. The pulse is not much altered. Respiration may be interrupted by rigidity of the respiratory muscles. The pupils are apt to be dilated during excitement. They are responsive to light as long as reflex irritability persists. Increased secretion of tears, and of mucus in the upper respiratory and oral regions, occur. Vomiting occurs as a very unpleasant com- plication if the stomach contains any food, especially when ether is employed. During this stage consciousness to pain is abolished, but, as a rule, surgical procedure is impracticable until complete relaxation occiu-s, with cessation of reflex excitement, which marks the beginning of complete anesthesia. Relaxation is generally accompanied by snoring inspirations due to vibration of the relaxed soft palate. C. Anesthesia. — AYith the occurrence of complete anesthesia the whole muscular system is relaxed, sleep is profound and reflex activity is absent; in fact, there is temporary total paralysis of nervous and muscular systems, except those parts concerned with respiration and circulation. The pulse is not much altered in rate, but blood-pressure may be lessened (vide ante). Respiration is full and regular, as during profound sleep. The pupils are usually contracted and do not respond to light. The cornea is insensible to touch. The general appearance does not differ much from that of a person in a deep sleep. However, with ether the face is apt to be more flushed than with chloroform. ^Yith nitrous oxide given alone some degree of cyanosis occurs. The Important Things to Watch during the administration of an anes- thetic may be grouped as below: First, as indicating the progress and degree of anesthesia: (a) The activity of the reflexes. (6) The degree of muscular resistance. (c) The condition of the pupil of the eye. As shown in Plate \, reflex activity persists after consciousness is lost, but disappears with surgical anesthesia. Therefore, as long as any response to irritation of a highly sensitive area occurs, and as long as 192 ANESTHETICS any muscular rigidity exists, we cannot say that the proper degree of anesthesia has been reached. The usual way of testing reflex irritability is by toching the cornea or conjunctiva of the eye with the finger, which should be clean. The reflexes of the eye being among the last to dis- appear, any response by a closing movement of the eyelids shows that irritability of reflex centers still persists, while absence of any response usually indicates that anesthesia is complete. Muscular resistance is usually tested by raising the patient's arm to full length perpendicularly and allowing it to fall. iVny slowness or inter- ruption in its fall shows muscular response and indicates that anesthesia is not complete, while a sudden drop of the arm, as if paralyzed, shows complete muscular relaxation and indicates that anesthesia to a surgical degree has been secured. Muscular resistance often persists after ordinary reflex response is lost. This is of special importance in dental operations, where it is fre- quently found that the jaws are rigidly closed wdien anesthesia seems complete. In such cases it is necessary to push the effect beyond the degree which might suffice for an operation upon an accessible surface, in order to secure relaxation of the jaws, unless a mouth-gag or a cork be used to keep the jaws apart during the wdiole period of inhalation. Again, owing to the necessity of suspending inhalation of the anes- thetic during the dental operation, as for extraction, it is advisable to push the administration to a profound degree, so that the effect may last during the brief operation. This is permissible with the safer anes- thetics, which do not endanger the heart's action. It may be stated, however, that an operation may be completed even after reflex activity is again evident, provided that muscular resistance does not prevent; for if consciousness be still abolished the patient cannot interpret the surgical irritation as pain, and will remember nothing of the opera- tion, even though some struggling may have occurred through reflex activity. Such a practice, however, is not permissible with chloroform, in fact is dangerous, as will be explained in discussion of that agent. The pupils remain responsive to light so long as anesthesia is not complete, w4th a tendency to dilatation during the early stages, due to the excitement that is more or less evident. With complete anesthesia the pupils contract and become fixed, i. e., they do not respond to light, and appear in all respects as they do during profound sleep. After complete anesthesia has been induced, dilatation of the pupil may mean either slight return of reflex activity, which will be accompanied by the eye reflex and may call for more anesthetic, or it may mean a paralysis. IMPORTANT THINGS TO WATCH 193 which indicates a most serious depression of the nervous system that may be speedily fatah The latter will be unaccompanied by any sign of reflex activity or of muscular resistance, but relaxation will be complete. Second, as indicating danger, note should be taken of: (a) The respiration. (b) The pulse (with chloroform especially) , (c) The pupil. It must be insisted upon that the respiration be watched closely throughout, for it has been shown that death by anesthetics is due, in the majority of cases, to failure of respiration centrally, by paralysis of the respiratory centers in the medulla. Early in the administration respiration may be interrupted by choking sensations, and after con- sciousness is lost there is often some stoppage due to reflex muscular action; with ether this may be so marked as to cause a considerable degree of cyanosis. These interruptions are temporary, and as long as the pupils are responsive they need not occasion any alarm, for any stoppage of respiration before anesthesia is complete is not dangerous, except, that mechanical closure of the glottis by falling back of the tongue might occasion a continued stoppage, resulting in fatal asphyxia. This cause will be removed by drawing the tongue forward by forceps or a silk ligature passed through it, or by either of two simple procedures that are usually successful — turning the head to one side so as to allow the tongue to fall to the side, and drawing forcibly forward both angles of the lower jaw. Whenever interruption of respiration has occurred reflexly or mechan- ically, the first succeeding inspiration is apt to be deep and forcible. With chloroform especially, care must be taken not to allow free access of the drug with this deep inspiration, for fear of suddenly poisoning the heart by too much or too concentrated vapor. During complete anesthesia respiration is slow and regular as in normal sleep. It is most important to watch the respiration at this time. Any irregularity or interruption is a danger sign, and must require sus- pension of the inhalation, free access of air, and respiratory stimulants. If cessation has occurred, artificial respiration must be resorted to at once. To begin with, these measures may be instituted without regard to the pulse, for, with respiration paralyzed, the pulse may still be feebly perceptible, or the heart may be beating so feebly as to cause no pulse in the peripheral vessels. In either case the rapid elimination of the drug 13 194 ANESTHETICS by exhalation, and the free supply of oxygen by inhalation, are most urgently required. TJie pulse tells us of the rapidity and rhythm of the heart's action and of the condition of arterial pressure. It may be felt at the wrist, but is very conveniently felt by the anesthetist at the temporal artery. Any excessive rapidity (say above 120 per minute) and, even more important, any irregularity or inarked weakness of the pulse beats, should enlist attention. Rapidity and irregularity are necessarily due to conditions in the heart or its regulating mechanism, while weakness of the pulse may be due in part to low blood-pressure from relaxation of the arterioles. Stimulation of the circulation during anesthesia requires those agents that will maintain arterial pressure, and forbids the use of vasodilators which lower arterial pressure. The recumbent posture with head low must be maintained when the pulse is weak or irregular. With ether, the pulse seldom shows any danger symptoms, but remains quite normal throughout, except that in prolonged anesthesia arterial pressure is lessened. With chloroform, the direct depressant action of the drug upon the heart and vasomotor system is added to the general depression of anesthesia, and there is accordingly a weaker pulse, lowered arterial pres- sure, and less ability to regain the normal in case danger symptoms occur. A sudden failure of the heart, even early, is sometimes observed with the administration of chloroform. This may be due either to cardiac disease which permits the organ to be easily overcome, or to too rapid or too concentrated inhalation of the vapor. The necessity impresses itself of watching the pulse carefully throughout the administration of chloroform. According to Levy there is less danger from overdose of chloroform than from intermittent administration. {See under Chloro- form.) The Pujnls. — The danger symptom that may be presented by the pupils occurs only during profound anesthesia, and consists of dilata- tion. This may represent stimulation of the dilator center due to asphyxia,* but it has also been taken to mean a paralysis of the con- tractor fibers. It is possible that in different cases both explanations may find application. Paralysis would, of course, be regarded as the more serious condition. During profound anesthesia the pupil should be observed veryjrequently, and any dilatation not accompanied by response of reflexes should require suspension of the anesthetic and immediate attention to the patient's condition. * Sollmann, Text-book of Pharmacology, 1901, p. 441. CONTRA-INDICATIONS TO ANESTHETICS 195 Recovery from Anesthesia varies in time from a very few minutes after nitrous oxide and chloride of ethyl, to several hours after ether. The patient may pass through a stage of excitement similar to that preceding anesthesia, but less pronounced as a rule. Vomiting almost invariably occurs when much ether or chloroform has been used. After these drugs there is also a tendency to sleep, and normal consciousness may not be restored for several hours. Contra-indications to Anesthetics. — In general, we may say that anemia, disease of brain, lungs, heart, bloodvessels or kidneys contra-indicate general anesthetics. But a general rule admits of many exceptions, and, therefore, with respect to this matter each case must be judged by itself. As to contra-indications to individual agents more definite statements can be made. For Nitrovs Oxide. — It is usually held that serious heart or lung affections, that will easily lead to embarrassment of respiration or circu- lation when the asphyxia accompanying the use of nitrous oxide is added, should prohibit the use of this gas; also that disease of the arterial walls to the point of weakening them, presents the danger of rupture under nitrous oxide. This statement is based upon the fact that asphyxia leads to contraction of arterioles, with increased blood-pressure in the smaller arteries. Apoplexy, from arterial rupture within the brain, would be the most serious result to be feared. These contra-indications may be largely removed by the combined administration of oxygen with the nitrous oxide. For Chloroform. — In addition to the general statement above, we should note that disease of the heart muscle (myocarditis, myocardial degeneration or fatty degeneration) prohibits the use of chloroform. As this drug is capable of causing fatty degeneration of various organs, the structure of all circulatory and eliminative organs should be normal in order to admit of its use. Valvular disease of the heart, if well compen- sated, is less a contra-indication than is degeneration of the heart muscle as indicated by weakness, irregularity or dilatation. It has been shown by experiments upon cats, that the administration of adrenalin under light chloroform anesthesia is usually fatal. In the human subject also cases of death have occurred under similar conditions.* Supra- renal preparations, therefore, are positively contra-indicated in chloro- form anesthesia. For Ether. — The general contra-indications given above apply typically to ether, with discrimination as to any special case. It is to be noted * Am. Year Book of Anesthesia, 1915, p. 118. 196 ANESTHETICS that ether has very little depressant action upon the heart; on the contrary, it diminishes the hemoglobin appreciably and would, accord- ingly, be contra-indicated in any case of anemia showing GO per cent, or less of hemoglobin. On account of the comparatively large amount of ether required, it is believed by some to be particularly damaging to the eliminative organs, especially the lungs and kidneys, but it is prob- able that the effects here are less permanent and less serious than those produced by chloroform.* While we should always give due place in our judgment to the general contra-indications previously stated, when any anesthetic is in question, yet, when we have mentioned the unpleasantness of ether inhalation, the excitement that it frequently causes, and the prolonged and uncomfort- able period of recovery, we have made our chief complaints against ether. It stands first as a safe general anesthetic for profound and pro- longed effect. Auto-intoxication and Asph3rxia. — One danger of anesthesia that has not been sufficiently recognized is that of auto-intoxication. Asphyxia is an important factor in causing this condition, as by the deficiency of oxygen the normal elaboration and final oxidation of tissue elements is interfered with; consequently elimination is deficient and acid waste products accumulate in the tissues. Also after chloroform and ethyl chloride (and other related chemical substances which yield a halogen acid, e. g., ethyl bromide and ethyl iodide), degeneration of liver cells easily occurs as well as other tissue changes. There is a growing belief that auto-intoxications and fatty degeneration of organs in connection with anesthesia are due mainly to acid products. Lack of oxidation may be responsible in part for the accumulation of these, or one of the halogen acids may be liberated from certain anesthetics. f Cases of death occurring several days after the use of ether or chloroform, the immediate effect of the drug having been recovered from, are often due to auto-intoxication rather than to the particular anesthetic employed. It is true that nitrous oxide anesthesia, as usually employed in den- tistry, is so brief that the asphyxia that necessarily attends it because of the closed inhaler used, may be disregarded as of light importance; but its prolonged use now so common in general surgery, should be accom- panied by inhalations of oxygen. While we may not insist upon the use of oxygen as routine practice in connection with anesthesia of moder- * See conclusions of Committee of the British Medical Association, Lancet, London, 1901, vol. i, p. 280. t Graham, Am. Year Book of Anesthesia, 1915, p. 150. AUTO-INTOXICATION AND ASPHYXIA 197 ate duration, it is certainly advisable in greatly prolonged anesthesia with any agent; and objection must be made to inhalers for ether, ethyl chloride, or chloroform that do not admit enough air for proper oxygenation of the blood. The practice of rebreathing the same gases during anesthesia also is to be discouraged, unless for short periods or under expert supervision. An expert will often employ rebreathing, but with sufficient pm-e oxygen to avoid asphyxia. Preparation of Patient for Anesthesia. — For ordinary nitrous oxide anesthesia it is only necessary to be assured of the non-existence of serious disease in vital organs and in the arterial walls, and to observe the general precautions to be given later. For prolonged use of the same agent, similar preparation should be made as for ether and chloro- form. Before employing ether, chloroform or ethyl chloride, preparation should be made in order to avoid unpleasant or dangerous complications both during and after the administration. Except in emergencies that seldom occur in dental practice, an anesthetist is not justified in adminis- tering one of these agents without first ascertaining that no disease exists in heart, lungs, brain, bloodvessels and kidneys, nor any anemia, suffi- cient to constitute a contra-indication. It is essential to examine the patient's urine in every case. The blood-pressure should be taken as a rule, and the blood examined in any case that presents the appearance of anemia or chlorosis. [Less than 60 per cent, of hemoglobin should contra-indicate the use of ether, chloroform or ethyl chloride, but nitrous oxide may be used with care.] To this routine is added the positive injunction to the patient to take nothing into the stomach for at least five hours before the operation is to occur. This will avoid vomiting during the administration. A free cathartic should be employed within the twenty-four hours preceding the operation, particularly if constipation is present. An imjjortant precaution, that should invariably be taken if the patient be a woman, is to have a third party present, which in case of dental operations may preferably be a friend of the patient. A case is recorded where the imaginations of an anesthetized woman were such as to form the basis of a charge of criminal assault against the operator;* therefore one should guard against such an unfortunate possibility in any case of anesthesia under his direction. Coming to the time of administration, any artificial denture or other * Reese. Medical Jurisprudence and Toxicology, second edition, p. 559. 198 ANESTHETICS appliance must be renl()^■e(l from the mouth. Wlien ether or chloroform is to be used it is well to protect the eyes from the irritating vapor by covering them with a towel. If the greatest care is not exercised as to quantity of liquid applied to the inhaler it may drop upon the face and irritate the skin. Some anesthetists protect the tissues about the mouth and nose by covering the skin and lips with a light application of sweet oil or vaseline. The patient must be informed of the pr()l)able unpleas- antness of the vapor, so as not to be surprised by the sense of sufl'ocation. The clothing about the neck, chest and waist should be sufficiently loose to allow of free respiratory movements, and the patient should finally l)e instrueteil to breathe deeply. In case of emergency requiring an o])eration at night, ether must not be used in the presence of a gas flame or ordinary fire. The vapor of ether Is explosive * It is also heavier than the air, and will fall to the floor and diffuse itself mainly in the lower part of the room. It may, therefore, reach an open fire at some distance in explosive strength, without being particularly evident in the upper part of the room. The only safe light to use about ether is the incandescent electric light, which is fully enclosed. Vov the same reason, it is necessary to observe some care in handling ether. It should be kept and handled in tin cans rather than in bottles, in order to avoid accidental breakage with dift'usion of the explosive vapor. Responsibility in the Use of Anesthetics. — With all precautions taken, it still remains a fact that occasional deaths attend the use of anesthetics. Therefore, the question of responsibility in their use becomes an impor- tant one. For slight operations, such as tooth extraction, that do not * In order to ascertain the degree of explosiveness of ether vapor, a series of ten experiments were made by Government Chemist Albert P. Sy, M.S., at the Sandy Hook ProA-ing Grounds, in March. 1904. The tests were made with mixtures of ether vapor and air in strong glass flasks, through which the electric spark was passed, explosion being e^^denced by blo^sing out of the cork. In four of the experi- ments, with mi.xtures containing from 0.9.3 per cent, to 1.65 per cent, by volume of ether vapor, no explosion occurred; while the other six experiments, \\-ith mixtures containing from 1.67 per cent, to 2.39 per cent, by volume of ether vapor, were each attended by explosion. The minimum percentage attended bj' explosion was 1.67 by volume, which is the equivalent of 0.355 pound of ether vaporized in 100 cubic feet of air. Report of War Department, Chief of Ordnance, 1904, vol. x, p. 163. These experiments would seem to incUcate that in a room of 1000 cubic feet space (10 X 10 X 10 feet) anything less than 3.5 pounds of ether could be vaporized with- out danger of explosion. This degree of concentration would never occur with the ordinary use of ether as an anesthetic. The chief danger wou'd probably be in the irregular diffusion of the vapor by reason of its weight, allowing concentration in some part of the room near a flame. NITROGEN II MONOXIDUM—NITROUS OXIDE 199 absolutely require it, it is well to place the responsibility of deciding for an anesthetic upon the patient. With the decision made and the proper agent selected, it remains with the operator to bring to its administra- tion the requisite knowledge and skill; and the dental practitioner must determine how far he will here assume the responsibility. It must be said that the dental curriculum of study does not provide sufficiently for training in physical diagnosis and general clinical work to fit the dental specialist for the office of anesthetist. It is doubtless proper for him to administer nitrous oxide, but to be prepared in all points that are involved in the use of ether and chloroform requires a broad medical training and considerable experience. The course that is most natural and that places the responsibility where it really belongs, is to refer the whole matter of general anesthesia in any case to the patient's own physician, both for decision as to the propriety of anesthesia and selec- tion of the agent, and also for its administration and the general care of the patient. These suggestions are based upon an appreciation of what might be the result of an accidental death, where it was made evident that the anesthetic was employed without every reasonable precaution having been taken. Recent years have seen the development of the professional anesthetist, to whom we owe much of the progress evident in our knowledge of anesthetics and in improved methods of employ- ment. It is customary now for a surgeon to have his own special anesthetist. In any case in which there is question as to the ad^^sa- bility of giving a general anesthetic, it is well to have the services of the expert in anesthesia who should, as a matter of course, have had a medical training. Nitrogenii Monoxidum. Nitrous Oxide. — A gas having the formula X2O, capable of being liquefied under pressiu^e. It is colorless, having a slight odor and a sweetish taste. It is soluble in water and in alcohol. It is not combustible, but will support combustion. This gas was formerly prepared by the practitioner for his own use, by heating ammonium nitrate in a retort to the point of decomposition. It was collected and stored for use in an ordinary gas tank over water. Care had to be exercised to avoid a degree of heat that would develop the higher, poisonous oxides of nitrogen. This method of home manu- facture is now well-nigh obsolete, as the gas can be obtained in liquid form in cylinders of convenient size, and with greater assurance of purity. Nitrous oxide is non-irritating when inhaled, and it has been abun- dantly proved to be the safest general anesthetic known. Its effects 200 ANESTHETICS upon vital structures are so slight and unimportant, and the duration of its main effect so brief, that in properly selected cases it should be abso- lutely safe. ^Yith the very few cases of reported death from inhalation of this gas, it may be questioned whether the results could be attributed entirely to it. It has been largely used to induce transient anesthesia for slight operations, its most extensive use having been for tooth extraction. At present it is also used in general surgery, and its use has been extended in two special ways, first, by its emplo.Miient to secure anesthesia quickly, to be followed by ether, thus shortening the period and removing the unpleasantnessof the early part of ether administration; and seco?id, by its combined inhalation with oxygen, whereby the element of asphyxia is removed, permitting the anesthesia to be continued indefinitely. By this latter method nitrous oxide has been adopted by many surgeons as the anesthetic of choice in general surgery; and even for major oper- ations it is largely used, always with oxygen, and supplemented by a small amount of ether in suitable cases. Nitrons Oxide Analgesia. — A comparatively new use to which nitrous oxide is adapted is that of inducing analgesia, without loss of conscious- ness, for any desired time during the preparation of cavities in sensitive teeth. A nitrous-oxide-oxygen mixture is used, such as experience shows will maintain a state of analgesia without any asphyxia or loss of con- sciousness. The nasal inhaler must be employed. As a matter of course, experience will be needed to employ this method expertly, but it con- tributes to the facility of handling a class of hypersensitive cases greatly to the patient's comfort. ComjjJete Anesthesia may usually be induced by pure nitrous oxide in from two to five minutes, and recovery occurs in an equally short time. With the full effect obtained quickly, it is not so easy to define stages of action, but we may note about the same order of paralysis as with ether. The disturbance of consciousness is quite characteristic, in that the emotions are prominently affected, laughing being so often induced as to lead to the popular designation of the substance as "laughing gas." Reflex activity is likewise often evident, the patient sometimes even needing restraint. "When the gas is given mixed with air, the excite- ment is apt to be greater and the anesthetic effect more slowly produced. The most striking feature of nitrous oxide anesthesia produced rapidly, is cyanosis due to the exclusion of oxygen — really asphyxia. It has been held by some that anesthesia by this agent is simply asphyxia; but, although asphyxia will induce unconsciousness, it is easily demonstrable that nitrous oxide has a specific anesthetic action, for, with a patient NITROGEN 1 1 MONOX I DUM— NITROUS OXIDE 201 fully under its influence, the addition of oxygen will remove the asphyxia without terminating the anesthesia, which will contmue as long as nitrous oxide is administered. Administration. — The routine way of employing nitrous oxide is by a closed inhaler, which may cover mouth and nose or nose only, Fig. 7. — Luke's nitrous oxide apparatus. (Brewer.) the latter for continued administration in operations about the mouth. The inlialer is of rubber, or of metal or celluloid with the edges applying to the face covered with a rubber air-cushion, so as to apply closely. Celluloid has the advantage of transparency. The part where the gas enters and the air of expiration escapes is usually of metal, while the tubes are of flexible material. For prolonged operations about 202 ANESTHETICS the mouth the pharyngeal method is often employed. Instead of the usual inhaler this method employs two small tubes which pass through the nostrils into the pharynx, thus leaving the face entirely uncovered. As to the apparatus, the old gas tank of the dental office, for nitrous oxide alone, has been supplanted by several makes of portable apparatus arranged for combined use of N2O and O, with means of easy regulation of the mixture. Some of these are sufficiently light and compact to be carried about when necessary. Such apparatus accommodates separate cylinders of N2O and of O, with rubber gas bag to receive the mixture, while the regulating mechanism permits the use of pure X2O or any desired mixture, or pure O if emergency requires. Advantages of Nitrons Oxide. — A summary of the points that give to N2O the place of preference is as follows: 1. Being non-irritating, its inhalation gives no discomfort. 2. Anesthesia is induced quickly and recovery follows quickly, with- out unpleasant after-effects. 3. It has very little effect either upon the blood elements (hemo- globin or blood cells) or upon blood-pressure. 4. It does not depress the heart to any appreciable degree. . 5. Its contra-indications and dangers are practically removed by the addition of oxygen. 6. Used with sufficient oxygen, its employment may be greatly pro- longed, with a minimum of auto-intoxication. 7. It permits the addition of ether vapor when a more profound effect is needed. 5. It is a practical general analgesic when the abolition of painful sensation is the only essential. Mthei. — Ether. — Ethylic Ether. — Composed of 96.5 per cent, of ethyl oxide [(C2H5)20] and 3.5 per cent, of alcohol; prepared by the action of sulphuric acid upon alcohol, hence sometimes called "sulphuric" ether. It is a light, colorless, volatile liquid, with a penetrating odor and dis- agreeable, burning taste,, having a specific gravity of 0.713 to 0.716 at 25° C. (77° F.). Its vapor is about 2^ times heavier than air, and may be explosive when mixed with air and brought into contact with a flame. It is soluble in about 12 times its volume of water, and is raiscible with alcohol, chloroform and oils. Average internal dose, TTl 15 (1 mil). Ether boils at about 35° C. (95° F.). One test of its strength is that, in a test-tube half-filled and containing fragments of broken glass, it should boil by the heat of the hand, when the tu})e is closely grasped and held for some time. The vapor being explosive, ether should be PLATE VI. Varjiis Center Vaso Motor Center Cervical Symjjathetic Solar Plexus ^THER. The blue color indicates depression caused by ether. Stimulant. Anodyne. Anesthetic. The action of these two substances is v< wliich th Ph; Ether, in the concentrated form which it is administered, is more in tating than chloroform, tiierefore tlie pi mary reflex stimulation and the lat' excitement are mucii more pronouncer It may cause danger by paralysis ( respiration, but the heart is depress* so slightly that recovery may usually 1 secured. Locally a])plied, the drug is an irritar Nervous System. Brain. Depresses cerebrum, abf)lis iiig all of its functions. Medulla. Of the whole central nt vous system the medulla is affecti last. In dangerous narcosis the i spiratory and vasomotor centers a ])aralyzed. Spinal cord. Abolishes all fur tions, the sensory side being par; yzed before the motor. Circulation. Not much altered from the normal u til anesthesia is profound, when ; terial pressure is diminished. Heart. Early may show reflex stim lation. Later not much affect^ unless administration is prolongs when some depression may occur. Capillary area. Home dilatation cutaneous arterioles usually occu with flushing of the face. Eye. Pearly the pupils are dilated. Duri' complete anesthesia they are cr tracted. With dangerous paraly; they dilate. Mesjiiratioit. May be irregular or i terruj)ted during partial ane.sthes During full anesthesia it is regul and normal, as during sleep, dangerous narcosis it foils, throu; paialysis of the respiratory center Temprrature is reduced during anesthes lletabolism. Influence is usually slig and transient. The drug is eliminat chiefly by the lungs. PLATE VII. CHLOROFORML^I. ssified as : Irritant. Anesthetic. Anodyne. Antispasmodic. imilar, the main differences being in the degree in fleet various organs. [ogic action : Chloroform is pleasanter to inhale, but much more depressant to nerve center's and heart. According to Cushny, it is 3 to 3H times _as de- pressant to the central ner\'ous sj-stem, and 25 to 30 times as depressant to the heart, as is ether. It usually causes death by paralysis of respi- ration, the heart continiiing to beat, though so greatly depressed as to prevent recovery in many cases. However, it is believed by many that the heart may in some cases be paralyzed first. This is probably true in cases of degen- eration of the heart. Locally applied, the drug is an in-itant, es- pecially when the vapor is confined, as in the production of a " thimble blister." Nervous System. Brain. Depresses the cerebrum, abolishing all of its functions. Medulla. Of the whole central nervous system the medulla is affected last. In dangerous narcosis the respiratoiy and pai-alyzed. Spinal cord. Abolishes all functions, the sensory side being paral- yzed before the motor. Circulation. Much more depressed by chloroform than by ether. Arterial press- ure decidedly diminished, probably by both cardiac and vasomotor depression. Heart. Depresses the heai-t muscle or its ganglia. By prolonged action may cause fatty degeneration. Capillary area. ^Arterioles relaxed by vasomotor depression. Eye. Early the pupiLs are dilated. During complete anesthesia they are contracted. With dangerous paralysis they dilate. Vagus Center Vaso Motor Center Cervical Sympathetic Respiration. During partial anesthesia it is dLstiirbed in a reflex way less than with ether. During full anesthesia it is regular and nor- mal as during sleep. In dangerous narcosis it fails through pai-alysis of the respiratory center. Temperature is reduced during anesthesia. Melaholism. Destruction of proteids is increased with less pei-fect oxida- tion. Fatty degeneration of heait, liver and kidneys may occur. The drug is eKminated chiefly by the lungs, but it has been found in the urine. The blue color indicates depression caused, by chloroform. ^THER 203 kept in tin cans so as to avoid danger of breakage with rapid diffusion of the vapor.* Plate VI represents the action of ether upon the central nervous system, the respiration and the circulation. (For preparations see Index of Drugs.) General Uses. — ^When applied to the skin the rapid evaporation of ether causes a decided cooling of the surface; applied to the mucous membrane it is irritating. The stimulant use of ether preparations depends largely upon this irritant quality. The spirit and compound spirit are employed in moderate doses as stimulants, the effect being reflex from local irritation of the mucous membrane. In large doses these preparations are anodyne after absorption. Ether is also a valuable solvent for resins, oils, iodoform and many other substances not readily soluble in water. As an Anesthetic. — Since its introduction, three-fourths of a century ago, ether has stood as our typical anesthetic, combining efEciency with a high degree of safety, and applicable in nearly all conditions requir- ing a general anesthetic. With a recognition of the greater dangers of chloroform, ether came to be accepted as the routine agent in general surgery. But in more recent years, the development of nitrous-oxide- oxygen anesthesia has given advantages that have led to its use instead of ether to a considerable ex?tent; but even this new^er method must rely upon ether as an addition in many cases, for profound anesthesia. So we may say that ether holds its place of primacy, while chloroform has fallen to a status of very restricted use. Administration. — It has long been held that the inspired air may be fully saturated with ether vapor and thus inhaled for a considerable period with safety; more than this, the older methods of etherization employed a nearly closed inhaler into which ether was poured by the one-quarter to one-half ounce at intervals. This demonstrated clinically that ether could be given with a limited supply of air supersaturated with ether vapor. This evidence of the safety of ether led to indifference as to method of its use, so that the giving of ether was oftentimes assigned to a junior hospital interne, or to an undergraduate with no training or experience in anesthesia. But that has all been changed with the recognition of experts in anesthesia, so that the surgeon now wants his special anesthetist or, at least, a person trained or experienced. The resultis that, with the knowledge of grave dangers incidental to pro- * Regarding the degree of explosiveness of ether vapor, see note, p. 128. 204 ANESTHETICS longed narcosis even with ether, great care is now taken as to the method of giving and amount given; for it is a cardinal point that the greater the amount introduced in a given time the more profound the narcosis, and the greater the interference with oxidation in the cell, and the occurrence of acid intoxication. Present-day methods of administering ether are safer, pleasanter and more economical. The old cone inhaler has been largely supplanted by ^^^ Fig. 8. — Sander's mask. inhalers of various makes, all of which secure a more perfect vapori- zation and more definite admixture with the inspired air. They allow free access of air, and the ether is added drop b}' drop instead of being poured in in bulk. Fig. 9. — Yankauer's folding mask The simplest form of open inhaler is the Esmarch (see Fig. 10), or some modification of it, so commonly used with chloroform. Similar to this, but adapted to the drop method for ether by being made to fit more closely to the face, inhalers such as are shown above are much used. The gauze covering is easily added for each administration. Other forms of apparatus present some refinements of method, but are less simple and pertain rather to the specialist in anesthesia. For the use of ether alone by the semi-open-drop method, the Ferguson double-chamber inhaler is typical. CHLOROFORM UM 205 The double chamber supphes a space in which the vapor is warmed to. some degree by the expired air, so that vaporization is faciUtated and the mixture is less cool for inspiration — a point to be considered in pro- longed anesthesia. This inhaler, covered with about 8 layers of gauze, allows an ether vapor percentage varying from 6 to 22 per cent., the average of which (12 to 15 per cent.) would represent the usual desired dilution. [15 to 30 per cent, is needed for induction, but the lower percentages suffice to maintain anesthesia.] The disadvantages of ether commonly experienced are two — first, the unpleasantness of the vapor, which will cause a sensation of irritation and suffocation if not skilfully given; and second, nausea and headache following the narcosis. The first can be met by inducing slight anesthesia with nitrous oxide or ethyl chloride, changing to ether when the sen- sations are benumbed; or a few di'ops of oil of orange preceding the ether will sufficiently mask its odor, if the latter is then given slowly at the start. However, there is usually no difficulty if the patient is instructed and reassured in advance and the ether given slowly and with plenty of air at first. ^Nlore difficulty is experienced with children before the age of cooperation, so that the preliminary use of ethyl chloride or nitrous oxide may be advisable; though much can be done with a sensible child through reassurance and the use of the pleasant oil of orange at first. The second disadvantage, nausea and headache following, cannot be met so easily. These symptoms belong to intoxication by narcotics generally, e. g., morphine and alcohol, and little can be done to mitigate them, except to limit the amount of drug used. Chloroformum. — Chlorofor:m [CHCI3]. — ^This stibstance is prepared by the action of clilorine with an alkali upon alcohol, and is composed of 99 to 99.4 per cent, by weight of absolute chloroform and 1 to 0.6 per cent, of alcohol. It is a heavy, colorless, volatile liquid, with an ethereal odor and sweet, burning taste, having a specific g^a^^ty of not less than 1.474 at 25° C. (77° F.). It is soluble in 210 volmnes of cold water and freely in alcohol, ether, benzin, benzol and the fixed and volatile oils. Chloroform should be kept in dark-colored bottles in a cool and dark place. It is not inflammable, but its heated A'apor will burn with a green flame. Average internal dose, lU 5 (0.30 mil.). Preparations : C : Aquae chloroformi (about 0.5 per cent.). f54 (15 mils.). Spiritus chloroformi (6 per cent.), TO, 30 (2 mils.). Linimentum chloroformi (30 per cent.), external use. 206 ANESTHETICS Plate VII represents the action of chloroform upon the central nervous system, the respiration and the circulation. Aside from its use as an anesthetic, chloroform has grneral uses as follows : As Anodyne. — Toothache may frequently be relieved by placing a loose pledget of cotton saturated with chloroform between the cheek and the alveolus of the affected tooth. In gastric or intestinal colic the drug may be given in a dose of 5- 15 ITl (0.30-1 mil.), dropped upon sugar or mixed with a fixed oil. In paroxysms of severe pain it may be inhaled cautiously; in labor, to lessen the severity of the pains during the expulsive period. Its use as an anodyne calls for discretion and the avoidance of every possibility of overdosage. It should always be given by a physician or under his direction, for it is not safe for a person to inhale this drug by his own administration. ^4^ Antispasmodic. — To relieve infantile convulsions, acute paroxysms of asthma, uremic and puerperal convulsions. In these conditions it should never be employed except with competent medical supervision. .4^ Irritant. — It may be used as a counterirritant in case of neuralgia or other localized pain. The effect will vary from mild irritation to the production of a blister, according to duration of the application. If the vapor be completely confined, as by placing the drug upon cotton and covering with a thimble, a small blister ("thimble blister") is quickly produced. As Solvent. — Chloroform is used as a solvent for oils, some resins, caoutchouc, gutta-percha, etc. As AN Anesthetic, in spite of its long history and earlier extensive use, chloroform today holds a secondary place, because of its dangers. It is much pleasanter to inhale than is ether and a smaller quantity is required, which advantages make it the agent of choice with young children, who seem to be less susceptible to its poisonous action. But the prevailing opinion today is that the use of chloroform with adults is hardly justifiable, except in selected cases. The danger from this agent depends upon its poisonous action upon the heart. Two facts furnish the basis of this danger: 1. It has long been held that chloroform is a direct heart poison, depressing its action greatly and being capable of causing fatty degener- ation of its structure. These effects are probably in direct proportion to the amoinit or concentration of the drug. 2. Recent studies have shown that under certain conditions, chloro- CHLOROFORMUM 207 form even in small amount affects the heart peculiarly,'^ rendering it irritable to accelerator impressions in a way that may cause irregularity, fibrillation and sudden death. This effect is not likely to occur during complete anesthesia, when exciting impulses are blocked. Here we have a new explanation of the cases of sudden death under chloroform, that occur when least expected and apparently unprovoked, i. e., before anesthesia is complete or during recovery from the anesthesia. Intermittent administration has also proved dangerous. Le^yf con- cludes that the "subject of light chloroform anesthesia requires very serious attention" and as a precaution "the first principles are to keep the patient /i/% anesthetized and to make the adminidration continuous.'' He argues against the idea of overdosage in these cases and advocates the use of higher percentages, temporarily, when necessary (3.5 to 4 per cent, of chloroform vapor). There should be no disturbance of the patient during induction of, or during recovery from, chloroform anes- thesia and the operation should not begin until anesthesia is complete. To make an incision with reflexes acti^-e is considered hazardous. Administration — The conclusion is clear that the use of chloroform should not be resorted to lightly and that, when employed, adminis- tration should be by an expert. Because of its depressant effect upon the heart, it should be given only with patient in the recumbent posture. This being usually impossible in dental operations furnishes additional reason for its non-employment. Chloroform should be given largely diluted with air, from an inhaler that cannot fit closely enough to exclude air. A convenient and simple one consists of a wire form four inches in diameter with a concavity to prevent contact with the nose. This is covered with a few layers of gauze, upon which the chloroform is dropped in small quantities (ten to twelve drops) frequently, or drop by drop more continuously (see Fig. 7). * It has been found that under chloroform anesthesia the heart exhibits an irrita- hility which may respond to certain exciting causes in a most pecuhar way, e. g., experiments upon cats vmder chloroform showed a remarkable development of irregu- larity of ventricles upon intravenous injection of adrenahn. The ventxicles beat rapidly and irregiilarly, exhibiting the condition kno-rni as ventricular fibrillation. This action is more intense if the chloroform is diminished so as to allow the corneal reflex to return, and the result then is usually fatal, the heart stopping suddenly after a period of irregularity. It is beUeved that accelerator impulses, from the central nervous system or reflexly through irritation of sensorj' nerves, maj" similarly influence the heart under chloroform. This would account for the cases of sudden death occurring early in the administration of chloroform. Le\w, "Cardiac Fibril- lation and Chloroform Syncope," Am. Year Book of Anesthesia, 1915. t Ibid., p. 130. 208 ANESTHETICS The inspired air should not usually contain more than 2 per cent, of the vapor of chloroform. This is in accordance with the conclusions of the Special British Chloroform Committee,* to the effect that 1 to 2 per cent, of chloroform in the air is sufficient for anesthesia, and that these proportions are safe; 0.5 per cent, is inefficient, while 5 per cent, is dangerous. Fig. 10. — -Esmarch's inhaler and chloroform bottle. The inhaler consists of a wire frame covered with a piece of flannel or gauze. ^thylis Chloridum, — Ethyl Chloride [C2H/I]. — This drug is pre- pared by the action of hydrochloric acid gas upon absolute alcohol. It is a very volatile, colorless liquid, having an agreeable odor and burning taste. It is very soluble in alcohol, but only slightly in water. Its most distinctive property is its low boiling-point (55° F.). Vaporizing rapidly at ordinary temperature, it is our most valuable and convenient refrig- erant analgesic. The vapor is very inflammable, therefore it should not be used near a flame. As a general anesthetic, ethyl chloride has been in use for a number of years, both as preliminary to ether, and used alone to induce transient anesthesia. It ranks with nitrous oxide as to rapid and transient action, but it is not destined to become popular because of its dangers. While its relative safety among anesthetics has not yet been definitely fixed by accumulated statistics, experience thus far places it below ether. In this respect it must, for the present, be classed with chloroform. * Supplement, British Medical Journal, 1903. MTHYLIS CHLORIDUM 209 An early series of 12,436 cases of anesthesia with ethyl chloride gives only one death that was proved to have been due to the drug. That case had a history of alcoholic abuse and the autopsy revealed degeneration of heart and arteries.