CAL BOOKS 1'^ Columbia ^nifaersiitp in tfje dtp of j^eto ^orfe gjcfjool of ISental anb 0val ^uiijtv^ Reference Eibrarp /?1 DENTAL MATERIA MEDICA, THERAPEUTICS AND PEESCMPTION WRITING. BY ELI H. LONG, M.D., PEOFESSOE OP DENTAL MATEEIA MEDICA AND THEEAPEUTICS IN THE DENTAL DEPAETMENT, UNIVEESITY OF BUFFALO ; PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS IN THE MEDICAL DEPARTMENT, UNIVERSITY OF BUFFALO; ASSISTANT ATTENDING PHYSICIAN TO THE BUFFALO GENERAL HOSPITAL. THIRD EDITION, REVISED AND ENLARGED. ILLUSTRATED WITH SIX ENGRAVINGS AND EIGHTEEN COLORED DIAGRAMS. LEA & FEBIGER, PHILADELPHIA AND NEW YOEK, 1909. <^ ^ ♦-f ,. 5\ t^i Copyright, 1909, by LEA & FEBIGER. Authority to use for comment the Pharmacopoeia of the United States of America (Eighth Decennial Revision), in this volume, has been granted by the Board of Trustees of the United States Pharmacopceial Convention; which Board of Trustees is in no way responsible for the accuracy of any translations of the OfiBcial Weights and Measures, or for any statement as to strength of Official Preparations. DORNAN, PRINTER, PHILADELPHIA. 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. Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/dentalmateriamed1909long PREFACE TO THE THIRD EDITION. The opportunity presented by the demand for a new edition has been utilized to effect a thorough revision to date without changing the essen- tial features of a work which appears to have met with approval. The author's original purpose was to select from the vast body of knowledge comprised in Materia Medica and Therapeutics such portions as were essential for students of dentistry, and to supply also in concise form what is necessary for them to know of pharmacology as related to the most important drugs of general effect. IMany years of experience in teaching had developed definite ideas as to the requirements of such a course, differing greatly as it does from the corresponding element in the medical curriculum. In this revision, aside from the enlargement or abridgment of certain topics, some decided changes will be found in several chapters. Under "Antiseptics" more attention is devoted to the volatile oils in regard to their definite characters, their action and their comparative values, and among miscellaneous drugs of this class recent observations as to potency are given. Among "Local Analgesics" the newer agents receive such attention as present knowledge warrants. The chapter on "General Anaesthetics" has required considerable change, the discussion of ethyl chloride especially calling for amplification in general, and recognition of its dangers. In a new chapter on "Dentistry during Pregnancy," the care of the teeth and operative treatment during gestation are discussed in relation to prophylaxis. The chapter on "Prescription Writing" is intended to answer practi- cal requirements, and to aid in correcting the proprietary formula abuse, which is antagonistic to scientific therapeutics. Few formulas are given in the book, and these are intended to be suggestive. This chapter is planned to aid the student to rise above dependence upon ready-made formulas, and to qualify him for the greater success which can be achieved by adapting his treatment to the case before him. This power is attain- able through a thorough knowledge of drugs and their chemical and pharmacological c[ualities. (v) vi PREFACE TO THE THIRD EDITION The arrangement of remedies Into groups, based on their action and uses, has been retained, as it aids the student in acquiring what is so im- portant, a comparative knowledge of drugs and their properties. While new remedies of value are duly recognized, little attention is given to those which are yet untried. Every year sees a vast number of these put out and recommended for commercial ends. The very few that are valuable survive. A book which aims to cover its subject con- cisely, scientifically, and practically must include the latest approved facts and exclude matters which have not reached that level. E. H. L. CONTENTS. PART I. PAGE INTRODUCTION 17 CHAPTER I. Drugs and Medicines: Their Constituents and Preparations ... 21 CHAPTER II. Remedies: Their Classification and Definitions ...... 38 CHAPTER III. ^ Administration of Medicines ......... 42 CHAPTER IV. Modes of Action of Medicines ...... i .. 51 PART II. LOCAL REMEDIES. CHAPTER V. Depletives . . . . . . . . . .55 CHAPTER VI. Counterirritants ........... 69 ( vii ) viii CONTENTS CHAPTER VII. PAGE Escharotics ............. 70 CHAPTER VIII. Demulcents and Emollients ......... 90 CHAPTER IX. Astringents and Hemostatics ......... 94 CHAPTER X. Detergents, Antacids and Alkalies ........ 112 CHAPTER XI. Antiseptics ............ 120 CHAPTER XII. Bleaching Agents . . . . . . . . . . . 150 CHAPTER XIII. Anesthetics. Local Analgesics .... . . . . . 155 PART III. GENERAL REMEDIES. CHAPTER XIV. Anesthetics . 173 CHAPTER XV. Stimulants 195 Tonics 204 CHAPTER XVI. Alteratives 211 Syphilis and its Treatment. . . ........ 213 CONTENTS IX CHAPTER XVII. PAGE Sedatives 217 First Dentition Complications and tiieir Treatment 220 CHAPTER XVIIL Eliminatives ^ 228 CHAPTER XIX. Dentistry during Pregnancy ■ • 233 PART IV. CHAPTER XX. Prescription Writing 237 Abbreviated Terms in Common Use in Prescriptions 259 CHAPTER XXI. Poisons 260 Table of Poisons and Antidotes 262 Index of Drugs 269 \ General Index ^^^ DENTAL MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. PARTI. 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. AVhether we regard the condition as normal or not, the fact is apparent that the prac- tice of dentistry today has little in common with general medicine. This is likely to be true to a degree for the future also, even though the tendency must be to broaden the curriculum of dental colleges, ^\h\\e there is evidence that the broadening process is going on, one special direction in which a more general knowledge is demanded is in diseases of the circulation, in view of the frequent use of general anaesthetics by the dental surgeon. A clinical course in physical diagnosis, sufficient to enable the student to detect diseases of the heart, lungs and blood- vessels, is a needed addition to the course of study. 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 brief explanatory text, the action of the most important 2 (17) 18 DENTAL MATERIA MEDIC A internal drugs upon the general system, nor for the somewhat extensive treatment of classes of remedies and preparation of drugs. Certain general terms require definition or comment at the outset. Materia medica, in a restricted sense, means the materials or substances used in medicine. In a broad sense, the term means the science that treats of drugs in their varied relations. 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 treat- ment of disease. While therapeutics should have a scientific basis in the knowledge of the action and effects of remedies, practical treatment of disease will always remain an art, because of the many modifying factors that render scientific precision impossible. Toxicology is that part of medical science which treats of poisons. It includes the action and effects of poisons, 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, as its main object, it furnishes a hst of recognized drugs, with descriptions, tests of purity, etc., and of preparations, with their formulas. The drugs and preparations thus recognized are called official. The book not only is the authority upon drugs and their preparations, but it forms the basis of our text-books on materia medica, pharmacy and therapeutics. The revision of 1900 for the first time contains also doses of official drugs and preparations. 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 the uses of drugs. But it is not an authorized work as is the pharmacopoeia. The National Formulary is a very important collection of formulas that are not official, but which are in common use. It is prepared under INTRODUCTION 19 the direction of the American Pharmaceutical Association, and is, there- fore, in a sense authoritative. The abbreviation (N. F.) is used to indi- cate this work. 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 therapeutic effect are terms distinct in meaning, and they should be properly understood. The action and the effect of a drug cannot be the same. The action may be obscure; the effect must be apparent. . To illustrate : Tincture of iodine applied in case of peri- cementitis has its action upon the mucous membrane (with indeed a local destructive effect which is not physiologic), but the physiologic effect that we desire is alteration of the disturbed circulation in the peri- cementum. 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 action of a drug, then, consists of a modification of conditions, chemic, thermic, electric or structural, which determines an alteration of function. This alteration, when apparent, is known as the effect of the drug. Within the limit 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 or healthy individual, but never the therapeutic effect. The presence of disease is always necessary to the production of any therapeutic effect. Some drugs may cause unpleasant or undesirable effects aside from their main action. These are called untoward effects, and their avoid- ance calls for discrimination in administration and dosage. Closely related is the matter of susceptibility to drug action, some individuals being very sensitive to the influence of a certain drug or drugs, and read- ily 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- 20 DENTAL MATERIA MEDIC A 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 employment of remedies, the term indication means the symptom or condition that calls for a particular remedy or course of treatment, while contraindication 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 posi- tive evidence of some particular disease. Diagnosis means the deter- mination, by means of symptoms or signs, of the character or name of the disease, while prognosis is the prediction of the course or termination 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 two meanings. Applied to a remedy, it means that the remedy can be invariably relied upon to pro- duce 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. Thus, the term is used among physicians to designate, 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 drug and medicine are not strictly synonymous, although popularly so regarded. Both mean material substances, therefore they exclude such agents as heat, light and electricity. All medicines are drugs, but all drugs are not medicines. 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. The following definitions show the essential difference in the meaning of the terms. 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. 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. A poisonous 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 quite inclusive, 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. 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 former were found to possess com- paratively slight medicinal value while in their simple form, and except (21) 22 DENTAL MATERIA MEDIC A for their power of chemical combination would have remained of little use. Their great value, therefore, depends upon the large number of useful combinations which they form. To illustrate : Mercury or quick- silver in its pure form is insoluble and non-medicinal, but combined with chlorine in a certain proportion it yields calomel, a valuable cathartic, and in another proportion it yields corrosive sublimate, a powerful anti- septic; again, it may be combined with sulphur to produce a valuable red coloring agent known as vermilion. And the almost endless variety of actual and possible combinations among the seventy-five chemical elements now known, provides a field from which" we draw the great majority of agents used in dentistry, with a limitless future as to new compounds. Much of both scientific and commercial activity 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 reproduced synthetically in the laboratory. Of such, salicylic acid and artificial oil of wintergreen furnish examples. The substances of the latter group mentioned above, the organic drugs, present a contrast to these, not only in being valuable in their original form, but as lending 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 sub- stances of medicinal value. These are called constituents 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. A great deal of the 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 prin- ciple is found to represent the drug fully it is commonly used in its stead. The classes of chemical medicines, therefore, will comprise chiefly the simple chemical elements and their many combinations, while those of organic medicines will comprise the crude substances of vegetable and animal orgin and their isolated active principles. Nearly all of the organic and many chemical drugs are not in proper form for administration without further preparation, hence we include DRUGS AND MEDICINES 23 with them 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 preparation, 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 suitable form, in definite strength, and in a permanent or stable condition. Occa- sionally chemical action is employed, but the larger number are produced without any chemical change occurring in the ingredients. The prep- arations produced without chemical action are known as galenical preparations, being so named after the ancient physician Galen. The need of standards of strength for these drugs and their prepara- tions has long been apparent from the observed variability in their action. The amount of active principle present seemed to present 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. This feature has been developed in the Pharmacopoeia to such an extent that the book now includes methods of assay for nearly fifty different drugs, besides many of their preparations. This contributes very much to definiteness and insures greater reliability and accuracy in the use of our most important medicines. Among all of the classes, the fiuidextracts 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 uniform, definite strength, and to keep indefinitely. The tinctures may be regarded as second 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. Plasters, liniments and ointments illustrate the adaptation of drugs to external uses. The various preparations are presented in the following 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. 24 DENTAL Materia medIcA CLASSES OF OFFICIAL PREPARATIONS. Acetum. A Vinegar. A solution of a medicinal substance in diluted acetic acid. Vinegars have an acid reaction. Acetum opii (10 per cent.). Acetum scillse. Aqua. A Medicated Water. A solution of a volatile substance in water. *Aqua ammonise (10 per cent.). Aqua cinnamomi. *Aqua ammonise fortior (28 per cent.). *Aqua creosoti (0.70 per cent.). *Aqua amygdalae amarse. *Aqua hydrogenii dioxidi (3 per cent.). Aqua anisi. Aqua menthse piperitse. Aqua aurantii florum. Aqua menthse viridis. Aqua aurantii florum fortior. Aqua rosse. Aqua camphorse. Aqua rosse fortior. *Aqua chloroformi (0.5 per cent.). 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 plumbi subacetatis. Ceratum camphorse. Ceratum resinse. Ceratum cantharidis (32 per cent.). Ceratum resinse compositum. Cerates are used only for local medication or protection. Charta. A Medicated Paper. A paper medicated either by absorp- tion or by adhesion to its surface. Charta potassi nitratis. (Not official. Used as a fumigation by burning.) Charta sinapis. (Used as a counterirritant. In efi^ect it is the equivalent of a mustard plaster and much more convenient.) CoUodium. A Collodion. A liquid preparation for external use, having as a basis a solution of guncotton in a mixture of ether and alcohol. CoUodium. CoUodium cantharidatum. CoUodium stypticum (20 per cent, tan- CoUodium flexile. nicacid). Collodia are employed to protect or to constrict tissue, or to apply an astringent or 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. DRUGS AND MEDICINES 25 Decoctum. A Decoction. A liquid preparation made by boiling a vegetable drug in water. Not used where active principle is volatile. 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 ad ju vans ' Elixir ferri, quininae et strychninse phos- Elixir aromaticum, phatum. Some elixirs are used only as vehicles, their alcoholic character per- mitting the addition of fluidextracts without precipitation. The National Formulary contains the formulas of a large number of elixirs for the ad- ministration of drugs of unpleasant taste. Emplastrum. A Plaster. A solid preparation for external use, adhesive at the temperature of the body. Emplastrum adhsesivum. Emplastrum opii. Emplastrum belladonnae. Emplastrum plumbi. Emplastrum capsici. Emplastrum resinse. Emplastrum hydrargyrl. Emplastrum saponis. *Emplastrum ichthyocollae. 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 resin- ous 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. 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 by rubbing up the drug with water without adding anything else. Emulsum amygdalae. Emulsum olei morrhuse cum hypophos- Emulsum asafcetidse (4 per cent.). phitibus. Emulsum chloroformi (4 per cent.). Emulsum olei terebinthinse Emulsum olei morrhuse (cod-liver oil). Emulsion of cod-liver oil is largely used, two official formulas being given; the National Formulary also furnishes a number, also one for castor oil. * Court-plaster, an exception to the rule, is applied with moisture. (Not official.) 26 DENTAL MATERIA MEDtCA Extractum. An Extract. A solid or semisolid concentrated prepara- tion of the soluble constituents of a drug. Extractum aloes. Extractum hyoscyami. Extractum belladonnse foliorum. Extractum kramerise. Extractum cannabis indicae. Extractum malti. Extractum colchici cormi. Extractum nucis vomicse. Extractum colocynthidis. Extractum opii. Extractum colocynthidis compositum Extractum physostigmatis. Extractum digitalis. Extractum rhamni purshianse. Extractum ergotse. Extractum quassise. Extractum gentiange. Extractum rhei. Extractum glycyrrhizse. Extractum scopolse. Extractum glycyrrhizse purum. Extractum stramonii. Extractum hsematoxyli. Extractum taraxaci. 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. Fluidextractum. A Fluidextract. An alcoholic or hydroalcoholic solution, one cubic centimeter of which represents one gram of the crude drug. [Acids or alkalies are sometimes used to aid in the extraction of the principles.] Flui dextraetum Flui dextraetum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum aconiti. aurantii amari. belladonnge radicis. berberidis. buchu. calumbse. cannabis indicse. cinchonse. cocse. convallarise. digitalis. ergotse. frangulse. gentianse. glycyrrhizae. guaranse. hamamelidis foliorum. Hydrastis. hyoscyami. ipecacuanhas. Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum aromaticum. Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum Fluidextractum kramerise. nucis vomicse. pilocarpi, pruni virginianse. quassias. rhamni pursliianse. rhamni purshianae rhei. rubi. sarsaparillse. scillse. scopolse. senegse. sennse. stramonii. uvse ursi. Valerianae. veratri. zingiberis. Fluidextracts constitute the largest and most representative class of preparations, there being 85 oflBcial. Their drug strength is uniformly 100 per cent. DRUGS AND MEDICINES 27 Glyceritum. A Glycerite. A solution of a medicinal substance in glycerin. Glyceritum acidi tannici (20 per cent.). Glyceritum hydrastis (100 per cent.). Glyceritum amyli (10 per cent.). Glyceritum ferri, quininge et strychninse Glyceritum boroglycerini (31 per cent. phosphatum. of boric acid). *Glyceritum phenolis (20 per cent.). Infusum. An Infusion. A liquid preparation made by macerating a vegetable drug in hot or cold water. Infusum digitalis. Infusum sennfe compositum. Infusum pruni virginianse. 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 ammonia. Linimentum chloroformi (-30 per cent.). Linimentum belladonnse. Linimentum saponis. Linimentum calcis. Carron oil. Linimentum saponis mollis. Linimentum camphorte. Camphor- f Linimentum terebinthinaj (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 obtam the desired product.] Liquor ammonii acetatis. Liquor iodi compositus (5 per cent. Liquor antisepticus. iodine). Liquor arseni et hydrargyri iodidi. Liquor magnesii citratis. Liquor arseni trioxidi (1 per cent.). Liquor plumbi subacetatis. Liquor calcis. Lime-water. Liquor plumbi subacetatis dilutus. Liquor chlori compositus (0.4 per cent Liquor potassii arsenitis. chlorine). Liquor potassii citratis. Liquor cresolis compositus. Liquor potassii hydroxidi (.5 per cent.). Liquor ferri chloridi. Liquor sodse chlorinatse (2.4 per cent. Liquor ferri et ammonii acetatis. chlorine). Liquor ferri subsulphatis. Monsel's Liquor sodii arsenatis. solution. Liquor sodii hydroxidi (5 per cent.). Liquor ferri tersulphatis. Liquor sodii silicatis (not official). Liquor formaldehydi. Liquor zinci chloridi (.50 per cent.). Liquor hydrargyri nitratis. * Formerly glyceritum acidi carbolici. t Linimentum terebinthina; (turpentine liniment) may be semisolid. ^S DENTAL MATERIA MEDIC A Massa. A Mass. A mixture of substances of the proper consistence to be made into pills. Massa ferri carbonatis. Massa hydrargyri. Blue fill (33 per cent, mercury). Mistura. A Mixture. An aqueous liquid preparation usually hold- ing some insoluble matter in suspension. Mistura cretse. Mistura glycyrrhizse comp. Brown mix- Mistura ferri composita. ture. Mistura rhei et sodse. Mucilago. A Mucilage. A solution of a gum or vegetable mucilage in water. Mucilages are used as demulcents, or as excipients in various preparations. Mucilago acacise (34 per cent.). Mucilago tragacanthae. Mucilago sassafras medullse. Mucilago ulmi. Oleatum. An Oleate. A solution of a medicinal substance in oleic acid. Oleic acid here contributes a superior penetrating quality. Oleatum atropinse (2 per cent.). Oleatum quininse (25 per cent.). Oleatum cocainse (5 per cent.). Oleatum veratrinse (2 per cent.). Oleatum hydrargyri (25 per cent, yel- low oxide). Oleoresina. An Oleoresin. A 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 lupulini. Oleoresina capsici. Oleoresina piperis. Oleoresina cubebse. Oleoresina zingiberis. The term also applies to certain natural products, consisting of mix- tures of oil and resin, which occur as exudates from the trees containing them. These may be liquid or solid. Examples are: Copaiba (liquid). Terebinthina (solid). Oleum. An Oil. A natural compound of one or more of the fatty acids with glycerin. True oils and fats must be capable of saponifica- tion, i. e., forming a soap when treated with an alkali. They vary in consistence and in melting point, chiefly on account of the varying pro- portions 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. DRUGS AND MEDICINES 29 The solid fats are: Adeps. Lard. Oleum theobromatis. Adeps lanse. Lanolin. Sevum prseparatum. 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 by dis- tillation. 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. Oleum sethereum. Oleum juniperi. *01eum amygdalae amarse (bitter almond). Oleum lavandulse florum. Oleum anisi (anise.) Oleum limonis (lemon). Oleum aurantii corticis (orange-peel). Oleum menthae piperitse (peppermint). f Oleum aurantii florum (orange flowers). Oleum menthse, viridis (spearmint). fOleum bergamottse (bergamot). Oleum myristicse (nutmeg). Oleum betulse (sweet birch). Oleum picis liquidse (wood tar). Oleum cajuputi. Oleum pimentse (allspice). Oleum cari (caraway). Oleum rosge. Oleum caryophylli (cloves). Oleum sassafras. Oleum cinnamomi. *01eum sinapis volatile (mustard). Oleum eucalypti (contains eucalyptol). Oleum tercbinthinse (turpentine). Oleum gaultherise (winter green). Oleum thymi. PiMa. 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 iodidi. Pilulse aloes et ferri. Pilxilse laxativse compositse. Pilulse asafoetidse (gr. 3 in each). Pilulse opii (gr. 1 in each). Pilulse catharticse compositse (gr. 1 Pilulse phosphori (gr. y^o in each) . of calomel included in each pill). Pilulse podophylli, belladonnse et capsici. Pilulse catharticse vegetabiles. Pilulse rhei compositse. Pilulse ferri carbonatis. 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. * 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 constituents 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 ITLi (0.03 gm.), the dose of the volatile oils is TT], 1-5 (0.06-0.30 gm.). t Not ofl&cial. 30 DENTAL MATERIA MEDIC A Resina. A Resin. A solid preparation cojisisting chiefly of resinous substances. They are insoluble in water, and are usually obtained by precipitation from tinctures by the addition of water. They soften with the aid of heat. Resina. Rosin. Resina podophylli. Resina jalapse. Resina scammonii. Resins as a class are soluble in alcohol, ether, chloroform, and oils. Gum-resins are related to the above, but differ from them in compo- sition and solubility. They contain a gum associated with the resin; therefore they are only partly soluble in alcohol and are partly soluble also in water. The two most important ones are: Asafoetida. Myrrh. Balsamic Resins and Balsams also belong to the group of resinous substances, being characterized by the presence of benzoic or cinnamic acid. They include: Benzoinum. Balsamum peruvianiim. 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. Sapo mollis. 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 gaultherise (.5 per cent. oil). Spiritus setheris compositus (32.5 per *Spiritus glycerylis nitratis (1 per cent, cent.). nitroglycerin.) Spiritus setheris nitrosi. Spiritus juniperi (5 per cent. oil). Spiritus ammonise (10 per cent.). Spiritus juniperi compositus. Spiritus ammonise aromaticus. Spiritus Lavandula; (5 per cent. oil). Spiritus amygdalse amarse (1 per cent. Spiritus limonis (5 per cent, oil, lemon- volatile oil.) peel added. Not official.) Spiritus anisi (10 per cent. oil). Spiritus menthse piperitse (10 per cent. Spiritus aurantii compositus. oil). Spiritus camphorse (10 per cent.). Spiritus menthse viridis (10 per cent. oil). Spiritus chloroformi (6 per cent.). Spiritus myrcise. Bay rum (not official). Spiritus cinnamomi (10 per cent. oil). Spiritus vini gallici (46-55 per cent. Spiritus frumenti (44-55 per cent. alcohol), alcohol). * This definition is a restricted one, intended to define the official soaps. Chem- ically speaking, the salt of a fat acid with any inorganic base is a soap. DRUGS AND MEDICINES 31 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 45 grains (grams 1 to 3). 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 sodium 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.) 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 — preserv^ation and pleasant taste — both of which are due to the large amount of sugar present. Syrupus (85 per cent, sugar). Syrupus acacise. Syrupus acidi citrici. Syrupus acidi hydrodici. Syrupus amygdalae. Syrupus aurantii. Syrupus aurantii florum. Syrupus calcii lactophosphatis. Syrupus calcis. Syrupus ferri iodidi. Syrupus ferri, quininee et strychninse phosphatum. Syrupus hypophosphitum. Syrupus hypophosphitum compositus. Syrupus ipecacuanhse. Syrupus kramerise. Syrupus lactucarii. Syrupus picis liquidse. Syrupus pruni virginianae. Syrupus rhei. Syrupus rhei aromaticus. Syrupus rosse. Syrupus rubi. Syrupus sarsaparillse compositus. Syrupus scillse. Syrupus scillae compositus. Syrupus senegse. Syrupus sennse. Syrupus tolutanus. Syrupus zingiberis. 32 DENTAL MATERIA MEDICA Tinctura. A Tincture. An alcoholic or hydroalcoliolic solution of a crude drug or of a non- volatile substance. Tinctures are weaker than fluidextracts and have no uniform strength as a class. Tinctura aconiti. Tinctura ipecacuanhse et opii (10 per Tinctura aloes et myrrhse. cent, opium). Tinctura asafoetidse. Tinctura kino. Tinctura aurantii amari. Tinctura kramerise. Tinctura aurantii dulcis. Tinctura lavandulse composita. Tinctura belladonna3 foliorum. Tinctura limonis corticis. Tinctura benzoini. Tinctura myrrhse. Tinctura benzoini composita. Tinctura nucis vomicae. Tinctura calumbse. Tinctura opii (10 per cent.). Tinctura cantharidis.. *Tinctura opii camphorata (0.4 per cent. Tinctura capsici. opium). Tinctura cardamomi composita. Tinctura opii deodorati (10 per cent.). Tinctura cinchonse. Tinctura pyrethri. Tinctura cinchonse composita. Tinctura quassise. Tinctura cinnamomi. Tinctura rhei. Tinctura digitalis. Tinctura rhei aromatica. Tinctura ferri chloridi. Tinctura scillse. Tinctura gallse. Tinctura strophanthi. Tinctura gambir composita. Tinctura tolutana. Tinctura gentianse composita. Tinctura Valerianae. *Tinctura guaiaci ammoniata. *Tinctura Valerianae ammoniata. Tinctura Hydrastis. Tinctura veratri. Tinctura hyoscyami. Tinctura zingiberis. *Tinctura iodi (7 per cent.). Iti point of number and importance tinctures hold a place second only to fluidextracts. There are 63 official, besides the following general formula : Tincturse Herbarum Recentium. Tinctures of Fresh Herbs. A general formula for these is official, directing 50 parts of the fresh herb to be macerated in 100 parts of alcohol for fourteen days. Trituratio. A Trituration. A powder consisting of a potent drug diluted and finely divided by means of sugar of milk. The U. S. P. gives a general formula for the preparation of 10 per cent, triturations. The following is the only official one named separately: Trituratio elaterini. (See remarks on tablet triturates following.) * In these some of the medicinal constituents are quite volatile. DRUGS AND MEDICINES 33 Trochiscus. A Troche or Tablet. A solid preparation in tablet form, consisting of one or more medicinal substances combined with sugar and mucilage. Trochisci (plur.) acldi tannic! (gr. Trochisci menthse piperitse (ttl I of oil 1 in each). in each). Trochisci ammonii chloridi (gr. 1^ Trochisci morphinse et ipecacuanhse in each). (gr. -^^ of morphine in each). Trochisci cubebse (n\^ f of oleoresin Trochisci potassii chloratis (gr. 2^ in in each). each). Trochisci gambir (gr. 1 in each). Trochisci santonini (gr. J in each). Trochisci glycyrrhizre et opii (gr. j^ Trochisci sodii bicarbonatis (gr. 3 in of opium in each). each). Trochisci kramerise (gr. 1 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 pleas- ant to take. A great variety of combinations are now prepared in this form, presenting a convenience of handling and of administration 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 hypodermic 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 main- tain 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 exter- nal use, having a melting point near the temperature of the body. Unguentum acidi borici (10 per cent.). Unguentum diachylon. Unguentum acidi tannici (20 per cent.). Unguentum gallse (20 per cent.). Unguentum aquse rosee. Unguentum hydrargyri (50 per cent.). Unguentum belladonnae (10 per cent. Unguentum hydrargyri dilutum (33 J extract). per cent.). 3 34 DENTAL MATERIA MEDICA Unguentum hydrargyri ammoniati (10 Unguentum potassii ioditli (10 per per cent.). cent.). Unguentum iodi (4 per cent.). Unguentum sulphuris (15 per cent.). Unguentum iodoformi 10 per cent.). Unguentum veratrinse (4 per cent.). Unguentum phenolis (3 per cent.). Unguentum zinci oxidi (20 per cent.). Unguentum picis liquidse (50 per cent.). Unguentum zinci stearatis (50 per cent.). Ointments are intended to protect, soften or medicate the skin. A few, such as unguentum hydrargyri, are used for the purpose of systemic medication by being rubbed into the skin. Vinum. A Wine. A sohition of a medicinal substance in white wine. Vinum antimonii. Vinum ferri. Vinum cocse. Vinum ipecacuanhge (10 per cent, fluid- Vinum colchici seminis. extract). Vinum ergotse. Vinum opii (10 per cent.). To these may be added the simple wines: Vinum album (sherry). Vinum rubrum (port). . (Each contains from SJ to 15 per cent, by volume of alcohol.) CONSTITUENTS OF DRUGS. 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; for every crude drug contains inert matter, while some have constituents of un- desirable action. It is important to know just which of the proximate principles are medicinally active ; and where such are capable of isolation there is evident advantage in their employment instead of the preparations of the whole drug. In the foregoing list 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. 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., DRUGS AND MEDICINES 35 opium cannot be official, nor, indeed, can it be imported, unless it con- tains 9 per cent, of morphine. Of all classes of active principles 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 most prominent members of this class are the following: Aconitine, obtained from aconite. Morphine, obtained from opivmi. Atropine, obtained from belladonna. Narcotine, obtained from opium. Caffeine, obtained from tea, coffee, Nicotine, obtained from tobacco. and guarana. Papaverine, obtained from opium. Cinchonine, obtained from cinchona. Pilocarpine, obtained from pilocarpus. Cocaine, obtained from coca. Quinine, obtained from cinchona. Codeine, obtained from opium. Sparteine, obtained from scoparius. Emetine, obtained from ipecacuanha. Strychnine, obtained from nux vomicae. Hydrastinine, obtained from hydrastis. Thebaine, obtained from opium. Hyoscyamine, obtained from hyoscy- Veratrine, obtained from asagrsea offi- amus. cinalis. Alkaloids hare a definite chemical composition. Most of them are crystallizable, although a few unimportant ones are liquid, e.g., nico- tine. As a class, we must accord them the pre-eminence 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 medi- cinal doses, and many of them are poisonous to the nervous system when given in large doses. Because of smallness of dose, ready solubility, 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. The pure alkaloids, as a rule, are nearly insoluble in water, but their basic character permits the formation of salts that are freely soluble. Therefore, almost without exception, a soluble salt of the alkaloid is used instead of the simple substance. They 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 as meconate of morphine, being combined with meconic acid; strychnine is combined in nux vomica with igasuric acid. 36 DENTAL MATERIA MEDICA 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. Thus apomorphine has been obtained from morphine, and homatropine from atropine. Some of these artificial 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. Incompatibility. In prescribing either a natural or an artificial alka- loid we must have in mind their incompatibility with certain other sub- stances, as given below: 1. With 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 incompatible with alkalies and alkaline carbonates, the mixture lead- ing to precipitation of the alkaloid. The danger here is from the de- posited 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 with any preparation containing it, the mixture resulting in a deposit of the tannate of the alkaloid. Note. — There seems 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. 3. With Metallic Salts. Certain metallic salts, especially double salts or double iodides, cause precipitation when mixed with alkaloidal solu- tions. Lugol's solution also will precipitate the salts from solution. Two other classes of chemical bodies belonging to the group of organic bases, but which are in no sense medicines, should be mentioned here because of their relation to the vegetable alkaloids. They are ptomaines, or putrefactive alkaloids, which are basic substances pro- duced by the action of bacteria upon organic matter, and leucomaines, 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 DBUGS AND MEDICINES 37 action to the vegetable alkaloids. Thus, tetanine, present in the dis- ease tetanus, produces the characteristic spasms of this disease, which resemble closely those produced by strychnine. Others are narcotic in action, bearing some resemblance to morphine or atropine, Glucosides. This class comprises those vegetable proximate prin- ciples which, when decomposed by boiling with acids or alkalies, or by 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 have neither alkaline nor acid properties. These two classes form a group, some members of which are of great value in medicine. Santonin, aloin, glycyrrhizin, 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 DEFINITIONS. 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 acquisi- tion, development, or propagation of disease, e.g., vaccination to pre- vent smallpox, and disinfection to prevent the spread of any infectious 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 correcting diseased conditions, when efficient, should be held as preferable to artificial medicinal or mechanical treatment. 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 intended to directly modify functions, or to antagonize the process of disease, or remove its results. They are known as medicines. 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. (38) REMEDIES 39 EEMEDIES Local Eemedies . General Eemedies Classification of Remedies. Local. General Depletives. Eubefacients. Vesicants. Escharotics. Demulcents. Emollients. Astringents. Hemostatics. Detergents. Antacids (alkalies). Antiseptics. Bleaching agents. Analgesics. Stimulants (tonics) Alteratives. Sedatives Antispasmodics. Eliminatives Antiseptics. Antitoxins. Digestants. Anthelmintics. Arterial stimulants Nerve stimulants Digestive stimulants. r Arterial sedatives Nerve sedatives Errhines. Sialagogues. Emetics. Expectorants. Diaphoretics. Diuretics- Cathartics. Diffusible. Cardiac. Vascular. Cerebral. Spinal. Vasomotor. Cardiac. Vascular. ' Anodynes. Hypnotics. Narcotics. Anesthetics. Antipyretics. DEFINITIONS. Local Remedies. Depletive. The class of local depletives includes the various means employed to abstract blood or serum from an inflamed or hyperemic area. Scarification, leeching and cupping are the common means. 40 DENTAL MATERIA MEDIO A Rubefacient. An agent that produces redness of the skin. Vesicant or Epispastic. An agent that produces a Ulster. 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. 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 nearly all of the vital processes. REMEDIES 41 Sedative. An agent that diminishes the acti\'ity of an organic function or process. Anodyne. An agent that reheves pain. An anodyne may depress the sensory nerve endings, or lessen the conductivity of nerve fibres, or diminish the receptivity of the brain centres. Hypnotic. An agent that induces sleep. Narcotic. An agent that produces stupor. The same agent may be anodyne in moderate dose and narcotic in large dose. Anesthetic. An agent that abolishes all sensation. Antip3n:etic. An agent that causes a reduction of the temperature in fever. Antispasmodic. An agent that relieves spasm or convulsion. There is no distinct class of antispasmodics. The term simply describes one effect of medicines that may be stimulating 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 stimu- lating 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. Digestant. An agent that aids the solution 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 are led to recognize various avenues and methods by which medicines are introduced to the system, and we will discuss them under the several headings here given. 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. 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, and we find that practically any swallowed substance that is even slightly soluble, will in time find its way into the fluids of the body. Solution and absorption 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 (42) ADMINISTRATION OF MEDICINES 43 substances that require an alkaline liquid to dissolve them may pass through the stomach unchanged. This is true of salol, which is insol- uble 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 solubility and rate of absorption. 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 w411 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 from the stomach 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 coTidition modifying the rate of absorption, that is best appreciated and most easily controlled, is the dilution of the drug by the stomach contents with which it becomes mixed and 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 six hours for complete absorption, because of its diffusion through one to two quarts 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 passes after a time into the duodenum, from which absorption con- tinues. Indeed, for all except simple solutions the small intestine is better adapted to absorption than is the stomach, but rapidity or cer- tainty of effect will be best secured by complete absorption during the shorter period of stomach activity. It follows that, in order to produce a certain degree of effect, a larger dose will be needed when given with a full stomach than if given before a meal, for the degree of effect depends usually upon the amount of 44 DENTAL MATERIA MEDIC A the drug circulating in the blood at one time. This amount will be determined by the quantity absorbed within a certain period, minus 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 morning 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 given in the morning upon arising, as a prompt effect from a smaller 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 the 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 ADMINISTRATION OF MEDICINES 45 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 high up in the colon. This can be done vi^ith a patient in the recum- bent posture, by raising the hips above the level of the head, or by introducing a flexible rubber tube to a depth beyond the sigmoid flexure and injecting through it. 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 rectum we may have a more rapid effect from the rectum. 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 centres of the site of absorption. A safe rule for most substances seems to be that the dose per rectum may be twice the dose per orem. By the Skin. We distinguish several methods of cutaneous medi- cation as follows: Epidermic, where a substance is applied to the superficial epithelium, as for the purpose of local medication or of counterirritation. When a systemic effect is desired a similar application may be made, with friction added in order to secure penetration into the skin. Thus mercurial ointment 'is very commonly employed in the treatment of syphilis. 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 employment. Also, on account of rapidity of absorption, the dose may usually be about one-half of the dose by * 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 a drug absorbed from the lower part of the rectum may pass directly into the internal iliac vein and reach the heart and general circulation with- out passing through the liver, which organ is credited with the power of lessening the toxicity of many poisonous substances. 46 DENTAL MATERIA MEDIC A the stomach. The method consists of the introduction of the medicine into the subcutaneous tissue by means of a small syringe 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 will find its place in meeting the following conditions: 1. Inability of the stomach to receive or retain the required medicine. 2. Any condition requiring the immediate action of a medicine, or absolute certainty of dosage. 3. Inability to swallow, as when unconscious, or after local injury. 4. Conditions needing local medication, as in the employment 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 injection 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 with 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 em- barrassment 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 ADMINISTRATION OF MEDICINES 47 bubbles within and cause them to rise toward the needle, and the plunger then gently forced onward until all air has escaped through the needle. The presence of a little 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 throwing 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 Syringe. 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. With either 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 with soft 48 DENTAL MATERIA MEDIC A soap and water, then sterilizing by the application of 50 to 70 per cent, alcohol, 5 per cent, solution of carbolic acid, oil of turpentine, 1 : 1000 solution of bichloride of mercury, 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 cjuickly 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 effect 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 re- duced, the injection should be made upon the trunk rather than upon the extremities — i. e., nearer the centre 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. When, however, the injection is for local analgesia the medicine is injected more super- ficially, directly into and beneath the skin or mucous membrane, the object here being to paralyze the sensory nerve endings, which are more abundant superficially. 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 hypodermic 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 duty 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 ADMINISTRATION OF MEDICINES 49 strong solution of the drug and placed directly over the part to be medi- 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, how^ever, 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 anesthetize pulps previous to immediate extraction. Further uses of cataphoresis 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 v^^ith 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 mostly used at present by this method is normal saline solution at the temperature of the blood. This is a solution of 6 parts of sodium chloride in 1000 of sterile v^^ater. It is intended to corre- spond to the blood serum in salinity, and it is used to substitute the latter v^henever deficient, as after severe hemorrhage or in collapse. Medi- cines may be added to this for intravenous use. 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 dis- ease, 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 under- neath 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 (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. 50 DENTAL MATERIA MEDIC A Although thus hmited, 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. Without this method general anesthesia would be impracticable, for it is not likely that sufficient of the anesthetic vapor could be absorbed by any other method without endangering life by the irritation that must follow the introduction of a large amount of ether or chloroform in liquid form. 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 h^ inhalation is now given an important place. CHAPTEE lY. 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 variable, 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. The simplest kind of medicinal action would seem to be one in which 'physical properties alone are concerned. Glycerin applied to a denuded surface or to a sensitive mucous membrane furnishes an example of such, its action being simply the abstraction of water from the tissues; but we must also note a secondary effect in the slight irritation which the loss of water occasions. Alcohol has a similar action, although more irritating because of its stronger affinity for water accompanied by coagulation of albuminous matter. The irritation 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 cjuantities 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 waste products are removed from the cells and in turn they receive fresh nutritive fluid from the blood. In emergency the same principle calls for the hypodermic injection of a normal saline solution in quantity, in order to supply fluid to the circulation, as after a severe hemorrhage. (51) u. 52 DENTAL MATERIA MEDIC A 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 fluids of different composition through 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 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 will pass into the bloodvessels (endosmosis). A single drug, potassium bitartrate, may illustrate both exosmosis and endosmosis : P'or if it be given in form of the salt with very httle 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 hyperisotonic and one of lower osmotic pressure being hypoisotonic. The salinity of the blood is imitated in the normal (isotonic) saline solution, containing 0.6-0.75 per cent, of sodium chloride, which is now so largely used as a restorative. Passing from the purely physical influences, we recognize also the factor of electric relations in the action of many substances. It has been ascertained that certain chemical compounds, when in dilute solution, as in the blood and tissues, are dissociated into ions of their elements or radicals and that these are charged with positive and nega- tive electricity. They do not necessarily act as the pure elements; in fact, they often exhibit entirely different properties, e. g., in the dissocia- tion 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. In the complexity of action of many of the chemical compounds, however, it is impossible to separate the physical, electric and chemical Modes oP aCtIon oP MEbiGiNEB 53 factors, but their recognition serves to explain something of drug action. The separation of the less irritating iodine ion, in the dissociation of potassium iodide, gives us the probable reason why so large amount of iodine can be taken in this combination without being poisonous. The chemical features of drug action can be very clearly demon* strated for certain substances of local use. In the tooth structure espe- cially, where the vital factors are slight, about as definite chemical reactions can be obtained as in the laboratory. The science of bleach- ing 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. In the use of simple irritants and astringents we observe some of the reactionary effects of drugs. These, secondary to the first local action, may constitute the real therapeutic effect desired. When we speak of irritation we mean a disturbance of tissue, or a reaction to a disturbance. Infiammatioii is a reaction of higher grade having, as a prominent feature, a great 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 (counterirritation) is believed to stimulate absorption by the lymphatics as well as a local increase of leukocytes. These observations emphasize the vital factor which aids in securing the therapeutic effect, or which may modify that effect, or 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 (idiosyncrasy) 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 influence 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 54 DENTAL MATERIA MEDIC A may irritate tissue primarily, inducing stimulation reflexly, or they may cause more rapid or more powerful discharges of energy in functional 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. It is well known that the blood possesses, in some degree, protective properties against certain toxic substances; and one of the important developments in therapeutics has been the discovery that the protective resources may be increased by medication of a peculiar kind, or added to artificially. The use of nuclein, which is a proteid compound with nucleic acid, obtained from animal cells or from the yeast plant, stimu- lates leukocytosis, which constitutes a valuable protective factor. Again, in some of the infectious diseases the blood reacts to the toxic products of the disease and develops an antitoxic body, which neutral- izes 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. In the event of diphtheria a quantity of antidiphtheric serum is injected hypodermically as early as possible, with the result commonly that the poison of the disease is perfectly neutralized. Antitoxins, being natural products of the blood, are harmless and may be used in strong dosage. The discovery of antitoxins may be termed a revelation of one of nature's methods of antagonizing disease, and it has opened up a large field of investigation which bids fair to yield still further therapeutic results. PART II. LOCAL REMEDIES. CHAPTER Y. DEPLETIVES. Depletive measures are those employed to abstract blood or serum from an inflamed or hyperemic area, usually with the purpose of relieving 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 hyperemia, when its continuance is likely to produce serious disturbance of tissue or function, A depletive measure need not always remove blood or serum from the body. It may draw it from the point of disease into another part. 