3IXVN 3NI3ICI3VY JO AHVagil IVNOIIVN 3NI3IQ3W jo AaVaan ivnoiivn SNniasw jo Aavaan "IVNOIIV CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN / ^ %^f i w^ DI1VN 3NIDI03W JO ASVJian IVNOIIVN 3NIDIQ3W JO AaVaan IVNOIIVN 3NIDIQ3W jo Aavaan TVNOIIV CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN /\f' 1 \^f\ 3IIVN 3NIDI03W JO AaVaail IVNOIIVN SNioiasw jo Aavaan ivnoiivn snidiqsw jo Aavaan tvnoiivi ICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN DI1VN 3NIDIQ3W JO ASVaail IVNOIIVN ICINE NATIONAL LIBRARY OF MEDICINE aNiDiaaw do Aavaan ivnoiivn 3nidici3w do Aavaan rvNOiivr NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIr- 3NIDI03W JO AaVa8IT IVNOIIVN 3NIDIQ3W JO AHVaaiT WNOIIVN 1NIDIQ3W JO Aavaan TVNOIIV ICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIr- -6 V^ -g / IN/ 3I1VN 3NIDI03W JO Aavaan IVNOIIVN JNIJIUdW iU Aavami iviiuiiyi' | |s^\ -§ < 3NIDIQ3W jo Aavaan 1 D hhiTBQOO WIN aaw jo Aavaan ivnoiivn NLM000867440 ^E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF i an ivnoiivn snidiqsw jo Aavaan ivnoiivn 3NiDia3w jo Aavaan ivnoiivn snidiqsw jo Aavaan M' s Cf ^ 7 1 > DF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ^i^" f0f rffei<#f i^fv {< an ivnoiivn ^ snidiqsw jo Aavaan ivnoiivn u snidiqsw jo Aavaan ivnoiivn snidiqsw jo Aavaan '-■ s O ' -- n' OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF c c ^^ «^\ / I \ £™-^ • ^ -. I \f^ ,®^ an ivnoiivn snidiqsw jo Aavaan ivnoiivn snidiqsw jo Aavaan tvnoiivn snidiqsw jo Aavaan *% OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF i an ivnoiivn snidiqsw jo Aavaan ivnoiivn snidiqsw jo Aavaan ivnoiivn snidiqsw jo Aavaan OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF / '■^ S; an ivnoiivn SNiDiasw jo Aavaan ivnoiivn snidiosw jo Aavaan ivnoiivn snidiosw jo Aavaan »& 1 ^ J %! ^! >%J ^! J )F MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF A ^^ •J" e "kUa-" A TEXT-BOOK OF PRACTICAL THERAPEUTICS, WITH ESPECIAL REFERENCE TO THE APPLICATION OF REMEDIAL MEASURES TO DISEASE AND THEIR EMPLOYMENT UPON A RATIONAL BASIS. BY HOBART AMORY HARE, M.D., B.Sc., PROFESSOR OF THERAPEUTICS AND MATERIA MEDICA IN ,THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; PHYSICIAN TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL | CONSULTING PHYSICIAN TO THE FRANKLIN REFORMATORY HOME; LAUREATE OF THE ROYAL ACADEMY OF MEDICINE IN BELGIUM, OF THE MEDICAL SOCIETY OF LONDON, ETC. FOURTH EDITION, ENLARGED AND THOROUGHLY REVISED. PHILADELPHIA: LEA BROTHERS & CO. 1894. RiA^-^-f Wi3 H?j1A -b t2>^4- Entered according to Act of Congress, in the year 1894, by LEA BROTHERS & CO., in the Office of the Librarian of Congress. All rights reserved. Westcott & Thomson, William J. Dornan, Slereotypers and Electrotypers, Philada. Printer. Philada. THIS VOLUME IS DEDICATED TO Dr. J. WILLIAM WHITE, PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OP PENNSYLVANIA, AS AN EVIDENCE OF FRIENDSHIP AND ESTEEM, BY THE AUTHOR X PREFACE TO THE FOURTH EDITION. The Fourth Edition of this work having been called for in less than four years after the appearance of the first, the Author has taken advantage of the opportunity to rewrite and add to many of the articles on drugs, remedial measures, and diseases, and to insert practical information concerning the value and prescription of the really useful new remedies. Articles on Methylene Blue, Chloralose, Pyrogallol, Condurango, Convallaria, Duboisine, and other remedies have been added to the part of the work dealing with drugs. In the part dealing with Remedial Measures other than Drugs articles have been written on Hypodermoclysis and Enteroclysis, Lavage, and upon Mineral Springs and Climatic Treatment. The latter article is not intended to be exhaustive, but to give the general practitioner an idea of the therapeutic value of certain well-known resorts, in order that he may offer rational advice to his patients as to where they should go in search of health. Several new articles in the part devoted to the Treatment of Individual Diseases have been inserted, and new or modified applications of the older remedies carefully noted throughout the entire book. In addition to these changes, the work has been revised in such a way as to render it uniform with the new U. S. Pharmacopoeia. As that authority directs the use of the metric system, the doses of all drugs are given in both Apothecaries' and Metric weights, thus (15 to 30 grains [1.0-2.0]), so that the physician may conveniently use either system, but it is to be clearly understood that where the doses are expressed in both systems, side by side, no attempt has been made to make the metric amounts more than approximate the quantities given in Troy weight. 5 6 PREFACE TO THE FOURTH EDITION. The fact that one fluidounce is nearly represented by 30 cc, while one solid ounce is represented approximately by 32 grammes, causes confusion. The author has therefore adopted the method advised by Oldberg in his valuable and well-known "Manual of Weights and Measures," and used 32 cubic centimetres or grammes as equivalent to 1 ounce, whether liquid or solid. The Author desires to express "his appreciation of the care with which Dr. de Schweinitz has revised the articles on Diseases of the Eye; Dr. Hirst, those on the Puerperal State ; and Dr. Martin, those on Syphilis and Genito-urinary Diseases and Antisepsis. The arti- cles on the treatment of diseases of the upper air-passages have been rewritten or revised by the Author. It is hoped that this new edition will prove even more useful than its predecessors to the doctor who needs a book for ready reference in daily practice. Philadelphia, 222 South Fifteenth Street. PREFACE TO THE FIRST EDITION. The object of this book is to provide the physician or under- graduate student of medicine with a reliable guide in the study of Therapeutics, or the application of remedial measures for the cure of disease. It has been written because, in the belief of the author, most of the text-books on this subject treat of it as if the student were already a skilled physician or experimental pharmacologist. As a consequence, two classes of undergraduate readers exist. One finds that the mixture of science and empiricism is too difficult for him to fathom, and is hopelessly confused; the other simply learns the reme- dies and doses by heart, and gives drugs with little idea as to what they are to do. Further than this, the physician is often at a loss to decide when a remedy is indicated, even though his theoretical know- ledge of the subject be very thorough. Thus, he is told that ammo- nium chloride is a remedy in bronchitis, but the exact stage at which it is to be employed is often not stated; or he knows that digitalis does good in cases of cardiac disease, but fails to recognize the fact that it is only when compensation is lacking that the drug is needed. For this reason Part IV. has been written, not with the object of providing a rigid .system for treating disease, but rather for the pur- pose of bringing together the best remedies, and of showing how and why they are given. Rational therapeutics at the present day does not consist, in a knowledge of doses and the materia medica, but exists as a complex art in which knowledge and its proper application, based on common- sense principles, go hand in hand. The treatment of " symptoms as they arise " by the employment of remedies recommended by some eminent authority is a variety of empiricism whose existence has 8 PREFACE TO THE FIRST EDITION. depended largely on the fact that many physicians of the past have either been so ignorant as to be led where a writer willed, or so sloth- ful as to be willing to let others think for them. Scientific research has so largely opened up to every one the possibility of using drugs with a distinct idea of the reason for their employment that the writer has endeavored to bring together in a readable form the com- bined results of laboratory and bedside experience, thinking the time ripe for such a task. It is true that several other books give, in a more or less thorough manner, a resume of the physiological action of the drugs of which they treat, but in even the best of them only the most trained student of pharmacology can discover the close rela- tionships which exist between the results reached by the physiologist on the one hand and the clinician on the other. The two parts of the study are usually so divorced by the prolonged mental effort neces- sitated by the arrangement of the text that the student either ignores the physiological action for the sections on therapeutics, or crams the former to pass an examination required by the teacher whose course he must follow. As a consequence, too many physicians regard pharmacology simply as a species of mental training, or believe it to be a waste of time and energy. No one can think that the writer of this book will ever deny the value of original research or bedside experience, but he does desire to weave science and practice into so close a network that the foundations of experience may be cemented by the mortar of exact knowledge. In some instances, however, science and practice seem to be absolutely opposed, and only future research can explain the apparent contradiction. Throughout this book, in every part where drugs or diseases are considered, the writer has arranged the titles in alphabetical order, according to their English names. This has been done because it is desired to afford the reader a ready-reference book to which he may turn at short notice for desired information, for at present the state of pharmacology is so unsettled that a true classification is impossible. Thus, morphine may be classed by one writer as a nervous sedative, by another as a sleep-producer, by a third as a bitter substance, and by a fourth as a respiratory depressant. Bromide of potassium can PREFACE TO THE FIRST EDITION. 9 with equal propriety be called a spinal sedative or a cerebral seda- tive, or caffeine be classed as a cerebral stimulant, a circulatory stim- ulant, or a diuretic. In order to make the book more complete, the preparations of the British Pharmacopoeia have been introduced; and with the same object in view, a dose-list of drugs, both official and unofficial, has been appended for ready reference. The subject of medical elec- tricitv has heretofore commonly found a place in most text-books on therapeutics, but has been advisedly omitted in this instance, since electrical therapeutics has outgrown any work save one devoted to that subject alone. For many of the articles on treatment the author wishes to thank friends who have earned prominence in connection with their special- ties. Thus Dr. G. E. de Schweinitz has contributed the articles on the treatment of diseases of the eye; Dr. Edward Martin, those on the treatment of venereal diseases and on antisepsis; Dr. Barton C. Hirst, those on the treatment of diseases of the puerperal state; and Dr. J. Howard Reeves, the articles on the treatment of diseases of the upper air-passages. All of these articles enhance the value of the book to so great an extent that the author feels sure they will be sought out and read with interest. In addition to the general index, a copious and explanatory index of diseases and remedies has been appended, which will prove sug- gestive and valuable to practitioners, and for which the author is indebted to his friend and student, Mr. J. G. Clark. Philadelphia, 222 South Fifteenth Street. Sept., 1890. X. ■3-^5 0^ CONTENTS. PART I. PAGE General Therapeutical Considerations.......... 17 PART II. Drugs.............................. 39 PART III. Remedial Measures other than Drugs..........359 Foods for the Sick . ....................406 PART IV. Diseases.............................413 Table of Doses of Medicines.................665 Tables of Relative Weights and Measures in the Metric and Apothecaries' Systems................681 Index of Drugs and Remedial Measures..........683 Index of Diseases and Remedies...............701 11 PART I. GENERAL THERAPEUTICAL CONSIDERATIONS. Before entering into a study of the action of drugs upon a living body, it is necessary that the student should possess a clear idea of what the word "therapeutics" means, the reason why we resort to drugs, and, more important than all, that he should grasp the limita- tions which govern the administration of remedies. Two very foolish and unfounded ideas have recently been put for- ward by certain physicians—one being, that medical therapeutics is useless; and the other, that this branch of medical knowledge is not advancing with so great a stride as is pathology or surgery. The individuals who laugh at the general use of drugs in disease belong . to one of two classes : either they have never tried them, or if so have used the drugs ignorantly or wrongly, or else they believe that they are promulgating a new theory, and do not know that the eras of excessive dosage and of nihilism are alike relics of the past. No reform has ever attacked a crying evil without becoming excessive and absurd itself, and if successful in accomplishing its object has generally resulted not in the mere remedy of the faults it antago- nized, but in so complete a reversal of popular opinion as to force its converts into ways as reprehensible as their former habits. Thus, in exactly the same manner that the excesses of Catholicism resulted in fanatical Puritanism, so did the careless methods of physicians during the past century lay the foundation for the growth of homoeopathy or therapeutic nihilism. At the present time, although we have much to learn, it can be said that we have benefited by both of these errors, and are in consequence taking a path which may be considered the happy medium. To the majority of the readers of this book, however, the harmful- ness of ovei'-dosing is sufficiently evident, and the cry of "no drugs at all " so absurd that no rebuttal need be offered. The statement that therapeutics is to-day move backward than are pathology and surgery is readily answered by a denial; for the thera- peutist is able to treat successfully many diseases of which the pathol- ogist knows nothing, and is obliged to rest his treatment on empiri- cism simply because he cannot tell how his drugs act if the pathologist cannot tell him what the disease is. Rheumatism is a good example of this very point. 18 GENERAL THERAPEUTICAL CONSIDERATIONS. In regard to surgery, every <>ne must recognize the extraordinary advances made in this branch of medical science, yet comparatively few realize that it is solely by the introduction of drugs that all its triumphs are posssble. The definition of the word " therapeutics " in Billings's Dictioitar// is: " That branch of medical science which treats of the application of remedies to the cure or alleviation of disease," and, practically, the term is almost universally used to signify the employment of drugs for such purposes. The credit for the intro- duction of new instruments may or may not be accorded to surgerv, but the discovery of new drugs must be accorded to therapeutics. \Ve find, then, that ether and chloroform began to revolutionize surgery fifty years ago, and that corrosive sublimate, carbolic acid, and other drugs have revolutionized it once more within the lifetime of every one who reads this book. Cocaine has changed the entire aspect of eye surgery and other minor operations, and has immediately averted an enormous amount of pain and suffering which the surgeon could not relieve, and certainly could not remove, in the absence of its influence. To the accusation of backwardness the therapeutist can well reply by asking the champion of any other branch of medical science to put forward one discovery which equals antipyrine or ace- tanilide in power to relieve disease or pain, or which can be applied as specifics to so wide a scope of ailments. In the language of one of the most progressive medical men of to-day in the United States, the man who does not believe in the proper use of drugs for the cure of disease must lack the very key- stone of the arch upon which all medical knowledge rests. The ultimate aim and object of all medical thought and effort is the cure or alleviation of disease, and therapeutics is the refined product culled from every department of medical learning. Like every other thing requiring a thorough knowledge of its component parts, it is often much abused by the careless and ignorant, but is a power for good in the trained hand of the properly educated physician. Further than this, therapeutics is the only universally used branch of medicine, for each and every branch must resort to it, and the most skilful operator who fails to treat his cases medicinally with equal skill will have worse results than he who, though bungling in his surgery, yet uses drugs intelligently after his slashing is finished. Homoeopathy depends upon more than one reason for its exist- ence. If infinitesimal doses are given, the patient is satisfied that he is receiving medicine, and Nature often produces her most rapid cures when left alone. Again, the entire basis of homoeopathic thera- peutics rests not upon the study of the causes of diseases, but upon the symptoms which constantlv present themselves. As a result of thus, so many minor symptoms are relieved that the patient's comfort is ensured and doubtless in many instances serious disorders are dis- covered which might otherwise be cast aside or go unseen. No detail should ue too small to attract the attention of the physician, and he who exercises care in detail must reap reward in larger measure. MODES OF ADMINISTERING DRUGS. 19 MODES OP ACTION OP DRUGS. Drugs act in two ways, which are sometimes called near and remote, direct and indirect. The near, or direct, action of a drug is that influence which is felt by the exercise of its effects directly upon the tissues with which it comes in contact; the indirect, or remote, influence is that result which comes as a sequence of its primary effect. As an illustration of this Ave may take the local use of can- tharides. The local, near, or direct effect of this is a blister; the remote or indirect effect is the absorption of exudations or the influ- encing of inflammatory processes. If pilocarpine is used, its direct effect is the sweating which ensues, while its indirect effect is the relief of dropsy through the removal of exudation by the increased action of the skin, salivary glands, and kidneys. MODES OP ADMINISTERING DRUGS. Drugs may be administered for the purpose of affecting the gen- eral system in many ways, but practically we employ only six methods, as follows: 1. By the mouth or stomach; 2. By hypodermic injection ; 3. By inhalation; 4. Bv the rectum ; 5. By inunction; fj. By the endermic method. By far the most usual manner of administering drugs is by way of the month, which is the most natural means of entrance into the body for foreign substances. Whenever medicines are used in this way, the physician should clearly bear in mind what the medicine is to'do after it is swallowed. Thus, if the drug is intended to act directly upon the stomach, it should not be given after meals, but some time before, since the food and gastric juice may afterward so cover the gastric mucous membrane that the medicament cannot act. Thus, in the case of chronic gastric catarrh or gastric ulcer, the nitrate of silver which is used should always be given half an hour or an hour before meals. On the other hand, if an ulcer or other trouble exist in the small intestine, the pill should be given some time after meals, and, if a heavy meal is taken, three or four hours after, since under these circumstances the medicine is swept out into the intestine almost at once, without remaining any time in the stomach, where it may be chemically altered. Very often it is necessary to give a medicine soon after food is taken, in order that it may not act in too powerful or concentrated a manner upon the viscus which The general rule, however, may be laid down that all medicines are to be taken after rather than before meals, unless a local gastric effect or very rapid absorption is desired. 20 GENERAL THERAPEUTICAL CONSIDERATIONS. Next to the use of drugs by the mouth, by far the most popular method is their administration by means of the hypodermic needle and syringe. The logic of this method rests upon the absorption of all soluble substances from the subcutaneous tissues with, great rapidity. Any substance soluble enough or suspendable enough to pass through a hypodermic needle without forming an obstruction may be employed, provided it is not too irritating and that it is " clean." The proper places to give such injections are the forearm on the extensor surface,1 the calf of the leg, the buttock, or the broad of the back—in other words, any spot where the tissues are not dense and unyielding. The skin of the part is to be grasped or pinched up with the thumb and forefinger of the left hand and the needle sent well into this raised fold, preferably above the finger and thumb, so that the pressure of the fingers may prevent pain and the too rapid entrance of the medicine into the system. The needle should always penetrate well into the loose connective tissue, so that the liquid injected may find lodgment in the loose and spongy subcutaneous tissues without separating the skin from its rather close adhesion to the tissues below or from the blood-vessels supplying it, for if suppu- ration occurs abscess and a slough may result. The dangers from hypodermic injections are chiefly two. First: The medicine mav enter a vein, owing to the penetration of its wall by the needle, and the entire dose be carried at once, en masse, to the vital centres. Second: The solution used may not be sterile or the needle may be dirty, and an abscess may result. The first dan- ger is to be avoided by injecting into spots not well supplied with veins, and the second by thoroughly washing both syringe and needle with water the instant before they are used, pushing a fine wire through the needle, and in some cases by soaking the latter in car- bolized oil. The liquid injected may be rendered sterile by using freshly boiled water and adding thereto carbolic acid in such propor- tion that one-half to one drop of carbolic acid is present in each injection. It is claimed by some that this use of carbolic acid seriously hinders absorption, and in cases of urgency it should not be used. Most hypodermic syringes hold from twenty to thirty minims. When drills are given by the rectum, we employ them for three purposes: Fii°st, to influence the general system by their absorption; 'econdly, to act locally upon any disease which may be present in this particular locality or in the colon; and, finally, to dislodge substances or parasites which it is desired to bring away. The word " enema is loosely used to denote all these injections, be their purpose what they mav, and is synonymous with " rectal injection " or the more old-fashioned word' "clyster." If nourishment is being given, the injection is called a "nutrient enema." Sometimes these injections are called "lavements." In this mode of administration it is very necessary that the pnysi- > Hypodermic injections into the anterior aspect of the forearm often cause much pain in the hand by irritating temporarily the branches of the radial or ulnar nerves. MODES OF ADMINISTERING DRUGS. 21 cian should use his medicaments in proper bulk; and it may be laid down as a rule that no more liquid should be injected than is neces- sary to convey the medicine or food, unless the injection is for the purpose of emptying the bowel of fiecal matter or other materials, or it be desired to distend the bowel in order to overcome obstruction, or to influence the colon by drugs, The reason for this lies in the fact that any large bulk of liquid sent into the rectum so stimulates its walls by distention as to cause spasmodic contraction, with expulsion of all the rectal contents, which is just what is needed when fVecal matter is to be removed, but the opposite of what is desired when retention of a remedy or food is necessary for absorption or local action. In rectal catarrh or ulcer two to four ounces of liquid are usually sufficient in an adult to accomplish any medicinal influence locally or by absorption, while as a laxative enema one to two pints may be employed. In the use of injections we frequently find that the rectum becomes irritable, and promptly resists all efforts to force the entrance of liquids or solids. This is to be avoided by giving the injection so gently that the bowel fails to recognize, as it were, the entrance of liquid, and by introducing a few drops of oil and laudanum in each injection. A large amount of distress often follows the gradual accumu- lation of faecal masses in' the colon which are not passed with the daily movement of the lower bowel. These can readily be removed by large injections of warm water or by the use of medi- cated liquids. A very important use of injections by the rectum is in the treat- ment of the various causes of intestinal obstruction. Here the great- est caution should be exercised that the injection be made with all possible gentleness, and slowly, the liquid being allowed to dribble into the bowel rather than to force its way. It is dangerous to use a greater pressure than is given by a fountain syringe at the height of tAvo or three feet, as rupture of the peritoneal coat of the bowel may occur. Where a large quantity of water is used it should be care- fully warmed to 100° or a little more, and it is well to add salt to it, so that it will represent the normal saline strength of blood-serum, namely, seven-tenths of one per cent. (For use of injections in special diseases see Part IV., and for Enteroclysis, Part III.) Suppositories are another means by which we introduce medicines into the bowel, either for local effect or to act after absorption of their contents upon the general system. When drugs are given by inhalation they are generally employed with the object of affecting the respiratory tract alone, although there are notable exceptions to this in ether, chloroform, nitrous oxide gas, and other volatile substances. Aside from anaesthetics, we find such remedial measures 'adopted as the inhaling of steam laden with the drugs employed, the respiring of air loaded with the fumes of the medicament, or the inhalation of gases, and last, and most commonly resorted to of all, the use of the atomizing spray, which, if properly 22 GENERAL THERAPEUTICAL CONSIDERATIONS. made and employed, so minutely divides the liquid containing the medicine that the inspired air carries it to the farthest bronchiole and pulmonary vesicle. As an example of the rules governing the administratien of drugs in this manner we find that compound tincture of benzoin may be taken by inhaling the steam arising from hot water containing it, but can- not be used in a spray because it occludes the fine points of the atom- izing tubes. In a similar manner we may inhale the smoke of bella- donna or tobacco-leaves to relieve asthma, or the fumes of chloride of ammonium for bronchitis in its later stages. Finally, Ave find that oxygen is sometimes very useful, the gas being readily inhaled, Avith good results in proper cases. The " spray " or atomizer is made in tA\o forms—one form of appa- ratus being worked through the agency of compressed air, the other through the escape of steam from a small boiler. Very feAV of the compressed-air atomizers throAV a spray fine enough to reach the deeper parts of the lung, particularly if the air is compressed by the hand. The inhalation of moist air is very useful in bronchitis, and greatly aids other remedial measures. Steam may be disengaged in a room by means of a kettle of boiling water or bj placing pieces of unslaked lime in a pan of Avater. Inunctions consist in the rubbing into the skin of medicines gen- erally of an oily or fatty nature, or Avhich assume this character through embodiment Avith oil or fat. The three substances most com- monly used in this Avay are cod-liver oil, mercurial ointment, and iodine ointment. They should ahvays be applied on some part where the derm is thin and Avell supplied Avith subcutaneous lymphatics, as in the axillae, the groins, or the insides of the thighs. Other sub- stances have been and may be used by inunction; but as this method is necessarily a disagreeable and dirty one, it is rarely resorted to unless the stomach is disordered or it is necessary to push the drug into the system by every possible avenue of entrance. The endermic method consists in the use of a blister, by means of which the epiderm is raised, when a little morphine or other alkaloid may be slipped under it and so absorbed through the true skin. It is a painful method, almost never to be resorted to, which has been entirely supplanted by the hypodermic method of medication. Remedies are administered in a number of forms, but chiefly as follows : Abstracts are dry powdered extracts mixed Avith sugar of milk until they are tAvice as strong as the crude drug. Abstracts are no longer official in the United States Pharmacopoeia. Aceta, or vinegars, are solutions of drugs in vinegar or acetic acid. There are tAvo in the United States Pharmacopoeia (Acetum Opii and Acetum Scillse) and three in the British. Alkaloids are organic bases, generally occurring in crystalline MODES OF ADMINISTERING DRUGS. 23 form and abstracted from crude drugs. They nearly ahvays repre- sent the active principle of the drug. Aouje, or Avaters, are used as vehicles either for the dilution of strong medicines or for the purpose of carrying minute amounts of flavoring materials. Cataplasms are not official in the United States Pharmacopoeia, but are in the British Pharmacopoeia. They are virtually poultices made of linseed-meal or of bread-crumbs. Cerates are ointments containing wax to render them harder than Avould ordinary fats. Chart.e. or papers, consist of bibulous paper soaked in a solution of the drug Avhich they are meant to carry. Confections are sometimes called electuaries or conserves, and are soft pastes Avhich contain the drug mixed Avith sugar or honey. Decoctioxs are solutions of drugs made by boiling and then strain- ing Avhile hot. Elixirs are diluted tinctures rendered pleasant to the taste by the addition of aromatic substances and sugar. Emplastra, or plasters, are made up of adhesive substances placed upon a backing of cloth or leather and designed to adhere to the skin, being so applied for the purpose of holding a medicinal substance in contact Avith the body, of acting as a protective, or of aiding in the approximation of the edges of a wound. Extracts consist of the soluble parts of plants reduced to a semi- solid or solid condition by evapoi-ation; the soluble constituents being taken from the plant by Avater or alcohol. Fluid Extracts are made in the same way as solid extracts, except that they are not so completely evaporated. Glycerita, or glycerins, are solutions of various substances in glycerin—the glycerin being used as a vehicle. Ixfusioxs are made by pouring boiling Avater on the crude drug and alloAving it to stand for a short time until the water cools, after Avhich the liquid is strained. Sometimes cold Avater is employed. Pills are small round masses Avhich, as a general rule, should not weigh more than three grains, in order to avoid their being too bulky. If the material is a heavy one, as much as five grains may be placed in each pill. Pills may be uncovered or coated Avith sugar or gelatin. If the pill is fresh and" the sugar pure, they are useful. Many pills are fraudulently coated with varnish and are insoluble. St'ppositories are small masses made into a cone shape and having for their basis cacao butter. They are designed to carry into the rectum certain medicines for absorption into the system or for local action. Tablets.—Under this name manufacturing pharmacists and others prepare compressed pills or lozenges, generally of small size, the mass being made to adhere by means of its being subjected to great pres- sure by special machinery. Smaller tablets are used for carrying poAverful drugs for hypodermic use. These, however, are often only lightly pressed, so as to render them easily soluble. Tinctures are solutions of the active principles of drugs in alcohol. 2-1 GENERAL THERAPEUTICAL CONSIDERATIONS. Triturates are made by adding 10 per cent, of the active medi- cine to 00 per cent, of milk-sugar. These are then carefully rubbed together until the tAvo are intimately mixed, and are very valuable in the administration of medicines to adults or to children. Troches, or lozenges, are flat, hardened masses designed for hold- ing medicines in the mouth, so that they may be slowly dissolved, thereby affecting the local mucous membrane Oixtmexts, or unguents, consist of the mixture of some kind of fatty substance Avith the medicine Avhich they are designed to carry. Wixes are made in the same Avay as tinctures—strong Avhite wine being used in the United States, and sherry or orange Avine in Great Britain, in place of ordinary alcohol. DOSAGE. There is, unfortunately, no absolutely fixed rule which can be applied to dosage, for several reasons. In the first place, the indi- vidual may not be readily affected by drugs, or the disease-process Avhich is present may so antagonize them as to render very large doses necessary. Further than this, the age and sex of a patient have much to do Avith the regulation of the proper amount of a drug Avhich Ave may give. Finally, that curious but common condition of suscep- tibility to various remedies, that we call idiosyncrasy, creeps in as an important factor in the decision as to the dose which should be given in each case. By far the nearest approach which Ave can make to absolute accuracy in dosage is to use drugs according to the weight of the patient, but this method possesses the disadvantages that Ave can- not ahvays Aveigh our patients, and that the presence of a lai-ge amount of fat or of dropsy will make an unknoAvn quantity in our calculation as to the true Aveight of the active part of the individual. At present Ave are accustomed to be governed by a list of doses to be given to all adults Avithin certain limitations, and Avhich are varied sufficiently to permit of great differences in the effects obtained. It is in this very point that the success of many a physician chiefly rests; for the use of a dose by " rule of thumb " is as empirical and lacking in thought as is use of a remedy, not because avc have a defi- nite action for it to carry out, but because it did some one else good A\ho Avas suffering from what appears to have been a similar attack. The dose must be varied to fit the case in the same manner that the cut of a coat must be varied to fit each individual. There are a number of approximate rules in regard to the doses Avhich are to be given in treating the diseases of children, the best of which is Young's rule. This is as folloAvs: Add 12 to the age and divide by the age. Thus, if a child is two years old, Ave have the folloAving formula: 2 + 12 = 1-1 -r- 2 = 7, or one-seventh of the dose for an adult is the dose for a child of tAvo years. This rule is not a law, hoAvever, for of narcotics children receive less than this (one-half), and of purgatives or laxatives more than this (tAvo or three times). IDIOSYNCRASY. 25 When drugs are given hypodermically the dose should be generally one-half to one-quarter of that given by the mouth, and if any thought of idiosyncrasy exist the dose shouldbe smaller still at the start if poAverful remedies are to be used, By the rectum the dose should be tAvice the amount given by the mouth, unless the drug be very poAverful or capable of very rapid absorption. IDIOSYNCRASY. This is one of the most interesting features of the study of the action of drugs. It is a frequent cause of disappointment to both patient and doctor, and an equally frequent cause of excessive action from Avhat the physician has thought to be a moderate dose. No rule can be laid down for the discovery of idiosyncrasy in a given case, except that females, particularly of the hysterical type, are more subject to it than are males, although certain men often present marked evidences of this tendency. No better illustration of idiosyncrasy can be adduced than the case which here folloAvs, nor than that of a friend of the author Avho cannot eat a strawberry Avithout suffering from a violent attack of hives. The first case is that of a Avoman of thirty years, suffering from severe headache, Avho received an eighth of a grain of the hydro- chlorate of pilocarpine, hypodermically, every tAventy minutes, until nearly three-fourths of a grain Avas taken, Avithout any evidence of its action either in salivary Aoav or SAveat. But the tolerance of drugs did not stop here. TAventy drops of tincture of cannabis indica every four hours failing to relieve the pain, half-grain pills of the solid extract Avere ordered, tAvo of which commonly affect a grown man most markedly. The extract had been proved to be active to other patients. In order to avoid any failure in absorption the pills Avere each cut in half before they Avere given, and fortlnvith administered, one every three hours, without any effect after ten had been taken. TAventy more of the pills from the same manufacturers, but from a different retailer, Avere now given, one every hour with the exception of a few irregularities in administration during the night, the entire twenty beino- swalloAved betAveen four o'clock one afternoon and two o'clock in the next afternoon. The thirty pills (fifteen grains) Avere taken in less than forty-eight hours without producing a single physio- loo-ical sign of the slightest character. That the doses Avere really SAvalloAved Avould seem to be undoubted, for their administration was carried out by a trained attendant, and their black color forbade their expulsion from the mouth on the bed Avithout attracting attention. The hypodermic injections Avere given by the author, and, as the solu- tion was used as fast as it was made, the patient must certainly have received all of the pilocarpine. As there Avas daily an afternoon rise of temperature amounting to several degrees, quinine bisulphate was ordered in the dose of fifteen grains, to be given after six poAvders of one-sixth of a grain of calomel had been taken ; this not only failed to control the fever, but also 26 GENERAL THERAPEUTICAL CONSIDERATIONS. produced no buzzing in the ears. The Avriter was noAv inclined to consider all the symptoms as hysterical, even including the evening rise of temperature. Twenty-four hours after the last dose of cannabis indica the attend- ant gave the patient, without orders, no less than sixty grains of anti- pyrine in sixteen hours without any physiological symptoms, and, under orders, she took from forty to fifty grains of bisulphate of quinine every day for three days without any signs of cinchonism. Wide experience has taught us, hoAvever, that several conditions act fairly constantly in regard to some idiosyncrasies. Certain dis- eased conditions—such as peritonitis or pain—allow large doses of opium to be given, and in lead-poisoning and paralysis patients may require enormous doses of active purgatives to move the bowels. The climate in Avhich the patient lives, or has been accustomed to live, renders him more or less susceptible to certain remedies. Thus the East Indian runs amuck after eating hasheesh or cannabis indica. or the Chinaman goes into a delightful dreamland from smoking opium, Avhereas the Anglo-Saxon experiences no such agreeable sen- sations, as a general rule. Southerners generally require larger doses of purgatives than Northerners, often because their livers are not as active. The temperament of an individual is also a highly important matter to be considered. It is a notorious fact that phlegmatic dark-skinned persons usually yield to drugs less readily than blonds and nervous persons, more especially in respect to the drugs Avhich act on the ner- vous system. Nervous light-haired Avomen stand belladonna very badly as a general rule, Avhile children Avill take large doses often Avithout discomfort. Opium is usually badly borne by children. Habit is another important factor governing idiosyncrasy. We all knoAv hoAv rapidly one becomes accustomed to tobacco, and how mor- phine habitues take enormous amounts of their favorite drug Avithout effect. ABSORPTION OP DRUGS. The knoAvledge of the rapidity with which certain drugs are absorbed from the various surfaces with Avhich they come in contact is of importance in order that Ave may knoAv Avhen to repeat the dose if the firsf amount does not produce the desired effect. The rapidity of absorption depends upon a number of factors. If the circulation is active, absorption is active, but if it be depressed, absorption is slow. Thus, in a person apparently drowned, absorption may not occur at all until the vital functions are restored, and repeated doses given to the patient Avhile unconscious, acting together, in the end poison him. This is often the case in delirium tremens where hypodermic injec- tions of morphine are given or Avhen the drug is administered bv the mouth. In dropsy absorption is peculiarly sIoav, and the dru'o- may remain in the tissues for days, only to be absorbed Avith the exu- dation after severe purgation or profuse diuresis, or tapping In STRENGTH AND RELIABILITY OF DRUGS. 27 general dropsies hypodermic medication is nearly always worse than useless. When the stomach or bowel is empty absorption from either is rapid, but when they are full it is very slow. In this fact we find the reason for the popular idea that a glass of whiskey when a man is hungry makes him drunk, whereas twice the quantity after dinner does not do so. Drugs in the stomach or boAvel have no influence over the general system unless they are irritants. They only act Avhen taken into the blood or lymphatics. Recent studies sIioav that alcoholic solutions of drugs are more rapidly absorbed than are watery solutions or those made Avith gly- cerin or milk. DURATION OF ACTION OP DRUGS. The duration of the action of drugs depends partly upon their rapidity of absorption, but chiefly upon the rapidity or sknvness of their destruction in the body or their elimination from it. Thus, volatile substances, such as ether, chloroform, and nitrite of amy], act only for a short time and are quickly eliminated, whereas bromide of potassium and digitalis continue active during many hours, and are slowly eliminated, as in the case of the former, or oxidized, as in that of the latter. Again, if curare is given hypodermically it Avill cause paralysis, but if taken by the stomach in moderate amount it Avill be eliminated by the kidneys as rapidiy as it is absorbed, and produce no effects if these organs are active. From studying the rapidity of the elimination of a drug Ave learn how often to order a dose. Thus, digitalis may be given once, tAvice, or thrice a day, but carbonate of ammonium every tAvo or three hours. When the physician is not careful in the use of a drug Avhich is eliminated sIoavIv, it may suddenly develop so severe an effect as to cause alarm, OAving to the accumulation of the poison in the body. This is called "cumulative action." STRENGTH AND RELIABILITY OF DRUGS. If a census could be made of those Avho die annually from the use of drugs Avhich are impure or useless from Aveakness, the Avriter believes that a most alarming array of figures Avould be presented. For many years this Avas unavoidable to a great degree, either because our knoAAledge of the active principles of drugs and the methods of isolating them Avas deficient, or because the time consumed in their transportation by sailing vessels or on the backs of natives from the countries in Avhich the natural products yielding the drugs Avere obtained, permitted deterioration to take place. At present these difficulties have been largely overcome. The trained pharmacist is taught how to make an essay for active principles in most of the valu- able alkaloidal drugs, and every physician should make careful inves- 28 GENERAL THERAPEUTICAL CONSIDERATIONS. tigation into the quality of all preparations Avhich he employs. That these remarks are not out of place will be seen by the fact that very recently an intimate friend of the Avriter bought from five of the lead- ing druggists of Philadelphia six ounces of tincture of nux vomica Avhich Avere stated to have been made according to the directions of the United States Pharmacopoeia. That made by perhaps the leading druggist of the five contained twice as much strychnine and brucine as it should, and had tAvice as much solid residue; or, in other words, a physician prescribing this tincture in full dose Avould probably have poisoned his patient and reported the case as one of unusual suscepti- bility to drugs ! On the other hand, the author has recently seen a tincture of nux vomica Avhich contained only a trace of alkaloid, but had much inert solid residue. In neither instance was the druggist a dishonest one intentionally, but one had used a crude drug Avhich was unusually rich in alkaloids, Avhile the other had purchased nux vomica beans Avhich, by reason of immaturity, bad surroundings, or exposure to weather, were very poor in active principles. All these disadvantages may be avoided if physicians will insist that the drug- gists Avho dispense the drugs they order shall either themselves pre- pare assayed products, or purchase such products from any one of the large manufacturing chemists Avho put assayed goods on the market. When this is impossible, the physician should employ the alkaloids in pill form, or, if solutions are desirable, the alkaloid may be added to alcohol and Avater and given by drops, as is the case Avith any ordi- nary tincture. Digitalis and veratrum viride are practically the only drugs Avith Avhich this cannot be done; in the first the action of the drug does not depend upon a single active principle, but upon a large number, and in the second the relative proportions of jervine and veratroidine cannot be Avell estimated by the physician. H. C. Wood records a case in Avhich opium poisoning occurred in a child Avho had taken a Dover's powder; the reason being that the amount of opium intended for many doses Avas in the poAvder that Avas dispensed, the other constituents not having been properly mixed with the opiate in compounding the prescription. Constant uncertainty is a dangerous element Avhen Ave are dealing Avith patients Avho are desperately ill; and in many cases failure and discouragement may both be avoided if the physician will see to it that the tools Avith which he Avorks are in good order and capable of doing Avhat he requires of them. A poor drug to the physician is worse than a rusty knife to the surgeon • for the injury in the one case is unknoAvn, Avhilst in the other it can be carefully watched and guarded. INDICATIONS AND CONTRAINDICATIONS AND DEFINITIONS. The indication for a drug is any symptom or series of symptoms Avhich Ave knoAv the drug will relieve without causing at the same time an evil effect to be felt by other parts of the body. A contra- indication is any coexisting state or tendency which will be made so INDICATIONS, CONTRAINDICATIONS, AND DEFINITIONS. 29 much, worse by the drug as to forbid its use. Thus, one might be tempted to give quinine in meningitis for the fever, yet this Avould be bad therapeutics, since quinine is contraindicated because it will intensify the meningitis. Abortifacients form a class of drugs Avhich, as such, ought never to be employed. If pregnancy is to be interrupted, the interruption should be produced by instrumental means, and then only after consultation. Alteratives are indicated Avhere cell-groAvth is active to excess, but contraindicated Avhere tissue break-down is present, or there exists a tendency thereto. Aniesthetics are drugs used to produce lack of sensation. They are either local or general. Many of the local anaesthetics produce loss of sensation through benumbing the parts by the cold they pro- duce. Cocaine is an example of a local anaesthetic Avhich causes anaesthesia by a direct paralyzant action on the peripheral sensory nerves. An aphrodisiacs are remedies used to diminish sexual desire. Antacids are employed in cases of gastric fermentation Avhen, as a result of the morbid processes, lactic and butyric acids, or even hydrochloric acid, are found in abnormal quantities. Anthelmintics are those remedies which are used for the purpose of removing intestinal Avorms. Antiarthritics is the name given those drugs Avhich are employed for the purpose of relieving inflammations occurring in joints, Avhether these be in an acute or chronic condition of disease. Colchicum, Avhich is one of this classs, is contraindicated, as a rule, in cases of gouty inflammations of the joints if the bowels are already moving too freely, as, under these circumstances, retrocedent gout is apt to occur. Antihydrotics are used to prevent excessive sweating, either when it is local or general. Camphoric acid is probably the best general antihydrotic. Ant/'period ics is a term applied to drugs or remedies employed for the prevention or cure of malarial poisoning. They are so named because they tend to break up the periodicity of the attacks, Avhich periodicity is a characteristic of such diseases. Antiphlogistics are remedies employed to prevent the progress of inflammatory processes. They are nearly all contraindicated in the presence of tissues possessing an impaired vitality through previous conditions of disease. Aphrodisiacs are remedies used to increase sexual desire and poAver. Astringents are employed for the purpose of contracting or con- stringing tissues. They act not by coagulation of albumin, but by their influence over the vital processes of the tissues with Avhich they come in contact. Theoretically, all astringents should be non-irri- tating, but practically they possess irritant properties, and are, in con sequence, contraindicated in the presence of very acute inflamma- tions as a rule. Three of the mineral astringents, however, possess 30 GENERAL THERAPEUTICAL CONSIDERATIONS. marked sedative properties in addition to their astringent power, and can therefore be used freely in acute inflammations Avhen locally applied. They are nitrate of silver, subacetate or acetate of lead, and the subcarbonate or subnitrate of bismuth. Bitters are remedies designed to increase the activity of the mucous membrane of the gastro-intestinal canal by increasing its tone. They may be divided into simple bitters and complex bitters. The first depend upon their bitterness solely for their activity; the second class is Avell represented by quinine or strychnine, both of Avhich are exceedingly bitter, but, in addition to their local effect on the gastro-intestinal mucous membrane, act as stimulants to other por- tions of the organism. A good example of a simple bitter is columbo. Many bitters contain so much tannic acid that they are not generally useful, and for this reason very feAv can be used Avith preparations of iron, since a tannate of iron Avould be formed. Cardiac sedatives are drugs Avhich decrease the force of the heart, and, as a class, the amount of blood expelled at each beat of the ven- tricles. They are indicated in arterial excitement, contraindicated in arterial depression. Cardiac stimulants are drugs which increase the force of the heart, thereby increasing the quantity of blood expelled from the ventricles. This may be accomplished by an increase in the rapidity of the beats or by a greater output of blood at each contraction, the diastole being sufficiently prolonged to admit of the ventricles being well filled. They are contraindicated in the presence of arterial excitement, and indicated in arterial depression. Carminatives are remedies given for the purpose of expelling flatus, particularly if there is reason to believe that the " Avind " has accu- mulated because of intestinal torpidity. Many of the carminatives are necessarily possessed of irritant properties, and are therefore con- traindicated in the presence of flatulence due to intestinal atony aris- ing from inflammation. The best carminative is spiritus aetheris com- positus, or Hoffmann's Anodyne. Cathartics.—These are drugs employed when a positive and decided action of the boAvels is desired. They occupy a position betAveen the purges and the drastics. (See Purges and Drastics.) The best example of a cathartic is probably jalap. Cholagogues are used Avhen it is desired to exert a stimulant influ- ence over the flow of bile, Avithout necessarily increasing intestinal peristalsis. Nitro-hydrochloric acid is, perhaps, the best type of a pure cholagogue, while podophyllum represents the class of chola- gogues which increase intestinal peristalsis in addition. Cholagogues are contraindicated in the presence of acute inflammation of the gall- bladder or liver. Counter-irritants are remedies used to produce irritation at a spot distant from a painful or inflamed area, in order to relieve the diseased parts by reflex action exerted through the nervous system upon the painful nerve or disordered capillary netAvork. Domdcents are substances used to protect any exposed parts of the body from irritation. INDICATIONS, CONTRAINDICATIONS, AND DEFINITIONS. 31 .Diaphoretics produce an increased secretion from the SAveat-glands. They may be considered as internal and external. The internal are represented by pilocarpine, Avhich stimulates the SAveat-glands them- selves ; the external are represented by the Turkish and Russian baths, which, by increasing bodily heat, cause a profuse SAveat by reflex action. Diuretics are used to increase the flow of urine from the kidneys. They act by stimulating the renal epithelium to greater activity, thereby increasing the excretion of both the Avatery and solid con- stituents of the urine ; or they simply increase the Avatery constituents by increased blood-pressure in the kidney. It is to be remembered that the vegetable salts of potassium and the lithium salts increase the solids in the urine, not by stimulating the secreting epithelium of the kidney, but by uniting Avith insoluble material in the system, forming soluble compounds which are then readily eliminated. (See Eliminators.) They are indicated in con- ditions of renal inactivity due either to functional or organic causes. Irritating diuretics, such as cantharides, for example, are contraindi- cated in acute nephritis. Such a diuretic is only to be used Avhere the kidneys are inactive through atony or prolonged chronic or sub- acute disease. Eliminators are drugs which, by forming soluble compounds with insoluble substances in the body, render them capable of being ex- creted by the excretory organs, such as the skin, kidneys, and boWels. Emetics are drugs used to produce vomiting. They act centrally Avhen, as is the case Avith apomorphine, they stimulate the vomiting centre, peripherally Avhen they irritate the Avails of the stomach. They are indicated when Ave wish to unload the stomach of unde- sirable materials, or when Ave desire to cause an increased Aoav of bile from the gall-bladder, which is accomplished by the pressure exerted upon this viscus Avhen the abdominal Avails and diaphragm contract in retching. When the ducts are mechanically obstructed by a gall-stone emetics are dangerous, as they may cause rupture of the gall-bladder. Sometimes Ave are able by the use of emetics to rid the lungs and stomach of mucus in bronchitis or gastric catarrh. The contraindications to emetics are cerebral congestion or menin- gitis, gastritis, gastric ulcer, advanced pregnancy, and hernia. Emmenaqoques are remedies used to produce or increase the men- strual flow. * Thev are of two classes—direct and indirect. The direct are all of them irritants, and are seldom of much value; the indirect are used to overcome the morbid condition underlying the menstrual disorder, and are therefore more rational. Thus iron and arsenic may be used in amenorrhcea due to anaemia with beneficial result. Expectorants are employed when it is desirable to promote secretion or to get rid of secretion in the bronchial tubes. Thus, in the early stacres of an acute bronchitis the mucous membrane is hyperaemiC and swollen, but dry and irritable. Ipecac and citrate of potassium form at this time a sedative expectorant mixture, which, while allay- ing irritation, promotes secretion, and so relieves the engorged area. 32 GENERAL THERAPEUTICAL CONSIDERATIONS. On the other hand, after the acute stage is passed, there may be so much atony of the mucous glands that the secretion is either too scanty or too viscid to be coughed up. Stimulant expectorants, such as chloride of ammonium, eucalyptus, and terebene, are noAV to be employed. These latter drugs are contraindicated in the acute inflam- matory stage of the disease, as they would simply stimulate the irri- tated mucous membrane to greater irritation. Hypnotics are drugs used to produce sleep. They may be divided into those which produce sleep and relieve pain, and those Avhich have no analgesic power. The latter are therefore not to be employed in ' sleeplessness due to pain, and the former are contraindicated Avhen pain is absent. Thus, chloral produces sleep if it be ordinary func- tional insomnia; but if the sleeplessness is due to pain, opium is the drug to be employed. Chloral, in ordinary doses, is the purest hyp- notic that we have. Mydriatics are drugs Avhich produce dilatation of the pupil or mydriasis. Conditions of the eye associated with increased intra- ocular tension are contraindications to mydriatics, as a rule. Myotics are drugs Avhich cause contraction of the pupil or myosis. They are best represented by eserine. Nervous sedatives are indicated and contraindicated in a reverse manner to nervous stimulants. Nervous stimulants are contraindicated in nervous excitement, indi- cated in nervous depression. Oxytoxics are drugs Avhich increase the expulsive poAver of the uterine muscular tissues. Revulsives are remedies used to produce increased activity of the general system or parts thereof through reflex influences—that is, they cause a determination of blood to one part, thereby relieving an engorged area. Thus, in cerebral congestion or effusion a vigorous purgative or cathartic may give relief by exercising a derivative effect. Revulsives are closely allied to counter-irritants. Roborants are drugs or measures devoted to the repair and build- ing up of tissues in the body, and comprise both foods and drugs. Roborant treatment also includes hygienic surroundings, fresh air, light and healthful employment. Tonics are used to increase vital activity. They are indicated in instances of local or general systemic depression, contraindicated in cases of inflammation or excitation Avith excessive functional activity. (See Bitters.) Vasomotor depressants are drugs Avhich decrease arterial pressure by an action on the vasomotor nervous system rather than by an action on the heart. They act by relaxing the blood-vessels. Vasomotor stimulants are drugs Avhich increase arterial pressure by an action oh the vasomotor system, thereby producing contraction of the blood-vessels. IN COM PA TIBILITY. 33 COMBINATION OF DRUGS FOR JOINT EFFECT. The study of the physiological action of drugs has. aided us very greatly in improving our therapeutic measures. Thus, Ave noAV know that chloral is a heart-depressant and cannot be used in very full doses, or pushed to produce sleep in persistent insomnia, Avithout grave danger ; Avhereas morphine, which also produces sleep, but does not depress the heart, but does depress the respiration, can be com- bined Avith it, and the two acting together, each in small dose, pro- duce a heavy sleep, although so little chloral is present that the heart is safe, and so small an amount of morphine is used that the respira- tion does not suffer. Another example of this is found in certain purgative pills Avhere the purgative agent is assisted by belladonna and nux vomica, the first of Avhich relaxes muscular spasm, Avhile the second acts as a tonic to the alimentary tract, the drugs combining to accomplish one result. Skill in the combination of drugs, not only for increased physio- logical effect, but also for the purpose of making their administration pleasant to the taste, has much more to do Avith professional success than is generally supposed. This is particularly so in regard to children, for parents dislike forcing their children to take doses Avhich they themselves regard as horrible, and they are ever ready to believe that as long as a medicine tastes good it is better than one Avhich tastes otherAvise. The medical practitioner who prescribes ever so wisely and appro- priately for a patient, but who is utterly regardless as to his combina- tions of drugs so far as taste is concerned, Avill sooner or later see a more ignorant man take from him that practice which his greater Avisdom entitles him to, but Avhich is driven from him by his 0A\n errors in this matter. While in some cases there is no alternative but to give a bad dose, in others a little thought and care will often avoid offending the taste of the patient. INCOMPATIBILITY. The chief value of a knowledge of chemistry or pharmacy to a practitioner of medicine is the avoidance of what is knoAvn as an " incompatibility," or the placing in one prescription of tAvo or more substances Avhich will undergo chemical interchanges, decompositions, precipitations, or cause the formation of explosive mixtures. It is impossible to detail all the incompatibilities, and only the most dan- gerous and common possibilities of error can be considered: 1st. An acid should never be combined Avith an alkali. 2d. An acid should not be added in any quantity to a tincture. The following prescription is an illustration of this : R.—Potassii iodidi................3l3/ Acidi nitro-muriatici.............£5]:. Tr. cinchonse comp............jharotics are grouped a number of substances capa- ble of acting as destructive agents upon the soft tissues of the body. They are— 1. Chromic acid. 2. Nitric acid. 3. Sulphuric acid. 4. Nitrate of mercury (solution). 5. Bromine. 6. Caustic potash. 7. Caustic soda. 8. Arsenious acid. 9. Chloride of zinc. 10. Vienna paste. 11. Canquoin's paste. XIII. Diaphoretics. The only ones that we know as direct stimulants to the glands are— 1. Pilocarpus or jaborandi. 2. Warburg's tincture. The others are— 3. Hot dry and hot moist baths. 4. Dover's powder. 5. Alcohol (particularly when hot). (5. Nitrous ether. XIV. DlGESTANTS. 1. Pancreatin. 2. Pepsin. 3. Hydrochloric acid. 4. Papain. 5. Diastase. XV. Disinfectants. 1. Corrosive sublimate. 2. Chlorine or chlorinated lime. 3. Carbolic acid. 4. Chloride of zinc. CLASSIFICATION OF DRUGS. 37 XVI. Diuretics. Those that increase both the solids and liquid constituents are probably— 1. Caffeine. 2. Squill. 3. Cantharides. 4. Buchu. 5. Blatta. ti. Juniper. 7. Turpentine. 8. Uva ursi. 9. Chiinaphila. 10. Cubebs. 11. Pareira brava. Those which increase the watery con- stituents of the urine without in- creasing the solids proportionately are — 1. Digitalis. 2. Vegetable salts of potassium. 3. Nitrous ether. 4. Lithium. XVII. Eliminatives. 1. The iodides. 2. The salicylates. 3. The vegetable salts of potassium. 4. The lithium salts. 5. Jaborandi. 6. Colchicum (probably). XVIII. Emmenagogues. The direct emmenagogues are— 1. Apiol. 2. Binoxide of manganese. 3. Permanganate of potassium. 4. Cantharides. 5. Aloes. 6. Myrrh. 7. Kue. 8. Savine. 9. Tansy. 10. Pennyroyal. 11. '. P., is a neutral Avhite salt of saline taste, readily deliquescent and soluble in water. It Avas at one time very largely used in the treatment of rheumatism in the "alkaline method," as Avhen it enters the blood it is changed into an alkaline carbonate. It has, however, been supplanted by the salicylates in the treatment of most cases of rheumatism. The dose should be from 1 to 2 ounces (32.0-04.0) a day. A combination of 10 grains 44 DRUGS. (0.65) of the iodide of potassium and 30 grains (2.0) of the acetate is useful in rheumatism in some instances. In hepatic torpor acetate of potassium is exceedingly useful, and aids in promoting the Aoav of bile as Avell as that of the urine. It has been used in the treatment of the uric-acid diathesis, and acts powerfully in rendering an acid urine alkaline. At one time it Avas supposed to purify the blood by aiding in the oxidation of effete material. The dose of potassii acetas is from 20 grains to 2 ounces (1.3-64.0), but the latter dose is only employed when a purgative effect is desired. ACETATE OF ZINC. Zinci Acetas, U. S. and B. P., occurs in the form of Avhite mica- ceous crystals, Avhich are efflorescent and quite soluble in Avater. It acts as a decided astringent to the skin and mucous membranes, but is less astringent than the sulphate of zinc. It is used as a collyrium in eye diseases, such as conjunctivitis, in the strength of 1 to 2 grains (0.05-0.1) to the ounce (30.0). In gonorrhoea it is often employed instead of the acetate of lead in injections of the strength of 1 to 20 grains (0.05-1.3) to the ounce (32.0) of rose-Avater. The treatment of poisoning by acetate of zinc is that adapted to gastro-enteritis. (See Gastro-enteritis, Part IV.) ACETIC ACID. Acidum Aceticum, U. S. and B. P., as used in medicine, is a clear liquid made up of 36 per cent, of acetic acid and 64 per cent. of water, and has a sweetish odor. It is obtained from Avood by destructive distillation. Acetum, or Vinegar, is practically a dilute acetic acid. Therapeutics.—Acetic acid is seldom used internally, except in combination with potassium or sodium. As a poAverful escharotic the glacial or absolute acetic acid (Acidum Aceticum Glaciate, U. S. and B. P.) is used. It can be applied to warts and other growths, and to old sores Avhere the granulations are profuse and slow to heal. The dilute acid (Acidum Aceticum Dilution, U. S. and B. P.) is used as a lotion in night-sweats and to arrest epistaxis and other small haem- orrhages. As a lotion to be Avidely employed it should be diluted one-half. Vinegar, or dilute acetic acid, has been used internally for the decrease of obesity, but is a harmful and useless remedy, dis- ordering digestion and reducing the patient's strength. In the folloAving mixture acetic acid has been used Avith success for the removal of vegetations about the external genitals: R.—Acid, salicylic.............gr. xxx (2.0). Acid, acetic............f^j (32.0).—M. S.—Apply with a camel's-hair brush. Very little pain is caused by this application. ACONITE. 45 Poisoning.—When over-doses of acetic acid are taken the treat- ment consists in the use of large doses of milk, alkaline liquids, such as lime-water, soap-water, etc., and the general measures adopted for the treatment of gastro-enteritis. (See Gastro-enteritis, Part IV.) Contraindications.—Nursing mothers should not take freely of vinegar, as it may produce a troublesome diarrhoea in the nursling. ACONITE, or MONKSHOOD. The aconite of the U. S. P. is derived entirely from the tuberous root of Aconitum Napellus. At one time the leaves Avere official, but are so no longer, and for this reason the term " radix " is not to be employed, as it is a useless distinction. Aconite is indigenous in Germany, France, and Switzerland, and is cultivated as a garden-plant all over Europe and America. The root is so strikingly like that of horseradish as to be readily confused Avith that article of food, but does not emit the pungent fumes of the latter Avhen it is scraped or broken. It is to be remembered, hoAV- ever, that it produces a distinct feeling of heat in the mouth Avhen cheAved. The active principle upon Avhich the therapeutical value of aconite Avould appear to depend is aconitine, but there is reasonable doubt whether this can be relied upon as completely as the fluid preparations of the crude drug; the aconitine of commerce, more- over, varies very much in strength, because some of it is amorphous and impure, while other samples are very pure and crystalline. Fur- ther than this, even the crystalline form is exceedingly variable. In addition to aconitine, Dunstan asserts that there are tAvo amorphous alkaloids — namely, aconine and napelline—and this investigator believes that there is a fourth alkaloid closely allied to napelline. Physiological Action.—Nervous System.—Aconite in full medi- cinal dose depresses the functional activity of the perceptiA'e centres in the brain, the sensory side of the spinal cord, and, finally, the peripheral ends of the sensory nerves. Applied to a mucous mem- brane, it acts as a local anaesthetic, but is too irritating for use in the eye. On the motor portion of the body it exerts little influence unless given in large poisonous doses, Avhen it paralyzes the motor tract of the spinal cord and the peripheral motor nerves. Circulatory System.—On the heart aconite acts, Avhen given in moderate doses, as a quieter of its moArements and force, and loAvers blood-pressure and pulse-rate by a direct action on the heart-muscle. There is no good experimental evidence of its possessing any direct influence on the vasomotor system, but clinically it seems to possess this poAver. In poisonous dose it causes first a very marked fall in pulse-rate, preceded sometimes by a quickening due to a condition of weakness and abortive cardiac action : this condition gradually passes into diastolic arrest of the heart-beat, the viscus becoming paralyzed and refusing to respond to stimuli. Respiration.—In moderate doses aconite quiets the respiratory movements slightly, particularly if the breathing is hurried before 46 DRUGS. its use. In poisonous doses it paralyzes the respiratory centres, and so causes death. Temperature.—Aconite acts as a distinct reducer of fever, prob- ably because of increased heat-radiation arising from relaxation of the capillaries and impaired circulation. Kidneys.—In fever aconite usually increases the urinary flow. Poisoning.—When aconite is taken internally in excessive amount it causes tingling of the mucous membranes A\'herever it touches them, which sensation finally amounts to severe burning. This soon passes aAvay, and is followed by a sense of tingling about the lips and finger- tips or all over the skin. At the same time the patient feels relaxed ; the pulse at first becomes slow and Aveaker, but later on rapid and running, so that it seems a mere trickle under the finger; sweating more or less severe is present, and fainting may ensue. Vomiting may occur, but is rare. The respirations noAV become sIoav and shal- Ioav, seeming to expand the lung in the smallest possible degree. The face is pallid and anxious. There may be exophthalmus, or the eyes may be sunken and dull. There is excessive pallor. Epilepti- form convulsions may be present, due to disorder of the circulation at the base of the brain. Previous to this there may be marked anaesthesia of the skin. The pupils may be normal, or dilated to a wide degree. The sclerotic coat of the eye is pale and pearly-look- ing. The temperature is very low. Death may be gradual or sud- den, the slightest movement of the body which can throw any strain on the heart stopping that organ in diastole. Treatment of Poisoning.—The patient is to be placed in a prone position or on a board, with the feet higher than the head, in order to confine the circulation as far as possible to the vital centres at the base of the brain. Hot bottles or bricks are to be placed about the body for the purpose of maintaining the bodily heat. Emetics are not to be given if the symptoms are severe, as vomiting may cause cardiac arrest owing to the muscular effort involved, or the stomach may be so depressed that the emetics will not act. If vom- iting comes on, let it be into a towel without the patient being allowed to raise the head. The stomach is to be washed out by means of a stomach-pump or a siphon made of rubber tubing. Ether may be given hypodermically, and followed by alcohol, and this again by digitalis. The ether acts at once, and iasts while the alcohol is being absorbed, and the alcohol supports the heart until the digitalis, Avhich is the physiological antagonist of aconite, but slow and prolonged in its effects, asserts itself. If the breathing fails, artificial respiration is to be employed, or if the heart seems about to cease its action, a whiff of the nitrite of amyl may start it going again, but only a few drops of the nitrite should be used, as large amounts depress this organ. Full hypodermic doses of strychnine, such as ^ to ^ (0.003- 0.006) of a grain, may be given to stimulate the respiration and heart. Aconite may cause in susceptible persons a vesicular, or even a pus- tular, eruption, or intense itching of the skin may be developed. Therapeutics.—The employment of aconite in disease is one of the most universally recognized procedures in medicine. It fulfils indi- ACONITE. 47 cations Avhich nothing else can, and lends itself to the control of a large number of morbid processes, its effect being uniformly explain- able by its knoAvn physiological action. It is used chiefly for its influence as a cardiac and circulatory quieter, for its effects on the peripheral sensory nervous system, as in the vomiting of pregnancy, and in those states in which, through inflammation elsewhere, the nervous system needs a sedative which w ill simultaneously reduce arterial tension. In the early stages of all acute inflammations aco- nite is of service. It may be applied locally over superficial nerves in neuralgia in the form of an ointment (2 grains [0.1] to 1 drachm [4.0], or as the oleate of aconitine, 2 grains [0.1] of the oleate to 100 [6.0] of sweet oil). In the earliest stages of gonorrhoea aconite in small doses frequently repeated is a most valuable remedy, and later in the disease tends to prevent chordee by its influence on the nervous centres. It is useful in croup, quinsy, sore throat, severe colds, bronchitis and asthma due to exposure, in their early stages. When suppression of menstruation follows an exposure to cold, this drug will often restore the normal Aoav. In pericarditis it is Aalu- able to allay the inflammation and quiet the excited heart, and it is also of great value in the earliest stages of pneumonia. It ought not to be used in adynamic, asthenic affections. Aconite is useless and harmful in prolonged acute diseases, such as scarlet fever, if constantly employed. . In persons who suffer from asthma which is preceded by coryza aconite does good in the earliest stages. In nervous palpitation of the heart and in the palpitation of exces- sive cardiac hypertrophy aconite is very valuable. In the epistaxis of full-blooded people it often affords great relief. Aconite is by far the best circulatory and nervous depressant for children suffering from sthenic fevers, particularly of the irritative type. Administration.—As a general rule, small divided doses ol the drug in the form of the tincture, \ to £ a drop (0.015-0.03) given every fifteen minutes, will act better than a full dose given at once, unless the condition of the patient requires very active treatment. Preparations.—Tincture of aconite (Tinctura Aconiti, U. b. and B P) is used in the dose of 1 to 5 drops (0.06-0.3) in water re- peated every hour if needed so often. A very useful way of employ- ing it is in the form of tablet triturates. The extract of aconite (Extractum Aconiti, U. S.) is given in the dose of ± to f of a grain (0 015-0.045), while of.the abstract (which is no longer official) 1 Wain (0.05) is used. The fluid extract (Extractum Aconiti Fluidum, U S.) is given in the dose of 1 to 2 minims (0.05-0.1). Fleming s tincture ought never to be used. The active principle aconitine is not official in the U. S. P. Its dose is ^ to ^ of a gram (0.0003- 0 0006s) but it ought never to be used internally. Ihe H. r. prepa rations that are not official in the U. S. P are: aconite-leaves \TZti Folia), aconitine (Aconitina): aconite ointment (Lnguent^m Aconitine), and aconite liniment (Limmentum Ac^i) The do e of the extract of aconite (Extractum Aconiti, B. P.) is ¥ to grain (0.03-0.06). 48 DRUGS. ADONIS VERNALIS. From Adonis vernalis, a plant indigenous in Europe and Asia, is derived a glucoside, Adonidin. When given to one of the mammalia —the dog, for instance—it causes an increase in heart-force and a rise of arterial pressure. In the frog poisonous amounts arrest the heart in diastole. The indications for the use of adonis are all conditions of cardiac failure, particularly the presence of cardiac dropsy. It is much infe- rior to digitalis and caffeine, but may be employed when these fail, as it sometimes succeeds under such circumstances. The dose of adoni- din is -§- to 4; of a grain (0.008-0.016) three times a day; or, 4 to 8 parts of the plant—all portions of Avhich are employed—may be added to 180 parts of water, and of this infusion a tablespoonful (16.0) may be given every four hours. AGARICIN. Agaric, or Touchwood, or Punk, has been used in the Southern United States very largely in the dose of 5 grains (0.3) every few hours in the treatment of the night-sweats of phthisis; and agaricin, the alcoholic extract of the drug, has been used with very extraordi- nary results, under these circumstances, by certain German and English physicians, in the dose of from 1 to 2 grains (0.05-0.1) every five hours. Its physiological action is unknown, but it is sup- posed to act upon the nerve-filaments in the sweat-glands. The writer has employed it frequently in varying dose, and has never seen any decrease Avhatever produced by it in the sweats of phthisis, although he has Avatched it most closely, expecting to see great relief folloAv its use. ALCOHOL. Ethyl Alcohol (Alcohol Ethylicum, B. P.) is the only alcohol used in medicine. Some of the other alcohols are exceedingly poisonous. Amylic alcohol is fusel oil. Alcohol is a liquid derived from the fermentation of starches or sugars in the presence of heat. It is official in four forms—namely, as Alcohol, U. S., containing 91 per cent, by Aveight of the spirit and 9 per cent, of water; Alcohol Absolution, U. S., containing not more than 1 per cent, by weight of water; Alcohol Deodoratum, containing 92.5 per cent, by Aveight of alcohol; and Alcohol Dilution, U. S., or dilute alcohol, 41 per cent, by weight spirit and the remainder Avater. The drug is generally given in the form of whiskey or brandy, and when the Avord alcohol is used in the saying, " Givethe patient alco- hol," one of these two liquids is ahvays meant unless it is othenvise stated. Physiological Action.—Nervous System.—Alcohol acts first as a powerful excitant, and aftenvard, Avhen given in very full dose, as a ALCOHOL. 49 most active depressant and paralyzant of the nervous system. Locally applied in small amounts to the peripheral nerves, it excites them at first and paralyzes them aftenvard. By the primary stimulation of the brain it increases the rapidity, but not the depth,'of thought, and it increases the reflex activity of the spinal cord, the muscles, and the nerves. In large doses it produces lack of co-ordination by depression of the brain and lower nervous system, the loss of co-ordi- nation being due largely to sensory paralysis, so that the poAver of touch is interfered Avith. This makes a drunken man fail to recog- nize the angles and surfaces of obstructions, and the impaired mental power and disordered judgment, combined Avith the badly-acting motor and sensory pathways, cause him to stumble and fall. Circulatory System.—When alcohol is ingested, either by man or the loAver animals, it stimulates the heart-muscle and increases the rapidity as avcII as the force of its beat. According to Dogiel, the increase in rate is partly due to stimulation of the accelerator nerves, but Castillo denies any such influence. Wood teaches that the effect of alcohol is not through any action upon these nerves, and is prob- ably correct in his belief. Along Avith the stimulation of the heart a rise of arterial pressure ensues, largely due to increased heart action and partly to vasomotor stimulation. In very large toxic doses alco- hol depresses and finally paralyzes the heart and vasomotor system as Avell as the nervous system. Respiration.—Respiration is stimulated by small doses of alco- hol and decreased by large ones. Temperature.—Alcohol at no time increases to any extent the actual number of heat-units in the body. It produces a sensation of Avarmth, and warms the extremities by causing the heart to pump hot blood from the centre of the body to the cold parts. If it be used in excess, the temperature rapidly falls, OAving primarily to the increase of heat-radiation produced by the excessive distribution of heat just named, and secondarily by the depression of vital poAver, Avhich is caused by a too rapid destruction of the tissues of the body in the effort induced by the drug. Calorimetrical studies shoAV that, Avhile more heat may be created under its influence, so much heat is dissi- pated that the temperature nevertheless foils. Bodily Metabolism.—The quantity of carbonic acid given off by the body under the use of alcohol is in most instances increased, but it may be decreased. The effect on the absorption of oxygen is not knoAvn. Some observers have noted an increase, some a decrease, of such absorption, and some no change at all Avhen alcohol is taken. Upon the giving off of nitrogenous substances it acts as a decided depressant, which seems to prove that it inhibits rapid tissue-changes and is a conservator of vital power. It adds force, but not tissue, to the body. Elimination.—Alcohol is largely "burnt up" in the body, but Avhen taken in excess of the latter's oxidizing power it is eliminated by the breath and by the skin, kidneys, and intestines. Digestion.—Alcohol added in any amount to food in a test-tube containino- digestive ferments retards or inhibits digestion, but in the , 50 DRUGS. stomach, on the other hand, it assists the process; for by reason of its irritant and stimulating properties it induces the secretion of an excess of the digestive juice. Therapeutics.—The employment of alcohol in disease can here be only briefly alluded to, special mention of its indications being named where the diseases in Avhich it is used are discussed. Its chief uses are as a rapidly-acting stimulant in all forms of cardiac failure due to shock or to" poisons, and as a systemic support and stimulant in low fevers and prolonged Avasting diseases, in old age, and in conva- lescence from acute disease. Some of the conditions, to state them specifically, in which alco- hol is indicated, are fainting, snake-bite, surgical shock, acute, sub- acute, and chronic pneumonia in its later stages, and excessive wasting due to prolonged suppuration. Alcohol should never be given in sthenic fevers unless some com- plication, such as syncope or pneumonia, comes on. The reason it is contraindicated is that in sthenic fevers the circulation is already suf- ficiently excited, and is generally in excess of the needs of the system. In exhausting fevers, such as typhoid or typhus, alcohol finds its true usefulness. While it is Avell to give alcohol in many cases from the beginning to the end of the attack, for the double purpose of aiding digestion and of supporting the system, its administration should not be a mere matter of routine, but should be based upon clear ideas of the indications it is calculated to fulfil. If the pulse is Aveak and the patient seems to be sinking, or the appetite is failing and adynamia is a pressing symptom, alcohol is indicated; but if the pulse is good, and the passage of the patient through his illness is not a stormy one, alcohol should be excluded from the sick-room. In phthisis, in neur- algia, and in similar states dependent upon depression of the system care must be taken to prevent the setting up of a "habit." Alcohol is very useful as a local application to ulcers and wounds, as it acts as an antiseptic and stimulant, and Avhen combined with salt forms a useful liniment in cases of debility and atony of the skin and subcutaneous tissues. Acute Poisoning.—In advanced poisoning by alcohol, Avith coma and total relaxation, external heat and hypodermic injections of digi- talis and strychnine are indicated if the heart or respiration seems failing. Belladonna should be administered to stimulate the vaso- motor system if the skin is relaxed and clammy, and counter-irrita- tion to the back of the neck is to be employed if any brain symptoms seem pressing. The after-treatment consists in the"use of substances stimulating to the stomach, such as ammonia, spirit of Mindererus and spices, unless there is gastric inflammation, when emollient sub- stances should be used to quiet the irritation. If persistent vomiting comes on, it must be quieted by the patient swallowing pieces of ice, by aconite, cocaine, or minute doses of ipecac. Counter-irritation should be applied over the belly. If the emunctories are not acting freely, thorough purgation by jalap or elaterium (40 grains (2.8) of jalap powder or -| of a grain (0.01) of elaterium) should be employed; or cal- omel folloAved by a saline may be given if milder effects are sought. ALCOHOL. 51 In vieAv of the frequency with Avhich alcoholic and opium poison- ing are confused, the following table is appended, Avhich will be found of value in making a differential diagnosis as to the condition of the patient: Alcoholism and Opium Poisoning. Alcoholism. Opium Poisoning. 1. Pupils normal or dilated. 1. Pupils contracted. 2. Kespiration nearly normal. Pulse 2. Respiration and pulse slow and full. rapid, and finally feeble. 3. Face may be pallid. 3. Face suffused and cyanosed. •4. Skin cool, perhaps moist. 4. Skin warmer than in alcoholic poi- soning. 5. Pulse rapid, at first strong, then 5. Pulse slow, strong, and full till late weak. in poisoning. There is scarcely any difference as to consciousness in the two conditions. The urine is always to be saved for medico-legal examination. Acute Alcoholism and Apoplexy. A Icoholism. Apoplexy. 1. Pulse rapid, compressible, and weak. 1. Pulse apt to be strong and slow. 2. Skin moist, or relaxed and cool. 2. Skin hot or dry. 3. Bodily temperature lowered. 3. Bodily temperature raised. 4. Pupils equally contracted or dilated; 4. Pupils unequal. generally dilated. 5. No hemiplegia. 5. Hemiplegia: one side tossed, the other remaining motionless. 6. Breathing not so stertorous nor so 6. Respiration stertorous, the lips being one-sided in lips. inflated on one side on expiration. 7. No facial palsy. 7. Facial palsy. s. Unconsciousness may not be com- 8. Unconsciousness complete. plete. The smell of alcohol in the breath is no guide, as acute alcoholism may have caused the rupture of a cerebral blood-vessel. Chronic Poisoning.—The treatment of this condition may be car- ried out in tAvo Avays: First, by the isolation of the patient and the complete AvithdraAval of the drug at once ; secondly, by, what is better, a gradual tapering-off in the daily amount of the spirit. In either instance isolation must be absolute, and all smuggling of alcohol to or bv the patient prevented. The attendants must be absolutely trust- worthy. Careful scrutiny of bed-clothes and closets will often be reAvarded by finding hidden bottles. The depression of the patient Avhen recovering from alcoholism must be met by the use of nutritious broths highly seasoned in order to stimulate the stomach, by easily digested or predigested foods, and by small doses of morphine or coca if the patient be very weak and need such a stimulus. Koumyss is an exceedingly valuable preparation under these circumstances. In the treatment of the atonic stomach of drunkards nothing does so Avell as the folloAving pill: R.—Oleoresin. capsici............n\,x(0.65). Olei caryophvlli............^l* (°-65)- Hvdrarg.chlor. mit...........gr. xx (1.3). Aloe Socotrime............• gr. xl (2.65).—M. Ft. in pil. No. xx. S.—One three times a day after or before meals. 52 DRUGS If this pill fails to move the bowels after thirty-six hours, a saline purgative should be used to avoid any danger of mercurialism. (See Capsicum.) Chronic alcoholism may produce cirrhosis of the liver, with the resulting symptoms, notably ascites. The following are the principal points in the differential diagnosis of Chronic Alcoholism and the General Paralysis of the Insane. Alcoholism. Paretic Dementia. 1. Attacks shorter, and more widely 1. Attacks more prolonged. separated by intervals of sanitv. 2. Delirium may be of any character. 2. Delirium of grandeur more marked and defined. 3. Visions more characteristic, and are 3. Visions often not evil, but pleasant. evil. 4. Tremors confined to head and arms. 4. Tremors more diffused. 5. Tremors removed by dose of alco- 5. Tremors made worse by alcohol. hoi. 6. Mental symptoms temporarily re- 6. Mental state made worse by alcohol. moved, or at any rate improved, by al- cohol. 7. Tremors occur chiefly in the morn- 7. Tremors not confined to the morn- ing, ing. There is danger of pneumonia from failure of the right side of the heart in subacute and chronic alcoholism, and the physician should always be on the lookout for this complication. Administration.—Brandy and Avhiskey are generally used as rapidly- acting stimulants. They should be exhibited in the form best adapted to the work they are intended to perform. If the action must be instantaneous, as in a case of fainting, they should be employed hot and concentrated, so that the stomach has not to Avarm the liquid before absorption. They are to be used hypodermically if still more rapid action is required. If administered to aid digestion and support the system, then they should always be given with the food—never alone, and never concentrated. They may be given as milk-punch or as eggnog, the latter being the " heavier " of the tyvo so far as diges- tion is concerned. Wine-A\hey is very light and useful. Mulled Avine and champagne are particularly useful in the treatment of irritable stomach. (For recipes for mulled Avine and Avine-Avhey see Foods for the Siek.) The champagne should ahvays be as devoid of sugar as possible—that is, Avhat is known as "extra dry." Gin is rarely employed as a stimulant, except Avhen given to young children or to adults Avhen the kidneys are torpid. Stout and porter are of value in A\asting diseases, in convalescence from acute diseases, and for nursing Avomen. Lager beer contains too little alcohol to be used as a distinct stimulant, but may be used in moderation to aid digestion, or ale may be employed instead. Clarets are useful aids to digestion, and port is also of value in these cases. Contraindications.—All states of cerebral excitement, unless due to exhaustion, acute inflammations, the alcoholic habit, apoplexy, menin- gitis, acute nephritis, aneurism, and advanced atheroma, contraindicate the use of alcohol. ALLIUM. 53 The official preparations of alcohol are as follows: Whiskey (Spiritus Frumenti, U. S.) should be at least three years old, and be made, in America, from rye for medicinal purposes. Brandy (Spiritus ViniGallici, U. S. and B. P.) is obtained by the distillation of fermented grapes or fruits, and should be from three to five years old before use. Cologne-Avater (Spiritus Odoratus) is used solely as a lotion and perfume. Red Wine( Vinum Ixubrum, U. S.) is made from grapes not deprived of their skins. White Wine (Vinum Album, U. S.) is the fermented juice of grapes the skins of Avhich have have been removed. Dilute Alcohol (Alcohol Dilution, U. S.), deodorized alcohol (Alcohol Deodoratum, U. S.), pure alcohol (Alcohol, U. S.), and absolute alcohol (Alcohol Absolution) are also official. The unofficial preparations are: Rum, Avhich is made from the fermentation of molasses, and con- tains about 40 to 45 per cent, of alcohol. Gin is made from rye or barley, Avith the addition of juniper-berries and hops. (Good gin and the Spiritus Juniperi Compositus of the C S. Pharmacopoeia are virtually identical therapeutically.) When diuresis is required and atony of the kidneys is present, Avithout inflammation, gin is a useful medicament, proArided that a stimulant is indicated. Gin is one of the alcoholic drinks most apt to produce cirrhosis of the liver. Port Wine ( Vinum Portense, B. P.) is a fermented Avine, to which pure spirit is added to increase its strength. It is one of the strongest table Avines, and is useful as a stimulant in convalescence. Sherry ( Vinum Xericum, B. P.) has about 30 per cent, of alcohol in it. It is not official in the U. S. P. Beer is made by a sIoav fermentation, while ale is made by a more rapid fermentation at a higher heat. Porter resembles the other malt liquors closely, except that it con- tains more solids, due to a scorching of the grain by a high heat. The B. P. preparations that are not official in the U. S. P. are rectified spirit (Spiritus Hectificatus), proof spirit (Spiritus Tenuior), sherry (Vinum Xericum), amylic alcohol (Alcohol Amylicum), and Mistura Spiritus Vini Geillici, which is a useful, pleasant and nutri- tious stimulant made by beating up the yolks of tAvo eggs with half an ounce of sugar, and then adding four ounces each of brandy and cinnamon-water. This is sometimes called "egg-flip." ALLIUM. Garlic, or Allium Sativum, U. S., is a stimulant to digestion, OAving to the volatile oil it contains, Avhich by its somewhat irritating proper- ties excites the gastric mucous membrane to increased secretion. In persistent colds, Avhere the bronchial tubes are particularly affected, a garlic poultice, made by pounding the bulbs in a mortar, is a very efficient, though disagreeable, remedy. In the treatment of children with colds garlic may be used boiled in milk, and the liquid given as 54 DR UGS. a drink, Avarm or cold, or the oil of garlic may be given in emulsion in the dose of 1 or 2 drops (0.05-0.1). It ought not to be given dur- ing the febrile stage, as it is stimulating. If the skin in any case is too delicate to permit of the use of pounded garlic alone, it may be mixed with equal parts of bran, and a regular poultice or plaster made thereof. Employed in this form, allium is useful if applied over the spine or feet in the treatment of the cerebral and spinal con- vulsions of infants; placed over the belly in cases of gastro-intestinal catarrh, it acts almost as well as a spice poultice. Allium-juice has also been used, in the dose of 2 to 5 drops (0.1-0.3) to relieve ner- vous vomiting. The dose of the syrup (Syrupus Alii, U. S.) for a child is 1 drachm (4.0), but 4 drachms (16.0) may be given to an adult. ALLSPICE. Allspice, or Pimenta (U. S. and B. P.), is the nearly ripe fruit of Eugenia Pimenta, a tree of the West Indies. It contains an official volatile oil (Oleum Pi'mentce, U. S. and B. P.), used for flavoring pur- poses, as a constituent of spice plasters, in diarrhoea mixtures, or as a carminative. It Avill also prevent the griping of purgative medicines. The dose of the oil is 1 to 5 drops (0.06-0.3). Aqua Pimenta' (B. P.) is given in the dose of 1 to 2 ounces (32.0-64.0). ALMONDS. Almonds are official in the form of the bitter almonds (Arnygdalus Amur a, U. S. and B. P.) and the SAveet almonds (Arnygdalus Dulcis, U. S. and B. P.). Bitter almonds develop hydrocyanic acid in the presence of Avater, by the reaction betAveen the amygdalin and Avater in the presence of the emulsin contained in them; this is not the case Avith sweet almonds. SAveet almonds, Avhen rubbed up in a mortar with water, form a pleasant-tasting emulsion of an agreeable odor that is very useful as a vehicle for remedies having a disagreeable taste. Almond bread has been proposed as a food for diabetics, owing to its containing virtually no starch; but it is requisite that the oils and saccharine constituents of the almond shall first be removed. (See Foods for the Sick.) When half an ounce of SAveet almonds are rubbed up Avith thirty grains of gum arabic and two drachms of sugar, to which is added gradually a half-pint of distilled water, the mixture being then strained, an emollient and soothing drink is formed, Avhich is very useful in irritations of the stomach and intestines and of the air-pas- sages and pharynx. The expressed or essential oil of almonds is a useful demulcent, and has been recommended in the cough of phthisis, given in the dose of a feAv drops in emulsion. Bitter almonds give off an oil (Oleum Amygdala? Amarw, U. S.), Avhich is exceedingly poisonous, OAving to the prussic acid Avhich it contains, and it is said that one drop will kill a cat, while seventeen drops have killed a man. ALOES. 55 Bitter almonds are used to allay irritable coughs and similar states, but are not frequently employed, because other drugs are less danger- ous, more stable, and more active as remedial agents. The emulsion of bitter almonds is made as is that of SAveet almonds, and may be used in teaspoonful doses for the same purposes and as a vehicle in cough mixtures. Both emulsions are useful as vehicles in the treatment of gonorrhoea, as they diminish the burning on urination. Almond emulsions, Avhen locally applied, are supposed to be of value for the removal of freckles and sunburn. The preparations of SAveet almonds are: an emulsion (Emulsion Amygdala?, U. S. and B. P.), dose 1 to 2 ounces (32.0-64.0); a syrup (Syrupus Amygdala?, V. S.), dose 2 drachms to 2 ounces (8.0- 1)4.0); a compound poAvder (Piilvis Amygdalcp Compositus, B. P.), given in the dose of 1 to 2 drachms (4.0-8.0); and the oil (Oleum Amygdabe Expression, U. S. and B. P.), the dose of Avhich is 1 to 4 drachms (4.0-16.0) Aqua Amygdalce Amar Aloes et Asuft id us and Linimentum Ammonia' (U. S.) are both official in the B. P. AMMONIAC. Ammoniac (Amnioniacum, U. S. and B. P.) is a resinous gum obtained from Dorcma Amnioniacum, and is used very little in medi- cine at the present time. Internally and externally it produces some irritation when brought in contact with the tissues, and may be used internally in the dose of 10 to 30 grains (0.65-2.0) in pills in cases of chronic bronchitis devoid of any active inflammatory process. It is official in the form of the plaster of ammoniac and mercury (Em- plastrum Ammoniaci cum Hydrargyro, U. S. and B. P.), which is used as a stimulant over enlarged glands. Finally, there is the emul- sion of ammoniac (Emulsum Ammoniaci, U. S. and B. P.), used in chronic bronchitis in the dose of a tablespoonful (16.0). AMMONIUM (NH4). The following salts of ammonium are official, and are used for various purposes: Acetate of Ammonium. Acetate of Ammonium is used in medicine in the form of the spirit of Mindererus (Liquor Ammonii Acetatis, U. S. and B. P.), dose 1 to 2 fluidrachms (4.0—8.0), for the purpose of acting as an antacid in gastric indigestion, and also as a mild diaphoretic Avhich is inferior to SAveet spirit of nitre. Benzoate of Ammonium. Benzoate of Ammonium (Ammonii Benzoas, U. S. and B. P.) is employed chiefly for its diuretic influences, Avhich depend entirely upon the benzoic acid present in the compound. It should be kept in well-stoppered bottles. As benzoic acid is eliminated as hippuric acid and ammonia as nitric acid, this drug may be employed in cases Avhere the physician desires to make the urine decidedly acid: as, for example, in patients suffering from catarrh of the bladder, Avhen the urine is loaded with phosphates, which may be dissolved by this acid- ulation. The dose is 10 to 30 grains (0.6-2.0), which should be dis- solved in Avater or administered in cachets or capsules. 62 DRUGS. Bromide of Ammonium. Bromide of Ammonium (Ammonii Bromidum, U. S. and B. P.) is really a crystalline salt, but is generally found in commerce as a white granular poAvder, Avhich, Avhen exposed to the atmosphere, becomes slightly yelloAvish. It is readily dissolved in Avater. Physiological Action.—Applied to the mucous membrane of the mouth, the bromide of ammonium produces a salty taste, is markedly pungent, and dissolves readily in the oral secretions. If large amounts are swallowed, it causes burning pain in the belly and eA-idences of gastro-enteritis. Nervous System.—The action of this drug upon this part of the body is its most important effect. Given to the loAver animals, it pro- duces in frogs total loss of reflex activity, preceded, it is said, in some cases by tetanic convulsions, although no such motor disturbances may take place. In a series of studies undertaken by the writer to deter- mine the exact effect of the drug it Avas found that the spinal cord Avas depressed, both on its motor and sensory sides, Avhile the nerves and muscles escaped. These results are in accord Avith those of other investigators, avIio also found that the nerves are unaffected. On the cerebral cortex it acts as a very distinct sedative. Circulation.—Upon the circulation bromide of ammonium acts as a stimulant in small doses, but as a cardiac paralyzant if a large amount comes in contact Avith the heart. In medicinal dose it is distinctly stimulant to the circulation, but not sufficiently so to render it a aluable as a circulatory stimulant, to the exclusion of other more poAverful preparations. Therapeutics.—The bromide of ammonium may be used in nearly every instance Avhere bromide of potassium may be employed, and possesses the distinct advantage of being less depressant to the gen- eral system than the latter drug. It is, hoAvever, more apt to disorder the stomach even if given in moderate doses. In epilepsy it Avould seem to be of as much value as the potassium salt, and may be com- bined Avith it in some cases Avith success. (See article onEpilepsy, Part IV.) According to DaCosta, the drug is of very distinct value in rheumatism in the dose of 60 to 80 grains (4.0-5.3) a day, Avell diluted Avith Avater, although its manner of action in this disease is not knoAvn. The usual dose is 10 to 30 grains (0.65-2.0). It is incompatible Avith spirit of nitrous ether. Carbonate of Ammonium. Carbonate of Ammonium (Ammonii Carbonas, U. S. and B. P.) undoubtedly has an action exactly like that of the liquid preparations of ammonia, and is used either alone or Avith the chloride in the treatment of bronchitis, particularly Avhen this disease occurs in babies and young children. It is also largely employed by surgeons in the treatment of children after a surgical operation "to overcome the respiratory and circulatory depression produced by the anaesthetic. AMMONIUM. 63 The dose is 2 to 10 grains (0.1-0.65) in syrup of acacia and Avater. It is a rapidly-acting cardiac and respiratory stimulant. R. Ammonii carbonat...........gr. xlviij (3.0). Syrup, acacise ............f^j (32.0). Aquiv dest............q. s. ad f^iij (96.0).—M. S.—Teaspoonful (4.0) every two hours for a child of three or four years. Chloride of Ammonium. The Chloride or Muriate of Ammonium (Ammonii Chloridum, U. S. and B. P.) has an entirely different action and therapeutic use from the rest of this group. It possesses almost no influence over the heart and respiration, but does exercise a very stimulant effect on mucous membranes, increasing the secretion of mucus. The consideration of its use in diseases of the lungs can be found in the articles on Pneu- monia and Bronchitis. Chloride-of-ammonium fumes can be obtained from a feAv grains of the drug heated in an iron spoon over a gas-jet or by means of a set of three Avash-bottles. In one of these is placed stronger A\rater of ammonia, in the other muriatic acid. Each of these is connected Avith a third bottle by means of glass tubing, this bottle being partly filled with Avater, through Avhich the fumes in passing become purified and form the fumes of chloride of ammonium. The drug may also be used in a spray from an atomizer. It has been employed in intermittent fever, but has gone out of use, and has also been used in neuralgias of the ovarian type by Goodell and others. In the treatment of chronic torpor of the liver and subacute hepatitis, and even in cirrhosis and hepatic abscess, it has been thought of value. Many clinicians have found it useful in the treatment of the gastric and intestinal catarrhs of children of a very subacute type, and it is the routine treatment for all such cases Avhich come under observation at the hospitals and elsewhere Avhere the author has charge. The dose is 2 to 15 grains (0.1-1.0), preferably given with liquorice and Avater to mask the taste. R. Ammonii chloridi............^i] (8.0). Extract ^vcyrrhiz............f %] (32.0). Aqua; dest,'............q. s. ad f giij (96.0).—M. S.—Teaspoonful (4.0) t. d. after meals for a child of five to ten years. The chloride of ammonium may, hoAvever, be given in compressed pills, provided a large draught of water or milk is taken simulta- neously to protect the stomach. (See article on Bronchitis for other prescriptions.) Iodide of Ammonium. Iodide of Ammonium (Ammonii Iodidum, U. S.) should be kept in dark, well-stoppered bottles, and if deeply colored should not be dispensed. It may be employed in the dose of 2 to 5 grains (0.1-0.3) in all cases Avhere the iodide of potassium is indicated, and seems to possess alterative influences equal to those of that salt. It has been recommended as a local application in cases of enlarged tonsils in the 64 DRUGS. form of a solution of 30 grains (2.0) of the salt to the ounce (32.0) of glycerin, particularly if struma is the cause of the enlargement. The application is to be made once a day Avith a SAvab or camel's- hair brush. It is necessary that this solution be not exposed to the air or it Avill undergo decomposition. Valerianate of Ammonium. Valerianate of Ammonium (Ammonii Valerianas, U. S.) is the salt of ammonium commonly used in the nervous unrest of pregnant or hysterical women, or at the menopause in the peculiar nervous dis- orders apt to occur at that period. In poisonous doses it paralyzes the spinal cord in the loAver animals. It is usually given in the form of the elixir of valerianate of ammonium, the dose of which is a tea- spoonful to a dessertspoonful, or it is combined with the bromides, under which circumstances it is much more efficacious. The dose of the salt itself is'10 to 15 grains (0.65-1.0). The sulphate of ammonium is never used in medicine. The phos- phate of ammonium is employed in rheumatism in the dose of 10 to 20 grains (0.65—1.3). It is no longer official. The B. P. preparations besides those already given are: Sulphide of Ammonium, Oxalate of Ammonium, Liquor Ammonii Citratis, dose 2 to 6 fluidrachms (8.0-24.0); Liquor Ammonii Citratis Fortior, dose 30 minims to 2 fluidrachms (2.0-8.0); Liquor Ammonii Acetatis For- tior, dose 25 to 75 minims (1.6-5.0). AMYL NITRITE. Amyl Nitrite (Amyl Nitris, U. S. and B. P.) is a very volatile, somewhat oily liquid possessing a peculiar penetrating pear-like odor. It is made by the action of nitric and nitrous acids upon amylic alco- hol, and is not to be confounded with nitrate of amyl, Avhich has a different physiological action and is never used medicinally. Nitrite of amyl should be protected from light, heat, and fire. Physiological Action.—When SAvallowed or inhaled the drug pro- duces staggering, fulness in the head, roaring in the ears, duskiness of the face, and finally utter muscular relaxation, so that the animal or man falls to the ground. The heart beats very rapidly and forci- bly, and the respiration becomes gasping. Nervous System.—Nitrite of amyl acts as the most rapid of all the nervous depressants and sedatives knoAvn, except prussic acid. Experiments show that its dominant action is on the motor side of the spinal cord. The motor cortex of the brain and the motor nerves are only affected by large amounts. Upon the nervous apparatus of sensation nitrite of amyl has no effect in medicinal amounts, and can never be used to relieve pain unless it be due to spasm or to angina pectoris. The muscles are depressed by toxic amounts. Circulation.—When nitrite of amyl is used the pulse becomes AMYL NITRITE. 65 exceedingly rapid, Avhile the arterial tension progressively falls. The increase in pulse-rate is due to depression of the centric inhibitory apparatus of the heart and to the sudden relaxation of the blood- vessels, by reason of Avhich, the resistance being taken aAvay. the heart beats faster. The fall of arterial pressure is due to depres- sion of the vasomotor centres and the muscular coats of the blood- vessels. In very small amounts the drug stimulates the heart-muscle (Reichert), but its dominant action is that of a depressant. The Blood.—In medicinal dose this drug produces a chocolate color of the arterial blood, due to the change of oxyhaemoglobin into metlnemoglobin. Urine and Elimination.—The urine sometimes contains sugar after the use of the nitrite of amyl, and there is increased diuresis. The drug is eliminated very rapidly from the body by the lungs and kidneys. Temperature.—If the nitrite of amyl be employed for any length of time, a most remarkable fall in bodily temperature ensues, Avhich is probably due to diminished oxidation, but possibly to some effect on the heat-centres governing heat-production and dissipation. The vascular dilatation also greatly tends to aid in the fall of bodily heat produced by the drug. Therapeutics.—Nitrite of amyl is used to relax general or local muscular spasms, for the relaxation of the spasm of epilepsy and for aborting an on-coming fit, for the prevention and subjugation of strych- nine convulsions and tetanus, and for the relief of angina pectoris, provided the attack is accompanied by high arterial tension. It may be used in puerperal eclampsia, but it is a dangerous remedy, because of its relaxation of the uterus and the consequent danger of post- partum hemorrhage. In dysmenorrhoea with uterine spasm it often gives great relief. Nitrite of amyl has been used in cases of sea-sick- ness as a prophylactic and cure Avith considerable success. In cardiac failure from fright or anaesthetics amyl nitrite is often of great value in single whiffs. If it does not act at once under these circumstancs, it is worse than useless to push it. It has also been found of value in whooping cough, laryngismus stridulus, asthma, spasmodic croup, and infantile convulsions. In migraine Avith local vasomotor spasm and true hemianopsia it is very useful. In strychnine poisoning and tetanus it must be used between the spasms or else given hypodermic- ally, as the respiratory cramp prevents its inhalation. Administration.—The drug may be given by placing three to five drops on a handkerchief and inhaling the fumes, or it may be dropped on sugar and taken by the mouth in the same quantity. It is important to remember the fact that the effects of the drug are more severe for a moment after its use than during its inhalation. The physician should warn the patient that the effect of the drug is sudden and alarming, and in nervous cases should direct that the inhalations be made gently, as a very full inhalation may produce unpleasant sensations of cardiac failure. The best Avay for patients to use the drug is to have it in pearls of glass, each holding 3 minims (0.15). One or more of these may 66 DRUGS. be crushed in the handkerchief and the fumes inhaled. Some of the pearls made by careless manufacturers are of such thick, strong glass that they are difficult to break, and if broken are apt to cut the fin- gers. These are, of course, to be avoided. ANTHRAROBIN. Anthrarobin, Avhich Avas originally discovered by Liebermann, seems to possess equal value Avith its relative chrysarobin, and to be capable of acting as efficaciously as this substance in the treatment of skin diseases. It is a yellowish poAvder, tolerably stable in a dry atmosphere, not soluble in acids or Avater, but readily soluble in dilute alkaline solution or alcohol, at first making a solution of a broAvn color, Avhich. as oxygen is taken up, passes to a green and finally to a violet. Therapeutically, anthrarobin has been employed by Rosenthal and by Behrend, and more recently Kobner has recorded his experience Avith it, employing it Avith good results in a 10 to 20 per cent, solu- tion in the various forms of tonsurans as a Avash. Rosenthal has used it in psoriasis and pityriasis versicolor and herpes, and Behrend asserts that it is often better in its effects upon the skin than chrysarobin, as it produces less inflammation and only discolors the skin slightly. It also possesses the additional value of making so slight a stain on the linen that it can be removed by Avashing. According to most authorities, it is best to keep the drug in alco- holic solution, and, if the bottle is Avell corked, such a mixture remains good for a Aveek. ANTIMONY. Antimony itself is rarely used in medicine, OAving to its insolubil- ity, but is generally employed as the tartrate of antimony and potas- sium, or Tartar Emetic (Antimonii et Potassii Tartras, U. S. ; Anti- monium Tartaratum, B. P.), or in the form of the sulphide (Anti- monii Sulphidum, V. S.)\ purified sulphide (Antimonii Sulphidum Purification, U. S.; Antimonium Nigrum Purification, B. P.); and sulphurated antimony (Antimonium Sulghuratum, U. S. and B. P.), sometimes called Kermes Mineral. The last three drugs are very rarely employed, and are unreliable preparations, although some prac- titioners use kermes mineral as an alterative circulatory depressant and sedative expectorant in the dose of •£- grain (0.01) every hour or tAvo. As an emetic the dose is 1 to 4 grains (0.05-0.2). The oxide of antimony (Antimonii Oxidum, U. S.) forms part of the Pulvis Aromaticus. Tartar Emetic. Tartar Emetic (Antimonii et Potassii Tartras, U. S. ; Antimonium Tartaratum, B. P.) is made by boiling the oxide of antimony with ANTIMONY. 67 bitartrate of potassium and Avater. Although it is really crystalline, it is generally sold as a fine poAvder, oAving to these crystals being easily pulverized. It is insoluble in absolute alcohol, but is soluble in ordinary Avater, and still more so in boiling water. In dilute alco- hol it is partly soluble. OAving to its chemical constitution tartar emetic should never be given Avith either acids or alkalies, and all drugs containing tannic acid are also incompatible Avith it, OAving to the fact that an insoluble tannate is rapidly formed, Avhich is absorbed very sIoavIv if at all. S<> complete is the insolubility of the compound so formed that tan- nic acid is the best antidote to the drug that Ave possess. Physiological Action.—Tartar emetic, Avhen applied to* mucous membranes, produces a burning sensation, and upon the skin it may readily cause a large amount of irritation if the part be delicate. If kept in contact Avith a mucous membrane, very distinct inflammatory changes occur, and if it be applied to the skin for any length of time, redness, folloAved by acne of a pustular character, appears, Avhich finally ends in ulceration and sloughing if the use of the drug is persisted in. Under these circumstances the vitality of the parts seems interfered Avith, and, as a result, healing takes place very sloAvly indeed. Nervous System.—Antimony is a depressant to the sensory side of the spinal cord and a paralyzant to all the spinal centres, motor and sensory, in poisonous dose. It is stated that Avhen an animal is under its influence sensation to heat and acids is lost before the ordinary sense of touch is destroyed. The convulsions Avhich sometimes ensue after poisonous doses in the loAver animals are due to anaemia of the brain brought on by the cir- culatory depression. Ringer and Murrell have proved antimony to be a motor-nerve and muscle poison. Circulation".—The chief influence of antimony is exerted upon the circulation. In small doses it lowers the pulse-rate by a direct depression of the heart-muscle, and simultaneously decreases arterial tension by an action upon the peripheral portions of the vasomotor system in the Avails of the blood-vessels, but the vasomotor influences may be in part centric, and this question must be considered as sub judice. The fall of arterial pressure is also due to failure of heart- force. With the loAvering of the pulse-rate there is nearly ahvays a corresponding decrease in cardiac poAver. When poisonous doses are employed, death ensues after great cir- culatory and respiratory depression, as will be seen below. The heart is found relaxed and flabby and utterly dead to all stimuli, although, if the dose has not been very excessive and digitalis is freely employed, the heart may be made to beat again ; this is at least true in the frog. The drug in poisonous doses is thought to depress the peripheral ends of the vagus nerves. Respiration.—The drug has little or no effect upon respiration except AA'hen given in lethal doses. Under these circumstances death is produced in three Avays, all of them acting together. Primarily, the respiratory centre in the medulla is depressed, and the governing 68 DRUGS. nerves of breathing, the pneumogastrics, are also rendered inactive; secondarily, the cardiac failure readily causes pulmonary congestion ; and, thirdly, the drug causes such an outpouring of liquid and mucus into the bronchial tubes that the patient is droAvned in his oavii secre- tion, which he is too Aveak to expel. Stomach and Intestines.—Antimony in toxic doses is a poAver- ful irritant to these portions of the body. In full medicinal amounts it acts as a sIoav but poAverful emetic, producing much nausea. The vomiting is due to an action on the vomiting centre in the medulla and to a direct action on the stomach itself. The drug is, therefore, a centric and peripheral emetic. Very full doses produce Avatery purging, attended Avith some grip- ing and tenesmus. Elimination.—Antimony escapes from the body in all the secre- tions, but largely by the boAvels. The latter method of elimination seems chiefly to folloAV poisonous doses, and purging is an effort at elimination. Poisoning.—When toxic doses of tartar emetic are taken, the pulse at first becomes slightly Aveaker and sloAver, the skin becomes moist and relaxed, a general sense of relaxation comes on, and simultaneously a sensation of severe nausea and gastric distress appears. FolloAving this condition violent vomiting asserts itself. The ejected mass consists of the contents of the stomach—mucus, bile, and Avatery fluids, and perhaps blood. Purging appears almost as early as the vomiting, and consists first of the normal contents of the intes- tines, then mucus, then bile, and, very rarely, blood. These signs may rapidly pass away and the characteristic peculiar " rice-Avater " stoolsx of antimonial poisoning appear. The general condition of the patient is now most serious. The face is pinched, livid, and cov- ered Avith a cold sweat. The pulse is rapid and shuttle-like—to and fro—or lost at the Avrist; the arterial tension is almost nil. The res- pirations are faint and fluttering, and so shalloAV as hardly to be seen or heard. Cramps in the calves of the legs attack the patient, due to the abstraction of water from the tissues by the violent purging, and the temperature falls loAver and loAver as death approaches. The general condition is such that all the signs point to Asiatic cholera, and antimonial poisoning cannot be separatee! from this disease during an epidemic Avithout a history of the case or a chemical analysis of the secretions, Avhich ought ahvays to be preserved.2 The treatment of antimonial poisoning consists in the internal ad- ministration of large amounts of tannic acid, in the use of the stomach- pump, and in the maintenance of an absolutely prone position. The patient should vomit into towels and not raise the head from the ground; the head, indeed, should generally be placed lower than the 1 A ':rice-water" stool is one which, on standing in a glass, separates into two lay- ers, the lower white and flocculent, the upper watery and almost clear. 2 This is a good opportunity to state that the secretions and excretions of a person dying of any poison should be placed in a chemically-clean jar capable of being sealed tight. The same rule of cleanliness applies to the'jars holding organs at the post- mortem. The jars should be ready, and no intermediate vessel used. They should be sealed at once, and kept so until claimed by the authorities. ANTIMONY. 69 heels. External heat, alcohol, and digitalis should be used thor- oughly, and opium should be employed hypodermically to allay pain and irritation, unless the respirations are too feeble. Fatty degeneration of the tissues may occur after acute antimonial poisoning. Therapeutics.—Tartar emetic is employed for at least five separate purposes, the most usual of which is as a circulatory quieter and seda- tive. The indications for antimony as a circulatory depressant are not so generally recognized at present as they Avere at one time, on account of the introduction of other drugs. Suffice it to state that all states of sthenic inflammation Avith a bounding pulse, high fever, and symptoms shoAving the patient to be possessed of robust constitution permit of its use, while ail asthenic conditions most emphatically contraindicate its employment. In the treatment of colds, to break forming diseases, and to allay inflammation it is given in moderate dose. It is useful in sthenic bronchitis as an expectorant. Under these circumstances it may be given in emetic dose; or, if emesis is not desirable, minute amounts given hourly are of value, such as -^ of a grain (0.001) every hour, or a teaspoonful of a solution of 1 grain (0.05) to ^ a pint (250 cc.) every hour may be used. This is a particularly useful method in children, as the solution is tasteless and it does not pro- duce nausea and vomiting. In the acute catarrh of children. Avhich affects the stomach and entire alimentary canal and is associated Avith little fever, the use of the drug is extremely valuable, and often aborts an attack Avhen given in the same dose as just described. As an emetic antimony is sIoav but forcible, and it ought not to be used in poisoning, OAving to its sloAvness. Before the introduction of anaesthetics emetic doses Avere employed to relax the muscles in reducing dislocations and fractures. Tartar emetic is harmful if irritation of the stomach is present or if kidney changes are rapidly progressing. If one good-sized emetic dose is not sufficient to produce vomiting, it should not be repeated, but some other emetic or the stomach-pump be used, lest antimonial poisoning complicate the case. The emetic dose must be large enough to be effective, or none at all should be given. If this rule is dis- obeyed, systemic changes come on Avith undesirable severity in those cases Avhere emesis fails to occur because of small doses. As a counter-irritant antimony is employed in the form of an oint- ment whenever a very sIoavIv acting and prolonged counter-irritation is to be maintained, as on the back of the neck in epilepsg or similar chronic states, and in old enlargements of the joints. Antimony acts well as a diaphoretic, but its use is undesirable, OAving to its disagreeable effects, such as nausea and intestinal dis- turbance, and because other, more pleasant, drugs act equally Avell. Administration.