* McCardief in 2000 cases saw neither asphyxia nor syncope in any case. His estimate later gives one death in 3000 cases. He has collected records of 21 deaths, and states that at least 30 deaths are known to have occurred under ethyl chloride, while several others have occurred from the proprietary mixture called somnoform. Of the 21 deaths recorded, only 3 were of children, and 8 occurred in dental cases. In these cases the "closed method" of inhalation is believed to have been commonly employed. This may have contributed an element of danger; for it cannot be too strongly emphasized that, with so powerful agents as chloroform, ethyl chloride and ether, the limitation of air, by use of a closed inhaler or a bag which requires rebreathing of the vapor- laden air, adds a danger of auto-intoxication which cannot be ignored. Experiences thus far lead the above author to regard ethyl chloride as a substitute for ether and chloroform rather than for nitrous oxide, though in children under eight it is usually to be preferred to nitrous oxide. It is to be used with caution in dental cases, and the recumbent posture is advised. Its depressant action is more evident upon the respiration than upon the circulation. When inhaled pure, without access of air, it causes death by paralyzing respiration. In 1000 cases by Waret he noted 6 cases of serious danger, all of which were due to interference with respiration and all recovered under the use of artificial respiration. The same writer, after much experience, adapts the rubber mouth-piece of the nitrous oxide inhaler to ethyl chloride (Fig. 8), as here described in his own words :§ "The mask is prepared for use by stretching two layers of small- * Lotheisen. Munch. Med. Woch., November 18, 1900, p. 601. t British Med. Jour., March 17, 1906. Here also are noted the foUo\\ang estimates of the danger ratio of ethyl chloride: Lotheisen first estimated the deaths as 1 : 2.500. A later (April, 1902) estimate by the same xsTiter, gives only 1 : 17,000. Seitz's estimate, at about the same time, is 1 : 16,000. In comparison, the following estimates are given for ether and nitrous oxide: Ether deaths, 1 : 16,000; nitrous oxide deaths, 1 : 1,000,000. I Journal of the American Medical Association, Xo. 8, 1902. § Medical News, August 3, 1901, p. 169. 14 210 ANESTHETICS meshed gauze over the end of the tube b, which is then held taut by being forced into the neck c of the funnel-shaped rubber mouth-piece a. The gauze can be renewed at will and the whole apparatus, because of its simplicity, easily rendered sterile, a feature devoutly to be wished for in the laughing-gas mask and other kindred devices. The tube h is the channel along which the stream of ethyl chloride is directed against the gauze c, intended, not merely to receive the ethyl chloride, but also by impact to break it into still finer particles. At this point the ethyl chloride, evaporating, expands and is held by the walls of the mouth- piece a and the sides of the tube h, which, therefore, act as a chamber to temporarily limit the vapors. "The entrance and exit of air are through one orifice, so as to mini- mize the loss of ethyl chloride and merely utilize the quantity momen- FlG. 11 tarily available for one or two respiratory acts. The stream is to be. delivered intermittently from tubes provided with an automatic cut-off." With ethyl chloride administered as described above, with proper admixture of air, anesthesia is induced in about the same time as nitrous oxide requires; the effects correspond very closely to those of the latter as to duration and recovery, but cyanosis is absent throughout. For use in dental practice it may be said that, compared with nitrous oxide, ethyl chloride is more convenient and equally efficient, though less safe and requiring selection of cases and cautious use. Somnoform, a proprietary mixture of ethyl chloride 60 parts, methyl chloride 35 parts, and ethyl bromide 5 parts, presents no advantage over pure ethyl chloride. Several deaths from its use have been reported. Comparative Safety of Anesthetics. — The relative toxicity of these agents must depend largely upon their chemical make-up. If we com- pare the chemical formuUe of the four leading anesthetics, viz.: COMPARATIVE SAFETY OF ANESTHETICS 211 Nitrous oxide N2O Ether C4H10O Ethyl chloride C2H5CI Chloroform CHCI3 we note differences that correspond to the increase in toxic power. Nitrous oxide is a very simple compound that has slight effect upon pro- toplasm. The hydrocarbon compounds have a more decided effect, that of ether being prolonged and profound without much danger from its action upon vital tissues; but with the introduction of a halogen element in combination with the organic radical, we find the harmful action to increase in proportion to the number of halogen atoms in the molecule. Thus, ethyl chloride contains a chlorine atom which makes it more toxic; while chloroform, with three atoms of chlorine is decidedly poisonous to tissues, frequently causing a positive degen- eration.* From these observations we are led to be skeptical as to the claims of safety for any new anesthetic containing a halogen element. Briefly then, it may be stated for the agents now most employed, that nitrous oxide is the safest anesthetic in ordinary use; next in point of safety is ether, while chloroform and chloride of ethyl remain the least safe. The comparative safety of ether and chloroform, as given in a number of series of statistics, shows some variation, but it may be taken as a fair statement that ether is five times as safe as chloroform. f A very interesting study of this question is that presented by the Committee of the British Medical Association appointed to investigate clinically the safety of the several anesthetics. j They studied 25,920 cases of general anesthesia, all occurring in the United Kingdom in the year 1892. Their conclusions include not simply deaths from anesthetics, but all cases of danger that could be attributed to the agent used. They found that dangerous sjTQptoms occurred: With ether, in 0.065 per cent, of cases.- With nitrous oxide and ether, in 0.096 per cent., and With chloroform, in 0.582 per cent. * The toxic effect may be due to halogen acids Uberated from these compounds. See Am. Year Book of Anesthesia, 1915, p. 150. t In connection with tliis, it is interesting to note the estimate of the comparative anesthetic power of ether and chloroform. It has been stated, as a result of experi- ments, that "the concentration of ether in serum necessary for complete anesthesia is 1 : 400; of chloroform, 1 : 4500 to 1 : 6000." Cited from Sollmann, American Medicine, September 10, 1904, p. 455. t Lancet, London, 1901, vol. i, p. 280. 212 ANESTHETICS This would make the danger ratio about as follows: Chloroform 9 Nitrous oxide and ether 1.5 Ether 1 It is conceded that nitrous oxide alone is least dangerous of all. Mixtures of Anesthetics. — Besides the combined use of ether with nitrous oxide or ethyl chloride, mixtures of anesthetics cannot be very strongly advised. The old A. C. E. mixture of alcohol 1 part, chloroform 2 parts, and ether 3 parts is now seldom used. The differences in specific gravity and volatility of the several liquids, make it difficult to know what proportion of each the vapor contains. The Schleich mix- tures for general anesthesia are not regarded, in general, with sufficient favor to constitute any recommendation of them. These must not be confused with the solutions for local analgesia, discussed on page 173. Schleich's idea in introducing mixtures of anesthetics for general anes- thesia, was to obtain a liquid with a desired boiling-point (at about the temperature of the blood), to secure which he employed mixtures of ether, chloroform and petroleum ether with boiling-points varying between about 100° and 108° F. His belief in the relation between the action of an anesthetic and its boiling-point has not been accepted. The mixture called somnoform (also advertised under the name of Brugg's ^Mixture) cannot be advised for the following reasons: 1. Being proprietary, its use is unethical. 2. It contains 5 per cent, of ethyl bromide [C2H5Br], which substance is regarded as less safe than ethyl chloride.* 3. ^Yith new agents, such as ethyl chloride, it is better to use the simple substance until its degree of safety has been determined, before resorting to any modification of it. Resuscitation in Danger Cases. — With nitrous oxide, ethyl chloride, ether, and usually with chloroform, the danger is paralysis of respiration. When the condition is simply this, reco\'ery may be expected, with proper treatment. But while the condition is a simple one with the three first-named agents, with chloroform there is always added a serious depression of the heart, and occasionally paraylsis of that organ. When the heart is paralyzed by chloroform its irritability is lost, which * Sollmann (Fliannticolofry, 1906, ]). 4:iG) .states that ethyl bromide "must not be pushed to the disapi)earanfe of reflexes, since the respiration is iJaralyzed about the same time. The zone of safety is, therefore, very narrow." The drug also deteriorates rapidly after exposure to air. RESUSCITATION IN DANGER CASES 213 means death. But absence of the pulse beat must not be at once taken to mean paralysis, for, with the depressant action of the drug upon the heart, its pulsations may have become so feeble as to be imperceptible in the peripheral vessels; and it is not proper to waste time at first to ascertain the heart's condition. The important thing immediately is arti- FiG. 12. — Sylvester's method of artificial respiration: movement of inspiration. ficial respiration, which is itself here the best cardiac stimulant, and with its faithful continuance the real condition of the heart will soon appear; for artificial respiration not only supplies oxygen but facilitates the action of the heart, by relieving engorgement of its chambers, each expansion of the lungs favoring the emptying of the right ventricle and each con- traction furnishing more blood to the left side of the heart for distri- FiG. 13. — Sylvester's method of artificial respiration: movement of expiration. bution. The invariable treatment, therefore, when respiration ceases, should be artificial respiration with free access of air, preceded, of course, bv withdrawal of the anesthetic. 214 ANESTHETICS Artificial Respiration. — Sylvester's method of artificial respiration is the one most connnonly employed. Figs. 12 and 13 show the position of patient and attendant. The movements of inspiration and expiration should succeed each other regularly at the rate of from twenty to twenty- five respirations per minute, or once in about three seconds.* In imitation of natural respiration the inspiratory period should be slightly longer than the expiratory. In connection with this method, massage of the heart by an assistant, by pressure during expiration underneath the left ribs and upward toward the heart, so as to press the latter between diaphragm and chest wall, has come to be employed as an important aid in reestablishing the heart's efficiency. It is most effectual in cases where the irrritability of the heart muscle is not much impaired. The Schdfer or Prone-pressure method has gained favor in this country, as being at least as efficient as the Sylvester method and more easily performed by one person, since it requires less muscular exertion. It is carried on as follows: Have patient lying flat, with face downward and turned to side, tongue drawn forward and arms extended above head. Kneel aside, or preferably astride, the patient's thighs. For the expira- tory movement place hands upon lower part of chest, thumbs nearly touching and fingers spread out over lower ribs; by a forward move- ment throw your weight, through your arms, upon patient's chest, thus compressing both chest and abdomen and effectually expelling air from lungs. For the inspiratory movement spring backward, relieving the pressure completely to allow chest to expand, but keeping hands in place. Time the movements to 15 to 20 complete respirations per minute, or by your own respiration — the forward expiratory movement with your expiration and the backward movement with your inspiration. The Howard method of artificial respiration also is convenient and useful. It is described as follows :t "The patient is turned upon his back, and a bolster of clothing or of other material is placed under him so as to throw his epigastrium forward. His wrists are crossed behind his head and held in that position. His tongue is drawn forward and held with a dry handkerchief in the extreme corner of his mouth. The operator now kneels astride the patient's hips, ' resting the ball of each thumb upon the corresponding costoxiphoid ligaments, the fingers * The average normal rate of respiration is about eighteen per minute, but as the need of aeration is urgent, and as artificial respiration is apt to be less efficient than the normal function, it is well to exceed the normal rate sUghtly. t Atkinson. American Text-book of Applied Therapeutics, 1896, p. 37. ARTIFICIAL RESPIRATION 215 falling naturally into the lower intercostal spaces. Resting his elbow against his sides and using his knees as a pivot, he throws his whole weight slowly and steadily forward until his mouth nearly touches the mouth of the patient, and while he might slowly count one, two, three; then suddenly, by a final push, springs himself back into his first erect position on his knees; he remains there while he might slowly count one, two, then repeats, and so on about eight or ten times in a minute." Fig. 14. — Schafer's prone-pressure method of artificial respiration, a, pressure being applied; b, pressure removed. The Laborde method of rhi^lbmic traction upon the tongue may be used as a stimulant to respiratory movements when there is any possi- bility of response, the tongue being grasped by the fingers over a drj' napkin, or by a tenaculum or forceps, and drawn forcibly forward at intervals of about four seconds. Laborde holds that this measm-e excites reflexly the movements of the diaphragm especially. A still more powerful means of exciting respiration reflexly, is that of rhythmically stretching the sphincter ani. This has been found very 216 ANESTHETICS useful in resuscitation from dangerous anesthesia and from opium poisoning. Medicinal Teeatmext. — While artificial respiration must be kept up until natural respiration is restored, or until the hopelessness of the case has been absolutely established, an assistant must keep note of pulse and give respiratory and cardiac stimulants hypodermically, as required. The same medicinal treatment will be indicated here as in poisoning by cocaine, being careful to avoid vasodilators, especially where the arterial pressure is greatly reduced. (See Plate IV, p. 177.) Strychnine^ atropine, caffeine and digitalis, therefore, will be the drugs indicated, the last named being less needed in cases of simple asphyxia. Meanwhile, the so-called diffusible stimulants, such as ammonia by inlialation, or aromatic spirit of ammonia by the mouth (y-1 teaspoonful (2-4 mils) if swallowing is possible, may be given. [The suprarenal preparations (adrenalin, etc.), would usually be classed with these arterial stimulants; but in case of danger from chloroform they would be absolutely contra-indicated, because of their peculiar and dangerous effect upon the heart under chloroform. (See p. 207, note.)] Alcohol. — Ethylic Alcohol. — Spiritus Vini liectificatns [C2H6O.] (For preparations and doses, see Index of Drugs.) In alcohol we have an anesthetic agent that is practically not used as such. It has been commonly regarded as a stimulant, but a study of its full action, com- pared with that of ether and chloroform, must convince one of a real similarity, approaching an identity, in their effects. ^Yhatever of stimulant effect it induces seems to be secondary to its local irritant action; in this respect it resembles ether. Its full anesthetic effect is so slowly produced and persists so long and is attended with such un- pleasant symptoms (those of drunkenness), that it cannot ordinarily be used as an anesthetic. That it is a poison cannot be questioned. That it is capable of acting as a food is in accordance with the teaching of most authorities, but it cannot be regarded as an economical food in health. Its precise action after absorption into the blood is not fully under- stood, except that in large doses it is anesthetic and poisonous. This latter fact should form the basis of a positive rule that alcohol should not be given in dangerous narcosis from ether or chloroform. It can only be admissible as a reflex stimulant, or as present in the aromatic spirit of ammonia or in other irritating diffusible stimulants. (The diagrams of Plate VIII are intended to show the present status of knowledge concerning the internal influence of alcohol.) PLATE VIII- ALCOHOL. T'sed commonly in the foi'm of Whisky, Brandy, or Wine. Classified as : Irritant. Stimulant. Asti'ingent. Narcotic. Antiseptic. Anesthetic. PliysioJogic action : " To summarize the physiologic effects of alcohol is very difficult, owing to the con- tradictory opinionsheld hy Skin\ good authorities. While most writers agree that the full effect of a large dose of the drug is that of a general depressant, tliere is no agreement as to the in- fluence of a small dose. Two diagrams are here presented : Diagi-am A represents the action of a small dose as taught by those who liold that its primai'y influence PLATE VIII.— B. includes stimulation of th' cerebrum and of the heart. Diagram B shows the de- pressant action of a large dose upon the nervous system, circulation, and digestion. Many observers deny the primary stimulant action, holding that the drug is a depressant from the first, or even in small dose. Tiie excitement of intoxication is not due to Btimulation, but to depression of the higher controlling centers. Local action.' Irritant, by reason of its affinity for water. When applied to the mucous membrane of the digestive tract, the ivi-i- tatiou probably induces reflex stimulation, which may account in part for the primary stimulant effect attributed to the drug. Diycsiion. In small doses, well diluted, alcoliol seems to increa gastric secretion and motility, wliile stronger solutions (5 per cent, or more) retard tbe digestiv -Is IX food the position of alcohol has not been very definitely determined. A small part only can be recovered as alcohol from the fluids of excretion. The gi-eater part therefoi-e is changed into other products, and is believed thereby to tribute some energy to the body. The economy to the system of its use may be open to question. Metabolism, Its influence upon nutritive changes and upon elimi- nation is uncertain. CHAPTER XV. STIMULANTS AND TONICS. STIMULANTS. A STIMULANT IS usually defined to be an agent that increases the activity of an organic function or process. But in the application of the principle of stimulation, a qualification of this definition should be noticed. We seek not simply to secure rapidity, but always efficiency of a function. Thus, in the majority of cases that call for a heart stimulant the heart's action is already rapid, and our most powerful stimulants, such as digitalis, in their full action actually slow the pulsations of the heart; but in spite of this the efficiency of the contraction is increased by them and the pulse improved in character. Again, the efficiency of a function may be lessened by undue inhibitory restraint. Here a stimu- lant result would require that the inhibitory influence be weakened. Belladonna acts in such manner, allowing the heart to beat more rapidly by depressing the inhibitory vagus nerve endings. Having in mind, therefore, the real object of stimulation, i. e., to secure efficiency of a function, we may employ agents that act in various ways, but always toward the same object. Direct stimidants have their action directly upon the organ or tissue sought to be influenced. Their action may be to increase nervous, muscular or secretory activity. Such an agent might be called a kinetic stimulant, in that it changes latent into active energy. This increase of activity is at the expense of the reserve energy of the organ, and tends toward its exhaustion. This is an important consideration in the choice of a stimulant, and, indeed, in the decision whether any stimulant shall be employed, for the rapid exhaustion of the reserve power of an organ may defeat the object of our stimulation. There are some stimulants, however, to which this objection scarcely applies — those that simply increase the irritability of nerve or muscle without calling forth any increase of activity, except in response to normal stimuli. These might be called potential stimulants, in that they increase the possibility of activity in response to normal stimuli. They do not tend particularly toward exhaustion of an organ. Strychnine is 218 STIMULANTS AND TONICS a stimulant of this kind, its action being to increase the irritability of nerve centers. Indirect stinmlants produce the stimulant result secondarily. Some of these act primarily by removing inhibitory influence and others by causing an irritation of sensory nerves. An example of the former is the belladonna action, noted above, which primarily lessens the inhibitory influence of the vagus upon the heart, and thereby allows the heart to beat more rapidly, which is the secondary or indirect stimulant eflFect. Examples of the latter are ammonia, alcohol and ether, which are locally irritating to mucous membranes. By irritating sensory nerve endings, they induce a reflex or indirect stimulant effect. Some stimulants are poisonous when given in excessive dosage; and the symptoms of toxic disturbances usually include delirium or con- vulsions. (Because of the sensitiveness of the system in childhood, children do not bear stimulants as well as sedatives. They need stimulation less often than do older persons, and the response to stimulants is usually prompt.) The Indication for Employing Stimulants is, in general, any depression of a function to a degree that may be regarded as below the yhysiologic minimum of its activity. ^Ye recognize that every organ has a certain range of action that may be called physiologic, within which it reacts to the work demanded of it, by increasing or lessening its activity. Func- tional activity, therefore, is a variable quantity, based upon the strength and nutritive resources of an organ, which are opposed by the amount of work imposed upon it. The physiologic minimum of activity, therefore, must vary as modified by these factors; but it may be defined to be the minimum of efficiency of a function under existing conditions. Now as long as an organ is working efficiently within its physiologic range it needs no stimulation. But when, either from its own inability or from excessive demands made upon it, its activity falls below its physiologic minimum, then stimulation may be employed to compel an extra ex- penditure of energy in enforced activity. It is observed, moreover, that normally acting organs do not show much response to stimulants, but that those whose action is deficient respond well. When an organ is doing all the work that is required of it, it is difficult to force its action; but when the need of doing more work is present and a stimulant is applied, there appears to be a cooperation of factors, the increased irritability or the more fowerfnl iminession contributed by the applied stimulant enabling the organ to respond to the need of increased work, which, after all, is its normal stimulus. STIMULANTS 219 Thus defined and limited, stimulants form a very important and indispensable class of remedies — the kinetic stimulants to serve as emergency remedies to tide an organ over a critical period, and the 'potential class to forestall failure of its function. Closely related to the latter are the agents usually classed as tonics, which may supply elements to the tissues or conserve the expenditure of energy by the cells. Irritant Stimulants. The indirect stimulants that produce a prompt circulatory effect have been termed diffusible stimulants. They are diffusible in effect rather than in action. Their action is mostly a reflex one, following local irritation of the sensory nerves in the mucous membrane. Their effects are usually transient. Alcohol fethylic). — The local action of this drug is fully considered in the chapter on Astringents; but the secondary effects arising from the marked irritation that attends its abstraction of water from the tissues and its coagulation of albumin, are those that may be called stimulant. They are reflex in nature, and are similar to the reflex effects following irritation of any sensory nerve. Alcohol should be used in a strength of not less than 50 per cent., in order to obtain the stimulant effect, which at best is slight and transient. It may be used either diluted or in the form of whisky or brandy. Pharmacologic experiments upon dogs do not prove alcohol to be a stimulant after its entrance into the circulation; there may be a slight temporary increase of pulse-rate^ but arterial pressure is not raised. On the whole, alcohol must rank as a rather feeble reflex stimulant, whose effect is uncertain and brief, and requiring, for continued effect, repeated doses that may later cause depression. For a single, prompt stimulant result, as in case of faintness, it is often useful. It should be remarked that what is popularly regarded as stimulation by alcohol, i. e., the hilarity, activity and talkativeness, are not stimulant effects at all, but rather the opposite. They correspond to the period of disturbed or imperfect consciousness common to anesthetics, and must be regarded as uncontrolled activity of the lower emotional and reflex centers, which occurs because the controlling function of the cerebrum has been depressed. In large doses alcohol soon produces its characteristic depression of the whole central nervous system, while its continued use leads to degen- erative changes in the arterial system, kidneys, liver and other highly vascular organs. 220 STIMULANTS AXD TOXICS ^ther. — Ether. — This drug is fully considered in the chapter on Anesthetics. Its stimulant secondary effects, following primary irri- tation, are similar to those of alcohol. It is used in the following preparations : Spiritus ^theris. — Spirit of Ether. — (contains 325 parts of ether and 675 parts of alcohol.) Average dose f3 1 (4 mils). Spiritus .ffitheris Compositus. — Compound Spirit of Ether. — Hoffman's Anodyne (contains 325 parts of ether, 650 parts of alcohol and 25 parts of ethereal oil. Not official.) Dose f3 1 (4 mils). These preparations are given mostly by the stomach. Ilypodermically they are quite irritating, although this should not prevent their use in emergency, if swallowing is difficult or impossible. Indeed, the greater irritation would likely induce greater reflex stimtdation. Ammonia [XII3]. — (For all preparations see Index of Drugs.) This substance has a decidedly irritant local action, and has the advantage of being a gas, which permits of inhalation. It is so volatile that it is always employed in solution, even for inhalation. In fact, the aqua ammonice fortior liberates the gas so rapidly as to be caustic in action, and is therefore not to he employed in any way as a stimulant, unless first diluted. The following preparations are commonly employed: Aqua Ammoniae. — Water of Ammonia. — (contains 10 per cent, by weight of the gas in water.) Average dose TH, 15 (1 mil) diluted. Spiritus Ammoniae Aromaticus. — Aromatic Spirit of Ammonia.* — Average dose m 30 (2 mils). The aromatic spirit of ammonia is the best one of this class of stimu- lants for stomach administration. Its stimulant action is of longer duration because of the gradual decomposition of the ammonium car- bonate, which thus liberates ammonia gas for some time. All ammonia preparations deteriorate with keeping unless kept tightly corked. Of the salts of ammonium the carbonate is a valuable stimulant. Miscellaneous Stimulants. Various other volatile substances ha\e a more or less direct stimulant action, the reflex factor being much less because they are less irritating. The volatile oils and substances related to them belong to this class. A few only among them are important enough to be employed. * Aromatic spirit of ammonia contains: Water of ammonia, 9 per cent.; carbonate of ammonium, 3.4 per cent., and small quantities of oils of lemon, lavender and nutmeg, with alcohol, 70 per cent. STIMULANTS 221 These are stimulating to the central nervous system and to the heart. In large doses they may depress. Locally some are irritating, while others are sedative. They are much used internally as carminatives, i. e., agents that relieve colic and cause expulsion of gas by relieving spasmodic contraction of the intestines. Camphora. — Camphok [doHieO]. — Average dose gr. 3 (0.2 gm.). A ketone derived from Cinnamomun camphora. It occurs in white, translucent, crystalline masses, which are soluble in alcohol, ether, chloroform, and oils, but almost insoluble in water. It has a strong odor and sharp aromatic taste. It is tough, but may be pow^dered in the presence of a little alcohol. (For preparations and doses, see Index of Drugs.) Locally, camphor preparations are sedative except for the alcohol present as the solvent. Internally, it is a general stimulant to the nervous system and heart, but in large doses it may depress the brain, so as to cause delirium or convulsions. The spirit may be inhaled in syncope or faintness. For internal use as a stimulant, camphor has acquired a place of first importance in the treatment of circulatory depression. It is given hypo- dermically, dissolved in a sterile fixed oil. For local application certain combinations which modify the action of camphor are sometimes used. The basis for these is the fact that when camphor is triturated with either phenol, chloral hydrate, menthol or thymol, the mixture becomes liquid and is suitable for external use. Of these. Camphorated phenol (Camphophenique) and Camphorated chloral are most frequently employed. Spiritus Camphorse. — Spikit of Camphor. — Contains 10 per cent, of camphor in alcohol. iVverage dose, lU 15 (1 mil). Oleum Menthse Piperitse. — Oil of Peppermint. — Average dose, lU 3 (0.2 mil). This is used mostly as a carminative, either in form of the spirit, or combined with cathartics to prevent griping. The local effect is sedative. Heat. — The stimulant effect of heat is made use of in various ways. In case of shock or collapse a hot-water bag placed directly over the heart, or heat applied to the extremities, will be found useful. Copious injections of very warm water, or preferably warm normal salt solution, into the rectum and colon, is a very excellent means of stimulation by heat. The restorative value of the salt is also here apparent. Liquir Sodii Ohloridi Physiologicus. — Normal Salt Solution. — This contains 0,85 per cent, of sodium chloride in sterile water. Its use by 222 STIMULANTS AND TONICS hypodermoclysis, or intravenously, should be regarded today as one of the most important means of stimulation. It is rather restoration, by a fluid corresponding closely in salinity to the blood serum, which may be deficient or improperly distributed. Loss of blood by hemorrhage or loss of serum by a serous diarrhea, would especially indicate the use of saline solution. It is also useful in any condition of extreme depression. In severe cases of typhoid fever and other exhausting diseases, the patient is oftentimes tided over a critical period which might otherwise be fatal, by the daily use of one to four pints of normal salt solution hypodermically. The solution is prepared quite hot and allowed to run slowly through a large-sized, long hypodermic needle from a fountain syringe into the lumbar region or underneath the breast. Other stimu- lants may be added to the solution. Belladonna — Atropina [0171123X03]. (Plate IX,) Belladonnce Folia. BelladonnoB Radix. — This drug holds a unique place as being a central stimulant and peripheral depressant to the nervous system. Either the alkaloid atropine or the tincture of bella- donna may be used as a respiratory and cardiac stimulant, atropine being always preferred for hypodermic use. But this drug must be regarded as a second-rate stimulant, and care must be taken not to exceed the physiologic limit, as it may then be disturbing or narcotic in effect. Locally applied, belladonna is anodyne, acting by depressing sensory nerve endings. It is used to allay local pain or irritation, as in neu- ralgia, for which purpose the plaster, ointment, or liniment of bella- donna, or the oleate of atropine may be applied. (For preparations and doses, see Index of Drugs.) Atropine in aqueous solution is dropped into the eye to dilate the pupil and to paralyze accommodation. Any preparation of belladonna or atropine promptly checks the excessive flow of saliva in mercurialism, for the treatment of which symptom it is our best agent. Sweating is also diminished by this drug, as are also various other secretions of the body. In checking secretion the drug acts by paralyzing the secretory nerve terminals within the glands. The official salt of the alkaloid is Atropinse sulphas. — Average dose gr. j^^ (0.0005 gm.). The following alkaloids have an action somewhat similar to that of atropine : PLATE IX. PLATE IX BELLADONNA. Leaves and root of Atropa B. The alkaloid Atropine represents tlia drng fiiHy. Classified as : Cerebral stimulant. Cardiac stimulant. Deli riant narcotic. Anodyne. Mydriatic. Antiliidrotic. Physiologic action : In general, '' atropine acts as a stimulant to the central nervous system and paralyzes the terminations of a number of the nerves, more especially of those that supply invol- untary muscle, secretory glands and the heart." [Cushny.] It paralyzes peripheral inhibition. It decreases the secretions generally, except the urine, and increases the body tempeiuture, producing a condition simulating fever. Nervous System. Brain. Stimulates the cerebrum, especially in its motor areas. Medulla. Stimulates respiratory center. Spinal cord. Depresses inhibitory centei-s. Sensory. Depresses sensory nerve endings. Motor. Depresses motor nerves. Secretory. Paralyzes the endings of many of the secretory nerves, censing a diminu- tion or arrest of the secretion ; hence there result dryness of the mouth, le.ssened secretion of gastric and pancreatic jiiices and of milk. The sweat glands are rendered less active. Vagus. Paralyzes the inhibitory terminations of the vagus within the heart, and the secretory terminations withm the digestive system. Muscular System. Depresses unstiiped muscle, but has no influence upon voluntary muscle. Lessens the movements of stomach, intestines, bladder, uterus, and in gen- eral the organs containing unstriped muscle, except the arterial walls. [Cushny.] Eye. Pupils are dilated by paralysis of terminals of the motor oculi nerve in the iris, whereby it paralyzes accommodation also. Most authorities state that it increases in- traocular pressure. Circidalion. Arterial pressure is increased, chiefly by its action upon the heart. Heart. Increases pulse rate by paralyzing inliibition (peripheral ends of vagus). The heart muscle or its accelerator nerves may feebly be stimulated. Rtapiralion. Stimulated by action upon respiratory center. Excretion. Perspiration is lessened. The drug is excreted rapidly by the kidneys, but its influence upon their activity is uncertain. The red color indicates stimulation, and the blue color depression. PLATE X CAFFEINE An alkaloid existing in coflfee, tea, guarana, and cola nut. Classified as : Cerebi-al stimulant. Cardiac stimulant. Respiratory stimulant. Diuretic. Physiologic action : Nervous System. Cerebrum. Stimulates cortex, increasing liie ac- tivity of psychic func- tions. Medulla. Stimulates res- piratory center and vaso- motor center. Yagus cen- ter may be stimulated, but the effect masked by the direct effect upon the heart. Muscular System. Irritability and working power of muscle tissue increased. Circulation. Arterial pressure may be increased slightly by vaso- motor activity. Heart. Stimulates heart muscle, tending to produce accelera- tion of the pulse. Capillary area. Tends to contract arterioles by stimulation of vasomotor center in the medulla, but this action is largely neutrallized by dilatation of the systemic arterioles by per- ipheral action. Excretion. Kidneys. Stimulates excretory function, both of the glom- eruli and the renal epithelium, causing increase of water and of solids, the increase of water being more marked. The diuretic effect may be prevented by the vasomotor action. Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus The red color indicates stimulation by Caffeine. PLATE XI. IVUX VOMICA. The seeds of Strychnos Nux V. The alkaloid Strychuine repre- sents the drug fully. Classified as : Bitter tonic. Cardiac stimulant. Nerve stimulant. Excitomotor. Physiologic action : Digestive Tract. Stimulates se- cretion of gastric juice and motility of stomach and intestines. Nervous System. Cerebrum. No effect upon cortex. Consciousness not influenced. Special senses rendered more acute. Medulla. Stimulates res- piratory and vasomotor centers. Vagus center may- be slightly stimulated. Spinal cord. Increases reflex irritability of the cord in its whole extent. Circulation. Arterial pressure increased. Heart. It is believed to stimulate either heart muscle or cardiac ganglia, or both. Capillary area. The splanchnic arterioles may be con- tracted by its action upon vasomotor centers, but the cuta- neous and muscular vessels tend to dilate. Excretion. Eliminated by the kidneys, appearing soon after ab- sorption, partly unchanged and partly changed. Contraction of renal vessels may hinder its elimination. Vagus Center Vase Motor Center Cervical Sympathetic The red color indicates the stimulant action of Nux Vomica or Strychnine. STIMULANTS 223 Homatropinse Hydrobromidum, an artificial alkaloid, is used as a mydriatic, producing a more rapid and more transient dilatation of the pupil than does atropine. It is used locally. (See Index of Drugs.) Hyoscyaminae Hydrobromidum, average dose gr. 2^^^ (0.0003 gr.). Obtained from Hyoscyamus and other Solanacece. Used as sedative. Scopolaminae Hydrobromidum (Hyoscinse Hydrobromidum), average dose gr. 2-^0" (0.0003 gm.). Obtained from Hyoscyamus leaves, Scopola root and other Solanaceoe. This is less stimulating than atropine; in fact, is used only as hj^notic and sedative. (See Index of Drugs.) Caffeina. Caffeine [CgHioNA+HaO]. (Plate X.) Caffeina Citrata. — Citrated Caffeine. — Average dose, gr. 5 (0.30 gm.). This alkaloid, obtained from tea and coffee, has an important use as a heart and cerebral stimulant and as a diuretic. It is entirely safe to be used in large doses, therefore it is one of the best stimulants to employ in poisoning by narcotics. The citrated caffeine is the prep- aration usually employed, because more soluble than caffeine. (See note on p. 177.) CaflEeinae Sodio-Benzoas. — Caffeine Sodio-benzoate. — Average dose by mouth, gr. 5 (0.30 gm.). hj-podermic, gr. 3 (0.20 gm.). This is the best salt of caffeine for hypodermic use, because of its free solubility in water, being soluble in 1.1 parts. Theobromine (from Theobroma cacao and from Guarana) has an action upon the circulation similar to that of caffeine, but is superior as a diuretic, and less stimulating to the cerebrum. (Not official.) Nux Vomica— Strychnina [C21H22N2O2]. (Plate XI.) (For preparations and doses, see Index of Drugs.) This drug easily ranks as one of the very best general stimulants. In large doses it is poisonous, but it is not narcotic, therefore it can be pushed to its physiologic limit with less danger than is the case with belladonna. It increases the irritability of nerve centers to normal stimuli, and does not tend directly to exhaustion. It is a valuable respiratory stimulant by action upon the centers. In all conditions of general depression, cardiac weakness, in infectious diseases, pneumonia, typhoid fever, in poisoning by cocaine, opium and other narcotics, it is useful. It is also used as a bitter, stomachic tonic. 224 STIMULANTS AND TONICS Internally any preparation may be given. Hypodermically a salt of the alkaloid strychnine is employed. The official salts of strychnine are: Strychninae Nitras. — Average dose, gr. 4,3 (0.0015 gm.). Strychninae Sulphas. — Average dose, gr. ^^ (0.0015 gm.). (For symptoms and treatment of poisoning by strychnine, see Table of Poisons and Antidotes.) Digitalis. (Plate XII.) (For preparations and doses, see Index of Drugs.) Digitalis is used whenever the heart is unequal to its task, by reason of dilatation or simple weakness. When extensive fatty degeneration is present, and in certain valvular defects, it is not the drug of choice, but may be required. As it "whips up" the heart to greater exertion, its use should be discontinued as soon as possible, so as to avoid exhaustion of the organ. It should be regarded as an emergencii drug in cardiac diseases. It is a great mistake to suppose that digitalis is needed in every case of valvular disease; for when any cardiac disease is fully compensated, and in simple hypertrophy, digitalis should not be used. When arterial pressure is high the drug is not indicated. In these con- ditions the drug may do harm. The tincture and the infusion are the preparations mostly employed. In emergency the tincture may be used hypodermically in full dose. The drug acts slowly, and it therefore cannot be relied upon alone as an emergency stimulant. Strophanthus, a drug that acts similarly to digitalis, is used as a sub- stitute for it. (For preparations and doses, see Index of Drugs.) Nitrites. (Plate XIII.) The nitrites are indicated in conditions of high arterial pressure, due to disease of the arteries or constriction of arterioles. They cannot be regarrled as direct heart stimulants of any decided power, but they act in an equivalent way, by reducing the work of the heart through dilating the arterioles. In this way the resistance against which the heart has to force the blood is largely removed, and at the same time its action is accelerated, so that a freer capillary supply results. Nitrites should not l)e used in conditions of low arterial pressure. Nitroglycerin in tablet form, or its 1 per cent, solution {Spiritus Glyceryl is Nitmtis) is PLATE XII. DIGITALIS. The leaves of D. Purpurea. Note. — The description below is of the action of the drug or of preparations fully representing it. Classified as: Cardiac stimulant. Cardiac tonic. Diuretic. Physiologic action : Stomach. Absorbed slowly. Irritant in large doses or when long continued. Nervous System. Brain. No influence upon the cerebrum. Medulla. Stimulates vagus centers. Circulation. Gives greater force and rapidity to arterial current. Heart. Stimulates the inhibitory influence (vagus, center), which slows the heart and tends toward relaxation. Stimu- lates the cardiac muscle and contained ganglia, giving greater force to the contractions. Capillary area. No direct action in therapeutic doses. With improved circulation in the brain, from the heart stimulant effect, relaxation of arterioles occurs which pre- vents any great increase of blood pressure. Excretion. Kidneys. Direct action upon the renal epithelium is uncer- tain. The urine is increased, but mainly through the in- fluence of an improved circulation. Vagus Center Vaso Motor Center- Cervical Symjiathetic Solar Plexus The red color indicates the stimulant action of Digitalis. PLATE XIII. ^iTITRITES. A-MYI. XlTEITE, 1TL 1-5 (Gm. .06-.30). NiTROGLYCEEi^r {Glonotn, Trinir trin). i77-7TV(Gra. .OOOo-.OOl). Arterioles dilated ^Section gi-- T Spieitus Glycerylis jS^ITKA- Tis, 1 per cent. Nitroglycerin. TTL ^2 (Gm. .03-.12J. SODITTJI iSTlTEITE, gr. 1-3 (Gm. .06-.20). Classified as : Vasodilators. Circulatory stimulants. Physiologic action : While the action of the ser- eral drugs of this group is rery similar, Amyl Nitrite (by inhalation) has the most rapid and transient effect, Nitroglycerin is most powerful, and Sodium Nitrite has the most permanent etiect. Nervous System. Brain. No direct influence iipon cerebrum. Medulla. Vagus center is indirectly depressed. Muscular System. Paralyzes the muscular coats of the arterioles and veins by direct action. Circulation. Causes a decided fall in arterial pressure ■n"ith accel- eration of the pulse. Heart. Any direct action upon the heart is doubtful. The acceleration is due mainly to depression of the vagus center through lessened blood pressure. Capillary area. DUates arterioles and veins, thereby in- creasing the volume and efficiency of the capillary circula- tion; vessels of face and abdominal organs are most affected. The influence upon arterial pressure and pulse rate is shown by the following sphygmographic pulse tracings: Vagus Center Vase Motor Center Cervical Sympathetic Solar Plexus Normal pulse tracing. Eate84; blood pressure normal. blood pressure The same after taking Nitroglycerin. Eate 96 greatly reduced. The red color indicates the stimulant effects of the nitrites ; the blue color indicates their depressant action upon the vagus center, which is the chief cause of the increase in pulse rate. Note. — The blood changes produced in animals by Amyl Nitrite are not seen in man fol- lowing therapeutic dosage. STIMULANTS 225 commonly employed. It is the best l•ep^esentati^■e of the group of nitrites. It is not necessary to give nitrites h\-podermically, as the effect of AiViYL NITRITE may be obtained almost instantly by inhalation, and a tablet of nitroglycerin placed under the tongue will produce its effect in from tlii'ee to five minutes. Its action also completely disappears in from thirty to sixty minutes. "When the drug is really indicated it may be given every hoiu" for several doses if necessary, or the dose may be increased as needed. Sodium Nitrite is employed when a slower but more sustained effect is desired. In conditions that are believed to be due to arterial spasm or con- striction, as angina pectoris and asthma, the nitrites are useful for temporary relief; and in arteriosclerosis they sometimes constitute the principal medicinal treatment. There is no doubt that the value of the nitrites was earlier over- estimated. Upon the plain indications mentioned above they occupy a place of usefulness that is their own, no other drugs being comparable to them; but it was unfortunate that the belief became current that they were direct heart stimulants. For, with this belief as a basis, they were used in such diseases as pnemnonia and other acute infectious diseases, when the blood pressm-e was already too low to allow efficiency of circulation, and in cases of chloroform narcosis, where the same con- dition prevailed. In fact, it was the practice of some, the more cardiac stimulation was needed, the more to resort to the nitrites; while it is true in the main that the more cardiac stimulation is needed the less are the nitrites indicated. The nitrites should be viewed as vasodilators, not as heart stimulants. But in their action as vasodilators they may be regarded as circulatory stimulants. The capillary area fed by the arterioles is, after all, the most important part of the circulation, for it is there, in the cells of the tissues, that all nutritive changes occur and all functional activity is maintained. In conditions of high arterial pressure, the blood supply to the capil- laries is often lessened by the tendency to constriction of the arterioles. The nitrites, by dilating the arterioles, will increase the blood supply to the capillary area and furnish better nutritive materials for cell activity — a true circulatory stimulation, but not heart stimulation. It is worthy of note that, whatever the beneficial result, the physiologic action of the nitrites is chiefly depressant to the ^'asoconst^icto^ muscle tissue in the arterioles. 