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 passed quickly into the cup immediately before applying, is the means commonly employed to exhaust the air. The vacuum permits the skin and underlying tissue to bulge into the glass and to become con- gested with blood. In this way, with each cup nearly or quite a table- spoonful of fluid may be drawn into the skin and just beneath it. With the employment 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 con- gestion or pneumonia, and a large number of cups may be applied, and repeatedly, to the surface of the chest. The cups cannot be applied upon an irregular or a hard convex surface. Wet Cupping is accomplished by first scarifying a limited surface with an ordinary lancet, or with the especially adapted spring lancet, then applying a cup as in dry cupping. The vacuum allows a free flow (53) 56 LOCAL REMEDIES 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, and passive congestion. After scarification, 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 Steno'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. AMien 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, for the relief of acute inflammation or congestion. For use in the mouth it is not generally 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 Fig. 1 (T Leech glass. a proper size to admit the leech and allow its distention by blood. It is drawn 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 c.c). If the leech does not bite readily it may be advisable to make a puncture with a fine DEPLETIVES 57 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. The suction may be interrupted at any time by sprinkling a little salt upon the leech, when it will drop off. The bite made 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 applicable to all means of local bleeding it must be borne in mind that the hemorrhagic diathesis (hemophilia) is an absolute contraindica- tion to their employment. Venesection or Phlebotomy. General bloodletting is accomplished by opening a vein (usually the median cephalic, just above the bend of the elbow). This therapeutic measure was much abused in earlier years, and the natural reaction resulted in its almost complete aban- donment. At the present time, however, it is often employed as an emergency procedure, in cases of severe toxemia or physical embar- rassment 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. In order to find the vein readily and to secure its distention and con- sequent 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 cephahc 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 readily 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 efiicient, 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 sahnes are most commonly used. When given in concentrated solution 58 LOCAL REMEDIES (hyperisotonic, see p. 52) 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 cir- culation 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 peris- taltic action. Jalap is milder than others, and very efficient when sim- ple 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 accumulation of serum in a serous cavity, as the pleural or peritoneal, or where car- diac 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 apphed 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 epis'pastics, agents that irritate sufficiently to cause an exudate of serum beneath the epidermis (a blister). 3. Escharotics, caustics or corrosives, 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; capsicum 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., tincture of iodine by a (59) 60 LOCAL REMEDIES single application will only irritate the skin slightly, but it will quickly corrode and destroy the superficial layer of a mucous membrane. 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 vdsely observed 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 point 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 Action of Counterirritants. The remedial effect of a counter- irritant is probably brought about by a threefold action. They influ- ence, first, the circulation; by causing a hyperemia at the point of irritation, the tendency of the blood supply will be in that direction and away from the original disease; second, they turn the attention of the system toward the new point of irritation and away from the dis- ease, partly a mental effect; and third, 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 lymphatic stimulants and are often employed to stimulate the absorption of a serous or inflammatory exudate. The terms derivative and revulsive are often applied to the action of counterirritants, the latter of the two referring especially to a very decided action, as in the prompt and violent effect of croton oil as a cathartic, when 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 irou;, the thermocautery and the galvanocautery, indicate the range of methods and effects that attach to the use of heat. COUNTERIRRITAXTS 61 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. Capsicum. Cayenne Pepper. The fruit of Capsicum fastigiatum. (For preparations and doses, see Index of Drugs.) 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 drug is like\sdse recommended 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 ^dth other drugs if desired. The drug and its preparations are capable of causing irritant poison- ings if taken internally in large doses. v/Sinapis Alba. White Mustard. The seed of Sina'pis alba. Sinapis Nigra. Black ]Mustard. The seed of Brassica nigra. (For preparations and doses, see Index of Drugs.) The commercial powdered mustard is a ground mixture of white and black seed. The black is the more powerful. IMustard in a dry state is not irritating, but the black mustard seed contains two sub- stances, sinigrin and 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 tem- perature 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 or colder is the agent to use to develop the valuable constituent of the drug. Taken internally mustard is an excellent emetic, the effect being due to 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 once is a most efficient emetic. Mixed with enough water to form a paste, mustard is applied between two layers of muslin to produce quick and moderate counter- irritation, which, if prolonged, may proceed to vesication. For a con- tinued rubefacient effect, the mustard may be diluted by mixing with 62 LOCAL REMEDIES 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 (charta sinapis), in which powered black mustard, freed from fixed oil by percolation with benzin, is mixed with a solution of india- rubber, and spread upon paper. 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 quicldy. It is very convenient also for more extensive irritation upon the surface of the body. Volatile oil of mustard may be used as an irritant, by being applied pure for limited effect, or diluted with alcohol for extensive effect. Oleum Terebinthinse. Oil of Turpentine. The volatile oil distilled from turpentine. (For preparations of terebinthina and doses, see Index of Drugs.) 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 3 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 if used full strength. The official 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. COUNTERIRRITANTS 63 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 there is little use for it in that capacity in dental practice at the present time. 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 ozonized oil, the old, French oil being most valuable = Fresh oil of turpentine will dissolve phosphorus and must, therefore, be avoided. Incom'patihility . Oil of turpentine will react violently with bromine or powdered iodine, and in contact with a mixture of nitric and sul- phuric acids it will ignite. lodum. Iodine. [L] A solid non-metallic element, found in sea-weeds and in natural mineral compounds, its chief commercial source being sodium iodate, obtained in Chili. (For preparations and doses, see Index of Drugs.) Pure iodine occurs in bluish-black, rhombic plates, having a penetrat- ing odor and sharp taste. It is slowly volatile, soluble in 10 parts of alcohol, and freely in ether; also soluble in an aqueous solution of potassium iodide and in glycerin, although nearly insoluble in water.* These solutions are brown in color, while chloroform and carbon disulphide each dissolve it with a violet color. Iodine in the form of the tincture (7 per cent.) is an irritant of great value, as applied 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 some- what. In common with other irritants it has the power to stimulate absorption by the lymphatics, which is regarded as a valuable part of its local action. The great advantages possessed by the tincture are * Iodine is soluble in about 5000 parts of water by weight. According to the U. S. Dispensatory, eighteenth edition, its solubiHty in water may be increased, not only by potassium iodide, but by sodium chloride, amrhonium nitrate and, to some degree, by tannic acid. g4 LOCAL REMEDIES promptness and limitation of its action. The alcohol coagulates 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 (N, F.),* which is much stronger than the official tincture, is used by some. It contains 16.5 per cent, of iodine and 3.3 per cent, of potassium iodide to aid its solution. It 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 seda- tive, f 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. As an antiseptic and disinfectant, iodine is very efficient. It may be applied in strong solution to ulcers, but is quite painful. For cleans- ing abscess cavities the tincture or the compound solution may be used somewhat diluted, either applied upon cotton or injected care- fully. 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). * This differs from Churrhiirs iodine caustic {Liquor lodi Causticus, N. F.), which has the following formula: -M. -:m. Note. — Boulton's solution {Liquor lodi Carholatus, 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 c.c. R. — Tincturte iodi compositse, 151 Phenolis (liquefied by heat), 55 Glycerini, 165; AquE3e, q. s. ad 1000 — M. Expose to sunlight until it has become colorless. Gm. or c.c. R .—lodi, 25 Potassii iodidi, 50 AquEe, 100 J A very useful formula is: R. — Tincturse iodi, Tincturae aconiti, aa fsij (Gm. 60) Chloroformi, f3j (Gm. 4) CO UNTERIBBITANTS 65 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 % 2. Compoiind solution of iodine, 5 % (Lugol's solution).* 3. Equal parts of tincture of iodine and tinc- ture of aconite. Comparative action upon mucous membrane. Mixed witii albumin. Most severe irritant; cor- rodes mucous mem- brane superficially and promptly. Moderate irritant; does not corrode. Moderate irritant ; cor- rodes more slowly than tincture of iodine alone, and sometimes only after several applica- tions. Immediate coagulation due chiefly to the alcohol present. Coagulation slight, slowly produced. and Immediate coagulation due chiefly to the alcohol present. The tincture may be combined with carbolic acid, which, \\dth 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 "wdll combine disinfectant, irritant and, indirectly, stimulant properties. When properly diluted the carbolic acid may contribute a local seda- tive effect. Water can be used to dilute the official tincture, as the formula now includes 5 per cent, of potassium iodide, which will hold the iodine in solution. Therefore, water can be added in any proportion without precipitation of iodine, which is a great advantage in some of the uses of the tincture. Iodine has a reputation as a stimulant to absorption by the lymphatics, in common with almost all counterirritants and altera- tives, with the advantage that it belongs to both of these classes. To influence the absorption of indolent swellings or to reduce enlarged lymph nodes, either the tincture or Lugol's solution may be applied (the tincture possessing the very great advantage of drying quickly), * The formula of Lugol's solution, Liquor lodi Compositus, is: I^.— lodi, Gm. 5 Potassii iodidi, 10 Aquae destillatse, q. s. ad 100| — M. The potassium iodide is needed to hold the iodine in solution. 5 66 LOCAL REMEDIES although after a number of appKcations the skin becomes blistered 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 that 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, pre- ferably in the form of starch paste. This should be given freely. Incompatibility. Free iodine is incompatible with starch, forming the blue iodized starch; with oil of turpentine, 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. Croton 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. 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 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 c.c.) having caused death. In the usual dose of one-half to two minims (0.03-0.12 gm.) it irritates the intestinal tract, producing purging in from one-half to two hours. On account of its prompt action it is often given for revulsive effect in cases of * Tinctura lodi Decolorata (N. F.) is prepared with the aid of sodium hyposul- phite 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. COUNTERIRRITANTS 67 cerebral hemorrhage or inflammation, and in uremic poisoning. Care must be taken in handling croton oil, and it should never be tasted. Cantharis. Cantharides. (Spanish Flies.) The dried insect, Can- tharis vesicatoria. Obtained in various European countries, the large Russian flies being preferred. (For preparations and doses, see Index of Drugs.) As a counterirritant, cantharis is used in the form of the cerate, applied as a plaster to the skin, 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 giving 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 skin should be oiled before applying, to ensure activity of the irritant principle can- tharidin, which is soluble in oils. The cantharidal collodion may be used instead of the cerate for ordinary application. It is believed to be safer, and it is much more convenient. 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 genitourinary 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. Oreosotum. Creosote. A mixture of phenols obtained by the distillation of wood-tar, preferably from beech wood. Creosote is irritant rather than corrosive. Formerly it was not easily obtained pure in commerce, having been commonly adulterated with carbolic acid. It, therefore, usually possessed the qualities of that substance. At the present time it is produced more extensively, and pure creosote can easily be had. It is less poisonous than was formerly supposed, and can be taken internally in quite large quantities if well diluted (as much as 1 fluidrachm (4 c.c.) daily has been administered). Applied to the mucous membrane in full strength, it is very irritating, but gg LOCAL REMEDIES not strictly corrosive. Mixed with egg albumin it does coagulate slightly, but more slowly than does carbolic acid. It may be applied to the gum to counteract a pulpitis or other localized inflammation, but it is far inferior to iodine or carbolic acid for this purpose. It is used chiefly as an antiseptic, and it will, therefore, be more fully discussed under that heading. Chloroformum. Chloroform. This drug is discussed fully in the chapter on anesthetics, but it is mentioned here on account of its irritant local action. This action is secured best when the vapor is confined. 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 applying it closely to the skin for five or 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 onlv 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 f^rst 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. 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 inter- ference. It is only in case of septic or unhealthy conditions that fre- quent 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 appli- cation 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 * JAnimentum calcis, composed of equal parts of linseed oil and lime-water. COUNTERIRBITANTS 69 an objection to its use is the fact that the drying of the linseed oil con- tained 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.* 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. * 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. 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 powerful 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 cor- rode deeply because the firm coagulura 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. The affinities noted suggest the antidotes in case of poisoning by each. The antidote to carbolic acid will be albumin, that to caustic potash a dilute acid, etc. 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. (70) ESCHAROTICS 71 Mineral Acids. Acidum Hydrochloricum. Hydrochloric Acid. (Muriatic Acid.) Contains 31.9 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 92.5 per cent., by weight, of absolute sulphuric acid [HgSOJ. AppHed to living tissue mi neral acid s all c oagulate albumi n, but nitric acid more firmly than the others.* Sulphuri c aci d 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 appli- cations 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. Empl oying in dent al practice the solvent power of these acids upon mineral salt s, 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 dentine. 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. Sulphuric ^'^ acid in 50 per cent, strength is mostly employed. Internally mineral acids are employed only in diluted form. They are further discussed under the heading of Restorative Tonics. * See Experiment, previous page. 72 LOCAL REMEDIES 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 sub- stance, and great care must be exercised to guard against poison- ing. 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 cp.se 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, jirst, that the corrosive action depends chiefly upon the concentration of the acid; and, second, that the affinities of the whole group are so nearly identical that the same antidotal treat- ment will apply to all. The first and most important thing to do is to diluteJhe^^KiisonJreelx^byJargejd^^ 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 necessary for its preparation, during which serious damage is being done by the corrosive poison if undiluted. But after free dilution the chemi cal antidote should be given, so as to completely neutralize the poison. An alkali will be selected, diluted if at all irritating, and given freely. Lime- water a nd magnesia are preferred to a carbonate, because the latter will, in reac- tion 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. I..ater 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 upon immediate treatment, as outlined. Organic Acids. Acidum Aceticum Glaciale. Glacial Acetic Acid [HC2H3O2]. Nearly or quite absolute acetic acid. It is liquid or crystalline, accord- ing to the external temperature, its melting point being a little below 60° F. It is colorless, and has a strong vinegar-like odor and a sharp acid taste. It is not a coagulant, but, on the contrary, is a solvent of ESCHAROTICS i6 albuminous and fibrous tissue. It is employed only as a caustic and to sof ten callous t issue. Acidum Trichloraceticum. Trichloracetic Acid [CjHClsOJ. Ob- tained by treating chloral hydrate with three times its volume of fuming nitric acid and subsequent exposure to sunlight and distillation, it occurs in colorless crystals that are very deliquescent. Either in crystals or strong solution it is used as a caustic t o remove redundant tis sue, 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 solv ent po wer up on the calcareous depos its. It is also used to obtund- Sensitive denti ne. Acidum Lacticum. Lactic Acid. A colorless, syrupy liquid com- posed of 75 per cent., by weight, of absolute lactic acid [IIC3H5O3] and 25 per cent, of water. 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 exu- dates, as in diphtheria, a 20 per cent, solution being applied. A solu- tion of 20 to 50 per cent, is used in the treatme nt of pyor rhea alveolaris to soften remnants of calculary 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- 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 Phar- macopoeia directs that it should be kept in strong, glass-stoppered bottles, not completely filled, in a cool place. The bottle should be opened cautiously with 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 74 LOCAL EEMEDLES accidental swallowing of this caustic, the symptom of irritation of the respiratory tract, with dyspnoea, will be prominent. This will call for a volatile antidote in addition to the free dilution of the poison by water. The proper an tidote w ill 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 albtimin. 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 Hydrate [KOH]. So per cent, at least. Sodii Hydroxidum. Caustic Soda. Soda. Sodium Hydrate [XaOH]. 90 per cent, at least. Potassa and soda are the only ones used in dental practice, and these very seldom. They are prepared in form of sticks, which deliquesce readily and must, therefore, be kept in tightly-corked bottles, and must not be handled ^^-ithout protection of the fingers. Their affinities are for water and acids. They do not coagulate albumin, therefore 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 neutrahzed 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 dihition is any dil ute ac id, giving preference to the less irritating vegetable acids, such a s^ vinegar an d lemon juice. (See Table of Poisons and Antidotes.) "\Miile only the strong alkalies are classed as escharotics, even the dilute solutions known as liquor potassii hydroxidi and liquor sodii hydroxidi ( about 6 per cent.) are decidedlv caustic and irritating to mucous membranes. As an alkali, soda is slightly stronger than potassa. Both are powerful saponifiers. ^ Unclassified Escharotics. Phenol. Caebolic Acid [CrjHoOH]. A crystalline product of distil- lation of coal-tar. (For preparations, see Index of Drugs.) The internal dose is i to 2 grains (gni. .03-.12i well diluted. Phenol Liquefactum. Liquefied Phexol. S6.4 per cent. ESCHAROTICS 75 [Crude phenol 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, sweet- ish odor, soluble in about 20 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 per- manent liquid form may be secured by the addition of 5 to 10 per cent, of water or glycerin. By exposure the liquefied drug 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 ofl^ the portion remaining liquid. In dentistry phenol is used more frequently than any other drug. 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 quickly and firmly, thus limiting penetration beyond the superficial layer of tissue. f Its analgesic effect, combined with a superficial but decided corrosive action, makes it an ideal caustic for limited application to a mucous membrane. Extensive application might, indeed, cause inflammation and symptoms of poisoning, 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 with tissues, the effect may be mitigated by the immediate ap- plication 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, with the results that any septic process present will be * United States Dispensatory, eighteenth edition, p. 37. "j" Experiment. To show the effect of phenol upon mucous membrane and tlae restorative effect of alcohol: Evert the lower lip 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. Note the difference in the two points after a few minutes. Also observe the results next day. 76 LOCAL REMEDIES antagonized, and the coagulum formed will protect exposed nerve end- ings. Thus applied to canker sores, it will relieve the pain for a con- siderable time and check the bacterial activity. The sore should first be 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 slower effect occurs from repeated applications, without the pain that may attend the use of arsenic and without any danger of systemic disturbance. As a counterirritant in pericementitis it may be applied to the gum in the place of, or combined with, a solution of iodine. Also for dis- infecting 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. Indeed, it is one of the very safest drugs to use in proximity to the pulp or to apply to an ex- posure, because of its analgesic action and its superficial effect. It is therefore made use of to lessen the pain of an exposed or irritated pulp and to obtund sensitive dentine. It has been used to lessen the sensi- tiveness of the gums in order to apply a rubber-dam ligature far beyond the gum margin. But for this, as for nearly every purpose as an anal- gesic, 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 power of this drug is very great, as the recently numerous deaths by suicide show. The symp- toms 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 power in coagulation. It must be given early to be of use. It is a true chemical antidote. Alcohol seems to act ESOHAROTWS 77 upon the corroded tissue, lessening the destruction that would follow, its action probably 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 carbolic 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 post-mortem. Corresponding to this action the urine in phenol poisoning often shows an olive-green or dark color. To counteract 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. 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 tissues. Used chiefly as a disinfectant canal dressing and as an obtundent. Liquor sodii carbolatis contains 50 per cent, phenol (see formula, p. 124). It is somewhat caustic if used in full strength. It provides a strongly alkaline application for limited use as a disinfectant. * See Experiment, p. 75 (note). f In the Philadelphia Medical Times, vol. xi., p. 284, Taylor records a case in which a man, who was supposed to have swallowed about one ounce of carbolic 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 where equal parts of carbolic acid and sweet oil, applied 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 application. Death has followed the application to the skin of half an ounce of carbolic acid in watery solution, for the purpose of destroying parasites. — Wood's Therapeutics, eleventh edition, p. 563. 78 LOCAL REMEDIES Chloral-phenol, prepared by triturating together with heat, 1 part chloral hydrate and 3 parts phenoL The product is an oily liquid which is 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 counier- irritant. Argenti Nitras. Nitrate of Silver [AgNOg]. Argenti Nitras Fusus. ^Moulded Nitrate of Silver. Lunar Caustic. Moulded sticks containing about 95 per cent, of silver nitrate. Argenti Nitras Mitigatus. Diluted Nitrate of Silver. Mitigated Caustic. ^Moulded sticks consisting of 1 part silver nitrate and 2 parts potassium nitrate. (For solubility and doses, see Index of Drugs.) 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 0.54 part and in 24 parts of alcohol. This drug in any form or strength of solution turns dark upon ex- posure 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 worn 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 for some time, but the effect is quite superficial because of the coagulum 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 in- fected tissue, and it, moreover, by coagulating the surface, checks hemor- rhage 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. ESCHAEOTICS 79 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 in- visible surfaces, where it is desired to have the irritation pronounced or productive of a secondary stimulation of the local circulation. Ac- cording 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 solu- tion of 1 to 10 per cent, strength, the weaker solutions being astringent rather than caustic. It is frequently applied to abort acute inflammations and as a stimulating caustic to indolent ulcers. In dental practice silver nitrate is used to check caries in temporary teeth, where filling is impracticable. It was first 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 millimeter (Jg- of an inch) into the dentine. 2. The albumin unites with the metallic salt in form of a precipitate. 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 saturated aqueous solution, at the point of decay. The fused stick may be em- ployed, or some of the crystal may be melted upon a heated platinum point and carried to the tooth, as recommended by Craven; or a silver ^ire dipped in nitric acid may be used. Holmes* advises, for approxi- mal 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. 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 under Antiseptics. Incompatibility. With albuminous matter coagulation occurs; with hydrocliloric acid, soluble cJilorides, or chlorine solutions, a precipitate of chloride of silver occurs; in contact with most metals it is reduced to metallic silver; an ac[ueous 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 with it the insoluble chloride of * Pental Cosmos, 1892, p. 982. 80 LOCAL REMEDIES 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 [A1K(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. Bromum. Bromine. [Br.] A heavy brown liquid, which evolves a brownish, very irritating vapor at ordinary temperature. It is seldom used as a caustic, but is very penetrating, and efficient to cleanse foul ulcers or check gangrene. On account of the irritating fumes, it must be handled under water when removed from the bottle. (See Table of Poisons and Antidotes.) Cupri Sulphas. Sulphate of Copper. Blue Vitriol [CuSO^ + 511^3]. As a mild caustic the pure crystal may be applied 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 Table of Poisons and Anti- dotes.) Pyrogallol. Pyrogallic Acid [CgH3(OH)3]. Obtained by dry dis- tillation of gallic acid. Occurs in white crystals, becoming darker upon exposure to air and light, very soluble in water and in alcohol. This substance chemically is not an acid. It has a strong affinity for oxygen, which explains its caustic action. Its aqueous solution at first is colorless and neutral, but, by exposure to the air, becomes brown- ish in color and acid in reaction from the absorption of oxygen. It will stain the skin temporarily and fabrics permanently. Death has occurred from its absorption through the skin. It is used chiefly in form of an ointment in diseases of the skin. Chromii Trioxidum. Chromic Anhydride. Chromic Acid [CrOg]. It occurs in purplish-red crystals, which are soluble and deliquescent, ESCHAROTICS 81 forming chromic acid. It is an energetic caustic, but rarely used. To remove small tumors and to lessen hypertrophy of erectile tissue covering the turbinated bones, it may be applied cautiously. It may be used to allay sensitiveness of dentine in very shallow ca\aties. It should not be mixed with other substances. With sugar, alcohol, tannic acid, ether, glycerin and other organic substances it may decompose with violence. Zinci Chloridum. Chloride of Zinc [ZnCl2]. (For zinc preparations, see Index of Drugs.) This substance occurs in white powder, or in irregular masses or fused sticks, all of which are intensely caustic and dangerous to taste, 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 penetrat- ing coagulant agent 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 affinity for water and its coagulant power, to which is added the irritant influence 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 case of recession or pyorrhea. The following is recommended when the aqueous solution proves very painful:* Gm. or c.c. R .—Zinci chloridi, 2 60 (gr. xl). Alcoholis, Chloroformi, aa ISl (f^ss). — M. (Hofheinz.) * Dental Cosmos, 1903, p. 31. 6 82 LOCAL REMEDIES 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. 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 potassium carbonate. (See Table of Poisons and Antidotes.) Incompatibility. The drug is incompatible with the antidotes men- tioned above and with nitrate 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 [AsjOg]. (For preparations and doses, see Index of Drugs.) Following the U. S. P. description, arsenic is "a heavy solid, occurring either as an opaque white powder, or in irregular masses of two varieties : one amorphous, transparent and colorless, like glass; the other crystal- line, 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 five 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; ESCHAROTICS 83 therefore, it is not escharotic by reason of any apparent chemical action. It stands by itself as a vital or alterative escharotic, 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 limited 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 7iot 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 applica- tion or to mitigate its action. The medicinal solutions officially prepared from it are all for internal use, to secure the general tonic and alterative effects of the drug. There- fore, when we speak of applying arsenic locally we mean always arsenic trioxide in powder form or in mixture. (See Index of Drugs.) 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 said to-day, after more than half a century of experience v^th 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 corre- sponding 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 carefully 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 foramen, a septic inflammation could not be expected from the action of the arsenic. Careful use of the drug implies, first, isolation of the tooth to be treated, by applying the rubber dam; second, the use of a small amount 84 LOCAL REMEDIES of the drug; third, careful sealing-in during the period of its action, and fourth, its thorough removal after devitalization is complete. Hofheinz formulates the follov^'ing 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. 5. Exert no pressure upon the pulp. 6. Never crowd it into root canals. 7. Take special care of the gum tissues if the ca^'ity 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 -g^g- to -YQ of a grain, which need never be exceeded for this use; according to ^Miller from yw *o yj i^ sufficient. It should be impressed upon the mind of the practitioner that any untoward effects, that may follow his emplo^Tuent of arsenic in a tooth, will be purely local and the result of either want 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 ^dews 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, which, ^xiih 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 capillary paralysis in the fact that intravenous injections 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 s^inptoms and the appearance of the discharges are almost identical 'w'ith those of cholera, and the destruc- tion of tissue found after death is regarded as due to degeneration and * Sollmann's Pharmacology, 1901. ESCHAROTICS 85 not to any direct action of the poison.) Regarding changes in the blood opinions differ, but Silberman* asserts that arsenic tends to cause intra- vascular coagulation, and the experiments of Heinzf 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 Schultz]}; is to the effect that arsenous acid is oxidized to arsenic acid by living tissue and the arsenic acid is again reduced to arsenous. This alternate with- drawal 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 factor of increased pressure, due to the intense hyperemia, and leading to stoppage of the circulation by strangulation of vessels or by thrombosis, is believed to contribute largely to the destructive 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 destroyed, 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 preferred 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, third edition, p. 615. t Ibid. t Ibid., p. 619. I 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. 36 LOCAL REMEDIES strong coagulant, such as carbolic acid, by coagulating the surface of the pulp where the application is made, will tend to hinder penetration of the arsenic, on which account it is inferior to a volatile oil. Some- times cotton fibre is incorporated with the paste, and being then dried is known as "devitalizing fibre."* To lessen the pain of de^^talization 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 kno^vn 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 dis- regarded. Any quantity not exceeding one-quarter of a grain may be regarded as safe to use. Substitutes for this drug are eucaine hydro- chloride and orthoform, either 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 experience ^^Ai\l 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 agents that paralyze the terminals of the sensory nerve, or at the centres of appreciation of painful sensation in the brain, by agents that depress or benumb those centres. 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 centrally upon the centres for painful sensation. Agents that act locally as anodynes have little or no central effect in ordinary doses, and, conversely, agents that relieve pain by depressing brain centres 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 * One formula for preparing devitalizing fibre contains: R . — Arseni trioxidi, gr. v (Gm. 0.30) Acidi tannic!, gr. ij (Gm. 0.12) Morphinse acetatis, gr. x (Gm. 0.60) Acidi carbolici, q. s. M. Make into a thin paste and mix with fine cross-cut cotton fibre, drv it, and separate into small pieces for convenient application. — Gorgas' Dental Medicine, fifth edition, p. 180. This formula may be variously modified, but especially in the substitution of cocaine for morphine, as the latter has almost no local action. ESCHAROTICS ' 87 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 sufficient 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. f The volatile oils, thymol, iodoform and carbolic acid are all feebly analgesic, but inferior to cocaine, while iodoform 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 vidll cause, after some hours, local irritation leading to engorgement of the gum, which will be followed 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 ^dtality 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 and washing away of any particles of the drug that may remain undissolved, by injecting a stream of water between tooth and gum, which should be separated for the purpose. As a rule, when the patient presents with these symptoms 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 hydrate| will neutralize it wherever accessible. The latter may be packed about the teeth and beneath the gum margin; or it has been suggested that if the cavity be near the gum the latter may be treated freely with the * Harris' 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 liniments are rubbed into the skin over it, but as a matter of fact, morphine seems entirely devoid of any such local action." Sollmann, 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 irrational." X See Table of Poisons and Antidotes. 88 LOCAL REMEDIES antidote before using the arsenic. Dialyzed iron has been recommended, but it is inferior to fresh ferric hydrate. Tincture of iodine is beUeved by some to be a useful apphcation, 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. Scarification 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 mth gastrointestinal irritation. There is in most cases sufficient time to administer an antidote and empty the stomach if the mistake of dosage is discovered at once. An ordinary 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 alum or common salt with a little water, or one-third of a teaspoonful of sulphate of zinc); meantime the antidote should be pre- pared and given. (See Table of Poisons and iVntidotes.) Cobalt (not official). "\'Miile 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. Atoxyl. Arsenic-acid Anilide (not official). This new compound contains 37.7 per cent, of arsenic. It has been employed, with reported success, as a substitute for arsenic in the devitalization of pulps. The advantage claimed is that it presents less danger of poisoning. It is true that it may be taken internally in much larger dose than arsenic (the dose being i to 3 grains). It is too recent a compound to permit of final conclusions as to its value. 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. Fortunately both the means and its use have become obsolete. Nevertheless heated metallic points and wire loops are frequently employed in general and special surgery to-day. The approved methods of applying the actual cautery are the following: * 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. ESCHAROTICS 89 Thermocautery, Under this term there is arranged an apparatus, by means of which a platinum point, pre\ioiisly 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. Platinum 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, preference 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 ^dth the resistance of only one cell. It furnishes a large quantity of electricity capable of producing a high degree of heat when it meets mth 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 manipulation 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. CHAPTEE VIII. ._/ DEMULCENTS AND EMOLLIENTS. DEMULCENTS. DE:\ruLCEXTS are agents that protect or soothe raw, irritated oi inflamed surfaces. They consist chiefly of oily, mucilaginous or albumi- nous substances, of v^-hich the ones here named are the most important: Oleum Oliva? (olive oil). Acacia (gum arable). Oleum Lini (linseed oil). Linum (flaxseed). Oleum Goss^-piiSeminis (cottonseed oil). Ulmus (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 combination is found in the time-honored "carron oil," kno-^m ofiicially as linimentum 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 ob\dated by substituting cotton- seed 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 should not be used, as they are solvents for these drugs. In any case where albtimin is the proper antidote it may be the demulcent of choice so as to serve a double purpose. The mucilaginous drugs are employed in aqueous solution, either infusion, mucilao-e or svrup, and are for internal use, being seldom applied externally except in poultices, ^"\^len 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. Certain sialagogues and expectorants may exert a secondary demulcent effect through stimulating secretion in the irritated or inflamed part. Gm. or c.c. * R .— Olei lini, 60 (fg ij) Liquoris calcis, 60 (f^ ij) — M. Sig. — Apply freely and cover with dressing. (90) DEMULCENTS AND EMOLLIENTS 91 Irritation of the air passages, and particularly an irritative cough, is often due to dryness of the mucous membrane. Sialagogues or expec- torants 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 quality 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 crystalline 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 (petrolatum) 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 distillation 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 LOCAL REMEDIES Glycerinum. Glycerin. This substance is obtained by decomposi- tion 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 glycerin [C3H,(OH)3]. 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. 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 effect 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 succeeded 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 course, 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: Sig.- -Acidi salicylici, Alcoholis, Gm or c.c. 1 30 (gr. xv) (fSJ) Glycerini, Olei amygdate Aquse, —Hand lotion! arnarse, q. s. 30 ad 90 (fSj) 30 (n^v) ad(f5iij).— M DEMULCENTS AND 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 v^ith 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. Incom'patihility . With horax 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 Glyceritum Acidi Tannici has the following formula: Gm. or c.c. R . — Acidi tannici, 201 Glycerini, 80| 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 astringents, we may include the checking of hemorrhage and of diarrhea by local medication. The terms hemostatic and styptic apply to agents that arrest hemorrhage. 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 sedatives. Other styptics, comprising a number of agents, induce contraction of the arterioles; ergot, antipyrin, adrenalin and the local apphcation of hot water, all act in this way, ergot acting only through the central nervous system. Collodion exerts pressure through contraction of its volume while drying. It must be borne in mind that the one object of employing any hemostatic is to secure coagulation of blood at the point of hemorrhage; and the employ- ment 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 cold, or agents like antipyrin or adrenalin, which cause 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 deficient, pressure upon the bleeding points, or, in extreme cases, ligation of the 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 : (94) ASTRIXGEXTS AXD HEMOSTATICS 95 Classificatiox of Hemostatics. Coagulant Astrixgexts. 1. Vegetable. Tannic acid. Drugs containing tannic acid; Nutgall. Hematoxylon. Gambir (catechu'). Hamamelis. Kino. Tea. Krameria. Cotree. Alcohol. 2. Mineral. Iron preparations: Tincture of ferric chloride. Solution of ferric chloride. Ferrous sulphate. Ferric subsulphas (ZMonsel's salt). Solution of ferric subsulphate. Alum. Copper sulphate. Lead acetate. SUver nitrate.* Zinc chloride.* Zinc sulphate. Vascular Astringents. 1. Those that act locally: Antipyrin. Adrenalin. Cocaine hydrochloride. Hydrogen dioxide (3 per cent."). Heat. 2. Those that act aper absorption into the general circulations Ergot. Galhc acid. Remedies tblvt Favor Coagulation of the Blood. 1. By reducing blood pressure: Cold. Arterial sedatives: Aconite. Yeratrum \"iride. 2. By acting on the blood to increase its coagulant property: Calcium chloride. Thyroid preparations. 3. By causing direct pressure or occlusion of i^essels: Collodion. \ Bandages, ligatures, and other surgical measures. * Caustic in full sTrensjth. 96 LOCAL REMEDIES 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 considerable 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 hyper- emia 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 circu- lation, and we also have the sedative effect of the cold upon the nerve endings. A pulpitis may sometimes be reheved 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 — first, as hot water applied to a surface where there is oozing from small vessels, the heat causing vascular constriction through irritation, and, second, 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 Aero. Tamim [HCi^HgOJ. Anorganic acid obtained usually from nutgall. It is a yellowish powder, becom- ing 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. Its chief action is that of a coagulant. It has a bitterish and astringent taste, but is non-irritating to the tissues. It is acid in reaction. It must be applied locally, 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. The drug may be ASTRINGENTS AND HEMOSTATICS 97 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 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. (For preparations and doses, see Index of Drugs.) Incompatibility. Tannic acid drugs are incompatible with albumin, al- kaloids, ferric salts, lime-water, mineral acids and most metallic salts. Galla. NuTGALL. 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. The tincture and the ointment are the chief preparations of nutgall. G-ambir. Catechu. An extract prepared from leaves and twigs of Ourouparia gambir. The compound tincture and troches are used. Kino. The inspissated juice of Pterocarpus marsupium. The tincture is the only official preparation. Krameria, Rhatany. The root of several species of Krameria. This drug has a number of preparations. (See Index of Drugs.) Hematoxylon. Logwood. The heart-wood of Hoematoxylon cam- pechianum. Besides tannin, this drug contains heematoxylin, which is used to stain microscopic specimens. The extract is official. Hamamelis. Witch-hazel. The leaves and bark of Hamamelis virginiana collected in autumn. The fluidextract is official. Tea and Coffee. Although not official, tea leaves and coffee seeds contain a large amount of tannic acid. While all tannins are similar, some may be distinguished by their 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. 7 98 LOCAL REMEDIES Alcohol. Rectified Spirit. Ethylic Alcohol [C2H5OH]. 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 liquid, with a burning taste and a distinctive odor. Alcohol boils at 172.4° F. This agent is neutral. It has a great affinity for water, even absorb- ing it from the atmosphere, and it coagulates albumin. It is inflam- mable, burning with a blue flame which is smokeless and which yields a high degree of heat. The following strengths of alcohol also are official, with whisky and brandy, which are strong alcoholic liquors: Alcohol Absolutum (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, which have a stronger affinity for water, and redistilling, all except a fraction of 1 per cent, of water can be removed. Absolute alcohol is equally difficult to keep in full strength on account of absorption 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 solvent and as a chemical. Alcohol Dilutum (48.9 per cent, by volume). This is composed approxi- mately of equal parts of alcohol and water and 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, by vol- ume of alcohol. It is distilled from fermented grain and should be at least four years old. 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. Whisky and brandy do not gain in alcoholic strength by age, but they develop flavor; and, in whiskey 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= ASTRINGENTS AND HEMOSTATICS 99 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 full 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. Gradually 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. iVlcohol, 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 apphed. 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. Hofheinz advocates the use of a mouth wash of alcohol 1 part and water 2 parts in pyorrhea alveolaris.