—The dose of tartar emetic Avhen there is an excited circulation is ^ to -fa of a grain (0.003-0.006) every three hours until an effect is obtained. As an emetic the dose is |- to 1 grain (0.03-0.06). The Avine of antimony ( Vinum Antimonii, U. S. ; Vinum Antimoniale, B. P.) contains only 2 grains of tartar emetic 70 DRUGS. to each ounce, and may be used in the dose of ^ to 1 teaspoonful (2.0-4.0), or, as an emetic, in the dose of 1 to 2 tablespoonfuls (15.0- 30.0). The compound pill of antimony (Pilulo? Antimonii Composite, U. S., or Plummer's pill) is used as an alterative, and contains sul- phurated antimony \ a grain (0.03), calomel \ a grain (0.03), guaiac 1 grain (0.06), and tragacanth; the dose is one to three pills. The ointment of antimony (Unguentum Antimonii Tartarati,B. P.) is used externally as a counter-irritant spread on a rag or piece of lint. Antimonial poAvder (Pulvis Antimonialis, U. S. and B. P.), or James's powder, contains oxide of antimony and phosphate of calcium, and is given occasionally as an antipyretic in the treatment of rheumatism and fever in the dose of 3 to i0 grains (0.15-0.65); it is best given in a pill. The compound syrup of squill (Syrupus Scilhv Compositus. U. S.), otherAvise knoAvn as " Coxe's hive syrup," contains three-fourths of a grain (0.045) of tartar emetic to the ounce. The dose is 20 to 30 drops (1.3-2.0) for an adult as a sedative, or from this amount to 1 drachm to a child as an emetic. Liquor Antimonii Chloridi, B. P., is not official in this country, and in England is rarely used as an escharotic. ANTIPYRINE. Antipyrine is a derivative of coal-tar, its chemical name being phenyldimethylpyrazolon. It is also called Phenozone (B. P.). In appearance it is a Avhite powder of a someAvhat bitter taste, and is very soluble in Avater, less so in ether, alcohol, and chloroform. When antipyrine is given to a man in full medicinal amount, it causes a buzzing and tightness of the.head not unlike that produced by quinine. The bodily temperature, if normal, is depressed a frac- tion of a degree, but no other symptoms are manifested. If the dose be quite large, some blueness of the lips and finger-nails appears, chilly sensations are experienced, and finally a profuse SAveat breaks out over the entire body, which is more severe if fever has previously existed. Large doses sometimes cause nausea and vomiting. Physiological Action.—Nervous System.—When a poisonous dose of antipyrine is given to one of the loAver animals, relaxation, utter loss of reflex action, and total inability to move come on at once, and death ensues. SomeAvhat smaller doses produce exceedingly severe tetanic and epileptiform convulsions, but consciousness seems to be preserved. It has been proved that the chief cause of the convul- sion is an action of the drug on the brain.1 Very large toxic doses, therefore, decrease reflex action, and smaller ones increase it, though medicinal amounts certainly lessen reflex activity to a notable degree. The cause of this failure of reflexes is depression of the sensory nerves and the receptive centres of the spinal cord. Medicinal amounts must, therefore, be regarded as very distinct nervous seda- tives, acting much more actively on the nerves of sensation than on those of motion. Applied beneath the skin or to a mucous mem- 1 See author's Boylston Prize Essay on Antipyretics. Philadelphia, 1891. ANTIPYRINE. 71 brane, antipyrine is a powerful local anaesthetic, the anaesthesia last- ing often for several days. Circulation.—The studies of a very large number of pharma- cologists prove most conclusively that antipyrine has no effect on the circulation of the loAver animals in moderate doses unless these be so frequently repeated that cumulative effects ensue. Many reliable clinical observers have asserted that the drug depresses the circula- tion in man in some cases, and antipyrine is certainly not a cardiac stimulant. The Avriter is confident, hoAvever, that antipyrine is not so distinctly a cardiac depressant as some think. Large, poisonous doses loAver blood-pressure, unless convulsions are present, when the pressure is raised. The action of the drug on the circulation is nevertheless a very unimportant part of its poAver, and in most cases is not to be considered in the treatment of disease unless the circulation is feeble. In many of the cases where vascular depression and collapse have folloAved its use it has been employed in excessive amounts, or the fall in bodily temperature has caused the untOAvard symptoms. (See Fever and its Treatment.) Blood.—No spectroscopic changes in the blood folloAv the use of medicinal doses of antipyrine in the ordinary individual, but in poi- sonous amounts it produces methaemoglobin. If the doses be toxic or idiosyncrasy exists, cyanosis may come on. That the blood is not destroyed by small amounts is proved by the absence of haematin in the urine of persons taking the drug. The corpuscles suffer no changes except in very pronounced poisoning, Avhen they are said in become crenated and shrivelled. Respiration.—When antipyrine is given in lethal doses, death results from failure of the respiratory centre. Ordinary doses have no effect on this function, but large ones make the breathing more rapid. Temperature.—In normal men and animals antipyrine in medi- cinal dose may be considered as Avithout effect so far as bodily tempera- ture is concerned. In fevered animals it has been found to loAver temperature by decreasing heat-production and increasing heat-dissi- pation. That it does not do this by an action on the blood seems proved by the fact that the blood is not affected by medicinal amounts. The SAveating does not cause the fall, since it takes place Avhen no SAveating occurs. It may, therefore, be considered that the drug directly affects the nervous heat-mechanism of the body. Kidneys, Tissue-waste, and Trine.—A large number of studies made upon man and the lower animals by competent investigators have brought about very considerable advances in our knoAvledge of the influence of antipyrine upon tissue-Avaste. It is useless to burden this volume witli a discussion of their methods and results, which may be found in the author's Essay on Antipyretics. Suffice it to say that, Avhile all observers are not agreed as to the effects produced, the deduc- tions apparently to be draAvn are that the drug diminishes the quan- tity of the urine excreted, and also decreases the elimination of the results of nitrogenous tissue-metamorphosis—or, in other Avoids, is a conservator of the tissues of the body. 72 DRUGS. Elimination.—The elimination of antipyrine goes on very rap- idly indeed, and begins almost at once after its ingestion. Maragliano states that it appears in the urine in three hours after it is taken, so that at the fourth hour elimination is at its height, although it continues for twenty-four or perhaps thirty-six hours. According to PavlinoAV, part of the antipyrine ingested is eliminated by the salivary glands. Toxic Effects from Prolonged Use.—After chronic poisoning by anti- pyrine a post-mortem examination shoAvs intense engorgement of the brain and meninges, Avith a serous exudate into the cerebral ventri- cles. The lungs are highly congested, the spleen is small and shriv- elled, and the kidneys are filled with blood and slightly inflamed. The liver is not much affected, but the blood-corpuscles are greatly decreased in number. Poisoning.—The treatment of poisoning by antipyrine consists in the administration of stimulants, the maintenance of bodily heat, the use of atropine to restore the tone of the vascular system, and, if cyanosis is alarming, the employment of oxygen inhalations. Antiseptic Power.—Antipyrine exerts a very distinct antiseptic action in small amounts, delays all forms of fermentation, and destroys germs Avhen it is present in large quantity. Therapeutics.—Antipyrine is employed in medicine for two great purposes—namely, for the reduction of fever and the relief of pain— but its employment as an antipyretic is noAV entirely surpassed by its use as an analgesic. As an antipyretic, antipyrine should be given in a feAv large doses rather than frequent small ones, as a general rule, since if the fever is of any severity the latter method of administering it Avill have no effect. On the other hand, too large doses may depress the tempera- ture to a point beloAv normal and induce collapse. In the article on Fevers (Part IV.) the conditions are indicated in Avhich the drug is best employed, these being the sthenic fevers as a rule, or instances Avhere excessive outbursts of fever necessitate prompt reduction of temperature. Under these conditions antipyrine is the best adjunct to the cold pack. In excessively high temperature in pneumonia it is of great value, and in scarlet fever and smallpox antipyrine is of ser- vice in some instances. In pneumonia, as a rule, the condition of the patient indicates at first cardiac depressants rather than antipy- retics. In phthisis antipyrine generally increases the SAveating, pro- duces oppression, and either fails to act at all or produces collapse by producing too great an effect. In sunstroke it frequently fails to influence the temperature. Be the fever what it may, provided it be associated Avith any dis- eased process, antipyrine is absolutely useless so far as any influence over the course of the disease itself is concerned. It is a remedy to be used in the treatment of symptoms, not in the removal of the cause of the fever. As an analgesic antipyrine is the peer of opium. Although the latter drug will relieve ail forms of pain if it be pushed, it possesses many disadvantages not found in antipyrine. In deep-seated pains .4 NTIPYRINE. 73 due to disease of the organs of the body, in inflammations and similar disturbances, antipyrine is useless. In neuralgic affections of all kinds it finds its sphere, particularly if the disorder be rheumatic, gouty, or due to nervous depression from disease. Under the latter circumstances it is best combined Avith caffeine and a little bromide of potassium. (See Neuralgia.) In rheumatism it will give relief in a fairly large number of cases, not only relieving the pain and fever if they be present, but also actually modifying the disease. It seems, however, to increase sweating in acute articular rheumatism. In gout it is stated to have a specific curative effect upon the disease over and above the relief of the pain, but this is doubtful. Its use in dysmenor- rhS.—One night and morning. The B. P. preparations not official in the U. S. P. are Enema Asafoetida' and Pilula Asafoetida? Composita, composed of asafoetida, galbanum, and myrrh ; dose 5 to 15 grains (0.35-1.0). ASPIDIUM. Aspidium, U. S., Filix Mas, B. P., or Male Fern, is employed in medicine as • a taeniacide or remedy against the tape-worm, and is a very efficient and valuable drug under such circumstances, being, per- haps, the most reliable of all the vermifuges except pelletierin. When BARIUM CHLORIDE. 83 employed the directions and precautions given in the article on Worms must be strictly folloAved. Administration.—Male fern is rarely, if ever, used at present in its crude form, being employed most commonly in this country in the form of the oleoresin (Oleoresina Aspidii, U. S.); dose Ay to 1 fluid- drachm in capsules, or as folloAvs: R.—Oleoresin. aspidii) -- „ , lQr.\ Tinct. vanillK }........aa ^xlv t3-0)' Pulv. acacia?............^ss (2.0). Aq. destillat............f £j (32.0).—M. S.—Take entire amount after fasting, and follow in two hours by a full dose of castor oil or sulphate of magnesium. The dose of the liquid extract (Extraction Filicis Liquidum) of the B. P. is 15 minims to 1 fluidrachm (1.0-4.0). Katamaya and Okamoto, Iavo Japanese investigators, both state that castor and other oils should not be used after filix mas is given, as oils increase its absorbability, and so predispose to the develop- ment of poisoning. AZEDARACH. Azedarach is the bark of the Melia Azedarach, or Pride of China, as it is sometimes called. It is found in Syria, Persia, the north of India, and in the Southern United States. The drug has but little toxic poAver, and children may eat of it largely Avithout ill effect. If very large amounts are used, gastro- intestinal inflammation occurs. It is employed as a remedy against the round-ivorm, and should be given in decoction made by boiling 2 ounces of the drug in 1|- pints (750 cc.) of Avater until there only remains a pint (500) of liquid. Of this from 1 to 2 tablespoonfuls (16.0—32.0) are to be given a child, and repeated every tAvo hours until the boAvels are opened. It has also been used as a fluid extract prepared by the ordinary means Avith alcohol, to Avhich some white sugar should be added. The dose of this extract is a teaspoonful, and is not to be repeated. The decoction is the best form in which to use the drug. BARIUM CHLORIDE. One of the most recent and one of the best evidences of the value of the study of the action of drugs upon the loAver animals is given us by this substance. It will be remembered that Brunton and Ringer of London, Robert and Bary of Dorpat, and BartholoAV and the writer in America have at various times published, during the last feAV years, studies concerning the effect of barium on the circulatory apparatus of the frog, dog, and man, and all of them are in accord in the statement that it sIoavs the heart very greatly, steadies its rhythm, and at the same time increases the volume of blood thrown out of the ventricle. They have also found that barium increases blood-pressure, and Robert has, by a series of careful experiments, 84 DRUGS. concluded that it brings about this change by an action on the mus- cular coats of the blood-vessels. If large doses are used in the Ioavci- animals, the heart suffers sys- tolic arrest from over-stimulation, and the strongest irritation of the vagus nerves fails to relax the systolic contraction. Still more inter- esting is the statement that this failure of the vagi to inhibit the heart is not the result of paralysis of these nerves, but is simply due to the excess of cardiac contractile power. The slowing of the pulse is not due to inhibitory influence, but depends solely upon the stimu- lation of the heart-muscle, although it Avould seem probable that the vasomotor stimulation, by increasing the arterial resistance, may be at least a factor in the reduction of the pulse-rate. At one time, in the dog, after large doses, there is a period of increase of pulse-rate Avhich is asserted to be due to stimulation of the accelerator nerves. In most works on chemistry barium is stated to be an irritant poison, but to produce such evidences of its presence the dose given must be extremely large, and many times greater than any amount useful for medicinal purposes. Therapeutics.—Barium chloride may be used in all forms of car- diac disease in Avhich failure of the heart-muscle is present. In the treatment of varicose vei)is it is said to be of value, both Avhen given internally and applied locally over the distended vessels. A point Avorthy of remark is the character of the pulse-Avave pro- duced. While its volume is increased, it does not give that sensation of tenseness to the finger that does digitalis, and the pulse-wave seems to be very considerably prolonged—a fact that the sphygmograph also records. Administration.—The solution of barium chloride to be used inter- nally should have the strength of 5 grains to the ounce (0.3 : 32.0) of Avater, and of this 1 or 2 teaspoonfuls (4.0-8.0) is to be given three times a day. BELLADONNA. Belladonna is botanically known as Atropa Belladonna, and is official in the form of the root (Belladonna? Badix, U. S. and B. P.) and leaves (Belladonna' Folia, U. S. and B. P.). It belongs to a very large class of plants which all have a similar physiological action. Belladonna contains an active principle in the form of an alkaloid known as atropine (Atropina, U. S. and B. P.), Avhich is insoluble in water. The sulphate of atropine (Atrophia? Sulphas, U. S. and B. P.) is soluble. Physiological Effects.—In man, full medicinal doses produce flush- ing of the face, redness and dryness of the fauces, dilated pupils, sometimes an erythematous rash over the skin, rarely diplopia and delirium. If the dose be still larger, the delirium becomes very marked and is wild and talkative. The pulse is rapid and Aviry. The rash which appears resembles that of scarlet fever, but lacks the punc- tations. The skin may desquamate after several days if the rash is severe. BELLADONNA. 85 In children, belladonna is usually borne very well indeed, and opium very badly. When belladonna asserts itself in children, the respiration is quickened, the eyes become bright and the cheeks red, but lines of pallor reach from the malar bones to the corners of the mouth, giving the face a curious expression. Nervous System.—Belladonna acts as a powerful excitant of the brain and spinal cord. When very large doses are given, paralysis of the spinal cord comes on, which is folloAved by tetanic spasms, and finally by recov- ery. The primary loss of power is due to paralysis of the entire cord, and the second state, of convulsions, to the escape of the motor and sensory patliAvays from the paralysis before the inhibitory centres recover. As a result, any peripheral irritation causes violent explo- sions of motor poAver.1 Even in large medicinal dose belladonna may be considered as a depressant to the motor nerves and as a quieter to sensory nerve-filaments. On voluntary muscles the drug has no effect, but upon unstriped muscles it acts as a depressant and antispasmodic. It distinctly lessens reflex action. Circulation.—Belladonna quickens the pulse by depression of the peripheral vagi and by stimulating the cardiac muscle. It pro- duces a rise of arterial pressure by stimulating the vasomotor centre and by the increased heart-action Avhich it causes. In poisonous doses it causes a fall of arterial pressure due to centric vasomotor palsy, and depression of the muscular coats of the blood-vessels, but not to cardiac depression, as has been generally taught, for Reichert has proved that the drug is not a heart-depressant unless the dose is simply overAvhelming. Sometimes Avhen belladonna is given the pulse becomes sIoav, but in these cases the sloAving is due to temporary stim- ulation of the peripheral vagi or to momentary depression of the car- diac motor ganglia. Respiration.—Atropine is a stimulant to the respiratory centre in ordinary amounts, but recent careful studies sIioav that its high reputation as a respiratory stimulant is not based either on clinical or experimental experience. In many cases it fails to increase the respiration at all, and it is certainly inferior to coffee and strychnine in the treatment of opium poisoning. In large doses it is a depressant and paralyzant to respiration, and produces death from respiratory failure due to paralysis of the motor neiwes supplying the respiratory muscles, and probably by depressing the respiratory centres. Abdominal Contents.—Belladonna increases peristalsis by de- pressing the peripheral ends of the inhibitory fibres of the splanchnic nerves, and by diminishing any tendency to spasm on the part of the muscular coats of the intestine. Action on Skcretion.—The drug decreases all the secretions of the body except the urine, Avhich is sometimes increased in amount 1 If a homely simile, found useful by the writer in teaching, may be used, the inhibitory centres may be represented by a schoolmaster and the motor and sensory centres by two boys. The escape of chloroform in the room paralyzes them all, but, finally, the boys recover before their master and go off as truants (convulsions); at last the master (inhibitory centres) recovers, and order, or health, is restored. 86 DRUGS. under its use. The decrease of secretion is due to paralysis of the peripheral nerve-filaments supplying the secretory cells of the glands. Bodily Heat.—When belladonna is used in large amounts there is nearly always a rise of temperature, which in children may amount to one or tAvo degrees. In advanced poisoning the temperature rap- idly falls. Elimination.—Atropine is eliminated by the kidneys and boAvels, and is partly destroyed in the liver. In a suspected case of poisoning the urine of the patient maybe dropped in the eye of an animal, and, if atropine or belladonna has been taken, mydriasis will result. Eye.—On the eye belladonna produces dilatation of the pupil by stimulating peripherally the sympathetic nerve-fibres of the iris and paralyzing the ocular motor fibres, but the dominant action of the drug "is undoubtedly exercised upon the muscular fibres of the iris (Jessup). Littauer'has recently asserted that dilatation is not due to sympathetic stimulation, but Jessup's conclusions are generally accepted as correct, although the teaching as to the influence of atropine on the eye has changed several times in the last ftnv years. Belladonna gen- erally increases intra-ocular tension. Treatment op Poisoning.—Poisoning by belladonna is to be treated by the application of external heat if the patient goes into collapse, and the use of strychnine if respiration fails. Opium may be employed in carefully graded doses as the physiological antagonist, but large doses are of doubtful service, particularly if the respirations are not in a satisfactory state. Therapeutics.—Belladonna is used to allay excessive secretion, to act as an antispasmodic, and to influence the circulatory apparatus Avhen local inflammations are beginning, particularly in secretory glands. In cardiac palpitation small doses of belladonna internally, or its external use over the praecordium in the form of a belladonna plaster or ointment, is very useful. It is also our most useful vasomotor stim- ulant in shock. Belladonna is of value in neuralgias and in the pains due to irritated peripheral nerves. To check secretion in night-sweats it is one of the best remedies Ave have, and it is useful in excessive idiopathic ptyalism, as seen in chil- dren, or in that due to mercurialization. In bromidrosis of the feet and other localized sweatings it is useful, and may be employed locally or taken internally for their cure. It is the best drug Ave have for checking the secretion of milk in an inflamed breast, and under these circumstances it is best to smear it over the gland in an ointment. Belladonna may be used in serous diarrhoea, as it checks the disorder by stimulation of the splanchnic vasomotor filaments of the intestinal blood-vessels, which being inactive permit a transudation of liquid into the bowel. Trousseau recommended as a local remedy 1 to 2 grains (0.05- 0.10) of the extract of belladonna Avith 6 to 8 grains (0.30-0.40) of tannic acid in leucorrhaa dependent upon disease of the uterine cer- vix. This should be placed on a pledget of cotton and applied to the affected part daily, being alloAved to remain all day. Ringer BELLADONNA. 87 states that if pain is also present in these cases the folloAving injec- tion is of value: R.—Sodii bicarbonatis............^j (4.0). Tr. belladonna-............, t'^ij (8.0). Aqua; dest.............q. s. ad Oj (500 cc).—M. This is to be injected into the vagina, the Avoman first being placed on her back Avith her buttocks raised, so that the drug may bathe the uterine cervix for some minutes. xVs an antispasmodic, atropine is to be used in torticollis, injected directly into the muscle itself, so as to act on its motor nerve-fibres, and it may be given in spasm of the intestine Avith cramps and griping, Avhile in cramps in the legs and body, either as a local application by means of liniments or Avhen employed internally, it is of service. In asthma of the spasmodic type belladonna is a sovereign remedy, particularly if it be combined Avith morphine. It may be used both as a prophylactic and as a cure during the attack. The belladonna- leaves may be smoked by rolling them into a cigarette or putting them into a pipe. This drug is used in whooping cough at all ages and in all stages, but it has generally to be given in large amounts in this disease to do any good. In spasm of the sphincter ani, that Avhich is either idiopathic or due to fissure, belladonna in the form of an ointment or suppository is of value. In spasm of the urethra and bladder the drug may be used internally and externally, and in the former state the ointment should be smeared along the under surface of the penis every night. This treatment is also useful in ehordee. In the colic resulting from the passage of hepatic and renal calculi belladonna in full dose Avill nearly always ghTe relief. Where urinary incontinence depends upon spasm of the bladder belladonna should be used. (See LTrinary Incon- tinence.) In dysmenorrhea in nervous Avomen, Avith spasm of the cervix uteri, it is of very great value applied as an ointment or in a vaginal suppository, or Avhen given by the mouth. For the nervous cough of children and adults belladonna is one of the best remedies we have. In constipation it does good by depressing the inhibitory nerves of the intestine. It is also of value in lari/ngismus stridulus and in hiccough. In spasms from peripheral irritations belladonna is of value. In iritis atropine is used to dilate the pupil and prevent adhesions. The solution to be dropped into the eye should contain 1 to 4 grains (0.05-0.20) of atropine sulphate to the ounce (32.0) of water. Atropine sulphate is also used for the purpose of producing mydriasis, before ophthalmoscopic examination, in solutions of the strength just given. It increases intra-ocular tension and is contra- indicated in glaucoma. When employed to act on the circulation it is to be used in shock and collapse from injury or in the course of severe disease. (See Shock.) During the progress of a case of pneumonia, typhoid fever, or other severe disease belladonna should be kept in the house, and administered freely if collapse or vasomotor relaxation suddenly asserts itself. Particularly is this true in the 88 DRUGS. case of pneumonia. The Avascular system after crisis will often be found much relaxed, and stimulants do not seem to do much good. The administration of atropine or belladonna Avill dry the leaking skin, and by increasing the vasomotor tone produce great improvement. In mas- titis, or inflammation of the breast, even Avhere pus is beginning to be formed, belladonna, if pushed, Avill give surprisingly good results if given internally and applied locally. In sore throat, Avhen the phar- ynx is hot and dry and has a sensation of rawness, Avhile the local capillaries appear injected and red, belladonna is often of the greatest service if given in full dose, aborting the "cold." In exophthalmic goitre belladonna is thought to act by stimulating the sympathetic nerves, and certainly gives relief in some cases, particularly if com- bined Avith strophanthus or digitalis. For the relief of local nerve- pains it is of value, and probably acts by quieting the irritated nerve. It should be applied in these cases in the form of an ointment or plaster, and be well rubbed into the part affected. In headache occurring in young persons, often due to over-Avork, with pain in the eyeballs and forehead and a sensation as if the orbits were too small for the eyeballs, belladonna is of service. In intercostal neuralgia or pleurodynia belladonna plasters may be applied to the spot Avhere the pain is felt, Avith relief. Use of Atropine in Poisoning.—Atropine acts as an andidote in cases Avhere poisonous mushrooms have been eaten, and is a physio- logical antidote to opium. Calabar bean or physostigma, and jaborandi. In opium poisoning it acts as an antidote in all parts of the body except the eye, ano1 in jaborandi poisoning the same facts hold true. In opium poisoning the drug should not be given after the respira- tions rise to ten from three or four per minute, as too much of the drug may be given and atropine poisoning may come on and compli- cate the case. The condition of the pupil is not a guide as to the effect of atropine in opium poisoning, because opium acts centrically and atropine acts peripherally on the nerves governing the iris. Atropine should be used in aconite, antimony, and hydrocyanic-acid poisoning for its influence on the vasomotor system, the respiratory centre, and the heart, and for the purpose of maintaining the bodily heat, the dissipation of Avhich it retards by preventing vasomotor palsy and consequent dilatation of the peripheral blood-vessels. It should be borne in mind that atropine is not the very best single antagonist to opium, and that in opium poisoning it ahvays should be largely aided by caffeine and strychnine. Administration.—The dose of the sulphate of atropine (Atrovinee Sulphas, U.S. and B. P.), is ^ to fa (0.0004-0.0015) of a grain. The alcoholic extract (Extraction Belladonna' Fdiorum Alcoholicum, U. S. and B. P.) is given in 1 to \ grain (0.01-0.015) doses, and the tincture (TineturaBelladonna?Fdiorum, U. S. and B. P.) in the dose of 5 to 15 minims (0.3-1.0). Both these preparations are derived from the leaves. The fluid extract (Extractum Belladonna' Badicis Fluidum, U. S.) is given in 1- to 2-minim (0.05-0.10) doses, while the extract of the B. P. is given in \- to 1-minim (0.015-0.05) doses. These preparations are derived from the root. Succus Belladonna? BENZOIN AND BENZOIC ACID. 89 B. P., is given in 5- to 15-minim (0.3-1.0) doses. The preparations of the B. P. not official in the U. S. P. are Liquor Atrophia? Sulphatis, given in the dose of 1 to 6 minims (0.05-0.32); Lamella? Atropince, each of Avhich contains -^fa-^ 0I> a grain of atropine ; and Unguentum Atropine/. Belladonna liniment (Linimention Belladonna', U. S. and B. P.), belladonna plaster (Emplastrum Belladonna', U. S. and B. P.), and the ointment (Unguentum Belladonna, U. S. and B. P.) are for external application. Recent experiments shoAv that belladonna decreases gastric secre- tion very considerably in some persons. It is better, therefore, not administer it just before or immediately after a meal. BENZOATE OP BISMUTH. This is a preparation Avhich has been highly recommended in Ger- many, and to some extent in this country, within the last few years, in the treatment of chancroid. LTnder its influence the sore heals up Avith great rapidity and leaves a comparatively small cicatrix. It may also be used in the treatment of all specific sores and for the dressing of indolent or sloughing ulcers. Benzoate of bismuth, Avhen properly applied, should be preceded by a careful Avashing of the diseased sur- face Avith a very Aveak bichloride-of-mercury solution, after which the bismuth is to be sprinkled over the Avound and the entire surface cov- ered Avith cotton, Avhich should be held in place by an adhesive strip. The only disadvantage in this dressing lies in the fact that it has to be changed once or tAvice in every twenty-four hours. Immediately after it is applied it may produce some tingling or burning, but this is never very severe. BENZOIN AND BENZOIC ACID. Benzoin (Benzoinum, U. S. and B. P.) is a resinous balsam derived from the Styrax Benzoin, Avhich is a native of Sumatra, Borneo, and Java. Benzoic acid is obtained by the sublimation of gum benzoin, or prepared artificially, chiefly from toluol. This last preparation is not to be recommended, as it often disorders the stomach and leaves a disagreeable taste in the mouth. It is benzoic acid which is gen- erally used in medicine. Physiological Action.—Locally applied in concentrated form, ben- zoic acid is an irritant, and taken internally in excessive amount it causes a sensation of Avarmth and burning. It is eliminated as hip- puric acid, and increases the acidity of the urine. On the lower forms of life it acts as an antiseptic and germicide. In persons having an idiosyncrasy to benzoic acid it is not uncommon for urticaria to folloAv the use of the drug. Sometimes a papular or erythematous eruption appears. Therapeutics.—Benzoic acid is useful in the treatment of chronic cystitis Avith alkaline urine Avhich is loaded with phosphates, and, 90 DRUGS. combined with cannabis indica, acts Avell in the later stages of gonor- rhoea. Senator states that in the dose of 2 or 3 drachms (8.0-12.0) a day it is a specific in acute rheumatism, and thinks it equal to sali- cylic acid. When these doses are to be used, the benzoate of sodium should be employed, owing to its solubility. In acute laryngitis accompanied by great hoarseness the inhalation of steam laden with compound tincture of benzoin is of the greatest service. A table- spoonful (16.0) of this tincture should be placed in a pitcher of boil-' ing Avater, the face held over the liquid, and a tOAvel throAvn over the head of the patient to retain the steam. The drug cannot be used in an atomizer, as it clogs the "tips." Taken internally, benzoic acid is useful in chronic bronchitis. Administration.—The dose of benzoic acid (Acidum Benzoicum, U. S. and B. P.) is usually 10 to 40 grains (0.6-2.6), but a drachm may be given in capsule. The gum itself is never used as such. The tincture (Tinetura Benzoiui, U. S.) is given in 30-minim to 1- drachm (2.0-4.0) doses, and the compound tincture (Tinetura Ben- zoiui Composita, U S. and B. P.) is composed of benzoin, aloes, sto- rax, balsam of Tolu, and alcohol, the dose of it being 1 to 2 fluid- drachms (4.0-8.0). The preparations official in the B. P., but not in the U. S. P., are the troches (Troehisci Acidi Benzoici) and Unguentum Cetacei. Adeps Benzoinatus (U. S. and B. P.), or benzoated lard, is sim- ply a non-rancid basis for many ointments, notably that of zinc. BICARBONATE OP POTASSIUM. This salt (Potaxsii Bicarbonas, U. S. and B. P.) is used for the same purposes as the citrate and acetate of potassium, and, as it is much less agreeable in taste, should not be employed Avhen they can be obtained. From the bicarbonate of potassium are made several very useful preparations: the liquor potassii citratis, by adding 120 grains (8.0) to 90 grains (6.0) of citric acid and 10 ounces (320.0) of water; the neutral mixture, by adding to 1 pint (500.0) of lemon-juice enough of the potassium salt to neutralize it. The dose of potassii bicarbonas is 5 to 40 grains (0.3-2.6), or even as much as 2 drachms (8.0) may be given if well diluted with water. BICARBONATE OP SODIUM. Bicarbonate of Sodium (Sodii Bicarbonas, U. S. and B. P.) is a salt largely used as an antacid in gastric fermentation and in sick headaches arising from this condition. Combined with calomel in poAvder, it certainly adds to its efficiency in increasing biliary flow, as all alkalies of this class liquefy and thin the bile. The drug has been Avidely employed in the treatment of rheumatism, and is found to be of great service in allaying pain and soreness in the joints when used in a lotion made by dissolving it in Avater and applying it to the part on lint or rags. In acidity of the stomach the following effer- BISMUTH. 91 vescing poAvder is useful: Bicarbonate of sodium (Sodii Bicarbonas), 30 grains (20) in one paper, and in the other 20 grains (1.3) of tar- taric acid (Acidum Tartaricum). These are each dissolved in half a tumbler of water, added to one another, and SAvalloAved during effer- vescence. BISMUTH. Bismuth (Bismuthum, B. P.) is official as the subcarbonate (Bis- muthi Subcarbonas, U. S.), the subnitrate (Bismuthi Subnitras, U. S. and B. P.), the citrate (Bismuthi Citrus, U. S. and B. P.), and the bismuth and .ammonium citrate (Bismuthi et Ammonii Citrus, U. S. and B. P.). The first and second are identical in their dose (5 to 20 grains) (0.3-1.3) and action, and may be employed interchangeably. The third and fourth are more astringent and more irritating than the other tAvo, and must be given in a smaller dose, which is 2 to 4 grains (0.1-0.2). Many years ago the drug Avas supposed to be cap- able of producing gastro-enteritis in large doses, but this Avas due to a contamination by arsenic. Bismuth may produce chronic poison- ing after prolonged use on Avounds or Avhen internally administered. The changes under these circumstances are the formation of black sloughs in the mouth and gastro-intestinal tract, desquamative nephri- tis, and albuminuria. The preparations of the B. 1J. not official in the U. S. P. are the Liquor Bismuthi et Ammonii Citratis, dose ^ to 1 fluidrachm (2.0—4.0), and the troches (Trochisci Bismuthi), 2 grains (0.1) in each. Bismuthi Carbonas, B. P., is the same as the subcar- bonate of the U. S. P. Therapeutics.—Bismuth is used as an astringent in large doses to cover the surface of inflamed mucous membranes and so to allay irri- tation. It is useful in irritative vomiting for this reason, and in diar- rhoea of a similar type in Avhich the stools are serous. If the passages are mucous, castor oil should precede bismuth in order to rid the ali- mentary canal of the mucous secretion already poured out. It is very useful Avhen combined Avith carbolic acid in serous diarrhoea, given in capsules containing 5 grains (0.3) of bismuth subnitrate and 1 drop (0.05) of carbolic acid (Wood). It is also to be used as a slow and feeble antacid. The Bismuthi et Ammonii Citrus is very astringent, and should be used in chronic serous diarrheas in the dose of 5 grains (0.3) every tAvo or three hours. The other preparations of bismuth are insoluble, and they should not be given in Avater, but this prepa- ration is soluble and may be given in solution. Bismuth is of service in dyspepsia Avhen lactic and butyric acid fermentation is present Avith excessive belching, and may be employed in gastralgia and gastric ulcer and gastritis as a sedative and astringent. Bismuth and ammo- nium citrate must never be employed if acute inflammation exists. When the salts of bismuth are used for any length of time, they cause the odor of garlic to appear in the breath, Avhich is due to the presence of an exceedingly slight trace of tellurium in the bismuth. The stools are apt to become black, and the tongue, if furred, may also be black about the centre when bismuth is used. 92 DRUGS. Where there is chapping of the hands or cheeks from exposure to cold or Avet the following prescription is useful: R .—Bismuthi subnitratis.........^iij (12.0). Zinci oleatis ............3UJ (12.0). Lycopodii .............3ij (8.0).—M. S.—Apply to the parts t. d. BISMUTH SALICYLATE. (See Salicylate of Bismuth.) BISMUTH SUBGALLATE. Dermatol, or the subgallate of bismuth, was first used by Heinz and Liebrecht. It is a fine yellow powder which is unaffected by long exposure to light and air, is entirely odorless, and is supposed to contain 55 per cent, of oxide of bismuth. Its external uses are iden- tical Avith the uses of iodoform, and it probably acts in much the same manner as does the latter drug—namely, by so drying the Avound that it becomes an unfavorable soil for the groAvth of germs. As dermatol is an astringent, it cannot be employed in the treatment of indolent ulcers, Avhich need stimulation rather than an astringent influence, and it would seem probable on theoretical grounds that it is not to be compared to iodoform in the treatment of cases in Avhich tubercular processes are going on. There is no doubt that dermatol is less poisonous than iodoform, but it must be capable of producing some untoAvard effects if used profusely for any length of time, since poisoning follows the pro- longed employment of bismuth preparations, as has been determined by Balzer, Dalche", and Villejean, for the symptoms of which see the article on Bismuth. Dermatol may be tried in cases of skin disease in Avhich there is much secretion, as in weeping eczemas and similar states, either in the form of a dusting-powder or in an ointment with vaseline or lano- lin in the proportion of | to 1 drachm to the ounce (2.0-4.0 : 36.0). Sometimes its efficiency can be much increased by the addition of an equal part of oxide of zinc to the prescription just given. Dermatol has been used in cases of purulent otitis media and many states requiring similar effects Avith marked success. Internally, it has been highly recommended in cases of fermenta- tive dyspepsia in the dose of 5 to* 10 grains (0.3-0.65), but its real value in this condition is as vet undetermined. BITARTRATE OF POTASSIUM. Potassii Bitartras, U. S., Potassii Tartras Acida, B. P., is some- times called "cream of tartar" or acid tartrate of potassium. It is a white gritty powder Avhich may occur in rhombic crystals. Owing BORAX AND BORIC ACID. 93 to its stability, it has been thought that it escaped from the body without oxidation, and so to differ from the other potassium salts formed from vegetable acids. This is probably incorrect. Therapeutics.—The bitartrate of potassium is the most diuretic of the potassium salts, and is used in chronic nephritis with gin or com- pound infusion of juniper, Avhen it is very useful in removing dropsy. 1 ounce' (32.0) of the salt is added to a pint (500 cc.) of the infu- sion of juniper-berries, and the entire quantity taken in divided doses in tAventy-four hours. In acute renal disease the drug should be used without the juniper. In large doses—h an ounce (16.0)—it acts as a Avatery purge, but is rarely so used. Where the urine is thick and alkaline bitartrate of potassium is a useful remedy to neutralize it and make it clear and normal in hue. BORAX AND BORIC ACID. Borax, or Sodii Boras (U. S. and B. P.), may be made by the action of boracic or boric acid upon soda, but the drug as it appears in commerce in America is derived entirely from natural deposits found on the shores of lakes in California and NeAada. The natural product is, of course, very impure, and has to be purified before it is marketable. Borax is soluble in tAvelve times its Aveight of Avater. Both borax and boric acid have been supposed to act as efficient germicides in strong solutions, but this has been proved incorrect. They are antiseptics, hoAvever, even Avhen in Aveak solutions. In the form of a lotion boric acid has been used as a remedy for erysipelas Avith a good deal of success, and it may be similarly employed in burns and scalds. Borax may also be used as a Avash in diphtheria and in aphthous stomatitis, cancrum oris, and gangrenous stomatitis. Internally, borax has been used in epilepsy, and may be tried Avith some slight hope of a good result. (See Epilepsy.) In the treatment of pruritus ani and vulva' and in bromidrosis and fetid sweating it is of great value Avhen used as a Avash. Strong solutions, locally applied, are useful in tinea tonsurans and tinea circinata. Boric acid may be given internally in cystitis to render the urine acid, and is useful in the removal of freckles Avhen applied as a wash to the skin. In per- sons having an idiosyncrasy to boric acid a bullous eruption of the skin may follow its use. Borax should not be used with glycerin, as an acid reaction is apt to occur. A very useful Avash for oral and nasal mucous membranes is " Dobell's solution," Avhich is composed of— B--|°^i.i. ^j? t.\.........aa £ (4.0). Sodii bicarbonatis I S',), dose 1 to 4 fluidrachms (4.0-16.0). The dose of the extract (Extracturn Calumba', B. P.) is 2 to 10 grains (0.1—0.65); the infusion (Infusum Calamine, B. P.), 1 to 2 fluidounces (32.0-04.0); and the tincture (Tinetura Calumbe, B. P.), J to 2 fluidrachms (2.0-8.0). CALX. Calx, or Lime, or Oxide of Calcium, is an alkaline earth which is incompatible with acids, ammoniacal and metallic bases, borates, alka- line carbonates, and astringent vegetable infusions. It is prepared by burning pure Avhite marble, oyster-shells, or the purest calcium carbonate. Therapeutics.—Lime is used for the purpose of acting as an eschar- otic, particularly on old ulcers and on hairy growths. It is never given internally except in the form of the hydrate or slaked lime. As an escharotic application lime is used in the official caustic Potassa cum Calce, U. S. When given internally it should ahvays be used 108 DRUGS. as Liquor Calcis, U. S. and B. P., or lime-Avater, and under these circumstances it acts as an antacid, as an aid to the digestion of milk by preventing too rapid and solid coagulation of the casein, and by exciting an increased gastric secretion. It is also feebly astringent. Given to infants and nursing Avomen, it is probably utilized in the body in the formation of bone. It is also of value in diabetes, in the uric-acid diathesis, and in the excessive nausea and vomiting very often seen in adults and children. Teaspoonful doses of milk and lime-Avater, equal parts, will often be retained when nothing else will remain in the stomach. The dose of lime-Avater is a teaspoonful (4.0) to 1 ounce or even 2 ounces (32.0-64.0). Externally applied, lime-water is of value in tinea capitis and similar states, and it is the best application in burns, Avhen it is to be mixed Avith equal parts of linseed or olive oil, form- ing the Linimentum Calcis, U. S. and B. P., or carron oil. As a local application in membranous croup and diphtheria lime-Avater has a high reputation, and is believed to dissolve the membrane. It may be used as a spray or by means of a swab. Litpior Calcis, or lime-water, is to be made by adding a piece of unslaked lime as large as a walnut to 2 quarts of boiled and filtered Avater in an earthen jar; after stirring it thoroughly allow it to settle, and pour off the clear liquid into a bottle. More water may then be added to the lime until it is all used. Sulphurated lime (Calx Sulphurata, U. S. and B. P.) is useful to cheek inflammation and hasten suppuration; the dose is fa of a grain (0.006). It is of value in acne pustulosa and all forms of suppura- tion in the skin. Where sulphurate of lime is not obtainable and successive crops of boils constantly appear, it is often possible to relieve the patient by baking egg-shells in an oven, powdering them, and then letting the patient eat 1 drachm (4.0) or more of the poAvder each day. The preparations of the B. P. that are not official in the U. S. are the saccharated solution of lime (Liquor Calcis Saccharatus), dose 15 to 60 minims (1.0-4.0), and slaked lime (Calcii Hydras), used in different preparations. (For Calx Chlorata see Chlorinated Lime.) CAMPHOR. Camphor (Camphora, 77. S. and B. P.) is derived from the Cin- namomum Camphora, which groAvs chiefly in China and Japan. The camphor used in the drug-stores is in reality refined camphor, and is so obtained by repeated sublimation. It is a volatile, irritant gum or resin, producing a burning taste and possessing a peculiar odor, soluble in 1000 parts of cold Avater and in 1 part of strong alcohol. Camphor is so volatile that if allowed to remain exposed to the air for any length of time it rapidly loses its bulk and eventually disap- pears. It is an exceedingly combustible substance, burning with a flame and much smoke. It may be Avhite or pinkish in color. CAMPHOR. 109 Physiological Action.—If taken in large amount, camphor pro- duces epileptiform convulsions, preceded by vertigo, roaring in the ears, and delirium. The pulse soon becomes rapid, feeble, and run- ning, and the skin livid, cold, and covered Avith SAveat. Great heat and burning may be felt in the belly, and, if the poisoning be sIoav, evidences of gastro-intestinal and renal inflammation ensue. In small doses it acts as a stimulant and adds a sensation of warmth to the stomach, while the pulse may become more rapid and stronger under its influence. At the same time there is a sedation of the nervous system and a general feeling of contentment. In large medicinal dose camphor is thought by some to act as a sexual stimulant, and by others as a sexual sedative. The stimulant effect is probably only produced by doses large enough to produce irritation of the genito- urinary tract. The convulsions folloAving poisonous doses are cere- bral in origin, and the drug, although largely destroyed in the body, is eliminated by the kidneys as camphoglycuric acid and escapes by the breath and perspiration. Therapeutics.—Internal Use.—Camphor is employed for the purpose of acting as a nervous sedative and antispasmodic in the treat- ment of nervous Avomen and children, and as a carminative in persons Avho suffer from intestinal flatulence. It is of value in nervous dys- menorrhea and headache, and is best combined Avith one of the neAV analgesics, such as antipyrine and acetanilid given in pill form. As it is virtually a volatile oil so far as its physiological action is con- cerned, it will be found useful in cholera morbus and all forms of serous diarrhea, but rarely in mucous diarrhoea. (See Diarrhoea.) In chordee, combined with bromides and similar depressants to the spinal cord, camphor is of great service in some cases, particularly late in the disease. In adynamic fevers it has been used as a diffus- ible stimulant by Graves and others Avith great success. Camphor is a very useful remedy in cases of sudden nervous depression. It may be given by the mouth or, if the emergency is a pressing one, by hypodermic injection. Under these circumstances it is best given in the form of camphorated oil in the strength of 1 part of camphor to 9 of sweet oil, which last should be perfectly sterile. The dose of this solution is 15 minims (1.0). When used in the nervous depres- sion of phthisis, Alexander asserts that its. continuous injection may result in cumulative action and develop the symptoms of mild camphor poisoning. In hiccough it is of great service, and in cardiac palpitation due to functional irritability it is found to be of value. In capillary bronchitis and catarrh of the air-passages it will be found useful in old or atonic cases. In chronic nasal catarrh spirits of camphor Avhen inhaled from the neck of a vial gives off enough of the drug to start up secretion and tone up the parts. It is also of value as a mouth-wash in persons who have foetid breath. External Use.—Externally camphor may be used as a stimulant to indolent sores and as a useful addition in small amount to the pre- cipitated carbonate of calcium as a dusting-powder in intertrigo. In the form of a liniment camphor is used over inflamed joints from 110 DRUGS. sprains or rheumatism, and in myalgia and neuralgia to relieve the pain and stiffness. Camphor may be inhaled or taken internally in cases of cold in the head with great relief and a decided influence in aborting the attack. After the attack is in full force it is useless, but used early it will decrease the frontal headache and the sneezing and running at the nose. In coryza from unknown causes with much lachrymation and incessant sneezing camphor will be found of benefit. It may be snuffed up the nostril in a fine poAvder, or powdered camphor may be put in boiling water and the fumes inhaled. The spirit may also be inhaled from a handkerchief. Camphorated alcohol, spirit of camphor, is a useful application for abortive purposes Avhen used over boils in their formative stage, if repeated two or three times a day for a feAV moments at a time. Fol- loAving these applications, the skin should be dried and camphorated oil applied. Ringer and Tilt both recommend that eau de Cologne, saturated Avith camphor, be rubbed into the head in the drowsiness and headache of the menopause, and a lotion of equal parts of aqua ammonia and spirit of camphor dabbed on the painful or hyperses- thesic spots at the top of the head, so commonly felt at the change of life or during menstruation, Avill be found to give relief. Administration.—Camphor is used internally in the form of the camphor-water (Aqua Camjdiore, U. S. and B. P.), dose J to 2 fluid- ounces (16.-64.) ; the spirit of camphor (Spiritus Camphore, U. S. and B. P.), dose J a fluidrachm (2.0), or in the form of the camphor itself, in pill, in the dose of 1 to 3 grains (0.05-0.15) in each pill. The best preparation for internal use is the spirit, or the camphor itself may be given. For external use we have, official, the camphor liniment (Lini- mentum Camphore, U. S. and B. P.) and the soap liniment, or Lini- mentum Saponis, U. S. and B. P., Avhich is the mildest of the tAvo. Ceratum Camphore is also official. A compound tincture of camphor (Tinetura Camqd/ore Composite/), composed of opium, benzoic acid, camphor, and oil of anise, is official in the B. P., dose 15 minims to 1 fluidrachm (1.0-4.0). Linimentum Camphore Composition, B. P., is composed of camphor, rectified spirit, and stronger ammonia. CAMPHOR MONOBROMATE. Monobromate of Camphor (Camphora Monobromata, U. S.) is made by heating together in a sealed tube camphor and bromine. It occurs in colorless crystals or scales, and has a mild taste resembling camphor. It is almost entirely insoluble in water, but freely soluble in alcohol, ether, and chloroform. Physiological Action.—Monobromate of camphor possesses powers partaking of the bromides and of camphor. In the frog it causes loss of reflex action, motor palsy and death by respiratory failure, and in Avarm-blooded animals violent convulsions, Cheyne-Stokes respirations, muscular tremblings, and Aveakness. The pulse is at first more rapid CANNABIS INDICA. Ill than normal, then sIoav and Aveak, death coming in coma or during the convulsions. Therapeutics.—Monobromated camphor Avill generally be found most useful for pain Avhen combined Avith other drugs, particularly in lum- bago, or the pain due to nervous disturbances. If used in hysterical females, it Avill often produce sleep, and is of value to those Avho are addicted to the camphor-habit, as it acts as a hypnotic and warms the stomach. Like camphor itself, it is a gastric irritant, and should not be employed Avhere gastritis exists. It has been used in spermatorrhea with great success, and in delirium tremens has been found of benefit in cases where the gastric mucous membrane is depressed and the nervous tAvitchings are troublesome. In whooping cough it may be tried, and it has even been used in chorea, epilepsy, and petit mal. In the nervous depression and pains of epidemic influenza monobromated camphor has been largely used. (See Acetanilid.) Administration.—It should never be used hypodermically, as it is too irritating, but administered in the dose of 5 grains (0.35) three times a day in pill, or in an emulsion made by dissolving it in six times its Aveight of expressed oil of almonds and then forming an emulsion Avith gum arabic and Avater in the usual manner. CAMPHORIC ACID. Camphoric Acid is made by the oxidation of camphor through the influence of acids, and has been used in the night-sweats of phthisis Avith great success. In a large number of cases suffering from night- SAveats the author has found this drug to act very favorably indeed Avhere other remedies failed. It may be resorted to in the dose of from 20 to 30 grains (1.3-2.0), taken an hour or tAvo before the sweat is expected. In very obstinate cases as much as 60 grains (4.0) should be given, but under these cir- cumstances it should be used in two separate doses of 30 grains (2.0) each, tAvo hours apart, in order to avoid irritating the stomach. It is best given in capsule, as it is insoluble in Avater. In other instances camphoric acid may be given in the folloAving formula: R.—Acid, camphoric...........^iv (16.0). Alcohol..............f3ij_(64.0). Mucilag. acacia?..... ... fSiij (96.0). Syr. aurantii corticis.....q. s. ad f^vj (128.0).—M. S.—Dessertspoonful (8.0) to a tablespoonful (16.0) one hour before sweat is expected. It is Avorthy of note that camphoric acid is possessed of little power, in the writer's experience, in cases of bromidrosis. CANNABIS INDICA. Indian Hemp (Cannabis Indica, U. S. and B. P.) is the floAvering tops of the female plant of Cannabis Sat/va. It is to be distinctly separated from the so-called American, American-Indian, or Canada hemp, or Apoeynum Cannabinum, which is an intense irritant and drastic. 112 DRUGS. Physiological Action.—Given in full dose to man, this drug causes exhilaration and periods of constant laughter arising from the slightest cause, the person seeming convulsed with merriment; in other cases the sensations are disagreeable, and even death may seem imminent to the deranged mind. Often the sensation of very full breathing comes on, and the patient thinks he is about to burst Avith the inflation of his lungs. After this deep sleep appears, lasting for many hours, even as much as fourteen or fifteen, Avithout any intervals of wake- fulness. If the dose be very large, the respirations are slowed very considerably, but no death from the use of cannabis indica by man is on record, and enormous amounts have been given to the loAver ani- mals Avithout causing a lethal effect.1 Applied to mucous membrane, it acts as a very severe irritant, and then as a local anaesthetic, but the primary effect is so poAverful as to prevent its local use to mucous membranes for the relief of pain. One of the most constant and pressing symptoms in poisoning in man is the marked sensation of prolongation of time, so that minutes seem like hours, and, in addition to this, a peculiar separation of the mental poAvers occurs, during Avhich both hemispheres of the brain seem to think differently on the same subject. Therapeutics.—Cannabis indica is one of the best additions to cough mixtures that we possess, as it quiets the tickling in the throat, and yet does not constipate or depress the system as does morphine. In advanced phthisis it is justifiable to constantly keep the patient in the state of euthanasia by its use. For the relief of pain, particularly that depending on nerve disturbance, it is very valuable. Before the introduction of antipyrine and its congeners tincture of gelsemium and the tincture or extract of cannabis indica Avere our best remedies in migraine. The gelsemium under such circumstances should be given in full dose, 20 drops (1.3) of the tincture, and be followed by 10 to 20 drops (0.65-1.3) of the fluid extract of cannabis indica, it being knoAvn that the sample about to be used is active. After this dose of gelsemium the patient should be carefully watched, lest he suffer from an excessive influence of the drug, as such an amount may produce great depression in susceptible persons. In true migraine Avith hemianopsia this treatment is often most effectual in aborting the attack. The prevention of further attacks is to be attained by the use of smaller amounts of the cannabis indica during the inter- vals, the gelsemium only being used at the onset of the symptoms. In paralysis agitans cannabis indica may be used to quiet the tremors, and in spasm of the bladder, due to cystitis or nervousness, it often gives great relief. In sexual impotence, not dependent upon organic disease, it is said to be of value combined Avith strychnine or nux vomica and ergot. When a patient suffers from sleeplessness Avhich is due in part to pain and in part to nervousness, the following pre- scription may be given : 1 The author has injected as much as 5 drachms of a fluid extract, active in the dose of 10 minims to man, into the jugular vein of a small dog without producing death for many hours. CANNABIS INDICA. 113 R.-Chloralis \ ..........aa 3j (4.0). Sodn bromidi j cu \ / Ext. belladonna" fl...........fgj (4.0). Ext. cannabis indica? fl.........fgj (4.0). Syr. acacia?.............■ f$vj (192.0).—M. S.—Tablespoonful (16.0), in water, at a dose at night, to be repeated once. In headaches at the menopause cannabis indica is useful, and if the headaches are associated Avith constipation and antenna, iron and aloes should be given simultaneously. Where headaches are due to retinal asthenopia a very useful prescription, according to de Schweinitz, is as folloAvs : R.—Tr. nucis vomica?...........fgij (8.0). Tr. cannabis indica?..........fgij (8.0).—M. S.—15 drops (1.0), in water, twice or thrice a day. The folloAving prescription has been found to be very efficient in the hands of the author in treating gastralgia and similar forms of pain: R.—Tr. capsici.............fcij (8.0). Tr. cannabis ind..........f.^ss (16.0). Tr. opii deodorata?.........f§j (32.0). Spt. chloroformi..........f|j (32.0). Spt. lavendul. comp.......q. s. ad f^iv (128.0).—M. S.—Teaspoonful (4.0) every hour until pain is relieved. In whooping cough and asthma cannabis indica sometimes proves of service. In uterine subinvolution, chronic inflammation and irritation can- nabis indica is of great value, and it has been found of service in metrorrhagia and nervous and spasmodic dysmenorrhea. Not only does it relieve the pain, but it seems to act favorably upon the mus- cular fibres of the uterus. In acute and chronic Bright's disease cannabis indica often allays the painful sensations over the renal region, and has been recom- mended by some Avriters in the cases in which bloody urine is present. In gonorrhea it is said to decrease the discharge and prevent chordee, and it has supplanted the use of copaiba and cubebs in some practi- tioners' hands. It should not be used in the early stages of gonor- rhoea, but in the later or subacute stages. There is some foundation for the belief that in small doses it acts as a sexual stimulant. The advantages possessed by it are its lack of constipative poAver, and the fact that it does not cause after-depression and nausea, its happy effect in most cases, and an increase rather than a decrease of the appetite under its influence. Administration.—The employment of this most valuable remedy is handicapped by its frequent lack of power—a fault Avhich is largely dependent upon its preparation. The drug as prepared by Parke, Davis & Co. has proved efficacious in the author's hands for a number of years. The physician should ahvays employ some preparation knoAvn by him to be active by personal trial before condemning the drug as a failure in a given case. The dose of the solid extract (Extraction Cannabis Indica?, U. S. and B. P.) is from \ to \ grain (0.015-0.03), that of the fluid extract 8 114 DRUGS. (Extractum Cannabis Indice Fluidum, U. S.) from 4 to 20 minims (0.3-1.3), and that of the tincture (Tinetura Cannabis Indice, U. S. and B. P.) from 15 minims to 1 drachm (1.0-4.0). CANTHARIS. Cantharis (U. S. and B. P.), or " Spanish Fly," is really a beetle, knoAvn as the Cantharis vesicatoria, and as such appears with irides- cent coverings or Aving-sheaths of a bluish or greenish hue. The insects come chiefly from Spain, Italy, and Sicily, and from the south- ern parts of Russia. Those from Russia are supposed to be the best. According to Leidy, the vesicating substance is in the blood, the eggs, and the secretions of the generative apparatus. The blistering sub- stance contains cantharidin as an active principle, but cantharidin is not medicinally employed. Physiological Action.—The ingestion of a moderate dose of can- tharides produces only slight stimulation of the genito-urinary system, particularly the kidneys and urinary tracts. Large amounts produce great pain in the lumbar region, burning in the bladder and entire urethra, priapism, agonizing vesical tenesmus, widespread acute nephritis, bloody urine, which is scanty at first, and finally sup- pressed, Avith great irritation of the external openings of the genito- urinary apparatus. The inflammatory changes Avhich are produced may cause sloughing of the penis or of the labia in the female. Violent gastro-enteritis is nearly always a pressing condition. A diagnostic sign of cantharidal poisoning, where the beetles have been SAvalloAved, is the appearance of pieces of the iridescent wings and coats in the vomit. Thirst is ahvays a prominent symptom of poisoning by cantharides. Therapeutics.—Cantharides are employed internally and externally. When given by the mouth the tincture is used as a uterine stimulant, to affect the uterine mucous membrane and relieve amenorrhea in cases Avhere atony and depression are the cause of the suppression. .Some persons teach that the tincture of cantharides is a valuable remedy in small doses in the second stage of acute desquamative nephritis, but in the instances Avhere the Avriter has seen it used it has made matters much Avorse, although it is supposed to decrease the quantity of the albumin and blood. In the later stages, Avhere the kid- neys are relaxed and torpid or Avhere albuminuria comes on on the slightest exertion, cantharides in the dose of 1 drop (0.05) of the tinc- ture three times a day are of great service. In cases of chronic nephritis, particularly where alcoholism is the cause of the disease and the kidneys are inactive, cantharidal tincture is very useful. In pyelitis and in chronic cystitis it is of service, and it has been recommended very highly in drop doses in irritability of the bladder in women and children. In these cases the bladder must not be inflamed, but irritable from depression. The use of canthar- ides isof value in incontinence of urine of a minor degree, as that occurring in some elderly or nervous females Avhen coughing, sneez- CAPSICUM. 115 ing, or laughing, and will often give relief after many years of suffering. In chordee, in the dose of 1 drop (0.05) tAvice or thrice daily, it, is of service. For impotence depending upon sexual excess Ringer asserts that the use of 10 to 15 drops (0.65-1.0) of the tinc- ture of cantharides, Avith full doses of the tincture of the chloride of iron and nux \romica, will often relie\re the patient and enable him to beget children. The drug has no true aphrodisiac influence except in toxic dose. In gleet of a very chronic type and in prostatorrhea it is of service. Dermatologists have used cantharides internally as a remedy in psoriasis, eczema, lichen, and prurigo, Avith asserted great success. The dose should be so small as not to irritate the stomach. The unofficial plasters of cantharides made by several firms are the best preparations to use for the production of a blister. In order to obtain a perfect effect the skin should be Avashed thoroughly Avith soap and Avater and dried Avith a towel, Avhich should be rough enough to produce reddening of the cuticle. After this wet the skin Avith vinegar, and while wet apply the blister. Externally, cantharides are used in the production of vesication for the purpose of AvithdraAving water from a small area or as a coun- ter-irritant of some severity in cases of deep-seated inflammations. (See Counter-irritation ) Care should be taken that a sufficient amount of the drug is not absorbed to cause strangury and renal irritation. In renal congestions and inflammations the use of can- tharides as a counter-irritant is often contraindicated for this reason. In the proportion of 1 drop (0.05) of the tincture of cantharides to 40 (2.65) of Avater it is said to be a very good application for burns, but Iioav it acts is not known. Administration.—The dose of the tincture (Tinetura Cantharidis, U. S. and B. P.) is from 1 to 10 drops (0.05-0.65), and it is the only preparation used internally. The cerate ((deration Cantharidis, U. S.) is used, spread upon a rag, to produce a blister, and the cerate of the extract, Avhich is no longer official, is used for the same purposes and in the same manner. The cantharidal collodion (Collodium Canthari- datum, U. S.) is a method of applying the blister Avhich is most cleanly, but there is more danger of absorption of the irritant if it is used. The collodion acts as a protective to the part. The papers of cantharides (Charta Cantharidis, B. P.) are used as blisters, but are Aveak in action. The liniment of Cantharides (Linhnentum Canthari- dis, Liquor Epispasticus, B. P.) is employed as a counter-irritant. "■Warming plaster" (Emplastrum Picis Cantharidatum, U. S.) is a mild counter-irritant to be employed Avhere a blister is thought to be too severe. The preparations of the B. P., other than those named, are Acetum Cantharidis, Charta Epispastica, Emplastrum Calefaciens, Emplastrum Cantharidis, and Unguentum Cantharidis. CAPSICUM. Capsicum, U. S., Capsici Fructus, B. P., or Cayenne Pepper, is the fruit of Capsicum Fastigiatum, a native of tropical Africa and 116 DRUGS. of Central America. It occurs in long ovoid pods, Avhich, Avhen ripe, are scarlet red and possess a very hot, burning taste. The active principle is capsicin, Avhich is a dark reddish liquid, or, in other Avords, is a volatile alkaloid. Physiological Action.—Locally applied to the skin or mucous membranes, capsicum causes great redness, and finally, in the case of mucous membranes, vesication. The alkaloid will also produce these changes in the skin. When used internally for any length of time in excess capsicum will cause a chronic or subacute gastritis Avith pain and discomfort over the liver and stomach. If single large doses are used renal irritation and inflammation ensue, with strangury and high-colored urine. Taken internally, capsicum is said to act as a circulatory stimulant. Therapeutics.—In cases of atony of the stomach due to general debility, errors in diet, and alcoholism of the chronic type capsicum is one of the best remedies we have. In cases of acute alcoholism the gastric mucous membrane is often too much irritated to permit of its use, but after the lapse of some days it may be found of benefit to increase the appetite. As a remedy for subacute alcoholism it is quite useful, since by its stimulating effect and hot sensation it often satisfies, at least to some degree, the craving for liquor. Under these circumstances it should be used in the dose of 5 to 10 drops (0.3- 0.65) of the tincture every four or five hours, or as the oleoresin in pill in the dose of ^ to 1 grain (0.03-0.05). The folloAving prescrip- tion has been found of great service in the wards under the writer's charge at St. Agnes's Hospital in these cases: R— Tr. capsici.............f gijss (10.0). Tr. opii deodorat..........f gij (8.0;. Spt. a?ther. nitrosi.........f.^iv (16.0). Spt. Lavandula? comp......q. s. ad f ^iv (128.0).—M. S.—Dessertspoonful (8.0) every four or five hours. In the flatulent colic of old persons and young adults capsicum will be found not only to act as a carminative, but also to prevent the development of the gas. In low fevers it has been used as a diffusible stimulant, but it is of doubtful value. It is rather in the anorexia of convalescence that capsicum acts most favorably. In chronic nephritis it is of considerable service, and it tends to check albumi- nuria, but it is only to be used in the chronic forms and stages of renal disease or in the treatment of functional torpidity of the kid- ney. The tincture is to be given under these circumstances in the dose of 20 drops (1.3) or less, but in some cases which are very chronic, as much as 40 drops (2.65) may be used. In sore throat and simple tonsillitis the tincture of capsicum and glycerin, half and half, are very useful as a local application applied by means of a SAvab. The same preparation may be used as a gargle for relaxed uvula and sore throat. Applied externally, capsicum acts as a counter-irritant, producing redness of the skin, but not a blister in the ordinary indi- vidual. It is one of the best moderate counter-irritants Avhich can be used, and it may be employed by saturating blotting-paper, time CARBOLIC ACID. 117 and time again, in the tincture of capsicum, alloAving it to dry between each dip. This paper should finally be placed Avhen warm and Avet over the part, and held closely to the skin by a compress. Capsicum plaster (Emplastrum Capsici, U. S.) is useful in lumbago, rheumatism, and in headache Avhen applied to the nape of the neck. The tincture is sometimes painted over chilblains Avhich are unbroken. The folloAving method, given by Ringer from Rheims, is very effica- cious in this annoying affection : kv Make a strong tincture of capsicum-pods by steeping them for several days in a Avarm place in tAvice their Aveight of rectified spirits of wine. Dissolve gum arabic in water to about the consistence of treacle. Add to this an equal quantity of the tincture, stirring together with a small brush or a large camel's-hair pencil until they are well incorporated. The mixture will be cloudy and opaque. Take sheets of silk or tissue-paper; give them, Avith the brush, a coat of the mixture; let them dry, and then give another. Let that dry, and if the surface is shining, there is enough of the peppered gum ; if not, give a third coat. This paper should be applied in the same A\ay as court-plaster to chilblains that are not broken and burns that are not blistered, and it will speedily relieve the itching and pain. It acts like a charm and effects a rapid cure. The same is true of discolored bruises. It likeAvise allays rheumatic pains in the joints." The dose of capsicum is 1 to 2 grains (0.05-0.1) in powder, on food or in pill. The dose of the tincture of capsicum (Tinetura Cap- sici, U S. and B. P.) is 10 to 30 drops (0.65-2.0), and of the oleo- resin (Oleoresina Capsici, U. S.) J to \ grain (0.015-0.03). The dose of the fluid extract (Extractum Capsici Fluid urn, U. S.) is 1 to 3 minims (0.05-0.15). The plaster (Emplastrum Capsici) is useful for external applications. CARBOLIC ACID. Carbolic Acid (Acidum Carbolicum, U. S. and B. P.) is also knoAvn as Phenol, Phenylic Alcohol, and Phenic Acid. Not only is it an acid, but in addition it is an alcohol of the peculiar group knoAvn as the phenols, Avhich are derived from coal-tar by a process of distillation. Carbolic acid is sold in several grades, No. 1 being the purest. Both Nos. 1 and 2 are crystalline, Avhile Nos. 3, 4, and 5 are impure, because of cresylic acid and other foreign substances. Only No. 1 should be used by the mouth. It has a peculiar characteristic odor, and varies in color according to its method of preparation and purity. It is soluble in 20 per cent. of Avater, but it is liquefied by the addition of 6 per cent, of water. Carbolic acid should be kept in dark amber-colored, well-stoppered bottles. If the crystals be exposed to the air, they undergo liquefaction, and in consequence the purest carbolic acid is usually prescribed in drop doses rather than in grains. It is soluble in alcohol, ether, chlo- 118 DRUGS. roform, glycerin, and most oils. It unites with alkaline bases to form salts, carbolates, but these are very readily decomposed by the feeblest acids, such as carbonic acid. Physiological Action.—Locally applied, carbolic acid produces at first a burning over the skin, accompanied by a diffuse reddening of the surface. If the solution be very strong, the part at once becomes temporarily painful, then bleached and numb, so that tactile sensibil- ity is destroyed. Applied to mucous membranes, it causes similar changes, but to a more marked degree, and may even act as a mod- erately severe caustic of a superficial type. OAving to the local coag- ulation of albumin produced by it, it cannot penetrate very deeply. Nervous System.—Carbolic acid acts as a depressant and para- lyzant to the peripheral sensory nerves Avhen locally applied. Upon the higher centres in the brain the acid produces a condition of depression and stupor. The convulsions which sometimes occur after toxic doses are spinal in origin, as they occur after section of the spinal cord. The motor nerves escape almost untouched, as do also the muscles. Circulation.—Upon the circulation in the higher animals the drug exercises a distinct depressant influence, stopping the heart in diastole in lethal dose and paralyzing the vasomotor centre even before the cardiac muscle is affected. These changes folloAv only lethal doses. Small medicinal doses have no effect of any moment upon the circulation. Respiration.—After large doses the breathing becomes more rapid and full. These changes, according to SalkoAvski and others, are due to stimulation of the respiratory centres and the peripheral vagi. Lethal doses almost invariably kill by failure of respiration due to depression of the centres. Temperature.—Carbolic acid acts as a depressant to normal bod- ily temperature even in medicinal dose, and also decreases the bodily heat in fever. It lowrers fever by diminishing heat-production and increasing heat-dissipation. This antipyretic power is hardly suf- ficient to permit of its use in disease. Kidneys and Elimination.—AVhen carbolic acid is given in overdose the kidneys may become so irritated that total urinary sup- pression may occur. When taken in large quantity it causes the urine to become brownish-black. This discoloration is due to an oxi- dized educt of carbolic acid Avhich is not yet isolated. The drug is eliminated as a sulpho-carbolate of sodium and potassium and as glyco-uronic acid and hydrochinon. Part of the carbolic acid is burnt up in the body. It is to be distinctly understood that the dark urine of carbolic- acid poisoning is not due to the presence of blood or any of its educts. Poisoning, Prolonged and Acute.—As the changes produced in the tissues of the body by acute and chronic poisoning by carbolic acid are identical, they may be considered together. Carbolic acid is one of the most rapidly-acting poisons knoAvn, notwithstanding the fact that feAv people seem to recognize it as such. CARBOLIC ACID. 119 If a large lethal dose be SAvallowed by a man, he may drop dead from its effects before he can go more than a few feet from the spot where he stood Avhen drinking it, or he may live a feAv hours. In cases Avhere death has occurred suddenly from the acid the cause has been failure of respiration. If the patient does not die at once, all the evi- dences of gastro-enteritis come on. Ariolent vomiting and purging may ensue, and burning pain in the entire abdomen is a prominent symptom. The skin is Avet Avith SAveat. the face pinched and anxious. Collapse, Avith a thready, imperceptible pulse and extreme dyspnoea, may be present. The mouth and lips may not smell of the drug, but the mucous membrane "will be seen to be corrugated and stained black if impure acid has been taken, or be Avhitish if the pure drug has been used. The eschar on the mucous membrane is a peculiar one, and is pathognomonic of the poison, having a white centre surrounded by a reddened and inflamed zone, the centre sometimes becoming dark broAvn or black. The post-mortem will show these spots in the oesophagus and stomach, and even in the intestines. All the internal organs, as the brain, kidneys, liver, and spleen, Avill be found filled AA'ith dark grumous blood, and on opening the body the strong odor of the acid Avill be perceived. A peculiar croupous exudate is sometimes found in the bronchial tubes, and fatty degeneration of a more or less wide- spread type often folloAvs carbolic-acid poisoning. Langerhaus has noted that in some of these cases evidences of croupous pneumonia exist. A very common symptom is hoarseness of the voice, due to an effect on the larynx after the drug is absorbed, and not from its local influence. A large number of cases are on record in Avhich carbolic-acid poi- soning has been produced by its absorption from surgical dressings. One of the earliest signs of such an accident is a darkened, smoky urine and a slight nervous unrest or cerebral disturbance. Very often pain in the lumbar region indicates kidney strain and irritation. The dressings should be, of course, at once remoAred. Treatment of Poisoning.—The chemical antidote to carbolic acid is any soluble sulphate, such as Epsom or Glauber salts, Avhich forms insoluble sulpho-carbolates. As these salts folloAv the acid into the blood-vessels and tissues to unite Avith it, the mere fact that hours have elapsed since the poison has been taken does not invalidate the propriety of using these sulphates. The further treatment consists in the administration of Avarm mucilaginous drinks, hot applications to the extremities, the ingestion of cardiac and respiratory stimu- lants, such as digitalis and strychnine, opium to relieve pain, and counter-irritation over the abdomen. Emetics and the stomach-pump should be used if possible, but the former are generally useless because of the state of the stomach. Therapeutics.—Internally carbolic acid is little used, but, never- theless, has a very favorable effect in certain states. In nervous vom- iting or in that due to gastric irritation the drug does good in ^- to 2-drop (0.03-0.10) doses by depressing the sensory nerves in the stomach. In diarrhoea depending upon fermentation from 2 to 4 drops (0.10- 120 DRUGS. 0.20) of the acid do great good, particularly if combined Avith 10 to 20 grains (0.65-1.3) of bismuth administered in powder or capsule. In gangrene and tuberculosis of the lung a spray of the acid in water in the strength of 5 to 15 drops (0.3-1.0) to the ounce (32.0) may do some good, and at least stop the cough and relieve the irrita- tion and tickling in the throat.1 Creasote is, hoAvever, generally pre- ferred in these conditions at the present time. Externally the acid is very largely employed as an antiseptic lotion, and in solutions in which to place instruments while operating. The solutions for this purpose should be in the proportion of 1 of acid to 20 of Avater. (See Antiseptics.) Carbolic acid is rarely used directly over wounds in dressings at present unless the dressing be one of carbolized oil. Other drugs have supplanted it. The use of the carbolized spray over wounds has been found to do more harm than good, and it ought never to be employed. In diphtheria, ulcerated sore throat, and even in ordinary stomatitis, carbolic acid will be found of value when used in a spray or mouth- Avash in the proportion of 1 part to 75 parts of water, and in ordi- nary sore throat in the strength of 1 part to 100 of water it will be found, Avhen applied on a SAvab or by a gargle, to relieve the pain and inflammation. In the treatment of burns carbolized sweet oil in the proportion of 1 drachm (4.0) of the acid to each 6 ounces (192.0) makes one of the best dressings that can be used. By means of the local anaesthesia produced by the acid, minor operations, such as /'ver- sion of the toe-nail or opening & felon, may be performed by soaking the part for ten minutes in a solution of 30 parts to 100, and apply- ing the pure acid by means of a brush to the line of the incision. Carbolic acid may be used as a lotion in the itching of jaundice in the proportion of 10 grains (0.65) of the acid to 2 drachms (8.0) of gly- cerin and 2 drachms (8.0) of water. In enlarged glands which have not yet gone on to suppuration intra-glandular injections Avith a hypo- dermic needle are of value in a large number of cases, the solution used being no weaker or stronger than 2 per cent. ; 5 to 10 minims (0.3-0.15) of this solution is sufficient for each gland. In the treat- ment of buboes 10 minims (0.65) of a solution of 8 grains (0.5) to the ounce may be injected into the swelling, the skin being first benumbed by an ether spray. This is a most successful treatment. The same treatment may be applied in chronic synovitis and repeated every three days, and boils and carbuncles may also be so treated Avith great success if the measure be used early enough to abort the trouble. In the form of an ointment carbolic acid may be used in the strength of 10 minims to the ounce (0.65 : 32.0) of simple cerate, par- ticularly in cases of subacute eczema Avhere there is a great amount of Aveeping and itching. As a disinfectant carbolic acid ranks among the poorest: 1 to 2 per cent, solutions, hoAvever, kill most spores and germs. Administration.—Carbolic-acid ointment (Unguentum Acidi Car- 1 The spray must be a very fine one, or it will not carry the drug far enough down into the lungs to do any good. CARBON 121 bolici, U S. and B. P.) and the glycerite (Glycerita Acidi Carbolici, U. S.) are the only official preparations of carbolic acid in the U. S. P. In the B. P. the folloAving preparations are official: Acidum Carbolicum Liquefaction, given in the dose of 1 to 2 minims (0.05- 0.10); Grlyceritum Acidi Carbolici; and Suppositoria Acidi Carbolici cum Sapone, each suppository containing 1 grain (0.05) of carbolic acid. CARBON (CHARCOAL). Carbo Ligni, U. S. and B. P., or Charcoal, is prepared by the exposure of soft Avood to a red heat, air being prevented from coming in contact with the Avood during the process. Charcoal when used for medicinal purposes should be a black, brittle, someAvhat shiny, porous substance, devoid of taste and odor, and completely insoluble in Avater. OAving to its poAver of absorbing a very large amount of certain gases, it is of value in medicine in states Avhere these gases abound. Therapeutics.—Charcoal is used externally as an application to old sores or sloughs to act as a deodorant and antiseptic. This is accom- plished by the absorption of any liquids Avhich may be present, thereby depriving germs of a nidus, and by its distinct oxidizing poAver. It may be applied in the form of a dry poAvder or in a poul- tice, Avhich is, hoAveArer, so uncleanly that other antiseptic dressings are better. The poultice (Cataplasma Carbonis, B. P.), if used, should be made in the following manner: Take of powdered wood-charcoal ^ ounce (16.0), bread-crumbs 2 ounces (64.0), linseed meal 14; ounces (48.0), and add boiling Avater 10 fluidounces (320.0). Macerate the bread-crumbs and meal for ten minutes over the fire, and then stir in the charcoal to the extent of half the amount just named. Spread out the poultice and sprinkle the remaining half of the charcoal over its surface, and apply to the part affected while hot. Internally, charcoal is used in powder in many conditions, and acts very Avell indeed in cases of so-called " sour stomach" from Avhich eructations of gas or sour liquids take place. The folloAving prescription will also be found useful in the atonic or subacute gastric catarrh of persons Avho are careless in eating and Avho have much belching: R.—Oleoresin. capsici.......gtt. x vel xx (0.65-1.3). Pancreatin. ........gr. xx (1.3). Pulv. zingiberis........gr. xl (2.65). Pulv. carbon, ligni......gr. xl (2.65).—M. Ft. in pil. No. xx. S.—One or two t. d. As ordinary charcoal is not ahvays obtainable, it may be substi- tuted by pieces of very thin toast burnt to a state of charcoal through and through. A feAv of these pieces will, when eaten, often stop all the symptoms mentioned. If the attack is very severe and vomiting eventually ensues, the ejecta Avill commonly be found to be odorless and not sour, and the stools will also be almost odorless, though 122 DRUGS. black. In fermentative and acid diarrheas in children and adults this method of treatment is often of value. When charcoal is used in any condition associated with irritation of the mucous membranes of the gastro-intestinal tract, it should always be very finely pul- verized. As a filter for impure water, charcoal, in mass or in powder, is one of the most satisfactory substances Ave have. CARBON DISULPHIDE. Carbonei Disulphidum, U. S., is a clear, colorless, highly refrac- tive liquid, having a strong characteristic odor, a sharp aromatic taste, and a neutral reaction. It should be kept in Avell-stoppered bottles remote from light or fire. Poisoning.—The symptoms of poisoning by disulphide of carbon consist in headache and nervous excitement resembling in many respects the symptoms of belladonna poisoning, particularly in the volubility of the patient and the evidences of hysterical tendencies. Prolonged exposure to the fumes of this drug causes great cachexia and pallor, accompanied by muscular Aveakness and failure of intel- lectual power. Sometimes convulsions of an epileptiform character come on. In other cases amblyopia is present as the result of expo- sure to its vapor. The treatment of poisoning by disulphide of carbon consists in quieting the nervous system, if convulsive disorders are present, by the use of bromide of potassium and chloral, and in supporting the circulatory system if any evidences of its failure manifest themselves. Circulatory depression is not, however, a common condition except in very advanced poisoning. Therapeutics.—Disulphide of carbon has been used in medicine externally over enlarged lymphatic glands. The application is made by placing the liquid in a bottle of such a size that the mouth of the vessel is large enough to cover the diseased area. In the bottle should be placed a sponge large enough to contain a fluidrachm (4.0) of the drug, and the skin over the gland should be well moistened with water. The vapor derived from the drug under these circum- stances is an active agent in promoting a cure. Disulphide of carbon has also been used in a similar manner in the treatment of neuralgia. CARBONATE OP POTASSIUM. Carbonate of Potassium (Potassii Carbonas, U. S. and B. P.). This salt is never used in medicine, except to prepare other salts, as it is disagreeable to the taste and is an irritant. (See Potassium Citrate.) CARBONATE OP ZINC. Precipitated Carbonate of Zinc (Zinci Carbonas Precipitatus, U. S. ; Zinci Carbonas, B. P.) is used as a protective, rather astringent pow- CASCARA SAGRADA. 123 der over surfaces covered by weeping eczema and similar moist dis- charges. It may be employed to fulfil all the indications commonly treated by the oxide of zinc. It is very largely used, not as the pre- cipitated carbonate, but as the impure or native carbonate, under the name of calamine. The folloAving prescription is useful for moist eczema: R.—Calamina?...........• ■ • 3J (4.0). Ung. zinci oxidi...........^vij (28.0).—M. S.—Apply to the eczematous spot. In cases of infantile intertrigo or redness of the buttocks and gen- itals from maceration due to diarrhoea or urination the folloAving lotion is very useful indeed: R.—Pulv. calamina? I -. „.. ,0 n, Pulv. zinci \ .........aa5ij(8.0). Glycerini..............£iv (16.0). Alcoholis..............f|ij (64.0) Aqua?.............q. s. ad Oj (J litre).—M. S.—Apply after each removal of the diaper. CARDAMOM. Cardamom (Cardamomum, U. S.) is the fruit of Elettaria Bepens, and is a bitter tonic possessing some aromatic properties. It is use- ful in cases of atony of the stomach and small intestine, particularly if combined Avith some other bitter, such as gentian, and a mineral acid. Cardamon is official in the B. P. as Cardamomi Semina. If the intestine is atonic and secretion is deficient, the folloAving prescription Avill be found of value: R .—Acid, nitric, dil............f 3j (4.0). Tr. cardamomi comp......q. s. ad f §vj (192.0). S.—Dessertspoonful (8.0) after each meal.1 Administration.—The official preparations of cardamoms are the tincture of cardamoms (Tinetura Cardamomi, U. S.), dose 1 to 3 drachms (4.0-12.0) ; and the compound tincture (Tinetura Cardamomi Composita, U. S. and B. P.), which is to be given in the same dose as the tincture. This tincture also contains cochineal, cinnamon, caraAvay, and glycerin. Cardamom is also a constituent of the official aromatic powder (Pulvis Aromaticus, U. S.). CASCARA SAGRADA. Cascara Sagrada is the bark of the lihamnus Purshiana, U. S., a plant growing in California. It is sometimes called California buck- thorn, to distinguish it from ordinary buckthorn or Bhamnus Fran- gula, which it closely resembles in many Avays, and Avhich may be used as a substitute for cascara sagrada in some cases. 1 While the rule that an acid is incompatible Avith a tincture is not recognized in this mixture, the quantities of acid and alcohol are so disproportionate that ether in any amount is not developed. 124 DRUGS. Therapeutics.—Cascara sagrada ought never to be used as a purge, but only as a laxative. It is by far the best remedy Ave have Avhen employed simply to empty the boAvel of faecal matter in cases of con- stipation, since it not only performs this function Avithout intestinal disturbance, but simultaneously acts as a tonic to the intestine, and so prevents the constipation Avhich usually folloAvs the use of all other drugs of its class. Cascara sagrada is most commonly employed in this country in the form of the fluid extract (Extractum Bhamni Pursl/i/ina' Fluidum, U. S., or Extractum Cascare Sagrada' Liquidiim, B. P.), in the dose of from 10 to 20 drops (0.65-1.3) at night or morning and night. If 20 drops (1.3) fail to act, 30 drops (2.0) may be used, but if larger doses are required other drugs should be employed, as fluidrachm doses have been known to produce irritation of the boAvel, Avith enteritis or intestinal catarrh. The objection to cascara sagrada is its bitter taste, Avhich may be partially overcome by the additional use of the Syrupus Aurantii, in the proportion of 1 part of the cascara extract to 2 parts of the syrup of orange-peel. Some of the preparations of this drug are now made in an almost tasteless form, such as " Cascara Cordial," or the non-bitter fluid extract made by a prominent firm in this country. The solid extract (Extractum Cascara' Sagrada?) is official in the B. P., and given in the dose of 2 to 8 grains (0.1-0.5) in pill. CASSIA FISTULA. Cassia Fistula, U. S., is the fruit of Cassia Fistula, or Purging Cassia, as it is sometimes called, and occurs in long, dark-brown pods containing a dark pulp in each segment. This pulp is the useful part of the drug, and is official in the B. P. as Cassie Pulpa. Cassia fistula ought never to be used alone, as it is too apt to cause pain and griping, but it is officially present in the Confection of Senna (Confectio Senna', U. S. and B. P.), and may be given in the dose of l drachm to 1 drachm (2.0-4.0) as a laxati\:e, or as much as \ ounce (16.0) may be used if a purgative effect is desired. CASTOR OIL. Castor Oil (Oleum Bicini, U. S. and B. P.) is a fixed oil derived by expression from the beans of Bicinus Communis, a plant of the United States and elsewhere, but originally derived from India. It contains an acrid substance, ricinoleic acid. Physiological Action.—The manner in which castor oil purges is somewhat in doubt, but its activity probably depends upon the pres- ence of the acid just named and the fact that it is an oil. As is well known, oils—such as olive oil, for example—if given in any quantity, tend to move the bowels, and the ricinoleic acid, which is somewhat acrid, stimulates the small and large gut, and so develops CASTOR OIL. 125 peristaltic movement. According to some writers, this acid is not set free until the oil is attacked by the pancreatic juice. That this acid possesses purgative properties of itself seems proved by the fact that the oil will purge when it is rubbed in by the skin, and that nursing mothers on taking the oil eliminate the acid in the milk to such an extent that the suckling is purged. According to the studies of Rutherford and Yignal, the oil has no effect over biliary secretion other than that violent purgation indirectly increases the Aoav, and the researches of Hess have shoAvn that the oil acts more rapidly in the small than in the large gut, and only produces peristalsis bv coming in contact with the mucous membrane. Therapeutics.—Castor oil is the blandest and most unirritating purge Ave have, Avith the exception of the sulphate of magnesium, Avhich is depletant and much more rapid in its effects. While the Epsom salt will act in one half to one hour if the stomach is empty, castor oil will generally act in four hours, or perhaps five. Its action is so regular that it can almost be used as a timepiece. Castor oil is used Avhenever irritant materials, such as bad food, putrid flesh, or decaying or green vegetables, have been eaten, even if the inflammation set up after them is very active. If hard bodies, such as broken cherry-stones, have been SAvalloAved, castor oil is a far better purge than sulphate of magnesium, as it is more gentle and lubricates the gut, thereby preventing scraping and irritation. Where mucus has accumulated in the bowel in children, and must be gotten rid of before other treatment is resorted to, castor oil should be used. Previous to parturition it has been largely used to relieve the boAvels of faecal matter, and is said by old practitioners to make the labor easier than if any other purge is used. It is also employed in the constipation folloAving acute diseases and in that occurring in infants and children. The disadvantages of castor oil lie in its taste, the fact that it is oily, that it tends to produce hemorrhoids if used constantly, and finally that its frequent use. or even a single dose, is generally fol- loAved by more obstinate constipation than before, so that the dose must be rapidly increased in size to be effective. This is one of the reasons why it is useful in irritative diarrhoeas. The effect of castor oil is very much increased if a little bicarbonate of sodium is given with it. Administration.—Castor oil is very much more agreeable to the taste if pure than if poorly prepared. It is also true that too great purity, so far as taste is concerned, renders it less active. The methods directed for taking castor oil are as various as the tastes of individuals. Its odor may be covered by a drop or tAvo of the oil of bitter almonds, but emulsions of the oil are not of any ser- vice, save to interfere with its efficiency. Some take the oil in the foam of beer or porter, others in syrup of sarsaparilla and soda- Avater, and still others in milk or cream. A good Avay to take it is to eat one or tAvo strong so-called cream peppermint drops, or even the crystalline peppermint drops, SAvalloAv the oil from a spoon which is to be placed Avell back in the mouth, and immediately eat several 126 DRUGS. other peppermints. This plan is improved by using the oil in milk or water, so that the liquid carries the oil down into the oesophagus Avithout its touching the mucous membranes. It may also be taken in highly seasoned beef-tea. Ringer recommends the following: \ ounce (16.0) of oil, fresh syrup of acacia 3 drachms (12.0), and dis- tilled Avater 5 drachms (20.0), flavored Avith a little oil of lemon or peppermint. Wood advises that it be mixed Avith glycerin, equal parts, to Avhich is added a drop or tAvo of oil of gaultheria or oil of cinnamon. By far the best Avay of administering it is in soft capsules containing from 4 to 1 drachm (1.0-4.0). Very feAV people are unable to swallow as much as a teaspoonful in capsule, and several of the smaller capsules may be given at once to complete the neces- sary dose. The capsules should be lightly dipped in water in order to render them slippery and so easily swallowed. The dose of castor oil for an infant is 1 to 2 teaspoonfuls (4.0- 8.0), and for an adult \ ounce to 1 ounce (16.0-32.0). OAving to the fact that the oil will very frequently produce griping, a few drops of laudanum should be added to it, or tincture of bella- donna may be used. If these cannot be employed, a drop of the oil of cinnamon is equally useful for this purpose. CATECHU. Catechu (U. S.) is derived as an extract from Acacia Catechu. The catechu of the U. S. P. is true catechu; that of the B. P. is in reality an extract of gambier, being derived from the leaves and shoots of Uuc/iria Gambier. Catechu depends for its medicinal use upon the astringent properties which it possesses. Beyond this power it has no particular value. It is of a dark-red color, has a someAvhat SAveetish taste, and is insoluble, like most extracts, in Avater. Therapeutics.—Like all the vegetable astringents, catechu is used as a remedy for diarrhea, particularly that of the serous type or that in Avhich the stools are of too fluid a consistency. If large amounts of mucus in the passages shoAv a catarrhal state of the boAvel, the mucus should be displaced by a purge of castor oil or sulphate of magnesium before the astringent is used. Catechu may or may not be combined with opium in cases of diar- rhoea, but the folloAving prescription will be found of service in many instances : For an adult: R.—Tinct. catechu composit.........f|ij (64.0). Tinct. opii camphorata?........f?ij (64.0). Mistura? creta?............f^ij (64.0).—M. S— Dessertspoonful (8.0) every four hours till relieved. To be shaken before using. In cases of sore throat where the secretion is excessive and the inflammation subacute catechu may be used as a gargle. In cases of spongy gums catechu is sometimes useful as a mouth- wash. If the powdered catechu is used internally, the dose is 20 to CERIUM OXALATE. 127 30 grains (0.1-2.0). The dose of the Compound Tincture of Catechu (Tinetura Catechu Composita, U. S.) is 1 to 2 fluidrachms (4.0-8.0). Its only constituent besides the catechu is cinnamon. The Troches of Catechu (Trochisei Catechu, U. S. and B. P.) are to be employed in sore throat, and are to be held in the mouth. They are not gen- erally used. The official preparations of the B. P., besides the ones given, are: Infusum Catechu, given in the dose of 1 to l1- fluidounces (32.0-48.0); the tincture (Tinetura Catechu), dose 1 to 2 fluidrachms (4.0-8.0); and a compound powder (Pulvis Catechu Compositus), composed of catechu, kino, and rhatany, the dose of which is 20 to 40 grains (4.0-8.0). CAUSTIC POTASH. Caustic Potash (Potassa, U. S. ; Potassa Caustica, B. P.) is a very deliquescent, hard, Avhite solid, possessing great caustic powrer, and used in medicine for the purpose of burning aAvay growths or exube- rant ulcers. A piece of the drug should be placed on the skin by means of a pair of forceps, Avhen it Avill at once soften doAvn and burn the tissues until it can reach no farther. The surrounding skin should be protected by Avax, suet, or oils, and a piece of adhesive plaster with a hole for the growth should first be applied to prevent any action on the surrounding healthy tissues. The burn produced by caustic potash is very painful, and cauterization through its influence should not be practised if it can be avoided. When the caustic has acted sufficiently, it is to be Avashed off with vinegar or other dilute acid. Vienna paste (Potassa cum Calce, U. S.) is used for the same purpose as is caustic potash. CAUSTIC SODA. Caustic Soda (Soda, U. S.; Soda Caustica, B.P.) is milder than caustic potash, and its action is more readily controlled. It should be used in the same Avay and for the same purposes as is caustic pot- ash, and the surrounding skin ought to be protected by adhesive plaster and oil or ointment. The soda must be kept in well-stoppered bottles made of hard, strong glass. The only official preparation of caustic soda in the U. S. P. is Liquor Soda?, or solution of soda. CERIUM OXALATE. Cerium Oxalate (Cerii Oxalas, U. S. and B. P.) is a Avhite granular powder, permanent when exposed to the air, odorless and tasteless, and insoluble in water and alcohol, but freely so in hydrochloric acid. Therapeutics.—It is used instead of bismuth in the treatment of the- vomiting of pregnancy or that due to uterine disorders and dis- 128 DRUGS. placements, and in some cases of gastric acidity. The dose is from 2 to 5 grains (0.10-0.3), given in pill form every four or five hours. CHENOPODIUM. Chenopodium (U. S.) is the fruit of the Chenopodium Ambrosioides, or American wormseed. The seeds contain a volatile oil and have a distinct and rather disagreeable aromatic odor. These seeds, rubbed up into a powder, form with a syrup an electuary Avhich is a most efficient remedy against the a scar is lumbricoides, or round-worm, as it occurs in children. The dose of the poAvdered seeds is from 10 to 30 grains (0.65-2.0). The better Avay of using chenopodium is in the form of the oil (Oleum Chenopodii, U. S.) in the dose of 10 drops (0.65) to a child of five years, either on sugar or in an emulsion made of gum acacia. If the patient is old enough, capsules may be used. The general dietetic measures adopted for the removal of worms should be insisted upon before the drug is given. (See article on Worms.) CHIMAPHILA. Chimaphila (U. S.), or Pipsissewa, is the leaves of Chimaphila Umbellata, an evergreen found in America, Europe, and Asia. Therapeutics.—PipsisseAva is a drug employed in atonic renal con- ditions, particularly of the functional type, as a stimulating diuretic, Avhich will bring into activity the secreting structure of the kidney and the mucous membranes of the genito-urinary tract. It is also a tonic to the stomach. For this reason it is often placed in mixtures given to dropsical patients if debility and anorexia are present. In the treatment of ulcers of the skin due to struma it is said to be of service, and it probably has some slight alterative power. The drug may be used in the form of a decoction, Avhich is not official, in the dose of 1 to 3 fluidounces (32.0-100.0), and as the fluid extract (Extractum ChimaphilceFluidum, U. S.) in the dose of ^ to 1 drachm (2.0-4.0). CHIRETTA. Chiretta (Chirata, U. S. and B. P.) is the plant Swertia Chirata, Avhich is a native of India. It is a bitter tonic, possessing a very distinct influence over the liver, and. unlike many bitter tonics, is devoid of tannic acid. For this reason it may be used with prepara- tions of iron. Chiretta may be given in all eases of indigestion and loss of appetite, particularly where the liver is torpid or if any tend- ency to constipation is present, although it is not directly laxative. When given in poAvder the dose is 20 grains (1.3); the dose of the fluid extract (Extractum Chirata? Fluidum, U. S.) is 30 drops to 1 drachm (2.0-4.0), Avhile that of the tincture (Tincture C Mr at re, U. S. and B. P.) is 1 to 4 drachms (4.0-16.0). The unofficial solid extract CHLORAL. 129 may be given in pill in the dose of 2 to 4 grains (0.1-0.2). The dose of the infusion (Infusum Chirate, B. P.) is a Avineglassful (32.0). CHLORAL. Although the name Chloral is applied to the substance used in medicine, chloral proper is never so employed, hydrate of chloral (Chloral Hydras, B. P. ; Chloral, U. S.) being the real preparation. Chloral hydrate is a Avhite, crystalline body, but is often sold in irreg- ular broken masses, Avhich are generally impure. It should be kept in tight bottles in a cool, dark place. Physiological Action.—When chloral is applied to a mucous mem- brane it causes distinct reddening and burning pain, and finally acute inflammation. It is, therefore, a local irritant. Chloral acts in the body as chloral, and is not broken up into formic acid and chloro- form, as Avas taught at one time. NERArous System.—In medicinal and toxic dose chloral produces sleep by quieting the intellectual centres in the brain, at the same time depressing the motor tract of the spinal cord and the motor nerves. In medicinal amounts it does not decrease sensation, but in toxic dose it does. Very o^ten hyperBesthesia results from small doses. Reflex action is decreased by its influence on the motor portions of the spinal cord. Circulation.—A dose of 10 to 20 grains (0.65-1.3) in the adult rarely causes any circulatory changes, but larger amounts produce a fall of arterial pressure and a slow, feeble, or sometimes a rapid-run- ning pulse, due to a direct depression of the heart-muscle, for chloral in overdose is a cardiac paralyzant. After death from chloral the blood may be found dark and grumous- looking, Avith the corpuscles broken down, but these changes occur only after very large doses. Respiration.—In moderate amounts no respiratory effect is felt, but in toxic doses the breathing becomes slower and slower and more and more shalloAv, until it stops in death. When death is caused by chloral it is due to respiratory failure, with an almost simultaneous arrest of the heart. Temperature.—Chloral tends to loAver bodily heat, and in large doses produce a very marked fall of temperature, Avhich does much toward causing death. Brunton has found that rabbits will survive very large doses of the drug if external heat is supplied to them. The fall of temperature is, at least in part, due to the failure of the circulation and vascular dilatation. Kidneys, Tissue-waste, and Elimination.—Chloral is elim- inated by the kidneys in the form of uro-chloralic acid and, if given in excess, as chloral. Large amounts irritate these organs, and may produce bloody urine, owing to the nephritis Avhich is set up as the drug passes through the renal structuies. After chloral is ingested the urine of a patient will often give Fehling's test for sugar. Poisoning.—When a poisonous dose of chloral is taken by man, the 9 130 DRUGS. person soon falls asleep and then sinks into a deep coma. The respira- tions become at first sIoav and labored, then shalloAv and feeble. The pulse, at first perhaps a little sloAved, soon becomes rapid, thready, and shuttle-like, and is finally lost at the wrist. The face is white and livid, the forehead and the hands covered with a cold sAveat, and the pupils. which are at first contracted, soon become Avidely dilated. Absolute muscular relaxation is present, and it is impossible to arouse the patient. Treatment of Poisoning.—The physician should apply external heat and use emetics in the early stages, or, if the case is seen too late for emetics to act because of systemic depression, he should use the stomach-pump. This latter means of removing the drug from the stomach is more reliable and safer, because the production of vomit- ing may result in efforts Avhich will strain the heart. Strychnine should be given in full dose, -fa to fa of a grain (0.003-0.006), to stimulate respiration, or atropine may be used for the same purpose. The heart is to be supported by 10-drop (0.65) doses of tincture of digitalis, given hypodermically every twenty minutes until some effect is noted; and, as the digitalis is rather sIoav in its action, it may be preceded by ether and ammonia or brandy or whiskey. The patient must not raise the head to vomit, and the head should be placed on a loAver level than the heels to keep up the circulation of blood in the brain. In chronic poisoning by chloral the patient suffers from weakness, mental and physical, Avith sudden flushings due to vasomotor disorder, from palpitation of the heart, and finally from petechial eruptions, ulcerations, and sloughs. The folloAving prescription may be used: R.—Chloralis...........^ij vel iv (8.0-16.0). Morphina? sulphatis.......gr. ij (0.1). Syr. lactucarii (Aubergier) .... 13ij (64.0). Aqua?.........q. s. ad fgiij (96.0).—M. S.—Dessertspoonful (8.0), in water, at 10 and at 11 p. m., if necessaiy. Therapeutics.—Chloral is the purest hypnotic that we have, and may therefore be used where simple nervous insomnia is present, but not when sleeplessness is due to pain. Under such circumstances it is to be employed in the combination of 10 grains (0.65) of chloral Avith 4; of a grain (0.01) of morphine, as a much more powerful hypnotic effect is produced by the combined action of the two drugs than by the use of either one of them alone. In tetanus and strychnine poisoning chloral is the best remedy Ave have, as it depresses the motor tract of the spinal cord. In such a case it should be given in 20-grain (1.3) doses combined with 60 grains (4.0) of bromide of potassium. If the convulsion prevents deglutition or is brought on by swalloAving, the remedy should be used by the rectum ; and if the spasm expels it from the rectum, the patient should be chloroformed long enough to allow the injection to be given and absorbed. The same remedies in small doses are to be used in infan- tile convulsions and in infantile colic in the dose of ^ grain to 1 grain (0.03-0.06) of chloral to 2 grains (0.1) of bromide of potassium or CHLORALAMIDE. 131 sodium in a teaspoonful of peppermint-Avater. In chorea, paralysis agitans, and delirium tremens chloral is of great service, but must be given cautiously in the latter condition, for fear it may depress the heart, which is already diseased by alcoholic excess. Cases are on record where chloral has caused sudden death from cardiac failure in the persons of alcoholics Avho were suffering from fatty heart. Chloral has been used for the relief of labor-pains, but is rarely so employed, and is not a good remedy. If much rigidity of the os uteri exists, chloral may be used Avith advantage to relax the spasm. The dose given should be 15 grains (1.0). In uremic cary to the carrying out of a reflex action, this is per- fectly possible and probable. 186 DRUGS. to be performed, and also in cases of superficial neuralgia, where the benumbing of the nerve often effects a permanent cure. Internally, by the stomach, ether is very useful in colic, although for flatulence of adults and children Hoffmann's anodyne is a more agreeable remedy. In cases of collapse the hypodermic and gastric use of ether makes it of great service Avhen cardiac action is very feeble, and it will give relief by inhalation in some of these cases more rapidly than the nitrite of amyl. In hiccough a few inhalations of ether will often stop the spasmodic movements, and local muscular spasms can be relieved in this way. Ether may be used to produce muscular relaxation Avhen the sur- geon attempts to reduce a strangulated hernia by taxis. In cases Avhere cod-liver oil cannot be digested ether may be given in 20-drop (1.30) doses in ice-water or capsule, either with or some minutes after the oil is taken, to aid in its digestion and absorption. The time of its use should be that at Avhich discomfort is apt to come on, and not at any stated moment. Administration.—Ether should be given, Avhen used internally, in ice-cold water, or, better still, in capsules, in the dose of 30 drops to ^ an ounce (2.0 : 16.0). If cold water is not used to dilute it, so great is the irritation of the fauces produced by the fumes of the ether that deglutition is impossible. Contraindications.—Ether should not be used by inhalation in bronchitis, acute nephritis, peritonitis, or gastritis, in aneurism, or in the presence of marked vascular atheroma. ETHYL BROMIDE. Bromide of Ethyl is obtained by distilling a mixture of alcohol, sulphuric acid, and bromide of potassium, and is a colorless fluid of neutral reaction, having a pleasant odor resembling chloroform. It evaporates with great rapidity, and any sample Avhich does not do this is to be discarded. Poured on the hand, it should leave no fatty feeling. It. should be remembered that the drug is decomposed by sunlight and Avhen in contact with pure air. In the presence of lamp- light the fumes form bromal hydrate and bromine. The drug should be kept in dark-glass bottles. The physician should distinctly sepa- rate in his mind bromide of ethyl from bromide of ethylene" The latter is a chemical product possessing very dangerous properties, and should never be used in medicine. There is reason to believe that unfavorable symptoms folloAv the use of bromide of ethyl only Avhen the drug is impure or is improperly used. Physiological Action.—According to the studies of Thornton and Meixell in the Laboratory of the Jefferson Medical College, the domi- nant action of the bromide of ethyl is on the respiratory, not on the circulatory, system. This effect 'is depressant, but only seen after excessive doses. The blood-pressure falls under its influence to a slight degree, and the pulse is slowed through an influence probably exercised on the inhibitory nervous mechanism of the heart. • ETHYL IODIDE. 187 Therapeutics.—Bromide of ethyl is a useful anaesthetic for short operations, such as opening boils or abscesses, or for the relief of the pain in other brief surgical procedures. Originally introduced into general use in this country by Levis, it has been found unsuited to major surgical cases, because if continued for a long time it seriously depresses the respiration. Bromide of ethyl has been found of the greatest value by Montgomery of Philadelphia as an anaesthetic in labor and for minor gynecological operations in office practice. He finds that the patient may be alloAved to inhale the drug from a HaAv- ley inhaler, for as soon as she has had enough to produce anaesthesia the inhaler drops from.her hand. The patient is also more obedient to the physician's directions, because of the fleeting influence of the drug, than Avhen chloroform or ether is taken, and it is not so apt to cause post-partum hemorrhage through uterine relaxation. A very great adAantage possessed by bromide of ethyl is the rapidity of its action. A Icav Avhiffs are generally all that is needed to cause anaesthesia. It rarely produces disagreeable effects. Cases of sudden death under its use are, hoAvever, on record, and in some instances nervous tAvitchings, and even tetanic spasms, have been knoAvn to folloAv its employment. These tetanic symptoms are, how- ever, fleeting and generally of little importance. Nausea and vomit- ing rarely folloAv its employment, but it is apt to leave an unpleasant garlic-like taste in the mouth, and a similar odor of the breath is frequently noted for several days after its use. Administration.—Bromide of ethyl should be administered but for a brief period, but Avhen taken should be inhaled freely. It cannot be given carelessly Avith good effect. If a good sample is employed, 45 minims to 3 drachms (3.0-12.0) is a sufficient amount. This quan- tity should be used at once, instead of added to the inhaler drop by drop, as in the case of chloroform, and the cloth or inhaler should be held close to the mouth and nose, instead of at a little distance, as is often necessary with other anaesthetics. ETHYL IODIDE. This is a colorless, non-inflammable liquid, Avhich really should be called hydriodic ethyl. Ethyl iodide must be kept in dark-colored bottles in a dark place to prevent it from undergoing decomposition. It is very volatile, and the fumes arising from it are slightly pungent, but not irritating in ordinary amounts. Unfortunately, the odor is disagreeable to most persons. Physiological Action.—Very little is knoAvn of the general physio- logical action of iodide of ethyl, and the drug Avould be a good one for laboratory investigation. It does not produce anaesthesia except in very large amounts. Therapeutics.—Iodide of ethyl is used in medicine entirely by inhalation for the treatment of subacute or chronic catarrh of the air- passages and for the purpose of rapidly impressing the system Avith iodine for alterative purposes, as it is the iodine in the remedy Avhich 188 DRUGS. produces the curative effects desired. In catarrhal states of the bron- chial tubes the stimulating effect of the iodine is supposed to cause free secretion and to prevent abnormal thickening of the mucus and dilatation of the air-passages. For this reason iodide of ethyl is sup- posed to be of service in asthma and its resulting emphysema. Very recently BartholoAv has recommended this drug in the treatment of pneumonia. It is said by that Avriter to be particularly useful in the later stages of this disease, as it aids in producing resolution, but the author has never seen it produce much effect. Administration.—10 to 20 drops (0.65—1.3) may be placed upon a handkerchief and inhaled, or a small vial filled Avith the drug may be held in the hand under the nostrils. LTnder these circumstances the heat of the hand sets free the necessary amount of vapor. EUCALYPTUS. Eucalyptus, U. S., is the leaves of the. Eucalyptus G-lobulus, or blue- gum tree, a native of Australia, but grown at present all over the world. Its chief medicinal constituent is the oil of eucalyptus (Oleum Eucalypti, U. ,S.), from Avhich is derived Eucalyptol, U. S., Avhich is a camphorous body obtained by redistillation Avith caustic potash or chloride of calcium. The oil of eucalyptus and eucalyptol are used for the same purposes, but the latter is the refined product of the former. Physiological Action.—Locally applied, the oil is a decided irritant. 10 to 20 drops (0.65-1.3) taken internally cause slight stimulation, fol- loAved by a sense of calm, Avhile larger doses produce disturbed diges- tion and loose, oily-odored stools. The pulse is increased in frequency and force, and intense headache may come on. After very large doses there is a fall in pulse-force, bodily temperature, and strength of limb, and the respirations are decreased. A peculiar loss of sen- sation in the loAver limbs may occur. If death takes place, it is due to respiratory failure. The drug is eliminated by the skin, kidneys, boAvels, and lungs. The urine may have the odor of violets, as it sometimes does after the use of oil of turpentine. The oil of eucalyptus has considerable antiseptic power. Therapeutics.—Eucalyptus is used in malarial fever Avhere quinine cannotbe had, or be borne by the patient OAving to idiosyncrasy. In bronchitis, in an emulsion or in capsule, it is of great value in the later stages (see Bronchitis), and it may be used in the subacute forms of gonorrhea in the same manner, since in its elimination by the lungs it acts locally upon the inflamed mucous membrane. The following prescription will ansAver: R.—Olei eucalypti.............fzi (4 0) Olei amygdalae dulc..........' fzi ('401—M Ft. in capsule No. x. 5J { '' S.—One t. d. after meals. Oil of eucalyptus is very useful in some forms of rheumatic head- ache or in headache dependent upon malarial fever. EUPHORBIA PILULIFERA. 189 Eucalyptol, U. S., is obtained from oil of eucalytus, and is largely employed by rhinologists and others in lotions and other nasal appli- cations It may be used in solutions of fatty oils, but is insoluble in Avater, although it is soluble in alcohol and ether. Administration.—The fluid extract (Extraction Eucalypti Fluidum, U. S.) is given in the dose of 10 drops to 2 drachms (8.0), the oil (Oleum Eucalypti, U. S. and B. P.) in the dose of 5 drops (0.35). The dose of eucalyptol is 5 grains (0.35) in capsule. Unguentum Eucalypti is official in the B. P., but is seldom used. EUONYMUS. Euonymus, U. S., or Wahoo, is the bark of Euonymus Atropurpu- reus, a native plant of the United States. It contains an active prin- ciple, Euonymi)/, B. P. As a laxative its action is very sIoav and moderate, but it is thought to act particularly on the liver, and may be used Avhen mild hepatic torpor is present. Administration.—The dose of the solid extract (Extraction Euonymi, U. S., Extraction Euonymi Siccum) is 3 to 10 grains (0.15-0.65). Of euonymin the dose is ^ to 1 grain (0.03-0.05). EUPATORIUM. Eupatorium, U. S., ThoroughAvort or Boneset, is the leaAres of the Eupatorium Perfoliatum, an American plant which is very largely used as a simple bitter tonic and diaphoretic in household medicine. The drug is generally given in hot infusion in cases of arrested men- struation due to cold or in the chill of a remittent or intermittent fever, and also for anorexia and debility. Its taste is very disagreeable, and in the dose of a pint (500 cc.) of the cold infusion it has been used as an emetic. The fluid extract (Extractum Eupatorii Fluidum, U. S.) is given in the dose of 30 drops to 1 drachm (2.0-4.0). EUPHORBIA PILULIFERA. This herb is sometimes called Snake-Aveed or Cat's-hair, and is a native of Australia and the West Indies, Avhere, like stramonium, it groAvs profusely as a Aveed by the Avayside. Physiological Action.—In toxic doses the drug kills small ani- mals by failure of the respiration and circulation, these two vital functions being greatly affected by doses Avhich exert no great influ- ence on the rest of the"body. In full dose it may cause some gastric irritation. Therapeutics.—Euphorbia pilulifera is one of the latest remedies introduced into medicine for the relief and cure of asthma, in Avhich disease the results obtained, after other remedies fail, are very extra- 190 DRUGS. ordinary if the reports of those Avho have given it a thorough trial can be accepted without reserve. As yet we do not knoAv the form of asthma Avhich is most relieved by its use, and its employment is purely empirical. It has also been" highly praised in the treatment of chronic bronchitis and emphysema. Administration.