15 226 STIMULANTS AND TONICS TONICS. Tonics are frequently defined as permanent stimulants. This conveys the idea of permanency of result which always pertains to the class, but we must note that tonics may not have any proper stimulating action. It is difficult to form a definition that will include all remedies of the class, because of the wide dift'erence in their nature and action. Their chief value is in relation to the reserve energy of organs, which they conserve by supplying the necessary materials for tissue renovation and for the production of energy, or by otherwise promoting nutrition. Iron is classed as a restorative tonic for the reason that it supplies a normal constituent to the blood and tissues. The ordinary foods hold a similar place and must be regarded as tonics in the sense that they restore needed material. On the other hand, bathing and massage will promote the general nutrition of the body, and are, therefore, tonic remedies. The simple bitters, such as gentian, taken into the stomach, stimulate the digestive functions and thus indirectly promote general nutrition, A simple classification which will aid our study of these substances, may be made as follows: Nutritional Tonics — those that promote the general processes of nutrition. Examples. — Bitter tonics, bathing, and massage. Restorative Tonics — those that supply material for tissue reconstruc- tion or energy production. Examples.^ — Iron, foods, and phosphorus. Nutritional Tonics. Among the class of nutritional tonics — i. e., those that promote the general processes of nutrition^ — are those that act by increasing the activity of digestion. These are known as stomachic tonics or simple bitters. Their chief characteristic is their bitterness, by which they seem to stimulate, possibly through primary irritation, the mucous membrane and secretory glands of the stomach. The immediate result of their presence in the stomach is to retard or lessen secretion, but this is soon succeeded by an increase of secretion, so that the full eftect, obtained fifteen to thirty minutes after administration, is an increase of gastric juice and of motility of the stomach. They should be given before meals so that their full action may be secured in time for the beginning of stomach digestion. The chief agents of this character are here given. (For preparations and doses, see Index of Drugs.) TONICS 227 Simyle Bitters. Calumba. — Columbo. — ^The root of Jateorrhiza palmata. Gentiana. — Gentian. — ^The root of Gentiana lutea. Quassia. — ^The wood of Picrasma excelsa or of Quassia amara. Of any of these the tincture (in case of gentian the compound tincture) is a leading preparation and may be given, in case of each, in a dose of f5 l-l (1-4 mils). The infusion of quassia is easily prepared with cold water, and may be given freely. To this group of simple bitters must be added several other drugs that are equally efficient as stomachics, but whose more important action gives them a larger place. They are sometimes called: Peculiar Bitters. Cinchona. — Peruvian Bark. — ^The bark of a number of species of cinchona. It contains quinine and many other alkaloids. (For prep- arations and doses, see Index of Drugs.) Quinine represents the drug fully. (For its combinations and doses, see Index of Drugs.) Besides being a bitter tonic, quinine is an efficient antiseptic, but its bitterness prevents its extensive internal use as such; although it is some- times employed as an intestinal antiseptic, given by stomach or injected into the colon. Its most valuable and distinctive use is in malarial fever (fever and ague), in which disease it is a specific, preventing in the blood the growth of the plasmodium malarise, upon which the disease depends. This must be regarded as a true antiseptic action, obtained after absorp- tion of the drug, which for this purpose is given in full dose of 15 to 30 grains (1-2 gm.) daily, in single or divided doses. A favorite method is to give 15 grains (1 gm.) in one dose daily, about three hours before the expected paroxysm. The average tonic dose of a quinine salt is gr. 1| (0.1 gm.), before each meal. A form of supra-orbital neuralgia supposed to be of malarial origin, known as hroiv ague, which presents the periodic character of malarial fever, in that it occurs at about the same hour each day, or every second day, continues with severity for some hours and then disappears, is promptly relieved by a full dose of quinine daily, three hours before the usual time of its onset. Quinine sulphate is the salt mostly employed, but it is only slightly soluble in water, except when an acid is added. The bisulphate is freely soluble. With the giving of large doses of quinine there occur the evidences of saturation, that are known as cinchonism. Ringing in the ears and fulness of the head are the symptoms of this condition, which is not serious, but passes away soon after cessation of the drug. Quinine 228 STIMULANTS AND TONICS is used much less now than it was in former years, before its precise action and its hmitations were understood. Nux Vomica. — The seeds of Strychnos Nux-vomica, containing not less than 2.25 per cent, of alkaloids. (For preparations and doses, see Index of Drugs.) The chief alkaloid, strychnine, has been fully considered as a stimulant. It is valuable also as a bitter tonic, as are the prepara- tions of nux vomica. All preparations are intensely and persistently bitter. The special value of this drug, in its general tonic use, lies in the fact that, after its local effect in the stomach, its absorption is followed by a general increase in the activity of all reflexes, through its action upon ner^•e centers of reflex action. This is the effect that pertains to the action of the alkaloid strychnine in its use as a stimulant. The tinc- ture of nux vomica is the preparation most commonly used as a bitter tonic. In large doses the drug is poisonous, causing very characteristic tonic convulsions which affect chiefly the muscles whose nerve supply is directly from the spinal cord. (See Table of Poisons and Antidotes.) Prunus Virginiana. — Wild Cherry. — The bark of Pntnus serotina, gathered in the autumn. (For preparations and doses, see Index of Drugs.) In addition to its action as a stomachic tonic, this drug pos- sesses decided sedative properties, which are due to the presence of hydrocyanic acid in its preparations. This substance does not exist in the crude drug, but is developed when the latter is treated with cold water. By a reaction between two constituents, amygdalin and emuhm, a volatile oil identical with oil of bitter almond is formed. This contains hydrocyanic acid. Wild cherry finds its special use where a general or local ner^'e sedative is indicated, in connection with a stomachic tonic. In cough mixtures its preparations fill a useful place. Its local sedative and tonic effects make it a remedy that is applicable in irritable con- ditions of the stomach, to control vomiting and improve digestion. Restorative Tonics. This class comprises both the ordinary food substances, that supply material for tissue reconstruction and energy production, and the medicinal agents that are really foods in the sense that they are neces- sary to the tissues. Passing the ordinary food substances with the simple mention of oxygen, water, starchy, fatty and nitrogenous foods and sodium chloride, our chief consideration will be gi^'en to the restoratives ordinarily regarded as me(ficines. Inasmuch as they aid chiefly by restoring some element that is lacking, their precise action requires no extended dis- TONICS 229 cussion. We are more concerned with the form or combination of the drug in order to pleasant administration and ready assimilation. Ferrum. — Iron [Fe]. — (For preparations, their reactions and doses, see Index of Drugs.) This metal is commonly employed either in its pure form of reduced iron or in one of its many combinations. The large number of these supply every need of form, and of adaptability to the various conditions that call for its use. Those most frequently used are ferrum reductum, massa ferri carbonatis, ferri pjTophosphas, tinctura ferri chloridi, and s}Tupus ferri iodidi. The last-named is alterative as well as restorative, and a most useful agent in the treatment of so-called scrofulous conditions in children. Besides these preparations the great variety of compound salts find special uses. Ferri hydroxidum, or ferric hydrate, is the most useful chemical antidote to arsenic. The real systemic action of iron is mainly in the blood, and, whatever salt or combination is employed, the iron is believed to be changed to the chloride before absorption. It furnishes material for the coloring matter of the red cells, therefore it is especially indicated where there is deficiency of hemoglobin (chlorosis). It should be insisted upon that it is unnecessary to use the new and largely advertised preparations of iron. As a rule they are expensive, and they are not at all superior to the older, well-known, official forms. The reaction of iron salts should be noticed, and for prolonged use those that are neutral selected by preference, so as to avoid damage to the teeth. Only those that have an acid reaction can affect the tooth struc- ture, but staining may follow the use of any preparation in a mouth that is not kept scrupulously clean. This stain, which is usually sulphide of iron, may be easily removed from the surface of the enamel, but in a cavity it may be more permanent. The tinctm'e of the chloride is one of the strongly acid preparations that must be used with care. Its contact with the teeth may be limited by taking it through a glass tube, but a more positive safeguard is to ensure neutralization of the acid by rinsing the mouth, before and after taking, with a solution of sodium bicarbonate or other alkali. Mineral Acids. — These are used internally only in the dilute form. Even then they should be further diluted, and the same precautions taken to protect the teeth as are mentioned above. Acidum Hydrochloricum Dilutum. — ^Diluted Hydrochloric Acid. — 10 per cent, by weight of absolute hydrochloric acid. Acidum Nitricum Dilutum. — Diluted Nitric Acid. — 10 per cent, b}^ weight of absolute nitric acid (not official). 230 STIMULANTS AND TONICS Acidum Nitrohydrochloricum Dilutum. — Diluted Nitrohydrochloric Acid. — 4 per cent, nitric acid and 18.2 per cent, hydrochloric acid. Acidum Sulphuricum Dilutum. — Diluted Sulphuric Acid. — 10 per cent, by weight of absohite sulphuric acid. Acidum Sulphuricum Aromaticum. — ^Aromatic Sulphuric Acid. — 20 per cent, by weight (or about 10 per cent, by volume) of absolute sulphuric acid in nearly pure alcohol. The average dose of either of these isTTl 15 (1 mil). They are given after meals, as a rule. A very important use of dilute hydrochloric acid is to restore the quality of the gastric juice when its acid is deficient. It being the normal acid of this digestive fluid, its administration furnishes one of the most typical instances of restorative treatment. Vegetable Acids. — These include: Acidum Citricum. — Citric Acid. Acidum Tartaricum. — Tartaric Acid. It is not easy to explain the action of vegetable acids upon the ground of supplying normal elements that are lacking in the system. But their use is established by long clinical experience in certain conditions of disturbed nutrition that follow prolonged abstinence from fresh foods, as with sailors upon long sea voyages. The disease induced is known as scurvy, and it seems to present an altered or depraved condition of the blood as its chief pathology. Upon the skin and mucous membranes more or less extensive spots of ecch\Tnosis occur, the particular kind of lesion being known as purpura. The abnormal condition of blood is usually promptly removed, with full return of health, by a free supply of fresh fruits, vegetables, and meats. Citric acid, alone or as present in the juice of lemons or limes, is a valuable addition to the dietetic treatment of scurvy. Orange-juice is likewise added to the diet of infants fed upon sterilized or pasteurized milk. Tartaric acid is used simply as a substitute for citric acid. Phosphorus [P]. — (For preparations and doses, see Index of Drugs.) This substance is of the greatest importance to the system, in its capacity as a restorative. Among other effects of its prolonged use, it has been shown to have the power of inducing more rapid growth of bone, as was found to result in experiments upon animals.* Accordingly, it may be of service in delayed dentition and in rachitis; but, owing to the very disagreeable taste of pure phosphorus, we usually have to be content with the use of phosphates, hypophosphites and dilute phos- * Therapeutics, H. C. Wood, eleventh edition, pp. 431-32. TONICS 231 phoric acid. The most common form of pure phosphorus for admin- istration is the official pill containing ^qq of a grain (0.0006 gm.). It is particularly indicated in certain diseases of the nervous system and in conditions of deficient bone nutrition. (For poisoning by phosphorus, see Table of Poisons and Antidotes.) Acidum Phosphoricum Dilutum. — Diluted Phosphoric Acid. — 10 per cent. This acid is used as a general nerve tonic and substitute for phosphorus. Average doselU 30 (2 mils). Sjrrupus Hypophosphitum. — Syrup of Hypophosphites. — (Incom- patible with tincture of chloride of iron.) Average dose f5 2| (10 mils). Syrupus Hypophosphitum Compositus. — Compound Syrup of Hypo- phosphites (not official). Average dose, f5 1 (4 mils). Syrupus Ferri, Quininse et Strychninse Phosphatum. — Syrup of the Phosphates op Iron, Quinine antd Strychnine (not official). Dose f5 i-1 (2-4 mils). The hypophosphites are useful, both as substitutes for phosphorus and as furnishing combinations of the drug that may be more easily appropriated by the system. They are certainly less unpleasant to take. They are largely used in rachitis, in wasting diseases such as tuberculosis, and in diseases of the blood and of the nervous system. Oleum Morrhuse. — Cod-liver Oil. — A fixed oil expressed from the fresh livers of Gadus morrhua and other species of Gadus. Average dose, f5 21 (10 mils). It is produced mostly upon the coasts of Norway, Newfoundland and Massachusetts. Its value is that of a fatty food which also contains traces of iodine, chlorine, bromine, phosphorus and sulphur. These contribute a slightly alterative property to the oil. It is used in wasting diseases, especially in tuberculosis, and in poorly noiu'ished children. The so-called scrofulous conditions are benefited by it. The taste of the oil is dis- agreeable to many, so it is used largely in the form of emulsion. The pure oil is sometimes used by inunction when stomach administration is impracticable. If taken about two hours after meals much of the unpleasantness in the way of eructations will be avoided. Typical emulsions are the following: Emulsum Olei Morrhuae. — Emulsion of Cod-liver Oil. — 50 per cent. Average dose, f5 4 (15 mils). Emulsum Olei Morrhuse cum Hypophosphitibus. — Emulsion of Cod- liver Oil with Hypophosphites. — ^This contains 50 per cent, oil, with hypophosphites of calcium, potassium and sodium (not official). Average dose, f5 4 (15 mils). CHAPTER XVI. ALTERATIVES. Alteratives have been defined as agents that counteract morbid states of tissues by altering the processes of nutrition in a favorable manner. They seem to have little direct influence upon irritability or functional activity of cells. Alteratives become a part of the cell contents for the time that they remain in the system, and some of the metallic alteratives become so fixed that they may be detected for weeks in the tissues. Their action is slow and their effects permanent, as might be expected of agents that enter so intimately into the composition of the cells. The typical conditions that call for their use are those that are brought about by the damaging influence of bacteria or toxic chemical bodies, that alter the nutrition of the cells. Syphilis stands as the dis- ease that probably most purely presents the indications for the use of alteratives. Altered states of the blood and of organs likewise call for their use. The precise mode of action of alteratives is obscure, their effects appearing without any evident changes of organic functions, except that of gradual improvement. Arseni Trioxidum. — i\.RSENic. — Arsenons Acid [AS2O3]. — The value of arsenic internally is mostly as a blood alterative, in those forms of anemia where the red cells are abnormal. It is also useful in certain nervous diseases, particularly in chorea (St. Vitus' dance), and in some chronic diseases of the skin. Liquor Acidi Arsenosi. — Solution of Arsenous Acid. — 1 per cent. Liquor Potassii Arsenitis. — Fowler's Solution. — Strength corresponds to 1 i)er cent, of arsenic trioxide. Liquor Sodii Arsenatis. — 1 per cent. These three solutions are uniform in strength and have the same average dose, TTl 3 (0.2 mil). The first is arid in reaction, while the second and third are (dixalinc. Liquor Arseni et Hydrargyri lodidi. — Donovan's Solution. — 1 per cent, each of arsenous iodide and mercuric iodide. Average dose, Ttl 1| (0.1 mil). The pure arsenic trioxide and Fowler's solution are the forms most ALTERATIVES 233 commonly employed. Beginning with small or moderate doses, they may be increased to the limit of toleration, which is shown by irritability of the stomach and puffiness about the eyelids. Donovan's solution is a more powerful general alterative, as it com- bines arsenic, mercury and iodine. Hydrargyrum, — Mercury. — Quicksilver [Hg]. — (For fuller list of preparations and doses, see Index of Drugs.) Mercury is used very largely in the form of combinations, but there are several preparations in which metallic mercury is used, reduced to a very finely divided con- dition. Following are the preparations most commonly used: Hydrargyrum cum Creta. — Mercury with Chalk. — Contains 38 per cent, by weight, of metallic mercury. Massa Hydrargyri. — Blue Mass. — Blue Pill. — Contains 33 per cent., by weight, of metallic mercury. Unguentum Hydrargyri. — Blue Ointment. — Contains 50 per cent., by weight, of metallic mercury. Oleatum Hydrargyri. — Oleate of Mercury. — Contains 25 per cent., by weight, of yellow mercuric oxide. Hydrargyri Chloridum Mite. — Mild Mercurous Chloride. — Calomel. Monochloride of Mercury. Protochloride of Mercury [HgCl]. Hydrargyri Chloridum Corrosivum. — Corrosive Mercuric Chloride. — Corrosive Sublimate. Bichloride of Mercury. Perchloride of Mercury [Hgcy. Hydrargyri lodidum Flavum. — Yellow Mercurous Iodide. Hydrargyri lodidum Rubrum. — ^Red Mercuric Iodide. Hydrargyri Salicylas. — Mercuric Salicylate. — Mercuric Subsalicy- late. — This salt is used largely hypodermically in the treatment of s}^hilis. Average dose, gr. i (0.06 gm.). The t}^ical use of mercury as an alterative is in the treatment of secondary s;vT)hilis. As it is desirable to obtain its full influence as soon as possible, the ointment or the oleate may be rubbed into the skin freely. Aside from these, the non-cathartic preparations may be em- ployed internally. Blue mass and calomel are seldom given in syphilis, but are ^^aluable cathartic agents. The constitutional symptoms produced by mercury, with the treat- ment of the same, are discussed in the article on Antiseptics. (See also the article later on Syphilis and its Treatment.) ledum. — Iodine [I]. — This substance is not commonly administered in its free state internally, because of its irritating character. It is, however, a valuable alterative, and may be taken in large quantity in non-irritant 234 ALTERATIVES combinations. The iodides, which contain a large proportion of iodine, constitute a distinct group of general alterative agents, the most useful of which is sodium iodide. Sodii lodidum [Xal]. — Estimated by the atomic weights of its com- ponents, this salt contains about 85 per cent, of iodine. Being much less irritating than iodine, it furnishes the means of getting a large amount of the latter into the system without much disturbance. This salt is used in the treatment of acute asthma, in chronic rheumatism and other conditions of tissue alteration, but its most extensive use is in tertiary syphilis. wSodium iodide possesses advantages over potassium iodide in the following points: It contains more iodine. It is slightly more soluble. It is less irritating, sodium being better tolerated by the system than is potassium. (See article below on S\^hilis and its Treatment.) Potassii lodidum [KI]. — Potassium iodide has about 70 per cent, of iodine in its composition. Its uses are the same as those of the sodium salt. Other iodides are useful according to the particular combinations employed. The following are some of the most important preparations in frequent use: Syrupus Ferri lodidi. — Syrup of Iodide of Iron. — This is " a very valuable preparation for use in the so-called "scrofulous" conditions. It may be taken for an indefinite period by children who show the characteristic enlargement of lymph nodes. Arseni lodidum [AsIs]. — Arsenous iodide is used chiefly in Donovan's solution, the liquor arseni et hydrarg^Ti iodidi. Syphilis and its Treatment. Syphilis is a disease that is contagious and infectious in nature, one that may be met with in any walk of life, whether acquired inno- cently or through vicious conduct. It may be inherited in certain of its forms. It is a disease, moreover, of which its possessor may be ignor- ant, both as to its character and the source of infection, since the lesion of original infection, the chancre, may occur upon various parts of the surface of the body, where infection must have been purely accidental. The importance of this to the dentist is emphasized by the further fact, that the highly infectious secondary lesions are prominent in the mouth and throat, constituting here a danger to the dental operator directly, and to others indirectly. Syphilitic lesions are commonly painless, SYPHILIS AND ITS TREATMENT 235 which adds to the danger of non-recognition of the superficial mouth lesions. The occasional occurrence of a chancre upon the hand of a dentist, justifies the advice that a constant lookout for the presence of the dis- ease, in mouths coming under examination, should be exercised. This implies a certain degree of familiarity with the symptoms of the disease. Every opportunit}', therefore, to study this disease should be improved, as a matter of personal safety and of duty to others. The dental specialist certainly owes it to his patients and to himself, to supplement his dental college course by a post-graduate study of syphilis in its chief clinical features. Without such thorough study of the manifestations of the disease, it is unsafe to attempt to diagnose its various lesions either of the mouth or skin, for the liability to error is very great ; and even physi- cians of experience will often seek expert opinion as to the nature of a suspected lesion. A word of caution is here appropriate. It may fall to the practitioner to discover a case of s^■philis, by mouth symptoms, where it had not been suspected; but he must be exceedingly cautious about discussing this finding with his patient. He is dealing with a matter for which he has not been consulted, and in any suspicious acts or words of his, lie the possibilities of much unpleasantness. If the patient be an innocent wife a statement of his discovery might produce domestic discord. "While she would have a most serious grievance, entitling her to om* pity, a revelation could only add to her unhappiness. A suggestion to her to see ^er family physician for certain general conditions that you find evidence of, would be the proper course; and even this advice must be given tactfully, without arousing suspicion as to the probabilities in the case, for, after all, a mistaken diagnosis is possible. Any other course would also endanger professional relations with the family physician. The point of greatest practical importance is, to be so careful in the manipulation of instruments as to avoid all danger of self-infection; for the saliva of a patient with secondary mouth symptoms may infect any abrasion of the skin that it comes in contact with. As a matter of course, all instruments and appliances used will be thoroughly sterilized imme- diately after the operation. As a basis for study, a scheme is herewith given, which mcludes stages of the disease with their characteristic sjTiiptoms, and the application of remedies appropriate to each: 236 ALTERATIVES .Syphilis, its Stages, Symptoms and Treatment. Stages. Symptoms. The chancre, located usually upon the geni- tals, but may occiu- upon any mucoas or cutaneous surface. Enlargement of lymph nodes in all parts of the body, but not distinctive of this disease. Primary symptoms appear about three weeks after infec- tions. The lesion is very infectious. Secondary symptoms occur about six or eight weeks after infection, unless earUer treatment has arrested the dis- ease. The lesions in the mouth (mucous patches) are exceed- iitgly infectious. Tertiary symptoms may be prevented by treatment. In cases not treated the tertiary symp- toms occur in from one-half to two years after infec- tion, but they may be delayed. The lesions are only slightly infectious. A superficial rash, sUght or abundant, dis- tributed upon all regions of the body. Sore-throat. Mucous patches anywhere upon mucous membrane of mouth or throat, usually u])on inner surface of cheeks or under tongue. Loss of hair, shght or marked. Deeper lesions of the skin, eithei" single or multiple, but not of general distribution. Periosteal pains, chiefly in head and long bones, occurring mostly at night. Gumma, occurring mostly upon skin, in the nervous system, or smaller bloodvessels, but occasionally in any part of the system. Deep ulcers of the skin sometimes resulting from the breaking down^ of gummata. Usualh^ single, or, if double, located upon symmetrical portions of body. Degenerations of circulatory or nervous systems. The arteries, brain and spinal cord are usual sites of degeneration. Medicinal treatment. > -, Salvarsan. Mercury. Sodium. iocUde. The discovery of the spirocheta pallida, beHe^'ed to be the cause of syphiHs, has rendered possible an early diagnosis in the primary stage, which permits the beginning of treatment at once, instead of waiting until the appearance of secondary s;^Tnptoms confirms the clinical diagnosis, as was formerly the common practice. The introduction of salvarsan also has marked an advance in the efficiency of treatment, whereby the disease may be arrested early and a cure effected without the occurrence of secondary symptoms. Outline of Treatment. — When a case is seen soon after the appearance of the chancre, the diagnosis should be made positive by the dark-field examination of scrapings or serum from the lesion. If this reveals the spirochete, treatment with .salvarsan should begin at once. This drug is administered intravenously in normal salt solution; 8 to 12 injections are gi\'en, at first weekly for five or six weeks, then at intervals of a month or more. In addition to this, a course of mercury is begun early and both remedies are continued during the first year. The preparations of mercury now most commonly employed are the oO per cent, ointment, SYPHILIS AXD ITS TREATMEXT 237 by inunction, pushed to the point of saturation, or salicylate of mercury gr. 1 (0.06 gm.) given each week by deep intramuscular injection. Other preparations may be employed, some using the bichloride h\-podermi- cally while others prefer the yellow iodide by mouth. Diu-ing the second year the same remedies may be continued at intervals, or treatment may depend upon the results of Wassermann blood tests made every two or three months. In case the s\Tnptoms do not yield readily, and particularly in the tertiary stage, an iodide by mouth (preferably soditun iodide) may be added to the treatment.* The question whether s^-philis may be cured has been regarded as a debatable one, but it is one which now admits of an affirmative answer. The fact remains, however, that very many cases are not permanently cured. AVhen we appreciate that a cm-e means the taking of medicines almost continuously for two years, and that syphilis is a disease whose SATnptoms yield very promptly to treatment, it caimot be expected that more than a small percentage of patients will continue treatment for the necessary length of time after they feel perfectly well. A positive ctu-e would mean a total of three years' observation, the first two with active treatment, and the absence of all symptoms with negative Wassermann tests thi'ough the third year. ^Marriage cannot be properly entered into without this thorough treatment and the three years of observation. The following additional drugs are simply mentioned as representative of the class of vegetable alteratives: Colchicum. — (For preparations, doses and uses, see Index of Drugs.) Guaiacum. — (For preparations, doses and uses, see Index of Drugs.) Sarsaparilla. — (For preparations, doses and uses, see Index of Drugs.) Sarsaparilla must be regarded as the least valuable of this group. In fact, its value is so slight that it is seldom used alone. The pro- prietary "sarsaparilla tonics" all contain stronger agents, usually cathartic in action. * The continued use of any iodide commonly produces a rash, consisting of pimples upon the face and elsewhere, which is beUeved to be nature's efforts to eliminate iodine. This is the chief sjTnptom of iodism, or saturation with the drug. CHAPTER XVII. SEDATIVES. A SEDATR'E is defined to be an agent that diminishes the activity of an organic function or process, the term depressant being equally applicable. All sedatives may be poisonous when given in large dose; and the toxic s\iTiptoms usually include narcosis. The division of the large list of sedative agents into groups designated by the terms arterial, nervous, etc., is a convenience, and helps to fix their characteristic action, but no distinct lines can be drawn between the groups. The terms point rather to the most prominent features of their action. (See classification, page 37.) In a practical sense the term applies to effect but not always to action. Stimulation of inhibition may produce a slowing or restraining effect, which we may call depression induced indirectly by stimulation. Instances of this kind are well illustrated in the action of aconite, as Plate XIV shows. Most sedatives, however, produce their effects by a direct depressant action upon either nerve or muscle tissue. As a rule, children bear the moderate action of sedatives very well. The nervous system during childhood is so sensitive and responsive, that disturbed function in most cases calls for depressant rather than stimulant treatment. Cold must be given a prominent place among the arterial sedatives. Just as the application of heat acts as a general stimulant, so the appli- cation of cold produces the opposite effect. Hyperemias and acute inflammations, whether in and about a tooth or elsewhere, injuries to tissues leading to extravasation of blood, cardiac and cerebral excite- ment, all may be greatly relieved by the application of cold. In this class of conditions, however, the rule should be recognized of employing either cold or heat according to which affords the most relief. Methods of applying cold are : the full or partial cold bath, the Leiter coil through which ice-water is allowed to run, the ice-bag, and the application of liquids that evaporate rapidly. The employment of freezing methods belongs to another chapter. Depletion of the Circulation, whether by bloodletting, sweating or active catharsis, is another means of reducing circulatory activity, in PLATE XIV. ACONITE. The tuber of A. Xapellus. The alkaloid Aconitiue repre- sents the drug fully, but is the most poisonous substance of its class. Therefore it is seldom used internally. Sensory nerve ending. Skin Classified as : Arterial depressant. , , '- depressed Cardiac depressant. Kerve depressant. Antipyretic. Physiologic action : Nervous System. Brain. No influence ni^on cerebrum. Medulla. Stimulates vagus center. depresses respiratory center. Spinal cord. Influence imcertain. Sensory nerve endings are depressed after a period of slight stimulation. / 1 Muscular System. Causes general muscular weakness. Circulation. Lessens force, rapidity and pressure of the arterial current. Heart. A direct influence upon the heart is uncertain, but by stimulation of inhibition the heart is slowed and its force weakened— the result being cardiac depression. (Accord- ing to some authorities, the drug depresses the heart muscle and its motor ganglia.) Capillary area. The vasomotor mechanism is not influ- enced by the drug in therapeutic doses. Temperature is reduced. Vagus Center Vaso Motor Center Cervical Symxjathetic The red color indicates the stimulant action of Aconite upon the vagus center, which causes slowing of the heart's action. The blue color indicates the depressant effect of the drug. PLATE XV. SODIUM BROMIDE. [NaBr] [This drug is regarded as the typical and most important agent of the group of bro- mides.] Classified, as : Cerebral depressant. Nerve depressant. Antispasmodic. Anaphrodisiac. iSkin Physiologic action: Nervous Systeni. Brain. Depresses the cerebral cortex, and espe- cially the motor areas. Medulla. Not affected by therapeutic doses. Spinal cord. Lessens reflex irritability, probably mainly through a depression of the sensory por- tion of the cord. Sensory nerve endings are not directly affected, any less- ening of sensation being due to central action. Sexual function is depressed. Circulation. Arterial pressure is lowered somewhat. Heart. Large doses depress the heart slightlj^ Capillary area. Full doses cause vasomotor relaxation. Elimination. The drug is absorbed rapidly from the stomach and intestines, but is eliminated slowly. It may be found in the several excretions, but chiefly in the urine. Other bromides have essentially the same action as sodium bromide, but the latter possesses a high efiiciency and is comparatively non- irritating. Vagus Center Vaso Motor Center Cervical Sympathetic The blue color indicates the sedative effects of the Bromides, their action upon the nervous system being much more important than that upon the circulation. BROMIDES 239 addition to which effect these measures also reduce toxemia, when that is a factor. Of the medicinal agents the most typical ones of the several groups are here presented. Aconitum. (Plate XIV.) This drug is used in fevers and inflammations, to reduce arterial pres- sure. The tincture is used internally, either 5 to 15 minims (0.30-1 mil) several times daily, or in two-drop doses hourly until the effect is secured. With an equal part of tincture of iodine, the tincture is used as an application in pericementitis and pulpitis. The alkaloid aconitine is applied locally in form of the oleate in the treatment of neuralgias, and in obstinate cases it may be given internally in doses of gr. ^q-q (0.00015 gm.). Veratrum Viride and Veratrine have an action which resembles closely that of aconite. (For preparations and doses, see Index of Drugs). The uses of these are very similar to those of aconite. In addition veratrum viride is used to reduce arterial pressure in puerperal con- vulsions. ' Acidum Hydrocyanicum Dilutum. — (See Index of Drugs.) The preparations of wild cherry {Prunus virginiana) owe their sedative value to the presence of a small quantity of hydrocyanic acid. These are useful as excipients in cough mixtures; but when a decided effect from definite dosage is desired, the dilute hydrocyanic acid (2 per cent.) is used in doses of 1 to 2 minims (0.06-0.12 mil). The strong hydrocyanic or prussic acid is never used, as it is too poisonous even to manufacture. Bromides. (Plate XV.) Sodii Bromidum. — Sodium Bromide [NaBr].^ — The sodium salt repre- sents the group well, and is entitled to preference over the potassium salt, as it contains more bromine and is better tolerated. Bromides are freely soluble in water and in alcohol. Since they are quite salty to the taste they must be given largely diluted. The average dose is gr. 15 (1 gm.). The bromides are used in any conditions where there is cerebral or nervous excitement; in headaches, injuries to the brain, meningitis, hysteria, in epilepsy and other convulsive disorders; to control vomiting of reflex or cerebral origin. They are of special value in the nervous 240 SEDATIVES and febrile disturbances that occur so readily during infancy. They may be given freely, but always well diluted so as not to irritate the stomach.* The importance of sedatives in the management of first dentition leads to a brief consideration of that subject following the antipyretic group. ANTIPYRETIC GROUP. These synthetic agents are coal-tar derivatives, all of which occur in the form of white crystalline powders. As antip\Tetic sedatives they have power to lessen temperature in fever, and in addition they have anodyne properties. In fact, since they have come to be recognized as sedatives, being on that account inad- missible in the severe fevers, they have found their most extensive use in the treatment of headaches, neuralgias and myalgias. They differ in their activity and safety. Antipyrina [CUH12X2O]. — Average dose, gr. 5 (0.3 gm.). This is the mildest in action and also most soluble. It is of some value as an anti- spasmodic in the treatment of infantile convulsions and w^hooping-cough. Incompatibility. — Antip\Tine is incompatible with spirit of nitrous ether and with solutions of carbolic acid. Acetphenetidinum.— Ppienacetine [CioHisNOa]. — Average dose, gr. 5 (0.3 gm.). This is more powerful than antip^Tine, but comparatively safe. It is practically insoluble in water. Acetanilidum [CgHgXO]. — Average dose, gr. 3 (0.2 gm.). This is the most powerful of the group and least safe. It is sparingly soluble in water. It has the power of producing alterations in the blood that may cause a decided appearance of cyanosis, when full doses are taken repeatedly, or too large quantity in a single dose. It must be used cautiously, if at all, and never continuously for any length of time. The compound powderf is a useful internal analgesic. The caffeine in this may aid the action of the acetanilid, but it chiefly antagonizes its * While the bromides in their ordinary uses are without danger, it should not be concluded that they are incapable of doing harm. Their prolonged use is not desir- able, l)ecause they certainly do depress cerebral and nerve functions. The only unpleasant symptom commonlj^ attending their prolonged use is the occurrence of pimples upon the face and elsewhere, which is believed to be nature's effort to ehm- inate bromine. t Pulvis Acetanilidi Composiius. (N. F.) Gm. or mils. I^. — Acetanilidi ...... 7 Caffeinse 1 Sodii bicarbonatis 2 — M. Of this the dose is 1| to 8 grains (0.10-0.50 gm.). ANTIPYRETIC GROUP 241 depressant action upon the nervous sj^stem and heart. Locally, acet- anilid is used as an antiseptic powder. Acid, Acetylsalicylic. — ^Aspirin (not official). — Dose, gr. 2-10 (0.12- 0.60 gm.). This drug has come into popular use under the proprietary name aspirin, as a remedy for headache and for various slight pains. It should be employed under the chemical name. First Dentition Complications and Their Treatment. It has been remarked that children bear sedatives relatively better than they do stimulants. The basis of this fact is found in the more sensitive nervous s^^stem of the child. If we compare the size of the brain at birth with the total weight of the body, we find that its relative size greatly exceeds that of the adult brain. At the same time its function is more complex in that it is concerned with the process of development, which becomes less active later on. In consequence of this greater sensitiveness of the child's nervous system, impressions are magnified; not only do slight mental impressions beget fear or emotional outbreak, but slight nerve irritation which in an adult would be unnoticed, or, at most, would cause slight discomfort, in a child may produce fever and convulsions. Accordingly, a stimulant that acts through exciting or irritating a function or tissue will disturb rather than soothe, while a sedative will lessen the sensitiveness of nerve tissue and prevent the disturbances of function. Although occasionally so much depression may occur as to call for stimulants, as a rule they may be dispensed with in childhood, while sedatives hold a place of supreme importance, both as agents to prevent and to control the serious nervous disturbances that occur so easily during that period of life. But the common causes of infantile disturbances are not external, but rather the irritations that proceed from functions abnormally performed within the body. These irritations may be of great variety; but as we see the extreme sensitiveness gradually disappear with the development of the child, we recognize that the maximum of suscepti- bility to irritation exists early, or during the period corresponding to first dentition. We must be reminded that during this period the whole digestive tract is being prepared for a more complex function, that of digesting food of firmer quality and greater variety. From the teeth downward the provisions for solution and absorption of food are being developed and adapted, and throughout there is connection with the same sensitive, directing and controlling central nervous system. This 16 242 SEDATIVES is often shown very emphatically by the occurrence of vomiting or con- vulsions after the self-indulgent parent has enjoyed seeing the infant sit at the table and partake of the common family dishes, for which its digestive apparatus has not yet been prepared. Of all of the developmental changes, the process of eruption of the teeth is the most visible; and it has, therefore, been blamed too indis- criminately for the disturbances that often coincide with it. It is so easy to satisfy anxious inquiry by the statement that the convulsion in a given case is due to teething, or, if that is improbable, to suggest that the child may have worms. Without denying for a moment that abnormal dentition may be the cause of most serious disturbances, we must take a comprehensive view of the developmental diseases of infancy and not be too much influenced by what we may see at either end of the digestive tract. Teething and worms each have a pathologic importance, but we must not allow them to usurp attention that belongs to factors less apparent, but undoubtedly more important in many cases. We must hold improper diet to be an influence of first importance, and this refers not only to character of food, but to quantity and to intervals of feeding as well. Fermentation and putrefaction of food materials, and even infection in the intestinal tract, are prominent factors of disease at any age; but in the sensitive child, with full digestive capacity vmdeveloped, such factors are of superlative importance. There is, however, occasionally seen a case of the most serious general disturbance, where dentition and the digestive function appear to be normal, that must be attributed to a special susceptibility or an abnor- mality in the nervous system itself. Again, we are convinced of the prominence of the central nervous system as a primary factor, when we see a child of unstable nervous constitution have a convulsion from a cause that a normal child will successfully resist. These considerations bring into prominence the part of treatment that refers to the nervous system. It involves temporary prophylaxis as well as relief, and includes daily supervision of the child's diet and habits, with the judicious use of sedatives in order to lessen the irrita- bility of nerve centers, so that they may respond less readily to irritating impressions. More important still is the prophylaxis that fortifies the nerve centers by increasing their stability or tone. Hygienic measures, including an abundance of fresh air, daily bathing with tepid or cold water, and proper feeding, meet this requirement. FIRST DENTITION COMPLICATIONS 243 Probably the majority of children suffer with irritability and feverish- ness at some time dm"ing first dentition. As a rule the daily discomfort becomes more marked as the day advances, until midnight or later, when sleep may occur with frequent interruptions. Convulsion or spasm often occurs in the severer cases. The treatment of the condition will include the hygienic measures previously mentioned. The child should be taken out into the open air as much as is possible during the day as a matter of routine prophylaxis. Fever and fretfulness may be lessened by cold sponging or the cool bath. Medicines may not be needed in the early part of the day, but later, as the irritability increases, the bromides may be given freely and continued until the child rests. If the gums show great hyperemia over advancing teeth, scarification by means of a clean finger-nail or the point of a well-guarded lancet may afford much relief, but indiscriminate lancing of the gum is not to be advised. To refer again to the medicines that are useful, both arterial and nerve sedatives have their place, according to the predominance of vascular or nervous disturbance. The tj^ical arterial sedative drug is aconite. This may be given in form of the tincture, in a dose of one-half drop every hour until the circulatory excitement has lessened. Spirit of nitrous ether may be combined with it for the purpose of inducing sweating, the occurrence of which will reduce the fever. A suggestive prescription for a child one to two years old is as follows : Gm. or mil. I^. — Tincturae aconiti 1 1 (ITlxv) Spiritus setheris nitrosi ... 30 1 (f§j) Glycerini 15 1 (fSiv) Aquae cinnamonii . q. s. ad 60 1 (foij) — M. Sig. — -One-half teaspoonful in water every hour until better. The indications for .this combination would be a full, rapid pulse with fever, and the medicine should be lessened or discontinued when these s}Tiiptoms abate. Aconite must be used with due care, for it is a poisonous drug in excessive dose; so the precise indications for its use and the favorable result of its action should determine the extent of its emplojTnent in any case. In most cases, the danger of convulsions, and the irritability of the nervous system, can be removed by the bromides, whose action is perfectly safe. Their use is addressed to the nervous element, which is usually \'ery prominent, while the circulatory disturbance is secondary and incidental. Therefore, the use of a bromide will, on the whole, 244 SEDATIVES be found most satisfactory, because it meets the primary indication of lessening the sensitiveness of the brain centers and, at the same time, can be used continuously in full doses without danger. Sodium bromide is the topical agent of the group, but it must always be given well diluted, so as to avoid irritating the stomach. The \\Titer has never found the drug to cause vomiting when given freely diluted. It may be given in a dose of 5 to 10 grains (0.30-0.60 gm.) to a child one year old in the emergency of a convulsion, but the dose for continuous administration is 1 to 3 grains (0.06-0.20 gm.). The following formula is simple and useful: Gm. or mil. I^. — Sodii bromidi 2 (gr. xxx) Syrupi 15 (f3iv) Aqu£e cinnamomi . . q. s. ad 60! (f5ij) — M. Sig. — A teaspoonful every hour while restless. The above formula may answer every purpose of necessary medication in the simple irritability of the period of first dentition. Following the directions previously given in respect to hygienic treatment, the bromide need not be given until the beginning of the daily period of increased irritability, which occurs toward evening. Then it may be given hourly until the child is able to rest. It is then advisable to stop the medicine until the next afternoon, or, at least, to reduce it to longer intervals of administration during the morning. A free purge, by the use of castor oil, is usually proper also, the dose being 1 to 2 teaspoonfuls (4-8 mils) or more, according to age. Convulsions. — When spasms occur, the twitching or stiffness of the muscles is attended by unconsciousness. This shows that the brain is concerned in the effects of the irritation, wherever the latter originates. The condition must be treated as an emergency, the aim being to restore consciousness and relieve the convulsion. The head is usually hot, while the extremities may be cold. The treatment will embrace several measures: 1. To lessen the h\'peremia and sensitiveness of the brain. 