* 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 most 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 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 favor coagulation of blood and contraction of arterioles. It must be said that alcohol contributes much to the local action of certain tinctures, of which tincture of myrrh is an example; indeed, in this preparation the alcohol is much more important and active than is the myrrh. (See under Antiseptics.) 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, which is soon followed by a reaction that is delightful. * Items of Interest, 1905, p. 63. 100 LOCAL REMEDIES 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 menstruum in fluid extracts, tinctures, spirits and elixirs, besides being used to extract many vegetable active prin- ciples. When selecting an astringent drug for use, it follows that the tincture of that drug (if its solution in alcohol is possible) will be espec- ially 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. Incompatibility. 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 may be precipitated by it from their aqueous solutions. Chromic acid is decomposed by alcohol. Methylic Alcohol (not official). Wood Spirit [CH4O]. A thin colorless liquid obtained in the destructive distillation of wood. It has a peculiar odor and burning taste, sp. gr. 0.802, and boils at 151.7° F. It burns with a pale, smokeless flame, giving less heat than ethylic alcohol. By partial oxidation it yields formaldehyde gas. A purified product is called Columbian Spirit. W^ood spirit is used as a substitute for ethylic alcohol as solvent and for external uses. Its use as a solvent may be proper, but its external application should be with caution on account of its poisonous nature.* Coagulant Astringents (Mineral). This group of drugs stands in contrast with the tannic acid group, as we might expect from their compound chemical nature. They are com- pounds of acids with metallic bases, so that, by their dissociation in con- tact 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 pharmacologyf 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 astrin- * A number of cases have been reported within recent years where blindness, more or less permanent, followed prolonged contact with the fumes of this drug. •j- See Cushny, Pharmacology and Therapeutics, second edition, p. 604. ASTRINGENTS AND HEMOSTATICS 101 gents have the property of precipitating albuminous or proteid sub- stances. This must be understood to be a definite chemical reac- tion, 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 any one will depend, as Cushny states,* upon "two factors — the nature of the precipitate and of the acid. The latter tends to exercise the same astringent or corrosive effects as if it had been applied uncombined, but its action may be modified by the presence of a layer 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 com- parison 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 follow- ing, all of which are acid in reaction: Ferri Chloridum. Ferric Chloride [FeCl3 + 6H20]. 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. Contains about 4.6 per cent, of metallic iron. Dose, ttlS to 30 (gm. 0.30-2). Liquor Ferri Chloridi. Solution of Ferric Chloride. Contains about 10 per cent, of metallic iron. Ferri Sulphas. Ferrous Sulphate. Copperas. Green Vitriol [FeSo,+ 7H,0]. Ferri Sulphas Exsiccatus. Dried Ferrous Sulphate. Ferri Subsulphas (not official). Basic Ferric Sulphate. MonseVs Salt. The chemical composition of this salt is variable. * See Cushny, Pharmacology and Therapeutics, second edition, p. 604. 102 LOCAL REMEDIES Liquor Ferri Subsulphatis. Solution of Basic Ferric Sulphate. Monsel's Solution. Contains 13.6 per cent, of metallic iron. This preparation is often improperly called pei'sulpkate of iron. The true persulphate is a neutral salt, while this is basic. The Br. P. very properly applies the term persulphate to the following preparation: Liquor Ferri Tersulphatis. Solution of Normal Ferric Sulphate [Fe2(SOj3]. This is properly the solution of persulphate of iron. It contains about 10 per cent, of metallic iron. 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 astringents for use in the mouth, the whole group here named are objectionable 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 bicarbonate is a useful alkali for the latter purpose. Hemostatic cotton is prepared by satu- rating 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 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. (For reactions, solubility and general uses of the iron salts, see Index of Drugs.) 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. FerroMS salts with oxidizing agents are converted 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]. This substance is potassium-alum as distinct from ammo- nium-alum, which was formerly official. It occurs in colorless crystals having an astringent taste and acid reaction. Soluble in 9 parts of cold Astringents and hemostatics 103 water, 0.3 part of boiling water, freely soluble in warm glycerin, but insoluble in alcohol. It coagulates albumin, acting superficially as an astringent and hemostatic. To check slight hemorrhages the pure crystal or strong solution may be applied. For nose-bleed 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. In large dose the drug is emetic. WTien 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 falumen exsiccatum) or " burnt " alum, and is more energetic in its action upon tissue, being even escharotic to loosely organized tissue. Incompatibility. Alumen is incompatible with alkalies and their carbonates. With metals soluble in dilute sulphuric acid the aqueous solution of alum will liberate hydrogen. Argenti Nitras. Nitrate of Silver [AgNOg]. This drug is described and discussed quite fully in the chapter upon Escharotics. As an astringent it is used upon mucous membranes in conditions of relaxation or of chronic catarrh, such as chronic pharyngitis, where the dilated capillaries give evidence of a decided loss of tone in the mucous mem- brane. The indications here are for a drug that will cause condensa- tion of the relaxed tissue with contraction of the dilated vessels. Nitrate 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 irritating, but superficial in its action. It coagulates albumin. Its irritant action is explained in part by the liber- ation 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 vascular tone will occur 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 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 silver '204 LOCAL REMEDIES nitrate are neutral. As a rule it is not prescribed in combination witli other substances. Cupri Sulphas. Sulphate of Copper. Blue Vitriol [CuSO^ + oH^O]. This substance occurs in bkie crystals of a raetahic, nauseous taste, sohible in 2.2 parts of -^"ater and in 3.5 parts of glycerin, but almost insoluble in alcohol. The solution is acid in reaction. It coarjulates albumin. It ranks Avith 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 sulphuric, one of the most irritating of acids. Its value in dental practice is hmited, beino- useful for limited application where a decided, though irritating, astrino-ent effect is desired. If it is allowed to enter a carious tooth stainino; is likelv to result. Internallv the drug is emetic in large doses, 5 gr. Tgm. 0.30). In case of poisoning by it albumin is the best chemical antidote. Plumbi Acetas. Acetate of Lead. Sugar of Lead [Pb(C,H302)2 + 3H,0]. (For preparations and doses, see Index of Drugs.) Occurs in colorless or whitish crystals or masses, having a shght odor and sweetish, astringent taste. It is somewhat efflorescent, absorbing carbon dioxide from the air; soluble in 2 parts of water and in 30 parts of alcohol. It is neutral or slightly alkaline in reaction. It coagulates albumin, being one of the active mineral astringents. It is classed as a sedative astringent because of the absence of any marked irritation from its application. This fact agrees T\-ith 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. V.lien used inter- nally this drug presents the danger of lead poisoning. Therefore, its use is somewhat restricted as to cpantity and length of time employed. In conditions of denuded surfaces, irritable ulcers, and acute local inflammations of the gums, the solution may be employed, l^ut swal- lo\s'ing the drug must be avoided. On account of this danger the lead preparations are seldom used internally, and even their external appli- cation to large surfaces may induce poisoning. For local use a simple solution of the salt in water or alcohol, or the 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 dihited solution, known as lead-water, is of proper strength for ordinary use; or a stronger applica- tion mav be obtained bv diluting the stronger solution, which is known ASTRINGENTS AND BEMOSTATICS 105 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 httle 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 [ZnClj]. 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 [ZnSO^ + THjO]. Occurs in colorless crystals, having an astringent, metallic taste, soluble in 0.53 part of water and in 3 parts of glycerin; insoluble in alcohol. It is acid in reaction. 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. In a dose of 10 to 30 grains (gm. 0.60-2) it is a reliable emetic, and is frequently employed to empty the stomach in cases of poisoning. It coagulates albumin. Incompatibility. Sulphate of zinc is incompatible with alkalies and their carbonates and with ammonium sulphide. Zinci lodidum. Iodide of Zinc [ZnlJ. This salt occurs as a white powder, having a sharp taste, very deliquescent, and becoming brown upon exposure from the liberation of iodine. It is freely soluble in * Lotio plumbi et opii (N. F.): Gm. or c.c. R . — Plumbi acetatis, 17 5 Tincturse opii, 35 Aquae, q. s. ad 10001 — M. \QQ LOCAL REMEDIES water and alcohol, and is acid in reaction. Its action is chiefly altera- tive combined with the characteristic action of the zinc ion. Dr. E. S. Talbot, after considerable experience with it, advises its use in inter- stitial gingivitis in the following combination with iodine, to which he gives the name of lodo-glycerole : Gm. or c.c. R. — Zinci iodidi, 15 (3iv) Aqu£e, 10 (fSijss) lodi, 25 (5vi) Glycerini, 50 (fjxiiss)— 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. 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 influence, 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. Antipyrina. Phenazone [CgH5(CH3)2C3HN20]. This substance is obtained, by a series of chemical reactions, from pyrrol, a base found in coal-tar. Chemically it is phenyldimethylpyrazolon, 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 introduced to medicine. It occurs in colorless crystals, having a bitter taste, neutral, soluble in less than 1 part of water and in 1 part of alcohol, freely soluble in chloroform and in 30 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 ASTRINGENTS AND HEMOSTATICS ]^07 to cause contraction of the arterioles, and in this way will efficientlv control any ordinary capillary hemorrhage. It w\\\ 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 c.c.) of a 10 per cent, solution may be used T\'ithout exceeding the internal adult dose. It is useful in stopping epistaxis (nose-bleed), the solution being sprayed into the nostril. Its uses as anodyne and sedative are discussed in another place. Incompatibility. The aqueous solution is incompatible \s'ith a dilute solution of carbolic acid; also with spirit of nitrous etlier when the latter is acid, as it is likely to be ordinarily. Adrenalin. This name is applied to a preparation, possibly the single active principle, obtained from the suprarenal glands of the sheep or ox. It is claimed to be a definite crystalline substance, and is used in the form of adrenalin chloride, which is obtainable in the strength of 1 : 1000 in normal saline solution. It may be used in this strength or diluted. It does not coagulate albumin. x\s a hemostatic its action is local upon the muscle tissue of the arterioles, causing constriction of the vessels. WTiile some effect may be obtained by its h}"podermic use, and still more by its intravenous injection, it being carried in the circulation to the bleeding point, the tisual and best means of employ- ing it is by local application to the part. Hemorrhages from small vessels or from the capillaries are best controlled by it. For checking epistaxis or hemorrhage follovving slight operations it is very efficient. Adrenalin is coming into favor as a heart stimulant in cases of shock and collapse, in which relation it is considered under Stimulants. Epinephrine is regarded as an alkaloid from the same source as adrenalin, and it possesses similar properties. Cocaine Hydrochloride. Hydrogen Dioxide (3 per cent.). Both of these agents possess some st}^tic power, but this is incidental to their more prominent action. They may be applied for the purpose of controllino; hemorrhage locallv, their influence being entirelv through stimulation of vascular constriction. Neither of them coagulates albumin. When employed as styptics the same strengths of solutions are applied as for their main uses, but with cocaine hydrochloride due precaution must be taken to avoid poisoning. Acidum Gallicum. Gallic Acid [HC.HjOg + H^O]. An organic acid, prepared from tannic acid, having a rather uncertain reputation 108 LOCAL REMEDIES as a general st^'ptic — i. e., acting throughout the system after absorption into the circulation. It occurs in whitish crystals, having an astringent taste, soluble in S3. 7 parts of water, in about 5 parts of alcohol, and in 12 parts of glycerin. It is acid in reaction. It does not coagulate albumin, therefore it has no appreciable local action. It may be giyen intenially in a dose of from 5 to 20 grains (0.30-1.30 gm.). It is not much to be rehed upon, still it is recommended by some in the hemorrhagic diathesis and to control internal hemorrhages that cannot be reached by local medication. Ergota. Ergot of Rye. This fungus, which replaces indi^•idual 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 transyersely. Uses as a Hemostatic. Ergot has no local action. The drug is useful onlv as it induces contraction of inistriped muscle after entering the circulation. Capillary hemorrhages that cannot be treated locally call for its administration by stomach or, in emergency, h}-podermically. The fluidextract is the preparation most commonly employed, in doses of j-1 fluidrachm 1 1-4 c.c). In hemophilia (hemorrhagic diathesis) it is one of the drugs recommended. It should never be used in case of hemorrhage from a good-sized vessel, for fear of increasing the flow through the rise of arterial pressure which the drug produces. (Plate I.) It is the drug of all drugs for the control of post-partum 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. 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 Aconitum napellus. The tincture is the preparation commonly used, the dose of which is .5-15 minims (0.30- 1 gm.). For its precise action, see Plate XIV., under Sedatives. Veratrum. The root of Veratrum viride. This drug is so similar in action and uses to aconite as to recjuire no special discussion here. The dose of the tincture is 5-20 minims ( 0.30-1.20 gm.J. PLATE I. ERGOT. A fungus replacing the grain of rye. [For preparations and doses, see Index of Drugs.] Classified as : Oxytocic. Vasoconstrictor. Hemostatic. Physiologic action : Digestive Tract. It is believed to stimulate gastric motility and intes- tinal peristalsis. Nervous System. Brain. Not affected. Medulla. Stimulates vaso- motor centre. Spinal cord. Stimulates centre 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 is increased. Heart. May be slowed, but influence not definite. Capillary area. Arterioles contracted chiefly by cen- tral vasomotor stimulation. Uterus. Stimulates uterine con- tractions, mainly by influ- encing centre in lower part of spinal cord. C erebrum Pons V Cci'ebellu'in Vagus Center Vaso Motor Center Cervical Symjpathetic Solar Plexus Pelvic Plexus Eed color indicates stimulation. ASTRINGENTS AND HEMOSTATICS 109 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, which present, as an important factor, deficient coagulation of the blood. The remedies employed may not all act in the same way, but each has been sufficiently successful to entitle it to trial in any severe hemorrhage and particularly in cases of hemophilia. Certain calcium salts have, indeed, fully proved their efficiency. Calcii Chloridum. Chloride of Calcium [CaCb]. [Do not con- fuse with chloride of lime, a chlorine disinfectant and bleaching agent.] Chemically pure calcium chloride occurs in hard white fragments, which are deliquescent and have a sharp, saline taste. It is neutral, soluble in 1.3 parts of water and in 8 parts of alcohol. When given internally it is believed to increase the coagulability of the blood. Good reports have been made of its value in hemophilia, used both locally and internally. The dose is 5-10 grains (0.30-0.60 gm.) every four or six hours, or a smaller quantity more frequently. 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 6J per cent, solution (30 grains to the fiuidounce). This drug certainly deserves a trial in any case of persistent hemorrhage. Calcium Lactate (not official) is less soluble than the chloride, but, for prolonged use, is better tolerated by the stomach. The dose is the same and in efficiency in treating hemorrhage it seems to be equal to it. Gelatin. A sterilized solution of gelatin in water, or in normal salt solution, is employed either subcutaneously or by rectum. For subcu- taneous injection a 2 per cent, solution is used in quantities varying from 2 fluidounces (60 c.c.) for a child, up to 8 fluidounces (240 c.c.) for an adult, repeated as the case may require. For rectal injection 4 to 8 fluid- ounces (120-240 c.c.) of a 5 per cent, solution may be used. Thyroid Gland. Both the extract of the thyroid 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 * Lancet, February 21, 1903. 110 LOCAL REMEDIES factor, this substance has been tried. Regarding its value in hemophilia, a very satisfactory result is reported of a case by Fuller.* The patient was a boy fifteen years old. Four maternal uncles and two elder brothers had bled to death. The patient had frequent copious hemorrhages from the nose and also bled severely with the loss of ternpor^r;.' rri-Th. For a year he had been in a very weak condition cause^i by sponiaii'^^ous attacks of hemorrhage from the kidneys. After failure with the usual remedies, 5 grains (0.30 gm.) of thyroid extract were given three times daily. After the second dose the bleechng ceased. The case was reported nine months after, during which time there had been no recurrence of hemorrhage. While the cases noted above are convincing, it must be said that experience with a large number of cases will be necessary before the extent of the usefulness of this group of drugs can be determined. Remedies that Cause Direct Pressure or Occlusion of Vessels. Mechanical Hemostatics. Under this hea'hng are included surgical measures, such as pressure, hgatures 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 obhteration beyond. Torsion means twisting of a vessel. Small vessels that are not easily hgated may be treated in this way. In case of persistent bleeding after extraction of a tooth, the most effectual remedy is pressure, for the apphcation 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 boihng, inserted into the l:>leei;ling socket. It is also recommended that warm wax or modehug compjuml 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. This wiU aid by direct coagulant action, though the cotton plug ^dll be less sohd 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 r>:> — iv i; f the necessary degree exerted by closiu'e of the jaws. The pres- r^ i- usually maintained by a bandage passing under the lower jaw am aijuut the head. * Medical News, Februarv 2S, 1903. ASTRINGENTS AND HEMOSTATICS 111 The collodion group act chiefly by exerting pressure. They are all highly inflammable, and must not be handled in the vicinity of a flame. Collodium. Collodion. A varnish that consists of a solution of 4 parts of pyroxylin 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. Incompatibility. Collodion is precipitated by carbolic acid. Collodium Flexile. Flexible Collodion. In this preparation 5 parts of Canada balsam and 3 parts of castor oil are added to 92 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. In this the formula is modified so as to contain 20 per cent, of tannic acid, which adds coag- ulant 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. CHAPTEH 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 desirable, 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 is that which contributes the scouring quality, as prepared chalk; another kind, that which will thoroughly cleanse all surfaces, as soap; and still another may be desired to exert a solvent or a pene- trating influence. Hydrogen peroxide is a very important detergent besides being an antiseptic. Its action is a double one. First, upon coming into contact with blood, pus, or loosely organized tissue, it is decomposed, yielding nascent oxygen, by which it acts as an oxidizing agent and antiseptic. Second, the freeing of oxygen causes gaseous expansion, by which foul materials may be loosened and carried away from the tissues mechanically. ANTACIDS (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. (112) DETERGENTS, ANTACIDS AND ALKALIES 113 The action of antacids is always chemical, for the acid character of a substance is lost only through combination or decomposition. In 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 prophy- laxis. 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 individual 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 may 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 114 LOCAL REMEDIES action will continue for hours, or through the night if applied at bed- time = The excessive or continuous use of antacids may disturb gastric diges- tion 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 into the stomach might hinder digestion by neutralizing the acid. Other^\-ise no harm is likely to arise from their use. Soaps. Soaps are compounds of the ordinary fat acids (oleic, palmitic, and stearic) wdth bases. In the process of saponification, by boiling a fat ^dth a base, the fat is decomposed, glycerin is set free, and the fat acids combine -^-ith 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, ^^^latever the consistence of the oil or fat employed, its reaction vdih sodium will produce a hard soap and with potassium a soft soap. Lrcad plaster is a familiar example of an insoluble soap. Sapo. Soap. ^Miite castile soap is the kind preferred. It is prepared from soda and olive oil. It should be hard, but easily cut when 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 drjdng at an elevated temperature, when the soap may be more readily pul- verized. It is capable of dissoh^ng fats, which property gives it its great value. ^ledicinally it is alkaline and somewhat antiseptic, pos- sessing detergent qualities in marked degree. Its chief dental use is in dentifrices, where, in powdered form, it maybe mixed ^\dth 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 marbled castile soap is less pure, as it contains ferruginous coloring matter. It is more strongly alkaline, harder, containing only about 14 per cent, of water, and is, therefore, more economical for ordinary uses. Soft soap, known officially as sapo mollis, prepared from potassa and linseed oil, contains considerable free potassium hydrate; therefore its alkaUnity is so strong as to be irritating to mucous membranes. It is used as a cleansing agent to the hands preparatory to sterilizing them for surgical work. Incompatibility. Soluble soaps are incompatible with all acids and with eartluj and metallic salts; they are precipitated in hard water, or in a solution of corrosive sublimate, as an insoluble soap. DETERGENTS, ANTACIDS AND ALKALIES 115 Sodii Bicarbonas. Bicarbonate of Sodium [NaHCOg]. A white, opaque powder, having a mildly alkaline taste, soluble in 12 parts of water, insoluble in alcohol. It is alkaline in reaction. 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 (8^ 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, in the mouth, any acids and acid iron preparations, when such are taken or used about the mouth. 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 intoxica- tions of the system, such as rheumatism. The internal dose is 5-30 grains (0.30-2 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. Incom'patibility. 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 [Nsl^B/^j + IO^^^]- Occurs in colorless crystals or white powder, having an alkaline taste, soluble in 20.4 parts of water and in its own weight of hot glycerin, insoluble in alcohol. It is alkaline in reaction, non-irritating to tissues, and its taste is bland and sweetish. The solution in glycerin is acid in reaction. This salt is really sodium diborate. 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 for the European market. In borax we have an agent that is both alkaline and antiseptic, and 116 LOCAL REMEDIES that maybe used freely in saturated solution (5 per cent.). It is, there- fore, admirably adapted to all uses that call for a mouth wash possess- ing 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 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. Syrup and honey are inferior as vehicles, because they ferment readily. 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 less soluble. A white precipitate is also thrown down by corrosive sub- limate. Liquor Calcis. Solution of Lime. Lime-water. A saturated aqueous solution of calcium hydroxide [Ca(OH)2]. It is readily prepared by treat- ing 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 acidity of the stomach. For the latter purpose it is very commonly 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. Incompatibility. Carbon dioxide gas produces in lime-water a cloudiness, due to calcium carbonate. Oxalic acid produces a white precipitate of calcium oxalate. With corrosive sublimate a yellowish precipitate occurs, and with calomel a black deposit. Magnesii Oxidum. Light Magnesia. Magnesia [MgO]. The light magnesium oxide is prepared by exposing light magnesium car- bonate 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 fifteen parts of water and allowed to stand for half an hour it gelatinizes, forming magnesium hydrate or "milk of magnesia." This drug is an agreeable antacid for stomach administration, and is at the same time laxative. This com- bination of properties makes it a useful agent for the treatment of intestinal disorders of childhood, the alkaline quality serving to neutralize any undue acidity, and the laxative action ridding the bowel of offensive contents. The dose is 5-60 grains (0.30-4 gm.). MfERGENTS, Antacids And alkalies 11*7 Magnesia should be kept from exposure to air, as it slowly absorbs moisture and carbon dioxide, forming a carbonate. In the form of the hydrate, or milk of magnesia, it is one of the most useful agents to neutralize acids in the mouth, being ranked first by some practitioners. This preparation is easily made in the way mentioned above and it keeps indefinitely. Its gelatinous consistence causes it to adhere to the teeth and remain about them for a con- siderable time, which is a decided advantage. It may be used freely in any mouth and at any age. Incompatibility. Magnesia is neutralized by acids. Greta Praeparata. Prepared Chalk [CaCOg]. 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 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 dis- orders. While solubility of a drug is usually desirable in order to rapid action, the insolubility of prepared chalk gives it a special place in dentistry. Having a mild scouring 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 ten- dency 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.) Incompatibility. In contact with acids chalk decomposes with effer- vescence, caused by the liberation of carbon dioxide. 118 LOCAL REMEDIES 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 through 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 a 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 co-operating, the tissues easily become clogged, so to speak, laying the foundation for the diseases mentioned. The presence of arteriosclerosis adds another contributing factor by lessen- ing the uniformity of blood supply to the capillaries. The relation of these conditions to oral pathology is being emphasized today in classi- fication and treatment 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 effect. Various alkaline mineral waters are taken with good results, and the salts of lithium have had a recent extensive use; but many physicians now give preference to pure water. Dis- * Balfour, The Senile Heart, MacMillan& Co., 1894, p. 14. DETERGENTS, ANTACIDS AND ALKALIES 119 tilled water, because of its greater solvent power, being devoid 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 increase 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 solutions of the cathartic and diuretic salts, while the latter permit of modification which places the kind and degree of the saline action under our control. (See Cathartics and Diuretics.) Certain artificial combinations, in imitation of the formulas of popular mineral waters, are upon the market, e. g., artificial Carlsbad salts. These seem to meet a demand, but their employment, as well as that of any mineral water, should be based upon proper discrimination as to indications for their use. CHAPTEK 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 counteract their influence and to remove their noxious products. If, however, we analyze modern antiseptic treatment, we find that the agents and means employed vary as to the precise part they play in bringing about the results. 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 disinfectant. 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 simple antiseptic — 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 gro\\1;h of another. To the writer it seems better to employ the term antiseptic in its general inclusive sense, to cover all agents employed to prevent, counteract, and remove the influence of disease germs, and to further designate difl^erences of action by using the adjective terms germicidal and dis- injectant. The intelligent use of antiseptics has been a matter of development during the past thirty years, following closely the progress made in the science of bacteriology. AVhen 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 (120) ANTISEPTICS 121 septic conditions and special diseases. In 1875 Lister set forth the germ theory as appKed to the infection of wounds. His work and methods were a great step toward reahzing the aseptic surgical methods of today and are referred to by an eminent surgical writer* as ha\ing "brought about an entire revolution in surgery and surgical technique, 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 mineral 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 mth 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 con- siderations will lead to the use of the terms "mouth disinfection" 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 sterilized 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 o'f the mouth is difficult of attainment, but the site of operation may usually be made aseptic after exclusion of the fluids by a sterile rubber dam, and the condition then maintained through the use of sterile instruments by sterile hands. 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 * Park's History of Medicine, second edition, p. 261. 122 LOCAL REMEDIES 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 .purpose, but its value is questionable. Absolute certainty should recjuire sterilization by heat. Acidum Boricum. Boric Acid. Boracic Acid [H3BO3]. This occurs in transparent, colorless scales or crystals, nearly tasteless, soluble in 18 parts of water, 15.3 parts of alcohol, and in 4.6 parts of glycerin. It is slightly 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 (5J per cent.) is largely used as an 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 w^ounds. Attention is directed to the formula of an antiseptic solution for general use, into which boric acid enters prominently, which is official under the name Liquor Antisepticus. It contains: Boric acid, 20.00 Gm. Benzoic acid, 1.00 " ThjTnol, 1.00 " Eucalyptol, 0.25 c.c. Oil of peppermint, 0.50 " Oil of gaultheria, 0.25 " Oil of thyme, 0.10 " Alcohol, 250.00 " Water, to make 1000.00 " This preparation should be used in preference to the many proprietary liquids of uncertain strength. Incompatibility. In aqueous solution boric acid is decomposed by carbonates, with the formation of borates. Whenever a stronger preparation of boric acid than the saturated solution is desired, it may be had in the official glyceritum boroglycerini (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. ANTISEPTICS 123 Sodii Boras. Borax. This salt has been discussed under Antacids. As an antiseptic it may be used freely in saturated solution (5 per cent.) as a mouth wash, or the crystal may be allowed to dissolve in the mouth. It really possesses in itself every essential quality of a mouth antiseptic, though of the weaker class of agents. It is alkaline, non-irritating, almost tasteless, and non-toxic. Dobell's solution* is a very useful combination. A saturated solution in glycerin (equal parts of each) is very efficient in the removal of the thrush fungus (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 mem- brane for some time. It should be applied several times daily. Phenol. Carbolic Acid. 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 by interference with penetration. Phenol LicLuefactum, Liquefied Phenol, containing 86.4 per cent, by weight of absolute phenol, is convenient for ready use and for diluting. Phenol is soluble in about 20 parts of water, giving a saturated solution of about 5 per cent. This is too strong for use upon mucous. membranes, although for the purpose of tooth disinfection the pure phenol may be used with due care. 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 counteracted by combining a solution of sodium bicarbonate with it. Upon the skin it may be used somewhat stronger, but even here the * The formula of Dobell's solution, as given in the National Formulary under the title Liquor Sodii Boratis Compositus is: Gm. or c.c. B . — Sodii boratis, 15 (3iv) Sodii bicarbonatis, 15 (5iv) Phenolis (crystals), 3 (gr. xlv) Glycerini, 35 (fgj) Aquse, ad q. s. 1000 (Oij) Dissolve the salts in one-half of the total quantity of water, then add the glvcerin and the phenol, previously liquefied by warming, and, lastly, enough water to make up the total quantity. 124 LOCAL REMEDIES continuous application of a solution as weak as 1 to 5 per cent, has been followed by gangrene, the result probably of thrombosis. This is especially liable to occur in a finger or toe where all vessels 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. A whole finger has been lost in this way as a result of the application of carbolic acid solution. It may be said of this agent that, having been one of the first substances 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, solution destroyed the staphylococcus pyogenes aureus, the most common and most resistant pus organism, in two minutes; a 2h per cent, solution required four minutes.* 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 carbolatisf contains 50 per cent, of carbolic acid. 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 mind that it is a poison — corrosive when applied in full strength to tissue; and also a systemic poison, when absorbed in quantity, producing irritation of the * Annals of Surgery, October, 1904. f Liquor sodii carbolatis (N.F.) corresponds very closely to the proprietary prepara- tion known as phenol sodique. It has the following formula: Gm. or c.c. R. — Phenolis (crystals), 50 Sodii hydroxidi, 3 5 Aquae, 46 5 Dissolve the soda in the water, add the phenol, and warm gently until it is dissolved. This preparafion should be freshly made. Used in full strength this combination would be caustic. ANTISEPTICS 125 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 and alcohol are the antidotes, and for systemic treatment soluble sulphates are employed. (See under Escharotics.) Incompatibiliti/. Phenol will coagulate albumin and collodion. In aqueous solution a white precipitate occurs with hromine 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 [C^H^.OH]. A mixture of three isomeric cresols obtained from coal-tar. It is a nearly colorless liquid, becoming yellowish or brownish upon prolonged exposure to Hght. Its odor is similar to that of phenol. It is soluble in 60 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.* Trichlorphenol [CgH^ClgOH] (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 substance, soluble in alcohol and ether. According to Nenckij a 2 per cent, solution was found to be more active than a 5 per cent, solution of phenol and only a little weaker than 1 : 1000 solution of bichloride of mercury. Creosotum. Creosote. Oil of Smoke. A mixture of phenols obtained by distillation of wood-tar. (For preparations and doses, see Index of Drugs.) 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 beech wood-tar by distillation, creosote is always liquid, nearly colorless when • fresh, but becoming yelloT\ash. The U. S. P. states that it should not 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 mth 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 * Harrington, Annals of Surgery, October, 1904. t U. S. Dispensatory, eighteenth edition, p. 1615. 126 LOCAL REMEDIES teeth by continuous treatment. The chief points of difference 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 20 parts of water. Soluble in about 140 parts of water. In antiseptic power creosote surpasses phenol,t and its internal use is safer. In recent years it has been used extensively as an internal 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.* It penetrates more deeply, 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 (f per cent.), but its unpleasant odor and taste are objectionable. The official aqua creosoti is prepared with 1 per cent, of creosote, in order to insure saturation. 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 swallowing 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. Guaiacol [QH^jOJ. A crystalline solid obtained from creosote and constituting from 60 to 90 per cent, of the latter. It is soluble in 53 parts of water, 1 part of glycerin and also soluble in alcohol and ether. Being a more definite substance, 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 cataphoresis. * 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, •j- See table on p. 132. ANTISEPTICS 127 Guaiacolis Carbonas. Guaiacol Carbonate [(C^H-OjgCOg]. A white crystalline powder, insoluble in water, soluble in 48 parts of alcohol, neutral and almost tasteless. Alcohol. This drug, fully considered in other places as astringent and stimulant, has some 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 antisep- tic 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. 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. Alcohol 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 resist- ing (non-sporing) bacteria, such as the pus organisms, in the dry state, are those containing from 60 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 mois- ture, 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. * Boston Medical and Surgical Journal, May 21, 1903. 128 LOCAL REMEDIES " 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 condition 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 anti- septic power should produce a valuable preparation. Tinctura Mjnrhse. Tincture of Myrrh has long been used as a local 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, for the latter precipitates the resinous portion of myrrh. It can only be mixed ^vith water or aqueous solutions in the presence of a large percentage 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.). Tinctura Benzoini Composita/'' Compound Tincture of Benzoin (10 per cent, benzoin). Benzoin contains resin, benzoic acid (about 14 per cent.) and traces of a volatile oil. Benzoic acid has been found, by a number of ob- servers, to rank among our very best non-irritating antiseptics, and it is freely soluble in alcohol; therefore, these tinctures should be valuable antiseptics, as they contain 2 to 3 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 * The formula of compound tincture of benzoin contains: Benzoin, 100 parts. Purified aloes, 20 " Storax, 80 " Balsam of tolu, 40 " Alcohol, to make 1000 " ANTISEPTICS 129 infected conditions of the^ upper air passages. A useful prescription for this purpose is the following: Gm. or c.c. H . — Phenolis liquefacti, 8 (foij) Tincturpe benzoini compositse, 24 (f3vj) Glycerini, q. s. ad 60 (foij) — ^I- 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. Acidum Benzoicum. Benzoic Acid [HC^HjOJ. An organic acid obtained from benzoin, or prepared artificially. This drug occurs in whitish crystals, with or without the odor of benzoin,* soluble in 281 parts of water, but with an equal quantity of borax it is soluble in 100 parts of water; soluble also in 1.8 parts of alcohol and in 10 parts of glycerin. It has an acid reaction. A solution of 1 : 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. f 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 solution of borax will dissolve 1 per cent, or more of benzoic acid and still be alkaline. Incompatibility. ^Mien a solution of benzoic acid has been neutralized by an alkali, as ^ath borax, a precipitate will occur when mixed with Jiydrochloric or dilute nitric acid, or with dilute solutions of Jerric salts, or with lead acetate, mercuric chloride or silver nitrate. Acid, Cinnamic [HCglljOJ (not official). A colorless, crystalline substance occurring in balsams and in old oil of cinnamon. It is C|uite similar to benzoic acid, into which substance it is convertible by oxida- tion. It is slightly soluble in water and readily soluble in alcohol. Its uses are the same as those of benzoic acid. Acidum Salicylicum. Salicylic i^ciD [HC^HjOg]. An organic acid obtained from vegetable sources or prepared from carbolic acid. Occurs in very fine, white needles or crystalline powder, having a sweetish taste. * Benzoic acid prepared artificially does not have the odor of benzoin, t The same applies to salicylic acid (see p. 128). 9 130 LOCAL REMEDIES It is soluble in 308 parts of water and in 2 parts of alcohol, 2 parts of ether, 80 parts of chloroform, 2 parts of olive oil, and in 60 parts of glycerin. It is acid in reaction. According to Miller,* 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 aqtieous solution is rather weak to be of much value as 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. Incoiiipatibility. "With 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 effen'esces, vidth the formation of salicylates. Sodii Salicylas. Salicylate of Sodiu:^! [NaC^HgOg]. This salt is much more soluble in water than is the acid, being soluble in 0.8 part, also in 5.5 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. Internal dose, gr. 5-30 (gm. 0.30-2), Phenylis Salicylas. Salol [C^gH^gOo]. Occurs in form of a white, crystalline powder, having a sweetish taste, almost insoluble in water, soluble in 5 parts of alcohol, and in ether, chloroform and oils. It melts at 42° C. (107.6° F.). Its use in dentistrj^ depends upon the ease T^dth which it can be fused, and the fact that, when fused at a temperature con- siderably above its melting point, recrystallization is retarded. ^Mascortf in 1894 advocated its use in melted form as a root-canal filling. Being a feeble antiseptic unless decomposed, its ready adaptability and non- irritating 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 tlirough the stomach unchanged, it is first decomposed into carbolic and salicylic acids by contact with the alkaline juices in * Micro-organisms of the Human !Mouth. f Dental Cosmos, 1894, p. 352. ANTISEPTICS 131 the small intestine, where the effect of these two antiseptic substances is then obtained. It is valuable in diarrheas and intestinal fermentation, but with large doses toxic effects of phenol are possible. Internal dose, gr. 1-10 (gm. 0.06-0.60). VOLATILE OIL GROUP. Volatile oils are odorous, volatile principles, not possessing the chemical qualities of true oils. They are colorless or nearly so when freshly dis- tilled, becoming somewhat colored with 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 penetrate well, and any irritation from brief application is but slight and moment- ary. 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 antiseptics, 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 effi- cient antiseptics, while non-irritating to soft tissues. In fact, he found oil of cloves to possess local analgesic properties to a marked degree. He regards oil of gaultheria as useless. Formalin he discards in the treat- ment of conditions about the mouth. * The Dental Review, August, 1898, p. 593. 132 LOCAL REMEDIES 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 When confined to When sprayed of mouth bacteria prevented by skin by rubber cap. upon artificial sore amounts given below in drops. (guinea- jMg) . (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 healing. (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 "t- . 1-4 drops, or 1: 454 36 hrs. No irritation. Inflammation sub- sided. Phenol (95%) 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. Oil of gaultheria. . . No action even in saturated solution (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. Applied 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. • Oleum Cinnamomi. Oil of Cinnamon. Oil of Cassia. A volatile oil distilled from Cassia cinnamon (bark and leaves), containing not less than 75 per cent, of cinnamic aldehyde, upon which its value depends. It is yellowish or brownish in color, becoming darker and thicker by age and exposure; sp. gt. about 1.055; soluble in 2 parts of 70 per cent, alcohol. The changes by age are due to the oxidation of cinnamic aldehyde to * For article forming basis of this summary, see Dental Review, Aug., 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. J The influence of phenol was transient, growth occurring after three days. ANTISEPTICS 133 cinnamic acid and resins; therefore, the oil should be kept from expo- sure to light and air in well-stoppered, amber-colored bottles, in a cool ^ place. Oil of cinnamon is non-coagulant to tissues, it is penetrating, it is agree- able in odor and the discomfort of its application to soft tissues is mo- mentary, 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 in dentistry (see preceding table). It is used for tooth disin- fection, 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. 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 composi- tion and uncertain value. Cinnaldehydum. Cinnamic Aldehyde [CgHgO]. An aldehyde ob- tained from oil of cinnamon or prepared synthetically. It should be 95 per cent, in strength. It is nearly identical with the official oil of cinnamon, 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. Its uses are the same as those of oil of cinnamon. / Oleum Caryophylli. Oil of Cloves. A volatile oil obtained from w cloves by distillation, 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 1 part of alcohol, the resulting solution having a slightly acid reaction. Sp. gr. about 1.050. Its chief constituent of value is •'eugenol, of which it should contain 80 per cent. While the change in color probably does not impair its value, it should be kept well protected from light and air, so as to retard its tendency to change. Oil of cloves has a high antiseptic value (1: 1150 for mouth bacteria), while Dr. Peck's experiments have proved positively that it is not only non-irritating locally, but that, when applied to inflamed or infected tis- sues, it is decidedly soothing, and healing progresses rapidly under its application. With other volatile oils it is non-coagulant to tissue. * The IJ. S. P. formula for aq. cinnamomi uses 2 parts of oil to 1000 of water. It is estimated that one-half of the oil is dissolved. 134 LOCAL REMEDIES 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 undoubtedly entitled to a larger place as an application to irritated and infected tissues. In addition to its dental uses, oil of cloves is employed in the preparo,- tion of microscopic specimens. Eugenol. [C10H12O2]. An aromatic phenol, the chief constituent of oil of cloves, but obtainable also from other sources. Sp. gr. about 1.073. It is similar to oil of cloves in all of its qualities and is applicable to the same uses. It may be mixed with alcohol in any proportion and it is soluble in 2 parts of 70 per cent, alcohol. The two following agents are very similar, both owing their value chiefly to cineol (identical with cajuputol and eucalyptol). Oleum Cajuputi. Oil op Cajuput. A volatile oil obtained from the fresh leaves and twigs of Melaleuca leucadendron. Its chief constituent is cineol, of which there should be at least 55 per cent. It is a light, thin, colorless or bluish-greeji liquid, with an aromatic odor and taste. It is soluble in 1 part of alcohol, the solution being neutral. Sp. gr. about 0.920. Oleum Eucalypti. Oil of Eucalyptus. Distilled from the fresh leaves of Eucalyptus globulus, this volatile oil owes its value to cineol (eucalyptol), of which it should contain 50 per cent. It is soluble in alcohol, the solution being neutral. Sp. gr. about 0.915. It is similar to oil of cajuput because of the presence of cineol in nearly the same proportion. It has no distinct value in comparison with other volatile oils, and preference is usually given to the following chief con- stituent, which is more definite than the oil. Eucalyptol. Cineol. Cajuputol [CjoHigO]. An organic oxide 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 proportion, the solution being neutral. Sp. gr. 0.925. When cooled to somewhat below the freezing-point it becomes crystalline, melting again at 30.2° F. It should be kept pro- tected 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. 