—Euphorbia pilulifera is best given in the form of the fluid extract in the dose of 30 drops to 1 drachm (2.0-4.0). The decoction is made by adding a " handful of stalks with the leaves on them to 2 quarts (2 litres) of boiling water, and boiling doAvn to 14j quarts (1J litres)." Of this decoction the dose is a small Avineglass- ful (64.0) three times a day. (See Asthma.) EUROPHEN. Europhen is the result of the action of iodine on isobutylorthocre- sol in the presence of an alkali, and appears as a fine yelloAv poAvder, soluble in alcohol, ether, chloroform, and oils, but insoluble in water. Introduced because it Avas hoped that it might prove a useful substi- tute for iodoform, its usefulness is still undecided, OAving to the short time that it has been before the profession. One advantage claimed for it is that it parts with its iodine very sloAvly, and so is not apt to produce toxic symptoms as rapidly as does iodoform. For this very reason, hoAvever, it lacks the remedial power of the older drug, except in those instances in Avhich a drying poAvder is needed Avhich will keep the Avound pure by making it too dry to be favorable to the groAvth of germs. When such an action is desired, europhen pos- sesses the additional advantage of being five times as bulky as iodo- form. In the treatment of tuberculous growths europhen has already proved itself very inferior to iodoform. OAving to its stability, it fails to part Avith its iodine except in the presence of moisture, and is use- less in dry skin diseases. It has been found useful in scrofuloderm, ulcer of the legs, and lupus. Europhen may be emplo}Ted externally in a salve of the strength of from 5 to 10 per cent., or Avith olive oil or lanolin. It can also be added to flexile collodion. The drug does not possess the odor of iodoform, but experience will probably prove it to be more irritating than the latter drug. The internal dose is 1 to 3 grains (0.05-0.15) in cases of syphilis. Europhen is incompat- ible Avith metallic oxides and the preparations of mercury, and also Avith the starch and zinc paste largely used by dermatologists. EXALGINE. This substance is really methyl-acetanilid, and closely resembles acetanilid or antifebrin in its effects. It is given for the same pur- poses as is acetanilid and antipyrine—namely, for the relief of pain in locomotor ataxia and other nervous affections—but never as an antipyretic. When used, exalgine should be given night and morn- ing as a rule, so that the doses shall not be near together. The FLAXSEED. 191 beginning dose should be from 2 to 4 grains (0.1-0.2), and not more than 15 grains (1.0) should be given in tAventy-four hours. It is stated by those who have used the drug that fever contraindicates its employment. The folloAving prescriptions will be found applicable: R.—Exalgini..............gr. xxx (2.0). Tinetura? aurant. dulcis.......'f3'j (8.0).—M. Ft. in sol. et adde Syr. aurantii ...........f.^ss (16.0). Aqua3 menth. piperit.....q. s. ad f^iv (128.0).—M. S.—A tablespoonful night and morning. Or, R.—Exalgini.............gr. xxx (2.0). Spt. frumenti ...........fgss (16.0).—M. Ft. in sol. et adde Svr. simplicis...........fjj (32.0). Aqua? dest..........q.s. ad fgiv (128.0).—M. S.—Tablespoonful night and morning. FLAXSEED. Flaxseed or Linseed (Union, U. S.) is the seed of Linum Usita- tissimum, or flax from AAhich linen is made; it is official in the B. P. as Lini Semina. It contains an oil and a mucilage, the first of Avhich is largely used in the arts, and the second is sometimes employed in medicine. The oil (Oleum Lini, U. S. and B. P.) is also used by physicians and pharmacists for various purposes. Therapeutics.—Flaxseed acts as a demulcent to inflamed mucous membranes, and is used largely in the treatment of acute cystitis, bronchitis, gastritis, nephritis, and similar states, in the form of flax- seed tea. This is prepared by mixing together 3 drachms (12.0) of flaxseed, not ground, 30 grains (2.0) of extract of liquorice, 10 ounces (320.0) of boiling Avater, and alloAving the mixture to stand one to four hours in a warm place. If the mixture is boiled, the oil is set free and makes the dose disagreeable. This infusion may now be made more tasteful and useful by the addition of a little lemon-juice and sugar and by the placing of from 1 to 2 drachms (4..0-8.0) of gum arabic in the pitcher containing it. If the cough is excessive, a little paregoric may be added. Linseed oil is used sometimes as a laxative in the dose of 2 ounces (64.0), and is said to be of service Avhen so given in the treatment of hemorrhoids. Flaxseed meal (Lihi Farina, B. P.) is employed universally Avhen moistened as a useful poultice. Under the name of Carron oil an emulsion of lime-water and lin- seed oil, equal parts, is the standard application for limited or exten- sive burns. An infusion of linseed (Infusum Lini) and a poultice (Cataplasma Lini) are official in the B. P. 192 DRUGS. GALLIC ACID. Acidum Gallicum (U. S. and B. P.) is usually prepared from tannic acid. It occurs in nearly colorless, long, needle-like crystals, which are soluble in 100 parts of cold water, 41 parts of alcohol, and 3 parts of boiling water. Physiological Action.—Gallic acid is an astringent, but not a coag- ulator of blood. Locally applied in bleeding, it is useless, but given internally in hemorrhages which cannot be acted upon by the direct locally application of tannic acid, it is useful as a haemostatic. It is eliminated from the body by the kidneys as gallic acid. Therapeutics.—Gallic acid may be used Avith much success in hema- turia, hemoptysis, colliquative sweats, and in bronchorrhea Avith pro- fuse expectoration. Combined with opium, it is one of the best remedies in diabetes insipidus, and is even useful in diabetes mellitus. In albuminuria dependent upon a relaxed, atonic state of the kid- neys and in acute or chronic diarrhea gallic acid may be used with advantage. In the form of the ointment it is useful in the treatment of psoriasis, and in the cure of ulcers and sores Avhich are actively discharging. A very useful application to external hemorrhoids is equal parts of stramonium ointment and gallic acid. Administration.—Gallic acid is given in the dose of 2 to 40 grains (0.1-2.6) in pill or solution. It ought never to be used with any salt of iron, as it is incompatible. The preparations used locally are Unguentum Acidi Gallici and Glycerinum Acidi Gallici, B. P., given in the dose of 10 to 60 minims (0.65-4.0). Nut-gall. Nut-galls (G-alla, U. S. and B. P.) are the small excrescences found upon the oak (Quercus lusitanica) formed by the ova of the fly Cynips Galle tinetorie. Their sole value depends upon the tannic acid con- tained in them, and they are official in the form of the tincture (Tine- tura Galle, U. S. and B. P.), dose l] to 2 fluidrachms (2.0-8.0), and the ointment (Unguentum Galle, U. S. and B. P.). Unguentum Galle cum Opio is official in the B. P., and is used as an astringent and sedative ointment. GAULTHERIA. Wintergreen, or Gaultheria Procumbens, is an American ever- green containing a volatile oil. The oil possesses a peculiar, exceed- ingly penetrating odor and a Avarm aromatic taste. It is about 90 per cent, salicylate of methyl. Salicylate of Methyl (Methyl Sali- ei/latis, U. S.) is an artificial product made official in the last revision of the U. S. P. Physiological Action.—OAving to the large amount of salicylate of methyl contained in the oil, its physiological action is almost identical with that of salicylic acid. GELSEMIUM. 193 Therapeutics.—Aside from its use as a flavoring substance, oil of gaultheria is largely used in all forms of rheumatism and in place of the ordinary salicylates. It does not so commonly disturb the diges- tion of patients as do the salts of salicylic acid or the acid itself. The oil (Oleum Gaultheria', U. S.) is best given in capsules or emul- sion or dropped on a teaspoonful of sugar three times a day after meals. The dose may be as high as 100 drops (7.0) a day; if 60 drops (4.0) three times a day do no good, pushing it further is practi- cally useless. The spirit of gaultheria (Spiritus Gaultherie, U. S.) is given in the dose of 10 to 20 minims (0.65-1.3). GELSEMIUM. Gelsemium, U. S. and B. P., or YelloAv Jasmine, as used in med- icine is the rhizome of the Gelsemium Sempervirens, a climbing plant of the Southern United States. It contains an alkaloid, gelsemine, and gelseminic acid. Physiological Action.—Nervous System.—Gelsemium paralyzes the spinal cord, particularly on its sensory side (?), although the motor side is certainly ultimately depressed. It does not influence the nerves or muscles except those of the head, on which it acts as a paralyzant, particularly affecting the motor fibres, Circulation.—Gelsemium is a depressant to the circulation, act- ing particularly on the heart. Respiration.—Gelsemium kills by paralyzing the respiratory cen- tres (Sanderson, Ringer, and Murrell). Temperature.—In overdose the drug loAvers bodily heat very markedly. Eye.—Gelsemium is a mydriatic of considerable power, causing, when dropped into the eye, Avide dilatation of the pupil, a result due . to paralysis of the oculo-motor nerve. Therapeutics.—Gelsemium is used in headache and migraine depend- ing on nervous troubles or upon eye-strain. It is particularly useful in combination Avith cannabis indica. (See Cannabis Indica and Migraine.) In malarial fever it is said to be of great service, but this is doubt- ful. In the early stages of pneumonia and pleurisy it has been highly spoken of by BartholoAV. Gelsemium has also been found of value in asthma, whooping cough, laryngismus stridulus, and nervous cough. In localized mus- cular spasm, such as seen in torticollis or wry-neck, and in spasmodic dysmenorrhea, it is of considerable service. It ought not to be used if the system is already depressed, but only in sthenic cases. When used as a mydriatic, TAveedy recommends it as equal to atro- pine in effect, but much more transient in its influence. He uses a solution of 8 grains of gelsemine to the ounce (0.5 : 32.0) of Avater, instilled, drop by drop, into the eye every fifteen minutes for one hour, and then every half-hour for tAvo hours. 13 194 DRUGS. Poisoning.—The most prominent symptoms of gelsemium poison- ing are ptosis and dropping of the jaAv. These are preceded by a sensation of languor, a desire to lie down, relaxation, and muscular Aveakness. Gelsemium is apt to cause temporary internal squint, OAving to its paralyzant action on the sixth pair of cranial nerves. The pulse becomes rapid and feeble, the skin wet and cold, the face pinched and anxious, the voice is lost in aphonia, and death ensues from centric respiratory failure and an almost simultaneous cardiac arrest. Sensation in man is impaired very late in the poisoning. The treatment of the poisoning consists in the use of cardiac stimu- lants, such as ammonia, digitalis, and atropine, the application of external heat, and the employment of atropine and strychnine for the purpose of stimulating the respiratory centre. Emetics and the stomach-pump are, of course, to be employed. Administration.—The fluid extract (Extractum Gelsemii Fluidum, U. S.) is given in the dose of 5 to 10 minims (0.35-0.65), and the tincture (Tinetura Gelsemii, U. S. and B. P.) 10 to 20 drops (0.65-1.3). In some parts of the United States physicians largely employ a very strong unofficial tincture of gelsemium, the dose of Avhich is 1 to 2 drops. Gelsemine may be used in the dose of fa of a grain (0.001). Extractum Gelsemii Aleoholicum, B. P., is given in the dose of 4- to | grain (0.008-0.015). GENTIAN. Gentiana, U. S., is the root of the Gcntiana Lutea, or Yellow Gentian, a European plant. It contains gentianine and gentisic acid, and has a bitter taste. This drug is official in the B. P. as Gentiane Bad'/x. Therapeutics.—Gentian is one of the most efficacious bitter tonics that we possess, as Avell as one of the most elegant. In the anorexia following acute diseases and in gout and malarial poisoning Avith dys- pepsia it is of service. Combined with bicarbonate of sodium, it is of great service in the treatment of the gastric and intestinal catarrh of children. Administration.—The compound tincture (Tinetura Gentiane Com- posita, U. S. and B. P.) is given in the dose of 1 drachm to a wine- glassful (4.0-64.0), the fluid extract (Extractum Gentiane Fluidum, U. S.) in the dose of 30 drops to 1 drachm (2.0-4.0), and the solid extract (Extractum Gentiane, U. S. and B. P.) in the dose of 1 to 8 grains (0.05-0.40). Infusum Gentiane Composition, B. P., is given in the dose of 1 to 2 fluidounces (32.0-64.0), and the compound tinc- ture (Tinetura Gentiane Compositus) in the dose of 4 to 1 fluidrachm (2.0-4.0). The compound tincture and infusion are composed of gen- tian, bitter orange-peel, and cardamoms. The following prescription is an excellent one for use in convalescence from prolonged fevers: R.—Acid, nitro-hydrochlor. dil........frf vel fzjj (4.0-8.0). Tr. nucis vomicae...........f?\ (4.0) Tr. cardamomi comp..........f?ij (64 0) a T Tr-gentian^ comp. . .....q. s. ad f|iv (128.6).-M. S.—Teaspoonful (4.0) in water after meals. GLYCERIN. 195 GERANIUM. Geranium, U. S., is the rhizome of Geranium Maculatum. It contains tannic and gallic acids, and is useful in diarrhoea as an astrin- gent. It is not the common red geranium seen in floAver-gardens. In infantile diarrheal geranium-root, boiled in milk in the propor- tion of one or two roots to the pint, Avill be found of great service and is tasteless. The dose of the drug itself is 20 to 60 grains (1.3- 4.0), and that of the fluid extract (Extractum Geranii Fluidum, U. S.) i to 1 fluidrachm (2.0-4.0). GINGER. Zingiber, U. S. and B. P., is the rhizome of Zingiber officinale, a plant of Hindostan, Jamaica, and other tropical countries. Black ginger is the dried rhizome Avith its bark, while white ginger has this covering removed. It contains a hot volatile oil and an aromatic resin, and is very largely used in domestic medicine as a carminative and stomachic. In the treatment of menstrual cramps it is often given, and is particularly useful in those cramps due to suppres- sion from exposure to cold. With purgative medicines ginger is employed for its flavor and the prevention of griping. Of itself it is decidedly constipating, and Avhen used in diarrhea mixtures is of value other than as a flavoring addition to the prescription. Administration.—The fluid extract (Extractum Zingiberis Fluidum, U. S.) is given in the dose of 10 to 30 drops (0.65-2.0), Avell diluted; the tincture (Tinetura Zingiberis, U. S. and B. P.), dose 20 drops to 2 drachms (1.3-8.0); the syrup (Syrupus Zingiberis, U. S. and B. P.), dose 30 drops to 2 drachms (2.0-8.0); the oleoresin (Oleoresina Zingiberis, U. S.), dose 4y to 1 drop (0.03-0.05), well diluted or in pill; and the troches (Trochisci Zingiberis, U. S.) used as stimulants to salivary secretion. In the B. P. a stronger tincture, Tinetura Zingiberis Fortior, is official, dose 5 to 20 minims (0.35-1.30). GLYCERIN. Glycerinum, U. S. and B. P., is a liquid obtained by the decom- position and distillation of fats. It possesses great power of absorb- ing water and of dissolving many substances. Even if pure it irri- tates the skin of susceptible persons by its absorption of water, and often causes a slight rash. Physiological Action.—Injected into the circulation in large amounts, glycerin causes convulsions, which are due to its hygroscopic power. According to the clinical researches of Pavy, glycerin increases the polyuria of diabetes almost one-half, and for this reason he thinks it is not to be employed in this class of cases as a substitute for sugar. Again, the experiments of Luchsinger and Weiss have shoAvn that the administration of this substance increases the amount of 196 DRUGS. glycogen in the liver to a very considerable extent; Avhile, on the other hand, the researches of Eckhard and Luchsinger have also proved that glycerin very frequently tends to prevent glycosuria Avhich has been brought about by puncture of the so-called diabetic centre in the floor of the fourth ventricle, if the drug be given hypo- dermically. Luchsinger, therefore, believed that Avhile glycerin might increase the amount of glycogen, it also prevented its trans- formation into sugar by inhibiting the amylolytic action of the hepatic ferment. Eckhard believes that the hypodermic injection of glycerin produces such radical changes in the blood and general sys- tem that no conclusion can be made of the proper influence exerted by it. In a paper exceedingly useful and interesting, both from a physiological and clinical standpoint, Ransom of London has recently gone over this Avork in a satisfactory manner, and has tried, Avith con- siderable success, to unravel the someAvhat complex pathology of the disease, as Avell as the equally complex and opposing statements of investigators as to the influence of glycerin. He points out that one element of fallacy in all these experiments is the fact that glycerin, when given hypodermically, must reach the liver so sloAvly and in such a diffused state as to be almost poAverless, and, in consequence, Ransom introduced the glycerin into the alimentary canal. All the experiments seem to have been made in a most painstaking and care- ful, manner, but, as we have no space for their detail, we must pass them by in order to reach the results attained. These are as folloAvs: 1. Certain forms of glycosuria may be checked by glycerin. 2. Gly- cerin acts more efficiently Avhen introduced into the alimentary canal than Avhen injected subcutaneously. 3. Glycerin checks glycosuria by inhibiting the formation of sugar in the liver. 4. By this means glycerin increases the quantity of glycogen found in the liver. While these conclusions are not final in proving the value of glycerin under such circumstances, it Avould seem probable that they are of great value in pointing toward a solution of one. of the most complex subjects with Avhich physicians are called upon to deal, and it is to be hoped that Ransom will publish other researches at a future time AAmich will further elucidate this difficult subject. The quantity of glycerin Avhich the Avriter Avould recommend to be given clinically by the mouth is 1 drachm (4.0) diluted at least one-half with water. Therapeutics.—Glycerin may be employed as a SAveetening agent in the food of diabetics and in cases Avhere sugar cannot be used. It has also been given as a laxative in 1- or 2-drachm (4.0-8.0) doses by the mouth, and in enema—1 to 4 drachms (4.0-16.0) Avith or without equal parts of water. In some cases it may be used in suppository in the official Suppositoria Glycerina, U. S. This latter method is very successful in chronic constipation. Its continued use by sup- pository may, however, result in rectal irritation. As an antiseptic it is used for preserving specimens and for keep- ing alkaloids in solution for hypodermic use. In acute coryza, applied by a spray or brush to the nostrils, it is sometimes of service; for this purpose it should be diluted four or five times with water. If used on the skin, it should be diluted one- GRIND ELI A ROBUSTA. 197 half Avith Avater. In cases of impacted cerumen in the external audi- tory canal glycerin is often of service in softening the mass. The uses of glycerin, other than those mentioned, are many. In the proportion of 1 part of glycerin and 1 of water it makes a very useful mouth-Avash in the sore and dry mouth of typhoid fever and for the removal of sordes. The same Avash, with lemon-juice added to it, is very agreeable and will relieve the dry, glazed tongue of advanced phthisis. Owing to the fact that glycerin is hygroscopic, it may be used as a depletant on a pledget of cotton in congestion of the uterine cervix, the tampon being reneAved daily. (See Boric Acid and Boroglyceride.) For the prevention of bed-sores Ringer recommends the daily Avash- ing and rubbing of the part likely to be affected, folloAved by the application of glycerin, and a draw-sheet placed smoothly against the patient to protect the bedding. Glycerin and Avhiskey is a favorite household remedy for colds and coughs, but is not very useful. Glycerite of starch (Glyceritum Amyli, U. S. and B. P.) is used as a protective. Glycerite of yolk of egg (Glyceritum Vitelli, U. S.) is used in making emulsions. A very useful ointment for the application of medicinal substances t;o the skin may be made by mixing constantly in the presence of heat 1 part of potato starch and 15 parts of pure glycerin. The result is a clear, transparent, jelly-like substance Avhich does not decompose, and has the advantage of holding the medicament which it carries in solution rather than by mechanical suspension. The B. P. preparations of glycerin are as follows: Glycerinum Acidi Carbolici, Glycerinum Acidi Gallici, Glycerinum Acidi Tannici, Glycerinum Aluminis, Glycerinum Boracis, Glycerinum Plumbi Sub- acetatis, and Glycerinum Tragacanthe. GOLD. Gold is not official in the U. S. Pharmacopeia, but has been recommended very highly by BartholoAv in chronic Bright's disease in the form of the chloride of gold and sodium (Auri et Sodii Chloridum, U. S.). The dose of this substance is fa to fa of a grain (0.003- 0.006) once, tAvice, or thrice a day. The author has not found it of much value. Gold has also been strongly recommended for indiges- tion Avith epigastric pain after eating Avhen looseness of the boAvels is present, and it is said to act as a powerful sexual stimulant and to be of service in impotence dependent upon inability to obtain an erection or Avhen there is deficient glandular action. In overdoses the drug causes gastro-enteritis. Magruder has recommended chloride of gold and sodium in the treatment of pertussis. GRINDELIA ROBUSTA. Grindelia, U. S., is an American plant (Grindelia Robusta) con- taining a resin, a volatile oil, and an alkaloid. 198 DRUGS. Physiological Action.—Upon the loAver animals and man this drug is not very powerful in its action, but may cause, in large doses, paralysis of the peripheral sensory nerves, the sensory centres in the spinal cord, and finally the motor centres and nerve-trunks. It sIoavs the heart by stimulating the vagi, and raises blood-pressure by stimu- lating the vasomotor centre. Therapeutics.—Grindelia robusta is an exceedingly useful remedy in some cases of asthma and in bronchitis in its later stages. It may be given in the dose of 20 to 60 drops (1.3-4.0) of the fluid extract (Extraction Grindelia' Fluidum, U. S.), or by inhaling the fumes of burning grindelia-leaves, Avhich are previously soaked in a solution of nitre, dried, and burned on a plate or rolled into a cigarette and smoked. In chronic cystitis it stimulates the bladder and is of great service. By diluting it 1 to 10 Avith Avater it forms one of the best lotions that Ave have for the relief of the dermatitis produced by poi- son ivy or Rhus Toxicodendron. Administration.—The only preparation Avhich is official is the fluid extract (Extractum Grindelie Fluidum, U. S.), dose 20 to 60 drops (1.3-4.0). GUAIAC. Lignum Yitae, or Guaiaeum Officinale, a West Indian tree, is used in medicine in tAvo forms—namely, as guaiac avooc! (Guaiaci Lignum, U. S. and B. P.), Avhich is in raspings and enters into the compound syrup of sarsaparilla, and guaiac resin (Guaiaci Resina, U. S. and B. P.), or guaiac, Avhich is soluble in alcohol, ether, and chloroform, but insoluble in water. Therapeutics.—Guaiac has been largely used in syphilis, but is noAV rarely, if ever, so emploA7ed. Given in acute tonsillitis in the dose of 30 grains in an emulsion made by the use of Avhite of egg, it Avill often abort the disease. In rheumatism it has been largely used. The ammoniated tincture of guaiac is sometimes employed in the treatment of sore throat, particularly if it be rheumatic in type, but is a disagreeable preparation to take into the mouth, and the sali- cylatis may ahvays be used in its place. Administration.—The tincture (Tinetura Guaiaci, U. S.) is given in the dose of 5 to 60 drops (0.35-4.0), and the ammoniated tincture (Tinetura Guaiaci Ammoniata, U. S. and B. P.) is used in the same dose, preferably in milk. Mistura Guaiaci, B. P., is given in the dose of 1 to 2 fluidounces (32.0-64.0). GUAIACOL. Guaiacol is a liquid constituting from 60 to 90 per cent, of creo- sote. It is obtained by the distillation of beeclnvood creosote, fol- lowed by a complicated process which it is not necessary to describe. In other cases guaiacol is obtained from beecliAvood creosote by pre- cipitation with barium hydrate. Much of the tk absolute guaiacol" GUAIACOL. 199 of commerce is impure. Chemically pure guaiacol, obtained by the process last named, is a light-colored fluid of an agreeable odor and soluble in Avater in the proportion of 1 to 85 (Helbing). It is easily soluble in alcohol and ether. Therapeutics.—Guaiacol has been largely used by some practition- ers, chiefly in Europe, for the treatment of tuberculosis as a substitute for creosote, because it is the principal ingredient of that drug. (See Creosote.) It Avas thought by Guttmann, Sommerbrodt, and others that the good effect of creosote Avas due to its destructive action on the bacillus, or that it so improved digestion as to increase the resist- ance of the patient to the spread of the disease. Recently, iioelscher and Seifert have asserted that guaiacol and creosote produce their good effects by forming compounds with the toxines or poisonous albuminoids formed by the bacilli, Avhich are ti\en eliminated from the body. The same rules govern the use of guaiacol*as govern the employment of creosote. It is best given Avith brandy, Avine, or other alcoholic drink, or in capsules Avith cod-liver or SAveet oil. 5 or 10 drops (0.35-0.65) of guaiacol may be added to a pitcher of hot Avater and the vapor inhaled three or four times a day in cases of subacute and chronic bronchitis. The dose by the stomach is 5 to 20 minims (0.35-1.5). Recent clinical observations prove conclusively that guaiacol pos- sesses powerful antipyretic influences. As pointed out by Sciolla in 1893, guaiacol Avhen painted on the skin of a febrile patient causes a pronounced fall of temperature, Avhich begins soon after the applica- tion is made, but is not fully accomplished for from tAvo to three hours. The application may be made to the skin of the abdomen, thighs, or chest, about 30 to 40 drops (2.0-2.6) being used Avith a brush. When a full effect is required, it is Avell to place an imper- meable dressing over the part painted to prevent evaporation and aid absorption. These applications may be resorted to as often as is necessary for the reduction of the fever, and, although the fall of temperature is sometimes very rapid and very great—as much as 7° F. in tAvo hours—DaCosta has never seen serious nervous or car- diac symptoms produced, but other observers have noted such unto- ward results. The temperature is very apt to speedily rise after the reduction, and this rise is often preceded by a chill. These applica- tions are thought to be capable of supplanting the cold bath, and they undoubtedly do reduce the temperature. On the other hand, the* cold bath, particularly Avhen used in typhoid fever, exerts bene- ficial effects other than the mere reduction of temperature. The true sphere of usefulness for guaiacol as an antipyretic seems to be that of a less valuable therapeutic measure than the bath, and equally poAverful and about as dangerous as the antipyretic drugs of coal-tar derivation. A serious objection to the external use of guaiacol is its disagree- able odor. Wl'ien used externally in the fever of tuberculosis its action is very satisfactory, but the presence of cavities contraindi- cates its use, it is said. Probably future reports will develop the fact that in cases of renal 200 DRUGS. irritation guaiacol will prove harmful. The studies of Stolzenberg shoAV that if too frequently and constantly used guaiacol produces in febrile patients a tendency toward depression. Thayer finds that great SAveating and depression generally folloAv its use in fevers. GURJUN OIL. Gurjun Oil, or, as it is sometimes called, Gurjun Balsam, or. Wood Oil, is the exudation obtained, by incision and the application of heat, from the bark of an East Indian tree. It is a transparent liquid possessing the consistency of olive oil, of a greenish-gray color when held up to the light. It has an aromatic odor resembling to some extent that of copaiba. It is not, however, so disagreeable to the taste. • Therapeutics.—Gurjun oil has been found of value in cases of chronic bronchitis where a stimulating expectorant of considerable power Avas desired, and this is particularly the case if the mucus in the bronchial tubes is very tenacious. The oil has also been found of value in gonorrhea and gleet as a substitute for copaiba and cubebs. Administration.—Gurjun oil is best given in the dose of from 1 to 2 drachms (4.0-8.0) three times a day, combined with spirit of nitrous ether, mucilage of acacia, and cinnamon-water, or mixed Avith extract of malt in the proportion of 2 drachms (8.0) of the oil to an ounce (32.0) of the extract. Persons having irritable stomachs may not be able to take this drug. HEMATOXYLON. Hematoxylon, U.S., Hematoxyli Lignum, B. P., or Logwood, is the heart-wood of Hematoxylon Campechicoium, a tree of the Amer- ican tropics. It contains an alkaloid, haematoxylin. Therapeutics.—ILematoxylon is a mild astringent, very useful in serous diarrheas and in the diarrhoeas of young children, as children do not dislike it, OAving to its agreeable taste. (See article on Diar- rhoea.). As it colors the stools and urine red, the nurse should be warned lest she be alarmed at the sight of Avhat looks like blood on the diaper after the drug is given to infants. If the urine is alka- line, the color may be violet or red. In leucorrhea its internal use is of service. The extract (Extractum Hematoxyli, U. S. and B. P.) is given in the dose of 8 to 30 grains (0.6-2.0), and Decoctum Hema- toxyli, B. P. in the dose of 1 to 2 fluidounces (32.0-64.0). An unofficial fluid extract is often to be found in the shops. The dose of this is i to 2 fluidrachms (2.0-4.0). HAMAMELIS. Hamamelis, U. S., Witch-hazel, or Hamamelis Virginiana, is a plant of the United States, devoid of any true active principle, but possessing extraordinary remedial power. HOFFMA NN 'S A NOD YNE. 201 According to the studies of Wood and Marshall, it has absolutely no physiological action, yet practically Ave knoAv it to be a most useful remedy. Therapeutics.—Hamamelis is Avonderfully successful in the treat- ment of uterine oozing from small blood-vessels, seems to do good even in hematemesis and hcemoptysis, and will sometimes arrest hematuria Avhen all other remedies fail. Applied by means of cloths to leg ulcers, it acts very thoroughly and relieves the surrounding angry-looking skin at once. In bleeding from the bladder it may be injected into this viscus daily in the form of the distilled fluid extract. Taken internally and applied locally, it is of value in the treatment of bleeding and the so-called blind piles. (See Hemorrhoids.) Injected into the part affected or taken internally, hamamelis is of value in persons suffering from varicose veins. Administration.—The one official preparation in the U. S. P. is the fluid extract (Extractum Hamamelid/s Fluidum, U. S.; Liquidum, B. P.), dose 5 to 20 drops (0.35-1.30). The dose of the distilled extract, which is not official and is a perfectly clear liquid, is from 30 drops to 1 drachm (2.0—4.0), and this is much the best preparation for internal and external use. Unfortunately, the preparations of the drug vary very much both in odor and efficacy. Some of the pro- prietary preparations of Avitch-hazel are more active than those ordi- narily dispensed in the drug-store. This is due to greater care in their preparation, and to the fact that they are sold in original packages without exposure to the air. Tinetura Hamamelidis, B. P., is given in the dose of 10 to 30 drops (0.65-2.0). HOFFMANN'S ANODYNE. Spiritus JEtheris Compositus, U. S. and B. P., consists of alco- hol, ether, and the heavy oil of wine. The Avriter has experimentally studied very thoroughly the action of the last-named ingredient, and finds : First. That the belief in heaAw oil of Avine being the quieting agent in Hoffmann's anodyne is fallacious. Second. The calmative effects of this mixture depend largely on the ether, rather than on the oil. Third. It Avould seem probable that in Hoffmann's anodyne Ave possess an agent in Avhich there are linked together three drugs of undoubted poAver, each one of Avhich successively substitutes the other, stimulating the system in the order here named—viz. ether, alcohol, and the heavy oil of Avine. On animal temperature, as ascertained by the thermometer in the rectum, the heaA-y oil of wine exercises no influence, even Avhen the arterial pressure is very low. That large doses of the heavy oil of Avine are in no Avay possessed of toxic effects is proved by the fact that 30 cc. of the drug, given by the mouth to a small dog Aveighing tAvelve pounds, failed to produce any apparent symptoms, except, perhaps, to stimulate him slightly. While the odor of the oil is 202 DRUGS. penetrating, it is by no means disagreeable, and it possesses but little taste other than that caused by the presence of an oily sub- stance. Therapeutics.—Hoffmann's anodyne is the best carminative that Ave possess for general use, and is one of the best remedies for singultus or hiccough. These effects are accomplished probably in two ways: The alcohol and ether act as irritants or stimulants to the intestine, and free peristalsis results, Avhile the heavy oil of wine acts, perhaps, as a nervous sedative. In angina pectoris this drug is often the best remedy we have, and in the cardiac palpitation of tobacco heart or that arising from indigestion it is very useful. In the nausea and depression seen after excessive smoking, Hoff- mann's anodyne should always be given in capsules or in cold water, preferably ice-cold, in order to prevent too rapid volatilization of the ether and consequent difficulty in swalloAving the liquid. The dose is 1 to 2 drachms (4.0-8.0) to an adult. HOMATROPINE. Homatropine is an artificial alkaloid obtained by prolonged and gentle heating of a solution of equivalent quantities of tropine1 and toluic acid in hydrochloric acid. The hydrobromate of homatropine (Homatropine Hydrobromas, B. P.) is a crystallizable salt of hom- atropine soluble in 10 parts of distilled water. Hydrobromate of homatropine, properly applied by frequent instil- lations, is a reliable mydriatic for the correction of anomalies of refrac- tion in healthy eyes. Experience is not at hand to determine its value for this purpose in eyes affected Avith retinal-choroidal disturbance. Atropine and hyoscyamine are preferred under such circumstances, for the obvious reason that their prolonged action is desirable as a method of treatment. The danger of systemic disturbance from hom- atropine is far removed, even Avhen repeated instillations have been made, and its temporary action upon the pulse causes no inconvenience to the patient. Slight hyperaemia of the conjunctiva almost invaria- bly folloAv its use, but true conjunctivitis, if it occurs at all, must be excessively rare. According to the studies of Dr. de Sclnveinitz and the Avriter, the drug has a physiological action closely allied to that of atropine, from Avhich it is derived. Homatropine mydriasis generally lasts from thirty-six to forty-eight hours, that of hyoscyamine eight to nine days, and that of atropine ten to tAvelve days. For the pro- duction of ordinary mydriasis the drug should be used in solution of the strength of 4 grains (0.20) to the ounce (32.0) of distilled water, Avhich is to be dropped into the eye every five or ten minutes. As the drug is expensive, only a feAv drachms of the solution of the strength named should be ordered for a patient. 1 Tropine is a product obtained [by splitting up atropine into tropine and tropic acid. HOPS. 203 HONEY. Honey, or Mel, U. S. and B. P., is the saccharine fluid deposited in combs by the honey-bee, or Apis Mellifica. It is used to cover the taste of disagreeable medicines. When it is abstracted from a pecu- liar variety of floAvers, it frequently has the odor of the fioAver, and Avhen taken internally may even produce the physiological effects of the plant from Avhich it is gathered. This accident occurs commonly in those parts of the country Avhere the bees have had access to moun- tain laurel and similar plants. Therapeutics.—Honey is used as an emollient in gargles and to relieve cough and dryness of the mouth and fauces. When used as a gargle it very distinctly increases the secretion of the mucous mem- brane, and so relieves the congestion. Under the name of Oxymel the B. P. recognizes a mixture of 8 parts of honey, 1 of acetic acid, and 1 of Avater. This is generally used as a vehicle for more active remedies in gargles or even for expectorant mixtures. Melted and strained honey is knoAvn as Mel Despionatum, U. S., and Mel Depuration, B. P. There are also a honey of roses (Mel Rose, U. S.) and a confection (Confectio Rose, U. S.), used as vehicles for other drugs. HOPS. Humulus, U. S., is the strobiles of ordinary hops, or Humulus Lupulus. They contain a liquid volatile alkaloid, lupuline, and a bitter principle, lupulinic acid. Hops are knoAvn under the name of Lupulus in the B. P. Much confusion has arisen in regard to the preparations of this drug, partly because Humulus is the official name in the U. S. P. and Lupulus in the B. P. This has been increased by the fact that the alkaloid of hops is called lupuline, Avhile the poAvder Avhich is found on the strobiles is called lupulin. Those preparations in the U. S. P. having the word " humulus " in their name are made from the hops themselves, those Avith " lupulin " in their name from the poAvder of the strobiles. Therapeutics.—Hops are used as antispasmodics and nervous seda- tives in cases of hysteria and nervousness. In priapism, vesical irrita- bility, and renal irritation they are of service. Even in delirium tremens they seem to be of value. For local application a hop poul- tice mav be made by placing the poAvdered strobiles in the mass, and employed in this Avay they are a favorite home remedy for local pain- ful infl/tmmations. Hops have been used in the form of a hop pillow in nervous insomnia, but the soporific influence is largely imaginary or depends on the fumes of the alcohol with Avhich the pilloAv is moistened. Administration.—The tincture (Tinetura Hamuli, U. S.) is given in the dose of | to 3 ounces (16.0-96.T)). Lupulin (Lupulinion, U. S. and B. P.), which is the poAvder found on the strobiles of hops, is given in the dose of 2 to 5 grains (0.1-0.35) or more; the oleoresin 204 DRUGS. of lupulin (Oleoresina Lupulini, U. S.) is given in dose of 10 to 40 drops (0.65-2.65) in capsules; and the fluid extract (ExtractumLupu- lini Fluidum, U. S.), in the dose of 30 to 120 drops (2.0-8.0). The preparations of the B. P. are the extract of hops (Extractum Lupuli), dose 5 to 10 grains (0.35-0.65); the infusion (Infusum Lupuli), dose 1 to 2 fluidounces (32.0-64.0); and the tincture (Tinetura Lupuli), dose J to 2 fluidrachms (2.0-8.0). HOPE'S CAMPHOR MIXTURE. This is a mixture originally made with nitrous acid, but largely used at present with nitric acid, OAving to the fact that nitrous acid is changed into nitric acid when water is added to it. The nitrous acid is, however, more efficacious than nitric acid in the serous or choleraic diarrheas Avhich it is used to combat. The formula is as folloAvs: R— Acidi nitrosi.............f^j (4.0). Aqua? camphorae...........f3viij (256.0). Et adde Tinct. opii.............gtt. xl (2.65).—M. S.—One-fourth of this in water every three or four hours. HYDRASTIS. Hydrastis, U. S., is the rhizome of the Hydrastis Canadensis, con- taining two alkaloids, knoAvn as hydrastine and berberine, and, per- haps, xanthopuccin. Physiological Action.—In poisonous doses hydrastis may cause con- vulsions folloAved by paralysis, according to the quantity of berberine or hydrastine present. The latter is more convulsive in its effects than the former. Upon the circulation hydrastine, Avhen injected into the jugular vein, causes a primary fall of arterial pressure, succeeded by a decided rise, and the studies of Cerna have proved that it is an active poison producing spinal convulsions folloAved by paralysis. Therapeutics.—Hydrastis is of service in chronic gastro-intestinal catarrh, particularly that folloAving the abuse of alcohol, and may be used as a stomachic and tonic after malarial fever and similar depress- ing diseases. Wherever membranes exist in a condition of loAvered tone this drug is indicated. Thus in catarrhal jaundice of a subacute type, in uterine catarrh, in leucorrhea dependent upon a relaxed state of the vagina, and in chronic nasal inflammations and irritations it Avill be found useful. Tincture of hydrastis is said to possess a distinct antimalarial influence. One of the best remedial measures that Ave have in the later stages of gonorrhea, when the acute period has passed, is the local and internal use of hydrastis. If it is used as an injection, 5 grains (0.3) of the commercial hydrastine to each ounce (32.0) of Avater should be employed twice a day. If this is not used, the following HYDROCHLORIC ACID. 205 infusion will be found of service: Take 1 drachm of the poAvdered root and add it to 8 ounces of boiling Avater; J to 1 drachm of the fluid extract may also be added to a pint of water and used as a A\rash in vaginal gonorrhea and leueorrhea. In chronic dyspepsia hydrastis seems to act as an antiseptic and as a curative agent upon the mucous membranes of the stomach. Administration.—The fluid extract (Extraction Hydrastis Fluidum, U. S. ; Liquidum, B. P.) may be given in the dose of 5 to 30 drops (0.30-2.0), Avhile the dose of the tincture (Tinetura Hydrastis, U. S.) is from 30 drops to 2 drachms (2.0-8.0). The Glyceritum Hydrastis, U. S., is used as a healing application to mucous membranes. Much doubt exists as to the dose of hydrastine. This arises from the fact that tAvo forms of it are sold. The most commonly seen is a dark-broAvn mass Avhich is very impure, and contains berberine and other substances. Its dose is 3 to 10 grains (0.15-0.65). The pure hydrastine, as made by Merck, is given in the dose of \ to \ grain (0.016-0.03). Hydrastinine hydrochlorate, an artificial alkaloid of hydrastine, has become official in the U. S. P. of 1890. HYDROBROMIC ACID. (See Bromides.) HYDROCHLORIC ACID. Acidum Hydrochloricum (U. S. and B. P.) is a clear, colorless liquid, possessing an acid odor and taste, devoid of astringency, but in concentrated form decidedly caustic. It should be kept in dark- colored bottles. In the strength of two-tenths of 1 per cent, it is present normally in the gastric juice, and aids the pepsin in the con- version of proteids into peptones and in the formation of pepsin from pepsinogen. Therapeutics.—In dyspepsia due to faulty gastric secretion, as in typhoid fever, and in gastric indigestion accompanied Avith fermenta- tion, this acid is of service. In combination Avith compound tincture of cardamoms it is of value in intestinal indigestion. (See Indiges- tion.) The acid is best used in the form of the official dilute acid (Acidum Hydrochloricum Dilution, U. S. and B. P.), dose 10 to 30 drops (0.65-2.0) in Avater. In the sick stomach and gastric distress folloAving an alcoholic debauch 20 drops (1.3) of the dilute acid in Avater are often of service. This acid is combined with nitric acid to form dilute nitro-hydro- chloric acid (Acidum Nitro-hydrochloricum Dilution, U. S. and B. P.), the dose of Avhich is 10 to 30 minims (0.65-2.0); also the pure acid (Acidum Nitro-hydrochloricum, U. S.), dose 1 to 5 minims (0.05-0.35). Hydrochloric acid causes, when taken in poisonous doses, violent gastro-enteritis and corrosion of the gastric walls, and its action should be combated by alkalies, soap, oils, and Avhite of egg. 206 DRUGS. HYDROCYANIC ACID. Hydrocyanic or Prussic Acid is a transparent, colorless, very vol- atile liquid, giving rise to vertigo Avhen inhaled in minute amounts and producing death if the fumes be concentrated. If the bottle containing the pure drug be opened, it should be done where there is sufficient draught between windows to prevent any contamination of the atmosphere of the room by the acid. Pure hydrocyanic acid is never used in medicine; the form employed is that of the dilute acid (Acidum Hydrocyanicum Dilu- tion, U. S. and B. P.), which contains about 2 per cent, of the drug. It must be kept in dark, tightly-stoppered bottles. Physiological Action.—This is one of the most rapid (if not the most rapid) lethal poisons known, only being approached by carbolic acid and nitrobenzole in the violence of its effects. OAving to its volatility, it is absorbed with great rapidity, and acts upon the respi- ratory centre and the heart, being eliminated almost immediately afterward. As a consequence, the survival of a patient twenty or thirty minutes after the ingestion of a poisonous dose is a favorable sign. The drug is an active paralyzant and exerts a lethal influence over every part of the body. The nervous system, heart, respiration, brain, and all vital parts are killed at once if much of it is present. Poisoning.—Death either comes at once, so that the person drops dead to the floor with a gasp, is for a moment convulsed, the face cyanotic, the eyes Avide open, Avith the teeth tightly shut, and the lips covered by a bloody froth, or three stages of poisoning may ensue if the dose has not been very large. In the first of these there is difficult respiration, sIoav cardiac action, and disturbed cerebration. In the second stage, which is convulsive, Ave find wild cries, dilated pupils, unconsciousness, vomiting, spasmodic urination and defecation, erections of the penis, and ejaculations of semen. In the third stage there is asphyxia, collapse, and paralysis, ending in death. The blood is found to be dark and venous-looking, but does not give the spectrum bands of cyano-haemoglobin. These bands only appear Avhen the drug is shaken with the blood outside the body. The diagnostic signs of death from prussic acid are the odor on the body, the wide-staring eye, the clinched teeth covered with froth, and the livid, cyanosed face. If the body be opened, the odor of hydrocyanic acid is marked, but rapidly passes away. The only poisoning producing symptoms resembling those which have just been described is that produced by nitrobenzole or essence of mirbane, which has a somewhat similar odor, but which is, hoAV- ever, more permanent, the odor remaining in the opened body for hours. Therapeutics.—Hydrocyanic acid is useful in cases of gastralgia of purely nervous origin, and in some cases of nervous vomiting, and in irritable stomach where, owing to a hyperaesthesia of the mucous membranes, the taking of food produces discomfort. In irritable coughs, due to tickling in the throat and bronchi, it is HYDROGEN PEROXIDE. 207 very extensively used, and has received high praise by those best qualified to judge. On the other hand, it has been claimed that owing to the extreme volatility of the drug it only acts for the moment, and that a dose every ten or fifteen minutes is necessary to produce any real effect. However this may be in theory, practically the acid certainly does aid in relieving cough. In these states the following prescription will be found of service: R.—Acid, hydrocyan. dil..........f 3J (4.0). Morphinae sulph............gr- ij (0.1). Syrup, pruni virg...........f t^iij (96.0).—M. S.—Teaspoonful (4.0) every four or five hours to an adult. In enteralgia or neuralgia of the intestines dilute prussic acid is very useful. Externally, the drug is useful in pruritus and other forms of itch- ing skin diseases, and the following formula Avill be found of service in pruritus vulvae : R.—Hydrarg. chlor. corros.........gr. jss (0.09). Acid, hydrocyanic, dil.........f,^j (4.0). Aquae amygdal. amarse........f ovJ (192.0).—M. S.—Apply to the itching surface with a small rag. The same prescription may also be employed in pruritus Avithout the bichloride, if so desired. The dose of dilute hydrocyanic acid is 1 to 5 drops (0.05-0.35). In certain forms of irritable cough inhala- tions of the vapor (Vapor Acidi Hydrocyanici, B. P.) are recom- mended ; these are prepared by adding 10 to 15 minims (0.65-1.0) of the diluted acid to 1 fluidrachm (4.0) of Avater, Avhich is then placed in a suitable apparatus from which is inhaled the vapor that arises. HYDROGEN PEROXIDE. Peroxide of Hydrogen is a clear, odorless, syrupy fluid of a specific gravity of 1.452, possessing a harsh, bitter taste. It is readily sol- uble in Avater, and its chemical formula is H202. Pure peroxide of hydrogen is never used in medicine, but in solutions of varying strength. The ordinary solution, as found in the shops and that now official (Aqua Hydrogenii Dioxidi, U. S.), is about 3 per cent., or, as it is generally called, a 10-volume solution. This term, " 10 volumes," signifies that it can yield 10 volumes of available oxygen; and it is upon this yield of oxygen that its activity depends. The specific gravity of this official solution is 1.006 to 1.012 at 59°. The reaction is acid, but this is due to a small amount of acid added to the solution to preserve it. The official solution of peroxide of hydrogen, Avhile the most stable that can be prepared, is nevertheless readily deterio- rated by exposure to heat, sunlight, or prolonged shaking. If placed in an absolutely clean, smooth glass vessel, it may be concentrated for immediate use by exposing it to a temperature of 140° F.; but exposure to a temperature above this point may result in its decompo- sition Avith explosive violence. Practically, this means of concentra- 208 DRUGS. tion is not convenient for the practitioner, and the ordinary official solution fulfils all ordinary requirements unless it has deteriorated by age. The great difficulty in the use of the solution of the peroxide is its liability to undergo change and become practically worthless. Wallian states that as a rough test for the value of a given solution a feAv crystals of permanganate of potassium may be placed in a test- tube, and 1 or 2 drachms (4.0-8.0) of the solution added. The vio- lence of the resulting effervescence is in direct ratio to its value as a remedial agent. Therapeutics.—The most valuable use of the peroxide-of-hydrogen solution in medicine is in the treatment of diphtheria. So far as Ave knoAv, it is the best application for the destruction and removal of the false membrane. There is no injury to the normal tissues, nor the danger of poisoning which sometimes follows the use of such drugs as carbolic acid. Applied to the false membrane, there is at once an active effervescence with some local tingling of the part. The mem- brane can afterward be removed in shreds. The solution should be applied by means of a swab or spray, but if the latter is used a glass atomizer must be used, as the peroxide is decomposed by coming in contact with metals. In the treatment of abscess-cavities, tubercular or septic in cha- racter, the peroxide of hydrogen is a very valuable application, and its use Avill often decide the presence of pus, since Avhen it meets with this material active effervescence ensues. Similarly, it is a valuable preparation for cleansing ulcers and malignant growths which have ulcerated. The employment of the peroxide internally, Avith the idea that it will yield oxygen to the body in cases A\rhere this gas is lack- ing, is futile. Even if the oxygen entered the blood, the amount disengaged from a possible dose would be too small to be of any value. Where the peroxide is used as a gargle it may produce pain through its attacking cavities in the teeth or the metallic substances Avith which they are filled. Taken internally, the peroxide of hydrogen is not poisonous. The internal dose of the Aqua Hydro genii Dioxidi of the U. S. P. is from 1 to 4 drachms (4.0-16.0), well diluted Avith water, and taken from a porcelain, not a metal, cup or spoon. HYOSCYAMUS. Hyoscyamus, U. S., or Henbane, is a plant of the Northern United States and Europe. The leaves (Hyoscyami Folia, B. P.) only are used, and from them are obtained two alkaloids—one known as hyos- cyamine, the other as hyoscine. The first has the same physiological action as atropine. (See Belladonna.) The second is quite different in its influence over the body. The only marked difference in the action of hyoscyamine and atropine is in the mydriasis produced by each. While that of atropine lasts, in man, from twelve to fourteen days, hyoscyamine generally remains for only seven to nine days. Some- HYOSCYAMUS. 209 times the development of mydriasis is preceded by violent pain in the eye due to cramp of the ciliary muscle. If so, the drug must be pushed to overcome the spasm. The strength of the solution to be used is 2 grains (0.1) to the ounce (32.0). OAving to the presence of hyoscine in hyoscyamus. it is more quieting and depressing to the nervous sys- tem than is belladonna. Therapeutics.—Hyoscyamus is used in every condition indicating the employment of belladonna ; or, in other words, Avherever local spasm or arterial relaxation exists or Avhere pain is due to spasm. It has been particularly recommended in nervous cough, in whooping cough, and in colic, and probably is better in its influences in these states than is belladonna. In combination Avith nitrate of silver the extract may be used Avith advantage in chronic gastric catarrh. In urinary incontinence due to irritable bladder it is very serviceable, and particularly is this true of this affection in children and old persons. Administration.—The drug itself is official in four forms and as hyoscyamine sulphate and hydrobromate. The dose of the tincture (Tinetura Hyoscyami, U. S. and B. P.) is 30 drops to 1 drachm (2.0—4.0): the alcoholic extract (Extractum Hyoscyami, U. S. and B. P.), dose 1 to 3 grains (0.05-0.15); the alkaloid (Hyoscyeonitac Sulphas vel Hydrobromas. U. S.). dose fa to fa of a grain (0.001- 0.0015); and the fluid extract (Extractum Hyoscyami Fluid/on. U. S.). dose 5 to 30 drops (0.35-2.0). The B. P. preparation, besides those given, is the juice (Succus II//osc//ami), dose 30 minims to 1 fluidrachm (2.0-4.0). Hyoscine. This is one of the alkaloids derived from hyoscyamus, and is a poAverful nervous depressant. Physiological Action.—Hyoscine quiets the cerebrum and produces deep sleep in a certain class of patients. In the lower animals or in man it may cause sleep or wild delirium. It causes loss of reflex action in overdose, Avhich is due to paralysis of the spinal cord and not of the nerve-trunks. L^pon the circulation it has little effect, but it is Avorthy of note that it does influence the vagus nerves, as does atropine, stimulating them at first, and finally paralyzing them, although the contrary has been asserted. In any event, the circu- latory effect is a minor one. In cases where hyoscine has acted in excess, or where an overdose has been given, pilocarpine may be used as a physiological antidote in full doses. Therapeutics.—Hyoscine is of value as a hypnotic in a very lim- ited class of cases, but in this class generally acts most favorably. These cases consist of those Avho, from acute mania, alcoholic mania, hysteria, or similar cause, suffer from insomnia, and perhaps use vio- lent struggles against proper control or refuse to SAvalloAV or retain food. The drug mav be given to such persons, hypodermically, in the dose of yfy to ¥L 0f a"grain (0.0006), or by the mouth in the dose „f -fa to fa of a grain (0.0008). The fact that it possesses no taste and is small in bulk renders it readily employed. In some 14 210 DRUGS. persons it utterly fails even in this particular type of cases.1 In delirium tremens it may cause evidences of cerebral congestion and Cheyne-Stokes breathing. Some cases are not quieted by the drug, but pace up and doAvn in a semi-sane condition until its action wears off. In the opinion of the writer the applicability of the drug is very limited indeed, and untoward effects are common. Hyoscine is certainly of great value in spermatorrhea and noc- turnal emissions. The drug is contraindicated in the sore throat of scarlet fever, as it may cause glottic spasm. In the insomnia of heart disease with nervousness it Avill cause sleep, but may also produce death by respi- ratory failure or cardiac arrest, and it is to be remembered that the drug Avill produce asthma rather than relieve it. The breathing in some persons may become under its influence croupy or rasping. Hyoscine is an uncertain remedy in nervous affections, sometimes acting very Avell, at others producing very alarming symptoms in cerebration, circulation, and respiration. Hyoscine is official in the form of Hyoscine Hydrobromate (Hyos- cine Hydrobromas, U. S.). HYPNAL. The chemical name of this substance is monochloral-antipyrine, and it is, as its name indicates, a compound of chloral and antipyrine. There is also a dichloral-antipyrine, Avhich contains more chloral. The compound is employed in treating those patients who suffer from pain and insomnia combined, the antipyrine relieving the pain and the chloral producing sleep. Opium is the only drug known which can be relied upon to act in this double manner, and the disadvantages of that medicament are often so prominent as to prevent its use. In cough arising from bronchitis or phthisis, and causing by its con- stancy loss of sleep, and in neuralgic insomnia, hypnal will be found of service. The dose is from 5 to 20 grains (0.35-1.3), best given Avith simple syrup and Avater or with syrup of orange-peel, or it may be used as follows : R.—Hypnal...............gr. xv (1.0). Chartreuse.............fxj (4.0). Distilled water........ , . f£ss (i6.0).—M. S —The entire amount to be taken in one dose. ICHTHYOL. Ichthyol is a substance obtained by distillation from a peculiar resinous accumulation found chiefly in the Tyrol, and supposed to be the result of a deposit of extinct fish. Ichthyol occurs as the ich- l The writer has given one-tenth of a grain of Merck's hyoscine in twenty-four hours, obtained from two different and reliable stores, without producing sleep, although the respirations were much quickened. ICHTHYOL. 211 thyosulphate of sodium or ammonium. The latter is the salt com- monly employed, and is semi-solid. Both of these contain about 10 per cent, of sulphur, and it is largely upon this that their therapeutic activity depends. The disagreeable odor of ichthyol depends upon the presence of an inseparable volatile oil. Therapeutics.—Ichthyol is Avithout doubt one of the most remark- able substances used for medicinal purposes Avhich has appeared in the last decade. In skin diseases it has been most highly recom- mended on both sides of the Atlantic, and is employed in the form of ichthyol ointment in chronic eczema, acne, urticaria, and even on lupus and keloids. In almost all chronic skin affections it is of the greatest value, and the Avriter has seen it exert a most favorable influence upon erysipelas both in hospitals and in his private practice. Under these circumstances the ointment should contain about 20 per cent, of ichthyol, or less. Some practitioners recommend that ich- thyol be applied in a Avatery solution of the strength of 1 drachm to the ounce (4.0 : 32.0) by means of a camel's-hair brush. Under these cir- cumstances it is necessary to Avash the parts with oil and water every day. using the greatest gentleness. It has also been found by the writer very efficacious in the pain and SAvelling accompanying acute rheuma- tism of the joints, both during and after the acute stage of the dis- ease. The strength for this use should be about 30 parts of ichthyol to 70 of benzoinated lard. In frost-bites, chilblains, and in burns it is of service, and Agnew has recommended it highly Avhen rubbed into lymphatic enlargements. Ichthyol has proved remarkably effica- cious in removing peri-uterine and other pelvic exudations Avhen used as a salve or in a vaginal suppository. For acute sprains, and for the removal of the SAvelling folloAving such injuries, its influence is extraordinary if it be Avell rubbed into the part affected. In severe eases of cracked nipples, Avith much induration, an oint- ment of ichthyol, 1 drachm to 4 (4.0-16.0) of lanolin Avill prove of value, but it must be wiped off before each nursing or the child will not take the breast. Often the odor remains and prevents nursing. Owing to the disagreeable odor of ichthyol, oil of citronella ought to be added to it, as follows : R.—Ichthyol..........gij (8.0). 01. citronella?........gtt. xv vel xxx (1.0-2.0). Adipis...........Ij (32.0).—M. The dose of ichthyol internally is 1 to 10 grains (0.05-0.65), given in pill. When used in this Avay the sodium salt should be used. Untoward Effects.—Bergerio and Peroni have both reported dis- agreeable symptoms from the intra-uterine application of ichthyol after curetting. As the drug ought not to be so used, such reports are of little practical value. IODIDE OF AMMONIUM. (See Ammonium Iodide.) 212 DRUGS. IODIDE OF ETHYL. (See Ethyl Iodide.) IODIDE OF POTASSIUM. The physiological effects of iodide of potassium (Potassii Iodidum, U. S. and B. P.) are entirely comparable to those of iodine itself, but it is employed for somewhat different purposes, is less irritant, more readily given, and perhaps more readily absorbed. Physiological Action.—Circulation.—Upon this part of the sys- tem iodide of potassium produces effects differing very slightly, if at all, from those caused by potassium itself. Small amounts raise the blood-pressure, and large quantities lower it (Prevost and Binet). Elimination.—Iodide of potassium is very rapidly eliminated, appearing in the urine, according to Doux, in thirteen minutes after it is ingested, and the daily amount excreted equals about 80 per cent. of the dose taken. All traces of the iodide in the urine cease four or five days after the last dose is administered (Elhers). Therapeutics.—The use of iodide of potassium may be divided into three great divisions, each of which is important. It is also employed for many conditions not included in these classes: 1. Syphilis.—The use of iodide of potassium in syphilis is recog- nized as a part of all treatment for its relief. ElseAvhere Dr. Martin has, in his excellent article (see Syphilis), treated of this question, and it is only necessary to call attention to the fact that the drug is generally Avell borne in large amounts by advanced syphilitics, although this is not always the case. The term " therapeutic test " is applied by one eminent teacher to signify a state of the system produced by syphilis in Avhich a diagnosis may be made by the fact that large doses of the iodide are borne without inconvenience. As already intimated, this resistance does not always prove the presence of syphilis, nor does its absence prove the absence of this disease. Persons having hereditary asthma, gout, rheumatism, or some similar diathetic malady often resist the iodide, and some syphilitics are affected Avith " iodism " after very small doses. In treating syphilis the drug should be used in the dose of 10 grains (0.65) three times a day, and this amount gradually increased a grain a day until symp- toms of "iodism" occur. The quantity borne often amounts to from 100 to 200 grains (6.0-13.0) a day. The best way to use the iodide of potassium is to order for the patient a saturated solution of the drug, Avhich contains in each drop about 1 grain, and at the same time a bottle of the com- pound syrup of sarsaparilla. To a tablespoonful of the latter the patient is to add the iodide solution, beginning Avith 10 drops (0.65) three times a day and increasing a drop every twenty-four hours. The iodide acts more slowly as an antisyphilitic than does mercury. In tertiary syphilis the iodide is invaluable. In nervous syphilis, be its manifestations Avhat they may, iodide of IODIDE OF POTASSIUM. 213 potassium is the standard remedy, only being supplanted by mercury Avhen it is necessary to break down a groAvth whose existence is a daily menace to the patient's life. 2. Metallic Poisoning.—Owing to the fact that iodide of potas- sium forms double soluble salts with all the metals in the tissues in chronic poisoning, thereby aiding in their elimination, it should always be employed in chronic lead, zinc, arsenic, or mercurial poisoning." 3. Antirheumatic.—Iodide of potassium is best suited, not to the acute sthenic stages of rheumatism, when the joints are very hot and painful, but to the secondary or subacute periods, when the joints are large and the case " hangs on "—noAV better, noAv worse. It acts best, under these circumstances, if combined Avith Avine of colchicum- root. (See Rheumatism.) It is also to be tried in sciatica, lumbago, and rheumatic neuralgia, and should be employed in chronic pleurisy, pericarditis, and hydrocephalus to cause absorption of the fluids. In aneurism, particularly that of the aorta, the drug does good, but its value rests largely upon the cause of the disease. If it is due to syphilis, the aneurism yields very rapidly to the drug. The pain, SAvelling, and pulsation generally decrease. In asthma iodide of potassium is valuable if the disease is of the pure bronchial type, but it ought not to be employed if it is gastric. In bronchitis and intestinal catarrh Avhere the condition of the mucous membranes is semi-chronic, and not relieved by chloride of ammo- nium, iodide of potassium should be used. If the bronchitis is chronic and the secretion profuse (bronchorrhoea), iodide of potassium Avill make it Avorse. The dose for an adult in all these instances should be about 3 to 5 grains (0.15—0.3) three times a day. In pulmonary emphysema iodide of potassium is often of great value. In chronic nephritis small doses (5 grains (0.35) t. d.) are thought by some to check the disease, but it is to be remembered that the drug may produce poisoning if the kidneys do not eliminate it, so that, if used at all, it must be with great care. If the drug is well borne, it will cause an extraordinary increase in the urinary flow, and Avill relieve any dropsy Avhich may be present very rapidly indeed. In bronchocele the employment of iodide of potassium internally and tincture of iodine externally is the best treatment Ave can use, and in acute coryza, or " cold in the head," 10 grains (0.65) of the iodide taken at the beginning of the trouble will often abort the attack. In hepatic cirrhosis, in its early stages, the iodide often does good, and in arteriosclerosis or atheroma of the blood-vessels it is of great service, according to many English, French, and American writers. A very important use of iodide of potassium is for the removal of enlargements of the cervical glands and those occurring in other parts of the body. In enlargements of the spleen, malarial or otherAvise, external paintings Avith iodine and the internal use of the iodide in small doses are of seiwice. In the later stages of pneumonia the iodides are useful to aid in the absorption of any exudates, but they are contraindicated in phthisis, except in the fibroid form and in 214 DRUGS. many of those cases Avhich are dependent upon syphilis as an under- lying dyscrasia, as they aid in the breaking doAvn of the lung. Untoward Effects.—In some persons, after the use of the iodide, coryza Avith a tearful condition of the eyes comes on, so that the edges of the lids become reddened and the nose runs constantly. This is folloAved, if the drug is pushed, by the more positive signs of " iodism " spoken of under Iodine. In other cases acne breaks out on the face and disorders of diges- tion and gastric irritability come on. The acne can nearly ahvays be prevented by giving arsenic at the same time with the iodide. In some cases petechial rashes break out on the leg, Avhile in others great mental and physical depression appears, so that listlessness or melan- cholia may develop. In persons susceptible to iodide of potassium care should be exer- cised Avhen it is first administered lest sudden and dangerous oedema of the glottis occur. Eisner has reported a case in Avhich death fol- loAved the administration of 30 grains of the iodide of potassium. Multiple hemorrhages from the skin and mucous membrane occurred. Sometimes the iodide of ammonium or iodide of sodium will be borne Avhen the iodide of potassium will not. If bullae or blebs follow the use of the iodides or other rashes appear, if is said that atropine Avill afford relief. Administration.—The iodide of potassium, OAving to its exceed- ingly disagreeable taste, should be given Avith the compound syrup of sarsaparilla, extract of liquorice, or in milk. Large amounts of these vehicles are to be used. A good Avay to give it, Avhen the physician fears it will disorder the stomach, is to add the drug to one of the liquid pepsins, and then to add this to warm milk, as in the directions for junket given in Part III. The curd completely covers the taste of the drug, as Avas first noted by Delavan of NeAv York. The dose varies from 5 to 60 grains (0.35-4.0), according to the condition of the patient. One of the best ways to take the drug is in capsule, but if this is done a drink of milk or water or other fluid should precede or folloAv it, in order to prevent the drug from coming in contact with the stomach in concentrated form. The preparations of the iodide of potassium are—Unguentum Potassii Inlidi, U. S. and B. P., and the liniment (Linimentum Potassii Iodidi cum Sapone, B. P.). The former should always be freshly prepared. IODIDE OF SODIUM. Sodii lodidum, U. S. and B. P., is used in the same doses and for the same purposes as the iodide of potassium. IODINE. lodum, U. S. and B. P., is a non-metallic element found largely in seaweed and in mineral iodates and iodides. It is soluble in ether IODINE. 215 and alcohol, but slightly so in water, and possesses an acrid, burning taste and a neutral reaction. Physiological Action.—The physiological action of iodine, so far as its alterative poAvers are concerned, is absolutely unknoAvn. Applied to the skin, it stains it yelloAV, broAvn, or black according to the free- dom of its application, and it acts without pain if the skin is intact. If very large amounts are used, it produces vesication. Upon mucous membranes iodine acts as a poAverful irritant. Germain-See believes it to be a stimulant to the nutritive processes of the body and to the circulatory system, and he is certainly correct in regard to the influ- ence it exercises over nutrition. Elimination.—The drug escapes chiefly through the kidneys, the skin, the salivary glands, and it even appears in the milk of nursing Avomen. Poisoning.—The symptoms of acute poisoning by iodine are those of acute gastro-enteritis, with severe pain in the oesophagus, stomach, and abdomen, accompanied by violent vomiting and purging. An early symptom is the persistent strong metallic taste in the mouth, with markedly increased salivation. The pulse becomes rapid, running, and feeble, the face deathly pale, total arrest of urinary secretion takes place through renal irritation, and death occurs bv failure of respiration, Avhich is accompanied by loss of all vital poAver. If the poisoning is not severe enough to cause death at once, a fatal result is, nevertheless, often reached after a few days by reason of a Avidespread fatty degeneration of the tissues. The treatment of the poisoning consists in the use of large amounts of starch in any of its forms as the antidote, the employment of emetics and the stomach-pump, the application of heat to the body and extremities, and, finally, the employment of hypodermic injections of alcohol, digitalis, ammonia, and atropine or strychnine, for the purpose of maintaining the strength of the circulatory and respira- tory system. Chronic Poisoning.—Under the name of " iodism " the profession recognizes a state of the body brought on by the prolonged and excessive use of iodine in any of its forms. The earliest signs of this state are shoAvn by a peculiar metallic taste in the mouth, par- ticularly before breakfast, slight tenderness of the teeth and gums, increase of salivary secretion, a little morning nausea and a lack of appetite for breakfast, and perhaps some coryza or evidence of gastric irritation. Acne rosacea often comes on very early. If the drug is continued, all these symptoms become more marked and the coryza becomes intense. Headache under the frontal bone and sore throat often appear, and the pustular and bleb-like changes in the skin go on to active suppuration. Sometimes large boils appear or purpura haemorrhagica comes on. In other cases the nervous system chiefly suffers. TAvitchings of muscles, neuralgic pains in the trunk and extremities, and Avasting of the testicles, mammae, and all other tissues occur as the result of trophic disturbances. Anaemia amounting to an actual cachexia is 216 DRUGS. commonly produced. Loss of vision and paralysis may ensue in extreme cases. Therapeutics.—In all cases where the system is in a state of chronic perverted functional activity, as in those diseases associated with disorder of the processes of nutrition, and often included under the single name of scrofulosis, iodine is of service. In enlargement of the lymph-glands it is, in its various forms, one of the best rem- edies Ave possess, but it ought not to be employed in those cases Avhere rapid changes are going on in the gland, such as the formation of pus, since under these circumstances it Avill increase the size of the slough. The drug ought never to be used in rapid phthisis, because it tends to disintegrate the tissues, and this is precisely Avhat the dis- ease is doing. In the exceedingly chronic form of pulmonary disease knoAvn as fibroid phthisis iodine may be used. AY hen inhaled in fumes it may be of service as a stimulant to the mucous membranes, but is never of' value in phthisis otherAvise. In countries Avhere exophthal- mic goitre is very prevalent iodine ranks as a most efficient remedy. In cystic enlargement of the thyroid gland it is valueless, but in sim- ple hypertrophy of the gland is of great value. In chronic bone disease iodine applied about the affected joint in the form of the ointment diluted one-half with lard, or in the pure tincture, will be found of service, and if anemia exists the syrup of the iodide of iron should be given internally. The other uses of iodine externally are many and important. As a slow counter-irritant, Avhich does not produce pain if properly employed, it is particularly useful in children, and may be employed in one to three coats, and no more. The proper Avay of using the tincture is to give one good black coat at one sitting, and not to repeat it until the skin has desqua- mated and become Avell reneAved. If iodine is applied soon after one good effective coat, it will cause agonizing burning pain, Avhich noth- ing Avill relieve except the removal of the iodine by the use of cologne- water, alcohol, Avhiskey, or gin. The application of any of the latter liquids causes such an increase in the pain as to be almost useless after the skin is broken. The best solution for its removal is one of iodide of potassium, Avhich should be folloAved by a starch poultice. A good rule to folloAv is never to cause pain by the use of iodine, as the drug acts equally Avell if applied in such a Avay as to avoid suffering. Iodine in the form of the tincture is applied as a counter-irritant paint in pleurisy, both to abort an attack and to aid in absorption of the fluid after it is throAvn out into the chest. In harassing irritative cough it may be painted over the supraclavicular spaces, and it will lessen the secretion in chronic bronchitis if used in this way. In chronic rheumatism affecting the joints and muscles it does good Avhen locally applied. Often in synovitis the local application of iodine causes increased swelling for some days. This should not cause alarm, for ultimately the swelling decreases very greatly, and the cases in which this occurs are generally the best' from a'prognostic point of vieAv. IODINE. 217 In the course of phthisis every noAV and then a "spot" in the chest Avill become u sore," probably due to a limited area of pleurisy, and under these circumstances tincture of iodine locally applied will give relief. In lupus the tincture may be painted around the edges of the groAvth, and even over its surface, with the object of retarding its spread. In chilblains an application of iodine ointment gives the greatest relief if diluted one-half Avith lard, and its use is probably the most efficacious measure at our disposal. In certain individuals who have tk pains in the chest " iodine ointment may do good if applied over the spot. As has been pointed out by others, iodine does good if muscular tenderness is present, Avhile it fails if pleuro- dynia or intercostal neuralgia is the cause of the suffering. The lat- ter troubles should be removed by the use of belladonna. In certain forms of skin diseases, such as tinea tonsurans and circinata, tincture of iodine may be applied Avith a camel's-hair brush, and even the entire scalp may be painted. A better way is to apply it to different spots each day. AVhen erysipelas is present, the tincture may be painted around the edges of the inflammation in order to prevent its spread. In old persons or those in middle life retraction of the gums from the teeth sometimes comes on, and Stille' recommends for this dis- order the use, by means of a camel's-hair brush, of a Avatery solution of iodine of the strength of 1 grain to the ounce (0.05 : 32.0), to be folloAved at once by a thorough rinsing of the mouth Avith pure Avater. In hydrocele iodine in the form of the tincture is the best remedy for effecting a permanent cure that Ave have. The sac should first be emptied by the use of a trocar and canula, and the iodine alone or with glycerin injected Avith a syringe, and then alloAved to escape. As the pain is most atrocious, the patient should first be put partly or entirely under the influence of ether or other anaesthetic. In white swellings and ovarian tumors as much as 10 ounces (320.0) of the tincture may be injected, but it is to be remembered that certain dangerous symptoms may arise. After its use in this Avay in the chest violent symptoms of poisoning have come on in some cases, the most common complication being convulsions. These are epileptiform in character and are folloAved by coma or collapse. In empyema a solution of iodine 6 grains (0.37), iodide of potas- sium 6 grains (0.37), and Avater 1 pint (500 cc), may be used daily as an irrigating fluid Avith good results. The tincture of iodine may be used, according to Ringer, as an inhalation Avith signal benefit in the following four instances : 1. In the chronic forms of phthisis (fibroid lung). When the expectoration is abundant and Avhen the cough is troublesome, its inhalation, used both night and morning, will generally lessen the expectoration and allay the cough. 2. In children six to ten years of age, Avho after meals, or, inde- pendently of them, on exposure to cold, are seized Avith hoarseness, a hoarse, hollow'cough and some Avheezing at the chest. This affection, involving the larynx, trachea, and larger bronchial tubes, and often 218 DRUGS. proving very obstinate, is apt to return and to persist a considerable time. 3. In some epidemics of diphtheria the inhalation recommended by Dr. Waring-Curran is of value, and consists of 4 grains (0.2) of iodine and 4 ounces (128.0) of water. A teaspoonful of this should be added to boiling water and kept hot by a spirit lamp, Avhilst the steam is inhaled. As the patient becomes accustomed to the iodine, the quan- tity of the solution may be increased till 4_ an ounce of it is used at each inhalation. It should be repeated many times a day, and each inhalation continued from eight to tAvelve minutes. 4. Some persons suffer Avith itching of the nose, of the inner canthus of one or both eyes, sneezing, running at the nose of a Avatery fluid, weeping of the eyes, and severe frontal headaches ; and these patients of various ages are greatly troubled, often for many years, with daily attacks of this character" lasting, it may be, several hours. Iodine inhaled often removes this affection at once, lessening the headache and discharge from the nostrils. Its effect is most marked in respect to the itching. Ringer generally adopts the folloAving simple, handy, cleanly, and effectual plan of inhalation : Heat Avell a jug capable of holding about 2 pints, by rinsing Avith boiling Avater, then partly fill Avith boiling water, into which pour 20 to 30 drops (1.3-2.0) of the tincture of iodine, then direct the patient to put his face over the mouth of the jug and breathe the iodized steam, covering the head to prevent the escape of the vapor. This inhalation should be used night and morn- ing for five minutes or a little longer. Occasionally an excess of iodine will temporarily produce a sensation of soreness in the chest and throat, accompanied Avith redness of the conjunctiva, running from the nose, and pain in the head. In some cases of acute coryza much relief may be obtained by sniff- ing the iodine from a bottle, as in the use of "smelling salts." The heat of the hand is sufficient to disengage the vapor in proper quantity. Administration.—Iodine is never used in solid form, and it has been taught that the tincture (Tincture Iodi, U. S. and B. P.) should not be given internally, on the ground that it is precipitated in the stomach. Whether this be true or false, it is a fact that the tincture has recently been largely used in the vomiting of pregnaneywith. very good results. The dose is 5 to 10 drops (0.35-0.65), Avell diluted. Inder the name of Lugol's solution (Liquor Iodi Compos/'tus,U. S.) iodine is frequently used internally ; the dose is 5 to 10 drops (0.35- 0.65), in Avater. The B. P. preparations not official in the U. S. P. are the liniment (Linimentum Iodi), the solution (Liquor Iodi), and Vapor Iodi, Avhich is prepared by adding 1 fluidrachm (4.0) of iodine to 1 fluidounce (32.0) of Avater, Avhich is gently heated and the rising vapor inhaled. Within recent years a so-called colorless tincture of iodine has been sold Avhich has obvious advantages, and is made by the folloAving process, according to Curtmann and Aiken of St. Louis : Take of iodine \\ ounces (48.0), alcohol 13 fluidounces (416.0), of stronger water of ammonia 3 fluidounces (96.0). Dissolve the iodine in the IODOFORM. 219 alcohol and add the ammonia. AIIoav to stand for four Aveeks Avith repeated shaking. Or the preparation may be made hastily by using an excess of ammonia, and aftenvard cautiously adding enough hydro- chloric acid to render the liquid only feeble alkaline. Iodide of nitrogen may be precipitated, Avhich is explosive. Unguentum Iodi, U. S. and B. P., is used locally over enlarged glands. In the case of children or adults Avho have delicate skins the ointment should be diluted one-half with lard. This ointment should ahvays be freshly made. Contraindications.—Iodine is contraindicated in renal diseases, except in small doses, during the progress of acute inflammation, and whenever tissues are rapidly undergoing degenerative changes. Hydriodic Acid. Hydriodic Acid is employed for precisely the same purposes as iodine itself. It is used almost entirely in the form of the official syrup (Syrupus Acidi Hydrt'odici, U. S.), Avhich is a syrupy clear liquid containing 1 per cent, of absolute hydriodic acid. Sometimes the syrup has a light-straAv color. Syrup of hydriodic acid should be kept in a dark place and not exposed to the air. The dose is 4; to 2 drachms (2.0-8.0), well diluted with water. The advantages claimed for hydriodic acid are activity, its agreeable taste as compared to iodide of potassium, and the rarity with Avhich it disorders the stomach. . IODOFORM. Iodoform (Iodoformum, U. S. and B. P.) occurs in small saffron- colored crystals Avhich possess a poAverful characteristic, penetrating odor, and strong taste. It is soluble in alcohol, ether, chloroform, benzol, and in fixed and volatile oils, but is insoluble in Avater. Physiological Action.—AYhen iodoform is absorbed from the stom- ach or from the skin from surgical dressings, it induces a train of serious and curious symptoms. Within half an hour iodine appears in the urine, and the evidences of its action assert themselves in one of two Avays. One set of symptoms resembles meningitis. The face is suffused, the pupils contracted, the respiration stertorous, and the pulse sIoav and full or rapid. Delirium of the Avildest cha- racter may ensue, so that the patient tears everything within reach. In another class of cases the symptoms resemble those of cerebral congestion in the flushed face, contracted pupils, sIoav breathing, and Ioav muttering delirium or perfect vocal quiet. Widespread fatty degeneration is found at the autopsy. The resemblance of the symptoms to cerebral congestion or menin- gitis should not mislead the physician into the belief that any head injury is present Avhen a limb has been dressed Avith iodoform after an accident. Iodoform Avhen given internally or absorbed from Avounds may cause amblyopia. 220 DRUGS. Locally applied to mucous membranes, the drug possesses very distinct anaesthetic power. Therapeutics.—Iodoform is used chiefly as a surgical dressing. It is antiseptic, but not germicidal. Germs' may be found in powdered iodoform, and will even grow in it. The drug does good by absorb- ing the liquids of the Avound, and thereby removing the nidus for germ-growth, and Avhen applied to large moist surfaces gives off free iodine and acts as well as a protective. There can be no doubt that iodoform Avhen applied to a wound does good, not by destroying the bacteria directly or indirectly, but by inducing chemical changes in their toxines. In syphilitic sores the folloAving dressing will be found of great service: Iodoform, 20 grains (1.3); oil of eucalyptus, % fluidounce (16.0); or a poAvder of iodoform \ an ounce (16.0), camphor 75 grains (5.0), and essence of roses 2 drops (0.1), may be employed. In eczema, Avith tingling and itching, the folloAving application will give relief (Ringer): R.—Iodoformi.............gr. iv (0.2). Olei eucalvpti............fgj (4.0). Petrolati '..............gj (32.0).—M. S.—Apply locally. Internally, iodoform is used in tertiary syphilis in all its forms in the dose of from 1 to 5 grains (0.05-0.35). Bartholow recommends it most highly in catarrhal jaundice and in the early stages of hepatic cirrhosis; indeed, he thinks its persistent use in small dose will cure this affection. The influence of iodoform upon the tubercle bacillus is very great, and it is noAV largely used in the treatment of tubercular disease of the joints and pleurae. The pus is alloAved to escape under antiseptic precautions; the cavity is Avashed out Avith Avarm boric-acid or carbolic- acid solutions of Ioav strength, and from 1 to 6 drachms (4.0-24.0) of an emulsion of iodoform and sterilized sweet oil are injected and allowed to remain. The strength of the iodoform-and-oil emulsion is 10 per cent. Should the abscess-cavity fail to heal after these injections have been repeated every feAV days for some time, it must be reopened, scraped, and injected again or packed Avith iodoform gauze. The iodoform also promotes healing through its alterative influence, which aids in the absorption of the inflammatory exudate. Should tubercular glands be present, injections may be made into them even if pus has not formed. Used by means of a powder-blower, iodoform will often relieve the hoarseness and discomfort of laryngeal phthisis, but it must be pulver- ized most minutely. Sometimes a spray may be used, which should consist of spirits of turpentine and sweet oil, half-and-half, and contain 2 grains (0.10) of iodoform to each ounce (32.0). This mixture may also be used in bronchial catarrh to lessen the cough and foetid dis- charge. In the early stages of phthisis several clinicians claim to have reached very good results by the daily hypodermic injection into the back of 30 minims (2.0) of a 1 : 100 solution of iodoform in oil of sweet almonds. IPECACUANHA. 221 In fissure of the anus and irritated hemorrhoids 5 grains (0.35) of iodoform in a suppository may be placed in the rectum, and after it has remained there a few minutes defecation may be had without pain. The pain folloAving operations on the female perineum may also be much relieved in this manner. In the tenesmus of cholera infantum an injection of 1 ounce (32.0) of SAveet oil Avith 5 grains (0.35) of iodoform will give great relief if used after or before enteroclysis. Administration.—The ointment (Unguentum Iodoform!, U. S. and B. P.) is useful Avhen applied over foetid sores. It should ahvays be freshly made. The drug itself may be given in 1- to 5-grain (0.05- 0.35) doses three times a day. The suppositories (Suppositoria lodo- formi) are official in the B. P. ; each one contains 3 grains (0.15) of iodoform. IODOL. This is a dark, dirty-yelloAvish-looking poAvder, soluble in alcohol, ether, and oils, but only slightly so in, Avater. Its uses in medicine are identical Avith those of iodoform, and it possesses the advantage of being not so penetrating in odor as the latter drug. In tubercular laryngitis the powder may be bloAvn into the larynx Avithout disagreeable results and Avith a favorable effect on the dis- eased process. Cerna has found iodol of very great service in dia- betes Avhen given internally, in the dose of from 2 to 6 grains (0.1- 0.3) three times a day, and it is said to be of value in tertiary syph- ilis in the same quantity. A very useful antiseptic dressing for small wounds and abrasions is made by adding 1 part of iodol to 10 parts of ether and 5 of gun- cotton, thereby preparing an iodol collodion. Ingalls recommends the following prescription in cases of eczema or abrasions of the upper lip and nostrils: R .—Acid, carbolic............TT\,vj (0.3). ()1. rosse..............TT\,v (0.3). Iodol................gr. xxv (1.65). Lanolin..............gss (16.0).—M. IPECACUANHA. Ipecacuanha, U S. and B. P., or Ipecac, is the root of Cephaelis Ipecacuanha, a small shrub of Brazil. It contains an alkaloid, eme- tine, and ipecacuanhic acid. Physiological Action.—Locally applied to mucous membranes, ipe- cac acts as an irritant, and if applied for a long period to the skin produces vesicles and irritation. Very minute doses have little notice- able effect, but large ones produce nausea, relaxation, vomiting, free secretion into the bronchial tubes, and a profuse Hoav of saliva. The emesis is due both to the irritation of the stomach and to an effect upon the vomiting centre in the medulla. 222 DRUGS. If emetine is given in lethal dose, death is due to failure of res- piration. Therapeutics.—Ipecac is used as an emetic where a fairly rapid action is required. It is particularly useful in cases where the stom- ach of a child is overloaded with food. In cases of poisoning it is hardly active or rapid enough as an emetic, and is not as good as mustard or sulphate of zinc. In babies and young children an attack of bronchitis often causes digestive disorders, by reason of the mucus coughed up from the lungs being at once swalloAved instead of spit out of the mouth. In these cases the stomach may be relieved and the state of the lungs improved by the use of an emetic dose of syrup of ipecac, 2 to 3 drachms (8.0-12.0). Often if the dose be not large enough to produce emesis it will purge the child and remove the mucus by the bowel. In obstinate vomiting small doses of ipecac will act as a most suc- cessful cure, provided that the vomiting is due not to inflammation and excitement, but to depression. The irritant effect of the ipecac stimulates the depressed organ up to a normal tone. The proper dose of ipecac for this purpose is 4; to 4; a grain (0.016-0.03) or less every half-hour until five or six doses are taken. Ipecac is also said to possess marked oxytocic properties, similar to quinine, Avhen given in small doses, 10 to 15 drops (0.65—1.0), of the Avine every two or three hours. In some cases of the vomiting of pregnancy it is very useful, in others it utterly fails. 1 drop of the Avine or 1 or 2 grains of the poAvdered ipecac is all that should be used. In vomiting Avith flatu- lence either ipecac or nux vomica is of service. In the morning vomit- ing of drunkards ipecac is of service, but it is not so good a remedy as small amounts of arsenic or hydrochloric acid. In true acute dysentery ipecac is the best remedy Ave possess. When the passages are large and bloody and the disease is malignant, as it occurs in the tropics, ipecac should be given in the folloAving manner : The poAvdered ipecac is to be administered in the dose of 60 grains (4.0) at once to produce vomiting. After vomiting has taken place small doses of 3 grains (0.2) are to be given every hour, and continued until a profuse black stool is passed. The passage of this stool is a most favorable prognostic sign, an4 its non-appearance is equally significant of danger. Vomiting is to be controlled with opium, and stimulants are to be freely used to avoid great depression. In /■holernic diarrheas and cholera morbus ipecac is often of great service in the dose of 3 grains (0.2) every two hours. No less a per- son than the great Trousseau asserted that ipecac was a hemostatic, and it is said to be a most effective remedy in hemoptysis in small doses. As an expectorant ipecac is to be used in the early stages of bron- chitis, to act as a sedative to the inflamed mucous membrane and to promote secretion. Under these circumstances it is best combined Avith citrate of potassium. (See Bronchitis). Ringer and Murrell have found that inhaling ipecac spray is very useful in chronic winter cough or bronchitis, particularly Avhen there IRON. 223 is present shortness of breath. The pure Avine may be used in a spray apparatus or be diluted one-half with Avater. While the throat may seem temporarily worse, the shortness of breath rapidly decreases and a great improvement takes place in the cough. In order to pre- vent the Avine Avhich collects in the mouth from being SAvalloAved, the patient should be directed to rinse his mouth thoroughly every feAV minutes, lest nausea and vomiting be produced. The inhalation should not last at first over three or four minutes, and, until it is knoAvn hoAv Avell the patient Avill bear the application, the Avine should be diluted tAvice or thrice. Administration.—The syrup (Syrupus Ipecacuanha', U. S.) is given in the dose of | to 1 drachm (2.0-4.0) as an expectorant, or in the same dose as an emetic to an infant. The Avine (VinumIpecacuanhas, B. P.) is given in the same dose as the syrup, the fluid extract (Extractum Ijwcaeuanhe Fluidum, U. S.) in the dose of 30 drops (2.0) as an emetic to an adult, and the troches (TrochisciIpecacuanhas, U. S. and B. P.) \ of a grain (0.016) each. Trochisci Morphince et Ipecacuanha;, U. S. and B. P., containing fa of a grain (0.002) of morphine and fa of a grain (0.006) of ipecac, are used in sore throat, dissolved in the mouth. Dover's powder (Pulvis Ipecacuanhas et Opii, U. S. : Pulvis Ipecacuanhee Compositus, B. P.) is given in the dose of 5 to 15 grains (0.35-1.0). It contains 1 grain (0.05) of opium, 1 grain (0.05) of ipecac, and 8 grains (0.5) of sugar of milk. (See Opium.) Emetine may be given in the dose of -fa to ^ grain (0.006-0.012) as an emetic. The pill of ipecac and squill (Pilula Ipecacuanhee cum Scilla, B. P.) is given in the dose of 5 to 10 grains (0.35-0.65). A inegar of ipecac (Acetum Ipecacuanhas, B. P.) is given in the dose of 5 to 30 drops (0.3-2.6) as an expectorant. IRON. Iron (Ferrum, U. S. and B. P.) is a metal and a food—a food because it forms part of the body Avhen taken into the organism and is used by the system in the making of blood. The number of its official salts and compounds is absurd, and half the list is rarely, if ever, used. Physiological Action.—Iron has little or no effect upon the system Avhen given in a single dose, but repeated doses cause an increase in the number of red blood-corpuscles, and plethora, or an increase in the quantity and quality of the blood. Much discussion has arisen as to Avhether iron Avhen given as a drug in form of one of the inor- ganic salts is absorbed. One theory has been that only the organic iron of the food is absorbed, and that metallic iron Avhen given freely alloAved this absorption to go on by stimulating the boAvel to its ab- sorption, or by entering into combination Avith sulphuretted hydro- gen thus permitted the organic iron to escape into the system. That both forms of iron are absorbed and eliminated is noAV certain. (For 224 DRUGS. a discussion of some of these views see article on Anaemia.) If given in excessive doses, much of it remains unabsorbed, is changed into the sulphide of iron in the bowels, and escapes with the faeces. Careful studies have shown that the iron, when once absorbed, escapes from the body very slowly, and that its pathway of escape is not by the bile or in the" urine, but by the walls of the intestine, which excrete it, so that it may be recovered from the faeces. It has been asserted that it is never released from the body, but this is untrue. AVhether it acts as a stimulant to blood-manufacture or simply supplies the glands Avith blood-making material we do not knoAv, but the latter is probably the correct vieAv. Iron causes oxidation to go on more rapidly by reason of its peculiar poAver of converting oxygen into ozone, and in this manner acts as a stimulant to nutrition and bodily activity. The studies of Skvortzoff are interesting in connec- tion with this subject. He found—1. That iron has no marked influ- ence or nitrogenous metamorphosis in the healthy body. 2. The ingestion of iron in daily doses of 0.02 to 0.03 gramme (0.3 to 0.5 grain) causes a very slight decrease in the assimilation of the nitrog- enous portions of the food. 3. After bleeding, the assimilation of nitrogenous substances increases a little, Avhether iron is used or not; but if iron is used at this time the haemoglobin is rapidly reproduced, and the drug Avould seem to be of value in restoring the bodily Aveight. The preparations of iron consist in the soluble and insoluble salts or forms. Of these the insoluble are better than the soluble, because nearly all the soluble salts of iron are precipitated by the gastric juice and have to be sloAvly redissolved. Therapeutics.—The chief indication for iron is anemia (see Anae- mia), and its chief contraindication is plethora. AYhen used in small dose (^ to 1 grain), it is quite as efficacious as in large amounts, and less apt to disorder the stomach. In some cases of anaemia of a semi-pernicious type large doses of iron are really needed, probably because the system is deranged in such a manner that an excessive loss or destruction of iron is constantly present. Large doses com- pensate for this leakage and afford the quantity needed for physio- logical purposes. It should not be used as a tonic unless some direct indication for its employment is present, and no drug is more abused in this respect than iron. As each of its preparations possesses some peculiarity, the use of each will be considered separately. Ammonio-ferric Alum. Ammonio-ferric Alum (Ferri et Ammonii Sulphas, U. S.) is often given in cases of atonic leucorrhea in the dose of 2 to 5 grains (0.1- 0.35). It is quite astringent. Aromatic Mixture of Iron. The Aromatic Mixture of Iron (Alistura Ferri Aromatica, B. P.) contains so little iron that it should not be administered in cases Avhere IRON. 225 a chalybeate influence is desired; it is, however, a useful tonic, given in the dose of 1 to 2 fluidounces (32.0-64.0). Aromatic mixture of iron contains cinchona-bark, calumba, cWes, iron, compound tincture of cardamoms, tincture of orange-peel, and peppermint-water. Arsenate of Iron. Arsenate of Iron (Ferri Arsenas, B. P.) is used in the dose of re to tV grain in anaemic subjects Avho are suffering from skin diseases. Basham's Mixture. Under the name of Basham's Mixture (Liquor Ferri et Ammonii Acetatis, U. S.) a very useful and elegant preparation of iron is employed, particularly in the anemia of Bright's disease. It is made up as folloAvs: Tincture of cbloride of iron.........2 parts. Dilute acetic acid..............3 " Spirit of Mindererus.............20 " Elixir of orange...............10 " Syrup...................15 " Water..................50 " The dose is from 1 to 8 drachms (4.0-32.0), well diluted, and it acts as a diuretic, diaphoretic, and chalybeate. Bromide of Iron. Bromide of Iron (Ferri Bromidum) is said by DaCosta to be use- ful in anemia, Avhen this state is associated with chorea, in the dose of 5 to 20 grains (0.35-1.3) given in syrup. In other nervous dis- eases accompanied by anaemia and insomnia the syrup of the bromide of iron (Si/rupus Ferri Bromidi) is useful in the dose of J to 1 fluidrachm'(2.0-4.0). Carbonate of Iron. The Carbonate of Iron (Ferri Carbonas Saccharatus, U. S. and B. P.) is very slightly astringent, and may be used in pill form under the name of Pilule Ferri Carbonatis, U. S. and B. P., sometimes called " Bland's pill," or in Griffith's pill, which also contains myrrh. The dose is 3 grains (0.15), and this preparation of iron may be largely used for the treatment of amenorrhea dependent upon anaemia. Under the name of Mistura Ferri Composite/, U. S., or Griffith's mix- ture, and B. P., Ave have a liquid preparation used for the same pur- poses as the pills, in the dose of 1 to 2 tablespoonfuls (16.0-32.0). Massa Ferri Carboneitis, U. S., sometimes called Vallet's mass, is given in pills in the dose of from 1 to 10 grains (0.05-0.65). Chloride of Iron. Tincture of the Chloride of Iron (Tinetura Ferri Chloridi, U. S.), often called Tincture of the Muriate of Iron, is one of the best and most useful preparations of iron that Ave have. It is the most diuretic 15 226 DRUGS. preparation of iron. This diuretic effect does not depend upon the presence of a muriatic ether, as has heretofore been taught, since hydrochloric ether is not present, and is hard to prepare except there is an excess of chlorine present. According to some researches vof Dr. S. AY eir Mitchell, the only ether present is nitrous ether, and this is devoid of power and in small quantity. As chloride of iron itself is diuretic, it is probably upon this that the diuresis produced' by it depends. The dose of the chloride of iron (Ferri Chloridum, U. S.) is 1 to 3 grains (0.06-0.18). Tincture of the chloride of iron is considered a specific in erysipelas, and should be given in very full dose and frequently repeated if it is to be of any service. 10 drops (0.65), well diluted, every hour is not too much. In chronic Brights disease it is of value and decreases the albuminuria. In anemia it is useful, and owing to its acid is a doubly effective tonic. In cases of slight anaemia in which very great arterial pressure exists Dr. Mitchell uses a purely milk diet, and an ounce of an old tincture of iron in the tAventy-four hours. While he recognizes the fact that iron prepa- rations are generally supposed to raise blood-pressure, he asserts that in this instance the blood-pressure is lowered. The dose of Liquor Ferri Chloridi, U. S., is 4 to 10 drops (0.2-0.65). It is rarely used internally, but chiefly as an astringent of great power. Liquor Ferri Chloridi, is identical Avith Liquor Ferri Perchloridi, B. P. Tinetura Ferri Perchloridi, B. P., is used internally in the dose of 10 to 20 minims (0.65-1.3). As a local application tincture of the chloride of iron is useful in diphtheria and membranous croup, and even in tonsillitis. In each of these maladies large doses of the tincture internally, with counter- irritation over the neck, are most useful. AVhen used internally it should be well diluted and taken through a glass tube to protect the teeth. The strong solution of perchloride of iron (Liquor Ferri Per- chloridi Fortior, B. P.) is a powerful styptic. Citrates and Tartrates of Iron. The four citrates of iron are soluble in water and very useful for this reason. Ferri Citrus, U. S., and Ferri et Ammonii Citras, U. S. and B. P., occur in garnet-red scales and are given in the dose of 5 grains (0.35). The solution of the citrate of iron (Liquor Ferri Citratis, U. S.) is given in the dose of 10 minims (0.65). The Ferri et Quinine Citras, B. P., and the Ferri et Strychnine Citras, U. S. and B. P., are given in the dose of 5 to 15 grains (0.35-1.0) and 1 to 3 grains (0.05-0.15), respectively. The new official Ferri et Quinine Citras Solubilis, U. S., is given in the dose of 1 to 2 drachms. Besides these citrates there are three tartrates—Ferri et Ammonii Tartras, U. S., and Ferri et Potassii Tartras, U. S., and Ferrum Tar- taratum, B. P., all given in the dose of 5 grains (0.35). Dialyzed Iron. Dialyzed Iron (Ferrum Dialysatum) is a very feeble preparation IRON. 227 of iron, lacking in astringency, easily precipitated from the solution in Avhich it occurs, but largely used in ancemia by some practitioners. The dose is 10 to 20 drops (0.35-1.3) in Avater three times a day. Sometimes river-water, if it contains much inorganic or organic matter, will precipitate it. OAving to the instability of dialyzed iron, it may be used Avithout any preparation as an antidote to arsenic. Liquor Ferri Dialysatus, B. P., is given in the dose of 10 to 30 minims (0.65-2.0). Hydrated Sesquioxide of Iron. Hydrated Sesquioxide of Iron (Ferri Oxidum Hydration, U. S.) is the antidote to arsenic, but to be efficacious it must be freshly prepared. It is to be made by precipitating any liquid preparation of iron by the addition of an alkali, such as ammonia, or by the addition of mag- nesia. If ammonia is used, the precipitate has to be washed with water several times to get rid of the alkali, Avhich Avill render the antidote too irritant to be SAvalloAved if it is alloAved to remain Avith the precipitate. Magnesia is an antidote in itself, and should be preferred under all circumstances. The antidote should be given in excess, and as much as a pint of the iron solution should be precipi- tated. The magnesia should be freely added, as too much of it can- not be given. The official antidote to arsenic is Ferri Oxidum Hydra- turn cum Magnesia, U. S. In the Prussian Pharmacopoeia this is knoAvn as the Antidotum Arsenici. (See Arsenic, Poisoning by.) Iodide of Iron. The Syrup of the Iodide of Iron (Syrupus Ferri Iodidi, U. S. and B. P.) is a transparent liquid of a SAveet, iron-like taste. It should contain no free iodine, and if it strikes a blue color Avith starch should be discarded. It is largely used in anaemia associated Avith scrofulosis and struma, and is useful in the eczema of young children Avhen this is dependent upon lack of vitality or anaemia. The dose to a child of tAvo years is 2 to 3 drops (0.1-0.15), Avell diluted, and to an adult 30 to 40 drops (2.0-2.65) in Avater, to be taken through a glass tube to protect the teeth. The saccharated iodide of iron (Ferri lod'/dum Saceharatum, U. S.) is used in place of the syrup in the dose of 2 to 5 grains (0.1-0.3). The official pills (Pilula, Ferri Iodidi, U. S. and B. P.) each contain jr of a grain (0.01) of reduced iron and 1 of a grain (0.075) of iodine, and are given in the dose of one to three pills. Lactate of Iron. The Lactate of Iron (Ferri Laetas, U. S.) is soluble in 48 parts of water, and is given in the dose of 5 grains (0.35). It is used for the same purposes as the other preparations of iron. Lactate of iron is one of the ingredients of Syrupus Flypophosphitum cumFerro, U> S., the dose of Avhich is 4; to 1 fluidrachm (2.0-4.0). 228 DRUGS. Ferri Subsulphas, or Monsel's Salt. Monsel's Solution (Liquor Ferri Subsulphatis, U. S.), sometimes wrongly called the Solution of the Persulphate of Iron, is one of the most poAverful styptics or haemostatics that Ave have. It is never to be employed Avhere a hemorrhage is to be attacked through the circu- lation, but only when the solution can come in direct contact Avith the bleeding spot. The objection to its use is the heavy, black, and dirty clot Avhich it forms on coming in contact Avith the blood. In hemop- tysis Monsel's solution should be used in fine spray consisting of from 10 to 60 drops (0.65-4.0) to the ounce of distilled water. In uterine hemorrhage from any cause the dilution may be half-and-half, or if the hemorrhage be from a polypus or the cervix uteri, the pure solu- tion should be used, locally applied. In nose-bleed Monsel's solution may be employed diluted one-half or pure, but it is disagreeable because of the'hard, black clotAvhich is formed and the uncomfortable sensations and pain produced in the nasal chambers. Plugging the nostrils Avith pledgets of cotton is generally sufficiently efficacious. In the intestinal hemorrhage occurring during or after typhoid fever Monsel's solution has been given, but ought not to be, as it is decomposed in the stomach before it reaches the intestine. Monsel's salt (Ferri Subsulphatis, U. S.) should be given in pills of 3 grains (0.15) each, the pills being made hard enough to escape into the intestine before the stomach breaks them doAvn. One, two, or three pills may be given and repeated in an hour. Hannatemesis due to bleeding in the stomach should be treated by 3-drop (0.15) doses of the solution in a little Avater. In tonsillitis and pharyngitis a most efficient application is pure Monsel's solution applied by means of a pledget of cotton or camel's- hair brush, or equal parts of the solution and glycerin may be used. This application is often as painful as it is efficient. In diphtheria this method of treatment is often of great service. The antidote to Monsel's solution is common soap. Oxalate of Iron. Oxalate of Iron (Ferri Oxalas) is given in the dose of 2 to 3 grains (0.1-0.15). Phosphates of Iron. There are tAvo phosphates of iron—Ferri Phosphas Solubilis, U. S. and B. P., and Ferri Pyrophosphas Solubilis, U. S. Phosphate of iron itself is very insoluble and is rarely used. The official forms are, hoAvever, quite soluble, and useful in the dose of 2 to 5 grains (0.1-0.35). Syrupus Ferri Phosphatus, B. P., is given in the dose of 1 fluidrachm (4.0). Phosphate of iron is one of the ingredients of the syrup of iron, quinine, and strychnine (Syrupus Ferri, Quinine et Strychnine Phosphatum, U. S), and is given in the dose of 1 fluidrachm (4.0). Reduced Iron. Quevenne's Iron (Ferrum Beduetum, U. S. and B. P.) is an iron- IRON 229 gray or reddish powder Avhich is frequently adulterated with lamp- black. If it is pure it should burn in sparks Avhen dropped into a flame, but if lampblack is present this will not occur. It should also yield no sulphuretted hydrogen on adding sulphuric acid to it. It is tasteless, and may be given to children for this reason in pills or gum-drops, or placed inside of small chocolate creams, or in the form of troches (Trochisci Ferri Redact/', B. P.), each lozenge containing 1 grain (0.05) of the reduced iron. It is used solely in anaemia, and is one of the least astringent of the iron preparations. Sulphate of Iron. Sulphate of Iron (Ferri Suljlias, U. S. and B. P.) is used inter- nally in the dose of 5 grains (0.35) in pill form in chronic diarrhea. Externally, in a solution of the strength of 5 to 25 grains to the ounce (0.35-1.65 : 32.0), it is used as an astringent lotion. Two other forms of the sulphate are also employed—namely, the dried (Ferri Sulphas Exsiccatus, U. S. and B. P.) and the granulated (Ferri Sulphas Granulatus, U. S. and B. P.), each of Avhich is given in the dose of 3 grains (0.1S). Valerianate of Iron. Aalerianate of Iron (Ferri Valerianas, U S.) is sometimes useful in hysteria Avith anaemia, given in the dose of 1 grain (0.06) or more. Wines of Iron. The Bitter AYine of Iron ( Vinum Ferri Amarum, B. P.) is useful in anemia, both in children and adults, and may be advantageously accompanied Avith cod-liver oil. It is given in a dose of 1 to 2 fluid- drachms (4.0-8.0) or more. This Avine is composed of soluble citrate of iron and quinine, tincture of SAveet orange-peel, syrup, and stronger white wine. AYine of the Citrate of Iron, or Vinum Ferri Citratis, U. S., is composed of the citrate of iron and ammonium, tincture of SAveet orange-peel, syrup, and stronger white Avine. The dose is identical Avith that of the bitter wine, and it is used for the same purposes. Hydrated Peroxide of Iron (Ferri Peroxidum Hydration, B. P.) is used in the dose of 5 to 30 grains (0.35-2.0). From the last prepa- ration iron plaster (Emplastrum Ferri, B. P.) is made. The plaster of iron official in the U. S. is prepared from the hydrated oxide of iron. The folloAving preparations of iron are also official: Liquor Ferri Acetatis,U. S., dose 15 minims to 1 fluidrachm (1.0-4.0), and Liquor Ferri Acetatis Fortior, B. P., dose 1 to N minims (0.05-0.6). Untoward Effects of Iron.—Iron is apt to cause gastric distress and frontal headache in persons avIio are susceptible to its use. Even one dose Avill cause this trouble in some persons. In many instances the frontal headache will be found to be due to the constipation which 230 DRUGS. has been brought on by the iron, and will be relieved if mild laxa- tives or purges are used. The state of the boAvels should ahvays be watched and laxatives given Avhenever constipation is present and iron is being administered. In rheumatic and gouty persons frontal headaches are a common symptom when iron is given, and purgatives will not generally give relief. Garrod and Haig have shoAvn that iron decreases the elimination of uric acid, Avhich may account for the production of headache in the case of rheumatic patients under its influence. Sometimes salts of iron produce vesical irritation and a constant desire to urinate, causing mucus to form in abnormal amount in the bladder. In children its use may result in nocturnal incontinence of urine. JALAP. Jalap (Jalapa, U. S. and B. P.) is the root of Ipomea Jalapa, a native of Mexico. It contains tAvo resins, jalapin and convolvulin, neither of Avhich is used in medicine by itself, though both of them enter into the Resin of Jalap of the U. S. P. In overdose jalap or its resin causes vomiting and purging, Avith gastro-enteritis. Therapeutics.—Jalap is used in medicine as a hydragogue purge to relieve dropsy of any origin. It may be used to deplete in cases of general plethora Avith cerebral congestion, and owing to its tasteless- ness is a useful cathartic in children if given in the proper dose— namely, 1 to 2 grains (0.05-0.10) in 4; an ounce of syrup of rhubarb. Combined with calomel, it is preferred to all other purges by some practitioners, particularly if the liver is torpid. Administration.—Jalap may be given in the form of the compound powder (Pulvis Jalape Compositus, U. S. and B. P.), dose 15 to 40 grains (1.0-2.65), Avhich is composed of 35 parts of jalap and 65 parts of bitartrate of potassium; and the resin (Hesina Jalape, U. S. and B. P.), dose for an adult 2 to 4 grains (0.1—0.2). OAving to the small size of the dose of the resin and its lack of taste, this preparation is to be preferred for children in the dose of \ to \ a grain (0.016-0.03). The tincture (Tinetura Jalape, B. P.) is given in the dose of | to 1 fluidrachm (2.0-4.0); the extract (Extractum Jalapa', U. S. and B. P.) is used in the dose of 5 to 15 grains (0.35-1.0). JEQUIRITY. This is a plant known as Abrus Precatorius, the seeds of Avhich are poisonous Avhen applied to a Avound. An active principle, abrin, is composed of paraglobulin and a-phytalbumose, Avhich closely resem- ble snake-venom in their action. Jequirity is never used internally in medicine in this country. An infusion of the powdered seeds, made by adding J a drachm to an ounce (2.0 : 32.0) of Avater at 140° F. is to be painted with a brush on the inside of the eyelids in eases of chronic granular conjunctivitis, in order to produce an acute diph- theritic inflammation Avhich will so change the chronic process present as to permit of a cure. If an excessive action i^ developed, it may KAM ALA. 231 be controlled by hot compresses made of very dilute solutions of cor- rosive sublimate. The solution undergoes decomposition with great rapidity, and should be prepared freshly each time it is used, or 4 to 8 grains (0.2-0.5) of boric acid should be added to preserve it. The drug is a poAverful cardiac depressant poison when injected into the circulation. AYhether the seeds produce poisoning when SAvalloAved is doubtful, some asserting that they cause gastro-enteritis, others that they are harmless. Probably much depends on the activity of diges- tion at the time of ingestion. JUNIPER. Juniper us is the fruit or berry of Juniperus Communis, an ever- green of Northern Europe and America. It contains a volatile oil and an amorphous principle, juniperin. Physiological Action.—Juniper acts as a gastric stimulant and tonic, as a mild diaphoretic if combined with alcohol, and as a marked stimulating, exciting diuretic. It escapes from the body by the kidneys. Therapeutics.—Juniper is valuable as a stimulant to the genito- urinary system Avhenever it is depressed or chronically diseased, as in chronic pyelitis, nephritis, and chronic catarrh of the bladder. In congestion of the kidneys, if not accompanied by active tissue-changes, it relieves these organs and does aAvay "with albuminuria. Used after an attack of acute Brights disease when reaction has set in and the secreting epithelium of the kidney is atonic, it is of value, but care should be taken that all inflammation has passed by or it Avill make the patient Avorse. In the later stages of scarlet fever, in which the renal condition corresponds to that just described, juniper is useful. In old persons a sensation of weight across the lumbar region is often readily removed by the use of juniper if the kidneys are inactive. Administration.—Juniper is used in the form of the compound spirit (Spiritus Juniperi Compositus, U. S.), composed of the oils of juniper, caraAvay, and fennel, combined Avith alcohol and water, in the dose of 1 to 4 drachms (4.0-16.0). Gin is virtually identical Avith the compound spirit. The infusion of juniper is made by add- ing an ounce (32.0) of the berries to a pint (4j a litre) of boiling Avater and alloAving it to stand in a Avarm place for an hour. The entire quantity is to be taken in tAventy-four hours, and the infusion is often combined with acetate of potassium or an ounce (32.0) of the bitar- trate of potassium in the treatment of dropsy. The spirit (Spiritus Juniperi,. U. S. and B. P.) is given in the dose of 30 minims to 1 drachm (2.0-4.0). The oil (Oleum Juniperi, U. S. and B. P.) is used in the dose of 1 to 4 minims (0.06-0.3). KAMALA. Kamala, U. S. and B. P., or Rottlera, as it is sometimes called, is the hairs and bristles from the capsules of Mallotus pMlippiensis, 232 DRUGS. a plant of Abyssinia, India, and China. It contains an active prin- ciple, rottlerin, which is not official. Given in the dose of 1 to 2 drachms (4.0-8.0), kamala acts as a drastic and as a remedy for tape- worm. It should be administered in syrup, and repeated in eight hours if no effect is produced. (See Worms.) KAOLIN. Kaolin is a soft white powder, a decomposition-product of mineral deposits containing feldspar. It is used externally as a dusting pow- der in eczema. KINO. Kino is the inspissated juice of the Pterocarpus Marsupium, a tall tree of India. It contains kino-tannic acid, and is used as an astringent in serous diarrhea. It is official in the form of the tinc- ture (Tinetura Kino, U. S. and B. P.), and is given in the dose of 1 fluidrachm (4.0). Kino may be used as a gargle in sore throat and for relaxation of the uvula. Under the name of Compound Powder of Kino (Pulvis Kino Compositus, B. P.) an efficient and pleasant antidiarrhea poAvder is used. This poAvder is not official in the U. S. P. The formula for each poAvder is 15 grains (1.0) of poAv- dered kino, 4 (0.2) of powdered cinnamon, and 1 (0.05) of powdered opium. KRAMERIA. Krameria, U. S., Krameria Badix, B. P., sometimes called Rhat- any, is the root of Krameria Triandra and Krameria Ixina, shrubs of Peru and NeAv Granada, and is employed in serous diarrheas with good effect. The tincture (Tinetura Kramerie, U. S. and B. P.) is given in the dose of 1 drachm (4.0), the solid extract (Extractum Kramerie, U. S. and B. P.) 5 to 10 grains (0.3-0.65), the fluid extract (Extraction Kramerice Fluidum, U. S.), dose 10 to 20 drops (0.05-1.3), and the syrup (Syrupus Kramerie, U. S.), dose 1 ounce (32.0). The troches (Trochisci Kramerie, U. S.) are held in the mouth for the purpose of producing a local astringent effect. An infusion (Infusion Kramerie) is official in the B. P dose 1 to 2 ounces (32.0-64.0). LACTOSE. (See Sugar of Milk.) LANOLIN. Lanolin which is practically the Adeps Lane Hydrastis of the U. S. and B P., is a fat derived from the wool of the common sheep, and is a whitish substance of peculiar stability, very difficult of LEAD. O o o loo saponification, and incapable of becoming rancid. Unna states that ointments of acids, hydrogen peroxide, and other substances may be made by it. One great objection to lanolin is its stickiness, Avhich is avoided by adding one-third of vaseline. Lanolin is supposed to possess very remarkable penetrating powers Avhen applied to the skin in cases Avhere much infiltration is present, particularly if it is com- bined Avith resorcin or some similar medicament. In itself it has little curative poAver, and is but little better than lard, suet, or any common fat as a basis for ointments. In some cases, Avhich are rare, it will cause irritation of the skin. LEAD. Plumbum, or Lead, is a metal possessing more or less power over the organism according to the salts Avhich are employed. It is not official as lead itself. Physiological Action.—Lead in one of its soluble salts, if applied to a mucous membrane, produces a bleaching Avhich is particularly noticeable where the redness of inflammation has previously existed. It has little effect in single dose, except by an indirect influence over the circulation, nervous system, or respiration. (For a description of the effects of lead in overdoses see " Poisoning," below.) The most irritant and poisonous salt is the nitrate, the next the subacetate, and the least poisonous of the soluble salts is the acetate. Acute Poisoning.—AYhen the acetate of lead is taken in poisonous amounts, it produces a sweet metallic taste in the mouth, folloAved by pain in the epigastrium and the vomiting of Avhite, milky-looking liquids or Avhite curds mixed Avith food. The white color is due to the presence of chloride of lead formed by the action of the gastric juice. The pain continually increases, and diarrhoea due to gastro-enter- itis may be set up, or, in other cases, obstinate constipation is present. The passages are generally black, this being due to the presence of the sulphide of lead. At the same time the pulse becomes rapid, tense, and cord-like, but after a time Aveak and compressible. The face is anxious and pale or livid. The thirst is excessive, and cramps in the calves of the legs or muscular twitchings may ensue. It is said that the characteristic blue line on the gums may occur in acute poisoning, but this is not based on fact. If coma comes on, death is assured. The treatment consists in the use of the chemical antidote, a sol- uble sulphate, in large quantity, in the administration of emetics, and the use of the stomach-pump if the vomiting produced by the drug is not sufficient to rid the stomach of all the poison. The best soluble sulphates to employ are Epsom and Glauber salts, because they are ahvays at hand, are readily soluble, and, in excess, act as purges, which will Avash out the intestinal canal. Hot applications should be applied to the belly and feet, and the pain and irritation Avhich is present relieved by opium. 234 DRUGS. Chronic Poisoning.