2. To remove the source of irritation, or lessen its severity. 3. To stop the convulsion directly, if that result does not follow the treatment under 1 and 2. Under the first heading we employ means of bringing blood to the surface of the body, such as the hot (very warm) bath to the whole body except the head. If the latter is hot, cold applications should be made to it, as this will aid in securing the same object by driving the blood from the brain. ]\Iustard flour (1 to 4 teaspoonfuls, mixed first with a CONVULSIONS 245 little cold or tepid water) may be added to the hot bath for a pronounced rubefacient eftect. Meanwhile, treatment coming under the second heading should be employed. ^Nhl\e the convulsion is present it may not be possible to at once remove the irritation, which may be in the digestive tract; but the severity of its effect upon the brain may be lessened by the administra- tion of sedatives. An excellent combination is that of sodium bromide and antip\Tine, the latter having both antispasmodic and antip^Tctic value, and producing also a tendency to perspiration. A combination, giving the emergency dose of sodium bromide as 5 to 10 grains (0.30- 0.60 gm.) and of antipjTine as U to 3 grains (0.10-0.20 gm.) according to age, is here given: Gm. or mil. I^. — Sodii bromidi 10 AntipyrinEe 3 Glycerird 10 Aquae menthse piperitse q. s. ad 60 (Sijss) (gr. xlv) (fSijss) (f5ij)— M. Sig. — One-half to one teaspoonful; may repeat in one hour. If the child does not swallow, as is apt to be the case, this must be given carefully, a few drops at a time. A full dose of castor oil should be given, if swallowing is possible, so that any irritant in the digestive tract may be carried onward. It is not advisable to give an emetic during a spasm, for fear of vomited matter being drawn into the trachea. If relief does not follow in say haK an hour, treatment coming under the third heading may be employed, and this will usually be the cautious use of chloroform by inhalation, the object being to relieve the spasm by direct action upon the brain, with which result sleep takes the place of the coma. From this sleep the child may awake relieved, but in severe cases it may still remain in the convulsion. Spasms can usually be con- trolled by chloroform, but its continuous inhalation is in itself danger- ous, so that reliance for permanent relief must be placed upon the other measures that remove the source of irritation, that relieve cerebral hj-peremia, and that lessen the irritability of the brain centers more permanently. Chloral hydrate is often used by rectum, in dose of a few grains (1-5), when convulsions are persistent. For treatment beyond the emergency period, the bromide and anti- p}Tine may be continued at the intervals necessary to prevent restless- ness and fever. A cathartic should be employed, unless previously given, to ensure emptying of the digestive tract, where the irritation may have 246 SEDATIVES originated. For this purpose castor oil is our first choice, being efficient and harmless. Succeeding the hot bath, the child should be wrapped in hot blankets, in order to keep the blood toward the surface and to favor sweating. If dentition is found to be abnormal or difficult, and teeth are nearly ready to appear, the gums may be scarified as mentioned before. But cutting the gums over teeth that are not likely to appear for several months is questionable practice, as the tissue will rapidly heal, and may even present the additional barrier of scar tissue to the later progress of the teeth. When, however, the gums are very much swollen and con- gested, scarification may be advisable independently of the state of progress in the eruption of the teeth. Other means of accomplishing the objects set forth above may be employed; simply the outline of common practice is here given. In the cases that present an evident infection, the treatment will, as a matter of course, vary according to its nature and the indications it furnishes. Chloralum Hydratum. (Plate XVI.) Chloral [C2HCI3O — H2O]. — Chloral hydrate is a typical hypnotic. It is used to induce sleep and to relieve convulsions. While at one time it was our only efficient hypnotic, it has been supplanted to a consider- able extent by the newer and safer agents. It does not relieve pain in safe doses. Care must be taken not to exceed the safe dose, gr. 5-20 (0.30-1.30 gm.), as it may easily be poisonous. Drugs having similar action: Sulphonmethanum.^ — Sulphonal. Sulphonethylmethanum. — Trional. — These drugs are safer than chloral but slower in action. Trional is more soluble than sulphonal, therefore usually preferred, but either must be given several hours before the eft'ect is desired. Dose of each, gr. 15-30 (1-2 gm.). Opium and its Alkaloids. (Plate XVII.) Opium is the concrete exudation obtained by cutting the unripe capsules of the opium poppy, Papaver somnifenim. It contains, in its fresh, moist condition, at least 9.5 per cent, of morphine (when dried about 10-10.5 per cent.), besides a number of other alkaloids. This drug, in its simple form, in its preparations, or as represented by its chief alkaloids, morphine and codeine, stands at the head of all agents PLATE XVI. CHLORAL HYDRATE. Dose: gr. 5-20 (Gm. .30-1.30J. Classified as : Hypnotic. ^Narcotic. Spinal depressant. Cardiac depressant. Physiologic action : Locally applied, it is somewhat irritant. Internally, it re- sembles chloroform in ac- tion, except that it is not anesthetic in safe doses. Nervous System. Brain. Depresses cerebrum. Induces sleep, but does not relieve pain. Medulla. Depresses respi- ratoiy and vasomotor cen- ters. Spinal cord. Depresses reflex centers. Muscular System. Causes general muscular weakness. Probably depresses muscular coats of the arterioles by direct action. Circulation. Eeduces arterial pressure in marked degree. Heart. Depresses the cardiac muscle, causing slower and weaker action. Capillary area. Dilates arterioles by depressing vasomotor center, and probably also by direct depressant action upon the muscular coats of the vessels. Hespiration. Depresses respiratory center. Temperature. Eeduced by full doses. Metaboli.rm. Destruction of proteids is increased with less per- fect oxidation. With prolonged administration fatty degen- eration of various organs may occur. Center The blue color indicates the sedative effects of Chloral. The marked depressant action upon respiratory and vasomotor centers, andupontheheart. renders Chloral much more dangerous than the bromides, whose effects are similar in kind. PLATE XVTI. MORPHINE. Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus In form of sulphate or hydro- chloride. Gr. |-| (Gm. .008-.015). Classified as : Anodyne. Narcotic. Physiologic action :^ The action of morphine is essen- tially that of a central nerve depressant, the local action of the drug, wherever applied, being almost nil. C'h ildren are very sensitive to th is drug, and, if needed, it shoidd be used in the iveakest preparations, and in less than the proportional dose. Nervous System. Brain, Depresses cerebrum, lessens power of attention, and diminishes sensation of pain. Medulla. Depresses resjjiratory center. Spinal cord. Does not perceptibly influence the cord. Note. — In the lower animals morphine is a stimulant to the spinal cord, but in man marked depression of the highly developed brain prevents any manifes- tation of spinal stimulation. Nerves. The peripheral nerves are not alFected bv ordinary doses. Muscular System. Not affected by ordinary doses. Circulation. Not much influenced by ordinary doses. Heart. Opinions difier. Any in- fluence of a moderate dose must be slight and probably indirect. Large doses slow the heart by stimulating inhibition. Capillary area. jSTot much influenced, except that the cu- taneous area of the head and neck may show dilatation. Respiration. Depressed to a degree corresponding with size of dose. Eye. Pupils conti-acted by central nerve influence. Digestive System. Stomacti. Secretion and motility lessened. Intestines. Peristalsis is greatly diminished. Elimination. Secretions generally are diminished, except the pei-spiration. The drug is partly changed in the system, but the greater part is eliminated by the gastro- intestinal tract. 1 For poisoning by Opium or Morphine, see Table of Poisons and Antidotes. Pelvic Plexus OPIUM 247 for the relief of pain. It is the drug of first importance among poisons, and, next to alcohol, is the one most frequently used in the way of habit. Whenever, therefore, it is used, poisoning and habitual use must be guarded against. It must be administered with some caution to persons whose susceptibilities are not known, and as a rule it should not be given to infants and young children. The prominence of the brain in child- hood makes the child exceedingly susceptible to the influence of this drug, whose action is chiefly upon the brain and medulla. Fortunately this drug is little needed in dental practice, because it has little or no local action. Its inutility to relieve pain by local applica- tion has been discussed in connection with arsenic. Practically the only conditions in which it is called for are severe pulpitis or pericementitis, which fail to be relieved by ordinary local treatment. Here a few small doses of the drug may be given to the patient, but it should not he prescribed in any quantity, for fear that the relief obtained might lead to an easy later resort to the drug, with formation of habit. In the rare cases where it becomes necessary to administer the drug to a child, a much smaller dose must be used than that which the rule would allow.* The preparation used mostly with children is the camphorated tincture of opium, commonly known as paregoric, which contains only 0.4 per cent, of opium. The rule should he not to give opium or morphine to children. Persons who take this drug habitually acquire a tolerance for it, that permits them to take very large doses. While the usual dose of morphine is I of a grain, a victim of the habit may come to use 10, 20 or 30 grains daily. Indeed, there is the need of increasing doses in order to maintain the original effect, even where it is taken for a comparatively short time for the relief of pain. This shows that the tolerance of the drug begins early. Again, when the system has become accustomed to its action, it is usually difficult to stop the use of the drug without some discomfort in the way of unrest, that is at once relieved b}- its readministration. On these accounts it is very easy to acquire the opium or morphine habit, and very difficult to overcome it without the fullest cooperation of the victim with the medical adviser; and with the habit once thoroughly established, subjection to the discipline of a hospital will usually be required in order to succeed. (For poisoning by opium or morphine, see Table of Poisons and Antidotes.) * See Cowling's rule in chapter on Prescription Writing. 248 SEDATIVES Morphina [C17H19NO3+H2O]. — This alkaloid was isolated from opium and described by Sertiirner in 1816, and was the first to be dis- covered of the whole class of alkaloids. It has stood during the years since as the most representative principle of opium; and, while its action varies slightly from that of the whole opium, the uses of the two sub- stances are identical, except that for hypodermic use a morj)hine salt is always employed. Being a very powerful drug, morphine has to be used with caution. For its action in detail, see Plate XVII. Its official salts are: Morphinse Hydrochloridum, soluble in 17.5 parts of water. Morphinse Sulphas, soluble in 15.5 parts of water. The average dose of each of these is gr. | (0.008 gm.), which may be increased as needed up to twice the quantity, in their ordinary use. Codeina [Ci8H2iN03+H20]. — Soluble in 88 parts of water. Codeine is less powerful and less depressing in action than morphine, and its after-effects are less unpleasant. Its official salts are: Codeinse Phosphas, soluble in 2.3 parts of water. Codeinse Sulphas, soluble in 30 parts of water. The average dose of each is gr. | (0.03 gm.) PLATE XVIII. CATHAKTICS. Cushny classifies cathartics into three groups: 1. Mild aperients, the castor oil group. 2. The anthracene purgatives. 3. The jalap and colocynth group. These correspond largely to groups A, B, and D as given below. The diagrams are intended to show the different ways in which cathartics may act. It is not possible to classify strictly, as the action of some is too extensive to be limited to one group. The numbers indicate the diagrams that represent what is believed to be the most prominent action in case of each drug, not always the complete action. [For preparations and doses, see Index of Drugs.] Group A. LAXATIVES. (1) Fruits, Sugar. Sulphur. Purges in small doses. Glycerin (by enema). (2) Geoup B. PURGES. , Aloe. (1) Mercurials. (4) Oleum Ricini. (4) Rhamnus Frangula. (1) Rhamnus Purshiana. (1) Group C. HYDRAGOGUES. Salines. Magnesii Citras. (3) Phenolphthalein. (4) Rheum. (1) Magnesia. (3) Senna. (1) (4) Elaterinum. (4) Magnesii Sulphas. (3^ Jalapa. (■1) Potassii Bitartras. (3) Senna. (1) Potassii et Sodii Tartras • (3) Sodii Phosphas. (3) Sodii Sulpiias. (3) Group D. DRASTICS. Coloeynthis. (5) Olcimi Tiglii. (5) Elaterinum. (3) (4) Podophyllum. (0) Jalapa. (3) (4) Scammoniuni. (5) Cambogia. (5) 1. Motility of large intestine stimulated. 2. Motility of rectum stimulated. The red color shows the site of action, and indicates stimulation of motility or secretion. 3. Secretion stimulated. 4. Motility of small intestine stimulated. PLATE XVIII. CATHARTICS. The natural provision for intestinal evacuation in- cludes three factore : First. A certain amount of indigestible matter in the food. Second. Peristaltic motion from the stomach down- ward. Third. A certain degree of fluidity of contents. A decrease of any one factor tends to constipation, while an increase tends to diarrhoea. Cathartics act by influencing these several factors. Laxative foods act by reason of their indigestible residue. Almost any cathartic may have simply a laxative effect when used in small doses. Purges, by their irritating action, stimulate peris- talsis, the milder ones acting mainly upon the large intestine (1). Some, in large doses, approach drastics in severity of action (5). The absence of bile dimin- ishes the activity of podophyllum, jalapa, rheiun, senna, and scammonium. Hydragogues act in two ways : The less irritating salines cause a marked increase of fluid by determining a flow of serum from the blood into the intestine (3). A low blood-pressure diminishes their activity. The more irritating hydragogues stimulate very promptly peristalsis of the small intestine, with the result that the fluid contents are hurried onward and absorption is lessened (4). Secretion also may be in- creased. Copious liquid stools result. Drastics stimulate powerfully the peristaltic move- ment of the whole tract (5), causing prompt, frequent stools, with severe gi-iping. In large doses they act as irritant poisons, and may cause contractions in the gravid uterus. Cholagogues favor the flow of bile into the duodenum, ^ probably through the increased peristalsis. The in- -J;Z- fluence of cathartics upon the function of the liver seems uncertain and indirect. Motility of whole intestinal tract stimulated. The red color shows the site of action, and indicates stimulation of motilitv or secretion. CHAPTER XVIII. ELIMINATn:ES. A GROUP of functions that are liable to disorder in connection ^Yith any general disease, comprises those that secure the discharge of waste or used-up matters from the body. These functions are called elimi- native, and the organs chiefly concerned in their activity are the skin, the kidneys, the intestines and the lungs. Eliminatims are those agents that increase the eliminative activity of these several avenues of excretion. Cathartics are agents that induce active evacuation of the intestines. (See Plate XVIII.) Diuretics increase the activity of excretion by the kidneys. Diaphoretics are agents that induce sweating. Emetics are agents that cause vomiting. Their action is not so purely eliminative, as vomiting is not a normal eliminative function, but rather a result of irritation, or a symptom of disease. Their eliminative value is seen mainly when a poison or foreign substance requires to be removed from the stomach. Expectorants are agents that increase the secretion of the air passages. In a study of the subject of elimination, we observe a certain comple- mentary relation between the activity of the skin and of the kidneys. A certain amount of water, holding excretory matter in solution, passes out of the body daily, chiefly by the skin and kidneys; and, while the solids are separated from the blood chiefly by the kidneys, the amount of water which they excrete varies greatly, being influenced especially by the activity of the skin. In summer, when perspiration occurs freely, the urine is scanty in quantity but concentrated; while in winter, when the cool temperature lessens cutaneous elimination, the water passes out mainly by the kidneys, causing a large amount of diluted urine. In the application of diaphoretics and diuretics we should take into account this relation, for some agents will act in either way. For example, sphit of nitrous ether, when taken in the evening, with the skin being kept warni during the night, will induce sweating; whereas, when it is given in the morning, followed by exposure to a cool out-of-door temperature, it will act as a diuretic. To some extent bowel activity also may relieve the kidneys. We have, therefore, two resources in the direction of 250 ELI MIX A TI VES vicarious elimination when the kidneys are disabled — viz., by catharsis and by diaphoresis; though they are only substitutes and much less efficient. The lungs eliminate volatile substances chiefly. DIURETICS. Diuretics increase activity of the kidneys in several ways. 1. Some alter the composition of the blood by increasing its salinity. The potassium salts especially act in this way. Potassium is less needed by the system than sodium ; therefore a moderate dose means an excess in the blood, which naturally passes out by the kidneys, carrying con- siderable water with it. This explains why potassium salts are diuretic while sodium salts are not. The most valuable for this purpose are the following : Potassii Acetas. — This salt is deliquescent. Average dose, gr. 15 (1 gm.). Potassii Citras. — This salt is deliquescent. Average dose, gr. 15 (1 gm.) Potassii Bitartras. — Cream of Tartar. — Average dose, gr. 30 (2 gm.). Potassii Nitras. — Nitre. — Saltpetre. — Average dose, gr. 8 (0.5 gm.). Of these potassium salts, the acetate, citrate and bitartrate are harm- less when given properly diluted, and their use may be continued indefi- nitely. The bitartrate is cathartic when given in large dose. The nitrate is used with caution, as it is believed to be more stimulating to the kidney. 2. Another class of diuretics act chiefly by increasing arterial pressure. In many cases where elimination is deficient, it is because the circula- tion is weak and the arterial pressure low; in fact, the balance of blood pressure has been transferred from the arterial to the venous side, which causes dropsy or edema. The best kind of diuretic here may be an agent that restores the balance of pressure to the arterial side, even though it does not directly stimulate the kidney structure. The follow- ing drugs act in this way: Digitalis. — The leaves of Digitalis purpurea. Strophanthus. — ^The seeds of Strophanthvs kombe and of S. hispidus. Sparteinse Sulphas. — A liquid alkaloid from Cytisus scoparivs. Scilla. — ^^QUiLL. — The bulb of Urginea maritina. (For preparations and doses of these, see Index of Drugs.) 3. Still other diuretics act by stimulating the secreting structure of the kidney, leading to a better excretion of solids. These are sometimes called stimulant, or specific, diuretics. Examples of this class are: Spiritus ^theris Nitrosi. — Spirit of Nitrous Ether. — Siveet Sjnrit of Xitre. EMETICS 251 Buchu. — The leaves of Barosma hetulina or of B. serratifolia. Cubeba. — CrBEB. — The dried, unripe fruit of Piper Cubeba. Oleum Juniperi. — Oil of Juniper Berries. Oleum Terebinthinae. — Oil of Turpentine. Potassii Nitras. — Saltpetre. Theobrominee Sodio-salicylas. — Dmretin. Uva Ursi. — The leaves of Ardostaphylos Uva ursi. (For preparations and doses of these, see Index of Drugs.) The above division into classes is convenient, but not absolute, as some diuretics act in more than one way. Such are classed according to their more prominent action. DIAPHORETICS. The agents that induce sweating are well represented by the following: Spiritus ^theris Nitrosi (with skin kept warm). Pilocarpinse Hydrochloridum. Pilocarpinse Nitras. (For doses and uses, see Index of Drugs.) Heat in form of hot-air cabinet bath, hot-air bed bath, hot mustard foot bath, and hot teas of various kinds drunk in good quantity, is a most important and probably the most reliable agency for inducing sweating. EMETICS. The agents that induce vomiting act either by irritating the mucous membrane of the stomach, causing reflex contraction of stomach, dia- phragm, and abdominal muscles, or, by acting directly upon the vomiting center in the medulla, they stimulate the same motor activities. The following act reflexly by irritating the stomach: Sinapis. — INIustard. — The ordinary ground mixture of black and white mustard seed is employed, a tablespoonful or less stirred up in a glass of cold water. Ipecacuanha. — The root of Cephcelis Ipecacuanha or of C. acuminata. Zinci Sulphas. — Sulpil\te of Zinc. Cupri Sulphas. — Sclpil\te of Copper. Antimonii et Potassii Tartras. — Tartar E:metic. The first three are commonly used, being reliable and safe. Sul- phate of copper is more irritating, therefore capable of doing harm. Tartar emetic is also very depressing, and has often caused poisoning. (For preparations and doses of these, see Index of Drugs.) Common salt and powdered alum also are useful emetics. 252 ELIMINATIVES Apomorphinse Hydrochloridum. — Hydrochloride of Apomorphine. — This is an artificial alkaloid derived from morphine. As it acts upon the vomiting center, it may be given hypodermically in cases of poison- ing by opium or other narcotics, where the patient does not swallow. The dose h>T)odermically is gr. ^ ^ (0.006 gm.). (See Index of Drugs.) The use of emetics has lessened somewhat since washing out of the stomach (lavage) has become such a common procedure. The latter has the advantages of emptying the stomach without an}' delay and permitting a thorough washing of its walls. The uses of syrup of ipecacuanha with children merit special atten- tion. In cases of spasmodic croup it is employed, in emetic dose, for the purpose of securirLg complete relaxation of the respiratory apparatus, with relief of the spasm in the larynx. Also in the treatment of bron- chitis in children too young to expectorate, its emetic action is employed in order to expel mucus from the air passages, where its accumulation interferes with breathing and provokes coughing. For both purposes mentioned sjTup of ipecacuanha is given in doses of one-half to one teaspoonful (2-4 mils.), repeated in half an hour if necessary, the pur- pose being to induce vomiting. EXPECTORANTS. Expectorants increase the secretion of the air passages. Some of the emetic drugs, and especially the following, may be expectorant in smaller doses : Ipecacuanha. — Ipecac. Apomorphinae Hydrochloridum. Antimonii et Potassii Tartras. — Tartar Emetic. (For preparations and doses, see Index of Drugs.) Ammonia and ammonium preparations are largely eliminated by the air passages, and they at the same time stimulate the mucous secretion. The chief ones of value are the two following, the first of which is also a general stimulant, and used on this account in the more depressing respiratory diseases, such as pneumonia. Ammonii Carbonas. Ammonii Chloridum. Other expectorants, stimulating in nature, include Cubeba. — Cubeb. Scilla. — Squill. (For preparations and doses, see Index of Drugs.) CHAPTER XIX. ANIMAL DRUGS. Substances of animal origin have from time to time found a place in our materia, medica. Some have fallen largely into disuse, such as musk and castor, of the antispasmodic class. More recently the digestive enzjTiies have been recognized as having a positive value and, while both pepsin and pancreatin are official, even their use has diminished very much with a better knowledge of the physiology of digestion. But the past decade has seen the fuller development of preparations of some of the ductless glands, representing internal secretions of the greatest importance to the nutrition and well-being of the body. These will be discussed as fully as the scope of this book demands. They are employed in the form of the dried gland or of an extract of the gland tissue and in case of the suprarenals an active principle (epinephrine) has been isolated. Thyroideum Siccum. — Dried Thyroids. — The th}Toid glands of animals used as food by man, dried and powdered. Average dose gr. 1^ (0.1 gm.). This substance is absolutely essential in the treatment of conditions due to deficient th\Toid secretion, the disease known as myxedema yielding very promptly to its use, while the more advanced state of malnutrition known as cretinism, if recognized earh^, shows the most remarkable improvement under its use. Since these conditions are due to deficiency of th\Toid secretion, it follows that the treatment must be continued through life. Suprarenalum Siccum. — Dried Suprarenals. — ^The suprarenal glands of animals used as food by man, dried and powdered. Average dose gr. 4 (0.25 gm.). The value of this substance depends upon its power of stimulating, by local action, structures innervated by the sympathetic nerves, particularly the unstriped muscles of the arterioles and the accelerator terminations in the heart. For emergency stimulation of the circulation it is given intravenously, since administration by stomach or hypo- dermically produces very little effect. The local action of this agent is very important in the treatment of 254 ANIMAL DRUGS hemorrhage from small vessels and in connection with cocaine or other analgesics. In the latter use, chiefly by hypodermic injection with the analgesic, its vasoconstrictor action prevents rapid absorption of the latter, holding it to the desired locality, thus rendering its action more efficient and safer. The active principle of the suprarenal gland (epineph- rine, Abel) is used largely in form of the 1 : 1000 solution called Solution of Adrenaline Chloride* (not official). — This may be added to analgesic solutions, at the time of use, within the limit of the internal dose of TH, 10-30 (0.60-2 mils). In nosebleed and other small hemor- rhages this is one of our most valuable local agents. Hypophysis Sicca. — Dried Pituitary Body. — The dried posterior lobe of the pituitary body of cattle. Average dose gr. | (0.03 gm.). The pituitary body seems to be related to the function of growth, its overaction causing an abnormal and excessive enlargement of part or whole of the body, the conditions known as acromegaly and gigantism. Its therapeutic value, however, depends chiefly upon its power to stimulate unstriped muscle, whereby it induces constriction of the peripheral arterioles, stimulates motility of stomach and intestines, increases the secretion of milk and stimulates uterine contractions. In ordinary doses it has little or no central action upon the nervous system. It is administered in solution either hypodermically or intra- venously, since it has little effect when given by mouth. The official solution is Liquor Hypophysis. — Solution of Pituitary Body. — Average dose: Ttl 15 (1 mil). Pituitrin, hypophysin, etc., are commercial extracts of the drug. Serum Antidiphthericum Purificatum. — Diphtheria Antitoxin. Serum Antidiphthericum Siccum. — Dried Diphtheria Antitoxin. — Aver- age dose: hypodermic, 10,000 units; protective, 1000 units. This agent consists of certain antitoxic substances obtained from the blood serum of the horse, after subjecting the animal to increasing doses of diphtheria toxin, whereby immunity against the toxin is secured. The purified antitoxin, as commonly used, either hypodermically or intravenously, has the antitoxic globulins dissolved in physiologic solution of sodium chloride and has a potency of not less than 250 antitoxic units per mil. Antitoxin is now fully relied upon both in treatment of diphtheria and to immunize against the disease. * This substance is also marketed under various other names, such as adnephrine, suprarenine, hemostasine, etc. ANIMAL DRUGS 255 Serum Antitetanicum Purificatimi. — Tetanus Antitoxin. Serum Antitetanicum Siccum. — Dried Tetanus Antitoxin. — Average dose: hypoderraic, 10,000 units; protective, 1500 units. This agent consists of certain antitoxic substances obtained from the blood serum of the horse, after a process of immunizing the animal against tetanus toxin. Used commonly in the physiologic sodium chloride solution (purified form) it is found more efficient as a preventive than as a curative agent; hence, it is common practice to inject hypo- dermically a protective dose after any injury that presents the prob- ability of tetanus infection. For some years past Fourth-of-July injuries have been thus treated, with the result that cases of tetanus, formerly very frequent after these injuries, have been reduced to a small percentage. Its use after the disease has developed is less successful, and here, as an aid to other treatment, it is administered intravenously or, better still, injected directly into the spinal canal. Tetanus anti- toxin has a potency of 100 units per mil. Pepsinum. — Pepsin. — ^White or yellowish scales or powder, being a mixture containing a proteolytic enzyme, obtained from the stomach-wall of the hog. It should digest not less than 3000 times its weight of egg albumen. Average dose, gr. 8 (0.5 gm.). While meeting certain indications of deficient digestive power in the stomach, pepsin is now used much less than formerly. It is often given in an acid solution in imitation of the gastric juice. Pancreatinum. — Pancreatin. — Extract of Pancreas. — A cream-colored powder containing amylopsin, trypsin and steapsin, obtained from the pancreas of the hog or the ox. It should change not less than 25 times its weight of starch into soluble carbohydrates. Average dose, gr. 8 (0.5 gm.). Since pancreatin contains at least three enzymes, it has a wider application to digestive diseases than does pepsin. It is administered usually in powder form, with addition of sodium bicarbonate to insure an alkaline medium for its action, in imitation of conditions found normally in the small intestine. In intestinal indigestion at any age it is found useful, and it is often employed to predigest (peptonize) food, especially milk, for administration either by mouth or by rectum. It is regarded as irrational to use pepsin and pancreatin together, since the former requires an acid medium for its action, while the latter acts best in an alkaline medium. CHAPTER XX. DENTISTRY DURING PREGNANCY. The decision of the question as to performing dental operations during gestation must usually rest upon the combined opinion of family physician and dentist. It is easy to formulate rules of practice, but these may just as easily be disregarded in the presence of an urgent condition. It must always be remembered that gestation is usually a normal, physiologic process, which should permit liberty of treatment within sensible limits instead of imposing too strict limitations. The factors that form the basis for the exercise of caution are: 1. Increased nervous susceptibility of the pregnant woman, particu- larly in the early months. 2. Danger of disturbance of the process of gestation through shock or violence. There may also be noted the prevalent belief that strong impressions upon the senses may be the cause of birthmarks. This belief, though it has the support of some authorities, cannot be given any physiologic basis. The fact that no nervous connection exists between mother and embryo weighs heavily against it; for that fact requires the assumption that some blood condition of the mother is capable of influencing in a peculiar way some particular embryonic tissue; in other words, to exert a selective influence. Assuming such an improbability, it still could not be believed that tissue once normally formed can be subject to such influence; therefore, it is safe to state that any detrimental impression can be potent, if at all, only during the early weeks of gestation, the time of conception doubtless being the most impressionable period. The period of greatest liability to possible dangers of this kind being then at a time when it is as yet uncertain whether pregnancy exists, it, indeed, being oftentimes unexpected, it is evident that we can exercise practically no control in this matter; and for the dental practitioner to observe the general rules to be given later, should suffice as far as he can be concerned. Coming to the practical question of dental operations, we recognize certain periods of greater susceptibility to disturbance. The first DENTISTRY DURING PREGNANCY 257 three months constitute the period of greatest nervous instability, as shown by reflex vomiting, which occurs in the healthiest women as well as in the less vigorous. The system is accommodating itself to the new order of affairs. Certain organs are undergoing change to accom- modate new or increased function. Latent weakness of organs is apt to become manifest. It is the period which usually determines whether accommodation and compensation can sufficiently occur, for it is the period of most frequent failure; which is to say that abortion occurs most frequently during the first three months. This period once passed without accident, health and vigor improve, so that after the fourth month the state of health is often the best ever experienced. This satisfactory status continues to the end of gestation; except that during the last two months there is danger of premature labor being induced through shock or violence. These considerations lead us to divide gestation, for our present pur- pose, into three periods, as follows : 1. First three months — the susceptible and accommodative period. 2. Fourth to seventh month inclusive — the period of vigorous health. 3. Last two months — the period of increasing discomfort. During the first period any considerable operation should be avoided, unless absolutely necessary. Prolonged filling operations, or extrac- tion of a tooth, had better be postponed until after this unstable period of accommodation and great susceptibility. But it must be plain that even the extraction of a tooth may occasion less disturbance than tooth- ache prolonged through several days with sleepless nights. In case of an extraction being positively necessary, an anesthetic may be used at the discretion of the family physician. From the foregoing it appears that the time of choice for dental operations lies within the second period, and preferably during the fifth and sixth months. At this time the general health is at its best and the danger of disturbing gestation at its minimum. There is no good reason why any necessary dental work should not be done during several months at this time. There should be every care taken to avoid the infliction of pain, and short sittings should be the rule. Anesthesia of short duration is admissible when necessary, the choice of agent to be left to the family physician. It should, however, be noted that all during gestation there is an essential tendency to toxemia upon slight- est provocation, because of the extra demand upon nutrition and elimi- nation. It is a question, therefore, whether any anesthetic should be used that will increase this tendency or add to its results. The exclu- 17 258 DENTISTRY DURING PREGNANCY sion of air during the induction of anesthesia, as is common with nitrous oxide, should be avoided, as directly contributing to auto-intoxication, and this means that inhalers that do not allow free access of air, or those that require the rebreathing of expired air, should not be used. In the third period a restrained posture in the dental chair for any length of time may mean serious discomfort. Add to this the danger, though slight, of provoking premature labor, and we are brought to the conclusion that dental operations should be avoided during the last two months, if possible. ^Yhere dental work seems necessary during this period, the operator should consult the family physician before undertaking the same; for it may be that there are unfavorable points in the patient's condition that are known only to her physician. Care of the Mouth during Pregnancy. — Because of the abundantly observed fact that caries of the teeth makes rapid progress in the teeth of pregnant women, care of the mouth with a view to prevention of caries becomes very important. It was earlier believed that the tooth structure suffered a change by giving up some of the mineral salts to meet the needs of the growing embryo. If this were true it would seem that Xatm-e had shown her- self seriously at fault in failing to provide sufficiently for the assimilation of materials that are very abundant in the foods commonly taken. How- ever, it has been shown by Black* that the teeth of females during the period of life when child-bearing occurs, average slightly harder and denser than the teeth of males during the same period of life; and the conclusion follows that the prevalence of caries must be explained in some other w^ay. When we consider the active part that acids take in the production of caries, it is only necessary to point out that the usual vomiting of pregnancy, which occurs during the first three months, brings acid stomach contents daily, and oftener, into the mouth and in contact with the teeth, and we have the basis of a rational explanation of the rapid progress of caries. Also, with the attention fixed upon other matters, and with more or less general indisposition, the teeth are very likely to be neglected just at a time when they need extra care. Upon the basis of this explanation the proph^daxis will be simple and efficient. If we are in a position to advise early, education of the patient comes first; then the simplest kind of an alkaline mouth- wash, such as lime-water or saturated solution of borax or of sodium * Dental Cosmos, May, 1895. CARE OF THE MOUTH DURING PREGNANCY 259 bicarbonate, used freely at frequent intervals and immediately after every occurrence of vomiting, and continued diu'ing the early months, ought to suffice in a special way. The usual directions as to general care of the mouth and teeth will, of course, be emphasized. Unfortunately, even the physician is not consulted in the average case until the period most important for prophylaxis is past; therefore, every suitable opportunity of educating mothers and those likely to be mothers, upon these points, should be improved. PART ly. CHAPTER XXI. PRESCRIPTIOX WRITING. The T\Titing of prescriptions is an art that requires practice for its perfection. Its basis must be a certain attainment in the knowledge of drugs, their activities and their doses, as related to their selection for certain diseases; also of their physical and chemical qualities as related to form of administration and possible combination with other sub- stances. \Yhile it is easy to order a simple solution of a common sub- stance, the forming of an original compound prescription, to suit a special condition, calls for the exercise of as much and as varied ability as does almost any function that pertains to the physician's duties. After the prescriber comes to a point in experience when his remedies are familiar and his own combinations of them are established, their prescription by him in any modification to suit special cases is com- paratively easy; but to the beginner in practice, nothing is much more difficult than to write original prescriptions with any degree of con- fidence. The art of prescribing is quite ancient, having been employed first by the physician to guide his assistant in preparing his medicinal mixtures, the office of physician haidng included also that of apothecary. Today, with pharmacy developed into a distinct profession, our prescriptions are intended to direct the preparation of a medicine to be supplied by the pharmacist to the patient, to be used according to the 'vsTitten directions of the prescriber. There is a marked contrast between ancient and modern prescriptions, in respect to their definiteness and simplicity. Reference to the works of Fallopius, who lived 1523-1562, furnishes an illustration of complexity in prescribing, in a formula written by him, which contains thirty-two different ingredients. Since the sixteenth century we have learned enough about the human body and its diseases to know that it is unnecessary to exhaust our materia medica in prescribing for any one disease, and, with a more 262 PRESCRIPTION WRITING definite knowledge of the action and effects of drugs, we find that only a few agents can be employed to real profit in meeting a pathologic con- dition. Hence, our prescriptions of today approach the extreme of simplicity, usually containing not more than three or four ingredients. The term "shotgun" prescription is derisively applied now^ to a formula containing a large number of substances, upon the supposition that it is expected to hit somewhere. A certain idea of definiteness, however, is traced back to Asclepiades (about 100 B.C.), who is credited with for- mulating the object of treatment to be to cure quickly, safely and pleasantly (curare cito, tide et jucunde), and this has led to a recognition of the typical formula as consisting of four ingredients, each related to this object and named accordingly. 1st ingredient — Basis or base. Cure. 2d ingredient — Adjuvant or auxiliary. Quickly. 3d ingredient — C'orrigent or corrective. Safely. 4th ingredient — Excipient or vehicle. Pleasantly. While these terms aid us in comprehending the full purpose of pre- scription writing, it must be understood that a formula need not contain more than one active agent, and that any combination of medicines should always be based upon definite objects to be attained, either as to form or utility. Several definitions are here necessary to the proper understanding of terms : A formula consists of the names and quantities of ingredients that are to enter into a medicinal preparation, wath directions for compounding them. An official formula is one that is contained in the United States Phar- macopceia. An extemporaneous formula is one that is made up by the prescriber for the occasion. A formula may be simple, containing only one medicinal agent, or compound, containing two or more active ingredients. A prescription consists of the formula for the preparation of a medi- cine, to which is added the directions for its use in a given case. Whenever a prescription orders an official formula, only the title of the latter need be given, without naming the ingredients. Thus, Dover's powder (containing opium 1 part, ipecacuanha 1 part, and sugar of milk 8 parts) is official under the title Pulvis Ipecacuanhse et Opii. In pre- scribing, therefore, it is only necessary to write — I|. — Pulveris Ipecacuanhse et Opii (quantity), SELECTION OF INGREDIENTS 263 instead of naming each ingredient and its quantity, as would be necessary if it were not official. A pharmacopoeia is a book of national authority, containing a list of recognized drugs and preparations, with their descriptions, tests and formulas. It is the authoritative standard for the purity and strength of drugs and for uniformity of preparations. It may give the average dose of each internal remedy, but it includes nothing of the actions and uses of drugs. While in most countries the pharmacopoeias are under governmental control, the United States Pharmacopoeia is under the control of the professions of medicine and pharmacy, and is revised by their direction every ten years. The points involved in making a compound prescription are: (a) Selection of the drugs to be employed. (b) Their solubility (unless powder form is desired). (c) Their compatibility in the desired combination. (d) Their dose. These points will be considered separately. SELECTION OF INGREDIENTS. Selection of drugs must depend primarily upon a knowledge of the conditions to be treated and acquaintance with the power of drugs to remedy the same, and secondarily upon the practicability of their adminis- tration or their combination with other necessary ingredients. Some drugs, by reason of their chemical properties, must always be given alone; others cannot be brought into solution; others are poisonous. Under this heading the main objects of combining medicines may be stated as follows: 1. To secure the combined effects of similarly acting medicines — e. g., strychnine, as a bitter tonic, may be combined with iron as a general restorative tonic. 2. To secure the effects of medicines that have distinct and unrelated actions — e. g., in the official Pilulse aloes et ferri, the aloes is a cathartic and the iron a restorative to the blood. 3. To secure the opposite effects of medicines. (a) By correcting or modifying the action of the base, as when tincture of aconite is added to tincture of iodine to render its action milder. (b) By rendering the action of the base safer. Here antagonism of drug actions is made use of, as in the common addition of atropine to morphine in order to counteract its depressant action upon the respiratory center. 264 PRESCRIPTION WRITING 4. To secure a suitable form. (a) By the use of special solvents to obtain a liquid form of an other- wise insoluble substance — e. g., salicylic acid requires 460 parts of water to dissolve it, but if borax is first dissolved to saturation salicylic acid is soluble in less than 100 parts of the solution. (fe) By securing a finely divided state of the drug. Sugar of milk is often used, on account of the hardness of its crystals, to rub up other drugs into very fine particles, as in tablet triturates. (c) By obtaining a inixture that is agreeable to the sight and -pleasant to the taste. 5. To obtain a combination to act as a new substance. (a) By simple mixture. Dover's powder contains opimn and ipecacu- anha, the combination having a diaphoretic effect not possessed to any degree by the separate drugs. (6) By chemioal action. Chemicals are sometimes combined in order to obtain a new definite compound by their reaction. 