132. ANTISEPTICS 135 Oleum Thymi. Oil of Thyme, A volatile oil distilled from leaves and flowering tops of Thymus vulgaris. It is colorless, having a strong odor of thyme, soluble in one-half its volume of alcohol, the solution ' being neutral or very slightly acid. It contains Thymol, a phenol [CiqH^^O], which occurs in large, colorless crystals, having a penetrating odor of thyme and an aromatic taste, soluble in 1100 parts of water, very soluble in alcohol, also soluble in oils. It is used as an antiseptic. An official combination is the following: '' Thymolis lodidum, Thymol Iodide [C20II24O2I2]. This substance, known also as Aristol, contains 45 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 Menthge Piperitae. Oil of Peppermint. A volatile oil dis- tilled from the leaves and flowering tops of peppermint. It is colorless, neutral and soluble in an equal volume of 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 internally as a carminative. Locally it is analgesic and antiseptic, and is, therefore, useful to relieve itching of skin or mucous membrane. It contains Menthol, a stearopten, which occurs in colorless crystals having the characteristic odor of peppermint. This 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. It is a useful antiseptic for internal administration and for local dental uses. As an analgesic antiseptic it may be dissolved in chloroform or in a volatile oil for use in pulp treatment. In neuralgias and head- aches the solid crystal is rubbed upon the skin of the painful area. Oleum Sinapis Volatile. Volatile Oil of Mustard. Oleum Terebinthinae. Oil of Turpentine. These two volatile oils have been discussed in their more important uses as irritants. As antiseptics they are chiefly used externally to dis- infect the skin or the hands of the operator in preparation for surgical operations. Turpentine is more applicable to the skin generally, while for hand disinfection flour of mustard is used with a little water in order to develop the volatile oil directly upon the surface and about the nails, Terebenum. Terebene, The reaction between oil of turpentine and 136 LOCAL REMEDIES sulphuric acid yields a colorless liquid, known as terebene. It has an agreeable odor and aromatic taste, and it should rank among the valuable 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 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 28 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 chlor- ine 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 bleach- ing. It is also a deodorant by its power of decomposing sulphuretted 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.* Follow- ing are the commonly used chlorine disinfectants : Liquor Chlori Compositus, chlorine water, contains about 0.4 per cent, of chlorine gas. Liquor Sodce Chlorinatce, Labarraque's solution, contains at least 2.4 per cent, of available chlorine. Calx Chlorinata, chlorinated lime, contains at least 30 per cent, of available chlorine. Incom'patihility. 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 mixed 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. 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 pulmonary diseases, when a powerful * Brunton's Pharmacology, 1885, p. 96. ANTISEPTICS 137 antiseptic vapor is needed, the tincture may be vaporized with steam in a strength not to exceed 10 minims (0.60 gm.) to a pint of boihng water, usually combined with carboKc acid, eucalyptol or similar drugs. In its other uses it has been considered under Irritants. lodoformum. Iodoform [CHI3]. 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 very penetrating odor resembling that of iodine. It is practically insoluble in water, soluble in 47 parts of alcohol, and in 5.2 parts of ether. It contains 96.7 per cent, of iodine, to which its antiseptic power has been supposed to be due. However, Heile * finds 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 as a 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 and second being now official. They are all nearly insoluble in water. Thymol Iodide (Aristol), containing 46.14 per cent, of iodine. lodolum (lodol), containing 89 per cent, of iodine. Antiseptol, containing 50 per cent, of iodine. Losophane, containing 78 per cent, of iodine. Sozoiodol, containing 53 per cent, of iodine, 20 per cent, carbolic acid, and 7 per cent, sulphur. This substance has acid combining prop- erties and forms a soluble salt, the sodium sozoiodolate. In addition to the above group, the following substance, derived from coal-tar, holds a place as an antiseptic powder: Acetanilidum [CgHgNO]. AcetaniHd, a white crystalline substance obtained by the interaction of glacial acetic acid and aniline, is em- ployed in very fine powder, as an antiseptic, by being dusted upon wounds after surgical operations. Being only slightly soluble, it is an excellent substitute for iodoform. It is soluble in 179 parts of water and in 2.5 parts of alcohol. * See Gould's Year-Book of Medicine, 1905, p. 498. 138 LOCAL BEMELIES MISCELLANEOUS ANTISEPTICS. Among the following agents will be found none of the ready-made proprietary solutions or mixtures that are advertised so largely as anti- septics. Such are entitled to no place in a book that aims to treat sub- jects in a scientific way, for the basis of their exploitation is commercial, 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 disin- fection, Wadsworth,* working in connection with the Health Department 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 fre- quently 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 diffusive 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 under 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 diffusible, efficient and harmless. Betanaphtol. Naphtol [C10H7OH]. A phenol occurring in coal- tar, but usually prepared from naphtalin. It occurs in colorless or buff-colored cr)'stals, having slight odor and sharp taste, soluble in 950 parts of water and in 0.61 part of alcohol. It is neutral. * Journal of Infectious Diseases, October, 1906. ANTISEPTICS ' 139 Betanaphtol 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 : 950 saturated aqueous solution, which may be used to irrigate wounds and as a mouth wash freely, to the full- strength alcoholic solution (1: 0.61) 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. Incom'patihility . With chlorine water or bromine water betanaphtol will produce a white turbidity. Resorcinol. Resorcin [C6H602]. A phenol from various sources. Occurs in colorless or pinkish crystals, having a sweetish taste, soluble in 0.5 part of water and very soluble in alcohol, also soluble in glycerin or ether. It is neutral or slightly acid. This drug is useful as a mouth antiseptic, a 2 per cent, solution in water being a proper strength for mouth wash or gargle. In this strength it is frequently employed in whooping-cough to cleanse the throat and posterior nares. Although similar to phenol in action and uses, it is not corrosive and is less dan- gerous. The internal dose is double that of phenol and 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 chlorid or bromine water. :^ Potassii Chloras. Chlorate of Potassium [KCIO3]. Occurs in colorless crystals or white powder, odorless, and having a salty taste. It is neutral, soluble in 16 parts of water, insoluble in absolute alcohol. 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, phosphorus or other easily oxidizable substances. It is not a strong antiseptic, a 3 per cent, solution failing to prevent 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 as an internal remedy in aphthous stomatitis. The dosage should be mod- erate because of possible deleterious effect upon the blood, as it may change hemoglobin into methemoglobin. Dose, gr. 1-10 (gm. 0.06-0.60). Incompatibility. Besides the dangers mentioned above, the drug is incompatible with strong sulphuric and hydrochloric acids. (A drop of 140 LOCAL REMEDIES sulphuric acid will ignite a mixture of equal parts of potassium chlorate and sugar.) An aqueous solution precipitates with nitrate of silver. Potassii Permanganas. Permanganate of Potassium [KMnOJ. Occurs in dark purple crystals, having a characteristic, unpleasant taste, neutral, soluble in 15 parts of water. 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. 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 superficial 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 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 applica- tion 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. Incompatibility. With organic substances, or triturated with sulphur or other inflammable substances, explosion may occur. With carbolic acid oxidation occurs. Alcohol decomposes it. This drug should be used cdone in a simple aqueous solution. Sodii Sulphis. Sulphite of Sodium [NaaSOg + 7H2O]. Exposed to the air this salt is efflorescent and gradually oxidizes to sulphate. It is soluble in 2 parts of water, the solution being either neutral or feebly alkaline; slighdy soluble in alcohol. It may be used as a bleaching agent, acting by the abstraction of oxygen from the color- ing matter. (See undjer Bleaching Agents.) * Brunton's Pharmacology, 1885, p. 96. ANTISEPTICS 141 Sodii Thiosulphas. Thiosulphate of Sodium. Hyposulphite of Sodium [Na2S203 + 5H20]. This salt is soluble in less than 1 part of water and the solution is neutral ; insoluble in alcohol. Its antiseptic power makes it a useful mouth wash. It is also a useful internal anti- septic. Weisse employs the hyposulphite to treat abscess cavities, by packing with gauze saturated in a solution of 5j to fSj of water (12| per cent.). Zinci Chloridi. 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 weak solutions are employed (1 to 5 per cent.). It must be remembered that its coagulation of albuminous matter liberates hydrochloric acid, which should not remain about the teeth, but must be neutralized at once. Argenti Nitras. Nitrate of Silver [AgNOg]. 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 occuring during birth, nitrate of silver is most relied upon as the germicide. Also, in order to prevent this serious malady, the advice of Crede* should be supported and followed, which is, that the eyes of all babes born in charitable institutions should invariably have a 2 per cent, 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 preva- lence in the same institutions. Whenever nitrate of silver is locally applied any excess may be completely neutralized by a solution of sodium chloride. * The justification for this 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 308 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. ■» ^ 142 LOCAL REMEDIES Certain other preparations of silver have been found 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 soluble in water and in albuminous fluids. The aqueous solution of this (usually 1 per cent.) may be injected into infected tissues, or even intravenously in cases of septicemia. It is also used in form of ointment rubbed into the skin. The following are also now employed in general surgery: Silver Lactate. Actol [AgCgHgOg + HgO]. A white powder, soluble in 20 parts of water, said to be an efficient germicide in 1 : 1000 solution. Silver Citrate. Itrol. A white powder, slightly soluble in 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. This substance is a silver albumose, containing 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 fol- lowed 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. A number of other organic preparations of silver have been introduced under various names; but protargol is quite representative of the class, possessing the essential advantages claimed for them. 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 capable of pro- ducing a permanent staining of tissues, which is outwardly shown by a slight blueness of the skin. 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 [HgClJ. This substance occurs in colorless, odorless crystals, having a dis- agreeable metallic taste, soluble in 13 parts of water, in 3 parts of alcohol, and in about 14 parts of glycerin. It is acid in reaction, although the addition of chloride of sodium to its aqueous solution will render it alkaline. Because of its corrosive properties, for general antiseptic pur- ANTISEPTICS 143 poses it is used only in dilute solution of 1 : 2000 to 1 : 10,000. However, for limited use as a powerful disinfectant, 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 tissue, 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 one 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 sterilize 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 used cautiously and for a short time, to irrigate wounds and abscess cavities, to disinfect ulcers, and as douches into the several passages of the body. Whenever used, a 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 substances. Incompatibility. Mercuric chloride mixed with lime-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 silver 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.) * 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. 144 LOCAL REMEDIES Systemic Poisoning or Mercurialism. Only the soluble salts of mercury are capable of causing local irritation, but any preparation of this metal may cause mercurialism. 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 h}'peremia 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 us the picture of salivation in positive degree; fortunately the superlative degree, with ulceration and loss of teeth, is almost never seen to-day 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 mercurialism should call forth no reflection upon the physician who prescribed mercurv. This for two reasons : First, 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. Second, the condition may be intentional, for, in the treatment of secondary syphilis, it is usual to push the drug to saturation at first, then from that point to diminish the dose to that proper for the individual to continue. Treatment of Mercurialism. The patient will complain of two symp- toms if the condition is well developed: First, soreness of the teeth, and second, the constant flow of saliva which may interfere with sleeping. These will need to be relieved. Relief of the pericementitis and stom- atitis must be brought about by elimination through other channels than the salivar)^ and oral glands. The bowel being the most natural route for the elimination of mercury, saline cathartics, freely given, by their power of withdrawing serum from the blood, will serve our purpose best. The salivation may be controlled by belladonna or its alkaloid, atropine. Of the tincture give 5 minims (gm. 0.30), or of atropine gr, _^ (gm. 0.0006) two or three times daily. This is the best drug for this purpose, as it checks the salivary secretion very decidedly and is ANTISEPTICS 145 not disturbing to the system if used properly. Opium and morphine also cause dryness of the mouth, but their systemic effects are unpleasant, 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 recently 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 recommended. Its peculiar detergent property makes it particularly applicable to severe cases, where ordinary antiseptics are less useful. With 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 (gm. 0.60-2) 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. Oarbo Animalis. Animal Charcoal. Prepared from bone; employed as a decolorizing agent in preparing organic solutions. Carbo Animalis Purificatus. Purified Animal Charcoal. The puri- fication 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 power. Obviously its application 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 solutions of drugs, for it is capable of extracting organic principles, such as alkaloids and resins,* whereby the strength of the product would be * U. S. Dispensatory, eighteenth edition, page 329. 10 146 LOCAL REMEDIES lessened. Because of this behavior toward organic principles, purified animal charcoal has been proposed as an antidote to 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 condition giving it three distinct properties which 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 hydrogen dioxide in water keeps its strength and qualities for months at ordinary temperatures. Higher strength solutions require the addition of considerable acid or other preservative, and must be looked upon as unstable and dangerous to handle. 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. It is used chiefly as a bleaching agent. The official solution is called Aqua Hydrogenii Dioxidi. Solution of Hydrogen Dioxide [HgOj]. This is a colorless liquid, slightly acid in reaction, and it contains, when freshly prepared, about 3 per cent., by weight, of the pure dioxide, corresponding to about ten volumes of available oxygen. It is some- times known as the "ten volume" solution, as it yields upon decom- position about ten times its own volume of oxygen. The acid it contains is necessary to its preservation. The most characteristic property of this liquid is its foamy decom- position in contact with 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 a stopper of cotton be used in the ANTISEPTICS 147 bottle instead of an ordinary 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 libera- tion of oxygen. Upon a tender mucous membrane the action may be so irritating as to require dilution of the liquid. The oxygen in nascent condition is a powerful germicide and disinfectant, cleansing the surface of the tissue thoroughly without injury, for it does not coagidate, 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 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. By free use with repeated injection, it should be possblie to reach and destroy every particle of pus and of disorganized tissue. 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 pyorrhoea, 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 astrijigent, 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 148 LOCAL REMEDIES might easily attend its use ordinarily in empyema of the antrum, on ac- count of pressure from the rapid expansion of the liberated oxygen. Systematic 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. The use of this substance as a bleaching agent is discussed else- where. Formaldehyde [HCO.H]. This valuable recent 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 with corrosive sublimate. It fills a place that no other agent does as a really effective and practicable disinfectant gas. It is far superior to sul- phurous acid gas in respect of efficiency, penetrating power and non- action upon metallic furnishings. Various lamps and other apparatus for generating the gas for extensive use have been desired, and small fumi- gators or candles for limited use, as in the disinfection of books, instru- inents and clothing in a small air space. The gas is very irritating to the eyes and to the air passages. 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 about 40 per cent, (not less than 37 per cent., U. S. P.) of formaldehyde gas. It has a pungent odor and caustic taste, being irritant to tissues. It is the commercial form of the drug and is miscible with water and with alcohol in any propor- tion. It should be neutral or only faintly acid in reaction. Upon standing it may become cloudy from the separation of paraformalde- hyde. A stronger solution is unstable. A much weaker solution must be used for application to living tissues, for this substance is charac- terized by its 'penetrating quality and irritant action. While this drug 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. It 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 * Cushny's Pharmacology, 3d edition, p. 429, ANTISEPTICS 149 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, \ per cent, of formalin should never be exceeded. For disinfection of pulpless teeth 5 per cent, may be used. Although this drug has not fully found its place in den- tistry, its qualities of penetrating and gradually hardening tissue would entitle it to thorough trial for purposes of pulp disinfection and mummi- fication. 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 experi- ments of Hunt and Jackson* 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 staphylococcus 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. f 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.! An important use of formaldehyde is in the hardening and preserva- tion of anatomic and pathologic 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. Hexamethylenamina. Urotropin [C6H12N4]. This substance is a chemical compound of formaldehyde and ammonia. It occurs in color- less crystals which are soluble in 1.5 parts of water and in 10 parts of alcohol. The aqueous solution is alkaline. The chief value of uro- tropin is as an antiseptic to the urinary tract. The explanation of its action is, that when eliminated by the kidneys it is decomposed into formaldehyde and ammonia, the former acting then as an antiseptic. It is a very efficient agent. * Transactions of the Dental Society of the State of New York, 1904, p. 94. t Annals of Surgery, October, 1904. t Dental Review, August, 1898, p. 607. CHAPTEE 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. Kirk, in the American Text-hook of Operative Dentistry, gives a systematic presentation of present-day knowledge of methods of bleach- ing discolored teeth, which must stand as the authority of to-day upon this special subject. The province of the chapter here presented is to deal with substances rather than detailed methods of their application. The chief agents employed to bleach teeth are discussed, therefore, 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. b. 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. Wliile the use of chlorine to secure a change of the metallic deposit to a chloride, followed by thorough wash- ing with warm distilled water, is held to be the general rule of treatment, its final success may depend upon the solubility of the chloride. Chlo- rides are commonly soluble in water, but silver chloride is an excep- tion, it being entirely insoluble. Hence, in removing silver stains the chlorine treatment is followed by a saturated solution of sodium thiosul- (150) BLEACHING AGENTS 151 phate (hyposulphite), which is a solvent for chloride of silver. In remov- ing 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 aflBnity 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 Sodae Chlorinatae. Solution of Chlorinated Soda. Labar- raque's Solution. This liquid contains at least 2.4 per cent, of available chlorine. Calx Chlorinata. Chlorinated Lime. This is a whitish powder con- taining at least 30 per cent, of available chlorine. The powder dete- riorates 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 chlorinated 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 tartaric 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. Hydrogen Dioxide. This substance and its properties are discussed fully in the chapter on Antiseptics. ^^Hiile the official 3 per cent, solution 152 LOCAL REMEDIES possesses some degree of bleaching power, its use has been largely super- seded bv that of the "caustic p^Tozone" or 25 per cent, ethereal solution. Its value depends upon the nascent ox^-gen "v\"hich it liberates. Kirk* states that "more rapid and permanent effects are produced when the p^Tozone solution is rendered alkaline," which may be done by the addi- tion of a httle 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. This agent is also employed by cataphoresis, for which purpose an aqueous solution must be prepared from the 25 per cent, ethereal solu- tion^ as the latter presents too great resistance to the current. This is accomplished by mixing two volumes of the 25 per cent, ethereal solution with one volume of water and heating gently until the ether is evap- orated. Care must be taken to prevent ignition of the ether vapor. The 3 per cent, aqueous solution may also be concentrated by careful heating at 60° C. a-iO° F.). Sodium Dioxide. Sodiu:m Peroxide [Xa202] (not official). 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 strono:lv alkaline. Its valtie as a bleacher is threefold: First, it liberates nascent oxygen as does hydrogen peroxide, but after parting with one of its atoms of ox;\-gen it still possesses caustic and alkaline properties. (Kirk.) Second, it possesses some solvent power upon albuminous matter. Third, it has the power of saponif\-ing 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 solu- tions are desired in some cases, they may be prepared from the saturated solution by diluting carefully with water. Benzoyl-acetyl Peroxide. Acetozoxe. Benzozone [C^li-COOOCOCIi^ fnot ofiicial). In a comparative experimental study of bleachersf Dr. Hoff has obtained results that wotdd 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 * American Text-book of Operative Dentistry. t Dental Cosmos, February, 1902. BLEACHING AGENTS 163 structure. It acts slowly, and it may be allowed to remain for some time within the cavity. This drug is obtainable in form of a whitish powder, consisting of 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 [SOj] (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 (SOg) possesses the stronger affinity, being oxidized in the presence of water to sulphurous acid (SO3H2), and finally to sulphuric acid (SO4II2). 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 solutions of iodine. 154 LOCAL REMEDIES Sodii BisulpMs. Bisulphite of Sodium [NaHSOs]. Sodii Sulphis. Sulphite of Sodium fNa2S03 + 7H20]. These salts are freely soluble in water, and when exposed to air lose 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 Sodium [Na2S203 + 5H20]. This salt, soluble in 0.35 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. AxESTHETics are agents used to abolish sensibility, for the purposes of surgical treatment, the relief of spasm, and the alleviation of severe pain. Complete cjene/al anesthesia includes unconsciousness, due to paralysis of the cerebral cortex, and loss of excitability of all centres of reflex action, except those concerned in the functions of respiration and circulation. Local anesthesia means usually the abolition of sensibility to pain 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 : (155) 156 LOCAL REMEDIES Refrigerant Analgesics, or those which cause an abstraction of heat from the part, even to tlie point of freezing the tissue, and Paralyzant Analgesics, or those which have a specific paralyzant action upon the sensory nerve terminals. The refrigerant class comprises: 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 vapor, requires a certain amount of heat to effect the change. The heat so required becomes latent in the new form of the substance and is 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: .ffither (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, but probably not explosive. LOCAL ANALGESICS 157 The comparison of boiling points and inflammability of the above agents indicates the superiority of ethyl chloride, which 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 at 46.4° F. of 0.918. The specific gravity of its vapor is 2.22. It is put up for use in sealed tubes containing 2^ 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. 2 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 co-operation. With this agent a number of teeth may be extracted at one sitting with prac- tically no danger; moreover, by inhalation the drug has been found to be a quick and powerful general anesthetic, whose safety seems to be equal to that of ether; so there is very little danger from any inhalation of the drug attending its local use. The full efi^ect of the 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. 158 LOCAL BEMEDIES On the whole, the use of this substance is to be highly recommended. 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. 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. Only the first is official. Cocaine Hydrochloride, soluble in 0.4 part of water, 2.6 parts of alcohol. Eucaine Hydrochloride (Beta),* soluble in 30 parts of water. (See p. 169.) Tropacocaine Hydrochloride, soluble in water. (See p. 169.) Holocaine Hydrochloride, readily soluble in boiling water, which upon cooling leaves a 2^ per cent, solution. (See p. 169.) Nirvanin, easily soluble in water. (See p. 169. ) Stovaine, easily soluble in water and in alcohol. (See p. 170.) Alypin, soluble in water and in alcohol. (See p. 170.) Novocaine, soluble in 1 part of water, 30 parts of alcohol. (See p. 170.) Orthoform, slightly soluble in water, freely in alcohol. (See p. 170.) These all obtund or paralyze the sensory nerve terminals wherever they are applied, affecting 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 h^-podermically ; except, that in the application to the very sensitive mucous membrane 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. Cocainse Hydrochloridum [C17H21NO4HCI] stands as the typical and chief agent of this class. It is a neutral salt of the alkaloid cocaine, from the leaves of Erythroxyloii coca and other varieties of coca, grown chiefly in Peru and Bolivia. ^"Miile the alkaloid was discovered about 1860, and its peculiar analgesic power obser^^ed soon after, its introduction to the medical world as a practical local analgesic was due to Karl Koller, who in 1884 reported experiments to the Congress of German Oculists. In a few weeks cocaine was being used all over the world. f * Alpha-eucaine, being more irritating, is now seldom used, y Park's History of ]\Iedicine, PLATE II. COCA. The leaves of Erythrosylon Coca or E. Truxillense. The alkaloid Cocaine fully rep- resents the drug. [For preparations and doses, see Index of Drugs.] Classified as : Cei'ebral stimulant. Mydriatic. Local analgesic. General protoplasmic poison. Physiologic action: Sensory The drug pro- nerve endings 1 r . 1 depressed — — duces liist a de- ,^ , . when locauy scendmg stimula- applied. 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 Vagus Center Vaso Motor Center Cervical Sympathetic poisoning may show mixed Voluniarxj symptoms of stimulation and depression. The two diagrams presented (Plates II. and III.) show the stimulant and depressant effects respectively. Stomach. The local effect is to benumb the sensory nerve endings in the stomach. Nervous Si/stem. Bi'ain. Stimulates the cerebral cortex. Medulla. Stimulates respii'atory 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. Eate 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 eflfects of Cocaine. LOCAL ANALGESICS 159 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. 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 sensibility of the organ, and thereby lessens 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. 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 ; there- fore 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 expression, and its impairment is, therefore, more easily appreciated. Being one of the drugs that combines a stimulant (early) effect with a depressant (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 seems to be more rapidly disastrous than those of morphine. * We are indebted to Dr. G. W. Crile for some facts concerning the value of cocaine in blocking nen-e trunks to the transmission of sensory impressions from an injured part of the body. By very careful experiments he has come to the conckision that one prominent factor in surgical shock is the depression of the vasomotor system by exhaustion of the centres. 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 abolish its power of carrying sensory impressions. 160 LOCAL REMEDIES 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 only soluble in 600 parts of water, while the hydrochloride is soluble in 0.4 part of water. It is also soluble in 2.6 parts of alcohol. It is obtained in form of crystals or a crystalline powder, permanent in the air and bitter to the taste, leaving a sensation of numbness upon 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 w^hen 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 carbolic acid may be added. One per cent, of this should prevent the growi;h of organisms, and in this strength the coagulant action of the drug is scarcely noticed. Boric acid likewise is used as a preservative in the proportion of 2h per cent, to the aqueous solution of cocaine. Salicylic acid is also recommended in the strength of 0.1 per cent. (1:1000). Chloretone is used by some in the strength of J to ^ per cent. Local Action of Cocaine. The chief interest of the dental surgeon in this drug centres about its use as applied locally to, or injected beneath, the mucous membrane. AYhen 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 the 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 occurs 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. Some 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 follow^ed by a relaxation that permits hyperemia 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. PLATE III. Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus COCAINE. 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. Cerebral functions are depressed, frequently with production of narcosis or convulsions. Medulla. Depi-esses respira- tory center and probably vaso-motor center. Spinal cord. Depresses re- flex centers. Circulation. Arterial pressure is lessened. Heart. Depressed by direct action of the drug. Capillary area. Arterioles 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 pai-al- yzant influence upon nei-ve tissue when locally applied. For local analgesic purposes the alkaloid Cocaine is employed in from J to 4 per cent, solutions. The blue color indicates the depressant eflfects of a toxic dose of Cocaine. LOCAL ANALGESICS 161 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 maximum quantity allowed to gain entrance into the circulation at one time should not exceed one-quarter of a grain. This ought to be the limit in the ordinary use of the drug 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 2 per cent, solution will usually suffice, and of this twelve and one-half 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 stom.ach 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 equal | of a grain, which would be within the safe hypodermic 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.| 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. * American Text-book of Operative Dentistry, second edition, page 641. t Wood's Therapeutics, eleventh edition, page 201. t Ibid. I Ibid. 11 162 LOCAL REMEDIES solution upon the conjunctiva of a girl of twelve years produced violent 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. We cannot avoid the impression that idiosyncrasy must account for the occurrence of such cases, but the fact that they are not rare should lead to the exercise of the greatest care and discrimination in the employ- ment of cocaine. In the interest of safety the weaker solutions may be employed in combination with other drugs that aid the action of cocaine, to which later reference is made. Schleich Method. Mention should also be made of a modification known as the Schleich 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 suffices for slight operations. While this method will probably never be extensively used in dental surgery, it has the advan- tage 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 usually 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 * The precise formulse of the three solutions are as follows: 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 LOCAL ANALGESICS 163 ingredients are given ; while if the practitioner orders by his own formula of official drugs, his pharmacist can guarantee accuracy. 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- onists to the drug. This implies 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 to-day. As a type of combination that will be found generally applicable, the following is suggested: Gm. o • c.c. . — Cocainse hydrochloridi, 16 (gr. iiss) Atropinse sulphatis, 008 (gr. i) Strychninse sulphatis, 03 (gr. ss) Phenolis, 12 Kij) Aquae destillatse, q. ; i. ad 15 (flss)-M. The cocaine strength of this solution will be 1 per cent., and each 15 minims will contain ^ grain, with jhu grain of atropine, and 3I5- 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 in 0.8 per cent, is for preservation. Even less will suffice to keep the solution 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 ad- vantage 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 chloride solution when used. General Action of Cocaine. Plates II. and HI. are intended to illus- trate the action of the drug upon the different parts of the system. * Dental Cosmos, September, 1908, p. 931. 164 LOCAL REMEDIES Aids to the Action of Cocaine. Other agents of the same class, that are less poisonous and sufficiently soluble, may supplant cocaine to some extent. Eucaine, tropacocaine and carbolic acid may be combined with cocaine in the same solution. If there is an open wound or denuded surface orthoform powder is useful. Agents that lessen the blood supply to the part, as cold applications, will aid slightly. The use of adrenalin as an aid to the action of cocaine is growing in favor. The claim that less cocaine is needed when so combined seems to be 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 circulation 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, which means that more remains just where its effect is wanted, and the danger of systemic poisoning is slightly 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 con- siderably 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, so as to lessen the circulation within it, the entrance of the cocaine into the general circulation will be limited and its local effect prolonged. Morphine has little or no local analgesic action,")" therefore it is without value as an aid to cocaine. Antagonists to the Action of Cocaine. Poisoning by cocaine may be due to: (a) Idiosyncrasy, rendering the patient very sensitive to its action. Q)) A weakened state of vital organs, rendering them more liable to depression by the drug. (c) An overdose. (See Plate III.) The most serious conditions in cocaine poisoning are depression of heart, vasomotors and respiratory centre. The combined result of these is to lessen the arterial pressure very decidedly, with a certain degree of * See Gould's Year Book of Medicine and Surgery, 1905 (Medical vol.), p. 472. t See notes on page 85. LOCAL ANALGESICS 165 asphyxia added. These are the conditions to be antagonized. There- fore, it appears at once that any agent that does not either stimulate the vasomotor system, the heart, or the respiratory centre, 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 reduce the arterial pressure.* Our best antagonists will be those that increase arterial pressure by stimulation of both vasomotor centres and heart, and which at the same time stimulate the respiratory centre. Three agents that act in all three ways are caffeine, strychnine and atropine. 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 dose of strychnine sulphate is -^-q to ^t o^ ^ grain (0.001-0.006 gm.) and of atropine sulphate TT^to g-Vof a grain (0.0005-0.001 gm.), and both are sufficiently soluble so that they may be combined in the same solution with cocaine. The dose for injection at one sitting should not exceed j grain of cocaine hydrochloride, y|-q of atropine sulphate, and -J^ of strychnine sulphate; then in case of danger symptoms 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. * Nitroglycerin has been prominently mentioned as an antagonist to cocaine, but if it is of value in any case, it must be only when employed with discrimination. If the action of adrenalin locally is an advantage, when combined with cocaine, then the local action of nitroglycerin cannot be, for they are exact antagonists in influencing the circulation locally. As to its general effect, it is contraindicated when blood pressure is low. In poisoning by cocaine it would be of no value if reduction of pressure had followed the early slight rise; and if there is much depression of the cir- culation it may do harm by further reducing blood pressure. It is doubtful whether nitroglycerin has any direct stimulant action upon the heart. (See Plate XIII.) f Caffeine in its simple form is soluble in 45.6 parts of water and 53.2 parts of alcohol at 25° C. (77° F.), but the addition of benzoate or salicylate of sodium renders it very soluble in water. Caffeine-sodium salicylate and caffeine-sodiimi benzoate each are soluble in 2 parts of water and may be used hypodermically in dose of 1 to 5 grains (0.06-0.30 gm.). Citrated caffeine forms a clear, syrupy liquid with about 4 parts of hot water. Upon dilution with water, tliis yields a white precipitate (caffeine), which redissolves when about 25 parts of water have been added. 166 LOCAL REMEBLES Acute Poisoning. The poisonous effects of cocaine are variable. The drug has the power to first stimulate and later depress the central ner- vous system, but when a toxic condition suddenly occurs there may be an irregularity of symptoms. There are likely to occur, however: (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. In treating the condition, we must rely upon 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 f5i-l (1-4 c.c.) of tincture of digitalis may be given h}^odermically. But it must be remembered that digitalis 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 hvpodermically in ordinary quantities; but its use by the latter method should be resorted to quite freely in emergency. One to 5 c.c. of the 1 : 1000 solution, diluted with ten times as much normal saline solu- tion, may be injected. 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, spirit of ammonia, alcohol, spirit or compound spirit of ether, each in dose of 15 to 60 minims diluted with twice as much water, and whisky and brandy, 1 to 2 fluid- drachms undiluted. 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. LOCAL ANALGESICS 167 esophagus and stomach may be decided, and the consequent reflex stimulation of the heart and respiratory center be efficient. Irritation of the skin by friction, slapping or faradism will act in the same way, but less efficiently than the above agents applied to the mucous mem- brane. Fig. 3 Sylvester's method of artificial respiration: movement of inspiration. 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. In connection therewith massage of the heart by an assistant, by pressure Fig. 4 Sylvester's method of artificial respiration: movement of expiration. between diaphragm and chest wall, particularly with the movement of expiration, has come to be employed as an important aid in re-estab- lishing the heart's efficiency. It is most effectual in cases where the irritability of the heart muscle is not much impaired. Sylvester's method of artificial respiration is the one most commonly employed. Figs. 3 and 4 show the position of patient and attendant. i68 LOCAL REMEDIES The movements of inspiration and expiration should succeed each othef 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. AVhenever artificial respiration is needed in any kind of poisoning, it should be continued until natural respiration is established. This may require hours of work by a relay of assistants. 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 falling naturally into the lower intercostal spaces. Resting his elbows 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, tivo, then repeats, and so on about eight or ten times in a minute.' " The Laborde method of rhythmic 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 dry napkin, or by a tenaculum or forceps, and drawn forcibly forward at intervals of about four seconds. Laborde holds that this measure 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 useful in resuscitation from dangerous anesthesia and from opium poisoning. Incompatibility. Cocaine hydrochloride is incompatible with alkalies and alkaline carbonates, with tannic acid, and with some metallic salts. It is decomposed by potassium permanganate. With solution of silver * 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 slightly. ■{• Atkinson. American Text-book of Applied Therapeutics, 1896, p. 37. PLATE V, Danger area Anesthesia area 1. Consciousness abolished 3, Hespiration paralysed 4, Circulation paralysed \ Heart 2. "Reflex activity abolished 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 irritable muscular structure, provides for its auto- matic, rhythmic action. This provision is quite independent of the cerebrospinal sys- tem.] LOCAL ANALgJESICS l6& nitrate a white precipitate of chloride of silver occurs. A white pre- cipitate also occurs with a solution of borax or with a strong solution of fhenol. According to Gorgas it reacts chemically with mercurous chloride and with mercuric oxide.* Substitutes for Cocaine. It cannot be said that any drug has yet been found that is equal to cocaine when we consider activity, solubility and reliability. But the several substitutes named in the cocaine group deserve mention, with a statement of the advantages claimed for them and the disadvantages attending their use. Any agent of this group, in order to be entitled to consideration, must compare favorably with cocaine not only as to efficiency, but in addition it must be less toxic, or its solutions must keep better, or it must possess some other decided advantage. EucAiNE Hydrochloride. Beta-eucaine Hydrochloride {C^^^^O^- HCl] (not official). This artificial alkaloid has found its place of usefulness as an efficient analgesic and it is less toxic than cocaine. It is soluble in about 30 parts of water and its solutions not only keep well, but may be boiled without injury. It is rated as about one-fourth as poisonous as cocaine, but it is more irritating and its combination with adrenalin is less efficient. It is used in from 2 to 5 per cent, solu- tions for direct application or hypodermic injection, and in 1 per cent, strength may be substituted for cocaine in the Schleich solutions for infil- tration anesthesia. Tropacocaine Hydrochloride (not official). Tropacocaine is an al- kaloid obtained from the leaves of Java coca, but prepared also syn- thetically. While less toxic than cocaine, twice the amount is needed to produce the same effect, and it is more irritating, but its solutions are said to keep better. Holocaine Hydrochloride (not official). This drug is an antiseptic, therefore its solutions will keep indefinitely. It is soluble in 50 parts of water. (See p. 158.) While it is claimed that its action is more powerful than that of cocaine, it is more irritating and more toxic. Sudden death has occurred during its use. Nirvanin (not official). This occurs in crystalline or powder form, is soluble in water and 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. It is reported to be only one-tenth as toxic as cocaine, and in efficiency to compare quite favorably with other substitutes for * Dental Medicine, fifth edition. 170 LOCAL REMEDIES that drug. As it is too early to give accurate conclusions from experience it should be used, if at all, with due caution. Stovaine (not official). The solution of this drug is acid. It is less toxic than cocaine, but it is less efficient and more irritating. The two following drugs seem to possess more advantages than the above. Novocaine particularly is gaining recognition as a really practi- cal and efficient substitute for cocaine. Alypiii (not official). This substance presents the advantage of being nearly as efficient as cocaine, while scarcely more irritating, and it is claimed to be less toxic. It is used in solutions of from 2 to 10 per cent. It causes some hyperemia when applied to the conjunctiva, and it is stated that hemorrhage following its use is not so easily controlled by adrenalin as after cocaine. Novocaine (not official). This drug is soluble in 1 part of water. It is non-irritating and causes no h}^eremia. It is much less toxic, though less efficient than cocaine, and its effect is more transient. Its action is increased by adrenalin. Prinz * 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 cliloride solution when used. Orthofonn (not official). This drug is inferior to cocaine because of slight solubility in water, but fills a distinct place among analgesics on ac- count of that fact. It is useful for prolonged effect dusted upon ulcerated or denuded surfaces. It cannot be used hypodermically to advantage, although some surgeons have reported success in its use in this way, the drug being suspended in water for injection. It is freely soluble in alcohol and in ether; also soluble in equal parts of alcohol and water. In powder form it is an ideal dressing for painful burns; and it may be dissolved in collodion for local use upon a dried surface for wounds resulting from injury or from surgical operations. It is not poisonous to the system in quantities ordinarily employed, the internal dose being * Dental Cosmos, September, 1908, p. 932. LOCAL ANALGESICS 171 from 1 to 15 grains (0.06-1 gm.). After extraction of teeth from an inflamed alveolar process, and when laceration of tissues in the mouth has been unavoidable, the resulting pain and soreness may be largely relieved by the application of orthoform in powder. It may also be packed into the tooth socket with good effect after extraction. Incompatibility. Orthoform is generally used alone. It is incom- patible with silver nitrate, potassium permanganate and with zinc chloride. 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 will probably soon be defined. When employed, the injection should be made as low down as possible, so as to avoid the effect of the drug upon the medulla. The method for the present should be used only in those cases where a general anesthetic is contraindicated, and where the site of injection may be at a point some distance from the medulla. PART 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 thirteenth 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 William 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 gas also was known for many years before it came to . be practically applied as an anesthetic. In 1799 Humphry Davy, of England, observed the exhilarating and intoxicating effects caused by inhaling this gas, and published his investigations in 1800. The credit * For a fuller discussion of the history of anesthesia, see Park's Epitome of the History of Medicine. (173) 174 GENERAL REMEDIES 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- tively 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 conscioiis sensation, but where the reflex centres of the spinal cord are still sensitive, as shown by muscular activity whenever sensory nerves are irritated. The typical anesthetics are peculiar in respect to the order in which they 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 pro- cedure; and so it appeared until it was ascertained that the paralysis was induced in such order that the centres 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 numbered 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) are affected later, being apparently more resistant to the influence of the drugs of this class. Mode of Induction of Anesthesia. Various 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 all theories have yielded to a positive belief that these substances produce their effects chiefly by a direct action upon the nerve centres. These theories have, however, emphasized certain factors which often contribute to the result and which may also be elements of danger. Thus, local anemia in the brain will undoubtedly facilitate anesthesia, but if that anemia be due to arterial disease, the dangers of the condition may contra- indicate the use of certain agents. Again, and more important, the ANESTHETICS 175 factor of asphyxia is present with anesthesia in the majority of cases where an agent is employed with a hmited supply of air. This is particularly true when either nitrous oxide or ether is used. It must be remembered that whatever abolishes brain function tends toward unconsciousness, whether it be injury, anemia, drug action, or want of oxygen; and whenever the inhalation of an anesthetic is con- ducted by a method that greatly reduces the amount of air, the factor of asphyxia must necessarily be present in some degree. This obser- vation might be taken as an argument in favor of chloroform, which is given so largely diluted with air, but the answer must be that there are greater dangers than asphyxiation; and chloroform is a drug whose depressant action upon vital structures greatly exceeds in its danger that of moderate asphyxia. 