—Chronic lead poisoning is rarely produced by the soluble salts of lead, nearly ahvays being due to the insoluble salts. The symptoms of chronic lead poisoning, or plumbism, are as various as it is possible to find variety in the signs of disease of every kind. There is no train of symptoms Avhich may not occur, and the occurrence of rare, anomalous symptoms in a given case should at once bring to the mind the thought of lead poisoning or syphilis. Chronic poisoning occurs in painters, manufacturers of lead salts, and every one who is largely thrown in contact Avith the metal in the arts. It occurs from the use of hair-dyes containing the acetate of lead, from drinking water which has passed through neAv lead pipe, and even from the biting of silk threads loaded with lead to increase their Aveight. Chromate of lead has been used to color sponge-cake Avhen eggs Avere thought too dear, and has killed many persons. Millers Avho have filled the holes in grindstones Avith lead have caused Avide- spread epidemics of Avhat has been called "dry cholera," and many persons have suffered from lead poisoning from eating apple-butter kept in jars glazed Avith lead. The most prominent, but by no means the most constant, symptom of chronic plumbism is bilateral wrist-drop, due to palsy of the exten- sor muscles of the forearm. The short extensor of the thumb gen- erally escapes the drug's influence. Sometimes internal squint arises from paralysis of the external rectus muscles. Another very com- mon symptom is colic centring around the umbilicus and radiating through the belly and loins. Obstinate constipation often accom- panies these symptoms, and the faeces, Avhen passed, are white and clay-colored. During an attack of lead colic the arterial tension is increased very markedly, the tongue is coated and Avhitish, and the bowels are obsti- nately confined. If these early Avarnings are disregarded and the exposure to the lead is continued, cerebral symptoms come on, the result of enceph- alopathia saturnina, or saturnine cerebritis. Saturnine epilepsy is not very rare. If convulsions come on, death generally ensues. The convulsions in some cases are not due to a cerebral' effect of the lead, but to uraemia from the renal changes Avhich it has caused. Renal disease is very commonly produced by lead, and it is not uncommon for chronic contracted kidney to be found at the autopsy of a sufferer from lead poisoning. If a patient with chronic lead poisoning have a urine with a persistent low specific gravity, the prog- nosis is grave as evidencing advanced kidney involvement. Asthma due to the inhalation of lead-dust is sometimes met with. The most important confirmatory evidence of chronic lead poisoning is a blue line on the gums just where they join the teeth. Its absence is not a negative sign, however, as poisoned persons cleanly in respect to their mouths often do not have it. Marked cachexia "or anaemia is commonly seen in chronic lead poisoning. After prolonged lead poisoning the "nerve-trunks are found atro- phied, and finally changed into fibrous cords. Poliomyelitis, anterior LEAD. 235 or posterior, may be present, and locomotor ataxia is commonly caused. It is said that the locomotor ataxia produced by lead may be distinguished from the idiopathic form by the fact that in lead poisoning the sphincters are affected, Avhile in the non-toxic variety they escape. In some cases trophic changes in the joints ensue, and plumbic gout is not rarely seen, or even lead arthralgia Avith deposits of urates in the joints. This condition is due to the fact, pointed out by Gar- rod and Haig, that lead forms insoluble salts Avith uric acid. Lead escapes from the body in the urine, the faeces, and all the secretions. It is chiefly eliminated by the liver and the bile. Treatment of Chronic Poisoning.—The treatment consists in three classes of remedial measures: 1st, the removal of the cause; 2d, the removal of the poison in the body; and, 3d, the treatment of the lesions produced by the poison. In lead colic hepatic purges, such as jalap and calomel, combined with opium to prevent pain, are indicated, and alum and opium or morphine are said to be almost specifics, the alum in 2-grain doses, the others in full amounts. In many cases purges fail to move the boAvels of a person suffering from chronic lead poisoning, and succeed only Avhen morphine is given to overcome the intestinal inhibition produced by the irritation caused by the lead. In the cerebral inflammation of lead poisoning a blister to the back of the neck, revulsives, and a pilocarpine sweat may be resorted to. To aid in the elimination of the lead, iodide of potassium, Avhich forms double soluble salts in the tissues with the metal, is to be used, 10 to 20 grains (0.65-1.3) three times a day. If progressive paralysis is present, AYood insists on the use of large doses of strychnine at the same time that the iodide is given. The strychnine should not, of course, be given with the iodide, as it is incompatible. Electricity should be used as a remedy to restore lost function. If the faradic current makes the muscles contract, it should be employed, and, if not, the galvanic should be used. Curiously enough, voluntary poAver sometimes returns before the muscles will react at all to electricity. It is said that baths of sulphuret of potassium should be used, 5 or 6 ounces (160.0) of the salt to each bath, Avhich is to be given in a Avooden tub. The patient should afterward be Avell soaped, then thoroughly rinsed off, and rubbed doAvn with a rough towel. As the salts of lead are used for different purposes, the therapeu- tics of each one will be taken up separately. Acetate of Lead. Acetate of Lead (Plumbi Acetas, U. S. and B. P.), or Sugar of Lead, has a SAveet, astringent taste, and is soluble in Avater, although the solution formed is slightly milky in appearance. 236 DRUGS. Therapeutics.—Acetate of lead may be used, and is largely employed, in the folloAving pill in the treatment of serous diarrhea : R .—Plumbi acetat............gr. xl (2.65). Pulv. opii.............gr. x (0.65). Camphor*.............gr. xl (2.65).—M. Ft. in pil. No. xx. S.—One every four hours. This pill may also be given in dysentery. Administration.—The B. P. recognizes the folloAving preparations of lead acetate: Pilula Plumbi cum Opio, dose 3 to 5 grains (0.1- 0.3); Suppositoria Plumbi Composita, each suppository containing 1 grain (0.06) of opium to 3 grains (0.18) of lead acetate; and an oint- ment (Unguentum Plumbi Acetatis). Carbonate of Lead. Carbonate of Lead (Plumbi Carbonas, U. S. and B. P.), or AYhite Lead, is insoluble, and is used as a coating or dressing for burns, scalds, or ulcers when rubbed up with linseed or other oil, or in the form of the ointment (Unguentum Plumbi Carbonatis, U. S. and B. P.). If a Avide surface is covered with this ointment, it may cause lead poisoning by absorption. Carbonate of lead may be used in the treatment of sunburn in the folloAving prescription: R.—Plumbi carbonat. . . Pulv. amyli .... Unguent, aquse rosa? . Olei oliva?..... S.—Apply to the inflamed skin Iodide of Lead. Iodide of Lead (Plumbi Iodidum, U. S. and B. P.) is occasion- ally employed in medicine; the dose is h to 2 grains (0.03-0.1). Emplastrum Plumbi Iodidi, P. B., and Unguentum Plumbi Iodidi, U. S. and B. P., are useful as external astringent and alterative applications. Liquor Plumbi Subacetatis. Liquor Plumbi Subacetatis, U. S. and B. P., or Goulard's Extract, is a colorless liquid, much used externally, when diluted Avith lauda- num, for sprains, bruises, and local inflammations, under the name of "lead-water and laudanum." "• L. and L.," as it is often called in the hospitals, is a useful application in the dermatitis produced by poison ivy. The proportion should be 4 parts of the pure lead-water, diluted with 16 parts of water, to 1 of laudanum, but this is varied as the inflammation or pain is the more severe. The official liquor is also official in a dilute solution (Liquor Plumbi Subacetatis Dilutus, U S. and B. P.), and as such is too Aveak for ordinary use, although it is commonly employed. The strong solution should be used in the 3J (4-0). 3j (4-0). % (32.0). f3ij (8.0).-M. LEPTANDRA. 237 strength of from 1 to 4 ounces (32.0-128.0) to the pint (500 cc.) of water. This solution should never be employed if the skin is broken, as absorption may occur, and, Avhat is more important still, the drug prevents healing by constringing and whitening the edges of the wound. If some bread-crumbs be saturated with this solution and applied to an inflamed finger, a felon can often be aborted in the early stages. The official dilute solution is useful as a lotion in eczema Avhich itches and tingles and is not dry in character. It should be applied once or twice a day, and it is Avell to follow the application of the lead Avith a Aveak sulphur bath or alkaline wash. (See Eczema.) Lead-Avater is also useful in pruritus pudendi, and the acetate of lead may be used as an injection in the dose of 1 to 8 grains (0.06- 0.5) to the ounce of water in cases of gonorrhea. The cerate (Cera- tum Plumbi Subacetatis, U. S.), the liniment (Linimentum Plumbi Subacetatis), and the glycerin (Glycerinum Plumbi Subacetatis, U. S. and B. P.) may be used for the same purposes as the Goulard's extract. Litharge. Litharge (Plumbi Oxidum, U. S. and B. P.) is used for the prep- aration of lead plaster (Emplastrum Plumbi, U. S. and B. P.), some- times called u Diachylon," and this is in turn employed for the manu- facture of resin plaster (Emplastrum Resince, U. S. and B. P.). It is also used in the preparation of the solution of subacetate of lead. Hebra recommends for sweating of the feet an application of equal parts of lead plaster and linseed oil? applied on linen and wrapped around the feet every third day. Nitrate of Lead. Nitrate of Lead (Plumbi Xitras, U. S. and B. P.) is never used internally, but as a powder, in the treatment of cases of onychia maligna and in the formation of Ledoyen's disinfecting solution. The latter discolors the paint in Avater-closets, dissolves the solder in drain-pipes, and is not a good preparation for general use. LEPTANDRA. The medicinal portion of Veronica Virginiea is the rhizome and rootlet, from Avhich are made the official extract (Extractum Leptan- dre, U. S.) and the fluid extract (Extractum Leptandra> Fluidum, U. S.). The dose of the former is from 1 to 8 grains (0.06-0.5) and of the fluid extract 5 to 40 minims (0.3-2.6). Physiological Action.—Very few experiments have been made as to the action of this remedy, and the only ones of importance are those of Rutherford and Vignal, who found that it possessed a mod- erate influence in increasing the flow of bile. In overdose it causes violent purging. 238 DRUGS. Therapeutics.—In the official preparations of leptandra, which are not as active as is the fresh drug, we have excellent substitutes for calomel, according to many clinicians. Those who have used leptandra also believe it to be of the greatest value in the indigestion of the intestinal type sometimes called " duodenal atony." The following pill is a good method of using the drug in these cases: R.—Ext. chiretta?.............gr. xx (1.3). Ext. leptandrse............gr. xx (1.3).—M. Ft. in pil. No. x. S.—One pill after each meal. Under the name of leptandrin we have an impure resin which is given in the dose of 2 to 5 grains (0.1-0.3). An alkaloid of doubtful existence is called leptandrine. LIPANIN. Lipanin is an artificially prepared mixture devised by Von Mering as a substitute for cod-liver oil, and consists in 6 parts of oleic acid added to 100 parts of olive oil. The advantages possessed by it are its lack of disagreeable odor and taste and its ready emulsification and digestibility. The commencing dose is 1 drachm (4.0) Avhich may be increased to 4 drachms (16.0). This mixture has been found of value in most of the diseases in which cod-liver oil is employed, and in the opinion of the author its efficacy is greatly increased if the hypophosphites of lime and sodium are used at the same time in the dose of 10 grains (0.65) three times a day. Iodine or one of its compounds may also be given if it is desired to exert an alterative influence. LIQUORICE. Liquorice (Glycyrrhiza, U. S.; Glycyrrhizas Radix, B. P.) is the root of Glycyrrhiza Glabra, a plant of Southern Europe and Asia. It is used to increase secretion in the mouth in the form of a solid extract, and when dissolved in water to form a vehicle for other drugs, particularly if they have a disagreeable taste. The powdered solid extract is a very mild and useful laxative. Administration.—The solid extract (Extractum Glycyrrhize, U. S. and B. P.) is used in a dose anyAvhere from 5 to 120 grains (0.35- 8.0). _ The pure extract (Extraction Glycyrrhize Purum, U. S.) is used in the same quantities as the ordinary extract. The fluid extract (Extractum Glycyrrhize Fluidum, U. S.) or the liquid extract (Extrac- tum Glycyrrhize Liquidum, B. P.) is used in 1- to 2-drachm (4.0-8.0) doses. Under the name of Brown Mixture or " Compound Liquorice Mixture " a very efficient expectorant solution is official (Mistura Glycyrrhize Composita, U. S.), which contains as its most important ingredients 12 parts of paregoric, 6 parts of wine of antimony, and 3 parts of sweet spirit of nitre. The dose is 1 to 4 drachms (4.0- 16.0). Pulvis Glycyrrhiza Composita, U. S. and B. P., or compound LITHIUM. 239 liquorice poAvder, contains, according to the U. S. P., 18 parts of senna, 16 of liquorice, 8 of fennel, 8 of washed sulphur, and 50 parts of sugar. According to the B. P., it should contain 2 parts of senna, 2 of liquorice-root, 1 of fennel-fruit, 1 of sublimed sulphur, and of sugar 6 parts. The dose is 1 to 4 drachms (4.0-16.0). It is largely used as an efficient laxative after childbirth and in cases Avhich suffer from constipation chiefly due to the inactivity consequent upon being in bed. The troches (Trochisci Glycyrrhiza' et Opii, U. S. and B. P.) contain fa grain (0.003) of opium and 2 grains (0.1) of extract of liquorice. Finally we have Glycyrrhizinum Ammoniatum, U. S., which is the SAveet principle of liquorice rendered soluble and easily tasted by the addition of ammonia. The dose of this preparation is 5 to 15 grains (0.3-1.0). LIQUOR POTASSA. Liepior Potasse, U. S. and B. P., is a solution of potassa contain- ing about 5 per cent, of potassium hydrate, and is a clear, odorless liquid of caustic taste and strongly alkaline reaction. It is used in medicine as an antacid and for the purpose of decreasing the acidity of the urine. In ingrowing toe-nail it is often used to soften the nail prior to packing with cotton or partial evulsion. Its dose is 5 to 30 drops (0.35-2.0) well diluted Avith water. LITHIUM. Lithium is used in several forms, but its salts may be divided into two classes—those Avhich act as lithium and those Avhich act as the acids forming them. In the first class Ave have the carbonate (Lithii Carbonas, U. S. and B. P.), dose 2 to 10 grains (0.1-0.65), the citrate (Lithii Citras, U. S. and B. P.), dose 5 to 20 grains (0.3-1.3), and the effervescent citrate (Lithii Citras Effervescens, U. S.), dose 1 to 4 drachms (4.0-16.0). In the second class Ave find the benzoate (Lithii Benzoas, U. S.), dose 5 to 30 grains (0.3-2.0); Lithii Bromidum, U. S., dose 10 to 40 grains (0.65-2.65), and Lithii Salicylas, U. S., dose 10 to 30 grains (0.65-2.0). Haig has pointed out that although lithia forms salts Avith uric acid in the test-tube, in the body it has a greater affinity for the acid sodium phosphate in the blood, and practically leaves the uric acid to itself. This is an important point, since it proves that the large amount of water generally taken with lithia has more to do with relieving gout than has the lithia. The carbonate and citrate are used in gout and rheumatoid arthri- tis for the purpose of entering into combination with the uric acid in the body to form soluble urates and prevent deposits in the joints. They have been said to dissolve calculi, but this is untrue, though they are used Avhen it is desired to render the urine alkaline. The carbonate is not soluble in Avater, and should be given in capsule or 240 DRUGS. freshly-made pill, but the citrate is soluble. The latter may be made from the former by taking 50 grains (3.3) of the carbonate, 90 grains (6.0) of crystallized citric acid, and warm distilled water 1 fluidounce (32.0). The acid should be dissolved first, and the carbonate added to the solution. The solution should then be kept hot until efferves- cence ceases. In cases of diabetes depending upon a gouty taint remarkable results are often obtained from the use of the citrate or carbonate of lithium and arsenic. The dose should be fa of a grain (0.002) of arsenite of sodium and 10 grains (0.65) of the lithium salt three times a day. (For the use of the other salts of lithium see the articles on the Bromides, Salicylic Acid, and Benzoic Acid.) It is Avorthy of note that in some cases citrate of lithium will dis- order the stomach and produce vomiting. Lithia-Avater, or the prepa- ration of the British Pharmacopoeia, Liquor Lit hie Effervescens, is useful in gout in quantities of 5 to 10 ounces (160.0-320.0) at a time. LOBELIA. Lobelia, U. S. and B. P., is the leaves and tops of Lobelia Inflata, a common Aveed of the United States. It contains an alkaloid, lobe- line, and lobelic acid. Physiological Action.—AY hen taken in overdose lobelia causes eme- sis, intense prostration, a feeble pulse, pale skin, livid face, muscular relaxation, and a cold sweat. A lolent purging may be present. It is said to paralyze the motor nerve-trunks, and it causes a fall of arterial pressure, folloAved by a rise, due to the asphyxia which it finally produces. Ultimately it paralyzes the respiratory centre and the peripheral vagi. The treatment of the poisoning is to administer opium to stop irritation and vomiting, to give alcohol and ammonia to support the heart, and in the use of external heat. Therapeutics.—Lobelia is used chiefly as an antiasthmatic, and has been equally praised and condemned by eminent authorities. The reason for this lies in the fact that it is generally useless in asthma unless given in almost poisonous dose. AYood teaches that it should rarely if ever be used, because of its poisonous effects even in doses medicinally active, while Sidney Ringer says that the drug is erro- neously thought to be dangerous. In asthma both of the gastric and bronchial form lobelia is undoubtedly of service. In some cases it fails as signally as it succeeds in others. If the asthma is due to or associated with cardiac disease, lobelia should never be employed. The drug should be taken in the dose of J a drachm (2.0) to 1 drachm (4.0) of the tincture at the first sign of an attack, or in 10-drop (0.65) doses every fifteen minutes until distinct nausea occurs or relief is obtained. In atonic constipation 10 drops (0.65) of the tincture at bed-time are often of service. Administration.—Lobelia is given in the form of the tincture (Tine- MAGNESIA. 241 tura Lobelie, U. S.), in the dose of 10 to 30 drops (0.65-2.0), or 1 to 2 drachms (4.0-8.0) as an emetic. The vinegar (Acetum Lobelia-) is no longer official, but is given in the dose of 20 to 30 drops (1.65- 2.0), and the fluid extract (Extractum Lobelia' Fluidum, U. S.) in the dose of 1 to 5 drops (0.05-0.35). or as an emetic in the dose of 15 drops (1.0). In the form of the infusion lobelia is useful as a lotion in the treat- ment of the dermatitis produced by poison ivy. The proportion used should be an ounce (32.0) to the pint (| litre) of water. The preparations of the B. P. are the Tinetura Lobelie, dose 10 minims to \ drachm (0-65-2.0), and Tinetura Lobelie MJtherca. dose 10 to 30 minims (0.65-2.0). LYCOPODIUM. Lycopodium, U. S., is a pale-yellow poAvder derived from Lyeo- podium Clavatum, a species of moss. It is used by pharmacists as a poAvder in Avhich to roll pills, and by physicians and nurses to prevent the intertrigo or chapping of the skin of infants and adults. LYSOL. This is a preparation made by dissolving in fat and saponifying with alcohol that part of tar oil Avhich boils betAveen 190° and 200° C and is a broAvnish, clear, oily fluid, smelling someAvhat like creo- sote. It is used for the same purposes as creolin, but possesses the advantage of forming a clear, soapy fluid, Avhen mixed Avith water, in Avhich instruments can be seen. If small instruments are used, the solution is too soapy and renders them slippery. Those Avho have used lysol claim that it does not affect the operator's hands except to render them soft and flexible. Experiment shoAvs it to be possessed of marked antiseptic poAver, and it is far less poisonous than carbolic acid. Used upon mucous membranes, the solution should not be stronger than 2 per cent. MAGNESIA. Alagnesia is the oxide of magnesium, made by exposing the car- bonate of magnesium to a red heat. It is used in the form of the light magnesia (Alagnesia Levis) as a dusting powder. The troches (Trochisci Magnesue) each contain 3 grains (0.015). Magnesia is an antidote to arsenic, and when employed to precip- itate a soluble preparation of iron it forms the Antidotum Arsenic/' (Ferrum Oxidum Hydration cum Alagnesia, U. S.). It is important that the student should not confuse magnesia and magnesium. The first is the oxide of the second, and is sometimes called calcined magnesia or " Husband's Magnesia." Magnesia is of little value except as a feeble antacid. Alagnesia and the carbonate of magnesium may be used interchangeably. lfi 242 DRUGS. MAGNESIUM. Magnesium is a metal never used as such, but ahvays in the form of one of its salts, Avhich are the sulphate, citrate, carbonate, and sulphite. The sulphite is a natural salt found in sea-water and in caves or in the Avater coming from the latter. The citrate and car- bonate are derived from the sulphate. The carbonate is insoluble in Avater and alcohol. The others are soluble. Magnesium Carbonate. The Carbonate of Magnesium is official in the form of the heavy and light poAvder (Magnesii Carbonas Ponderosa, U. S. and B. P., and M/gnesii Carbonas, US.; Alaguesii Carbonas Levis, B. P.). These tAvo substances do not differ in respect to their effects. The light mag- nesium is never given internally, because of its bulk, but it is used as a dusting powder in intertrigo, and in the form of Avhite cubes rubbed on the skin to prevent excessive perspiration and as a cosmetic. The heavv magnesium is used as an antacid, and is not, as has been thought by some, in any sense a laxative, as it possesses no such poAver. AYhen the stomach or intestines contain much acid from fermentative changes, these acids may, however, unite Avith the mag- nesium and form a slightly laxative salt. In sick headaches due to great gastric acidity carbonate of magne- sium is often of service. The dose of the carbonate is from 5 to 60 grains (0.3-4.0) It should not be used constantly, as there is danger that it Avill accumulate in the intestines. Liquor Magnesii Carbon at is, B. P., is given in the dose of 1 to 2 ounces (32.0-64.0) as a laxative. Magnesium Citrate. The Citrate of Magnesium (Magnesii Citras) is a much more irri- tating purge than the sulphate, but it is more agreeable to the taste. It is official in tAvo forms, one of Avhich is the solution (Liquor Mag- nesii Citratis, U. S. and B. P.), which is effervescent and should never be used unless freshly prepared. It is made by adding bicar- bonate of potassium to a syrupy solution of the citrate of magnesium containing an excess of acid, and corking the bottle tightly, the cork being tied doAvn Avith a strong cord. Care should be taken that the bottle is a strong one. The dose is half to one bottle. It is too irri- tating to be used Avhere inflammation of the alimentary canal exists, but is useful in the treatment of sick and bilious headache. The Granulated Citrate (Magnesii Citras Effervescens, U. S.) is less agreeable to take. It should be dissolved in water, about 1 to 3 drachms (15.0-45.0) of the salt being used in each dose, and SAval- loAved Avhile the solution is effervescing. It must be kept in bottles tightly corked. Magnesium Sulphate. Sulphate of Magnesium (Magnesii Sulphas, U. S. and B. P.) MANNA. 243 is a Avhite granular powder of neutral reaction, salty taste, and is soluble in Avater. It is the form generally knoAvn by the laity as "■ salts," although in some parts of the country this also includes the sulphate of sodium. According to the studies of Hay and others, sulphate of magnesium is a purge by reason of its abstraction of Avater from the intestinal blood-vessels. All strong saline solutions above the strength of T per 1000 abstract liquids "from the tissues Avhen brought in contact Avith them. On the other hand, if a saline solution be less strong than 7 per 1000, it will abstract salts from the tissues and replace them Avith water. The recollection of these facts readily makes clear the mode of action of magnesium sulphate. When- ever a thorough purgative action is required—that is, Avhere depletion of the intestine or absorption of exudations is to be attained—the mag- nesium should be given in concentrated form, so as to make its solu- tion of as high a percentage as possible. Magnesium sulphate may be given by enema with the double purpose of unloading the boAvels and acting as a depletant. The best mixture for this purpose seems to be that proposed by AYatkins—namely, 2 ounces (64.0) of magne- sium, 1 ounce (32.0) of glycerin, and 4 ounces (128.0) of water. In cases of dropsy the use of concentrated solutions is particularly necessary, and from 1 to 2 ounces should be given before breakfast or on an empty stomach in as little Avater as Avill dissolve the salt. (See Dropsy.) In enteritis and peritonitis this use of magnesium is Avidely recog- nized as a proper measure. The sulphate is not irritating, and may be given freely Avhen inflammation exists. (See Peritonitis.) It forms a large part of most of the natural purgative Avaters. The B. P. recognizes an enema, Enema Magnesii Sulph/ttis, composed of sulphate of magnesium 1 part, olive oil 1 part, starch mucilage 15 parts. MANGANESE. Manganum, or Manganese, is official in the form of the black oxide (Mangani Diox/'dum. U. S. and B. P.) and the sulphate (Mangaui Sulphas, U. S.). The first of these, under the name binoxide of manganese, has been highly praised in amenorrhea dependent upon functional disturbance and anaemia. The dose is 3 to 5 grains (0.15- 0.3) three times a day, in pill form, and the drug should be taken for a feA\ days before the expected or proper date for menstruation. The sulphate is rarely if ever employed, but may be tried in malarial jaundice. The dose is 1 to 2 grains (0.05-0.1). MANNA. Manna, U. S. and B. P., is the concrete juice of the exudation of Fraxinus Ornus, a tree of Europe. It occurs in small or large roundish masses, looking someAvhat like a gray-colored gum arabic. It has a SAveet taste and odor. Sometimes the taste is a little bitter. 244 DRUGS. Therapeutics.—Manna is the most feeble of the laxatives, and causes a slight flatulence in some persons. In children fed by the bottle one of the most frequent disorders is obstinate constipation, and for its relief 1 to 2 drachms (4.0-8.0) of the sweet variety of manna may be dissolved in the milk of each bottle. When given to older children or adults, manna is always combined with other more power- ful drugs, chiefly to cover their taste. It may be combined with advantage with rhubarb and senna, and it enters into the official Infusum Sennas Composition, U. S., the dose of which is from 1 to 4 fluidounces (3.20-64.0). MATRICARIA. Matricaria, U. S., German Chamomile, consists in the floAver-heads of Matricaria Chamomilla, a European plant, possessing mild tonic properties in moderate dose. In larger amounts it acts as an emetic and anthelmintic. In the form of an infusion of the strength of 1 to 2 ounces to the pint (32.0-64.0: \ litre) it has been largely used as a diaphoretic, and, in small doses, to prevent colic in teething children. MENTHOL. (See Peppermint.) MERCURY. Hydrargyrum, U. S. and B. P., Mercury or Quicksilver, is a heavy fluid metal of a peculiar color and appearance. As mercury it is used in medicine in the form of the ointment, the plaster, gray powder, and blue mass. Physiological Action.—When mercury is taken into the body in one of its insoluble and mild preparations, it may cause no evidence of its presence until by frequent dosage the system in general begins to feel its influence. The first evidences of this are to be found in the mouth, and consist in tenderness of the teeth when the jaws are firmly and quickly closed, foetid breath, sponginess of the gums, which finally may bleed at the slightest touch, swelling of the tongue, and, most prominent of all, excessive salivation, a condition some- times called ptyalism. If the use of the drug is persisted in, all these symptoms groAv Avorse. Eczema, and finally sloughs of the chin and chest develop as the result of the constant dribbling of saliva and the direct depressing effect of the drug on the tissues. The teeth drop out, the maxillary bones undergo necrosis, and amid a general melting doAvn and decomposition of the tissues the patient dies. The blood is affected, and becomes very thin, fluid, and poor in its corpus- cular elements. These symptoms ensue on the use of mercury in continued doses, and rarely folloAv exposure to the drug in the pro- cesses of the arts. In the arts—as, for instance, in the making of MERCURY. 245 looking-glasses—workmen are often affected by various trains of symptoms varying very widely in their course. In some cases the nervous system becomes chiefly affected. Tremors of all sorts arise, paralysis agitans is developed Avith its typical characteristics, and Avidely different changes and degenerations in the spinal cord ensue. Chorea often comes on in chronic mercurial poisoning, and its occur- rence in an adult should cause inquiry as to any possible exposure to mercury. In other cases brownish discoloration of the skin, resem- bling Addison's disease, appears. Blindness, deafness, sensory dis- turbances, such as hvperaesthesia and anaesthesia, are developed, and localized wasting of muscles or groups of muscles may assert itself. In still other eases the blood becomes impoverished and mercurial cachexia is developed. It is Avorthy of note that children under three years are rarely salivated by the use of mercury, but this is no reason for using this drug carelessly in this class of cases, since the other changes in the organism nevertheless occur. The question as to the form in Avhich mercury finds entrance into the system is one of interest and importance. According to certain Avriters, it is changed into an albuminate, and so circulates in the blood, but, Avhile this is probably true, it is not knoAvn to be a fact. Some have supposed that the bichloride is held in solution as an albuminate of the oxide of mercury united "with sodium chloride, but others have asserted that metallic mercury in a state of minute subdivision circulates in the blood: this point, however, cannot be considered settled, and the drug undoubtedly accumulates in all the tissues, more especially in the liver and kidneys. Mercury in all its forms is absorbed and eliminated by the kid- neys, liver, skin, and salivary glands. No secretion of the body, even to the semen, fails to carry it out of the system, but it is to be remembered that, although these parts are actively engaged in its elimination, the drug nevertheless rapidly accumulates in the body. Winternitz asserts that the drug is excreted with equal rapidity whether given in its soluble or insoluble forms, or, in other words, that calomel is absorbed and eliminated as rapidly as is corrosive sublimate. Balzer and Klumpke have made a long series of observations at the Lourcine Hospital in Paris on the rapidity of the elimination of mercury by the kidneys during a treatment of long standing. While there are many methods for the estimation of mercury in organic fluids, these investigators throughout adopted that of AYitz, as modi- fied by SouchoAV and MichaeloAvskv, Avhich permits of the easy detec- tion of the jjfaf of a grain (0.00006) in an ounce (32.0). After a single dose of mercury the elimination of the drug is rapid, and sometimes complete in tAventy-four hours, but if a continuous treat- ment is interrupted, its excretion continues for some time, and Kuss- maul and Gorup-Besanez have found it in the liver as much as a year after its administration has been stopped. The amount of mercury that can be readily eliminated for many weeks from the kidneys Avhen the body is saturated is about fa of a grain (0.004) daily. 246 DR UGS. Therapeutics.—The employment of mercury in medicine centres around four great points—viz".: 1st, its value in syphilis and kindred states; 2d, its use as a purge; 3d, its power as an antiseptic and cp-rmicide; and 4th, its action as an antiphlogistic: the first and fourth points are fulfilled by all the mercury salts more or less per- fectly, the second only by blue mass and calomel, the third by the bichloride and biniodide of mercury. In syphilis mercury is to be given, not because the patient shows symptoms of the secondary or tertiary type of the disease, but because the conditions present do or do not call for its employment. Many writers have insisted that it ought only to be employed in the secondary stages, and while this is, as a general rule, correct, certain conditions may call for it at any time. (See Syphilis.) Mercury is often administered by means of fumigations or inhala- tions both "for the removal of local and general syphilitic disorders. The best apparatus for either purpose is one devised by Bumstead, and it is both simple and inexpensive. It consists of a sheet-iron cup so bent that the bottom of the vessel, instead of being flat, pro- jects into the centre of the cup, thereby forming a raised centre Avith a little ditch about it. The top of this projection is flattened, and on its apex is placed the calomel Avhich is to be sublimed. The sur- rounding ditch is then filled Avith hot water, and the cup placed over an alcohol flame, which disengages the vapor of the calomel and Avater. When inhalations are used the face should be held some six or eight inches away from the cup to permit the fumes to pass through the air. Under these circumstances the quantity of calomel used should not exceed 4 or 5 grains (0.3), and the mouth should be rinsed out to prevent mercurial stomatitis unless a local action on the buccal mucous membrane is desired. Not more than eight or ten inspira- tions should be taken at one sitting. If general fumigations are to be practised, the patient places the lamp and cup with 30 grains (2.0) of calomel on it under a chair, on Avhich he sits Avrapped in a heavy blanket. We believe that the ultimate conclusion of the profession in regard to the hypodermic injection of mercurials in syphilis will certainly be identical with that governing its use of quinine in malarial fever. There can be no doubt that a certain number of instances do arise in Avhich, by reason of severe infection, susceptibility of the patient, or inability to take mercury by the ordinary means, hypodermic injec- tions are absolutely necessary. In the same way that Ave give qui- nine by the mouth, the rectum, and hypodermically in pernicious malarial fever, so do Ave give mercury by the mouth, by inunctions, by sublimation, and by the hypodermic needle in malignant syphilis. The reasons for believing that hypodermic injections of mercurials are not to be resorted to as a routine treatment of syphilis are several. In the first place, all forms of hypodermic medication possess disad- vantages not possessed by the use of drugs by the mouth. There is ahvays some danger of entering a vein, of producing an abscess, or of causing local pain. AYhen mercurials are so employed, the danger MERCURY. 247 of abscess, of pain, or of milder inflammatory manifestations is greatly increased, and the presence of an indurated spot where the hypodermic injection has been given proves that it is not the simplest form of medication in syphilis. Of the mercurial preparations Avhich are best administered hypodermically in syphilis, the tAvo Avhich sur- pass all others are undoubtedly the bichloride of mercury, in the dose of 1 grain, dissolved in 10 or 15 drops of distilled water, every second or third day, or gray oil (Oleum Cinereum), Avhich Avas first introduced into medicine by Lang of Alenna. (See Gray Oil, under Mercury.) In all cases the injection should be given deeply and in some por- tion of the body in Avhich the tissues are loose, as the buttock or the broad of the back. The employment of mercury as a purge or laxative having a special action on the liver is constantly resorted to. The two prepa- rations used are blue mass and calomel, but the latter is more active. They both cause soft and watery stools, according to the dose in Avhich they are given, but the blue mass is rarely, if ever, used except for the production of a laxative effect. Much discussion has arisen as to Avhether mercury does affect the liver, and Avhether the peculiar greenish or broAvnish-yelloAv stools produced by it are due to the presence of bile or mercury. If there is one point firmly fixed in the mind of the average practitioner of medicine, it is that the mild chloride of mercury increases the quantity of bile in the intestine. If such a belieA'er is questioned as to whether this increased amount of biliary fluid is due to a true increase in secretion or simply to an increase in the floAv of bile from the gall-bladder, he Avill either state that he is unable to ansAver the question or that he believes that it is an increased secretion. Practically, the position of the profession in general in regard to the purgative influence of calomel is that the drug exercises a stim- ulating effect upon the biliary gland. Careful experimentation upon the loAver animals by several competent observers, and careful studies made by physiological chemists, fail, hoAvever, to give us very much light upon this subject. It is held by some that calomel never acts as calomel, but is converted by the hydrochloric acid of the gastric juice into corrosive sublimate, and that this drug then stimulates the liver to increased activity. On the other hand, the best chemical investigations shoAV positively that the feeble acidity of the gastric juice and the temperature to Avhich the calomel is exposed are not favorable to the conversion of a sufficient quantity of calomel into corrosive sublimate to account for any hepatic influence. Thus it Avas found by Rutherford and Vignal, in their Avell-known series of studies upon the influence of drugs upon the secretion of bile, that if 5 grains of calomel are subjected, at 100° F., for seventeen hours to the action of normal gastric juice, not more than -fa of a grain of mercuric chloride is produced. As calomel does not remain in the human stomach for more than a night at the utmost, and generally but a very feAv hours, it is not likely that as 24» DR UGS. much as fa of a grain of mercuric chloride is produced from the moderately large dose of 5 grains. In contradiction of this, Bucheim, AYinkler, and others assert that no conversion Avhatever takes place at the temperature of the body. and Jaennel's later studies support this view. The other theory as to the change Avhich takes place in calomel prior to its action upon the liver is that it escapes into the intestine, Avhere it is decomposed and the gi'ay oxide of mercury precipitated, Avhich may, hoAvever, be held in solution by any fatty materials, which, being mixed Avith alkaline liquids, practically form soaps. It is thought by AVood and others that this is the more probable result, particularly in vieAV of the fact that calomel acts more like blue mass than cor- rosive sublimate. Further than this, these opinions are confirmed by the fact, Avith which all of us are familiar, that the hepatic influence of calomel is much more positively asserted if at the same time small doses of the bicarbonate of sodium are administered. Under these circumstances the bicarbonate of sodium naturally diminishes, to some extent at least, the acidity of the gastric contents, and also directly or indirectly tends to increase the alkalinity of the contents of the duodenum. As if to increase the complexity of the problem, the studies of Rutherford and Arignal seem to prove conclusively that in the dog, at least, mercuric chloride has a direct stimulant effect upon the hepatic cells; whereas, calomel, while producing purgation by increas- ing the secretion of the intestinal glands, in no way increases the true secretion of bile; and this Avould seem to indicate that, after all, the influence of calomel upon the liver is due to a very minute portion of it being changed into corrosive sublimate. Probably the truth of the matter is, that Ave have as yet no definite scientific explanation of how calomel really does act. It may be that the solution of the problem lies in the hepatic influence exercised by the presence of minute quan- tities of corrosive sublimate, and the purgative effect produced by that portion of the calomel Avhich has not been converted into the strong chloride of mercury. This is rendered the more likely in view of the fact that the corrosive sublimate has been found a feeble intestinal stimulant, while the calomel has been found to produce active purga- tion in dogs, without producing an increase in biliary flow, Avhen the drug has been introduced into the duodenum. It has been suggested, too, that calomel itself may stimulate the bile-expelling mechanism, while the minute portion of corrosive sub- limate increases the secretion of the liquid; and, again, that by means of the purgative effect that it produces certain substances Avhich have been in the intestine are immediately removed, and, as a consequence, a depressant influence upon the hepatic cells no longer exists. While, at first sight, the argument seems a forcible one that a vast clinical experience in regard to calomel is far superior to any series of experiments on dogs, it is only just to remember that in the entire series of remedies supposed to produce an hepatic effect calomel is the only one which failed to influence the liver of the dog as the others influenced the liver of man. MERCURY. 249 It is to be hoped that those physicians Avho have opportunities to examine persons suffering from biliary fistula will take the oppor- tunity, Avhenever it arises, of Avatching the influence of calomel upon the floAv of bile from the fistulous opening. This subject also is of interest to the practical physician in rela- tion to the administration of calomel in compressed tablets or other preparations Avhen mixed with Avhat might be called excipients. Under these circumstances, if one of the excipients is bicarbonate of sodium, the tablet almost ahvays undergoes a change and becomes of a gray color. Those Avho have used pills or tablets of calomel Avhich have been kept for a long period of time seem to be universally in accord with the statement that they have lost the hepatic effect Avhich a recently-prepared poAvder always possesses. Thus it has been fre- quently found that no biliary flow occurs under the use of stale tab- lets. Avhereas free bilious purging folloAvs the administration of freshly- prepared poAvders. Calomel and blue mass are largely used in the condition knoAvn as biliousness, and undoubtedly give relief. (See Biliousness.) If the tongue is heavily coated, the breath foul, the conjunctiva a little icte- roid, and headache is present, either of them should be employed. In remittent malarial fever the use of small repeated doses of calomel Avill often bring relief from the vomiting, and it should ahvays be given in the treatment of malarial disease before quinine is used if a thorough action of the antiperiodic is required. The disinfectant and germicidal power of bichloride of mercury and of the biniodide is very Avell established by clinical experience and experimental investigation. The strength of the bichloride in solution for antiseptic purposes may vary from 1 to 2000 to 1 to 20,000 of water, and for disinfectant use from 1 to 500 to 1 to 1000. (See Antiseptics.) In using the bichloride of mercury as an antiseptic it is necessary to add a feAv grains of tartaric acid to the solution to prevent its unit- ing with the albumin of the tissues to form an insoluble and useless albuminate. The same is true of the mercury biniodide. The antiphlogistic or anti-inflammatory action of mercury is very marked indeed, but its employment is absolutely limited under these circumstances to one variety of inflammation—namely, the sthenic or dynamic form. In inflammation arising during the course of some exhausting disease mercury is not only contraindicated, but harmful. Thus, if a man in health is stricken with pleurisy or peritonitis or meningitis or any acute inflammation of a serous membrane, be the cause Avhat it may, the exudate poured out will probably be fibrinous, and capable of undergoing organization, thereby causing adhesions of the pleural surfaces, of the intestines, or of the meninges of the brain. On the other hand, if a man be taken Avith pleurisy or men- ingitis during the course of phthisis or typhoid fever, the exudate will be serous and large in quantity. It is in the first case that mercury should be used to prevent the fibrinous exudate or to make it serous. In the second instance it will do harm by increasing the exudation. 250 DRUGS. When given as an antiphlogistic the drug is often combined Avith opium to relieve the pain and irritation and to prevent purging. In meningitis arising from head injuries this is the routine treatment, and may be carried out by the use of powders containing 4, grain (0.015) of calomel and | grain (0.015) of poAvdered opium every hour till 1 or IJ grains (0.05-0.07) of each are taken. The simultaneous use of the ice-bag to the head and perfect quiet will often bring relief very rapidly. Mercury is also the best remedy in sthenic endocarditis, and should be given in full dose. The bichloride may be used in small doses in place of the calomel, and does not, of course, produce the same tend- ency to laxity of the boAvels. At the same time, it often seems to be less efficacious. Mercury in myocarditis and pericarditis is also of service, and certainly exerts distinct prophylactic poAver in the early stages of diphtheria and membranous croup. (See Diphtheria.) Leaving the general subject of mercury, Ave may noAV consider each individual preparation. Ammoniated Mercury. White Precipitate, or Ammoniated Mercury (Hydrargyrum Ammo- niation, U. S. and B. P.), is used in an ointment ( Unguentum Hydrar- gyri Ammoniati, U. S. and B. P.) in various skin affections. It should generally be diluted Avith lard. In ozena, Avhether syphilitic or not, Trousseau has recommended the employment of the folloAving poAvder as a snuff: R.—Hydrargyri ammoniati.........gr. iv (0.2). Pulv. sacchar. alb............§ss (16.0).—M. S.—To be used as a snutf, after thoroughly bloAving the nose. The red precipitate may be used instead of the Avhite. This treat- ment removes the stench and may cure the complaint. It may, Iioav- ever, irritate the mucous membrane, in Avhich ease it should be used in the strength of 2 grains to the J ounce (0.1 : 16.0). It is never used internally. Bichloride of Mercury. The Bichloride of Mercury, or Corrosive Sublimate (Hydrargyrum Chloridum Cmrosivum, U S. ; Hydrargyri Percliloridum, B. P.) as it is called, is an exceedingly poisonous and irritating substance Avhen taken in concentrated form. Taken internally, it causes violent pain in the stomach, vomiting, purging of mucus, blood, and the contents of the intestine, collapse, syncope, and death. If taken in poisonous amount, the patient should be made to SAvalloAv large amounts of the antidote, Avhite of egg, the stomach should' be Avashed out Avith the stomach-pump, heat should be applied about the body, and the proper stimulants be given if the pulse or respiration fail. If death does not occur at once, the patient generally has a protracted convalescence or else dies from the MERCURY. 251 organic changes produced in the gastro-intestinal tract, such as stric- tures, sloughs, destruction of the peptic glands, and ulcerations. The bichloride of mercury is an exceedingly useful preparation of mercury for hypodermic injection in syphilis, and is better than calomel for this purpose. About 1 grain (0.012) may be injected deeply and gently into the cellular tissues every two or three days. When the injections are made the greatest possible cleanliness should be obtained. The needle should be aseptic and the hands of the operator Avell disinfected. The best place for the injection is in the gluteal region or betAveen the shoulder-blades. Mercury bichloride, aside from its antiseptic use (see Antiseptics), is of great value Avhen given internally, not only in syphilis, but in other states not associated Avith any such depraved condition, as in chronic Brights disease. In diphtheria it may be used to prevent fibrinous exudation as readily as calomel (see Diphtheria), and in ton- sillitis, Avhere the inflammation is severe, it is often used with great service. When using a solution of bichloride of mercury as an antiseptic, tartaric acid should be added to the solution to prevent the precipita- tion of the mercury in the form of an albuminate. In small amounts—that is, in Jw to fa of a grain (0.0015-0.0017) three times a day—the bichloride is one of the best remedies Avhich Ave possess for the treatment of anemia, be its cause Avhat it mav. Bichloride of mercury is of value in minute doses of ^^to fa of a grain (0.0003) in the ill-smelling green stools of summer diarrheas in adults and children, and it has been recommended that a solution be made of i a grain (0.03) in 5 ounces (160.0) of Avater, and a tea- spoonful given every hour until relief is obtained. The Avater used in making the solution should be distilled, and it may be Avell to add to it a little tartaric acid to prevent precipitation of the bichloride by organic matter Avhich may have gotten into the Avater. This treat- ment is particularly useful in mucous diarrhea in which blood and mucus are thoroughly mixed. Patients in the dispensaries often speak of these passages as containing >l corruption," and others think they consist of "lumps of flesh," OAving to the masses of blood and mucus. AYhether the disease be acute or chronic, the bichloride, used in the Avayjust described, Avill be found of service. In dysentery and the diarrhea of adults the same treatment may be resorted to, using 2 teaspoonfuls of the solution instead of 1. It is hardly necessary to add that the greatest care must be bestoAved upon the diet and clothing. The author has treated a child suffering from persistent diarrhtea for months Avith varying success, only to succeed Avhen, it being found that the abdomen Avas exposed to the air, the mother Avas forced to apply and keep on the child a flannel binder. In some cases in Avhich an obstinate syphiloderm is present 4; an ounce (16.0) of corrosive sublimate and 1 ounce (32.0) of chloride of ammonium may be added to a Avarm bath, Avhich should be taken every feAV days. 4 a grain (0.03) of the bichloride of mercury in 6 ounces (192.0) of Avater is said to be most efficient as an injection in gleet, if used every three or four hours. (See Gonorrhoea.) 252 DRUGS. In all parasitic affections of the skin a solution of 2 grains (0,1) of bichloride to the ounce (32.0) of water may be sopped on the part three times a day. A solution of perchloride of mercury (Liquor Hydrargyri Perchloridi) is official in the B. P. : it is prepared by adding J- grain (0.03) of the perchloride of mercury to 1 ounce (32.0) of water, with 4; grain (0.03) of ammonium chloride to hold it in solu- tion. (For the antiseptic uses of the bichloride of mercury see Anti- septics and Disinfectants.) Biniodide of Mercury. Mercury Biniodide (Hydrargyri lodidum Bubrum, U. S. and i?.P.) is a bright-red poAvder, possessing irritating powers equal to or above those of the bichloride, and causing symptoms, Avhen taken in over- dose, closely resembling those produced by the latter drug. OAving to the formation of the salt, it is thought to be particularly useful in the later stages of syphilis. The dose is fa to y1-^ of a grain (0.003- 0.006). (See Syphilis.) An ointment ( Unguentum Hydrargyri Iodidi Ixubri, B. P.) is useful as an application in goitre and obstinate skin diseases. At one time it Avas thought that biniodide of mercury Avas a better antiseptic than the bichloride, but recent researches have proved that this is not a fact. Black Wash. Black AVash (Lotio Hydrargyri Nigra, B. P.) is made by adding 1 drachm of calomel to a pint (4.0 : ^ litre) of lime-water. It is used for Avashing syphilitic sores and wounds and in various forms of eczema. Blue Mass. Blue Mass (JIassa Hydrargyri, U. S. ; Pilula Hydrargyri, B. P.) is made by rubbing up metallic mercury with liquorice and other excipients, and is often called Blue Pill. Each grain of the mass contains ^ grain (0.02) of mercury, and it may be given in the dose of from ^ to 20 grains (0.03-1.3) for the same laxative purposes for Avhich Ave use calomel. Blue mass is rarely used to produce systemic effects. Calomel. Calomel (Hydrargyri Chloridum Aide, U. S.; Hydrargyri Subchlo- ridum, B. P.), or the Mild Chloride of Mercury, is an insoluble salt Avhich is, nevertheless, freely absorbed. Calomel when used as a laxative purge should be given in the dose of \ to \ grain (0.01-0.03) every half-hour or every fifteen minutes until 1 or 2 grains (0.05-0.1) are taken, as it will act as efficiently in this way as if 10 grains (0.65) are given at one dose, and there is" no dan- ger of producing ptvalism. The reason that small doses are as efficient as large ones lies in the fact that only the calomel Avhich is changed into the gray oxide is active, and, as the amount of alkaline juice in MERCURY. 253 the intestine is small, only a minor part of a large dose of calomel acts, the major portion escaping unchanged. This is the reason that bicarbonate of sodium is added to calomel powders, to aid the intes- tinal juice in the reduction of the salt. If purgation does not occur after a dose of calomel, a saline purge may be given at the end of tAventy-four hours, and this must ahvays be used if large doses of the mercurial are employed, to avoid possible mercurialization. Mercury in the form of calomel is very largel}T used hypodermic- ally, being held in solution by a mucilage, or, better still, by fluid cosmoline. Best of all, however, is the employment of chloride of sodium in water Avith the calomel, in the proportion of 5 parts each to 50 parts of Avater. It should be injected deeply into the tissues, not immediately underneath the skin, the greatest cleanliness being necessary to avoid abscesses. The best place for these injections is in the fold of the buttocks, but sloughing, tetanus, and even gan- grene, has folloAved its employment in this Avay. (See also Salicylate of Mercury and Bichloride of Mercury.) In dysentery of the acute form calomel and ipecac are the two best remedies. (See Dysentery and Ipecac.) The calomel should be given in small doses, repeated every hour or half-hour until a favor- able change in the number and character of the stools appears. Cal- omel is not to be used if great asthenia complicates the disease. In children A\ho seem constantly " under the weather " and never quite Avell, Avho have flatulence, fetid breath, and ill-smelling, pasty stools, calomel often gives great relief in the dose of fa of a grain (0.003) every half-hour until four doses are taken, this treatment being pursued eArery fourth or fifth morning. In jaundice due to exposure to cold and to slight hepatic conges- tion l of a grain (0.01) of calomel every half-hour until J grain (0.03) is taken Avill often bring relief. Calomel is generally prescribed in conjunction Avith sugar of milk, Avhite sugar, or bicarbonate of sodium, Avhich are added to increase the bulk and Avieldiness of the powder, and, in the case of the latter ingredient, to increase its activity. OAving to its lack of taste, calo- mel is often placed on the tongue in children, but in this instance white sugar is to be used in small quantity, as the other vehicles are less agreeable. The most agreeable form of administration is in triturates. It is important to remember that calomel, Avhen used as an anti- syphilitic, produces salivation very much earlier than the other mer- curials. Sometimes calomel is of value Avhen dusted into the eye in cases of phlyctenular conjunctivitis which are strumous. This practice must not be resorted to if iodine or iodides are being taken inter- nally, as the iodine is eliminated by the tears and forms a compound which burns the conjunctiva. A very important use of calomel, and one Avhich has been brought forward very recently as new, but which is really many years old, is its employment in dropsy as a diuretic, either alone or combined with squills or digitalis, or with opium to prevent purging. The dose is 254 DRUGS. small, about 1 grain (0.05) thrice a day, and if a diuretic influence does not assert itself in forty-eight hours it should not be continued. Hoav calomel acts to produce the increased urinary Aoav under these circumstances Ave do not knoAv. Some suppose that it aids the absorp- tion of liquid from dropsical tissues, and so increases urinary secre- tion ; others think that it stimulates the renal epithelium to greater activity. The latter seems the least probable of the two, but neither theory has been proved correct, although experimentation supports the vieAv first named. The full urinary effect of the drug is not felt till the second or third day of its use, and speedily passes away, par- ticularly as purging is often induced very early. Still another use of calomel is in typhoid fever, in which disease it has been highly recommended in small repeated doses, particularly if constipation is present. In the opinion of the author this is disadvantageous as a routine measure and entirely uncalled for, although in the very early stages of the disease, Avhen the boAvels are confined and the tongue coated, a dose of 1 grain (0.05) in fourths Avith a little bicarbonate of sodium is useful. Sydney Ringer has called attention to the fact that in constipa- tion or in "biliousness" podophyllin does more good than calomel, provided that the stools are dark in color, whereas if the same signs are present, but the stools light and clayey in color, calomel is more efficient. The author has proved the correctness of this assertion so frequently that lie is convinced of its truth. Calomel has been recommended in the condition of anorexia and depression folloAving acute diseases, and Avhen the tongue is covered by a thick yelloAv coat it is the remedy for the gastro-intestinal tor- por ahvays present. While purgative doses of calomel certainly are of value, the use of freshly-prepared nitro-muriatic acid is, hoAvever, highly preferable to the mercurial salt in many such instances. Calomel is often given in small doses to "settle the stomach." Sometimes it Avill act in this way, but in other cases it will seem to increase the nausea and bring on vomiting. This is true of both adults and children, and it is impossible to tell beforehand which Avill occur. Ringer asserts that in a peculiar form of vomiting occurring in very young children, Avhich comes on immediately after the food is swalloAved, the rejection of milk being forcible, and perhaps so sudden that it is not even curdled, and Avhich is not accompanied by much straining, calomel will often give relief Avhen all other remedies fail. It should not be resorted to until some eAddences of Avasting occur, as this action of the stomach in many children only rids that organ of that part of the milk which is in excess, and is a purely physiological regurgitation. The calomel may be given in the dose of fa of a grain (0.005) every hour, or, if preferred, gray powder in the dose of l of a grain (0.02) every hour for three doses is equally efficient in these cases. Calomel will often remove syphilitic condylomata if dusted over them for some time, and an ointment made of 1 drachm (4.0) of cal- omel to 1 ounce (32.0) of lard is very useful in pruritus. Calomel ointment (Unguentum Hydrargyri Subchloridi, B. P.) is MERCURY. 255 often useful in the treatment of small patches of eczema, or the fol- lowing prescription may be given for its use: R-—Hydrarg. chlor. mit..........gr. xl (2.65). Magnesia; carbonatis.........gr. xl (2.65). Unguent, aquae rosae.........§j (30.0).—M. Gray Oil. Gray Oil is prepared as follows: 2 drachms (8.0) of lanolin is rubbed up Avith enough chloroform to emulsify it. The rubbing process is continued until most of the chloroform is evaporated, and Avhile the mixture is still in a fluid state metallic mercury in double the amount of lanolin, 4 drachms (16.0) is added and the tritu- ration continued. By this means an ointment of mercury is left Avhich equals 2 parts of mercury and 1 of lanolin. This is some- times called Strong Gray Ointment. For hypodermic injection 3 parts of this gray ointment are added to 1 part of olive oil, or it may be still further diluted by adding olive oil in the proportion of half- and-half. Of this mixture 1 to 2 minims (0.05-0.1) may be injected every second or third day. AYith some practitioners this preparation is considered much the better for hypodermic use in syphilis. Mercury -with Chalk. Mercury Avith Chalk (Hydrargyrum cum Greta, U. S. and B. P.), or Gray Powder, is slightly purgative, but is chiefly employed in the treatment of infantile syphilis, as it "will not freely purge. It is com- posed of 38 parts of mercury, 12 parts of sugar of milk, and 50 parts of prepared chalk. The dose is 1 to 10 grains (0.06-0.65). Chil- dren suffering from syphilitic marasmus seem fairly to fatten on it. This preparation is also of service in adults, and may be employed Avhenever the laxative effect of mercury is not desired. In the treatment of infantile diarrhoea Avith Avatery, colorless stools containing undigested food gray powder in small doses is often very useful. Mercury Ointment. The Ointment of Mercury, Mercurial Ointment (Unguentum Hydrargyri, U. S. and B. P.), sometimes called Blue Ointment, is made by rubbing up mercury Avith suet and lard until it is extin- guished, or, in other words, until the globules of mercury cannot be seen with a magnifying poAver of ten diameters. The ointment of mercury is used externally in certain skin affec- tions and for the purpose of influencing the general system in cases Avhere the drug cannot well be taken by the mouth. In syphilis Avhere a mercurial effect is to be reached the ointment in small amounts should be thoroughly rubbed into the skin in various parts of the body—one evening in the left groin, the next in the right groin, the next evening in the left axilla, and the fourth evening in the right 256 DR COS. axilla, beginning on the fifth evening in the left groin once more. This avoids local irritation of the skin by means of too frequent applications, places the drug on spots Avhere it is readily absorbed, and very rapidly influences the system of the patient. In infantile syphilis this method may be employed, or a flannel binder covered with the ointment may be placed about the belly. The clothes should not be changed too frequently, as their saturation with the drug aids in producing the impression upon the system, and the wearing of an undershirt saturated Avith the ointment after a feAv days' Avear is a very valuable, though someAvhat dirty, method of producing mercu- rialization. The ointment of mercury is sometimes rubbed into the skin over enlarged glands. Under the name of Oleate of Mercury (Oleatum Hydrargyri, U. S. and B. P.) a very efficient and more agreeable application than the ointment is used in the same manner or still further diluted with lard. It is made from the yellow oxide of mercury. (See Oxides of Mercury-) For pediculus pubis, or in any case Avhere parasites, such as the flea or louse, infest the region of the genitals or any spot covered by a hairy groAvth, mercurial ointment may be used as a remedy, OAving to its lethal influence over these troublesome pests. Care should be taken that it does not cause salivation of the patient, and it must not be alloAved to remain on the parts, but be wiped off in the course of an hour or tAvo or less. The folloAving Avords from the pen of Dr. Joseph Leidy are sufficiently interesting to demand a place at this juncture: u We may here say that if it is once understood that all insects, including lice, are destroyed quickly by the application of any fixed or volatile oil, physicians will see there is no necessity of employing remedies of a noxious character to the patient. The fat of mercurial ointment is probably more active than the mercurial oxide." Mercurial suppositories (Suppositoria Hydrargyri, P. B.) are used Avhen a mercurial effect is desired without the danger of interfering with the digestion. Linimentum Hydrargyri, B. P., and Emplastrum Hydrargyri, U. S. and B. P., are used for the same purposes as is the ointment of mercury. The plaster is made Avith olive oil, resin, and lead plas- ter instead of ordinary suet or lard. Nitrate of Mercury. The Solution of Mercuric Nitrate (Liquor Hydrargyri Nitratis, U. S. and B. P.), Acid Nitrate of Mercury, is an exceedingly active, penetrating caustic, so rapid in its effects that it seems to drop through the tissues. It may be employed for the removal of epitheliomato and large ivarts, and should be applied by means of a. glass rod. This treatment may also be resorted to Avith advantage in lupus until the surface of the growth is level Avith the skin. The surrounding parts should be protected by lard or oil. As this treatment is very painful, the spot should aftei-Avard be covered with flexible collodion. MERCURY. 257 Citrine Ointment (Unguentum Hydrargyri Nitratis, U. S. and B. P.) is used in chronic skin diseases of the scalp and trunk. It is too strong for ordinary use, and should be diluted one-half or less Avith lard according to the stimulating effect required ; the dilute ointment is official in the B. P. as Unguentum Hydrargyri Nitratis Dilution. Oxides of Mercury. The Yellow and Red Oxide of Mercury (Hydrargyri Oxidum Flavian, U. S. and B. P.) and Hydrargyri Oxidum Bubrum, U. S. and B. P., Red Precipitate, are used largely as a dressing for syph- ilitic sores Avhen diluted about one-half with chalk or other poAvder. If used pure, they are someAvhat caustic. From the yellow oxide is made the Oleate of Mercury (Oleatum Hydrargyri, U. S. and B. P.), which is used for the same purpose as ordinary mercurial ointment. In intestinal and gastric indigestion, with foul belching and very ill-smelling stools which are due to intestinal sepsis, the yellow oxide is sometimes given in the dose of fa to -fa of a grain (0.001-0.0012) in trituration. Red Precipitate Ointment (Unguentum Hydrargyri Oxidi Bubri, U. S. and B. P.) and the Ointment of the Yellow Oxide (Unguentum Hydrargyri Oxidi Flava, U. S.) are largely used, diluted one-half with lard, in chronic scaly skin affections, in obstinate conjunctivitis, and in granular lids. (See Styes.) They should ahvays be freshly prepared. Protiodide of Mercury. Mercury Protiodide (Hydrargyri Iodidum Flavian, U. S.) is much more mild than the biniodide, and is given for exactly the same purposes. It is very useful in chronic Bright's disease. The dose is 4; to 4/ of a grain (0.01-0.016) three times a day. (See Syphilis for method of administration.) Yellow Sulphate of Mercury. Hydrargyri Subsulphas Flavus, U. S., has been used under the name of Turpeth Mineral as an errhine in chronic ophthalmia and also as a prompt emetic in croup. It is a quick and certain emetic, and, it is claimed, does not produce depression, but the writer would recommend great care in its use. The dose for a two-year-old child is 2 to 5 grains (0.1-0.35), repeated in fifteen minutes if necessary. If as much as 5 grains (0.35) has been given, and emesis does not follow, other emetics or the stomach-pump must be used to pre- vent gastro-intestinal irritation. Yellow Wash. YelloAv AYash (Lotto Hydrargyri Flava, B. P.) is made by adding 30 grains (2.0) of corrosive sublimate to a pint Q- litre) of lime-Avater. It is used for the same purposes as the black Avash, but is much more stimulating. 17 258 DRUGS. Incompatibles.—Bichloride of mercury should never be given Avith any other substance except iodide of potassium and chloride of ammo- nium, as it is incompatible Avith almost every other drug. AYith the iodide of potassium it may be used, because the precipitate formed is at once redissolved and the resulting mixture is highly alterative. Calomel should never be given with iodides or bromides, and hydro- chloric acid may convert it into the bichloride if the acid is present in any amount. One of the best ways to employ any of the various forms of mercury is in the form of triturates, Avhich may be prepared by triturating 10 parts of the drug Avith 90 parts of milk-sugar. The minute subdi- vision of the medicament aids in its efficiency, because of its more ready absorption. METHYL BLUE. Methyl Blue or Methyl Violet is an aniline dye often sold under the name of Pyoktanin. AYhen used medicinally, it must be perfectly pure and deprived of its contaminating matter, arsenic, Avhich if pres- ent causes local irritation of the part to Avhich it is applied. Pyok- tanin Avas introduced to professional notice under this name by Still- ing as an antiseptic, but careful study has proved it to be of very feeble poAver over the groAvth of germs. In all conditions of the eye in Avhich antiseptic lotions are indicated pyoktanin has been stated to be of value, but elseAvhere in surgery it is practically useless as an antiseptic. Even in the eye it possesses, according to De SchAveinitz, a very limited range of usefulness, being no better than the older antiseptics, except in diseases of the lachrymal apparatus. The fact that pyoktanin stains everything it touches- is a great disadvantage in its use. It may be tried in blepharitis, eczema of the eyelids, con- junctivitis, both simple and phlyctenular, and in the treatment of corneal ulcer. AYhen so employed it should be applied in the strength of 1 to 1000 of water. It should be remembered that any pure aniline dye may be used in place of pyoktanin. Thus we have yelloAV pyoktanin or auranine. Methyl blue and similar aniline substances are widely employed by some persons in the treatment of malignant neoplasms. The solution (1 to 500 of Avater) should be filtered through hot asbestos to render it sterile, and every antiseptic precaution carefully adhered to in giving the injection. The dose is 1 to 3 drachms (2.0-12.0) of this solution every other day or every third day, and the injection is to be given either into the growth itself if it is large, or just at the side, in the healthy tissues, if it is small. Too much should not be injected into one spot, lest it cause a slough. This treatment does not cure the disease. It relieves pain and quiets the patient, and in rare cases stops the growth of the tumor. If the growth sloughs, complete anti- septic dressing is necessary. An antiseptic pyoktanin-gauze dressing should ahvays be used Avhile the treatment is going on. METHYLENE BLUE. 259 METHYL CHLORIDE. Methyl Chloride is a colorless gas, easily liquefied under pressure, with an odor resembling that of ether and chloroform, used to produce local anaesthesia, Avhich it does by absorbing a large amount of heat on passing from the liquid to the volatile state as it strikes the skin. It is usually kept in a small flask Avhich has its end fused into a fine point. This is broken off, and the heat of the hand volatilizes the drug, which is then forced out of the flask in a fine spray. The nozzle should be held ten to tAvelve inches from the part to be frozen. The skin of the part to be anaesthetized should be washed with soap and ether to remove all fatty substances before the spray is used. Under these circumstances the skin becomes pale in a few seconds, and afterAvard perfectly Avhite and parchment-like in appearance. Local anaesthesia is noAV complete, and minor surgical operations, such as opening boils or abscesses, can be performed Avithout pain. The spray should not be continued more than two to four minutes, as local death of the tissues may result. A great advantage of the spray of methyl over that of ether is its slight inflammability and rapidity of action. Methyl chloride is to be distinctly separated from methyl- ene chloride. The first is monochlormethane, the second dichlorme- thane. METHYLENE BLUE. Methylene Blue is to be definitely separated in the mind of the student from methyl blue, Avhich is practically Avhat is known by the trade-name " Pyoktanin." It has been employed in the treatment of malignant growths and in malarial fevers Avith asserted success, although its use in the first group of cases is decidedly problematical. AYhen used in the treat- ment of sarcoma and cancer, from \ to 2 grains (0.03-0.12) in Avatery solution are injected directly into the growth. The neoplasm, it is said, ceases to groAv, shrinks, and comes away, leaving a fairly healthy sloughing surface. This treatment is so uncertain that it should only be tried in inoperable cases. In malarial fever of the intermittent type methylene blue seems to possess very distinct curative poAvers, if we can rely on the studies of Thayer, Kasembeck, Mya, and others. It is not so powerful as quinine by any means, but has its chief sphere of usefulness in patients Avho cannot take quinine or Avhere quinine has been tried unsuccess- fully. This antimalarial influence is due to its destruction of the Plasmodium malarie, but it must be continued after the attacks have ceased and for some little time after the physician fails to find the micro-organism, as relapses are common. Untoward symptoms from its use are not common, but when they do occur consist in slight vertigo, nausea, and some strangury. The urine is ahvays blue from the elimination of the drug through the kidneys. Particularly good results seem to folloAv the use of methyl- ene blue in children suffering from malaria. The dose is 2 to 4 260 DRUGS. grains (0.1-0.2) every four hours to adults, or 1 to 2 grains (0.05-0.1) to children of five years, preferably given in capsule. METHYLENE CHLORIDE. Methylene Chloride is made from chloroform or by the action of chlorine on marsh-gas, and is a colorless liquid resembling chloroform in odor. It is readily decomposed by light, which process may be hindered by the addition of a little absolute alcohol. Therapeutics.—It is. employed as an anaesthetic in a manner like chloroform, and was introduced as a safe substitute for that drug, but it is of doubtful safety and is little used. It has been used as a spray for the production of local anaesthesia. As stated under Methyl Chloride, it is not to be confounded Avith that drug. In England, under the name of methylene chloride or methylene, a mixture of ethyl ether and methylene chloride has been Avidely employed. This preparation is, of course, to be distinguished from true methylene chloride. The amount of this mixture used to produce anaesthesia is 1 to 2 drachms (4.0-8.0) for minor and 3 to 6 drachms (12.0-24.0) for major operations. The term "methylene chloride" has also been applied to a mixture of chloroform and methyl chloride. MEZEREUM. Mezereum, U. S. (Mezerei Cortex, B. P.), is the bark of Daphne Mezereum, a plant of Asia, Europe, and Great Britain. It is sup- posed by some to be possessed of extraordinary alterative power, but this is certainly a mistake, as its influence in this line is very feeble. It is never used internally except in compound decoction of sarsa- parilla. It is distinctly irritant, and in overdose causes all the symp- toms of gastro-enteritis. Mezereum is so irritant as to have been used externally as a counter-irritant in the form of the ointment (Unguentum Mezerei). It enters into the compound syrup, fluid extract, and decoction of sarsaparilla. The official preparations of mezereum are the fluid extract (Extractum Alczerei Fluidum, U. S.) and the ethereal extract (Extractum Mezerei xEthereum, B. P.), both of which are used as external irritants. MUSK. Musk (Aloschus, U. S. and B. P.) is obtained from the preputial follicles of the musk deer of Thibet, and is a substance possessing the most remarkable penetrating powers so far as odor is concerned. Very little of the musk for sale in the shops is pure, and most of it is not musk at all. Its price varies very greatly, but if sold for less than twenty-five cents a grain it is probably Avorthless or impure. Therapeutics.—For some unknown reason musk acts as.a diffusible MUSTARD. 261 stimulant and supports the system. It is also an antispasmodic and ner\-ous sedative. In all low fevers Avhere the strength of the patient is fast ebbing aAvay and the nervous symptoms are those of the most advanced depression, rectal injections of musk in starch-water should be employed. The dose should be 5 to 10 grains (0.35-0.65). This drug is of value Avhere either nervous excitement or nervous collapse is present, but is not to be employed until it is absolutely needed to carry the patient past a crisis. If frequently employed, it loses its power and the expense is a needless one. Musk is one of the best remedies in obstinate hiccough. The dose of the tincture (Tinction Moschi, U. S.) is 30 drops to 1 drachm (2.0-4.0), and of musk itself 5 to 10 grains (0.35-0.65). MUSTARD. Mustard is official in the form of Sinapis Alba, U. S., and Sin- apis Albee Semina, B. P., or Avhite mustard, and Sinapis Nigra, U. S.. and Sinapis N'/gre Semina, B. P., or black mustard. Both of these contain an irritant oil (Oleum Sinapis Volatile, U. S.; Oleum Sinapis, B. P.) as their chief active constituent. Therapeutics.—Mustard is often used in the form of mustard flour as an emetic Avhen stirred up in Avater in the proportion of a table- spoonful to a glass of Avater. It is also employed as a counter-irritant and as a condiment. If given in excessive dose, it Avill cause violent gastritis, and chronic gastritis is often set up by its constant use. It is contraindicated internally during the existence of acute gastritis and all similar states. AYhen used as a counter-irritant mustard is applied to relieve the pain of colic due to -flatulence and acute inflammation, in muscular rheu- matism and inflamed joints, and for neuralgia, and it may be applied at the nape of the neck in cases of headache and cerebral congestion. When applied to the skin of an ordinary individual, it will produce a bad burn if left on more than a feAv minutes, and it should be mixed Avith Avheat flour in the proportion of half-and-half for tender skins. Children generally wi 11 not stand more than one-fourth mustard. The plaster should be made with warm Avater or vinegar, or a little brandy may be used. Mustard plaster (Cataplasma Sinapis) is official in the B. P. The scald or burn produced by mustard is peculiar in its slowness to heal, and in the fact that it is tender and reddened for days. If the burning of the mustard becomes excessive, it should be treated by a piece of lint soaked in lime-Avater and olive oil, half-and-half, or olive oil alone may be used. The oil of mustard is very irritant, and almost epispastic in its effects. It is given in the treatment of the atonic stomach of drunk- ards in the dose of -} to J a drop (0.016-0.03). Charta Sinapis, U. S. and B. P., or mustard-papers, are sometimes called sinapisma, and these afford a ready means of applying this counter-irritant. They are generally very strong, and should be covered by one or two 262 DRUGS. layers of old and moistened linen to prevent too great an action. (See Counter-irritation.) The compound liniment (Linimentum Sinapis Composition, U. S. and B. P.) is composed of the oil of mustard, castor oil, extract of mezereum, and alcohol. MYRRH. Myrrha, U. S. and B. P., is a gum-resin obtained from Com- miphora Myrrha, a tree of Arabia. It occurs in dark-colored tears, and contains an active principle, myrrhin. Therapeutics.—Myrrh, in medicinal amount, is a stimulant to the circulation and to the uterine and the bronchial mucous membranes. In amenorrhea due to functional inactivity, or anemia, " iron and myrrh " is a standard remedy. The tincture of myrrh, diluted one-half, is useful in ulcerated sore throat as a gargle, and the pure tincture is sometimes applied Avith a small brush or by the end of the finger to spongy or tender gums. In leucorrliea depending upon uterine trouble and in chronic cystitis myrrh is. often of service. Sometimes it enters into expec- torant mixtures given in the later stages of bronchitis. The dose of the tincture (Tinetura Alyrrhe, U. S. and B. P.) is 10 to 30 drops (0.65-2.0). It also enters into the composition of Pilule Aloes et Myrrhe, U. S. and B. P., dose two to five pills, and Tinetura Aloes et Myrrhe, U. S. and B. P., the dose of which is 1 to 2 fluidrachms (4.0-8.0). NAPHTHALIN, or NAPHTALENE. Naphthalinum, U. S., is a coal-tar derivative occurring in color- less mica-like crystals, possessing a peculiar smell, and soluble in alcohol to some slight extent. Helbing states that naphthalin Avhen pure is colorless and without action on moist litmus-paper. It should also dissolve in concentrated sulphuric acid Avithout color Avhen gently Avarmed. After it is taken for some time, or even after the first dose, the patient will state that Avhen he belches the gas has the smell and taste of burning rubber. The drug possesses distinct antiseptic power, and for this reason has been employed in certain gastric and intestinal diseases asso- ciated with fermentative changes or dependent upon ulceration and organic lesions. In fetid diarrhoea it may be given as a deodorant and cure. When given to children, as in summer diarrhea, the dose should be l to I grain (0.01-0.015) every two or four hours, but adults mav take as much as 5 to 10 grains (0.35-0.65). More than this will dis- order the stomach. The drug should be given in poAvder, in capsule, or Avith sugar. It has not been as widely employed as was expected when it first came before the profession, and certainly often fails to do good. In cats and rabbits naphthalin when administered continuously for a considerable period of time may produce cataract. NITRATE OE SILVER. 263 NAPHTOL. Naphtol (U. S.), often called Beta-naphtol, has been introduced in the U. S. P. of 1890. It is used for precisely the same purposes as naphthalin internally, and is generally artificially prepared from naphtalin. It is also used in antiseptic dressings. The dose is 2 to 5 grains (0.15-0.3). NITRATE OF POTASSIUM. Nitre (Potassii Nitras, U. S. and B. P.), or Saltpetre, occurs in long needle-like crystals and has a sharp, saline taste. Sal prunella is saltpetre melted and run into moulds. Next to the chlorate of potassium, this is the most poisonous of the potassium salts, and produces Avhen taken in overdose symptoms of violent gastro-enteritis. While it does not affect the blood, it is more irritant than the chlorate. Nitrate of potassium is rarely employed at present, and has been very properly put aside as inferior to the harmless vegetable potas- sium salts (the citrate, acetate, and bitartrate). If used in rheuma- tism, the dose should be 1 ounce (32.0) in a pint (| litre) of barley- Avater or syrup of acacia and Avater, to be taken in divided doses of a tablespoonful every three hours. Nitrate-of-potassium papers (Charta Potassii Nitratis, U. S.) are made by dipping unsized paper in a solution of the drug of the strength of 20 parts of the salt to HO parts of distilled water. They are rolled into cigarettes and smoked by asthmatics, or burned in a pan and the fumes arising from them inhaled. J. Solis-Cohen thinks that asthmatics are more benefited by smok- ing nitrate-of-potassium papers than by any other remedy. The paper should be medium thin bibulous paper. If too thick, it gives off too much heat and gas; if too thin, it does not hold enough of the drug. NITRATE OP SILVER. Nitrate of Silver (Argenti Nitras, U. S. and B. P.) is a heavy, crystalline salt of silver readily soluble in its own weight of Avater. It is official as the pure nitrate (Argenti Nitras, U. S. and B. P.) and as the sticks or fused rolls (Argenti Nitras Fusus, U. S.), or lunar caustic. The latter are never used in medicine internally, only the crystals being employed. Applied to the tissues of the body or other substances, it causes a broAvn and finally a black stain, Avhich is due to the formation of an oxide of silver. Physiological Action.—Nitrate of silver is one of the feAv astrin- gent substances Avhich are applicable to inflamed mucous membranes, as it is, Avith lead, bismuth, and zinc, one of the feAv drugs of the class Avhich is not irritant as well as astringent. Locally applied, it acts in pure form as a powerful caustic, Avhich is, however, very 264 DRUGS. superficial indeed, as the drug coagulates the albumin Avith Avhich it comes in contact and thereby forms a coat Avhich protects the tissues beneath. The action of the drug upon the circulation, respiration, and sim- ilar vital functions is only partly knoAvn, and has no relation to its employment in medicine. Nitrate of silver is eliminated from the system very sloAvly indeed. Poisoning.—Almost immediately after the ingestion of a poisonous dose of nitrate of silver violent pain in the belly, with vomiting and purging, comes on. At the same time evidences of widespread gas- tro-enteritis develop. The abdominal Avails are knotted and hard, and perhaps scaphoid. The face is anxious and livid and covered with a sweat. AYhen the vomiting occurs the ejecta are seen to be broAvn or blackish, or even white and curdy. The lips are stained Avhite, then broAvn, then black. In some cases the nervous symptoms are severe and convulsions Avith delirium may occur. The convulsions are epileptiform. Death ensues either from gastro-enteritis or from centric respiratory failure, accompanied by a profuse exudation of liquid mucus into the bronchial tubes. The treatment consists in the use of common salt, Avhich is the chemical antidote, the employment of opium and oils to allay irrita- tion, and in the ingestion of large draughts of milk and of soap and Avater for the purpose of diluting the poison and protecting the mucous membranes of the oesophagus and stomach from the action of the irri- tant. The bodily heat must be maintained. Chronic Poisoning.—This is a form of poisoning quite frequently seen. The most prominent symptom is the pale slate-blue color of the skin, which causes the indmdual to be most livid and death-like in appearance. Argyria, as chronic silver poisoning is called, is caused by the continued employment of the drug until it is deposited in the tissues. It is then found in every part of the body. The first signs of dis- coloration can generally be seen in a darkening of the conjunctiva over the sclerotic coat of the eye or in a dark line on the inner part of the lips. The treatment of argyria is not hopeful so far as the color of the skin is concerned, but it may be improved by the use of iodide of potassium to aid in the elimination of the poison. Therapeutics.—Internally, this salt is used as a cure for gastric ulcer, and it is certainly the best remedy Ave possess if combined with extract of hyoscyamus or opium in pill form. In chronic gastric catarrh and gastritis nitrate of silver is very useful when the patient is troubled with sour eructations or when vomiting occurs after meals. AYhen used in these states it should be given in i- to |-grain (0.01- 0.16) doses, half to one hour before each meal, in order that the stomach may be exposed to its effects and not be protected bv food. In intestinal ulceration the drug has been highly recommended by Dr. Pepper, and under these circumstances should be given in hard or keratin-coated pills, in order that it may escape through the stom- ach Avithout being chemically changed. In ulceration of the cecum NITRATE OF SILVER. 265 and rectum and in acute and chronic dysentery the disease should be attacked by rectal or colon injections of nitrate of silver. If the caecum is involved, the solution must be in large quantity in order to reach the part affected, but if the rectum is diseased, the amount of liquid injected should not exceed 4 ounces, the bowel in either case being Avashed out beforehand by warm Avater to rid it of faeces. Soap and Avater and salt and water must not be used for this purpose, as thfe soap which remains in the boAvel will prevent the silver salt from acting. The strength of the solution employed should be 1 drachm to 3 pints (4.0 : 1500 cc.) of Avater in caecal trouble, and 3 grains (0.18) to each 4 ounces (128.0) in rectal trouble. If the latter con- dition is very obstinate and chronic, the strength may be raised to 5 grains (0.3) to each 4 ounces (128.0). ATheneArer nitrate-of-silver injections are used in this way, a solu- tion of salt and Avater should be made, ready for use, and injected if the action is too severe or as soon as it is thought that the drug has acted Avith sufficient thoroughness. Nitrate of silver is the only remedy of any value in idiopathic anterior and posterior spinal sclerosis, but often fails. Nitrate of silver has been largely used in epilepsy and chorea, but is noAV seldom so employed, and does little good in most cases. Dr. AYilliam Pepper speaks highly of the continual administration of nitrate of silver in pill form in the dose of \ to \ grain (0.01- 0.015) through the entire attack of typhoid fever, and believes it greatly modifies the severity of the disease. Externally, nitrate of silver is used for many purposes, and will often prevent the pitting of small-pox if on the fourth or fifth day the vesicles are punctured by a needle dipped in a solution of nitrate of silver in the strength of 20 grains (1.3) to the ounce (32.0) of water. Others simply paint the skin over the eruption with a solution of 5 to 1" grains (0.35-0.65) to the ounce, claiming that this method is equally effective and prevents inflammation and sup- puration. Higginbottom has highly recommended the use of nitrate of silver over erysipelatous inflammations, but the practice is not often resorted to, and is now supplanted by better measures. (See Erysipelas.) In other inflammations of a superficial character nitrate of silver is of great value. Painted in strong solution over the scrotum in the early stages of orchitis or epididymitis, it will often relieve the pain and swelling, and felons can sometimes be aborted by its early application over the surface of the finger. In all inflammations of the pharynx, larynx, fauces, and mouth solutions of silver nitrate are to be used in varying strength. Some- times after slight exposure to cold or dampness the posterior wall of the pharynx suddenly becomes sore and raw, feeling as if the mucous membrane had been scarified. A solution of nitrate of silver Avill relieve this, and if it is employed in the strength of 60 grains (4.0) to the ounce (32.0) of Avater, the application will be more efficacious and less painful than if Aveaker solutions are employed. In laryngeal phthisis a spray used from an atomizer in the strength 266 DRUGS. of \ to 2 grains (0.03-0.1) to the ounce (32.0) of Avater may do good service. In whooping cough Ringer recommends the use of a spray in the strength given above for the purpose of relieving the cough in its vio- lence and frequency and of obtaining a good night's rest. The appli- cations should be made when the stomach is empty, as they are apt to bring on retching. The end of the atomizer must be Avithin the mouth or the skin of the face Avill be stained. • In the later subacute stages of gonorrhea an injection of nitrate of silver of the strength of 2 to 4 grains (0.1-0.25) to the ounce (32.0) is very useful. In uterine ulceration and in leucorrhea Avhen the cervix is boggy and tender, the application of the. solid nitrate-of-silver stick is of service. Its use is often folloAved by headache about the vertex, and this in turn is to be relieved by 10-grain (0.65) doses of the bromides. In pruritus pudendi vel ani and vulve a solution of 4 to 6 grains (0.25-0.40) to the ounce (32.0) should be painted with a camel's-hair brush over the parts to relieve the itching. The application is to be made from two to four times a day. Bed-sores may be aborted if, as soon as the skin reddens, a solu- tion of nitrate of silver of the strength of 20 grains (1.3) to the ounce (32.0) is applied with a brush to the part. This measure fails in paralytics. Boils which begin in a small limited papule Avith a surrounding area of inflammation may be aborted by the use of a strong solution of this salt. In granular lids, conjunctivitis, and similar affections about the eye nitrate of silver in stick form or in solution is largely and success- fully employed. (See Conjunctivitis.) When it is desired to remove nitrate-of-silver stains, they should be washed Avith a solution made of cyanide of potassium 24; drachms (10.0), iodine 15 grains (1.0), and water 3 ounces (96.0). Administration.—The dose of nitrate of silver is 1 to \ of a grain (0.01-0.015) in pill form. Mitigated caustic, or diluted nitrate of silver (Argenti Nitras Dilutus, U. S. ; Argenti et Potassii Nitras, B. P.), is composed of equal parts of nitrate of silver and potassium nitrate, and is used as a mild caustic. The drug when given continuously should be discontinued for four or five days at the end of the third Aveek, as it is so sloAvly eliminated as to accumulate in the body and cause argyria. NITRIC ACID. Nitric Acid (Acidum Nitricum, U. S. and B. P.), the strongest and most corrosive of the mineral acids, is a clear liquid, becoming slightly yellow with age, which acts, when in pure form, upon the tissues of the body as a powerful caustic. It should be kept in dark, glass-stoppered bottles. Applied to the mucous membranes, well diluted, it acts as an irritant or astringent, and Avhen taken internally NITRIC ACID. 267 exerts a stimulating influence over the secretory glands of the stomach and small intestines. It does not tend to relax the boAvels, as does nitro-hydrochloric acid. Poisoning.—AYhen nitric acid is taken in concentrated form it pro- duces a Avidespread gastro-enteritis, great pain in the mouth, oesoph- agus, and abdomen, and finally death, from the inflammation induced or from collapse. If the patient survives the acute stages, he may die from secondary changes in the stomach and boAvels, such as stric- ture or destruction of the peptic tubules. The stain made by the acid about the mouth and clothes is deep lemon-yellow. Renal irritation is often a severe symptom, and the passages from the boAvels and the urine may be bloody. The antidotes are any alkali of a mild type, as magnesium, chalk, or AvhiteAvash from the Avails of the room, the use of oils and opium to relieve irritation, and the proper maintenance of bodily heat. Therapeutics.—Nitric acid is used externally in medicine as a caustic for chancres and chancroids, the surrounding tissues being protected by oils or ointments. It may also be used on warts, in cases of gangrene to destroy the tissues, and on phagedenic ulcers. AYhenever the acid is to be applied for such purposes, a solution of soap and Avater should be at hand to neutralize its effects as soon as it has acted deeply enough. Nitric acid is also used externally in a dilute form, 5 to 30 drops (0.35- 0.65) to the ounce, as a stimulant and astringent to indolent ulcers. Internally, nitric acid is used as a tonic and astringent. In the oxalic-acid diathesis Avhen oxaluria is present, nitric acid will give relief Avhen nitro-muriatic acid cannot be obtained, although the latter is far preferable. AYhen small ulcers exist in the mouth or stomatitis is present, 3 drops (0.25) of nitric acid at a dose, in water, wdll often be of service, but it should be taken through a tube to protect the teeth. In gastric indigestion in Avhich, soon after a meal, sour food regurgitates into the mouth, a few drops of nitric acid will often give relief. In intestinal dyspepsia coming on some hours after meals, and in Avhich not only discomfort but pain may be felt in the hypochon- drium, nitric acid Avith some simple bitter tonic is most efficient, and it will often cure the green diarrhea of children, particularly in the summer, bringing about these changes not only by its astringent poAver, but also by its stimulating effect on the intestinal glands. Combined Avith some good pepsin, it will give relief in the chronic diarrhoea of children associated Avith lientery, and in Avhich the stools may be pasty or watery and at the same time ill-smelling. Ringer recommends the employment of nitric acid in the treat- ment of piles. The strong acid should be used, and simply touched to one or tAvo points, not SAvept over the Avhole surface. The pain is very slight, or none at all may be felt. A slough results, and finally comes away, leaving a cicatrix which as it contracts diminishes the size of the pile. The same author also states that a lotion of dilute nitric acid in the proportion of \ to 1 drachm (2.0-4.0) to a pint (500 cc.) of water is of service in bleeding hemorrhoids, arresting the bleeding, con- 268 DRUGS. stringing the parts, and relieving the sensation of weight and fulness so often a pressing symptom. The dose of dilute nitric acid (Acidum Nitricum Dilution, U. S. andB. P.) is 3 to 15 drops (0.25-1.0), well diluted, and taken through a tube to protect the teeth. NITRITE OF POTASSIUM. Nitrite of Potassium is a salt used largely in modern medicine to take the place of nitrite of amyl, but it possesses greater stability, and is, therefore, more permanent in its effects. It is used for the relief of angina pectoris or heart-pang, in the treatment of gastralgia, and even in epilepsy. The dose is from 3 to 5 grains (0.25-0.3), although much larger doses have been employed. These larger doses are, how- ever, not devoid of danger. Nitrite of potassium is eliminated by the lungs and by the kidneys as a nitrate. Cobalto-nitrite of Potassium. This preparation has been suggested and tried successfully as a sub- stitute for the nitrite of potassium. As it is a more stable compound, it is less rapidly broken up in the system, and so exercises a more pro- longed influence. For this reason it does not act so vigorously or suddenly, which is a great advantage in some cases. Its use is iden- tical Avith that of the rest of the nitrite group. The dose of cobalto- nitrite of potassium is 4y grain (0.03) every three hours. NITRO-GLYCERIN. Nitro-glycerin is a compound Avhich, in its pure state, is used largely as an explosive, but it is employed in medicine in a dilute form as a useful drug in those instances where a someAvhat rapid and powerful effect is to be exercised over the vascular system. Its physiological action is identical Avith that of the other nitrites, such as the amyl nitrite, except that it is not so fugacious as the latter, nor so persistent in its effects as the nitrites of sodium and potassium. The dose is 1 to 2 drops (0.06-0.12) of a 1 per cent, solution in a little water or in a pill, and no more than this may be employed at one dose unless the patient takes the remedy for a considerable period of time, Avhen as much as 60 drops may be administered. Often good results are only obtained by giving ascending doses. It is noteworthy that patients rapidly become immune to the drug, and Reading has recorded a case in which, after a year of treatment, 1 drachm (4.0) of a 10 per cent, solution Avas taken daily Avith good effect. The drug is largely employed in angina pectoris, and sometimes in epilepsy and chorea and in gastralgia. DaCosta and others have highly recommended this drug in the treatment of chronic parenchymatous nephritis, as it very distinctly decreases the escape of albumin from the kidneys. In NITRO-HYDROCHLORIC ACID. 269 interstitial nephritis, Avith cardiac disturbance resulting from the renal changes, in Avhich there is a marked increase in arterial pres- sure, so that auscultation reveals at the second right costal cartilage an accentuated second sound due to the forcible closure of the aortic leaflets, nitro-glycerin often produces a good effect by reducing the pressure and relieving the heart of strain. AYhen attacks of angina pectoris seem to be accompanied or preceded by marked vascular spasm, nitro-glycerin is also indicated. In cases of asthma dependent upon engorgement of the mucous membranes of the bronchial tubes it is very serviceable. Humphreys asserts that nitro-glycerin is a most valuable drug in vomiting of all kinds, except that of pregnancy and peritonitis. The solution used in medicine is too weak to be explo- sive. Tablets of nitro-glycerin (Tabdie Nitro-glycerini, B. P.) each contain yl^ of a grain (0.0006). Nitro-glycerin is sometimes called trinitrine or glonoin. The U. S. P. of 1890 has introduced a Spiritus Glonoini, Avhich is an alcoholic solution of glonoin. It should be kept in tightly-stoppered tins, never in glass, and be stored in a cool place, away from heat. Its explosiveness is in direct ratio to the eAraporation of its alcohol. The dose of the spirit is the same as that of the watery solution—namely, 1 to 2 drops (0.05-0.1). The watery solution is not explosive. NITRO-HYDROCHLORIC ACID. Nitro-hydrochloric Acid (Acidum Nitro-hydrochloricum, U. S.) is a liquid giving off a distinct odor, and possessed of a very caustic poAver, staining the tissues of the body a light yellow. It is official in the form of the dilute acid (Acidum Nitro-hydrochloricum Dilution, U. S. and B. P.) Avhich is often lemon-yellow, in Avhich case it is useless except as an ordinary acid. When Ave Avish to use the acid for its own peculiar effects, the official dilute acid ought ahvays to be sup- planted by the freshly mixed strong acid and be of an orange color. If this cannot be obtained, the physician should prepare the compound for himself by adding 4 parts of medicinally pure nitric acid to 16 parts of hydrochloric acid, and alloAving the mixture to stand in an open bottle until the fumes are no longer given off in excess, when it must be tightly corked and kept in a dark place. This acid ought to be freshly prepared every few days. Poisoning.—The symptoms caused by poisonous doses are those of violent gastro-enteritis Avith vomiting and purging of bloody matters. Death may occur from perforation of the alimentary canal, from inflammation of the abdominal viscera, and from destruction of the peptic tubules or constrictions of the oesophagus or bowel. The treat- ment consists in the use of alkalies, such as magnesium, lime, white- Avash, soap, and oils, with opium to allay irritation. The use of external heat to prevent collapse is also to be resorted to. Therapeutics.—Nitro-hydrochloric acid is an invaluable remedy in many cases of indigestion arising either in the stomach or boAvels, as it acts as a tonic and stimulant to secretion. Upon the biliary flow 270 DRUGS its action is quite marked, and it may even cause bilious purging if pushed to any extent. It is therefore largely used in hepatic torpor, either acute or chronic, and in the early stages of hepatic cirrhosis should ahvays be resorted to. In the chronic hepatitis of hot climates it is exceedingly useful, but it is not to be employed in acute sthenic hepatitis, as it is a stimulant to the liver, Avhich, under these condi- tions, needs quieting. When used in chronic hepatitis it should be given in full dose and pushed to its physiological limit, as evidenced by the bilious purging produced or by signs of gastro-intestinal irri- tation. A useful additional means for obtaining the beneficial effects of this acid is to use it by means of the foot-bath or general bath. As used by Johnson in India, the acid for this bath is prepared by slowly and carefully adding together 2 parts of nitric acid, 3 parts of hydro- chloric acid, and after tAventy minutes mix carefully Avith these dis- tilled water 5 parts. For the general bath (in a wrooden tub) take 5 pailfuls of Avater, 64 fluidounces (2 litres +) of the acid mixture, and enough boiling Avater to raise the temperature to 98°. Keep the patient in the bath tAventy minutes. Then rub him thoroughly with Avarm towels and place him in a dry, warm bed. For the foot-bath add 6 ounces (180.0) of the acid to 2 gallons (7 litres) of water at 98°, and bathe the thighs and calves of the legs for tAventy minutes Avith a sponge Avet Avith the mixture. This is a very useful treatment, according to Stille, for cases of alcoholic hepatic torpor. If in either case the skin becomes irritated less acid is to be used. In ordinary so-called biliousness, which is not biliousness, but intestinal indigestion, this acid is often of great service. (See Indi- gestion and Biliousness.) It is also of value in dysenteric diarrhoea where the dysentery rests upon defective secretory action on the part of the glands Avhich pour out the proper fluids for digestion. In chronic diarrhea its persistent use for a week or tAvo should be tried. * Administration.—The strong freshly-mixed acid should be given to the adult in the dose of 1 to 3 drops (0.05-0.18) three times a day, Avell diluted, and taken through a tube after meals. If the patient is intelligent, he should be ordered J ounce (16.0) of the pure acid and told hoAv to drop it. If he is not, the physician must order it partly or entirely diluted in the prescription, and in so small an amount that it may be renewed before it loses any of its powrer. AYarning should be given of its effects on any clothes with Avhich it may come in contact, and care should be taken that the bottle is held some dis- tance aAvay from the face when the cork is AvithdraAvn, as the acid, if it is fresh, may spurt out and burn the eyes and face. NITROUS OXIDE. This gas is obtained by a complicated process Avhich requires the use of such cumbersome apparatus that its manufacture is out of the question for the ordinary practitioner of medicine, while the fact that XUTMEG. 271 several large firms prepare the gas and sell it in cylinders ready for use renders its preparation on a small scale unnecessary. The gas is devoid of odor, but pbssesses a slightly SAveet taste. Physiological Action.—OAving to the symptoms sometimes produced in patients inhaling this gas, it has received the popular name of |'laughing gas," but a condition of hilarity is rarely seen Avhen the inhalations are full and deep, and only comes on in the majority of cases Avhere the gas is taken in small amounts or very slowly. AYhen used properly, the patient is directed to take long deep inspirations from the tube placed in the mouth, the nose being held so that the nostrils are closed. Under these circumstances the face becomes for a moment flushed, then of a deadly pallor, and finally the jaAV drops if the effect is very great. At this time anaesthesia is complete and the operation is to be rapidly performed. According to the most recent studies upon this gas (AYood and Cerna), it causes at first a rise of arterial pressure, followed by a fall if the asphyxia caused by its inhalation is very severe. The anaes- thesia is probably chiefly due to the non-oxygenation of the blood during the time the gas is in this fluid, or, in other words, it is largely due to asphyxiation. It has been thought that the use of this drug produces temporary glycosuria, but recent studies render this doubt- ful, to say the least. AYhere permanent glycosuria has been pro- duced, some injury to the vascular system in the region of the dia- betic centre in the floor of the fourth ventricle has in all probability occurred. The gas ought not to be given to those Avho are advanced in years or have atheromatous blood-vessels, since the rise of arterial pressure consequent upon the asphyxia may rupture a cerebral blood- vessel and thereby cause an apoplexy. Nitrous oxide gas Avhen inhaled very rarely produces any disagreeable after-effects, save a little light-headed sensation or dizziness for a feAv hours. Therapeutics.—Nitrous oxide is a useful anaesthetic in all minor operations, such as opening an abscess, boil, or felon, or even ampu- tating a thumb. It possesses two disadvantages, the first of Avhich is its brevity of action, since its continued administration is dangerous; the other, the difficulty in carrying it about from place to place. It possesses a great advantage in almost absolute safety, very few deaths having been caused by it directly. It is the safest of all anaesthetics, not even excepting cocaine, Avhich latter drug has largely supplanted the gas for many minor surgical operations. AYhen teeth are to be extracted, a plug or cork is placed betAveen the jaws before the gas is given, to keep them apart. Under these circumstances the cork should ahvays be attached to a string, so that if it slips into the back part of the mouth it may be AvithdraAvn before it chokes the patient to death. NUTMEG. Myristiea, U. S. and B. P., or Nutmeg, is the kernel of the seed of Myristiea Fragraus, an East and A\7est Indian plant, mace being the outside covering of the same. Nutmeg is a soporific and nervous 272 DRUGS. sedative, exercising a peculiar influence over the cerebrum. It is also used as a flavoring substance in somnifacient mixtures, and is of value in prescriptions for serous diarrhoea. The oil (Oleum Myris- ticee, U. S. and B. P.) is given in the dose of 1 to 3 drops (0.05- 0.15). The spirit or essence (Spiritus Myristice, U. S. and B. P.) is used in the dose of 1 to 2 fluidrachms (4.0-8.0). Several cases of poisoning by nutmeg are reported, the most recent by Dr. Reading of Woodbury, N. J. The symptoms closely resem- ble those produced by excessive doses of cannabis indica. NUX VOMICA. Nux Vomica ( U. S. and B. P.) is the seeds or beans of the Strych- nos Nux-vomica, an East Indian tree. It contains two alkaloids, strychnine and brucine, and depends largely for its medicinal poAver on the former. For this reason the statements made in regard to the physiological action of strychnine may practically be considered as applicable to the entire drug. Physiological Action.—AYhen strychnine is given to man or the loAver animals in full medicinal dose it increases reflex activity, res- piratory rate, pulse-force, arterial pressure, acuity of vision and hear- ing, and causes general systemic irritation or excitement. Nervous System.—On the nervous system strychnine exerts its chief influence. It excites the spinal cord in its motor tracts, and probably increases the receptive activity of the sensory centres. It also has some slight influence in increasing the conductive power of the motor and sensory nerves. In overdose strychnine produces spinal or tetanic convulsions by an action exerted on the spinal cord. AAThen enormous doses are given intravenously, total paralysis, resembling that caused by curare, precedes the convulsions, and if. artificial respiration is not used the animal dies from failure of respiration. If death takes place from the effects of the drug, the motor neiwes are found to be depressed, partly as the result of the poisonous action of the strychnine, and partly as the result of the exhaustion of the nerve-trunks by the con- vulsing impulses which they have carried. Circulation.—Nux vomica increases the force of the pulse-beat and the pulse-rate by a stimulation of the heart-muscle and its gan- glia, Avhile the rise of arterial pressure which it causes is due to stimulation of the vasomotor centre. If very poisonous doses are injected intravenously, a fall of arterial pressure occurs instead of a rise, Avhich is due to vasomotor depression and paralysis. Respiration.—Strychnine is one of the most constant and pow- erful stimulants to the respiratory centre that we have, and it not only increases the rate, but the respiratory capacity. Temperature.—Ordinary doses have no effect upon temperature, but poisonous doses may raise it by reason of the convulsions. Elimination.—Strychnine is eliminated from the body by the NUX VOMICA. 273 kidneys as strychnine and strychnic acid. Most of it is oxidized and destroyed by the liver. Poisoning.—AYhen a poisonous dose of strychnine is taken, it acts either suddenly or gradually. If suddenly, the man or animal may be, Avithout any premonition, throAvn several feet and become rigid by contraction of his muscles. If the onset is gradual, some stiffness at the back of the neck and uneasy startings may precede the general nerve-storm. The convul- sions are tetanic, or, in other Avords, tonic, and the body is thrown into opisthotonos; that is, resting on the head and heels at each con- vulsion. Sometimes the trunk is tAvisted sideways or Avith the back in the air (emprosthotonos). The eyes are open and fixed, the corners of the mouth draAvn back into risus sardonic us, and respiration during a severe convulsion is impossible, OAving to the respiratory muscles being in a state of tetanic rigidity. The slightest noise, draught of air, or touch may cause a convul- sion or convulsion after convulsion, because the sensory impulse, reaching the spinal cord, causes a spasmodic motor impulse to be sent out to the muscles. The convulsions are not absolutely continuous, but periods of utter or partial relaxation occur, during wrhich the patient breathes easily. The cramp-like contractions of the muscles are exceedingly painful, and the patient either dies of cramp asphyxia—that is, through fail- ure of respiration because his chest-muscles are locked in spasm— or, much more rarely, from exhaustion. Reichert has shown that it requires five hundred times the ordinary fatal dose of strychnine to cause death if artificial respiration is properly maintained. Treatment of Poisoning.—The attendant should give at once, if no symptoms have yet appeared, inhalations of nitrite of amyl, and mean- while employ the stomach-pump, using the nitrite to prevent any con- vulsive tendencies during the operation. Draughts of Avater contain- ing tannic acid, as the chemical antidote, are to be administered, and after the stomach is Avashed out 60 grains (4.0) of bromide of potas- sium and 20 grains (1.3) of chloral in solution are to be given. These are the physiological antidotes, for the bromide of potassium depresses the sensory side of the spinal cord, and the chloral depresses the motor tracts. If the convulsions prevent swalloAving, the patient must be chloroformed witli care, and the physiological antidotes given in starch-Avater by the rectum, muscular relaxation being maintained by the anaesthetic until the drugs are absorbed. Ether cannot be used as a relaxant, as it is too irritant and too slow. Nitrite of amyl is also a physiological antidote, but it is useless if a complete convulsive attack is present, as it cannot be inhaled if the chest is immovable. Neither can any other relaxant, such as chloroform, be used under these circumstances. These drugs should be gently given betAveen the paroxysms. If relaxation does not occur, the nitrite of amyl should be injected hypodermically. AYhile a light touch may produce a spasm, a firm, hard grasp of the limb often relieves the pain of the cramp. Sensation and con- is 274 DRUGS. sciousness are preserved in strychnine poisoning unless the asphyxia destroys them. Differential Diagnosis.—The convulsions of strychnine poisoning do not resemble epilepsy, because they are so distinctly tonic and never clonic. From tetanus strychnine poisoning is to be separated by the fact that in tetanus the locking of the jaws comes first, Avhile in strychnine poisoning it comes last. The convulsions of tetanus rarely, if ever, completely relax, Avhile those of strychnine do have periods of relaxation. There is a different history in each case—in one perhaps of an injury, as of a nail run into the foot; in the other, of a dose of poison having been swalloAved. The differential diagnosis of strychnine poisoning from hysterical convulsions is more difficult. The convulsions are rarely so persist- ently tonic in hysteria, and the peculiar expression of the hysterical face is often seen in such cases. The history of the patient, if obtain- able, will throw much light on the case and aid very materially in the separation of the tAvo conditions. As the treatment of all these states is virtually identical, the employment of the measures just suggested may be resorted to in each instance, and the diagnosis made aftenvard. Therapeutics.—Nux vomica, or its chief alkaloid strychnine, is used for several purposes in medicine. OAving to its bitter character- istics it may be employed as a simple bitter tonic or as one especially influencing the nervous system. It may also be used as a respiratory, cardiac, and ocular stimulant. In cases of functional nervous atony, or depression, strychnine does good, but in organic disease, if used during the period of acute inflammation, as after an apoplexy or in acute infantile palsy, it is distinctly harmful. Some cases of apoplexy can never take the drug Avithout a spasm coming on in the paralyzed part or parts. In acute or subacute neuritis strychnine ought never to be used in any Avay Avhatever, as the nerves are already inflamed, and are not to be still further irritated by the employment of nervous excitants. In pro- gressive lead palsy large doses of strychnine should be constantly used to stop the progress of the disease, iodide of potassium also being employed to cause the elimination of the lead. In amaurosis dependent upon the excessive use of tobacco or alco- hol strychnine is almost a specific, and in eye-strain resulting from insufficiency of the ocular muscles it does great good, curing the insuf- ficiency and improving the general condition of the muscles. Accord- ing to De SchAveinitz, the patient should use ascending doses of the tincture of nux vomica, beginning Avith 3 drops (0.15) three times a day, and increase the amount 2 drops (0.1) a dav until distinct physiological effects are produced. Sometimes 60 'drops (4.0) may be used in twenty-four hours after tolerance is reached. In pneumonia and all other acute diseases in which sudden collapse is liable to occur strychnine is of the greatest service at the time of need. Often it will pull the patient out of a sinking attack which seems certain to end in death. It should be used freely by the hypo- dermic needle, and is often improved in its effects by the addition of OPIUM. 275 T3T to tut svain (0.0004-0.0006) of atropine to each injection. (See Pneumonia and Shock.) There is no drug knoAvn Avhich is so antidotal to the effects of overdoses of chloroform as is strychnine. In cases of sudden acci- dent during the use of this anaesthetic the physician should give hypodermic or even intravenous injections of -fa grain (0.003) of strychnine as a powerful, rapidly-acting cardiac and respiratory stimulant. In dyspnea from any cause, such as that of old persons Avith win- ter cough or bronchorrhea, in emphysema, phthisis, and in idiopathic shortness of breath, strychnine is of service, and it is a valuable drug for the treatment of opium poisoning, preserving the reflexes and stimulating the respiratory centre. Strychnine is a very valuable remedy in surgical shock, and is a better antidote to opium than is belladonna. In atony of the bowels strychnine is of sendee, and it is to be added to purgative pills to avoid their depressing after-effect on the intestines. AYhere a lesion exists in the brain, strychnine may be used to keep up the nutrition of a limb Avhich is paralyzed, but if the palsy be due to disease of the trophic cells in the spinal cord, it does little good except to stimulate the remaining cells to greater effort. The folloAving prescription is a useful one in gastric and intestinal atony and in chronic bronchitis : R.—Tr. nucis vomica?........... f^j (4.0). Liq. potassii arsenitis..........f ,^ss (2.0). Aquae...............q. s. ad f ^iij (96.0).—M. S.—Teaspoonful (4.0) t. d. after meals. According to Ringer, sick headaches, due to errors in diet and Avithout much nausea, can be put aside for the day by the use of 1 drop (0.05) of the tincture of nux vomica in a teaspoonful (4.0) of water every five or ten minutes until 10 drops (0.65) are taken. Administration.—The extract of nux vomica (Extractum Nueis Vomica', U. S. and B. P.) is given in the dose of 4; to ^ of a grain (0.01-0.016); the fluid extract (Extraction Nueis Vomica? Fluidum, U. S.), in the dose of 1 to 5 drops (0.05-0.3); the tincture (Tinetura Nueis Vomice, U. S. and B. P.), in the dose of 5 to 30 drops (0.3— 2.0). Strychnine Sulphas, U. S. and B. P., is given hypodermically in the dose of -fa to 2V 0I> a grain (0.002-0.003), and by the mouth in the same amounts. In cases of severe surgical shock as much as ^ grain (0.016) may be used hypodermically. OPIUM. Opium (U. S. and B. P.) is the juice or milky exudation appear- ing on the surface of the unripe capsules of Avhite poppy or Pa paver Somniferum, a native plant of Asia, now groAvn in many other parts of the world. Good opium, according to the U. S. P., should contain at least 9 276 DRUGS. per cent, of morphine, but the powdered opium (Pulvis Ojn'i, U. S.) should contain not less than 13 or more than 15 per cent, of morphine. The chemical composition of this drug is very complex, no less than seventeen alkaloids having been obtained from it, the most important of Avhich are morphine, codeine, narcotine, thebaine, nar- ceine, papaverine, pseudomorphine, and laudanine. It also contains meconic acid and meconine. Physiological Action.—Opium, when given in full dose, produces in the loAver animals, such as the frog, violent spinal convulsions; in the dog, great increase in reflex activity; and in man, deep sleep, the spinal symptoms being in abeyance. Nervous System—Opium has a double action on the nervous system. It quiets the brain, but excites the spinal cord if given in very large doses. In the frog, which has no brain of any size, the spinal action predominates; in man, Avhose brain is proportionately larger than his spinal cord, the cerebral effect is the dominant influ- ence. In the animals betAveen the frog and man opium either pro- duces convulsions and sleep or sleep alone. If the dose is large, the spinal cord becomes depressed in all animals and the reflexes fail. The motor nerve-endings are also somewhat depressed under these circumstances, but the sensory nerves generally escape. Circulation.—Small therapeutic doses of opium have no effect upon the circulation, but large ones slow the pulse, increase its force, raise arterial pressure, and cause the respirations to become deepened and more full and at the same time a little sloAver. The sloAving of the pulse depends upon stimulation of the pneumo- gastric nerves peripherally and centri'cally ; the increase in pulse-force rests upon the stimulation of the heart-muscle and its ganglia; the rise of pressure is due to the increased heart-action and vasomotor stimulation. After poisonous doses all these changes become more marked, and finally go on into a rapid-running pulse and great depression, due to a reversal of all the influences named; the vasomotor centre is depressed, as are also the pneumogastric nerves. Respiration.—In very minute doses opium is a feeble stimulant, or at least not a depressant, to the function of respiration. In over- dose it is one of the most powerful paralyzants of the respiratory cen- tres in the medulla oblongata, causing death in this Avay. Temperature.—The bodily temperature is raised slightly by full doses and loAvered by poisonous amounts of opium. Tissue-avaste.