6. For preservation of the medicine. Alcohol, glycerin, or sugar in large quantity, may serve not only as excipients, but also to preserve medicinal preparations which are to be kept for some time. It is not considered good pharmacy to add antiseptics to medicines. Sugar in dilute solution will ferment easily at a summer temperature, but when used in strong solution (70 to 85 per cent.), as in some of the official syrups, it will preserve the preparation indefinitely. Knowing what substances we wish to combine, the form of the com- bination must be determined, whether powder, pill, capsule, or liquid. For the first three the quality of solubility is unimportant, but when the medicine is to be in liquid form, solution must be secured whenever it is possible. SOLUBILITY. The prescriber should familiarize himself with the solubility of each of the solid substances that he is likely to use, for the reason that no rule of solubility can be laid down. A few general statements, however, may serve some purpose. It is found that salts are usually more soluble in water than in alcohol. Substances that are soluble in water are quite likely to be soluble in glycerin. Gums and mucilages are soluble in water, but insoluble in alcohol. Resins and resinous substances are soluble in alcohol, but insoluble in water. SOLUBILITY 265 Substances that are soluble in alcohol are generally soluble also in ether, chloroform and benzin. Water stands as the most universal solvent and vehicle in medicinal combinations. Alcohol is most valuable in preparations that are to be kept, because of its preservative power in addition to being an excellent solvent. Glycerin has solvent powers similar to those of water, and it is also a good preservative. With some drugs it is necessary to add an acid, and with others an alkali, to aid solution — e. g., borax will aid solubility in water of both benzoic and salicylic acids; on the other hand, quinine sulphate has its solubility in water increased by the addition of sulphuric acid. A number of substances can be conveniently handled in saturated solution, some to be used in full strength, others requiring dilution. The following table furnishes the degree of solubility, and also the approx- imate percentage strength of saturated aqueous solutions, of a number of the most commonly used substances : [For solubility of other agents, see Index of Drugs.] Percentage strength Soluble in parts of saturated of water. solution. Acid, benzoic 275 0.36 per cent. Acid, boric 18 5.5 " Acid, carbolic (phenol) . .• . . 15 to 20 5 " Acid, salicylic 460 0.22 " Acid, tannic 0..34* 300 " Alum 9 11 " Ammonium carbonate 4 25 " Ammonium chloride 2.6 40 " AntipjTine 1 100 " Betanaphtol 1000 0.1 " ^ 4t 25 " Caffeine, citrated 1 „_ I 2o 4 " Caffeine sodiobenzoate 1.1 90 " Calcium chloride 1.2 83 " Chloroform 200 0.5 " Cocaine hydrochloride 0.4 250 " Codeine phosphate 2.3 45 " Copper sulphate 2.5 40 " Corrosive sublimate 13.5 7.4 " Creosote 140 0.71 " Iodine 3000J * U. S. P., 1900. t Citrated caffeine with about 4 parts of hot water forms a clear, syrupy solution which, when diluted, deposits caffeine, which redissolves with 25 parts of water. X The solubihty of iodine is increased by the addition of potassium iodide, as in Lugol's solution and in the tincture. 266 PRESCRIPTION WRITING Soluble in parts of water. Lead acetate Magnesium oxide . Magnesium svdphate . Morphine sulphate Potassium bicarbonate 1.4 15* 1 15.5 3 Potassium bitartrate 155 Potassium bromide Potassium carbonate . Potassium chlorate Potassium iodide . Potassium nitrate . Potassium permanganate Potassium sulphate Quinine bisulphate ... 1.5 ... 0.9 . . . 11.5 ... 0.7 ... 2.8 . . . 13.5 ... 9 ... 9 Quinine sulphate 725 Resorcinol 0.9 Saccharine (benzosulphinide) . . . 290 Silver nitrate 0.4 Sodium benzoate 1-8 Sodium bicarbonate 10 Sodium borate 15 Sodium bromide 1-1 Sodium chloride 2.8 Sodium thiosulphate (hyposulphite) . 0.5 Sodium saUcylate 0.9 Strychnine sulphate 32 Sugar 0.5 Thymol 1000 Zinc acetate 2.3 Zinc chloride 0.25 Zinc sulphate 0.6 Percentage strength of saturated solution. 70 per cent. 100 6.5 33 0.65 66 110 8.7 143 36 7.4 11 11 0.14 110 0.35 250 55 10 6.6 90 36 200 110 3.1 200 0.1 43 400 166 The following table is of convenience in preparing any solution of a desired percentage strength. Quantities are expressed in the old system of measures, with metric equivalents also given. The result is not absolutely exact, but sufficiently so for practical purposes: Amount of solution wanted. Quantity of drug needed for i% strength. 1% strength. 2% strength. 5% strength. 10% strength 1 fluidrachm (4 c.c). 1 fluidounce (30 c.c). 1 pint (500 c.c). iV gram (0.02 gm.). 2 I grains (0.15 gm.) 40 grains (2.5 gm.). 4 grain (0;04gm.). 5 grains (0..30 gm.). 80 grains (5 gm.). 1^ grains (0.08 gm.). 10 grains (0.60 gm.). 25 drachms (10 gm.). 3 grains (0.20 gm.). 24 grains (1.50 gm.). 6 J drachms (25 gm.). 6 grains (0.40 gm.). 48 grains (3 gm.). 12^ drachms (50 gm.). * With 15 parts water magnesia does not dissolve, but forms the gelatinous milk of magnesia. INCOMPATIBILITY 267 To illustrate: suppose a fluidounce (30 c.c.) of a 2 per cent, solution of cocaine hydrochloride is wanted. Opposite the desired quantity in the first column find the quantity expressed in the 2 per cent, column, which in this case is 10 grauis (0.60 gm.). This dissolved in the fluid- oimce of water will make the desired strength of solution. INCOMPATIBILITY. Unless the ingredients of a prescription are compatible with each other the object of their combination may be lost, for a reaction may occiu- between two drugs, with the result that the activity of each is altered or destroyed. Again, such reaction may. in case of certain sub- stances, produce poisonous compounds. Incompatibility may be physical or chemical. Physical Incompatibility consists of (a) alterations in conditions of solubility without any chemical change, and also (h) pertains to the inability of certain substances to mix with each other, as oil and water. Examples of physical incompatibility are: 1. Gums and mucilaginous substances are precipitated from aqueous solutions by alcohol and alcoholic liquids — e. g., syrup of acacia with tincture of chloride of iron will precipitate the acacia. 2. Resinous substances are precipitated from alcoholic solutions by water — e. g., tinctiu-e of m\Trh with water will become tiubid from precipitation of resin. Chemical Incompatibility consists in chemical reactions between sub- stances, whereby their nature is altered. There may be: 1. Simple chemical change without any ^"isible result. 2. Simple chemical change with or without loss of medicinal acti\"ity. 3. Precipitation of a new compound that is insoluble. 4. Coagulation. 5. Formation of poisonous compounds. 6. Formation of explosive compounds. It is difficult to bring aU instances of chemical incompatibility under rtile; and the knowledge of chemistry necessary to predict always that incompatibility will or will not occtu*, is not a common possession. In addition to the more important incompatibilities previously given in connection with the individual drugs, there are given below some general statements that will serve as a basis for study. A cardinal rule to be observed is that drugs should never he prescribed with their chemical tests, unless a chemical reaction is desired. 268 PRESCRIPTION WRITING 1. Alkalies, hydrates and carbonates react with acids and acid salts. 2. Alkalies, hydrates and alkaline carbonates react with salts of alkaloids. If the latter are in solution, precipitation of the pure alkaloids occurs. 3. Solutions of tannic acid react with salts of copper, iron, lead and mercury. 4. Solutions of tannic acid react with alkaloids and with their salts. 5. Acids or acid salts react with alkalies, hydrates, carbonates and with salts of glucosides. Other common incompatibilities that do not admit of classification include : The reaction of certain salts with each other — e. g., nitrate of silver with any chloride. Alcohol and chloral hydrate. Antip,\Tine and spirit of nitrous ether (when acid). Borax and solution of corrosive sublimate. Carbolic acid (pure or saturated aqueous solution) and cocaine hydrochloride. Carbolic acid (pure or sat. aq. soln.) and antipyrine. Carbolic acid and collodion. Glycerin with potassium chlorate and tincture of chloride of iron. Iodine (in solution) and starch. Lime-water with calomel or corrosive sublimate. Potassium iodide and spirit of nitrous ether (if acid). Potassium permanganate and sulphur (explode when triturated). Potassium permanganate and glycerin, s>Tup or other liquids con- taining organic matter. Powerful chemical drugs and oxidizing and reducing agents should be prescribed alone. It would be well to avoid combining the following with other substances:. Acids, strong. Alkalies and their hydrates. Arsenic. Mercuric chloride. Potassium chlorate. Potassium permanganate. Silver nitrate. Tannic acid. ANTAGONISM OF DRUGS 269 It should be noted that chemical incompatibility may be intentional, in order to obtain a new substance — e. g.,in. preparing ferri hydroxidum, magnesium oxide (alkaline) and solution of a ferric salt (acid) are mixed, the result being a precipitate of the hydroxide. Also, in the employ- ment of chemical antidotes in the treatment of poisoning, their value is based upon their incompatibility with the poison. ANTAGONISM OF DRUGS. The term therajjeutic incompatibility does not apply to the combina- tion of drugs, but to their action. It is often used to designate what is better known as antagonism of drugs. We recognize and employ the opposite effects of drugs to the extent- of combining them in order to guard against poisoning, and of adminis- tering, in case of poisoning, a drug that shall counteract or antagonize the toxic action. In this sense we speak of such drug as a physiologic antidote to the poison. But while we thus employ antagonism of drugs to good purposes, in our prescriptions we avoid combinations that will neutralize the desired effect of the principal drug or drugs, unless a corrective action is needed, as when belladonna or a volatile oil is added to a strong cathartic drug to prevent griping. Antagonism of drugs can seldom be absolute — i. e., there are very few drugs whose effects exactly neutralize the effects of other drugs. In cocaine poisoning we find that two drugs, at least, are needed to fully cover the depressant action of the poison. (Plate IV.) Antagonism, therefore, is usually only partial, but it still may meet the most serious sjinptom in a case. Thus in poisoning by morphine the most dangerous condition is that of paralysis of the respiratory center. Strychnine will antagonize this condition, though it has almost no influence upon the narcosis. Among the medicines discussed in this treatise the most positive antagonistic relations are the following: Drug. Aconite Atropine Bromides ) Chloral / Antagonist ' Atropine Nitrites . Caffeine . Digitalis . Aconite . Digitalis . Morphine Caffeine . Atropine Digitalis . Strychnine Site of antagonism. Vagus nerve. Vagus nerve. Heart. Heart. Vagiis nerve. Vagus nerve. Respiratory center, cerebrum. Brain, circulation. Brain, circulation. Heart. Medulla, spinal cord. 270 PRESCRIPTION WRITING Drug. Caffeine Chloroform Cocaine Digitalis Ether Morphine Nitrites Strychnine Antagonist. f Aconite . I Bromides, chloral I Morphine [ Anesthetics . f Caffeine . \ Strychnine [ DigitaUs . f Atropine I Caffeine . j Strychnine [ DigitaUs . Aconite . Atropine Bromides, chloral Chloroform . Cocaine . Nitrites . I Caffeine . \ Strychnine . f Atropine ] Caffeine . [ Strychnine . ' Aconite . Atropine Caffeine . DigitaUs . Ergot Strychnine . ' Bromides, chloral Chloroform . Ether . . . Morphine Nitrites . Site of antagonism. Heart. Brain, heart. Brain, respiratory center. Brain, respiratory center, heart. Cerebrum, respiratory center, heart. Heart, respiratory center, spinal cord. Heart, vasomotor system. Cerebrum, respiratory center, heart. Cerebrum, respiratory center, heart. Respiratory center, heart, spinal cord. Heart. Heart. Vagus nerve. Heart. Heart, vasomotor system. Heart. Vagus center, vasomotor system. Cerebrum, respiratory center. Respiratory center, spinal cord. Cerebrum, respiratory center. Cerebrum, respiratory center. Respiratory center, other reflex centers. Vagus nerve. Vasomotor system. Vasomotor system. Vagus center, vasomotor system. Vasomotor system. Vasomotor system. Medulla, spinal cord. Heart, respiratory center, spinal cord. Respiratory center, spinal cord. Respiratory center, other reflex centers. Vasomotor system. Antagonism of local remedies depends chiefly upon their chemical qualities, the action being usually an antidotal one, as when an acid is neutralized by an alkali, or silver nitrate by sodium chloride. This part of the subject is treated whenever necessary in connection with the various local remedies. (For chemical antidotes, see Table of Poisons and Antidotes.) DOSES. Posology, or the science of dosage, constitutes an important part of our knowledge of drugs. Whether we use few or many substances, safety requires us to know concerning each, what quantity may be expected to produce a certain desired effect and also what quantity must not be exceeded when it is necessary to secure its full physiologic influence. Conditions in disease vary so greatly, and the individual susceptibilities of patients are so uncertain, that we must regard the statement of a single definite quantity for a dose as being somewhat arbitrary. There- fore, it is advisable to know, not a single quantity, but a range which THE PRESCRIPTION 271 shall include the mmimimi and the maximum of ordinary dosage. Idio- syncrasy forbids the use of certain drugs with certain individuals. It also modifies the action of the drug in some cases. Tolerance for certain drugs, particularly morphine, may be established, so that those who take it habitually frequently come to use doses many times greater than the ordinary poisonous dose. The mode of administration, whether by stomach or hjTJodermically, wUl modify dosage. (See chapter on Admin- istration of ^Medicines.) After all, the dose of a drug is a relative quantity, which reciuires to be varied, according to conditions, within a certain range of efficiency and safety. The doses of the principal drugs, or of one or two preparations of each, which represent them fully, should be learned. Dosage for Children. — The doses usually given in text-books and tables are for adults. For children only a fractional quantity, proportional to the age, may be used. The simplest rule for the calculation of a child's dose is that kno^\Ti as Coiding's Rule, which is: Divide the age of the child at its next birthday by 24, Thus a child three years old wiU have 2"4 or I of the adult dose. Young's rule, which divides the child's age by 3 the age + 12, gives a slightly larger fraction; thus t — 7^=5- In con- nection with such rules it must be borne in mind that children are very susceptible to the action of opium and morphine; therefore, these drugs, always to be avoided ■^■ith children if possible, may only be gi^'en in much smaller quantity than the proportional dose by rule. THE PRESCRIPTION. A proper prescription always consists of five parts: 1. The heading. 2. Names and quantities of ingredients. 3. Directions to the compounder. 4. Directions to the patient. 5. Date and signatiu-e. These will be considered in order: 1. The Heading. — Anciently the prescription was begun with a prayer to Jupiter or other heathen deity. Later this was shortened to the simple sign of Jupiter (1^) . With an upright stroke before it we have a resem- blance to the sign I^, which we use today. To us this sign really means: "Take," being an abbreviation of the imperative form recipe of the Latin verb recipio — to take. 272 PRESCRIPTION WRITING 2. Names and Quantities of Ingredients. — ^The names are usually written in Latin, for the reasons that this is not subject to the changes of a modern language and, being a universal language of science, it is known the world over. A formula in Latm, therefore, can be read anywhere in the world of science today, and doubtless will be just as current one hundred years hence as now. The quantities are expressed either in the terms of apothecaries' weight and corresponding liquid measure, or in terms of the metric system. The latter has the advantage of simplicity in being a decimal system. Calculation by it is easier, and there is less danger of error, because the position of a figure denotes its value, and not an added sign that may be poorly written. 3. Directions to the Compounder. — In most cases the precise mode or detail of compounding is better left to the dispenser, who is trained in that art, and the simple abbreviation ]M., which stands for the Latin imperative misce, meaning "mix," is sufficient. Only when the pre- scriber has special directions to give, or when directing the number of pills or powders into which a mixture is to be divided, need he write out his directions in full. Li such case Latin may be used, but plain English is preferable, unless the prescription is likely to go to a foreign country. 4. Directions to the Patient. — This part added to a formula makes of it a prescription. It is begun with the abbreviation Sig. (or S.), which stands for the Latin signa, meaning "Write;" and whatever is directed should follow this sign and be written without abbreviation, so that it may be copied verbatim upon the label. Not only should these direc- tions be written out in full, but they should be read to the patient or attendant, in order to guard against danger through a possible error in copying. The directions to the patient must state how the medicine is to be used — if locally, the word " apply" may be included ; there is good reason also for placing immediately after the "Sig." the term "mouth- wash," "gargle," "ointment," "wash," or whatever will best designate the nature of the local application and serve to guard against its being taken internally; if internally, the directions must include dose in drops, teaspoonfuls, etc., and the time or intervals of taking. This part of the prescription must be very explicit, and the common phrase "use as directed," with only verbal directions to the patient, should be discarded. In case a poisonous application is ordered it is well to add the word "Poison" to the directions, with, however, verbal explanation to the patient or attendant as to its proper use. THE USE OF LATIN IN PRESCRIPTIONS 273 5. Date and Signature. — The date is essential for reference, and the prescriber's signature for authenticity. It is common practice, however, to use printed forms which have the prescriber's name and address above or below the blank space reserved for the prescription proper, in which case the signature is often omitted. The name or initials of the patient should be added, in order to avoid the use of the wrong medicine, in case of more than one prescription being filled at the same time for different members of a family. Sometimes a special note in addition to all the above will be advisable, as when quite large doses of a drug are ordered; the statement "large dose intended," or writing out the quantity, will show the dispenser that the amount ordered is correct. Again, the evil of repeating prescriptions by unprofessional phar- macists may be guarded against by writing prominently upon the prescription the words "not to be repeated." The reference above to improper pharmacy leads the author to express his appreciation of the professional pharmacy which is so evident today. The knowledge of doses that the pharmacist is required to possess is a safeguard against errors of dosage in prescriptions. The prescriber is responsible for whatever he writes, but physicians have often been saved the humiliation of discovered error in prescribing, or the results that might follow, by the cooperation of the pharmacist in calling attention confidentially to the same — a kind of favor too often unappreciated by the prescriber. THE USE OF LATIN IN PRESCRIPTIONS. To write prescriptions in best form requires some knowledge of Latin, especially of the declensions of nouns and adjectives, but not more than can be acquired in a very short time with the aid of a Latin grammar. To one not sufficiently familiar with the language, this course is earnestly advised, as repaying well the effort that is necessary.* As a means of review, and in order to emphasize what is really essential to our purpose, a brief outline of the essential grammatic forms is here given, without any attempt at completeness. Many case-endings are never used in prescriptions, and are, therefore, omitted. The genitive endings are given prominence because they are almost invariably employed. * A very useful aid is the Latin Grammar of Pharmacy and Medicine, Robinson. P. Blakiston's Son & Co., Philadelphia. 17 274 PRESCRIPTION WRITING Declensions of Nouns and Adjectives. Nouns. 1st Declension. Fern. 2d Declension. Masc. Neut. 3d Declension. Masc. and Fem. Neut. 4th Declension. Masc. and Fem. Neut. Singular. ' Nominative a (e) Genitive ae (es) Accusative am (en) Ablative a (e) Plural. Nominative ae Genitive arum Accusative as us (os) um (on) um (on) (various) Exceptions: (as Nom.) um (ium) Theobroma — tis, Rhus — ois, is of and Physostigma | the 3d declension. — tis, are of the 3d declension. The 4th declension includes only four names of drugs: Cornus Fructus Quercus Spiritus Indeclinable: Amyl Buchu Catechu Elixir Gambir Kino Sassafras Alcohol I are regarded by Eucalyptol > some authorities Menthol J as indeclinable. Adjectives. 1st and 2d Declension. [ 3d Declension. i Masc. Neut. Fem. Masc. Neut. and Fem. Singular: Nominative a us (er) um is (s) e (s) Adjectives of other ter- minations and plural Genitive ae i i is forms are very seldom used in prescriptions. Accusative am um um em e (s) The rules of Latin grammar apply as to relation of nouns, adjectives, verbs ancJ other parts of speech. WEIGHTS AND MEASURES 275 Use of Cases. — The nominative case is never used in a prescription, as the sentence is ahvays introduced by the imperative recipe, the sub- ject of which is tJiou understood. The complete sentence would be: Take thou ] of a substance | a quantity. ■ I (genitive) | (accusative) The genitive case of the name of ingredient is required when the quantity is expressed by a noun, as: Take thou | of a substance | one ounce. I (genitive) | (accusative) The accusative case of the name of the ingredient is required when the quantity is expressed by a simple numeral adjective, as: Take thou /owr pills = I^. Pilulas iv. The ablative case is used after the preposition cum (meaning ivith), as: I^. — Ferri hydroxidi cum magnesii oxido, 5j. Verbs. — The few verbs employed are in the imperative form except where the directions to the compounder are ^\Titten in Latin, when the passive form may be also needed, as: I^. — Massse hydrargj'ri, gr xxx. Fiant pilulae, vj. (Let be made pills six.) WEIGHTS AND MEASURES. The system of weights and measm'es most approved in scientific circles is the metric system. Being a decimal sy.stem, it is easily mastered, and no student in any department of medical science should be excused from acquu'ing a practical familiarity with its use. The United States Pharmacoiceia employs it exclusively in the expression of quantities of ingredients. While it is not possible to discard the apothecaries' system entirely at the present time, because of the large number of practitioners who have used it for years, whenever the old system is employed its denominations may be reduced to three, as follows: A jyothecaries' . Liquids. 60 grains (gr.) = 1 drachm (5) 60 minims (Ttl) = 1 fluidrachm (fo) 8 drachms = 1 ounce (§) 8 fluidrachms = 1 fluidounce (fg) The use of the scruple 3 (20 gr.) often leads to a confusion of signs, and the pound (16 oz.) is seldom required in prescribing, so they are omitted. 276 PRESCRIPTION WRITING The Metric System. — In studying the metric system advantage may be taken of its similiarity to our American system of money, using the latter to illustrate the former in a very simple way, as appears below. In the comparison below, the decimal point, or perpendicular line, is the dividing point between units and fractions: (y °^ m I Q O S United States money 10 Metric weight Grams 10 Metric capacity Milliliter or Cu. centimeter 1 CD r^ -— 1 1 1 1 1 Note. — In practical use we disregard the term decigram, much as we do the term dime, using centigrams, as we do cents, for any fraction of the unit; but the term millioram, is much used because of the small fractions which so many doses require. 15.4 grains. 1.5 0.15 " 0.015 " Approximately. 15 grains. li " 16.23 minims. 1.6 0.16 0.016 " Approximately. 16 minims. U " Equivalents of apothecaries' weights and liquid measures in grams and cubic centimeters are : EXACTLY. Gm. APPROXIMATELY. Gm. EXACTLY. Gm. APPROXIMATELY. Gm. Tou grain -id " = .000648 .00108 .0006 .001 10 grains 15 = .6479 .9717 .60 or 1. t'o " \ = .00648 .006 15.43 " = 1. 1. = .0081 .008 20 = 1.296 1.30 1 " 5 = .0162 .0324 .015 .03 30 1 Drachm : 1.944 3.888 2. 4. 1 Grain 3 grains 4 " = .0648 .1944 .2592 .06 .20 .25 or .065 2 drachms 4 1 Ounce = 7.776 15.551 31.102 8. 15.50 31. 5 " = .3239 .30 WEIGHTS AND MEASURES Zi i EXACTLY. APPEOXniATELT. EXACTLY. AFPEOXniAIELY. C.c. C.c. Cx. Cj:. 1 Minim = .06161 .06 1 Fluidrachm = 3.696 3.7 -I \f;riirrii = .24644: .25 1 Fltiidotmce = 29.573 30. PI Afinim? = ..30S0.5 .30 1 Pins- = 473.179 475.* 10 Afinim? = .6161 .60 1 Quart = 946.35S 950.* lo Afinim? = .924 ■ 1. 1 GaUoQ = 3785.432 3800. 16.23 Minim- = 1. 1. =. — A?=:=.CX1M-IT£LY 4- 1 ' APPBOXilMATEL.Y% IN;- 1 LITER CONTAINS 1000 MILULITERS OR CUBIC CENTIMETERS HOLDS 1 KILOGRAM OF DISTILLED WATER AT 4-'='C. EQUIVALENT OF 2.11 PINTS MEASURES ta.23 MINIMS Fig. 15. — Diagram shomag: 1. The capacity of 1 Hter with its equivalents. 2. Linear measures — decimeter and centimeter, with equivalents. 3. The cubic centi- meter or mLUiHter, and gram, with equivalents. (Slightly reduced in size.) The several units of the metric system are: Unit of length: ]»kleter = 0ne forty-miUionth part of the earth's meridian ^39.37 inches). Unit of capacity: Liter = One cubic decuneter (1.05 quarts). Unit of weight: Gram = Weight of one Cuhic centimeter or Milliliter of distilled water at 4° C, the pomt of greatest density of water (15.4 grams) . Following are given the exact and approximate equivalents of the metric measures of length, capacity and weight. * For ordinary purposes .500 c.c. is the convenient approximate equivalent of a pint and 1000 c.c. of a quart. 278 PRESCRIPTIOX WRITIXG LENGTH. EXACT EQCIVALEIO-S. .03937079 inch Millimeter, .001 .3937079 inch Centimeter, .01 3.937079 inches Decimeter, .1 39.37079 inches Meter, 1. 32 feet 9.7079 inches Dekameter, 10. 328 feet 1.079 inches . Hektometer, 100. 3280 feet 10.79 inches . . . . Kilometer, 1000. 6.213824 miles Mj-riameter, 10000. APPRO.XIMATE EQUIVALENTS. ■}s of an inch. i of an inch. 4 inches. 3 feet 3 inches. 2 rods. 20 rods, f of a mile. 6t miles. EXACT EQUIV.VLEN'TS. Liquid. .2705624 f5 .338158 f5 .845395 gi. 1.0567454 qts. 2.64186 gal. 26.4186 gal. 264.186 gal. 2641.86 gal. Dry. .06102705 cu. in. .6102705 cu. in. 6.102705 cu. in. .90813 qt. 1.13516 pks. 2.8379 bu. . 1.30802 cu. yds. 13.0802 cu. yds. CAPACITY. Millihter, Centiliter, Deciliter, Liter, Dekaliter, Hektoliter, Kiloliter, MvTialiter, APPROXIMATE EQUIVALENTS. .001 .01 .1 1. 10. 100. 1000. 10000. Liquid. Dry. 16 m .06 cu. in 2.7 f5 .6 cu. in. 3.3 f5 6 cu. in. Iqt. .9 qt. 2 . 5 gal. 1 pk. 26 gal. 2.8 bu. 8.3 bbls. 35 cu. ft. 84 bbls. 13 cu. yds. EXACT EQUIVALEXT.S. WEIGHT. Avoirdupois. Troy. .01543234874 grain . MUligram, .001 .1543234874 grain . . Centigram, .01 1.543234874 grains . . Decigram, .1 15.43234874 grains . . Gram, 1. 5.6438304 drs. 2.572 5 Dekagram, 10. 3.5274 oz. 3.215 3 Hektogram, 100. .2.2046 lbs. 2.679 lbs Kilogram, 1000. 22.046 lbs. 26.79 lbs M\Tiagram, 10000. APPROXIMATE EQUIVALENTS. Avoirdupois Troy. 6^0 grain. 5 grain. 1.5 grains 15 grains. . 5.6 drs. 2.5 3 3.5 oz. 35 . 2.2 lbs. 2.6 lbs. . 22 lbs. 26 lbs. ^Metric eqiii\'alents of our common linear measures are: Meters. E.XACTLY. APPROXI.MATELT i Inch = .00635 or 6.35 Millimeters. 6i Millimeters. I Inch = .01905 ' 19.05 19 llnch = .0254 ' 2.54 Centimeters 2j Centimeters. 6 Inches = .1524 ' 15.24 15 10 Inches = .2540 ' 25.40 25 IFoot = .3048 ' 30.48 Centimeters 30i 1 Yard = .91439 ' 91.439 90 1 Rod = 5.02914 ' 5.02914 Meters. 5 Meters. 1 MUe = 1609.3264 ' 1.6093264 Kilometers. 1.6 Kilometers. While the gram is a measure of weight and the mUUliter of capacity, liquids may be weighed and expressed in grams. But the U. S. P. weighs solids and measures liquids in its formulas. To avoid confusion in prescribing, we specify both grams and milliliters in our prescription forms: B Cm. or mil. WEIGHTS AND MEASURES 279 Thus whole numbers (to left of line) will be read as grams if they represent solids and as milliliters if liquids, while decimal quantities will be read as centigrams and milligrams in either case, as the difference between the measure and weight of so small quantities is very slight. Rules for Converting Quantities to Metric Terms: 1. If in grains (or minims), multiply the number by 0.065 (fluids 0.06) or divide by 15 (fluids 16). The result will express the quantity in grams or decimal of a gram. 2. If in drachms, multiply the number by 4 (fluids 3.70). The product will express the quantity in grams. 3. If in ounces, multiply the number by 31 (fluids 30). The product will express the quantity in grams. Rules for Converting Quantities from Metric Terms: 1. Divide grams by 0.065 (fluids 0.06) or multiply by 15 (fluids 16). The result will be in grains (or minims). 2. Divide grams by 4 (fluids 3.70). The result will be in drachms. 3. Divide grams by 31 (fluids 30). The result will be in ounces. In learning doses in metric terms, it is well to begin with convenient quantities that approximate the usual dose; thus: For substances with a minimum dose of e'o' of a grain, adopt 0.001 gm. (1 milligram) as the convenient basis. For substances with a minimum dose of 1 grain, adopt 0.05 gm. (5 centigrams) as the starting-point. For substances having the minimum dose of 10 grains, adopt 50 gm. (50 centigrams) as the starting point. For larger doses adopt grams and half -grams as nearly as possible. Rules for Use of the Metric System in Prescribing : The difficulty of applying the metric system to prescription writing by those accustomed to think in the old system is very largely removed by following the rule given below, which does away with the need of calculating total quantities, and renders prescribing much easier. As there are between fifteen and sixteen grains in a gram, the ordering of fifteen or sixteen doses always establishes a relation between the two systems, which permits us to apply the following rule.* * Long. Medical News, Philadelphia, March 25, 1893. 280 PRESCRIPTION WRITING 1. jNIake the whole quantity to consist of sixteen doses: then — 2. The number that represents the single dose of an ingredient in grains or minims will express the required quantity of that ingredient in grams or milliliters. For example: Gill, or mil. I^. — Potassii bromidi (single dose 10 grains) . . . 10 1 Morphinae sulphatis (single dose J grain) . . 1 25 Spiritus setheris nitrosi (single dose 30 minims) 30 ] Aqua", q. s. ad (16 teaspoonful doses) . . . 60 1 M.— Sig., etc. The same rule applies in prescribing powders or pills: Gm. or mil. I^. — Pulveris ipecacuanha^ et opii (single dose 5 grains) 5 Pulveris digitalis (single dose 1 grain) ... 1 Strychninae sulphatis (single dose -'o grain) . . 02 Misce et divide in chartulas numero x\'i. It is found in practice that sixteen is a very convenient and usually sufficient number of doses in the average case, or until the treatment is to be modified. However, when one has mastered the application of the rule, it is a simple matter to double the quantities for twice the number or doses, or to reduce them for a lesser number. AYhile this rule does not apply in making solutions without definite dosage, the convenience of the decimal system in ordering and preparing percentage solutions is apparent. With a total quantity of 1000, 100, or 10 mils, the calculation of quantity of ingredients is very simple. COMMON MEASURES AND THEIR EQUIVALENTS. In the fourth part of a prescription (directions to the patient), the amount to be taken should be expressed in domestic measures as far as is possible, so as to be perfectly plain to the user. The use of the measur- ing glass, marked for quantities to correspond to the common measures of teaspoon, tablespoon, etc., should be encouraged in the interest of accu- racy; for there is some variation in size of teaspoons as there are grades of fulness to the spoon, one person making it even full and another filling it to its capacity, which may mean a difference of fully thirty minims. The common practice of ordering doses in so many drops is likewise inaccurate unless one is sure of the size of the drop of the particular liquid as administered ; for there is a great difference in the size of drops, dependent not only upon the density and character of the liquid but also upon the shape of the opening from which it is dropped. For example, in dropping water from the mouth of an ordinary medicine bottle each drop may contain 1^ minims, while from an eye dropper the drops may ORDER OF WRITING A PRESCRIPTION 281 not measure more than ^ minim, varjdng according to size of opening and thickness of the glass. Drops of alcohol are approximately one- half the size of drops of water under like conditions, while drops of ether and chloroform are still smaller. (See below.) It should be borne in mind, therefore, that although drops of aqueous solutions approximate minims in size, drops of alcoholic solutions, as tinctures, are about one-half as large and the number in a given dose will be correspondingly greater. But it is evident that the purpose of accurate dosage would be best served by the use of a pipette, marked for minims, in measuring out small doses. Tables of the number of drops in a fluidrachm are of comparative rather than positive value, because of the difference in size of drops of the same liquid under different conditions. However, it is well to re- member the following easily-learned facts in regard to the size of drops: Water, aqueous solutions and acids have about 60 drops to a fluidrachm or teaspoonful. Alcohol, tinctures and spirits have about 100 to 120 drops to a fluidrachm. EtJier and chloroform have still smaller drops, with from 120 to 250 to a fluidrachm. The approximate equivalents of common measures are: A drop (of water) =1115- A teaspoon =f51, A dessertspoon =f52, A tablespoon =fo4, A wineglass =f§2, A teacup '=fo4, A tumbler =fo7, ORDER OF WRITING A PRESCRIPTION. It is well to follow a regular order in writing prescriptions both in the interest of economy of time and thought and in order to lessen the danger of errors by omission. Certain parts of the work can be made^quite mechanical including the use of a prepared form of blank something like the following: A. L. Seek, M.D. 160 West 70th Street, Hours: 2 — 4 New York. Gm. or mil. 1, or 0.0:3-0.06 gm. or 4 mil. or 8 or 15 or 60 or 120 or 200 282 PRESCRIPTIOX WRITIXG If the old system of weights and measures is to he employed this blank will omit the upright line and the abbreviations above it. The order usually followed in writing a prescription is as follows: 1. Decide what drugs are needed and select the preparation of each to be used; then write the names of all ingredients, as below. Supposing our case to be a child of fi^'e with a cough that is spasmodic in character, we may wish to write: I^.— Potassii bromidi, Tincturae belladonnae, Spiritus setheris nitrosi, Aquse, Syrupi lactuccarii, 2. Decide upon the number of doses and bulk of each dose, by which you arrive at the total quantity of the mixture. For a child of five the single total dose may well be a teaspoonful and the number of doses 16, which gives a total quantity of 2 fluidounces or about 60 c.c. 3. ^lultiply the single dose of each ingredient by the number of doses. Employing Cowling's rule for dosage for children: "Divide the age at next birthday by 24," we obtain 2I or \ as the fraction of the adult dose to be used. But even with the use of the rule we must exercise dis- crimination. In this instance, potassium bromide being a rather harmless drug, we shall want a full dose in order to secure its depressant effect upon nerve centers, so we may exceed the proportional amount of the average adult dose. Let us take 6 grains (gm. 0.40) as the dose. Sixteen doses will give us 96 grains as the total quantity, or, approximately 1| drachms (gm. 6). Of tincture of belladonna we take according to the rule \ of the average adult dose, ^ of 8 minims X16 doses =32 minims, or approximately \ fluidrachm (mils 2). Of spirit of nitrous ether we take \ of 30 minims as the single dose or 8 minims (gm. 0.50). Sixteen times this will give us approximately 2 fluidrachms (mils 8). The two last ingredients are vehicles, water being used as a solvent and diluent and syrup of lactucarium as a pleasant excipient with very feeble medicinal power. The dose of these, there- fore, is unimportant. Of water we use a convenient quantity to insure solution of the potassium salt, say \ fluidounce (mils 15). The vehicle last to be added may ha\e its quantity definitely expressed, being the difference between the sum of other liquids in the mixture and the total desired bulk; but a simpler procedure is to order sufficient of the vehicle to be added to make up the total — (juantuvt sufficit (q. s.) ad (up to) fgij (mils 60). We then have COXSTRUCTIOX OF PRESCRIPTIONS 283 Gm. or niiL I^. — Potassii bromidi oiss or 6| Tincturse belladonnse . . . . . . foss " 2' Spiritus setheris nitrosi ^ foij " 8 Aquse ,. . foiv " 15 S\Tupi lactucarii q. s. ad fgij " 60 [In arriving at the above quantities in metric terms we may apply the simple rule for the use of the metric system fp. 279.)] "Whenever we order the same quantity of each of two ingredients, we may use the abbreviation aa,' meaning of each. Had we made the quantity of water in the above the same as that of the spirit of nitrous ether we could have written them thus: Gm. or mil. ' Spiritus setheris nitrosi, Aquse aa foij or 8 4. The names and quaiitities of ingredients having been determined, the next step is to give the directions to the compounder (third part of prescription). In this case we need only to direct that the substances be mixed, leavmg to the compounder's art the precise order or method to be followed. We, therefore, simply use the abbreviation of Misce, — ■ M., which is placed either to the right on a line with the name of last ingredient or to the left on a line below. 5. Add directions to the patient (fourth part of prescription), to be preceded by the character Sig. or S. (see page 272). 6. The date name, or initials of patient and signature will complete the prescription (see page 273). CONSTRUCTION OF PRESCRIPTIONS. Dentifrices. — If we desire to T\Tite a prescription for a tooth powder, we consider first the essential qualities of the ingredients which should enter into it. Ordinarily we want a tooth powder to be: 1. Antacid. 2. Slightly abrasive 'just sufficient to remove acciun illation of deposits) . 3. Aseptic or antiseptic. 4. Pleasant to the taste. Occasionally also we desire it to be Astringent or Stimulating, but these two qualities are needed in pathologic rather than normal conditions. The formula need not be complicated. Prepared chalk 284 PRESCRIPTION WRITING and powdered soap will really cover all essentials, except that taste may be further consulted as to flavoring. Written out in simple English, we may have a combination something like this, using our own preference for either the apothecaries' or the metric weights: 1. Take fof prepared chalk, ten ounces, or 310 grams. 2. -j of powdered soap, two ounces, or 62 grams. [of oil of wintergreen, five minims, or . 30 grams. 3. Mix and triturate thoroughly. 4. Write: Use with toothbrush each evening. 5. For A. B., Oct. 10, 1902. (Chas. Dale). But custom and certain advantages lead us to prefer the use of Latin terms and other characters as follows: Gm. ^. — Creta^ pra^paratae §x or 310 Saponis pulv 5ij or 62 Olei gaultherise TTlv or 30 M. — Triturate thoroughlj*. Sig. — Use with toothbrush each evening. For A. B., Oct. 10, 1902 (Chas. Dale.) This formula is simply suggestive and admits of any desired modi- fication or addition. Other ingredients and other proportions of these ingredients will be employed at pleasure. If we analyze the qualities of such a combination we find the value of each ingredient to be distinct, as here indicated: Crela prceparata is antacid and slightly abrasive. Sapo is alkaUne, detergent and antiseptic. Oleum gaultherice is a flavoring agent. It will be noticed that the Latin names of ingredients, and their adjectives, are given in the genitive case. The reason for this appears in the English version of the formula, the reading being: Take ten ounces of prepared chalk, etc. The antacids that serve the same purpose as prepared chalk, but which are less abrasive, are magnesium oxide, magnesium carbonate, sodium bicarbonate and borax, the last-named being also antiseptic. Powdered pumice and charcoal are too gritty and harsh for continued use. They may injure both the gums and the enamel, and they are, therefore, to be discarded from our formulas. Powdered orris root (Radix Iridis Florentinse) is valued by many, CONSTRUCTION OF PRESCRIPTIONS 285 because of its reputed tonic influence upon the mucous membrane, but it is not an antacid. The antiseptics, other than soap, that may be employed, are borax, resorcin, naphtol and boric acid. The last named may be combined with sufficient antacid to leave the reaction of the mouth alkaline or neutral. The flavoring agents include any of the pleasant volatile oils, or powdered drugs containing them — e. g., powdered cinnamon. Some of the volatile oils are costly, and, therefore, not commonly used. Oil of rose is the most expensive. These oils are not included for any medicinal effect, but only as flavoring agents; therefore they are used in very small quantity. Coloring agents, such as carnaine or an aniline color, may be added if desired, but metallic pigments had better be avoided, for fear of staining exposed dentine. If the dentifrice is preferred in form of a paste, sufficient glycerin may be added, but syrup or honey are to be avoided on account of being readily fermentable. For the same reason sugar is inferior as a sweeten- ing agent. Saccharine may be used, as it does not ferment, and, being about 500 times sweeter than cane-sugar, a small quantity will suffice. Anyone desiring his own special formula for a dentifrice can easily attain his object through a little experimentation with the substances here suggested, and the effort will be profitably expended. The thought should be prominent, however, that strong antiseptics are not constantly needed in normal conditions; and the more thoroughly the mouth and teeth are habitually cleansed the less will they be required. Mouth Washes. — Washes for the mouth and teeth may be needed for the following purposes : 1. To neutralize acid fluids, whether introduced or present as abnormal secretion. 2. To cleanse the mouth. 3. To disinfect when ferments or septic bacteria are active. 4. To prevent, as an antiseptic, the growth of ferments and septic bacteria. 5. To exert an astringent action upon the mucous membrane. 6. To stimulate nutrition of the mucous membrane. Many agents are employed to accomplish these purposes, and the possible combinations are without number. But it may be stated as a cardinal rule, that mouth washes should possess antacid and antiseptic properties. It is impossible even in health to maintain a strictly aseptic 286 PRESCRIPTION WRITING condition of the mouth, while in disease, local or general, efforts are still less availing. It is often essential, therefore, that an antiseptic be freely emplo\'ed, always, however, with due appreciation of the harm that may follow the improper use of the stronger agents. Some agents addressed to a single purpose (as a detergent or an astring- ent) may be used alone in aqueous solution. Alcohol is not a suitable vehicle in mouth-washes unless its astringent action is desired, but its aid as a solvent may be necessary. In any case it must always be diluted. The two main points to consider in prescribing a mouth wash are efficiency, and safety to the soft tissues. Certain agents, including creosote, borax and boric acid, are regarded as quite efficient in a saturated aqueous solution and may be used freely without harming the tissues; but phenol, corrosive sublimate, chloride of zinc and formaldehyde would be very irritating in saturated solution. They must be very largely diluted for use in mouth washes. One of the most efficient agents is phenol, but it should not be used stronger than 1 per cent.; and, though it is only very slightly acid in reaction, it is well to use an alkali with it as follows: Gm. or mil. I^.— PhenoUs 2 Sodii bicarbonatis .... 15 Glycerini 30 Aquae q. s. ad 200 Sig. — Use as mouth wash every three hours (gr. xxx) (3iv) (5j) (f§vij)--M. Another efficient similar combination in Dobell's solution. (See formula, p. 127). The excellent work of Dr. W. D. Miller has shown benzoic acid and salicylic acid to be among our most efficient mouth antiseptics when used in 1 per cent, solution; but they are only slighty soluble in water, requiring 275 and 4()0 parts respectively, and they are acid in reaction. It is found, how^ever, that with the aid of borax a 1 per cent, alkaline solution of either of these may be prepared ; although it is probable that their antiseptic power is less in an alkaline solution. A saturated aqueous solution of borax, with 1 per cent, of either salicylic or benzoic acid added, is presented in the following: Ciin. i>r mil. I^. — Sodii boratis 5: (3iss) Acidi saUcylici 1 1 (gr. xv) AqujB 100 (f5iij)— M. Dissolve the borax in the water, then add the sahcyHc acid. Sig. — Mouth wash. ABBREVIATED TERMS USED IN PRESCRIPTIONS 287 Gm. or mil. I^. — Sodii boratis Si- (3iss) Acidi benzoic! ..... 1 (gr. xv) Aquae 100 (f5iij)— M. Dissolve the borax in the water, then add the benzoic acid. Sig.— Mouth wash. Flavoring agents may be used in the above at pleasure, in the form of medicated waters, such as aqua cinnamomi, or a little volatile oil. Creosote may be ordered in its official preparation: mil. I^. — Aquae creosoti 100 Sig. — Mouth wash. Use after each meal and at bedtime. Hydrogen dioxide is entirely safe to use in the official 3 per cent, solution, but it is acid in reaction. It is useful in septic conditions. ABBREVIATED TERMS USED IN PRESCRIPTIONS. The use of abbreviations in the names of ingredients and in the direc- tions to the patient is to be discouraged. The following list is intended more for reference in interpreting abbreviated prescriptions than for use in writing. aa ana . .of each. a. c ante cibum . . . . . before meals. ad to, up to. adde add. ad. Ub ad libitum . . . . .at pleasure. aq aqua water. aq. bull aqua bulhens .... boihng water. aq. dest aqua destillata .... distilled water. aq. ferv aqua fervens .... hot water. b. i; d bis in die twice daily. Br. P British Pharmacopoeia. CO cubic centimeter. eg centigram. chart charta, chartula ... a paper, a little paper. cochl. mag. . . . cochleare magnum . . tablespoon, cochl. med. . . . cochleare medium . . . dessertspoon, cochl. parv. . , . cochleare parvum. . . . teaspoon. coUyr coUyrium eye wash. coUut coUutorium .... mouth wash. CO., comp compositus, a, um . . . compound. cong congius gallon. cort cortex bark. cum with. dil dilutus, a, um .... diluted. div divide divide. ext extractum extract. ft fiat, fiant ..... let (it) (them) be made. fl fluidus, a, um . . . . fluid. fol foUa leaves. 