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 fatty 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 suflBcient quantity. Nitrous oxide may need to be excluded from this explanation; and while it is probably true that all anesthetics do not act in the same way, there can be little question as to the fact of their central action. The direct action of the drug upon nerve centres then constitutes the essential point in anesthesia production. Equally does it furnish the index as to danger or safety in the course of its inhalation. Plate V. will aid us in appreciating the stages through which the action of anes- thetics 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 Consciousness.* 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. * This stage is described by some authorities as the stimulant stage, but the stimu- lant effects noted are mainly reflex, while the real condition is one of depressed consciousness. There is frequently noticed quite early a very brief period of com- plete relaxation, during which a slight operation might be performed. 176 GENERAL REMEDIES The cerebrum is very quickly affected, with the production of various manifestations of disturbed or uncoijtrolled 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. The pupils are responsive to light and are apt to be dilated. The special senses are 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 centres here concerned are mostly situated in the spinal 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 when ether is used, than with chloroform. The pulse is not much influenced except in point of arterial pressure, which is reduced, especially so by chloroform. 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, occurs. Vomiting occurs as a very unpleasant com- plication if the stomach contains any food, especially when ether is employed. During this stage conscious sensation of pain is abolished, but, as a rule, surgical procedure is impracticable until complete relaxation occurs, 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. With the occurrence of complete anesthesia the whole muscular system is relaxed sleep is profound, reflex activity is absent; in fact, there is temporary total paralysis of nervous and muscular sys- tems, except those parts concerned with respiration and circulation. The pulse is not much altered in rate, but blood pressure is somewhat lessened. Respiration is full and as regular as during profound sleep. The pupils are contracted and do not respond to light. The cornea is insensible to touch. The general appearance does not differ much from ANESTHETICS I77 that of a person in a deep sleep. However, with ether the face is apt to be more flushed than with chloroform. With 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. (b) The degree of muscular resistance. (c) The condition of the pupil of the eye. As shown in Plate V., 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 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 touching 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 centres 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. Any 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 when 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 whole 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 12 178 GEXEBAL REMEDIES surgical irritation as pain, and will remember nothing of the opera- tion, even though some struggling may have occurred through reflex activity. The pupils remain responsive to light so long as anesthesia is not complete, with a tendency to dilatation during the early stages, due to the excitement that is more or less evident. AYith 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 acti^dty, which will be accompanied by the eye reflex and may call for more anesthetic, or it may mean a paralysis, which indicates a most serious depression of the nervous system that may be speedily fatal. The latter will be unaccompanied by any sign of reflex activity or of muscular resistance, but relaxation will be com- plete. Second, as indicating danger, note should be taken of: (a) The respiration. (6) 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 centres in the medulla. Early in the administration, respiration may be interrupted by the chokuig sensations experienced by the patient, and after consciousness is lost there is usually some stoppage due to reflex influences; 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 dra^^ing 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. AYhenever 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 ANESTHETICS 179 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 by exhalation, and the free supply of oxygen by inhalation, are most urgently required. The 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 marked 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 pressure, 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. The Pupils. The danger symptom that may be presented by the pupils occurs only during profound anesthesia, and consists of dilata- 180 GENERAL REMEDIES tion. This may represent stimulation of the dilator centre due to asphyxia,* but it has also been taken to mean a paralysis of the contractor fibres. 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 very jrequently, and any dilatation not accompanied by response of reflexes should require suspension of the anesthetic and immediate attention to the patient's condition. Recovery from Anesthesia varies in time from a very few minutes after nitrous oxide and chloride of ethyl, to a number of hours after ether. The patient often passes through a stage of excitement similar to that preceding anesthesia, but as a rule less pronounced. Vomiting almost invariably occurs w^hen 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. Contraindications to Anesthetics. In general, we may say that serious disease of brain, lungs, heart, bloodvessels or kidneys contraindicates 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 contraindications to indi^'idual agents more definite statements can be made. For Nitrous 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 belief that the element of asphyxia leads to contraction of arterioles, with increased blood pressure in the smaller arteries. Apoplexy, from arterial ruptiu-e 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- * Sollmann, Text-book of Pharmacology, 1901, p. 441. Anesthetics l8l sated, IS less a contraindication than is degeneration of the heart muscle as indicated by weakness, irregularity or dilatation. For Ether. Whatever contraindications apply to chloroform will apply with less force to ether, with the added qualification that ether has very little depressant action upon the heart. 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 probable 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 contraindications 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. Autointoxication and Asphyxia. One danger of anesthesia that has not been sufficiently recognized is that of autointoxication. 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 waste products accumulate in the tissues. The result will be interference with function, and possibly degeneration. Cases of death occurring several days after the use of ether or chloroform, the immediate effect of the drug having been recovered from, are probably due more to autointoxication than to the particular anesthetic employed. It is true that nitrous oxide anesthesia, as usually employed, 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 pro- longed use should be accompanied by inhalations of pure oxygen. It may be too early to insist upon the use of oxygen as routine practice in connection with anesthesia of moderate duration, but it is certainly advisable in greatly prolonged anesthesia with any agent. Objection must be made to inhalers for ether, ethyl chloride, or chloroform that do not admit enough air for proper oxygenation of the blood. Preparation of Patient for Anesthesia. For ordinary nitrous oxide anesthesia it is only necessary to be assured of the non-existence of * See conclusions of Committee of the British Medical Association, Lancet, London, 1901, vol. i. p. 280. 182 GENERAL REMEDIES 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 either of these, 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 administering ether or chloroform without first ascertaining that no disease exists in heart, lungs, brain, bloodvessels and kidneys, sufficient to constitute a con- traindication. It is wise to examine the patient's urine in every case. 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 important 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 appliance must be removed from the mouth. When 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 probable unpleas- antness of the vapor, so as not to be surprised by the sense of suffocation. The clothing about the neck, chest and waist should be sufficiently loose to allow of free respiratory movements, and the patient should finally be instructed to breathe deeply. In case of emergency requiring an operation at night, ether must not be used in the presence of a gas flame or ordinary fire. The vapor of * Reese. Medical Jurisprudence and Toxicology, second edition, p. 559. ANESTHETICS 183 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. For 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 diffusion 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 absolutely recjuire 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 administration the requisite knowledge and skill ; and the dental practitioner must deter- mine 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 * 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 Proving 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 evidenced by blowing out of the cork. In four of the ex- periments, with mixtures containing from 0.93 per cent, to 1.65 per cent, by volume of ether vapor, no explosion occurred; while the other six experiments, with mixtures containing from 1.67 per cent, to 2.39 per cent, by volume of ether vapor, were each attended by explosion. The minimmn percentage attended by 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 indicate that in a room of 1000 cubic feet space (10x10x10 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 would 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. 184 GENERAL REMEDIES 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. Nitrous Oxide (not official). A gas having the formula NjO, capable of being liquefied under pressure. It is colorless, odorless, and has a sweetish taste. It is soluble in water and in alcohol. It is not com- bustible, 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 wellnigh 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 proven to be the safest general anesthetic known. Its effects 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. With 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, jirst, by its employment to secure anesthesia quickly, to be followed by ether, thus shortening the period and removing the unpleasantness of the early part of ether administration ; and second, by its combined inhalation with oxygen, whereby the element of asphyxia is removed, permitting the anesthesia to be continued indefinitely as with other agents. This latter method is undoubtedly destined to greater use in cases where other anesthetics are contraindicated. Complete 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 \^^-^^^ Cerebellum -Section of j. — -j I Capillary Ai\ *S' Late Effec\ K Vagus Cent\ Vaso Motor Center 'Cervical Sympathetic -Solar Plexu The bluJ^te blue color indi depression cause chloroform. PLATE VI. PLATE VII. Va(ius Center Vaso Motor Center 'Cervical Sympathetie Solar Plexus ^THEE. CHLOROFORMUM. Classified as : Stimulant. Anodyne. Irritant. Anodyne. Auestlietic. Anesthetic. Antispasmodic. The action of these two substances is very similar, the main differences being in the degree in which they aiTect various organs. Physiologic action : The blue color indicates depression caused by ether. Ether, in the concentrated form in wliich it is administered, is more irri- tating than chloroform, tlierefore the pri- mary reflex stimulation and the later excitement are much more pronounced. It may cause danger by paralysis of respiration, but the heart is depressed so slightly that recovery may usually be secured. Locally applied, the drug is an irritant. Nervous System. Brain. Depresses cerebrum, abolish- ing all of its functions. Medulla. Of the whole central ner- vous system the medidla is affected last. In dangerous narcosis the re- spiratory and vasomotor centers a."e paralyzed. Spinal cord. Abolishes all func- tions, the sensory side being paral- yzed before the motor. Oirculafion, Not much altered from the normal un- til anesthesia is profound, when ar- terial pressure is diminished. Heart. Early may show reflex stimu- lation. Later not much affected unless administration is prolonged, when some depression may occur. Capillary area. Some dilatation of cutaneous arterioles usually occurs, with flusliing of the face. Eye. Early the pupils are dilated. During complete anesthesia they are con- tracted. With dangerous paralysis they dilate. Mespiration. May be irregular or in- terrupted during partial anesthesia. During full anesthesia it is regular and normal, as during sleep. In dangerous narcosis it fails, through paialysis of the respiratory center. Temperature is i-educed during anesthesia. Metabolism. Influence is usually slight and transient. The drug is eliminated chiefly by the lungs. Cliloroform is pleasanter to inhale, but much more depressant to nerve centers and heart. According to Cushny.it is 3 to Si,^ times as de- pressant to the central nervous system, and 36 to 48 times as depressant to the heart, as is ether. It usually causes death by paralysis of respi- i^tion, the heart continmng 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 paiulyzed first. This is probably true in cases of degen- eration of the heart. Locally applied, the drug is an irritant, 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 respiratory and vasomotor centers are paralyzed. 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 heart 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. piratlon. During partial anesthesia it is disturbed 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 paralysis of the respiratory center. Temperature is reduced during anesthesia. Metatiolism. Destruction of proteids is increased with less perfect oxida- tion. Fatty degenei'ation of heart, liver and kidneys may occur. The drug is eliminated chiefly by the limgs, but it has been found in the urine. The blue color indicates depression cajsed by- chloroform. ANESTHETICS 185 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 excitement 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 fully under its influence, the combined inhalation of oxygen and nitrous oxide will remove the asphyxia without terminating the anesthesia, which will continue as long as nitrous oxide is administered. .ffither. Ether. Ethylic Ether. Composed of 96 per cent, of ethyl oxide [(02115)20] and 4 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 0.716 to 0.717 at 25° C. (77° F.). Its vapor is heavier than air, and may be explosive when mixed with air and brought into contact with a flame. It is sol- uble in about 10 times its volume of water, and is miscible with alcohol, chloroform and oils. Ether boils at about 35° C. (95° F.). One official 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 tube is closely grasped and held for some time. The vapor being explosive, ether should be 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 and doses, see Index of Drugs.) Administration of Ether. Ether is best administered by an inhaler that admits sufficient air for oxygenation, but so arranged that the air becomes saturated with the ether vapor. For occasional administration no inhaler is better than one prepared at the time by folding within a towel a newspaper of ordinary size, previously folded to a width of 5 or 6 inches ; then rolling into proper shape to fit about the mouth and * Regarding the degree of explosives of ether vapor, see note, p. 183. 186 GENERAL REMEDIES nose, and pinning securely, the towel being pinned loosely also at the distal end. The folded newspaper is sufficiently impervious to prevent loss of ether and it makes a firm cone. A piece of gauze or cotton placed within will hold the ether, which is at intervals poured directly upon it. In hospitals the drop method has come into favor. It consists of the use of a number of layers of gauze about 6 inches square, pinned upon a simple wire frame like that of the Esmarch inhaler. Upon this the ether is dropped quite constantly, insuring saturation of the air inhaled. Ether is frequently preceded by ethyl chloride or nitrous oxide to the point of unconsciousness. 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. Chloroformum. Chloroform [CHCI3]. This substance is prepared by the action of chlorine 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. (For preparations and doses, see Index of Drugs.) It is a heavy, colorless, volatile liquid, with an ethereal odor and sweet, burning taste, having a specific gravity of not less than 1.476 at 25° C. (77° F.). It is soluble in 200 volumes 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 vapor will burn. Plate VII. represents the action of chloroform upon the central nervous system, the respiration and the circulation. Uses. As a General Anesthetic. In its practical application it has been found to be jive times as dangerous as ether, chiefly on account of its depressant action upon the heart. Therefore, it should not be used except in suitable cases, and where the use of ether is impracticable. When it is employed, the patient should be in the recumbent posture throughout the period of anesthesia, in order to reduce the work of the heart to a minimum. This being often impossible in dental operations, furnishes additional reason for its non-employment. Indeed, the relatively high death-rate from the use of this agent in the dental chair ANESTHETICS 187 proves the danger of the sitting posture when the heart is depressed by chloroform. When used as an anesthetic this drug must be administered very cautiously. The greatest danger seems to be from too rapid admin- istration, whereby the blood receives a large amount of the vapor in a very short space of time. In this way the heart may be depressed beyond recovery at any time during administration. To guard against this, 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 Fig. 5 Esmarch's inhaler and chloroform bottle. The inhaler consists of a wire frame covered with a piece of flannel or gauze. gauze, upon which the chloroform is dropped in small cjuantities (ten to twelve drops) frequently. (See Fig. 5.) The inspired air should never 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. 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- ISHfL (0.30-1 cc), dropped upon sugar or mixed with a fixed oil. * Supplement, British Medical Journal, 1903. 188 GEXEEAL REMEDIES In parox^^'sms 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. As Antispasmodic. To relieve infantile convulsions, actite paroxysms of asthma, tiremic and puerperal con^.idsions. In these conditions it should never be employed except with competent medical supervision. As 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. .fflthylis Chloridiun , Ethyl Chloride [C2H5CI]. This drug is pre- pared by the action of hydrochloric acid gas upon absolute alcohol. It is a very volatile, colorless licjuid, ha\'ing an agreeable odor and burning taste. It is very soluble in alcohol, but only slightly in water. Its most distmctive 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 now been in use for several years, both as preliminary to ether and chloroform, and used alone to induce transient anesthesia. It belongs in a class with nitrous oxide rather than with ether and chloroform, in that it is best adapted to minor operations that do not require profound or con- tinued anesthesia. Being a new agent, its relative safety among anes- thetics has not yet been definitely fixed by accumulated statistics, but experience thus far places it about equal with ether, or less safe. V ith longer experience in its use it may come to rank higher, but it is cer- tainly less safe than nitrous oxide. 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.* * Lotheisen. Miinch. Med. Woch., Xovember 18, 1900. p. 601. ANESTHETICS 189 McCardie * in 2000 cases saw neither asph}'xia 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, v/ithout access of air, it causes death by paralyzing respiration. In 1000 cases by Ware t 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. G), as here described in his own words : % "The mask is prepared for use by stretching two layers of small- meshed gauze over the end of the tube h, 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 * British Med. Jour., Mar. 17, 1906. Here also are noted the foUoTv-ing estimates of the danger ratio of ethyl cliloride: Lotlaeisen first estimated the deaths as 1 : 2500. A later (April, 1902) estimate by the same writer, 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. t Journal of the American Medical Association, No. 8, 1902. % Medical News, August 3, 1901, p. 169. 190 GENERAL REMEDIES 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 min- imize the loss of ethyl chloride and merely utilize the quantity moment- arily available for one or two respiratory acts. The stream is to be delivered intermittently from tubes provided with an automatic cut-off." Fig. 6 "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, about as cheap, 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 formula? of the four leading anesthetics, viz. : Nitrous oxide N^O Ether C.HjqO Ethyl chloride C,B.f\ Chloroform CHCL, ANESTHETICS 191 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 degeneration. 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 are ether and chloride of ethyl, while chloroform remains 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.* 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. f 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 symptoms 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. 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 * In connection with this, 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. f Lancet, London, 1901, vol. i. p. 280. 192 GENERAL REMEDIES 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 mixtures 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 162. Schleich's idea in introducing mixtures of anesthetics for general anesthesia, was to obtain a liquid with a desired boiling point (at about the tempera- ture 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. With 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, recovery 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 paralysis of that organ. When the heart is paralyzed by chloroform its irritability is lost, which 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 w^aste time at first to ascertain the heart's condition. The important thing immediately is arti- ficial respiration, which is itself here the best cardiac stimulant, and with its faithful continuance the real condition of the heart will soon appear; * Sollmann (Pharmacology, 1906, p. 436) states that ethyl bromide " must not be pushed to the disappearance of reflexes, since the respiration is paralyzed about the same time. The zone of safety is, therefore, very narrow." The drug also deteriorates rapidly after exposure to air. ANESTHETICS 193 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 contrac- tion furnishing more blood to the left side of the heart for distribution. The invariable treatment, therefore, when respiration ceases, should be artificial respiration with free access of air, preceded, of course, by withdrawal of the anesthetic. Sylvester's method is easily applied and efficient. (See Figs. 3 and 4.) Massage of the heart, as well as it can be accomplished between diaphragm and thoracic wall by the hands of a second person properly applied, should accompany artificial respiration. AMiile these measures are being employed without interruption, another assistant may note pulse and give respiratory and cardiac stimulants h\^oderniically, 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. 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 inhalation or the aromatic spirit of ammonia by the mouth (if swallowing is possible), may be given. The body should be recum- bent, with the head low. Artificial respiration must be kept up until natural respiration is restored, or until the hopelessness of the case has been absolutely established. If respiration is not readily restored by the above means, a powerful reflex influence may be invoked by stretch- ing the sphincter ani. With a rectal speculum or dilator introduced into the anus, rh}i;hmic manipulation, so as to stretch the sphincter at regular intervals, may be made. Drawing forward the tongue by the forceps, or by a ligature passed through it, is another, but less efficient, means of reflex stimulation. Alcohol. Ethylic Alcohol. Spiritus Vini Redificatus [C2HgO], (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. "\Miatever of stimulant effect it induces, seems to be secondary to its local irritant action; in this respect it resembles ethero 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 13 194 GENERAL REMEDIES 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 omy 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.) ALCOHOI Used commonly in the Whisky, Brandy, or Classified as : Irritant. Stimi Astringent. Narc Antiseptic. Anes Physiologic action : To summarize the ph eflTects of alcohol difficult, owing to tradictory opinion! good authorities, most writers agree full effect of a la: of the drug is tl general depressant no agreement as t fluence of a small Two diagrams are hen Diagram A represei taught by those w includes stiinulatic cerebrum and of tl Diagram B shows pressant action of dose upon the system, circulatio digestion. Many o deny the primary depressant from ih of intoxication is r higher controlling Local action. Irritai applied to the muc tation probably in in part for the prii Digestion. In small gastric secretion a cent, or more) reta As a food the positi determined. A sr from the fluids o1 changed into othc tribute some enerj of its use may be o Metabolism. Its influ nation is uncertain. ALCOHOL. PLATE VIII PLATE VIII.— B. Used commonly in the form of Whisky, Brandy, or Wine. Classified as : Irritant. Stimulant. Astringent. Narcotic. Antiseptic. Anesthetic. Physiologic action : To summarize the physiologic eifects of alcohol is very difficult, owing to the con- tradictory opinions held by Skin-^ good authorities. While most writers agree that the full effect of a large dose of the drug is that of a general depressant, there is no agreement as to the in- fluence of a small dose. Two diagrams are here presented : Diagram A represents the action of a small dose as taught by those who hold that its primary influence includes stimulation of the cerebrum and of the heart. Diagram B shows tlie de- pressant action of a large dose upon the nervous system, circulation, and digestion. Many observers deny tlie primary stimulant action, holding that the drug is a depressant from the first, or even in small dose. The excitement of intoxication is not due to stimulation, but to depression of the higher controlling centers. Local action. Irritant, by reaison of its aifinity for water. When applied to the mucous membrane of the digestive tract, the irri- tation probably induces reflex stimulation, which may account in part for the primary stimulant effect attributed to tlie drug. Sigeslion. In small doses, well diluted, alcohol seems to increase gastric secretion and motility, wliile stronger solutions (5 per cent, or more) retard the digestive process. As a food the position of alcohol has not been very definitely determined. A small part only can be recovered as alcohol irom the fluids of excretion. The greater part therefore is changed into other products, and is believed thereby to con- 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. Vagus Center Vaso Motor Center Cervical Sympathetic ■Solar Plexus 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 only 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. Nitroglycerin acts somcM^hat in such manner, allowing the heart to beat more rapidly by depressing the vagus inhibitory centre. 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 stimulants 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 (195) 196 GENERAL REMEDIES a stimulant of this kind, its action being to increase the irritability of nerve centres. Indirect stimulants produce the stimulant result secondarily. Some of these act primarily by removing inhibitory influence and others by causing an irritation of sensory nerves. Examples of the former are nitroglycerin and atropine, both of which primarily lessen the inhibitory influence of the vagus upon the heart, and thereby allow the heart to beat more rapidly, which is the secondary or indirect stimulant effect. The latter are exemplified by ammonia, alcohol and ether, which are locally irritating to mucous membranes. By irritating sensory nerve endings wherever applied, 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- Aailsions. (On account of the sensitiveness of the system in childhood it should be noted that children do not bear stimulants as well as they do seda- tives. They present the need of stimulation less often than do older persons, and the response to stimulants is usually very prompt.) The Indication for Employing Stimulants is, in general, any depression o^ a function to a degree that may be regarded as below the physiologic minimum of its acti\'ity. We recognize that e^'ery 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, influenced on the one hand by the strength and nutritive resources of an organ, which are opposed on the other hand by the amount of work imposed upon it. The physiologic minimum of activity, therefore, must vary as modified by these influences ; 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 expenditure 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. ^Vhen 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 co-operation STIMULANTS AXD TOXICS 197 of influences, the increased irritability or the more 'powerful impression contributed by the appHed stimulant enabling the organ to respond to the need of increased work, which, after all, is its normal stimulus. 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 are termed diffusible siimidants. 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 (ethylic). 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 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 centres, which occurs because the controlling function of the cerebrum has been depressed. 198 GENERAL REMEDIES 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. iEther. Ether. (For doses, see Index of Drugs.) This drug is fully considered in the chapter on Anesthetics. Its stimulant secondary effects, following primary irritation, are similar to those of alcohol. For use as a stimulant it is usually combined in the following preparations: Spiritus .ffitheris. Spirit of Ether. This contains 325 parts of ether and 675 parts of alcohol. Spiritus .ffitheris Compositus. Compound Spirit of Ether. HoJI- man's Anodyne. This contains 325 parts of ether, 650 parts of alcohol and 25 parts of ethereal oil. These preparations are given mostly by the stomach. Hypodermically 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 stimulation. Ammonia [NHg]. (For preparations and doses, see Index of Drugs.) This substance has a decidedly irritant local action, and has the advan- tage of being a gas, which permits of inhalation. It is also given in solu- tion in water and alcohol. The gas is so volatile that it is always em- ployed in solution, even for inhalation. In fact, the aqua ammonise fortior liberates the gas so rapidly as to be caustic in action, and is there- fore not to be employed in any way as a stimulant, unless first diluted. The following preparations are commonly employed: Aqua Ammonise. Water of Ammonia. Contains 10 per cent, by weight of the gas in solution in water. Spiritus Ammonise. Spirit of Ammonia. Contains 10 per cent, by weight of the gas in solution in alcohol. Spiritus Ammonise Aromaticus. Aromatic Spirit of Ammonia. The formula* of this gives us a preparation whose stimulant action, when given by the stomach, is of longer duration than that of any other. This is because of the gradual decomposition of the ammonium carbonate, which thus liberates ammonia gas for some time. All of the ammonia preparations require dilution for internal administration. They deteri- orate with keeping. Of the salts of ammonium the following is a valuable stimulant : * Aromatic spirit of ammonia contains : Water of ammonia, 9 per cent. ; carbonate of ammonimn, 3.4 per cent., and small quantities of oils of lemon, lavender and nutmeg, with alcohol, 70 per cent. STIMULANTS AND TONICS 199 Ammonii Carbonas. Carbonate of Ammonium [NH^HCOg.NH^NHg- CO2]. The stimulating value of this salt depends upon its liberation of ammonia gas, of which it should yield at least 31.5 per cent. When exposed to the air this readily occurs, rendering the surface of the crys- talline mass opaque and useless. This should be removed and only the translucent inner part of the crystal used, A solution of the salt given by the stomach liberates the gas for some time, which makes it a very valuable diffusible stimulant, being the most permanent in action of all agents of the group. It enters into the composition of aromatic spirit of ammonia. Miscellaneous Stimulants. Various other volatile substances have a stimulant action that is more essential and direct, 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 deserve mention. 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 carmina- tives, i. e., agents that relieve colic and cause expulsion of gas by relieving spasmodic contraction of the intestines. Camphora. Camphor [C^^H^^O]. A stearopten derived from Cinna- momum 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 powdered 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 the pure camphor in pill or capsule, the spirit, the volatile oil, or camphor-water, may be used, although the last named is a very weak preparation. 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. 200 GENERAL REMEDIES Of these, Camphorated 'phenol (Camphophenique) and Camphorated chloral are most frequently employed. Spiritus Camphorse. Spirit of Camphor. This contains 10 per cent, of camphor in solution in alcohol. Oleum Teretinthinse. Oil of Turpentine. While this substance is a useful stimulant, its odor, taste and poisonous quality prevent its common use for this purpose. Oleum Menthse Piperitse. Oil of Peppermint. 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. Normal Saline Solution (0.6 per cent, of sodium chloride in sterile water) used by hypodermoclysis, or intravenously, should be regarded to-day 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 exhaust- ing 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 stimulants may be added to the solution. Coca. The leaves of Erythroxylon coca or of E. Truxillense. By referring to Plate II. it will be seen that coca (or cocaine) has a general stimulant action when given in small doses. Practically it is seldom employed as a stimulant for several reasons — it is poisonous, its action is uncertain, as depressing effects may occur early from it, and there is great danger of acquiring the habit of using it. About the only place of usefulness that it occupies as a stimulant is with old people, where the cerebral and circulatory functions are failing and the danger of forma- tion of habit is slight. The fluid extract of coca is the preparation most useful. The indiscriminate use of "wine of coca" is to be condemned. PLATE IX. BELLADONNA. Leaves and root of Atropa B. The alkaloid Atropine represents the drug fully. [For preparations and doses, see Index of Drugs.] Classified as : Cerebral stimulant. Deliriant narcotic. Mydriatic. Cardiac stimulant. Anodyne. Antihidrotic. 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 tempei-ature, producing a condition simulating fever. Nervous System.. Brain. Stimulates the cerebrum, especially in its motor areas. M^eduUa. Stimulates respiratory and vasomotor centers. Spinal cord. Depresses inhibitory centei-s. Nerves. Sensory. Depresses sensory nerve endings. Motor. Depresses motor nerves. Secretory. Paralyzes the endings of many of the secretory nerves, causing a diminu- tion or arrest of the secretion ; hence there result dryness of the mouth, lessened secretion of gastric and pancreatic juices 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 within the digestive system. Muscular System. Depresses unstriped muscle, but has no influence upon voluntary muscle. Lessens the movements of stomach, hitestines, bladder, uterus, and in gen- eral the organs containing unstriped muscle, except the arterial walls. [Cushky.] Eye. Pupils are dila,ted by paralysis of terminals of the motor oculi nerve in the iris, with possible stimulation of the sympathetic terminals. It paralyzes accommodation. Most authorities state that it increases inti-aocular pressure. Circulation. Arterial pressure is increased, chiefly by central vasomotor stimulation. Heart. Increases pulse rate by paralyzing inhibition (peripheral ends of vagus). The heart muscle or its accelerator nerves may feebly be stimulated. Capillary area. Arterioles are contracted. Respiration. 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. PLATE IX. Sweat glands lesn active Motor nerves and sensory yierve endings depressed. Vagus Center Vaso Motor Center Cervical Sympathetic Pelvic Plexus The red color indicates stimulation, and the blue color depression. CAFFEINE. An alkaloid existing in coflFee, tea, guarana, and cola nut. [For preparations and doses, see Index of Drugs.] Classified as : Cerebral stimulant. Cardiac stimulant. Respiratory stimulant. Diuretic. Physiologic action : Nervous System. Cerebrum. Stimulates cortex, increasing the ac- tivity of psychic func- tions. Medulla. Stimulates res- piratory center and vaso- motor center. Vagus cen- ter may be stimulated, but the effect masked by the direct effect upon the heart. PLATE X. Vagus Center Vaso Motor Center Cervical Symioathetic Voluntary Muscle Solar Plexus Muscular System. Irritability and working power of muscle tissue increased. Circulation. Arterial pressure increased by vasomotor activity. Heart. Stimulates heart muscle, jiroducing acceleration of the pulse. Capillary area. Contracts arterioles by stimulation of vaso- motor center in the medulla, and probably also by direct action upon the constrictor fibers in the vessel walls. 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. The red color indicates stimulation by Caffeine. STIMULANTS AXD TOXICS 201 Belladonna — Atropina [C^-HjaNOg]. (Plate IX.) BelladonnoB Folia. Belladonnos 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 general 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. 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 Atropinae sulphas. The following alkaloids have an action somewhat similar to that of atropine : 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, HyoscinaB Hydrobromidum, both from Hyoscyamus leaves, and Scopolaminae Hydrobromidum, from Scopola root, are less stimulating than atropine to the central nervous system, and more hypnotic and sedative. (See Index of Drugs.) Caffeina. Caffeine [CgH.oNp^+Hp]. (Plate X.) Caffeina Citrata. Citrated Caffeine. 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 preparation usually employed, because more soluble than caffeine. (See note on p. 165.) 202 GENERAL REMEDIES Theobromine (from Theohroma 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 centres to normal stimuli, and does not tend directly to exhaustion. It is a valuable respiratory stimulant by action upon the centres. 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 stomachic tonic. Internally any preparation may be given. Hypodermically a salt of the alkaloid strychnine is employed. The official salts of strychnine are: Strychninse Nitras. Strychninse Sulphas. (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 valvular disease or simple weakness. When extensive fatty degenera- tion 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 exliaustion of the organ. It should be regarded as an emergency drug in cardiac diseases. The vasoconstrictor action is sometimes objectionable, in which case it may be overcome by combining it with nitroglycerin. When 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 conditions 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. PLATE XI. NUX VOMICA. The seeds of Strychnos Nux V. The alkaloid Strychnine repre- sents the drug fully. [For preparations and doses, see Index of Drugs.] Classified as : Bitter tonic. Cardiac stimulant. Nerve stimulant. Excitomotor. Physiologic action : Digestive Tract. Stimulates se- cretion of gastric juice and motility of stomach. Nervous System. Cerebrum. No effect upon cortex. Consciousness not influenced. Special senses rendered more acute. Medulla. Stimulates i-es- 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. Arterioles are contracted by its action upon vasomotor centers of medulla and cord. Excretion. Eliminated by the kidneys, appearing soon after ab- sorption, partly unchanged and pai'tly changed. Contraction of renal vessels may hinder its elimination. Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus The red color indicates the stimulant action of Nux Vomica or Strj'chni7ie. PLATE XII. DIGITALIS. The leaves of D. Purpurea of the second year's growth. [For preparations and doses, see Index of Drugs.] Note. — The description below is of tlie action of the drug or of preparations fully representing it. Classified as : Cardiac stimulant. Cardiac tonic. Vasoconstri ctor . Diuretic. Physiologic action : Stomach. Absorbed slowly. Irritant in large doses or when long continued. Nervous System. Brain. No influence upon the cerebrum. Medulla. Stimulates vasomotor and vagus centers. Muscular System. Stimulates directly the constrictor fibers of the arterioles. Circulation. Gives greater force and rapidity to arterial current, with higher blood-pressure. Heart. Stimulates the inhibitory influence (vagus, center and periphery), which slows the heart and tends toward relaxation. Stimulates the cardiac muscle and contained ganglia, giving greater force to the contractions. Capillary area. Arterioles contracted both by direct local action and by stimulation of the vasomotor center in the medulla. Excretion. Kidneys. Direct action upon the renal epithelium is uncer- tain. The urine is increased, but mainly through the in- fluence of higher arterial pressure. Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus The red color indicates the stimulant action of Digitalis. PLATE XIII. ZS^ITRITES. Amyl Nitrite, IfTL 1-5 (Gm. .06-.30). Nitroglycerin {Glonoin, Trini- ty in). gi'-T*Wo(Gm. .0005-.001). Spiritxjs Glycerylis Nitra- Tis, 1 per cent. Nitroglycerin. 1TL ^2 (Gm. .03-.12). Sodium Nitrite, gr. 1-3 (Gm. .06-.20). Classified as : Vasodilators. Circulatory stimulants. Physiologic action : While the action of the sev- eral drugs of this group is very similar, Amyl Nitrite (by inhalation) lias the most rapid and transient effect. Nitroglycerin is most powerful, and Sodium Nitrite has the most permanent effect. Nervous System. Brain. No direct influence upon cerebrum. Medulla. Depresses vagus center. Muscular System. Paralyzes the muscular coats of the arterioles. Circulation. Causes a decided fall in arterial pressure with 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. Capillary area. Dilates arterioles, thereby increasing the volume and efficiency of the capillary circulation. The influence upon arterial pressure and pulse rate is shown by the following sphygmographic pulse tracings : Vagus Centei Vase Motor Center Cervical Symjoathetio Solar Plexus Normal pulse tracing. Eate 84 ; blood pressure normal The same after taking Nitroglycerin. Eate 96 ; blood pressure 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 AND TONICS 203 The drugs of the following group each have an action similar to that of digitalis and may be used as substitutes for it. Squill, in addition, is expectorant and more decidedly diuretic. Convallaria. Lily of the Valley. Scilla. Squill. Strophanthus. (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. It cannot be regarded as a direct heart stimulant of any decided power, but it acts 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 the capil- lary circulation is much freer. By depression of the vagus inhibitory centre, these drugs also allow greater rapidity of the heart's action. Nitrites should not be used in conditions of low arterial pressure. Nitroglycerin in tablet form, or in the 1 per cent, solution (Spiritus Glycerylis Nitratis) is commonly employed. It is the best representa- tive of the group of nitrites. It is not necessary to give nitrites hypodermically, as the effect of amyl nitrite may be obtained almost instantly by inhalation, and a dose of nitroglycerin placed under the tongue will produce its full effect in from three 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 hour for several doses if necessary, or the dose may be increased as needed up to gr. -^-^ (0.001 gm.) or more. 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. It may be said to-day that the value of the nitrites has been 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 is unfortunate that the belief has become current that they are direct heart stimulants. For, with this belief as a basis, they are quite extensively used in such diseases as pneumonia and other acute infectious diseases, where the blood pressure is already too low to allow efficiency of circulation, and in cases of chloroform narcosis, where the 204 GENERAL REMEDIES same condition prevails. In fact, it is the practice of some, the more cardiac stimulation is 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. Cardiac stimulation is seldom needed unless the arterial pressure is low, and a drug that will tend to reduce it still farther is certainly contraindicated, unless in combination with a true heart stimulant such as digitalis. Therefore, the real indications for the nitrites are found in the arterial system rather than in the heart, and they consist of peripheral arterial spasm, or of more permanent constriction due to disease of the arterial walls, or of the natural loss of elasticity in the arterial system that occurs with age. In either condition the heart is not likely to need any stimulation, unless degeneration has occurred or its nutrition is disturbed. The nitrites, therefore, 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 that is present. 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 — an efficient heart action being a prerequisite. It is worthy of note that, whatever the beneficial result, the physiologic action of the nitrites is chiefly depressant upon vagus centres and upon vasoconstrictor muscle tissue in the arterioles. 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 difference 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 STIMULANTS AND TONICS 205 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 reconstruction 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 hitters. 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 effect, 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.) Simple 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 f5j-iv (4-15 c.c). 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; 206 GENERAL REMEDIES 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. Its cost also is somewhat prohibitive of general use as an antiseptic. Its most valuable and dis- tinctive 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. It is obtained after absorption 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. A form of supraorbital neuralgia supposed to be of malarial origin, known as brow ague, which presents the periodic character of malarial fever, in that it usually 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 is used much less now than it was in former years, before its precise action and its limitations were understood. In large doses it has been supposed to be antiphlogistic — combating inflammation. This belief was supported by the fact that quinine may be seen, under the micro- scope, to possess the power of checking the ameboid movements of leukocytes. However well founded its reputation in this direction has been, we see to-day that its use has declined somewhat, except as a bitter tonic and in the treatment of malarial fevers ; nor are very large doses now given, as was formerly the practice. Nux Vomica. The seeds of Strychnos Nux-vomica, containing not less than 1.25 per cent, of strychnine. (For preparations and doses, see Index of Drugs.) The representative alkaloid, strychnine, has been STIMULANTS AND TONICS 207 fully considered as a stimulant. It is valuable also as a bitter tonic, as are the preparations 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 nerve centres of reflex action. This is the effect that pertains to the action of the alkaloid strychnine in its use as a stimulant. The tincture of nux vomica is the preparation most commonly used as a bitter tonic. In large doses the drug is poisonous, causing very char- acteristic tonic convulsions which affect chiefly the muscles whose nerve supply is directly from the spinal cord. (See Table of Poisons and Antidotes.) Pninus Virginiana. Wild Cherry. The bark of Prunus serotina, gathered in the autumn. (For preparations and doses, see Index of Drugs.) In addition to its action as a stomachic tonic, this drug possesses 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 emulsin, a. volatile oil identical with oil of bitter almond is formed. This contains hydro- cyanic acid. Wild cherry finds its special use where a general or local nerve 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 necessary to the tissues, but which may be supplied in pure or special forms aside from food. 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 given to the restoratives ordinarily regarded as medicines. Inasmuch as they aid chiefly by restoring some element that is lacking, their precise action requires no extended dis- cussion. We are more concerned with the form or combination of the drug in order to pleasant administration and ready assimilation. 