—Opium acts as a preventive to tissue-Avaste, decreasing the elimination of urea and other results of nitrogenous breakdown. Elimination.—The drug escapes, if gh-en in excess as morphine, chiefly by Avay of the intestines and kidneys, but most of it is destroyed in the body. Experiments made by Alt and Tauber show that mor- phine is chiefly eliminated by the stomach, and that if this viscus is frequently washed out during a case of poisoning, recovery is much aided, as by this means reabsorption is prevented. Pupil.—Opium contracts the pupils by a centric stimulation of opium. 277 the oculo-motor nerves, and perhaps by depression of the sympathetic fibres. Stomach, Intestines, and Secretion.—Opium depresses the motor activity of the stomach and intestines and produces constipa- tion. It does this by stimulating the splanchnic inhibitory fibres of the intestine and thereby preventing peristalsis. In very large doses it increases peristalsis by paralyzing these fibres. Opium checks every secretion in the body except that of the skin. Acute Poisoning.—AVken opium is taken by man in overdose it causes drowsiness, deep sleep, full breathing,' a sIoav, full pulse, a Avarm, dry skin, contracted pupils, and pleasant—or, more commonly, in the Anglo-Saxon race, disagreeable—dreams or no dreams at all. Preceding this period there may be a brief one during Avhich the person feels self-satisfied and contented. The duration of this agree- able sensation only lasts a short time, and if the dose is large does not occur or at once passes off. It has been called the first stage, while the more marked symptoms just described have been grouped into a so-called second stage. During the sleep of the second stage the patient can be roused by shouting in his ear or by violent shaking, but sinks back into slumber at once on being left alone. The face is suffused and reddened, and may be finally distinctly cyanotic. Many of the symptoms resemble those of congestion of the brain. The breathing may be puffing and stertorous. AA^hen the patient is aAvakened he breathes more rapidly, and for this reason the duskiness of the face disappears and the normal hue returns. Death never occurs in the second stage of opium poisoning from the poison alone, but if a complicating disease is present death may take place at this time. The third or fatal stage emerges from the second by a process so gradual that no abrupt line of separation can be noted. The face becomes at first more cyanotic, then pale and livid ; the respirations, Avhich have been eight to ten to the minute, are noAV only four or five, and finally such prolonged pauses occur that all hope of another res- piration is lost by the attendant. AYhile the sIoav breathing is at first deep, it noAV rapidly becomes shalloAv, and muscular relaxation is present to the greatest degree. The skin, previously dry, is Avet with the SAveat of death, the patient is so deeply narcotized that nothing can arouse him, and he dies from respiratory failure, although the heart ceases almost simultaneously from the asphyxia. The pupils do not dilate in the third stage, except in the relaxation of death. Treatment of Acute Poisoning.—After employing the usual methods resorted to for the purpose of unloading the stomach, and after ghdng permanganate of potassium or tannic acid, preferably the former, as the chemical antidote, the patient should receive one or tAvo cups of strong black coffee, hot and concentrated. The heat in the liquid is useful in maintaining bodily temperature, and the caf- feine stimulates the respiratory centre and keeps the man aAvake. Coffee should be used even before any symptoms come on, in order to 278 DRUGS. put them off if possible. If atropine be at hand and the respirations are becoming very slow, -fa-^ to fa of a grain (0.0006-0.001) should be given hypodermically, but this dose should not be repeated after the respirations increase to ten or twrelve, and atropine is not a poAv- erful physiological antagonist. Strychnine is, however, much better than atropine as an antidote to opium, and should be given hypoder- mically in full dose, repeated frequently enough to keep the nervous system of the patient active and respiration intact. The pupil is no guide as to the action of atropine, as the action of these two drugs (opium and atropine) on the eye is not antagonistic. Alcoholic stimulants may be called for, and ammonia as a cardiac and respiratory stimulant may be resorted to. In the third stage heat should be applied to the trunk and extrem- ities. Much emphasis has been placed on keeping the patient awake, and it has been thought that the cause of death Avas the deep sleep. This is not so. The man must be kept awake in order that he will supplement the efforts of his depressed respiratory centres by volun- tary breathing. If he sleeps, he forgets to breathe, and sleep means death for this reason, and not because sleep in itself produces death. Besides the use of the hot strong coffee, the patient may be kept awake by lashing him Avith SAvitches or by keeping him Avalking up and down betAveen two attendants. Both of these measures are rep- rehensible if anything better can be done—the first method because it covers the patient Avith cuts and bruises, the second because it may aid in the production of death by exhaustion. If an ordinary med- ical faradic battery is at hand, the full force of the current may be alloAved to come in contact Avith the skin from tAvo small poles Avet Avith salt Avater, or, better still, the dry or wire electric brush should be SAvept over the body while the negative pole is held in the hand of the patient or pressed against his skin. This causes the most exqui- site pain in the normal individual, but if the brush is kept moving will not cause any bruises or discoloration. (See Asphyxia.) Arti- ficial respiration may be resorted to. Chronic Poisoning.—Morphine or opium Avhen taken constantly generates a habit. The person—or morphine-habitud, as he is some- times called—depends for a comfortable existence on the drug, and day by day increases his dose until the most extraordinary amounts are taken by the stomach or by means of the hypodermic needle. If the drug is withheld, a train of symptoms typifying depression or exhaustion ensues. The pulse is scarcely to be felt, horrible mental depression and melancholia come on, the miserable man or Avoman wrings his or her hands, and begs, screams, hoAvls, or yells for mor- phine, only to break doAvn and cry on being refused the customary dose. Diarrhoea of a serous type and most violent in character, with cramps in the muscles, may assert itself, and must be controlled by astringents and an active line of treatment as far as possible free from opium. (See Diarrhoea.) A characteristic symptom of chronic opium-eating is the develop- ment of the most remarkable and clever lying in previously truthful OPIUM. 279 persons. In the same breath that the patient begs the physician to cure him, and not give him another dose of morphine, he will lie to obtain the drug in a surreptitious manner, and may even have the drug in his mouth at the moment he speaks. It will often be found hidden in the seams of the clothing in small packages, and the nurse should be absolutely reliable, and for ever on the watch lest the drug be obtained by smuggling. Any sudden improvement on the part of the patient should be placed to the credit of more morphine, not to professional skill. Treatment.—The best way to treat such cases is to "taper off" the daily dose, and to decrease by a sixth or a fourth the total cus- tomary amount in each tAventy-four hours. The sudden complete AvithdraAA'al of the drug is an unnecessarily severe measure, and its withdraAval in a sloAver manner than that named is simply prolonging the treatment beyond reasonable limits. Cocaine has been used to tide over the crisis after the AvithdraAval of morphine, but too fre- quently the patient passes from opium to the cocaine, and finally to the alcohol, habit, all of AA-hich are equally bad. If the circulation flags, digitalis and strychnine may be given and the remaining symp- toms treated as common sense indicates. Sometimes paregoric is tak^n in excess, and the Avriter has seen and treated a case in Avhich over a pint of paregoric Avas taken every day% AAThen a mother is an opium-eater, the neAvborn child often suffers from collapse on the second or third day after its birth, OAving to the lack of its customary dose of opium. Therapeutics.—Opium is used for relief of five great conditions, which will be spoken of seriatim, the minor uses of the drug being considered aftenvard: Pain.—Opium, as is knoAvn to every one, is the best remedy that Ave possess for the relief of all forms of pain, except in those instances Avhere neuralgia exists. Avhen antipyrine and its felloAV-compounds exceed it in medicinal value. In one form of pain opium is not to be employed—namely, that arising from cerebral congestion and cere- britis, for it is distinctly contraindicated in these affections, as it makes them Avorse. In acute or traumatic meningitis, hoAvever, opium is of great service, either alone or combined Avith mercury in sthenic cases. In the treatment of cases of renal and hepatic colic associated Avith spasm, and in dysmenorrhea, belladonna and opium given together Avill relieve the spasm and pain, and yet so counteract each other elseAvhere in the body as to be devoid of effect upon other organs. Persons suffering from pain will ahvays bear very much larger amounts of opium than painless individuals. Insomnia.—Opium, Avhile capable of producing sleep in almost every case in Avhich it is given, save in those persons Avho by reason of idiosyncrasy are made Avakeful by it, is only to be used in those instances Avhere the sleeplessness is due to pain. If constantly used in insomnia or pain, the opium habit is rapidly contracted, and for this reason the use of the drug should be alternated Avith chloral, cannabis indica, and other soporific drugs. 280 DRUGS. In some cases chloral and morphine, when given in small doses in combination, will so act upon the brain as to produce sleep. In the insomnia of typhoid fever, opium may be used, particularly during convalescence, but it must be employed most carefully. Inflammation and Irritation.—Opium seems to possess some influence over inflammation Avhich Ave'cannot explain, and both small and large doses are particularly valuable in inflammations of serous membranes, such as peritonitis, meningitis,and pericarditis. It allays the nervous excitement and anxiety folloAving hemoptysis, and the intense unrest caused by itching skin diseases, as, for example, the irritation of small-pox. Sometimes intense irritation or inflammation produces so great an effect upon unstriped muscular fibres as to cause spasm or paralysis, as in retention of urine, cystitis, or the constipa- tion folloAving inflammation of the bowels from irritating foods; under these circumstances the employment of opium is indicated, and is usually very successful. In irritative coughs morphine given in syrup of wild-cherry bark does good in the dose of -fa to fa of a grain (0.005). Opium should rarely be employed in haemoptysis, as it increases the blood-pressure, and in this manner an increased Aoav of blood from the ruptured vessel. (See Haemoptysis.) In some cases of irritable cough due to tickling in the larynx a drachm or tAvo of paregoric added to hot Avater and the steam inhaled gives great relief. Whenever the cough is in excess of the expectoration—that is, greater than is necessary to free the lung from mucus—morphine may be given in small doses. If the lungs contain more rales after than before its use, it must be stopped, as the increase in the number of rales indicates an increase in the accumulation of mucus. In the treatment of strangury and rectal inflammation, provided they are not acute, after operation on the pelvic organs, and in cys- titis, suppositories in the strength of ^ or J. of a grain (0.016-0.03) of the watery extract of opium are very useful. In excessive vomit- ing from any cause, except it be from a previous dose of opium, enemata of deodorized laudanum 30 drops (2.0) and starch-water 4 ounces (128.0), Avith 20 grains (1.3) of bromide of sodium, will be found of value. (See Aromiting.) For sprains and bruises lead-water-and-laudanum is one of the best applications. If the skin is broken, laudanum may be used alone to relieve pain, and, by its alcohol, to act as an antiseptic. Opium is also a useful drug in the treatment of internal and external burns to relieve the pain and irritation. Over-secretion.—In serous diarrhea, diabetes insipidus and mel- litus, and in the treatment of over-secretion on the part of all secret- ing surfaces except the skin, opium may be used. It is said to decrease the amount of urine before decreasing the amount of the sugar in diabetes. HoAvever this may be, the employ- ment of morphine or codeine in diabetes is a very valuable form of treatment. The doses should be rapidly increased, as the effect is only obtained under such circumstances, and diabetic patients seem OPIUM. 281 peculiarly immune to the nervous influence of these drugs. Mor- phine is, therapeutically, the more powerful of the two Alkaloids. Neither of them, probably, cures the disease, but so modifies it as to make life bearable and happy. (See article on Diabetes, Part IAr.) Opium should not be used in mucous diarrhea until after the mucus already present is swept out of the intestinal canal bv castor oil or magnesium sulphate. Minute doses of fa to ^L 0f *a grain (0.001) of morphine will sometimes check summer diarrhoea in chil- dren at once Avhen given hypodermically. Systemic Strain.—In prolonged strain upon the system, as in great physical effort, or more frequently in old age to smooth out the cares of the remaining years of life and decrease avoitv, opium is useful. In asthenic fevers it is thought to be supportive, but its use is apt to cause so many other conditions, such as constipation, anorexia, or mental depression, that alcohol is much better for this purpose. In very advanced phthisis it is often justifiable to give enough opium to keep the patient free from pain and discomfort for the remaining hours of his life, but care must be taken that the dose does not inter- fere Avith his breathing and so hasten death. In muscular rheumatism and similar states, Avhere a ltcold" has been taken, opium in the form of Dover's poAvder will often produce a cure, particularly if employed in combination with hot drinks and a hot foot-bath. In heart disease, particularly of the mitral valves, the patient can often breathe easily only AA'hen aAvake, starting up Avhen he falls asleep and gasping for breath. It is stated by some Avriters that morphine will relieve this state and permit sleep, but that it will not be of service in aortic disease. While this may be partly true, the drug will often give great relief in all forms of cardiac dyspnea, and ought ahvays to be tried. Care should be taken that the first dose is small, as in some instances it increases the discomfort. The relief obtained is supposed to be due to cardiac stimulation by the drug, and, Avhile this is no doubt correct, other cardiac stimulants, such as digitalis, will fail when morphine succeeds. The presence of cyanosis and lividity is said to be no contraindication to the hypo- dermic use of morphine under these circumstances,, provided the dose is not unreasonably large. Administration.—Recent studies upon the action of opium and its alkaloids show that it acts in an inhibitory manner upon gastric diges- tion and absorption, decreasing the amount of hydrochloric acid in the gastric juice. Unless there is an excess of acid present, it is Avell not to give opium or morphine at meal-times, but some hours after. Opium itself is used in the form of the powder (Pulvis Opii, U. S.) in the dose of from 4 to 1 grain (0.010-0.05). The solid preparations are the deodorized opium (Opium Deodoratum, U. S.), which is deprived of its narcotine, dose J to 1 grain (0.03-0.05); the pills of opium (Pilulxe Opii, U. S.), each containing 1 grain (0.05); and the Avatery extract (Extractum Opii, U. S. and B. P.), dose \ to| a grain (0.016- 0.03). Of the liquid preparations Ave have paregoric (Tinetura Opii Camphorata, U. S.; Tinetura Camphore Composita, B. P.), dose 1 282 DRUGS. drachm to 2 tablespoonfuls (4.0-32.0); laudanum (Tinetura Opii, U. S. and B. P.), dose 10 to 30 drops (0.65-2.0); the deodorized tincture (Tinetura Opii Deodorati, U. S.), dose 10 to 30 drops (0.65- 2.0); the Vinum Opii, U. S. and B. P.—or, as it is sometimes called, Sydenham's Laudanum—dose 5 to 10 drops (0.35-0.65); and Acetum Opii, U. S., or Black Drop, dose 5 to 10 drops (0.35-0.65). Under the name of Dover's PoAvder (Pulvis Ipecacuanha' et Opii, U. S.) a powder containing 1 grain (0.05) of powdered opium, 1 grain (0.05) of powdered ipecac, and 8 grains (0.50) of sugar of milk is largely used. This is more efficacious if separated into fifths and taken in divided doses. The tincture of ipecac and opium (Tinetura Ipecacuienhe et Opii, U. S.) is given in the dose of 4 to 15 minims (0.3-1.0). All the liquid preparations of opium are 10 per cent, strong, except paregoric, Avhich is much Aveaker. The preparations of opium official in the B. P., other than those named, are—Confectio Opii, dose 5 to 20 grains (0.3-1.3); Extractum Opii Liquidum, dose 4 to 20 minims (0.3-1.3); Pulvis Opii Co in- positus, composed of opium, pepper, ginger, caraAvay-fruit, and trag- acanth, dose 2 to 5 grains (0.1-0.35); Tinetura Opii Ammoniata, dose J to 1 drachm (2.0-4.0); and Trochisci Opii (fa grain [0.006] of opium in each), dose one to four. Pilula Sapouis Composita, B. P., is purely a preparation of opium. It is sometimes necessary to give this drug to patients Avithout their knoAvledge, and it may be prescribed in this Avay, the patient not learning from the prescription the nature of the medicine. The B. P. also recognizes a liniment (Linimentum Opii) and a plaster (Emplastrum Opii) for local application, and an enema (Enema Opii), composed of 4; a drachm (2.0) of the tincture of opium and 2 ounces (64.0) of starch mucilage. Ordinary opium is apt to produce nausea and depression, as already stated, but the deodorized opium is not so apt to produce these symp- toms, since it is deprived of the narcotine found in the crude drug. The deodorized laudanum is substituted for the ordinary laudanum for the same reasons. Morphine is used to relieve pain rather than opium, because it.does not cause so much constipation, but opium is better to check diarrhoea. Paregoric is particularly useful in diar- rhoea because it contains a volatile oil and camphor. Untoward Effects.—Opium in many persons produces after its primary influence great nausea, and sometimes vomiting. The men- tal depression may be simply overAvhelming, and the very fact of having to drag out existence is a curse. These symptoms are said to be largely done aAvay with by the use of 20 grains (1.3) of bromide of potassium, Avhich must be taken at the same time as the opiate, and by employing the preparations of opium largely devoid of narcotine, such as the deodorized tincture. Haig is responsible for the assertion that, as opium frees the blood of uric acid by causing its retention in the tissues of the body, the pleasant effects are so produced, and that, the retention being cumulative, no sooner does the effect of the opiate pass off than the uric acid is set free in the blood, and as a result OPIUM. 283 depression ensues. He states that if salicylates are given wdth the opium the retention does not occur, and the unpleasant sequelae are much modified or prevented. After the untoward symptoms come on coffee and stimulants may be used. Children bear opium badly, and some children are very much more susceptible than others to its influence. One-eighth grain of morphine has caused death in an adult Avhen given hypodermically. If the drug enters a vein, the patient may give one gasp and fall back apparently dead. Sometimes the drug causes collapse, or in other cases an eruption over the body. Codeine. (See p. 159.) Morphine. Morphina, U. S. and B. P., is the chief alkaloid of opium, but owing to its insolubility is rarely used. Sulphate of Morphine (Morphine. Sulphas, U. S. and B. P.) is given in the dose of \ to J grain (0.008-0.03). either by the mouth or hypodermically. Besides the sulphate of morphine Ave have the acetate (Morphine Acetas, U. S. and B. P.) and the muriate (Mor- phinee Hydrochloras, U. S. and B. P.), both given in the dose of \ to 4 grain (0.008-0.03). In the U. S. Pharmacopoeia of 1870 a solution (Liquor Morphinee Sulphatis, B. P.), was official, dose 1 to 2 drachms (4.0-8.0), but it is no longer official and should not be called for. Magenclie's solution is sixteen times as strong as this liquor (16 grains to the ounce), and is not official. The Avords u Liquor Morphinae Sulphatis " will generally cause Magendie's solution to be dispensed in NeAV York State, and care should be taken that poisoning does not result. Pulvis Morphinee Compositus, U. S., or Tully's Powder, is given in the dose of 10 grains (0.65); troches of morphine and ipecac (Trochisci Morphinee et Ipecacuanhee, U. S.) are given one or tAvo at a time. The following additional preparations of morphine are official in the B. P. : Liquor Morphine Hydrochloratis, dose 10 to 40 minims (0.65-2.65); Tinetura Chloroformi et Morphine, dose 5 to 10 minims (0.35-D.65) ; Suppositoria Morphinee and Supposiforia Morphine cum Sapoue, each s-.ippository containing 4 grain (0.03) of morphine; Trochisci Morphinee and Trochisci Morphine et Ipecacuanha', each lozenge containing fa of a grain (0.002) of morphine, dose 1 to 4. Liquor Morphinee Acetatis is given in 20- to 40-minim (2.65) doses. Injectio Morphinee Hypodermic,,. B. P., contains 1 grain (0.05) of the acetate of morphine in each 10 minims (0.65) of water. It is said bv Alt that morphine when given hypodermically is elim- inated bv the stomach, and so causes nausea, but if the stomach be well washed out this is avoided. Incompatibles.—Morphine is incompatible with tannic or gallic acid or astringent solutions containing them, with alkalies, such as potas- 284 DRUGS. sium, sodium, and ammonium, but Avith the chloride of ammonium it is not incompatible. With tincture of chloride of iron it forms a deep red color (meconic acid). OX-GALL. Inspissated Ox-gall (Fel Boris, U. S.) is, as its name implies, dried ox-bile. It is used in medicine for the purpose of relieving certain forms of indigestion which depend upon deficient secretion of bile or which occur in persons Avho digest fats Avith difficulty. In full doses it is apt to cause some looseness of the bowels, and it may be given with this object. AYhen it is used the fact should be remem- bered that bile prevents the gastric juice from acting upon proteid or albuminous substances, shrivelling them up, and in addition so alter- ing the gastric liquids as to decrease their digestive power. AYe learn, therefore, that this drug must be administered some hours after meals as a rule, or, in other wTords, Avhen gastric digestion is ended and intestinal activity is beginning. The dose of inspissated ox-gall, Avhich is dried by evaporation from 100 to 15 parts, is 5 to 15 grains (0.35-1.0). Purified Ox-gall (Fel Boris Purification, U S.; Fel Bavin urn Purification, B. P.) is given in the same dose as the inspis- sated bile. It is made by evaporating 3 parts of pure ox-gall to 1 part, and then adding to this part an equal amount of alcohol, which constituents are mixed thoroughly, and after standing twenty-four hours the clear liquid is decanted and the residue is evaporated to a consistency capable of forming a pill. OXIDE OP ZINC. Commercial Oxide of Zinc (Zinci Oxidum Venale) is not used in medicine, but in the purified form is largely employed in the shape of Zinci Oxidum, U. S. and B. P., which is insoluble in water. In the form of the oxide-of-zinc ointment (Unguentum Zinci Oxidi, U. S. and B. P.) this drug affords one of the most generally used applica- tions in the treatment of skin diseases, burns, and sores. In all states where the surface of the skin is dry it is contraindi- cated, but where the eruption is moist it is useful. In the treatment of the chloasma of pregnancy the folloAving prescription is of service: R .—Zinci oxidi.............gr. iij (0.18). Hydrarg. ammoniat. gr. j (0.06). 3ijss (10.0). Sijss (10.0). gtt. x (0.65).—M. Olei theobroma? Olei ricini Essent. rosas S.—Apply to the face night and morning In eczema Avith many vesicles use— R.—Pulv. camphora..........Jss (2.0). Pulv. zinc, oxidi..........^ijj (12^0). Glvcerini.............gtt. xl (2.65). Adipis benzoinati..........JJj (32.0).—M. S—Apply to the part without other treatment or precede it by powdered bis- OXYGEN. 285 In poAvdered form zinc oxide is useful in the treatment of inter- trigo and in conjunctivitis. AYith bismuth subnitrate and pepsin it is largely used by some practitioners in the treatment of the summer diarrhea of infants or adults. In the night-sweats of debility or phthisis oxide of zinc in the fol- loAving formula has been highly recommended, but probably depends largely for its action on the second ingredient : R .—Zinci oxidi.............gr. xxx (2.0). Extract, belladonna?.........gr. iij (0.18).—M. Ft. in pil. No. x. S.—One at night before going to bed. BartholoAV recommends the oxide of zinc for cases of asthma and whooping cough, given to an adult in the manner just indicated. OXYGEN, OXYGEN-WATER. The gas Oxygen is noAv widely used in medical and surgical prac- tice in three forms, as follows: By the inhalation of the gas itself from a cylinder in Avhich it is compressed until 40 gallons occupy a very small space ; by drinking oxygen-Avater, Avhich is distilled Avater saturated Avith the gas; and finally, by the use of the dioxide or peroxide of hydrogen, Avhich is applied locally to diseased surfaces. (See Hydrogen Peroxide.) Inhalations of oxygen are useful in the second and third stages of pneumonia where the patient is about to die from deficient aeration of the blood, with resulting heart-distention. They are also of value in advanced bronchitis, particularly that of old persons, and for the resuscitation of persons asphyxiated by coal-gas (Hare and Martin). In phthisis and other exhausting diseases oxygen will allay dyspnoea and oppression. In the preparation of the solution of oxygen gas the Avater must be distilled, so that it may be as free as possible from other gases. The bottling should be done under a pressure of 150 to 200 pounds, and the contents draAvn off by means of a tap such as is used in siphons or for champagne bottles. Birch of England has found that the addition of a little nitrous-oxide gas to this Avater adds piquancy to its taste and increases its stimulating effects. The value of this preparation is undoubted, and Avhen taken into the body it has proved of the greatest service in chronic dyspepsia, persistent vomiting, and headaches both digestive and neuralgic. In constipation depending upon intestinal atony oxygen gas is said to give relief if it is taken in solution just before going to bed. It is hardly necessary to state that the Avater should be swalloAved as soon as possible after it is taken out of the bottle Avhich has contained it. In some cases wrhere general systemic torpor is present oxygen- Avater taken after each meal, or even more frequently, may be used Avith advantage. One or two tumblerfuls may be taken each time. 286 DRUGS. PANCREATIN AND PANCREATIC EXTRACTS. Under these names a number of firms noAV sell an extract from the pancreatic gland or juice, and the U. S. P. recognizes the name of Pancreatinum. It contains, or should contain, the four pancreatic ferments—trypsin, Avhich digests proteids (meat, eggs, etc.); steapsin, which splits up and emulsifies the fats; amylopsin, which has dia- static poAver (that is, converts starch into sugar), and finally, a milk- curdling ferment. A preparation equally useful Avith the commercial pancreatin may be made by the physician in the folloAving manner: Take the pancreas of a pig Avhich has been killed about six hours after a full meal, the organ being therefore active, and, after chopping it up finely, add to it four times its Aveight of dilute alcohol and allow it to stand for twelve hours. Decant or filter off the alcohol, and give the filtrate in the dose of 1 to 2 drachms (4.0-8.0). Or, better still, as follows : AYash and chop up finely a fresh pancreas, and allow the gland to soak in alcohol (absolute) twenty-four to forty-eight hours. After this squeeze out the alcohol and add to the gland ten times its Aveight of glycerin. This must stand forty-eight hours and then be filtered and be used in doses of 30 drops (2.0) to each glass of milk. (See Peptonized Foods.) Some doubt has been cast upon the usefulness of the employment of pancreatin in foods unless this ferment was allowed to act upon the aliment before it was SAvallowed by the patient, on the ground that pancreatin is destroyed and rendered inert in the presence of an acid. This objection is not a valid one, because food remains in the stomach for from fifteen minutes to half an hour before enough gastric juice is secreted to interfere with the pancreatic action. It is during this preliminary period that the work of the pancreatin is accomplished. PAPAIN, PAPAYOTIN, AND PAPOID. Papain, Papayotin, and Papoid are names given to a digestive fer- ment derived from the juice of Cariea Papaya. This ferment pos- sesses the power of changing proteids into peptones in the presence of an acid or an alkali, or even in a neutral mixture, thereby differ- ing from pepsin and pancreatin. This power would be of very great value, since the drug would then be useful in all forms of dyspepsia, were it not that careful experimentation renders it doubtful as to Avhether papain, papayotin, or papoid can really supplant either of the animal ferments named above. The dose of all these products is from 1 to 8 grains (0.05-0.6) in solution, or better in pill. The plant has the reputation of being capable of causing abortion. PARALDEHYDE. Paraldehydum, U. S. and B. P., is a form of aldehyde used as a soporific and nervous sedative, and is a clear, colorless liquid with an PENT A L. 287 ethereal odor and a burning, followed by a cool, taste. It should be kept in dark Avell-stoppered bottles in a cool place. Paraldehyde is readily soluble in alcohol, moderately so in water, less so in hot water. It possesses the great disadvantages of being necessarily given in large dose and having a disagreeable taste and odor. It is also very apt to disorder the stomach. Paraldehyde kills when taken in overdose by respiratory failure, but is not so depressant to the heart as is chloral. It requires frequent repetition and soon loses its power. The dose is 20 drops to 1 drachm (1.3-4.0) in capsules, or, better still, it may be used, after the formula of Yvon, as follows: R.—Paraldehyde.............^ijss (10.0). Alcoholis (90 per cent.)........£§jss (45.0). Tinctune vanillae...........f ^ss (2.0). Aquse............\ . . . fjj (32.0). Syrupi simplicis.......q. s. ad f.^iv (128.0).—M. S.—A dessertspoonful (8.0) every half-hour until sleep is obtained. PAREIRA. Pareira, U. S. (Pareiree Badix, B. P.), is the root of Chondoden- dron Tomentosum, a plant of Peru and Brazil, and is used as a diu- retic of an alterative or stimulant character and for the relief of chronic inflammations of the genito-urinary type in general, such as pyelitis, cystitis of a subacute type, and similar pathological states. The dose of the unofficial infusion is a Avineglassful (32.0), and the fluid extract (Extractum Pareiree Fluidum, U. S.) is given in the dose of a teaspoonful (4.0) three times a day. The B. P. prepara- tions of this drug are—the decoction (Decoction Parch-as), dose 1 to 2 ounces (32.0-64.0) ; the extract (Extraction Pareiree), dose 10 to 20 grains (0.65-1.3); and Extractum Pareiree Liquidum, dose 1 to 2 drachms (4.0-8.0). PENTAL. Pental is an impure amylene first described in 1844 and used in 1856. It at once dropped out of notice until a few years ago, when it was brought forAvard as an anaesthetic for use in minor or brief operations. Pental is a colorless liquid, insoluble in Avater, but read- ily mixed with ether, chloroform, or alcohol. It is very inflammable, but not affected by exposure to light and air. Physiological Action.—Our knowledge of the physiological action of pental is exceedingly limited. AYood and Cerna, from a very incomplete and imperfect study, conclude that it is a powerful cardiac and respiratory poison. Therapeutics.—Pental is to be employed by means of a Junker inhaler if its use is continued for any length of time. If it is to be taken for a few minutes, an ordinary chloroform mask or towel may be used. The quantity to be employed for the production of anaesthesia is about 2 to 3 drachms (8.0-12.0). Pental is an anaesthetic which 288 DRUGS. so far promises very little, and which will probably be used by a very limited number of practitioners, as it possesses no particular advan- tages over older and safer anaesthetics. It is, hoAvever, right to state that some surgeons employ it Avith great satisfaction. Thus Phillip asserts that it is regarded as indispensable in the Children's Hospital of Berlin, as it acts very rapidly, produces little excitement, and per- mits rapid return to consciousness. It has been given in this insti- tution one thousand times. PEPO. Pepo, U. S., Punlpkin-seed, the seed of the ordinary domestic pumpkin, is a useful and efficient vermifuge against the tape-worm. The seeds are not only efficient, but harmless to the host of the Avorm. The outer coverings of the seeds should be removed, and the remain- ing part rubbed up into an emulsion with Avater or into an electuary Avith sugar, the dose of the seed being 2 ounces (64.0). This mass should be taken on an empty stomach, and followed in from one to tAvo hours by an active purge. PEPPER. Piper, U. S., or Black Pepper (Piper Nigrum, B. P.), is the unripe fruit of Piper Nigrum, a vine of India, Java, Borneo, and Siani. It contains an alkaloid, piperine, Avhich is official. Therapeutics.—Black pepper may be used as a counter-irritant or internally as a carminative and stimulant to the alimentary canal. It may also be used in all cases of atony of the mucous membranes of the genito-urinary system, but is contraindicated Avhenever acute inflammation is present, as in acute gonorrhea. It may be used in the treatment of great flatulence Avith marked relief. Piperine (Piperinum, U. S.) has been used as an antiperiodic Avith varying success, and is given in the dose of 1 to 5 grains (0.05-0.35). The oleoresin (Oleoresina Pi peris, U. S.) is given in the dose of \ to 2 drops (0.016-0.1) in laxative pills, to prevent griping. A con- fection (Confectio Piperis) is official in the B. P., given in the dose of 1 to 2 drachms (4.0-8.0). PEPPERMINT. Mentha Piperita, U. S., is official in the form of the leaves and tops. It has an aromatic odor and taste. Locally applied, the oil acts as an irritant and local anaesthetic. From this oil is obtained menthol, a camphoraceous substance of a hot burning taste, possess- ing marked power as a local anaesthetic. (See Menthol on next page.) Therapeutics.—Peppermint is used very largely as a domestic rem- edy for flatulence and infantile colic. Sometimes the oil is added to PEPPERMINT. 289 purgative pills to prevent griping, and it may be employed to cover the taste of many medicines which are disagreeable to take. In this respect it is used as are all the volatile oils. In the colic of children of six months to a year, Avhen it is unusually severe and associated with nervous symptoms, the folloAving Avill be found of value: R — Chloralis............. gr. xvj (1.0). Potassii bromidi..........gr. xxxij (2.0). Aq. menth. piperit..........13ij (64.0).—M. S.—Teaspoonful (4.0) in a little warm water every four hours. When used in the treatment of neuralgia, oil of peppermint should lie placed on a piece of linen or muslin rag and applied over the affected spot. Care must be taken that it does not blister the skin. If, after its removal, the burning is too severe to be borne, a little cosmoline or olive oil should be applied. Oil of peppermint is sometimes placed on cotton and inserted into dental cavities for toothache. It is to be remembered that the more menthol is present in the oil the more active will it be as an anaesthetic, and that the Chinese oil contains more menthol than the American oil. Administration.—Peppermint is used in the form of the oil (Oleum Menthe Piperita', U S. and B. P.), dose 1 to 4 drops (0.05-0.25); the spirit (Spiritus Mentha} Piperita}, U. S. and B. P.), dose 10 to 30 drops (0.65-2.0); the Avater (Aqu/r Mei/the Piperita', U. S. and B. P.), dose 1 to 2 drachms (4.0-8.0); and, finally, as the Troches (Trochisci Alei/the Piperita', II. S.), to be held in the mouth in indef- inite number. Essentia Menthe Piperita', B. P., is given in the •lose of 10 to 20 minims (0.65-1.3). Menthol. Menthol, U. S., or Mint Stearopten, or, as it is sometimes called, Mint Camphor, is derived chiefly from the essential oil of peppermint. It occurs in colorless prismatic crystals with a strong odor of pepper- mint. Upon it rests much, if not all, of the therapeutic activity of peppermint. Menthol is slightly soluble in water, very soluble in alcohol, ether, and in oils. Alenthol has been used in the vomiting of pregnancy Avith great advantage in hourly doses of a teaspoonful of the folloAving: R.—Menthol...............gr. xv (1.0). Spt. frumenti..............f.^vj (24.0). Syrupi.................-fgj (32.0). Alenthol has also been used as a carminative and in gastralgia in the dose of from 1 to 2 grains (0.05-0.1) three times a day in pill or in alcoholic solution. It is contraindicated in acute inflammation of the gastric mucous membrane. As menthol exercises a local anaesthetic effect on the skin as well as on mucous membranes, it is used externally over the course of neuralgic nerves and in migraine. Menthol when used as a depletant on the mucous membranes of 19 290 DRUGS. the throat or nose causes a contraction of the local blood-vessels, Avhich is not folloAved by the excessive dilatation produced by cocaine when used for similar purposes. In acute coryza its local application to the mucous membrane by a spray or dropper is often a source of great relief in a solution of about 1 grain (0.05) to the ounce (32.0) of Avater, or, better still, 3 grains (0.25) of menthol in \ an ounce (16.0) of albolene. Another very useful method of applying menthol is by means of a simple inhaler consisting of a small glass tube of about one-quarter of an inch in diameter and tAvo and a half inches in length. Both ends are closed by a piece of gauze and tAvo perforated corks, the menthol being placed in betAveen. The air is now draAvn through this tube, and, being heavily loaded Avith the fumes, clears the nostril and relieves the stuffiness. It is not to be only smelled, but inhaled. Care should be taken that the crystals are not allowed to enter the nostril, as they are almost cauterant in poAver. Sometimes, Avhere great excoriation of the alae of the nose exists, the too persistent use of the menthol may produce small herpetic spots about the nostrils. Emplastrum Menthol, B. P., is used as a mild local irritant and anaesthetic. PEPSIN. Pepsinum, U. S. and B. P., is the digestive ferment of the gas- tric juice. That sold in the shops is generally derived from the pig, and is prepared by many persons in many Avays. Much of the pep- sin of the market contains more peptone than pepsin, and much mucus and albumin. Used Avith hydrochloric acid in weak solution, it carries out the digestive action of the stomach. Pepsin containing peptone has the peculiar musty smell of peptone, and if the peptone is in excess will absorb moisture and become sticky on exposure to the air. Therapeutics.—Pepsin is a much-overrated remedy for indigestion. Pancreatin will ahvays be found more serviceable, and should be given either immediately or one or tAvo hours after meals. Pepsin should be used immediately after the food or with it. Hydrochloric acid should ahvays be given, as its presence converts any pepsinogen in the gastric tubules into pepsin. Pepsin is official in the U. S. P. as Pepsinum and Pepsinum Sacchareitum. The dose of the latter must be 20 to 30 grains (1.3-2.0), to be of any service. It is a weak and almost useless preparation, made up chiefly of milk-sugar. Liquor Pepsini is given in the dose of 2 drachms (8.0). Pure pepsin should be given in 5- to 15-grain (0.35-1.0) doses. According to the U. S. P. of 1890 official pepsin must have the power to digest three thousand times its weight of albumin. PERMANGANATE OP POTASSIUM. Potassii Permeoiganas, U. S. and B. P., is a salt of a dark pur- plish-red color, appearing in small crystals and readily soluble in PETROL A TUM. 291 Avater. In the presence of moisture it rapidly gives up the oxygen which it contains and becomes the binoxide of manganese. By reason of this oxidizing poAver the permanganate of potassium is largely used as an antiseptic and deodorant. It should not be employed as a disinfectant, because its action is too fleeting, but in saturated solution, folloAved by oxalic-acid solution, it proves itself the best disinfectant for the hands in surgical practice. (See Antisepsis.) Permanganate of potassium is given in the same dose for amenor- rhoea as the binoxide of manganese, but is much less efficacious. It is also very apt to irritate the stomach. The permanganate is thought to be useful in dyspepsia, flatulence, lithemia, and obesity, and in the former states is certainly of service, being a destroyer of the abnormal products by oxidation. OAving to this oxidizing poAver, it has been asserted by AY eir Mitchell and Reichert to be the most efficient antidote to snake-venom if placed in the wound before the poison is absorbed. It should also be injected hypodermically about the bite. Permanganate of potassium is the best antidote in poisoning by morphine and that caused by many other vegetable alkaloids. OAving to its rapid absorption of oxygen, it acts as an antiseptic, and may be used in the Avashing of tvounds, ulcers, and sores, and as a lotion in the form of a gargle or on a SAvab in diphtheria and scarlet fever. The solution used should be from 20 to 60 grains (1.3-4.0) to the pint (4; litre); the former is used on mucous membranes, the latter for sores and Avounds. In fetid rhinitis and otitis media permanganate solution is useful as a Avash in the propor- tion of 1 grain (0.05) to the ounce (32.0). AYhen given in solution permanganate of potassium should be dissolved in distilled Avater, and it should never be mixed in a mortar Avith any organic matter, as it will explode. A solution (Liquor Potassii Permanqanas) is official in the B. P. PETROLATUM. Under the name of Petrolatum Molle, U. S., or Soft Petrola- tum, or Unguentum Petrolei, is sold a semi-solid substance derived from certain kinds of petroleum, and sometimes called (Josmoline or Araseline. OAving to its soothing poAvers and non-rancidity, it is used as an emollient dressing in sores and skin affections. It has no value except as a protective, and may be given in capsules in cases of gas- tro-intestinal irritation in any quantity as a soothing treatment. It does not affect the passages from the bowels and is not absorbed, although assertions to the contrary have been made. Cosmoline is a useful vehicle for medicines for the skin. Under the name of fluid or liquid petrolatum (Petrolatum Liepiidum, U. S.) a fluid form is sold, which is much used in the form of a spray in the treatment of rhinitis and after irritant applications to the nasal cavities. The U. S. P. noAV recognizes, in addition to these tAvo preparations, Petrolatum Spissum, which has the consistence of a cerate. 292 DRUGS. PHENACETIN, or ACETPHENETIDIN. Phenacetin (Phenacetinum, B. P.) is a coal-tar product introduced several years ago as an antipyretic of the same character as antipy- rine, and, while more apt to disintegrate the blood than the latter drug Avhen given in large amounts, is not very dangerous, because its influence upon other vital parts is not severe. AYhen this drug is carelessly made an impure product is the result, Avhich produces irritation of the kidneys, and, in consequence, causes grave complications. Reuter states that the impurity may be dis- covered by placing a small amount of chloral hydrate in a test-tube, melting it at the temperature just sufficient to liquefy it, and then adding the suspected sample of phenacetin in the proportion of one- fifth. If the phenacetin is impure, it will become purple, then red, and finally blue. Physiological Action.—Unfortunately, our knoAvledge of the phys- iological action of phenacetin upon the nervous system is not as thorough as is desirable. AYe knoAv, hoAvever, that it is a distinct nervous sedative, and that it acts particularly on the spinal cord in its sensory path. Upon the circulation the drug has little or no effect, unless given in doses far above those generally employed or continued in over- dose for some time. The blood after the ingestion of these doses becomes dark and blackish from the formation of methaemoglobin, and the urine becomes dark yelloAv and reacts with Fehling's solu- tion. Upon normal bodily heat and the heat of fever the drug exerts a depressing effect, decreasing the production and dissipation of heat. Therapeutics.—Our knowledge concerning the influence of phen- acetin upon the human body in disease may be divided into tAvo separate parts, in much the same manner that we divide antipyrine— namely, its uses as an antipyretic and as an analgesic. Like the other members of the antipyretic group which are blessed with this double action, its antipyretic influences Avere first observed, and shall therefore first be spoken of. The employment of this drug in medicine Avas first attempted bv Hinsberg and Kast, Avho from the very first spoke of it in the highest terms of praise. They found that it seldom, if ever, caused serious untoward effects, and that its power over fever, in the dose of from 3 to 8 grains (0.15-0.5), was quite extraordinary. Very shortly after the paper of these Avriters appeared Kohler published the report of its use in some fifty cases in the clinic of Bamberger of Arienna, the febrile affections being tuberculosis, pneumonia, typhoid fever, pleurisy, and several other diseases of like character. He found, as have most of his successors, that the fall of fever does not occur for nearly half an hour after the dose is taken, and that the stage of apyrexia con- tinues for from four to eight hours afterward. As a general rule, SAveating Avas not noted as being present to any great extent, but in phthisis and advanced typhoid fever there can be no doubt that chilliness and an abnormal fall of temperature may PHENA CETIN. 293 come on. Cyanosis and vomiting did not occur in a single one of Kohler's cases. In a very instructive case of pneumonia due to septic infection in a patient of tAventy years phenacetin not only lowered the fever, but in addition decreased, to a large extent, the blood in the urine, and did not in the slightest degree influence the kidneys unfavorably. That the drug has power is evidenced by the fact that Kohler used it only when the temperature reached as' high as 103°, 104°, or 105° F., and in these cases the temperature fell not less than from three to five degrees. It is a very important fact to be remembered that morning doses of phenacetin seldom have as poAverful an influence as evening doses. Two morning doses are only equal to one evening dose in most cases, and it Avould seem better in phthisis to give the drug about noon to prevent the evening exacerbation of temperature than to resort to it at a time nearer the pyrexial period. The conclusions of Kohler have been confirmed by Hoppe in a long series of studies, and this writer also points out the deleterious excess of apyrexia Avhich sometimes comes on in debilitated cases of phthisis under its use. One of the advantages of haAdng several drugs belonging to one elass is the benefit often derived from the use of one Avhere another has failed. Thus Hueber found that in several instances phenacetin Avas successful where antipyrine had not acted, and believes it to be the more poAverful drug of the tAvo—a conclusion also reached by Heusner, Avho thinks that 15 grains (1.0) of phenacetin are equal to half as much antifebrin and to 30 grains (2.0) of antipyrine. Lepine, AArho has studied with so much care the other antipyretics, also believes it to be superior to them all; and in this Guttman is largely of the same opinion. These conclusions are, in the author's belief, far too favorable, for, Avhile he has found the drug to possess poAverful antipyretic activity and to be useful in nearly all the fevers Avhere antipyrine can be employed, he does not look upon it with the same degree of con- fidence that he does the latter drug Avhen anxious to reduce a fever Avhich seems dangerous and worthy of rapid and certain reduction; neither does he believe it to be as safe as antipyrine. Upon the nervous system phenacetin acts as an antineuralgic—is » of service in migraine and ordinary headache from eye-strain, in the pains of tabes dorsalis, in intercostal neuralgia, and in rheumatism. Sometimes it cures these troubles Avhen antipyrine fails. Altogether, we may consider phenacetin a rival of antipyrine in the poAver to relieve pain. For neuralgia the following prescription may be ordered: R.—Phenacetin..........., cr. x (0.65). Cafleinse citratis...........gr. v (0.35). Sacchar. lactis............gr. xx (1.3).—M. Ft. in chart No. v. S.—One powder every two hours while pain lasts. In subacute rheumatism and in the lumbar or muscular pains of 294 DRUGS. influenza a poAvder or pill of 4 grains (0.3) of phenacetin and 5 grains (0.35) of salol given three or four times a day is most efficient. PHENOCOLL. Phenocoll is a compound closely allied to phenacetin. It is ahvays used in the form of the hydrochloride of phenocoll, which occurs in a fine white poAvder, quite soluble in Avater and forming a neutral solution. It is incompatible with alkalies. It is used as an antipyretic. Physiological Action.—A number of studies of the action of phe- nocoll hydrochloride upon the animal organism have been made by Robert and Aon Mering in Europe, and by AYood and Cerna, and Ott in America. These investigators have found that it separates itself from most of the coal-tar antipyretics in that it has little effect on the red blood-corpuscles. It does not cause as great a sweat Avhen the fever falls as do its near antipyretic relations. Von Mering has shoAvn that phenocoll has little lethal power, but Ott asserts that it kills by failure of respiration, and causes paraplegia, cyanosis, and depression of the heart in poisonous dose. Therapeutics.—AYhatever advantages further clinical experience Avill sIioav this drug to possess over its older felloAvs in the antipyretic field, it can never be Avidely used as a remedy for fever, since no drug is noAV Avidely employed for this effect except in a limited class of cases. As pointed out in the article on the treatment of Fever, antipyretic drugs are of little value as compared to bathing. Phenocoll may be given for the same purposes and under the same circumstances in the presence of fever as can antipyrin or acetanilid, but, like these drugs, is contraindicated in advanced exhausting diseases, such as consump- tion. A number of clinicians have tried phenocoll hydrochloride for the relief of rheumatism and to remove neuralgic pain, Avith asserted success. As yet it has not been used largely enough to ensure its continuance as a remedy of positive value, except in cases of malarial fever, in Avhich it seems to possess distinct remedial poAver. The dose of phenocoll hydrochloride is 5 to 8 grains (0.35-0.6) two to five * times a day. It is best given in capsule. PHOSPHATE OF SODIUM. Sodii Phosphas, U. S. and B. P., is a preparation Avhich ought never to be used to supplant phosphorus, as it has an entirely differ- ent effect. It is particularly useful in bottle-fed children, Avho continu- ally alternate between diarrhea and constipation, and is also useful in rickets. It should be added to each bottle of milk in the dose of 2 to 4 grains (0.1-0.2). Phosphate of sodium is slightly laxative. BartholoAv believes phosphate of sodium to be the best remedy that we have in hepatic cirrhosis and jaundice. To adults it should be given in the dose of 20 grains to 2 drachms (1.3-8.0) once, tAvice, or thrice a day according to the laxative effect desired. PHOSPHORUS. 295 Many cases of Avretchedness or headache due to an excess of uric acid in the blood are relieved by the phosphate of sodium or of cal- cium, since both substances cause the disappearance of the acid from the blood, not by causing its elimination, but by causing its deposit in the tissues in the form of urates. The use of these so-called acid phosphates is therefore ultimately harmful in gouty or rheumatic persons. PHOSPHIDE OP ZINC. Zinci Phosphidum, U. S., is often used in place of phosphorus, OAving to its greater stability and readiness of administration. The dose is fa of a grain (0.006) three times a day. It is used in gela- tin-coated pills. PHOSPHORIC ACID. The pure acid is very rarely employed in medicine, but when given is used in 2- to. 8-drop (0.1-0.5) doses. In the form of dilute phosphoric acid (Acidum Phosphorieum Dilution, U. S. and B. P.) it is widely employed in the dose of 20 drops to 1 drachm (1.3-4.0) as a tonic and gastric stimulant. It is not a food to the nervous sys- tem, does not resemble phosphorus in its physiological action, and is not to be employed in its place. It does good in nervous exhaustion simply by stimulating the stomach and thereby aiding the organ in the digestion of food. PHOSPHORUS. Phosphorus, U. S. and B. P., is a non-metallic element, gener- ally obtained from bones, and is very soluble in oils, less so in ether and alcohol. Its odor is very characteristic and peculiar. AYhen placed in a dark room after exposure to light it is luminous, and if exposed to the air will ignite. It should be kept in tightly-stoppered bottles under Avater. Very commonly it is contaminated by arsenic and sulphur. • Physiological Action.—Phosphorus is found in large amount, com- paratively speaking, in the bones and in the nervous system, and is a stimulant to the groAvth of both. It acts, therefore, as a direct tonic to nervous tissue and is a producer of bone. Upon tissue-Avaste the drug acts as a depressant, thereby preserving the body, as it decreases the elimination of urea and diminishes the quantity of carbonic oxide exhaled. Upon the growth of bones phosphorus has a most remarkable influence, causing, Avhen it is given to young animals, great increase in the size of these parts. The first change noted is an enlargement, which consists in a jelly-like mass containing little or no bone salts, and this is finally converted into a very hard material Avhich may fill the entire canal in the centre of the bone. Kissel has stated that this 296 DRUGS. does not occur, but his results must be doubted in vieAv of the thorough studies of A\regner. Acute and Chronic Poisoning.—AYhen phosphorus is taken in poi- sonous dose, often from the ends of matches, no symptoms may come on for eight or ten hours. At the end of that time the peculiar taste of phosphorus may be noted in the mouth, the breath is heavily laden Avith its odor, and burning pain in the oesophagus, stomach, and abdomen ensues. Vomiting and purging noAV assert themselves, and both the matters Avhich are vomited and those Avhich are passed from the boAvels may be luminous in the dark, OAving to the presence of phosphorus. The vomit at first consists of food, then mucus, then bile, and then perhaps blood. All the symptoms of a mild gastro- enteritis may develop, but it is to be noted that constipation of an obstinate type may replace the purging. Arery soon the liver increases in size, and gives rise to general hypochondriac pain and tenderness as Avell as local swelling. At the end of twenty-four hours, or per- haps after the second day, a cessation in the symptoms occurs, and, if the physician be not on his guard, this will lead him to a hopeful prognosis, but in the course of a feAv hours jaundice begins in the conjunctiva and then extends over the entire body. AYith the onset of jaundice the vomiting and pain return Avith reneAved vigor. The matters vomited are often the color of "coffee-grounds," due to exuded and altered blood. The bowels are absolutely confined, or the feAv hard masses passed are white and clay-like because of the absence of biliary coloring matter. There is no bile in the vomit in this stage, because the hepatic ducts have been closed by the inflam- mation which has been produced in the liver. Later, nervous symp- toms ensue. Muscular tyvitchings, headache, vertigo, wild delirium, erotic convulsions, and finally unconsciousness and death, occur. Sometimes the convulsions occur just before dissolution. Even if the patient survives the acute stage of the poisoning, he generally dies of the changes produced in his organism, Avhich consist in Avidespread fatty degeneration. These fatty changes occur even in the acute period of the poisoning. Atrophy of the liver, destruction of the gastric tubules, pancreatic involvement, and kidney degenerations aid in producing the ultimately fatal results. During the* poisoning by phosphorus the urine is scanty and per- haps albuminous, and is peculiar because of the unusual substances which, are found in it. The most unusual of these is sarcolactic acid, which results from the breaking doAvn of the muscular tissues. Leucin and tyrosin are also found, and tube-casts Avith fatty globules in them are seen. Free fat-globules may also occur. Bile acids and bile col- oring matter are found in large amount, and the urine is generally dark-colored for this reason. As phosphorus is eliminated as hypo- phosphoric acid, this substance is also present. The symptoms of phosphorus poisoning may so closely resemble those of acute yellow atrophy of the liver as to make a differential diagnosis impossible unless some evidence of the presence of phos- phorus is obtainable. In chronic poisoning by phosphorus, Avhen, by the inhalation of its PHYSOSTIGMA. 297 fumes, systemic changes occur, the most common lesion is necrosis of the lower jaAv, Avhich may be Avidespread or limited. It never occurs in those Avho have no solution of continuity in the teeth or gums, and for this reason it is necessary that the employes in match-factories should have their teeth constantly attended to. It is said that pans contain- ing turpentine Avhen set around the room will protect the Avorkmen, but this is certainly incorrect. Treatment of Acute Poisoning.—The antidote to phosphorus is generally taught to be the sulphate of copper, Avhich will also act as an emetic if given in excess, but recent studies made by Thornton in the laboratory of Jefferson Medical College prove that it is as dangerous a poison as the phosphorus. Peroxide of hydrogen and permanganate of potassium are probably the best antidotes. Oil of turpentine, in America, is not only valueless as an antidote, but harmful, for only old, ozonized French oil of turpentine is antidotal in its influence. As phosphorus is soluble in oils, Ave simply aid in its absorption if any such substances are given. Therapeutics.—OAving to its influence on the development of bone, phosphorus is very useful in rachitis and osteomalacia. It is also useful in the SAveats of general or nervous debility and in nervous exhaustion, and in some eases of melancholia depending upon over- work. In the course of prolonged exhausting diseases, as typhoid fever or typhoid pneumonia, the drug is of service if the nervous system seems to be particularly affected, and in convalescence it is of service in aiding to build up the shattered forces of a patient. In the sequelae of acute and chronic alcoholism and in morphio- mania it is of service. Phosphorus is also employed in sexual exhaustion or abuse. In boils and carbuncles and similar disorders phosphorus is very useful, particularly so in acne indurata. In pneu- monia some physicians use minute doses Avith the belief that it aids in the production of resolution, one of the most enthusiastic of these being Dr. Boardman Reed. In the neuralgia from nerve-depression and in /■erebral softening and meningitis of a chronic type phosphorus often does good. The dose of phosphorus is fa^ to fa of a grain (0.0006-0.0012) in pill form (Pilulee Phosphori, U. S. and B. P.), but it may be grad- ually pushed to fa of a grain (0.003) if urgently needed. Phospho- rated oil (Oleum Phosphoratum, U S. and B. I\) and Spiritus Phos- phori. U. S., are given in the dose of 1 to 5 minims (0.05-0.35). Elixir Phosphori (U. S.) is given in the dose of 15 minims to 1 drachm (1.0-4.0). The beginning dose of phosphorus should not be above fa-$ of a grain (0.0006), for fear of some idiosyncrasy. PHYSOSTIGMA. Physostigma, U. S. (Physostigmatis Semen, B. P.), is a seed derived from Physostigma Venenosum, a tree of AArest Africa, often called Calabar bean. It contains tAvo alkaloids, eserine or physostig- 298 DRUGS. mine and calabarine. The former is the most important from a med- ical point of vieAv. Physiological Action.—Calabar bean is a general paralyzant, but if the alkaloid calabarine be present in excess it may be a convulsant. Nervous System.—On the spinal cord in poisonous dose this drug acts as a direct depressant poison, particularly affecting the motor tracts. On the motor nerves it exerts no influence at all unless given in large toxic doses, Avhen it depresses their peripheral ends. The sensory nerves generally escape, but sometimes even they are involved. On the voluntary muscles the drug in these doses causes tAvitchings, due to a direct influence over their fibres. In all medici- nal doses the drug is a stimulant to unstriped muscular fibre. Circulation.—Calabar bean causes comparatively little circu- latory change, but it produces a rise of arterial pressure, based largely upon a direct stimulation of the heart, and slows the pulse by peripheral stimulation of the cardiac inhibitory nerves. Respiration.—In moderate amount Calabar bean causes no inter- ference Avith the respiration, but in poisonous dose produces death by paralysis of the respiratory centre. Pupil.—Physostigma causes myosis" or contraction of the pupil bv stimulation of the oculo-motor nerves peripherally, by depression of the sympathetic fibres, and by causing contraction of the blood-ves- sels of the iris. It decreases intra-ocular tension. Alimentary Tract.—Physostigma is a stimulant to intestinal peristalsis, increasing the muscular activity in the walls of the gut and acting as a tonic to these fibres. Poisoning.—Calabar bean is used in Africa as an "ordeal bean" to determine Avhether a person is or is not guilty of a crime. If an individual eats it and survives he is guiltless," but if he dies he is guilty, according to this rather fatalist belief. If he does survive, it is generally by reason of the calabarine producing vomiting and purging, and so ridding the patient's stomach of the poison before it is absorbed. Poisonous doses of physostigma cause muscular tremors, folloAved by complete muscular relaxation. The pupils contract, the respira- tions become slow and irregular, and all reflex action fails. A7omit- ing or purging may or may not occur. Treatment of Poisoning.—This consists in the use of atropine, which is the physiological antidote, in the application of heat to the body, and the use of respiratory and cardiac stimulants, such as digi- talis, alcohol, or ammonia. Therapeutics.—Calabar bean is employed in many affections, such as trismus neonatorum, tetanus, and other spasms, with only mode- rately good results. It is, however, of value in atony of the bladder and intestines and in catarrh of the bowels. The author has used it with great success in cases of gastric and intestinal dilatation. In bronchial asthma and emphysema it will aid in the expulsion of the mucus by its influence over the muscular fibres in the walls of the air-tubes. It is also useful in purgative pills. (See Consti- pation.) PILOCARPUS. 299 Administration.—Physostigma is used in the form of the extract (Extractum Physostigmatis, U. S. and B. P.) in the dose of \ of a grain (0.008), Avhich may be readily increased to ] of a grain (0.016). The tincture (Tinetura Physostigmatis, U. S.) is given in the dose of 5 to 20 drops (0.3-1.35). This tincture is tAvice as strong as that official in the U. S. P. of 1880. Eserine (Physostigmina, B. P.; Physostigmine Salicylas, U. S., and Physostigmine Sulphas, U. S.) may be used in the dose of fa of a grain (0.0008) three times a day. In the eye, of the strength of 1 to 2 grains to the ounce (0.05-0.1 : 32.0) of Avater, eserine is used in the treatment of corneal ulcerations and for the relief of glaucomatous states Avith high intra-ocular tension. If, for anv reason, atropine mydriasis is to be rapidly overcome, eserine is to be used, but it is not so powerful as atropine, and it Avill require larger amounts of the solution to produce contraction than it took of atro- pine to cause mydriasis. Lunelle Physostigminee, B. P., each con- tain yoVo of a grain (0.00006) of physostigmine. Tavo salts of eser- ine or physostigmine are noAV on the market—namely, the sulphate and the salicylate. The former is much more soluble, and is gener- ally to be employed. The salicylate is largely used, nevertheless, by ophthalmologists. The dose of both salts is t4-q- to -fa-^ of a grain (0.0004-0.0006). PILOCARPUS. Pilocarpus, U. S. (Jaborandi, B.SP.), is derived from the South American tree, Pilocarpus Selloanus or Pilocarpus Jaborandi. It contains tAvo alkaloids, knoAvn as pilocarpine and jaborine, a volatile oil, and other minor constituents. The alkaloid pilocarpine is non- crystallizable and occurs as a soft mass. The salts of pilocarpine are, hoAvever, crystallizable. Physiological Action.—AAThen jaborandi is taken in medicinal dose by a healthy man, it causes a deep flushing of the face and neck, fol- loAved by the outbreak of a profuse SAveat, Avhich, though beginning in these regions, rapidly spreads over the entire body. Accompany- ing the sweat, the salivation is often exceedingly profuse, so that saliva dribbles from the mouth. Nausea frequently comes on, and severe vomiting mav appear in susceptible persons either during or after the SAveating. On the contrary, some individuals are singularly insusceptible to the influence of pilocarpus, and this is particularly so, according to Ringer, Avith children, Avho will often take as much as 60 grains (4.0) of the crude drug before they perspire. Some adults also refuse to yield to its influence.1 The sweat lasts from three to five hours. Nervous System.—Moderate doses have no effect on this part of the body, but poisonous amounts cause in the frog tetanic reflex con- vulsions, and finally paralysis, the latter being due to depression of ' The writer has reported a case (see Idiosyncrasy) where a woman of thirty years received £ of a grain of the muriate of pilocarpine hypodermically in half an hour without any efiect. 300 DRUGS. the muscles and spinal centres. The nerves escape. Medicinal doses in man exercise no effect over the nerves. Circulation.—In large doses there is no doubt that jaborandi acts as a cardiac depressant rather than as a stimulant, and, while there may be no evidence of an experimental character pointing to such a conclusion, the fact exists in practical medicine. The drug causes in the lower animals a slow pulse and increased arterial pres- sure, in moderate quantities, the first change being due to an action on the inhibitory centres in the heart or on the peripheral vagi. Ringer, on the other hand, has proved that it slows the beat of the ventricles in the frog when they are separated from these centres, and believes that the drug acts directly on the motor centres of the heart-muscle and the muscle itself. In man the drug does not sIoav the pulse, but quickens it very markedly, often as much as forty to fifty beats per minute. The rise of arterial pressure seen in the animal is often replaced by a fall of pressure in man, and, though the pulse in ani- mals is generally made stronger from its use, in man it is generally weaker. Temperature.—Jaborandi loAvers bodily temperature to a con- siderable degree, probably by the dilatation of the peripheral capil- laries and the profuse sweat Avhich it produces. This fall is some- times preceded by a brief rise. Kidneys and Tissue-avaste.—Upon the kidneys jaborandi acts very slightly or very strongly, according to the dose that is given. Large doses, Avhich produce a profuse sweat, naturally decrease the urinary secretion, and small ones undoubtedly increase it. Upon the tissue-changes in the body under pilocarpine no researches have been made, but it is an undoubted fact that the excretion of urea is largely increased in disease under the influence of this drug. Eye.—Jaborandi contracts the pupil by acting peripherally on the nerves of the iris. Skin.—The amount of SAveat caused by the drug in man may equal as much as a pint, and it is generally first acid, from the secre- tions of the sebaceous glands, then neutral, and finally alkaline. The sweating is not due to vasomotor palsy, but to stimulation of the ends of the nerves supplying the glands and of the SAveat-glands themselves. Sometimes excessive salivary secretion supplants that of the skin. Pilocarpine increases the gastric, salivary, and lachrymal secre- tions, as well as that of the skin and kidneys. It also seems to have considerable influence over the secretion of milk. Therapeutics.—Jaborandi, or, better still, its alkaloid, pilocarpine, is of great value for the relief of dropsy of the renal type. In that due to cardiac disease it is generally too depressing, and the author knoAvs of a case in Avhich a fatal result followed its use under these circumstances. It may be used to abort an attack or paroxysm of malarial fever, but because of its depressant influence should never be employed in asthenic fevers, such as typhoid fever. In pleurisy Avith effusion it may be used, but more efficient remedies are elaterium, or salines given in concentrated form and at the proper time of the day. PILOCARPUS. 301 (See Magnesium Sulphate and Dropsy.) Spaulding and De SchAveinitz have both recommended very highly the use of pilocarpine hypoder- mically in the dose of fa to fa grain (0.005-0.006) a day for opacities of the vitreous humor of the eye. The fluid extract of jaborandi may be employed, but is apt to nauseate the patient. Diaphoresis should not be produced. MitkoAvski has tried pilocarpine in catarrhal jaundice of a persistent type Avith great benefit, in the hypodermic dose of 4; grain (0.01) every other day for three weeks. In uremic poisoning pilocarpine is the most efficient and rapidly acting remedy that Ave have, and Avhen used in Bright's disease it is of value in sev- eral Avays—first, by removing the strain on the kidneys ; second, by eliminating the uraemic poison; and third, by decreasing the inflam- matory condition in the kidneys by loAvering the blood-pressure, Avhich, it will be remembered, is the more constant effect of the drug in man. Care should ahvays be used in the use of the drug lest car- diac depression ensue, and alcohol or strychnine may often be used with advantage to guard against this accident. The drug in small doses certainly increases renal activity. The hypodermic dose as a renal stimulant should be about fa to fa of a grain (0.002-0.003). In some forms of profuse sweating, such as come on at night in gen- eral debility, pilocarpine, if given hypodermically or by the mouth about two hours before the sweat in the dose of fa of a grain (0.003), is often useful even where atropine fails. Pilocarpine certainly has a decided effect in encouraging the growth of hair, and applied locally will often do good in partial baldness. If too much pilocarpine is used, it is apt to cause the development of small pustules about the hair-follicles. BartholoAv recommends the folloAving application for baldness: R.—Extract, pilocarpi fluid.........f |j (32.0). Tinetura; cantharidis..........f .^ss (16.0). Liniment, saponis...........f §jss (48.0).—Al. The author has found the folloAving prescription peculiarly effica- cious in falling of the hair : R.—Extract, pilocarpi fluid.........f ,zj (4.0). Tr. capsici..............f gj (32.0). Tr. cantharidis............fzss (16.0). 01. ricini .............f zj (4.0). Alcohol. . .'...........q. s. f |iv (128.0).—M. S.—Apply with friction in spots to the scalp, night and morning. Antagonisms of Jaborandi.—Jaborandi is a physiological antidote to atropine and to agaricin. Four times the dose of pilocarpine must be used to equal a dose of atropine. Administration.—The dose of jaborandi is 40 grains (2.65), used in the form of the powdered leaves in infusion. The fluid extract (Extractum Pilocarpi Fluidum, U. S.) should be used in the dose of 30 drops to 1 drachm (2.0-4.0). Pilocarpine is far superior to jabo- randi, in that it does not so often produce nausea and vomiting. It is used in the form of the hydrochlorate (Pilocarpine Hydrochloras, 302 DRUGS. U. S.), in the dose of from \ to 4, of a grain (0.008-0.03) hypoder- mically, or \ to 4; of a grain (0.015-0.03) by the mouth. The preparations of the B. P. are—the extract (Extractum Jabo- randi), dose 2 to 10 grains (0.1-0.65); the infusion (Infusum Jabo- randi), dose 1 to 2 fluidounces (32.0-64.0); the tincture (Tinetura Jaborandi), dose \ to 4; fluidounce (8.0-16.0); and the nitrate of pilo- carpine (Pilocarpine Nitras), dose fa to J grain (0.003-0.03). Clinical reports shoAV that pilocarpine in small doses is a very good remedy in tobacco and alcoholic au/blyopia. DaCosta, Salinger, and Barr have highly recommended the hyj)odermic injection of pilocar- pine in erysipelas as a preventive and curative measure in the early stages of this disease, and their reports are so encouraging as to A\ar- rant a careful trial of the method. The proper dose is -jt- grain (0.01) every three hours until free SAveating ensues. After this is accom- plished the doses may be repeated every four or six hours. The author would fear that such active treatment might seriously affect the strength of the patient unless stimulants were also used. PIPERAZINE. This is a substance, the chemical formula of Avhich is C4HI0N2, Avhich has been recently introduced into medicine for the treating of the uric-acid diathesis. It is not stable, and Avhen exposed to the air attracts water and carbonic acid. Aqueous solutions are decidedly alkaline, but do not have any distinct taste. Piperazine is peculiar in its power to dissolve uric acid, dissolving twelve times as much as Avill carbonate of lithium, Avhile it is also entirely soluble in water, Avhich lithium is not. AAThen taken into the body the drug is partly oxidized and partly eliminated unchanged. Theoretically, piperazine, Avhen taken into the body, forms with uric acid a urate of piperazine, Avhich is soluble and readily eliminated. Experiments have been made to determine this point Avith very satis- factory results, but repeated clinical observation has shoAvn that the administration of the drug causes an increase in the amount of urea in the urine Avith a decrease in the uric acid, indicating that under its influence oxidation is more complete. Therapeutics.—Piperazine is used for the purpose of preventing the formation of renal and vesical calculi in the uric-acid diathesis, and also in cases where the excess of uric acid in the urine tends to pro- duce irritation of the bladder. Similarly, its action has been found of value in treating vesical irritation due to this cause by washing out the bladder Avith a solution of piperazine of the strength of 1 per cent. Piperazine has also been injected into uric-acid deposits about the body or applied to the broken-doAvn surfaces of these deposits in 1 per cent, solution, but the author has not been favorably impressed Avith this method, and Avould advise against its use—first, because it does little if any good, and, second, because the method is painful and apt to cause sloughs by interfering with nutrition of the skin when already lacking in health. PITCH 303 The dose of piperazine is 15 grains (1.0) in tAventy-four hours. It is best given by dissolving this amount of the drug in 1 pint (1 litre) of Avater, and directing the patient to take a Avineglassful of the solu- tion frequently through the day. OAving to the effect upon the drug of exposure to air, it cannot be given in pill or powders, and should be freshly mixed each day. The Avriter has failed to obtain any results from the use of this drug in his practice. SteAvart has noted, as untoAvard effects of full doses of piperazine, tremors, hallucinations, and clonic spasms. PISCIDIA ERYTHRINA. Piseidia Erythrina is a drug Avhich is stated to possess marked nar- cotic and pain-relieving properties. It is sometimes called Jamaica dogAvood. Its poAvers as a soporific and analgesic do not compare with those of opium, but it is stated to be devoid of the unpleasant after-effects of the latter drug. Further studies concerning its effects on the animal economy are needed. According to Dr. Isaac Ott and Dr. Nagle, the drug has little or no effect on the motor and sensory nerves, and its dominant effect on the circulation is to increase arterial pressure through stimulation of the vasomotor system. The indica- tions which have been met best by piseidia are dysmenorrhea due to irregular flow and spasm of the uterine cervix and fundus, to allay nervous irritability, and to relieve pain or insomnia due to pain. Administration.—The dose of the fluid extract of piseidia erythrina is l to 2 drachms (2.0-8.0); of the solid extract, 2 to 10 grains (0.1- 0.65). The alkaloid piscidine is not knoAvn to represent all the prop- erties of the drug, and is not used in medicine. PITCH. Pix is a resinous exudation derived from several species of pines, firs, and spruces, and is, in one of its forms, obtained by the eA'apora- tion of Avood-tar. It is used for various purposes, according to its derivation. Burgundy Pitch (Pix Burgundica. U. S. and B. P.) is derived from Norway spruce, or Abies Excelsa, a plant of Europe and Asia. It softens and melts at the temperature of the body and is useful in plasters. In muscular rheumatism and in chronic bronchitis pitch is a mild and fairly useful local remedy. In the form of the plaster (Emplastrum Fids Burgundice, U. S. and B. P.) and in the form of Avarming plaster (Emplastrum Picis Cantharidatum, U. S.) it is emploA'ed for the relief of deep-seated sprains and bruises, and acts as a mild counter-irritant, Avhich may blister a tender skin. Canada Pitch (Pix Canadensis, B. P.) is obtained from the hemlock spruce of Canada and the United States, and is used for the same purposes as Buro-undv pitch. The Canada-pitch plaster (Emplastrum Picis Canadensis)'is employed for the same conditions as the plaster of Burgundy pitch. 304 DRUGS. Tar. Under the name of Pix Liqiiida, U. S. and B. P., or Tar, Ave have an empyreumatic oleoresin obtained by destructive distillation from F/'uus Palustris and other varieties of pine. It is a thick, dark oil, slightly soluble in water and soluble in alcohol, oils, and solutions of potassa and soda. By distillation of tar Ave obtain oil of tar (Oleum Fids Liquide, U. S.), Avhich is sometimes used by inhalations from an atomizer in bronchitis, but is not a particularly useful application. It should be diluted Avith some other oil or Avith fluid cosmoline. Tar itself is used in subacute and chronic bronchitis in 2-grain (0.1) pills and as a remedy for gastro-intestinal catarrh. Externally, it is used in psoriasis and other skin diseases needing stimulation. In obstinate diarrhea AATood has highly recommended a mixture of tar made as follows: Add a pint of tar to a gallon of lime-Avater, and alloAv this solution to stand one week, stirring it every feAv hours. Decant the clear liquid and percolate it through poAvdered Avild-cherry bark, allowing 1 ounce of the bark to be present for each pint passed through it. The dose is a wineglassful (30.0). In chronic bronchitis tar-Avater is largely used, as a popular rem- edy, in Europe and England. Tar-A\ater is made by shaking 1 part of tar Avith 4 parts of Avater several times during tAventy-four hours, decanting, and filtering. The dose is from 1 to 2 pints (4-1 litre) a day as a drink. It at first increases the expectoration, but finally decreases it. Syrup of Tar (Syrupus Picis liquide, U. S.) is simply sweet- ened tar-Avater. In skin diseases of the dry, scaly sort, such as psoriasis, tar oint- ment (Unguentum Picis Liquide, U. S. and B. J\), equal parts of tar and suet, is very useful if frequently applied, or the following may be used: aa .^vj (24.0). aa gij (64.0). . ziv (16.0). If the skin is tender, this prescription should be diluted with lard. Sometimes children will suffer from a persistent dry chronic eczema which resists all treatment; the following may then be employed with advantage: R.—Picis liquid...............3ss (2.0). Sulphur, prsecip..............^ss (2.0). Unguent, zinc, oxidi..........gj (32.0). S.—Apply night and morning. Tar should not be used on the face, as it will stain the skin. Wine of Tar (Vinum /Vr/.s) is made by adding together tar 1 pint, glycerin, white wine, and honey, of each 4 a pint, dilute acetic acid 1 ounce, and 3 quarts of boiling Avater, and shaking constantly at a temperature of 160° F. for several hours. It is then set aside R.—Sulphur, prsecipitat.) Picis liquida? i Saponis viridis \ Adipis J Pulv. cretap .... POMEGRANATE. 305 to stand for some days and repeatedly filtered or strained through muslin. The dose is 1 to 4 ounces (32.0—128.0). It may be used instead of tar-A\ater or tar-syrup. PODOPHYLLUM. Podophyllum, U. S. (Podophylli Bhizoma, B. P.), May Apple or Mandrake, is the rhizome and small roots of Pod........aa f^ij (8.0). Tinct. opii J Liniment, saponis ......q. s. ad f^vj (192.0).—M. Soap Plaster (Emplastrum Saponis, U. S.) is used as a thick, heavy protective in bed-sores or Avhere bed-sores are feared. It is also used as a support about sprained joints. SODIO-SALICYLATE OF THEOBROMINE. This compound, knoAvn as diuretin (or sodio-theobromine-salicy- late), derives its name from the extraordinary poAver Avhich it is said to possess of producing a great increase in the urinary Hoav from the kidneys. This poAver depends entirely upon the theobromine, Avhich is a crystallizable, bitter, and volatile alkaloid, closely allied to caf- feine and xanthine, and derived from the seeds of Theobroma Cacao, or the source of ordinary chocolate. (Jwing to the insolubility of theo- bromine, it has been found necessary to combine it Avith sodium salicy- late, as under these conditions it is readily absorbed. The diuretic properties of this alkaloid Avere first discovered during a series of experiments made by Schroder in Strasburg in lNSO, Avho found that the diuresis produced in man and the loAver animals Avas very marked. A large number of clinical trials in Europe and America have confirmed his observations, but there are a number of cases in Avhich it signally fails, particularly in chronic Bright's disease. Theobromine does not have so stimulating an effect on the heart as does its relative caffeine, so that the circulatory effect, Avhile showing a stimulant rather than a depressing tendency, is very slight. It 328 DRUGS. slightly increases muscular power, but its peculiar affinity for the renal structures surpasses all its other activities. As the action of the drug depends upon its ability to stimulate the secreting epithelium of the kidney, the physician should remember that in cases of advanced renal disease, where the secreting structures are almost entirely destroyed, no result can be expected from its administration; but it is probable that the drug is useful in almost all conditions of dropsy, whether due to renal inactivity or cardiac disease, and is harmless to the patient even if the diuretic effect does not ensue. The only contraindication to the use of theobromine or diuretin is the presence of acute nephritis, when, of course, sedatives rather than stimulants are needed. So far as the writer is aware, no study as to the proportion of solids and liquids in the urine under the influence of this drug have been made, but the fact that it stimulates the epithelium or secreting structures of the kidney would indicate that the solids are increased. As diuretin only contains from 30 to 50 per cent, of theobromine, it has to be given in very large amounts, as much as 1 to 2 drachms (4.0-8.0) in tAventy-four hours, preferably in divided doses of from 10 to 20 grains (0.65-1.3) in capsule or in warm water. The former method is the better, as the taste of the drug is disagreeable and soapy. It must not be exposed to the air, as it undergoes decomposition. In all the cases in which the Avriter has tried sodio-salicylate of theobromine he has failed to see any effect produced, and, Avhile he has no confidence in the drug, he mentions it because others claim to have obtained good results from its use. SODIUM. Sodium is a metallic element, the salts of Avhich are usually white and colorless. It is not used in medicine, but many of its salts are employed. Unlike the potassium salts, the salts of sodium seem to exert comparatively little effect upon the animal economy. The salts vary in their poAver Avith the acid forming them. Acetate of Sodium (Sodii Acetas, U. S. and B. P.) is rarely if ever used in medicine as a substitute for acetate of potassium. The dose is 20 to 40 grains (1.3-2.65) three times a day. SODIUM ETHYLATE. Sodium Ethylate is a Avhitish powder, decomposed in the presence of water into alcohol and caustic soda, but soluble in absolute alcohol Avithout decomposition. Sodium ethylate is employed in medicine as a depilatory—that is, for the purpose of removing hairy growths. To accomplish this pur- pose it is necessary that the growth be clipped close to the skin, and that the drug be dissolved in absolute alcohol and applied over the roots of the hair Avith a glass rod. SOLANUM CAROLINENSE. 329 Soon after this application a crust forms, Avhich should not be detached for two or three Aveeks, but Avhich, on its removal at the end of this time, generally shows that all the roots of the hair have been destroyed. If not, the operation may be repeated as soon as the skin is in a condition to bear it. To prevent pain, a 5 per cent. solution of cocaine may be used hypodermically at the spot to be cauterized. It is worthy of remembrance that moles and small birth- marks, or naevi, may be relieAred by a similar application. SODIUM HYPOSULPHITE. Hyposulphite of Sodium, or Thiosulphite of Sodium, occurs in large, transparent, colorless plates Avhich effloresce Avhen exposed to the air. It has slight alkaline reaction, is soluble in about equal parts of Avater, but insoluble in alcohol. Therapeutics.—Hyposulphite of sodium is used in the proportion of 1 drachm (4.0) to the ounce (32.0) of Avater or lard in the treat- ment of parasitic skin diseases, particularly those due to the tri- cophyton fungus, such as pityriasis versicolor. It is also very useful, locally applied, in poisoning from poison ivy, and in cases of pruritus due to other causes, in the strength of 4 a drachm (2.0) to the ounce (32.0) of Avater. In malarial hematuria hyposulphite of sodium is often ghren with advantage in the dose of from 10 to 30 grains (0.65- 2.0) every four hours. How it acts in this condition Ave do not know. SODIUM SULPHATE. Sodii Sulphas, U. S. and B. P., or Glauber's salt, is one of the most irritant of the saline purges, rarely used in medicine for human beings, but largely employed by Aeterinarians. The purgative dose for man is half an ounce to an ounce (16.0-32.0). If any intestinal inflam- mation is present, it is contraindicated. It produces large Avatery stools, Avith a good deal of griping. Sulphate of sodium is a promi- nent constituent of Carlsbad water, Hunyadi Janos, Hunyadi Arpad, and similar Avaters. SOLANUM CAROLINENSE. Solanum Carolinense, or Horse Nettle, is a Ioav perennial plant of the natural order Solanacece, a native of the South-eastern United States. The drug has been introduced into medicine for the purpose of relieving epilepsy, particularly when the disease occurs in childhood. In a very limited employment of the drug the Avriter has found it very serviceable in diminishing the frequency and severity of the attacks. The dose of the fluid extract is 2 to 15 minims (0.1-1.0) three times a day. 330 DRUGS. SOMNAL. Somnal is stated to be ethylated chloral-urethan, and seems to possess marked hypnotic power. It is a clear, colorless liquid of a hot, burning taste, resembling SAveet spirit of nitre. The dose is 20 to 40 drops (1.3-2.6) in liquorice-Avater or syrup of raspberry, and the sleep produced by it is said to last seven to eight hours. No very definite reports have yet been made concerning it, but in a number of cases in which the writer has used it it has acted very well, although droAvsiness is usually present on the next day. SOYA BEANS. Soya Beans are derived from Glycine hispida, a plant of Japan and China. These beans are ground up into a flour, and from this is made a bread which has proved itself very useful in diabetes mel- l/'tus. It is supposed to contain less than 3 per cent, of starch or sugar, and by many authorities is regarded as superior to the best gluten bread. The cost is practically the same as that of good gluten bread, and the taste affords a pleasant change for the patient. If crackers are made of the soya-bean flour, they Avill remain good indefinitely, but in warm weather the bread must be freshly made every two or three days. The beans themselves contain a purga- tive oil, and this must be removed from the flour before it is used. Unless almond bread is unusually well made, soya bread is far prefer- able in every way. SOZOIODOL. Sozoiodol is an antiseptic preparation first made and employed by one of our own countrymen in San Francisco, but at that time the preparation of it was so imperfectly carried out that foreign matters made it too irritating for general use, and it Avas discarded, only to be better prepared and more widely used in Germany some years later. Therapeutics.—Sozoiodol has been found of value as an antiseptic and disinfectant in the treatment of wounds Avhich are in an unhealthy state, and for acute stomatitis and pharyngeal catarrh it may be employed locally in the form of a 5 per cent, watery solution. It has also been found useful in acute purulent conjunctivitis and in oph- thalmia neonatorum, in the proportion of 2 parts of sozoiodol to 30 parts of water. In urethritis of a specific type we may employ the preparation known as zinc-sozoiodol in a 2 per cent, solution with advantage, and this compound is also of value in mild and malignant vaginitis if preceded by pyroligneous acetic acid or nitrate of silver, applied by means of a speculum. In the treatment of gynaecological cases, particularly in catarrh of the cervix uteri, Nitschman uses sozoiodol in the form of a poAvder applied by means of a tampon Avith good results, and it would seem SPIGELIA. 331 to be Avorthy of trial in many other states of the mucous membranes than those just named. SPIGELIA. Spigelia, U. S., Pinkroot, is the root and rhizome of Spigelia Mardandiea, or Carolina Pink, a plant of the Southern United States. Poisoning.—Almost immediately after the ingestion of a poisonous dose of spigelia the animal has short and quick expiratory move- ments, amounting almost to a cough.1 Soon after the pupils become widely dilated, the eyeball is turned inAvard, and at the same time the orbit becomes very fixed in this position, so that the eye cannot folloAv any object, such as a pencil, Avhen it is moved from side to side. Constant retching, Avith no result, noAV comes on, the animal standing and apparently suffering .from no sensory or motor palsy. There is no change in gait. Soon after this marked exophthalmia is developed. The retching, having lasted about five minutes, noAV passes off, and at this time signs of muscular Aveakness and lack of co-ordination appear, the Avalk becoming staggering both in the fore and hind legs. The respirations noAV become very rapid, resembling those of a dog after a long run on a hot day. The tongue hangs from the mouth and is dry and red, and the nose is hot and no longer moist. Muscular poAver is progressively lost, so that the dog fre- quently falls when endeavoring to Avalk, but sensation does not seem to be affected. About this period the animal lies down and passes into a deep sleep, Avhich, in turn, soon changes into coma, and death follows Avithout any movement being made, evidently from a general failure of vital force. The respirations, as death approaches, become sIoav, and are finally extinguished simultaneously with cardiac arrest. The palsy is spinal in origin, the motor and sensory nerve-trunks and the muscles escaping the paralysis. Therapeutics.—Spigelia is one of the most efficient remedies in the treatment of round-worms, and is not dangerous Avhen given Avith care. A\Then employed for the removal of Avorms the usual precaution should be taken in regard to the ingestion of food (see article on AVorms), and the drug should be followed by a purge to SAveep out the worm while it is narcotized. The purge should be one Avhich is rapid in its action, such as the sulphate of magnesium. Administration.—The dose of spigelia in the form of the fluid extract (Extractum Spigelur Fluidum, U. S.) is 2 drachms (8.0); that of the unofficial fluid extract of spigelia and senna (Extractum Spigelie et Senne Fluidum) is \ to 1 drachm (2.0-4.0) for a child of two years of age; \ an ounce (16.0) is the dose for an adult. The addition of fluid extract of senna makes the drug more efficient, and the mixture is generally not disliked by children. It is to be remem- bered that this latter mixture is no longer official. 1 See investigation by author in The Medical Neivs, March 12, 1887. 332 DRUGS. SQUILL. Scilla, U. S. and B. P., is the sliced bulb of Urginea Maritima, a plant ef the countries bordering on the Mediterranean. It con- tains scillin, scillipikrin, and scillitoxin, all of Avhich possess poison- ous properties ami none of Avhich are used in medicine alone, except by a feAv persons. Poisoning.—In poisonous doses squill produces vomiting, purging, dulness, stupor, intermittent palsy, convulsions, and death in ten to twenty hours. These symptoms are preceded by a great fall in tem- perature. The urine is suppressed or bloody and acute nephritis is produced. Gastro-enteritis may be marked. Therapeutics.—Squill is largely used as a stimulant or irritant diuretic, not to affect the renal epithelium directly and promote secre- tion, but rather to tone up and excite to normal effort a kidney depressed by disease, as in very chronic Bright1 s disease or renal con- gestion from cardiac trouble. In cardiac dropsy, combined with digi- talis, squill is a standard and much-used remedy, and is undoubtedly of value in aiding in the absorption of effusions in the pericardium, pleura, and abdomen. Squill is usually given in dropsy, in pill form, as follows: R.—Pulv. scilla?..............gr. x (0.65). Pulv. digital, fol............Bj (1.3).—M. Ft. in pil. No. x. S.—One t. d. -after meals. The employment of squill in bronchitis, although largely resorted to, is not a very good practice, since its irritant action on the kidneys and stomach may cause trouble. The period for its administration is in the beginning of the second stage, when secretion is scanty or so excessive as to need proper stimulation of the mucous membranes to bring on a healthy action. Sometimes Coxe's Hive Syrup is used, either as an emetic in drachm doses every ten minutes until it acts, or as an expectorant in the dose of 30 drops to 1 drachm (2.0-4.0) for an adult. As it contains antimony, it should be given with care. Administration.—The fluid extract (Extractum Scille Fluidum, U. S.) is given in the dose of 1 to 5 drops (0.05-0.3); the iincture (Tincture Scille, U. S. and B. P.) in the dose of 5 to 30 drops (0.3-2.0); the vinegar of squill (Acetum Seillee, U. S. and B. P.) in the dose of 10 drops to \ drachm (0.65-2.0). The compound syrup (Syrupus Scille Compositus, U. S.), or Coxe's Hive Syrup, is com- posed of squill, tartrate of antimony and potassium, precipitated phosphate of calcium, alcohol, sugar, and water, and is given in the dose of 20 drops to 1 drachm (1.3-4.0). The folloAving prescription will be found useful in bronchitis in its subacute stages in a child of one to five years: R.—Vini ipecac...............f^j (4.0). Tinetura? scilla?............f ^ij (8.0). Svr. tolutan..........'. . . . f.^v (20.0). Aqua?................fgj (32.0).— M. S.—Teaspoonful (4.0) every three or four hours. STILLINGIA. 333 The plain syrup (Syrupus Scille, U. S. and B. P.) is given in the dose of i to 1 drachm (2.0-4.0), the honey (Oxymel Scille, B. P.) in the dose of i to 1 drachm (2.0-4.0), and the compound pill (Pilule Scille Composita, B. P.) in the dose of 5 to 10 grains (0.3-0«65). STARCH. Amylum, U. S. and B. P., is Avheat starch, but good corn starch is usually employed by many persons. In very fine powder starch is used as a dusting poAvder in intertrigo or chafing. Its more import- ant uses are, hoAvever, its employment in the form of starch-water for carrying drugs into the rectum, and in the form of a poultice for cases of skin disease Avhere it is desired to remove crusts. Starch-Avater is made by boiling starch in the proportion of 2 table- spoonfuls to 1 pint of Avater, Avhich is then boiled to paste and diluted by the addition of Avarm Avater to the consistency of syrup. Starch- water is not only useful as a vehicle for drugs given by the rectum, but as a sedative injection in proctitis and rectal irritation. The starch poultice is made by boiling the starch to a pasty con- sistence or adding enough boiling Avater to a paste made by rubbing cold Avater and starch together to produce a gelatinous mass. 30 grains (2.0) of boric acid to the ounce (32.0) render it antiseptic. STILLINGIA. Stillingia, U. S., Queen's Root, is the root of Stillingia Sylvatica, a plant of the United States, the active principle of Avhich is stil- lingin. Physiological Action.—There can be no doubt that this drug acts in two Avays : first, by its immediate effects on the system, and second, by its more slowly-shoAvn alterative influences. In overdose it causes bilious purging, increased heart-action, and active secretion from the bronchial mucous membrane. Therapeutics.—Stillingia is highly recommended in habitual con- stipation, as it increases intestinal secretion, and it is even said to act as a specific in hemorrhoids dependent largely for their existence upon hepatic engorgement and intestinal atony. BartholoAv recommends the folloAving prescription under these cir- cumstances : R .—Extract, stillingia- fluid.........f ^v (20.0). Tinetura? belladonna? "| Tinetura? nueis vomica? >-....-- aa f ,^j (4.0).—M. Tinetura? physostigmatis J S.—20 drops (1.3) in water t. d. before meals. Tincture of aloes may also be added to this prescription if consti- pation is present. "In syphilis of an obstinate and rapid type stillingia should be used as an aid to other drugs. In pasty-looking, Avhite, " putty-faced " children, who are anaemic 334 DRUGS. or strumous, and who never have any appetite, or are subject to mid- dle-ear trouble and general debility, stillingia is of value. It should be used, under these circumstances, for some time. The» only official preparation is the fluid extract (Extractum Stillingie Fluidum, U. S.), Avhich should always be made of the fresh root, the dose of Avhich is 10 to 60 drops (0.65-4.0). STRAMONIUM. JamestoAvn AAreed, or Datura Stramonium, is official in the form of the leaves (Stramonii Folia, U. S.) and the seeds (Stramonii Semen, U. S. and B. P.). It contains an alkaloid knoAvn as daturine, which is physiologically identical with atropine. Physiological Action.—(See Belladonna.) Therapeutics.—The uses of stramonium are identical Avith those of belladonna. Administration.—The extract (Extractum Stramonii Seminis, U. S. and B. P.) is used in the dose of 4y to J grain (0.01-0.03), the fluid extract (Extractum Stramonii Seminis Fluidum, U. S.) in the dose of 1 to 5 drops (0.05-0.35), and the tincture (Tinetura Stramonii, U. S. and B. P) in the dose of 5 to 30 drops (0.3-2.0). It should be remembered that this tincture is nearly tAvice as strong as the tincture prepared according to the U. S. P. of 1880. The ointment (Unguentum Stramonii, U. S.) is used for the same purposes as is belladonna ointment. The dose of daturine is Y2\T to -fa of a grain (0.0005-0.0008). STRONTIUM. This substance has lately been introduced into medicine in the form of the bromide (Strontii Bromidum, U. S.), lactate (Strontii Lactas, U. S.), iodide (Strontii Iodidum, U. S.) and phosphate, largely through the studies of Laborde, See, Paul, and others. The bromide of strontium is used for precisely the same effects as are the other bromides, but it is claimed that, as the strontium has a distinct nutritive influence over the system, the Avell-knoAvn disadvantages of the potassium salt are avoided. The dose of bromide of strontium is from 30 to 60 grains (2.0-4.0). In addition to the ordinary effect of bromides, Se"e found the bromide of strontium to be very useful in overcoming attacks of gastric ^indigestion associated Avith pain in the stomach and hyperacidity; and the author has confirmed this state- ment. The lactate of strontium seems to be indicated chiefly in cases of albuminuria due to renal atony. It does not increase urinary floAV, and is contraindicated in the presence of the uraemia and high fever of acute parenchymatous nephritis. In chronic parenchyma- tous nephritis, such as is due to rheumatism or gout, it is of value. Unfortunately, as soon as the lactate of strontium is Avithdrawn the albuminuria is apt to recur if the disease is not entirely cured. The dose of the lactate of strontium is 60 to 100 grains (4.0-7.0) a day. SUGAR. 335 Fortunately, strontium possesses no toxic power Avhatever, and overdoses are not folloAved by any bad consequences. If the stron- tium is contaminated by barium, serious effects are produced. The Avriter has often been much disappointed in the use of the lactate of strontium in albuminuria, but others of Avide experience seem to regard it as very constant in producing good results. STROPHANTHUS. Strophanthus, U S. and B. P., is an African plant (Strophanthus hispidus), from the seed of Avhich the natives make komb£ arrow- poison. There are many varieties of Strophanthus. The active principle is strophanthin, from Avhich is derived strophanthidin. It has been claimed that strophanthus contains a local anaesthetic prin- ciple, but Dr. de Schweinitz and the author found it to be possessed of this power only in dogs and not in man. Therapeutics.—Strophanthus may be used in all forms of cardiac disease to supplant digitalis, but it is not its equal. From the cases of cardiac disease seen frequently by the Avriter he has reached the conclusion that digitalis gives relief to patients under the age of tAvelve years in a much smaller proportion of cases than it does in adults, and that, though the stomach is no more frequently disordered, increased dyspnoea, nervous irritability, and cyanosis often folloAv its use. On the other hand, strophanthus generally gives good results in this class of cases. As every one knoAvs, there are a certain number of cases where digitalis seems to do harm in adults, the explanation being that under such circumstances the ventricle is so overstimulated that the auricle cannot empty itself thoroughly, and becomes congested in consequence. Strophanthus acts exceedingly Avell in those instances Avhere digitalis fails, and this is particularly true in children. It will relieve cardiac dropsy by its action on the heart, but does not possess marked diuretic properties. Untoward Effects.—Strophanthus when given in full dose frequently causes diarrhoea. Administration.—Strophanthus is given in the form of the tincture (Tinetura Strophanthi, U. S. and B. P.) in the dose of 3 to 6 drops (0.2-0.35) three times a day. Strophanthin mav be given hypo- dermically in the dose of fa^ to fa of a grain (0.0006-0.0012). Its effects Avhen so used are said to last a Aveek, but this statement can scarcely be correct. SUGAR. Saecharum, U. S. (Saccharum Purificatum, B. P.), is the refined juice of Saccharum Offiehiarum, or Sugar-cane, or the juice obtained from the Sugar-beet. It is an antiputrefactive, but not an antifer- mentative. Mixed Avith iron preparations, it prevents oxidation. As it is a hydrocarbon, it is a nutrient and a developer of adipose tissue, 336 DRUGS. or, in other words, is a food. Its use is contraindicated in obesity, during the existence of fermentative changes in the stomach and intestine, and in diabetes mellitus. SUGAR OP MILK. Saccharum Lactis, U. S. and B. P., is derived from the whey of coav's milk by evaporation, in the proportion of about 5 per cent., and is then purified by re-crystallization. It has little sweetening poAver compared to cane-sugar and possesses a peculiar flat taste. It is, how- ever, less apt to ferment and is better for infants than is cane-sugar. Milk-sugar is largely used in triturations, because by its hardness it aids in the subdivision of the medicament. It is also used to increase the bulk of small powders Avhere such drugs as podophyllin and calomel are prescribed. Recent studies, both scientific and clinical, have shown lactose to be possessed of very great diuretic power Avhen given in full doses. The adAantage claimed for lactose as a diuretic is its direct action on the kidney and the slight effect exercised upon the rest of the organism. It is, therefore, in renal dropsy or renal inactivity that this substance is particularly indicated. The dose of lactose in cases of dropsy should be as great as from 2 to 4 drachms (8.0-16.0), given daily, dissolved in a quart (1 litre) of Avater. It has been found that the lactose acts best in those cases in Avhich there is no albuminuria. These recent studies are of interest in view of the well-knoAvn clin- ical fact that the addition of lactose to the milk of bottle-fed babies always causes profuse diuresis. SULPHATE OP ZINC. Zinci Sulphas, U. S. and B. P., is a white, somewhat efflorescent salt, of a sharp acid taste, and is soluble in Avater. In large amounts it acts as an irritant, and is employed as an irritant peripheral emetic in the dose of 10 to 30 grains (0.65-2.0). It is not so severe as sul- phate of copper in its emetic and poisonous properties, and may be repeated if the first dose does not produce vomiting. In Aveak solu- tions it may be used as an astringent application by injection in gon- orrhea and other affections of the urethral mucous membrane. In , 2-grain (0.1) pills it is sometimes given in serous diarrheas, particu- larly if it be combined with opium or minute doses of podophyllin (fa of a grain [0.001] at a dose). In conjunctivitis and other eye affec- tions the drug is used in the form of a Avash. (See Conjunctivitis.) SULPHIDES. Baths of the various sulphides, such as those to be obtained at sulphur springs, are very useful in many cases of skin disease of an SULPIWNAL. 337 obstinate type, such as psoriasis, lid/en, and eczema. They are also employed in chronic rheumatism and gout. In laryngeal hoarseness and pharyngeal affections, such as folloAV public speaking and exposure to cold, sulphides or sulphur-waters are very useful, and little doubt exists but that their persistent employ- ment is one of the best means to cure the obstinately atonic state of the throat sometimes seen in public speakers. As Avas first noted by Dr. Ringer, the sulphides, particularly in the form of calx sulphurata, are very useful in all cases Avhere pus is about to form. They may lie employed in cases where successive crops of boils occur, and in adenitis of the neck and glandular SAvellings occurring else- where. If they do not stop the formation of pus, they aid in its inspissation and absorption. Children should take a teaspoonful (4.0) every hour of a solution containing 1 grain (0.05) of calx sulphurata to the | pint (250 cc.) of Avater. Adults may be given sulphide of calcium in gelatin-coated pill, dose \ to 4 a grain (0.015-0.03) three times a day. The solution must be freshly prepared, as it undergoes oxidation, changing the drug into a sulphate. SULPHOCARBOLATES OF SODIUM AND ZINC. The sulphocarbolates of zinc and sodium are largely employed bv some practitioners as mild antiseptic local stimulants, either in pow- der or in solution, on ulcers and sores. Much more commonly they are given internally for the production of gastro-intestinal antisepsis when there is diarrhea Avith foetid, ill-smelling stools, as in the boAvel disorders of hot Aveather in children or adults or in the course of typhoid fever. How much good they do in the latter disease, so far as the disease itself is concerned, is uncertain, but they undoubtedly render the stools less foul and tend to check the diarrhoea. The suh phocarbolate of zinc is the better of the two for these purposes. The dose is 2 to 3 grains (0.1-0.15) in pill four or five times a day. The sulphocarbolates are probably eliminated from the body unchanged. SULPHONAL. Sulphonal, B. P., is a synthetically prepared substance first manu- factured in Germany by Baumann, and possesses the chemical name of diethyl-sulphon-dimethyl-methane. It is a colorless, odorless, solid substance, soluble in 100 parts of cold and 18 to 20 parts of hot water, and is readily soluble in alcohol and ether. The drug is not affected by any of the ordinary acids, and is very stable. Physiological Action.—Several quite interesting researches upon this comparatively neAV hypnotic have been carried out recently. Smith of London has studied its action on the activity of tissue-change, and also attempted to determine the changes in the drug during its pas- sage through the body. Without taking up space Avith a full consid- 22 338 DRUGS. eration of his method of experimentation, we find that his conclusions may be summed up as folloAvs: In moderate doses the drug is com- pletely changed during its passage through the body into a sulphur- etted organic substance, and the elimination of sulphuric acid is not increased by taking sulphonal. Dr. Smith does not give us the exact nature of tlie substance derived from sulphonal, but promises to inform us further concerning it in a later contribution. Another paper upon the physiological action of sulphonal has been published by Dr. AVil- liam F. Shick of Easton, Pa., Avho has found, by a series of experi- ments, first, that sulphonal Avhen given by the stomach acts very slowly, on account of its insolubility, but that subcutaneously in warm solution it is much more active. The drug was also found to produce a general relaxation of the muscles, and a staggering gait after its hypnotic poAver had passed by. The spectroscope failed to show any changes in the blood. The motor nerves Avere not affected. Shick believes that the action of the drug is exerted upon the higher nerve-centres. He also found a decreased reflex activity, and believes this lessening to be due to stimulation of SetschenoAv's reflex inhibi- tory centre. On the circulation the drug was found to have but little poAver. AVhen sent directly into the blood there Avas produced a slight decrease in arterial pressure, followed very soon after by an increase. Upon the respiration the drug Avas found to act as a depressant when given in full doses. Therapeutics.—Sulphonal finds its place in medicine as a somni- facient or hypnotic, valuable when functioned nervous insomnia is present, useless Avhere advanced disease, such as cardiac trouble, is responsible for the Avakefulness. In insanity it often produces sleep, and is of great service in the various mental disturbances character- ized by lack of sleep and often affecting persons of unsound mind. Sulphonal may be defined very briefly by any one Avho has largely used it or watched the reports made of its progress. This definition is that the drug does possess sleep-producing poAver of moderate amount—not equal to chloral or potassium bromide, but greater than that of paraldehyde—and that it will sometimes succeed where the other hypnotics fail. Administration.—Sulphonal being virtually insoluble in cold Avater, it may be given in large capsules or in mucilage of acacia, so as to be held in suspension until swallowed. The insolubility and bulki- ness of the drug render its use difficult. It is best given in hot water (about 6 ounces), as suggested by Stewart. This makes a solution, and as soon as the liquid is cool enough to be SAvalloAved it should be taken before precipitation occurs as the result of cooling. Sulphonal should be used several hours—say two or three—before the patient retires. If taken late at night, the patient frequently fails to get to sleep until the morning hours. This difficulty is partly avoided by the use of a hot solution, but even then is apt to arise. The dose is 20 to 40 grains (1.3-2.6). Untoward Effects.—AVhen sulphonal is taken in full dose for long periods of time, great sleepiness and Aveariness, with an unsteady gait, develop, Avhich may go on to paralysis of the lower extremities SULPHUR. 339 if the use of the drug is persisted in. In some eases the paralysis is progressive, and in others hvperaesthesia and abnormal sensations develop. In all such cases there is great disturbance of digestion with scanty secretion of urine, Avhich contains an unusual substance. giving this secretion the color of port Avine. In the author's experi- ence sulphonal often. produces heaviness and a staggering gait the day after it is taken. There are numbers of eases of death on record from acute and chronic poisoning by sulphonal. In both classes of cases the death Avas by respiratory failure preceded by deep uncon- sciousness. SULPHUR. Sulphur is a non-metallic element official in three forms in the U. S. P.—namely, as Sulphur Sublimation, or sublimed or flowers of sulphur; Suljd/ur Precipitation, U. S. and B. P., or precipitated sulphur; and Sulphur Lotion, or Avashed sulphur. Much confusion exists among students as to the differences betAveen these various forms of sulphur. Sulphur itself is an element Avhich is prepared for medicinal uses by being heated and sublimed (Sulphur Sublimation), or floAvers of sulphur. Sulphur lotum, or Avashed sul- phur, is prepared in order to get rid of sulphuric acid and other con- taminating substances, and is made from sublimed sulphur. Sulphur praecipitatum is also made from sublimed sulphur, and is more bland and minutely subdivided. Some believe it differs from sublimed sulphur in its therapeutic properties by reason of a small amount of Avater supposed to be present. It is sometimes called milk of sulphur. AAhen sulphur is prescribed for internal use the sublimed sulphur is generally designated. Physiological Action.—Sulphur has little physiological influence over the general system. AVhen taken internally it causes a soft. mushy stool of a yelloAv color Avith a strong odor of hydrogen sul- phide. The drug acts particularly on the skin and mucous membranes. The juices of the intestines break up some of it into sulphuretted hydrogen and sulphides. Therapeutics.—Sulphur is used as a mild laxative, never as a purge. In stricture tie by Henry and others. Under these conditions it should be used in gelatin-coated pill, and a glass of water or milk taken to avoid the burning sensation. In the treat- ment of stomatitis or tenderness of the gums after mercurialization the folloAving mouth-Avash may be used: R.—Thymol.............gr. x (0.65). Sodii boratis............gr. xv (1.0). Aqua?.............. m (64.0).-M. S— Place a teaspoonful (4.0) of this in .] a tumblerful of water and use as a gargle. Thymol has been used for dressing wounds, but is too costly. In summer Aveather it cannot be employed, because of its power of attract- ing flies, Avhich make the patient's life miserable. The dose is |- to 2 grains (0.03-0.1), in capsule or in wafer, and it is better to folloAv its use by a glass of milk to prevent the drug from irritating the stomach. 348 DRUGS. In typhoid fever as much as 30 grains (2.0) in twenty-four hours may be given. If very large amounts (100 grains [7.0]) are taken in a day, poi- soning may result, but as much as this must be used before danger is present. Thymol Iodide. This compound of iodine and thymol, sometimes called aristol, but more correctly dithymol diiodide, has been introduced into medicine for the purpose of substituting iodoform. It does not possess the unpleasant odor of iodoform, and it is stated to be less apt to produce poisoning by absorption. A great deal of contradictory experience has accumulated as to its exact value, but the result of a careful examination of clinical reports is that in some respects it is a better drug than iodoform and in others not so good. Tichhoff and Neisser state that Avhen taken internally thymol iodide is incapable of causing toxiemia, but this can only be true when moderately large doses are given. Upon cocci and bacilli thymol iodide has less poAver than iodoform. In regard to the poAver of this drug in healing Avounds or sores, the decision has been reached that whenever secretion is free it is contraindicated, as the thymol seems to increase moisture. On the other hand, in those instances where in disease of the skin or mucous membrane an undue dryness is present the effect produced is often favorable. Upon lupus little effect is produced unless the sur- face is first curetted. Finely-powdered thymol iodide has been found of very unusual value in the treatment of interstitial keratitis by de Schweinitz and AVallace Avhen dusted into the eye each day. In an ointment of ^ to 1 drachm to the ounce of lard (2.0-4.0 : 32.0) thy- mol iodide may be used in psoriasis, but it is not as useful as is chrysarobin in this affection. TOBACCO. Tabacum, U. S. (Tetb/tcum Folia, B. P.). is the dried leaves of Nicotian// Tabacum, a native of tropical America, but cultivated all over the temperate zone. It contains a liquid alkaloid, nicotine, but does not contain nicotianin, as no such principle exists.1 AVhen smoked it yields pyridine, Avhich is sometimes used in medicine bv itself. Physiological Action—Tobacco in overdose is a nauseating emetic, very depressant in its influence on respiration and the circulation. The pupils are contracted by its influence, the bodily temperature is lowered, and the skin becomes cold and clammy. Upon the motor nerves tobacco acts as a depressant poison. Nicotine is one of the most violent poisons knoAvn, and is almost as fatal as hydrocyanic acid, death having taken place in three minutes after the ingestion of a poisonous amount. The drug, Avhen smoked or chewed to any extent by young per- 1 See author's Prize Essay on Tobacco. Philadelphia, 1885. TRIONAL AND TETRONAL. 349 sons, stunts the growth of all parts of the body, and is very apt to cause in all persons granular sore throat, pharyngitis, laryngitis, and faucitis. Sometimes angina pectoris is developed. " Tobacco heart " is a term applied to a condition of this viscus characterized by disor- ders in its rhythm or poAver, palpitation, arhythmia, and dyspnoea often being present. The treatment of poisoning by tobacco consists in the use of strych- nine to stimulate the nervous system and the respiratory centre, and in the employment of cardiac stimulants, external heat, and atropine. In the mild form of poisoning folloAving excessive smoking, in Avhich slight nausea is felt, the author has found 1 to 2 drachms (4.0- 8.0) of Hoffmann's Anodyne taken in ice-Avater most effective. Therapeutics.—Tobacco is used to relieve constipation by some practitioners, and for this purpose the wine ( Vinum Tabad) is usually employed in the dose of 10 minims (0.65) every night on retiring to bed. The drug has been employed in many affections, such as asthma, intestinal obstruction, and dropsy, but has passed into disuse because the symptoms produced were often excessively severe and very serious to the patient. Applied in solution to pruritus ani and vulva-, tobacco is frequently of service, but absorption may occur and produce unto- Avard effects. It ought not to be used on piles for this reason. TRICHLORACETIC ACID. Trichloracetic Acid is a compound of chlorine and acetic acid occurring in deliquescent crystals and used as a rapid, active eschar- otic upon venereal and other Avarts. A peculiarity in its effect is that it produces a dry scab which speedily falls off, leaving a healing surface beneath. It is also claimed that its action is not folloAved by secondary inflammation and pain. It is used by applying a crystal to the Avart or other growth. TRIONAL AND TETRONAL. These two substances are very closely related to sulphonal, and are practically identical Avith that drug in their effects on the general system. They occur in shining, odorless, colorless plates Avith a very faint taste. Trional and tetronal are used for the relief of insomnia of a functional type, and the sleep produced by these ordinarily comes on in about twenty to thirty minutes after the drug is taken, and lasts five to six hours. The dose is 15 to 30 grains (1.0-2.0). Trional and tetronal are slightly soluble in water and very soluble in alcohol. Advantages in their use are lack of disagreeable taste and the absence of symptoms of circulatory depression. The best way to administer trional or tetronal is in hot broth or tea or Avhiskey. It is Avise to gradually decrease the dose if the drug is taken night after night. Tetronal is more expensive than trional, but sometimes succeeds Avhen trional fails. AVhen trional is taken in full dose for several Aveeks, it pro- duces very distinct alterations in the blood, Avhich are manifested 350 DRUGS. by hsematoporphrynuria—a state in which the urine is dark red or almost black. The drug should be stopped at once Avhen the urine begins to be red. TURPENTINE. Terebinthina, U. S., occurs in tAvo forms—namely, as turpentine derived from the ordinary yelloAv pine (I,inus Palustris) and other varieties of pine, and as Canada turpentine (Terebinthina Canadensis, U. S.) derived from Abies Balsamea, or silver fir, or species of cone- bearing trees other than Finns Palustris. The turpentine derhred from the latter sources is sometimes called "Balm of Gilead." Much confusion often exists in students' minds as to the difference between oil of turpentine (Oleum Terebinthina', U. S. and B. P.) and spirit of turpentine, both of Avhich are the same substance under a different name. This oil is not, hoAvever, the same thing as " tur- pentine," for the oil is distilled from turpentine. The distilled oil is a thin, clear fluid having a peculiar odor and taste, and is irritant to the skin and mucous membranes. It is exceedingly inflammable, should never be placed near a light, and if added to any strong min- eral acid takes fire. When turpentine is spoken of in this book or in medicine gen- erally, the doubly distilled oil of turpentine (Oleum Terebinthina Bectificatum, U. S.) is Avhat is meant unless the contrary is stated. Physiological Action.