288 PRESCRIPTION WRITING gtt gutta, guttse .... drop, drops. gm gram. gr grain. h. s hora somni at bed-time. in d in die daily. L liter. liq liquor solution. mil milliliter. TTl minim. M misce mix. mist mistura mixture. N. F National Formulary. no numerus, numero . . . number, in number. noct nocte by night. non. rep non repetatur . . . . let it not be repeated. O octarius pint. ol oleum oil. cm omni mane every morning. omn. bih omni bihora .... every two hours. omn. hor omni hora every hour. omn. noct. . . . omni nocte every night. part, seq partes sequales .... equal parts. p. c post cibum after meals. pil pilula pill. p. r. n pro re nata as occasion arises. pulv pulvis powder. q. i. d., q. d. . . . quater in die . . . ^ four times a day. q. s quantum sufficit ... as much as necessary. I^ recipe take. rad radix root. rect rectificatus rectified. rep repetatur let' it be repeated. s. a secundum artem . . . according to art. ss semissis a half. S., Sig signa sign (write). or signetur let it be labeled. sine without. solv solve dissolve. spir spiritus spirit. sp.gr specific gravity. syr syrupus syrup. tab tabella tablet, troche. tal tahs such, Uke this. t. i. d., t. d. . . . ter in die three times a day. tinct., tr. ... tinctura tincture. trit. ..... tritura triturate. troch trochiscus troche, lozenge. ung unguentum ointment. U. S. P United States Pharniacopa;ia. vel or. vin vinum wine. wt weight. CHAPTER XXII. POISONS. A poisox may be defined to be a substance which, when introduced into the body, causes disease or death. But, in accepting this definition, foreign bodies or agents that act mechanically must be excluded, as, for example, a bullet. Certain substances also that produce disease in the system are not usually classed among poisons. Of these there are: Venom, the natiu-al protective secretion of certain reptiles and insects. Virus, a rather indefinite term that has been applied to the microbic cause of an infectious disease or to the characteristic poison developed in coiuse of the disease. ^Yith the recognition of the definite organisms that cause the several infectious diseases the term virus has fallen somewhat into disuse. In its place we have the more definite terms of hacteriinn, as the cause, and toxin, a poisonous product of the growth of the bacterium. [Antitoxin is a substance formed in the body as a reactionary protec- tion against the action of a toxin of a disease. The presence of a toxin is necessary to stimulate the formation of the antitoxin which is capable of neutralizing it. The most familiar example of an antitoxin is that of diphtheria, which is prepared in the blood of the horse and used to neutralize the toxin of the disease in the human being.] Ptomains are basic organic compounds formed by the action of bacteria upon nitrogenous matter. Some are poisonous, and some resemble vegetable alkaloids in their action. Leukomains are basic substances that result from tissue metabolism. Some of these are poisonous. The usual use of the term poison refers to drugs that, when taken in overdose or in concentrated form, produce disease or death. The law recognizes the responsibility that attaches to the sale of poisons, and requires, in most communities, that all poisons, except those dispensed upon a physician's prescription, shall be distinctly labeled, and, in case of the more powerful substances, that a record shall be made of the sale. The substances included in the list of poisons vary very greatly in their action, as to time required for their poisonous effects, part of the 19 290 POISONS system attacked, and character of symptoms produced. Thus arsenic, one of the most destructive poisons, acts slowly, while carbolic acid may cause death in a very short time, as is true also of hydrocyanic acid. Strychnine causes frightful convulsions, while morphine produces coma. The simple outline here given serves to aid in grouping poisons accord- ing to site of action: 1. Those acting locally: (a) Corrosives. (6) Irritants. 2. Those acting upon the blood, or blood poisons. 3. Those acting upon the nervous system, or nerve poisons. 4. Those acting upon special organs: (a) Upon heart. (6) Upon kidneys. (c) Abortives. Concerning abortives, it should be noted that they are really irritants. Among other effects they may disturb the gravid uterus, but this is only one of the dangers of their action. As a class they must be regarded as very dangerous agents and at the same time uncertain as to any special action. (For s\Tiiptoms and treatment of poisoning by the various substances, see Table of Poisons and Antidotes.) Modes of death are appropriately defined at this place as related to poisons. 1. Failure of Circulation. — Syncope is sudden failure of the circulation, due to depression of the heart from various causes. It may be temporary, as in case of ordinary fainting, or it may be complete, due to paralysis of the heart. Asthenia is gradual failure of the circulation by depression of the heart, as occurs in fatal cases of acute infectious diseases. 2. Failure of Eespiration. — Asphyxia is the condition of non-oxygen- ation of the blood. It may be caused by complete shutting off of the air (apnea), as in drowning, or it may be due to the displacement of oxygen by other gases. It may be partial or complete. 3. Paralysis of Brain Centers. — Coma is a paralysis of the conscious and the reflex centers of the brain. It may be caused by pressure, as in apoplexy, or it may be due to the action of a narcotic. The sig7is of death usually relied upon are cessation of respiration, cessation of circulation and paralysis of pupil. TABLE OF POISONS AND ANTIDOTES. (This table is adapted from the author's Tables for Doctor and Druggist, by permis- sioa of the pubhsher, E. G. Swift, Detroit, Mich.) Poison. Toxic dose. Action. Prominent symptoms. Antidotes and treatment. (Antidotes in italics.) Acid, carbolic •».^__i2henol) Acid, hydrocyanic. Acid, prussic .(U.S. P. 2%) Bitter almond, oil Potass, cyanide Acid, oxalic . Soluble oxalates Mineral acids. Acid, hydrochloric, nitric, sulphuric, tZ Aconite . . . . Tincture of root Aconitine 1/A.mmonia Water of (10%) Stronger water of (28%) Carbonate of am- monium . Arsenic trioxide . ^— ^Arsenous acid, white arsenic Arsenic disulphide, red sulphide of arsenic, realgar Arsenic trisulphide, orpiment. King's yellow Arsenite of copper . Scheele's green Aceto-arsenite of cop- per; Paris green; , Schweinfurth green 1 /Belladonna (leaves, ^ ■ berries or root) Atropine By stomach By inhalation . m30 gr. 3-4 fatal 34 m22 gr. Vso f3i* fatal gr. 2 fatal gr. i-i fatal Corrosive; systemic poison Depresses brain and heart Irritant; general depressant Corrosive Depresses heart and nervous system Irritant Caustic Escharotic ; irritant when diluted Deliriant narcotic ; dilates pupil and paralyzes accommo- dation Caustic ; sedative to nerve centers Dryness of mouth and pharynx; eyes bright, pupils dilated; face flushed; rapid respira- tion; delirium, convul- sions, stupor Severe symptoms of irri- tation; depression of nerve centers; paral- ysis Pain followed by numb- | ness; white stain; col- lapse; stupor; dyspnea Sudden various symp- toms of depression ; dyspnea Abdominal pain, vomit- ing, collapse, stupor Thirst, vomiting, burn- ing pain in throat and stomach; tissues cor- roded; more or less collapse Tingling and numbness; slow, weak pulse; dys- pnea; pupil usually dilated Irritation in air pass- ages and stomach with pain, vomiting and purging ; prostration ; odor of ammonia Faintness ; gastro-intes- tinal irritation, vom- itiiig and piirging, thirst ; collapse ; cramps, conviilsions or coma ; in some cases collapse is most promi- ' nent symptom, in | others stupor; some i cases resemble cholera; usually the symptoms , do not develop quickly i Emesis: Albumin, alcohol, sul- phate of magnesium or other soluble sulphate; oil or other demulcents; stimulants. Artificial respiration; stomach tube; cold douche to head and chest, or alternate with hot; ammonia inhalation; mixture of persulphate and protosulphate of iron. Carbonate of lime in any form, magnesia, lime-water ; anodynes, demulcents, stimulants. Glass of waterf immediately to dilute acid, follow by lime- water, magnesia, soap or plaster from wall; no carbonates; de- mulcents, stimulants; mor- phine hypoderm. if needed; do not use stomach pump. Empty stomach; atropine, am- monia, digitalis with glonoin; strychnine; slight galvanic shock recommended; tannin in aconitine poisoning. Water immediately to dilute, follow by lemon-juice or vinegar. Inhalation of acetic acid vapor; stomach pump should not be used; demulcents, anodynes, stimulants. Aid emesis (unless vomiting has been profuse) by the use of mustard or sulphate of zinc; may wash out stomach by means of flexible tube, but stomach pump should not be used; freshly prepared hy- drated sesquioxide of iron% freely, and follow by an emetic, then by castor oil; demulcents anodynes, stimulants, external warmth. Emetics or stomach tube; tannic acid, animal charcoal, follow by emetic, and later by castor oil; heat or cold externally, or alternately; _ artificial respira- tion and stimulants if neces- sary; morphine maybe of value. Dilute with large draughts of water; very dilute solutions of alkalies; ether; brisk cathartic alkalies. Ammonia by inhalation. * Poisonous effect depends more upon concentration than upon quantity. t There can be no objection to the use of water in sulphuric acid poisoning, if sufficient is employed. In mixing 100 c.c. of water at 70° F. with 10 c.c. of sulphuric acid, the temperature increased to only 111° F.; and in mixing 200 c.c. of water (a glassful) with 10 c.c. of sulphuric acid, the temperature increased to only 94° F. J This is the Ferri Hydroxidum, U. S. P. To prepare it freshly use tincture of chloride of iron, Monsel's solution, or solution of tersulphate of iron (any solution of & ferric salt) and milk of magnesia. Dilute the iron solution with several times as much water, also the milk of magnesia with an equal quan- tity. Mix the two and administer freely at once, giving one-half to one glassful (100 to 200 mils.) of the mixture. [Water of ammonia may be substituted for the mil k of magnesia, but the product requires washing to remove the sharp taste and odor of ammonia.] 292 TABLE OF POISONS AND ANTIDOTES Prominent symptoms. Antidotes and treatment. {Antidotes in italics.) Camphor . . . . gr. 20 Cannabis indica Cantharides . Tincture Cantharidin (active principle) Carbolic acid; see Acid, carbolic Carbonic anhydride,* carbonic acid gas Carbonic oxidet . Charcoal gas Coal gas Illuminating gas Castor-oil beans . (seeds of Ricinus communis) Chloral hydrate . gr. 23 f51 fatal Three seeds fatal gr. 30 Disturbs brain and nerve centers Intoxicant Irritant; sometimes aphrodisiac Regarded as narco- tic Destroys I oxygen- carrying power of the red blood cor- puscles Irritant Hypnotic; sedative; paralyzes nerve centers; narcotic Bv inhalation Chloroform By stomach . f54 fatal to adult; fol to child mio quickly inhaled has I been fatal Coal gas; see Carbonic / oxide VCocaine . gr. J oi Cocaine hydrochloride less 1 gr. I I fatal Locally irritant; anesthetic 34 51 fatal. Anesthetic; paralyzes nerve centers; may paralyze heart Stimulant; later de- pressant; locally paralyzant Irritant Vertigo; pain in stomach; delirium or stupor; convulsions Hilarity; mental confu- sion; pupils dilated; drowsiness Gastro-intestinal irrita- tion with pain, vomit- ing and purging; pain in loins; severe irrita- tion of genito-urinary organs; sometimes erotic excitement; col- lapse, stupor, coma; in some cases delirium or convulsions Headache, giddiness, drowsiness; cyanosis if oxygen is excluded Headache, vertigo, pros- tration, vomiting, dys- pnea; feeble and rapid pulse, stupor; in some cases convulsions Severe gastro-intestinal irritation Stupor; pupils at first contracted, later di- lated; temperature re- duced; respirations slow, or later may be rapid and shallow When taken by the stomach: gastric irri- tation, vomiting, odor of chloroform; later, stupor, coma When inhaled: loss of consciousness ; syncope sometimes early; pro- found narcosis; death by failure of heart or respiration Faintness and collapse, or delirium, or convul- sions; symptoms irreg- ular Gastric irritation with pain and vomiting of greenish matter, purg- ing; jaundice in some cases; convulsions or paralysis may follow. Emesis; follow by castor oil or sulphate of magnesium; stimu- lants if necessary to support nerve centers. Meet indications as they arise (there is no case on record of fatal poisoning by this drug). Emesis; stomach tube may be used; demulcents; no oils should be employed, as they dissolve cantharidin and favor its absorption; anodynes by the rectum; opium, cocaine, belladonna; morphine hypo- dernucally, or anesthetics if suffering is intense; leeches to hypogastrium; warm baths; mild diuretics and cathartics. Supply fresh air or oxygen; arti- ficial respiration and stimu- lants if necessary. The hemoglobin being so altered as to be incapable of taking up oxygen, the treatment by fresh air and oxygen is not so suc- cessful as in simple asphyxia; still this means of giving oxygen to the blood cells that remain uninjured should be employed; in urgent cases transfusion of blood. Emesis, demulcents, anodynes and stimulants if necessary. Emesis or stomach tube; exter- nal warmth very important;! arouse patient; stimulate re- flexes by external application of mustard, friction, slapping smartly ; faradization; atropine, strong coffee, strychnine, am- monium carbonate and digi- talis if urgent; artificial or forced respiration; oxygen. Emetic or use of stomach tube; arouse patient; recumbent pos- ture; stimulants; strychnine, caffeine, digitalis; external warmth, artificial respiration if necessary. Stop inhalation and supply fresh air; head low to favor gravi- tation of blood to the brain; artificial respiration, external warmth and friction; faradiza- tion to muscles of respiration; massage of heart; strychnine, caffeine, digitalis. Tannic acid, potassium perman- ganate or purified animal char- coal; empty stomach; treat conditions as they arise. Aid emesis; alhumin freely is best antidote; milk, mucilaginous drinks; ferrocyanide of potas- siitm if pure; opium; stimula- tion if necessary. Copper salts . Arsenite; see Arsenic Carbonate ' ' Natural ' ' verdi- gris Subacetate, verdi- gris Sulphate, blue vi- triol * An atmosphere containing 1 to 2 per cent, of carbonic anhydride, with a corresponding diminution of oxygen, is poisonous; with 5 to 10 per cent, of carbonic anhydride, and oxygen correspondingly lessened, death will occur, while it requires 10 to 20 per cent, to extinguish a flame. t Carbonic oxide is more poisonous. According to Sollmann (Pharmacology) it combines with hemoglobin 200 times more readily than does oxygen. J Brunton and Strieker found that animals which had received a dose of chloral that would certainly kill them if they were left exposed, recovered when wrapped up in cotton-wool, and if the dose were increased so as to kill the animal even when thus wrapped up, it could still be kept alive by being put into a warm place so as to keep up its temperature artificially. A still larger dose was fatal. TABLE OF POISONS AND ANTIDOTES 293 Poison. Toxic dose. Prominent symptoms. Antidotes and treatment. (A'ntidotes in italics.) Corrosive sublimate; see Mercuric chlor ride. Creosote . . . . Croton oil. Cyanide of potas- sium; see Acid, hydrocyanic Elaterium Elaterin (several times stronger than elaterium) Ether, by stomach . by inhalation . Formalin . Fungi* .... Amanita muscaria, Agaricus phalloides and others (the irri- tant principle is destroyed by boil- ing, drying, or by acids, alkalies or alcohol; but the narcotic principle, muscarine, resists the action of heat, drying, or these re- agents) Hyoscyamus, hen- bane Hyoscyamine Hyoscine Iodide of potassium (acute poisoning) Iodine (acute poison- ing) Tincture. Iron salts .... Chloride, tinct. of Sulphate, copperas Laudanum. See Opium Lead salts Acetate ; sugar of lead Carbonate; white lead Oxide, red; red lead Mercuric chloride (.corrosive subli- mate; bichloride of mercury) Mercuric cyanide (similar to above) mso fatal Irritant Irritant; drastic cathartic Drastic cathartic Irritant Anesthetic Irritant Irritant ; narcotic gr. 3 fatal Similar to belladonna; but more hypnotic Irritant Irritant Irritant Irritant in acute poisoning Corrosive Gastro-intestinal irrita- tion Violent gastrointestinal irritation; purging, collapse and other symptoms resembling those of cholera Violent vomiting and purging with severe griping; collapse Gastro-intestinal irrita- tion Narcosis; cessation of respiration Severe pain in throat and stomach; vomit- ing Gastro-intestinal irrita- tion, pain and vomit- ing; various nervous syrnptoms; headache, vertigo, visual dis- turbances; in some cases delirium or coma Same as in belladonna poisoning Gastro-intestinal irrita- tion, vomiting and purging; headache, in some cases salivation; frequently an erup- tion; prostration Similar to above Gastric irritation and pain; vomiting Gastro-intestinal irrita- tion with severe colic, vomiting, constipa- tion; if severe, convul- vulsions may occur Symptoms occur quite promptly; burning in throat and stomach, nausea and vomiting; abdomen swollen and tender; severe purg- ing with straining; discharges frequently bloody; collapse, stu- por, convulsions Dilute freely with water, then emesis; follow by demulcents. Demulcents, anodynes; mor- phine hypodermically. Anodynes, morphine hypoder- mically, demulcents, stimu- lants. Stimulate elimination; demul- cents; stimula-nts if needed. Stop inhalation; abundance of fresh air; artificial respiration, external warmth, strychnine, caffeine; faradization. Dilute poison with warm water freely; if vomiting does not occur the stomach should be thoroughly washed by means of tube; demulcents, anodynes; ammonia as antidote. Emetic and cathartic (common salt or mustard as emetic) ; demulcents and other treat- ment according to indications; atropine hypodermically is recommended as physiological antidote; tannic acid has been thought to be useful; purified anim,al charcoal. Same as for belladonna poison- ing. Aid emesis; demulcents, dilu- ents, anodynes, stimulants if needed. Starch freely, follow by evacu- ants; other treatment as above. Dilute with draught of water immediately; dilute solution of sulphide of potassium, so- dium or ammonium; aid emesis by large draughts of warm water; demulcents, anodynes; stimulants. Aid emesis; sulphate of mag- nesium or other soluble sul- phate, followed by emetic; stimulate sweating by exter- nal warmth; later iodide of potassium or very dilute sul- phuric acid, or both. Albumin freely (white of one egg to each 0.25 gm. (4 grains) of poison swallowed) ; as a substitute for albumin wheat- flour paste or milk; emesis after poison is neutralized; demulcents, morphine hypo- dermically; stimulants inter- nally and heat or friction externally; continue white of egg for one to two weeks. * For an extensive and illustrated description of edible and poisonous fungi, see Reference Hand- book of the Medical Sciences, vol. iii, New York. 294 TABLE OF POISONS AND ANTIDOTES Poison. Toxic dose. Action. Prominent symptoms. Antidotes and treatment. {Antidotes in italics.) Mercury salts (The salts other than bichloride and cyanide are toxic in proportion to sol- ubility) Morphine See Opium. Nitrite of amyl . Nitroglycerin, glonoin Nux vomica . . . gr. 30 Alcoholic extract, ; gr. 3 Strychnine . . gr. | Irritant Opium Camphorated tinc- ture; paregoric (contains about J grain of opium to a fluidrachm) Tincture; lauda- num (this and all other fluid prep- arations except paregoric contain 10% of opium) Codeine Morphine . Narcotine Heroin Increases irritabil- ity of spinal cord gr. 4-5 ; 1st stage fatal gr. h fatal 2d stage narcotic Symptoms of gastro- intestinal irritation in varying degree, ac- cording to the amount and solubility of salt Flushing of face, suc- ceeded by pallor; pu- pils dilated; respira- tion irregular; pulse weak Muscular twitching; tonic spasms, with intervals of rest; ex- treme extension of back so that body may rest upon the heels and head; cor- ners of the mouth drawn up; later jaws become fixed; death by asphyxia or exhaus- tion; consciousness re- mains until near death Often slight stimula- tion or excitement Intoxication, drowsiness and stupor; pupils are contracted; pulse slow and full; respiration slow and often stertor- ous; face flushed, sometimes cyanosed; unconsciousness seems complete; but patient can be partially aroused during this stage by shaking or shouting I Prompt emesis by mustard or I sulphate of zinc; follow by { albumin or milk, after which induce further emesis and pur- gation; meet other indications as they arise. Cold to head, artificial respira- tion, ergot, strychnine, digi- talis; warmth externally. If seen early evacuate stomach, then give tannic acid freely, and follow by a quick emetic; bromide of sodium in large doses, gm. 4-16 (31-4), every half hour, if necessary; chloral, gm. 1-2 (gr. 15-30); keep patient very quiet; when con- vulsions are severe, inhala- tions of ether or chloroform; forced respiration* if asphyxia threatens; curarine hypoder- mically has been suggested; bladder should be emptied. Evacuate stomach by use of mustard stirred up in luke- warm water, aided by sul- phate of zinc, gm. 1.3-2 (gr. 20-30) if vomiting does not speedily occur; meanwhile tan- nic acid should be given freely, or ipotassium perm,anga- nate; wash out stomach; the stomach tube may be useful; apomorphine 0.005 gm. ('/12 gr.) hypodermically as emetic if patient cannot swallow. Maintain respiration: (1) By arousing patient and stimu- lating reflex activity by ex- ternal stimulation, shouting, smart slapping, frictions; far- adization, alternate douche of quite hot (as hot as the hand can bear) and ice-cold water to head and chest; cautious inhalations of ammonia; (2) by strong coffee freely or caf- feine hypodermically; atropine hypodermically in ordinary doses only, to be repeated ac- cording to the state of the respiration; strychnine. (3) If respiration is slow, or rapid and shallow, so that in either case insufficient air enters the lungs, artificial respiration or forced respirationt must be employed without intermission until proper respiration is established; inhalation of oxy- gen; catheterization should not be neglected, and large ene- mata of warm water may aid elimination. * See note under Opium. t The principle of forced respiration, as practised in physiological experiments was applied to the treatment of opium poisoning by the late Dr. George E. Fell, of Buffalo, N. Y. The apparatus used consists of bellows, face-mask and the necessary rubber tubes, with stopcock arranged to facilitate imitation of the natural respiratory rhythm, and to allow the addition of oxygen to the inspired air. Dr. Fell employed the method in eleven cases that seemed hopeless with the use of ordinary means of treatment and in three cases that were absolutely hopeless. Of the eleven cases eight were saved. The puhnotor is an apparatus that supplies oxygen in connection with forced respiration. In expert hands it is efl5cient, but is not so commonly available as ordinary artificial respiration. TABLE OF POISOXS AXD A XT I DOTES 295 Poison. Toxic dose. Prominent symptoms. Antidotes and treatment. (Antidotes in italics.) See Acid, oxalic Oxalates ^1 Oxalic i^ acid J Paregoric; see Opium Paris green; see Arsenic Phosphorus . Potassa .... Soda (Soda as a poison is very similar to potassa.) Liquor potassse Liquor sodae Conimercial potash and soda are im- pure carbonates containing much free alkali Potassium bitartrate; cream of tartar Potassium chlorate . Potassium nitrate Potassium sulphate . Prussic acid; see Acid, hydrocyanic Red lead; see Lead salts Red precipitate; see Mercury salts gr. 1 fatal 34* 3d stage, paraly- zant Irritant Caustic 52 fatal fatal 36 fatal 310 fatal Irritant ; purgative Irritant believed to pro- duce serious changes in the blood Irritant Irritant Prostration, coma; res- piration may become more rapid and shal- low, but is usually slow then ceasing entirely; pulse weaker and more rapid; face is cyanosed, though sometimes pal- lid ; before death occurs pupils become dilated; reflexes abolished; con- \mlsions may occur; death usually by fail- ure of respiration Symptoms usually do not appear until after a few hours; then weakness, nausea with vomiting, and other symptoms of gastric irritation; vomited matters are luminous in the dark, and have the odor of phosphorus; later jaundice and in gome cases delirium, con- vulsions, coma; hem- orrhages may occur; temperature may be greatly reduced; in some cases death oc- curs early and symp- toms are not typical Burning and pain in stomach and abdo- men; severe vonaiting and purging; prostra- tion Sustain circulation; strychnine, caffeine, external heat and fric- tion; digitalis if heart failure threatens; strong infusion of coffee by enema; keep up arti- ficial or forced respiration with or without oxj'gen; morphine is eliminated into the stomach, therefore it should be washed out frequently with a solution of potassium permanganate. Sulphate of copper, 0.2 gm. (3 grains) in dilute solution every five minutes as antidote and to induce emesis; if at hand crude acid French oil of turpen- tine, or, as a substitute for it, old oxidized oil of turpentine, and follow by a quick saline cathartic; ordinary turpentine is of no value and may be dangerous, as oils should be avoided because they are sol- vents for phosphorus; after poison is neutralized and removed employ demulcents; mucilaginous drinks, anodynes and stimulants if necessary. A large draught of water im- mediatelj% and follow -nith diluted xineaar or lemon-juice; albumin, oils, acidulated de- mulcent drinks; opium or morphine to relieve pain; stimulants. Gastro-intestinal irrita- tion Gastro-intestinal irrita- tion -with pain and vomiting; irritation of kidneys, often with suppression of urine and other symptoms of acute nephritis; cyanosis and nervous symptoms may occur Gastro-intestinal irrita- tion with violent vom- iting, and in some cases purging; mus- cular weakness, col- lapse; various ner^-ous symptoms may occur Similar to above Demulcents; chalk or magriesia mixed with water; opium. Demulcents, saline purgatives and diuretics; calomel may be valuable; coffee or caffeine; stimulants moderately; heat externally; transfusion of blood is recommended. Dilute at once with large draught of warm water and promote emesis; give brisk non-irritating cathartic; follow- by demulcent drinks; keep patient warm; anodj'nes and stimulants as needed; if col- lapse occurs, warmth, friction, or mustard externally. Same as for potassium nitrate. ■ Poisonotis effect depends rather upon concentration than quantity. 296 TABLE OF POISONS AND ANTIDOTES Poison. Toxic dose. Action. I Prominent symptoms. Antidotes and treatment. (Ay^tidotes in italics.) Silver nitrate Soda; see Potassa Stramonium (Similar to bella- donna as a poi- son) ; see Bella- donna Strychnine; see Nux vomica Sugar of lead; see Lead salts Tobacco gr. 30 Irritant . „ - Irritant; Nicotine (one of A few ■ sedative the most active ' drops poisons known) i prob- ably fatal Turpentine, oil of . ... Irritant; narcotic Verdigris; s^e Copper salts White lead; see Lead salts Zinc chloride . "Burnett's Disin- fecting Fluid" has 200 grains of zinc chloride in one fiuidounce Zinc sulphate Severe gastric irritation, Solution of common salt freely; vomiting, convulsions; albumin; mucilaginous drinks; later diarrhea other treatment as the case may require. 32-4 Corrosive Irritant; emetic Nausea, vomiting, in some cases purging; pain in stomach; prostration; delirium; cramps; rapid, weak pulse; collapse Gastric irritation; vom- iting and purging in some cases; irritation of urinary organs with urine lessened; uncon- sciousness; convul- sions; collapse Violent irritation of stomach immediately, with vomiting and pain; tissues corroded; nervous symptoms; collapse Gastric irritation; vom- iting Aid emesis by large draughts of warm water; tannic acid; strychnine, demulcents, ano- dynes, stimulants, external warmth, etc. Evacuate stomach by use of mustard or stomach tube, or if vomiting has occurred aid by large draughts of warm water; sulphate of magnesium as cathartic; hot fomentations to loins; demulcents; stimu- lants and anodynes if needed; warmth and friction externally. k glassful of milk or water immediately to dilute poison; albumin; dilute solution of car- bonate of potassium or sodium; demulcents, anodynes, stimu- lants. Dilute solution of carbonate of potassium or sodium., or tannic add; albumin; demulcents; anodynes and stimulants if necessary. INDEX OF DRUGS. OFFICIAL DRUGS AND PREPARATIONS ARE GIVEN THEIR PHARMACOPCEIAL TITLES. (Doses and uses are adapted from the author's Tables for Doctor and Druggist, by permission of the publisher, E. G. Swift, Detroit.) Abbreviations : * UnoflScial. Ac. = acid. Al. = alkaline. Insol. = insoluble. Misc. = miscible. N. = neutral. Part. = partly soluble. SI. sol. = slightly soluble. V. s. = very soluble. Spar. == sparingly soluble. Page Drug. Reac- tion. Solubility in Dose. LTses. in text. Water. Alcohol. Gm. or mil. 90 Acacia, gum Arabic 2 insol. Demulcent: In irrita- Mucilago acacise, ac. Freely tion in digestive 35% tract; in emulsions Syrupus, 10% ac. Freely to hold oil or other matter in suspension 143 Acetanilidum, anti- N. 190 3.4 gr. 1-5 0.06-0.30 Antipyretic, Anodyne: 240 febrin In acute fevers cau- *Pulvis acetanilidi gr. 2-15 0.12-1 tiously; in head- compositus aches; locally in powder as antiseptic. 161 *Acetozone, benzoyl- acetyl peroxide, benzozone si. sol. gr. 1-5 0.06-0.30 Antiseptic; bleaching agent. 240 Acetphenetidinum, 1310 15 gr. 2-10 0.12-0.60 Antipyretic, Anodyne: phenacetin In headaches. Acidum aceticum, ac. local Solvent: To soften cal- 36% use lous tissue, corns, Acidum aceticum dil- ac. mi5-60 1-4 etc; hemostatic. utum, 6% 73 Acidum aceticum gla- ciale, 99% ac. Caustic. 241 *Acid, acetylsalicylic, aspirin Acid, arsenous; see Arseni trioxid ac. 300 3 gr. 5-20 0.30-1.30 Anodyne, Antipyretic: In rheumatism, head- aches. 134 Acidum benzoicum ac. 275 2.3 ] Antiseptic: The acid Ammonii benzoas N. 10 35.5 gr. 5-20 0.30-1.30 and its combinations *Lithii benzoas si. ac. 3 13 given internally as Sodii benzoas N. 1.8 61 urinary antiseptics. 126 1 Acidum boricum. si. ac. 18 18 gr. 5-15 0.30-1 Antiseptic: Saturated boric acid aqueous solution as 120 Sodii boras, borax al. 15 insol. gr. 5-20 0.30-1.30 mouth wash or to 126 i purulent inflamma- 126 Glyceritum boro- glycerini (a soln. of boroglycerin, 31% N. local use tions; borax has sim- ilar uses, is alkaline and antiseptic. boric acid) j* Acidum oapiphoric ac. 125 sol. gr. 10-30 0.60-2 To control night- 1 Acid, carbolic; see . sweats of phthisis. Phenol Acid, chromic; see Chromii trioxid " 133 *Acid, cinnamic ac. si. sol. sol. j Antiseptic: Similar to 1 benzoic acid. 230 Acidum citricum ac. 0.5 1.8 gr. 5-20 . 30-1 . 30 i Restorative tonic: In i Syrupus acidi citrici, f3l-4 4-15 1 scurvy, as a substi- 1% ; tute for lemon-juice. 108 , Acidum gallioum 1 ac. 87 5 gr. 5-20 . 30-1 . 30 Astringent: as system- ic hemostatic. 71 j Acidum hydrochlori- ac! ..... : Caustic. 291 cum, 32% 298 INDEX OF DRUGS Page Solubility in Dose. Drug. Reac- tion. Uses. in text. Water. Alcohol. Gm. or mil. 229 Acidum hydrochlori- cum dilutum, 10% ac. m5-20 0.30-1.20 Digestant: when acid- ity of gastric juice is deficient. 228 Acidum hydrocyani- ac. mi-3 0.06-0.20 Sedative: in cough and 239 cum dilutum, dil. vomiting; use with 291 prussic acid, 2% caution. 73 Acidum lacticum, 85- 90% Acid, muriatic; see Acid hydrochloric ac. sol. sol. mi5-60 1-4 Antiseptic; Solvent: Applied to diphther- itic membrane and in pyorrhea alveo- laris. 71 Acidum nitricum. ac. Caustic: Locally to 291 aqua fortis, 68% sloughing ulcers, and 229 Acidum nitricum dil- utum, 10% ac. m5-20 0.30-1.20 caries of bone; dilute acid as tonic and 71 Acidum nitrohydro- chloricum, aqua ac. stimulant to liver and digestive secretions. 230 regia Acidum nitrohydro- chloricum dilutum ac. m5-20 0.30-1.20 Tonic; Digestant: Same uses as dilute hydrochloric and ni- tric acids. Acidum oleicum si. ac. insol. sol. extern. To prepare oleates. 291 *Acid, oxalic Acidum phosphori- cum, 86% ac. ac. 8 2.5 Irritant poison: As reagent; to remove stain of potassium permanganate, or of rust, fruits and ink. 231 Acidum phosphori- cum dilutum, 10% ac. m5-30 0.30-2 Restorative tonic: In neurasthenia. *Acid, picric, carba- ac. 86 sol. Reagent; Coloring zotic acid agent. 134 Acidum salicylicum ♦Ointment, 10% ac. 460 2.7 gr. 5-20 0.30-1.30 extern. Antiseptic; Antipyre- tic: As preservative; Ammonii salicylas N. i' '3' gr.' 5-i5 0.30-1 salicylates in acute 135 Sodii salicylas si. ac. 0.9 9.2 gr. 5-30 0.30-2 rheumatism. Strontii salicylas 19 61 gr. 5-30 0.30-2 71 Acidum sulphuricum, ac. Corrosive: Dilute acid 291 94% as astringent. 230 Acidum sulphuricum dilutum, 10%, ac. m5-20 0.30-1.20 [ The aromatic acid as 230 Acidum sulphuricum aromaticum ni5-20 0.30-1.20 solvent for quinine- sulphate. 162 Acidum sulphuro- sum, 6% of sul- phur dioxide gas ac. f3^-2 2-8 Disinfectant; Bleach- ing agent: In para- sitic skin diseases; 162 *Sodii bisulphis ac. 3.5 70 internally in form of Sod. sulphis exsic- N. 2 si. sol. gr. 5-30 0.30-2 sulphites or thio- cat. 1 sulphate, as antisep- 147 Sodii thiosulphas N. 0.5 insol. tic. 163 (hyposulphite) 96 Acidum tannicum ac. 0.33 0.22 gr. 1-30 0.06-2 Astringent: Applied as 114 *CoIlodium stypti- cum, 20% local use hemostatic; to con- tract tissue as in 93 Glyceritum acidi tannic, 20% Unguentum, 20% Trochisci local use local use gr. 1 each catarrhal pharyngi- tis, and to check secretion, as in diar- rhea. 230 Acidum tartaricum ac. 6!75 3:3 gr. 5-20 0.30-1.30 Substitute for citric acid or lemon-juice. 73 Acidum trichloraceti- cum ac. V. s. V. 8. Caustic: Test for albu- min. 239 Aconitum, aconite gr. i-1 0.15-0.06 Cardiac sedative: To 291 root (a. napellus) reduce arterial pres- Plate Extract gr. Vio-i 0.006-0.015 sure in inflammation xiv Fluidextractum aconiti mi-1 0.15-0.06 and sthenic fevers; locally sedative in 64,65 Tinctura aconiti, 10% m5-i5 0.30-1 form of plaster, tinc- ture, or the oleate of 291 Aconitina, aconitia ♦Oleate of aconitine, 2% Actol; see Argenti lactas al. 3200 22 gr. '/400 local use 0.00015 aconitine, in neural- gia. 91 Adeps, lard Adeps, benzoinatus extern. As basis for oint- ments; benzoinated lard keeps better than ordinary. INDEX OF DRUGS 299 Page Drug. Reac- tion. Solubility in Dose. Uses. in text. Water. Alcohol. Gm. or mil. ! 91 Adeps lanae, lanolin (purified fat of sheep's wool) Adeps 1. hydrosus, hydrous wool-fat, contains about 30% of water misc. spar. extern. Lanolin has advan- tage of being able to hold an aqueous sol- ution. 107 *Adrenalin (claimed to be the crystalline active ' Chiefly \ local use Preparations from the adrenals are arterial stimulants injected principle of supra- ' intravenously, and renal glands) hemostatics locally; ♦Adrenalin chloride to constrict arteri- 107 ♦Epinephrine (alka- loid obtained from suprarenal glands) oles, solutions of ac- tive principle, 1:1000 to 1:3000, are ap- plied; the chloride is mostly used. 202 iGther, ethylic ether, N. 12 misc. m5-30 0.30-2 Anesthetic; Local irri- Plate 96% tant: Stimulant by vi Spirit us aetheris, 32.5% N. f3i-l 1-4 reflex irritation; the spirits used for stim- 220 =^Spiritus setheris compositus ; Hoff- f3i-l 1-4 ulating and anodyne effects. man 's anodyne *jEther, nitrous 250 Spiritus aetheris ni- N.t f3i-i 1-4 Diuretic; Diaphoretic: 251 trosi, sweet spirit of nitre or ac. In fevers and in ne- phritis. 165 jEthylis chloridum si. sol. V. s. Anesthetic; Analgesic: 208 ethyl chloride ♦Agaric, spunk (a fungus) Albolene; see Petrola- tum _ local use Used locally as freez- ing agent. Absorbent; Hemostatic. ♦Albumin al. sol. insol. Freely Demulcent; Antidote; 98 Alcohol, ethyl alco- N. misc. Solvent; Preservative; 131 hol, 94.9% by vol. Antiseptic: Locally Plate irritating to mucous viii 1 membranes accord- 98 Dehydratum, 99% N. ing to concentration; 98 Dilutum, 49%, N. f31-8 4-30 internally stimulant 98 ♦Spiritus frumenti, whisky, 44-55% N. f3l-8 4-30 but in large doses is sedative. 98 ♦Spiritus vini gallici, brandy, 46-55%, N. f3i-8 4-30 100 ♦Alcohol, methyl, wood alcohol N. misc. Solvent; Antiseptic: Not used internally; fumes have caused blindness. Poison. Plate Aloe, aloes (inspis- sol. in gr. 1-10 0.06-0.60 Bitter tonic; Cathartic; xviii sated juice of leaves) boiling water Emmenagogue: In habitual constipa- ♦Extractum aloes gr. 1-3 0.03-0.20 tion; in hemorrhoids Pilulae aloes 1-4 pills not due to active ♦Pilulee a. et ferri 1-4 pills congestion; in amen- Tinctura f3J-l 1-4 orrhea, anemia, chlorosis. Plate Aloinum, aloin (from N. 65 sol. gr. i-1 0.015-0.06 Cathartic. xviii aloes) V. s. in boiling water 102 Alumen, alum, alum- inum and potass, sulphate or alumi- num and ammo- nium sulphate ac. 7.2 insol. gr. 5-30 0.30-2 1 Astringent: Gargle or wash; to check su- perficial hemorrhage ; large dose emetic. 80 Alumen exsiccatum. ac. 20 insol. local use Astringent; Caustic: 103 dried alum Applied to excessive granulations. 220 ♦Ammonia, a gas al. sol. sol. Aqua ammoniae, a al. - mio-30 0.60-2 Stimulant: Inhaled in 10% solution of syncope; solvent. the gas in water t Spiritus aetheris nitrosi easily becomes acid, and is usually so as found in the stores. 300 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Dose. Uses. in text. Water. Alcohol Gm. or mil. 73 Aqua ammoniiB al. Aq. ammonise fortior 291 fortior, 28% Linimentum, 25% extern. is caustic. *Spiritus ammonise, ai mi6-3o 0.60-2 1 10% 't Internally as stimu- 216 Spiritus ammonise al. f3i-l 1-4 J lant. 220 aromaticus Liquor ammonii ac. fSM 8-30 Diaphoretic in fevers. acetatis Ammonii benzoas N. 10 35 gr. 5-30 . 30-2 1 Same as benzoic acid. Plate Ammonii bromidum N. 1.3 12 gr. 5-30 0.30-2 Sedative: In epilepsy, XV whooping-cough. 220 Ammonii carbonas al. 4 t gr. 2-10 0.12-0.60 Stimulant; Expector- ant: In pneumonia, typhoid conditions. Ammonii chloridum N. 2.6 100 gr. 2-10 0.12-0.60 Expectorant in bron- Trochisci anmionii If gr. in chitis; alterative in chloridi each myalgia. Ammonii iodidum N. 0.6 3.7 gr. 2-10 0.12-0.60 Alterative in syphilis, scrofula. ♦Ammonii nitras N. 0.5 20 To prepare nitrous oxide. Ammonii valeras ac. V. 8. V. a. gr. 5-15 0.30-1 Stim,ulant in hysteria ♦Amygdala amara, Nerve sedative in cough bitter almond seeds and vomiting; the Oleum amygdalae N. 300 sol. mi-i 0.01-0.03 preparations of bit- amarffi j ter almond contain Spiritus, 1% oil N. ms-io 0.30-0.60 : hydrocyanic acid in Amygdala dulcis. sm.all amount. sweet almond seeds i Emulsion amygdalae Freely As vehicle. Oleum amygdalae f3l-4 4-15 1 Demulcent. expressum 225 Amylis nitris, nitrite N. insol. misc. mi-5 0.06-0.30 Inhaled in angina pec- Plate of amyl toris, asthma, hic- xiii cough, epilepsy. '294 Amylum, starch Glyceritum amyli ♦Anesthesin Animal charcoal; see Carbo Freely Demulcent: Dusting powder. Demulcent. Local analgesic. Anisum, anise seed gr. 10-30 0.60-2 Aromatic, Carminative: Aqua anisi N. f5i-l 8-30 In colic. Oleum N. l' mi-5 0. 06-0. 30 Flavoring agent. Spiritus f3i-l 1-4 251 Antimonii et potassii si. ac. 12 insol. / gr. i-2 , I gr. Vij-1 0.03-0.12 Emetic. tartras, tartar eme- 0.005 Sedative; Expectorant: tic Depresses heart. ♦Vinum antimonii m5-60 0.30^ Expectorant. 107 Antipyrina, phena- N. i' i'3 gr. 2-10 0.12-0.60 Antipyretic in acute 240 zone *Antisei3tol ; see cin- chonine iodosul- phate fevers; anodyne in neuralgias, migraine, myalgia, pertussis, infantile convulsions; 54 ♦Antitoxin, a serum that is antidotal to the toxin of a cer- | tain disease; as an , example, see Serum antidiphthericum [ t hemostatic locally to check capillary hem- orrhages. 252 ApomorphinsB hydro- N. 40 50 gr. i/io-i/io 0.003-0.006 Emetic: Hypodermi- chloridum (from [ cally when patient morphine) cannot swallow, as in opium narcosis. 148 *Argentum, silver, a Silver salts are astrin- i metal gent and antiseptic; 149 *Argenti citras, itrol ' si. sol. extern. 1 a form of metallic sil- 149 *Argenti lactas, actol 20 extern. 1 ver soluble in water. 78 Argenti nitras N. 0.4 30 gr. i-J 0.01-0.03 also citrate, lactate 103 and nitrate are used 148 i as antiseptics; nitrate 78 *Argenti nitras dilutus, N. sol. sol. as astringent; in mitigated caustic, chronic dysentery; 33 h% i diarrhea of typhoid 78 : Argenti nitras fusus, N. sol. sol. fever; to check car- lunar caustic, 96% ies in temporary teeth; also as caws^if; locally to abort in- flammation. t Decomposition occurs. INDEX OF DRUGS 301 Page Drug. Reac- tion. Solubility in Dose. Uses. Water. 1 Alcohol Gm. or mil. N. Argenti oxidum ' al. ] si. sol. Aristol; see Thymolisj [ iodidum Arnica (flowers) Tinctura arnicse 82 Arseni trioxidum, =i „/. i^ ^^ 232 arsenic ®^- ^°- I 100 291 i Liquor acidi arsen- osi, 1% Liquor potassLi arsen- itis, Fowler's sol. Liquor sodii arsena- tis, 1% (Pearson's sol. Vio as strong as above) 232 Liquor arseni et I hydrargyri iodidi, j Donovan's solution *Solution of potas- 1 slum arsenate and bromide, Clemen's solution Arseni iodidum N. Sodii arsenas iN.oral: Salvarsan I N. Neosalvarsan _ N. I Sodium arsanilate, ! . . I atoxyl _ I ' Sodii arsenas exsic- j al. catus I Sodii cacodylas Asafetida; a gum- resin Emulsum asafetid», milk of asafetida Pilulae asafetidae insol. si. sol. gr. 4-2 mi5-45 gr. Veo-Vio m2-io . 03-0 . 12 In nervous diseases. 1-3 0.001-O.006i 0.12-0.60 m2-10 0.12-0.60 m2-10 0.12-0.60 12 12 10 V. s. 28 si. sol. 12 m2-8 m2-io gr. Vso-'/io gr. Vao-Vio gr. 1-8 gr. 2-10 gr. 8 0.12-0.. 50 0.002-0.006 0.002-0. 0061 0.05-0.50 , 0.12-0.60 I 0.5 As a liniment. Escharotic: lias slow but powerful action; to devitalize pulps of teeth; in small doses alterative tonic; to improve the nu- trition in anemia, chorea, chronic dis- eases of the skin; antiperiodic in ma- larial fever. Donovan's solution as a combination of alteratives is used in syphilitic and tuber- culous (scrofulous) conditions; sod. ca- codylate and arsani- late are less toxic salts of arsenic; sal- varsan is largely used in early stages of syphilis. 3.1 si. sol. gr. i/eo-Vio iO. 001-0. 006i Tinctura *Aseptol, a33|% solution of ortho- phenolsulphonic acid Aspidium, male fern (root) Oleoresina aspidii Aspirin; see Acid, Plate acetylsalicylic ix Atropina, from bella- 222 , donna 291 i Atropinse sulphas Homatropinse hy- drobromidum Aurantii amari cor- tex, bitter orange- peel Fluidextractum aurantii amari Tinctura Aurantii dulcis cor- tex, sweet orange- peel Oleum aurantii Syrupus aurantii Spiritus a. comp. Tinctura a. dulcis *Aurantii flores, orange flowers Aqua aur. florum Aqua a. fl. fortior Syrupus a. florimi part sol. 2.5 part sol. gr. 4-3 gr.1-8 f54-l 3 gr. in each f34-l 0.03-0.20 0.06-0.50 15-30 al. N. N. 455 0.4 6 insol. 5 40 34-2 gr. 1/120-V60 gr. Vi2ff-^/6o gr. Vi!0-'/6o 2-8 1-2 Stimulant; Laxative: As antispasmodic in hysteria, chorea and other nerv-ous spas- modic conditions; in flatulent colic. Antiseptic: Locally in dilute solution. Anthelmintic: To de- stroy tapeworm. f3i-4 f3l-2 mi-5 Freely 0005-0.001 Stimulant; Mydriatic: To dilate pupil and .0005-0.001 paralyze accommo- .0005-0.001! dation; to relieve peripheral irritation, cough, asthma, etc.; as respiratory stimu- lant in opium poison- ing; homatropine is a more transient myd- riatic. Bitter tonic: Carmina- tive ; preparations used chiefly as vehicles. 1-2 4-8 0.06-0.30 Preparatio'ns as flav- oring agents and vehicles. Flavoring agent. As vehicles. Flavoring agents. As vehicle. 302 INDEX OF DRUGS Page in I text. 1 Drug. Reac- tion. Solubility in Dose. Uses. Water. Alcohol. Gm. or mil. N. 134 222 Plate 291 *01eum a. florum oil of neroli *Aurum, gold Auri et sodii ohlor- si. ac. idum *Aurum bromide *Aurum chloride ♦Solution of gold and arsenic bro- mide, "arsenauro" ♦Solution of gold, arsenic and mer- cury bromide "mercauro" Balsam of copaiba; see Copaiba Balsamum Peruvi- anum Balsamum tolutanum Syrupus tolutanus Tinctura tolutana Basham's mixture; see under Ferrum Bearberry; see Uva ursi Belladonnse folia, deadly night-shade (leaves) Extractum bella- donnse foliorum Emplastrum Tinctura bella- donnse foliorum Unguentum bella- donnse; Belladonnse radix (root) Fluidextractum bel- ladonnse radicis Linimentum bella- donnae; see Atropine Benzinum (from petroleum) Benzoinum Tinctura benzoini Tinctura benzoini composita, Friar's balsam i*Benzol (from coal- ' tar) *Benzosol, guaiacol benzoate 266 Benzosulphinidum, 285 saccharin (a coal- I tar product) 145 ' Betanaphtol, naphtol 179 Betaeucainse hydro- 182 chloridum, eucaine 133 ♦Bismuth; a metal Bismuthi subcar- bonas Bismuthi subnitras Magma bismuthi, milk of bismuth ♦Bismuth oxyiodide (subiodide) Bismuthi subgallas, dermatol insol. sol. insol. N. N. si. ac. N. insol. 290 1000 30 insol. insol. insol. insol. 1 part sol. sol. sol. 0.8 35 insol. insol. insol. insol. Perfume. gr. 1/30-1/ 10 0. 002-0. 00e> Alterative: In syph- ilis, action similar to gr. Vioo-Vio 0.0006-0.006 gr. i/eo-'/so 0.001-0.002 m5-15 m5-15 mio-30 f3§-l extern. m5-15 extern. gr. 1-2 ini-2 extern. gr. 5-30 TU5-60 m5-60 gr. 2-10 gr. 1-5 gr. 2-10 gr- i-i gr. 5-20 gr. 5-20 iZi-2 gr. 5-10 gr. 5-15 0.30-1 0.30-1 0.60-2 8-30 2-4 bichloride of mer- cury; in sclerosis of liver and kidneys, impotence, amenor- rhea, nervous disor- ders, diabetes; the bromide in epilepsy; the chloride recom- mended in tubercu- lous disorders. In scabies. Stimulant; expectorant. As vehicle. As vehicle. Mydriatic: Atropine to dilate pupil. 0.0075-0.03 Attodyne: To quiet peripheral pain and irritation; in asthma, 0.30-1 nen'ous cough, irri- I table bladder, incon- tinence of urine; combined with ca- 0.06-0.12 thartics to prevent griping; in small 0.06-0.12 doses stimulant to the heart and respi- ration; in opium poisoning; vasomotor stimulant; to check sweating. Solvent. gr. 1-2 0.06-0.12 0.30-2 0.30-4 0.30-4 To prepare benzoic acid; Antiseptic. Tinctures inhaled in respiratory diseases and applied as local stimulants and anti- septics to mucous membranes. Solvent. 0.12-0.60 0.06-0.30 0.12-0.60 0.015-0.03 0.30-1.30 2-8 Antiseptic: In intes- tinal diseases and phthisis. Sweetening agent: Is 500 times sweeter than cane-sugar. Antiseptic. Local analgesic: Less powerful and toxic I but more irritating, I than cocaine. 0.30-1.30 ! Locally sedative and slightly astringent; in vomiting, diar- rhea, gastric ulcer. 0.30-0.60 0.30-1 Antiseptic to dress wounds and ulcers. Antiseptic: As substi- tute _ for iodoform; also internally. INDEX OF DRUGS 303 142 291 251 Drug. Reac- tion. Solubility in Water. Alcohol 177 216 223 Plate 117 223 227 142 160 90 119 121 *Bismuth tribromphe- nolate, seroform Bisulphide of carbon; see Carbonei disul- phidum Bitter almond; see Amygdala amara Bitter orange peel; see Aurantii Blackberry; see Ru- bus Black haw; see Vibur- num prunif olium Black wash Blue ointment Blue pill; see under Hydrar- gyrum Borax; see Sodii boras Brandy; see under Alcohol Bromoformum Bromum, bromine Brown mixture; see under Glycyrrhiza Buohu (leaves) Fluidextractum buchu Buckthorn; see Fran- gula Cacao butter; see under Theobroma ^'Caffea (C. arabica), coffee (seeds) Cafleina, caffeine (theine) Caffeina oitrata, 50% caffeine Caffeina citrata effer- vescens, 2% caf- feine Caffeinae sodioben- zoas Cajuput, oil of; see Oleum cajuputi Calcium; see under Calx Calomel; see under Hydrargyrum Calumba (Jateorhiza palmata), columbo (root) Tinctura Calx, lime Calx chlorinata, bleaching powder, chloride of lime Calcii sulphidum cru- dum Linimentum calcis, carron oil Liquor calcis, lime- water *SyTupus calcis *Calcium, a metal Calcii bromidum Calcii carbonas prsecipitatus Cretse prseparata, prepared chalk Mistura cretse Pulvis cretse compositus insol. insol Gm. or mil. Uses. 300 28 al. N. or al. sol. sol. sol. sol. 1.1 840 part si. sol. 0.7 aim. insol. mi-5 extern. gr. 15-60 mi5-60 0.06-0.30 66 sol. sol. 30 insol. part insol. 1.3 insol. gr. 1-5 gr. 2-10 3i-2 gr. 2-10 gr. 5-30 f31-2 gr. i/i»-l f31-8 mi5-60 gr. 5-30 gr. 5-30 f32-8 gr. 5-60 1-4 1-4 0.06-0.30 0.12-0.60 2-8 0.12-0.60 0.30-2 4-8 Antiseptic: Has been used in root filling. 