208 GENERAL REMEDIES 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 pyrophoephas, tinctura ferri chloridi, and syrupus 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 and jerri hydroxidum cum magnesii oxido are the most useful chemical antidotes to arsenic. The real systemic action of iron is always in the blood, and whatever salt or com- bination 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 is the typical condition that is usually promptly met by iron in any form. Improvement in the blood results in a better state of the whole system. It should be insisted that it is entirely unnecessary to use the new and largely advertised preparations of iron. As a rule, they are expensive, and not at all superior to the older well-known 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 structure, 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 tincture 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 safe- guard 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, by weight of absolute nitric acid. STIMULANTS AND TONICS 209 Acidum Nitrohydrochloricum Dilutum. Diluted Nitrohtdrochloric 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 absolute sulphuric acid. [Acidum Sulphuricum Aromaticum contains 20 per cent, by weight of absolute sulphuric acid in nearly pure alcohol]. The dose of either of these is rrL 5-20 (0.30-1.20 gm.). They are given after meals, as a rule. x\ 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 ecchymosis 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. 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 gro-^th 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- phoric acid. The most common form of pure phosphorus for admin- istration is the official pill containing y^q- of a grain (0.0006 gm.). It is * Therapeutics, H. C. Wood, eleventh edition, pp. 431-32. 14 210 GENERAL REMEDIES 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. In neurasthenia it is a useful agent. Syrupus Hypophosphitum. Syrup of PIypophosphites. (Incom- patible with tincture of chloride of iron.) Syrupus Hypophosphitum Compositus. Compound Syrup of Hypo- phosphites. Syrupus Ferri, Quininae et Strychninse Phosphatum. Syrup of the Phosphates of Iron, Quinine and Strychnine. 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 Morrhuae. Cod-liver Oil. A fixed oil expressed from the fresh livers of Gadus morrhua and other species of Gadus. 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 nourished 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 (about the time the contents of the stomach pass on into the small intestine), so as to shorten the time of its stay in the stomach, much of the unpleasantness in the way of eructations will be avoided. The official emulsions are the following: Emulsum Olei Morrhuae. Emulsion of Cod-liver Oil. 50 per cent. Emulsum Olei Morrhuae cum Hypophosphitibus. Emulsion of Cod- liver Oil with Hypophosphites. This contains 50 per cent, oil, with hypophosphites of calcium, potassium and sodium. 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 in certain organs 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 com- position of the cells. The typical conditions that call for the use of alteratives are those that are brought about by the damaging influence of external causes, usually bacteria or toxic chemical bodies, that alter the nutrition of the cells. Syphilis stands as the disease that probably most purely both presents the indications for the use of, and responds most readily to the action of, alteratives. Altered states of the blood and of various 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. Arsenic. Arsenous 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 chlorosis and in certain nervous diseases, particularly in chorea (St. Vitus' dance), and in some chronic diseases of the skin. (For reactions and doses of the following preparations, see Index of Drugs.) Liquor Acidi Arsenosi. Solution of Arsenous Acid. 1 per cent. Liquor Potassii Arsenitis. Fowler's Solution. Strength corresponds to 1 per cent, of arsenic trioxide. Liquor Sodii Arsenatis. 1 per cent. Liquor Arseni et Hydrargyri lodidi Donovan's Solution. 1 per cent, each of arsenous iodide and mercuric iodide. The pure arsenic trioxide and Fowler's solution are the forms most commonly employed. Beginning with small or moderate doses, they (211) 212 GENERAL REMEDIES 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. It is interesting to note that in some parts of the world persons become habituated to taking quite large doses of arsenic. Hydrargjnrum. 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 reduced to a very finely divided condition. Following are the preparations most commonly used: Hydrargynim cum Creta. Mercury with Chalk. Contains 38 per cent, metallic mercury. Massa Hydrargyri. Blue Mass. Blue Pill. Contains 33 per cent, metallic mercury. Unguentum Hydrargyri. Blue Ointment. Contains 50 per cent, metallic mercury. Oleatum Hydrargsrri. Oleate of Mercury. Contains 25 per cent, yellow oxide of mercury. Hydrargyri Chloridum Mite. Mild Chloride of Mercury. Calomel. Monochloride of Mercury [HgCl]. Hydrargyri Chloridum Corrosivum. Corrosive Chloride of Mer- cury. Corrosive Sublimate. Bichloride of Mercury [HgClJ. Hydrargyri lodidum Flavum. Yellow Mercurous Iodide. Hydrargyri lodidum Rubrum. Red Mercuric Iodide. The typical use of mercury as an alterative is in the treatment of secondary syphilis. 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 valuable 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.) lodum. 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 combinations. The iodides, which contain a large proportion of iodine, constitute a distinct group of general alterative agents, the most typical of which is potassium iodide. ALTERATIVES 213 Potassii lodidum [KI]. Estimated by the atomic weights of its components, this salt contains 76 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, where its influence is so certain and striking as to entitle it to be regarded as an absolute specific for that disease in that stage. (See article below on S}^hilis and its Treatment.) Sodii lodidum [Nal]. Sodium iodide has about 84 per cent, of iodine in its composition. Its uses are the same as those of the potassium 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 [Aslg]. Arsenous iodide is used chiefly in Donovan's solution, the liquor arseni et hydrargyri 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 innocently or through vicious conduct. It may be inherited in cer- tain of its forms. It is a disease, moreover, of which its possessor may be ignorant, both as to its character and the source of infection. Wliile the latter is comparatively seldom true, the fact is sufficiently established by occurrence of the lesion of original infection, the chancre, upon various parts of the surface of the body, where infection must have been purely accidental. The importance of these facts 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, which adds to the danger of non-recognition of the superficial mouth lesions. The occasional occur- rence of a chancre upon the hand of a dentist, justifies the advice that a constant outlook for the presence of the disease, in mouths coming under examination, should be exercised. This implies a certain degree of familiarity with the symptoms of the disease. Every opportunity to 214 GEXERAL REMEDIES acquire this knowledge should be improved as a matter even of personal safety, but still more 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 SA'philis in its chief clinical features. A word of caution is here in place. It may fall to the practitioner to discover a case of s^-philis, by mouth s^miptoms, where it had not been suspected; but he must be exceedingly cautious about discussing this finding ^rith. 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. AMiile she would have a most serious grievance, entitling her to our pity, a revelation could only add to her unhappiness. A suggestion to her to see her family physician for certain general conditions that you find evidence of, would be the proper course; and even this ad^ice must be given tactfidly, 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 greatest point of 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. It is further under- stood, as a matter of course, that all instruments and appliances used will be thorotighly sterilized immediately after the operation. As a basis for study, a scheme is herewith given, which includes stages of the disease with their characteristic s^inptoms, and the application of remedies appropriate to each. " This is arranged in accordance with the usual custom, sufficiently founded upon long experience, which is that the treatment by alteratives is commonly postponed until the diagnosis has been established by positive secondary s^Tnptoms; otherwise the treatment might prevent a diagnosis, and the patient would not know whether he were s\'philitic or not. Positive knowledge upon this point is so important, in xie^x of the cpestions of marriage, of prolonged treat- ment, and of personal care as to spreading of infection, that the matter of a few weeks' treatment may be properly disregarded, particularly so as it is believed that nothing is lost, in the efficacy of treatment, by the delay. The chief remedy during the secondary stage is mercury. This drtig is administered by inimction or internally, in full dosage, until the first ALTERATIVES 215 signs of mercurialism appear in a slight soreness of the teeth when the jaws are forcibly closed. Then the dose is diminished, but continued in such quantity as is necessary to keep the system just at the point of saturation. This treatment is continued for several months, when potassium iodide is added. The combination of the two, known as "mixed treatment," is continued, with a gradual diminution of mercury and increase of potassium iodide, until finally the treatment ends with a course of the iodide alone.* The practice of physicians differs in detail as to method and time, but the general plan is essentially that presented here. Syphilis, its Stages, Symptoms and Treatment. Primary symptoms appear about three weeks after infec- tions. The lesion is \ very infectious. SYMPTOMS. f a. The chancre, located usually upon the geni- '] I tals, but may occur upon any mucous or j J cutaneous surface. ' b. Enlargement of lymph nodes in all parts { of the body, but not distinctive of this | l_ disease. J Secondary symptoms f occur about six or eight weeks after infection. The le- sions in the mouth 1 (mucous patches) are exceedingly in- fectious. A superficial rash, slight or abundant, dis- ") tributed upon all regions of the body. b. Sore throat. | c. Mucous patches anywhere upon mucous mem- | brane of mouth or throat, usually upon f inner surface of cheeks or under tongue. d. Loss of hair, slight or marked. Tertiary m/mptoms 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, or not at all, infectious. f a. Deeper lesions of the skin, either single or I multiple, but not of general distribution. I b. Periosteal pains, chiefly in head and long bones, occurring raiostly 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. Usually single, or, if double, located upon symmetrical portions of body. . Degenerations of circulatory or nervous sys- tems. The arteries, brain and spinal cord are usual sites of degeneration. MEDICINAL TREATMENT. Unimportant. Mercury. I Potassium iodide. The question whether syphilis may be cured has been regarded as a debatable one, but it is one which now, in the minds of experienced syphilographers, admits of an affirmative answer. The fact remains, however, that comparatively few cases are permanently cured. When we appreciate that a cure means the taking of medicines almost con- * The continued use of any iodide commonly produces a rash, consisting of pimples upon the face and elsewhere, which is believed to be nature's efforts to eliminate iodine. This is the chief symptom of iodism, or saturation with the drug. 216 GENERAL REMEDIES tinuously for two or three years, and that syphihs is a disease whose syraptoms yield very promptly to treatment, it cannot be expected that more than a small percentage of patients will continue treatment for the necessary length of time after they feel perfectly well. With the discovery of the spirocheta pallida a new chapter in the study of syphilis and its treatment has been opened. The relation of this bac- terium to the disease is being studied by various observers and it is coming to be quite generally regarded as the specific cause of syphilis. With the cause thus recognized, improvement in management of the disease is quite sure to follow, for the purely empirical treatment of the past will in time be placed upon a scientific basis, and it is to be hoped that the period of treatment necessary to a cure may be shortened. The following additional drugs are simply mentioned as represen- tative 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. PLATE XIV. ACONITE. The tuber of A. Xapellus. The alkaloid Acouitiue repre- sents the drug fully, but is the most poisonous substance of its class. Therefore it is seldom used internally. [For preparations and doses, see Index of Drugs.] Classified as Sensory ..■11 nerve endina,'- Arterial depressamt , , ^ ^ _ ^ ^ depressed Cardiac depressant. Kerve depressant. Antipyretic. Physiologic action : S^ervous System. Brain. Xo influence upon cerebrum. Medulla. Stimulates vagus center. depresses respiratory center. Spinal cord. Influence uncertain. Sensory nerve endings are depressed after a period of slight stimulation. Muscular System. Causes genei-al muscular weakness. Circulation. Lessens force, rapidity and pressure of the arterial current. Heart. A dii-ect influence upon the heart is uncertain, but by stimulation of inhibition the heart is slowed and its force weakened — the result being cardiac depression, f Accord- ing to some authorities, the drug depresses the heart muscle and its motor ganglia.) Capillary area. The vasomotor influence of the drug is uncertain. Temperature is reduced. Valgus Center Vaso Motor Center Cervical Syjiijiathetic The red color iudicates 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. CHAPTEK XYII. SEDATIVES. , A SEDATIVE 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 symptoms 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 39.) Just as with stimulants, so with sedatives, the term applies to effect, but not always to action. Stimulation of inhibition may produce a slowing or restraining effect, which we may call sedation 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, may all be greatly relieved by the continuous 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. (217) 218 GENERAL REMEDIES Depletion of the Circulation, whether by bloodletting, sweating or active catharsis, is another means of reducing circulatory activity, in addition to which effect these measures also reduce toxicity, when that becomes necessary. Of the medicinal agents the most typical ones of the several groups are here presented. Aconitum. (Plate XIV.) This drug i^ used in fevers and inflammations, to reduce arterial press- ure. The tincture is used internally, either 5 to 15 minims (0.30-1 c.c.) several times daily, or in two-drop doses hourly until the effect is secured! It must be noted that the new official tincture of aconite (U. S. P., 1900) is less than one-third as strong as that heretofore, the proportion of drug used having been reduced from 35 per cent, to 10 per cent. With an equal part of tincture of iodine, the tincture is used as an application in pericementitis and pulpitis. In neuralgias the alkaloid aconitine is employed locally in form of the oleate. 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 liidex 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 gm.). The strong hydrocyanic or prussic acid is never used, as it is too poisonous even to manufacture. Bromides. (Plate XV.) This group of salts are freely soluble in water, salty to the taste and slightly irritating to the mucous membrane if applied pure. Potas- sium bromide is most commonly used, although the sodium salt is pre- ferred by some because slightly, less irritating. 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 PLATE XV. POTASSIUM BROMIDE. [KBr] [This drug is regarded as tlie typical and most important agent of the group of bro- mides.] Classified as : Cerebral depressant. Nerve depressant. Antispasmodic. Anaphrodisiac. Sensory nerve endings depressed Vagus Center Vaso Motor Center Cervical Sympathetic Solar Plexus Physiologic action : The depressant effect is due in part to the potassium base, which is especially depressant to the heart. Nervous System. Brain. Depresses the cerebral cortex, and espe- cially the motor areas. Medulla. Depresses the respiratory center slightly, slowing the respiration. Spinal cord. Lessens reflex irritability, probably mainly through a depression of the sensory portion of the cord and the peripheral terminals of the sensory nerves. Sensory nerve endings are depressed, causing a slight degree of anesthesia in some regions. Sexual function is depressed. Circulation. Arterial pressure is -lowered somewhat. Heart. Depresses the heart slightly. Capillary area. Full doses cause vasomotor relaxation. Elimination. The drug is absorbed rapidly from the stomach, but is eliminated slowly. It may be found in the several excre- tions, but chiefly in the urine. Doses and compai-ative action of the bromides : Potassii Bromidum .... gr. 5-60 (Gm. .30-4). Sodii Bromidum gr. 5-60 (Gm. .30-4). Less irritating and rather less depressing. Ammonii Bromidum .... gr. 5-30 (Gm. .30-2). Least depressing owing to the ammonium base. 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. SEDATIVES 219 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 to the management of first dentition leads to a brief consideration of that subject following the antipyretic group. ANTIPYRETIC GROUP. These newer synthetic agents are coal-tar derivatives, all of which occur in the form of white crystalline powders. As antipyretic 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. (For solubilities and doses, see Index of Drugs.) Antip3n:ina [CjjHj2N20]. This is the mildest in action and is also most soluble. It is of some value as an antispasmodic in the treatment of infantile convulsions and whooping-cough. Incompatibility. Antipyrine is incompatible with spirit of nitrous ether and with solutions of carbolic acid. Acetphenetidinum. Phenacetine [C^oHj3N02]. This is more powerful than antipyrine, but comparatively safe. It is practically insoluble in water. Acetanilidum [QHgNO]. 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 con- tinuously for any length of time. The compound powderf is a useful * 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, because they certainly do depress cerebral and nerve functions. The only unpleasant symptom commonly attending their prolonged use is the occurrence of pimples upon the face and elsewhere, which is believed to be nature's effort to elim- inate bromine. t Pulvis Acetanilidi Compositus. (U. S. P.) Gm. or c.c. R . — Acetanilidi, 7 Caffeinse, 1 Sodii bicarbonatis, 21 — M. Of this the dose is IJ to 8 grains (0.10-0.50 gm.). 220 GENERAL REMEDIES internal analgesic. The caffeine in this may aid the action of the acetanilid, but it antagonizes its depressant action upon the nervous system and heart. Locally, acetanilid is used as an antiseptic powder. 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 system 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 inactive 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 hfe. 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. Thus we may fix the time of greatest disturbance, but must study further the causes. 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 con- nection with the same sensitive, directing and controlling central nervous system. This is often shown very emphatically by the occurrence of SEDATIVES 221 vomiting or convulsions 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 undeveloped, 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 centres, so that they may respond less readily to irritating impressions. More important still is the prophylaxis that fortifies the nerve centres 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. Probably the majority of children suffer with irritability and feverishr 222 GENERAL REMEDIES ness at some time during 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 typical arterial sedative drug is aconite. This may be given in form of the tincture, in a dose of | to 1 a 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 c.c. R . — Tincturse aconiti, 1 Spiritus {Etheris nitrosi, 30 Glycerini, 15 cinnamomi, q. s. ad 60 {xri XV) (fij) (fSiv) (f5ij)-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 symptoms 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 employment 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 very prominent, while the circulatory disturbance is secondary and incidental. Therefore, the use of a bromide will, on the whole, be found most satisfactory, because it meets the primary indication of lessening the sensitiveness of the brain centres and, at the same time, can SEDATIVES 223 be used continuously in full doses without danger. Potassium bromide is the typical agent of the group, but it must always be given well diluted, so as to avoid irritating the stomach. The writer 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: B.- -Potassii bromidi, Gm. or c.c 2 (gr. xxx) Syrupi, 15 (fSiv) Aquge cinnamomi, q. s. ad 60 (fgii)-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 c.c.) or more, according to age. Convulsions. "V^Tien 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 hyperemia 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. Mustard flour (1 to 4 teaspoonfuls, mixed first with a little cold or tepid water) may be added to the hot bath for a pronounced rubefacient effect. 224 GENERAL FEME DIES ^Meanwhile, treatment coming under the second heading should be employed. ^Miile the conAtilsiun 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 tipon the brain may be lessened by the administra- tion of sedatives. An excellent combination is that of potassium bromide and antip^Tine. the latter having both antispasmodic and antip;'.Tetic valtie^ and producing also a tendency to perspiration. A combination, giving the emergency dose of potassium bromide as 5 to 10 grains 0.30— 0.60 gm. ' and of antip^Tine as 1^ to 3 grains 0.10-0.20 gm; according to acre, is here c^iven: Gm. or c.c. R . — Potassii bromidi, 10 ABtipyrini, 3 Glycerini, 10 Aquse menthse piperitse, q. s. ad 60 (Sijss) (gr. xlv) (fdijss) 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 dtiring a spasm, for fear of vomited matter being drawn into the trachea If relief does not follow in say half an hour, treatment coming tmder the third heading may be employed, and this will tisually 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, .^^pasms 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 hyperemia, and that lessen the irritability of the brain centres more permanently. Chloral is often used by recttmi, in dose of a few grains ( l-oj, when con\iilsions are persistent. For treatment beyond the emergency period, the bromide and anti p^Tine may be contintied at the intervals necessary to prevent restless- ness and fever. A cathartic shotdd be employed, tmless pre^■^otlsly given, to ensure emptying of the digestive tract, where the irritation may have originated. For this purpose castor oil is our first choice, being efficient and harmless. Succeeding the hot bath, the child should be v»Tapped PLATE XVI. Arterioles dilated CHLORAL HYDRATE. Dose: gr. 5-20 (Gin. .30-1.30). 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- ratory 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. Keduces 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. Vagus Center Vase Motor Center Cervical Sympathetic ^Solar Plexus Depresses respiratory center Reduced by full doses. Respiration. Temperature. Metabolism. Destruction of proteids is increased with less per- fect oxidation. With prolonged administration fatty degen- eration of various organs may occur. The blue color indicates the sedative effects of Chloral. The marked depressant action upon respiratory and vasomotor centers, andupon the heart, renders Chloral much more dangerous than the bromides, whose etfects are similar in kind. PLATE XVTI. 3IOKPHIXE. Vagus Center Yaso Motor Center Cervical Sympathetic [For preparations, doses, and general uses of Opium, see Index of Drugs.] In form of suuhate, acetate, or HTDEOCHXOErDE. Gr. \-^ (Gni. .OOH-.Oloj. Classified as : Anodyne. Xarcotic. Phy.siologic action •} The action of morphine is essen- tially that of a central nerve depressant, the local action of the drug, wherever applied, being idmost nil. Children are very sensitive to this drug, and, if needed, it should be used in the iceakest preparations, and in less than the proportional dose. 2Servous System. Brain. Depresses cerebrum, especially in its higher intellectual functions. Medulla. Depresses respiratory center. Spinal cord. Does not perceptibly influence the cord. XOTE. — In The lo-wer 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 affected by ordinary doses. Muscular System. Xot affected by ordinary doses. Circulation. Xot much influenced by ordinary doses. Heart. Opinions differ. Any in- fluence of a moderate dose must be slight and probably indirect. Large doses slow the heart by stimulating inhibition. Capillary area. ZSTot much influenced, except that the cu- taneous area of the head and neck may show dilatation. Jtespiration. Depressed to a degree corresponding with size of dose. Eye. Pupils contracted by central nerve influence. Digestive System. Stomacli. Secretion and motUity lessened. Intestines. Peristalsis is greatly diminished. Elimination. Secretions generally are diminished, except the perspiration. partly changed in the system, but the greater part is eliminated b^ intestinal tract. 1 For poisoning by Opium or Morphine, see Table of Poisons and Antidote; Pelvic Plexus The drug is the rastro- SEDATIVES 225 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, ^^^len, however, the gums are very much swollen and con- gested, scarification may be advisable independently of the staie 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 — HgO]. Chloral hydrate is a t\-pical h}^notic. It is used to induce sleep and to relieve convulsions. It has been sup- planted to a considerable extent by the newer and safer hypnotics. 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: Butyl-chloral Hydrate (not official). Very similar to chloral in action. Dose, gr. 5-15 (0.30-1 gm.). Sulphonmetlianimi. Sltlphonal. Sulphonethylmethanum. Trional. Safer than chloral, but slower in action. Trional is more soluble than sulphonal, therefore usually preferred. Dose of each, gr. 15-30 (1-2 gm.). Opium Alkaloids. fPlate XVII.) Opium is the concrete exudation obtained by cutting the unripe capsules of the opium poppy, Papaver samniferum. It contains, in its fresh, moist condition, at least 9 per cent, of morphine (when dried about 12 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 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. \^Tienever, therefore, it is used, poisoning and habitual use must be 15 226 GENERAL REMEDIES guarded against. It must be administered with some caution to persons whose susceptibihties 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 be prescribed, for fear that the relief obtained might lead to an easy later resort to the drug, with formation of habit. A prescription might facili- tate such abuse of the remedy. It is also desirable for the patient to be ignorant of the name of the drug given. 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 be 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 J 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 efl^ect, 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 by 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 co-operation 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.) Morphina [Ci7HjgN03 + H20]. This alkaloid was isolated from opium and described by Sertiirner in 1816, and was the first to be dis- * See Cowling's rule in chapter on Prescription Writing. SEDATIVES 227 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 morphine 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 Acetas, soluble in 2.25 parts of water. Morphinae Hydrochloridum, soluble in 17.2 parts of water. Morphinae Sulphas, soluble in 15.3 parts of water. The dose of each of these is gr. |-— ^ (0.008-0.015), which may be increased slightly; Codeina [C^gHg^NOg + IIgO]. Soluble in 88 parts of water. Codeine is less powerful and depressing in action than morphine, and its after- effects are less unpleasant. Its official salts are: Codeinse Phosphas, soluble in 2.25 parts of water. Codeinse Sulphas, soluble in 30 parts of water. The dose of each is gr. i-1 (0.015-0.06 gm.). Heroine (not official). This artificial alkaloid is said to have a more depressant effect upon the respiratory centre than morphine or codeine; the dose is gr. yL-i. (0.005-0.01 gm.). CHAPTER XVIII, ELBIIXATIVES. A GROUP of functions that are liable to disorder in connection with 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. Eliminatives are those agents that increase the eliminative activity of these several avenues of excre- tion. Cathartics are agents that induce active evacuation of the intestines. (See Plate XVIII.) Diuretics are agents that 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 the study of the general subject of elimination, we observe a certain complementary 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, 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 diapho- retics and diuretics we should take into account this relation, for some agents will act in either way. For example, spirit of nitrous ether, when taken in the evening, with the skin being kept warm during the night, will induce sweating; whereas, when it is given in the morning, followed (228) PLATE XVIII, CATHARTICS. These diagrams are intended to shovr the ditTerent ways in vrhicli cathanics may act. It is not possible to classify strictly, as the action of some is too extensive to be limited to one gi-oup or illusti-ated by a single diagram. The numbers indicate the diagrams that represent what is believed to be the most prominent action in case of each drug, without intending to show the com- plete action in every instance. [For preparations and doses, see Index of Drugs.] GRorp A. LAXATIVES. Fruits. (1) Sugar. Sulphur. Purges in small doses. Glycerin (by enema). (2) Groi-p B. PUKGES. Aloe. (1) Mercurials. (4) Oleum Eicmi. (4) Ehamnus Frangula. (1) Khamnus Purshiana. (1) Eheum. (1) Magnesia. (3) Senna. (I) (4) GRorp C. HYDEAGOGUES. Salines. Magnesii Citras. (3) Magnesii Sulphas. (3) Potassii Bitartras. (3) Potassii et Sodii Tartras. (3) Sodii Phosphas. (3) Sodii Sulphas. (3) Elaterintim. (4) Jalapa. (4) Senna. (1) (4) Group D. DEASTICS. Colocynthis. (5) Elaterinum. (3) (4) Jalapa. (3) (4) Cambogia. (5) Oleum Tiglii. (.5) Podophyllum. (5) Scammonitim. (5) The red color shows the site of action, and indicates stimulation of motility or secretion. 3. Secretion stimulated. PLATE XVIII. CATHARTICS. The natural provision for intestinal evacuation in eludes three factors : 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, rheum, 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 ti-act (5), causing prompt, frequent stools, with severe griping. 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- fluence of cathartics upon the function of the liver seems uncertain and indirect. The red color shows the site of action, and indicates stimulation of motility or secretion. ELIMINA TIVES 229 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 vicarious elimination when the kidneys are disabled — viz., by catharsis and by diaphoresis ; though they are only substitutes and much less efficient. The lungs are concerned only with the elimination of volatile sub- stances. 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 w^ay. 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 w^ater 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. Potassii Citras. This salt is deliquescent. Potassii Bitartras. Cream of Tartar. Potassii Nitras. Nitre. Saltpetre. (For doses and uses, see Index of Drugs.) 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, which is typical of its group, which includes: Strophanthus. Convallaria. Lily of the Valley. Sparteinse Sulphas. Scilla. Squill. (For preparations and doses of these, see Index of Drugs.) 230 GENERAL REMEDIES 3. Still other diuretics act by stimulating the secreting structure of the kidney, leading to a better excretion of solids. These are sometimes called stimulating, or specific, diuretics. Examples of this class are: Spiritus iEtheris Nitrosi. Spirit of Nitrous Ether. Sweet Spirit of Nitre. Buchu. Caffeina. Cubeba. Cubeb. Oleum Juniperi. Oil of Juniper Berries. Oleum Terebinthinse. Oil of Turpentine. Potassii Nitras. Theobromine (not official). 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. Pilocarpinae Nitras. (For doses and uses, see Index of Drugs.) Heat in form of hot-air cabinet bath, hot-bed air 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 centre in the medulla, they stimulate the same motor activities. The following act reflexly by irritating the stomach: Sinapis. Mustard. The ordinary ground mixture of black and white mustard seed is employed, a tablespoonful or less stirred up in a glass of cold water. ELIMINATIVES 231 Ipecacuanha. Zinci Sulphas. Sulphate of Zinc. Cupri Sulphas. Sulphate of Copper. Antimonii et Potassii Tartras. Tartar Emetic. 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. Apomorphinae Hydrochloridum. Hydrochloride of Apomorphine. This is an artificial alkaloid derived from morphine. As it acts upon the vomiting centre, it may be given hypodermically in cases of poison- ing by opium or other narcotics, where the patient does not swallow. The dose hypodermically 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 any 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 securing complete relaxation of the respiratory apparatus, with relief of the spasm in the larynx. Also in the treatment of bronchitis in children too young to expectorate, its emetic action is employed in order to expel m.ucus from the air passages, where its accumulation interferes with breathing and provokes coughing. For both purposes mentioned syrup of ipecacuanha is given in doses of one-half to one teaspoonful (2-4 gm.), 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. 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. -32 GEXERAL REMEDIES The chief ones of vah.e are the ,™ following, the first of which is also a genera stimulant, and nsed on this account in the tnore depress^ respiratory diseases, such as pneumonia. epressing Ammonii Carbonas. Ammonii Chloridum. Other expectorants, stimulating in nature, include Cubeba. Cubeb. SciUa. Squill. (For preparations and doses, see Index of Drugs.) CHAPTER XIX. 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 suflfice as far as he can be concerned. Coming to the practical question of dental operations, we recognize (233) 234 General remedies certain periods of greater susceptibility to disturbance. The first three months constitute the period of greatest nervous instabihty, 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 ac- commodate 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 more 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 DENTISTRY DURING PREGNANCY 236 used that will increase this tendency or add to its results. The exclu- 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 accesss of air, or those that require the breathing again 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. Where 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 ob- served 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 Nature 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 way. 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 prophylaxis 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- * Dental Cosmos, May, 1895. 236 GENERAL REMEDIES wash, such as lime-water or saturated solution of borax or of sodium bicarbonate, used freely at frequent intervals and immediately after every occurrence of vomiting, and continued during 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 IV. CHAPTER XX. PRESCRIPTION WRITING. The writing 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 substances. While it is easy to order a simple solution of a common substance, 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 comparatively easy; but to the beginner in practice, nothing is much more difficult than to write origmal prescriptions with any degree of confidence. The art of prescribing is quite ancient, ha\T[ng been employed first by the physician to guide his assistant in preparing his medicinal mixtures, the office of physician having included also that of apothecary. To-day, 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 written directions of the prescriber. There is a marked contrast between ancient and modern prescriptions, in respect to greater definiteness and simphcity. Reference to the works of Fallopius, w^ho 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 exliaust our materia medica in prescribing for any one disease, and, with a more definite knowledge of the action and effects of drugs, we find that only (237) 238 PRESCRIPT lOX WRITING a few agents can be employed to real profit in meeting a pathologic con- dition. Hence, our prescriptions of to-day 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 pleas- antly (curare ciio, 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 — Corrigent or corrective. Safely. 4th ingredient — Excipient or vehicle. Pleasantly. "\Miile these terms aid us in comprehending the full purpose of pre- scription T\Titing, 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, with directions for compounding them. An official formula is one that is contained in the United States FJiar- 7nacop(£ia. 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 Puhis Ipecacuanhse et Opii. In pre- scribing, therefore, it is only necessary to write — R. — Pulveris Ipecacuanhse et Opii (quantity), PRESCRIPTION WRITING 239 instead of naming each ingredient and its quantity, as would be necessary if it were not official. A pharmacopceia 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 now gives 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 Pharmacopceia 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. (6) Their solubility (unless powder form is desired). (c) Their compatibility in the desired combination. (<^) Their doses. 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 administration 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. 240 PRESCRIPTIOX WPJTIXG (6) 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 centre. 4. To secure a suitable form. (a) By the use of special solvents to obtain a liquid form of an otlier- wise insoluble substance — e. g., salicylic acid requires SOS parts of water to dissolve it, but if borax is first dissolved to saturation saHcylic acid is soluble in less than 100 parts of the solution. (h) 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 mixture that is agreeable to the sight and pleasant to the taste. 5. To obtain a combination to act as a new substance. (a) Dover's povrder contains opium and ipecacuanha, the combina- tion haAing a diaphoretic eft'ect not possessed to any degree by the separate drugs. (b) Chemicals are sometimes combined in order to obtain a new definite compotnid by their reaction. 6. Tor preservation of the medicine. Alcohol, glycerin or stigar in large c^uantity, 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 diltite sohition will ferment easily at a summer temperature, but when used in strong solution (70 to So per cent.), as in some of the official syrups, it will preserve the preparation indefinitely. Knowing what substances we vvish 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 tise, for the reason that no rtile of solubility can be laid down. A few general statements, however, may serve some purpose. It is found that salts are ustiallv jnore soluble in icater than in alcohol. PRESCRIPTION WRITING 241 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. 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 for a time, because of its preservative power in addition to being an excellent sol- vent. 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: Percentage strength Soluble in parts of saturated of water. solution. Acid, benzoic 281 0.35 percent. Acid, boric . 18 5.5 Acid, carbolic (phenol) . 20 5 Acid, gallic . . 84 1.19 Acid, salicylic . 308 0.32 Acid, tannic . ' 0.34 300 Alum . 9 11 Ammonium carbonate . 4 25 Ammonium chloride 2 50 Antipyrine . 1 100 Betanaphtol . . 950 0.1 Caffeine . 46 2.17 " Caffeine, citrated . f 4* 1 25 25 " 4 * 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. 16 242 PRESCRIPTION WRITING Chloroform Cocaine hydrochloride . Codeine sulphate ... Copper sulphate Corrosive sublimate Creosote .... Iodine .... Lead acetate .... Magnesium oxide . Magnesium sulphate Morphine acetate (fresh) Morphine sulphate Potassium bicarbonate Potassium bitartrate Potassium bromide Potassium carbonate Potassium chlorate Potassium iodide . Potassium nitrate . Potassium permanganate Potassium sulphate Quinine bisulphate Quinine sulphate . Resorcinol .... Saccharine (benzosulphinide) . Silver nitrate Sodium benzoate . Sodium bicarbonate Sodium borate Sodium bromide Sodium carbonate (monohydrated) Sodium chloride Sodium thiosulphate (hyposulphite) Sodium salicylate . Strychnine sulphate Sugar ..... Thymol .... Zinc acetate .... Zinc chloride Zinc sulphate ... s Dluble in parts of water. . 200 Percentage strength of saturated solution. 0.5 per cent. 0.4 250 a 23 4.3 2.2 45.4 li . 13 7.7 « . 140 0.71 (( . 5000* 2 50 it . 15t 0.85 117 >i 2.5 40 « . 15.3 6.5 (( 3 33 « . 200 0.5 « 1.5 66 it 0.91 109 it . 16 6.25 (I 0.7 133 it 3.6 28 ft . 15 6.6 it 9 11 it 8.5 11.7 ti . 720 0.14 ti 0.5 200 it . 250 0.4 (t 0.54 200 it 1.6 62.5 it 12 8.3 it 20.4 5 it 1.7 60 it 3 33 it 2.8 36 it 0.35 286 it 0.8 125 it 31 3.2 it 0.5 200 a 1100 0.09 it 2.5 40 it 0.3 333 it 0.53 188 a * The solubility of iodine is increased by the addition of potassium iodide, as in Lugol's solution. t With 15 parts water magnesia does not dissolve, but forms the gelatinous milk of magnesia. PRESCRIPTION WRITING 243 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 Quantity of drug needed for wanted. %% strength. 1% strength. 2% strength, i 5% strength. 10% strength. 1 fluidrachm (4 c.c). j% grain (0.02 gm.). f grain (0.04 gm.). 1^ grains (0.08 gm.). 3 grains (0.20 gm.). 6 grains (0.40 gm.). 1 fluidounce (30 c.c). 2J grains (0.15 gm.). 5 grains (0.30 gm.). 10 grains (0.60 gm.). 24 grains (1.50 gm.). 48 grains (3 gm.). 1 pint ( 500 c.c). 40 grains (2.5 gm.). 80 grains (5 gm.). 2§ drachms (10 gm.). 6| drachms (25 gm.). 12^ drachms (50 gm.). 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 grains (0.60 gm.). This dissolved in the fluid- ounce 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 occur 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 (b) 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., tincture of myrrh with water will become turbid from precipitation of resin. 244 PRESCRIPTION WRITING Chemical Incompatibility consists in chemical reactions between sub- stances, whereby their nature is ahered. There may be: 1. Simple chemical change without any visible result. 2. Simple chemical change with or without loss of medicinal activity. 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 all instances of chemical incompatibility under rule; and the knowledge of chemistry necessary to predict always that incompatibility will occur, is not a common possession. The attempt is made to give the more important incompatibilities in connection with the individual drugs in the text of the book. Here, however, are given some general statements that will serve as a basis for study. These may be introduced by the important rule that drugs should never he prescribed with their chemical tests. 1. AlkaUes, 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. Antipyrine 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. PRESCRIPTION WRITING 245 Lime-water and calomel. Lime-water and corrosive sublimate. Potassium iodide and spirit of nitrous ether (if acid). Potassium permanganate and sulphur (explode when triturated). Potassium permanganate and glycerin, syrup 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 sub- stances : Acids, strong. Alkalies and their hydrates. Arsenic. Creosote. Iron salts. Mercuric chloride. Potassium chlorate. Potassium permanganate. Silver nitrate. Tannic acid. It should be noted that chemical incompatibility may be intentional, in order to obtain a new substance — e. g., in preparing ferri hydroxidum ammonia-water (alkaline) and solution of ferric sulphate (acid) are mixed, the result being a precipitate of the desired substance. ANTAGONISM OF DRUGS. The term therapeutic 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 admin- istering, in case of poisoning, a drug that shall counteract or antagonize the toxic action. In this sense we speak also of such drug as a physio- logic antidote to the poison. While we thus employ antagonism of drugs to good purposes, in our prescriptions we should avoid combinations that will neutralize the desired effect of the principal drug or drugs. Antagonism of drugs can seldom be absolute— i. e., there are very few drugs whose effects exactly neutralize the effects of other drugs. In the treatment of cocaine poisoning we have seen that two drugs, at least, 246 PRESCRIPTION WRITIXG are needed to fully cover the depressant action of the poison. Antagon- ism, therefore, is usually only partial, but it still may meet the most serious symptom in a case. Thus in poisoning by morphine the most dangerous condition is that of paralysis of the respiratory centre. Strych- nine 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 \ Chloi-al I Caffeine Chloroform Cocaine Digitalis Ether Morphine Kitrites Strychnine Antagonist. Site of antagonism. Atropine ]S itrites Vagus nerve. Vagus nerve. Caffeine Heart. , Digitalis Heart. r Aconite ■<. Digitalis Yagus nerve. Vagus nerve. (. Morphine . Kespiratory centre, cerebrum. f Caffeine Brain, circulation. 1 Atropine Brain, circulation. Digitalis Strychnine . Heart. Medulla, spinal cord. r Aconite Heart. ] Bromides, chloral. Brain, heart. Morphine . . Anesthetics . Brain, respiratory centre. Brain, respiratory centre, heart. f Caffeine Cerebrum, respiratory centre, heart. 1 Strychnine . Heart, respiratory centre, spinal cord. L Digitalis Heart, vasomotor system. f Atropine Cerebrum, respiratory centre, heart. 1 Caffeine Strychnine . Cerebrum, respiratory centre, heart. Kespiratory centre, heart, spinal cord. ^ Digitalis Heart. f Aconite Heart. 1 Atropine Vagus nerve. J Bromides, chloral. Heart. 1 Chloroform . Heart, vasomotor system. Cocaine [ iS itrites Heart. Vagus centre, vasomotor system. / Caffeine \ Strychnine . Cerebrum, respiratory centre. Kespiratory centre, spinal cord. f Atropine -] Caffeine Cerebrum, respiratory centre. Cerebrum, respiratory centre. (^ Strychnine . Kespiratory centre, other reflex centres. ' Aconite Vagus nerve. Atropine Vasomotor system. Caffeine Vasomotor system. Digitalis Vagus centre, vasomotor system. Ergot. Vasomotor system. Strychnine . Vasomotor system. ' Bromides, chloral. ^ledulla, spinal cord. Chloroform . . Heart, respiratory centre, spinal cord. Ether. . . Kespiratory centre, spinal cord. Morphine . . Kespiratory centre, other reflex centres. Nitrites . . Vasomotor system. PRESCRIPTION WRITING 247 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 shall include the minimum 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 hypodermically, will modify dosage. (See chapter on Admin- istration of Medicines.) After all, the dose of a drug is a relative rather than a positive quantity, which requires to be varied, according to con- ditions, within a certain range of efficiency and safety. The doses of the principal drugs, or of one or two preparations of each, which repre- sent them fully, should be learned. Of the occasional and unimportant drug, the dose will be learned only to be forgotten, and will require to be learned anew when it chances to be needed. 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 known as Cowling's Rule, which is : Divide the age of the child at its next birthday by 24. Thus, a child three years old will have 2^ or I of the adult dose. In connection with such calculation 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 with 248 PRESCRIPTIOX WRITIXG children if possible, may only be given iu rather 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 signature. These will be considered in order: 1. The Heading. Anciently the prescription was begun with a prayer to Jupiter or other heathen deity. I^ater this was shortened to the simple sign of Jupiter (%). "With an upright stroke before it we have a resem- blance to the sign I^, which we use to-day. To us this sign really means : "Take," being an abbre^^ation of the imperative form recipe of the Latin verb recipio — to take. 2. Names and Quantities of Ingredients. Tlie 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 Latin, therefore, can be read anwhere in the world of science to-day, 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, and in directing the number of pills or powders into which a mixture is to be divided, need he write out his directions in full. In 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 Prescription Writing 249 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. 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 to-day. 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 co-operation of the pharmacist in calling attention confidentially to the same — a kind of favor too often unappreciated by the prescriber. 250 PRESCRIPTION WRITING 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. Declensions of Nouns and Adjectives. 1st Declension. 2d Declension. 3d Declension. 4th Declension. Koims. Fern. Masc. Neut. Masc. -.T . and Fem. ^®'^''- Masc. -VT . and Fem. ^^'^'^• Singular : Nominative a (e) i us (os) um (on) (various) us u Genitive ae (es) 1 is us u Accusative Ablative Plural : Nominative am (en) a (e) ae um (on) o i a em (as Xom.) e es a The 4th declension includes only four names of drugs : Cornus Fructus Quercus Spiritus Genitive arum Oram nm (ium) Accusative as OS a es a Exceptions : i Theobroma — tis, Rhus— ois, is of and Physostigma , the 3d declension. —tis. are of the 3d declension. Indeclinable : Amyl Gambir Alcohol ) are regarded by Buchu Kino Eucalyptol v some authorities Catechu Sassafras Menthol ) as indeclinable. Elixir Adjectives. 1st and 2d Declension. Fern. Masc. Neut. 3d Delension. and Fem. •^^'^^• Singular : Nominative Genitive Accusative a us (er) um ae i i am um um is (s) e (s) is em e (s) Adjectives of other ter- minations and plural forms are very seldom used in prescriptions. * A very useful aid is the Latin Grammar of Pharmacy and Medicine, Robinson. P. Blakiston's Son & Co., Philadelphia. PRESCRIPTION WRITING 251 The rules of Latin grammar apply as to relation of nouns, adjectives, verbs and other parts of speech. Use of Cases. The nominative case is never used in a prescription, as the sentence is always introduced by the imperative recipe, the sub- ject of which is thou understood. The complete sentence would be: Take thou I of a substance I a quantity. I (genitive) I (accusative) The genitive case of the name of ingredient is required when the quantity is expressed by a noun, as: Take thou I of a substance I one ounce. I (genitive) I (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 Jour pills = R . Pilulas iv. The ablative case is used after the preposition cum (meamng with) , as: R. — Ferri hydroxidi cum magnesii oxido, gj. Verbs. The few verbs employed are in the imperative form except where the directions to the compounder are written in Latin, when the passive form may be also needed, as: R. — Massse hydrargyri, gr. xxx. Fiant pilulae, vj. {Let be made pills six.) WEIGHTS AND MEASURES. The system of weights and measures most approved in scientific circles is the metric system. This should be mastered by every student in scientific fields to-day. 