—Turpentine Avhen taken internally produces a sense of Avarmth in the stomach, a quickened pulse, a Avarm skin, and slightly accelerated breathing. In overdose it may cause intoxi- cation. Upon the circulation it produces a very slight rise of arterial pressure, increased pulse-rate, and increased heart-force. On the nervous system the drug, in large amounts, causes loss of sensation before voluntary motion. The drug is eliminated by the kidneys and lungs, and gives the odor of violets to the nrine. Poisonous doses cause strangury, bloody urine, renal inflammation, and cyanosis, with dilated pupils and gastro-enteritis. Therapeutics.—External Use.—Turpentine is used as a local application for the purpose of producing counter-irritation over any area Avhere deep-seated inflammation exists. Under these circum- stances it is almost ahvays used in the form of a stupe, made as fol- Ioavs : Place a tin cup containing the turpentine in a vessel containing hot Avater, so that the turpentine may be avarmed Avithout coming near a flame. Dip a piece of flannel into very hot Avater and Avring it out in a twisted toAvel, and, Avhen it is so dry that no Avater drips from it, dip it into the hot turpentine and Avring it out again to free it from any excess of the drug. The cloth, while hot, should be applied, and alloAved to remain until discomfort ensues, Avhen it should be Avith- drawn, as it will blister the skin if left on too long. In children and adults turpentine may be rubbed on the chest in bronchitis with much relief, but in the former class it should be diluted Avith sweet oil, half and half, or even two-thirds of oil. TURPENTINE. 351 Internal Use.—Turpentine is used internally as a stimulant of a diffusible type in the course of the exhausting fevers, particularly if any flatulence exists or if any ulceration of the bowels is present. In typhoid fever turpentine stupes, turpentine enemata, and the administration of the drug by the mouth are the best ways to over- come tympanites. At the end of the second Aveek, when the tongue is red, dry, cracked, and brown, the teeth covered with sordes, and tympany is Avell marked, turpentine should be used in emulsion in the dose of 5 to 10 drops (0.3-0.65) three times a day. Again, in con- valescence from typhoid fever, when diarrhoea is persistent and relapses are constant and due to an unhealed state of Pever's patches, turpentine is the remedy par excellence. In intestinal and other passive hemorrhages such as monorrhagia or hematuria, the drug is often of service. Used against the tape-worm, turpentine is given in the dose of \ an ounce to 1 ounce (16.0-32.0), mixed with an equal amount of castor oil. This treatment is a someAvhat dangerous practice, but is efficient. In chronic and well-advanced kidney disease very large doses of poAver- ful diuretics are often required to stimulate the kidneys sufficiently to cause urinary flow, and turpentine may be used under these cir- cumstances. Turpentine is contraindicated 'in any acute inflammation of the gastro-intestinal tract and in acute nephritis. In lumbago the dose of 20 drops (1.3) is said to be very useful, and many have found it of value Avhen inhaled from boiling water in bron- chitis of a subacute or chronic form. In gleet it is given by the mouth to stimulate the genito-urinary tract. Turpentine should be tried in the treatment of purpura hemorrhagica, as it has been found of value. Administration.—Turpentine may be given for the relief of flatu- lence by placing 5 drops (0.3) on a piece of sugar, or in emulsion made by using acacia and a flavoring substance, as folloAvs: R.—Ol. cinnamomi...........gtt. xx (1.3). Ol. terebinthina?...........fzjv (16.0). Mucil. acacise.........q. s. ad f^iv (128.0).—M. S.—A teaspoonful (4.0) every four hours in typhoid fever. A more agreeable preparation, not to be used in typhoid fever, is that recommended by Bartholow, as follows: R .—Olei terebinthina?..........fzj (4.0). Olei amygdal. expres.........f^ss (16.0). Tinetura? opii...........f^ij (8.0). Mucil. acacia?............f^v (20.0). Aqu;e lanro-cerasi..........f^ss (16.0).—M. S.—A teaspoonful (4.0) every four hours for tympanites. AVhen used as an enema the folloAving is useful: R .—Olei terebinthina?..........f^j (32.0). Olei oliva?.............f^jss (48.0). Camphora? ............gr. xx (1.3). Mucil. acacia? ...........f^ss (16.0). Aqua?...............fgx (320.0).—M. S.—To be injected as an enema for the relief of tympanites and to aid in the removal of hardened faces. Stir thoroughly before using. 352 DR UGS The Liniment of Turpentine (Linimentum Terebinthine, U. S. and B. P.) is largely used as a stimulating application to sprains and enlarged joints. Turpentine is of service in ringworm, applied with a brush to the part affected. The folloAving preparations are official in the B. P. : Confectio Terebinthine, dose 1 to 2 drachms (4.0-8.0); Enema Tere- binthine, Unguentun/ Terebinthine* and Linimentum Terebinthine Aceticum. The ointment is used as a counter-irritant and stimulant to the part to which it is applied. The liniment acts in the same Avay when applied to sprains and bruises. UVA URSI. Uva Ursi, U. S., Bearberry, is the leaves of Arctostaphylos Uva Ursi, a Avidely-distributed evergreen shrub. The drug is knoAvn in the B. P. as Uve Ursi Folia. Its active principle is arbutin, some- times called ursin. Therapeutics.—Uva ursi is employed in medicine as a Aveak, astrin- gent diuretic, possessing alterative power over the genito-urinary appa- ratus. It is used in pyelitis, cystitis, and in chronic gonorrhea or qleet. AAThen taken in overdose it escapes from the body as hydro- chinone, making the urine dark-colored or black. Administration.—Arbutin itself is often used in the dose of 3 to 5 grains (0.15-0.35). The dose of the extract (Extractum Uve Ursi, U. S.) is 1 to 4 grains (0.05-0.2), of the fluid extract (Extractum Uve Ursi Fluidum, U. S.) is 2 to 4 drachms (8.0-16.0) three times a day. An infusion (Infusum Uve Ursi) is official in the B. P., dose 1 to 2 ounces (32.0-64.0). VALERIAN. Valerian ( Valerian//, U. S.) is the rhizome and rootlet of Vale- riana Officinalis, a plant of Europe, but cultivated in America. It is official in the B. P. as Valeriana Bhizoma. Its active principle is apparently a volatile oil (Oleum Valerianic, U. S.). It also con- tains valerianic acid. Physiological Action.—A7alerian is a very feeble depressant to the nervous system, tending to produce nervous rest, but in cats it excites sexual activity to a great degree, probably from its odor. A\7hen very large doses are given to man, it causes a sense of Avarmth in the stomach, a slightly quickened pulse, and perhaps nausea and vomit- ing. Still larger amounts produce purging and mental hebetude. Therapeutics.—A'alerian is used alone or in combination with other drugs to quiet nervous females and to relieve nervousness and insom- nia. In hysteria it is often very serviceable, and, combined with morphine, is much used in the treatment of delirium tremens. Administration.—The fluid extract (Extractum Valeriana' Fluidum, VERA TR IN A. 353 U. S.), dose 1 fluidrachm (4.0), and the ammoniated tincture (Tine- tura Valeriane Ammoniata, U. S. and B. P.), dose 1 to 3 drachms (4.0-12.0), are the best preparations for ordinary use. The infusion, Avhich is not official, is given in the dose of a Avineglassful, Avhile that of the simple tincture (Tinetura Valeriana', U. S. and B. P.) is 1 to 3 drachms (4.0-12.0). The dose of the oil (Oleum Valeriane) is 2 to 4 drops (0.05-0.2). An infusion (Infusum Valeriane) is official in the B. P. in the dose of 1 to 2 ounces (32.0-64.0). VALERIANIC ACID. Acidum Valerianicum is an oily, colorless liquid of a strong odor and burning taste, but is not employed in medicine except in the form of its salts, such as the valerianate of zinc, iron, quinine, or ammo- nium, all of Avhich are employed, partly for their sedative effects and partly for their influence as tonics. The dose of Zinci Valerianas is 4; to 3 grains (0.03-0.15), that of Quininee Valerianas, U. S., 1 to 3 grains (0.05-0.15), of Ferri Valerianas 2 to 10 grains (0.1-0.65), and of Ammonii Valerianas 2 to 10 grains (0.1-0.65). Under the name of "the pill of the three valerianates" Goodell recommends the following in nervousness and hysteria : R.—Quinina? valerianat. "| Ferri valerianat. >....... aa ^j (1.3).—M. Ammon. valerianat. ) Ft. in pil. No. xx. S.—One or two three times a day. VERATRINA. Veratrina, U. S. and B. P., is an alkaloid derived from Veratrum Sabadilla, and occurs in a grayish powder, Avhich, if it enters the nose, produces Adolent sneezing Avhich lasts for hours. Physiological Action.—Xervous System.—Veratrine has little effect on the cerebrum, but it does excite the spinal cord and the voluntary muscles, thereby giving rise to tetanic or tonic convulsions, Avhich are never clonic or epileptoid. The dominant action of the drug is paralytic, and the nervous symptoms just named soon give place to paralysis. The muscles lose their contractile power and the nervous centres are depressed. Circulation.—In poisonous dose the heart is sloAved by the drug, greatly Aveakened, and finally stopped in diastole, and is found after death' to be soft and flabby. In smaller doses it at first slows the pulse by stimulating the peripheral inhibitory nerves and the centres in the medulla, but later these parts are paralyzed. It first stimulates the vasomotor centre, then paralyzes it. Respiration.—The drug kills by failure of respiration, due to paralysis of the respiratory centres. 23 354 DRUGS. Temperature.—Veratrine ahvays causes a fall of bodily heat. Poisoning.—The symptoms of poisoning in man are collapse, a pale, cold, Avet skin, pinched features, and a rapid, thready pulse, accompanied by violent vomiting and muscular tremors. Tetanic convulsions may come on and resemble those of strychnine in that they arise from the slightest touch or draught of air; after death the muscles will be found to have lost their irritability. Therapeutics.—A'eratrine is never used internally. It is employed chiefly in the form of an ointment rubbed into the skin over muscular rheumatism and rheumatic joints and over neuralgic nerves. The official ointment (Unguentum Veratr/'nee, U. S. and B. P.) or the oleate (Oleatum Veratrinee, U. S.) should be used, the latter most carefully, as absorption of the drug may take place in sufficient quantity to poison the patient. VERATRUM VTRIDE. Veratrum Viridc, U. S., Indian Poke, Poke-root, or Swamp Hellebore, is an American plant largely used for the purpose of allaying inflammation; it is official in the B. P. under the name of Veratri Viridis Bhizoma. It probably contains a number of principles, the chief of Avhich are, hoAvever, jervine and veratroidine. Veratrum viride is the safest and best circulatory depressant that Ave have for use in adults. Physiological Action.—The physiological action of this drug is to be considered under the effects of its two alkaloids before the com- plete effect is studied. Jervine. AAnen jervine is given in full toxic dose it causes great slowness of movement,- relaxation of the muscles, through which thrills con- tinually run, and finally the animal falls to the ground. A iolent epi- leptiform convulsions may now ensue, but no tetanus is present. The convulsions soon give place to paralysis, and are characterized by their lack of force. Sensation is not affected until the near approach of death brings on anaesthesia. There is no evidence of gastro- enteritis and no vomiting or purging. The saliva is ahvays increased and pours from the mouth. Death results by failure of the respira- tory centres and an almost simultaneous failure of the heart. The heart and circulation are greatly depressed, and the pulse-rate and force are far below their normal rate and strength. The blood-pressure is very Ioav, except when the convulsion pro- duces a temporary rise, but the condition of the vagi is apparently normal. Jervine acts as a direct depressant to the vasomotor centres. The convulsions are due to the disturbance of the circulation at the base of the brain (AVood), and the spinal cord is directly depressed by the action of the jervine on its motor tracts. VERATRUM VIRIDE. 355 Veratroidine. This alkaloid is much more irritating than jervine, and in over- dose causes vomiting and purging. The muscular tAvitchings and convulsions caused by jervine are also produced by veratroidine, but are generally not so severe. It also depresses the spinal cord in its motor tracts. On the circulation veratroidine sIoavs the pulse by stimulating the pneumogastric centres, but finally quickens it if given in very large doses, by paralyzing the peripheral vagi. The following summary, given by AArood, of the circulatory effect of veratrum viride, from a study of its alkaloids, is so brief and terse as to be worthy of insertion here : u Veratrum viride sIoavs the pulse by a direct depressant action on the heart-muscle (jervine) and by stim- ulating the pneumogastric nerves (veratroidine); it lowers blood-pres- sure by an action on the heart-muscle (jervine) and by depression of the vasomotor centre (jervine)." Poisoning.—Veratrum viride, while one of the most poAverful drugs we have, is one of the least dangerous, since it almost invariably causes vomiting before enough of the drug is absorbed to produce serious consequences. The vomiting is partly due to the veratroidine and partly to the presence of an irritant resin. In poisoning, cardiac stimulants, atropine, external heat, the placing of the head below the feet on an inclined plane, and the use of strychnine as a respiratory and nervous stimulant are to be resorted to. Therapeutics.—The chief use of veratrum viride is as a circula- tory sedative in acute, sthenic, or dynamic inflammations. In pneu- monia, pleurisy, acute hepatitis, peritonitis, and cerebritis it is of the greatest value if given at the proper stage, when only congestion or hyperaemia is present. After the onset of the lesions follow- ing this period its use is not only valueless, but malpractice. The only objection to the employment of veratrum viride in peritonitis lies in its tendency to produce vomiting, Avhich is, of course, harmful when the peritoneum is inflamed. For this reason aconite is preferred to Areratrum viride in peritonitis. OAving to its physiological influence veratrum viride bleeds a man into his OAvn blood-vessels, and the indi- cations for its use are the same in inflammation as they Avould be for bleeding. In puerperal fever it has been highly recommended, but must be most carefully employed. AVith a large number of practi- tioners veratrum viride is considered by far the best remedy in puer- peral eclampsia. If given in this condition the dose must be large, as much as 20 to 30 drops (1.3-2.0) of the tincture. If SAvallow- ing is difficult, it may be used hypodermically in half the dose, pro- vided the circulation is carefully Avatched to avoid too great depres- sion. It acts in eclampsia chiefly by its depressant effect on the motor tracts of the spinal cord. It is also of value in excesshre car- diac hypertrophy and in the irritable heart of strong, healthy men. In aneurism Avhere the circulatory disturbance is great and the arterial 356 DRUGS. pressure high the drug may be used, Avith great care, to decrease the pressure and prevent rupture of the diseased vessel. Contraindications.—Areratrum viride is contraindicated in all conditions of depression or exhaustion, and, if vomiting is feared, must not be given in peritonitis or gastritis, as it may cause emesis and in this way disturb and irritate the abdominal contents. Administration.—The drug in inflammation should be given every half-hour or hour, and at least 1 drop (0.05) of the tincture should be used each time in a healthy adult. In the course of two or three hours or less the skin becomes moist or relaxed, the pulse slower and less angry, and slight nausea may be present. These symptoms shoAv that the drug is exerting its influence, and it should now be withdraAvn or in very sthenic cases pushed a little farther. If vomiting comes on before the drug has acted on the circulation, 5 to 10 drops (0.35- 0.65) of laudanum should be given fifteen minutes before each dose of veratrum viride. The bfest preparations to employ is the tincture (Tinetura Veratri Viridis, U. S. and B..P.), dose 1 to 3 drops (0.05- 0.15). The fluid extract (Extractum Veratri Viridis Fluidum, U. S.) is given in the dose of 1 to 3 drops (0.05-0.15). Under the name of Norwood's Tincture a saturated tincture has been sold. It is not official, and ought never to be used. VIENNA PASTE. Potassa cum Calce, U. S., is a milder and more manageable eschar- otic than is caustic potash, and is used for the same purposes. (See Caustic Potash.) WARBURG'S TINCTURE. AArarburg's Tincture is a complex liquid formed by the mixing together of no less than thirteen ingredients. Its inventor, Dr. A\rar- burg, held its composition as a secret for a time, but finally made it public. Since he published the original formula it has been consid- erably altered, and some of the preparations now sold as AArarburg's tincture contain none of the original ingredients. Further than this, some of these ingredients are noAV not obtainable. It ought to be made as follows, if possible: Aqueous extract of aloes........... 28 grai Rhubarb.................448 Angelica-seed................448 Elecampane.................224 Saffron...................224 Fennel...................224 Gentian..................112 Zedoary-root..............• . . 112 Cubeb...................112 Myrrh...................112 White agaric................112 Camphor..................112 Sulphate of quinine......•......1280 Dilute alcohol enough to make 8 pints. ZINC. 357 The coarse vegetable portions of this list are to be ground into a coarse poAvder, and the myrrh and camphor, Avhich have been pre- viously pulverized, added to them. The entire mass, less the quinine, is then digested for twehre hours in a Avell-covered vessel on a water- bath, the alcohol being prevented from evaporating as much as pos- sible. The liquid is now to be strained under pressure and the sul- phate of quinine added and dissolved. Therapeutics.—AVarburg's tincture, next to pilocarpine, is the most powerful SAveat-producer that Ave have, and possesses in addition very remarkable antimalarial poAver. In this last respect it far exceeds quinine as a remedy in pernicious malarial regions for acute attacks and as a prophylactic. Its advantages over quinine rest in its favor- able action Avhere congestions accompany the paroxysm. Administration.—To be of any value AVarburg's tincture should be given according to the folloAving rules: The boAvels of the patient should be first opened thoroughly by a saline purge, and 4; an ounce (16.0) of the tincture should be given in one dose undiluted, no drink being taken. After the lapse of tAvo or three hours a second J ounce (16.0) is given in the same way, and very shortly a profuse sweat appears, Avhich often marks the crisis of the disease, and recovery soon takes place. ZINC. Zincum is not employed in medicine in its metallic form, but in the form of several of its salts, of Avhich there are a large number, each of Avhich will be found under the names of the acids forming them. (See Sulphate of Zinc.) Physiological Action.—Xearly all the salts of zinc are someAvhat astringent, and when taken internally act as depressants to the ner- vous system. Some of them are more irritating than others, such as the chloride and sulphate, Avhereas the valerianate has almost no poAver except so far as the valerianic acid is concerned. All of the salts when taken for a long time in excess produce organic changes in the nervous system, generally represented by a myelitis, which differs from that caused by lead, which is ascending, while that of zinc is transverse. Zinc is eliminated by the liver and kidneys. Chronic poisoning among workers in zinc is rare, but has occurred. The symptoms closely resemble those of chronic lead poisoning. PART III. REMEDIAL MEASURES OTHER THAN DRUGS.- FOODS FOR THE SICK. ACUPUNCTURE. This is a term applied to the insertion of a small pointed instru- ment into the tissues of any part of the body for the purpose of relieving pain, SAvelling, or dropsies. AVhen used in painful affections it accomplishes its best results in lumbago and sciatica, particularly in the former. AVhen treating lumbago in this manner the Avriter takes tAvo darning-needles, places them in boiling Avater to render them aseptic, inserts them one to one and a half inches, and alloAVS them to remain in place for several minutes. They are then sloAvly AvithdraAvn, care being taken to prevent them from breaking off. Often after this treatment the patient can at once move more freely, to his great delight. Kinger has, Avith his usual clear clinical insight, noted that this treatment is more successful in those Avho have bilateral pain than in those Avho have one side affected, and the Avriter has found this statement invariably true. In sciatica acupuncture is less successful than it is in lumbago, but is ahvays to be tried. The needle should be carried doAvn until it reaches the nerve, and perhaps pierces its sheath, and it must be absolutely aseptic. BartholoAv has recommended the use of a hypo- dermic needle for the simultaneous injection of a feAv minims of chlo- roform or morphine. Sometimes the best results are reached from inserting the needle immediately below where the nerve finds exit from the pelvis. In other cases it is asserted that the insertion of a needle on the sound side over a spot corresponding to that Avhich is sore may do good. Acupuncture is useless in acute rheumatism and for the lumbar pain produced by fevers. Sometimes a rhigolene spray may be used to freeze the skin, over the parts with advantage in lumbago or sciatica. Acupuncture is occasionally resorted to for the relief of dropsy, but it is not commonly employed, although it is often a useful meas- ure. AArhen the skin of the limbs becomes so tense Avith an effusion as to endanger its life, the tension should be relieved by incisions, not punctures ; but saline purges are better for the removal of dropsy, if they can be used. Punctures rapidly close and make hard spots, 359 360 REMEDIAL MEASURES OTHER THAN DRUGS. while incisions remain open and permit free drainage. Immediately after the incisions are made the parts are to be dressed Avith cotton previously saturated Avith boric-acid solution and dried, or by absorb- ent cotton sterilized by baking it in an oven. It is hardly necessary to point out that the incision must be made under antiseptic precau- tions. (See Antiseptics.) ANTISEPTICS. The term "antiseptic," as generally used, does not necessarily imply the power to destroy pathogenic germs. Any substance which inhibits the growth of micro-organisms, Avhich destroys or renders innocuous the poisonous products of their action upon the tissues of the body, or Avhich retards or prevents the absorption of such products is properly termed antiseptic. Since germicides necessarily possess antiseptic attributes, they should, strictly speaking, be classed with antiseptics; in this portion of the work, hoAvever, only such drugs as are sufficiently innocuous to allow of their use in the human body or upon its surface will be considered. Some of these—as, for instance, carbolic acid and bichloride of mercury—are efficacious solely from their germicidal properties. Others, and of this class iodoform is the most important and typical example, exert their influence, not upon the micro-organisms, but upon the toxic substances formed by these organisms. Of the long list of antiseptics Avhich have Avithin recent years received warm commendation at the hands of individual Avriters, there are comparatively feAv which have retained the confidence of the profession after prolonged trial. Only these few Avell-proven drugs will be discussed in this article. • Heading the list, and in its germicidal poAver far surpassing all others, is Bichloride of Mercury. Long since the researches of Koch have shoAvn that this salt is efficacious as a germicide in a Avatery solution of 1 : 50,000. He stated, hoAvever, that Avhere albumin was present the bichloride Avas decomposed and rendered inert. The same change Avas observed Avhen solutions were allowed to stand for some length of time, even Avhen distilled water was used as a solvent. By the addition of either sodium chloride or a Aveak acid such decomposi- tion was prevented. From this it MIoavs that under ordinary circumstances solutions of bichloride should be freshly prepared, or, if it is desirable to keep them for a long time, a sufficient amount of sodium chloride should be added to prevent precipitation of the mercury salt. Koch advised that as much salt should be added as would equal the weight of the sublimate. Other observers, however, have advised ten times this Aveight of sodium chloride. Since Avhenever bichloride solutions are used in Avounds or in cavities of the body they are brought in contact with blood-serum or other albumin-bearing substances, care must be taken that the antiseptic powers of the mercury lotion are not destroyed by the decomposition ANTISEPTICS. 361 of its active principle. The poAver of the solution may be preserved by using it in such large excess that the small amount of chemical change has practically no effect, or by combining Avith it, as stated above, an acid Avhich will not in itself be unduly irritating to raAv surfaces. This end is accomplished by tartaric acid. In making up a solution 1 part of bichloride and 5 parts of tartaric acid are added to as much Avater as is needed. Thus, in making up a solution of 1 : 1000 for surgical purposes, the folloAving prescription may be employed: R.—Hydrarg. chlorid. corros......gr. xv (1.0). Acid, tartaric.......gr. xv vel 3J (4.0). Aquae dest.............Oij (1 litre).—M. Bichloride solutions are used in the strengths of 1 : 500, 1 : 1000, 1 : 2000, and 1 : 4000 in the treatment of ordinary Avounds. For the irrigation of large cavities solutions of a strength greater than 1 : 10,000 should rarely be employed, and even these dilute lotions have, Avhen used in the peritoneal cavity, given rise to toxic symp- toms. The 1 : 2000 solution is the one generally employed for steril- izing Avounds and irrigating during operations. The stronger solu- tions of 1 : 500 or 1 : 1000 are used in cleansing the surface of the body. The ordinary method of preparing a surface of the body for opera- tion is as folloAvs : The part is first thoroughly scrubbed Avith green soap and warm Avater, is shavred, and is Avashed again as before. It is then cleansed with alcohol or ether, after which a scrubbing Avith bichloride solution of 1 : 500 should folloAv, and should be continued for at least two minutes. If no surgical interference is immediately indicated, the whole operative region should be enveloped in toAvels Avrung out in a solution of 1 : 1000 or 1 : 2000, and kept thus protected until the sur- geon is prepared to operate. The moment the skin is incised no lotion stronger than 1 : 2000 should be employed, or if the more powerful solutions are used they should immediately be flushed out Avith one of less strength. The dressings, unless some particular form is used, may consist of boiled, bleached, and sun-dried gauze, soaked in a 1: 500 bichloride solution and subsequently Avashed and Avrung out in a 1 : 4000 dilution of the same antiseptic. Xext in order of importance and in efficacy among the antiseptic preparations is Carbolic Acid and its solutions. The particular value of this drug lies in the fact that its potency is equally developed in both albuminous and non-albuminous solutions. Like the mercury salts, its great disadvantage lies in its toxic properties. It is usually used in solutions of 1: 20 and 1 : 40. The carbolic acid of commerce is found in a liquid form, dissolved in alcohol, and represents a strength of about 05 per cent. In making the solution for surgical purposes an ounce of this liquid is added to 20 or 40 ounces of water, accord- ing to the strength of the solution desired. Although carbolic acid is soluble in 15 parts of Avater, this solution does not take place imme- diately, and in making solutions of a strength of 1 : 20 either the water'must be hot or a certain amount of time and considerable agi- 362 REMEDIAL MEASURES OTHER THAN DRUGS. tation of the mixture are required, otherAvise globules of almost pure carbolic acid are deposited in the bottom of the tray or vessel into Avhich the solution is poured, and these, by coming in contact Avith instruments or with the hands of the operator, exert an undesirable cauterant effect. The 1 : 20 solution is used for the disinfection of instruments and the cleansing of surfaces. For half an hour before an operation it is customary to submerge all instruments Avhich Avill be required in a solution of this strength, and Avhen the surgeon is ready to use these instruments the solution is diluted to 1: 40 by the addition of an equal volume of Avater Avhich has been boiled. If a carbolic lotion is em- ployed for irrigation or for cleansing sponges during an operation, it should not be stronger than 1 : 40. A property possessed by carbolic acid, Avhich renders it an unsafe medium for the impregnation of gauze, is its volatility. After an exposure of a feAv hours to the atmosphere it entirely evaporates, leaving not an antiseptic, but simply a sterile, dressing. This fact is utilized by the surgeon in the preparation of the deeper layers of the dressing, which come in immediate contact Avith the lips of the Avound. Since all antiseptics are more or less irritating to raAV surfaces, heal- ing will be promoted by a sterile rather than by an antiseptic appli- cation. By moistening a piece of boiled and sun-dried gauze, suf- ficiently large to cover the Avound-edges, in a carbolic solution of 1 : 20 the antisepticity of this dressing is assured, and in a very feAv hours the heat of the body causes the entire evaporation of all the carbolic acid, leaving a sterile, non-irritating surface in contact Avith the wound. If protective is used or oiled silk is applied beneath the dressing, these materials should be treated with carbolic acid in the same Avay. In addition to its toxic effect upon the patient, carbolic acid greatly irritates the hands of the surgeon, and if used in a strength of more than 1 : 40 causes so much benumbing of tactile sensibility that manipulative skill is seriously interfered Avith. The cracked and fis- sured fingers resulting from the use of carbolic lotions are familiar to all, and at times produce results of far more serious import than tem- porary pain and discomfort: many recesses are provided in the depths of Avhich septic germs may successfully resist the action of antiseptic Avashes. There can be no question that septic poisoning has been frequently due to this fact. Bichloride-carbolic Acid Solution.—Since bichloride, though the most powerful antiseptic, has but little penetrating poAver and is rendered inert by albumin, and since carbolic, though of more feeble antiseptic strength, possesses the very qualities of penetration and non-neutralization Avhich bichloride lacks, it Avould seem natural that the best results might be obtained by a judicious mixing of these two antiseptics. In recent times this procedure has been adopted in many clinics and Avith most satisfactory results. For cleansing the hands and purifying operation areas, in place of a simple bichloride mixture a solution Avhich represents bichloride ANTISEPTICS. 363 1: 500 and carbolic acid 1: 40 is employed. Immediately before ope- ration all sponges are Avrung out from this solution. For flushing Avounds, for cleansing sponges during the course of operation, and for the final soaking of the antiseptic dressing imme- diately before its application, a solution of bichloride of mercury 1: 4000 and carbolic acid 1 : 100 is employed. The method of preparing these solutions is of course exceedingly simple. If crude drugs are used, these are put into a given measure of Avater in sufficient quantity to represent the strength desired, but Avhen, as is frequently the case, these solutions are made up in stand- ard solutions, some thought is required to avoid mistake. Thus, given a standard solution of 1: 2000 bichloride and one of 1: 50 carbolic, mixture of these tAvo would make the lotion customarily employed in clinical practice—h e. bichloride 1: 4000 and carbolic 1: 100. The calculation involved in making this solution from standard lotions of carbolic 1 : 20 and bichloride 1: 1000 is someAvhat intricate, and liable to result in error; hence it is best either to pre- pare the entire solution freshly each time or to keep on hand prepa- rations of such strength that the calculation is easily and quickly made. Iodoform occupies a unique place among antiseptics in having been almost universally accepted and used by surgeons and clinicians, in spite of the fact that its germicidal action has been Avell proved by laboratory research to be practically nil. It is found that nearly all forms of pathogenic germs groAv abundantly upon culture materials the greater part of Avhich is made up of iodoform, and that injections of such germs, mingled Avith large quantities of iodoform, produce the characteristic effect upon living tissues Avith almost as great cer- tainty as though this drug had not been used; furthermore, it has been shoAvn that iodoform is not even sterile, and that as employed by surgeons it was frequently a cause of infecting previously aseptic wounds. In spite of this overwhelming evidence against it the drug steadily groAvs in favor. Kecent researches have explained, in part at least, the reason for this contradiction between experimental and practical results. It has been Avell said that the human body is not a test-tube, and that bacteriological research cannot supplant the evidence of clinical observation. Elaborate investigation shoAved that this drug acted as a powerful antiseptic, not by destroying the germs, but by undergoing a decomposition in their presence, the products of Avhich render the ptomaines, the result of germ-groAvth, inert. In this Avay suppuration is, to a certain extent, inhibited, or if present its disas- trous effects upon the system at large are prevented, since these are due to ptomaine absorption rather than to a direct effect of the micro- organisms themselves. It has been apparently proved that ptomaines, in themselves and Avithout the presence of micro-organisms, can gen- erate pus, but that Avhere such ptomaines are mixed Avith iodoform before infection no pus is formed. If these septic chemical compounds are rendered inert, a poAverful adjuvant to the destructive action of the germ upon living cells is removed, and thus the system is often 364 REMEDIAL MEASURES OTHER THAN DRUGS. enabled to overcome one enemy Avhere tAvo would have prevailed. The fact that iodoform is in itself not sterile is, from a practical stand- point, most important. Fortunately, sterilization is readily accom- plished. A thorough Avashing in a 1:1000 bichloride solution destroys all micro-organisms, and the poAvder, after being Avashed with freshly- distilled Avater, may then be used Avithout fear of producing infection. It will be readily understood from the foregoing that iodoform is of little service in aseptic Avounds; that it becomes of utility in direct proportion to the foulness of discharge ; and that to exert its influence it must be applied directly to the part, It is liable, in suppurating wounds, to form a hard crust Avith the discharges, thus frustrating one of the most important indications in antiseptic surgery—i. e. drainage. Particular care should be exerted to see that the exuda- tion from the surfaces of the Avound has a free exit. As employed in surgery, iodoform, after having been sterilized, is placed in small pill-boxes or Avide-mouthed jars, over the opening of which is tied a single layer of antiseptic gauze; through this the iodo- form is sprinkled as desired over Avound surfaces. Kreolin, or Creolin, a preparation obtained from English coal by dry distillation, has been steadily and rapidly groAving in popular favor, and because of its feeble toxic action is often preferred to car- bolic acid. In addition to its poAverful germicidal effect, it is non- irritant and practically non-toxic. The claim first advanced that this preparation Avas absolutely non-poisonous can no longer be supported, since cases have been reported where toxic symptoms have folloAved its use: these Avere probably due to individual idiosyncrasy, a factor which we can never hope entirely to overcome. It is certainly true that kreolin is the least poisonous of all the poAverful antiseptics heretofore used. As an additional advantage, in place of the harsh, irritating effect produced upon surfaces by carbolic-acid solutions, kreolin exerts an influence very like that of an oily or mucilaginous preparation. The extravagant claims advanced for kreolin in regard to its germicidal property have not been confirmed by bacteriological inves- tigation. In solutions containing albumin it is not efficient as a germ- icide in strengths of less than 1 : 100, its power being someAvhat beloAv that of carbolic acid; since, hoAvever, its toxic properties are much less marked than those of the latter drug, it can be safely used in stronger mixtures, and therefore, for practical purposes, its strength is greater. Kreolin, though insoluble in water, readily forms an emulsion quite as efficacious in its antiseptic properties as a true solution. Since this emulsion is opaque, it is scarcely applicable for immersing and steril- izing instruments, the latter not being readily found. It is admirably suited, however, for cleansing the hands, a 5 per cent, solution neither cracking the skin nor benumbing the sensory nerves. In irrigating large Avounds, cavities of the body, and particularly as a means of preventing sepsis or aborting it in gynaecological Avork, kreolin can be warmly commended. It may be employed in a strength of from 0.2 to 5 per cent. ANTISEPTICS. 365 Barring the opacity of its emulsion in water, it would be the medium par excellence for rendering instruments sterile and main- taining them in this condition during an operation. Among the many antiseptic agents of less importance may be men- tioned Peroxide of Hydrogen. This drug comes in what is termed a fifteen-volume solution. By this it is meant that fifteen volumes of feebly combined oxygen are contained in each volume of the liquid. It is applicable, not to sterile surfaces, but to suppurating Avounds and sinuses. It is alleged that peroxide of hydrogen immediately destrov'S the micro-organisms of pus, converting, in one or tAvo applica- tions, a septic Avound into one Avhich is sterile and Avhich Avill promptly heal. It is used in the strength of from 5 per cent, up to full con- centration. Its disadvantages lie in the fact that it is expensive, that from higher acidity it is often irritating, and that it readily undergoes decomposition. In this latter circumstance, possibly, lies the explanation of its want of popularity, since the preparations vary so greatly in strength that it is impossible to determine to Avhat extent they should be diluted or Avhat may be their potency AA'hen applied. AAxhen this drug is poured into a suppurating sinus or cavity an ebullition takes place, Avhich ceases only Avhen the drug is exhausted or the infected surfaces are rendered sterile. Chloride of Zinc has been extensively employed in some clinics as an antiseptic application. It is used in 10 per cent, solutions, and is applied AA'hen the field of operation is probably infected by pre-exist- ing pus-formation. Although bacteriological research has shown that this agent possesses feeble antiseptic poAver, clinical experience dem- onstrates its great value when applied to infected surfaces. Lately the Sulpho-carbolate of Zinc has to a great extent replaced the chlo- ride, as it is less toxic and irritating and far more potent. For the sterilization of mucous surfaces a saturated aqueous solu- tion of Boric Acid is commonly employed. Double Cyanide of Mercury and Zinc. This is the latest antiseptic prepared and extensively used by Lister. Though it has not become widely popular, Lister's commen- dation of it is so Avarm that a general description of its use is in place. The drug comes to the surgeon in the form of a fine powder. AAThen employed for charging a dressing it is diffused by means of pestle and mortar in solution of bichloride of mercury (1 : 4000) in sufficient abundance to drench the fabric thoroughly, for Avhich 4 imperial pints to 100 grains of the salt will be found adequate. This Avill give a percentage of betAveen 2 and 3 of the cyanide to the dry gauze. The gauze should ahvays be used moist, and if it be prepared for immediate use, as by the dispenser of a hospital, the process of drying may be omitted, and the gauze, after being hung up for a Avhile to drain, is further deprived of superfluous moisture by placing it for a Avhile in a folded sheet. It may afterAvard be conveniently kept moist by wrapping it in a piece of mackintosh cloth. AAhen 366 REMEDIAL MEASURES OTHER THAN DRUGS. obtained dry from the manufacturer it should be moistened again with a Aveak corrosive-sublimate solution before it is used." The advantages claimed for this dressing are that it is not irritat- ing to the skin, and that the antiseptic substance is not soluble, hence is not washed out by discharges. An omission of the details of cleansing the hands of the surgeon and assistants in preparing for an antiseptic operation is scarcely permissible in Avriting upon the subject of antisepsis. The most approved method is as follows: The hands and forearms are thoroughly brushed in hot soap-suds for several minutes, after Avhich the nails are carefully cleaned by a knife and brush, and the washing again repeated; the hands are then washed in alcohol for one minute, special attention being paid to the nails; finally they are soaked for three minutes in a solution of bichloride (1 : 1000), and during the course of the operation are occasionally Avashed in a solution of the same strength. If it is neces- sary to lift a chair, to turn the patient, or to touch any object which has not been previously sterilized, the hands should be enveloped in toAvels wrung out in 1 : 1000 solution or immediately Avashed again. Another method which has been found by Kelly to be the best, bac- teriologically and practically, is to cleanse the hands and nails by scrubbing with hot water and soap, and then to immerse the hands and arms in a saturated solution of permanganate of potassium made with hot Avater. After this the skin is decolorized by immersion in a saturated solution of oxalic acid. Finally, the oxalic acid is washed off with hot sterilized Avater. CLIMATIC TREATMENT. (See Springs and Climates.) COLD AS A REMEDY. Cold, or the rapid abstraction of heat, is a remedial measure that can nearly always be obtained, and is possessed of very great power for good in properly selected cases. At the very first we may divide its use into its local application, for a superficial limited, deep-seated, or distant influence, and its general application for the purpose of affecting the entire body. AVhen cold is applied for its limited and local action it is always used Avith tAvo objects in view—namely, to cause localized contraction of blood-vessels which through inflammation are engorged, so that the parts are reddened and swollen, or temporarily to anesthetize or benumb a nerve-fibre for the immediate relief of pain, and with the hope that the temporary paralysis may ultimately result in such nerve- changes as to produce a cure. For these reasons cold, in some form, is a popular remedy for a COLD AS A REMEDY. 367 burn or sprain or any injury likely to be folloAved by inflammatory processes. In some eases, it is true, hot water or dry heat is equally efficacious, and this fact will be referred to again Avhen speaking of heat. (See Heat.) It may, hoAvever, be' stated, as an almost invaria- ble rule, that the choice of heat or cold is to be governed by the sen- sations of the patient, Avho will generally assert that one of the two is the more agreeable. Cold or heat causes relief of pain in inflammation by producing contraction of the local blood-vessel Avails. As a result, inflammatory exudates do not occur, congestion is relieved, and as the pressure on the nerve-filaments ceases the pulsating pain of inflammation passes away. A very useful remedy for the sprain of an ankle Avhen it is a recent accident is to let the patient sit Avith the foot elevated, Avith a cloth wrung out in ice-Avater or an ice-bag applied over the part affected. In the treatment of localized pain cold is used in a number of Avays, largely depending in their choice on the Avill of the physician and the Avealth of the patient. The simplest, cheapest, and perhaps the most efficient method of using cold is to place cracked ice in a pig's or sheep's bladder, and, after tying the opening to prevent leak- age, to lay the bladder directly on the skin, surrounding it Avith a toAvel, so as to preArent the moisture, which appears on the surface from condensation, from Avetting the clothing. AVhere a very limited and comparatively transient effect is needed, it is customary in hospital and private practice to use a piece of ice sprinkled with a little fine salt, and held against the skin by means of a toAvel in the hands of a physician. Actual freezing can often be produced in this manner very rapidly. AAHiere a more rapid and elegant method is desired, sprays of various very volatile liquids may be driven against the part by an atomizer. Probably the most readily employed of these liquids is ether, which is fairly effective if it is used in a fine spray and driven against the skin in such a Avay as to favor rapid evaporation. Another of these agents is rhigolene, which is one of the lightest and most volatile of the liquid products of coal-tar, and is used in a spray from an atomizer in the same manner as is ether. Chloride of methyl is a liquid of a SAveetish smell and taste, used as a substitute for rhigolene as a local anaesthetic through the intense cold produced by its appli- cation. The fluid is directed against the skin over the involved area by means of a nozzle attached to the cylinder containing it. (See Chloride of Ethyl and Methyl.) It is hardly necessary for the Avriter to repeat that, as the last three applications are very inflammable, they should not be used near a light or fire. Aside from the local effects of cold on inflammatory processes, it is largely resorted to for the relief of neuralgia of a superficial type, and has often been used for the cure of deep-seated neuralgias, as over the course of the sciatic nerve in sciatica. Generally, hoAvever, it is employed in neuralgia of the supraorbital nerve, Avhere, owing to the superficial position of these fibres, the cold can readily penetrate. 368 REMEDIAL MEASURES OTHER THAN DRUGS. The skin should be distinctly whitened and blanched, and even hard- ened, by the cold before its application is stopped, and if one applica- tion does not cause a cure, it may be repeated every day for several Aveeks in obstinate cases. Sometimes cold is used to benumb the skin or subcutaneous tissues in cases Avhere a minor surgical operation is to be performed, and it is undoubtedly superior to cocaine Avhere one wishes to open boils or small abscesses. It is also valuable Avhen the physician is using the actual cautery, and in all these cases may be employed as is indicated above. The local employment of cold for the influencing of deeply-seated organs is a Avell-recognized therapeutic measure of great practical and physiological interest, and is closely associated Avith the subject of counter-irritation. (See Counter-irritation.) According to AVinter- nitz, cold applied to the feet affects the cerebral circulation, cold to the thighs the circulation in the lungs, and cold to the back the cir- culation around about the pituitary region. That these assertions are true Ave do not positively know, but the fact that AVinternitz has reached them by a series of experimental studies indicates their cor- rectness to a great extent, and they also find additional support in the popular and medical confidence in the use of cold to the head and heat to the feet in cerebral diseases. Practically, cold has been employed Avith no small degree of suc- cess in the treatment of pneumonia and pleurisy in the form of the ice-poultice or ice-jacket. The only thing needful for such treatment is a condition of strength on the part of the patient, for it should not be used in adynamic cases. When the ice-poultice is used it is made by taking a mass of finely-chopped ice, draining it of all Avater, and mixing it thoroughly with dry sawdust in sufficient quantity to absorb all the water derived from the ice as it melts. This is then basted into a quilt, so arranged that all of the contents will not sag to the lower border, and wrapped around the chest, the mass being thoroughly covered by a layer of well-oiled silk. Cold has also been highly recommended when used in pneumonia in another manner, and by no less prominent an authority than Niemeyer, Avho speaks of it as follows: " I have made extensive employment of cold in the treatment of pneumonia, and, relying upon a large number of very favorable results, can recommend this procedure. In all cases I cover the chest of the patient, and the affected side in particular, with cloths which have been dipped in cold Avater and wrung out. The compresses must be reapplied every five minutes. Unpleasant as this procedure is in almost all cases, yet even after a feAv hours the patients assure me that they feel a material relief. The pain, the dyspnoea, and often the frequency of the pulse are reduced. Sometimes the temperature goes down an entire degree. My patients often retain this surpris- ing condition of improvement throughout the entire duration of the attack, so that their outward symptoms would hardlv lead one to imagine the grave internal disorder. The relatives of the patient, too, who do not fail to perceive the improvement, noAV readily assist in the treatment to which at first they Avere opposed. In a few cases, COLD AS A REMEDY. 369 and only in a feAv, the use of cold affords no relief, and the trouble- some manipulation for its application increases the distress of the suf- ferers so much that they refuse to keep it up. In such cases I have not insisted upon the further application of cold. An the hospital at Prague every case of pneumonia is treated Avith cold compresses, and, according to the statements of Smoler, it is exceptional for a patient not to feel material relief from this treat- ment. I should only ascribe a palliative influence to their use had not the duration of the disease in many instances been decidedly shortened and the convalescence hastened by means of their energetic and methodical employment. In fact, in but feAv cases have Ave seen the disease delay its departure until the seventh day. Many have improved on the fifth, and a very large number as early as the third day; nay, I have repeatedly found it impossible to keep patients Avith recent pneumonia in the hospital for a longer period than a Aveek. Cold is rightly regarded as one of the most efficient antiphlo- gistics in inflammation of external organs. Its action is directly tonic upon the relaxed tissues and dilated capillaries." In endocarditis, and especially in pericarditis, do Ave find an ice- bag placed over the heart a valuable remedial procedure, for it relieves palpitation and quiets the heart, decreases the pain and diminishes the inflammation. The use of a cold bath for the purpose of increasing the tone of the system is as old a custom as any Avhich Ave have, but, like all other things in medicine, cannot be used Avithout distinct indications for its employment, or. to speak more correctly, the absence of cer- tain contraindications. The most universal exception to its use which Ave find is that class of persons Avith Avhom bathing of any kind, par- ticularly when it is frequently repeated, does not agree. The Avriter is sure that a much larger number of persons belong to this class than is generally recognized, and he has seen cases of nervous exhaus- tion and general loss of vivacity and vitality occur as a result of too frequent bathing. This is the case more especially with daily bathers Avho use cold or Avarm fresh water, particularly if the bath be taken in the morning. Before passing on to a consideration of the physiological action of a bath, and Avhy and when Ave should use it, it is proper to call attention to the fact that a very large proportion of children who are bathed daily are allowed to lie and soak in the tub, and as a result become debilitated and fretful, only to recover Avhen the bath is used once or tAvice a Aveek, and replaced in the interval by a nightly spong- ing off Avith salt and whiskey or salt and Avater. Through practical experience and much experimental research of a more or less reliable character, Ave noAV knoAv that the folloAving phenomena accompany the use of a cold bath in a healthy person with Avhom such a bath agrees: On entering the Avater he shivers, thinks it almost unbearably cold, his teeth chatter, and he gasps if the cold suddenly touches the bellv-wall or an equally sensitive surface. In a moment, hoAvever, reaction sets in, and the extremities, heretofore blue, trembling, and 2-4 370 REMEDIAL MEASURES OTHER THAN DRUGS. covered Avith cutis anserin/i, become Avarmer and flushed. The pulse is increased in force and frequency, and the respirations are deeper and more thoroughly performed. As a result of this each portion of the body receives a more perfect supply of blood and feels rejuve- nated. FolloAving this stage of exhilaration, a third comes on, in Avhich the blueness and depression of the first stage recur in an exag- gerated degree, but this condition does not ensue unless the person remains too long in the water. If he leaves the bath while in the acme of his exhilaration, the stimulus may remain Avith him through- out the rest of the day. The reason for the occurrence of this train of symptoms is not far to seek. The chilliness of the first stage shows that the great abstrac- tion of heat is lowering the bodily temperature, the centres for calori- fication in the body not manufacturing all the heat that is needed for the preservation of the normal temperature. At first the cold drives the blood hurrying into the Avarm recesses of the body, leaving the surface of the body cold; but in a few moments the system is aroused to the recognition of the fact that it must increase its exertions in the propulsion of blood and manufacture of heat, and so, Avith an effort it puts forth all its power, picks up each corpuscle that is hiding from the cold in the internal organs, and, after imbuing it with warmth obtained by increased heat-production in the sources of heat-manu- facture, forces it out to the surface of the body along Avith its fel- lows, which are driven to all parts of the system. This is not a mere figurative way of putting the matter,, for cold ahvays contracts blood-vessels and reflexly stimulates the vital centres to increased activity. When the bath is too prolonged the result of over-stimulation ensues, and the depression of the nervous system and circulation may be sufficiently severe to interfere greatly Avith normal functional activity. Just at this point it becomes clear why persons " catch cold," or, more technically speaking, are attacked by local or general conges- tions. One person who is Aveak may never reach the stage of stimu- lation of which we have just been speaking, because his system has not enough units of force in it to unite and expend them upon the functional activities named, and, as a consequence, the blood, which at the first shock has hurried into the internal viscera, is not driven back to its duty, but, sulking in its retreat like a deserting soldier, alloAvs disaster and disease to ensue because its superior officer, the central nervous system, cannot gather together enough force or authority to make it do its duty. These cases present evi- dences, therefore, of circulatory and systemic depression or have con- gestion of the lungs, liver, or other parts. In the strong person exactly the same state of affairs obtains in the third stage of depres- sion, but only after the strength of the system has been expended in the activity of the stage of exhilaration. Cold salt baths, particularly if they are sea baths, are more stimu- lating and not so relaxing as is fresh-Avater bathing. Cold effusions to the head, and, better still, the use of an ice-bag, COLD AS A REMEDY. 371 have long held a high position in the treatment of meningitis and head injuries, and a hot bottle to the feet and cold to the head will often cause sleep in persons Avho habitually suffer from insomnia. This is particularly the case Avith those persons Avho have Avakefulness from mental ovenvork. On the other hand, eases Avith insomnia from cerebral anaemia do Avell if a cold plunge-bath is taken before going to bed, although in still other cases a hot bath is more efficacious. (See Heat.) The latter instances are not due to anaemia, but to ner- vous irritability, Avhich the heat quiets, Avhereas the insomnia of cere- bral anasmia is relieved by a cold plunge by reason of the increased circulatory activity produced by the bath. A\Then cold is to be applied to the head continuously, it is often convenient to employ a coil made of rubber tubing and so shaped as to fit the vertex. One end of the tubing should reach to a tub of cold Avater on one side of the bed and the other to an empty tub on the other side. By sucking on one tube siphonage is established, and as soon as the liquid has been transferred from one tub, the stream may be reversed and the water passed back again to its former receptacle. The use of a cold bath after a person becomes heated is popular^ supposed to be dangerous. On the contrary, every athlete knoAvs that nothing is so refreshing and so preventive of muscular stiffness after severe exercise and SAveating as a cold plunge- or shoAver-bath ; but he also recognizes the fact that a plunge is all that is permissible, and it is only the person who possesses the healthy circulatory poAver which "will enable him to rebound from momentary depression to increased activity that should resort to such procedures. Cold Avater dashed or sopped against the perineum or the scrotum and the lumbar region is a favorite remedy for nocturnal seminal emissions with some practitioners, and the scrotum may be submerged in a tumbler of cold Avater for a feA\ minutes at night for a similar purpose. A very useful treatment of dysentery is to gently inject into the rectum about one or tAvo quarts of cold Avater—if necessary it may be icy cold ; and a similar application for piles is a useful adjunct to all forms of treatment for these troublesome formations. So highly do some physicians praise this method that the writer has thought it proper to quote from a paper of Dr. J. AVilliam White upon this subject. He says: 'b I desire to call the attention of the profession to a method of treatment which, although not altogether new, is yet not appreciated as, in my judgment, it should be. I refer to a moderately forcible stream of Avater of varying temperature in the treatment of a number of affections of the rectum, anus, and genito-urinary apparatus. The tonic and astringent effect of such a stream of Avater upon any living tissue is, of course, a Avell-understood fact, and has been employed in the arrest of hemorrhage, in the treatment of inflammation, and in various conditions. But it has only been in exceptional cases, and usually by the aid of more or less troublesome apparatus, that it has been used in the class of cases to which I now refer. 372 REMEDIAL MEASURES OTHER THAN DRUGS. ki The bidet, as I have noAV for a few years prescribed it, should be of the variety Avhich can be attached to the Avater-closet seat habit- ually used by the patient. It should have a nozzle capable of throw- ing a stream of about the calibre of an ordinary lead-pencil or a lit- tle less. The head of Avater should be sufficient to make it impinge upon the parts exposed to it Avith enough force to excite there a little sensation of smarting or tingling. That degree of force will, for example, be sufficient to enable the patient to take an enema, or, if a female, to take a vaginal injection. The bidet pipe should be mov- able by means of a handle, so that the stream can be directed against any portion of the external genitals, the perineum, the anus, or the surrounding parts. It should also have connection Avith the hot and cold Avater-supply of the house, so that the water may be used of any temperature which the physician may prescribe or Avhich the sensa- tions of the patient may make desirable. Stopcocks should regulate the size and force of the stream, and should be so placed as to be easily reached by the hand of the individual sitting upon the Avater- closet seat. Such an apparatus can be put in place by any experienced plumber in any ordinary Avater-closet at an expense of from fifteen to twenty dollars, and, in Philadelphia at least, the usual head of wrater obtainable even in third-story rooms is quite sufficient for all thera- peutic purposes. " The diseases in which it may be desirable to use this method of treatment may be divided into tAvo classes : First, those affecting the lower end of the boAvel and its outlet; second, those involving the genito-urinary system. Among the first the most important are hem- orrhoids, internal and external, prolapsus ani, and slight cases of prolapsus recti; pruritus ani and eczema of the margin of the anus should also be included in this group of cases, in Avhich it has noAV for some time been my habit to prescribe the systematic employment, twice daily, of the bidet, one immediately after the daily stool, and for the second time, by preference, just before going to bed. As a rule, in all the mi(hvinter months the ordinary temperature of the Schuylkill Avater is that to be preferred, although I am largely gov- erned by the feelings of the patient in this respect. An enema should be taken at each of these times, the lower portion of the rec- tum being thus thoroughly Avashed out at least twice daily, after Avhich the stream of Avater is alloAved to play upon the affected region for a period of from five to fifteen minutes. The ordinary and useful effect of cool sponging or Avashing immediately after stool in cases of hemorrhoids is by this means enormously increased. Internal hemorrhoids will, under this treatment, in many cases almost entirely disappear, unless they are exceedingly large and have been frequently inflamed or strangulated and badly neglected; external hemorrhoids, even when fleshy, will shrivel' and become scarcely noticeable. " I could detail a number of cases of this character taken from my practice of the last tAvo years. In some instances inAvhich I had been habitually called in, at intervals of a feAv months, in the case of old people, the result has been practically their disappearance from my COLD AS A REMEDY. 373 list of patients; and they speak in the Avarmest manner of the great comfort derived from this simple method of treatment, 11 Perhaps nothing is more distressing among minor affections than the trouble described as pruritus ani, and variously attributed to liver disease, constipation, gastric troubles, latent goiit, uterine disease, parasites, neuroses, and a number of other causes, varying from eat- ing of shell-fish or excessive smoking to alleged hereditary predis- position. There are very feAv practitioners of any experience who have not discovered hoAv difficult it is in any particular case of pru- ritus to assign distinctly the annoying symptoms to any one of these causes. Often the Avhole list may be carefully gone through and eliminated, or the proper remedies may be applied successively, as different theories are adopted, without the slightest benefit resulting. Ointments, lotions, and ordinary cool bathing will be tried in great variety, but Avithout avail, and such patients will often go from one physician to another or fall into the hands of quacks Avhile seeking proper professional relief. My list of cases of this character which I have noAV treated by means of the ' bidet' comprises eight. kk Nearly all my cases have resulted in cure, requiring to attain that end simply different lengths of time of the application of the douche, Avith A'ariations of the temperature of the water and occasion- ally the use of some emollient salve. I have been particularly struck by the fact that these cases include among their supposed causes Avidely distinct conditions, and the uniformity Avith Avhich they have yielded to this simple treatment has led me to regard with suspicion the orthodox etiology of the disease. In procidentia ani and in slight cases of prolapsus recti I have had very satisfactory, though of course less striking, results. In a few instances the trouble almost entirely disappeared, and in all of them it was distinctly relieved. These cases require for their successful treatment a much longer application of the douche, and the Avater should, in my judgment, be at one or the other extreme of temperature—either quite cool or as hot as can be com- fortably borne. u I am quite aAvare that the use of cold Avater in these affections is not in the least a novel plan of treatment; but the method under consideration combines the effects of temperature Avith a sufficient force of the stream, and admits of the prolonged application of the remedy Avithout effort on the part of the patient, Avho is in the most suitable position for this treatment—practical points Avhich induced me to make this mention of my results in rectal and anal cases. " Agnew says of pruritus that among the local remedies frequent ablutions Avith cold Avater should be mentioned, and of prolapsus ani et recti that L in all cases Avhere remedies have proved unavailing, or where patients have declined an operation, much good may be done by douching the parts Avith cold water and applying an oiled com- press ;.' and Allingham says of the same class of cases that ' the fre- quent and bountiful application of cold Avater is to be most strongly recommended ;' but feAv authors, so far as I knoAv, have especially alluded to the method of application by means of a bidet. "My second class of cases includes, chiefly, certain prostatic 374 REMEDIAL MEASURES OTHER THAN DRTrGS. troubles, varicocele, atonic impotence in the male, and pruritus of the vulva or vaginitis in the female. In case of variocele, although I have not succeeded in effecting a cure in any instance by this method, I have certainly seen advancing enlargements of the sper- matic veins becoming stationary, long relaxed and pendulous scro- tums become firm and much smaller, and the mental condition of the patient, Avhich is so important an element in many of these cases, shares in the improvement. In chronic prostatitis, a most intractable and distressing ailment in many instances, it has come to be a part of my routine treatment to order the use of cold perineal douches by means of the bidet, associated with frequent cold enemata given in the same manner; and I believe to-day that if I had to diseard all therapeutic measures but one in these cases, I would retain this one. in a certain number of cases of impotence associated Avith general muscular Aveakness, loss of tone, lack of general strength and vitality. accompanied by imperfect or rapidly-subsiding erections, I have found that the cold douche applied with some force and for considerable lengths of time to the perineum and testicles has been productive of marked benefit. k' In tAvo cases of pruritus vulvae my results have been good, though less striking .than in similar disease affecting the region of the anus. In vaginitis, Avhere the Avoman has sufficient intelligence to learn how to take an injection by means of the bidet, it offers an admirable method of cleansing the vagina, of carrying away thor- oughly all accumulated secretions, of reducing heat and SAvelling, and at the same time of avoiding the frequent introduction into the inflamed canal of a foreign body in the shape of the nozzle of a syringe. My opportunities for observation in this class of cases have been limited, OAving to the disinclination of these patients to procure the bidet, and owing to their irregular habits of life and their fre- quent changes of residence; but I have seen enough of its good results to make me feel confident that it is a valuable addition to our therapeutic agencies. "After all, in every one of the cases Avhich I have mentioned its use is simply the application of the most elementary and common- sense principles to every-day practice, but I am satisfied that this particular method of applying these principles has not received the attention Avhich it merits." Cold in Fevers. The proper manner to employ cold Avater in fever should be thor- oughly understood. It may be used at a number of temperatures, according to the effect desired, such as cool, moderately cold, and very cold. Very commonly in the course of a fever the patient is restless, uncomfortable, and sleepless, yet has not a temperature fraught with any harm. Such a case may be sponged off Avith tepid water or with a little alcohol and water, or salt and Avhiskey, with great benefit in the production of sleep, the reduction of fever, and the advantage of ner- COLD AS A REMEDY. 375 vous quiet. Sometimes the sponging is successful when used only over the aims and legs, but more frequently it should be extended at least to the spinal column. If tepid sponging does not loAver the fever in a given case, then ordinary cool tap-water should be employed ; and it is Avell to remem- ber that the secret of successful sponging lies in the use of a sponge not saturated to overfloAving, but only sufficiently Avet to leave a thin film of moisture on the skin, Avhich cools the patient by its rapid evaporation and does not Avet the clothes and the bed. There are many cases where sponging, even with ice-Avater, fails to reduce the fever, and in these, the fever must be lowered by the "cold pack," as it has been called. The name is unfortunate, as it is indicative of a very severe exposure, Avhich really does not occur. The application is carried out as folloAvs: A small canvas cot should be placed by the side of the bed of the patient and covered by a large rubber cloth, Avhich, by being raised at the head and depressed at the foot, forms a channel for the Avater. Over this, again, is placed an ordinary sheet. The patient, after being stripped, is laid upon this sheet, Avhich is then folded over him, and a fine spray from an ordinary Avatering-pot for flowers alloAved to play upon his body from end to end. The temperature of the Avater depends upon the effect required. The bed should be so arranged that the Avater will not remain in puddles under the patient, but drain off constantly into a bucket at the foot. The sheet being wet alloAVS evaporation to go on, and a rapid fall in the fever results. It is of the greatest importance that the attendant lightly but briskly rub the patient all over Avith the hands, so as to bring the blood to the surface and prevent internal congestions. During this procedure the thermometer should be placed in the mouth or pushed deeply into the rectum, and the fall in the tempera- ture Avatched. As soon as it reaches 101° or 100° F. the bath must cease, lest the fall continue and collapse ensue. On the removal of the patient the surface should be gently dried with toAvels, and the bed-clothing consist of only a sheet, or a sheet and one blanket in cold weather. Above all things, it must be remem- bered that the patient is not to be wrapped up in a blanket, and not only this, but that he must not be placed in a blanket Avhile still in a Avet sheet. The Avet sheet, if surrounded by a blanket, soon places the patient in a typical Russian or Avarm moist bath, calculated to to raise instead of lower the fever. Where sunstroke (thermic fever) is present the patient may have chopped ice applied or be put directly into a bath-tub of ice-water, but in any event the attendants must rub the patient's skin to bring the hot blood to the surface and prevent congestions. Cold water- may also be injected into the bowel in cases Avhere the skin is cold, but the central temperature very high. (See Enteroclysis.) The treatment of rheumatic hyperpyrexia by cold is quite as suit- able as is this treatment of other fevers whenever the hyperpyrexia is so excessive as to endanger life. The presence of pneumonia and bronchitis does not contrain- 376 REMEDIAL MEASURES OTHER THAN DRUGS. dicate the use of cold in fevers, and no fear of " cold being taken " need exist unless the bodily temperature is loAvered below the nor- mal point or to one degree' above it. According to Lieberrneister, intestinal hemorrhages contraindicate the use of cold, but this state- ment has been contradicted by no less a writer than AVunderlich. (For Brand's cold treatment of typhoid fever see Typhoid Fever.) COUNTER-IRRITATION. Counter-irritation is a term applied to the use of substances irri- tating to the surface with which they come in contact, and employed for the purpose of influencing morbid processes in more or less dis- tant parts or of affecting the general system. It has been thought that this method savors of the doctrine of "like cures like," but in reality it is based on sound physiological laAvs. and is so logical as to have-been described by the founder of homoeopathy as useless. The entire basis for the employment of counter-irritation rests upon reflex action, or the conduction of a nervous impulse to a centre, Avhich, when so stimulated, sends out an impulse to the part of the bod)' Avhich is diseased. The use of counter-irritation may be divided into four parts or purposes: The first is for affecting inflammations or congestions; the second for causing the absorption or removal of inflammatory depos- its after true inflammation has ceased; Avhile the third purpose is for the relief of pain ; and the fourth for the effect Avhich can be exer- cised upon the general system by blisters in systemic disease. In the same manner that Ave can divide the indications for coun- ter-irritation into four parts, so can we also divide its forms into three varieties, according to their severity. The most severe are the caus- tics or escharotics, the next the epispastics or blisters, and finally the rubefacients or reddeners. The proper manner of employing a counter-irritant to affect inflam- mations is not to apply it directly to an actually inflamed area, but a little to one side of it or at a spot knoAvn to be connected intimately Avith the diseased area by nerve-fibres. Thus, it is well known that in diseases of the eye the blister should be applied back of the ear, and that in abdominal neuralgia or in pleurodynia the best results are reached, not from the applica- tion of a blister to the spot Avhere the pain is felt, but to the point upon the vertebral column where the nerve at fault takes its exit. The reason for this is that pain is ahvays referred to the peripheral end of an irritated nerve, and pleurodynia or abdominal pain often arises from vertebral disease or inflammation about the spinal liga- ments or the foramina of exit for the nerves. In a similar manner Ave sometimes apply a blister, in the early stages of hip disease, not to the knee or ankle, Avhere the pain is felt, but at the seat of the trouble—namely, the hip. Counter-irritation is contraindicated by the presence of any acute inflammation directly under the spot Avhere it is proposed to place a blister; that is, if any reddening of the skin CO UNTER-IRRITA TION. 377 is present the blister or other form of irritation must not be applied there. If used at all, it must be some little distance away, or a series of small flying blisters should be placed around the inflamed zone. A flying blister is one Avhich is small in area—say as large as a Lima bean—and of comparatively slight action, healing rapidly after its effects have passed by. Among the inflammatory affections in Avhich Ave find counter-irri- tation very serviceable may be mentioned pleurisy, pneumonia, iritis, synovitis (rheumatic or traumatic), cerebritis, and peritonitis (acute or chronic). A host of more subacute or chronic inflammations are also benefited by this measure, some of Avhich are gleet, chronically enlarged joints, and inflamed glands. In all these states the blister, or more rarely the rubefacient, is to be resorted to; and while it is true that nearly all of these conditions are accompanied by fever, and that fever is generally held to be a contraindication to*the use of counter-irritation, blisters undoubtedly do good at such times. In pneumonia or pleurisy, along Avith the use of veratrum viride in the very earliest stages of the disease, a cantharidal blister of the size of a silver dollar should be applied near the spot where the most pain is felt or on the back near the spine. AVhere joints are inflamed the blisters should be at some distance from the seat of the SAvelling, although it is often useful to place the counter-irritant on the inner or outer aspect of the knee-joint if the skin is not reddened. In peri- tonitis the blisters are best applied directly over the seat of tender- ness, and in cerebritis at the nape of the neck. In gleet a little can- tharidal collodion may be painted alonij the under surface of the penis or upon the perineum with great advantage in obstinate cases. AArhere inflammation is chronic and resists cantharidal blistering, then resort is often had to more severe forms of counter-irritation by means of the red-hot—not A\hite-hot—iron, or the use of escharotics, such as caustic potash or soda or arsenic. The reason for using these is that they all cause so much tissue-change in the part that the counter-irritation is very prolonged. Sometimes antimonial ointment is applied constantly until a slough forms, to accomplish the same purposes. For the removal of the products of inflammation Ave resort to can- tharidal blisters or drugs possessing poAveis as local irritants and at the same time as alteratives. Thus, in pleurisy Avith effusion it is very proper to employ a good-sized cantharidal blister if the effusion has a tendency to remain unabsorbed. Some have thought that the absorption Avhich folloAvs is due to the abstraction of serum Avhich takes place in the bleb formed, but this is a mistaken idea, as one often sees an effusion absorbed Avhich far exceeds in quantity the amount of liquid in the blister. Under these circumstances the spot for applying the blister is, as a rule, immediately under the arm, about Iavo or three inches beloAv the axilla. The blister, Avhile it is useful in causing absorption in chronic effusions and deposits about joints, is not so good as are alterative irritants; for example, iodine, Avhich in the form of a thorough application at one sitting until the skin is black—not vcIIoav or red—is often of service. In other cases, 378 REMEDIAL MEASURES OTHER THAN DRUGS. particularly in very chronic states, iodine ointment, alone or with lard, may be rubbed into the parts with advantage, care being taken to stop its use for a day or two as soon as the skin gets red. This same treatment is also useful in treating enlarged glands in the neck and elsewhere. One of the best treatments for epididymitis is to paint the scrotum black with many coatings of a strong solution of silver nitrate or iodine, to insist on total rest in bed, and to resort to the local use of cold. The testicles should also be supported by a suspensory or adhesive strips during this treatment, and aconite given if fever is present. For the relief of pain we very commonly resort to the rubefacients rather than epispastics, since the more moderate applications are equally effective in most instances, and do not leave evil effects behind to remind the patient of his attack. Every one Avho has had stomach-ache and remembers the relief obtained by the use of a mustard plaster or spice plaster recognizes the value of this means of obtaining relief, and it only remains for the Avriter to state that headaches are often amenable to similar treat- ment. These headaches may be neuralgic or due to dyspepsia or to cerebral anaemia or congestion, but counter-irritation Avill neverthe- less do good. If neuralgic, a little menthol or oil of peppermint may be applied over the course of the nerve—which application, if the pain be supraorbital, will require care lest the oil gain access to the eye. For the treatment of pain in the belly or chest or elseAvhere we have four means of producing counter-irritation in the shape of rube- facients : The first is mustard ; the second, capsicum ; the third, the turpentine stupe; and the fourth, the spice poultice. The mustard plaster should be made by mixing mustard flour with warm vinegar or water, and adding varying proportions of ordinary flour to modify its action. If the skin is tender, half mustard and half wheat flour may be employed, or if a child is to be treated the proportion may have to be only one-fourth mustard. The plaster is made by placing a stout piece of paper on a table and putting over it a piece of heavy muslin or linen. On this is smeared the mus- tard, and over the mustard mass is placed a thin piece of linen, which prevents the poultice from adhering to the skin and modifies the burning according to its density. By folding the edges of the paper so that it resembles a picture-frame Ave have at a hand a cheap, effective, and strong plaster, the back of Avhich is supported by the paper. The spice plaster is made by mixing equal parts of allspice, cloves, cinnamon, and nutmegs, and adding thereto one-half part of black pepper. These constituents are made into a homogeneous mass by using a knife-blade to mix them, and are then sewed up in a bag which is quilted to prevent sagging of the contents. One side of the poultice is now wetted Avith warm brandy, whiskey, or vinegar, and applied to the part desired. DISINFECTION. 379 If the skin is tender the proportions of pepper and cloves should be decreased. This plaster may be allowed to remain over the affected parts for hours or even days, and is very useful in the treatment of gastric catarrh and indigestion, particularly that occurring in children. The turpentine stupe (see Turpentine) is not to be alloAved to remain very long on the skin, as it may blister a tender cuticle, and the pepper plaster may be so active as to produce unbearable pain if it is not Avatched. The proper Avay of treating all such burns from counter-irritation is to apply simple cerate, cosmoline, or SAveet oil, to Avhich may be added carbolic acid in the proportion of 1 : 100. The carbolic acid not only acts as an antiseptic, but as a local anaesthetic, while the oil acts as a protective from contact Avith the air. Much difference of opinion exists as to the proper treatment of the blister formed by cantharides. AA'here the blisters are small—that is, the size of the end of a finger—they may be alloAved to break of them- selves, and then be dressed Avith dry cotton; if they are large, the blebs should be punctured at their most dependent part Avith a needle and dressed with dry absorbent cotton, as by so doing the new skin rapidly forms underneath and is soon able to carry on its normal functions. The proper treatment of the blister Avhile it is forming is to apply a poultice, which Avill decrease the pain and aid in the formation of the bleb. DISINFECTION. Before discussing the subject of Disinfection, we must turn our attention to Avhat Ave mean by the terms employed Avhen speaking of this subject in general. At present Ave recognize that the Avord germ- icide is a term applicable solely to agents capable of killing the loAver forms of life, whereas antiseptics are substances Avhich simply render the material Avith Avhich they come in contact so antagonistic or unsuited to germ-development as to render their presence for any leno-th of time impossible, at least in an active state. To use a simile: the killing of the inhabitants of a district by shooting them Avould stop all growth and be germicidal, Avhereas the destruction of crops in these same parts Avould only be antiseptic; or, in other words, the people mio-ht remain, but Avould have to starve to death. (See article on Antiseptics.) AVe noAV speak of germicides as disinfectants, but never of anti- septics as disinfectants if Ave use these terms correctly. " Germicide " and "disinfectants" are therefore synonymous words. From Avhat has just been said it is evident that Ave should ahvays resort to disinfectants rather than antiseptics, for although the latter are good, the former are better. We have three ways of destroying germs which are particularly useful: The first is the total destruction riot only of the germs, but also of their resting-place, by means of fire, which may be used in 380 REMEDIAL MEASURES OTHER THAN DRU'.S. the case of old furniture, mattresses, and similar materials, and Avhich may be extended to everything about the patient if it is necessary to stamp out a brisk epidemic before it can get Avell under Avay. The second is the use of moist .heat in the form of superheated steam, or, better still for common purposes, the use of boiling Avater; and, thirdly, by means of disinfectant materials Avhich have a proved reliability. Moist heat in the form of superheated steam is infinitely prefer- able to dry heat, but as superheated steam cannot be readily obtained, physicians usually direct the clothes to be boiled for at least tAvo hours. Very often the bed-clothes are taken from a sick-room, trailed through the house, and finally deposited at any spot until a conve- nient time for boiling them occurs. This is radically wrong and capa- ble of causing a Avidespread distribution of the disease. In all such cases the bed-clothes should be rolled off the bed in a bundle and com- pletely submerged in a bucket or tub of boiling Avater, or, better still, in a corrosive-sublimate solution of the strength of 1 : 1000, before they are taken from the room. This tub is iioav to be carried at once - to the fire, and the clothes lifted out dripping Avet and plunged into a clothes-boiler in Avhich the water is actively boiling. The lid of the boiler is at once to be put on to increase the heat and prevent the escape of any germs in the steam or in the hot air Avhich arises from the surface of the Avater. The active boiling should be continued for one or tAvo hours, and Avater be continually added to prevent scorch- ing of the contents of the boiler. It is important that food be not cooked on the stove at the time the clothes are being boiled, and no food should be in the room. If boiling cannot be resorted to for any reason, the clothes may be soaked in a 1 : 500 solution of corrosive sublimate or a 1 : 20 solu- tion of carbolic acid, although neither of these is so sure a method of disinfection. The proper care of a room after it has been occupied by a case of infectious disease is of great importance, and is generally sadly mis- managed. Very commonly sulphur is burnt, and this, as usually employed, is perfectly useless, OAving to leaking AvindoAvs and doors, which permit most of the generated gas to escape. To be of any value the burning of sulphur must be preceded by packing the windoAV- and door-cracks Avith cotton or soft paper. Broken roll-sulphur is moistened Avith alcohol, Avhich is then lighted. By far the best method of disinfection is to take all movable objects out of doors into the fresh air, and then to Avash the floor, sills, and casings, using a scrubbing-brush, hot water, and soap. The Avater remaining in the bucket should afterAvard be boiled to kill the germs Avhich may be in it. This scrubbing being accomplished, the same surfaces should be scrubbed a second time Avith a solution of corrosive sublimate (1 : 500 or 1 : 1000), and left wet, so that the salt of mer- cury may remain on them. Cracks and crannies are to receive par- ticular attention. If corrosive sublimate cannot be used, then car- bolic acid (1 : 10 or 1 : 20) may be resorted to. ENTEROCLYSIS. 381 By far the best disinfectant for all diseases is good ventilation. Not only should as much air as possible be alloAved to enter the sick- room, but after the case has vacated the premises the Avindows should remain open for weeks if possible. Fresh air dilutes germs as fresh water dissolves or dilutes dirt. Disinfection of the discharges of the patient is an important duty to be remembered. The urine and faeces should ahvays be received in a vessel containing enough corrosive sublimate solution (1 : 500) to kill all germs, and to prevent their escape into the air or into Avater or food Avhen the discharges are throAvn aAvay. The disinfect- ant should be placed in the bed-pan before, not after, it is used. The bed-pan or chamber should not be alloAved to stand in the room, but be removed and emptied at once in such a manner that it cannot contaminate any Avater or food. Its contents should not be throAvn upon the ground, as the air will dry them and cause the germs to fly in the form of dust anyAvhere and everyAvhere. In very con- tagious diseases bathing or SAvabbing off the patient Avith Aveak anti- septics may be tried. Thus 1 : 10,000 of bichloride of mercury may be used and the patient afterAvard wiped off Avith a Avet towel. The question as to wdiich are the best disinfectant substances is one Avhich has attracted the attention of physicians and original inves- tigators for years. The result of a vast amount of study and experi- ence shoAvs that corrosive sublimate is the best of all disinfectants in the proportion of 1 : 250 to 1 : 500, or even Aveaker, and that for cheapness, activity, and general usefulness chlorinated lime is better still. The disadvantages in the use of corrosive sublimate lie in its ready decomposition, its formation of an albuminate Avhen albumin is present, its uselessness Avhere lead pipes are present, and, above all, its expense. Chlorinated lime depends entirely upon its chlorine for any disinfectant poAver Avhich it may possess. Chlorine gas itself is not readily handled, but the lime enables us to put it Avhere Ave will. It cannot be employed to disinfect colored fabrics, as it bleaches them. A\Thenever chlorinated lime is bought the physician should see that all its chlorine has not departed from it, as most of the material kept in the stores is so old as to be Avorthless. For scrubbing floors, chlorinated lime may be made into a solution by adding a cupful to a bucket of water, and in privies it may be spread thickly ove- the surface of the mass of filth. It is useless to place chlorinated lime around the room for the pur- pose of disinfecting the air, as the amount of chlorine to the volume of air to be disinfected is as nothing. ' Copperas, or sulphate of iron, while largely used as a disinfectant by some persons, is in reality only an antiseptic. ENTEROCLYSIS. Enteroclysis, or the Avashing out of the bowel by means of large md slowly injected clysters for the purpose of medicating or cleans- 382 REMEDIAL MEASURES OTHER THAN DRUGS. ing both the large and small intestine, has within the last few years become one of the most valuable therapeutic measures Ave possess. Not only is it of value for the purposes named, but for the relief of intestinal obstruction, for the preservation of bodily heat by the use of hot Avater, and for the reduction of fever by the use of cold water. The treatment of choleraic diarrhoea in all its forms by enterocly- sis was first used by Cantani Avithin the last decade. The method yielded such good results in his hands that he enthusiastically employed it in a large number of cases, and caused a number of other physicians to use it. The method consists in the slow irri- gation of the large and small boAvel by Avay of the rectum by means of a solution urged on by the hydrostatic pressure of a fountain- syringe. The solution contains as its chief constituents tannic acid, which is added in the proportion of from 1 to 5 drachms to 2 quarts of Avater, Avith IJ ounces of Avine of opium. Carbolic acid is too poisonous, salicylic acid too insoluble, corro- sive sublimate too poisonous and too easily decomposed, to be used in this manner. In some cases Cantani employed a mixture made of Infusion of chamomile-flowers Tannic acid........ Gum arabic........ Tincture of opium ..... Cantani considers that the passage of the ileo-caecal valve is essen- tial for the success of his methods, and if this is the case the report- er's who have failed to obtain satisfactory results from this treatment have probably failed to do more than irrigate the colon. The import- ance of irrigating the ileum is great, since it is in this portion of the alimentary canal that the cholera germs are most active. Bela Angyan of Buda-Pesth in 1886 treated 76 cases of choleraic diarrhoea with 76 recoveries, 85 cases of cholerine with 85 recoveries, 90 cases in the algid stage of true cholera with 58 recoveries, and 211 in a far advanced stage of asphyxia Avith 44 recoveries and 167 deaths. Nor is this treatment by tannic-acid injections founded upon mere em- piricism, for Cantani and others have found that tannic acid, in the strength of 1 per cent., inhibits the growth of intestinal germs in one and a half hours at 98° F., while 4; per cent, in six hours seriously impairs their vitality. Cantani also asserts that tannic acid neutral- izes the toxines formed by these micro-organisms. This treatment therefore contracts the leaking blood-vessels, stops the growth of the bacilli, prevents the absorption of toxines, acidifies the intestine, stimulates the nervous system, Avarms the body, prevents anuria, and avoids collapse. The employment of irrigation of the colon in cases of dysentery is by no means of recent date. It is only, however, Avithin the last few years that this method of treatment has been Avidely employed or considered. Aside from the fact that we can bring medicaments in direct contact with the diseased mucous membranes, there is no doubt Avhatever that the mere passage of Avater at suitable temperatures 2000 parts. 10 " 30 " ENTEROCLYSIS. 383 over the boAvel-Avall is of value, since by this means Ave remove mucus and pus, and so dilute the poisons manufactured by the germs of the disease that their further action is largely inhibited. That the irrigation treatment is of value has been shoAvn by Johnston of Washington, Avho in a recent paper details exhaustively the advan- tages accruing from this practice and the harmfulness of opium, par- ticularly by suppository. This drug, though temporarily causing a decrease in the stools, ultimately increases the trouble by locking in the bowel the very material Avhich we wish removed. As Johnston well points out, our sole object is to keep the colon and rectum clean. If this can be done without the use of antiseptics in the fluid injected, so much the better. In adults the use of irrigation in dysentery should be carefully carried out by means of an inflow and outfloAv tube, the first being attached to a fountain-syringe. The outfloAv tube must be large enough to permit of the liquid leaving the boAvel Avith a readi- ness equal to that of "its infloAV, and must be so straight and patulous as to permit of the fluid carrying aAvay with it any flakes of mucus or other foreign matter from the bowel. The method employed in giving the injection, the temperature of the water, and the gentleness of the operation are exceedingly important, and will be discussed on the succeeding page. The amount of Avater employed in irrigation of the bowel in dysentery is not to be measured by quarts, but by results. It should continue to Aoav in until it comes from the out- floAv tube perfectly clear, shoAving that our object—namely, thorough cleansing of the boAvel—has been accomplished. The best medica- ment to be added to the Avater is boric acid or tannic acid, each of which is harmless and capable of doing much good. The question as to what is the best method of treating a case of intestinal obstruction by other than operative means is one Avhich is of interest to the physician as Avell as the surgeon. Such cases gen- erally come into the hands of the general practitioner first, and it is for him to decide, as a rule, Avhether the surgeon shall be called in consultation. Measures devoted to the relief of the patient Avithout the use of the knife are first to be tried. No one Avho has studied this subject can doubt that enferoclysis is the best form of treatment Avhich Ave can apply. Used properly, there is little danger of its doing harm, and much chance of its accomplishing good. The author is not one of those Avho place much confidence in the reports of cases of volvulus overcome by this means. The true indication for rectal injections is intussusception or obstruction due to impacted fasces. A very important point to be decided in connection "with this sub- ject is the amount of pressure that can be used in the stream of Avater Avhich is employed, the length of time during which the injection may be given, and, finally, the temperature and character of the fluid injected. AVhile it is true that most physicians have a general idea of the correct thing to do under these circumstances, experience shoAvs that when the case stares one in the face the minor points connected with the treatment are not to be ignored. As is well knoAvn, the great majority of cases of intussusception take place at the ileo-caecal valve, and, if not here, in the sigmoid flexure. Pressure by injection is 384 REMEDIAL MEASURES OTHER THAN DRUGS. therefore readily brought to bear on the area involved. A moment's recollection will show that rectal injections are generally performed not only Avith force, but Avith rapidity ; but this is Avrong, as clinical experience and experiments made by Dr. Martin and the author have proved. It has been claimed that certain pressures will cause rupture of the peritoneal coat of the intestine, but avc failed in the dog to produce this lesion by any pressure Ave could employ, since before this occurred the liquid passed through the stomach and mouth. To employ a pressure exceeding eight pounds is, hoAv- ever, distinctly dangerous, not because the intestinal Avail in health Avill not stand this, as a rule, but because it is near the injury line, and if any disease or softening of the boAvel exist, it is almost certain to cause rupture. A pressure of from tAvo to five pounds is, as a rule, as much as may be employed, and this pressure should be obtained by degrees, starting the injection at such a point of pres- sure that it amounts to hardly more than a trickle, and increasing the pressure as the antagonism of the boAvel is overcome. Finally. when the bowel is fully distended up to the point of obstruction, the pressure on the no longer moving column of Avater may be increased, if necessary, to six or eight pounds by raising the bag of Avater. In infants, in Avhom invagination so often occurs, a pressure greater than tAvo pounds is dangerous, and it is of vital importance that the pressure be employed properly, otherwise it Avill do more harm than good in several Avays. As a rule, in our anxiety to give the patient relief at once Ave are inclined to use too much force and too large a bulk of Avater, and think that active force, if such a term may be used, is to be resorted to. Those Avho have seen these cases have learned by experience the harmfulness of such measures, and have also learned how great is the expulsive poAver of the boAvel Avhen it is excited to contraction. If this poAver be brought into activity, it will be almost impossible to inject fluid into the rectum, and, Avorse than all, the muscular fibres of the intussuscipiens take a still tighter grasp on the intussusception. In order to determine the exact amount of pressure permissible in such cases, Dr. Martin and the author carried out a series of experi- ments, and found from the very first that the force exercised is a com- paratively unimportant factor compared Avith speed—that is to say, an injection of tAvo quarts of water, made very slowly, Avas less apt to cause intestinal opposition than one pint rapidly sent into the gut. This is, perhaps, the most important point to be remembered. The dangerous practice of using a Davidson or any other kind of artificial- force syringe in the treatment of this class of cases is to be con- demned. Three unreported cases of rupture of the boAvel and death from the employment of the Davidson syringe for this purpose have occurred, because the amount of force used Avas indeterminable, and because it Avas injected Avith a jerking instead of a constant Hoav. The amount of fluid injected should be large, and if it is impossible to get a large amount into the boAvel, it is probably because the infloAV has been so rapid as to excite intestinal opposition. If, by a sIoav trickle of Avater into the boAvel, gradually increasing the pressure, we are HEAT. 385 unable to give relief in forty-five minutes, it is necessary either to give this treatment up as useless, or else alloAv the liquid to flow aAvay and resort to the measure again in some hours. Practical experience has shoAvn that the second or third injection sometimes succeeds, prob- ably because it is more skilfully given and the first has prepared the Avay for the others, but it is to be remembered that the chances for reduction of the obstruction are best with the first injection if it is properly given. Frequently-repeated small injections are abso- lutely unjustifiable. Finally, the author cannot leave this subject Avithout saving a Avord concerning the temperature of the injected liquid and its constitution. An injection of this kind goes into the very heat-citadels of the body, and if too cold, as it often is, produces dangerous chilling of organs Avhich are ordinarily especially protected from cold by the omental apron and intestines. By repeated experiment Ave found that water at 05° F. lowered the bodily heat three degrees in thirty minutes. The use of colder water than this (52° F.) resulted in death in twelve hours, and the post-mortem showed intense congestion of the colon, Avhich contained bloody mucus. The use of water of too high a temperature is also dangerous, lest it produce heat-stroke. Of course no one Avould use Avater hot enough to produce local harm, yet it is necessary to have just enough heat and no more. Martin and the author proved that the use of water at 115° F. caused in tAventy-five minutes a rise of bodily tempera- ture in the axilla of nearly five degres, and developed marked symp- toms of heat-dyspnoea. The temperature which it is right to employ Ave found to be 101° to 103° F. as the water entered the boAvel, or even as high as 104° F. in the Avater-bag if a long tube Avas used, as under these circumstances the water is rapidly cooled. An interest- ing result of these experiments as to heat is that Avhen cold Avater was used it took four times as long to make the injection as Avhen moderately warm Avater Avas employed. If very large injections are used, a normal saline solution of 7 :1000 (1 drachm to 1 pint) should be employed to avoid the abstrac- tion of vital salts from the intestinal Avail, with consequent passage of Avater into the tissues, making them boggy, according to the laAV of osmosis. In regard to the effect of distention of the bowel by injection on the circulation and respiration, there is practically none, but the pas- sage of large amounts of Avarmed fluid directly into the closed ab- dominal cavity causes death rapidly. HEAT. Heat is used locally for a number of purposes in the same manner as is cold, and, as Avas stated in the article on Cold, the choice of heat or cold in the treatment of any acute form of inflammation depends almost entirely upon the Avish of the patient, Avho generally can tell at once Avhich will give him the greater comfort. 25 386 REMEDIAL MEASURES OTHER THAN DRUGS. In sprains of the ankle nothing compares to a hot foot-bath pro- longed for hours, the object being to decrease the pain and swelling, thereby regaining the use of the limb. To carry this out effectively, a piece of rubber tubing of small size should be led from a wooden bucket, which-, being a bad conductor of heat, prevents the water from being rapidly chilled, to a sink or large tub near by, when by starting the water by suction a continuous but very small stream can be made to flow from the bucket, Avhile by means of another sim- ilar arrangement running either from another tub—or, better still, from a hot-A\ater spigot—a small stream of hot Avater continually enters to take the place of that AvithdraAvn by the first siphon. Under these circumstances a very constant temperature of the Avater can readily be maintained. The high degree of heat which can be borne by gradually increasing the temperature of the Avater in the supply- tube is very extraordinary, the favorable results obtained being in direct ratio to the height of the temperature. BetAveen these soak- ings the part should be dressed Avith lead-Avater and laudanum, and rubbed noAV and then with camphor liniment containing laudanum. In spasmodic affections involving either striped or unstriped mus- cular fibre the local application of heat is a very useful means of relief. Sometimes in lumbago or muscular stiffness in other parts of the body the use of an ordinary laundry iron over the affected part Avill prove of great service, the skin being covered by several layers of newspaper to afford a smooth surface over Avhich to pass the iron and to protect the parts from too great heat. In chordee the best means for rapid relief, other than the use of drugs or general relaxants, such as amyl nitrate, is to steep the penis in hot water. A hot sitz-bath before going to bed is a good prophy- lactic against this painful complication of gonorrhoea. In croup of the spasmodic type the local application of a hot com- press, made by wetting spongiopiline with hot water, is very useful, or, if spongiopiline cannot be had, several layers of flannel should be wetted, placed on the neck, and covered with cotton and oil-silk so as to prevent the roll from becoming chilled. Where attacks of dysmenorrhea depend upon spasmodic closure of the cervix, with simultaneous spasm of the fundus uteri, a hot sitz- bath or vaginal injection is useful, and this treatment is also of value where uterine congestion results in leucorrhoea or a sensation of weight in the pelvis. Sometimes attacks of torticollis may be sub- dued by applying hot compresses to the sterno-mastoid muscle. In universal or partial spasm of the body, as well as that repre- sented by chorea, a hot pack is of great service, and it is to be used in the following manner: The child, having first been stripped of all clothing, is placed upon a bed which is covered by a rubber blanket, and immediately wrapped in a woollen blanket which has been dipped in hot water and the excess of water wrung out of it. Over this Avet blanket is immediately wrapped a dry one, to retain the heat, and very soon the patient begins to perspire freely. Care should of course be taken that the temperature of the patient does not rise too high before SAveating comes on. This hot pack will sometimes quiet a case HEAT. 387 of chorea Avhich has resisted all forms of treatment so far as drugs are concerned. Cases of insomnia are often benefited by a similar expedient, and mild cases of sleeplessness will occasionally rest quietly after an ordinary hot bath. A Avet pack Avhich speedily becomes a warm one is used in cases Avhere, during the course of an eruptive fever, the eruption fades and it is desired to bring it out on the surface. It is also useful.in those cases of severe chorea in Avhich the child can stand the first shock of the cold. It consists in Avrapping the child in a cold wet sheet and over this Avrapping one or tAvo blankets. In a feAv minutes the sheet becomes heated from the body, and the SAveating Avhich results is profuse. Cold should be applied to the head to relieve cerebral hyperaemia and to prevent overheating during this treatment. The use of heat in tAvo forms has been and is largely used at present for medicinal purposes, Avhen the skin or kidneys are torpid, to aid in the elimination of impure and effete materials from the blood and tissues. These tAvo forms of heat, the dry and the moist, are commonly called the Turkish and Russian baths respectively, and may be taken under home arrangements or in one of the establish- ments found in all large cities. The first of these is in the form of dry heat, the second is moist heat. The Turkish bath consists of a series of rooms ranging in tem- perature from 100° F. to 150° F. or more, into Avhich the individual passes successively until the hottest room is reached. In each cham- ber he lingers until the system becomes accustomed to the high tem- perature, and perspiration is Avell established before he enters the hottest room, Avhere he remains for a varying length of time accord- ing to the advice of his physician or his own whim or comfort. The rule governing his stay is that he must leave it at once if any sense of oppression is experienced or if perspiration does not Aoav freely. Sometimes a glass of cold water taken at this time causes a sudden profuse SAveat, and also relieves any overheating by abstracting many units of heat. The cold Avater in the centre of the body causes con- traction of the blood-vessels in these parts, and the blood, rushing to the surface, causes the SAveat-glands to pour out their secretion. FolloAving the stay in the Avarm room, the individual passes into still another chamber, where he is shampooed from head to foot, Avell rubbed, and the blood made to circulate through the skin. The shoAver-bath is then used, at first hot or Avarm, and finally changed to a dash of cold, or, better still, the patient plunges into a long tank, SAvims to the other end, and is there met by an attendant Avho rapidly dries his skin, Avraps a cover round him, and shoAvs him to a lounge, Avhere he is supposed to recline and sleep for an hour or less. The air of this sleeping-room is at the ordinary temperature of a living- room. Reviewing for a moment the effects of this bath, we find that the first two-thirds are devoted to the opening and stimulation of the pores of the skin, Avhile the last third is devoted to the contraction of these pores and their supplying blood-vessels. In other words, it 388 REMEDIAL MEASURES OTHER THAN DRUGS. is necessary to use the cold to prevent gradual chilling of limited areas, Avhich Avould result in internal congestion. If the patient receives a cold douche, the natural rebound prevents congestion of a permanent nature, whereas if he is exposed to cold a long time, these stagnated areas become permanently diseased. The physician must always remember that this cold douche or plunge is a sine qua non, and that a rest after the bath before dressing is almost equally important. If the patient is too Aveak to bear the cold, he must not use the bath. The indication for the Turkish bath as a medicinal measure is any condition of the emunctories of the body Avhereby effete matters are not properly eliminated, as in Bright's disease in its various forms. The increased action of the skin not only casts off impurities for the time being, but frequent repetition of the bath causes functional hypertrophy of the sweat-glands, and eventually enables them to do more A\rork, or, in other Avords, to cast off an increased quantity of effete material. As a consequence of this the patient is able to avoid uraemia or other evidences of Bright's disease, and, employing the normal epithelium still left in the kidney for constant use, uses the bath once, tAvice, or thrice a Aveek with the object of abstracting the excess of impurities Avhich the impaired kidneys cannot remove. The frequency of the bath depends, therefore, upon the rapidity Avith Avhich the effete materials accumulate. In a case of Bright's disease the patient should not attempt to use the room containing high heat at first, and should be accompanied by a medical attendant to Avatch for untoAvard effects, particularly if the heart is diseased or uraemia is already shown by headache or other signs. If SAveat- ing does not come on at once, danger is at hand from acute uraemia, renal and cerebral congestion, or heat-stroke. Not only is the Turkish bath useful for kidney disease, but it is often of great service in rheumatism. The acute form of rheumatism is rarely so treated, because cardiac complications often forbid expo- sure to heat, and fever is generally present. In subacute and chronic rheumatism the case is different, and the enlarged joints or inflamed muscles yield like magic in some instances to such treatment. Fur- ther than this, the muscular stiffness following prolonged or severe effort can be so avoided, and neuralgia depending upon rheumatic or gouty taint may be relieved by the hot-air bath. Acute colds affecting the head or elsewhere, if taken at an early formative stage, can often be aborted by a good Turkish bath, and when further developed are often greatly relieved by the same means. If, however, congestion of the lung, pneumonia, or chronic bronchitis, Avith emphysema or a dilated weak heart, are present, the bath may be dangerous. In acute pharyngitis, in Avhich the pharynx feels like a raw surface or ".as if it Avere filed or scraped," the bath will give relief in many instances. Sometimes in suppression of menstruation from cold the Aoav may be restored by a Turkish bath. Some persons complain that they are ahvays catching cold upon the slightest provocation and apparently Avithout cause. One class HEAT. 389 seem to have delicate mucous membranes readily susceptible to irri- tation and inflammation ; the other have dilated or relaxed peripheral capillaries, Avhich readily alloAv the blood in them to become chilled, and the individual consequently suffers from internal local congestions. Tavo separate means of treating such cases exist. The first set will do Avell on minute doses of arsenous acid (grain y^ to -gL) three times a day, used for Aveeks; the second will be cured of their habit by the use of a Turkish bath tAvice or thrice a Aveek, since by this means the peripheral capillaries are toned up and made more active. The Turkish bath, as thoroughly carried out in large cities, is not obtainable for those living elseAvhere, so it is Avell to describe a home modification Avhich, Avith attention to detail and care, may pnwe almost, if not quite, as effective a remedy. The patient is placed upon a chair, naked, and under the chair a small alcohol lamp is put, Avhich is lighted. The individual is noAV Avrapped thoroughly, chair and all, Avith one or tyvo large blankets, and the heat of the lamp soon causes profuse SAveating. Many cases are, hoAvever, on record Avhere the lamp has been upset and the patient badly burned. The best Avay is to have the lamp a little to one side and its flame immediately under the mouth of an inverted funnel attached to a piece of tin tubing, the free end of Avhich is placed under the blanket, so that the hot air and vapor may surround the bodv^. If the tube be covered Avith cloth, the loss of heat is slight and the danger of burning the patient is removed. If this is not practicable, several Aery hot bricks or stones, thoroughly heated in an oven, may be placed under the chair, or small heated logs may be substituted. AAhen the patient is too feeble to leave the bed, then it is wise to place an alcohol lamp at the foot of the couch, with an inverted funnel attached to a tube Avhich passes under the bed-clothes in such a Avay as not to bring the hot air directly against the skin of the patient. The bed-clothing may be slightly raised to alloAv the hot air to enter. This is a valuable mode of using external heat in cases of shock. The vapor of the alcohol lamp tends to sAveat the patient. The Russian bath differs from the Turkish in that the heat used is moist, not dry. As a consequence the danger of heat-stroke and similar states is much increased, because eAraporation from the skin does not go on so rapidly and the body is not cooled so Avell in con- sequence. In its place the patient may be given a Avarm pack, Avhich consists in Avrapping him in a sheet and surrounding him Avith large blankets Avrung out of Avater as hot as can be borne, which are in turn covered with a dry blanket to prevent cooling. (See page 386.) This method of treatment is useful in the same states as is the Turkish bath, but is more rarely used. The Avarm pack just named is also employed to develop the rash of any of the exanthematous fevers Avhen it is suppressed by cold or is not " Avell out " on the skin. The temperature of the patient must be Avatched, lest he fails to have SAveating and develops heat-stroke in consequence. A thermometer should be kept constantly under the tongue during the use of the pack. 390 REMEDIAL MEASURES OTHER THAN DRUGS. The hot moist bath can also be obtained by placing a patient on a Avicker chair under Avhich is placed a bucket of hot water. The patient is surrounded by a blanket, and a hot iron or stone is put into the Avater, causing the development of a great amount of steam. A valuable method for using moist heat in a mild form is the "bronchitis tent." (See article on Bronchitis.) AArhenever the Russian bath is used, except in the exanthematous fevers, it should be followed by a cold douche. Although these baths have been used in the treatment of cases of heart disease to relieve dropsy and renal engorgement, they are not safe and should not be generally employed. All acute or chronic diseases of the lung, except acute bronchitis of a mild form, contra- indicate their use. Kalashnikoff has made a series of observations on the therapeutic effects of heat on syphilis, and especially on syphilitic eruptions, his patients being inmates of the St. Petersburg Lock Hospital for AVomen and Children. The heat Avas applied, Avhere possible, by means of partial hot-air baths to the affected part for half an hour tAvice a day, the diseased area being enveloped in hot flannel immediately afterAvard, and remaining so protected until the next hot-air bath. The temperature never exceeded 116° F. (46.6° C). AAThen the eruption was on the back or neck or on some part Avhich could not be inserted in a hot-air chamber, India-rubber hot-water bottles or tubes, through Avhich hot water Avas kept flowing, Avere employed. AArhen both arms or legs were affected in a symmetrical manner, the treatment was confined to one side, the other being left untreated for the purpose of comparison. The results shoAved that the heat treatment acted very energetically and beneficially on syphilides, both Avhen employed alone instead of mercurials and iodides, and also when used in conjunction Avith these remedies. Often heat proved beneficial Avhen the ordinary specifics had failed. Among other observations it Avas noted that hard chancres healed and the induration disappeared in from eight to sixteen days ; roseola and papular erythema disappeared in from four to eight days; various forms of papular and impetiginous syphilides, Avith marked pigmenta- tion, disappeared in from eight to tAventy-one days; non-ulcerated tubercles and gummata disappeared in from seven to twenty-four days, but those Avhich had already begun to ulcerate required from one to six Aveeks; periostitis Avas cured in from ten to tAventy-four days; ostoses were not affected; syphilitic ulcers, consequent on the break- ing doAvn of gummatous periostitis, required treatment of from six Aveeks to three months or more, Avhile necrosis of bone frequently required many months' treatment before the sequestra could be got aAvay. HYPODERMOCLYSIS. Hypodermoclysis is a method of supplying fluid to the body to replace that lost through excessive purging as in cholera, or in cases of hemorrhage. Further, it may be used to Avash from the body various impurities circulating in the blood or other liquids and to INTRAVENOUS INIECTION. 