0.006-0.06 4^30 1-4 0.30-2 0.30-2 8-30 0.30-4 Anesthetic: recom- mended in pertussis. Caustic; Reagent; Anti- septic. Stimulant; diuretic; in inflammation of the genito-urinary tract. Stimulant; Diuretic; Stimulates cerebrum and heart; in opiiom poisoning strong in- fusion or decoction by enema or caffeine hypodermically ; in headaches, cardiac failure. Bitter tonic: In atonic indigestion; it con- tains no tannin. Caustic. Disinfectant. To prevent suppura- tion. Externally to b\irns. Alkali: In vomiting, diarrhea; to correct acidity and irritabil- ity of stomach; anti- dote to oxalic acid. Sedative: Same use as sodiima bromide. Preparations of the carbonate are used in indigestion, vom- iting, and diarrhea; prepared chalk as an antacid to the mouth and in den- tifrices. 304 INDEX OF DRUGS Solubility in Dose. p?ge Drug. Reac- tion. Uses. in text. Water. Alcohol Gm. or mil. Ill Calcii chloridum N. 1.2 10 gr. 5-10 0.30-0.60 Alterative: Hemosta- Calcii lactas 20 aim. gr. 5-10 insol. 0.30-0.60 tic; Chloride and lactate internally in hemorrhages. Calcii hypophosphis N. 6.5 insol. gr. 2-10 0.12-0.60 Tonic; Alterative: _ In *Syrup f31-3 4-12 anemia, rhachitis, caries. 231 Syrupus hypophos- phitum f31-3 4-12 Syrups of hypophos- phites in wasting 231 *Syrupus hypophos- phitum compositus f3i-3 4-12 diseases, tuberculo- sis, rhachitis, ner- vous diseases. Syrupus calcii lac- f31-3 4-12 Similar uses to above. tophosphatis *Calcii sulphas exsic- N. 378 insol. Used in making im- catus, plaster of pressions, casts and Paris plaster-of-Paris ban- dages and jackets. *Calcium iodide 0.5 gr. 2-4 0.12-0.25 Alterative; Antiseptic: In pulmonary syph- ilis. Cathartic: In dropsies. Cambogia, Gamboge gr. 1-3 0.06-0.20 221 Camphora, camphor si. sol. sol. gr. 1-5 0.06-0.30 Stimulant; Anodyne: 292 To relieve spasm or Aqua camphorae f3l-4 4-15 cramp, dysmenor- *Ceratum extern. rhea, cholera, colic, 221 Spiritus, 10% Linimentum cam- phorae, camphor- ated oil, 20% izi-l 1-2 diarrhea, nervous depression, head- ache, neuralgia; spir- it inhaled in syncope; liniment externally; *Acid camphor mix- f3l-4 4-15 in diarrhea. ture, Hope's mix- ture Camphora monobro- N. aim. 6.5 gr. 1-5 0.06-0.30 Monobromate is seda- mata insol. tive to nervous sys- tem; in insomnia and hysteria. 292 Cannabis; C. sativa or indica, Indian hemp (tops of fe- male plant) .... gr. 2-5 0.12-0.30 Anodyne; Deliriant; Hypnotic: In mi- graine, neuralgia, dysmenorrhea, irri- Extractum cannabis gr. i-l 0.01-0.03 table bladder, reten- Fluidextractum mi-4 0.06-0.25 tion of urine; in tet- Tinctura m5-20 0.30-1.20 anus, delirium tre- mens, acute mania. 67 Cantharis, Spanish Vesicant: To produce 292 flies • blister in neuralgia, Ceratum canthar- rheumatism; coun- idis extern. teract local inflam- Collodium canthar- mations; promote idatuni absorption of effu- sions. Tinctura canthar- mi-4 0.06-0.25 Tincture internally is idis diuretic and irritant; use cautiously; ap- plied locally diluted, to stimulate growth of hair. 61 Capsicum (C. frutes- cens), Cayenne pepper (fruit) Emplastrum gr. 1-3 0.06-0.20 extern. Local stimulant and irritant: To stimu- late unhealthy con- dition of the gums; in atony of stomach, Oleoresina iiij-i 0.01.5-0.06 diarrhea, colic, indi- Tinctura ms-io 0.30-0.60 gestion of alcohol- ism; plaster as mild counterirritant. 152 *Carbo animalis, ani- mal charcoal ♦Carbo animalis puri- ficatus Freely Decolorizing agent. As antidote in alka- loidal poisoning; to decolorize and purify liquids. Absorbent: Internally 152 Carbo ligni, wood Freely charcoal in flatulent indiges- tion. INDEX OF DRUGS 305 Page Drug. Reac- tion. Solubility in Water. Alcohol, Dose. Uses. Gm. or mil. ! 139 Plate xviii Carbonei disulphi- dum Cardamomum, car- damon (seed) Tinctura carda- momi Tinctura c. comp. *Carinine, carminic acid (from coc- cus) Carron oil; see under Calx Caryophyllus (euge- nia aromatioa), cloves (flower buds) Oleum caryophylli Cascara sagrada, rhamnus purshiana (bark) Extractum cascarae 156 245 246 Plate xvi 292 Fluidextractum Fluidextra^t, arom. Cassia, oil of; see under Cinnamo- Tniim Castor oil; see Oleum ricLui Catechu; see Gambir Cera alba, white wax Ceratum Cera flava, yellow wax Cetaceum, sperma- ceti Chalk, prepared; see under Calcium Charcoal; see Carbo. *Chinosol, quinosol Chloralum hydratum, chloral *Butyl-chloral, cro- ton-chloral *Chloral-camphor *Chloral-phenol *Chloral-menthol *Chloretone, acetone- chloroform Chloride of lime; see Calx chlorinata 142 *Chlorine; a gas 142 Liquor sodse chlori- 160 142 160 natse, Labarraque's solution, 2.5% chlorine Calx chlorinata, j al. chloride of lime, | 30% chlorine I 526 sol. insol. sol. sol. gr. 10-15 f3i-l f3§-2 insol. spar, insol. spar. insol. a_lm. insol. insol. 0.25 1.3 insol. sol. sol. sol. sol. V. s. mi-5 3i-l gr. 1-5 mio-30 mi5-60 extern, extern. part. part. gr. 5-15 gr. 5-15 1 \ extern. gr. 5-15 f3i-i 0.60-1 1-4 2-8 gr. 2-10 0.12-0.60 0.06-0.30 1-4 0.06-0.30 0.60-2 1-4 0.30-1 0.30-1 0.30-1 2-4 Solvent for rubber. Aromatic: As flavor- ing agent and car- minative; in flatu- lent colic. Coloring agent. " Aromatic: As condi- ment and carmina- tive; the oil in pre- paring microscopic specimens. Tonic cathartic; in chronic constipation. In cerates and oint- ments; as impres- sion and modelling material. In cerates and oint- ments. Antiseptic: For treat- ing pus cavities (1 to 2% sol.) ; internally as intestinal anti- septic. Hypnotic; Sedative: In insomnia, mania, te- tanus, convulsions of children, strychnine poisoning, epilepsy, other spasmodic affections, deliriiim of fevers, cholera; use cautiously. Croton-chloral, simi- lar to chloral in ac- tion, is said to have a special anodyne effect upon the fifth cranial nerve. Locally in neuralgia as anodyne and coun- terirritant. Hypnotic; Analgesic. Antiseptic: Externally as disinfectant wash ; bleaching agent: to bleach discolored teeth. Disinfectant; Bleaching agent. 20 306 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Water. Alcohol Dose. Uses. Gm. or mil. I 205 Chloroformum N. Plate Aqua chloroformi, vii I about 0.5% 67 ! Linimentum, 30% 292 1 Spiritus, 6% ! A stronger spirit I (J chloroform) is I known as chloric 1 ether SO I Chromii trioxidum, : chromic acid 227 j Cinchona, Peruvian bark Cinchona rubra Fluidextractum cin- chonse Tinctura Tinctura cinchonae composita; see Quinina Cinchonidinse sul- N. phas 210 143 Cinchoninse sulphas *Cinchonine iodosul- phate, antiseptol Cinnamomum, cin namon (bark) *C. cassia C. saigonicum C. zeylanicum Aqua cinnamomi 138 ! Oleum cassise, oil of I si. ac. cinnamomi Spiritus Tinctura Cloves ; see Caryo- phyllus 88 j*Cobalt 169 *Coca, erythroxylon Plates! coca (leaves) 63 58 insol. insol. sol. 72 10 sol. 169 292 Plates ii, iii 248 294 Cocaina (from ery- throxylon coca and its varieties) Cocainae hydrochlori- dum *01eatum cocainae, ' 5% Coccus, cochineal (an insect) ; used as col- oring agent; see also Carmine ' Codeina (alkaloid I from opium) Codeinse phosphas Codeinae sulphas I Cod-liver oil; see Oleum morrhuse Coffee; see Caffea Colchici cormus (corm of colchi- cum autumnale) Extraetum colchici cormi Colchici semen (seed) Fluidextractum col- chici seminis Tinctura colchici seminis Colchicina (alkaloid from c. autumnale) Cold cream ; see under Rosa al. ac. N. 600 0.4 6.5 3.2 120 2.3 30 m2-io f5i-i f3^-2 gr. 10-30 gr. 10-30 mio-30 f3i-2 f3l-2 gr. 1-20 gr. 1-20 extern. gr. 1-10 f5i-l mi-s mio-60 m5-30 extern. 3i-i gr. k-h locally gr. i-1 0.12-0.60 \ Anesthetic; Anodyne: 8-30 I By inhalation most- I ly; in convulsions, extern. dysmenorrhea and 2-8 other spasmodic pain; locally as ano- dyne and irritant; internally in colic. Caustic: Local use only. 0.60-2 Bitter astringent tonic: in atonic indiges- 0.60-2 tion, relaxed condi- . 60-2 tions of mucous membrane of diges- 2-8 tive tract; general 2-8 tonic; antiperiodic; in malarial fevers, periodic neuralgia. 0.06-1.30 I The alkaloids possess the tonic and anti- malarial \'irtues of cinchona; in medi- cinal value they stand in the follow- ing order: 0.06-1.30 Quinine. Cinchonidine. Cinchonine. Antiseptic: An odor- less substitute for iodoform (50% iodine) . 0.06-0.60 \ Aromatic; Condiment. 8-30 0.06-0.30 0.60-2 0.30-2 As vehicle. Flavoring agent: Used as carminative in flatulence; antiseptic; spirit and tincture as vehicle. 325 1280 gr. i-1 gr. i-1 0.015-0.06 0.015-0.06 gr. 2-10 0.12-0.60 gr. J-2 0.03-0.12 gr. 1-8 mi-8 0.06-0.50 0.06-0.50 m 10-60 0.60-4 V. 8. gr. Via) 0.0005 Eschar otic: To devital- ize pulps of teeth. 1-4 Stimulant: In action similar to coffee; large doses are seda- tive; the alkaloid co- caine is a local anal- gesic, stimulant and 0.01-0.03 mydriatic; locally or hypodermically in 1 to 4% aqueous solu- tion to abolish sen- sation; applied to the eye it dilates pupil; use cautiously to avoid poisoning or habit. 0.015-0.06 Same use as opium; The after-effects are less unpleasant; in diabetes. Alterative: In full doses diuretic and cathartic; its chief use is in subacute or chronic rheuma- tism and in rheuma- tic gout; in ascites due to hepatic ob- struction; colchicine may be given hypo- dermically. ■j Decomposition occurs. INDEX OF DRUGS 307 Page Drug. Reac- tion. Solubility in Dose. Water. .Alcohol. Gm. or mil. Uses. 114 Collodium, collodion 11-i Collodium flexile, flexible collodion 67 Plate xviii 110 130 131 131 129 91 251 252 Collodiuni canthari- datum *Collodiuni stypti- cum, 20% tannic acid Colocynthis (citrul- lus c, fruit) Extractum colo- cynthidis Extractum c. com- positum Pilulae catharticse compositaef *Pilul£e catharticse vegetabiles Columbo; see Calum- ba ''Convallaria (c. maja- lis) ; lily of the val- ley (root) *Fluidextractum convallarise Copaiba, balsam of copaiba *01eum copaibae Copperas ; see Ferri sulphas Copper salts; see under Cuprum Corrosive sublimate; see under Hydrar- gyrum Cotarninffi hydro- chloridum (from narcotine, an opium alkaloid) Cotton; see Gossyp- ium Cotton-seed oil; see under Gossypium Cream of tartar; see Potassii bitartras Creosotum (distilled from wood) Aqua creosoti, 1% Guaiacol Guaiacolis carbonas Creosoti carbonas ^Creolin (from coal tar Cresol (from coal tar) Liquor oresolis, comp. lysol Creta prseparata; see under Calcium Croton oil; see Oleum tiglii Cubeba (Piper e. , un- ripe fruit) Fluidextractum cubebae Oleoresina Oleum Trochisci N. N. or N. 53 insol. insol. sol. sol. 60 sol. sol. 50 insol. sol. Protective to slight wounds and to check superficial hemor- rhages. Vesicant: For blister- ing purposes. Styptic. gr. 1-3 10.06-0.20 Tonic cathartic: In [ constipation; in full gr. J-l ,0.015-0.06 doses powerful hy- dragogue cathartic; gr. 5-15 I 0.30-1 in dropsies; given usually in combina- 1-3 pills 1-5 pills gr. 5-30 m5-30 foi-l Tn5-15 mi-8 131-4 ni2-15 gr. 5-30 m5-30 mi-5 mi-2 f3i-l TT15-15 m5-15 gr. i of oleoresin in each tion. . 30-2 ; Heart stimulant; Diu- retic: Similar to digitalis in action; in 0.30-2 large doses cathartic. l-i Diuretic; Expectorant: In later stages of 0.30-1 gonorrhea; chronic I cystitis and chronic bronchitis. 0.03-0.20 Hemostatic: In hemor- rhage from small vessels. 1.06-0.50 Antiseptic: In aque- ous solution as ■4-15 mouth- wash; to 0.12-1 check fermentation 0.30-2 within the digestive 0.30-2 tract; in vomiting, flatulence and fer- mentative diarrhea; internally in phthisis and other pulmon- ary diseases: guaia- col and its salts have similar uses. 1.06-0.30 ^ Antiseptic: Valuable for general use as douche; in cystitis, intestinal disorders. Antiseptic. 0.03-0.12 extern. 1-2 Aromatic stimula?it; diuretic: Expector- 1-2 ant: In bronchitis, pharyngitis and 0.30-1 laryngitis; chronic 0.30-1 inflammations of genito-urinary tract. t X grain of calomel in each. 308 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Dose. Uses. in text. Water. Alcohol. Gm. or mil. 80 ♦Cuprum, copper 104 Cupri sulphas Deadly nightshade; see Belladonna Dermatol; see under Bismuthum ac. 2.5 500 gr. i-5 0.03-0.30 In full dose emetic; locally astringent and irritant; to stimulate indolent ulcers; as a mild caustic applied to granular eyelids. Diacetylmorphina, al. 1700 ; 31 gr. '/sr-'/io 0.002-0.006 Sedative: In cough heroin mixtures; being more Diacetylmorphinae N. 2 sol. gr. V.o-Vio 0.002-0.006 powerful than mor- hydrochloridum phine, it must be Diachylon ointment; used with caution. see under Plumbum 177 Digitalis (d. pur- gr. i-2 0.03-0.12 Heart stimulant and 224 purea, leaves) tonic; Diuretic; 250 Fluidextractum mi-2 0.03-0.12 Strengthens and Plate Infusum f3l-4 4-15 slows heart beats; xii Tinctura, 10% m5-20 0.30-1.20 in weak circulation Plate due to heart dilata- iv tion or exhaustion. ♦Digitalin gr. '/eo-'/io 0.001-0.002 A product of uncer- tain and variable character. Diuretin; see under Theobroma Dobell's solution; see under Sodii boras Donovan's solution; see under Arseni trioxid Dover's powder; see under Opium Plate Elaterinum (from N. insol. 325 gr. ViO-Vio 0.003-0.006 Hydragogue cathartic: xviii elaterium) In dropsies, cerebral 293 Trituratio elaterini, 10% gr. i-1 0.03-0.06 hyperemia threaten- ing apoplexy. Emetinse hydrochlor- si. ac. V. s. V. s. gr. J 0.02 Emetic: May be used idum (alkaloid of hypodermically; ipecacuanha) recommended in 107 Epinephrine; the ac- pyorrhea. tive principle of suprarenal glands; see Suprarenalum siccum Epsom salt; see Mag- nesii sulphas 108 Ergota, ergot of rye Oxytocic; Vasoconstric- Plate i Extractum ergotse, "ergotin" gr. 2-8 0.'l'2-<)'.5 tor: To stimulate contraction of uterus Fluidextractum f3i-i 1-4 after labor; to check capillary hemor- rhages, menorrhagia, Eriodictyon, yerba diarrheas; to reduce santa (e. californi- cerebral and spinal cum, leaves) hyperemia. Fluidextractum mi5-30 1-2 Stimulant expectorant: eriodictyi In chronic pulmon- Eserine; see under ary diseases; in Physostigma syrup to cover bitter Ether, chloric; see taste of quinine. under Chloroform Ether, ethylic; see ^ther 212 ,*Ethyl bromide, hy- spar. sol. inhaled Anesthetic: Prompt in drobromic ether action, but danger- Ethyl chloride; see ous. yEthylis chloridum ! ;*Ethyl iodide, hydri- insol. sol. inhaled Anesthetic; Alterative; j odic ether Stimulant. ♦Ethylene bichloride, inhaled Anesthetic: Probably Dutch liquid ranks between ether and chloroform in safety. Anesthetic: Probably ♦Ethylidene chloride inhaled i less depressing than chloroform. INDEX OF DRUGS 309 Page Solubility in Dose. Drug. Reac- tion. Uses. in text. Water. Alcohol. Gm. or mil. 179 Eucaine; see Beta- eucaine Eucalyptus (e. globu- lus, leaves) Formerly in malarial fevers; oil is anti- Fluidextractum eu- iZi-2 2-8 septic, used ^ mostly calypti by inhalation in 137 Oleum N. insol. 4 m5-15 0.30-1 chronic catarrhs of 140 Eucalyptol (from ol. eucalypti) N. insol. sol. m2-io 0.12-0.60 respiratory tract; eucalyptol has same 137 Eugenol (a constitu- si. ac. sol. mi-5 0.06-0.30 Similar to oil of cloves. 139 ent of oil of cloves) *Europhen, 28% insol. sol. extern. Antiseptic: Substitute iodine for iodoform. 229 Ferrum, iron N. insol. inso Tonic: Restorative to Ferrum reductum, N. insol. inso gr". l-'5 0.06-6! 30 the blood in anemia, reduced iron chlorosis, amenor- Liquor ferri et am- ac. fSl^ 4-15 rhea, infectious and monii acetatis. wasting diseases; the Basham's mixture preparations may be grouped as follows: Ferri carbonas sac- N. part. insol. 1 Oxides and carbon- charatus Massa f . carbonatis, [ gr. 2-10 0.12-0.60 ates; their prepara- tions and reduced Vallet's mass J iron are restorative, Pilulse f. carbonatis, 1-2 pills but not astringent. Blaud's pill Ferri chloridum, fer- ac. V. s. V. s. gr. 1-5 0.06-0.30 The mineral acid salts ric chloride of iron are astringent, 102 Liquor f. chloridi ac. m2-8 0.12-0.50 and besides being 101 Tinctura f. chloridi ac. m5-20 0.30-1.20 tonics, are used as Ferri et ammonii N. sol. insol. hemostatics. The citras Ferri et quininae ac. V. s. part. gr. 2-10 0.12-0.60 sulphates are largely used in this way; the citras tincture of the chlor- ide is valuable for internal use, com- bining tonic prop- erties of iron and hy- drochloric acid; it has long been used both internally and locally in erysipelas. PilulsB ferri iodidi 1 to 2 pills The compound salts 229 Syrupus f. iodidi N. Ta5-30 0.30-2 possess special value 88 Ferri hydroxidum insol. insol. 31-4 4-15 according to the 291 cum magnesii combination. note oxido; ferric hy- drate ; hydrated oxide Ferri phosphas si. ac. sol. insol. } gr. 1-5 0.06-0.30 *Ferri pyrophosphas si. ac. sol. insol. 293 Ferri sulphas, ferrous ac. 1.4 insol. The iodide is altera- sulphate, copperas tive, possessing a Ferri sulphas exsic- ac. sol. insol. gr. 1-2 0.03-0.12 special value for catus scrofulous children. Ferri sulphas granu- ac. sol. insol. The hydrated oxide latus is the best anti- 102 *Subsulphate, Mon- sel's salt sol. gr. 1-3 0.06-0.20 dote in arsenical poisoning, before the 102 Liquor ferri subsul- phatis, Monsel's solution ac. m2-io 0.12-0.60 poison has been ab- sorbed; see Table of Poisons. 102 Liquor f. tersulph. ac. Used chiefly to pre- pare other salts. 88 *Dialyzed, scales gr. 1-5 0.06-0.30 Recommended as an liquid mio-30 0.60-2 antidote to arsenic, Flaxseed; see Linum but less valuable than hydrated oxide. 156 ♦Formaldehyde, a gas Disinfectant: Most 156 Liquorformaldehydi, formalin, 37% n". or si. ac. extern. efficient disinfectant for rooms, clothing, 158 Paraformaldehydum, paraform, solid for- maldehyde Fowler's solution; see under Arseni tri- oxidum Foxglove; see Digi- talis si. sol. insol. gr. 2-10 0.12-0.60 books, etc.; in solu- tion of 1% or less as antiseptic; to soft tis- sues in very dilute solution on account of its irritant action; paraform may be used internally; to preserve anatomical specimens. 310 INDEX OF DRUGS Page in text. Drug. Reac- tion. Solubility in Dose. Water. Alcohol. Gm. or mil. Uses. Plate xviii 97 97 137 140 111 29 Frangula (rhamnus f.), buckthorn (bark) Fluidextractum frangulae Friar's balsam; see under Benzoin Galla, nutgall (from quercus infectoria) Unguentiim Gambir, catechu Tinctura gambir composita Gamboge; see Cam- ^Gaultheria, winter- green (leaves) ' Oleum gaultheriffi, X. or methyl salicylate si. ac. *Spiritus Gelatinum Gelatiniim glycerin- atum part. sol. sol. 227 Gentiana (g. lutea, root) Extractum gentianse Fluidextractum Tinctura comp. Ginger; see Zingiber Glauber's salt; see Sodii sulphas Glonoin; see Nitro- glycerin 92 Glycerinum, glycerol 265 29 Suppositoria glj'cer- ini 91 Glycyrrhiza (g. gla- bra), licorice root Elixir glycjTrhizae Extractum Extractum punmi Fluidextractum Mistura comp. brown mixture Puh-is compositus Glycyrrhizinum am- moniatum Gold; see Aurum Golden seal; see Hy- drastis Gossypium purifica- tum, cotton (g. herbaceum, hairs of seed; Oleum gossypii sem- inis (cotton-seed oil) Goulard's extract ; see Plumbum Gray powder; see Hy- drargyrum Green soap; see Sapo mollis sol. f3M gr. 10-30 f34-2 3i-2 mi-10 f3l-2 gr. 2-10 m5-30 f3J-2 ms-eo sol. f3l-4 34-2 gr. 2-10 0.60-2 2-8 2-8 Cathartic: Fresh bark is harsh, old bark is mild and efficient; in chronic constipation. Astringent: Virtues due to the tannic and gallic acids con- tained. Astringent: Owes its value to tannic acid. Aromatic; Astringent: Substitute for sali- 0.06-0.60 cylic acid in rheu- matism; used as fla- 4—8 voring agent. r . . . . To prepare capsules and suppositories; as coating for pills; in hemophilia by rec- tum or subcutane- ously. Bitter tonic: Simple stomachic and gen- 0.12-0.60 eral tonic; contains 0.30-2 no tannin. 2-8 0.30-4 freely freely freely freely 4-15 2-8 Vehicle; SoherU; Pre- servative: Locally demulcent and emol- lient; in enema or suppository for con- stipation; sweeten- ing agent. Laxative: For intro- duction into the rec- tum. Expectorant: Demul- cent: In cough mix- tures; to cover taste of bitter drugs. Vehicle. Contains Laxative: senna. 0.12-1.20 Same uses as licorice. To prepare surgical dressings; as absor- bent. Emollient: substitute for olive oil; applied to burns, etc. INDEX OF DRUGS 311 Page Drug. Reac- tion. Solubility in Water. Alcohol Dose. i Gm. or mil. Uses. 97 158 233 150 233 293 233 232 Guaiacum (g. officin- ale or g. sanctum) guaiac (resin) Tinctura guaiaci Tinctura guaiaci ammoniata Guaiacol; see under Creosotum Guarana (from Paul- linia cupana, seeds) Fluidextractum guaranse Gum Arabic; see Acacia Guncotton; see Pyro- xylinum 'Gutta-percha (solu- ble in chloroform, oil of turpentine, carbon disulphide or benzin) *Hamamelis, witch- hazel (h. virginiana leaves and bark) Aqua hamamelidis Fluidextractum *Hedeoma, penny- royal (leaves and fl. tops) Oleum hedeomae *Heroin; see Diacetyl- morphine Hexamethylenamina, urotropin Hoffman's anodyne; see under ^ther *Holocaine hydrochlo- ride Homatropine; see under Atropine Honey; see Mel. Hydrargyrum, mer- cury, a metal Hydrargyrum cum creta, gray powder, 38% Massa hydrargyri, blue pill, 33% Oleatum (25% yel- low oxide) Unguent um, blue ointment, 50% Unguentum hyd. dilutum, 30%, Hydrargyrum ammo- niatimi, white pre- cipitate Unguentum hy- drargyri ammo- niati, 10% Hydrargyri chlori- dum corrosiviim, mercuric chloride, corrosive sublimate Hydrargyri chlori- dum mite, mercur- ous chloride, calo- mel ♦Hydrargyri cyani- dum Hydrargyri iodidum flavum Hydrargyri iodidum j rubrum Liquor arseni et hydrargyri iodidi, Donovan's solution insol. N. 40t insol. aim. insol. 13.5 insol. 12.8 aim. insol. aim. insol. insol. 12.5 insol. aim. insol. 3.8 insol. 15 insol. 115 gr. 5-30 0.30-2 m-2 f3i-l 3i-l 31-2 f3l-2 mi-5 gr. 5-15 gr. 2-10 gr. 2-10 2-8 1-4 1-4 1-4 2-8 2-8 0.0&-0.30 0.30-1 extern. 0.12-0.60 0.12-0.60 Alterative: In rheuma- tism, gout, tonsil- litis, myalgia, sciatica and syphilis. Tonic; Stimulant: Similar in action to coffee; used in mi- graine. Protective: In making splints and surgical appliances; as tem- porary filling for teeth. Feeble astringent: In hemorrhages, hemor- rhoids; locally to bruises and inflam- mations. Aromatic; Carmina- tive: In colic; used also externally. Antiseptic: When given internally lib- erates formaldehyde during elimination by the kidneys. Local analgesic: Same uses as cocaine, but probably more toxic. Metallic meicury used in gray powder, blue pill, and ointment, in a very finely di- vided state; prepa- rations of mercury are alterative and purgative; it is the chief remedy in sec- ondary syphilis ; blue pill is cathartic, but should be followed by a saline; ointment and oleate by inunc- tion to obtain sys- temic effect. gr. i/eo-Vio 0.001-0.006 The most poisonous I salts are corrosive I chloride, cyanide and I red iodide. Corrosive gr. 4-10 . 03-0 . 60 sublimate is efficient for internal use; in secondary and ter- tiary syphilis, is fre- gr. V6(r-Vio 0.001-0.0061 quently combined : with iodides; it is a gr. 6-j 0.01-0.03 powerful antiseptic I in 1:2000 or weaker :r. i/eo-Vio |0. 001-0. 006 solution as douche or irrigation. mi-8 0.06-0.50 t Soluble in boiling water, which upon cooling leaves a 2.5 per cent, solution. 312 INDEX OF DRUGS Page 1 Solubility in Dose. Drug. tion. Uses. in text. Water. Alcohol. Gm. or mil. Unguentum hy- Calomel is a mild and drargyri nitratis, certain cathartic as citrine ointment occasional purge in Hydrargyri oxidum aim. insol. fevers and inflam- flavum insol. matory diseases; an Unguentum hy- extern. efficient diuretic in drargyri oxidi flavi dropsies; in diar- 10% rheas in small doses; Hydrargyri oxidum 1 aim. insol. 1 locally as a sedative, rubrum, red pre- insol. I alterative applica- cipitate tion to ulcers. Hydrargyri salicylas aim. insol. aim. insol. gr. i-1 . 0.008-0.06 i The salicylate may be i usedhypodermically. ♦Black wash (1 gm. extern. Black wash and yellow calomel, 115.5 c.c. wash are applied to lime-water) syphilitic ulcers. ♦Yellow wash (1 gm. extern. corrosive subli- mate, 308 c.c. lime- water) Hydrastis, golden gr. 5-60 0.30-^ Bitter tonic: in atonic seal (h. canadensis, indigestion; altera- root) tive to mucous mem- Extractum hydrastis gr. 2-15 0.12-1 branes; in diseases Fluidextractum m5-60 0.30-4 of genito-urinary or- Glyceritum, 100% m5-60 0.30-4 gans. Tinctura iZh-2 2-8 Hydrastina ai. si. sol. 170 gr. i-i 0.015-0.03 Hydrastininse hydro- ac. V. s. V. s. gr. 1-1 0.03-0.06 Hemostatic: In uterine chloridum hemorrhages, dys- menorrhea. 115 Hydrogen dioxide, si. ao. local use Disinfectant: To clean 153 official as liquor hydrogenii dioxidi (3%), peroxide of hydrogen, 10-vol- ume solution, in water ulcers and wounds; to clean pulp cham- bers and canals. 80 Ethereal solution of local use Caustic: to bleach 161 hyd. dioxide, 25% Hydronaphtol ; see Betanaphtol teeth. 223 Hyoscinse hydrobro- 293 midum; see Scopo- lamine 293 Hyoscyamus, hen- bane (h. niger, Ivs. and fl. tops) gr. 2-10 0.12-0.60 In action it is similar to belladonna, but more sedative and Extractum hyos- gr. i-2 0.03-0.12 hypnotic; in insom- cyami nia, mania, delirium Fluidextractum m2-io 0.12-0.60 tremens; it quiets Tinctura f3i-i 1-4 peripheral irritation, 223 Hyoscyaminse hydro- bromidum Hypophosphites N. V. 8. 2!5 gr. i/joo 0.0003 nervous cough, irri- tability of bladder. Hyoscyamine is ano- dyne and mydriatic. Tonic; Restorative: 231 Syrupus hypophos- phitum £31^ 4-15 In wasting diseases, tuberculosis, rachitis. ♦Syrupus hypophos. f31-2 4-8 nervous diseases. compositus 254 Hypophysis sicca, dried pituitary body gr. i-1 0.015-0.06 Oxytocic: Causes stim- ulation of vascular system, with in- Liquor hypophysis mi5 1 creased blood-pres- ♦Pituitrin m8-30 0.5-2 Bure. ♦Ichthyol b1. ac. sol. part. extern. Antiseptic; Alterative: ♦Lotion or ointment extern. Applied to skin dis- Indian hemp; see eases, inflammations. Cannabis indica Iodine; see lodum 143 lodoformum, iodo- form. 96.7% iodine Unguentum iodo- formi, 10% N. aim. insol. 60 gr. 1-5 0.06-0.30 extern. Used externally; alter- ative; antiseptic: as powder to wounds and ulcers. 143 ♦lodolum, iodol, 89% iodine insol. 9 gr. 1-3 0.03-0.20 Antiseptic: Same uses as iodoform. INDEX OF DRUGS 313 Page Drug. Reao- i tion. Solubility in Dose. Uses. Water. Alcohol. 63 lodiim, iodine 65 Liquor iodi compo- 143 situs, Lugol's solu- 233 tion, 5% iodine, 293 ; 10% iodide of po- ^ tassium I i Tinctura iodi, 7% I Unguentum, 4% 91 I Ipecacuanha, ipecac 251 I Ccephaelis i. root) 252 ■ , I Fluidextractum ipe- j cacuanhse ' ' Syrupus, 7% Pul\as i. et opii; see under Opium Tinctura i. et opii; see under Opium; see Emetine 284 ;*Iris florentina, orris i root Iron; see Ferrum Itrol; see Argenti citras Jaborandi; see Pilo- carpus Plate I Jalapa (exogonium xviii j purga, root) Puhas comp. Resina *Juniperus commu- nis (ripe friut) 251 Oleum juniperi j Spiritus Spiritus comp. *Infusion 97 : Kino (pterocarpus marsupium, inspis- sated juicej Tinctura kino 97 *Krameria, rhatany (k. triandra and k. ixina, root) *Extractum kra- *Fluidextractum *Tinctura *Trochisci Labarraque's tion; see Chlorine Lactuoarium, lettuce (lactuca \'irosa, concrete juice) Syrupus lactucarii Tinctura Lanolin; see Adeps lanse hydrosus Lard; see Adeps Laudanum ; see un- der Opium Laughing gas; see Nitrogenii monoxi- dum ''Lavandula officinalis, lavender (flowers) Oleum lavandulae Spiritus Tinctura comp. Lead; .see Plumbum Lemon peel; see Lim- onis cortex Licorice root ; see Glycyrrhiza Lily of the valley; see Convallaria Lime; see Calx 2950 12 . 5 si. ac. insol. I sol. insol. si. sol. solu- under sol. mi-o ITll-3 gr.' i-30 mi-5 mi5-30 TTl5-f32 gr. 5-30 gr. 5-20 3J-2 gr. 1-10 3i-i m2-io f3i-i f3i-i f5i-2 gr. 5-15 f3i-2 gr. 5-15 gr. 5-10 m5-30 f3f-2 1-5 troches gr. 5-30 f31-4 f3i-i Gm. or mil. 0.06-0.30 0.06-0.20 extern. 0.06-2 0.06-0.30 1-2 0.30-8 0.30-2 0.30-1.30 2—8 0.06-0.60 1-4 0.12-0.60 1-4 4-15 15-60 0.30-1 1-8 0.30-1 Alterative; Antiseptic: In tertiary sj-philis, scrofula, glandular enlargements; inter- nally mostly in the form of iodides; the tincture is much used as a counter- irritant; to disinfect wounds, to prepare site of operation. Expectorant. Emetic in large doses; one of the safest emetics; in cough mixtvires, and in treatment of pyor- rhea; sjTup to chil- dren in croup and bronchitis, to rid air passages of mucus ; in diarrheas combined with other remedies; diaphoretic when combined with opivim. Used chiefly in tooth powders; tincture in perfumery and as flavoring. Hydragogue cathartic: In dropsies; as de- pleting agent in cere- bral hyperemia or serous effusions. Stimulant diuretic: Usually combined with other diuretics; in dropsies, chronic catarrhs of urinary tra'ct. Astringent: In diar- rheas; as gargle. Astringent: In diar- rheas, hemorrhages; locally to relaxed 0.30-0.60 I mucous membranes, spongy gums; as 0.30-2 injection in fissure 2-8 of anus or hemor- rhoids. 0.30-2 4-15 1-4 j Mild sedatire and hyp- [ notic, somewhat like I opium, but much feebler; used chiefly I as vehicle. mi-5 0.06-0.30 Flavoring agent: f3l-l 2-4 carminative. f3i-l 2-4 As 314 INDEX OF DRUGS Page in text. Drug. H Pac- tion. Solubility in Water. Alcohol.' Gm. or mil. Uses. Limonis cortex, lemon peel Oleum limonis *Spiritus *Limonis succus, lemon-juice Syrupus acidi citrici Linseed oil; see under Linum 91 Linum (1. usitatis- simum), flaxseed 90 Oleum lini, linseed I oil *Infusion *Lithium, a metal Lithii bromidum Lithii carbonas Lithii citras ♦Litmus, lacmus *Tincture Lobelia (1. inflata), Indian tobacco (leaves and tops) Fluidextractum lo- belise Tinctura 143 *Losophane, cresol tri- ■iodide, 78% iodine Lugol's solution; see under lodum Lunar caustic ; see under Argentum Lycopodium (1. cla- vatum and other species) (sporules) *Lysol; see under Cre- sol *Magnesiftm, a metal 120 I JVIagma magnesiae, 291 I milk of magnesia Magnesii carbonas 120 ! Magnesii oxidum • Magnesii oxidum ponderosum, heavy mag. oxide Plate Magnesii sulphas, Epsom salt Male tern; see Aspi- dium Maltum, barley malt Extractum nialti Mandrake; see Podo- phyllum *Mariganum, manga- nese Mangani dioxidum prsecipitatum Potassii perman- . ganas Manna (from frax- inus ornus) ♦Mastiche, a resin from pistacia len- tiscus May apple; see Podo- phyllum si. al. al. N. Ta2-10 freely f31-4 iih-2 0.6 78 1.4 misc. aim. insol. spar, spar. V. s. insol. aim. insol. insol. 13.5 insol. insol. insol. aim. insol. gr. 5-20 gr. 2-10 gr. 1-5 mi-5 nV5-30 f31-4 3i-2 0.12-0.60 freely 4-15 15-60 freely Preparations of lemon peel used chiefly as flavoring agents; the syrup of citric acid as vehicle. Antiscorbutic: In scur\'y, acute rheu- matism; refrigerant drink in fevers; to lessen acidity of urine; as vehicle. In poultices; infusion as demulcent drink; oil is demulcent; ap- plied freely to burns. 0.30-1.30 \ Antacid; Diuretic: Salts used to produce 0.12-0.60 I alkalinity of urine in uric acid diathe- sis, gout. Coloring agent: To prepare test paper for acids and alkalies. 0.06-0.30 Emetic; Expectorant: ' Too harsh as an emetic; used as anti- 0.06-0.30 spasmodioinasthma; in bronchitis; has 0.30-2 been used in poison- ing by poison ivy. Antiseptic: Locally in solution or ointment in parasitic skin dis- eases, but not when acute inflammation is present. Applied to excoriated surfaces as protective and absorbent; in pre- paring pills. 4-15 gr. 5-60 ! 0.30-4 insol. t 5i-l f31-4 gr. 2-10 gr. ^-2 5i-l 8-30 4-15 Antacid; Laxative; also as antidote. Antacid; Laxative: In acidity of stomach. To prepare antidote to arsenic; light and heavy oxides and carbonate are mild laxatives; the sul- phate is active ca- thartic; as cathar- tic in fevers, inflam- mations, obstruction to portal circulation, dropsies. Food tonic; Digestant: In wasting diseases; to aid digestion of starch. (7. 12-0.60 j Tonic in small doses; 0.03-0.12 8-30 insol. part. emmenagogue. Antiseptic: Used loc- ally in diphtheria, scarlatina, etc. Demulcent; Laxative, In dentistry to fill cavities of carious teeth temporarily. t Decomposition occurB. INDEX OF J DRUGS 315 Page Drug. Reac- tion. Solubility in Water. Alcohol Dose. Gm. or mil. Uses. 141 141 137 140 246 294 Plate xvii 132 296 179 Mel, honey Mel depuratum, Mentha piperita, peppermint (leaves and tops) Aqua mehthse pip- eritse Oleum Spiritus Menthol (from oil of peppermint) Mentha viridis, spearmint (leaves and tops) Aqua menthse v. Oleum Spiritus Menthol; see under Mentha piperita Mercury; see Hy- drargyrum Methyl salicylas, oil of wintergreen ♦Methylene bichloride ♦Methylene chloride Monsel's salt; see under Ferrum Morphina (from opium) ♦Morphinae acetas Morphinge hydro- chloridum Morphinae sulphas *Pulvis morphinse compositus; Tul- ly's powder Mustard; see Sinapis Myristica (m. fra- grans), nutmeg Oleum myxisticse Myxrha, a gum resin from commiphora myrrha Tinctura myrrhse Naphtol; see Beta- naphtol ♦Nicotine (from tobacco) *Nirvanin si. ac. N. N. N. or si. ac. N. or si. ac. sol. si. sol. sol. sol. 224 294 Plate 199 N. or si. al. N. or si. ac. N. or si. ac. N. 176 *Nitroglycerin, glo- Spiritus glycerylis nitratis, 1% solu- tion of nitrogly- cerin in alcohol Nitrogenii monoxi- dum, nitrous oxide (laughing gas) Nutgall; see Galla Nutmeg; see Myris- tica 3340 2.25 17.5 15.5 insol. part. N. sol. sol. 210 216 565 part. V. s. V. s. fSi-2 mi-5 m5-i5 gr. 1-3 f§i-2 mi-5 m5-i5 mi-10 gr. 5-15 gr. 5-15 mi-5 freely Vehicle; Demulcent. Aromatic stimulant: The water as vehicle; all preparations as carminative; in flat- ulence, colic; the oil locally is anodyne; diluted to relieve pruritus. Menthol locally as anodyne in head- aches; internally as antiseptic. Similar to pepper- mint, but weaker. 15-60 As vehicle. 0.06-0.30 0.30-1 15-60 0.06-0.30 0.30-1 0.03-0.20 0.06-0.60 f3i-l gr. i-5 gr. Vzoo-'/M mi-3 Same uses as oil of gaultheria. Anesthetic: Not so safe as ether. Anesthetic: used most- ly locally. Anodyne: In large doses narcotic; uses same as those of opium, but it is . 007.5-0 . 15 less constipating and acts more quickly; preferred for hypo- dermic use; poison- ing and habitual use . 30-1 must be guarded against. . 30-1 Aromatic; Stimulant: In large doses nar- 0.06-0.30 cotic; used as a con- diment; as carmina- tive; the volatile oil is rubefacient. Tincture locally as antiseptic and stimu- lant to mucous mem- branes; applied to spongy gums. 0.002-0.006 Sedative: 'PoiBonous. 0.03-0.30 Local analgesic: Same uses as cocaine, being less toxic. 0.0003-. 001 Arterial stimulant: In ] cardiac diseases, ar- I teriosclerosis; ner- 0.06-0.20 i vous disorders de- pending upon arte- rial tension; angina pectoris; headache and neuralgia, inhaled i Anesthetic: Has very transient effect, therefore suitable for slight operations,but with oxygen, its in- halation may be con- tinued for extensive operations. 316 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Water. Alcohol. Dose. Gm. or mil. Uses. 223 228 I Plate xi I 294 137 140 231 Plate Plate xviii 66 246 Plate xvii 114 294 262 247 294 Mux vomica (strych- , . . i ... nos n. v., seeds) ' Extractum nucis i . . i ... vomicEe Fluidextractum | . . ... Tinctura I . . ... See Strychnina I ♦Oleum betulae, oil of N. insol sweet birch Oleum cadinum (from ac. juniperus oxyced- rus) oil of cade Oleum cajuputi, oil N. of cajuput Oleum morrhuse, cod- si. ac liver oil . Emulsum olei mor- j Oleum olivse, olive oil Oleum ricini, castor oil Oleum santali, oil of si. ac sandal-wood Oleum tiglii, croton ac. oil aim. insol. insol. insol. insol. insol. insol. sol. part. sol. si. sol. 1 sol. insol. si. sol. I 255 Opium ; concrete juice of unripe capsules of opium poppy (papaver somnifer- um), containing not less than 9.5% morphine Opium deodoratum Opium granulatum Opii pulvis, each contains 10-10.5% morphine Extractum opii *Pilul8e opii The following contain each 10% opium: *Acetum opii, black drop Tinctura opii, laud- anum Tinctura opii deo- dorati *Tinctura ipecacu- anhse et opii *Vinum opii Pulvis ipecacuanhse et opii, Dover's powder, 10% opium Tinctura opii cam- phorata, paregoric, 0.4% opium See Codeina and Morphinse Orange peel; see Aurantii cortex Orris root; see Iris florentina ♦Orthoform N. Otto of rose; see under Rosa Oxygenium, oxygen Pancreatinum, pan- creatin si. sol. sol. sol. insol. gr. J-2 gr. i-i mi-2 Tn5-20 lUl-5 mi-10 f3i-i f32-8 f5i-2 Tn2-10 nij-2 gr. i-1 gr. 1 in each m3-i5 gr. 3-15 m3-20 child f31-4 adult gr. 1-15 i 0.03-0.12 Bitter tonic; Stimulant I to nervous system; |0 . 0075-0 . 03 in atonic indigestion, gastric catarrh; in paralysis, inconti- 0.03-0.12 nence of urine, neu- 0.30-1.30 ralgia and respira- tory and cardiac weakness. 0.06-0 30 Same uses as oleum gaultheriffi. Externally: In scabies, psoriasis. 0.06-0.60 Stimulant: Antiseptic: As carminative. 4-15 Tonic: Alterative: As a fatty food in wast- 8-30 ing diseases. freely 8-^0 Laiatire; Cathartic. Emollient 0.12-0.60 Alterative: Gonorrhea, chronic bronchitis. 0.015-0.12 Drastic cathartic: Used as revulsive; extern- ally it is vesicant. gr. J-2 0.015-0.12 Anodyne and narcotic: danger of poisoning and habitual use must be guarded against; it lessens secretions except perspiration; mod- erate doses, accord- I ing to some, stimu- gr. J-l J ! . 015-0 . 10 late the heart ; af ter- 1 effects of a full dose I are headache, nausea I and constipation. 0.0075-0.06 Used to relieve pain and spasm; in diar- rhea and dysentery to lessen peristalsis; in pneumonia, bron- chitis, and pleuritis to allay pain and cough. In peritonitis 0.20-1 typhoid fever, t>T3h- litis, etc., to lessen pain and peristalsis; in heart diseases i with angina pectoris i or cerebral anemia; 0.20-1 j Dover's powder is ' diaphoretic, very use- 0.20-1.20 j ful in pulmonary dis- eases, myalgia, lum- 4-15 I bago, etc. ; for hypo- i dermic use morphine is preferred. gr. 5-15 0.06-1 inhaled 0.30-1 Analgesic: Applied locally to painful ulcers or wounds. Restorative: In pul- monary diseases, ap- nea, croup, diph- theria; also used with anesthetics. Digestant: Aids diges- tion of starches, fats and proteids; also used to peptonize milk and other foods before feeding. INDEX OF DRUGS 3i: Page in j text. ' Drug. Reac- tion. Solubility in Dose. Water. AlcohoL Gm. or mil. Uses. 255 28 90 75 127 291 128 Plate xviii 135 230 295 ParafEnum (from pe- , troleum) I Paraf orm ; see under Formaldehyde Paraldehydum Paregoric; see under Opium Pearson's solution; see under Arseni triosid Pennyroyal; see Hedeoma Pepo, pumpkin seed Pepper. Cayenne; see Capsicum Peppermint; see ^lentha piperita Pepsinum, pepsin Peroxide of hydro- gen; see hydrogen dioxide Petrolatum, vaseline Petrolatum album, albolene Petrolatum liquidum insol. insol. X. or si. ac. si. ac. 50 f3i-i 51-3 aim. gr. 1-15 insol. ♦Petroleum, coal oil Phenacetin; see Acet- phenetidinum Phenol, carbolic acid Phenol liquefactiun, 87% Glvceritum pheno- lis, 20% Unguentum *Liquor sodii carbo- latis, phenol so- dique Phenolphth aleinum , phenolphthalein Phenylis salicylas, salol Phosphorus Pilula phosphori See Acidum phos- phoricum See HjT)ophosphites Physostigma (p. ven- enosum), calabar bean Extractum physos- tigmatis Tinctura *Eserine (same as physostiginine) Physostigminae sali- cylas Pilocarpus (p. jabo- randi. leaflets) Fluidextractum pil- ocarpi PilocarpinsB hydro- chloridum Pilocarpinas nitras Pilulse catharticEB comp ; see under ColocjTithis si. ac. 15 N. aim. insol. 6670 insol. 400t f5i-l X. or si. ac. local use gr. 1-5 gr. 1-5 gr. Vijo gr. i/ioo in each gr. i-2 gr. Vio-i mio-30 gr. '/loo-^'ii gr. 5-60 m5-60 30-90 Protective: To protect surfaces from moist- ure or air. Hypnotic: Less cer- tain than chloral, i but safer. Anthelmintic: Given in emulsion to re- move tapeworm. 06-1 Digestard: In indi- gestion due to lack I . of gastric juice. ' Basis for ointments. 8-30 LaxatiieinterraaMy; de- mulcent locally; as I vehicle. I Source of rhigolene benzin, petrolatum, paraffin, etc. 0.03-0.12 Corrosize; Antiseptic; I Local sedatixe in di- I lute solution; as mouth-wash, gargle ' or internal antisep- tic; in vomiting, diarrhea, and indi- gestion due to fer- mentation. 0.06-0.30 Cathartic: Safe and efficient; reagent. 0.06-0.30 Intestinal antiseptic; in diarrhea, fermen- tative indigestion, rheumatism. 0.0005 Resioratire tonic: In depressed condition of neri-ous system, neuralgia ; largely employed in form of phosphoric acid, phosphates, and hy- pophosphites as gen- eral restorative in wasting diseases. 0.03-0.12 Sedative; Myotic: To depress excitability of spinal cord; in 0.006-0.03 tetanus, strj-chnine poisoning, progres- 0.60-2 sive paralysis of the insane; to contract pupU. 0.0006-.002 To contract pupil. 0.30-4 0.30-4 0.3 gr. Vif-i 0.005-0.02 gr. >/ii-i 0.005-0.02 Powerful diaphoretic; sialagogue; in acute catarrh, acute in- flammations of ser- ous membranes; in acute sthenic fevers and dropsies when heart is not weak; pilocarpine may be used h>-podennically . t Absolute alcohoL 318 INDEX OF DRUGS Page in text. Drug. Reac- tion. Solubility in Dose. Water. .-Vlcohol. Gm. or mil. Uses. *Pilul£e catharticae veg.; see under Colocynthis Piperina (from pep- X. per, piper nigruin) *Piperazine, piperazi- dine Pituitrin; see under HjTJophysis Pix liquida, wood tar ac. (from pine) Oleum picis liquidse Syrupus Unguentum, 50% [ . . Plaster of Paris; see Calcii sulphas *Platinum, a metal *Platinic chloride ♦Plumbum, lead 104 Plumbi acetas, sugar si. al. 293 of lead Liquor plumbi sub- al. acetatis, Goulard's extract 105 Liquor plumbi sub- al. acetatis dilutus, lead-water ♦Plumbi nitras ac. Plumbi oxidum, lith- al. arge Emplastrum plum- bi, lead plaster; diachylon plaster Unguentum diachy- lon Plate Podophyllum, man- xviii drake (p. pelta- i turn, root) ♦Extractum podo- phylli Fluidextractum Resina, "podophyl- Un" ♦Potassium, a metal 250 Potassii acetas Liquor potassii ar- senitis; see under Arseni trioxid Potassii bicarbonas 250 Potassii bitartras, 295 cream of tartar 239 Potassii bromidum Potassii carbonas 145 Potassii chloras 295 Trochisci potassii chloratis 250 Potassii citras Liquor potassii citratis 293 *Potassii cyanidum 74 Potassii hydrox- 295 idum, caustic potash Liquor potassii hy- droxidi, 4.5% *Potassa cum calce, Vienna paste, 50% each potash and lime Plate Potassi et sodii tar- xviii tras, Rochelle salt Pulvis effervescens compoaitus, Seid- litz powder Potassii hypophos- phis 234 Potassii iodidum insol. sol. si. sol. V. s. 1.4 1.85 aim. insol. sol. gr. 1-5 gr. 8-15 gr. 5-15 38 spar, insol. £31^ gr. 1-2 0.06-0.30 . 50-1 0.30-1 extern. 4-15 extern. Antiperiodic; Antipy- retic. .\s solvent for uric acid; in gout and allied conditions. Used externally in chronic eczema, pso- riasis; with atom- izer or in the form of sjTup in laryngitis, bronchitis, catarrhs, phthisis. gr. 2-10 0.12-0. CO m5-15 0.30-1 . 03-0 . 12 AUerative. 0.03-0.12 Sedative astringent: Acetate used as seda- extern. tive application to irritable ulcers; in skin diseases; astrin- extern. gent in inflamma- tions and catarrhal discharges ; intern- extern, ally in hemorrhages, extern. diarrheas, gastric xilcer; nitrate as deo- extern. dorant to foul ulcers; with glycerin as as- tringent to fissured extern. nipples; oxide used to prepare lead plas- ter, which forms the basis of many other plasters. Cathartic: Efficient in torpor of the liver; in chronic constipa- tion; the resin used in laxative pills. insol. sol. gr. M 0.007.5-0.0 al. 6^5 2^9 gr. 5^30 0.30^2 al. ac. X. al. X. 2.8 155 1.5 0.9 11.5 aim. insol. aim. insol. 250 insol. si. sol. gr. 5-30 3^-4 gr. 5-60 gr. 5-30 gr. 2-10 0.30-2 2-15 0.30HI 0.30-2 0.12-0.60 al. si. ac. 0.6 b1. sol. gr. 2i in each gr. 5-30 f3l-8 0.30-2 4-30 al. al. 2 0.9 si. sol. 3 gr. >/50-'/,o 0. 003-0. 00( al. al. ■ITl-5-15 weM diluted 0.30-1 extern. al. 0.9 aim. insol. 5i-i set of two powders 8-30 X. 0.6 9 gr. 5-20 0.30-1.30 N. 0.7 22 gr. 5-30 0.30-2 Alkali: Potass, hy- droxide is caustic; liq. pot. hydrox. di- luted and the carbo- nates are used as alkalies. The salts with vege- table acids also act as alkalies, being converted into carbo- nates in the system, and in elimination they are diuretic; in fevers, rheumatism; to produce alkalin- ity of the urine; bi- tartrate and Rochelle salt are cathartics; chlorate is detergent when applied to mu- cous membranes — poisonous in large doses; best used alone as may form explosive mixtures. Bromide is a nerre sedative with same action as sodium bromide, but slightly less efficient and more irritating. Iodide is alterative and sialagogue; in IXDEX OF DRUGS m Page ; Drug. Reac- tion. Solubilit J' in Water, i Alcohol. Gm. or mil. Uses. 250 Potassiinitras, nitre, X, 293 saltpetre 1-16 Potassiiperman- X. 162 ganas *Potassii sulphas X. 2.8 aim. insol. 13 . o decomp 9 insol. gr. 5-15 gr. i-2 Prepared chalk; see\ under Calcium 149 *Protargoi, a proteid compoimd of silver 228 Pnmus vorginiana (p. serotina), wild cherry bark *Fluidestract\iin pruni virginianae *Infusion Synipus Prussic acid ; see Aci- dum hydrocyani- cum^ dil. Pumpkin seed; see Pepo PjTethrum (anacy- clus p., root) Tinctura pjTethri Pyrogallol, pjTogal- lic acid *Ointment, 2-3% 114 , Pyroxj-Unum, soluble guncotton 227 Quassia (picrasma escelsa, wood; Tinctura *Infusion *Quercus, white oak (bark; *Fluidextractuni 227 Quinina Quininae bisulphas Quinina dihj-dro- chloridum Quininse hydrobro- 1 midum Quininse hydrochlo- ridum Quininae salicylas Quininae sulphas [ *Compound tinc- ' ture (, Warburg's; 181 Quininae et ureae hy- drochloridum [ Quininae tannas I Red precipitate: see Hydrargyri oxidum rubrum Resina (from turpen- tine), rosin Ceratima resinae. basdicon ointment 145 Resorcinol, resorcin Rhamnus frangula. buckthorn; see Frangula Rhatany; see Kra- meria sol. N.or i^T l.Z ac. insol. t al. ac. ac. N. X. al. X. X. 1560 9 0.6 40 si. sol. 725 0.9 si. sol. insol. 0.9 0.8 23 12 0.9 0.8 14 107 2.4 si." sol. sol. 0.9 3i-i fa 1-2 131-4: 3i-l I'oi-l f51-2 f3i-l gr. 1-20 152-6 gr. 1-15 gr. 2-10 . 30-1 tertiarj- syphilis, asthma, chronic 0.03-0.12 bronchitis, chronic rheumatism; in lead 2-15 poisoning to pro- mote elimination. Permanganate as ardi- septic; nitrate is diureiic; nitre paper as a fumigation in asthma; sulphate is a .mild cathartic, but seldom used; useful to hasten hardening of plaster of Paris. . Cyanide is in action I similar to hydrocy- anic acid; poisonous. Antiseptic: Applied in 1 to 5% solutions. 2-4 Bitter tonic: Se/Jaiite, by virtue of hycUo- cyanic acid, which 2—4 is developed in the cold infusion; in 30-60 pulmonary diseases, 4-15 coughs, dyspepsia. 1-4 li Sialagogue; Irritant: As gargle; as sntiff extern. in chronic catarrh. Caustic: Poisonous. Externally in skin diseases. To prepare collodion and xelltiloid. Bitter tonic; Anthel- mintic: In atonic in- 1—4 digestion; infusion as 30-60 enema to remove thread-worms ; con- tmns no tannin. Astringent: Same uses as tannic acid. 1-1 Quinine is the chief remedy used in ma- larial fevers; the sulphate is used 0.06-1.30 j mostly, but the bi- 1 sulphate is more ' soluble; the hydro- bromide, hydrochlo- ride and dihydro- chloride are recom- 8-25 mended for hypo- dermic use. 0.06—1 Local analgesic: Has prolonged action. 0.12-0.60 The tannate is less active, but is nearly tasteless. In plasters and oint- ments, extern. Resin cerate is applied to bruises, ulcers, etc. 0.12-0.30 -intiseptic: May use internanj-; in per- tussis, 2% solution used as a spray to the upper air tract. Soluble in 25 parts of a mixture of 3 vols, ether with 1 voL alcohol. 320 INDEX OF DRUGS Page Reac- Solubility in ' Dose. Uses. in ijiug. tion. 1 text. Water. Alcohol. Gm. or mil. Plate Rheum, rhubarb (r. gr. 3-30 0.20-2 Astringent; Cathartic. xviii officinale, root) Small doses tonic to Extractum rhei gr. 3-15 0.20-1 intestinal tract; lar- Fluidextractum m3-30 0.20-2 ger doses safe, effi- Pilulae compositse 1-3 pills cient laxative; cath- Puh-is compositus 3i-i 1-4 artic effect apt to be Syrupus Syrupus aromatieus ':::] child 31 child 4 followed by consti- pation unless com- Tinctura f3i-2 2-8 bined with more Tinctura aromatica f31-l 1^ powerful agents, as in compound pill; its astringency makes it a valuable laxative in diarrheas. 165 ♦Rhigolene (from pe- troleum) Rochelle salt ; see Potassii et sodii tartras Used as local anal- gesic. *Rhus glabra, sumach 3i-l 1-4 Astringent: As mild (fruit) astringent, gargle, or ♦Fluidextractum f3i-l 1-4 lotion. rhois glabra ♦Rosa damascena, damask rose 285 Oleum rosse, otto of rose Rosa centifolia Aqua rosse Aqua ros£e fortior Unguentum aquse rosse, cold cream Rosa gallica, red rose (dried petals) N. insol. si. sol. Flavoring agent: Per- fume. Rose water as vehicle or flavor. Cold cream to soften the skin; applied to chapped hands. Flavoring agent. Fluidextractum f3i-i 1-4 Fluid extract as vehi- Mel., honey of rose ... freely cle; the honey locally as mouth- wash. ♦Rubus, blackberry Astringent: In diar- (bark of root) rheas. ♦Fluidextractum f3§-2 2-8 ruhi ♦Syrupus £31-2 4-8 Saccharine; see Ben- zosulphinidum 30 Saccharum, cane- N. 0.5 170 Sweetening agent; Pre- 264 sugar servative. Syrupus Syrup as vehicle. 