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; but no student in any depart- ment of medical science should be excused from acquiring a practical familiarity with the metric system. The United States Pharmacopceia employs it exclusively in the expression of quantities of ingredients. \Mierever the old system is employed its denominations may be reduced to three, as below: Apothecaries'. Liquids. 60 grains (gr.) = 1 drachm (5) 60 minims (rr\^) = 1 fluidrachm (f3) 8 drachms = 1 ounce (5) 8 fluidrachms = 1 fluidounce (f5) The use of the scruple 9 (20 gr.) often leads to a confusion of signs, and the pound (16 oz.) is seldom required in prescribing. 252 Prescription writing The Metric System. Among the advantages of the metric system the one most prominent is that of being a decimal system. It corresponds in this respect with our American system of money. The latter can, therefore, iUustrate the former in a very simple way, as appears below, the decimal point or a perpendicular line being the dividing point between units and fractions : United States money 10 Grams Metric weights 10 Equivalents in 1 apothecaries' weight Cu. centimeters Equivalents in 1 liquid measure a = g 03 bo 50 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 milligram is much used because of the small fractions which so many doses require. 1 1 1 1 1 1 15.4 grains. 1.5 " 0.15 " 0.015 " Approximately. 15 grains. IV2 " 1/6 " 1/60 " Approximately. 16.23 minims. 16 minims. 1.6 " 11/2 " 0.16 " 1/5 " 0.016 " i/sn " The units of the metric system are : Unit of length: Meter = One forty-millionth part of the earth's meridian (39.37 inches). Unit of capacity: Liter = One cubic decimeter (1.05 quarts). Unit of weight : Gram = Weight of one cubic centimeter of distilled water at 4° C. (15.4 grains). Equivalents of apothecaries' weights and liquid measures in the metric terms are: Metric A bhreviations. Gm. or c.c. dg. eg. mg. 1 grain = approximately 1 drachm = approximately 1 ounce = approximately 4 31 1 minim = approximately 06 1 fluidrachm ■= approximately 3 7 1 fluidounce = approximately 30 1 pint = approximately 475* 1 quart = approximately 950 * For ordinary purposes 500 c.c. is the convenient approximate equivalent of a pint and 1000 c.c. of a quart. 065 PRESCRIPTION WRITING 253 The gravi is a measure of weight and the cubic centimeter of capacity, but Uquids may be weighed and expressed in grams or decimals of a gram. The United States Pharmaco'poeia weighs sohds and measures liquids. In prescriptions, fractional quantities are expressed in decimals of the gram, whether they are liquid or solid. Equivalents of common measures (approximate) are: A drop = 0.03-0.06 gm. (three to six centigrams). A teaspoonful = 4-5 c.c. (four to five cubic centimeters). A dessertspoonful = 8-10 c.c. (eight to ten cubic centimeters). A tablespoonful = 15 c.c. (fifteen cubic centimeters). A heaped tablespoonful = 20 c.c. (twenty cubic centimeters). Rules for Converting Quantities to Metric Terms: 1. If in grains (or minims), multiply the number by 0.065 (fiuids 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 (fiuids 3.70). The product will express the quantity in grams. 3. If in ounces, multiply the number by 31 (fiuids 30). The product will express the quantity in grams. Rules for Converting Quantities from Metric Terms: 1. Divide grams by 0.065 (fiuids 0.06) or multiply by 15 (fiuids 16). The result will be in grains (or minims). 2. Divide grams by 4 (fiuids 3.70). The result will be in drachms. 3. Divide grams by 31 (fiuids 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 -^-^ 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 254 ' -PRESCRIPTION WRITING by following the rule given below. This does away entirely with the need of calculating total quantities, and renders prescribing much easier than with the old system. 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.* 1. Make 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 cubic centimeters. For example: Gm. or c.c. B . — Potassii bromidi (single dose 10 grains), 10 Morpliinee sulphatis (single dose \ grain), 25 Spiritus setheris nitrosi (single dose 30 minims), 30 Aquse, c|. s. ad (16 teaspoonful doses), ' 60 M.— Sig., etc. The same rule applies in prescribing poM^ders or pills : Gm. or c.c. B . — Pulveris ipecacuanhae et opii (single dose 5 grains), 5 Pulveris digitalis (single dose 1 grain), 1 Strychninfe sulphatis (single dose Jq grain), 02 Misce et divide in chartulas numero xvi. The convenience of the decimal system in ordering and preparing percentage solutions is apparent. With a total quantity of 1000, 100, or 10 c.c. the calculation of quantity of ingredients is very simple. CONSTRUCTION OF PRESCRIPTIONS. Dentifrices. If we desire to write 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 prevent accumulation of deposits). 3. Aseptic or antiseptic. 4. Pleasant to the taste. * Long. Medical News, Philadelphia, March 25, 1893. PRESCRIPTION WRITING. 255 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 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 f of prepared chalk, ten ounces, or 310 grams. 2. J of powdered soap, two ounces, or 62 grams. I of oil of wintergreen, five minims, or 0.30 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. R. — Cretse prseparatae, $x or 310 Saponis pulv., Sij or 62 Olei gaultherise, Tt\^v or 30 M. — ^Triturate thoroughly. Sig. — Use with toothbrush each evening. For A. B., Oct., 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: Greta prseparata is antacid and slightly abrasive. Sapo is alkaline, detergent and antiseptic. Oleum gaultherise 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. 256 PRESCRIPTION WRITING 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, 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 carmine 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 280 times sweeter than cane-sugar, only a small quantity is needed. 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. PRESCRIPTION WRITING 257 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 condition of the mouth, while in disease, local or general, efforts are still less availing. It is often essential, therefore, that a positive aid in the nature of an antiseptic should be freely employed, always, how^ever, 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 astringent) 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. 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 carbolic acid, 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 carbolic acid, 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 c.c R • — Acidi carbolici, 2 Sodii bicarbonatis, 15 Glycerini, 30 Aquse, q. s. ad 200 (gr. xxx) (Sj) (f5vij)-M. Sig. — Use as mouth wash every three hours. Another efficient similar combination is Dobell's solution. (See formula, p. 123.) 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 slightly soluble in water, requiring 281 and 308 parts respectively, and they are acid in reaction. It is found, however, 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 ^cid added, is presented in the following: 17 258 PRESCRIPTION WRITING Gm. or c.c. R . — Sodii boratis, 5 (3iss) Acidi salicylici, ' 1 (gr. xa') Aqufe, " 100 (fsiij)-^. Dissolve the borax in the water, then add the saUcyhc acid. Sig. — Mouth wash. Gm. or c.c. R. — Sodii boratis, 5 (3iss) Acidi benzoici, 1 (gr. xv) Aqu«, 100 (fsiij)— M. Dissolve the borax in the water, then add the benzoic acid. Sig. — ^Nlouth 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 : c.c. R. — Aquae creosoti, 100 Sig. — [Nlouth wash. Use after each meal and at bedtime. Hydrogen peroxide is entirely safe to use in the official 3 per cent, sokition, but it Is acid in reaction. It is useful in septic conditions. ORDER OF WRITING A PRESCRIPTION. In ordering a combination for local use the strength of solution is the important consideration, while in a prescription for internal effect the dose is most important. In either case the order to be followed in writing is this: 1. ^Yrite heading and names and quantities of all ingredients thus: R . — Potassii bromidi, Spiritus Eetheris nitrosi, AquEe, S\Tupi lactucaiii. 2. Decide upon the size of the combination and the number of doses. The example may be for a feverish child; the dose a teaspoonful, and the total mixture 2 fluidounces or 60 c.c. This would give us 16 doses. 3. Multiply the single dose of each ingredient by the number of doses, thus: Of potassium bromide we will give a single dose of 6 grains, 6 X 16 doses = 96 grains or about IJ drachms. Of spirit of nitrous ether the single dose of 15 minims X 16 = 240 minims or 4 fluidrachms. Of PRESCRIPTION WRITING 259 water we will use enough to ensure ready solution, say 6 fluidrachms ; and syrup of lactucarium will make up the balance — quantum sufficit (q. s.) ad (up to) foij. The result will be: I^. — Potassii bromidi, Spiritus setheris nitrosi, Aquse, Syrupi lactucarii, Gm. ore.c oiss or 6 fSiv " 15 fSvj " 24 q. s. ad foij " 60 Or we may apply the simple rule previously given for the use of the metric system (p. 254). 4. Add the 3d, 4th, and 5th parts of the prescription. Whenever we order the same quantity of each of two ingredients, we may use the abbreviation aa, meanimg of each: 'Bj.. — Sodii bicarbonatis, Sodii salicylatis, aa 3j A little practice, as a matter of course, is necessary to easy prescription writing. The author feels that the foregoing will efficiently aid the ambitious student in this direction. ABBREVIATED TERMS IN COMMON USE IN PRESCRIPTIONS. ad . ad lib. ad libitum aa. ana b. i. d. bis in dies Br. P. . c.c. cum fiat, fiant gm. gr. ... gtt. nt . . . . M. misce N.F. . p. r. n. pro re nata q. s. quantum sufficit R. recipe ss. semissis S. Sig. signa sine t. i. d. ter in die U. S. P. . , to, up to. at pleasure. of each. twice daily. British Pharmacopoeia. cubic centimeter. with. let (it) (them) be made. gram. grain. drop or drops. minim. mix. National Formulary. as occasion arises. as much as necessary. take. a half. write. without. three times a day. United States Pharmacopoeia CHAPTER XXI. POISONS. A POISON 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 natural 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 course of the disease. With 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 bacterium, 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 protection 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 labelled 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 (260) POISONS 261 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. (b) 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. (b) 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 symptoms 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 Respiration. 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 Centres. Coma is a paralysis of the conscious and the reflex centres of the brain. It may be caused by pressure, as in apoplexy, or it may be due to the action of a narcotic. The signs of death usually relied upon are cessation of respiration, cessation of circulation and paralysis of pupil. 262 TABLE OF POISOXS AXD ANTIDOTES Table op Poisoxs axd Antidotes. (This table is adapted from the author's Tables for Doctor and Druggist, by permission of the publisher, E. G. Swift, Detroit, Mich.) Poison. Toxic dose. Action. \ Prominent symp- toms. Antidotes and treatment. {Antidotes in italics.) Acid, carbolic (phenol) Acid, hj'drocyanic. Acid, prussic (U. S. P. 2%). Bitter almonds. Potass, cyanide. Acid, oxalic Soluble oxalates. ni3o Mineral acids. _ Acid, hydrochloric, nitric, sulphuric, Aconite Tincture of root. AconitLne. Ammonia Water of ammonia (10%). Stronger water of (28%). Carbonate of Am- monium. Arsenic trioxide, Arsenous acid, white arsenic .... Arsenic disulphide, red sulphide of arse- nic, realgar. Arsenic trisulpyde, orpiment. King's yellow. Arsenite of copper, Scheele's green. Aceto-arsenite of copper. Paris green. Schweinfurth green Belladonna (leaves, berries or root) Atropine ni22 gr. Ve f3l * fatal. gr. 2 fatal. Corrosive; systemic poison. Depresses brain and heart. Irritant; general depressant Bromine. By stomach By inhalation . gr. V2-H fatal. f I Corrosive Depresses heart and ner\'ous system. Irritant. Caustic. Escharotic irritant when diluted. Pain followed by numb- ness; white stain; col- lapse; stupor; dyspnea. Sudden various symp- toms of depression; dyspnea. lAbdominal pain, I vomiting, collapse, ' stupor. Thirst, vomiting, burn- I ing pain in throat and ' stomach; tissues cor- roded; more or less collapse. iTingUng and numb- j ness; slow, weak pulse; I dyspnea; pupil usually I dilated. Irritation in air pass- ages and stomach, with pain, vomiting and purging; prostra- tion. Odor of am- monia. Emesis: Albumin, alcohol, sul- phate of jyiagnesiuni 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, foUow by lime- water, magnesia, soap or plaster from wall; no carbonates. De- mulcents, stimulants; morph- ine hypoderm. if needed; do not use stomach pump. Empty stomach. Atropine, ana- monia, digitaHs with glonoin; strychnine. Slight galvanic shocks 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. Deliriant narcotic ; dilates pupil and paralyzes accommo- dation. Caustic; sedative to nerve centres. Faintness; gastro- _ :Aid emesis (unless vomiting has intestinal irritation.! been profuse) by the use of vomiting and purg-! mustard or sulphate of zinc, ing; thirst; collapse; May wash out stomach by cramps, con\'ulsionsl means of flexible tube, but or coma. In some stomach pump should not be cases collapse is most used. Freshly prepared Ay- prominent symptom,, drated sesquioxide of ironX or in others stupor. ' hydrated sesquioxide of iron Some cases resemble with magnesia freely, and fol- cholera. Usually the! low by an emetic, then by symptoms do not de-i castor oil. Demulcents, ano- velop quickly. djmes, stimulants, external I warmth. DrjTiess of mouth and Emetics or stomach tube. Tan- pharynx; eyes bright, nic acid, animal charcoal, fol- pupils dilated; face low by emetic, and later by flushed; rapid respi- castor oil. Heat or cold ex- ration; delirium, con- ternally; or alternately. Arti- "vnlsions, stupor. I ficial respiration and stimulants if necessary; morphine may be I of value. Severe _ symptoms of Dilute with large draughts of irritation; depression water. Very dilute solutions of nerve centres; par-; of alkalies; ether; brisk cathar- alysis. | tic alkalies. lAmmonia 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. t This is the Ferri Hydroxidum, U. S. P. To prepare it freshly, have always on hand in separate bottles 200 c.c. (f56J^) of Solution of Tersulphate of Iron and 220 c.c. (f§7) of Water of Ammonia. When wanted, dilute the solutions largely, mix with constant stirring, strain, and wash with water, then give freely suspended in water. The Ferri Hydroxidum cum Magnesii oxido (U. S. P.) is a preparation of similar value. It is prepared by mixing the iron solution with a mixture of magnesia and water. In preparing either of the above, either tincture of chloride- or Monsel's solution may be substituted for the tersulphate. TABLE OP POISONS AND ANTIDOTES 263 Poison. Toxic dose. Action. Prominent symp- toms. Camphor Cannabis indica . Cantharides Tincture. Cantharidin (active principle) . Carbolic acid. jSee Acid, carbolic. Carbonic anhy- _ dride,* carbonic acid gas. Carbonic oxidef • ■ • Charcoal gas. Coal gas. Illuminating gas. Castor-oil beans . . . . (Seeds of Ricinus communis.) Chloral hydrate . . . . Chloroform . By stomach By inhalation .... Coal gas. See Car- bonic oxide. Copper salts Arsenite. See Arsenic. Carbonate, "Natural" verdi- gris. Subacetate, verdi- gris. gr. 20 gr. 23 fgl fatal. Three seeds fatal, gr. 30 fSl fatal to child. f54 fatal to adult. rrii5 quickly inhaled has been fatal 34 Disturbs brain and nerve centres. Intoxicant Irritant; sometimes aphrodisiac Regarded by some as narcotic. Destroys oxygen- carrying power of the red blood cor- puscles. Irritant. Hypnotic; sedative; paralyzes nerve centres. Narcotic. Locally irritant; anesthetic Anesthetic; paralyzes nerve centres; has a direct paralyzing effect upon heart. Irritant. Vertigo; pain in stomach; delirium or stupor; convulsions. Hilarity; mental con- fusion; pupils dilated; drowsiness. Gastrointest. irritation with pain, vomiting and purging; pain in loins; severe irritation of genitourinary or- gans; sometimes erotic excitement; collapse, stupor, coma; in some cases delirium or con- vulsions. Headache, giddiness drowsiness; cyanosis if oxygen is excluded; coma. Headache, vertigo, prostration, vomiting, dyspnea; feeble and rapid pulse, stupor; in some cases convul- sions. Severe gastrointestinal 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, syn- cope sometimes early; profound narcosis. Death by failure of heart or respiration. Antidotes and treatment. {Antidotes in italics.) Gastric irritation with pain and vomiting of greenish matter, purging; jaundice in some cases; convul- sions or paralysis may follow. Eme.sis. Follow by castor oil or sulphate of magnesium. Stimulants if necessary to support nerve centres. 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- dermically, or anesthetics if suffering is intense. Leeches to hypogastrium. Warm baths; mild diuretics and cathartics. Supply fresh air or oxygen. Artificial respiration and stim- ulants 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 successful 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. Ex- ternal warrnth very important! Arouse patient. Stimulate re- flexes by external application of mustard, friction, slapping smartly; faradization; atropine, strong coffee, strychnine, arn- monium carbonate and digi- talis if urgent ; artificial or forced respiration; inhalation of oxygen very useful. Emetic or use of stomach tube. Arouse patient; recumbent posture. Stimulants; strych- nine, caffeine, digitalis; ex- ternal warmth, artificial respi- ration 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 of diaphragm and other muscles of respiration ; massage of heart; strychnine, caffeine, digitalis. Aid emesis. Albumin freely is best antidote. Milk, mucil- aginous drinks; ferrocyanide of potassium if pure; opium; stimulation if necessary. * An atmosphere containing 1 to 2% of carbonic anhydride, -with a corresponding diminution of oxygen, is poisonous; with 5 to 10% of carbonic anhydride, and oxygen correspondingly lessened, death will occur, while it requires 10 to 20% 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. X 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, as a matter of course, necessarily fatal. II See note under Opium. 264 TABLE OF POISOXS AXD ANTIDOTES Poison. Toxic dose. Action. Prominent symp- toms. Antidotes and treatment. (Antidotes in italics.) Sulphate, blue ^■it^iol. Corrosive subKmate See Mercuric chlo- ride. Creosote , Croton oil Cyanide of potas- sium. See Acid, hydrocyanic. Elaterium Elaterin (several times stronger than elaterium). Ether, by stomach Ether, by inhalation Formalin Fungi* . Amanita muscaria, Agaricus phalloides, and others. (The irritant principle is destroyed by boil- ing, drying, or by acids, alkahes or alcohol; but the narcotic principle, viuscarine, 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 subU- mate. Bichloride of mercury.) Mercuric cyanide. (Similar to above.) ol fatal TTISO fatal. gr. .3 fatal. Similar to belladonna. but more hypnotic. Irritant. Irritant. Irritant. Irritant in acute poisoning. Irritant. Irritant; drastic cathartic. Drastic cathartic. Irritant. Anesthetic Irritant. Irritant; narcotic. Gastrointestinal irri- DUute freely with water, then tation. ' emesis; follow by demulcents. Violent gastrointes- Demulcents, anodynes; mor- tinal irritation; purg- phine hypodermicaUy. ing, collapse, and other symptoms sembUng those cholera. Violent vomiting and Anodynes, purging, with severe mically, griping; collapse. ' lants. morphine hypoder- demul cents, stimu- Gastrointestinal tation. Narcosis; cessation of respiration. Severe pain in throat and stomach; vomit- ing. Gastrointestinal irri- tation, pain and vom- iting; various nervous symptoms; headache, vertigo, ^■isual cUs- turbances; in some cases delirium or coma. Stimulate elimination; demul- ! cents; stimulants 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, ano- djTies. Ammonia as antidote. Emetic and cathartic (common salt or mustard as emetic); demulcents and other treat- ment according to inchcations; atropine hypodermicaUy is recommended as physiologic antidote. Tannic acid has been thought to be useful. Purified animal charcoal. Same as in belladonna Same as for belladonna poison- poisoning. I ing. Gastrointestinal irri- Aid emesis. Demulcents, dilu- tation, vomiting and' ents, anodynes, stimulants if purging; headache, in needed. some cases saHvation; frequently an erup-, tion; prostration, Similar to above. Gastric irritation and pain; vomiting. Gastrointestinal irri- tation with severe coUc, vomiting, con- stipation; if severe, convulsions may occur. Corrosive. Symptoms occur^ quite promptly; burning in throat and stomach, nau.sea and vomiting; abdomen swollen and tender; severe purg- ing with straining; discharges frequently bloody; collapse, stupor, convulsions, j '.Starch freely, foUow 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, ano- dynes; 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 v;heat- flour paste or milk. Emesis after poison is neutralized; demulcents, morphine hypo- dermicaUy; stimulants inter- nally and heat or friction exter- nallj'; continue white of egg for one to two weeks. * For an extensive and illustrated description of edible and poisonous fungi, see Referencw^ Handbook of the Medical Sciences, vol. ui., New York. TABLE OF POISONS AND ANTIDOTES 265 Poison. Toxic dose. 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 Alcoholic extract Strychnine Opium . Camphorated tine ture. Paregoric (contains about 34 grain of opium to a fluidrachm) . Tincture. Lauda num. (This and all other official fluid preparations ex cept paregoric con- tain 10% of opium.) Codeine. Morphine Narcotine. gr. 30 gr. 3 gr. }4 gr. 4-5 fatal. Action. Prominent symp- toms. Antidotes and treatment. (Antidotes in italics.) Irritant. Increases irritability of spinal cord. 1st stage. Symptoms of gastro- intestinal irritation in varying degree, ac- cording to the amount and solubiUty 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 m9uth drawn up; later jaws become fixed; death by asphyxia or ex- haustion; conscious- ness remains until near death. Often slight stimiila- tion or excitement. gr. H fatal. 2d stage, narcotic. Intoxication, drowsi- ness and stupor; pu- pils are contracted; pulse slow and fuU; respiration slow and often stertorous; face flushed, sometimes cyanosed; uncon sciousness seems com plete, but patient can be partially aroused during this stage by shaking or shouting. Prompt emesis by mustard or 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- taUs; warmth externally. If seen early evacuate stomach, then give tannic acid freely, and follow by a quick emetic. Bromide of potassium in large doses, gm. 8-16 (32-4) and chloral, gm. 1-2 (gr. 15-30) every half-hour if necessary; keep patient very quiet. _ When convulsions are severe, inhala- tions of ether or chloroforrn. Forced respiration* if asphy.xia 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..30-2 (gr. 20-30) if vomiting does not speedily occur; meanwhile tannic acid should be given freely, or potassium permarifja- nate. Wash out stomach. The stomach tube may be useful. Apomorphine 0.005 gm. (^lu gr.) hypodermically as emetic S patient cannot swaUow. Maintain respiration: 1. By arousing patient and stimu- lating reflex actixdty 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 respirationf must be em- ployed 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 physiologic experiments has been apphed to the treatment of opium poisoning by 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 has 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. High authorities have pronounced forced respiration as no better than the usual methods of artificial respiration, but the experience given above would seem to place the method among the most effectual means at our command for resuscitation of seemingly hopeless cases of opium poisoning. 266 TABLE OF POISONS AND ANTIDOTES Poison. Toxic dose. Action. Prominent symp- toms. Antidotes and treatment. (Antidotes in italics.) Oxalates. ") See Oxalic > Acid, acid. ) oxalic. Paregoric. See Opium. Paris green. See Arsenic. Phosphorus Potassa Soda. (Soda as a poison is very similar to potassa.) Liquor potassse. Liquor sodiB. Commercial potash and soda are im- pure carbonates containing much free alkali. Potassium bitar- trate. Cream of tartar. Potassium chlorate Potassium nitrate Potassium sulphate, Prussic acid. See Acid, hydrocyanic. Red lead. See Lead salts. Red precipitate. See Mercury salts. Third stage, paralyzant. gr. 1 fatal. ;4* 52 fatal. o6 fatal. olO fatal. Irritant. Caustic. Prostration, coma; res- piration may become more rapid and shal- low; pulse weaker and more rapid; face is pallid and sometimes cyanosed; before death occurs pupils become dilated; re- flexes aboHshed; con- vulsions may occur; death usually by fail- ure of respiration. Irritant purgative. Irritant; believed to produce serious changes in the blood. Irritant. Irritant. .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 oxygen. Morphine is eliminated into the storaach, therefore it should be washed out frequently with a solution of potassium -permanganate. 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 some 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 ir stomach and abdo- men; severe vomiting and purging; prostra- tion. Sulphate of_ copper, 0.20 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 neutraUzed and re- moved employ demulcents; mucilaginous drinks, anodynes and stimulants if necessary. Pi. large draught of water im- mediately, and follow with diluted vinegar or lemon-juice; albumin, oils, acidulated de- mulcent drinks; opium or mor- phine to reUeve pain; stimu- lants. Gastrointestinal irri- tation. Gastrointestinal irri- tation with pain and vomiting; irritation CI kidneys, often -with suppression of urine and other symptoms of acute nephritis; cyanosis and nervous symptoms may occur. Gastrointestinal _ irri- tation with ^aolent vomiting, and in some cases purging; mus- cular weakness, col- lapse; various nerv- ous symptoms may occur. Similar to above. Demulcents; chalk or magnesia mixed with water; opium. Demulcents, saline purgatives and diuretics; calomel inay 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; anodynes and stimulants as needed. If col- lapse occurs, warmth, friction, or mustard externally. Same as for potassium nitrate. * Poisonous effect depends rather upon concentration than quantity. TABLE OF POISONS AND ANTIDOTES 267 Poison. Toxic dose. Action. Prominent symp- toms. Antidotes and treatment. (Antidotes in italics.) Silver nitrate Soda. See Potassa. Stramonium. (Similar to bella- donna as a poison.) See Belladonna. Strychnine. See Nux vomica. Sugar of lead. See Lead salts. Tobacco Nicotine (one of the most active poisons known.) Turpentine, oil of. Verdigris. See Copper salts. White lead. See Lead salts. Zinj chloride "Burnett's Disin- fecting Fluid" has 200 grains of zinc chloride in one fluidounce. Zinc sulphate .... gr. 30 A few drops prob- ably fatal. 32-4 Irritant. Severe gastric irri- j Solution of common salt freely; tation, vomiting, con- albumin; mucilaginous drinks; vulsions; later diar- other treatment as the case rhea. may require. Irritant; sedative. Irritant; narcotic. Corrosive. Irritant; emetic. Nausea, vomiting, in some cases purging; pain in stomach; prostration; delirium; cramps; rapid, weak pulse; collapse. Gastric irritation; vomiting and purg- ing in some cases; irritation of urinary organs with urine lessened; unconscious- ness; convulsions; col- lapse. Violent irritation of stomach immediately, with vomiting and pain; tissues corroded; nervous symptoms ; collapse. Gastric irritation; vomiting. 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; siilphate of mag- nesium as cathartic; hot fo- mentations to loins; demul- cents; stimulants and anodynes if needed. Warmth and friction externally. A 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 acid; albumin; demulcents; anodynes and stimulants if necessary. INDEX OF DRUGS. OFFICIAL DRUGS AND PREPARATIONS ARE GIVEN THEIR PHARMACOPEIAL 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 ; * Unofficial. Ac. = acid. Al. = alkaline. Insol. = insoluble. Misc. = miscible. N. = neutral. Part. = partly soluble. sol. SI V. s. Spar. : slightly soluble. = very soluble. = sparingly soluble. Solubility in Dose. Page in Drug. Reac- Gm. or c.c. Uses. text. tion. Water Alcohol 90 Acacia, gum Arabic 2 insol. Demulcent. In irri- Mucilago acacia; ac. freely tation in digestive 34%. tract; in emulsions Syrupus, 10 J^. ac. freely to hold oil or other matter in suspension. 137 Acetanilidum, anti- N. 180 2.5 gr. 1-10 0.06-0.60 Antipyretic. Anodyne. 219 febrin. In acute fevers cau- Pulvis acetaniUdi gr. 2-15 0.12-1 tiously. In head- compositus. aches. Locally in powder as antiseptic. 152 *Acetozone, ben- zoyl-acetyl per- oxide, benzozone. si. sol. gr. 1-5 0.06-0.30 Antiseptic. Bleaching agent. 219 Acetphenetidinum, phenacetin. 925 12 gr. 2-10 0.12-0.60 Antipyretic. Anodyne. Acidum aceticum, ac. local Solvent. To soften . ?•?%■ use. callous tissue, corns, Acidum aceticum ac. etc. Hemostatic. dilutum, 6%. 72 Acidum aceticum glaciale, 99%. Acid, arsenqus. See Arseni trioxid. ac. Caustic. 129 Acidum benzoicum^. ac. 281 2 Antiseptic. The acid 122 115 Ammonii benzoas. lathii benzoas. Sodii benzoas. Acidum _ boricum, boric acid. Sodii boras, borax. N. si. ac. N. si. ac. al. 10.5 3 1.(1 18 20.4 25 13 43 15.3 insol. ■ gr. 5-20 gr. 5-15 gr. 5-30 0.30-1.30 0.30-1 0.30-2 and its combinations given internally as urinary antiseptics. Antiseptic. Saturated aqueous solution as mouth wash or to 123 122 Glyceritum boro- glycerini (a soln. of boroglycerin, 31% boric acid). N. local use purulent inflamma- tions. Borax has similar uses, is alka- line and antiseptic. Acidum camphori- ac. 125 sol. gr. 10-30 0.60-2 To control night- cum. Acid, carbolic. See sweats of phthisis. Phenol. Acid, chromic. See Chromii trioxid. 129 *Acid, cinnamic. ac. si. sol. sol. Antiseptic. 209 Acidum citricum. ac. 0.54 1.08 gr. 5-30 6.30-2 Syrupus acidi citrici. f5i-4 4-15 scurvy, as a substi- 1%. tute for lemon-juice. 107 Acidum galHcum. *Glycerite. ♦Ointment, 10%. ac. 84 5 gr. 5-20 0.30-1.30 Astringent. As sys- temic hemostatic where local treat- ment is impossible. (269) 270 INDEX OF DRUGS Page Drug. Reac- Solubility in Dose. in Gm. or c.c. Uses. text. tion. Water Alcohol 71 Acidum fivdrochlori- ac. Caustic. 262 cum, 31.9%. 208 Acidum hydrochlori- cum dilutum,10% ac. ni5-20 0.30-1.20 Digestant. When acidity of gastric juice is deficient. 207 Acidum hydrocyan- ac. mi-3 0.06-0.20 Sedative. In cough 218 icum dilutum, dil. and vomiting. Use 262 prussic acid, 2%. with caution. 73 Acidum lacticum, 75%- . . „ Acid, muriatic. iSee Acid hydrochloric. ac. sol. sol. nil5-60 1-4 Antiseptic. Solvent. Applied to diphther- itic membrane and in pyorrhea alve- olaris. 71 Acidum nitricum, ac. Caustic. Locally to 262 aqua fortis, 68%. sloughing ulcers, and 208 Acidum nitricum dilutum, 10%. ac. Tn5-20 0.30-1.20 caries of bone. Di- lute acid as tonic and 71 Acidum. nitrohydro- chloricum, aqua regia. ac stimulant to hver and digestive secretions. 209 Acidum nitrohydro- chloricum dilutum ac. ni5-20 0.30-1.20 Tonic. Digestant. Same uses as dilute hydrochloric and nitric acids. Acidum oleicum. si. ac. insol. sol. extern. To prepare oleates. 262 *Acid, oxalic. Acid, phenic. »Siee Phenol. Acidum phosphori- cum, 85%. ac. ac. 8 2.5 Irritant poison. As reagent. To remove stain of potassium permanganate, or of rust, fruits, and ink. 210 Acidum phosphori- cum dilutum, 10% ac. rn5-30 0.30-2 Restorative tonic. In neurasthenia. *Acid, picric, carbo- ac. 86 sol. Reagent. Coloring zoic acid. agent. 129 Acidum salicylicum. *Ointment, 10 %. ac. 308 2 gr. 5-30 0.30-2 extern. Antiseptic. Antipy- retic. In solution as 130 Sodii sahcylas. si. ac. 0.8 5.5 gr. 5-30 0.30-2 preservative. Sodi- um salicylate in acute rheumatism. 71 Acidum sulphuri- ac. Corrosive. Dilute acid 262 cum, 92.5%. as astringent. 209 Acidum sulphuricum dilutum, 10%. ac. m5-20 0.30-1.20 (' The aromatic acid as 209 Acidum s. aromati- cum. Tn2-15 0.12-1 ^ solvent for quinine sulphate. 153 Acidum sulphuro- sum, 6% of sul- phur dioxide gas. ac. f3J^-2 2-8 Disinfectant. Bleach- ing agent. In para- sitic skin diseases. 154 Sodii bisulphis. ac. 3.5 70 ] Internally in form of 140 Sodii sulphis. N. 9 si. sol. [gr. 5-30 0.30-2 sulphites or hyposul- 141 Sodii thiosulphas N. 0.35 insol. phites, as antiseptic. 154 (hyposulphite). J 96 Acidum tannicum. ac. 0.33 0.22 gr. 1-30 0.06-2 Astringent. Applied 111 CoUodium stypti- cum, 20%. local use as hemostatic. To contract tissue, as 93 Glyceritum acidi tannic, 20%. Unguentum, 20%. Trochisci, local use local use gr. 1 each in catarrhal pharyn- gitis, and to check secretion, as in diar- rhea. 209 Acidum tartaricum. ac. 0.7 2 gr. 5-30 0.30-2 Substitute for citric acid or lemon-juice. 73 Acidum trichlor- aceticum. ac. V. s. V. s. Caustic. Test for al- bumin. 218 Aconitum, aconite gr. H-2 0.03-0.12 Cardiac sedative. To 262 root (a. napellus). reduce arterial press- Plate ♦Extract, gr. Vw-H 0.006-0.015 ure in inflammations XIV. Fluidextractum aconiti. WA-2 0.03-0.12 and sthenic fevers. Locally sedative in 63,65 Tinctura aconiti. )T15-15 0.30-1. form of plaster, tinc- Aconitina, aconitia. al. 3200 22 gr. 1/400 0.00015 ture, or the oleate of *01eate of aconitine. local use aconitine, in neural- 2%. gia. Actol. See Argenti lactas. 91 Adeps, lard. Adeps benzoinatus. extern. As basis for oint- ments. Benzoinated lard keeps better- than ordinary. INDEX OF DRUGS 271 Page Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. 91 107 107 185 Plate 198 230 156 188 127 Plate viii. 98 98 98 100 Plate xviii. Plate xviii. 102 80 103 Adeps lanae, lano lin (purified fat of sheep's wool). Adeps 1. hydrosus, hydrous wool-fat, contains about 30% of water. ♦Adrenalin (claimed to be the crystalline active principle of supra- renal glands). ♦Adrenalin chloride. ♦Epinephrine (al- kaloid obtained from suprarenal capsules). ..Ether, ethylic ether, 96%. Spiritus ffitheris 32.5%. Spiritus _ aetheris compositus. Hoff- man's anodyne. *^ther, nitrous. Spiritus setheris nitrosi, sweet spirit of nitre. .Ethylis chloridum, ethyl chloride. ♦Agaric, spunk (a fungus). Albolene. See Petro- latum. ♦Albumin. Alcohol, ethyl alco- hol, 94.9% by vol. Absolutum, 99%. Dilutum, 48.9%. Spiritus frumenti whiskey, 44-55%. Spiritus vini gallici, brandy, 46-55%. ♦Alcohol, methyl wood alcohol. Aloe, aloes (inspis sated juice of leaves). Aloe purificata. Extractum aloes. Pilulae aloes. Pilulae a. et ferri. Tinctura. Aloinum, aloin (from aloes). Pilulse laxativse compositae. Alumen, alum, aluminum and potass, sulphate. Alumen exsiccatum, dried alum. Alumini sulphas. N. N. N.t 10 al. N. N. N. N. N. N. si. sol. sol. misc. sol. in boiling water. insol. 65 V. s. in boiling water. sol. insol. 17 insol. 1 insol. J Chiefly (.local use m5-30 foM-l foM-1 local use freely f51- fol- f51-8 gr. 1-10 gr. 1-10 gr. Ji-3 1-4 pills 1-4 pills fs M-1 gr. ?^-2 1-3 pills gr. 5-30 local use local use. 0.30-2 1-4 2-8 4-30 4-30 4-30 0.06-0.60 0.06-0.60 0.03-0.20 1-4 0.03-0.12 0.30-2 Uses. Lanolib has advan- tage of being able to hold an aqueous so- lution. Preparations from the adrenals are arterial stimulants in.iected intravenously, and hemostatics locally. To constrict arteri- oles, solutions of ac- tive principle, 1 : 1000 to 1:3000, are ap- phed. The chloride is mostly used. Anesthetic. Local irri- tant. Stimulant by reflex irritation. The spirits are used for stimulating and ano- dyne effects. Diuretic. Diaphoretic. In fevers and in nephritis. A nesihetic. A nalgesic. Inhaled, produces anesthesia quickly and safely. Absorbent. Hemo- static. Demulcent. Antidote. Solvent. Preservative. Antiseptic. Locally irritating to mucous membranes accord- ing to concentrajtion. Internally stimulant but in large doses is sedative. Solvent. Antiseptic. Not used internally. Fumes have caused blindness. Bitter tonic. Cathartic. Emmenagogue. In habitual constipa- tion. In hemor- rhoids not due to active congestion. In amenorrhea, anemia, chlorosis. Cathartic. i stringent. Gargle or wash. _ To check superficial hemor- rhage. Large dose emetic. Astringent. Caustic. Applied to excessive granulations. Astringent. Antiseptic. t Spiritus aetheris nitrosi easily becomes acid, and is usually so a,s found in the stores, 272 INDEX OF DB UGS Page ia text. Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. Uses. 198 73 198 Plate XV. 199 29 203 Plate xiii. 265 231 106 219 54 ♦Ammonia, a gas. Aqua ammonise, a 10% solution of the gas in water. Aqua ammoniae fortior, 28%. Linimentum. Spiritus ammoniae, 10%. Spiritus amnionise aromaticus. Liquor ammonii acetatis. Ammonii benzoas. Ammonii bromi- dum. Ammonii carbonas. Ammonii chlori- dum. Trochisci ammonii chloridi. Ammonii iodidum. ♦Ointment, 10%. *Ammonii nitras. Ammonii valeras. Amygdala amara, bitter almond seeds. Aqua amygdalae amarae. Oleum amygdalae amarae. Spiritus. Amygdala dulcis, sweet almond amyg- Emulsum dalae. Syrupus. Oleum amygdalae expressum. Amylis nitris, nitrite of amyl. Amylum, starch. Glyceritum amyli. Anesthesin. Animal charcoal. See Carbo. Anisum, anise seed. Aqua anisi. Oleum. Spiritus._ Antimonii et potas- sii tartras, tartar emetic. Vinum antimonii. Antipyrina, phena- zone. *Antiseptol, cincho- nine iodosulphate, 50% iodine (a substitute for iodo- form). ♦Antitoxin, a serum that is antidotal to the toxin of a certain disease. As an example, set Serum antidiph- thericum. al. sol. sol. al. al. ■ al.' ■ al. ac. N. 10.5 25 si. ac. 1.2 12.5 al. 4 t N. 2 50 N. 0.6 9 ■ N.' ■ "6.5 "'26' ac. V. s. V. s. N. N. 300 sol. N. N. insol. misc. ' N.' ■ N. 1 si. ac. 16 insol. N. 1 1 niio-30 till 0-30 f5M-l f5M-l gr. 5-20 gr. 5-30 gr. 2-15 gr. 1-30 1)4 gr. in each gr. 2-10 gr. 2-8 fo2-4 1715-10 f3i-4 mi-3 freely gr. 10-30 f5M-l nii-5 f31-2 gr. }-^-2 gr. 1/10-}^ rri5-60 gr. 5-20 0.60-2 extern. 0.60-2 1-4 8-30 0.30-1.30 0.30-2 0.12-1 0.06-2 0.12-0.60 extern. 0.12-0.50 8-15 0.01-0.03 0.30-.60 • 4-15 0.06-0.20 0.60-2 8-30 0.06-0.30 4-8 0.03-0.12 0.006-0.03 0.30-4 0.30-1.30 Stimulant. Inhaled in syncope. Solvent. Aq. ammoniae fortior is caustic. Same uses as aqua ammoniae. Diaphoretic in fevers. Same as benzoic acid. Sedative. In epilepsy, whooping-cough. Stimulant. Expecto- rant. In pneumonia, typhoid conditions. Expectorant in bron- chitis; alterative in myalgia. Alterative in syphilis, scrofula. To prepare nitrous oxide. Stimulant in hysteria. Nerve sedative in cough, vomiting. The preparations of bitter almond con- tain hydrocyanic acid in small amount. As vehicle. As vehicle. Demulcent. Inhaled in angina pectoris, asthma, hic- cough, epilepsy. Demulcent. Dusting powder. Demulcent. Local analgesic. Aromatic Carminative. In colic. Flavoring agent. Emetic. Sedative. Expectorant. Depresses heart. Expectorant. Antipyretic in acute fevers. Anodyne in neuralgias, migraine, myalgia, pertussis, infantile convulsions. Hemostatic locally to check capillary hem- orrhages. t Decomposition occurs. INDEX OF DRUGS 273 Page in text. Drug. Plate Apomorphinse hy- drochloridum (from morphine). Aqua hydrogenii di- oxidi (3%), per- oxide of hydro- gen, pyrozone, 10- volume solution in Yv^ater. ♦Ethereal solution of hyd. dioxide, 25%. *Argentum, silver, a metal. *Argenti citras, itrol. *Argenti lactas, actol. Argenti nitras. Argenti nitras di- lutus,' mitigated caustic, 333^%. Argenti nitras fusus, lunar caus- tic. 96%. Argenti oxidum. Aristol. _ See Thy- moUs iodidum. *Armoracia, horse- radish (root). Arnica (flowers). Tinctura arnioae. Arseni trioxidum, arsenic. Liquor acidi arsen- osi, 1 'A. Liquor potassii arsenitis, Fowler's sol. _ Liquor sodii arsenatis, 1 %. (Pearson's sol. ^/lo as strong as above.) Liquor arseni et hydrargyri iodidi Donovan's solu- tion. _ ♦Solution of potas- sium arsenate and bromide, Clemen's solution. Arseni iodidum. Sodii arsenas. Asafetida. A gum resin. Emulsum asafetidae, milk of asafetida. PUulae asafetidae. Tinctura. *Aseptol, a 33 H% solution of ortho- phenolsulphonic acid. Aspidium, male fern (root). Oleoresina aspidii. Atropina. Atropinae sulphas. Homatropinae hy- drobromidum. See Belladonna. Reac- tion. N. si. ac. N. N. N. al. si. ac. ac. al. N. Solubility in Water Alcohol 40 si. sol. 20 0.54 sol. sol. si. sol. {loo} N. N.oral. al. 12 1.2 part. sol. 450 0.38 5.7 Dose. Gm. or c.c. Uses. 40 24 sol. sol. insol. si. sol. 28 si. sol. part. sol. 3.7 32.5 18 gr. 1/20-Vio local use local use extern, extern, gr. H-1 gr. K-2 3M-2 Tni5-45 gr. Veo-^/lo ni2-io 1112-10 rn2-io 1112-10 ni2-io gr. 1/30-Vio gr. Vso-Vio gr. 1-8 3 gr. in each. f3J^-l 5J^-2 f3M-l gr. V120-V6O gr. 1/120-V6O gr. 1/120-^/20 0.003-0.006 0.015-0.06 0.03-0.12 1-8 1-3 0.001-0.006 0.12-0.60 0.12-0.60 0.12-0.60 0.12-0.60 0.12-0.60 0.002-0.006 0.002-0.006 0.06-0.50 15-30 2-4 2-8 1-4 ,0005-0.001 .0005-0.001 .0005-0.003 Emetic. Hypodermi- cally when patient cannot swallow, as in opium narcosis. Disinfectant. To cleanse ulcers and wounds. In infec- tious diseases. To cleanse pulp cham- bers and canals. Caustic, used chiefly to bleach teeth. Silver salts are astrin^ qent and antiseptic. A form of metallic sil- ver soluble in water, also citrate and lac- tate are used as anti- septics. Nitrate as as- tringent. In chronic dysentery, gastric ulcer, diarrhea of ty- phoid fever. To check caries in tem- porary teeth. Also as caustic. Locally to abort inflammation. In nervous diseases. Tonic. In indiges- tion, scurvy. As a Uniment. Escharotic. Has slow but powerful action. To devitalise 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. Stimulant. Laxative. As antispasmodic in hysteria, chorea, and other nervous spas- modic conditions. In flatulent coUc. Antiseptic. Locally in dilute solution. Anthelmintic. To de- stroy tapeworm. Stimulant. Mydriatic. To dilate pupil and paralyze accommo- dation. To relieve peripheral irritation, cough, asthma, etc. As respiratory stim- ulant in opium poi- soning. Homatropine is a more transient mydriatic. 274 INDEX OF DRUGS Solubility in Dose. Page Drug. Reac- in Gm. or c.c. Uses. text. tion. Water Alcohol Aurantii amari cor- Bitter tonic. Carmin- tex, bitter orange- ative. Preparations peel. used chiefly as Fluidext ract um iZ}4-l 2-4 vehicles. aurantii amari. Tinotura. f5i-2 4-8 Aurantii dulcis Preparations as fla- cortex, sweet voring agents and orange-peel. vehicles. Oleum aurantii N. insol. 4 Flavoring agent. corticis. Syrupus aurantii. 1 Spiritus a. comp. I freely As vehicles. Tinctura a. dulcis. ♦Aurantii flores, orange flowers. Aqua a. floruni. Flavoring agents. Aqua a. fl. fortior. SjTupus a. florum. As vehicle. *01euni a. florum. ' N." ■ insol. "i" Perfume. oil of neroU. *Aurum, gold. Auri et sodii si. ac. V. s. part. gr. Vso-Vio 0.002-0.006 Alterative. In syph- chloridum. ilis, action similar *Aurum bromide. gr. Vioo-^/io 0.0006-.006 to bichloride of mer- *Aurum chloride. sol. sol. gr. '/eo-Vso 0.001-0.002 cury. In sclerosis ♦Solution of gold m5-i5 0.30-1 of liver and kidneys, and arsenic bro- impotence, amenor- mide, ' 'arsenau- rhea, nervous disor- ro." ders, diabetes. The ♦Solution of gold. ms-is 0.30-1 bromide in epilepsy. arsenic, and mer- The chloride recom- cury bromide. mended in tubercu- "mercauro." lous disorders. Balsam of copaiba. See Copaiba. Balsamum Permd- ac. 5 extern. In scabies. anum. Balsamum toluta- ac. sol. niio-30 0.60-2 Stimulant expectorant. num. Syrupus tolutanus. f 5 y2-i 15-30 As vehicle. Tinctura tolutana. fol-2 4-8 As vehicle. Basham's mixture. See under Ferrum. Bearberry. See Uva ursi. 201 Plate Belladonnse folia, deadly night- gr. 1-3 0.06-0.20 Mydriatic. Atropine to dilate pupil. ix. shade (leaves). 262 Extractum bella- donnae fohorum. Emplastrum. gr. Va-H extern. 0.0075-0.03 Anodyne. To quiet peripheral pain and irritation; in a.sthma, Tinctura _ bella- TT15-15 0.30-1 nervous cough, irri- donna foliorum. table bladder, incon- Unguentum bella- extern. tinence of urine; donna. combined with ca- Belladonnse radix gr. 1.-2 0.06-0.12 thartics to prevent (root). griping. In small Fluidext ract um nii-2 0.06-0.12 doses stimulant to belladonnas radicis the heart and respi- Linimentum bella- e.xtern. ration. In opium. donnae. poisoning. Vaao- See Atropine. motor stimulant. To check sweating. Benzinum (from N. insol. 6 Solvent. petroleum). 128 Benzoinum. To prepare benzoic Tinctura benzoini. 'f'sJ^-i" 2-4 acid. Antiseptic. Tinctura benzoini f3}^-i 2-4 Tinctures inhaled in composita. Friar's respiratory diseases balsam. and applied as local stimulants and anti- septics to mucous membranes. ♦Benzol (from coal- sol. Solvent. tar). ♦Benzosol, guaiacol insol. gr. 2-10 0.12-0.60 Antiseptia. In intes- benzoate. tinal diseases and phthisis, INDEX OF DRUGS 275 Page 256 122 80 136 230 Drug. 165 201 Plate 205 See pruni Benzosulphinidum, saccharine (a coal- tar product). Betanaphtol,naphtol ♦Bismuth. A metal. Bismuthi subcar- bonas. Bism.uthi subnitras. *Bismuth oxyiodide (subiodide). Bismuthi subgallas dermatol. Bisulphide of car- bon. See Carbonei disulphidum. Bitter almond. See Amygdala amara. Bitter orange-peel. See Aurantii. Blackberry. See Rubus. Black haw. Viburnum folium. Black wash, Blue ointment. Blue pill. See under Hydrargyrum. __ Borax. See Sodii boras. Glyceritum boro- gl.ycerini, 31% boric acid. Brandy. See under Alcohol. Bromoformum. Bromum, bromine. Brown mixture. See under Glycyr- rhiza. Buchu (leaves). Fluidextractum buchu. Buckthorn. See Frangula. Cacao butter. See under Theobroma *Cactus grandiflorus (cereus g.). *Fluid extract, *Tincture. *Ca£fea (C. arabica), coffee (.seeds) Caffeina, caffeine (theine). Caffeina citrata, 50% caffeine. Caffeina citrata ef- fervescens, 2% caffeine. Cajuput, oil of. See Oleum cajuputi. Calamus, sweet flag (root). Fluidextractum calami. Calcium. See under Calx. Calomel. See under Hydrargyrum. Calumba (.Tateo rhiza palmata) columbo (root). Fluidextractum calumbae. , Tinctura. Reac- tion. Solubility in Water Alcohol N. si. ac. N. 250 950 insol. insol. insol. insol. 300 28 45.6 sol. sol. 25 0.6 insol. insol. insol. insol. sol. sol. 53.2 sol. sol. Dose. Gm. or c.c. gr. 1-8 gr. 2-10 gr. 5-60 gr. 5-60 gr. 5-10 gr. 5-15 extern. gr. 15-30 TT115-30 nii-5 ni5-20 gr. 1-5 gr. 2-10 31-8 gr. 15-60 nil5-60 gr. 5-30 ni5-30 fa 1-4 0.06-0.50 0.12-0.60 0.30-4 0.30-4 0.30-0.60 0.30-1 0.06-0.30 1-2 1-2 0.06-0.30 0.30-1.20 0.06-0.30 0.12-0.60 4-30 Sweetening agent. Is 280 times sweeter than cane-sugar. Antiseptic. Locally sedative and slightly astringent. In vomiting, cUar- rhea, gastric ulcer. Antiseptic to dress wounds and ulcers. A ntiseptic. As substi- tute for iodoform; also internally. Uses. -intiseptic. Anesthetic. Recom- mended in pertussis. Caustic. Reagent. Antiseptic. Stimulant diuretic in chronic inflamriiation of the genitourinary tract. Heart tonic. In action similar to digitahs. Stimulant. Diuretic. Stimulates cerebrum and heart. In opium poisoning strong in- fusion or decoction by enema or caffeine hypodermicaUy. In headaches, cardiac failure. 1-4 Aromatic stimulant. In indigestion. 1-4 0.30-2 0.30-2 4-15 Bitter tonic. In atonic indigestion. It con- tains no tannin^ 276 INDEX OF DRUGS Solubility in Dose. Page in Drug. Reac- Gm. or Uses. text. tion. Water Alcohol c.c. Calx, Ume. al. 760 insol. Caustic. 136 Calx chlorinata, al. part. part. ■gr.'2-5' 6.'l'2-0.36 Disinfectant. 151 bleaching powder, chloride of Ume. Calx sulphurata al. si. sol. insol. gr. Vio-l 0.006-0.06 To prevent suppura- tion. Externally to burns 90 Linimentum calcis. carron oil. and scalds. 116 Liquor calcis, lime- water. al. fol-8 4-30 Alkali. In vomiting, diarrhea. To cor- *Potassa cum calce. al. extern. rect acidity and irri- Viennae paste, a tabihty of stomach. caustic. Syrupus calcis. al. nil5-60 1-4 Antidote to oxalic ♦Calcium, a metal. acid. Calcii bromidum. N. 0.5 1 gr. 15-30 1-2 Sedative. Same use as potassium bromide. ■ Calcii carbonas ] Preparations of the 6 praecipitatus. aim. insol. carbonate are used 117 d Cretae praepa- ■al. insol. gr. 5-60 0.30-4 ■ in indigestion, vom- G rata, prepared iting, and diarrhea. O ■ SI chalk. Prepared chalk as t Mistura cretae. , fo2-4 8-15 an antacid to the O Pulvis cretae compositus. gr. 6-60 0.30-4 mouth and in denti- frices. 109 Calcii chloridum. N. 1.3 8 gr. 5-10 0.30-0.60 A Iterative. Hemo- static. Internally in hemorrhagic dia- thesis. Calcii hypophosphis. N 6.5 insol. gr. 2-5 0.12-0.30 Tonic. Alterative. In anemia, rhachitis, *Syrup. f3l-2 4-8 caries. 210 Syrupus hypo- phosphitum. f3i-2 4-8 Syrups of hypophos- phites in wasting 210 Syrupus hypo- phosphitum com- positus. f5l-2 4-8 diseases, tuberculo- sis, rhachitis, ner- vous diseases. Calcii phosphas aim. insol. gr. 5-30 0.30-2 Similar uses to above. praecipitatus. insol. Syrupus calcii lac- fol-2 4-8 Similar uses to above. tophosphatis. Calcii sulphas ex- N. 378 insol. Used in making im- siccatus, plaster pressions, casts, and of 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 drop- Cambogia, Gam- gr. 1-3 0.06-0.20 boge. sies. 199 Camphora, cam- si. sol. sol. gr. 3-10 0.20-0.60 Stimulant. Anodyne. 263 phor. To reUeve spasm or Aqua camphorae. f§J^-2 15-60 cramp, dysmenor- Ceratum. extern. rhea, cholera, colic, 200 Spiritus, 10%. Linimentum cam- phorae, camphor- ated oil, 20%. ■f3J^-i' 2-4 diarrhea, nervous de- pression, headache, neuralgia. Spirit in- haled in syncope. Liniment externally. *Acid camphor fol-4 4-15 In diarrhea. mixture, Hope's mixture. ♦Volatile oil of camphor. Camphora mono- tni-3 0.06-0.20 Stimulant. N. aim. sol. gr. 2-10 0.12-0.60 Monobromate is seda- bromata. insol. tive to nervous sys- Canada balsam. tem. In insomnia See Terebinthina and hysteria. Canadensis. 263 Cannabis indica (C. sativa, grown in E. Indies), Indian hemp. (Tops of female plant.) gr. 2-5 0.12-0.30 A nodyne. Deliriant. Hypnotic. In mi- graine, neuralgia, dysmenorrhea, irri- table bladder, reten- Extractum canna- gr. K-H 0.01-0.03 tion of urine. In bis indicae. tetanus, delirium Fluidextractum. ni2-5 0.12-0.30 tremens, acute ma- Ti nctura. m5-30 0.30-2 nia. INDEX OF DRUGS 277 Page Drug. Reac- tion. Solubility in Dose. Water Alcohol Gm. or CO. Uses. 67 263 61 145 145 133 Cantharis, Spanish flies. Ceratum canthar- idis. Collodium canthar idatum. Tinctura idis. canthar Capsicum (C. fas- tigiatum) , Cay- enne pepper (fruit). Fluidextractum capsici. Emplastrum. Oleoresina. Tinctura. Caraway. See Carum Carbo animalis, animal charcoal Carbo animalis purificatus. Carbo ligni, charcoal. wood Carbonei disul- phidum. Cardamomum (elettaria repens), cardamom (fruit). Tinctura carda- momi. Tinctura c. comp. *Carmine, carminic acid (from coc- cus). Carron oil. See un- der Calx. Carum (c. carvi) , caraway (seed). Oleum cari. Caryophyllus (euge- nia aromatica) cloves (flower buds). Oleum caryophylli Cascara sagrada. See Rhamnus. Cassia, oil of. (com mercial oil of cin namon). Castor oil. See Oleum ricini. Catechu. See Gambir. *CeUuloid, zylonite. Cera alba, white wax. Ceratum. Cera flava, yellow wax. Cetaceum, sperma- ceti. Chalk, prepared. See under Calcium. Charcoal. (See Carbo. 