391 flush out the kidneys. It consists in the introduction into the subcu- taneous tissues of normal saline solution, Avhich is rapidly absorbed by the vessels. As is Avell knoAvn, a quantity of liquid equal to four times that of the normal amount may be passed directly into the veins Avith- out producing a rise of blood-pressure, and experiment has shoAvn that Avithin fifteen minutes after the fluid Hoavs into the subcutaneous tissues an increased Aoav from the kidneys takes place. It is not safe to infuse a greater quantity of liquid than 1 drachm to each pound of body- weight in each fifteen minutes, as, if this amount is exceeded, the accumulation of the liquid in the system is so great that the tissues become bathed and finally droAvned, because the kidneys cannot excrete the liquid fast enough. In the best article on this subject yet published in this country, Hildebrand of San Francisco carefully indicates the limits to Avhich the method may be carried, and shows that if the pro- portions already named be preserved, the operation of hypodermoclysis of normal saline solution may be prolonged indefinitely, and that as the process goes on the urine becomes paler and is loAvered in specific gravity until it is practically identical Avith the infloAving stream. To carry out the operation the sterilized liquid to be infused—namely, 7 parts of sodium chloride to 1000 parts of Avater (3| grains to the ounce)—is placed in a glass jar Avhich is absolutely aseptic, and to Avhich the air only gains access by means of a glass tube filled with sterilized cotton. From the lowTer part of the vessel leads a tube to Avhich is attached a trocar also rendered absolutely sterile. The skin over the place Avhere the liquid is to enter is to be rendered absolutely sterile, and the trocar is then inserted into the subcutaneous tissues of the thighs, or, preferably, of the abdomen, and the liquid alloAved to Aoav at the rate named, the pressure being obtained by raising the con- tainer two or three feet above the belly-wall. As the liquid enters a SAvellinc appears in the subcutaneous tissues, Avhich soon disappears after the infusion ceases, and is much aided in its absorption by the use of massage. AA^hen hypodermoclysis is employed after hemorrhage the results are often extraordinary, and Cantani, Avho has used the method to overcome the drying of the tissues in cholera, praises it most highly, as does also his critic, Oser. The cyanosis decreases rapidly, the pulse improves Avonderfully, and the respirations are no longer dif- ficult. Sahli of Berne has used hypodermoclysis Avith very good results in the treatment of uraemia, and he thinks that not only are the poisons Avashed out of the system by this method, but in addition that the dilution of the poisons prevents them from acting so forcibly. In septicaemia, diabetic coma, and similar states this method of treat- ment should be employed and results carefully recorded and reported. In cases of surgical shock warm saline fluid used by hypoder- moclysis is often of great service. INTRAVENOUS INJECTION. Intravenous injection is a method which is to be employed only under extraordinary circumstances and Avith only a feAv drugs. Thus 392 REMEDIAL MEASURES OTHER THAN DRUGS. in the case of snake-bite it may be advisable to resort to such an injection of diluted aqua ammonia or ether, or even Avarm brandy or Avhiskey. Under these circumstances the injection should be made into a A^ein in the leg, rather than one in the arm, as the drug under these circumstances does not reach the heart in so concentrated a form and cardiac depression is thereby avoided. The objections to intravenous injections are several. In the first place, the veins are apt to be collapsed and hard to find, and it is still more difficult to puncture one Avithout wounding the opposite Avail of the vessel. Again, phlebitis is a very probable sequel, and thrombosis and embolism are by no means impossible. It is needless to say that the solution Avhich is injected into a vein should ahvays be of a neutral or alkaline reaction in order to avoid coagulation of the blood. (See Transfusion.) KATAPHORESIS. By the term " kataphoresis " we mean a method resorted to by physicians having for its purpose the introduction into the body of drugs through the influence of electricity. Correctly speaking, kata- phoresis is an osmosis of medicaments through the tissues, the osmosis being carried on by the galvanic current and the drug being carried through the tissues betAveen the two poles. Ojiinine, iodide of potassium, the various soluble salts of mercury, and chloroform and ether may be so used. The ordinary sponges or absorbent cotton tips of the electrodes may be saturated Avith the medicament to be used, and the constant current employed, the current being reversed every few minutes. The positive pole of the battery is placed over the affected part, and the negative at a little distance away. In cases of neuralgia, chloroform and alcohol, of each one-half, or even pure chloroform, may be employed, and in syphilitic nodules, Avhen the patient's stomach cannot bear drugs, kataphoresis Avith iodides over the part affected may be resorted to. The iodide of lithium is commonly employed in the strength of 5 per cent, in these cases. The strength of the current depends upon the size of the electrodes and the sensations of the patient. It is not necessary to use a stronger current than the patient can bear Avith comfort. LAVAGE. This is a term applied to washing out of the stomach in cases of gastric dilatation, fermentative dyspepsia, and more rarely in cases of gastric carcinoma. It is particularly valuable in the two first- named conditions, not merely for its curative poAver, but also to rid the stomach of mucus and render it clean before fresh food is placed in it. Originally proposed by Epotius in 1863, it has been most widely employed in children by Epstein, who in one article alone records it's LAVAGE. 393 employment in 286 cases of gastric disease in infancy, the patients being less than one year of age. Epstein employs a No. 8 or a No. 10 Nelaton catheter for the tube, and Avarm Avater holding in solution a little benzoate of magnesium or boric acid, the latter being resorted to chiefly when fermentation- and decomposition-products are present. If none of these conditions are present, ordinary water will usually suffice. The liquid employed should always be warmed. Others—as, for example, Lorez—use the ordinary catheter, of the size knoAvn as No. 13 or No. 15, in children, but for an adult a tube should be used of at least four and a half to five feet, of which eighteen inches pass into the mouth, the remain- ing portion reaching to the basin Avhen lowered to allow siphonage. The question as to the variety of tube to be employed is a vital one, since a poorly-devised apparatus not only gives no relief, but disgusts both the patient and the physician Avith the technique of the method. The tube should be more like a holloAv bougie than a cathe- ter, in order that its calibre may be great enough to carry off some of the semi-solid materials present. If this rule is not carried out, two evil results follow: In the first place, the tube and its apertures rapidly, or even at once, become clogged; secondly, the liquid is drained away, leaving behind a mass Avhich is semi-solid, to be sure, and less bulky, but Avhich is nevertheless the quintessence of the nastiness of fermentation, and quite as qualified to leaven any fresh food on its entrance as the liquid Avould be. The holes in the gastric end of the tube should therefore be large enough to take in fairly large masses. In some cases the ordinary siphon may be used, but Avhere there is any solid food or resistance suction by means of a stomach-pump is necessary. The best tube is one of red Para rubber Avith a closed end and lateral holes, No 10. The methods by which lavage is employed, further than those we have named, are as folloAvs: The tube should be passed back- ward against the roof of the mouth, so that by following the curve of the hard and soft palates it is directed into the pharynx and oesophagus, and then by gentle pressure forced on doAvn into the stomach. At the same time the patient should be directed to SAvallow. The mucus in the throat sufficiently lubricates the tube, and oil is to be avoided. If gagging is excessive, the pharynx maybe first painted with cocaine. The irritability of the pharynx usually rapidly disap- pears, and it is surprising how quickly the patient may become accus- tomed to the operation, and submit to it Avithout any feeling of dis- comfort. After the tube has reached the stomach a small funnel is to be fitted in its external end, Avhich is then held above the head of the patient Avhile water prepared in the way Ave have mentioned is poured into it until the stomach is filled, Avhen the funnel end is Ioav- ered and the stomach is emptied by siphonage. The stomach-pump has one very serious disadvantage, Avhich is present Avith even more force in the case of a child than in an adult— namely, the danger of injury to the coats of the organ. This appa- ratus is also more costly and cumbersome, and for children the siphon is poAverful enough in its action to take aAvay all excuse for the use 394 REMEDIAL MEASURES OTHER THAN DRUGS. of the more complicated apparatus unless the contents of the stomach are in bulk. It is particularly necessary in children, if a catheter is used and on account of the lack of intelligent aid and their liability to gulp, that every care should be taken that the tube does not slip entirely out of reach into the stomach; and for the prevention of this danger a string should be attached to the external end of the catheter before it is introduced, and the tube should ahvays be at least thirty inches in length. LEECHING. Leeching is a method of abstracting blood for the purpose of relieving local inflammations or acute congestions. There are two forms of leech commonly employed in medicine, both of which are imported. A small leech is found in many streams in the United States. Leeches, after attaching themselves to the skin by means of their sucking apparatus and teeth, secrete a liquid which prevents coagulation of blood, and this accounts for the persistent hemorrhage sometimes seen after a leech-bite. Therapeutics.—The reasons for using venesection or depletion have already been considered, and we can therefore pass directly to the uses to Avhich leeches are put. In cases of meningitis they may be applied to the temples or to the nape of the neck, and in the treat- ment of SAvollen joints, such as occur after sprains, they are useful. In orchitis they should not be placed upon the scrotum, but on the perineum. In conjunctivitis or inflammation of the eye they should be applied upon the temple or back of the ears, not upon the lid itself. Employment.—Leeches if singly applied may be placed on the skin under an inverted Avineglass or under a large pill-box. If they will not take hold, a, little SAveetened milk may be placed on the skin or a drop of blood extracted from the finger may be placed there. In all cases the skin should be carefully washed before the leech is used. AAThen the leech has taken enough blood, it can be made to let go its hold by sprinkling it Avith salt. Each leech will take about 1 drachm of blood. Leech-bites should be Avatched lest prolonged consecutive bleeding exhaust the patient. In case of such an accident styptics are to be employed. As leech-bites make permanent scars, the ani- mal should not be applied on the face or other exposed surface. REST CURE. The rest cure, so called, is a method devised and elaborated by Dr. S. Weir Mitchell of Philadelphia for the relief of a large class of patients Avho, for various reasons, are generally ailing from apparently no organic disease, and yet Avhose condition is often so alarming as to lead to the belief that some hidden cause of a severe train of symp- toms must be present. In many such instances a careful study of REST CURE. 395 the case will shoAv that there is a cause, near or remote, which has exhausted the patient's vital forces Avithout producing anything else than functional disturbances of the body. Thus a prolonged nerve- strain in nursing a sick relative may so exhaust the strength of a hitherto healthy Avoman as to produce hysteria, anaemia, and great disturbances of nutrition, or, in another instance, cause neuralgia, disordered menstruation, and uterine or ovarian pain. In males mental, sexual, or physical vigor may be impaired, owing to pro- longed anxiety in business. Be the symptoms Avhat they may, as long as they are dependent upon nerve-strain this "cure" is to be resorted to, and if properly carried out is often blessed with surpris- ing results. Before describing the method in detail it is proper to state that its entire rationale rests upon the remembrance that every movement is an expenditure of force, and that a system which has already overdraAvn its reserve fund of strength must be as careful Avith its funds that remain as a bank should be under the same cir- cumstances. It having been decided that the rest cure is to be employed, the directions are given as folloAvs: A bright, airy, easily-cleaned, and comfortable room is to be selected, and adjoining it, if possible, should be a smaller one for an attendant or nurse. The patient is put to bed and kept there for from three to six Aveeks, as may be necessary, and during this time is alloAved to see no one except the nurse and the doctor, since the pres- ence of friends requires conversation and mental effort. The patient, in severe cases, must be fed by the nurse, in order to avoid the expend- iture of the force required in the movements of the arms. No sitting up in bed is alloAved, and if any reading is done it must be done by the nurse, who can read aloud for an hour a day. In the case of Avomen the hair should be dressed by the nurse to avoid any physical effort on the part of the patient. To take the place of ordinary exercise two measures are employed, the first of Avhich is massage or rubbing of the body, the second elec- tricity. By the kneading and rubbing of the muscles and skin the liquids in the tissues are absorbed and poured into the lymph-spaces and a healthy blush is brought to the skin. This passive exercise is performed in the morning or afternoon, and should last for from a half to one hour, every part of the body being kneaded, even to the face and scalp. In the afternoon or morning the various muscles should be passively exercised by electricity, each muscle being made to contract by the application of the poles of the battery to its motor points. Both these forms of exercise do not call for any expenditure of nerve-force, though they keep up the general nutrition. The fol- loAving programme for a day's existence is an example of what the physician should order: '7.30 a. m. Glass of hot or cold milk, predigested, boiled, or raw as the case requires. 8 a. m. The nurse is to sponge the patient Avith tepid water or with cold and hot water alternately, to stimulate the skin and circu- lation, the body being well wrapped in a blanket, except the leg or 396 REMEDIAL MEASURES OTHER THAN DRUGS. portion Avhich is being bathed. After this the nurse should dry the part last Avetted Avith a rough toAvel, using some friction to stimulate the skin. 8.30 a. m. Breakfast. Boiled, poached, or scrambled eggs, milk toast, water toast, or a finely-cut piece of a mutton-chop or chicken. 10 a. m. Massage. 11 a. m. A glass of milk, or a milk-punch, or egg-nog. 12 m. Reading for an hour. 1 p. m. Dinner. Small piece of steak, rare roast beef, consomme' soup, mutton broth, and any one of the easily-digested vegetables well cooked. 3 p. m. Electricity. 4.30 p. m. A glass of milk, or milk-punch, or egg-nog. 6.30 p. m. Supper. This should be very plain, no tea or coffee, but toast and butter, milk, curds and Avhey, or a plain custard. 9.30 p. m. A glass of milk or milk-punch. In this Avay the day is Avell filled, and the time does not drag so heavily as Avould be thought. If the stomach rebels at over-feeding, the amounts of food must be cut doAvn, but Avhen all the effort of the body is concentrated on respiration, circulation, and digestion a large amount of nourishment can be assimilated by the exhausted body, which before this treatment is undertaken may have had its resources so scattered as to be unable to carry out any physiological act per- fectly. For the treatment to be successful the rules laid doAvn should be rigidly folloAved and never remitted for a single hour. MINERAL SPRINGS AND CLIMATE. This article is intended to give the practitioner and student a gen- eral idea of Avhere to send patients Avho can afford to resort to treat- ment depending upon Avatering-places and climates. It is manifestly impossible to include the names of all the health-resorts, and the object has been to indicate the diseases which are benefited by these treatments, taking certain Avell-knoAvn resorts as types of each class. Springs. Medicinal springs are usually resorted to for the double purpose of drinking and bathing in the Avaters, although in many instances one of these methods so far exceeds the other in popularity that it alone is employed. For general purposes Ave may divide these medicinal or beneficial Avaters into four classes—namely, those Avhich act, first, by their purity chiefly ; second, by the presence of more or less active alkaline ingredients; third, by the heat Avhich the Avaters contain as they leave the earth ; and, fourth, by reason of the sulphur and iron Avhich they contain. The first class—namely, those which act by reason of their purity—are indicated chiefly in cases Avhere through high living MINERAL SPRINGS AND CLIMATE. 397 or other cause the system becomes laden Avith impurities through imperfect elimination of tissue-Avaste. Most of the popular lithia Avaters depend chiefly upon this ability to dissolve effete materials, and very little upon the lithia, Avhich is often present in very small amount. (See Lithium.) Aside from their purity, they also act by reason of the salts of sodium and calcium Avhich they contain. Good results folloAv their use in the uric-acid diathesis Avhere the urine is scanty, high-colored, and acid. They do good in cases of irritable bladder by washing out this viscus with mild urine in large quantities, and because of this influence are credited with Avonderful cures of vesical calculus. AAhen vesical calculi have broken doAvn while these Avaters Avere being taken, the fortunate result has been coincidence rather than medicinal interference. It is impossible for them to dis- solve stones, but their constant use may prevent the formation of new ones. Perhaps the best representative of such Avaters is Londonderry lithia Avater. A subdivision of this class consists of those waters Avhich contain someAvhat larger amounts of mineral substances, chiefly potassium, sodium, and calcium salts. Because of the poAver possessed by alka- line salts in aiding in oxidation, these Avaters are used in cases Avhere the effete matters of the body seem to escape only partly oxidized, and where the kidneys, and perhaps the liver, seem torpid. Such springs are the Kissingen and Atichy at Saratoga. If very mild purgative prop- erties are also desired, the Geyser Spring at Saratoga may be used. In Europe the most famous springs of this class are at Vichy (Grande Grille), A'als, and Contrexeville in France, and Kissingen in Bavaria. The second class of springs are those Avhich contain salts of sodium, calcium, potassium, and magnesium in sufficient amount to possess very active diuretic and purgative properties. They find their thera- peutic application in cases of hepatic torpor or congestion associated Avith goutv or rheumatic tendencies, particularly in those individuals Avho have been high livers, Avho lay on too much fat, so clogging their organs, and. finally, in those who through illness or exposure to hot climates have subacute or chronic atony of the liver, of the organs of digestion, and of the lymphatics. Nearly ahvays these patients also suffer from more or less constipation and gastro-intestinal catarrh, and are often obese. The sulphate of sodium is an ingredient of many purgative mineral Avaters, and the activity of a water depends very often on the percentage of this salt Avhich is present. The pur- gative action of a Avater also depends upon the time at Avhich it is taken. AA7hen taken on an empty stomach it is of course more active. AVhen taken early in the morning before eating and at the natural temperature such a water produces a loose Avatery movement, not only unloading the boAvel of faecal matter, but by its alkalinity loosen- ing catarrhal secretions and unloading the liver of congestion. The quantity to be taken in twenty-four hours varies from 1 to 4 pints, but this question can only be decided by the local physician, Avho studies the effect of the Avater on the patient. The best-known waters of this class are the Champion, Congress, Hathorn, and Carlsbad Springs at Saratoga, NeAV York, the Crab Orchard in Kentucky, and 398 REMEDIAL MEASURES OTHER THAN DRUGS. the springs of Carlsbad and Marienbad in Bohemia, and Friederich- shall in Germany. The hot springs depend chiefly on their heat, as already stated, and differ in chemical composition. They find their value in the treatment of chronic skin diseases, specific or otherwise, and also are useful in aiding in the treatment of rheumatism, gout, and syphilis. Their good results are produced by their heat, Avhich varies from 93° F. to 150° F., and the advantages ahvays derived from properly employed hydrotherapeutic measures. It is in chronic or subacute cases that they do the most good. Hot baths are also of great value in the treatment of chancroid and malignant syphilis. The results achieved depend upon the increased activity of the skin, the improve- ment of the peripheral circulation, and the increased powers of absorp- tion produced through increased cellular activity. Patients should ahvays select a competent local physician at such places. In cases of syphilis the methods to be followed are as folloAvs: The patienr^ should take the bath at a temperature of 90° F., and remain in it for about twenty minutes. After this he is rapidly but thor- oughly dried by an attendant, who at once proceeds to rub into the skin of one thigh an amount of mercurial ointment varying from a feAv grains to a drachm. This is well rubbed into, not smeared over the skin, a different limb after each bath. The number of baths and inunctions depends upon the condition and necessities of the case, care being exercised not to push the mercury too freely in those who are very susceptible to its use. These baths also aid in the absorp- tion of mercury when it is administered by means of fumigation. The most celebrated of these springs are the Hot Springs of Arkansas and those found at Aix-la-Chapelle in France. As types of the fourth class of springs Ave have the AVhite Sulphur Springs in West Virginia and the Richfield Springs in New York, which are used for the relief of catarrhal inflammations of the mucous membranes of the alimentary canal and respiratory passages, and more rarely for catarrhal states of the genito-urinary tract. Not only do they exert the peculiar remedial poAvers long knoAvn to belong to sulphur and its compounds by reason of the sulphuretted hydrogen gas contained in them, but they also possess distinct purgative effects. Their chief mineral constituents consist of sulphate of sodium and magnesium, Avhich unload the boAvels and portal system in the same manner as do the Champion, Congress, Hathorn, and Carlsbad Springs at Saratoga and those at Crab Orchard. Taking the AVhite Sulphur as a type of its class, it is better than the Saratoga springs in catarrhal states for the reasons given. Rockbridge Alum Spring in A^irginia is used in cases of chronic diarrhoea Avith very useful results in many cases. It is not so useful in acute inflammations of the intestine as in the diarrhoea due- to chronic disorder. As iron is present in it and in most alum springs in considerable amount, this Avater is useful in anaemic cases, but is contraindicated by fevers, by chronic congestions, chiefly of the liver, and by plethora. Often in place of alum Ave find salines associated MINERAL SPRINGS AND CLIMATE. 399 Avith the iron, and these waters are particularly indicated in the catarrhs associated with anaemia. Such a spring exists at Bedford, Pennsylvania. In Europe the chief iron springs are at St. Moritz in Switzerland and Tunbridge AYells in England. Neither of these contains much sulphur or alum. Climates. The practitioner is most frequently consulted as to the possible benefit of climatic changes by persons 'suffering from pulmonary dis- ease, such as tuberculosis of the lungs, asthma, chronic bronchitis, and emphysema—more rarely by those convalescing from pneumonia or other severe acute illness. The general rules to be followed in all cases are—first, choose a climate having as large a number of clear days as possible, in order that an out-of-door life in the sunshine may be had in plenty; second, the nearest place to the home Avhich is available in order to avoid fatigue, expense, and home-sickness; and third, see that the resort chosen has comfortable accommodations, good drug-supplies, and a capable physician to be called in case of need. In a case of tuberculosis and in all patients suffering from the pulmonary com- plaints named above the folloAving rules may be adhered to, except in persons suffering from attacks of acute bronchitis, Avho ahvays need a climate providing moisture and Avarmth. Some tubercular patients do best in a high, dry air, and others in a lower and more moist temperature—the first being represented by that of Colorado Springs (6000 feet) in America and by San Moritz (6000 feet) and Davos Platz (5000 feet) in SAvitzerland, where the altitude is not only very great, but the air very cold in Avinter. The days in these places are many of them clear, but apt to be Avindy. Feeble persons cannot stand high Avinds, as a rule. The second climate is repre- sented by that of Florida. In the majority of cases, however, some more moderate climate is useful, and this can be obtained in LowTer California, as at San Diego, a place Avhere there is virtually perpetual summer, or at Asheville, N. C. (2200 feet), or Thomasville, Georgia (330 feet), Avhere the air is moderately dry and the climate not subject to sudden changes of temperature or to frequent storms. In other wTords, a spot is desirable Avhere a patient can remain the year round, and, if Avell enough, engage in business, avoiding the cold, sharp March Avinds of the Middle, Eastern, or North-Avestern States, and the necessity of leaving Florida on the advent of summer. Physicians have attempted for years to formulate rules for phthis- ical patients as to the climate to be sought. In very many cases the various health-resorts have to be chosen by experiment, not by judgment beforehand. In cases of phthisis Avith profuse bronchial secretion a high, dry climate is generally the better, but in cases which suffer from dryness of the air-passages a sea-voyage or a warm moist climate is better, on general principles. It is probably true, however, that high altitudes and rarefied air are not to be sought 400 REMEDIAL MEASURES OTHER THAN DRUGS. where a distinct tendency to hemorrhage is present, unless the ascent or removal to the rarefied air is very gradual, several Aveeks being passed before the lung is exposed to the low pressure of great heights. The following excellent and concise advice, given by Dr. W. Hale AArhite in his book on General Therapeutics, is so worthy of repeti- tion that it is inserted here. He says : "It is of such importance that only suitable cases should be sent to high altitudes that Ave must point out those that are unsuitable : " 1. Those in Avhom there is considerable affection of the bronchial tubes, for the dryness of the climate increases the kind of bronchitis Avhich commonly accompanies phthisis. " 2. Patients Avith much emphysema or bronchiectasis, because of the probably diminished absorption of oxygen and the difficulty of respiration experienced on first arriving. " 3. Patients Avith disease of the heart must not go to a high alti- tude, because of its effect upon the pulse and upon respiration. "4. Cases liable to acute febrile attacks, Avhether or not these indicate an occasional increase of mischief in the lungs, should remain on a Ioav level. " 5. Patients Avho are very excitable or suffer from insomnia should not go, for a visit to a place at a great elevation promotes these symptoms. AVomen do not acclimatize so well as men. " 6. Cases in Avhich there are very extensive lesions, or which are very advanced, are unsuitable. " Pneumonic phthisis, if at all acute, is made worse by a high altitude. " 8. Patients Avho cannot take exercise should not go. " 9. The very old and the very young had better be treated at home. " 10. Sir Andrew Clark (London Lancet, January 5, 1889) states that patients Avho go to Alpine health-resorts suffering from albumin- uria, or those Avho develop it whilst there, seldom derive any good from their change. "There are many conditions which have been thought to contra- indicate this treatment, but Avhich do not, and they had therefore better be mentioned. They are— "Pulmonary Hemorrhage.—It is now known that this, so far from being a contraindication to treatment by high altitudes, is actually relieved by it. The exact explanation cannot be given." With this the author of this book cannot agree. " Fever.—If this is not excessive, and if it does not indicate any active changes in the lungs, it is often improved. "Simple Diarrhcea and Simple Dyspepsia.—These are both benefited. "Night-sweats.—There is a common belief that these forbid this treatment; on the contrary, they often disappear on removal to a high altitude. "The Presence of Cavities.—This is not a contraindication, unless a very large area of lung is destroyed. SUSPENSION. 401 ki There is no need, after these tAvo lists, to say Avhat cases are suit- able for this climatic treatment: it may, however, be observed that those in which there is threatened phthisis, Avith a strong hereditary predisposition, and those of imperfect thoracic development, are much benefited. According to most authorities, it cannot be too strongly urged that so long as the condition and disease of the patient allow the reverse indications to be neglected a mountain climate should be tried." To these rules the author would add the folioAving invariable rule : viz. Do not send a case aAvay to die. If the disease is so far advanced that no good can be derived from a trip abroad, it is cruel to make a wretched patient exhaust his strength, his money, and his happiness by seeking health which it is impossible for him to obtain. A patient of the Avriter's returned on one occasion from a stay of a few days at a noted Southern resort for consumptives, Avho, Avhen reprimanded for his imprudence, replied: " Doctor, I would rather be at home, and die at once, than drag out a feAv more years surrounded by a crowd of coughing, haAvking, and Avasting consumptives." This reply evi- dences clearly the necessity of avoiding " consumptive resorts" as much as possible in these cases, and in directing the mind of the patient from depressing thoughts and his oAvn ailment. In the treatment of renal and cardiac disease high altitudes are not particularly desirable. The chief desideratum is out-of-door life, Avith avoidance of chilling of the skin by sudden changes in tempera- ture or strong wdnds. San Diego represents the necessary climate in such cases. There is a class of persons who .often haAre no actual disease of a chronic type, Avho nevertheless pass healthier lives if aAvay from rig- orous climates for at least part of the year. A\Tithout having acquired tuberculosis, their lungs are delicate naturally or because of attacks of disease, or, again, they become asthmatic or rheumatic in cold weather. In this country Asheville, N. C, and Thomasville, Ga., or San Diego or Coronado Beach, California, afford the climate desired, Avhile in Europe patients are sent to what is knoAvn as the " Riviera." which is the district bordering on the Mediterranean Sea from Genoa to Nice and Avhich is dotted Avith climatic resorts. This district has often as many as tAvo hundred clear days betAveen October 1st and May 1st. In the French Riviera the resorts are Cannes, Nice, Monaco, Monte Carlo, and Mentone; in the Italian Riviera, Bordi- ghera and San Remo. In Naples and Spezzia the climate is more (lamp and colder, but nevertheless quite sunny. So much depends upon the location of the hotels in these places, as far as their salubrity in relation to air and dampness is concerned, that the patient should ahvays consult a local physician before settling doAvn permanently at anv of these resorts. SUSPENSION. The treatment of locomotor ataxia and allied affections by means of suspending the patient has, during the last few years, been found 26 402 REMEDIAL MEASURES OTHER THAN DRUGS so valuable for the relief of symptoms as to have taken a permanent place in therapeutics. The method is not confined to cases depend- ing upon diseases of the vertebrae producing lesions in the spinal cord, but is equally useful in instances where the lesion is primarily situated in the nervous centres. The pain, nervous shootings, and tinglings, as Avell as the muscular contractions, Avhich often trouble the patient very greatly, are all relieved, and in some cases Avalking is possible Avhere, before the treatment, crutches Avere entirely relied upon. The knee-jerk, Avhen absent or excessive, tends to return to the normal state, and the bladder and rectum become more regular in their functions. The patient should use one of the apparatuses made by most large surgical-instrument makers, Avhich consists in a cushioned head-strap and a cushioned leather loop for each axilla. The traction on the head should not be sufficient to cause discomfort; in other words, the weight of the patient should be equally distributed betAveen the shoul- ders and the head. A rope is run from the harness to a pulley in the ceiling, and by this means the patient may be slightly raised from his chair—say two inches—once a day, for thirty seconds at first, which may gradually be increased to ten minutes. The swinging should be resorted to at first every second and third, and finally every, day. If several pulleys are put in the circuit of rope, the patient can soon learn to lift himself, making the rope fast to a cleat in a heavy chair or table, or even holding it in the hands. It is important that the patient after each SAvinging should rest for thirty minutes to an hour, and Avhen let down to his chair the movement should be most gentle and not jerking or sudden. The same rule as to gentleness applies to raising the patient. TRANSFUSION. Very closely allied to the intravenous injection of medicines is the transfusion of saline liquids, blood, or defibrinated blood for the pur- pose of replacing the vital fluid which may have been lost by hemor- rhage. It must be distinctly understood that transfusion is not to be resorted to in the presence of heart failure arising from other causes than hemorrhage, nor for the purpose of improving the state of the blood in the vessels. Its effect is only temporary, and it is used solely for the purpose of bridging the chasm until the system can manufac- ture normal blood after a sudden loss. It has been found that the transfusion of pure blood even in the " direct method," Avhich will be presently described, is no better than the employment of a properly made saline fluid, because the corpuscles are killed by the change of abode, even from man to man, and their destruction gives the kidney the work of eliminating the free haemoglobin. Direct transfusion may be performed by the employment of a large number of complicated pieces of apparatus, but the simplest manner of procedure is as folloAvs, provided a good-sized vein is used and the blood-donor is full-blooded, as he ought to be: An incision is made TRANSFUSION. 403 in the arm of the donor over the longitudinal axis of the vein, gen- erally a prominent one on the flexor surface of the forearm or arm. As soon as the vessel has been cleanly dissected from the surrounding tissues, a bull-dog clip should be placed above and below the point where it is intended to make the incision in the vessel. At the same time a silk ligature is passed under the vessel. The vessel is noAv longitudinally incised, and a small glass or metal canula furnished wdth a shoulder is slipped into the opening, with its point toAvard the wrist, after which the ligature is tied so as to hold the canula in place. The opposite end of the canula should be attached to a short rubber tube of about eight inches in length, and the moment this is in place the canula and tube should be filled Avith a normal saline solution. (See beloAv.) The same process is then repeated Avith the vein of the recipient, except that the canula is not armed Avith a rubber tube, and is pointed toAvard the body of the patient, or, in other Avords, in the direction of the blood-stream. The only point where great care is to be exercised is in the filling up of the tubes Avith saline solution to displace the air.1 The tubes being completely filled, the ends are joined by slipping the tube of the recipient into the rubber tube of the donor. The bull-dog clip next the shoulder of the recipient is noA\ removed, and the one next the hand of the donor is taken off, thus alloAving the blood to Aoav from one person to the other. It is necessary that the other clips should remain to prevent hemorrhage by anastomosis back of the canulas. If the pressure is Ioav in the vein of the donor, the passage of the blood from the one to the other must be aided by stroking the tube in the direction of the Aoav, using enough compression to dis- place the fluid. If the tubing is elastic and strong, this method is fully as good as that of Aveling, Avhere it is necessary to use a ball syringe to propel the blood and fill the tubes. The normal saline liquid already named consists in a solution of common salt of the strength of nearly 6 parts to the 1000, or, in other words, six-tenths of 1 per cent.—or, in other Avords. IJ drachms—of pure common salt to a quart of distilled Avater. It is called a normal solution because its percentage of saline is exactly that of the blood. The amount of blood transfused may be from 2 ounces up to the point at which its AvithdraAval causes the donor to feel faint, but 8 ounces is generally the maximum amount used. It is to be remem- bered that the passage of the liquid must be gradual, not sudden, and that an excessive amount may cause cardiac distress. The use of defibrinated blood ought never to be resorted to Avhen direct transfusion or a proper saline is to be had, as the difficulty in separating all the minute coaguli is very great, and it is also difficult to maintain the temperature. If direct transfusion is not wished for, the saline solution named may be gently forced into the vein by means of a good hydrostatic syringe raised very slightly above the 1 Whether or not small amounts of air finding entrance into the veins do any harm is not decided. A number of deaths in man from this cause are reported, but the experiments of Senn and of the author show that large amounts have to be introduced before death occurs. As the dread of such an accident is part of the medical teaching of the past, it is at least well to respect it. 404 REMEDIAL MEASURES OTHER THAN DRUGS. level of the patient. The water used should ahvays be boiled and filtered to render it aseptic. The solution used should, of course, be warm, at a temperature of about 100° or 101° F., and the presence of any foreign or insoluble substance must be strenuously guarded against. Indeed, it is ahvays best to pass the liquid through a fine sieve before it is used. The quantity of saline used should not exceed 1 pint, and this is usually more than should be given, unless the hemorrhage has been exceedingly severe and the patient really improved by the addition of each ounce of liquid. In a large number of cases Avarm fresh milk, just as it is drawn from the coat, has been used as an injection into a vein Avith success, but it always causes albuminuria, and is not as good as directly trans- fused blood, nor better than saline solutions unless it is taken directly from the udder of the cow as it is milked. The possibility of the cow being tuberculous is also to be remembered. Abdominal transfusion of both saline solutions and milk have been successfully carried out, the reason being that the peritoneal cavity is a vast absorbent surface which rapidly takes up liquids if the systemic vessels are not as full as they normally should be. The method con- sists in puncturing the abdominal Avail as if for aspiration for dropsy. The tube from a hydrostatic syringe is now attached to the canula, and the liquid, having been Avarmed, is allowed to slowly flow into the belly. This method is not to be relied on where death seems very imminent, as it is not rapid enough in its effects. VENESECTION. Bleeding, or Phlebotomy, is so rarely practised to-day that very many of the profession have never abstracted blood for therapeutic purposes or have even seen it done by some one else. Furthermore, it is to be feared that many of the younger physicians would hardly know how to bleed if called upon to do so at a crisis. All this is wrrong, for bleeding is a measure undoubtedly of the greatest value and one Avhich every one may be called upon to resort to. Like many therapeutic measures, it was sadly abused in the early part of this cen- tury, and'people Avere bled when taken ill with the same regularity that they were put to bed. The indications for venesection are as clear and Avell defined as are the indications for any remedy. Briefly stated, Ave may say that all states of the circulatory apparatus denoting high arterial tension and excitement are indications, and that Aveakness, low arterial tension, and systemic or circulatory depression are contraindications. Since the use of veratrum viride has become more common, the conditions indi- cating venesection have been lost sight of, because this drug so dilates the blood-paths that a man is bled into his oAvn blood-vessels. Having made clear the general indications for the use of venesec- tion, Ave may pass on to state some of the diseases in Avhich it may be well resorted to. Of these, pneumonia, pleurisy, meningitis, and peri- tonitis, if they are sthenic, are typical examples, since all of them VENESECTION. 405 are accompanied by arterial excitement and characterized by local congestions affecting the lung, pleura, cerebral membranes, or peri- toneum. (See Pneumonia.) By the abstraction of blood the vascular tension is loAvered and the engorged area relieved. In the first place, the congested area is made up of relaxed blood-vessels, Avhereas the remaining blood-vessels of the body are tense, and, as a consequence, the blood is urged to the spot already engorged. In the second place, the abstraction of blood from the tense blood-vessels renders the gen- eral pressure loAver than that in the diseased area, and the congestion is relieved. In apoplexy the extravasation of blood into the brain causes great arterial excitement, as a general rule, and this in turn results in increased intracranial hemorrhage. Bleeding is therefore strongly indicated, not'only to prevent inflammation, but also to prevent further leakage into the brain-substance. The method by Avhich venesection is practised is yet to be described. It is a very simple operation if an assistant is present to make pres- sure on the vein or entire arm. Often this pressure is best exercised by means of a handkerchief or bandage tightly tAvisted about the arm above the spot Avhere the incision is to be made. Under these circumstances the veins of the arm become prominent and distended, and one of them may be readily bared by a short longitudinal incision of half an inch, the fascia being separated until the glistening blue surface of the vessel appears free from fat or connective tissue. Into this vessel, Avith the edge of the knife turned upAvard, a small longi- tudinal incision is made, care being taken that the point of the blade is not driven in far enough to injure the posterior Avail of the vein. If a clot forms and stops the flow, it must be removed by an aseptic cloth, Avhile if the Aoav is to be stopped Ave may remove the bandage above and apply a compress over the incised vein, which compress may be held in position by a bandage. FOODS FOR THE SICK. PEPTONIZED MILK. Take a perfectly clean, clear glass quart bottle and place in it the contents of one of Fairchild Bros.' peptonizing tubes or Parke, Davis & Co.'s peptonizing tablets, that containing the sodium and that containing the pancreatin, and a teacupful of cold Avater, and after shaking pour into the bottle a pint of perfectly fresh, cool milk and stir the mixture thoroughly. Next place the bottle containing the milk in a can of water at such a temperature that the whole hand may be indefinitely submerged in it Avithout pain. If complete diges- tion of the milk is desired, this application of heat may be continued as long as tAventy minutes, but in most cases five minutes are sufficient. If carried on longer than tAventy minutes, the milk will become bitter and disagreeable to the taste through the development of peptone in excess. Immediately after taking the bottle from the hot Avater it should be placed on ice, in order to check further peptonizing and to keep the milk from spoiling; or if the ice is not available the Avater-bath should be quickly brought to a boil in order to prevent further action of the ferment, and the bottle corked and then be put in a cool place. This recipe may be used Avhere it is thought necessary to digest the milk before it is SAvalloAved. Where Ave desire simply to aid digestion it is best to folloAv the directions already given, except that the bottle is not heated, but at once placed upon ice and allowed to remain there, being slightly warmed when it is desired to give it to a child, or it may be given as a cool and refreshing drink to an adult, the heat of the body rapidly causing the ferment to do its Avork as soon as the food enters the stomach. When irritability of the stomach exists in adults, this peptonized milk may be made more agreeable to the taste by folloAving the directions given in the first recipe, except that it must remain in the hot water for no less than tAvo hours, when it is poured out into a tin cup or pan and rapidly brought to the boiling-point. After this it is strained through a piece of coarse muslin and placed upon ice. Before giving it to a patient this mix- ture may be flavored Avith lemon- or orange-juice or any form of acid that is desired, Avithout the milk becoming curdled. Peptonized milk punch is made from milk prepared in the Avay already described in the first recipe by adding St. Croix or Jamaica rum or brandy, and is a pleasant nutrient, particularly if the surface of the liquid is sprinkled Avith a little grated nutmeg. 406 PEPTONIZED ENEMA. 407 A very refreshing and agreeable drink may be made by diluting peptonized milk one-half Avith highly-charged carbonic-acid water, and swalloAving it Avhile effervescing. PEPTONIZED BEEP. The folloAving method of preparing Peptonized Beef is recom- mended by the Fairchilds, and is very useful, as is also peptonized oyster stew, as first introduced by my friend, the late Dr. N. A. Randolph. Take \ pound of finely-minced raAv lean beef; cold Avater, \ pint. Mix in a saucepan. Cook over a gentle fire, stirring constantly until it has boiled a feAv minutes. Then pour off the liquor for future use, beat or rub the meat to a paste, and put it into a clean fruit-jar with \ a pint of cold water and the liquor poured from the meat, and add Extracti pancreatis (Fairchild).....20 grains (1.3). Sodii bicarb..............15 " (1.0). Shake well together, and set aside in a warm place, at about 110° to 115° F., for three hours, stirring or shaking occasionally ; then boil (/uickly. The liquid may then be strained or clarified with white of egg in the usual manner, and seasoned to taste Avith salt and pepper. In the great majority of cases it is not necessary to strain the peptonized liquor, for the portion of meat remaining undissolved will have been so softened and acted upon by the pancreatic extract that it Avill be in very fine particles and diffused in an almost impalpable condition, and is therefore in a form ready for assimilation in the body. Peptonized Oysters.—Peptonized Oysters are prepared by mincing six to tAvelve large oysters, and adding to them, Avhen mixed with a moderate amount of their oAvn liquid, 5 grains (0.35) of pancreatin or peptonizing poAvder and 20 grains (1.3) of sodium bicarbonate. The cup containing this mixture is noAV placed in warm water at 100° F., and alloAved to remain there from ten to tyventy minutes, according to the degree of digestion desired. After this the liquid mass is quickly brought to a boil to cook the oysters and stop diges- tion, and served Avith pepper and salt as required. Any condiment or flavoring substance may be used. PEPTONIZED ENEMA. A very useful nutrient enema may be prepared by folloAving the directions given above for peptonizing milk, except that air egg, yelk and Avhite, should be beaten up in the milk before the ferment is added. The effect of this enema may be increased by the addition of a teaspoonful to an ounce of Avhiskey or wine. This should be Avarm Avhen injected into the rectum. 408 FOODS FOR THE SICK. DIGESTED GRUEL. Digested Gruel may be made by taking thoroughly boiled hot gruel made from oatmeal, barley, wheat, or from arrow-root, to the amount of 4; pint (250 cc), and adding thereto, while it is hot, | pint (250 cc.) of fresh, cold milk; to this may now be added the contents of one peptonizing tube, and the mixture allowed to stand in mode- rately hot water or in a warm place for tAventy minutes before it is placed upon ice. KOUMYSS. This is a preparation of milk Avhich is very useful for children and adults during convalescence from acute or subacute exhausting dis- eases. Even young children of three or four years will take a fancy to it if it is not made too sour by continuing the fermentation process too long. The liquid is prepared as folloAvs : Add to 1 pint (500 cc.) of cool, perfectly fresh milk 2 teaspoonfuls (8.0) of sugar, and place it, after shaking thoroughly, in a beer or claret bottle. Then add \ of a cake of Fieischman's compressed Vienna yeast, and tightly cork the bottle, standing it in a warm place or in a water-bath at 99° to 100° F. for eight to ten hours. Then place in a cool place or on ice and use as needed. It must be remembered that the development of carbonic gas is very great in this liquid, and that if an ordinary cork is inserted it must be tied in before the heat is applied. Further than this, the cork must be pulled very gently or the liquid will squirt all over the room. The best thing to use when about to drink the koumyss is a "champagne tap," by means of which the liquid may be draAvn off as needed. DIET LIST. The following bills of fare are used in the Children's Hospital in this city with good results, are easily prepared, and the directions readily carried out by the inexperienced: Diet in Castro-intestinal Catarrh for a Child of Seven Years. Breakfast, 7.30 a. m. : Milk, with lime-water; 4 teaspoonfuls of lime-Avater to each tumblerful of milk. The lightly-boiled yelks of two eggs, thin slices of well-toasted bread or stale bread. Dinner, 12 m. : A mutton-chop Avithout fat, broiled, or a slice of roast beef or mutton, occasionally a bowl of meat broth. Stale bread or toast. Supper, 7 i\ m. : Milk and lime-water. Stale bread or toast, or milk-toast. For drink: Filtered or boiled Avater. Starch foods to be avoided as much as possible. BEEF TEA. 409 Diet for a Child Two Years Old. Breakfast, 7.30 a. si. : Milk. The lightly-boiled yelk of an egg. Thin bread and butter (the bread to be one day old). Lunch, 11 a. si.: Milk. A thin slice of bread and butter. Dinner, 1.30 p. si. : Beef-tea or small piece of minced roast beef or mutton devoid of gristle. One Avell-mashed potato, moistened with gravy. Rice and milk. Supper, 6 P. M. : Milk. Bread and butter. For drink : Boiled or filtered Avater. Diet for a Child One Year Old (5 meals a day). First meal, 7 A. M. : 2 teaspoonfuls of grated fl<#ur-ball (prepared as directed beloAv) in 4 a pint of milk. Second meal, 10.30 a. m. : 4 a pint of milk with 4 tablespoonfuls of lime-Avater. Third meal, 2 p. m. : The yelk of 1 egg beaten up in 1 teacupful of milk. Fourth meal, 5.30 P. m. : Same as the first. Fifth meal, 11 p. M. : Same as the second. Flour-ball is to be made by taking one pound of good flour— unbolted, if possible—tie it up very tightly in a pudding-bag; put it in a pot of boiling Avater early in the morning, and let it boil until bed-time, then take it out and let it dry. In the morning peel off the surface and throAV aAvay the thin rind of dough, and Avith a grater grate doAvn the hard, dry mass into a powder. To use this, take from 1 to 2 teaspoonfuls of the poAvder, rub it doAvn until smooth Avith a tablespoonful of cold milk, and add 1 tumblerful of hot milk, stirring it well all the time. Diet for a Child from Six to Twelve Months Old (5 meals a day). First meal, 7 a. si. : Mellin's food 1 tablespoonful or flour-ball grated 1 or 2 teaspoonfuls (prepared as directed above), hot Avater 4 tablespoonfuls : Avarm milk enough to make \ a pint. Dissolve the Mellin's food or rub down the grated flour-ball in the hot Avater by stirring, then add the milk ; mix thoroughly. Second meal, 10.30 a. s\., and third meal, 2 p. m. : A breakfast- cupful of milk Avith 4 tablespoonfuls of lime-water. Fourth meal, 5.30 p. m. : Same as first. Fifth meal, 10.30 P. si. : Same as second. BEEF TEA. Take 1 pound of lean beef and mince it. Put it, with its juice, into an earthen vessel containing a pint of tepid water, and let the whole stand for one hour; strain well, squeezing all the juice from the meat. Place on the fire, and sloAvly raise just to the boiling-point, stirring it briskly all the time. Season with salt and pepper to taste. In administering this ahvays be careful to stir up the sediment. 410 FOODS FOR THE SICK. Or, take 2 pounds of beef, without fat or bone, half a breakfast- cupful of cold water; place it in a jar in a saucepan of Avater. Sim- mer four hours. RESTORATIVE BEEP ESSENCE (Ringer). Take 1 pound of fresh beef, free from fat, chop it up fine, and pour over it 8 ounces of soft Avater, add 5 or 6 drops of hydrochloric acid and 50 or 60 grains of common salt; stir it well, and leave it for three hours in a cool place. Then pass the fluid through a hair sieve, pressing the meat slightly, and adding gradually toward the end of the strainteg about 2 ounces more of Avater. The liquid thus obtained is of a red color, possessing the taste of soup. It should be taken cold, a teacupful at a time. If preferred Avarm, it must not be put on the fire, but heated in a covered vessel placed in hot water. Should it be undesirable for the patient to take the acid, this soup may be made by merely soaking the minced beef in distilled water; or, take 1 pound of lean beef, free from fat and skin, chop it up very fine, add a little salt, and put it into an earthen jar with a lid, such as is used for roasting venison, fasten up the edges with a thick paste, and place the jar in the oven for three or four hours. Strain through a coarse sieve, and give the patient tAvo or three teaspoonfuls at a time; or, cut up in small pieces 1 pound of lean beef from the sirloin or rump, and place it in a covered saucepan, Avith 4 a pint of cold Avater, by the side of the fire for four or five hours, then alloAv it to simmer gently for two hours, skim it Avell, and serve. BARLEY-WATER. To prepare barley-Avater, put tAvo good-sized teaspoonfuls of washed pearl barley with 1 pint of cold water in a saucepan, and boil slowly doAvn to tAvo-thirds. Strain. Barley-water for Adults. Take of finest barley |- pound; to this add 1 quart of water and boil to 1 pint; strain and add 1 quart of boiled milk. To this add 6 ounces each of brandy and lime-Avater; SAveeten to taste; flavor with nutmeg and rind of lemon rubbed with sugar. This forms a most nourishing and palatable drink Avhen kept cold on ice. RICE-WATER. Rice-Avater is made by boiling 2 ounces of clean rice in 2 quarts of Avater for an hour and a half. BRAN BREAD FOR DIABETICS. 411 WINE-WHEY. Boil 1 pint of fresh milk; Avhile boiling pour in 1 small tumbler- ful of sherry Avine (8 tablespoonfuls); bring it to the boil a second time, being careful not to stir it; as soon as it boils set it aside until the curd settles, and pour off the clear Avhey. ALMOND BREAD FOR DIABETICS. Take of blanched SAveet almonds \ pound; beat them as fine as possible in a stone mortar: remove the sugar contained in this meal by putting it into a linen bag and steeping it for a quarter of an hour in boiling Avater acidulated Avith vinegar; mix this paste thoroughly Avith 3 ounces of butter and 2 eggs. Next add the yelks of 3 eggs and a little salt, and stir Avell for some time. AVhip up the Avhites of 3 eggs and stir in. Put the dough thus obtained into greased moulds, and drv bv a sIoav fire. BRAN BREAD FOR DIABETICS. Take a sufficient quantity (say 1 quart) of Avheat bran; boil it in tAA'0 successive Avaters for a quarter of an hour, each time straining it through a sieve; then wash it Avell Avith cold Avater (on the sieve) until the water runs off perfectly clear; squeeze the bran in a cloth as dry as possible, then spread it thinly on a dish and place it in a slow oven; if put in at night, let it remain until morning, when, if perfectly dry and crisp, it will be fit for grinding. The bran thus prepared must be ground in a fine mill and sifted through a wire sieve of such fineness as to require the use of a brush to pass it through; that Avhich remains in the sieve must be ground again until it becomes quite soft and fine. Take of this bran powder 3 ounces (some patients use 4 ounces), the other ingredients as follows: 3 new-laid eggs, 11 ounces (or 2 ounces if desired) of butter, and about 4 pint of milk; mix the eggs Avith a little of the milk, and warm the butter Avith the other portion ; then stir the Avhole Avell together, add- ing a little nutmeg or ginger or any other agreeable spice. Bake in small tins (patty-pans), Avhich must be Avell buttered, in a rather quick oven for about half an hour. The cakes, Avhen baked, should be a little thicker than a ship's biscuit: they may be eaten Avith meat or cheese at breakfast, dinner, and supper; at tea they require rather a free allowance of butter, or they may be eaten Avith curd or any of the soft cheeses. " It is important that the above directions as to Avashing and dry- ing the bran should be exactly folloAved, in order that it may be freed from starch and rendered more friable. The bran in its com- mon state is soft, and not easily reduced to fine powder. In some seasons of the year, or if the cake has not been Avell prepared, it changes more rapidly than is convenient, OAving to moisture. This 412 FOODS FOR THE SICK. may be prevented by placing the cake before the fire for five or ten minutes every day." MULLED WINE. Boil some spices, cloves, nutmeg, cinnamon, or mace in a little water, and add as much of this decoction as is necessary to flavor a Avineglassful of sherry or any other wine. Add sugar to taste, and bring the mixture to the boiling-point. If claret is used, it will require more sugar than if a less sour wine is employed. The vessel for heating the wine .should be scrupulously clean. WATERED TOAST. Brown several pieces of bread, and carefully butter the toast so that the butter is equally distributed. Place enough salt over the toast to flavor it and add pepper to taste. Finally pour as much boiling water on the edges of the crust as is necessary to thoroughly soak them, and serve to the patient. This is a more agreeable dish than would be imagined, and is useful where milk toast is distasteful. JUNKET. Add from 4; to 1 teaspoonful of Fairchild's essence of pepsin or Parke, Davis & Co.'s pepsin cordial to a pint of milk, Avhich should be at body-heat. Place the milk in a cool place, and after the curd has formed serve cold and flavor with poAvdered nutmeg or vanilla. If there be too great feebleness of digestion to digest the curd, the liquid whey may be given, as it contains the salts and soluble albu- minoids. PART IV. DISEASES. ABORTION. The treatment of abortion divides itself into three parts: the first for its prevention, the second for its arrest Avhen threatened, the third for its proper care when inevitable. In the preventive means Ave find, as in nearly every branch of medicine, that the use of hygienic measures is more important than the employment of drugs. If the previous abortions are known to be due to syphilis, endometritis, or uterine displacements, these conditions must be relieved by the proper remedies. If there exists no apparent cause for the interruption of normal gestation, the patient should use a simple diet, lead a quiet life, avoid all sexual intercourse, sleep on a hard bed, and resort only to gentle exercise. Fresh air is, however, a necessity, and should be plentifully supplied. The food should be light, but nutritious and palatable, and a sufficient variety supplied to avoid any repugnance to a given dish. In many cases abortion rests upon deficient nutrition of the foetus, either by reason of faulty assim- ilation on the part of the mother or because of poor food, so that if anaemia, debility, or other impoverished states of the maternal system be present, these should be treated at once. The clothing should be loose, the night's sleep undisturbed and of full length, and the mind be set at rest as far as possible in respect to household and other wor- ries, and particularly diverted from the thought of possible uterine disturbance. The use of drugs is to be limited strictly to the fulfilment of a dis- tinct indication, and the employment of cathartics is to be avoided, the bowels being kept in order by fresh fruits in moderate quantity or by mild laxatives, such as cascara sagrada in small doses and com- pound liquorice powder. If these fail, rhubarb may be resorted to, and castor oil in capsule may be used. Podophyllin, senna in full doses, saline purges in active amounts, and aloes are not to be used if they can be avoided. If the woman be exceedingly stout and pleth- oric, saline purges are indicated to act as depletants. It is hardly necessary to add that elaterium and scammony or jalap are not safe, and can only be used if dropsy and asoites are present, and where we must choose the least of tAvo evils. Strychnine, Avhich stimulates the spinal cord, should never be employed, and cantharides, oil of erigeron, and manganese ought not to be used unless they are for some reason 413 414 DISEASES. very necessary. Although quinine is not of itself abortifacient, it is unsafe if an abortive tendency is present, and can only be used in cases in Avhich the abortion is brought on by malarial poisoning, Avhen it Avill act as a preventive. The only drug which seems to be of any service as a prophylactic to be taken all through pregnancy is the fluid extract of viburnum prunifolium, the dose of which is J to 1 drachm (2.0-4.0). This drug is said to be a uterine sedative and to have no injurious effects upon the mother or child. Cimicifuga racemosa is probably equally valuable as a prophylactic against abortion in the dose of 10 to 20 drops (0.65-1.3) of a good sample of the fluid extract, given night and morning. The arrest of threatened abortion is one of the most difficult duties which come to the physician, and there is no doubt that large doses of morphine or opium are the best means of quieting the uterus that Ave have. While viburnum prunifolium may be resorted to, Ave do not knoAv enough of it to rest assured of its value, but it should be tried if opium is not at hand or fails. The patient should be at once quietly placed in bed in the most comfortable position, be so covered as to prevent overheating and taking cold, and receive by the hypodermic needle \ grain (0.016) of morphine, or, better still, a rectal injection of Avarm starch-Avater containing 30 drops (2.0) of laudanum. The bulk of the injection should be small in order not to disturb the bowels, and must be at the bodily temperature. If this is not done, a suppository of the aqueous extract of opium, containing \ to \ grain (0.016-0.03), should be used. Ice-cold drinks should be given, and no tea or coffee alloAved. This treatment quiets the uterus, allays ner- vousness and restlessness, and at least puts off the abortion for a feAv hours. Aenesection has been practised in very plethoric Avomen with advantage. When an abortion is inevitable, it is to be treated by measures directed to the avoidance of hemorrhages, the thorough delivery of the ovum and its appendages, and the prevention of inflammation and septi- caemia. For the prevention of hemorrhage a number of balls of absorbent cotton tightly Avound w ith thread to the size of a small egg should be packed into the vagina back of and around the cervix until the bleeding is controlled, and, while a small amount of iodoform may be dusted over them before they are inserted, no astringents are to be applied, unless it be tannic acid to coagulate the blood in the cotton, as astringents cannot reach the bleeding spot. Sponges ought never to be used, as they often fail to control the bleeding and rapidly become septic. By means of this packing the blood in the uterus cannot escape, and, as the uterine Avails contract, they urge the liquid betAveen the membranes, thereby causing complete separation. Ergot should be used after the tampons are applied in the dose of a fluidrachm of the extract or a tablespoonful or two of the Avine. Generally after twenty-four hours the removal of the tampons Avill show the ovum to be in the vagina, but if part of it remains in the uterus, the folloAving measures should be resorted to : The administration of ergot should be stopped unless the hemorrhages are severe, and the uterine cavity ABSCESS. 415 is to be cleared by the use of the fingers of the attendant, who grasps the membranes and draws them aAvay. In skilful hands the curette may be employed. If the cervical canal is too small, it mrrst be dilated by dilators or by packing it Avith sponge tents. After the membranes are removed the tincture of iodine may be applied to the inner surface of the uterus as a haemostatic, antiseptic, and alter- ative, or, better still, the uterus should be douched Avith a 2 per cent. solution of creolin. in Avarm Avater, about a quart being used. The after-treatment consists in the use of small doses of ergot and quinine, of vaginal antiseptic irrigation, or even of uterine irrigation if it is needed, and the maintenance of perfect rest for one or tAvo Aveeks, or longer if possible. Ergot ought not to be given if there is reason to believe that portions of the membranes or blood-clots are in the uterus, as by contraction of the os uteri it may imprison materials which then become septic. (See Puerperal Diseases.) Should fever arise, the uterus should be carefully curetted and the intra-uterine douches of creolin continued until the fever disappears. ABSCESS. The medical treatment of abscess resolves itself into the use of drugs to prevent the formation of pus, to cause its fatty degeneration and absorption, to quiet the systemic disturbance if the inflammation be severe, and to support the body if the suppuration be prolonged or in large amount or if debility exists. The treatment may also be divided into that suited to acute and that to chronic abscess. As acute abscess in its early stages is simply a localized inflamma- tion Avith hyperaemia and an outpouring of leucocytes, it may often be aborted by the use of aconite or veratrum viride in full dose to quiet the circulatory excitement and relieve the congestion. This is particularly true where the pain is pulsating. At the same time, if the swelling is superficial, a poultice, made by moistening bread- crumbs Avith lead-Avater, should be placed over it, or lead-water may be placed on lint and applied in this way. Belladonna ointment smeared over the same area may be of service, and the tincture may be used internally if aconite cannot be had. If a gland be involved, the needle of a hypodermic syringe may be inserted obliquely into its centre and 5 to 10 minims (0.3-0.65) of a 2 per cent, solution of carbolic acid injected into the SAvelling. This method has been found of singular efficacy in bubo where pus seemed just about to form. It is almost ahvays curative, but should not be used in a stronger or weaker solution than that named. Another useful abortive method for the treatment of the early stages of abscess is the application, externally, of a strong solution of nitrate of silver, 20 to 40 grains to 1 ounce (1.3-2.0 : 32.0) of Avater, by means of a camel's-hair brush, all over the skin, covering the area involved, or by the use of the tincture of iodine in a similar manner. Internally, calx sulphurata, in the dose of -^ grain (0.006) given every hour or Iavo, may be used as an abortive, or at least to promote • 416 DISEASES. arrest and cause absorption. If it becomes evident that pus is going to form, then resort must be had to poultices, Avhieh by their heat and moisture will aid in the formation of pus by favoring the escape of leucocytes and by softening the tissues. If pus forms and fluctuation ensues, the abscess should be freely opened, drained, Avashed out by a solution of carbolic acid in the strength of 1 : 20, or of bichloride solution 1 : 5000, and dressed Avith antiseptic gauze. If it is tuber- cular, the abscess may be opened in the ordinary manner, all diseased tissues removed by scraping, and the cavity packed with iodoform gauze, or it should be drained by aspiration, and an ethereal solution of iodoform injected and alloAved to remain in the abscess-cavity if it is a small one. The opening is noAV closed by a pledget of cotton wet with tincture of benzoin, and an antiseptic dressing applied over it. Not more than 20 grains (1.3) of iodoform should be so used in the treatment of tubercular abscess. A very good treatment for slow abscess is to Avash out the cavity Avith a 10 per cent, solution of peroxide of hydrogen. If the abscess is chronic (cold abscess) and associated Avith great weakness, resort must be had to the internal use of iron in the form of the tincture of the chloride, cod-liver oil Avith hypophosphites, qui- nine as a tonic to prevent hectic fever, and the use of nutritious, easily-digested food. Alcohol may be used and should be given with milk. The folloAving tonic pill and solution are of service: R.—Strychninse sulph...........gr. j (0.05). Ferri redact.............gr. xv (1.0). Quinina? sulph............gr. xx (1.3).—M. Ft. in pil. No. xx. S.—One t. d. after meals. Or, R .—Tr. cinchonse comp. I Tr. gentian, comp. V......aa f^iij (96.0).—M. Tr. cardamom, comp. J S.—Dessertspoonful (8.0) t. d. after meals. Having described the means of treatment, it is to be explained how these measures act. The aconite quiets the circulation and thereby relie\^es the inflammation, the lead-water acts locally as an astringent and sedative, while the belladonna by its action on the blood-vessels contracts the dilated capillaries and allays pain. When carbolic acid is injected into an enlarged gland, it acts as an anaes- thetic, as an antiseptic to the germs ahvays present, and as an astrin- gent and stimulant. The nitrate-of-silver applications act by con- stringing the blood-vessels, as local sedatives, and as counter-irritants. The iodine applications do likewise, and also exercise an alterative influence. The physiological action of calx sulphurata is unknown. The object in using the antiseptic irrigations is self-evident, and the employment of iodoform in tubercular abscess rests upon the studies of Brims of Tubingen and many others, who have found by experi- ment that iodoform is fatal to the bacillus tuberculosis. As large numbers of corpuscles are destroyed in the formation of A CNE.—A DENITIS. 417 pus, and other sources of vitality are sapped by its formation, the use of hypophosphites and iron to replace the loss is necessary, and of cod-liver oil and tonics to increase the blood-corpuscles and the assimilation of food. ACNE. This affection occurs in so many forms and arises from such differ- ent causes that a thorough consideration of its treatment cannot be here gi\ren: suffice it to state that arsenic is a remedy Avhich will often cause a cure and prevent a relapse if used in small doses for a long period; that is, 1 to 3 drops (0.06-0.18) of FoAvler's Solution three times a day for a month or two. This is particularly useful if debility and anannia underlie the disease. If the anemia be marked, the proper treatment is that directed to the cure of this condition (see Anaemia); if obstinate constipation is present, relief must be obtained by saline purges and the boAvels kept in order by cascara sagrada or some similar drug. If scrofulosis exists, cod-liver oil is of great ser- vice, or if much pustulation is present, calx sulphurata, in the dose of ^ to |- of a grain (0.006-0.008), may be used in pill form three times a day. In menstrual acne sulphur may be used internally to open the boAvels and applied as a wash to the face in the folloAving form: R .—Sulphuris..............3j (4.0). Glycerini..............f|j (32.0). Aquae rosse..........q. s. ad fgviij (250.0).—M. S.—Apply twice or thrice a day. Or the following may be used in cases of severe inflamed acne: R.—Sulphuris iodidi ..........gr. xxx (2.0). Cerati simplicis...........Jj (32.0).—M. S.—Apply to the parts night and morning. If the skin is very atonic, muddy, and torpid, it should be bathed night and morning Avith hot Avater and castile soap, or even with the tincture of green soap, and Avell rubbed Avith a rough toAvel. If the green soap causes irritation, some bland application should folloAv it, such as simple cerate or the emulsion of the oil of bitter almonds. If the pustules be large, they may be incised and vent given to their contents, the sac being touched Avith a drop of carbolic acid. If induration is great, ichthyol ointment of the strength of 20 parts of ichthyol to 100 of lard should be Avell rubbed in, or resorcin, 10 to 20 grains to the ounce of lard (0.65-1.3 : 32.0), be applied. Mer- curial ointment may also be used to relieve induration, but several days must elapse between its use and that of sulphur, as a black sulphuret of mercury may be formed and stain the face. ADENITIS. Adenitis is an inflammation of the lymphatic glands, generally arising from scrofulosis, unless there be some specific trouble, such as 27 418' DISEASES. syphilis, present. Less commonly it occurs in the neck from the irri- tation produced by the eruption of milk-teeth, sometimes from blows or exposure to cold. If the condition consists in a simple enlargement, it should be treated by inunctions of iodine ointment and lard, half-and-half, night and morning, care being taken that the ointment is stopped as soon as any reddening of the skin appears or if fluctuation develops. If the ointment cannot be used, the tincture of iodine should be thor- oughly painted over the swelling with a brush, but is less efficacious. The following prescription makes a useful application: R — Ichthyol..............3iv (16.0). Adipis benzoinat...........^ij (64.0).—M. S.—Rub a small piece of the ointment into the swelling t. d. Syrup of the iodide of iron, in the dose of 5 to 20 drops (0.35- 1.3), is to be given if the patient is a child, and tonics must be used to improve the systemic condition. As soon as fluctuation or redden- ing shoAvs the formation of pus, all this treatment should be stopped, and a poultice be applied for twenty-four or forty-eight hours till the swelling goes down or is ready for lancing. Lancing is better than allowing the abscess to break, as the scar left in after years is a mere line instead of a large cicatrix. If the enlargement be scrofulous, the folloAving treatment, recom- mended by Treves and Griinfeld, is of value, and should be carried out if the patient will submit to it: The entire removal of the glands should be effected by dissection alone; directors, handles of scalpels, or fingers should be used to separate the glands from the surrounding cellular tissue as closely from the capsule as a nerve is cleaned in the dissecting-room. AVhen sufficient of the anterior surface is exposed, a thick thread is passed through the gland and drawn gently, when, by continuing the dissec- tion, the operator may gradually get to the back of the gland, remov- ing portions of the mass at a time. The cavity should be packed with iodoform gauze, and the Avails scraped if an abscess has existed. ALCOHOLISM. (See Alcohol.) ALOPECIA. This disease, Avhen due to a parasite, is best treated, according to Crocker, by first pulling out all the loose hairs around the bald spot and then painting the affected surface with linimentum cantharidis (liquor epispasticus). Three coats of this liquid should be employed, and each coat allowed to dry before the next is applied. In other cases an ointment of chrysarobin, i to 1 drachm (2.0-4.0) to the ounce (32.0) of lanolin, may be used, but care must be exercised that too much staining of the skin and clothes does not result. Another AMBLYOPIA AND AMAUROSIS. 419 equally good application is 2 grains (0.1) of mercury bichloride to 1 drachm (4.0) of rectified spirit and 7 drachms (28.0) of oil of turpen- tine. This mixture may be rubbed in Avith the finger over and around the patch. If the patient's skin will stand it, 5 grains (0.3) of the corrosive sublimate may be used in place of 2 grains (0.1). AMBLYOPIA AND AMAUROSIS. Amblyopia (or dull vision) and amaurosis (or blindness) usually refer to defective sight or its total loss, the result of functional dis- turbance of the retina, optic nerve, or visual centres, and unaccom- panied by changes in the eye-grounds in the beginning of the disease. These terms, hoAvever, also include cases of partial or complete blind- ness in which optic-nerve atrophy subsequently develops, and are often used to describe ocular disorders not limited by the definitions here employed. These cases may be gathered into certain groups: I. Congenital amblyopias and amblyopias from non-use of the eyes. In the former there is often a high degree of error of refraction, usually far-sightedness; the latter is seen Avhen an eye is debarred from binocular vision by a squint. In both the treatment consists in as perfect a correction of the optical error as possible, and, in case one eye alone is involved, the separate exercise of its functions. Con- genital amblyopias may include incurable defects in the structure of an eye. II. Amblyopias the result of (a) general diseases or conditions— typhoid fever, the exanthemata, syphilis, scurvy, malaria, colds, etc.; (b) local diseases or conditions—hemorrhoids, hemorrhage, pregnancy, disordered menstruation, kidney disease, diabetes, migraine, disorders of the nervous system, etc. The remedies indicated by the special cause are to be employed, the medicinal agents most usually needed being mercury, iodide of potassium, pilocarpine, particularly in uraemic amaurosis, emmena- gogues, and tonics, especially hypodermics of strychnine. As local measures repeated fly-blisters to the temples, wet and dry cups, and the constant electric current are used. The nape of the neck may be cauterized. In hysterical cases metallotherapy may be tried. III. Amblyopias the result of the action of certain medicinal and toxic agents. The abuse of alcohol, and particularly of tobacco, produces a form of amblyopia characterized by the development of a scotoma or an area in the centre of the field of vision in which the appreciation of red and green is lost or greatly diminished. Quinine in excess has, in a number of instances, being folloAved by temporary blindness, Avhich is usually denominated quinine amaurosis. Of less frequent occurrence are the cases of amblyopia produced by the toxic action of salicylic acid, lead, silver, mercury, osmic acid, nitrobenzol, filix mas, and the Arapor of sulphide of carbon. In all instances the patient must 420 DISEASES. be Avithdrawn from the influence of the poison ; in tobacco amblyopia, in its early stages, this is usually sufficient to effect a cure. The rem- edies which have proven of the greatest utility are digitalis, inhala- tions of nitrite of amyl, nitroglycerin, and strychnine. Iodide of potassium should be exhibited in chronic cases, and always in ambly- opias the result of lead-poisoning. The constant current has also been employed. IAr. Amblyopias the result of direct or indirect injury or from reflex irritations. Traumatic amblyopias may folloAv a blow upon the eye itself or an injury to the skull or spinal cord. To carious teeth, intestinal irrita- tions, and the presence of parasites a certain number of amblyopias have been attributed, but, while it is not possible to disprove the association, such cases must be received with doubt. After the removal of the cause strychnine should be exhibited. Optic neuritis most frequently depends upon coarse diseases of the brain (tumor, abscess) or inflammation of its membranes (meningitis). It is also a symptom of numerous disorders—suppression of the menses, exposure to cold, rheumatism, anaemia, syphilis, uraemia, lead poisoning, etc. The remedies are those naturally suggested by the disease or condition which has called it into existence. The prog- nosis depends upon the cause. Mercury, iodide and bromide of potas- sium, the salicylates, pilocarpine, local bloodletting, and fly blisters are the remedies commonly employed. Optic-nerve atrophy is either primary or secondary to disease of the brain or spinal cord or consecuth'e to an antecedent neuritis. After all irritation has subsided the greatest improvement may be expected from hypodermic injections of strychnine, which should be pushed to the point of tolerance. Temporary improvement follows the inhalation of nitrite of amyl, and, in the hope of improving the circulation in the optic nerve, nitroglycerin, digitalis, and similar cardiac tonics may be employed. The constant electric current has been employed with benefit, especially by voltaic alternations, Avhich are more active than simple closures. The folloAving remedial agents have also been employed: Suspension, stretching the optic nerve, Sequardian injections, nitrate of silver, lactate of zinc, phosphorus, and, quite recently, hypodermics of antipyrine. Mercury may be used Avith benefit in early stages of the degenerative process, but is of doubtful value in advanced cases. It may be administered in the usual manner or by subconjunctival injection in the dose of -fo mg. Suspension and injections of testicular juice have little or nothing to commend them. AMENORRHCEA. This condition depends upon so many causes for its existence that it must be treated in many different ways. If anaemia or chlorosis shows that a deficient supply of blood is present, measures adapted to the relief of such a state are required (see Anaemia), Avhile if plethora is ANEMIA. 421 a cause depletants in the shape of saline purges are needed, but aloes are harmful. In a similar manner, in amenorrhoea due to constipa- tion saline and other purges may be used, but the best of these is aloes; and, as constipation and anaemia often exist hand in hand, a combination of aloes and iron in a pill is commonly resorted to. The iron improves the blood, and the aloes stimulates and congests the pelvic viscera by bringing blood to the sexual organs. Aloes also increases the assimilation of iron in some unknoAvn manner. The following pill is often of service, and is especially recommended by Goodell: R.—Extract, aloes aqueosi.........3j (4.0). Ferri sulphat. exsiccat.........gij (8.0). Asafcetid.-e..............giv (16.0). Ft. in pil. No. c. S.—From one to three pills three times a day. Cimicifuga has been highly recommended in chronic and appa- rently causeless amenorrhoea in the dose of 30 drops (2.0) of the fluid extract at the time for a proper Aoav to occur. Within the last feAv years the binoxide of manganese, in the dose of 1 to 3 grains (0.05-0.15), has come prominently forward as a remedy in simple idio- pathic amenorrhoea, and is undoubtedly of service, but it should be taken for at least tAvo weeks before the date upon which each men- struation is expected to occur. Potassium permanganate is also use- ful during the same period in similar states, but it is inferior to the binoxide of manganese in the author's experience. Apiol, the active principle of parsley, may be given in capsules in the dose of 3 to 10 grains (0.15-0.65) for the same condition, and oils of rue. savine, and tansy have also been employed in capsule in the dose of 5 drops (0.1) three times a day. In all forms of amenorrhoea a hot sitz-bath at the time for the expected ''period" is of service, more particularly if the patient has " caught cold." The bath should be persevered in for several nights, and care should be taken to avoid exposure. Often a little mustard added to the Avater Avill increase the efficacy of this treatment. Under the name of " DeAvees's Emmenagogue Mixture," first deA'ised by Professor Dewees of Philadelphia, the following formula has been largely used in functional and organic amenorrhoea: R .—Tinct. ferri. chloridi........f^iy (12.0). Tinct. cantharidis.........f.^j (4.0). Tinct. guaiac. ammon........f.jjss (6.0). Tinct. aloes............f|ss (16.0). Syrupi.........q. s. ad f$vj (192.0).—M. S.—Tablespoonful (16.0) three times a day. ANEMIA. It is, unfortunately, only too true that the entire subject of blood- making and blood-breaking is as yet very imperfectly understood, but many of our therapeutic facts rest on rational ground now, if not before, 422 DISEASES. and if the pathologist will give us more information upon these subjects, other remedial measures will be introduced or the empirical employ- ment of others still further explained. Practically speaking, the therapeutist recognizes two very important points, the causes of Avhich the pathologist must eventually solve—namely, that one class of anaemias are due to defective or deficient haemogenesis, and another to excessive haemolysis. The former are generally believed to form the simple class, and the'latter the essential or pernicious class. It is in the deficient haemogenesis class that we fail to produce good results. More than this, the causes of excessive haemolysis are so various that we can further divide them into removable and permanent, the remov- able being represented by the cases in which copraemia or auto-intox- ication takes place, and the others by the true pernicious anaemia, about Avhich we really know very little, save that most observers find evidence of profound haemolysis in the percentage of iron in the liver, Avhile in the dark-colored urine they believe a destructive agent exists Avhich prior to its excretion has slaughtered many corpuscles. Unfor- tunately, it is at present impossible for us to separate clinically the haemogenous anaemia from that of haemolytic excess, unless we find evidence of great corpuscular disintegration in a copious elimination of haemoglobin in the urine, or a jaundice evidently haematogenous in character, or a large number of defective corpuscles, Avhich Avould per- haps indicate defective haemogenesis rather than that they Avere scarred veterans of a battle Avith a poison in the liver-cells or else- Avhere. Post-mortem signs often aid us in the differential diagnosis, but this is too late to be of any benefit to the doctor or patient. There is one point, however, about which there can scarcely be any doubt, and that is that in many cases iron is greatly abused, being given Avhen there is no indication for it or more frequently given in excessive dose. By excessive dose the author refers to as much as 6 to 10 grains in a day of reduced iron. The amount of iron in the human body is very small, and every study ever made of its absorption and elimination after absorption has shoAvn that these processes are very sIoav. Hamburger recovered from the faeces nearly all the iron admin- istered, and Jacobi proved that even Avhen the iron was injected into the veins 10 per cent, was at once eliminated by the boAvels, liver, and kidneys, and the remainder deposited in the liver, spleen, and other tissues in the same manner as is any metallic substance. The researches of Gottlieb have also been in confirmatory lines. AVhen we consider that there is in the human blood only about 39 grains of iron, all told, we can see that the use of 12 grains a day in the course of a little over three days places a double quantity of the metal in the economy, which is not needed, and is either cast out or deposited at any convenient spot, there to lie undisturbed until it can be extruded. Much, of course, depends upon the cause of the anaemia, but there is only one excuse for the use of the doses just named—viz. a condition of the digestive apparatus Avhich results in the formation of a sul- phide of iron in great quantity, so that only an infinitesimal amount escapes into the system. This perhaps explains the empirical fact that ANAEMIA. 423 in some cases of chlorosis or intense anaemia iron has to be given in large doses to accomplish any good. One of the best and most recent papers on this subject is that of Ralph Stockman, Avho gives a masterly summary of the subject of the absorption of iron in chlorosis. In this summary he points out that Ave have three chief theories as to the action of iron in anaemia. The first, the absorption theory, is based on the fact that as iron is taken into the body Avith the food, the iron of the haemoglobin must be obtained from this source, and therefore that medicinal iron given by the mouth must be absorbed. The second theory rests upon the belief that iron is not absorbed when given by the mouth in addition to that in the food, but simply acts as a stimulant to the mucous membrane of the alimentary canal, therefore increasing the digestion of food, and so overcoming anaemia by the general improvement coin- cident upon proper nutrition. The third theory is that of Bunge— namely, that in chlorotic conditions there exists an excess of sulphur or sulphuretted hydrogen in the bowel, Avhich changes the iron in the food into a sulphide of iron, Avhich Bunge states cannot be absorbed. He believes that the inorganic iron Avhich is given as a medicine saves the organic iron of the food by combining Avith the sulphur, and so indirectly cures the anaemia by the protection afforded the food-iron. It is important to remember that each of these theories has been supported by many careful experiments, but it is also Avell to bear in mind that the hypotheses and the experiments supporting them may be erroneously based. Thus, Ave have no right to imagine that the inorganic preparations of iron have a stimulating poAver over the ali- mentary mucous membrane, or, even if they have, that this poAver is exercised in the peculiar line of aiding in the absorption of the organic iron of the food. Again, the researches of Hamburger, Damaskin, Gottlieb, Midler, Jacobi, and Socin, Avhich shoAV that after the internal use of inorganic iron there is no increase in the iron in the urine, are valueless so far as the conclusions draAvn by them are concerned—namely, that as there is no increase in iron in the urine, there is none in the blood, and therefore it is not absorbed. These conclusions are not justified, because they are based on the erroneous vieAv that because iron is not in the urine it is not in the blood, and because it is not in the blood it is not absorbed. Every one knows that in the case of chronic lead poisoning, Avhen the body is saturated Avith the metal, there is often no lead in the urine, the poison being deposited in the tissues; and if this is true of lead, it may be of iron. Particularly is this to be remembered when Ave find Stockman quoting the researches of Mayer, Bidder, and Schmidt, and a host of others, who have proved that Ave are not to look to the kidneys as the path for the excretion of iron, but to the intestinal Avails. Finally, Stock- man has proved that A\rhen iron is used hypodermically it cures anae- mia when it cannot stimulate the digestion or counteract sulphides. AATe learn from practical experience several things which science does not tell us—namely : Iron will not cure all cases of anaemia, even if they belong to a functional type, but other methods must be resorted to at the same time or separately for their cure. The insol- 424 DISEASES. uble salts of iron are better remedies for absorption than the soluble salts, because they are not precipitated in the stomach, and for this reason reduced iron is the best chalybeate for uncomplicated cases. Besides using iron in this form, Ave should employ laxatives if the boAvels are confined; mineral acids, particularly nitric and nitromuri- atic, for their effect on the function of the small intestine and liver; and, in addition, bitter tonics of a more or less simple form, accord- ing to the exigencies of the case, using quinine if malaria seems lurk- ing in the body, simple bitters if the stomach lacks tone, aromatic bitters if from atony of the muscular coats the digestive tract seems sluggish, with a resulting formation and accumulation of flatus and digestive juices. The preparations of iron best employed in anaemia are the insol- uble salts just named, such as Quevenne's iron and the carbonate, but there are indications Avhich must be regarded as to the salt to be used. In many anaemic persons, particularly females, the tongue is broad and Avhite, not from coating, but pallor—is flabby and torpid- looking. Under these circumstances the bowels should be kept mov- ing by mild purges, and the sulphate or some other astringent prepa- ration of iron be taken by the patient. In the anaemia caused by rapid childbearing and lactation, cod-liver oil, the hypophosphites and phosphates of lime, should be used, Avhile the iron and quinine in tonic dose may be of service in all forms of the disease. AVith some practitioners Blaud's pill is very much used, made as folloAvs: R.—Ferri. sulph. exsiccat. \ .. .. fQ n, Potassii carbonatis /.........aa 3" &M)- Syrupi • • -..............q. s.—M. Ft. in pil. No. xlviii. S.—One to three pills three times a day, after meals. Although it is perfectly true that Ave have almost no knowledge of the manner in Avhich alteratives act in instances of disease where, through morbid functional activity, enlarged glands or growths appear, it is evident that they must act upon the trophic nerves or directly upon the nourishment of the affected parts. If they are used in large quantities, they act as depressants to the normal nutri- tion of the body, producing primarily a decrease in the vitality of morbid growths, so that they melt down and disappear, and they may finally so reduce the condition of the healthy tissues as to cause sloughs and ulcerations. Whether these changes are due to over- stimulation of nutrition—that is, to an excessive trophic change— or wmether they depend upon actual loAveri^g of the tone of the parts, we do not know. One thing we do know, however, and that is that small doses of most of the so-called alterative drugs act as very dis- tinct stimulants to the development of normal structures, and in no instance do Ave find this more typically represented than in the effect which they exert upon the blood. Quite a number of years ago Keyes of New York emphasized the value of minute doses of mercury bichloride in syphilitic and other anaemias, and abundant clinical observation has certainly confirmed his vieAvs. The dose of bichloride ANAL FISSURE. 425 of mercury in anaemia should be about A^. 0f a grain (0.0016). Not only will minute doses of the bichloride of mercury act in this Avay, but small amounts of calomel or mercury itself will have such an effect. Inunctions of very small amounts of mercurial ointment once a day or every other day, in adults and in children, will increase the fulness and redness of the cheeks and lips and the number of the corpuscles, the piece of ointment used being no larger than the half of a very small pea. This treatment will be found of service in cases not necessarily dependent upon specific taint or scrofula. The marked increase in the nutrition of children of a syphilitic taint Avho are suf- fering from marasmus under the internal use of gray powder and such inunctions gives further evidence of this fact. Arsenic also is of value in anaemic conditions, and may be em- ployed in relatively larger doses than mercury, but, nevertheless, smaller amounts than are usually given in chorea and similar states. Osier has shown the value of the drug in anaemia, and so has Barton in England. Any one of the preparations of arsenic may be employed, but not more than -^ grain (0.004) of arsenous acid should be taken in a day, although more has been used Avith no less benefit to the patient. Most of the drug, under these circumstances, is in excess, and is cast off in the urine and faeces unused and wasted, straining and irritating the emunctories of the body during its passage through them. Arsenite of copper is also a remedy of very considerable value under these circumstances in the dose of from T^ to oV 0I" a grain (0.0006-0.003) three times a day. Bullock's blood, fresh or dried and redissolved, may be used by the rectum in the treatment of anaemia in those cases where iron fails, and a change of air and diet may often produce a cure which no drug can bring about. Diet is an important part of the treatment of anaemia. The food should be good, Avell flavored, and varied, as Avell as easy of digestion. It should contain, as far as possible, the remedies needed by the sys- tem, such as bone^salts, iron, and alkalies, and should be accompanied by some red wine, such as port. At present Ave may conclude that pathology has not found out the real cause of these troublesome cases, and that until physiology can put its finger upon the most intricate mechanism of blood-making with a positive, clear statement of its function and the physiological chemistry of the manufacture of haemoglobin, we must remain satis- fied to resort to the remedies Avhich experience or common sense tells us will be of value to our patients. ANAL FISSURE. This is one of the most painful affections to which man is subject, and requires intelligent treatment, generally by surgical means if the result is to be curative, although great relief can be obtained by the use of drugs. 426 DISEASES. The most painful and annoying feature of the lesion is the vio- lence of the pain on defecation, which is so severe that any emptying of the bowel is impossible except on rare occasions, when the pain is concentrated in one effort. To relieve this pain and enable the patient to have a fairly com- fortable stool, nothing is so good as an iodoform suppository contain- ing 2 to 10 grains (0.1-0.65) of the drug. Iodoform being a local anaesthetic, the passage takes place almost Avithout the patient's knoAvledge. If much spasm of the sphincter is present, extract of belladonna, \ grain (0.015), may be added to each suppository. For the cure of the fissure a drop of strong carbolic acid may be applied to the spot, and a lotion of tannic acid, glycerin, and water used if hemorrhoids are also present. Ringer highly recommends the appli- cation to the fissure, by means of a brush, of a solution of bromide of potassium, IJ drachms to 1 ounce (6.0:32.0) of glycerin. In order that the passages may be soft and yet the patient not be purged, sulphur should be given in the dose of 20 to 40 grains (1.3-2.6) every night, or, if this cannot be used, castor oil may be given. The best way to give the sulphur is by combining it with poAvdered cinnamon or aromatic powder. Sometimes relief is obtained by the use of flexile collodion painted over the fissure. ANEURISM. The treatment of aneurism by drugs is, unfortunately, not very suc- cessful, but is at least worthy of trial in all cases. Vascular disease resulting in such a lesion depends upon so many causes Avhich may modify the treatment that the history of the case should be Avell borne in mind. The most common causes are syphilis, rheumatic taint, and traumatism, and very often injury is superimposed upon one of the systemic taints named. A\rhatever the cause of the disease may be, iodide of potassium is par excellence the remedy most apt to do good, and it will nearly always give relief, even if it does not cure. The doses should be large, 10 to 20 grains (0.65-1.3) three times a day if the patient will bear them, and the prognosis under this treatment is far more favorable if the cause be syphilis than if the dis- ease be idiopathic or traumatic. For successful treatment the recum- bent position must be insisted upon and the patient kept quietly in bed, changing his position as little as possible and confining himself to the most simple and easily digested diet, Avith entire avoidance of all stimulating substances either in the Avay of food or drink. Often an absolute milk diet is to be adhered to. If the heart is excitable and irregular and the vascular system irritable, Avith a high arterial tension, the circulation must be quieted by small doses of veratrum viride, say 1 or 2 drops (0.05-0.1) twice or thrice a day, but dig- italis is not to be employed, since it increases the strain upon the aneurismal sac, although it does quiet the irregular heart beat. Aconite may also be used with care, but it is inferior to vera- trum viride. If the pain be very great—and it often is severe, par- ANGINA PECTORIS. 427 ticularly at night—opium is indicated and sleeplessness should be allayed, not by full doses of morphine, but of morphine and chloral; or, better still, croton-chloral should be so ordered that the patient receives l grain (0.075) of morphine and 10 grains (0.65) of croton- chloral in pill at bed-time. All attempts to cure aneurism by the use of other drugs, unless syphilis indicates mercury, are useless when the lesion is thoracic or abdominal, and when it occurs in the extremities, as in popliteal aneurism, surgical measures are to be resorted to as the chief means of cure. If dyspnoea in thoracic aneurism is marked, slight inhalations or "whiffs" of chloroform are useful. As we do not know how alteratives act, other than that they gov- ern nutrition, Ave cannot explain the value of iodides in aneurism. ANGINA PECTORIS. The exact pathological changes existing in angina pectoris are by no means clearly understood, but without doubt many cases are due to spasm of the blood-vessels, which results in distention of the left side of the heart, which organ is already dilated or enfeebled by disease. Often, too, the coronary arteries have undergone athe- romatous changes, thereby aiding in the cardiac debility, Remedies which ordinarily relieve pain act too sloAvly or too feebly to be of service in angina pectoris, and if successful would only relieve the symptom without removing the cause. The indication in the great majority of cases is to relax the vascular spasm, this relieving the overburdened heart. As first pointed out by Brunton, the nitrites possess this poAver, and to him belongs the credit of first applying this class of drugs to this ailment. All the nitrites are useful, but the nitrite of amyl and nitroglycerin are the best remedies for the attack itself, and the nitrite of potassium or sodium for the intervening periods or where the paroxysm is prolonged. The reason for this lies in the fact that the sodium and potassium salts are more stable than the other two compounds, are more sIoavIv broken up in the body, and therefore more prolonged in their effects. In an attack a few drops of the nitrite of amyl should be given by inhalation from a handkerchief, or the nitroglycerin can be used in the dose of 1 drop of a 1 per cent. solution by the mouth. The dose of the sodium and potassium nitrites is 3 grains (0.15) three times a day, but all these drugs are useless unless the arterial tension is high and the heart throbbing or irreg- ular in its exercise of power. If vascular relaxation is present, they should be supplanted by stimulants, such as alcohol, in full dose, in warm Avater. Digitalis tincture in the dose of 10 drops (0.65) may be given hypodermically during the attack to stimulate the heart if it is Aveak, and betAveen the attacks to improve its condition. The writer has found 20-grain (1.3) doses of antipyrine of great service in some cases. Ether given hypodermically is often of service, but Hoff- mann's Anodyne may be used by the mouth or hypodermically instead of ether with better results. 428 DISEASES. If the nitrite does not relie\re the pain, or if it cannot be used because of some contraindication, morphine must be given hypoder- mically in the dose of ^ to J grain (0.016-0.03), but it should never be given by the mouth under these circumstances, as its absorption Avill be too sIoav and its' effects Avill come on after the pain has ceased. The cure of the patient rests upon the elimination of all causes which can possibly produce a nerve-storm from cardiac irritability, and in the administration of arsenic in full dose for long periods of time. Phos- phorus is another remedy which is of undoubted value, and should ahvays be tried in the dose of j^-q grain (0.0006) three times a day after meals. The following is a valuable prescription for use between the attacks: R— Tine, digital............."Ixlviij (3.0). Tine, strophanthi .........TTLxlviij (3.0). Nitroglycerin! (1 per cent.).....tTl,xxiv (1.6). Tine, cardamomi........q. s. f§iij (96.0).—M. S.—Teaspoonful (4.0) three times a day. The diet should be moderate and easy of digestion, and salads, lobster, and similar articles of food abandoned. If the patient is inclined to take exercise of a violent character, he must be restrained, but some exercise must be insisted on if it is possible. Tonics, fresh air, freedom from mental worry and avoidance of exposure and cold are also necessary, and running for a car, or per- forming any act calculated to suddenly increase arterial pressure and cardiac Avork, is to be avoided. Cocaine has been highly recommended for the cure of angina pec- toris, but is as yet untried, except in a few cases. In that form of angina pectoris occurring in nervous females, some- times called pseudo-angina pectoris, 1 drachm of ether in ice-water or capsule will often abort the attack, or if the paroxysm is caused by dyspepsia and if the stomach be overloaded, the sufferer may be relieved by the stomach-pump. Between the attacks aconite tincture in the doses of 2 to 3 minims (0.1-0.15) three times a day is useful. ANOREXIA. Anorexia is only a symptom of disease, generally associated with debility or other systemic disorder, such as fever or many exhausting diseases. It is best treated by a careful diet, the use of the bitter tonics, such as gentian, cardamoms, and the mineral acids, or by the use of one of the following prescriptions : R.—Acid, arsenosi............gr. i (0.03). Extract, nueis vomicae........gr. iv (0.3). Quinina; sulph............gr. xx (i.3).—M. Ft. in pil. No. xx. S.—One t. d. after meals. Or, R.—Acid, hydrochlorici dil.........f|ss (16.0). Tinct. cinchona? comp.........f^vj (192.0).—M. S.—Dessertspoonful (8.0) three times a day, after meals, Avell diluted with water. APOPLEXY. 429 (For the use of other bitter tonics see Calumba, Quassia, Chamo- mile, Cardamom, and Nux Vomica.) None of these drugs are suit- able if there is any acute irritation or inflammation of the stomach or intestines. (See Indigestion.) APOPLEXY. AMien a person suffers from a stroke of apoplexy, the chief aim of the physician must be to loAver the blood-pressure, and so to decrease hemorrhage, and, as the blood-pressure is nearly always excessive under these circumstances, its reduction may be considered as a routine treatment. If the person be at all full-blooded, copious venesection is to be employed, any one of the veins in the arm on its anterior surface being most conA^enient. (See Venesection.) At least 1 pint (500 cc.) should be Avithdrawn and the condition of the pulse carefully noted. If bleeding is impossible, veratrum viride or aconite must be used to loAver blood-pressure, the latter in full dose, 5 drops (0.35) of the tincture. Hot mustard plasters must be applied to the feet, or a warm mustard foot-bath be used if this is practicable. Ice in an ice-bag or Avrapped in a toAvel may be applied to the head, and if vomiting comes on care must be taken that the stertorous breathing does not draAV into the lungs particles of the half-ejected food. Some- times croton oil, 1 drop (0.05), placed on the tongue with 5 drops of sweet oil, may cause a depletant catharsis, or ^ grain (0.01) of elaterium may be used. The head must be kept high and the feet low down. These are the methods to be used immediately after the rup- ture of the blood-vessel. The object to be sought, after the " stroke " has occurred and the hemorrhage has ceased, is the removal of the extravasated blood, the restoration of function in the paralyzed parts, and the prevention of secondary lesions consequent upon inflammation of the brain as a result of the injury to its substance. If the patient survives the attack, no drugs should be used save arterial sedatives for one or two days, until the clot in the ruptured vessel has become firmly fixed, unless symptoms of meningitis arise, Avhen these drugs must be pushed, and opium and calomel administered in small antiphlogistic doses, J grain (0.016) of each every four hours. Meningitis and cerebritis rarely occur if the veratrum viride or aconite is properly used. After the clot has firmly formed and has plugged the blood- vessel, Ave may proceed to take measures for the absorption of the exudate, the chief measure consisting in the use of iodide of potas- sium in as large doses as the patient will bear without the production of iodism. This drug should not be resorted to until several days, or even tAvo or three weeks, have elapsed after the attack. Mercury in small doses may also be given. In order that the muscles of the extremities may not waste and become powerless from disuse, passive exercise, rubbing, and, if pos- sible, massage, must be resorted to. Electricity may be applied to them in the form of the slowly-interrupted current, and strychnine 430 DISEASES. may be used hypodermically or by the mouth as a stimulant to the trophic centres in the spinal cord. None of these measures are to be employed if any inflammation exists in the'brain, as they Avill increase the cerebral disorder, and at least three weeks should elapse after the attack before they are resorted to. Electricity applied to the head to remove the lesion is useless, as the current does not go through the brain, but around the skull by means of the scalp. A very careful diet is to be maintained. Meats are to be used very sparingly, the bowels maintained in perfect regularity, and no wines are to be taken nor any stimulants used, lest they cause a second rupture of the weakened vessel in the brain. Apoplexy must be carefully differentiated from acute alcoholism and opium poisoning, which it much resembles. (See Alcohol.) If respiration fails, nothing can be done with much advantage, but belladonna or strychnine may be given hypodermically. The use of electricity to stimulate the phrenic nerve and diaphragm Avhen respi- ration fails is a remnant of senseless medical practice, and is partic- ularly useless in apoplexy. (See Asphyxia.) Above all things, stimulants are contraindicated during the acute attack, even though the pulse fails, as they increase the hemorrhage into the brain. ASPHYXIA. With the advent of the production of artificial anaesthesia by the use of certain chemical compounds the importance of this subject necessarily became enormously increased, and no one can doubt that the majority of cases of arrested respiration depend for their exciting cause upon such agency or are due to the inhalation of noxious gases. It is of the greatest importance that a clear idea of the necessities of the case be grasped by the physician under such circumstances, and that his action be one of rapidity and clearness so far as the ultimate result which he seeks is concerned. By some curious fallacy of teaching the greater part of the profession have been taught to faradize the diaphragm into contraction Avith the rapidly-interrupted electrical current by the application of one pole over the phrenic nerve in the neck and the other over the abdomen. It requires but little thought to show that such a method is ludicrous in the extreme, for by using such a current on any muscle we produce a condition of spasmodic contraction or tetanus. Every one knows that the diaphragm relaxed by paralysis or contracted by spasm, so long as it is immovable, is quite useless to the patient. If any current is to be employed, it should be that which is slowly interrupted, and which will alter- nately contract and relax this important respiratory muscle. There can be little doubt that the rapidly-interrupted current has caused persons to renew their respiratory movements, but in these cases the result has been dependent almost certainly on the reflex excitability of the cells in the spinal cord and medulla rather than on an action ASPHYXIA. 431 upon the phrenic nerve. If such an action is required, the poles of the battery may be swept over the body so as to cause peripheral irritation. The absurdity of the application of the rapidly-interrupted cur- rent to the phrenic nerve is not alone dependent upon the points we have named. It has recently been proved by careful observation on the part of Dr. Martin and the author that the application of the electrode over the phrenic nerve in the neck may cause cardiac arrest through diffusion of the current to the vagus nerve, and Griswold reached conclusions of an identical character in the year 1885. If electricity is used, it should be employed solely as a peripheral irritant, with the object of arousing the patient, as would a dash of cold water. The question at once arises as to the best thing to do Avhen such an accident occurs. If the arrest has occurred when the patient is under chloroform, his head should be lowered and the feet raised almost perpendicularly. The neck should not be extended, but held in the normal position, so that the chin is someAvhat shot forward and at a right angle to the body line. If the neck be extended, the glot- tis does not open as Avell as Avhen the position named is assumed. While one assistant supports the head in this position, another should use artificial respiration by Sylvester's method, and it Avill then be readily seen that there is an increased volume of air passing in and out of the chest. The drawing forward of the tongue is not so important as is imagined, unless it is pulled upward and toAvard the teeth in the upper jaAv. The use of ammonia, when given intrave- nously into the leg as a rapidly acting respiratory and cardiac stimu- lant, may be resorted to, and dashes of cold and hot water should be employed, not only for their excitation of the peripheral nerves, but also for the purpose of keeping the bodily temperature from rising above or falling beloAv the normal line, the latter danger being, of course, the most pressing. The hypodermic injection of ether during asphyxia from ether anaesthesia is a ridiculous therapeutic attempt, for if the system and respiratory centres are so depressed by the ether already taken into the blood through the lungs as to have their func- tions in abeyance, why should we add still greater depression by injecting more of the same drug? Let everything that is done be born of sense and thoughtfulness of the exact action and result desired, and let nothing be done simply because some other person has done it, great though he may be in the practice of the healing art. Measures for the relief of persons suffering from any malady depend not upon empirical laAvs, but upon the good common sense of the physician in charge, even if the measure is a most revolutionary one in character. AVhen practising artificial respiration in cases of asphyxia Sylves- ter's method should ahvays be employed. This consists of laying the patient on some hard, flat surface, kneeling above his head, and then, after grasping the arms at the elbows, bringing them upward and outward, so that they folloAv the plane on which the body is extended. This movement causes expansion of the chest, or inspiration. After 432 DISEASES. a moment's pause the arms are lifted up and brought toward one another, and then, while still approximated, pushed down to their original position upon the floating ribs, upon which they are pressed. This last movement drives out the air from the chest, or causes expi- ration. These movements should be at the rate of from sixteen to twenty per minute, about that of normal respiration, and be persisted in for at least forty-five minutes, even though the case seems hope- less, as cases have recovered after as long a period of apparent death as an hour. While they are being carried on the patulousness of the upper air-passages is to be maintained. In some researches made by Dr. Martin and the writer the folloAv- ing rules regarding the position of the head, neck, epiglottis, and tongue were formulated: The fingers are passed behind the angles of the lower jaw and the latter is pressed forward; this elevates the epiglottis and the base of the tongue about a quarter of an inch from the post-pharyngeal wall. Extending the head and pushing it for- ward so that the neck makes an angle of forty-five degrees with the plane of the table draws the base of the tongue and the hyoid bone far fonvard, this motion being at the same time imparted to the epi- glottis, so that the latter stands upright and is separated from the posterior wall of the pharynx by an interval of about an inch. By tightly closing the jaw the antero-posterior space is still further increased. The epiglottis may prevent free entrance of air to the lungs, even though the tongue is pulled forAvard. Any means which accom- plishes the anterior projection of the hyoid bone immediately and infallibly raises the epiglottis and the base of the tongue, and the hyoid bone may be made to project anteriorly by direct pressure upon its cornua, by direct pressure or traction applied to the tongue far back behind the anterior half arches of the palate, and by the action of gravity in the abdominal decubitus, or by extension of the head upon the neck, although flexion of the neck Avith extension of the head upon the neck does away with the epiglottis as an obstruct- ing factor as completely as any other posture. ASTHENOPIA. Asthenopia, or weak sight, depends upon exhaustion of the power of accommodation in cases of refractive error, usually hypermetropia, or upon insufficiency of the external ocular muscles. The former is sometimes called accommodative asthenopia, and the latter muscular asthenopia. The treatment of these conditions requires the prescrib- ing of the proper pair of glasses, combined, if necessary, with prisms and with systematic exercise of the ocular muscles. Locally, a weak solution of the sulphate of eserine or pilocarpine acts as a stimulant to the ciliary muscle, and internally good results follow the use of large doses of the tincture of nux vomica or strychnia. R.—Eserinse sulph............gr. ^ (0.002). Aq. destill.............fgj (32.0)—M. S.—2 drops (0.1) night and morning. ASTHMA. 433 Or, R—Pilocarpin. nitrat..........gr. ,L (0.003). Aq. destill.............fgj (32.0).—M. S.—2 drops (0.1) night and morning. Another form of asthenopia is termed neurasthenic asthenopia or retinal anesthesia, and presents a number of eye-symptoms in con- nection with a general depression or debilitated state of the nervous system, the eye itself, hoAvever, being a healthy organ. The chief symptoms are fluctuation in visual acuity, rapid disappearance of objects looked at, contraction of the field of vision, imperfect retinal images, often associated with dread of light. The mere prescription of glasses in these cases to correct any refractive error is not suf- ficient. Much relief will often be obtained if hot compresses at 110° F. be made to the closed eyelids for five minutes at a time. The patient requires the same general treatment that would be applied to any neurasthenic case. All the functions of the body must be care- fully examined into and placed in as normal a condition as circum- stances will alloAv. Especially valuable are rest, massage, salt baths, and full doses of strychnia, together with iron if there be anaemia. ASTHMA. Asthma is one of the most difficult diseases to successfully treat that the physician has to deal with. The disease in all its forms depends upon interference with the free entrance and exit of the air to and from the lungs, and this is generally, if not ahvays, dependent upon a spasm of the muscular fibres in the Avails of the bronchial tubes, although it has been asserted to be due to a sudden SAvelling or hyperaemia of the bronchial mucous membrane. Both of these states are probably present in varying degree in all cases The spasm has been proved by Longet, AA'illiams, Romberg, Paul Bert, Bierner, and very recently by Sandmann, to be due to a neurosis of the pneumogastric or vagus nerve, Avhile the swelling of the mucous membrane has been seen by Stoerk and others. This has formed tAvo schools of teaching concerning the pathology of this disease, when a little attention to the physiology of the subject Avould at least sIioav that no difference need exist, the vagus nerves governing not only the muscular fibres, but also the blood-vessels of the bronchial tubes. The discovery of Michaelson that injury of the recurrent laryngeal nerves causes catarrhal inflammation of the bronchial tubes, particularly those of the upper lobes, renders the analogy betAveen acute asthma and laryngeal spasm Avhich has been spoken of by many Avriters still more interesting. One other step remains for a thorough understanding of the man- ner in Avhich the disease is produced. Gastric, dyspeptic, or intestinal asthma arises from indigestion, as its name implies, and is caused by the irritation of the afferent filaments of the vagus in the Avails of the stomach and intestine, thereby causing reflexly a contraction and 2S 434 DISEASES. hyperaemia of the bronchial tubes. In a similar reflex manner hyper- trophies of portions of the nasal chambers or abnormal conditions of the nasal mucous membranes in general may result in an asthmatic attack. Having obtained some idea of the cause of an attack, let us turn to the treatment of the affection. By far the most serviceable remedy in asthma is belladonna, Avhich, as has been pointed out Avhen that drug Avas studied (see Belladonna), exercises in medicinal dose a decided sedative and depressing influ- ence on the peripheral filaments of the vagus nerves, not'only so far as the heart is concerned, but also, through the pulmonary fibres, upon bronchial secretion, Avhich is ahvays diminished by the drug, probably by this vagal influence. It is evident, therefore, that the use of belladonna or atropine, although originally employed in an empirical manner, is really based upon rational ideas, and as the physiological action of stramonium, hyoscyamus, and similar members of this group is nearly identical with belladonna, their influence for good is also explained. The experiments of Ott proved that lobelia is a peripheral pneumogastric depressant, and those of Rosenthal and the author likewise showed that tobacco has a similar effect. The same is also true of nitrite of amyl and the other nitrites, Avhich also relax unstriped muscular fibre. AVe have before us, therefore, a list of the most efficacious and best antiasthmatics, all of them being depressant to the periph- eral vagi. The other remedies commonly employed are chloroform by inhala- tion, which relaxes the spasm of muscular fibre by its local influence, and morphine, Avhich acts as a nervous sedative, prevents reflex irri- tation, and quiets the patient, acting at the same time as a heart stim- ulant and unloading the engorged cardiac cavities. The relief obtained by the inhalation of the fumes of nitrate of potassium, See asserts, depends upon the formation of the protoxide of nitrogen and carbonic acid gas, which act as local anaesthetics. The practical treatment of an attack of asthma consists in the use of morphine hypodermically in the dose of 4; to \ grain (0.01-0.015), alone or in combination Avith atropine. Cigarettes made of paper soaked in a solution of nitrate of potassium and belladonna may be used (see formula under- Belladonna), or they may be made in the following manner: R.—Foliorum belladonna? . Foliorum hyoscyami Foliorum stramonii Extracti opii .... Aquie lauro-cerasi . . gr. vj (0.36). gr. iij (0.2). gr. iij (0.2). gr. \ (0.015). q. s.—M. These various leaves are broken up like commercial tobacco, and moistened by adding the cherry-laurel water, Avhich should contain the opium. Finally, a whole leaf soaked in the same fluid is used as a cover, or a piece of cigarette paper may be employed in the same manner. In some cases a very useful treatment is the smoking of nitre- ASTHMA. 435 paper cigarettes. Avhich are prepared before rolling not only by soak- ing the paper in a solution of nitrate of potassium (see Nitrate of Potassium), but also by dipping them, after drying them, in tincture of belladonna or stramonium, and allowing the alcohol to evaporate from the paper Avhile it is hung in the air. A remedy very recently brought forward in this country for the relief and cure of asthma is euphorbia pilulifera, the fluid extract of which may be given in the dose of 4; to 1 drachm (2.0-4.0) once, tAvice. or thrice a day. (See Euphorbia Pilulifera.) The author finds the folloAving formula very useful in asthma: R.