30 Saccharum lactis, N. '5' aim. The hardness of its sugar of milk insol. particles make it Sage; see Salvia useful in preparing triturations. SaUcinum, salicin N. 23.6 88.5 gr. 5-30 0.30-2 Tonic; Antiperiodic: (from several spe- In rheumatism, ma- cies of salix and larial fevers. populus) Salol; see phenylis salicylas Saltpetre; see Potas- sii nitras ♦Salvia (s. officinalis) 3i-l 1^ Astringent: Infusion sage leaves 1 as gargle, often with alum. 35 Santoninum (from N. insol. 43 gr. i-1 0.015-0.06 Anthelmintic: To de- 1 santonica), san- chUd stroy round worms. 1 tonin used cautiously. 29 Sapo, white Castile al. V. B. V. 8. gr. 5-15 0.30-1 Seldom internally ex- 117 soap cept in suppository Linimentum extern. or pill; powdered. 117 1 Sapo mollis, soft al. V. 8. v.'s. ' extern. used as an alkali and 1 soap, green soap detergent in denti- 1 Linimentum.saponis al. extern. frices; soft soap as mollis antiseptic; in diseases of the skin. 237 i SarsaparillaCroot) 1 Tonic; Alterative: Has Fluidextractum '.'.'. '.'.'. ! fji-i 2-4 very feeble medi- Fluidextractum f3i-l 2-4 cinal powers; used comp. i chiefly as vehicle for Syrupus comp. .. 1 ... 1 ... i f5i-l 8-30 [ stronger alteratives. IXDEX OF DRUGS 321 Page Drug Reac- tion. Solubility in Dose. Water. AlcohoLj Uses Gm. or mil. 250 252 223 293 Plate xviii 254 255 61 Sassafras (s. varii- folium, bark of root) Oleum sassafras Scilla, squill (urgi- nea maritima, bulb) Acetum scilla? Fluidestractum Syrupus Syrupus comp., hive syrup (0.2% tartar emetic) Tinctura Scopolaminse hydro- broraidum, hyos- cine hydrobromide (from various plants of the Solan- aceae, but chiefly from the seed of hyoscyamus and stramoniiim) Senega (polygala s., root) Fluidestractum senegse Syrupus Senna (cassia acuti- f olia and c. angusti- folia, leaves) Fluidestractum Infusum comp. Pulvis glycyrrhizse compositus Syrupus Serum antidiphtheri- cum, diphtheria antitoxin Serum antitetanicum, tetanus antitoxin 61 S 61 251 118 118 127 Sinapis alba, white mustard seed Sinapis nigra Garas- sica nigra) , black mustard seed Emplastnim sinapis, mustard paper Oleum sinapis vola- tile *Flour of mustard is a mixture of white and black Slippery elm; see fjlmus Soap; see Sapo 'Sodium, a metal j Sodii acetas Sodii arsenas; see under Arseni Sodii benzoas Sodii bicarbonas Trochisci sodii bi- carbonatis Sodii bisulphis; see under Acid, sul- phurosum Sodii boras, borax *Liquor sodii bora- tis compositus, DobeU's solution 1.5 20 insol. al. or X. al. N. or al. al. 0.8 1.8 10 sol. 19 61 inaol. insol. mi-5 mio-.3o mi-o f5i-i m5-30 m5-30 gr. I/mo gr. 10-20 mio-20 31-2 iZi-2 f51-4 3i-2 fBi-l 1- 31-4 lUs- 1-4 The warm infusion is diaphoretic; regarded as alterative, but 0.06-0.30 has feeble power. Diuretic; Expectorant: In large doses emetic; like digitalis, it strengthens pvilse and increases excre- tion of urine; in bronchitis , croup ; the compound sjTup cautiously with chil- dren. Mydriatic: Resembles atropine and hyos- cyamine in action and uses; with morphine to induce "twilight sleep." 0.60-2 0.06-0.30 1-4 0.30-2 0.30-2 0.0003 . 60-1 . 30 0.60-1.20 2-8 4-8 2-8 30-120 2-8 8-30 gr. 10-30 0.60-2 gr. 5-30 . 30-2 gr. 3 in each gr. 5-30 Stimulant expectorant; Diuretic: In chronic bronchitis, asthma, croup; often com- bined with squiU. Cathartic: Efiacient and safe in any con- dition, except intes- tinal inflammation: the confection and compound licorice powder are mild, useful for children and in pregnancy. In diphtheria, hj-po- dermically, to antag- onize poison of the disease. In tetanus (lockjaw) hjTpodermically to antagonize poison of the disease; it is most successfully used as a prophylactic to prevent development of tetanus. Rubefacient; Irritant emetic: Mustard owes its irritant pro- perty to the vola- tile oil, which is de- veloped in the pres- ence of cold water. 0.0075-.015 The volatUe oil is antiseptic, but very irritating. The general action and uses of sodium salts are similar to those of potassium; as alkalies they are less disturbing; be- ing better tolerated by the system they are more slowly eli- minated, therefore less diuretic. Liq. sod. hydros., the acetate and carbon- ates as alkalies, the bicarbonate more than all others for internal use. 4-15 extern. 0.20 in each 0.30-2 extern. 4-' 21 322 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Dose. Uses. in text. Water. Alcohol. Gm. or mil. 239 Sodii bromidum Sodii cacodylas; see under Arseni tri- oxidum N. 1.1 16 gr. 5-60 0.30-4 Benzoate and borate are antiseptic; the former in cystitis, to prevent decomposi- Sodii carbonas mon- al. 3 insol. gr. 5-10 0.30-0.60 tion of urine; borax ohydratus as mouth-wash in 48 Sodii chloridum, N. 2.8 aim. 5J-4 2-15 thrush. 221 common salt insol. Bromide is sedative; 221 Liquor sodii chlo- ridi physiologicus, normal salt solu- tion N. 1-2 pints 500-1000 large doses by ene- ma to control obsti- nate vomiting due to reflex causes; most Sodii citras al. 1.3 insol. gr. 5-30 0.30-2 efficient remedy in 161 ♦Sodium dioxide al. sol. extern. epilepsy; in infantile convulsions, head- 74 Sodii hydroxidum, al. 0.9 V. 8. aches, fevers, in- 295 caustic soda somnia, nervousness. Liquor sod. hy- al. TR5-15 0.30-1 hysteria; sedative to droxidi, 4.5% diluted sexual organs. Sodii hypophosphis N. 1 25 gr. 5-20 0.30-1.30 Chloride in normal 234 Sodii iodidum al. 0.5 2 gr. 5-30 0.30-2 (O.SS'c) solution as Plate Sodii nitris al. 1.5 si. sol. } gr. 1-3 0.06-0.20 cleansing lotion in xiii Sodii perboras al. sol. diphtheria, nasal ca- Sodii phenolsulpho- N. 4,2 146 gr. 1-10 0.06-0.60 tarrh, pharyngitis. nas and hypodermically Plate Sodii phosphas al. 2.7 insol. gr. 5-51 0.30-30 or intravenously as xviii restorative. Dioxide is a caustic and bleaching agent; in saturated solu- tion to bleach teeth; 135 Sodii salicylas ac. 0.9 9.2 gr. 5-30 0.30-2 perborate also as bleaching agent. Hypophosphiteis toiiic. Phosphate and sul- phate are laxative. Nitrite has same uses Plate Sodii sulphas, Glau- N. 2 insol. 31-S 4-30 as nitroglycerin. xviii ber's salt Sodii sulphis; see under Acidum sul- phurosum Sodii et potassii tar- tras; see Potassii et sodii tartras Sodii thiosulphas (hyposulphite) See under Acid sulphurosum Soda powders, effer- vescing powders, consist of one powder of bicarbo- nate of sodium and one of tartaric acid, taken together Salicylate has same uses as salicylic acid. Phenolsulphonate is used internally for same purposes as carbolic acid. 143 ♦Sozoiodol, sozoiodolic acid, 53% iodine Spanish flies; see Cantharis ac. si. sol. extern. Antiseptic: In solution or as dusting powder. Sparteinse sulphas N. 1.1 3 gr. V.o-l 0.006-0.06 Heart stimulant; Diu- (from scoparius) retic: Acts more Spearmint; see promptly than digi- Mentha viridis talis. Spermaceti; see Ceta- ceum SpiritUB aetheris ni- trosi; see under jEther, nitrous Squill; see Scilla Starch; see Amylum Storax; see Styrax 296 Stramonii folia (da- tura s., leaves) gr. 1-3 O'. 06-0. 20 Narcotic; Anodyne: Leaves as fumiga- Extractum stra- gr. i-i 0.008-0.015 tion in asthma; sim- monii ilar to belladonna; Tinctura m5-30 0.30-2 as antispasmodic and Unguentum extern. anodyne in asthma, chorea, neuralgia,dys- menorrhea; ointment to painful ulcers. IXDEX OF DRUGS 323 in I text. Drug. Reac- tion. Solubility in Dose. Uses. Water. Alcohol. Gm. or mil. 177 216 223 Plates iv, xi 294 133 246 246 Plate xviii 253 62 296 141 63 'Strontium, a metal Strontii bromidujn Strontii iodidum Strontii salicylas Strophanthus (s. Komb§, seeds) Tinctura stro- phanthi Strychnina (from mix vomica) Strychnine nitras StrychninEe sulphas StjTas, storax Tinctura benzoini composita, 8% of storax Sugar; see Saccharum Sugar of lead; see Plumbi acetas Sugar of milk; see Saccharum lactis Sulphonethylmeth- aniim, trional Sulphonmethanum, sulphonal Sulphur lotum ■washed sulphur S. prfficipitatum S. subUmatum, flow- ers of sulphur Unguentum sul- phur is, 15% Sulphuric ether; see ^ther, ethylic Sum^ach; see Rhus glabra Suprarenalum siccum, dried suprarenal glands: see under Adrenahn Sweet almond; see Amygdala dulcis Sweet birch oil; see Oleum betulae Sweet spirit of nitre; see under iEther, nitrous *Tanacet\im, tansy (t. •^-ulgare, leaves and tops) *Volatile oil Tartar emetic ; see Antimonii et po- tassii tartras Terebenmn (from turpentine) *Terebinthina, tur- pentine, an oleo- resin from pine Oleum terebinthinse Oleum t. rectifica- tum Emiilsum olei tere- binthinse, 15% Linimentum, 35% i Terpini hydras, ter- pin hydrate *Tetronal *Theobroma cacao (seeds) Oleum theobroma- tis, cacao butter 0.35 0.2 19 6240 42 32 sol. sol. 61 gr. 1-60 gr. 5-30 gr. 5-30 0.06-4 0.30-2 . 30-2 m2-15 0.12-1 150 81 [•gr. '/60-V.o 0.001-.006 insol. 1 warm gr. 5-20 m5-60 0.30-1.30 0.30-1 N. 200 ' sol. N. 365 60 N. ] N. [ ac. insol. 1 si. sol. ; in ab- solute alcohol gr. 5-30 0.30-2 . 30-2 gr. o- 30 3i-2 1-8 extern. gr. 1-10 0.06-0.60 N. si. sol. ' 3 ac. insol. sol. N. or insol. 5 si ac. N. insol. 5 N. 200 13 450 ... sol. 3^1 mi-3 m5-i5 TTlo-15 f3f-2 Salts of strontium act as do those of other earth metals; they are not poisonous, but are believed to aid nutrition. Heart stimulant; Diu- retic: Effect upon heart similar to that of digit aUs. BMer tonic; Xerze stimulant: Action and uses same as those of nux vom- ica, which drug it represents fully. Expectorant; Antisep- tic: In catarrhs, purulent mucous discharges; to pre- serve fats. Hypnotic: Both are less depressing and safer than chloral. j Laxative; Alterative: I In chronic eczema, psoriasis, and other skin diseases, inter- nally and externally; , very effectual exter- nally for scabies; washed s. most suit- 1 able for internal use. 0.06-0.20 0.30-1 Emmenagogue; An- thelmintic: Danger- ous in large doses. i Stimulant expectorant: In cough, chronic bronchitis, hay asthma. gr. 2-10 gr. 15-30 insol. 100 Anthelmintic. Stimulant: Diuretic: Externally vesicant; internally in t>-phoid conditions, intestinal ulceration and hem- orrhages; the crude i French oil in phos- phonis poisoning. . 12-0 . 60 Antiseptic; Expecto- rant; in bronchitis. Hypnotic. To prepare chocolate. In preparing supposi- tories. 2-15 0.30-1 2-8 extern. 1-2 324 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Date. Uses. m text. Water. Alcohol Gm. or mil. 223 ^Theobromine si. sol. sol. gr. 2-10 0.12-0.60 Diuretic: Similar to 251 Theobromine and sodium salicylate, diuretin al. 1 si. sol. gr. 5-15 0.30-1 caffeine, but less stimulating to cere- brum; very efficient as diuretic. *Thiosinamine (from si. sol. sol. gr. h-2 0.03-0.12 Resolvent; Antiseptic; vol. oil of mustard) To soften scar tissue. ♦Thymus vulgaris, 3i-i 1-4 Aromatic stimulant: thyme (leaves) Mostly as infusion; 140 Oleum thy mi N. insol. 2 mi-5 06-0.30 oil as carminative. 140 Thymol N. 1010 1 gr. 1-30 0.06-2 Antiseptic: Internally in hookworm disease. 141 Thymolis iodidum, aristol, 43% iodine insol. 675 extern. Antiseptic: Substitute for iodoform. 253 Thyroideum siccum, dried thyroid gland gr. 1-5 0.06-0.30 To supply the thyroid substance, as in myxedema, cretinism and obesity; in some cases of goitre. Tragacantha, gum part. insol. Excipient in making tragacanth pills and troches; Mucilago traga- freely mucilage as vehicle. eanthse Tricresol, see Cresol Trinitrophenol, picric ac. 78 12 gr. i-2 0.03-0.12 Mostly externally; as acid application, in weak Trional; see Sulphon- solution, to burns. ethyhnethanum Tully's powder; see under Morphina 181 *Tropacocaine hydro- chloride (from "small-leaved coca") Turpentine; see Tere- binthina al. sol. sol. gr. i-1 0.015-0.06 Local anesthetic: Sim- ilar to cocaine, but less toxic. 90 Ulrnus (u. fulva), slippery elm (in- ner bark) *Mucilago ulnii *Decoction Urotropin; see Hexa- methylenamina freely freely Demulcent; Emollient: As poultice; intern- ally in pharyngitis, diarrhea, dysentery, cystitis, irritation of urinary tract. 251 Uva ursi, bearberry (arctostaphylos u. u., leaves) Fluidextractum uvse 3i-l f3i-l 1-4 1-4 Astringent; Diuretic: In chronic disorders of urinary tract. ursi Valeriana, valerian gr. 10-30 0.60-2 Stimulant; Antispas- (v officinalis, root) modic: In hysteria, Tinctura Valerianae f3i-l 1-4 chorea, and other Tinctura v. ammo- f3i-l 1-4 functional nervous niata disorders, headaches; Vaseline; see Petro- in typhoid conditions. latum Veratrina (from sab- al. si. sol. 2.3 gr. >/jo-V.o 0.002-0.006 Has been employed adilla) externally in neu- *01eatum veratrinae. extern. ralgia and rheuma- 2% tism, but rarely used Unguentum, 4% extern. internallj'. 239 Veratrum viride, Am. hellebore (root) gr.' i-30 0.06-2 Sedative: In action similar to aconite; Fluidextractum ver- mi-30 0.06-2 in sthenic fevers. atri viridis mania, puerperal Tinctura m5-30 0.30-2 convulsions. Veronal ac. 170 v. s. gr. 5-15 0.30-1 Hypnotic. Viburnum pninifol- Tonic; Uterine seda- ium, black haw tive: Used to pre- (bark) vent abortion ; in Extractum viburni gr. 5-15 0.30-1 dysmenorrhea. prunifolii Fluidextractum f3i-l 1-4 Vienna paste; «ee under Potassium *Vinum album, white ac. Stimulant: Wines de- wine (8.5 to 15% pend largely for by vol. absolute their medicinal value alcohol) upon alcohol. IXDEX OF DRUGS 325 Page in test. Drug. Reac- tion. Solubility in Water. 'Alcohol. Dose. Gm. or mil. Uses. *Vuium rubrum, red ac. Use same as of vinum •srine (8.5 to 15% [ album. ! by vol. absolute \ alcohol) i 1 Warburg's tincture; 1 see under Quinine 1 Wax; see Cera j Whiskey; see under Alcohol White oak; see Quer- Zinc salts are astrin- cus 1 gent, and in large 1 White precipitate; see [ doses irritant; sul- 1 Hydrargjnim am- [ phate and acetate moniatum are most -valuable as Wild cherry; see astringents; in weak Prunus virginiana solution to inflamed Wine, see Vinum mucous membranes, Wiatergreen; see conjunctivitis ure- Gaultheria thritis, vaginitis, ca- Witch-hazel; see [ tarrhs, etc.; in large Hamamelis doses they are emetic Wood spirit ; see Alco- the sulphate being a i hoi, methyl mild, efficient and i Wood tar; see Pix prompt emetic for Yellow wash; see un- any age; oxide is der Hydrargyrum used externally as a Zincum, zinc, a metal sedative to wounds. Zinci acetas N. or si. ac. 2.3 30 gr. 1-2 0.03-0.12 ulcers and in dis- eases of the skin. 80 ' Zinci chloridum ac. 0.25 1.3 extern. Chloride is a powerful 105 ! Liquor zinci chlo- escharofic and anti- 147 ridi, 50% septic. 296 Phosphide and valer- 106 Zinci iodidum ac. Y. S. _v. s. gr. 1-3 0.06-0.20 ate in nervous con- 106 [ Zinci osidum insol. insol. gr. 1-5 0.06-0.30 ditions, hysteria. Unguentum zinci extern. Iodide is used mostly ' oxidi, 20% as an alterative exter- Zinci phenolsulpho- ac. 1.6 1.8 gr. 1-3 0.06-0.18 nal remedy: may be nas used incleaningteeth *Zinci phosphidum .... insol. insol. gr. Vkt-i/s 0.006-0.02 and in gingivitis. jQ- ! Zinci sulphas ac. 0.6 insoL < gr. i-2 gr. 10-30 0.03-0.12 0.60-2 Astringent. Emetic. 251 1 Zinci valeras ac. 70 22 gr. i-3 0.03^.20 1 Zingiber, ginger (z. gr. 5-15 0.30-1 Aromatic stimulant: officinale, root) Condiment; as car- j Fluidextractum 1115-15 0.30-1 minative in flatu- zingiberis lence : mild stimu- Syrupus f51-4 4-15 lant in atonic indi- Tinctura f3i-i 1-4 gestion: the syrup Oleoresina •■ i ... 1 mi-i 0.01.3-0.06 as vehicle. GENERAL INDEX. Some drugs not listed in the General Index may be found in the Index of Drugs. A. C. E. MIXTURE, 212 Abbreviations, 287 Abortive poisons, 290 Abscess, 65, 155 alveolar, 76, 81 Absorption of medicines, 42, 44, 49 Acacia, 90, 297 AcetaniUd, 143, 240, 297 compoimd powder of, 240 poisonous effects of, 240 Acetozone, 161, 297 Acetphenetidinum, 240, 297 Acetum, 24 Acid, acetic, 24, 297 glacial, 73, 297 acetylsaUcylic, 241, 297 arsenous. See Arsenic, benzoic, 134, 286, 297 boracic, 126, 297 boric, 126, 297 carboUc, 75, 127, 291, 317 as antiseptic, 127 as caustic, 75 poisoning^ 76, 129, 291 chromic, 80, 306 cirmamic, 133, 297 citric, 230, 297 gaUic, 97, 108, 297 hydrochloric, 71, 291, 297 dilute, 229, 298 hydrocyanic, 228, 239, 291 dilute, 239, 298 lactic, 73, 298 nitric, 71, 291, 298 dilute, 229 nitrohvdrochloric, 71, 291, 298 dilute, 230 oxalic, 291, 298 phosphoric, dilute, 231, 298 prussic, 291, 298 sahcylic, 134, 286, 298 sulphuric, 71, 291, 298 aromatic, 230, 298 dilute, 230, 298 sulphurous, 162, 298 tannic, 33,96, 298 glycerite cf, 93 tartaric, 230, 298 i Acid, trichloracetic, 73, 298 Acids, mineral, 71, 291 poisoning by, 72, 291 mineral, dilute, 229 organic, 73 vegetable, 230 Aconite, 110, 239, 291, 298, Plate XIV. antagonists to, 269 tincture of, 64, 65, 243 Aconitine, 239, 291, 298 Action of medicines, 19, 50 chemical, 52, 70, 159 electrical, 51 physical, 50 Actol, 149, 300 Actual cauter5^ 88 Adeps lanse, 91, 299 Adjectives, declensions of, 274 Administration of medicines, 41 Adrenalin, 107, 175, 254, 299 as an aid to cocaine, 108, 175 as hemostatic, 108 .Ether. See Ether. .^thyhs chloridmn. See Ethyl chloride. Air embolism, 45 Albolene, 90 Albumin, 90, 299 as antidote, 77 Alcohol, absolute, 98 as anesthetic, 216 as antidote, 77 as astringent, 99 as preserv^ative, 265 as solvent, 100, 264 as stimulant, 178, 219 dehydrated, 98 diluted. 98 ethvhc; 98, 131, 216, 219, 279, Plate Ylll. germicidal power of, 131, 184 methyhc, 100, 299 Alkalies, il5 caustic, 73 Alkahm'ty of blood in anesthesia, 188 Alkaloids, 32 artificial, 33 incompatibihtv of, 34 of opium, 246,-248 solubilitv of, 33 Aloes, 299, Pkte XVIII. 328 GENERAL INDEX Aloin, 35, 299, Plate XVIII. Alpha-eucaine, 167, note Alteratives, 37, 232 Alum, 102, 299 as emetic, 251 burnt, 80, 103, 299 Alumen, 102, 299 exsiccatum, 80, 103, 239 Alveolar abscess, 76, 81. See Abscess. Alypin, 179 Ammonia, 49, 220, 291, 299 spirit of, 220 aromatic, 178, 216, 220, 300 water of, 220 stronger, 73, 291, 300 Ammonium bromide, 300, Plate XV. carbonate, 220, 291, 300 chloride, 91, 252, 300 Amygdalin, 35, 228 Amyl nitrite, 176, 225, 294, 300, Plate XIII. Analgesia, 164 Analgesics, 38, 164 local, 164 paralyzant, 165, 167 refrigerant, 164, 165 Anesthesia, 164, 186, 191, Plate V. anemia in, 187, 197 asphj^xia, 188, 196 at night, 198 autointoxication in, 196 blood changes in, 187 pressure in, 188 contraindications to, 195 dangers of, 193, 206 local, 164 pharyngeal method, 202 precautions concerning, 197 preparation of patient for, 197 pulse in, 184 pupils in, 192, 194 recovery from, 195 respirations in, 191, 193, 212 responsibility in, 198 resuscitation from, 212 stages of, 190 Anesthetics, 39, 164, 185 action of, 187, Plate V. blood changes induced by, 187 comparative safety of, 210 general, 185 historv of, 185 local, 164 mixtures of, 212 responsibility for use of, 198 Animal charcoal, 152, 304 purified, 152, 304 drugs, 253 Anodyne, 39 Antacids, 38, 115 Antagonism of drugs, 269 Antagonists of cocain, 176, 270, Plate IV. Anthelmintic, 40 Antidiphtheric serum, 54, 254, 321 Antidote, physiologic, 269 Antidotes, chemical, 70, 72. See Table of Poisons and Antidotes. Antimonii et potassii tartras, 251, 300 Antipyretics, 39, 240 Antipyrine, 107, 240, 245, 300 Antiseptics, 38, 39, 124 Antiseptol, 143, 306 Antispasmodic, 39, 245 Antitetanic serum, 255, 321 Antitoxin, 39, 54, 254, 255, 289. 300 Aphthous stomatitis, 146 ulcers, 76 Apomorphine, 33, 252, 300 Apothecaries' weights, 275 Apothesine, 167, 179, 183 Aqua, 24 ammonia;, 24, 220, 291, 299 fortior, 24, 73, 220, 291, 300 cinnamomi, 138, 306 creosoti, 131, 287, 307 fortis, 71 regia, 71 Argenti citras, 149, 300 lactas, 149, 303 nitras, 78, 103, 149, 296, 300 dilutus, 78, 300 fusus, 78, 300 mitigatus, 78, 300 Arg>'ria, 78, 150 Argyrol, 149 Aristol, 141,324 Arsenic, 82, 232, 291, 301 as alterative, 232 antidote tc, 291 action of, 84 as devitalizer, 83 as escharotic, 82 combinations with, 85 iodide, 234, 301 poisoning by, 87, 88, 291 local, 87 rules for applying, 84 trioxide, 82, 232, 291, 301 Ar.«enical paste, 85 Arsenous acid, 82, 232, 291, 301 solution of, 232 Arteriosclerosis, 122 Artificial alkaloids, 33 respiration, 178, 213, 214 Howard method. 214 Laborde method, 215 Schiifer method, 214, 215 Sylvester method, 213 Asepsis, 125 Asphyxia, 188, 196, 290 Aspirin, 241, 297 Asthenia, 290 Astringents, 38, 94 coagulant, 96 mineral, 100 vascular, 106 vegetable, 96 Atoxyl, 301 GENERAL INDEX 329 Atropin, 32, 177, 222, 291, 301, Plates IV and IX. antagonists to, 269 in mercurialism, 152 B Bacterin, 54 Balsamic resins, 29 Balsam of Peru, 134 Balsams, 29 Belladonna, 222, 291, 302, Plate IX. in mercurialism, 152 Benzin, 265, 302 Benzoic acid, 134, 286, 297 Benzoin, 133, 302 tincture of, 133, 302 compound, 133, 302 Benzosulphinidum, 266, 285, 302 Benzoylacetyl peroxide, 161, 297 Betaeucaine, 179, 182, 302 Betanaphthol, 145, 302 Biborate of sodium. See Borax. Bicarbonate of sodium, 118, 321 Bichloride of mercurj^, 150, 233, 293, 311 Bisulphide of carbon, 305 Bitter tonics, 43, 226 Black wash, 312 Black's "1-2-3" mixture, 137 Blaud's pill, 309 Bleaching agents, 38, 159 action of, 159 Blindness of infants, 148 Blistering agents, 59 Blisters, treatment of, 68 Blood serum, 112 Bloodletting, general, 57 local, 56 Blood-pressure in anesthesia, 188 Blue mass, 27, 233, 311 ointment, 233, 311 piU, 27, 233, 311 vitriol, 80, 104, 292; 308 Boracic acid. See Acid, boric. Borate of sodium, 120, 126, 286, 297 Borax. See Borate of Sodium. Boric acid, 126, 297 Borine, 144 Boroglycerin, glycerite of, 126, 297 Borolyptol, 144 Bougies, 29 Boulton's solution, 64 Bowel, medication by, 43 Brandy, 98, 299 Bromides, 239, 244, Plate XV. antagonists to, 270 Bromine, 142, 291, 303 Brow ague, 227 Brugg's mix-ture, 212 Buchu, 251, 303 Burnett's disinfecting flmd, 82, 296 Burnt alum, 80, 103, 299 Butvlchloral, 305 Cacao butter, 29, 323 Caffeine, 177, 216, 223, 303, Plate X. antagonists to, 270 citrated, 177, 303 Caffeine-sodium benzoate, 177, 223, 303 sahcvlate, 177 Cajuput,"'oil of, 137, 140, 316 Cajuputol, 140 Calcined magnes-a, 120, 314 Calciiim chloride, 111, 304 lactate, HI, 304 Calomel, 233, 311 Calumba, 227, 303 Calx chlorinata, 142, 160, 303 Campho-phenique, 78 Camphor, 221, 292, 304 spirit of, 221 Camphorated oil, 304 phenol, 78 Canker sores, 76 Cannabis indica, 292, 304 Cantharidal collodion, 67, 307 TDls^stGr 67 Cantharides, 67, 292, 304 preparations of, 67, 304 Capsicum, 61, 304 tincture of, 61 Carbo animalis, 152, 304 purificatus, 152, 304 ligni, 152, 284, 304 CarboUc acid, 75, 127, 130, 291 gangrene, 128 poisoning, 76, 128, 291 from local use, 77 Carbon disulphide, 305 Carbonic oxide, 292 Care of mouth during pregnane^-, 258 Caries in deciduous teeth, nitrite of silver in, 79 in pregnancv, 258 Carlsbad salts, 123 Carron oil, 68, 90, 303 Cascara sagrada, 305, Plate XVIII. Cassia, oil of, 137, 138, 306 Castor oil, 27, 245, 316, Plate XVIII. beans 292 in first dentition, 244, 245 Cataphoresis, 47, 65 Cataplasm, 91 Catechu, 97. See Gambir. Cathartics, 39, 58, 249, Plate XVIII. Caustic alkalies, 73 lunar, 78, 300 mitigated, 78, 300 potash, 74, 295, 318 pyrozone, 80, 154, 161 soda, 74, 295, 322 . Caustics, 38, 59, 70 Cautery, actual, 88 galvano-, 89 thermo-, 89 Cavenne pepper, 61, 304 Cerates, 24 330 GENERAL INDEX Chalk, prepared, 121, 284, 303 Chancre, 236 Chapped hands, 92 Charcoal, 152, 284, 304 animal, 152, 304 purified, 152, 304 Chemical affinities of corrosives, 70 Chinosol, 135, 156, 305 Chloral hydrate, 245, 246, 292, 305, Plate XVI. antagonists to, 269 phenol, 78 Chlorate of potassium, 145, 295, 318 Chloride of ethyl, 165, 208, 299 of zinc, 80, 105, 147, 296, 325 Chlorinated lime, 142, 160, 303 Chlorine, 142, 160, 305 bleaching agents, 160 preparations, 142, 305 Chloroform as anesthetic, 205, Plate VII. administration, 207 antagonists to, 270 as anodyne, 206 as irritant, 67, 206 contraindications to, 195 dangers of, 194, 206, 207, 292 general uses of, 206, 306 history of, 185 in convulsions, 245 inhaler, 208 Cholagogues, Plate XVIII. Chromic acid, 80, 306 Chromium trioxide, 80, 306 Churchill's iodine caustic, 64 tincture of iodine, 64 Cinchona, 227, 306 Cinchonine, 32, 306 iodosulphate, 143, 306 Cinchonism, 227 Cineol, 140 Cinnamic aldehyde, 138, 139 Cinnamon, oil of, 137, 138, 306 spirit, 138, 306 water, 138 Cloves, oil of, 137, 139, 305 Coagulant astringents, 96 Coagulation of blood, agents that favor, 110 Coal-gas poisoning, 292 Cobalt as escharotic, 88, 306 Coca,..169, 306, Plates II and III. Cocaine, 32, 169, 292, 306, Plates II and III. action of, 169, 171, Plates II and III. aids to action of, 175 antagonists to, 176, 270, Plate IV. dangers of, 176 general action, Plates II and III. uses of, 174 habit, 47, 170, 175 hydrochloride, 86, 169, 292, 306 local action of, 169, 171 poisoning, 172, 176, 292 Schleich method of using, 173 solutions of, 168, 173, 267 Cocaine, substitutes for, 178 comparison of, 182 toxicity of, 182 Cocainization of spinal cord, 184 Codeine, 32, 248, 294, 306 Cod-Uver oil, 231, 316 Coffee, 97, 303 Colchicum, 237, 306 Cold as analgesic, 165 as hemostatic, 96 as sedative, 238 Collodion, 24, 114, 307 cantharidal, 24, 67, 307 flexible, 24, 114, 307 styptic, 24, 114, 307 Columbo. See Calumba. Coma, 290 Combinations of drugs, objects of, 263 Commercial preparations, 144 Common measure equivalents, 280, 281 Compound solution of iodine, 63, 65 313 spirit of ether, 220, 299 tincture of benzoin, 133, 302 Conductive anesthesia, 169 Constituents of drugs, 22, 32 Contraindications, definition, 20 to chloroform, 195 to ether, 195 to nitrous oxide, 195 Convallaria, 307 Convulsions during dentition, 242, 244 Copperas, 293, 309 Copper salts, poisoning by, 292 sulphate, 80, 104, 251, 292, 308 Corrosive subUmate, 150, 233, 293, 311 poisoning, 151, 293 Corrosives, 70, 290 Cotarnine, 110, 307 Cottonseed oil, 90, 310 Counterirritants, 59 degree of action, 59 modes of action, 60 rules for applying, 60 Courtplaster, 25 CowUng's rule, 271 Cream of tartar, 51, 250 Cred(5's method, 148 Creolin, 307 Creosote, 130, 137, 293, 307 carbonate, 131, 307 Cresol, 129, 307 Creta prsparata, 121, 284, 303 Croton oil, 27, 58, 66, 293, 316 Cubeb, 91, 251, 252, 307 Cubic centimeter, 277 Cumulative effect, 20 Cupping, dry, 55 wet, 56 Cupri sulphas, 80, 104, 251, 292, 308 Death, modes of, 290 signs of, 290 GENERAL INDEX 331 Deciduous teeth, phenol in, 76 silver nitrate in, 79 Declension of nouns and adjectives, 274 Decoctions, 24 Decolorized tincture of iodine, 66 Demulcents, 38, 90 Dentifrices, 283 Dentine, sensitiveness of, 76, 80, 81, 121 Dentistry during pregnancy, 256 Dentition, first, 241 complications of, 241 convulsions during, 242, 244 lancing of gums in, 56, 243, 246 Deodorant, 124, 152 Depletion, general, 58, 238 Depletives, 38, 55 as sedatives, 238 Depressants, 238 Derivative action, 60 Detergents, 38, 115 Devitalizers, arsenic, 83 phenol, 76 Devitalizing fiber, 86 Diagnosis, definition, 20 Dialyzed iron, 88, 309 Diaphoretics, 39, 249, 251 Digestant, 40 Digitahs, 177, 224, 250, 308, Plates IV and XII. antagonists to, 270 cumulative effect of, 20 Diluents, 121 Dioxide of hydrogen, 80, 115, 153, 161, 312 sodium, 161, 322 sulphur, 162 Disinfectant, 124 Dispensatory, definition of, 19 Dissociation of drugs, 52 Dissolution, 20 Distilled oils, 28, 136 Diuretics, 39, 249, 250 Diuretin, 251. 324 Dobell's solution, 127, 321 Donovan's solution, 232, 301 Dosage by rectum, 44 for children, 271 hypodermic, 44 Doses, 270 Dover's powder, 262, 316 Drastics, Plate XVIII. Drop method for ether, 204 Drops in flui drachm, 281 Drug, definition of, 18, 21 habit, 33, 47, 247 Drugs, chemical, 21, 70 classes of, 21 constituents of, 32 effects of, 19 index of, 297 modes of action of, 50 official, 18 organic, 21^ 22 preparations of, 22 Dry cupping, 55 E Effects of drugs, 19, 52 Elaterin, 30, 293, 308, Plate XVIII. Elimination of drugs, 43 Eliminatives, 37, 249 Elixirs, 25 Emetics, 39, 249, 251 Emetine, 32, 308 EmolUents, 38, 91 Emplastrum, 25 Emulsin, 228 Emulsions, 25, 231 Endermic method, 44 Epidermic method, 44 Epinephrine, 94, 107, 308 Epispastics, 38, 59 Ergot, 108, 308, Plate I. Errhine, 39 Erythroxylon coca, 169 Escharotics, 38, 59, 70 mode of action, 70 Esmarch inhaler, 208 Ether, ethyhc, 165, 202, 220, 293, 299 action of, 187 administration of, 203 antagonists to, 270 as anesthetic, 203, Plate VI. as stimulant, 220 contraindications to, 195 disadvantages of, 205 drop method, 204 explosiveness of vapor, 198 general uses of, 203, 220 history of, 185 inhalers, 204 spirit of, 220, 299 compound, 220, 299 spray, 165 nitrous, spirit of, 250, 251, 299 Ethyl bromide, 212, 308 chloride, 165, 208, 299 as general anesthetic, 208 as local analgesic, 166 deaths from, 209 inhaler, 209 safety of, 208, 211 spray, 165, 166 Eucaine. See Betaeucaine. Eucalyptol, 137, 140, 309 Eucalyptus, oil of, 140, 309 Eugenol, 137, 139. 309 Expectorants, 39, 249, 252 Experiments, 70, 75 Extracts, 25 ethereal, 27 fluid, 25 Fats, 28 Ferric chloride, tincture of, 101, 229, 293, 309 solution of, 102, 309 hydrate. See Ferri hydroxidum. 332 GENERAL INDEX Ferri hydroxidum, 83, 229, 291, 309 cum magnesii oxido, 291, 309 subsulphas, liquor, 102, 309 sulphas, 293, 309 exsiccatus, 309 tersulphatis, liquor, 102, 309 Ferrous sulphate, 293, 309 dried, 309 Ferrum, 229, 309 First dentition. See Dentition. Flavoring agents, 285 Flaxseed, 90, 91, 314 Fluidextracts, 23, 25 Formaldehyde, 156, 309 Formahn, 137, 156, 293, 309 germicidal power of, 137, 144, 157 Formocresol, 158 Formulary, National, 19 Formulas, definitions of, 262 Foul breath, 133 Fowler's solution, 232, 301 Frangula, 310, Plate XVIII. Freezing mixture, 165 spray, 165 Fulminating silver, 80 Fungi, poisoning by, 293 Galenical preparations, 23 Galla, 97, 310 GalUc acid, 97, 108, 310 Galvanocautery, 89 Gambir, 97, 310 Gaultheria, oil of, 137, 140, 284, 310 Gelatin, 111, 310 General remedies, definitions of, 38 Gentian, 227, 310 Germicide, 124 Gingivitis, interstitial, 106. See Pyorrhea alveolaris. Glacial acetic acid, 73, 297 Glonoin. See Nitroglycerin. Ghicosides, 34 Glycerin, 92, 265, 310 Glycerite of boroglycerin, 126, 297 of tannic acid, 93 Glycerites, 26 Glycerol. See Glycerin. Glycothymoline, 134 Glycyrrhiza, 91, 310 Glycyrrhizin, 35, 310 Gold and sodium chloride, 302 Gonococcus, 148 Goulard's extract, 105, 318 Gout, 122 Gram, 277 Granular eyelids, 80 Guaiacol, 131, 307 carbonate, 131, 307 Guaiacum, 237, 311 Gum arabic, 90, 297 resins, 29 Gums, lancing of, 56, 243, 246 Gun cotton, 24, 319 H Habit, drug, 33, 47, 247 Halogens, 142 Hamamelis, 97, 311 Heart during anesthesia, 194, 206, 212 massage of, 214 Heat as counterirritant, 59, 60 as hemostatic, 96 as stimulant, 221 sterilization by, 46, 126 Hematoxylon, 97 Hemoglobin in anesthesia, 187 Hemophilia, 57, 111, 112 calcium salts in, 111 Hemorrhage after tooth extraction, 113 control of, 94 postpartum, 110 Hemorrhage diathesis, 57, 111, 112 Hemostatic cotton, 102 Hemostatics, 38, 94 coagulant, 96, 100 mechanical, 113 vascular, 106 Heroin, 294, 308 Hexamethylamina, 158, 311 Hofi"man's anodyne, 220 Holocaine hydrochloride, 311 Homatropine, 223, 301 Honey, 315 Hot mustard foot-bath, 62 Hot-air bath, 58 Howard method of artificial respiration, 214 Hydragogues, 58, Plate XVIII. Hydrargyri chloridum corrosivum, 150, 233,293,311 mite, 233, 311 iodidum flavum, 233, 311 rubrum, 233, 311 sahcylas, 233, 237, 312 Hydrargyrum, 233, 311 cum creta, 233, 311 Hydrastinine, 32, 110, 312 Hydrochloride of cocaine, 86, 169, 292, 306 Hydrocyanic acid, 228, 239, 291 Hydrogen dioxide (peroxide), 115, 153, 161, 312 caustic, 80, 154, 161, 312 Hydronaphtol. See Betanaphtol. Hygienic remedies, 36 Hyoscine, 223, 293, 321 Hyoscyamine, 32, 223, 293, 312 Myoscyamus, 293, 312 Hypertonic solution, 51 Hypnotics, 39, 246 Hypodermic method, 44 dangers of, 45 how to employ, 46 syringe, 46 sterilization of, 46 use of, 46 tablets, 31 Hypodermoclysis, 48, 222 Hypophosphites, syrups of, 231, 312 GENERAL INDEX 333 H\-popliysis sicca, 254, 312 H^'posuTphite of sodium, 147, 163, 322 HjiDotonic solution, 51 Ice and salt mLxture, 165 Idiosj-ncrasy, 53 T mm nnity, 54 Imponderable remedies, 36 Incompatibility, 34, 267 chemical, 267 intentional, 269 of acids, 268 of alcohol, 100 of alkahes, 268 of alkaloids, 34 of alum, 103 of antip\Tuie, 107, 268 of benzoic acid, 134 of betanaphtol, 145 of borax, 119, 268 of boric acid, 126 of calomel, 268 of carbohc acid, 129, 268 of chalk, 121 of chlorides, 268 of chlorine, 142 of cocaine hydrochloride, 175, 268 of collodion,"^114, 268 of glucosides, 268 of glycerin, 93, 268 of gums, 267 of iodine, 268 of iron sahs, 102, 268 of lead acetate, 105 of hme-Tvater, 120, 268 of magnesia, 120 of mercuric chloride, 151, 268 of oil of turpentine, 63 of orthoform, 181 of phenol, 129, 268 of potassiimi chlorate, 147, 268 iodide, 268 permanganate, 147; 268 of resins, 267 of resorcui; 145 of saUcyhc acid, 135 of silver nitrate, 80^ 268 of soap, 118 of sodium bicarbonate, 118 borate, 119, 268 of spirit of nitrous ether, 268 of sulphurous acid, 162 of tannic acid, 97, 268 of zinc chloride, 82 sulphate, 106 physical, 267 therapeutic, 269 Index of drugs, 297 Indication, definition of, 20 Infusions, 26 Inhalation, medication by, 49 Inhalers, 204, 208, 210 Interstitial gingivitis, 106. 5ee Pyorrhea alveolaris. Intravenous injection, 48 Iodide of potassium, 234, 293, 318 rash, 237, note of sodium, 234, 322 Iodides, 234 Iodine, 63, 143, 233, 293, 313 caustic, 64 compound solution of, 63, 65, 313 ointment of, 66, 313 tincture of, 63, 65, 143, 293, -313 ChirrchiU's, 64 decolorized, 66 with aconite, 64, 65 Iodized phenol, 78 Iodoform, 143, 312 substitutes for, 143 lodo-glycerole, 106 lodol, 143, 312 Ions, 51 Ipecacuanha, 91, 251, 252, 313 Iris florentina, 284, 313 Iron, 229, 309 action of, 229 astringent salts of, 101 chloride of, 101 tincture of, 101, 229, 293. 309 dialyzed, 88, 309 effect of, upon teeth. 229 hvdrated oxide of, 88, 229, 291. 309 with magnesia, 229,291,309 persulphate of, 102, 309 preparations for internal use, 229 pyrophosphate of, 229, 309 subsulphate, 102, 309 s^Tiip of iodide of, 229, 234, 309 Irritants, 59, 290 Isotonic solution, 51 of cocaine, 174 Itrol, 149, 300 Jalap, 58, 313, Plate XVIII. Juniper, oil of, 251, 313 Kixo, 97, 313 Krameria, 97, 313 LABARRAQrE's solutiou, 142, 160, 305 Laborde method, 215 Lactic acid, 73, 298 Lancing of giuns, 56, 243 LanoUn, 91, 299 Lard, 28, 91, 298 Latin declensions, 274 in prescriptions, 273 Laudanima, 294, 316 334 GENERAL INDEX Laughing gas (nitrous oxide), 199, 315 Laxatives, Plate XVIII. Lead acetate, 104, 293, 318 and opium wash, 105 salts, poisoning by, 104, 293 water, 105, 3 18 Leech glass, 57 Leeching, 56 Leiter coil, 96 Leucomaines, 34, 289 Leukocytosis, 53 Licorice root, 91, 310 Lime-water, 119, 303 Liniments, 26 Linimentum calcis, 68, 90, 303 Linseed, 91 314 oil, 27, 90 poultice, 91 Liquor acidi arsenosi, 82, 232, 301 arseni et hydrargyri iodidi, 232, 301 calcis, 119, 303 cresolis compositus, 129, 307 ferri chloridi, 102,309 subsulphatis, 102, 309 fonnaldehydi, 137, 156, 293, 309 hydrogenii dioxidi, 154 hypophysis, 254, 312 iodii carbolatus, 64 causticus, 64 compositus, 65, 3 13 potassii hydroxidi, 75, 318 sodaj chlorinata-, 142, 160, 305 sodii boratis compositus, 127, 321 carbolatis, 79, 128, 317 chloridi physiologicus, 168, 221 hydroxidi, 75,322 zinci chloridi, 81, 325 Liquors, 26 Listerine, 144 Liter, 277 Lithemia, 122 Local analgesics, 164 anesthesia, 164 technique of, 167 remedies, 55 definitions of, 38 Logwood, 97 Losophane, 143, 314 Lotio plumbi et opii, 105 Lugol's solution, 65, 313 Lunar caustic, 78, 300 Lungs, medication by, 49 Lysol, 129, 307 M Magma magnesise, 120, 291, 314 Magnesia, 120, 314 milk of, 120, 291, 314 Magnesium oxide, 120, 314 sulphate, 314, Plate XVIII. Massa, 27 hydrargyri, 27, 233, 311 Massage of heart, 214 Materia medica, definition of, 18 Mechanical hemostatics, 113 Medicine, definition of, 18, 21 Medicines, administration of, 41 constituents of, 23, 32 modes of action of, 50 preparations of, 22, 24 Mel, 285, 315 Menthol, 141, 315 Mercurial ointment, 233, 311 Mercurialism, 151 treatment of, 152 Mercury, 22, 233, 311 bichloride of, 150, 233, 293, 311 monochloride of. 233, 311 oleate of, 27, 233, 311 salts, poisoning by, 151, 293, 294 with chalk, 233, 311 Meter, 277 Methyl salicylate, 140, 315 Metric system, 276 equivalents of, 276, 278 rules for use of, 279 Milk of magnesia, 120, 291, 314 Milliliter, 277, 278 Mineral acidS: 71, 229, 291 antidotes to, 72 poisoning by, 72 astringents, 100 waters, 121 Mitigated caustic, 78, 300 Mixtures, 27 Modes of action of medicines, 50 of death, 290 Monsel's salt, 102, 309 solution, 102,309 Morphine, 32, 87, 114,246, 248, 294, 315, Plate XVII. antagonists to, 270 for children, 247 habits, 33, 47, 247 Mouth-washes, 116, 285 purposes of, 285 to be antacid, 116 Mucilages, 27 Mucous patches, 236 Muriatic acid. See Acid, hydrochloric. Mustard as emetic, 61, 251,'321 as irritant, 61 bath, 62, 244, 251 plaster, 62 volatile cil of, 28, 61, 321 Myrrh, tincture of, 132, 315 N Naphtol, 145, 302 Narcotic, 39 habit, 47 National Formular>% 19 Nerve blocking with cocain, 170, note. Neutral principles, 35 Nicotine, 296, 315 Nirvanin, 179, 182, 315 GENERAL IXDEX 335 Nitrate of silver, 78, 103, 148, 296, 300. Nitre, 250, 295, 319 Nitrite of amvl, 225, 294, 300, Plate XIII. of sodium, 225, 322, Plate XIII. Nitrites, 224, 294, Plate XIII. antagonists to, 270 Nitrogen monoxide . iSee Nitrous oxide. Nitroglycerin, 176, 224, 294, 315, Plate XIII. spirit of, 224, 315 Nitrous oxide, 199, 315 administration of, 201 advantages of, 202 analgesia, 200 anesthesia, 200 contraindications to, 195 history' of, 185 inhalers, 201 Normal salt solution, 51, 168, 221 Nose-bleed, 103, 107 Noims, declensions of, 274 Novocaine, 167^ 180 Nuclein, 68, note. NutgaU, 97, 310 Nux vomica, 223, 228, 294, 316, Plate XI. Objects of combining drugs, 263 Odol, 144 Official drugs, definition of, 18 formulas, definition of, 262 Oil, carron, 68, 90, 303 castor, 27, 245, 316, Plate XVIII. cod-liver, 231, 316 emulsion of, 231 cottonseed, 27, 90, 310 croton, 66, 203, 316, Plate XVIII. linseed, 27, 90 of bav, 137 of bitter ahnond, 28, 291 of cajuput, 137, 140, 316 of cassia, 137, 138, 306 of cinnamon, 137, 138, 306 of cloves, 137, 139, 305 of eucalj'ptus, 140, 309 of gaultheria, 137, 140, 284, 310 of juniper, 251, 313 of mustard, 28, 61, 321 of peppermint, 137, 141, 221, 315 of rose, 285, 320 of smoke, 67. 130, 307 of theobroma, 29, 323 of tiu-pentine, 64, 141, 251, 296, 343 of vitriol, 71 of wintergreen, 140, 284, 310 olive, 27, 90, 316 Oils, distiUed, 28, 136 essential, 28, 136 fixed, 27 . volatile, 28, 136 antiseptic power of, 137 Ointments, 31 Oleate of me^cur^', 27, 233, 311 Oleates, 27 Oleoresins, 27 Opium, 42, 114, 246, 294, 316, Plate XVII. alkaloids of, 32, 246 as hemostatic, 114 for children, 247 habit, 33, 47, 247 poisoning, 294 Organic acids, 73 Orpiment, 291 Orris root, 284, 313 Orthoform, 86, 181, 316 after extraction of tooth, 181 Osmosis, 51 Oxalates, 291 Oxj'gen bleaching agents, 161 Paliiitix, 27 Pancreatin, 255, 316 Papaver somniferum, 246, 316 Paraformaldehyde, 158, 309 Paregoric, 247, 294, 316 Paris green, 291 Peck, A. H., experiments with antisep- tics, 136, 137 Peppermint, oil of, 137, 141, 221, 315 Pepsin, 255, 317 Per chloride of mercur\% 150 Pericementitis, counterirritants in, 61, 62 hot mustard foot-bath in, 63 iodine in, 64 morphine in, 247 Permanganate of potassiimi, 146, 162, 314 Peroxide of hydrogen, 115, 153, 161, 312 of sodium, 161 Persulphate of iron, 102 Petrolatum, 28. 90, 317 hquidum, 90 Phagoc\'tosis, 54 Pharmacolog\", definition of. 18 Pharmacopoeia, U. S., 18, 24, 263 Pharmacy, definition of, IS Phar\Tigitis, chronic, 103 Phenacetine, 240, 297 Phenazone, 107. 300 Phenol, 75, 127, 130 291, 317 coefficient, 124, note. germicidal power of, 128, 137 liquefied, 75, 127 poisoning, 76, 128. 291 sodique, 128. 317 Phenolphthalein, 317, Plate XVIII. Phenyl saKcylas, 135, 317 Phlebotomv, 57 Phosphoric acid, dilute, 231, 298 Phosphorus, 230. 295, 317 Ph^'sical action of medicines, 50 Physiologic action, 19 " antidote, 269 effect, 19 salt solution, 51, 168, 241 Pills, 28 336 GENERAL INDEX 318, Pilocarpine, 32, 251, 317 Pituitarj' body, 254, 312 Plasters, 25 Plumbi acetas, 104, 293, 318 Podophyllum, 318, Plate XVIII. Poisons, 21, 289 table of, 291 Potash, caustic, 74, 295, 318 Potassa, 74, 295 Potassium acetate, 250, 318 and sodium tartrate, XVIII. bitartrate, 51, 250, 295, 318, XVIII. bromide, 239, Plate XV. chlorate, 145, 295, 318 in mercurialism, 146, 152 citrate, 250, 318 cvanide, 78, 293, 318 hydroxide, 74, 295, 318 iodide, 65, 234, 293, 318 in mercurialism, 152 nitrate, 2.50, 295, 319 permanganate, 146, 162, 314 as antidote, 147, 294, 295 to remove stains of, 146 sulphate, 295, 319 Poultice, 91 Pregnancy, dentistrv' during, 256 care of the mouth during, 258 caries during, 258 Preparations of drugs, 22 classes of, 24 galenical, 23 Prepared chalk, 121, 284, 303 Prescription, construction of, 283 definition of, 262 parts of, 271 use of Latin in, 273 writing, 261 Proof spirit, 98 Proprietary' solutions, 144 Protargol, '149, 319 Proud flesh, 69, 80 Proximate principles of drugs, 22, 32, Prunus Virginiana, 228, 239, 319 Ptomaines, 34, 289 Ptyalagogue, 39 Pulp, devitalization of, 76, 83, 88 Pulpitis, 64, 76 Pulse during anesthesia, 194 Pulvis acetanilidi compositus, 240 ipecacuanhjB et opii, 262, 316 Pumice, powdered, 284 Pumpkin seed, 317 Pupils during anesthesia, 192, 194 Purges, Plate XVIII. Pyorrhea alveolaris, 73, 80, 81, 138, PyroxTlinum, 114, 319 QuA-ssiA, 227, 319 Quicksilver, 233, 311 Quinine, 32, 227, 319 and urea hvdrochloride, 181, 319 sulphate, 155, 227, 319 Quinosol, 135, 156, 305 R Reactionary effects of drugs, 53 Realgar, 291 Plate I^sctmn, medication by, 43 Reducing agents , 162 Plate Remedies, 36 general, 37, 185 hygienic, 36 imponderable, 36 local, 37, 55 mechanical, 36 medicinal, 36 preventive, 36 Remedy, definition of, 21, 36 Resins, 28 balsamic, 29 gum, 29 Resorcin, 145, 319 Respiration, artificial, 178, 213, 214 methods of, 213-215 during anesthesia, 191, 193, 212 Restorative tonics, 228 Re^allsive action, 60 Rhatany, 97, 313 Rhigolene sprav, 165 Rhubarb, 320, Plate XVIII. Ringer's solution, 168 Rochelle salt, 318, Plate XVIII. Rose, oil of, 285, 320 Rosin, 62 Rubefacients, 38, 59 Saccharine, 285, 302 Saccharum, 264, 320 lactis, 31, 320 note. Salicj'late of mercurv, 233, 237, 312 of phenvl, 135, 317 of sodium, 135, 322 Salicylic acid, 134, 286, 298 Saline cathartics, 58, Plate XVIII. solution, 48, 168, 221 Salivation, 151 treatment of, 152 Salol, 135, 317 Salt action, 51 solution, normal, 48, 168, 221 Saltpetre, 250, 295, 319 Santonin, 35, 320 145 Sapo, 29, 117, 284, 320 moUis, 29, 117, 320 Sarsaparilla, 237, 320 Scarification, 56 Schleich method, 173 mixtures, 212 Scilla, 250, 2.52, 321 Scopolamine hydrobromide, 223, 293, 321 GENERAL IXDEX 337 • SeurT\', 230 Sedatives, 37, 39, 238 for children, 238, 247 Seidlitz powder, 318 Seller's solution, 144 Senna, 321, Plate XVIII. Sensitive dentine, 76, 81, 121 Serum antidiphthericum, 254, 321 antitetanicum, 255, 321 Sialagogue, 39, 91 Silver citrate. 149, 300 lactate, 149, 300 nitrate, 78, 103, 148, 296, 30O removal of stain of, 78 to check caries, 79 soluble, 148 Sinapis, 61, 251, 321 Sinapism, 62 Sinigrin, 61 Skin grafting, 69 SUpper^- ehn. 90, 324 Soap, castile,' 29, 117, 284, 320 soft, 29, 117, 320 Soaps, 29, 117, 320 Soda, caustic, 74, 295 Sodium bicarbonate, 118, 321 bisulphite, 162, 298 borate, 118. 126, 286, 321 bromide, 239, 322, Plate XY. chloride, 48, 221. 322 as emetic, 251 diborate. See Sodiimi borate. dioxide, 161, 322 hvdroxide, 74, 295. 322 h^TJosulphite, 147, 163. 322 iodide, 234, 322 nitrite, 225, 322, Plate XIII. perborate, 127. 322 salicvlate, 135, 322 sulphate, 322. Plate XYIII. sulphite. 162. 298 thiosulphate. 147, 160. 163, 322 Solubihties, 264, 265 Solutions, 26 percentage, 265 table for preparing, 266 saturated, 265 Solvents, 265 Sonmoform. 210. 212 deaths from, 210 Sozoiodol, 143, 322 Spanish flies. 67, 304 Spermaceti, 28, 305 Spinal cocainization, 184 Spirit of ammonia, 220 aromatic, 178, 216. 220, 300 of ether, 220, 299 compound, 220, 299 of nitrous ether, 250, 251, 299 Spirits, 2£r Spiritus aetheris nitrosi, 250, 251, 299 frumenti. 98, 299 \Tni gallici, 98, 299 rectificatus, 216 Spirocheta paUida, 236 Squill. 250. 2.52, 321 Standardization of drugs, 23 Stenson's duct, 56 Sterilization, 46. 126 StemutatorA-. 39 Stimulants. *37, 217 definition of, 38, 217 diffusible, 219 direct, 217 for children, 218 indication for, 218 indirect, 218 ' irritant, 219 kinetic, 217 potential, 217 reflex, 219 Stomach administration, 41 Stomatitis. 127, 146, 152 Stovaine. 181 Stramonium. 296, 322 Strophanthuls. 224, 250, 323 St^^-chnine, 177, 216, 223. 294. 323, Plates lY and XI. antagonists to. 270 Styptic coUodion, 24. 114. 307 Stypticin. 110 Styptics, 94, 106 Substitutes for cocaiae. 178 Sudorifics. 39, 251 Sugar, 30. 264. 320 of lead, 104, 293, 318 of mUk, 30,320 Sulphate of copper. SO. 104, 251, 292. 308 of zinc. 105. 251. 296. 325 Sulphonal. 246. 323 Sulphonethyhnethane, 246, 323 Sulphonmethane, 323. 246 Sulphur, 323 dioxide. 162 Sulphuric ether. See Ether. Stilphtirous acid. 162, 298 Suppositories, 29 glycerin. 29 Suprarenal glands. 107, 253, 323 Suprarenalum sicciun, 107, 253, 323 Sweating bj' hot-air bath, 58 bv drugs, 251 Sweet'spirit of nitre, 250, 251, 299 Svlvester method of artificial respiration, "213, 214 S\-ncope. 290 during anesthesia, 194 Synthetics. 22. 240 SjTtilis, 20, 234 catise of, 236 curability of, 237 mercmy in. 236 salvarsan in. 236 self-infection by. 235 s\Tnptoms of. 236 treatment of, 234-237 Sj'ringe for local anesthesia, 168 SjTups, 30 of h^-pophosphites. 231. 312 of iodide of iron, 229, 234, 309 338 GENERAL IXDEX Table for preparing percentage solutions, 266 of poisons and antidotes, 291 Tablet triturates. 31 Tablets, compressed, 31 h\'podermic, 31 Tannic acid, 33, 96, 298 glycerite of, 93 Tartar emetic, 251, 300 Tea, 97 Terebene, 141, 323 Theobroma, 323 oil of, 323 Theobromine, 223, 251, 324 sodium salicylate, 251, 324 Therapeutics, definition of, 18 Thermocau ter\', S9 Thimble bUster, 6S, 206 Thiosulphate of sodiimi, 147. 100. 163, 322 Th^-mol. 140, 324 iodide. 141. 324 Th}Toid gland 112. 253. 324 Th^Toideum siccum, 112. 253, 324 Tincture of aconite. 64. 65, 243, 291, 298 of benzoin. 133. 302 of capsiciun. 61, 304 of chloride of iron, 101 229, 293, 309 of m^Trh, 132, 315 Tinctures, 23, 30 Tobacco, 296 Tolerance for drugs. 20, 247 Tonics. 39. 226 bitter. 226. 227 nutritional. 226 restorative 226. 228 Tooth paste. 285 powders, 283 Toothache, 62, 64. 76. 206. 247 Toxic effect of a drug, 19 Toxicity of anesthetics, 210 Toxicology-, 18, 289 Trichloracetic acid. 73, 298 Trichlorphenol, 129 Tricresol, 129 Trional, 246, 323 Triturates, 30 Troches, 31 Tropacocaine hydrochloride, 181, 183, 324 Turpentine liniment, 26. 63 oil of, 62. 141,251, 296, 323 stupe, 63 Vaccixatiox. 36, 54 Vaccines. 40. 54 Vascular astringents. 106 Vaseline, 28, 91, 317 ^'asodilato^s, 225 Vegetable acids, 230 alteratives, 237 astringents, 97 Venesection, 57 Venom. 289 Veratrine, 32, 324 Veratrum, 110. 239. 324 Verdigris, 292 Vermifuge. 40 Vesicants, 38, 59 Vienna paste, 318 Vinegars. 24 Vinum. 324, 325 Virus. 289 Vitriol, blue. 80 oil of. 71 white. 105 Volatile oils, 28, 136 comparative action of. 136. 137 W Wadsworth, comparison of antiseptics, 144 Warts, nitric acid applied to. 71 Wassermann test. 237 Waters, medicated, 24 mineral. 123 Wax, 28, 305 Weeping gums, 73 Wet cupping, 56 Weights and measures, 275 \Miisky, 98, 299 \Miite\-itriol. 105 Whooping-cough. 145 Wild cherry, 22S, 239, 319 Wines, red. 325 white. 324 Witch-hazel. 97. 311 Wood alcohol. 100. 299 charcoal. 152. 304 spirit. 100, 299 blindness from, 100 U Ulmfs, 90. 324 Unguentum, 31 hydrarg>Ti. 233. 311 United States Pharmacopoeia, 24, 263 Untoward effects of drugs, 19, 53 Uric acid, 122 Urotropin, 158. 211 Uva ursi, 251, 324 Yeast, brewers', 68 Yellow wash, 312 Zixc chloride. 80. 105. 147. 296. 325 iodide. 106. 325 oxide, 106. 325 sulphate, 105, 251, 296, 325