526 sol. insol. insol. insol. insol. insol. sol. insol. aim. insol. rrii-5 gr. 1-3 WA-2 TTlM-l 1115-10 freely gr. 10-15 f5l-2 f:^2-4 gr. 15-30 nii-5 gr. 2-15 mi-5 0.06-0.30 0.06-0.20 0.03-0.12 extern. 0.015-0.06 0.30-0.60 0.60-1 4-8 8-15 1-2 0.06-0.30 0.12-1 0.06-0.30 Vesicant. To produce blister in neuralgia, rheumatism; coun- teract local inflam- mations; promote absorption of effu- sions. Tincture internally is diuretic and irritant. Use cautiously. Ap- plied locally diluted, stimulates growth of hair. In alopecia areata. Local stimulant and irritant. To stimu- late unhealthy con- dition of the gums. In atony of stomach, diarrhea, colic, indi- gestion of alcohol- ism. Plaster as mild oounterirritant. Decolorizing agent. As antidote in alka- loidal poisoning. To decolorize and purify liquids. Absorbent. Internally in flatulent indiges- tion. Solvent for rubber. Aromatic. As flavor- ing agent and car- minative. In flatu- lent coUc. Coloring agent. Arom,atic. As condi- ment and carmina- tive. Aromatic. As condi- ment and carmina- tive. The oil in pre- paring microscopic specimens. Non-medicinal. In making trusses, plates for artificial teeth, etc. In cerates and oint- ments. As impres- sion and modelling material. In cerates and oint- ments. 278 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Dose. Water Alcohol Gm. or c.c. Uses. 225 Plate xvi. 263 Chloralum hydratum 136 151 136 136 186 Plate vii. 68 263 80 206 137 *Butyl-chloral, cro- ton-chloral. *Chloral-camphor, *Chloral-phenoI. *Chloral-menthol. Chloral formami- dum, chloralamid *Chloretone, acetone- chloroform. Chloride of lime. See Calx chlorinata. ♦Chlorine. A gas. Liquor chlori com- positus, 0.4%. Liquor sod« chlo rinatffi, Labar- raque's .solution, 2.4% chlorine. Calx chlorinata, chloride of lime, 30% chlorine. Chloroformum. Aqua chloroformi, 0.5%. Emulsum, 4%. Linimentum, 30%. Spiritus, 6%. A stronger spirit (K chloroform) is known as chloric ether. Chromii trioxidum, chromic acid. Cinchona, Peruvian bark. Cinchona rubra. Fluidextractum cinchonae. Tinctura. Tinctura cinchonse composita. See Quinina. Cinchonidinse sul- phas. Cinchoninae sul- phas. *Cinchonine iodo- phate, antiseptol. Cinnamomum saigo- nicum, saigon cin- namon (bark). sol. sol. insol. sol. '18.7" sol. sol. sol. 1.3 125 V. s. part. part. 200 sol. V. s. t 63 72 58 insol. 10 gr. 5-20 gr. 5-20 > extern, gr. 10-30 gr. 5-15 f5i-4 f3J^-l Tn2-10 f5?4-i f31-4 'fo^-2" gr. 10-60 gr. 10-60 TTllO-60 3J^-2 f3l-4 gr. 1-30 gr. 1-30 extern. 0.30-1.30 0.30-1.30 0.60-2 0.30-1 4-15 2-4 0.12-0.60 8-30 4-15 extern. 2-8 0.60-4 0.60-4 0.60-4 2-8 4-15 0.06-2 0.06-2 Hypnotic. Sedative. In insomnia, mania, tetanus, convubions of children, strych- nine poisoning, epi- lepsy, other spas- modic affections, delirium of fevers, cholera, and cholera morbus. Use cau- tiously when heart is weak. 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. Safer than chloral. In insomnia of fevers, whooping- cough, asthma, and other spasmodic af- fections. Hypnotic. Analgesic. Antiseptic. Externally to foul ulcers and as disinfectant wash. Bleaching agent. To bleach discolored teeth. Disinfectant. Bleach- ing agent. Anesthetic. Anodyne. By inhalation most- ly. In convulsions, dysmenorrhea, and other spasmodic pain. Locally as anodyne and irritant. Internally in coUc. Caustic. Local use only. Bitter astringent tonic. In atonic indiges- tion, relaxed condi- tions of mucous membrane of diges- tive tract; general tonic. A ntiperiodic. In malarial fevers, periodic neuralgia. The alkaloids possess the tonic and anti- malarial virtues of cinchona. In medi- cinal value they stand in the follow- ing order: Quinine. Cinchonidine. Cinchonine. Antiseptic. An odor- less substitute for iodoform. t Decomposition occurs. INDEX OF DRUGS 279 Solubility in Dose. Page in Drug. Reac- Gm. or Uses. text. tion. Water Alcohol c.c. Cinnamomum zey- Aromatic, Condiment. lanicum, Ceylon cinnamon (bark). Aqua cinnamomi. fBJ^-1 15-30 As vehicle. 132 Oleum cinnamomi. si. ac. insol. sol. rni-s 0.06-0.30 Flavoring agent. Used Spiritus. rnio-30 0.60-2 as carminative in Tinctura. f3i-2 4-8 flatulence. Antisep- Clemen's solution. tic. Spirit and tinc- See under Arseni ture as vehicle. trioxid. (" Oil of Cassia " is Cloves. See Caryo- oil of Chinese cinna- rhyUus. mon.) 88 ♦Cobalt. extern. Escharotic. To devi- talize pulps of teeth. 158 Coca, erythroxylon oK-l 1-4 Stimulant. In action 200 coca (leaves). similar to cofiee. In Plates riuidextractum f3M-l 1-4 debihty of old peo- ii, iii. cocse. ple. Large doses Vinum. f3l-4 4-15 are sedative. Locally Cocaine (from sev- " al.' ■ 'eoo' ■■5" depresses sensation. eral varieties of To relieve vomiting. coca). The alkaloid cocaine 158 Cocainae hydrochlo- N. 0.4 2.6 gr. ye-'A 0.01-0.03 is a local analgesic. Plates ridum. stimulant, and myd- ii, iii. Oleatum cocainse, 5%- , . , Coccus, cochineal (an insect). Used as coloring agent. See also Carmine. locally riatic. Locally or hypodermically in 1 to 4% aqueous solu- tion to aboUsh sen- sation. In supposi- tory to relieve tenes- mus in dysentery. Applied to the eye it dilates pupil. Use cautiously to avoid poisoning or habit. 227 Codeina (alkaloid N. 88 1.6 gr. M-1 0.015-0.06 Same use as opium. 265 from opium). The after-effects are Codeinae phosphas. ac. 2.25 261 gr. M-1 0.015-0.06 less unpleasant. In Codeinee sulphas. N. 23 1035 gr. M-1 0.015-0.06 diabetes. • Cod-liver oil. See Oleum morrhuae. Coffee. See Caffea. 216 Colchici cormus (corm of colchi- cum autumnale). gr. 2-10 0.12-0.60 Colchicum is a vege- table alterative. In full doses diuretic Extractum colchici gr. J^-2 0.03-0.12 and cathartic. Its cormi. chief use is in sub- Colchici semen gr. 1-5 0.06-0.30 acute or chronic (seed). rheumatism and in Fluidextracturn rTii-5 0.06-0.30 rheumatic gout. In colchici seminis. ascites due to he- Tinctura colchici TniO-60 0.60-4 patic obstruction. seminis. Colchicine may_ be Vinum colchici TTllO-60 0.60-4 given hypodermi- seminis. cally. Colchicina (alkaloid N. 22 V. s. gr. Vioo 0.006 from c. autumnale) Cold cream. See under Rosa. 111 Collodium, collo- dion. extern. Protective to slight wounds and to check 111 Collodium flexile, flexible collodion. superficial hemor- rhages. 67 Collodium canthar- idatum. extern. Vesicant. For bhster- ing purposes. 111 Collodium stypti- cum, 20% tannic acid. extern. Styptic. Plate Colocynthis (citrul- gr. 1-3 0.06-0.20 Tonic cathartic. In xviii. lus c, fruit). constipation. In fuU Extractum colo- gr. M-1 0.015-0.06 doses powerful hy- cynthidis. dragogue cathartic. Extractum c. com- gr. 5-15 0.30-1 In dropsies. Given positum. usually in combina- Pilulae catharticae 1-3 pills tion. compositae.t Pilulae catharticae 1-5 pills vegetables. Columbo. See Ca- lumba. t 1 grain of calomel in each. 280 INDEX OF DRUGS Solubility in Dose. Page in Drug. Reac- Gm. or c.c. Uses. text. tion. Water Alcohol Convallaria (c. ma- gr. 5-30 0.30-2 Heart stimulant. Diu- jalis). lily of the retic. Similar _ to valley (root). digitalis in action. Flnidextractum rn5-3o 0.30-2 but safer. In large convallarise. doses cathartic. Copaiba, balsam of f3M-l 1-4 Diuretic. Expectorant. copaiba. In later stages of Oleum copaibae. Tri5-15 0.30-1 gonorrhea; chronic Copperas. See Ferri cystitis, and chronic sulphas. bronchitis. Copper salts. See under Cuprum. Corrosive sublimate. See under Hydrar- gyrum. Cotton. See Gossyp- ium. Cotton-seed oil. _ See under Gossypium. Cream of tartar. See Potassii bitartras. 67 Creosotum (distilled N. 140 sol. mi-5 0.06-0.30 Antiseptic. Locally 125 from wood.) sedative. In aqueous Aqua creosoti, 1 %. f3l-4 4-15 solution as mouth- 126 Guaiacol. "53' sol. Tn2-10 0.12-0.60 wash. To check Guaiacolis carbo- insol. 48 gr. 5-30 0.30-2 fermentation within nas. the digestive tract. In vomiting, flatu- lence, and fermenta- tive diarrhea. Inter- nallyand as inhala- tion in phthisis and other pulmonary dis- eases. Guaiacol and its salts used for same purposes. *Creolin (from coal misc. sol. mi-s 0.06-0.30 Antiseptic. Valuable tar). for general use as douche; in cystitis, intestinal disorders.' Cresol. 60 misc. WA-2 0.03-0.12 Antiseptic. Creta praeparata. See under Calcium. Croton oil. See Oleum tiglii. 91 Cubeba (Piper c., 3J^-l 2-4 Aromatic. Stimulant 230 unripe fruit). diuretic. Expecto- 232 Fl uidextractum cubebae. foH-1 2-4 rant. In bronchitis, pharyngitis and Oleoresina. Tri5-15 0.30-1 laryngitis; chronic Oleuni. TTl 5-20 0.30-1.20 inflammations of Trochisci. gr. M of oleoresin in each. genitourinary tract. 80 *Cuprum, copper. 104 Cupri sulphas. ac. 2.2 400 gr. Vio-15 0.006-1 In full dose em,etic; 263 *Cuprum arsenite._ *Daturine (alkaloid from stramonium, probably identi- cal with atropine. Deadly nightshade. See Belladonna. Dermatol. See under Bismuthum. Diachylon ointment. See under Plum- bum. si. sol. gr. Viao-Veo 0.0005-.001 locally astringent and irritant. To stimulate indolent ulcers. As a mild caustic applied to granular eyelids. The arsenite in anemia, nervous disorders, and diarrheas. 202 DigitaHs (d. pur- gr. J^-3 0.03-0.20 Heart stimulant and Plate purea, leaves). tonic. Vasoconstrictor. xii. Extractum digi- gr. ^-1 0.015-0.06 Diuretic. Strengthens 229 tali.s. and slows heart Flnidextractum. mH-3 0.03-0.20 beats. In weak cir- Tnfusum. f3l-4 4-15 culation due to heart Tinctura. tTl5-30 0.30-2 dilatation or ex- haustion. ♦Digitalin. gr. Veo-Vso 0.001-.002 A product of uncer- tain and variable character. INDEX OF DRUGS 281 Solubility in Dose. Page Drug. Reac- in Gm. or c.c. Uses. text. tion. Water Alcohol Diuretin. See under Theobroma. Dobell's solution. See under Sodii boras. Donovan's solution. See under Arseni trioxid. Dover's powder. See under Opium. Elastica, India-rub- In making bandages ber, caoutchouc. and various surgical and dental appli- Plate ances. xviii. Elaterinum (from N. insol. 262 gr. ■';oo-'/i2 0.003-.005 Hydragogue cathartic. 264 elaterium). In dropsies, cerebral Trituratio elater- gr. M-1 0.03-0.06 hyperemia threaten- ini, 10%. ing apoplexy. *Emetine (alkaloid si. sol. sol. gr. 1/120-V40 0.0005 to Emetic. May be used of ipecacuanha). 0.0015 hypodermicaUy. *Eosin. sol. gr. Vs-H 0.0075 to 0.015 Coloring agent. Epsom salt. See Magnesii sulphas. 108 Ergota, ergot of rye. Oxytocic. Vasocon- Plate Extractum ergotse, ■gV. 5-15 "36-i"' strictor. To stimu- i. ' 'ergotin." late contraction of Fluidextractum. f3M-l 1-4 uterus after labor. Vinum. f3l-4 4-15 To check capillary hemorrhages, menor- rhagia, diarrheas. To reduce cerebral Eriodictyon, yerba and spinal hyper- santa (e. caUforni- emia. cum, leaves). Stimulant expectorant. Fluidextractum 'rfll5-30 ■■■i-2'" In chronic pulmo- eriodictyi. nary diseases. In Eserine. See under syrup to cover bitter Physostigma. taste of quinine. Ether, chloric. See under Chloroform. Ether, ethyUc. See ^ther. 192 *Ethyl bromide, hy- drobromic ether. Ethyl chloride. See yEthylis chlor- idum. spar. sol. inhaled Anesthetic. Prompt in action, but dan- gerous. *Ethyl iodide, hy- insol. sol. inhaled A nesthetic. A Iterative. drioic ether. Stimulant. ♦Ethylene bichlo- inhaled A nesthetic. Probably ride, Dutch Uquid. ranks between ether and chloroform in safety. Anesthetic. Probably *Ethylidene chlo- inhaled ride. less depressing than chloroform. 169 *Eucaine hydro- chloride. Eucalyptus (e. globu- lus, leaves). N. 28 Local analgesic. Less powerful and toxic, but more irritating, than cocaine. Formerly in malarial Fluidextractum 'f3K-2' ■■■2-8" fevers. 00 is anti- eucalypti. septic,_ used mostly 134 Oleum. N. insol. sol. Tri5-30 0.30-2 by inhalation in 132 Eucalyptol (from ol. N. insol. sol. rri5-3o 0.30-2 chronic catarrhs of 134 eucalypti). respiratory tract; 134 Eugenol (a con- stituent of oil of cloves). eucalyptol has same uses. Eupatorium, bone- 3M-1 1-4 Bitter tonic. Diapho- set (e. perfoliatum, retic. Used in in- leaves and fi. tops) fusion in colds and Fluidextractum f3M-l 1-4 fevers, dyspepsia. eupatorii. *Europhen, 28.1 % insol. sol. extern. A ntiseptic. Substitute iodine. for iodoform. 282 INDEX OF DRUGS Solubility in Dose. Page in Drug. Reac- Gm. or c.c. Uses. text. tion. Water Alcohol Exalgine. See Methy acetanilid. 208 Ferruin, iron. N. in sol. insol. Tonic. Restorative to Ferrum reductum, N. insol. insol. ■gr.i-5' 6.06-0.36 the blood in anemia, reduced iron. chlorosis, amenor- ♦liquor ferri ace- ac. m2-io 0.12-0.60 rhea, infectious and tatis. wasting diseases. Liquor ferri et am- ac. fol-4 4-15 The preparations monii acetatis. may be grouped as Basham's mix- follows: ture. Oxides and carbon- Ferri carbonas sac- N. part. insol. gr. 2-10 0.12-0.60 ates. Their prepar- charatus. ations and reduced Massa f. carbonatis, gr. 1-5 0.06-0.30 iron are restorative, Vallet's mass. but not astringent. Pilulae f. carbonatis 1-2 pills Blaud's pill. Ferri ohloridum, ac. V. s. V. s. extern. The mineral acid salts ferric chloride. of iron are astringent, 101 Liquor f. chloridi. ac. m2-io 0.12-0.60 and besides being 264 Tinctura f. chloridi. ac. ms-so 0.30-2 tonics, are used as Ferri citras. ac. sol. insol. gr. 1-5 0.06-0.30 hemostatics. The Ferri et ammonii N. sol. insol. gr. 1-5 0.06-0.30 sulphates are largely citras. used in this way. Ferri et quininte ac. sol. part. gr. 2-10 0.12-0.60 The tincture of the citras. chloride is valuable Ferri et quininffi si. ac. V. s. part. gr. 2-10 0.12-0.60 for internal use, com- citras solubilis. bining tonic prop- Ferri et strych- si. ac. sol. part. gr. 1-3 0.06-0.20 erties of iron and ninae citras. hydrochloric acid. It Ferri hypophosphis. si. sol. gr. 2-10 0.12-0.60 has long been used both internally and locally in erysipelas. Pilulse ferri iodidi. 1 to 2 pills The compound salts 213 Syrupus f. iodidi. ' N.' ' TT15-30 0.30-2 possess special value 87 Ferri hydroxidum insol. insol. 51-4 4-15 according to the 262 ferric hydrate. combination. The Ferri hydroxidum 31-4 4-15 compounds with cum magnesii ammonium are more oxido. stimulating, and Ferri phosphas solu- si. ac. sol. insol. gr. 1-5 0.06-0.30 those with phos- bilis. phoric acid are ton- Ferri pyrophosphas si. ac. sol. insol. gr. 1-5 0.06-0.30 ics, with more gen- solubilis. eral value in wast- ing diseases. 101 Ferri sulphas, fer- ac. 0.9 insol. The iodide is altera- 264 rous sulphate. tive, possessing a Ferri sulphas exsic- ac. sol. insol. Ur. H-2 0.03-0.12 special value for catus. scrofulous children. Ferri sulphas gran- ac. sol. insol. The hydrated oxides ulatus. are the best anti- 101 *Subsulphate, Monsel's salt. sol. gr. 1-3 0.06-0.20 dotes in arsenical poisoning, before the 102 Liquor ferri sub- sulphatis. Monsel's solution. ac. rri2-io 0.12-0.60 poison has been ab- sorbed. See Table of Poisons. The vegetable acid salts are mild in action. 102 Liquor f. tersulph. ac. Used chiefly to pre- Ferri et ammonii si. ac. ■2;7' insol. gr! 2-10 6.12-0.66 pare other salts. sulph., iron alum. Ferri et ammonii N. V. s. insol. gr. 5-15 0.30-1 tartras. Pilulse aloes et f. 1 to 3 pills Syrupus f., quinines ;;;;; f3M-l 2-4 et strychninae phosphatum. ♦Albuminate. sol. gr. 10-30 0.60-2 88 *Dialyzed, scales. gr. 1-5 0.06-0.30 Recommended as an liquid. fniO-30 0.60-2 antidote to arsenic, Filix mas. See As- but less valuable pidium. than hydrated oxide Flaxseed. See or hydrated oxide Linum. with magnesia. INDEX OF DRVGS 283 Page in text. Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c Uses. 148 148 Plate xviii. 97 97 132 109 31 205 92 241 244 91 ♦Formaldehyde, a gas. Liquorformaldehydi, formalin, 37 %. Fowler's solution. jSee under Arseni trioxid. Foxglove. See Digi- talis. Frangula (rhamnus f.), buckthorn (bark, at least one year old). Fluidextractum frangulae. Friar's balsam. See under Benzoin. *Fuchsine, roseine. Galla, nutgall (from quercus lusitani- ca). Tinctura gallse. Unguentum. Gambir, catechu. Tinctura gambir composita. Trochischi. Gamboge. See Cam- bogia. *Gaultheria, winter- green (leaves). Oleum gaultheriae. Spiritus. Gelatinum. Gelatinum glycer- inatum. Gentiana (g. lutea, root). Extractum gen- tianae. Fluidextractum. Tinctura comp. Ginger. See Zingi- ber. Glauber's salt. See Sodii sulphas. Glonoin. See Nitro glycerin. Glycerinum. N. or si. ac. Suppositoria glycerini. Glycyrrhiza _(g. gla- bra"), Ucorice root. Extractum glyoyr- rhizae. Extractum purum. Fluidextractum. Mistura comp. brown mixture. Pulvis compositus. Trochisci g. et opii. N. or si. ac. sol. part. sol. f5H-2 ■■3i-2' f51-2 gr.'io-SO f3}^-2 1 gr. each 5M-2 Tni-5 f31-2 gr. 5-30 gr. 2-10 ni5-30 f3l-4 Tri5-60 f3l-4 3J^-2 1 to 5 troches 2-8 2-8 4-8 4-8 extern. 0.60-2 2-8 2-8 0.06-0.30 4-8 0.30-2 0.12-0.60 0.30-2 4-15 0.30-4 freely freely freely 4-15 2-8 Disinfectant. Most efficient disin- fectant for rooms, clothing, books, etc. In solutions of 1% or less as antiseptic. To soft tissues a weak solution must be em- ployed on account of its irritant action. To preserve anatom- ical specimens. Cathartic. Fresh bark is harsh, old bark is mild and efficient. In chronic constipation. Coloring agent. Astringent. Virtues due to the tannic and gallic acids con- tained. Astringent. Owes its value to tannic acid. Aromatic. Astringent. Substitute for sali- cylic acid in rheu- matism. Used as fla- voring agent. To prepare capsules and suppositories. As coating for pills. In hemophilia by rec- tum or subcutane- ously. Bitter tonic. Simple stomachic and gen- eral tonic. Contains no tannin. Vehicle. Solvent. Pre- servative. Locally demulcent and emol- lient. In enema or suppository for con- stipation. Applied upon cotton to soften and aid resolution of inflammatory thick- ening of tissues. Sweetening agent. Laxative. For intro- duction into the rectum. Expectorant. Demul- cent. In cough mix- tures. To cover taste of bitter drugs. Laxative. Contains senna. 284 INDEX OF DRUGS Page Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. Uses. 97 97 227 169 Glycyrrhizinum am- moniatum. Gold. See Aurum. Golden seal. See Hydrastis. Gossypium purifi- catum, cotton (g. herbaceum, hairs of seed). Oleum gossypii seminis (cotton- seed oil). Goulard's cerate. Goulard's extract. See Plumbum. Gray powder. See Hydrargyrum. Green soap. *See Sapo mollis. Guaiacum(guaiacum officinale), guaiac (resin). Tinctura guaiaci. Tinctura guaiaci ammoniata. Guaiacol. iSee under Creosotum. Guarana (from Paullinia cupana, seeds). Fluidextractum guaranie. Gum Arabic. See Acacia. Guncotton. See PyroxyUnum. *Gutta-percha. (Soluble in chloro- form, oil of turpen- tine, carbon _ disul phide or benzin.) *Solution. Hamamelis, witch- hazel (h.virginiana leaves and bark). Aqua hamamelidis. Fluidextractum Haematoxylon, log- wood (h. campe- chianum, wood). Extractum hema- toxyU. Hedeoma, penny- royal (leaves and fl. tops). Oleum hedeomae. *Heroine (from morphine). *Heroine hydro- chloride. Hexamethylena- mina, urotropin. Hive syrup. See un- der Scilla. Hoffman's anodyne. See under vEther. *Holocaine hydro- chloride. Homatropine. See under Atropine. Honey. See Mel. Horseradish. See Armoracia. Humulus (h. lupu- lus), hops. ♦Tinctura humuli. See Lupulinum. sol. insol. insol sol. 1.5 40t sol. gr. 5-15 0.30-1 Same uses as licorice. To prepare surgical dressings. As ab- sorbent. gr. 5-30 f3J^-l f3J4-l 3M-1 f3! 0.30-2 2-4 2-4 1-4 1-4 insol. insol. sol. 10 3M-2 f3H-2 gr. 5-15 Tni-5 gr. Vio-K gr. 5-15 extern. 2-8 2-8 0.30-1 0.06-0.30 0.006-0.01 0.30-1 f3l-2 4-8 Emollient. Substitute for olive oil. Ap- plied to burns, etc. Alterative. In rheu- matism, gout, tonsil- litis, myalgia, sci- atica and syphilis. Tonic. Stimulant. Similar in action to coffee. Used in mi- graine. Protective. In making splints and surgical appliances. As tem- porary fillingf or teeth The solution is used in slight wounds. Feeble astringent. In hemorrhages, hemor- rhoids. Locally to bruises and inflam- ations. Coloring agent. Astringent. In diar- rhea, hemorrhages. Aromatic. Carmina- tive. In colic. Used also externally. Sedative. Depresses respiratory centre with less cerebral effect than morphine. To relieve cough. Antiseptic. When given internally lib- erates formaldehyde during elimination by the kidneys. Local analgesic. Same uses as cocaine, but probably more toxic. Tonic. Anodyne. In sleeplessness, deliri- um tremens, fevers. Externally — poultice. t Soluble in boiling water, which upon cooling leaves a 2}4% solution. INDEX OF DRUGS 285 Page in text. Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. Uses. 212 142 212 264 212 211 201 Hydrargyrum, mer cury, a metal. Hydrargyrum cum creta, gray pow- der, 38%. Emplastrum hy- drargyri. Massa hydrargyri, blue pill, 33%. Oleatum (20% yellow oxide). Unguentum, blue ointment, 50%. Hydrargyrum am- moniatum, white precipitate. Unguentum hy- drargyri ammo- niati, 10%. Hydrargyri chlori- dum corrosivum, mercuric chloride, corrosive subli- mate. Hydrargyri chlo- ridum mite, mer- curous chloride, calomel. *Hydrargyri cyani- dum. Hydrargyri iodidum flavum. Hydrargyri iodidum rubrum. Liquor arseni et hydrargyri iodidi, Donovan's solu tion. Liquor hydrargyri nitratis. Unguentum hy- drargyri nitratis, citrine ointment Hydrargyri oxidum flavum. Unguentum hy- drargyri oxidi flavi, 10%. Hydrargyri oxidum rubrum, red pre- cipitate. Unguentum hy- drargyri oxidi rubri, 10%. *Black wash (1 gram calomel, 115.5 c.c. lime- water). *Yellow wash (1 gram corrosive sublimate, 308 c.c. lime-water.) Hydrastis, golden seal (h. canadensis, root). Fluidextractum hydrastis. Glyceritum, 100%. Tinctura. Hydrastina. Hydrastininae hy- drochloridum. Hydrogen peroxide. See Aq. hydrogenii dioxidi. Hydronaphtol. See Betanaphtol. *Hyoscine (from hyoscyamine). Hyoscinae hydro- bromidum. N. N. insol. al. aim. insol. 13 insol. 12.8 aim. insol. aim. insol. insol. gr. H-10 gr. J^-15 aim. insol. aim. insol. aim. insol. .si. sol. si. ac. insol. 15 insol. 130 insol. insol. 135 1.5 gr. Veo-Vio gr. J-j-10 gr. Veo-Vio gr. Ve-l gr.;Vco-Vio mi-io 16 gr. 5-60 TT15-60 1715-60 f3>^-2 gr. H-V2 gr. 1/12-M 0.03-0.60 extern. 0.03-1 extern, extern, extern. extern. 0.001-0.006 Metallic mercury used only in gray powder, blue pill, and oint- ment, in which it ia very finely divided. Preparations of mer- cury are alterative and purgative. It is the chief remedy in secondary syphilis. Blue pill is cathartic, but should be fol- lowed by a saline. Ointment and oleate by inunction to ob- tain systemic effect. 0.03-0.60 0.001-0.006 0.01-0.06 0.001-0.006 0.06-0.60 extern. 1/160- extern. extern. 0.30-4 0.30-4 0.30-4 2-8 0.015-0.03 0.005-0.01 0004-.0012 The most poisonous salts are corrosive chloride, cyanide, and red iodide. Corrosive subhmate is active and efficient for internal use. In secondary _ and ter- tiary syphilis, is fre- quently combined with iodides. In dis- eases with fibrinous exudation, it is of value. In dysentery, in weak solution by enema. It is a pow- erful antiseptic exten- sively used in 1 : 2000 or weaker solution as douche or irrigation. Calomel is a mild and certain cathartic as occasional purge in fevers and inflam- matory diseases. An efficient diuretic in dropsies. In diar- rheas in small_ doses. In enterocolitis. Locally as a seda- tive, alterative ap- plication to ulcers. Oxides and nitrate used externally. Black wash and yellow wash are applied to syphilitic ulcers. Salivation (which is always to be avoid- ed) is easily pro- duced by blue pill and calomel. Bitter tonic. In atonic indigestion. Altera- tive to mucous mem- branes. In diseases of genitourinary or- gans. Hemostatic. In uter- ine hemorrhages, dysmenorrhea. Hypnotic. Sedative. 286 INDEX OF DRUGS Page in text. Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. Uses. 264 201 210 137 137 63 136 212 65 66 91 231 256 Hyoscyamus, hen- bane (h. niger, Ivs. and fl. tops). Extractum hyos- cyami. Fluidextractum. Tinotura. Hyoscyaminoe hy- drobromidum. Hyoscyaminae sul- phas. Hypophosphites. Syrupus hypophos- phitum. Syrupus hypophos. compositus. *lohthyocolla, isin- glass. *Ichthyol. *IjOtion or oint- ment. Indian hemp. See Cannabis indica. India-rubber. See Elastica. *Indigo (from sev- eral species of indigof era) . Iodine. See lodum. lodoformum, iodo- form, 96.7% iodine. Unguentum iodo- formi, 10%. lodolum, iodol, 89% iodine, lodum, iodine. Liquor iodi com positus, Lugol's solution, 5% dine, 10% iodide of potassium. Tinctura iodi, 7%. Unguentum, 4% *Decolorize(i tinc- ture. Ipecacuanha, ipecac (cephaelis i. root) Fluidextractum ipecacuanhse. Syrupus, 7%. Pulvis i. et opii. See under Opium. Tinctura i. et opii. See under Opium. *Troehisci. Vinum, 10%. See Emetine. *Iris florentina, orris root. *Tincture. *Oil of orris root. Iron. See Ferrum. Isinglass. See Ich- thyocolla. Itrol. See Argenti citras. Jaborandi. See Pilo- carpus, N. N. si. ac. N. V. s., 0.5 part, sol. aim. insol. insol. 5000 2 6.4 insol. part. 46.7 9 10 gr. 5-15 gr. M-2 rn5-i5 f3l-4 gr. i/eo-Vsi gr. -i/s: f3i-2 fol-2 gr. 1-3 gr. 3^-3 ■ nji-io ■ nii-5 gr. 1-30 fTni-5 lTni5-30 rn5-f52 .gr. H in each mi-60 5«-i f3l-2 0.30-1 0.03-0.12 0.30-1 4-15 In action it is similar to belladonna, but more sedative and hypnotic. In insom- nia, mania, deli"ium tremens. It quiets peripheral irritation, nervous cough, irri- tability of bladder. 0. 001-0. 002|Hyoscyamine is ano- dyne and mydriatic. 0.001-0.002 Tonic. Restorative. In wasting diseases, tuberculosis, rachitis, nervous diseases. 4-8 4-8 freely. extern, extern. 0.06-0.20 extern. 0.03-0.20 6.06-0.66 0.06-0.30 extern, extern. 0.06-2 0.06-0.30 1-2 0.30-8 0.06-4 1-4 4-8 Demulcent. Protect- ive. In pharmacy as a clarifying agent. Antiseptic. Alterative. Applied to skin dis- eases, inflammations. Coloring agent. Used externally. Alter- ative. Antiseptic. As powder to wounds and ulcers. Antiseptic. Same uses as iodoform. Alterative. Antiseptic. In tertiary syphilis, scrofula, glandular enlargements. In- ternally mostly in the form of iodides. The tincture is much used as a counter- irritant. _ Vapor in- haled in phthisis. Used in dysentery in in full doses. Expectorant. Emetic in large doses. One of the safest emetics. Syrup may be given to children in croup and bron- chitis to rid air pas- sages of mucus. In cough mixtures. The wine in drop doses to check vomiting. In diarrheas combined with other remedies. Diaphoretic when combined with opium. Used chiefly in tooth powders. Tincture in perfumery and aS flavoring. Perfume. INDEX OF DRUGS 287 Solubility in Dose. Page in Drug. Reac- Gm. or c.c. Uses. text. tion. Water Alcohol Plate Jalapa (ipoma?a j., gr. 5-20 0.30-1.30 Hydragogue cathartic. xviii. root). In dropsies. At com- *Extractum jalapae. gr. 2-8 0.12-0..50 mencement of acute Pulvis comp. 3J^-2 2-8 fevers or inflamma- Resina. si. ac. insol. sol. gr. 1-10 0.06-0.60 tions. As revulsive or depleting agent in cerebral hyperemia or serous effusions. *Juniperus commu- 3}€-i 1-4 Stimulant diuretic. nis (ripe fruit). Usually combined 230 Oleum juniperi. in sol. 10 ni2-io 0.12-0.60 with other diuretics. Spiritus. f5J^-i 2-4 In drop.sies, chronic Spiritus comp. f3l-4 4-15 catarrhs of urinary ♦Infusion. f5}^-2 15-60 tract. 97 Kino (pterocarpus marsupium,_ in- spissated juice). Tinctura kino. slowly sol. sol. gr. 5-30 f5J€-2 0.30-2 1-8 Astringent. In diar- rheas. As gargle. 97 Krameria, rhatany (k. triandra and k. ixina, root). gr. 5-30 0.30-2 Astringent. In diar- rheas, hemorrhages. Locally to relaxed Extractum kra- gr. 5-10 0.30-0.60 mucous membranes, meriae. spongy gums. As Fluidextractum. ni5-30 0.30-2 injection in fissure Syrupus. f 3 1-^-4 2-15 of anus or hemor- Tinctura. f3J^-2 2-8 rhoids. Trochisci. 1-5 Labarraque's solu- troches. tion. See under Chlorine. Lactucarium, lettuce gr. 5-60 0.30-4 Mild sedative and hyp- (lactuca virosa, notic, somewhat hke concrete juice). opium, but much Syrupus lactucarii. f3l-4 4-15 feebler. Used chiefly Tinctura. f3K-2 1-8 as vehicle. Lanolin. See Adeps lanse hydrosus. Lard. See Adeps. Laudanum. See un- der Opium. Laughing gas. See Nitrous oxide. ♦Lavandula offi- cinalis, lavender (flowers). Oleum lavandulae mi-5 0.06-0.30 Flavoring agent. As florum. carminative. Spiritus. f3J^-l 2-4 Tinctura comp. foH-1 2-4 Lead. See Plum- bum. Lemon peel. See Limonis cortex. Licorice root. See Glycyrrhiza. Lily of the valley. See Convallaria. Lime. See Calx. Limonis cortex, Preparations of lemon lemon peel. peel used chiefly as Oleum limonis. 3 rri2-io 0.12-0.60 flavoring agents. The ♦Spiritus. freely syrup of citric acid as vehicle. Limonis _ succus, ao. freely. Antiscorbutic. In lemon- juice. scurvy, acute rheu- *Syrup. ac. freely. matism. Refrigerant Syrupus acidi cit- ac. ■ if3 1-4 ■ 4-15 drink in fevers. To rici. Linseed oil. See un- der Linum. lessen acidity of urine. As vehicle. 91 Linum (1. usitatis- In poultices. Infusion simum), flaxseed. as demulcent drink. 90 Oleum lini, linseed oil. ♦Infusion. Liquorice root. See Glycyrrhiza. Litharge. See Plum- bi oxidqm. f5>^-2 1.5-60 freely. Oil is demulcent. Ap^ plied freely to burns. 288 INDEX OF DRUGS Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. Uses. 137 116 Plate xviii. 140 ♦Lithium, a metal. Lithii benzoas. Lithii bromidum. Lithii carbonas. Lithii citras. Ijthii citras effer- vescens. Lithii salicylas. *Litmus, lacmus. ♦Tincture. Lobeha (1. inflata), Indian tobacco (leaves and tops). Fluidextractum lo- beliffi. Tinctura. *Lobeline (alkaloid). Logwood. See Heb- matoxylon. *Losophane, cresol triiodide, 78% io- dine. Lugol's solution. See under ledum. Lunar caustic. See under Argentum. Lupulinum (from humulus) (gland ular powder). Fluidextractum lupulini. Oleoresina. Lycopodium (1. cla- vatum and other species) (sporules) *Lysol (from coal tar). *Macis, mace (aril- lode of nutmeg). Oil of mace. ^-2 0.03-0.12 Sedative. Myotic. To bar bean. depress excitability Extractum physos- gr. 1/10-^ 0.006-0.03 of spinal cord. In tigmatis. tetanus, strychnine Tinctura. TniO-30 0.60-2 poisoning, progres- *Eserine (similar to sive paralysis of the physostigmine). insane. To contract *Physostigmine. pupil. Physostigminae sali- ac. 72.5 12.7 gr. V100-V30 0.0006-.002 To contract pupil. cylas. Physostigminse sul- ac. V. s. V. s. gr. 1/100-^/30 0.0006-.002 phas. Pilocarpus (p. jabo- gr. 5-60 0.30-4 Powerful diaphoretic. randi, leaflets). Sialagogue. In acute Fluidextractum ni5-60 0.30-4 catarrh, acute in- pilocarpi. flammations of ser- 230 Pilocarpinffi hydro- chloridum. N. 0.3 2.3 gr. H-M 0.0075-0.02 ous membranes. In acute sthenic fevers Pilocarpine nitras. ac. 4 60 gr. K-M 0.0075-0.02 and dropsies when PUulffi catharticEe heart is_ not weak. comp. See under Pilocarpine may be Colocynthis. used hypodermic- Pilulffi catharticee ally. veg. See under Colocynthis. Piperina (from N. insol. 15 gr. 1-5 0.06-0.30 Aniiperiodic. Anti- pepper). pyretic. *Piperazine, piper- sol. • gr. 8-15 0.50-1 As solvent for uric azidine. acid. In gout and allied conditions. Pix liqtiida, wood ac. si. sol. sol. foM-1 1-4 Esed externally in tar (from pine). chronic eczema, pso- Oleum picis extern. riasis. _ With atom- hquidae. izer or in the form of Syrupus. f5i-4 4-15 syrup in laryngitis. tnguentum, 50%. extern. bronchitis, catarrhs, Plaster of Paris. See phthisis. under Calcium. *Platinum, a metal. *Platinic chloride. V. s. V. s. gr. J^-2 0.03-0.12 Alterative. *Plumbum, lead. 104 Piumbi acetas, N. 2 30 gr. Ji-5 0.03-0.30 Sedative. Astringent. 264 sugar of lead. Ceratum piumbi subacetatis, Gou- lard's cerate. extern. Acetate used as seda- tive application to irritable ulcers; in skin diseases. As- Liquor piumbi sub- al. extern. tringent in inflam- acetatis, Goulard's mations and catar- extract. rhal discharges. In- 104 Liquor piumbi sub- acetatis dilutus, lead-water. al. extern. ternally in hemor- rhages, diarrheas, gastric ulcer. Iodide Piumbi iodidum. N. 1300 spar. gr. i/jo-1/5 0.006-0.012 as ointment in Piumbi nitras. ac. 1.85 spar. extern. chronic eczema and Piumbi oxidum, al. aim. insol. extern. psoriasis. Nitrate as litharge. insol. deodorant to foul Emplastnun pium- extern. ulcers. With glycerin bi, lead plaster. as astringent to fis- Diachylon plaster. sured nipples. Oxide Enguentum diach- extern. used to prepare lead ylon. plaster, which forms the basis of many other plasters. Plate Podophyllum, man- gr. 5-20 0.30-1.30 Cathartic. Efficient in x^•iii. drake (p. pelta- tum, root). torpor of the liver. In chronic constipa- *Extractum podo- gr. 2-10 0.12-0.60 tion. The resin used phylU. in laxative pills. Fluidextractum. ni5-20 0.30-1.20 Resina, "podophyl- Un." _ *Potassium, a metal. insol. sol. ST. Vs-l 0.0075-0.06 Alkali. Potass, hy- 229 Potassii acetas. Liquor potassii arsenitis. See un- der Arseni triox. 'ki.' "OA '"2 gr'. 5-60 ' 6!36-^4 ■ droxide and potassa with hme are caustic. Liq. pot. hydrox. di- luted, and the carbo- Potassii biear- al. 3 aim. gr. 5-60 0.30-4 nates are used as al- bonas. insol. kalies. 229 Potassii bitartras. ac. 200 si. sol. 5J^-4 2-15 266 cream of tartar. Index of drugs ^9S Solubility in Dose. Page in Drug. Reac- Gm. or CO. Uses. text. tion. Water Alcohol 218 Potassii bromiduta. N. 1.5 180 gr. 5-60 0.30-4 The salts with vege- Potassii carbonas. al. 0.9 insol. gr. 5-30 0.30-2 table acids also act 139 Potassii chloras. Trochisci potassii chloratis. N. 16 si. sol. gr. 3-20 gr. 2H in each. 0.20-1.30 as alkalies, being con- verted into carbon- ates in the system. 229 Potassii citras. al. 0.5 si. sol. gr. 5-30 0.30-2 and in elimination Liquor potassii al. f31-8 4-30 they are diuretic. In citratis. fevers, rheumatism. Potassii cyanidum. al. 2 si. sol. gr. 1/20-M 0.003-0.015 To produce alkalin- 74 Potassii hydrox- al. 0.4 2 ity of the urine. Bi- 266 idum, caustic potash. tartrate and Rochelle salt are cathartics. Liquor potassii hy- al. ni5-i5 0.30-1 Chlorate is detergent droxidi, 6%. well di- luted. when applied to mu- cous membranes. In *Potassa cum calce, al. extern. pharyngitis and lar- Vienna paste, 50% yngitis, used locally. each potash and Best used alone, as lime. it may form explo- Plate Potassi et sodii al. 1.2 aim. §J€-1 8-30 sive compounds. xviii. tartras, Rochelle salt. Pulvis effervescens compositus, Seid- litz powder. insol. 1 set of powders. Nitrate is diuretic. Nitre paper as a fumigation in asth- ma. Sulphate is a mUd cathartic, but Potassii hypophos- N. 0.5 7 gr. 5-20 0.30-1.30 seldom used; useful phis. to hasten the hard- 213 Potassii iodidum. N. 0.7 12 gr. 5-60 0.30-4 ening of plaster of Paris. Bromide is a nerve 229 Potassii nitras, N. 3.6 aim. gr. 5-20 0.30-1.30 266 nitre, saltpetre. insol. sedative. The most 140 Potassii perman- N. 15 decomp gr. J^-2 0.03-0.12 efficient remedy in 153 ganas. epilepsy. In infan- Potassii sulphas. N. 9 insol. 33^-4 2-15 tile convulsions, headaches, fevers, insomnia, nervous- ness, hysteria. Seda- tive to sexual organs. Iodide is alterative and sialagogue. Es- pecially valuable in tertiary syphihs. In asthma, chronic bronchitis, chronic rheumatism. In lead poisoning to pro- mote eUmination. Prepared chalk. See Cyanide is in action under Calcium. similar to hydrocy- anic acid. Permanganate as antiseptic. 142 *Protargol, a pro- teid compound of silver. Prunus Virginian a sol. Antiseptic. Applied in 1 to 5% solutions. 207 3J^-l 2-4 Bitter tonic. Sedative (p. serotina), wild by virtue of hydro- cherry bark. cyanic acid, which Fluidextractum iZVi-l 2-4 is developed in the pruni virginianae. cold infusion. In Infusum. f51-2 30-60 pulmonary diseases, Syrupus. f3l-4 4-15 coughs, dyspepsia. Prussic acid. See Acidum hydro- cyanicum dil. Pumpkin seed. See Pepo. Pyrethrum (ana- 5H-1 2-4 Sialagogue. Irritant. cyclus p., root). As gargle. As snuff Tinctura pyrethri. extern. in chronic catarrh. 80 Pyrogallol, pyrogal- lic acid. ♦Ointment, 2 to 3% n'. or ac. "i.6' . .^. . Caustic. Externally in skin diseases. 111 Pyroxylinum, sol- uble guncotton. insol. t To prepare collodion and celluloid. t Soluble in 25 parts of a mixture of 3 vols, ether with 1 vol. alcohol. 294 mmx OF DRVGB Solubility in Dose. Page in Drug. Reac- Gm. or c.c. Uses. text. tion. Water Alcohol Pyrozone. See Aqua hydrogenii diox. 205 Quassia (picrasma excelsa, wood). Bitter tonic. Anthel- mintic. In atonic in- Extractum quas- gr. H-3 0.03-0.20 digestion and diar- siae. rhea. Infusion as Fluidextractum. f3M-i 1-4 enema to remove Tinctura. f3J^-2 2-8 thread-worms. Con- ♦Infusion. f5i-2 30-60 tains no tannin. Quercus, white oak Astringent. Same uses (bark). as tannic acid. Fluidextractum. f3M-l 1-4 206 Quinina. al. 1750 0.6 Quinine is the chief Quininae bisulphas. ac. 8.5 18 remedy used in ma- Quininae hydro- N. 40 0.67 larial fevers. The bromidum. ■gr. 1-^20 0.06-1.30 sulphate is used Qmninse hydro- N. 18 0.6 mostly, but the bi- chloridum. sulphate is more Quininse salicylas. al. 77 11 soluble. The hydro- Quininae sulphas. N. 720 861 bromide and hydro- ♦Compound tinc- fo2-6 8-25 chloride are recom- ture (Warburg's). mended for hypo- Red precipitate. See dermic use. Hydrargyri oxi- dum rubrum. Resina (from tur- insol. sol. In plasters and oint- pentine), resin. ments. Ceratum resinae, extern. Resin cerate is ap- basilicon oint- plied to bruises, ul- ment. cers, etc. 139 Resorcinol, resorcin. Rhamnus frangula, buckthorn. See Frangula. N. 0.5 0.5 gr. 2-10 0.12-0.60 Antiseptic. May use internally. In per- tussis, 2% solution used as a spray to the upper air tract. Plate Rhamnus purshiana, 3M-1 1-4 Tonic cathartic. In XVIU. cascara sagrada (bark). Fluidextractum rhamni purshianae Rhatany. See Kra- foM-1 1-4 chronic constipation. Plate Rheum, rhubarb (r. gr. 3-30 0.20-2 Astringent. Cathartic. XVIU. officinale, root). Small doses tonic to Extractum rhei. gr. 3-15 0.20-1 intestinal tract. Lar- Fluidextractum. f5M-l 1-4 ger doses safe, effi- Mistura rhei et f5M-2 8-60 cient laxative. Cath- sodae. artic effect apt to be Pilulae compositae. 1-3 pills. followed by consti- Pulvis compositus. 3H-1 2-4 pation unless com- Syrupus. Syrupus aromatic- ::::[ child 31 child 4 bined with more powerful agents, as cus. in compound pill. Its astringency makes it a valuable laxative in diarrheas. Tinctura. f3l-4 4-15 Mixture of r. and soda Tinctura aromatica f3l-3 4-12 is antacid and laxa- tive. 156 *Rhigolene (from pe- troleum). Rochelle salt. See Potassii et sodii tartras. Used as local anal- gesic. Rhus glabra, su- 3J€-l 1-4 Astringent. As mild mach (fruit). astringent, gargle, or Fluidextractum f3M-l 1-4 lotion. rhois glabrae. *Rosa damascena, damask rose. Aqua rosae. Rose water. As ve- Aqua rosae fortior. hicle or flavor. Unguentum aquae Cold cream to soften rosae, cold cream. the skin. Applied to chapped hands. 256 Oleum rosae, otto of rose. Rosa gallica, red rose (dried petals). Confectio rosae. N. insol. si. sol. Flavoring agent. Per- fume. Flavoring agent. The confection as ex- cipient in pill masses. INDEX OF DRUGS 295 Page 31 240 32 Drug. Reac- tion. Solubility in Water Alcohol 30 114 216 Fluidextractum. Mel., honey of rose. Syrupus. Rubus, blackberry (bark of root"). Fluidextractum rubi. Syrupus. Saccharine. oee Benzosulphinidum Saccharum, cane- sugar. Syrupus. Saccharum lactis, sugar of milk. Sage. See Salvia. Salicinum, salicin (from several spe- cies of salix and populus). Salol. See phenyHs salicylas. Saltpetre. See Po tassii nitras. Salvia (s. officinalis) sage leaves. *Sandarach, a resin. Santoninum (from santonica) , san- tonin. Trochisci santonini. Sapo, white CastUe soap. Emplastrum sa- ponis. Linimentum. Sapo mollis, soft soap, green soap. Linimentum sapo- nis mollis. Sarsaparilla (root). Decoctum sarsapa- rillse comp. Fluidextractum. Fluidextractum comp. Syrupus comp. Sassafras (s. varii- folium, bark of root). Oleum sassafras. Plate 'Scammonium, resinous product of convolvulus s. Resina scammonii Scilla, squill (urgi- nea maritima, bulb). Acetum scillae. Fluidext ractum. Syrupus. Syrupus comp., hive syrup (0.2% tartar emetic). Tinctura. Scopola (s. carnio- Uca, root). Extractum scopolse. Fluidext ractum. Scopolaminae hy- drobromidum. Seidlitz powder. See under Potassii et sodii tartras. 229 232 0.46 h" 21 138 insol. 71 Dose. insol. insol. al. al. sol. 34 insol. sol. Gm. or c.c. Uses. ■ f 51-2 ■ f3J^-2 f31-2 o^-l f51-4 f3J^- gr. 5-30 3^-1 gr. H-l child. gr. H in each, gr. 5-15 f5J€-i 3M-1 ini-5 gr. 2-10 2-5 1-5 1-4 freely. 4-8 2-8 4-8 indef. indef. indef. 0.30-2 1-4 0.015-0.06 0.03 in each. 0.30-1 Fluid extract _ and syrup as vehicles. The honey locally as mouth-wash. Astringent. In diar- rheas. Sweetening agent. Preservative. Syrup as vehicle. The hardness of its particles make it useful in preparing triturations. Tonic. Antiperiodic. In rheumatism, ma- larial fevers. Astringent. Infusion as gargle, often with alum. Used as a varnish. Anthelmintic. To de- stroy round worms, used cautiously. nilO-45 mi-5 f3^-l TT15-30 tTl5-30 g. Vio-J^ WA-2 gr. Vi80-^/60 extern, extern. 2-4 30-120 2-4 2-4 8-30 1-4 0.06-0.30 0.12-0.60 Seldom internally ex- cept in suppository or pUl. Powdered, used as an alkali and detergent in denti- frices. Soft soap as antiseptic. In dis- eases of the skin. Tonic. Alterative. Has very feeble medi- cinal powers. Used chiefly as vehicle for stronger altera- tives. The warm infusion is diaphoretic. Regard- ed as alterative, but has feeble power. Hydraqogue cathartic. In cerebral disorders as derivative. In 0.12-0.30 dropsies. 0.06-0.30 Diuretic. Expectorant. In large doses emetic. Like digitalis, it 0.60-3 strengthens pulse 0.06-0.30 and increases excre- 2-4 tion of urine. In 0.30-2 bronchitis, croup. The compound syrup cautiously 0.30-2 with children. 0.006-0.03 0.03-0.12 0.0003-.001 Similar to belladonna in action. Mydriatic, Resembles atropine and hyos- cyamine in action and uses. 296 INDEX OF DRUGS Solubility in Dose. Page Drug. Reac- in Gm. or c.c. Uses. text. tion. Water Alcohol Senega (polygala s.. gr. 10-20 0.60-1.30 Stimulant expectorant. root). Diuretic. In chronic Fluidextractum niio-20 0.60-1.20 bronchitis, asthma, senegae. croup. Often com- Syrupus. f3l-2 4-8 bined with squill. Plate Senna (cassia acuti- 31-3 4-12 Cathartic. Efficient xviii. folia and c. an- gustifoUa, leaves). and safe in any con- dition, except intes- Confectio sennae. 51-2 4-8 tinal inflammation. Fluidextractum. f51-3 4-12 The confection and Infusum comp. f3i-2}^ 30-75 compound licorice Pulvis glycyrrhizae 3J^-2 2-8 powder are mUd, compositus. useful for children Syrupus. f5M-i 8-30 and in pregnancy. Serum antidiphtheri- In diphtheria, hypo- cum, diphtheria dermically, to an- antitoxin. tagonize poison of the disease. Sevum prseparatum, insol. 44 extern. As basis for cerates mutton suet. boiUng and ointments. 61 Sinapis alba, white mustard seed. indef. Rubefacient. Irritant emetic. Mustard 61 Sinapis nigra (bras- extern. owes its irritant 230 sica nigra), black mustard seed. Charta sinapis, mustard paper. extern. property to the vola- tile oil, which is de- veloped in the pres- ence of cold water. 61 Oleum sinapis vola- N. insol. sol. WA-K 0.0075-.015 The volatile oil isara- 135 tile. *Flour of mustard is a mixture of white and black. Slippery elm. See Ulmus. Soap. See Sapo. *Sodium, a metal. , tiseptic, but very irri- tating. The general action Sodii acetas. 'al.' "i' " ■ 23 ' gV. 10-30 " 6!66-2 ' and uses of sodium Sodii arsenas. See salts are similar to under Arseni. those of potassium. Sodii benzoas. N. 1.6 43 gr. 5-30 0.30-2 As alkalies they are 115 Sodii bicarbonas. al. 12 insol. gr. 5-30 0.30-2 less disturbing; be- Trochisci sodii bi- gr. 3 in 0.20 in ing better tolerated carbonatis. each. each. by the system they Sodii bisulphis. See are more slowly eli- under Acid, sul- minated, therefore phurosum. less diuretic. 115 Sodii boras, borax (sod. diborate). al. 20.4 insol. gr. 5-30 0.30-2 Liq. sod. hydrox., the acetate and carbon- 123 *Liquor sodii bo- ratis compositus, Dobell's solution. al. extern. ates as alkalies, the bicarbonate more than all others for 218 Sodii bromidum. N. 1.7 12.5 gr. 6-60 0.30-4 internal use. Sodii carbonas al. 2.9 insol. gr. 5-15 0.30-1 Benzoate and borate monohydratus. are antiseptic. _ _ The Sodii chloras. N. 1 100 gr. 5-15 0.30-1 former in cystitis, to 49 Sodii chloridum. N. 2.8 aim. gr. 5-60 0.30-4 prevent decomposi- 200 common salt. insol. tion of urine. Borax 152 *Sodium dioxide. al. sol. extern. as mouth-wash in thrush. Caustic. 74 Sodii hydroxidum, al. 1 v. s. 1115-15 0.30-1 266 caustic soda. Liquor sod. hy- droxidi, 5.6 %. well diluted. Sodii hypophosphis N. 1 25 gr. 5-20 0.30-1.30 Bromide is sedative. 213 Sodii iodidum. al. 0.5 3 gr. 5-30 0.30-2 Large doses by ene- Sodii nitras. N. 1.1 100 gr. 5-30 0.30-2 ma to control ob- Plate Sodii nitris. al. 1.4 si. sol. gr. 1-3 0.06-0.20 stinate vomiting due xiii. to reflex causes. Plate Sodii phosphas. al. 5.5 insol. gr. 5-51 0.30-30 Chlorate and iodide xviii. Sodii phenolsulpho- nas. N. -1.8 130 gr. 1-10 0.06-0.60 resemble correspond- ing potassium salts. Liquor sod. phos- f3l-4 4-15 Chloride in normal phatis comp. (0.6%) solution as 130 Sodii salicylas. *Sodium silicate. ac. 0.8 boiling. 5.5 gr. 5-30 0.30-2 cleansing lotion in diphtheria, nasal ♦Liquor sodii sili- ai.' extern. catarrh, pharyngitis, catis, solution of and_ hypodermically soluble glass. or intravenously as restorative. INDEX OF DRUGS 297 Page Drug. Reac- tion. Solubility in Water Alcohol Dose. Gm. or c.c. Uses. Plate xviii. 137 267 165 193 202 Plates iv.,xi. 266 Sodii sulphas, Glau- ber's salt. Sodii sulphis. See under Acidum sulphurosum. 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 to- gether. *Sodium tetraborate (neutral sod. bo- rate). Soluble glass. See under Sodium. *Sozoiodol._ sozoio- dolic acid, 53% iodine. Spanish flies. See Cantharis. Sparteine sulphas (from scoparius). Spearmint. See Mentha viridis. Spermaceti. See Cetaceum. Spiritus setheris ni- trosi. See under ^ther, nitrous. Squill. See Scilla. Starch. See Amy- lum. Storax. See Styrax. Stramoii foha (da- tura s., leaves). Extractum stra- monii. Fluidextractum. Tinctura. Unguentum. See Daturine. Strophanthus (s. Komb6, seeds). Tinctura stro- phanthi. Strophanthinum. Strychnina (from nux vomica). Strychninse nitras. Strychninae sul- phas. Styrax, storax. Tinctura benzoini composita, 8% storax. Suet. See Sevum. Sugar. See Sac charura. Sugar of lead. See Plumbi acetas. Sugar of milk. See Saccharum lactis. 2.8 insol. si. sol. 1.1 2.4 V. s. 6400 42 31 insol. sol. 110 120 65 51-8 gr. 3-10 gr. Vio-1 gr. 1-5 gr. H-Vi mi-5 ni5-30 ms-io ^/eoo-'/ioo grain. gr. i/eo-Vio gr. Veo-Vio gr. 5-20 f3J^-l 4-30 0.20-0.60 0.006-0.06 0.06-0.30 0.015-0.03 0.06-0.30 0.30-2 extern. 0.12-0.60 .0001-.0006 0.001-.006 0.001-.006 0.001-.006 0.30-1.30 2-4 Dioxide is a caustic and bleaching agent. In saturated solu- tion to bleach teeth. Hypophosphite is tonic. Phosphate and sul- phate are laxative. Nitrite has same uses as nitroglycerin. Salicylate has same uses as salicylic acid. Liquor sodii silicatis, to prepare immov- able surg. dressings. Phenolsulphonate is used internally for same purposes as carbolic acid. Antiseptic. Same uses as boric acid. Antiseptic. In solu- tion or as dusting powder. Heart stimulant. Diu- retic. Acts more promptly than digi- talis. Narcotic. A nodyne. Leaves used as fumi- gation in asthma. General action sim- ilar to that of bella- donna. As antispas- modic and anodyne in asthma, chorea, neuralgia, dysmen- orrhea. Ointment to painful ulcers. Heart stimulant. Diu- retic. Effect upon heart similar to that of digitalis. Used in cardiac diseases, dropsy. Bitter tonic. Nerve stimulant. Action and uses same as those of nux vom- ica, which drug it represents fully. Expectorant. A nti- septic. Tn catarrhs, purulent mucous discharges. To pre- serve fats. ^98 tNDlSX OF DRUGS Solubility in Dose. Page in Drug. Reac- Gm. or c.c. Uses. text. tion. Water Alcohol 225 Sulphonethylmeth- anum, trional. N. 195 V. s. gr. 5-30 0.30-2 I Hypnotic. Both are less depressing, 225 Sulphonmethanum, sulphonal. N. 360 47 gr. 5-30 0.30-2 j therefore safer, than chloral. Plate Sulphur lotum, N. 1 sl.sol.in abso- lute al- cohol. ~ Laxative. Alterative. xviii. washed sulphur. In chronic eczema. S. praecipitatum. insol. i ohi-1 1-4 psoriasis, and other S. subUmatum, ac. 1 skin diseases, inter- flowers of sulphur. J nally and externally. Unguentum sul- extern. Very effectual exter- phuris, 15%. nally for scabies. Sulphuris iodidum. ac. aim. insol. t gr. 1-4 0.06-0.25 Washed s. most suit- able for internal use. Sulphuric ether. See The iodide is used in JSther, ethylic. scrofulous diseases Sumach. See Rhus of the skin. glabra. *Svapnia, a purified sol. sol. Dose and uses same opium. as opium. Sweet almond. See Amygdala dulcis. Sweet birch oil. See Oleum betulse. Sweet flag. See Cal- amus. Sweet spirit of nitre. See under JEther, nitrous. Syrup of hypophos- phites. See Hypo- phosphites. 267 *Tabacum, tobacco (nicotiana t., Ivs.) See Nicotine. gr. 1-5 0.06-0.30 Emetic sedative. De- pressing and danger- ous. Seldom used. Tamarindus, tam- ac. freely. Laxative. In confec- arind (t. indica, tion of senna. Also fruit). in infusion as acidu- lous drink in fevers. *Tanacetum, tansy o>€-l 1-4 Emmenagogue. An- (t. vulgare, leaves thelmintic. Danger- and tops). ous in large doses. *Volatile oil. 1111-3 0.06-0.20 Tar. See Pix Uquida. Tartar emetic. See Antimonii et po- tassii tartras. Terebenum (from N. si. sol. 3 n[5-15 0.30-1 Stimulant expectorant. turpentine). In cough, chronic Terebinthina, tur- ac. insol. sol. bronchitis, hay pentine, an oleo- asthma. resin from pine. 135 Oleum terebin- N. or insol. 3 irn5-30 2-15 Anthelmintic. thinse. si. ac. 0.30-2 Stimulant. Diuretic. 230 Oleum t. rectifica- tum. N. insol. 3 Externally vesicant. Internally in _ ty- Emulsum olei tere- f 5 1^-2 2-8 phoid conditions, binthinse, 15%. chronic inflamma- 62 Linimentum, 35%. Terebinthina cana- densis, balsam of fir. Canada bal- sam. extern. tions of mucous membranes, intes- tinal ulceration and hemorrhages. The crude French oil in phosphorus poison- ing. Used in mounting mi- croscopic sections. Terpini hydras, ter- N. 200 10 gr. 2-10 0.12-0.60 Antiseptic. Expecto- pin hydrate. rant. In bronchitis. *Terpinol. insol. sol. rn5-i5 0.30-1 Same uses as above. *Tetronal. 450 sol. gr. 15-30 1-2 Hypnotic. *Theobroma cacao. To prepare chocolate. (seeds). 31 Oleum theobro- matis, cacao but- ter. N. insol. 100 In preparing supposi- tories. t Alcohol dissolves out iodine. INDEX OF DRUGB 299 Page in text. Solubility in Dose. Drug. Reac- tion. Water Alcohol Gm. or CO. Uses. 202 ♦Theobromine. si. sol. sol. gr. 2-10 0.12-0.60 Diuretic. Similar to ♦Theobromine sali- si. sol. gr. 2-10 0.12-0.60 caffeine. butless stim- cylate. ulating to cerebrum. ♦Theobromine and sol. gr. 15 1 Recommended as diu- sodium salicylate, retic. diuretin. ♦Thymus vulgaris, 3M-1 1-4 Aromatic stimulant. thyme (leaves). Mostly as infusion. 135 Oleum thymi. N. in sol. 0.5 nii-5 0.06-0.30 Oil as carm.inative. 135 Thymol. 1100 1 gr. 1-8 0.06-0.50 Antiseptic. 135 ThymoHs iodidum, aristol,46% iodine. insol. 675 extern. Antiseptic. Substitute for iodoform. Tragacantha, gum part. insol. Excipient in making tragacanth. pOls and troches. MucUago traga- freely. Mucilage as vehicle. cantha;. Trional. See S'olph- onethylmethanum Tully's powder. See under Morphina. 169 ♦Tropacocaine hy- drochloride (from "small-leaved coca"). Turpentine. *See Terebinthina. al. sol. sol. gr. M-1 0.015-0.06 Local anesthetic. Sim- ilar to cocaine, but less toxic. 90 Ulmus (u. fulva) , Demulcerd. Emollient. sUppery elm (in- As poultice. Inter- ner bark). nally in pharyngitis. MucUago ulmi. freely. diarrhea, dysentery. ♦Decoction. freely. cystitis, irritation of Urotropin.