—Sodii iodidi............gr. ij (0.1). Potas. bromidi.........gr. ij (0.1). Ext. euphorbia? piluliferse fl.....mjij (0.15). Nitroglycerin!..........gr. ^ (0.0003). Tr. lobelia?...........n\,ij (0.1).—M. Ft. in pil. vel capsul. No. i. S.—From 1 to 4 three times a day. It will be seen that each ingredient of this pill has a different action. The action of iodides in asthma is Avell knoAvn, as is also that of the bromides. The euphorbia pilulifera has been found useful in asthma empirically. The nitroglycerin depresses the peripheral ends of the Aragus nerves, and acts as a stimulant to the heart Avhen engorged "with blood by relieving the inhibitory action of the vagus and relieving the blood-vessels elseAvhere. The tincture of lobelia acts a depressant to the vagus also. A valuable prescription for asthmatics, particularly in those cases which have cardiac symptoms, is the one calling for digitalis, strophan- thus, and nitroglycerin in the article on Angina Pectoris. The irse of amyl nitrite by inhalation, 3 to 6 drops (0.15-0.4) on a handkerchief, is imaluable in many cases, and it rarely fails to relieve the spasm. < hving to the engorgement of the heart consequent upon the embarrassment of respiration, this nitrite must be used with care, and in one or tAvo instances it has proved dangerous by causing cardiac failure. Sometimes tobacco may be smoked, and it is particularly efficacious in those Avho are not accustomed to its constant use. Lobelia Avhen employed should be used in full emetic dose (1 drachm [4.0]) in the form of the tincture if an attack is present. If an attack is feared, 10 drops (0.65) of the tincture every four hours may be ghren if the heart is in good condition. A treatment of asthma Avhich is very successful Avhen it arises from nasal disorders consists in the application to the nasal cavities, at the onset of the attack, of the folloAving solution by means of a brush or spray : R.—Cocain. h\'droehlorat.........gr. xv (1.0). Aqua? destillat. . .....q. s. ad f^iv (16.0)—M. S—Apply as directed. If this solution is thoroughly applied and the other directions given are carried out, very rapid relief will often be obtained. Unfor- 436 DISEASES. tunately, we cannot readily separate those cases Avhich are due to nasal disease and those produced by other causes, and in consequence this treatment Avhen tried for the first time in a given case is purely experimental. The curative treatment of asthma to a very large extent rests upon the use of iodide of potassium, and in the careful regulation of the diet and boAvels, particularly if the trouble seems to be dependent upon indigestion. As the attacks are generally nocturnal, the even- ing meal should be taken early, be light and easily digested, and tea and coffee should be avoided at this time. .The patient should avoid dusty streets and live in the open air as much as possible, and a damp atmosphere is usually preferable to a dry one, provided it is not too cold. This rule is subject to many variations, and each case will be found to be a laAv unto itself, and each patient must try different climates until the proper one is found. Arsenic may be used, par- ticularly if the mucous membranes are beloAv par, and a dose of bromide of potassium or sodium, 30 grains (2.0) half an hour before retiring to bed, may be of service. Grindelia robusta is largely used as a prophy- lactic in the dose of 10 to 30 minims (0.65-2.0) of the fluid extract three times a day. Lobelia may also be used in the form of the tincture, 10 drops (0.65) three-times daily. Compressed and rarefied air is of service, and inhalations of oxygen are valuable if the cyanosis is extreme. In many cases the greatest relief Avill be given by the bronchitis tent. (See Bronchitis.) In some cases the presence of nasal polypi or other irritations of the air-passages causes asthma to appear, and they must be removed before a cure can be attained. In other instances arsenical wall- papers are the cause of the trouble. BED-SORES. Bed-sores depend upon disturbances of nutrition resulting from pressure exercised in such a manner that the local circulation is inter- fered with at a time when the vitality of all of the tissues is depressed by disease or injury. In most instances the part involved becomes chafed by creases in the sheets, by crumbs of food, or by moisture from the discharges of the rectum and bladder. The chief thing to be done is to prevent the trouble by careful nursing and cleanliness, Avhich must be supplemented by measures devoted to the hardening and improving of the skin covering the parts Avhere the sores are apt to appear, as over the buttocks and sacrum. To permit of a good supply of blood, the patient should be turned on one side or the other every feAv hours and the skin rubbed thoroughly with a dry towel to cause a healthy transudation and absorption of the nutritive juices. Salt and Avhiskey, 2 drachms (8.0) to the pint (500.0), may be rubbed over the skin, or tincture of catechu and the dilute solution of the subacetate of lead applied to harden it. BILIOUSNESS. 437 If this is not used, a mixture of alum and spirit of camphor is useful, made by adding 1 ounce (32.0) of powdered alum to the whites of 4 eggs and mixing this Avith 2 ounces (64.0) of the camphorated spirit. Where the skin is very red and angry-looking, but still intact, a solution of nitrate of silver of the strength of 20 grains to 1 ounce (1.3: 32.0) is to be thoroughly painted over the spot. All these remedies act in hardening the skin through their astringency, or by acting as sedative astringents to the inflamed capillaries of the part. AVhen a bed-sore is developed measures must be taken for its cure and the prevention of its spread. AVith this object in vieAV the body must not rest on the part affected if it can possibly be avoided, and in order that the sore may be protected and the pressure equalized, a large piece of soap-plaster, Avith its edges deeply incised to make them pliable, should be applied after the sore has been thoroughly Avashed out by means of a SAvab or syringe filled with a 1 : 5000 solu- tion of bichloride of mercury, and afterAvard dusted Avith iodoform. Sometimes large squares of lint heavily covered Avith zinc ointment are serviceable in lieu of the soap-plaster. If the sores spread and burroAv through the parts, the sinuses should be freely opened and irrigated with peroxide of hydrogen, all dead tissues being cut aAvay to avoid sepsis. Nitrate of silver in the strength of 20 grains to 1 ounce (1.3 : 32.0) may also be used as the patient recovers if the ulcers seem slug- gish, and a smooth slip-sheet should always be placed under the but- tocks. If possible, supportive measures and an increased amount of predigested food should be given if the sloughs are large. The inter- nal use of iron is particularly valuable in the form of the tincture of the chloride in full doses (say 20 drops [1-3]) every four hours. BILIOUSNESS. This is a term used to designate a state Avhich presents different symptoms in different cases, but ahvays includes languor, headache, or dizziness, perhaps some yelloAving of the skin and conjunctiva, and a general sense of atony, mental depression, and discomfort. It depends not upon an excessive secretion of bile, but upon some per- version of its function or secretion or its retention in the bile-ducts. Further than this, most of the symptoms do not depend directly upon the changes in the bile, but upon failure of proper digestion in the stomach and intestine, coupled Avith the development of irritative decomposition-products of various kinds. The stomach, intestine, liver, pancreas, and their juices all form a complex intenvoven chain of function in Avhich if one link breaks the entire chain becomes dis- turbed. The entrance into the stomach of certain food-stuffs Avhich are either ill prepared or improper for gastric digestion rapidly causes the development of active fermentation and a splitting up of these bodies, Avith the formation of lactic and butyric acids, which irritate the gastric mucous membrane, and thereby bring about a faulty gas- 438 DISEASES. trie secretion of mucus, which aids in making still further trouble. By the same means the circulation of the stomach is disturbed and becomes abnormal, and the intestine, liver, and pancreas receive reflex irritation to which they are not normally exposed. Further than this, the irritated stomach fails to convert its contents into pep- tones and the general features of chyme, and too early or too late drives out into the duodenum a mass of semi-digested and fermenting material utterly unfit for intestinal digestion and absorption, thereby disordering the functions of these parts still further at a time when they are not prepared for the reception of any food. The secretiCn poured out by the different glands varies from the normal; the alka- line juices are not able to overcome the normal acid of the gastric juice plus the lactic and butyric acids; and finally the reaction of the intestine becomes acid instead of alkaline, Avith resulting irrita- tion and secretion of morbid juices and mucus. The trouble when existing in the stomach gives rise to headache and discomfort, a bad taste in the mouth, and perhaps pain, and is folloAved by fever, lan- guor, jaundice, and flatulence Avhen the intestine is affected. The cause of these symptoms rests upon the fact that, while gastric juice and bile are antiseptic, pancreatic juice mixed Avith food undergoes rapid decomposition, with the development of products of decomposi- tion, such as skatol and indol and a large number of poisonous alka- loids. Normally, these are not alloAved to form, OAving to the pres- ence of antiseptic bile, which also hurries on the absorption of the food; but if the bile is retained in its ducts, its secretion is impaired and its constitution altered by the disorder of the liver which results reflexly from the gastric and intestinal irritation. Unfortunately, the complication does not cease at this point, for the liver in health has other functions to fulfil, one of the most important of Avhich is the arrest and destruction of all poisons of an organic character which come to it from the stomach and boAvel. Not only are decomposition- products destroyed by it, but all the vegetable alkaloids are rendered innocuous if present in ordinary amounts.1 The disorder of hepatic function, therefore, permits the entrance into the general circulation of these.substances, Avhich are very various as regards their powers and effects. Thus, Brunton has pointed out that one of these com- pounds closely resembles curare, in that it poisons the peripheral ends of the motor nerves, and thereby is at least partly responsible for the muscular relaxation and languor often seen in patients suffering from so-called "biliousness." Other substances act as do digitalis, atro- pine, muscarine, and picrotoxin, and the number of these various compounds is infinite.2 It is impossible to give space to a further consideration of these poisons, but what has been said sIioavs clearly that "biliousness" only expresses a state in which absorption of the bile is not the sole cause of the symptoms, but that other poisons are at work. The 1 See studies of Schiff, Lautenbach, and many others, including Ludwig and Schmidt-Mulheim. 2 See the researches of Schweringer, Zuelzer and Sonnerscheim, Bence Jones, Dupr6, liorch and Fasbender, Brieger, Sehmiedeberg, and Harnach. BILIOUSNESS. 439 methods of treating biliousness are therefore not to be considered as depending upon some regular routine, but upon a study of the case and its symptoms. Arery frequently, after several days of minor discomfort, the attack Culminates in a severe sick headache, after Avhich vomiting comes on and relief is obtained almost at once. Such patients can generally be relieved in the very first part of their discomfort by emetic doses of ipecac or apomorphine, 30 to 60 grains (2.0-4.0) of the former, or ^ grain (0.004) of the latter hypodermically. The manner in which this treatment does good is very evident. It compresses the liver and expels inspissated bile by the compression exercised by the abdom- inal Avails and diaphragm in the effort of vomiting, and thoroughly excites to normal secretion the torpid glands of the stomach and intestine. The vomiting also rids the stomach of the fermenting masses and bacteria contained in them, and renders the alimentary canal pure. This purity may be increased betAveen the paroxysms by draughts of Avarm Avater or water containing a feAv grains of bicarbonate of sodium or salicylic acid. AAhen it becomes evident that an attack is about to begin—that is, when constipation, slight droAvsiness, or-languor after meals sIioavs the tendencies present—one of two drugs should be used, either podophyllin if the stools be dark, or calomel if they be light-colored: ^ grain (0.01) of the former to an adult is generally enough, or 1 grain (0.05) of calomel divided into six poAvders, one of Avhich is to lie taken every fifteen minutes, is a good dose, to be folloAved in four hours by a saline. If the attack is sudden in its onset, no time is allowed for these hepatic stimulants, and a saline should be used in a good-sized dose at once, not because it causes a Aoav of bile, but because it sAveeps the poisonous matters out of the gut before com- plete absorption can occur, and aids in restoring the normal intestinal alkalinity. The prevention of "biliousness" depends upon the maintenance of a normal, easily digested diet, upon the formation and excretion of normal bile, and the prevention of fermentation and decomposition in the alimentary tract. The term "■ normal diet " is a very elastic one. and varies Avith each case. AVhile certain forms of food are generally considered good or bad, easv of digestion or difficult of assimilation, it nevertheless remains a fact that many of the simplest foods are capable of acting as poisons. A large number of persons cannot take milk or eggs because their digestion of these substances is faulty, and the Avriter is cognizant of one case Avhere lobster salad can be eaten at bedtime without discom- fort, while an egg at breakfast Avill cause a severe headache or pain in the belly. Rules as to diet must not be tl iron-clad," but based on observation. Bv far the best means of maintaining hepatic activity in cases where this organ is torpid is horseback exercise, particularly if the exercise is taken on a trotting horse, as the jolting of the liver keeps the chain of digestive functions active ;md prevents the secretions 440 DISEASES. from becoming clogged. Along Avith this exercise massage of the hypochondrium and belly-walls is useful, and the movement of stoop- ing over, bending from side to side, and bending backward Avith the feet close together, is of value. Coffee is often the cause of bilious- ness because of its oil. The use of pure, dark orange-colored, undiluted nitromuriatic acid in these cases in the dose of 3 drops three times a day in half a tumblerful of water is invaluable, and the fluid extract of stillingia in the dose of 20 drops (1.3) is of service, as is also the solid extract of euonymus in the dose of 3 grains (0.15). 5-grain (0.35) doses of extract of chirata in pill are also useful in hepatic atony of a mild type. R.—Ext. chiretta? Podophyllin . Euonymin Leptandrin . Creosoti . . Ft. in pil. No. xx S.—One pill every night The knoAvledge of the action of many of the poisonous materials formed in the alimentary canal renders it possible for us to relieve the patient by other means than those Avhich maAT be generally resorted to Avhen the attack is present. Thus, if the pupils are dilated, the skin hot and dry, the eyesight dim, and the pulse rapid, the alkaloid pro- ducing these signs of atropine poisoning may be antagonized by opium in small dose, or if the pulse be slow and full, the arterial tension high, and there is throbbing in the head with frontal headache, the alkaloid representing digitalis may be antidoted by the use of aconite. If nervousness and irritation are present, the bromides and chloral may be used. For some unknown reason the use of caffeine in the headaches of biliousness nearly ahvays makes them Averse, particularly if the head- ache is due to OArer-indulgence in coffee. If the face is flushed, a mustard plaster or cup to the nape of the neck may be used, and a hot foot-bath is often of service. In cases Avhere the bilious attacks are associated Avith catarrh of the stomach, intestines, or bile-ducts, chloride of ammonium, in 5- grain (0.3) doses, three times a day, is very useful, as is also the protiodide of mercury, Avhen triturated Avith sugar of milk, in the dose of J¥ to ^ of a grain (0.001-0.0015) three times a day. Fre- quently the use of salol or salophen in 10-grain (0.65) doses, three times a day, does much good in these cases, acting as an intestinal antiseptic. (See Salol.) BLEPHARITIS. Blepharitis is divided clinically into an ulcerative and non-ulcera- tive variety. The indication of prime importance in the treatment of this affection is the removal of the scars and crusts before the gr. xl (3.0). gr. iv. (0.2). gr. viij (0.5). gr. viij (0.5). gr. x (0.65).—M. BOILS. 441 application of the local remedies. This may be accomplished by the use of alkaline solutions, bicarbonate of sodium or biborate of sodium (8 grains to the ounce [0.6 : 32.0]), or a 5 per cent, solution of chloral, as recommended by Gradle. The salves that have met Avith the great- est success are Pagenstecher's ointment (yellow oxide of mercury, 1 grain [0.05], vaseline 1 drachm [4.0]), dilute citrine ointment, pyro- gallic-acid ointment, or a 3 per cent, milk-of-sulphur ointment, to Avhich resorcin may be added. The latter application is useful in the squamous variety alone. In the ulcerated form, if the crusts are tenacious, these, as Avell as the stunted cilia, must be removed Avith forceps, and yellow-oxide-of-mercury salve or some similar application applied. Excellent results follow touching the crater-like abscesses which exist in edges of the lid Avith nitrate of silver. If there is an accompanying conjunctivitis, a boric-acid solution is suitable, Avhile under any circumstances obstruction of the lachrymal duct —a frequent accompaniment of the disease—must be removed, and the nasal passages explored for any chronic inflammatory condi- tion. The relation betAveen this disease and the presence of refrac- tive errors demands the correction of the later, should these exist, before a hope for cure may be entertained. BOILS. Boils are dependent upon an impoverished state of the system, due to several causes, or, more rarely, to some local trouble situated in the skin, as in the persons of oil- or paraffin-Avorkers. Their constitutional treatment rests upon the use of fresh air, cod- liver oil, iron, arsenic, phosphate of sodium, and, if any boils are present at the time, the use of the sulphurate of calcium in the dose of -jig- grain (0.006) every five hours. The sulphurate of calcium hastens the maturation of boils and prevents the formation of neAV ones, but is useless, according to its original user, Dr. Ringer, in the boils Avhich appear during the course of some cases of diabetes. The local treatment of boils may be divided into the abortive and curative methods. The abortive method consists in painting the inflamed spot, Avhen the trouble first begins, Avith a solution of gun- cotton (collodion), and reneAving the coat hour after hour until a heavy contractile covering is formed. If pus forms under this, it may be absorbed, but if this does not occur, then the boil must be opened under antiseptic precautions and properly dressed. A strong solution of nitrate of silver is also very useful at the very beginning of the formation of a boil if painted over the part in the strength of 20 grains to the ounce (1.3 : 32.0). The other local applications consist in the use of the extract of opium or belladonna over the part to relieve pain and decrease the inflammation. Poultices may also be used to relieve the sensation of tenseness and mature the boil, and should contain SAveet oil and laudanum. Ringer recommends the application of alcohol and camphor over the skin in the early stages. After the skin is wiped dry it is to be smeared Avith camphorated oil. Stehvagon uses the following : 442 DISEASES. R.—Ichthyol.................3j (4.0). Emplast. plumbi............3ij (8.0). Emplast. resina?.............gij (8.0).—M. S.—Apply to the part. He also approves of the injection of a few minims of a 5 per cent. solution of carbolic acid into the apex of the boil if its formation is assured. BREASTS (INFLAMED). Alastitis is, from a medical point of vieAv, readily treated. Lacta- tion should at once cease, and the breast be dressed by the use of a sponge compress, underneath Avhich belladonna ointment is to be copi- ously smeared. Belladonna is a useful remedy both before and after very acute inflammation has begun, and its use should be persisted in for twenty-four hours. At the same time that these measures are resorted to, the circula- tion should be thoroughly impressed by aconite or veratrum viride, and mild saline purges should be given. If the milk persists in form- ing, it must be removed by the breast-pump. For the surgical treat- ment of mastitis the reader should refer to books on surgery. BRIGHT'S DISEASE (ACUTE). The treatment of acute nephritis accompanied by any active inflammatory change requires care and intelligence. The pain in the loins, and perhaps the bloody mine, Avhich is scanty and high- colored, febrile disturbance, and the history of exposure or other exciting cause, all form a clinical history typical in its major points. Here, as elseAvhere, for the reduction of inflammation circulatory depressants are to be resorted to, and aconite is generally most ser- viceable. The patient should be kept quietly in bed and supplied with a milk diet, cups or leeches being used over the loins if the urine is scanty. Blisters are not advisable, as the irritant substances pro- ducing them may be absorbed and cause increased renal irritation. The restlessness Avill generally be quieted by the aconite ; but if this fails, resort must be had to bromides or small doses of opium, Avhich must be given cautiously, as these drugs are not readily eliminated when the kidneys are diseased. Cannabis indica is thought to be of great service if bloody urine is present, but chloral is generally too irritating to the kidney to justify its employment. The appearance of large amounts of blood in the urine at about the fifth day of the illness is an indication, according to Sydney Ringer, for the use of drop doses of tincture of cantharides, given every few hours. Should the urine be scanty and of high specific gravity, and constipation be present, a purgative dose (£ an ounce [16.0]) of sulphate of mag- nesium should be used to aid in the elimination of impurities by the bowel. AVarm mucilaginous drinks, as flaxseed tea, are of service, and the use of the citrate of potassium and the SAveet spirit of nitre should be resorted to to increase urinary flow. BRIGHT'S DISEASE. 443 If dropsy or symptoms of uraemia come on, they must be relieved by the use of hydragogue purges, such as elaterium, Avhich is partic- ularly useful in that it is supposed to aid in the elimination of the urea by the boAvel. Jaborandi or pilocarpine may be used to SAveat the patient at this time or in the earlier stages with advantage ; -| grain (0.008) of the hydrochlorate should be given hypodermically and repeated in fifteen minutes if no SAveat appears ; but it should never be forgotten that Avhen the heart is feeble or the patient sus- ceptible pilocarpine may produce serious collapse. This can generally be guarded against by the use of strychnine in J ,-grain (0.003) doses. Hot-air baths are often useful to provoke a SAveat. (See Heat, in Part III.) Generally these cases go on to recovery, although convalescence is often someAvhat prolonged. The treatment of the later stages con- sists in the use of stimulants to the kidneys to arouse them from the atony consequent upon the excitement of inflammation. To this end digitalis and squill, or digitalis and calomel, or caffeine citrate, may be used in small amounts, gradually increased and folloAved by the compound spirit of juniper or gin as the case progresses. If the renal structure is persistently atonic, f to 1 drop (0.01-0.05) of the tincture of cantharides at each dose may be used, and, as anaemia is often a prominent symptom, tincture of the chloride of iron, Avhich is both a diuretic and a tonic, should be resorted to. If renal hemor- rhage is excessive, gallic acid and ergot are indicated to control the bleeding. A milk diet should be rigidly enforced. (See Uraemia.) BRIGHT'S DISEASE (CHRONIC). The treatment of chronic nephritis is a very different matter, so far as prognosis is concerned, from that of the acute form. It is almost, if not quite, impossible to cure the condition present, and Ave can only improve the state of the kidneys and other organs by care and the use of proper drugs. As Tyson has aptly put it, we must try to arrest the development of the renal lesions and improve the general health, treat the symptoms Avhich are not dependent upon the nephritis, except indirectly, and, last, treat those signs Avhich are due to the nephritis itself. To arrest the disease all alcoholic drinks should be avoided as far as possible, and business cares and Avorries be cast aside. Great care should be taken to avoid cold, and a Avarm climate is generally to be recommended to the patient, since sudden changes of temperature tend to produce congestion of the kidneys by the chilling of the skin. The diet and drink are important considerations, and should con- sist largely of milk. Many physicians direct that skimmed milk be used. The author believes that this advice is not Aviso, as it deprives the patient of the nutritive fats. Avhich he needs and Avhich are not contraindicated, whereas the proteids of skimmed milk, Avhile the best form of albuminoid food Ave can give, are not advantageous, but have to be used to maintain nutrition. If the cream in the milk dis- agrees with the patient, it may be removed in part or diluted by the 444 DISEASES. addition of water. Beyond this we can do little toward a cure. To allay symptoms we can do much, and the albuminuria can be greatly decreased by the use of digitalis, squill, the acetate and bitartrate of potassium, and the iodides; nor should the bichloride and protiodide of mercury be forgotten, as they are very valuable indeed. These rem- edies are also of value to relieve the dropsy, and the most efficacious treatment of all is a combination of the bitartrate of potassium and juniper-berries, so that 1 ounce (32.0) of the former is dissolved in 1 pint (500 cc.) of an infusion of the latter and taken in twenty-four hours. A most valuable aid in decreasing the albuminuria is the use of 1 to 3 drops of tincture of cantharides in Avater three times a day, particularly if the kidney seems torpid and is secreting too little urine. If dropsy develops, hydragogue purges are useful, such as jalap and elaterium, and hot baths, Turkish or Russian, are to be given, not only to relieve the dropsy, but to so hypertrophy the excre- tory glands of the skin that they will be able through greater activity to relieve the kidneys. (See Heat.) Sugar of milk may be given in the dose of 40 to 80 grains (2.65-5.5) a day as a diuretic, and butter- milk is a useful form of food. (See Sugar of Milk.) Ascites or thoracic effusions should be treated by tapping. In the1 chronic interstitial forms of this disease Bartholow has highly recommended the use of the chloride of gold and sodium in the dose of -^V t° rV grain (0.003-0.006). The anaemia is to be com- bated by the use of the tincture of the chloride of iron, or Basham's Mixture (see Iron), and oxygen inhalations. The arsenite of sodium and the carbonate or citrate of lithium are also said to be of value in chronic contracted kidney, particularly if it is dependent upon a gouty taint. The dose of the former should be ^g- grain (0.003), and of the latter 5 grains (0.35), three times a day. BRONCHITIS (ACUTE). In the early stages of bronchitis there is ahvays present a very distinct hyperaemia, followed by a true inflammation of the mucous membrane lining the bronchial tubes. When these changes are con- fined to the larger bronchi, the term " bronchitis " is employed, but when the minute bronchioles are invaded, the disease is known as "capillary bronchitis." In the article on Pneumonia and elsewhere in this book the writer has spoken of the various stages of inflamma- tion, the measures indicated under such circumstances, and has de- scribed the action of the various drugs. In many cases the phy- sician only sees the patient Avhen the second stage of his disease is present, but if the individual presents himself at once, the folloAving history and physical signs will indicate the treatment to be employed: After exposure, more or less severe, to Avet, dampness, or dry cold, a sensation of oppression comes on, associated with a feeling of " tight- ness across the chest or a sensation as if a bolus of food was under the sternum. Aching and pain may then be traced OArer the lines of the bronchial tubes, while the dry hacking cough increases the dis- BRONCHITIS. 445 comfort and seems to strain the tubes till each one can be outlined on the chest-wall by the patient. The cough, Avhen it occurs, is vir- tually unproductive, and often hurts the larynx and throat. On mak- ing a physical examination by auscultation there Avill be found over the posterior aspect of the chest, betAveen the shoulder-blades, sounds of bronchial breathing, Avhich are rougher tharr normal, and due to the air passing over an inflamed, SAvollen, and roughened mucous membrane. This bronchial roughening may be sufficient to cause a harsh respiratory sound over the entire chest, and the expiratory sounds may be heard a little louder than usual. No other changes from the normal can be noted, but isolated spots of discomfort may be pointed out by the patient Avhere aches, " catches," or "kinks" seem to be present in a previously normal tube. Percussion, palpa- tion, and inspection show nothing more of note. Some fever may be present. If possible, the patient is to be put to bed. If he be strong and hearty and if the signs of inflammation are severe enough to cause alarm, a full dose of pilocarpine may be ordered for the production of a SAveat. particularly if there is a great necessity for rapid cure without regard to the nausea Avhich may be produced by the drug. If this is done, no other medicine need be used, but the employment of a mustard foot-bath and a drink of hot brandy or whiskey and water should be ordered. In the majority of cases, however, this treatment is not called for, as it is unnecessarily severe, and the pilocarpine should be replaced by full doses (2 to 4 drops [0.1-0.2]) of the tincture of veratrum viride or a teaspoonful of the Avine of antimony in adults, or 4 to 1 drop (0.025- 0.05) of the tincture of aconite in children, the employment of hot drinks and a foot-bath being also insisted upon. Generally it is Avell to combine Avith the aconite some SAveet spirit of nitre, as folloAvs : R— Tinct. aconit.............ti\,yiij (0.6). Spt. a?ther. nitros...........f ^ij (8.0). Aquee.............q. s. ad f ,fj (32.0).—M. S.—A teaspoonful (4.0) to a child or a dessertspoonful (8.0) to an adult in water every hour. In many adults 5 to 10 grains (0.30-0.65) of Dover's poAvder Avith a hot drink is better. If the attack is not aborted, Avhile the first stage is still present, before secretion is established, resort should be had to ipecac and to citrate or acetate of potassium, which act as sedatives to the inflamed mucous membranes and aid in the formation of secretion, moistening the inflamed surfaces and thereby overcoming the dryness and irritation. The potassium salts also act as febrifuges, and should be used in full doses, as much as 40 grains to 1 drachm (2.6-4.0) in a day, in addi- tion to the aconite already recommended. The following prescription illustrates their employment: R — Syrupi ipecac..........f^j vel f^iij (4.0-12.0). Potassii citratis........,^iv (16.0). Aqua? destillat......q.s. ad f^vj (192.0).—M. S.—Dessertspoonful (8.0) every four hours for a child of five years. 446 DISEASES. Or, R.—Syrupi ipecac.............f,ljj (64.0). Succi limonis............fjj (32.0). Potassii carbonatis..........^iv (16.0). Spirit. a?ther. nitrosi........f.^j (32.0). Aqua? destillat..........q.s. ad fgvj (192.0).—M. S.—Dessertspoonful (8.0) every four hours for an adult. This mixture should not be corked for some time after it is made. For a child this prescription should be reduced just one half in each part with the exception of the water. In some cases, particularly if the patient be a child, large doses of the citrate or other salt of potassium exert a depressing influence and have to be decreased. The use of antimony as a remedy in the early stages of bronchitis should only be resorted to when a very poAverful action is required and the individual is very strong and sthenic. Under these circum- stances it may be given in full-enough dose to produce marked nausea, and even vomiting, Avith a profuse sweat. Along with the depression a profuse outpouring of liquid takes place in the bronchial tubes, which speedily relieves their congestion, and in consequence brings on the second stage of the disease in an hour or two instead of in two or three days. Unless some pressing need requires it, most persons Avill regard this remedy as Avorse than the disease. Counter-irritation may be applied to the chest in the shape of a mustard or spice plaster, or dry cups may be employed, several on each side of the vertebral column at about the sixth rib. If the sore- ness of the bronchial tubes is not relieved by this means, inhalations of steam arising from boiling Avater placed before the patient may be practised, either through a cone, one end of Avhich covers the top of a pitcher and the other end of which covers the mouth and nose of the patient, or by covering the head and pitcher with a towel. The use- fulness of this method may be much increased by the addition of 1 tablespoonful of compound tincture of benzoin to each pint of water. When fever is persistent quinine should be used, in addition to the aconite already recommended, and if the cough is excessive and annoy- m& ¥4 t0 tV grain (0.003-0.005) of morphine may be given to an adult in each dose of the solution just named, or a fewr drops of the spirit of chloroform may be added to the prescription. In children and in adults, both in the first stage of bronchitis and in the later stages, the use of the so-called "bronchitis tent" is of great value. It consists of a canopy raised over the bed a sufficient distance to allow of the circulation of plenty of air. Through one side of this canopy passes a tube leading from a tin pail or kettle of boiling water. under Avhich is an alcohol lamp to keep the temperature of the water sufficiently high. By this means the air breathed by the patient is so saturated with moisture that the mucous membrane lining the air- passages is soothed and quieted. In order that the full benefit of this measure be understood, it must be remembered that a mucous membrane in the early stages of inflammation is always dry and red, lacking its normal moisture, and that the upper air-passages fail to catch upon their surfaces, by reason of their dryness, particles of dust, BRONCHITIS. 447 and do not moisten the air before it reaches the lungs. Again, it will be remembered that the bronchial mucous membrane is covered with ciliated epithelium, Avhich, by the constant upward wavy motion of its cilia, urges out of the lung all impurities. Dryness of the surface at once stops this ciliated movement, Avith unfavorable results. The employment of the "bronchitis tent " is equally useful in adults, but less readily employed, owing to the size of the bed. Having considered the treatment of the first stage of bronchitis, Ave pass to that of the second. The condition of the mucous mem- branes is now quite different from that Avhich we have.just been speaking of. In the place of an absolute lack of secretion we have a profusion of cast-off epithelial cells, a large amount of mucus, and more or less liquid poured out upon the Avails of the bronchial tubes. forming obstructions everywhere to the ready passage of air. The secretion is apt to be more or less viscid, ropy, and, Avhen it is coughed up after considerable effort, appears in lumps, particularly in the morning. This state is one in Avhich the excitement of inflammation is folloAved by local depression and an effort on the part of the tissues to rid themselves of the congestion and of the useless epithelial forma- tions. The physical signs on listening to the chest are now found to consist in a large number of loose rales Avhich are distinctly Avet and moist. Later they become markedly liquid and bubbling, and so large as to cause gurgling on inspiration and expiration. Sometimes they are musical or squeaking. Generally the latter signs do not come on until the case is far adAranced, and, if a cure is soon to be reached, they only last a feAv days or hours, as the mucus is so loose as to be easily coughed up and the lung readily cleared. The object of the physician is to use remedies Avhich will stim- ulate the bronchial tubes and increase the volume of liquid poured out. For this purpose the bronchitis tent may of course be employed, but the drugs to be used internally are ammonium, chiefly the chlo- ride, and the pitches and turpentines, such as terebene, pyridine,1 or even turpentine itself. Allium or garlic is often of great service at this time or a little later in the course of the ailment. It may be used by boiling garlic in milk or by the application of an onion or garlic poultice, or by the use internally of a teaspoonful of syrup of garlic four times a day. In the majority of instances an ammonium mixture Avill be the best and most serviceable prescription, in one of the following forms: R.—Ammonii chloridi.........31'j (8.0). Ext. glvcvrrhiz. fluid........^ij (8.0). Aqua? destillat........q. s. ad fjiij (96.0).—M. S.—Teaspoonful (4.0) every four hours. Or, R.—Ammonii chloridi..........£ij (8.0). Mist, glycyrrhiz. comp.......fi-iij (96.0).—M. S.—The same dose. 1 Pyridine, not pyrodine, is used by placing 1 fluidrachm (4.0) on a hot shovel or saucepan in a small room, the patient breathing the fumes, Avhich are carried to him by the air of the apartment. 448 DISEASES. The disadvantage of the latter prescription is the presence of anti- mony in the compound liquorice mixture, Avhich is contraindicated if debility exists. If the cough is troublesome, a little morphine or belladonna may be added; or the following be used, particularly if any signs of car- diac failure appear: R.—Ammonii chloridi - - ... Ammonii carbonatis...... Ammonii bromidi....... Extract, glycyrrhiz. fluid. . . • ■ Aqua? destillat......... S.—Dessertspoonful (8.0) every four hours In this prescription the first constituent acts particularly on the air-passages, the second stimulates the heart and respiration, and the third allays the cough, while the liquorice covers the salty taste of the ammonium. R.—Codein...............gr. ij vel iv i O.-0.2). Ammon. chlorid...........3J (4.0). Ext. glycyrrhiz. fl..........f.^j (32.0). Aqua?............q. s. ad fgij (64.0).—M. S.—Teaspoonful (4.0) every two hours in water. Ammonium chloride may be also used by means of the steam atomizer or by inhalation of its fumes by the use of some of the apparatus used for this purpose. In obstinate cases the inhala- tions of the fumes from chloride of ammonium may be very necessary. These may be obtained by attaching a long piece of rubber tubing to one end of a glass tube about one and a half inches in diameter, and placing in the centre of this tube a drachm or two of sal ammoniac, the tube being placed in a horizontal position, each end resting on a thick book or other support. The open end of the glass tube is lightly packed Avith cotton, and a small alcohol lamp passed backAvard and forAvard under the tube Avhere the ammonium salt is lying. The patient may noAV gently inhale through the rubber tubing, and take the fumes Avhich are set free directly into the air-passages. A very simple and ready Avay of using this salt without apparatus is to place a feAv grains of it in an iron spoon and heat the drug over a gas-jet, the fumes being inhaled Avhen the spoon becomes Avell heated. (See article on Ammonium Chloride.) An oro-nasal respirator, with the sponge saturated Avith equal parts of terebene, iodide of ethyl, and chloroform, may be worn in order to allay cough and loosen the mucus. Counter-irritation may do good at this stage, particularly if applied over some aching bronchus, and a blister or plaster may be employed, or even a dry cup resorted to. If the administration of the chloride of ammonium does not aid in the expulsion and liquefaction of the secretion and rid the lungs rap- idly of the mucus, the use of terebene in 5- or 10-minim (0.35-0.65) capsules may be resorted to with great success. If capsules cannot be supplied, terebene may be made into an emulsion with acacia or trag- Si (4-0). 33 (4-0). 5i (4-0). 3iv (16.0). fgvj (192.0).- -M. BRONCHITIS. 449 acanth and given in this Avay. Sometimes terebene Avill irritate the kidneys and produce a sense of Aveight across the loins ; if this occurs its use should be stopped. In other cases it will disorder the stomach or cause diarrhoea. These effects are not, however, commonly seen. Terpine hydrate in 10-grain (0.65) doses may be used three times a day, or terpinol in the dose of 8 to 10 grains (0.5-0.65) in capsules or pills. Certain of the volatile oils and resins are also of value at this time, notably the oleoresin of cubebs and copaiba, Avhich, however, pos- sess the disadvantage of disordering the stomach. ^ The oil of eucalyp- tus is also of great value, and may be given in capsule or emulsion in the dose of from 1 to 5 drops (0.05-0.35) every five hours. The oil of sandalwood in the dose of 5 to 10 minims (0.35-0.65) is very valuable, and is not so apt to disorder the stomach, boAvels, and kidneys as are some of the other remedies named. The balsams of Peru and Tolu may be used, but ought ahvays to be combined Avith other more active drugs. Apomorphine has been highly recommended in the subacute stage of bronchitis as an expectorant for the purpose of loosening the phlegm and increasing secretion. The dose should be from -^ to ^ grain (0.003-0.006) by the mouth to an adult, three times a day, under such circumstances. Squill has had a very good reputation in this stage of bronchitis, but is a very poor remedy as compared to most of those now in use, irritating the stomach and kidneys and acting comparatively slightly on the diseased area. AVhile the proper use of these remedies usually brings about the results desired, in others a stage of profuse secretion comes on Avhich in its treatment is identical Avith that seen in chronic bronchitis, chronic "winter cough," and emphysema, so these diseases will therefore be considered together. In old persons suffering from dilated bronchial tubes, from emphy- sema, and from chronic bronchitis there is constantly poured into the air-passages so free a secretion that persistent coughing is necessary to rid the lung of enough of the mucus and liquid to enable the man to breathe. Any excess of this exudation droAvns him in his OAvn secre- tions, and the constant obstruction to the ready flow of air and blood in the lung soon produces dilatation and Aveakness of the right side of the heart. The same condition in a more acute form sometimes asserts itself in young children and in adults. In children it some- times comes on so suddenly as to be knoAvn as "acute suffocative catarrh," Avhile in older persons it appears Avith sufficient severity to make the condition of the patient most serious. Of the treatment of the latter state the Avriter will speak at once. The objects desired are to rid the lung of the liquid secretions, to prevent the outpouring of more exudations, and to support the patient until the crisis is past. AVhere the exudations rapidly fill the lung, nothing is better in the strong child or adult than an active emetic, such as apomorphine, hypodermically, in the dose of ^ grain (0.006) to an adult or ^V to a child, Avhich is not to be repeated; if this dose fails to act in ten minutes, ipecac may be used instead in the form of the powder, a small teaspoonful for a man or 5 to 10 grains (0.35- 29 450 DISEASES. 0.65) for a child, or, if the poAvder be not at hand, a Avineglassful (32.0) of the Avine or syrup of ipecac to an adult or two teaspoonfuls (8.0) to a child may be given. Digitalis should be administered to support the heart, and strychnine be employed in full dose to stimulate the respira- tory centre and excite the nervous system, which is generally depressed by the increasing carbonic acid in the blood. For the same purpose caffeine or strong coffee may be used. Oxygen may be inhaled, and to stop the profuse secretion atropine may be used by the mouth or hypo- dermically. If death seems at hand, hot and cold dashes of Avater may revive the patient sufficiently to keep up respiratory movements until voluntary efforts are made once more by the patient. The alternate use of hot and cold Avater is necessary for the exaggeration of periph- eral sensation, and the hot Avater aids in preserving the bodily tem- perature. Sometimes letting the patient hang his head over the bed when he coughs may aid in the expulsion of the liquid. The treatment of the more moderate condition of excessive secre- tion in the bronchitis of old persons, which is more slow in its prog- ress, but which may end as fatally as similar attacks in the young, is someAvhat similar to that just given. Injurious results are often produced by the physician failing to recognize that the secretion is suf- ficiently liquid, and that ammonium and such expectorants are not only useless, but harmful, because they increase the quantity of these liquids. Under these circumstances a fine spray of a solution of tan- nic acid of the strength of from 2 to 30 grains (0.1-2.0) to the ounce may be used, or of alum solution from a feAv grains to saturation. Monsel's solution should be employed in the dose of 10 to 15 drops (0.65-1.0) to the ounce (32.0) of water, or acetate of lead may be used in the strength of from 1 to 15 grains to the ounce (0.05-1.0 : 32.0). Lobelia induces a too free secretion, and is contraindicated under such circumstances. The use of opium to check the excessive excre- tion is a measure of doubtful value, as it checks the cough, and thus causes the lung to become more rapidly filled with mucus. Bella- donna, which checks secretion even more than opium, stimulates the respiratory centre, and is for this reason a doubly useful remedy. Counter-irritation may do good, and if the patient be strong free purgation should be resorted to. Strychnine is, however, the best of all remedies to help the patient to get rid of the sputum. It should be given in the dose of YV grain (0.006) or more three times a day. In those cases Avhere dilatation of the tubes is present in old per- sons, Calabar bean, in the form of the tincture (4 to 8 drops) or extract of physostigma, is of service, owing to its action as a tonic on the muscular fibres of the Avails of the tubes, preventing further bronchial dilatation and aiding in the expulsion of the secretion as rapidly as it is formed. The use of remedies designed to allay the cough in these cases is absolutely unjustifiable, as it results in the retention of the profuse secretion. The question as to whether the cough is excessive or not must depend on the ability of the lung to rid itself of the secretions in its bronchial tubes. BURNS AND SCALDS. 451 BURNS AND SCALDS. The treatment of burns and scalds is both internal and external, the first being devoted to the quieting of the nervous system after the injury, the relief of pain, and the treatment of shock, and the second to the care of the injured surfaces. Immediately upon being called to a case of burn it is the duty of the physician to determine hoAv badly shocked the patient is, Avhat the condition of the pulse mav be, and Avhether or not the lungs and air-passages are involved. After these mental notes he should give a hypodermic injection of % to | grain (0.016-0.03) of morphine and -^ of atropine (0.001), and then roll the entire body in a large quilt to maintain the bodily heat Avhile the sufferer is being transferred to the hospital or the house to Avhich he belongs. In some cases the shock is so great that the pulse flags at once, the temperature falls, and collapse ensues. Stimulants hypodermically, external heat, and Avarm drinks of water and Avhiskey are indicated, followed by ^o grain (0.003) of strychnine and 5 minims (0.3) of tincture of digitalis if the circulation does not respond to the less powerful stimulants. If time and circumstances permit, the dressings should be applied before moving the patient, but this is rarely possible. By far the best dressing is lint wrung out of a mixture of linseed oil and lime- water, equal parts, or, if desired, the oil may be rendered antiseptic by the addition thereto of 1 part of carbolic acid to 20 parts of oil. This mixture is also of service in that it acts as a feeble local anaes- thetic. The cloths should be renewed every tAvelve or tAventy-four hours, as may be needed, or they may be substituted by lint wrung out of a saturated watery solution of boric acid. If the burn is not very diffuse, a solution of the tincture of can- tharides, 1 part to 40, upon a rag, is said to relieve pain and aid in healing, but if the burned surface be extensive this treatment cannot be resorted to, owing to possible irritation of the kidneys, Avhich are already overtaxed by the interference with the functions of the skin. In comparatively small burns a saturated solution of carbonate of sodium (washing soda) often does great good in relieving the pain. This relief may depend on the solvent power of this salt over albu- minous deposits, formed by the heat, which irritate the peripheral nerves. A large number of other remedies have been and can be used, but are no better than those named, and less generally employed. A very important point in the subsequent treatment of burns is the remembrance of the close relationship existing between the internal organs, particularly the duodenum and the kidneys, and the cuticle. AVhen we recollect that Ave try to influence internal congestions—such as pulmonary congestion—for example—by the application of irrita- tion to the skin of the chest, we see at once that a widespread and severe burn is practically a huge counter-irritant and must reflexly affect the viscera. Again, the skin, being prevented from exhaling impurities, forces 452 DISEASES. the kidneys to do the work, and if the kidneys fail under the strain death results. AVhenever the urine is high-colored and cloudy the citrate of potassium should be freely given, 20 grains (1.3) in water three times a day, combined with 30 drops (2.0) of sweet spirit of nitre, care being taken that the depressant effect of the potassium is counter- balanced by stimulants. CHANCROID. The chancroid is a contagious, non-specific ulcer, which has no period of incubation, is distinctly inflammatory in type, and is usually multiple. It is further distinguished from the primary sore of syph- ilis by the fact that it is auto-inoculable, is not followed by secondary eruptions, and, if it involves the lymphatics at all, produces a mono- ganglionic unilateral SAvelling which frequently attains a considerable size and suppurates. Chancroid, being a purely local affection, would seem to require nothing beyond local treatment: this is true of the uncomplicated sore, but where phagedena or serpiginous ulceration sets in, the question of constitutional treatment is of paramount importance. The treatment of uncomplicated chancroid is as simple as it is efficient. One thorough cauterization converts the sore into a healthy ulcer, the cicatrization of Avhich is quickly and surely accomplished. As the most efficient means of thoroughly destroying the chancroidal ulcerations the actual cautery is chiefly commended. This is, hoAv- ever, objectionable to patients. Sulphuric or nitric acid will be found equally serviceable. The pain of these applications may be greatly lessened by the previous employment of a 20 per cent, solution of cocaine. When the surface involved is large the patient should be etherized. The cardinal point in the cauterization of chancoids is to reach and destroy all the diseased area. Each pocket and sinus must be thoroughly acted upon, otherAvise it remains as a focus for reinfec- tion. A convenient Avay of both destroying the chancroid and pro- viding for the after-dressing is offered in the application of Ricord's paste. This is made by adding to finely powdered charcoal enough strong sulphuric acid to form a paste of about the consistency of castor oil. This is then applied to every portion of the ulcer. The acid shortly dries out, leaving a dressing of charcoal, which in a few days drops off, exposing a healthy, nearly healed, granulated surface. Where nitric acid is applied the subsequent dressing consists, pre- ferably, in the application of dusting poAvders, iodoform being the best. There has been a tendency of late years to substitute for this treat- ment one less radical, more acceptable to the patient, and in many cases almost equally satisfactory in results. It is certainly true that many of the chancroids as found in persons of robust health shoAV little tendency to spread beyond comparatively narroAv limits, and are amenable to mild treatment. It must be remembered, hoAvever, that, as long as the smallest portion of such an ulcer remains unhealed it CHANCROID. 453 may at any time take on all the features of a virulent ulceration. Moreover, the patient is constantly exposed to the risks of a chan- croidal bubo—a complication so troublesome that the possibility of its development constitutes the strongest argument against palliative treatment. AAThere the ulceration is entirely superficial, constituting the eroshre form of chancroid, iodoform, dusted over the surface of the carefully cleansed granulations, offers the best form of palliative treatment. As a cleansing and stimulating Avash to precede the application of the iodoform 1 drachm (4.0) of nitric acid to the pint (500 cc.) of Avater is most satisfactory. The objection to iodoform lies in its disagree- able and penetrating odor. To prevent this, great care should be exercised in applying the poAvder to see that none is distributed else- where than upon the sore. The odor can also be disguised to some extent by thoroughly mixing Avith the iodoform a small quantity of one of the essential oils, such as oil of peppermint or attar of roses, using not over 5 minims (0.35) to 1 drachm (4.0) of the poAvder. There is no dusting poAvder which can entirely take the place of iodoform, yet when the objections to the use of the latter are insu- perable aristol or iodol may be substituted, or a mixture of 1 drachm (4.0) 0f zinc oxide and 3 drachms (12.0) of subnitrate of bismuth, or equal parts of calomel and bismuth. AA^here the discharge is profuse, poAvdered tannin may be combined Avith the dusting poAvder in the proportion of 1 part to 4. In the ordinary uncomplicated chancroid these dry dressings are greatly to be preferred to Avet applications: Avhen, hoAvever, the sore is attacked by a high grade of inflammation and becomes indurated, prolonged immersion of the part involved or of the Avhole body in hot water may be folloAved by the application of dressings kept constantly Avet with the dilute nitric-acid lotion, as given above, or Avith weak carbolic solution, 5 grains to the ounce (0.35 : 32.0) of water, or with lead-water and laudanum. AAThere the chancroid assumes the phagedenic type, extending with great rapidity and causing extensive sloughing and destruction of tissue, free cauterization either Avith the hot iron or by means of nitric acid should be instituted immediately, every portion of the ulcerating surface being thoroughly destroyed. This should be folloAved by prolonged hot sitz-baths or general Avarm baths, the patient remaining in the water for days at a time if necessary, and, if practicable, eating and sleeping Avith the body still immersed. If this is not possible, baths of from two to four hours' duration should be given tAvo or three times daily. After cauterization, poAv- dered iodoform is the best local application in phagedenic cases. In addition the patient may be given full doses of opium, and should receive a tonic and supporting treatment. Should the chancroid assume the serpiginous type, sloAvly extend- ing in spite of treatment, till in the course of months or years large areas are destroyed by the process, the Avarm bath, continued night and day for Aveeks at a time, together Avith thorough cauterization of the entire diseased surface Avith the hot iron, represents the most satisfactory method of treatment. 454 DISEASES. The chancroidal bubo is best avoided by prompt and thorough cauterization of the sore: Avhen it occurs, hoAvever, it should be first treated by rest, pressure, and counter-irritation, since it may be a simple inflammatory adenitis, and Avith care may not run on to sup- puration. Iodine may be painted around the SAvollen area, the patient should be put to bed, and a compress, together with a spica bandage of the groin, should be applied, or this may be substituted by a hot bag placed upon the inflamed gland. At the first sign of suppura- tion the bubo should be opened freely, should be Avashed out with bichloride solution, 1 : 1000, peroxide of hydrogen half strength, or chloride of zinc 40 grains to the ounce (2.65 : 32.0) of Avater, and should be packed Avith iodoform gauze. If the bubo takes on phag- edenic action, it should be treated precisely as the phagedenic chan- croid. CHOLERA, ASIATIC. The treatment of this exceedingly dangerous disease is prophy- lactic, curative, and convalescent. The first measures consist of strict quarantine, both public and private, the avoidance of all Avater for culinary purposes which has not been boiled at least an hour and cooled in a place devoid of germs, and the employment of those foods Avhich, while preserving the normal bodily health, in no way predispose to intestinal dis- turbances, as do some of the fruits, as melons and grapes. If these things are attended to, little remains to be done; but it is Avorthy of remark that sulphuric acid is a drug which is harmless in itself, yet apparently one Avhich is possessed of distinct prophylactic poAver in this disease. Dividing the disease into three stages, Ave find as the earliest symp- tom some disturbance of peristaltic movement, Avith or without pain, or in other instances the patient is attacked Avith a sudden flux of the intestinal contents. If there is a history of the ingestion of bad or indigestible food, there is no doubt whatever that this foreign material must be gotten rid of by the use of castor oil or sulphate of magnesium, the latter being the best, because it is more rapid and less apt to cause griping. No purgative should be given unless the history of the ingestion of bad food is most direct and clear. AVhen the attack is sudden in its onset, as is usual, the question arises, Shall we resort to opium by the mouth ? The answer, after having carefully considered the statements of a large number of authors, is that Ave should not use opium by the mouth or hypo- dermically except in cases where the pain or cramps are so excessive as to absolutely require the drug. In other words, it is to be given for the pain, not for the diarrhoea. Should opium be used, it is infinitely better to employ it by the rectum in the manner to be described later, and if it is necessary to use it by the mouth, only the deodorized opium or the deodorized laudanum should be em- ployed, since these preparations are less apt to cause nausea than their felloAvs. Any one Avho has seen the nausea and depression folloAving the use CHOLERA ASIATIC. 455 of full doses of opium in those who are susceptible to it will be strongly impressed Avith this fact: and in America, at least, adults of the better class, as Avell as children of all classes, are often so seriously depressed by full doses of opium as to be on the verge of collapse. Not only Avould the onset of such symptoms seriously complicate like symptoms caused by the disease, but there seems to be no doubt that the use of the drug so seriously perverts the functions of the stomach as to make the entrance of germs comparatively easy. Recent researches in regard to the bacillus of Koch shoAv that an acid medium is unfa- vorable to its existence, and other researches have proved that opium seriously inhibits the secretion of gastric juice. If these two results are correct, then the generally accepted assertion of Hueppe, that the bacilli find a strong barrier in the acid secretion of the stomach, is not only important, but of such a character as to prohibit the use of opium. Finally, it has recently been pointed out that the stomach actually excretes opium, even Avhen it is given hypodermically, and that the opium-nausea can be avoided in the ordinary individual if the stomach be Avashed out as fast as elimination takes place. The hypodermic method is therefore little better than the mouth-adminis- tration of the drug. Combining all these disadvantages with the fact that the majority of observers are doubtful as to its usefulness, we ought certainly to resort to opium most cautiously, if at all. Camphor, on the other hand, seems to be universally regarded as a most useful drug, tending at once to stop diarrhoea and relieve the pain and cramps from the beginning to the end of the attack. AVhether camphor exercises any germicidal effect on the cholera bacillus Ave do not know. Certain it is that volatile oils all possess distinct antisep- tic powers. Aside from any such influence, camphor is useful as a general systemic stimulant, and has been proved by wide clinical observation to have a very extraordinary poAver in the control of all forms of serious diarrhoea, particularly true cholera. The spirit of camphor proved most effective in the cholera epidemic of 1866 in Bohemia, and the patients themselves stated that they could not praise sufficiently the delightful sensation of abdominal Avarmth and stimulating effect of the drug. Particularly Avas this the case Avhere other alcoholic preparations had been used, such as "schnapps." Frequently the use of camphor so controlled the diarrhoea and stimulated the torpid kidneys that anuria Avas set aside in tAventy-four hours. Under these conditions camphor Avine Avas found to be very useful, and Avas made by adding 75 grains of finely-poAvdered camphor to a bottle of strong red wine, to Avhich wras also added gum arabic and alcohol. The camphor Avas first dissolved in the alcohol, and then thoroughly mixed Avith the Avine. The dose of this mixture was a teaspoonful, in peppermint tea, every hour to a child of six years. For an older child a dessert- spoonful, and for an adult a Avineglassful. Those Avho first used this mixture were wiser than they thought, for the recent studies of Pick have shown that both red and Avhite Avine are distinctly inhibitory to the growth of the spirillum of cholera, probably because of the tannic or other acid which they contain, as Avell as the alcohol. 456 DISEASES. A remedy, the use of which is based on very rational grounds, is salol, and probably the newTer drug salophen, which, theoretically, is much better than the former, because it is less poisonous. According to the interesting studies of LbVenthal, salol seems to be peculiarly antagonistic to the bacillus of Koch. This investigator added to a 50-gramme alkaline solution of pancreatic juice 10 grammes of salol, and to this mixture 3 centimetres of a good bouillon culture of the bacillus. Examinations in from forty-eight hours to a Aveek shoAved this to be absolutely sterile. It Avas further proved that the salol was inactive until broken up into its component parts—phenol and sali- cylic acid. In his experiments on mice Lowenthal found the drug protective. Hueppe also asserts that the use of salol prevents the development of anuria. This is probably accomplished by its action on the bacillus, thereby preventing the diarrhoea and the formation of the toxine, both of which influence the blood and kidneys. Gonzalez of Salvador, Avho used salol in the dose of 30 grains at the first and 15 grains at the second dose, lost only 3 cases out of 53 sufferers. Nicholson of Patna, India, has also obtained splendid results from salol. Given in 15-grain doses every three or four hours for a day or two, salol produced a Avonderful improvement, and in all his 18 cases recovery took place, although 11 of them were in a state of col- lapse when the salol was first given. Hehir treated 88 cases with corrosive sublimate, with a mortality of 44 per cent., and 11 cases Avith salol Avith no deaths. The use of a remedy originally proposed by Dr. R. G. Curtin has been proved by recent study to be eminently rational. This remedy is sulphuric acid. This drug not only is acid, and so deleterious to the bacillus, but, in addition, is astringent, and is probably elimi- nated as a sulphate by the lower bowel. As is Avell known, ordinary cholera morbus yields readily to its influence. In addition to the treatment already given, Avhich may be used in the second as well as in the first stages, we have measures which must be resorted to for the relief of the dominant symptoms which mani- fest themselves as the disease progresses. The symptoms noAV to be combated are vomiting, excessive purg- ing, cramps in the extremities, and, as the result of these, exhaustion, collapse, and the advent of the algid stage. By far the best results obtained by any one line of therapeutics at this time certainly fol- Ioavs the employment of salol and camphor by the mouth, Avith entero- clysis and the use of hot baths; or, if these are not possible, hypo- dermoclysis and the employment of a hot-water bed; or, finally, hot bottles and bricks, for the patient largely dies of cold and of internal congestion of thickened blood, the circulation of which the heart and vasomotor system are unable to control. Atropine and strychnine are very useful, but ether is better than either, given subcutaneously or by the mouth, as a diffusible stimulant. A7ery extraordinary results are said by Italian observers to follow the rectal injection of a solution of common salt in the proportion of 1 drachm to the pint (4.0 : 500 cc.) of warm AATater. In other CHOLERA INFANTUM. 457 instances the use of tannic acid in the strength of from 1 to 8 drachms to the pint (4.0-32.0 : 500 cc.) of water has proved very satisfactory. The amount used at each injection should be about 2 quarts (2 litres) and the injection made as gently as possible in order to urge the fluid high into the bowel. The inflow tube should be a soft female catheter, and the overfloAv tube tAvice as large as the infloAV tube. The tubes are to be inserted side by side after thorough oil- ing. The injection may be used every two hours and continued till the outflow is clear. This is done to wash out poisonous materials and to supply liquid to the system. A solution much stronger or weaker than that named is dangerous, for similar reasons to those given under the head of Dropsy and Saline Purgatives. (See, also, Enteroclysis, Part III.) Another useful measure is hypodermoclysis, or the passage of a solution similar to that just named into the subcutaneous tissues of the thigh or belly-wall. (See Hypodermoclysis, Part III.) If done slowly these injections are absorbed readily and supply liquid to the depleted blood-vessels. Arery recently Harkin has Avritten in high praise of the so-called kk vagus treatment " of cholera, and has recorded cases in his OA\n and others' practice Avhich reached brilliant cures by the use of a fly- blister over the course of the vagus nerve on both sides of the neck, just beneath the angle of the loAver jaAv. The explanation of this treatment rests in the belief that cholera is dependent upon some impairment of the functions of this nerve in the abdomen. CHOLERA INFANTUM. Cholera Infantum is a term often applied to all the forms of active serous diarrhoea afflicting children in the summer months, Avhether its cause be exposure to high heat, the use of bad food, or both. In reality, the term should be applied to that form of serous diarrhoea in Avhich heat is the most common cause, and in Avhich symptoms of lowered vitality and collapse rapidly come on, Avith coldness of the extremities, pinched face, and Avrinkled skin. The treatment by the use of drugs is identical in all forms of serous diarrhoea in children so far as the purging is concerned, but the removal of the cause requires great care in its discovery and skill in its cure. In cities, where the heat is often great, the air damp and impure, and the food not ahvays fresh, cholera infantum often appears as a form of thermic fever or heat-exhaustion, or, in other Avords, as sun- stroke. Often in these cases the temperature in the rectum will be found febrile, Avhile that of the axilla is beloAv normal, and, as pyrexia does harm to the internal organs, the internal temperature must be lowered by cool drinks, by swallowing pieces of ice, and the irri- gation of the boAvel Avhich Avill be described in a moment. The diar- rhoea in such cases is dependent upon a relaxation of the blood- vessel Avails in the intestine by reason of the influence of the high heat upon the splanchnic nerves, and to irritant matters derived from 458 DISEASES. food resulting from defective secretion of the digestive juices. If the thermometer placed high up in the rectum shoAvs a subnormal tem- perature, heat-exhaustion is present, not thermic fever, and the treat- ment is reversed. Hot drinks are to be used, external heat applied, and friction of the limbs resorted to, or the child may be put in a hot bath at a temperature of 105° F., its temperature being care- fully Avatched lest it rise suddenly to above the normal. Aromiting is nearly ahvays a prominent symptom in cases of cholera infan- tum, and if milk is used at all, it is better to use predigested milk in teaspoonful doses every fifteen or twenty minutes, although absolute avoidance of milk and the use of a feAv drops of beef-juice for tAventy- four hours is better still. If vomiting is active and collapse is threat- ened, a few drops of good brandy should be used in each teaspoonful of nourishment. There is another form of cholera infantum which is not due to a high atmospheric temperature alone, but more commonly to the inges- tion of irritant foods or foods unsuited to a child, obtained by the patient surreptitiously or through the ignorance of the parents. If there is such a history and some of the masses of undigested food have been passed, a purgative dose of castor oil (1 to 2 teaspoonfuls [4.0-8.0] to a child of two years), with 20 drops (1.3) of paregoric, should be used to sweep out the offending materials and allay irrita- tion, and be folloAved at once by the treatment Avhich will be spoken of in a moment. Care, of course, should be taken to maintain the bodily heat or lower it if it is above the normal, and a Avatch must be kept upon the pulse and breathing to note any changes requiring stimulants. Clinically, there is still another class of cases. The physician will be called to see a child with the same history of having taken indi- gestible food or of curds in the stools. Careful examination will showT that there is much bearing down, or in other cases a simple running off of the liquid from the bowel almost Avithout effort. Very soon, indeed, the passages become entirely colorless, except for a speck or two of green, Avhich shoAvs the presence of the peculiar micro- organism Avhich produces this color. The diapers have a peculiar mousy odor, and are characteristic; that is, they seem to be only wet and odoriferous, and contain no solid matter. If closely exam- ined, they will be seen to be soiled by a small amount of a whitish substance, looking like a paste made of Avater and fine chalk. Such a passage bodes ill for the child unless treatment is instituted. The physician should order, at once, -^ grain (0.003) of podophyllin for a child of six months, to be taken in tAvo doses, half an hour apart, in 20 drops of brandy Avith a little AArater. Tavo hours after this the dose should be repeated, and again in two hours more if necessary. By the end of the fourth hour there will be generally seen in the move- ments of the boAvels a trace of color, and this will gradually become more marked if the case is to have a favorable termination. As soon as the movements have changed from the pasty-white motions named to those having a bilious color, then, and not till then, are astringents to be employed. If they are used before this, the CHOLERA INFANTUM. 459 diarrhoea may become less for a feAv hours, but the child absorbs poisons from its alimentary canal and rapidly goes into collapse. The rationale of this treatment rests upon the fact that OAving to the disease every gland connected with the alimentary canal has become inactive through the influence of the micro-organisms. It is absolutely necessary to bring about glandular activity, and podophyllin, in the experience of the author, is the best remedy for this state. During the period that the podophyllin is acting it is Avell to apply a spice plaster to the belly or to immerse the child in a hot bath to preserve its bodily temperature. It is of the utmost importance to stop all milk-feeding at this time. Nothing in the Avay of food may be given except Aalentine's or AVyeth's beef-juice, 10 drops (0.65) every two hours Avith a little cold Avater. A remedial measure carried out with great success in cities in the treatment of cholera infantum is the use of irrigation of the boAvels, or rather Avashing out of the colon. This is accomplished by the use of the solution named in the articles on Cholera and Enteroclysis. The infloAv tube should be of soft rubber, like a female catheter. The outflow tube should be larger, in order to carry off flakes of food or mucus. They may be inserted side by side after being oiled. The pressure used should be by a fountain-syringe raised not more than three feet above the buttocks, and the outfloAv should be clear and unobstructed. The irrigation may be resorted to every hour or two and continued until clear fluid Aoavs aAvay. The solution should, of course, not be too cold or too hot—say 100° F. After these measures have been resorted to, and the chief object— namely, a colored stool, not green—obtained, if the diarrhoea con- tinues it must be stopped at once to prevent the depletion of the tis- sues. The medicinal treatment should consist in the use of a mixture such as the folloAving for a child of a year or eighteen months: R.—Acid, sulph. aromat..........gtt. xxx (2.0). Tr. opii camphorat..........fgiij (12.0). Elixir, curacoa?...........f,2[ij (8.0). Aqua? cinnamomi ..... . q. s. ad f^iij (96.0).—M. S.—Teaspoonful (4.0 j in a little water every two hours. Or, R.—Acid, sulph. aromat..........gtt. xxx (2.0). Ol. caryophylli...........Trlyiij (0.5). Tr. opii camphorat..........fgj (4.0). Spirit, chloroformi.........gtt. xlviij (3.0). Syr. zingiberis........q. s. adf^iij (96.0).—M. S.—Teaspoonful (4.0) every two hours. If preferred, the tincture of kino or compound tincture of catechu may be substituted for the oil of cloves or the spirit of chloroform, or, again, the fluid extract of haematoxylon may be taken in the place of either of these. Where the vomiting is very severe and incessant, the purging pro- fuse, ill-smelling, and mouse-like in odor, a rectal injection of starch- Avater, 3 ounces (96.0), containing 10 drops (0.65) of laudanum, is to be employed, and at the same time }ofa grain (0.01) of gray powder 460 DISEASES. (hydrargyrum cum creta) given every hour. The gray poAvder may be substituted by -fa of a grain (0.005) doses of calomel. Very minute doses of arsenic given by means of the following solution are often of service in checking the vomiting and purging, and should be resorted to if necessary : R— Liq. potassii arsenitis.......gtt. j vel ij (0.1). Aqua? cinnamomi........f^j (32.0).—M. S.—Teaspoonful (4.0) every fifteen minutes until four teaspoonfuls (16.0) are taken. In still other cases the remedies named above only stop the diar- rhoea for the time being, and it returns as soon as they are with- drawn. In such a case the following is of value to restore the lost tone of the parts involved: R— Resina? podophylli........gr. J (0.03). Liq. potass, arsenit.........gtt. iij vel vj (0.18). Liquor calcis..........fgiij (96.0).—M. S.—Teaspoonful (4.0) every five hours. Shake well before using. • Or a powder may be used: R .—Eesina? podophylli........gr. } (0.016). Pulv. ipecac...........gr. j (0.06). Sacchar. lact...........gr. xx (1.3).—M. Ft. in chart. No. x. S.—One powder every five hours. A very important, never-to be-forgotten measure in cholera infan- tum is the use of counter-irritation over the belly by means of a mus- tard plaster (1 part mustard flour to 4 of wheat flour) or by a spice plaster. The plaster should be renewed as often as it cools, and kept on continuously if the skin will stand it. CHOLERA MORBUS. This acute, painful, rapidly-exhausting disease arises from expo- sure to cold, the ingestion of poisonous or irritating foods, exposure to excessive heat, or a number of similar causes. In reality, it may be regarded in one instance as a gastro-enter- itis, and in another as an acute serous diarrhoea associated with much pain of a griping, rending character. Nothing compares to counter- irritation for the purpose of affording relief. A large mustard or capsicum draft should be placed over the abdomen and alloAved to remain as long as it can be borne. If the patient knows that he has taken irritant foods, castor oil with 15 to 20 drops (1.0-1.3) of laud- anum added to it, to prevent griping, should be employed to sweep out the offending masses before any other remedies are used, and be folloAved by an antidiarrhoea mixture, such as here folloAvs: R.—Acid, sulph. aromat........fsjij vel f^iv (8.0-16.0). Extract, hematoxylon fluid. . . . ^ij (8.0). Spt. chloroformi........f^ss (16.0). Syr. zingiberis......q. s. ad fsjiij (96.0).—M. S.—Teaspoonful (4.0) every two hours. (See article on Diarrhoea.) CHOREA. 461 CHLOROSIS. (See Anaemia.) CHOREA. St. Vitus's Dance is a nervous affection, generally occurring in children, yielding to treatment quite readily in some cases, and in others remaining persistently severe, and even becoming worse, under the physician's care. The disease is ahvays to be treated by the removal of all sources of reflex irritation, such as Avorms, a long prepuce if it is irritated by retained urine or smegma, or other trouble of this character, and in the avoidance of punishment or severe rebuke on the part of the attendants. Except in that form of the disease closely associated with or dependent upon rheumatism, the profession universally em- ploy arsenic in one of its forms as a specific remedy. Generally Fowler's solution is used, and, unless the parents are intelligent enough to drop medicine carefully from a bottle or dropper, the phy- sician should order a three-ounce mixture (96.0) Avith 48 drops (3.1) of Fowler's solution, so that each teaspoonful will contain 2 drops of the drug. Very frequently, to be effective, arsenic must be used in ascending doses, increased one drop (0.05) a day, and in consequence the dilution just spoken of has to be avoided and the importance of care in measurement urged upon the patient's relatives. Whenever arsenic is used the physician should instruct the attend- ants to stop administering the drug if any puffiness under the eyes is seen in the morning on arising from bed, or if any pain in the bowels ensues, as these symptoms shoAv that the full medicinal action of the drug is being felt. When arsenic fails, cimicifuga in the dose of 20 to 30 drops (1.3- 2.0) of a fresh fluid extract to a child of ten years may be used as the next best remedy. Where the disease is associated with rheumatism, near or remote, the salicylates or iodides may be of value, and should be thoroughly tried. In some cases of chorea the muscular jerkings are so severe that sleep is impossible, and the patient has to be held in bed and the bed- covers tied doAvn. These cases will often obtain a quiet night by the use of the hot pack at bed-time. (See Heat.) The child should be placed in a blanket previously dipped in Avater as hot as can be borne by the patient and thoroughly wrapped up in another (dry) blanket to retain the heat, and then be allowed to sweat. Care must be taken that a heat-stroke does not result, and, if sweating does not come on and oppression ensues, the blanket must be removed. The sheets should be ironed to have them warmed for the patient Avhen he is returned to bed, and it is often better to let him sleep betAveen dry blankets. The efficacy of this treatment is largely increased by the use of a dose of bromide of sodium or potassium and a little chloral, as folloAvs: 462 DISEASES. R—Chloralis...............gij (8.0). Sodii bromid..............5SS (l6.0). Aqua? dest............q. s. ad f ^iij (96.0).—M. S.—A teaspoonful (4.0) in water every five hours for three doses. The nitrate and oxide of silver have been largely used in chorea, but are not reliable remedies in this disease. The dose of the first should be | to ^ grain (0.008-0.010), and of the second £ to J grain (0.01-0.016) in pill form. Acting on the belief that chorea is due to failure of the inhibitory centres, Wood has employed quinine as a stimulant of these inhibitory centres, with success in some cases. Full doses should be given, 5 to 10 grains (0.3-0.65) three times a day. CHOROIDITIS. Choroiditis, or inflammation of the choroid, is revealed only by ophthalmoscopic examination, and may consist merely of increased vascularity, of cloudiness due to serous effusion, or of yellowish-Avhite patches surrounded by masses of dark pigment, indicating an atrophy of the choroid as well as the retina. Numerous groups and clinical varieties of choroiditis are described by systematic writers, but it is not easy in each instance to determine the cause, which may be local in the eye or comprise a constitutional origin, such as syphilis, scrof- ula, or gout. In the early or hyperaemic stages bleeding from the temple is advisable, and later mercury, especially in the form of the bichloride, or iodide of potassium, may be given. The constitutional state which is present will indicate the suitable general medication. All use of the eyes should be forbidden. COLIC (HEPATIC). This exceedingly painful condition, due to the passage of a gall- stone through the bile-duct, is ahvays associated with faintness, nausea, and great agony. The object of the physician must be to relieve this pain, not only by the use of anodynes, but also by aiding in the escape of the stone into the bowel. To relieve the pain a hypodermic injection of mor- phine I to | grain (0.015-0.03), accompanied by ^ grain (0.001) of atropine, is indicated. The opium not only decreases the pain, but allays spasm, and the belladonna relaxes the spasm of the muscular coats of the ducts and allows the stone to pass through the relaxed passage-Avay. Hot applications, such as turpentine stupes, may be used over the liver, but relaxation is not to be obtained by the use of nauseating emetics, as the retching or vomiting may rupture the dis- tended gall-bladder. Severe rubbing should not be used for the same reason. Very recently the use of olive or cotton-seed oil has been largely resorted to in this affection, and, while we are not sure of the means by CON J UNCTIVITIS. 463 which it acts, the studies of Rosenberg and others point to the chang- ing of the oil into glycerin and fatty acids, the first of Avhich liquefies and increases the Aoav of bile. The oil is used during the attack of pain, and must be swallowed in the dose of half a pint at least; smaller quantities do not suffice. Its action may be aided and its retention in the stomach promoted by the addition of a drachm of ether to each dose. Shortly after the oil is SAvalloAved sudden relief often occurs, due to the escape of the stone into the bowel. The stools should then be carefully watched for gall-stones, but care should be taken that the lumps of soap Avhich are passed, made from the oil by the alkaline juices in the intestines, are not mistaken for true biliary calculi. If the pain does not yield to morphine, chloroform or ether may be inhaled for the relaxation of the spasm and the relief of pain. The treatment of the state predisposing to the formation of hepatic calculi consists largely in the use of a moderate, regular diet, devoid of much fats, wines, or beers, and in the following of an out-door life. CONJUNCTIVITIS. Simple Conjunctivitis, sometimes called catarrhal, acute, or muco- purulent ophthalmia, is characterized by congestion of the conjunctiva, loss of transparency of the palpebral portion, and some dread of light, Avith a discharge sufficient only to glue the lids in the morning or free and muco-purulent. In the milder stages the use of a boric-acid lotion (10 grains to the ounce [0.65 : 32.0]) is suitable, and the lids should be frequently Avashed Avith neutral soap and water; if there be much muco-purulent discharge, the lid should be everted and an application made of a solution of nitrate of silver (from 2 to 5 grains to the ounce [0.1-0.35 : 32.0]). If the discharge becomes great, bichloride of mercury, 1 : 10,000, may be employed Avith advantage, and the nitrate-of-silver solution increased to 10 grains to the ounce (0.65 : 32.0), the excess being neutralized Avith a solution of salt or washed away with tepid Avater. Much inflammatory reaction in this disease may be alleviated by cold compresses. These are rendered more efficacious if dipped in equal parts of Avater and the extract of ham- amelis. Patients suffering from catarrhal conjunctivitis should be protected from tobacco-smoke, bright light, dust, or any mechanical irritant. Atropine usually is unnecessary unless a corneal ulcer com- plicates the affection. The patient may wear smoked glasses, but under no circumstances must the eyes be bandaged or heive poultices applied to them. Domestic medication of this sort may change a simple ophthalmia into a serious and purulent inflammation. Topical medications other than those mentioned are biborate of sodium (gr. iv—viij to the ounce), alum (4 to 8 grains to the ounce [0.3-0.5 : 32.0]), sulphate of zinc (1 to 2 grains to the ounce [0.05-0.1 : 32.0]), Avhich may be suitably combined Avith boric acid, creolin, 1 per cent. solution, peroxide of hydrogen, and pyoktanin, 1 : 1000; the latter remedy, hoAvever, has not justified the claims which have been made 464 DISEASES. for it. During the subsidence of the inflammation, and if it shows any tendency to become chronic, the application of an alum crystal or a solution of tannin and glycerin (10 grains to the ounce [0.65 : 32.0]) is suitable. It should be remembered that muco-purulent oph- thalmia may become epidemic in croAvded institutions, and great care should be taken to isolate cases. One soiled towel may be the source of infection to a great number of children. Constitutional treatment ordinarily is not required, but proper hygiene, fresh air, good food, the intelligent use of laxatives, tonic doses of quinine, and whatever treatment is indicated by any associated condition, are useful. The associated conditions most commonly are nasal catarrh, bronchitis, a general cold, eczema of the face, and the exanthemata. Burns of the Conjunctiva.—Immediately after the accident all foreign particles should be removed or neutralized with a weak acid or alkaline solution if a liquid caustic or acid solution has entered the eye; then a few drops of cod-liver oil may be instilled and atro- pine employed (suitably incorporated with liquid vaseline) to prevent iritis. The chief danger lies in the formation of severe corneal inflammation and symblepharon; the latter may sometimes be pre- vented by daily breaking up the granulation-tissue or by the insertion of a piece of gold-beater's skin between the inner surface of the lids and the eyeball. The associated conjunctivitis and keratitis require treatment differing in no way from that described in the idiopathic forms of these affections. Purulent Conjunctivitis, Avhich is commonly seen in the adult in the form of gonorrhceal ophthalmia and in the infant as ophthalmia neonatorum, is produced in both varieties by the introduction into the eye of a specific virus from either the urethra or the vagina. The chief danger of the disorder is destruction of the vitality of the cornea and loss of sight. The most important indication is to pre- vent this danger by reducing the amount of swelling of the lids and conjunctiva and the profuse discharge, Avhich are the characteristics of the disease. These indications are met best in the following man- ner : Hourly cleansing of the eyes with an antiseptic solution, pref- erably bichloride of mercury (1 : 8000) or a saturated solution of boric acid. During the acute inflammatory stage, and before the discharge is profuse, astringents and cauterants must not be applied. When this stage has arrived and the conjunctiva is profusely covered Avith discharge, the lids should be carefully everted once a day, wiped clean of every particle of pus, and carefully touched with a solution of nitrate of silver (10 to 20 grains to the ounce [0.65 : 32.0]), and the excess neutralized with a feAv drops of a solution of common table salt. In the early stages iced compresses Avrung out of car- bolized water and frequently changed will help to reduce the reaction, or these compresses may be made by placing squares of lint upon a block of ice and thus securing intense cold. If the vitality of the cornea is threatened, it is advisable, in many instances, to substitute for the cold applications hot compresses of a temperature of 110° F. These may be applied for from ten to twenty minutes every tAvo or four hours, according to the exigencies of the" case. The appearance CONJUNCTIVITIS. 465 of ulceration in the cornea calls for the use of atropine or eserine. Atropine Avas formerly employed almost exclusively; in recent times great success has followed the adoption of eserine. This is especially applicable if the ulceration should form in the periphery of the cornea. In adults high reaction and violent inflammation may be alleviated by the use of leeches to the temple. Bleeding of any sort is not applicable to neAvborn infants. Other applications Avhich have met with favor at the hands of various surgeons are solutions of sul- phocarbolic acid, sulphate of alum, sulphate of zinc, nitrate of silver, creolin (1 per cent.), and iodoform ointment. Both blue and yelloAv pyoktanin have been recommended, but do not yield satisfactory results. Peroxide of hydrogen is a good cleansing agent, but heal- ing does not progress as favorably under its influence as Avith bichlor- ide of mercury and nitrate of silver. Solutions of permanganate nf potassium and aqua chlorini have many advocates. Mules has recommended a treatment Avith alcohol and corrosive sublimate. The preventive method of treating ophthalmia neonatorum that has obtained the happiest results is that instituted by Crede—namely, the dropping of a 2 per cent, solution of nitrate of silver into the eyes of the neAvborn infant. If one eye alone is attacked in gonor- rhceal ophthalmia, the other should be protected by covering it with Buller's shield, Avhich consists of a Avatch-glass fixed in a square of plaster, Avhich is carefully applied so that the crystal comes directly in front of the eye, and the plaster covers the surrounding area. Chronic Conjunctivitis may result from an antecedent acute inflam- mation of the conjunctiva or exist as an idiopathic affection, especially in elderly people, in Avhom it sometimes becomes a troublesome symp- tom, especially if complicating cataract. The characteristic lesions are roughness of the papillae of the conjunctiva, sAvelling of the caruncle, and soreness of the angles of the eyelids. There are no granulations, although the disease is sometimes inaccurately spoken of as granular lids. A soothing Avash is indicated (10 grains of boric acid to the ounce [0.65 : 32.0] of water), to Avhieh may be added 2 grains (0.1) of cocaine, provided the cornea is not ulcerated, and for Avhich a similar boric-acid lotion Avith 4 grains (0.3) of salt to the ounce (32.0) may be substituted. A very suitable local application is lapis divinus (sul- phate of copper 1 part, alum 1 part, nitrate of potassium 1 part, fused together, and camphor equal to one-fiftieth of the Avhole added. The mass is run into sticks, and the application made to the everted lips, or 1 grain (0.05) of the same preparation to the ounce (32.0) of water may be dropped into the eye). Other useful applica- tions are tannin and glycerin (10 grains to the ounce [0.65 : 32.0]), velloAv-oxide of mercury salve, and alum crystal. If refractive error exist, this should be corrected, it is to be remembered that chronic conjunctivitis distinctly contraindicates any operative interference in the eye, as, for instance, cataract extraction. Lachrymal Conjunctivitis is a name given to a chronic form of inflammation of the conjunctiva, associated Avith obstruction in the lachrymal duct, and characterized by a tear-soaked appearance of the eye, small pustules at the roots of the lashes, and a gummy discharge 30 466 DISEASES. along the palpebral margin. This can be cured only by relief of the stricture of the nasal duct Avhich causes it, but may be alleviated Avith the same remedies recommended in the treatment of chronic conjunc- tivitis. Good results are reported from the use of pyoktanin. Follicular Conjunctivitis—a disease sometimes mistaken for granular lids, but having a distinct clinical difference, inasmuch as the SAvollen follicles are absorbed Avithout the production of cicatricial changes in the conjunctiva—requires for its local treatment Aveak astringents and antiseptic lotions, and the application to the swollen follicles of an ointment of sulphate of copper (gr. \ to the drachm [0.025 : 4.0]), dusting in calomel either alone or Avith equal parts of subnitrate of bismuth, or iodoform or aristol used in the same Avay. If the disease is stubborn, the SAvollen follicles should be crushed Avith forceps. This disease, or one analogous to it, is sometimes produced by the prolonged instillation of atropine, and less frequently by eserine and cocaine. If this is its cause, the drug must be suspended and the surface painted Avith an alum crystal. Granular Conjunctivitis.—This disease may be divided into acute and chronic granulations. In the former astringents and caustics are inadvisable, the eyes requiring Aveak antiseptic solutions like boric acid or salicylic acid and the instillation of atropine. Leeches to the temple "will aid in reducing the inflammatory reaction. In the chronic disease the object of treatment is to bring about absorption of the granulations Avhich are its characteristic lesion, not by an application so caustic as to destroy the mucous membrane around them, but of sufficient vigor to produce healthy reaction. The folloAving applica- tions comprise those which have been employed Avith the greatest success: 10-grain (0.65) solution of nitrate of silver if there is dis- charge, applied once a, day with neutralization of the excess ; sulphate of copper in the form of a crystal, carefully applied to the everted lids and the retrotarsal folds; pure carbolic acid, applied with a camel's-hair pencil and the excess Avashed aAvay with Avater; glycerole of tannin (tannic acid grs. 30 [2.0], glycerin 1 oz. [32.0]), best applied Avith a cotton applicator ; boroglyceride from 20 to 50 per cent., accord- ing to the vigor of the granulations. Strong solutions of corrosive sublimate are employed in the folloAving manner: Solutions of the strength of 1 : 300 or 1 : 500 are painted on the everted lids every second day, the pain of the application being alleviated by the pre- vious instillation of cocaine, Avhile three times daily the eyes are irrigated thoroughly Avith a solution of the mercury salt, 1*: 7000. Among the many other applications Avhich may be used in this disease the folloAving may be mentioned: liquor potassa, beta-naphthol, iodo- form or aristol in powder or salve, an ointment of the yelloAv oxide of mercury, calomel, and hydrastin. The surgical means Avhich are employed to destroy the granulations are scarification of the con- . junctiva, an inadvisable method; excision of the granulations, use- ful if these exist in isolated groups; crushing the granulations Avith specially devised forceps, a method often folloAved by satisfactory results; scarification, folloAved by a vigorous brushing of the affected tissue with a brush containing short bristles, previously dipped in a CONJUNCTIVITIS. 467 strong (1 : 500) solution of corrosive sublimate (Grattage); and excision of the fornix conjunctiva. In long-standing cases asso- ciated with inveterate pannus De Wecker has proposed the use of an infusion of jequirity (3 per cent.). This produces an intense mem- branous conjunctivitis. Avhich must be treated by iced compresses or similar measures to reduce its reaction, but Avhen it has subsided the pannus is often relieved. This method has not been employed in recent times to the extent that it Avas practised when first introduced. Diphtheritic Conjunctivitis is rare in this country, but on the con- tinent of Europe occasionally occurs as an epidemic. It may appear alone or in association Avith diphtheria of the throat and nose. The initial subjective symptoms are those of purulent ophthalmia; the characteristic objective symptoms, a board-like infiltration of the lids Avith a deposit of gray membrane upon the palpebral conjunctiva. More than in any other eye disease destructive inflammation of the cornea is threatened. In the early stages the eye should be fre- quently cleansed with boric-acid or bichloride-of-mercury solutions, and atropine instilled, AA'hile hot compresses help to maintain the nutrition of the cornea more perfectly than the cold compresses Avhich Avere formerly recommended for antiphlogistic purposes. TAveedie has highly recommended a solution of quinine (3 grains to the ounce [0.25 : 32.0]); Burgomaster, insufflation of floAvers of sulphur; Avhile in France the local application of lemon-juice or citric-acid ointment has been endorsed; GalezoAvski uses oil of cade (1 : 10). In the early stages all caustics are contraindicated; after absorption of the membrane and re-establishment of the discharge the cautious use of nitrate of silver in the manner described under Purulent Ophthalmia mav be employed. The constitutional measures for diphtheria are necessary. Chemosis of the Conjunctiva, in Avhich this membrane is infiltrated with serum, is usually a symptom of other ocular disorders, and sub- sides Avith the general treatment directed to their relief. Good results mav follow nicking the SAvollen tissue Avith a pair of scissors, the application of a Avarm, moist compress, and the use of astringents, especially alum. Hemorrhage beneath the Conjunctiva (subconjunctival ecchymosis) may folloAv an injury, occur, during a paroxysm of whooping cough. and occasionally, in elderly people, may appear spontaneously. No treatment materially hastens the absorption of the blood, unless it be massage of the globe through the closed lid; any associated conjunc- tival irritation may call for a boric-acid and cocaine wash. Xerosis of the Conjunctiva, depending upon a cicatricial metamor- phosis and the absence of normal moisture, is seerr after long-standing inflammations (granular lids, diphtheria, pemphigus), and is incur- able. The affection may be relieved by the local use of glycerin, almond oil, emulsion of cod-liver oil, or the use of weak alkaline solutions. Transplantation of the rabbit's conjunctiva has been tried Avithout success. 468 DISEASES. CONSTIPATION. This troublesome state depends on a number of causes, the most common of Avhich is the following of a sedentary life totally devoid of the exercise intended to keep the intestinal and hepatic secretions in an active state. Another frequent cause is simple laziness, which causes the patient to resist the call of the boAvel for evacuation until this part of the body becomes indolent and atonic, Avhile modesty often causes constipation in females, because a Avoman prefers to suf- fer rather than go to a closet Avhich may be somewhat publicly sit- uated. In other instances constipation seems to be hereditary, and to depend upon deficient nerve-supply or muscular Aveakness and lack of secretion in the loAver bowel, or upon hepatic torpor. Whatever the causes are, they should be sought for, and, if pos- sible, removed, the physician not being content to order purgatives, Avhich, while they may give temporary relief, soon lose their power. Further than this, it must be remembered that hygienic measures ahvays take first place in the method of treatment, and, if possible, drugs should occupy a very secondary role. Particular attention should be paid to diet, and the physiology of peristalsis must be well borne in mind. It has been proved by a lavge :number of studies, both in the nor- mal intestine and by the use of purgatives, that peristalsis is almost entirely a reflex action depending for its existence upon the integrity of the nervous plexuses in the intestinal Avails—namely, those of Auerbach and Meissner—the first of Avhich are situated between the longitudinal and circular muscular fibres Avhich they supply, the latter existing in the submucosa and supplying the walls of the villi, the glands of Lieberkuhn, and the small arteries and venules. It has also been found that the vagus nerve, Avhen stimulated reflexly or directly, increases peristalsis, and that moderate stimula- tion of the splanchnic nerves decreases it.1 It at once becomes evi- dent that any decrease in the normal activity of these nerves and nerve-centres must speedily result in constipation, and the costive condition consequent upon hepatic torpor is due to the fact that the intestinal Avails do not receive the proper stimulation from the bile to set in motion a reflex peristaltic Avave the result of Avhich will be evacuation. This fact rests upon the results of direct experiments, Avhich prove the bile to be primarily an intestinal stimulant, antisep- tic, and promoter of secretion. Other series of experiments have shoAvn that the circulation of the blood through the intestines greatly influences peristalsis, and disor- ders in the blood-supply readily bring on intestinal disorder. 4 The deductions to be draAvn from these facts are many. In the first place, it is evident that the maintenance of an active, normal circulation of blood in the abdomen and a free pouring out of bile fro^in the liver and gall-bladder are necessary to a healthy peristalsis; 1 §pme persons believe that Meissner's plexus receives impulses from the walls of * the intestine and transmits them to the motor plexus of Auerbach, which then sets in motion peristalsis. CONSTIPATION. 469 and Ave find that, aside from drugs, Ave have a number of remedial measures Avhich are to be resorted to according to the means of the patient. By far the best of these is horseback exercise for at least an hour a day or every other day, Avhich by the motion actively stirs up and excites the abdominal viscera as no other measure can do. If for any reason horseback exercise is impossible, then abdominal mas- sage carried out by a capable masseuse is to be tried, the hands fol- loAving more particularly the course of the ascending, transverse, and descending colon, the kneading movements being also applied to the hypochondriac regions. If neither of these measures can be used, then the patient must resort to those gymnastic movements which involve the abdominal muscles, either by the use of dumb-bells or pulleys, such as are sold under the name of "home gymnasiums," or by bending the body forward, backAvard, and laterally, with the fists pressed into the hypogastrium. At the same time that these measures are directed the diet of the patient must be so regulated that the food shall contain a large amount of residue—that is, after digestion enough of the husk of the grain or enough vegetable fibre must be left free in the intestines to form a stimulus to the intestinal Avail as it slips over the mucous membrane. If a meat diet is largely used, so little residue is left after digestion that constipation ensues, but if vegetables are largely eaten the reverse is the case. No better evidence of this can be adduced than the hard, clay-like passages of the dog and the soft passages of the coav. Very often a plateful of cracked wheat (Avheaten grits) eaten at breakfast each morning, or the use of bran bread, will relieve a chronic tendency to constipation. In these cases milk as a prominent article of diet is to be avoided above all things, since it is almost entirely assimilated and leaves no residue, though it supplants other foods. Green or canned corn is of great service. Fruits do good in constipation in one of two Avays—they either contain residual materials or sufficient vegetable acid salts to be laxative. Figs, by reason of their many small seeds, Avhich scrape the mucous membrane during peristalsis, are particularly Araluable, and apples, prunes, dates, and tamarinds are all useful. It must be remembered that straAvberries, raspberries, and blackberries are generally constipating rather than purgative. In regard to drink, nothing is so good as a glass of cold Avater taken on arising in the morning or just before breakfast, or, if the cold cannot be borne, then a glass of as hot Avater as can be SAvalloAved Avith comfort may be substituted. Coffee is constipating to most per- sons, largely because of its empyreumatic oil, and tea has 'the same tendency because of its tannic acid. Brandy, as every one knoAvs, is distinctly constipating, and Avhiskey possesses so little poAver to the contrary as to be devoid of influence in either direction. Beers differ in their properties, some of them increasing and some of them decreas- ing intestinal activity. The patient suffering from constipation should go to stool regularly after breakfast every day even if the attempt is abortive, and so train the bowel to having a movement at this time. The use of drugs for the relief of constipation is capable of division 470 DISEASES. into two parts : first, the employment of remedies to unload the bowel, Avhich has become filled; second, the use of drugs Avhich Avill so influ- ence the intestines as to cause evacuation and produce normal activity, or, in oljier Avords, drugs which will cure the tendency instead of giving temporary relief. Of the first class Ave find the various pur- gative salts, jalap, colocynth, senna, mercury, castor oil, and rhu- barb ; of the second class, aloes, cascara sagrada, manna, tamarinds, rhamnus frangula (buckthorn), phosphate of sodium, and small doses of podophyllin. The physician should bear in mind that defecation is a normal physiological act which must be continued all through life, and it is almost as foolish to stimulate the boAvel continuously to peristalsis as to perpetually employ heart stimulants or respiratory excitants. Although they are habitually employed by many persons in dailv doses, the purgative salts are exceedingly harmful in such instances, rapidly losing their power and decreasing the patient's strength by the abstraction of liquids and salts from the blood. They often pro- duce anamiia Avhen constantly used. These salines are to be employed simply to unload the bowel Avhen an excess of faecal matter has accu- mulated or Avhen irritant materials are to be SAvept out of the aliment- ary canal. In some cases of pelvic congestion associated Avith con- stipation magnesium sulphate may be given by enema in the propor- tion of 2 ounces (64.0) of the salt, 1 ounce (32.0) of glycerin, and 4 ounces (128.0) of Avater. In some rare instances, Avhere great pleth- ora exists, a course of Hunyadi water, Friedrichshall or Carlsbad waters is of service, but these instances are rare indeed in America. Jalap, colocynth, and senna are not to be used constantly, as thev are too active and the reaction from their effects causes constipation. Rhubarb is commonly used, but is of its class peculiarly unfitted to its task. Although it purges, it is distinctly astringent, and is there- fore more constipating in the end than if no drug had been used. Mercury is exceedingly harmful if used continuously as a purge. and is the cause of much ill-health, of bad teeth, and of digestive troubles. Castor oil is notorious for its tendency to cause ultimate constipation. Of the curative class of laxatives none compare to cascara sagrada, particularly in the form of the non-bitter fluid extract or cascara cor- dial. Originally, this drug as prepared was very bitter, but it is now made almost tasteless by certain manufacturers. This is the only drug which alone moves the bowels and at the same time tends to make future passages more easy and regular; the dose is 10 to 20 drops (0.65-1.3) of the fluid extract or 1 to 6 drachms (4.0-24.0) of the cordial. There is almost no griping produced by it. For the regulation of the bowels of young children, particularly if the case be somewhat "rickety " in tendency, phosphate of sodium in the dose of 5 to 10 grains (0.35-0.65) in milk is the best laxative, and the same salt may be used in 30- to 60-grain (2.0-4.0) doses in adults. Manna is to be classed as a laxative fruit, but even it sometimes make the intestinal torpidity ultimately much Avorse. The tAvo remaining drugs of this class, aloes and podophyllin, should always be used in CORNS. 471 combination Avith other non-purgative drugs, as is seen in the follow- ing formula: R.—Aloes socotrina*.......gr. xx vel xl (1.3-2.65). Extract, nueis Aromica>.....gr. iv (0.3). • Extract, physostig......gr. iij (0.25). Extract, belladonna- . . . . gr. iv (0.31.—M. Ft. in pil. No. xx. S.—One pill at night or night and morning. Or, R.—Resina? podophylli.....gr. ij vel iv (0.1-0.3). Extract, nueis vomica'.....gr. iv (0.3). Extract, physostig.......gr. iij (0.251. Extract, belladonna?......gr. iv. (0.3).—M. Et. in pil. No. xx. S.—One night and morning. The object of using several of these drugs is seen at a glance. We have already learned that nearly all purgatives tend to produce griping. The nux vomica acts as a bitter tonic and stimulant, and prevents subsequent atony of the mucous membrane, as Avell as increases reflex action, and consequently improves peristalsis; the physostigma is a tonic to the unstriped muscular fibre and gives it strength ; the belladonna aids peristalsis by depressing the inhibitory fibres of the splanchnic nerves, by allaying spasm, and by decreasing griping. In using these drugs, aloes and podophyllin, we should remember that aloes is sIoav and acts particularly on the loAver bowel, and that podo- phyllin acts chiefly on the upper boAvel and is the sloAvest purge in the list of purges. In the flatulence of old persons associated Avith constipation a little asafoetida or capsicum should be added to the pill of aloes just named. In some instances constipation arises from reflex irritation or from ovarian or bladder trouble or from chronic lead poisoning. This form of constipation may resist all purgatives and yield to opium or to tobacco, Avhich quiets reflex action. Tobacco depresses the inhibitory nerves of the gut. and devotees of the " Aveed " often use it as a lax- ative. The employment of enemata as a routine practice is to be discour- aged. In cases Avhere it is necessary to use them for temporary relief and to get rid of flatulence, a little soap, common salt, or a feAv drops of turpentine may be added to the water. Recently the injection of glycerin (1 to 2 ounces [32.0-04.0]) has been largely resorted to, either pure or diluted one-half, and this method has been improved upon by the use of glycerin suppositories containing many drops of the drug. Glvcerin acts in these cases as an irritant to the mucous membrane, and causes secretion by this means and by its abstraction of Avater from the tissues by reason of its hygroscopic poAvers. It is capable, hoAvever, of causing a good deal of rectal irritation in some persons. CORNS. These troublesome formations are best treated by the use of sali- cylic acid, the folloAving formula being applied night and morning for 472 DISEASES. several days, after which the part should be Avell soaked in hot water, Avhen the entire corn will readily come aAvay, or in some cases several attempts Avill be necessary : R— Acid, salicylic............gr. xxx (2.0). Extract, cannab. indica'.......gr. x (0.65). Collodii..............f^ss (16.0).—M. S.—Apply with a camel's-hair brush. The same acid may be used in alcohol, and lactic acid in the same proportion is often of service. In the so-called "soft corns," with much inflammation, the foot should be washed and dried, and a saturated solution of nitrate of silver, 60 grains (4.0) to 2 drachms (8.0), applied to the part every four or five days. CORYZA (ACUTE). The treatment of coryza of the acute variety, the form which most frequently presents itself to the physician for relief, is folloAved in marry instances by such marked amelioration of the symptoms and shortening of the attack as to encourage medical interference. It must be remembered, hoAvever, that the duration of the condition before the patient presents himself has much to do with the progno- sis, for if the tissues of the nasal chambers have become boggy and swollen with exudation recovery must be more prolonged than if rem- edies are applied in the early stages of the catarrhal process. The treatment locally consists in the folloAving measures for relief: By means of a medicine-dropper or an atomizer a feAv minims of a 4 per cent, solution of cocaine are dropped into the nostrils, the patient's head being Avell tipped back. After the peculiar constringing influ- ence of the cocaine has shrunken the congested mucous membrane, so that the patient can draw air through the nostrils, the nasal cham- bers should be washed clean of mucus by means of the following lotion in an atomizer-: R.—Sodii chloridi...........gr. xv (1.0). Acid, boric..............gr. x (6.65). Sodii borat..............gr. x (0.65). Aqua? dest..............fgiij (96.0).—M. The parts being thoroughly cleansed, a fine spray of the folloAving should be used as antiseptic, sedative, anaesthetic, and protective: R.—Menthol.............gr. viij (0.5). Camphor.............gr. v (0.3). Albolene .............f^j (32.0).—M. In this prescription the menthol exerts an anaesthetic effect, and pro- longs the constriction of the parts produced by the cocaine, so avoid- ing the secondary capillary dilatation due to that drug. The camphor exercises its Avell-knoAvn soothing influence, and the albolene protects the membrane from dust and irritants. If the congestion has a tend- CROUP. 473 ency to return, it is Avell to use a solution of antipyrine, 2 to 4 grains to the ounce (0.1-0.2 : 32.0) of Avater, as a spray to prolong still further the effect of the cocaine. The albolene spray should folloAv, not precede, the antipyrine, as the oil would prevent the antipyrine from acting. Under no circumstances should the antipyrine be used Avithout the cocaine preceding it, as the pain is too severe. The internal treatment consists of a hot foot-bath, with mustard in it in the early stages of the disease, and the taking of a hot drink, such as lemonade Avith whiskey in it, on going to bed. Often 20 or 30 drops (1.3-2.0) of SAveet spirit of nitre added to this will increase its diaphoretic effect. In other cases, particularly in strong, hearty men, 5 to 10 grains (0.3-0.65) of Dover's poAvder at bed-time will be better. This line of treatment is of little value after secretion has been fairly established, and in its place supportive measures are indi- cated. Small tonic doses of quinine, 2 to 4 grains (0.1-0.2) three times daily, sometimes combined Avith the use of 5 to 10 grains (0.3- 0.65) of chloride of ammonium, as prescribed in the article on Bron- chitis, are useful. Where much headache is present full doses of the bromide of potassium or sodium are to be given, and the spray treat- ment already named is to be persisted in Avhile the attack lasts. CROUP. (See Diphtheria.) CROUP (SPASMODIC). As this is a spasm of the glottis depending for its causation upon catarrh of the mucous membrane of the larynx, and as it is due most commonly to some reflex irritation, such as dentition, indigestible food, or sudden atmospheric changes, the treatment is both prophy- lactic and curative. Prophylaxis consists in the avoidance of cold, the use of a simple diet, particularly at the evening meal, the render- ing of the air of the bedroom moist by means of steam or at least by the avoidance of dust-laden, furnace-heated air, and by the removal of dental irritation and nasal hypertrophies, Avhich make the child a "mouth-breather." Small doses of the bromides, chloral, belladonna, or opium may be resorted to at bed-time. A very useful prescription for this purpose is that Avhich folloAvs: R.—Sodii bromidi............3J (4.0). Syrupi lactucarii . .'......f^ij (64.0).—M. S.—Teaspoonful to a dessertspoonful (4.0-8.0) on going to bed, and once or tAvice dur- ing the night if needed. When the attack is present a cold cloth should be Avrapped about the neck and the child placed at once in a hot bath, the air of the room being moistened by the steam escaping from a kettle of boiling Avater or by pouring water upon unslaked lime. If the paroxysm is very severe, a few Avhiffs of amyl nitrite may be employed, or anti- 474 DISEASES. monial wine in the dose of 2 drachms (8.0) may be used to cause vom- iting. It is also useful to disseminate the fumes of menthol through the air of the room by heating some crystals in an iron spoon. If the fumes are strong enough to produce a distinct odor, they are present in sufficient amount. The drugs first named do good by decreasing reflex excitability, while the emetics indirectly relax the spasm by the nausea and depression Avhich they produce. CYSTITIS (ACUTE). If, by reason of exposure to cold, injury, the introduction of for- eign bodies, such as dirty catheters, or the presence of gonorrhoea or other disease due to a septic poison, an acute inflammation of the bladder ensues, it is accompanied by a sensation of weight and ves- ical fulness, by pain, tenesmus, and inability to retain the urine. Sometimes the last-named condition may be reversed and retention of the urine be present. If the general system responds to the local inflammation, as evi- denced by increased arterial excitement and fever, aconite in full doses of the tincture should be used, and it should be combined Avith small amounts of SAveet spirit of nitre and citrate of potassium, as follows : R— Tinct. aconiti............f^j (4.0). Spirit. a?ther. nitrosi..........f^j (32.6). Liquor potassii citratis.....q. s. ad f^vj (192.0)—M. S.—Dessertspoonful (8.0) every four hours until all fever ceases and the pulse is quiet. At the same time a hot compress should be applied over the blad- der, but it should not contain turpentine or any irritant substance which may be absorbed from the skin and when eliminated by the kidneys irritate the bladder-Avails. Leeches may be placed upon the perineum or cups applied to the region of the sacrum. In some cases belladonna may be used Avith or Avithout aconite in the dose of 5 to 10 drops (0.65) of the tincture three times a day, and it is worthy of note that this drug is particularly serviceable in the cystitis due to cold; 5 drops of liquor potassa every four hours may be substituted for the citrate of potassium, or the acetate of potassium may be used. If there is much pain and bearing-down, an enema of 30 drops (2.0) of laudanum in 2 ounces (64.0) of starch-water may be employed, or the opium may be given in suppository. Sometimes a belladonna suppository is of more service, and an iodoform suppository will often relieve the pain by its local anaes- thetic effects. Hot enemata, without any drugs, are often valuable as a means of relief, and a hot sitz-bath is very efficacious. Can- nabis indica, if an active preparation can be had, is better than opium «o relieve the pain, since it seems to affect the bladder favorably. The other curative measures are hygienic, and consist in the main- tenance of the recumbent posture, absolute physical and mental rest. CYSTITIS. 475 the avoidance of all foods Avhich are stimulating, as rare meats and highly-seasoned dishes, and abstinence from all varieties of alcoholic beverages. Should the inflammation be severe enough to become purulent, the physician should order salol in the dose of 10 grains (0.65) three times a day. This drug, being broken up in the boAvel into carbolic acid and salicylic acid, is so eliminated and renders the urine anti- septic. Laxatives are to be employed Avith persistence if the boAvels are confined, and salines in the early stages are generally better than vegetable purges. Quinine should not be used against the fever, as it is contraindi- cated. OAving to its irritant effects upon the bladder. CYSTITIS (CHRONIC). The treatment of chronic cystitis is entirely different from that of the acute form, and consists in the use of remedies Avhich will stim- ulate the diseased mucous membrane, cause a normal secretion of mucus, and so influence the urine that the mucus already formed will be passed out and the fluid rendered alkaline or acid, as may be desired. When the secretion of mucus in large amount is persistent. the urine should be rendered alkaline by the use of liquor potassa or the citrate, acetate, or bicarbonate of potassium. The bitartrate of potassium is eliminated as the bitartrate of potassium, and, as it is acid, cannot be employed. We acidify the urine when it is necessary to dissolve the phos- phates and to prevent deposits in the bladder and elsewhere. The two best drugs for this purpose are boric acid in the dose of 5 to 10 grains (0.65) or benzoic acid in the same amount. Both of these may be given in pill form, made by adding a little glycerin. The rule may be laid clown that if the urine is high-colored and is strongly acid, alkalies are useful; Avhereas if it is light in color, but loaded with phosphates, the acids named should be employed. Salol maybe given to prevent decomposition of the urine. One of the best measures for the relief of chronic cystitis is to Avash out the bladder daily by irrigation Avith warm Avater or Avater containing bichloride of mercury in the proportion of 1 : 10,000, as this Avashes aAvay all mucus and uric-acid deposits and prevents irri- tation. Solutions of nitrate of silver have been used with great suc- cess Avhere the discharge is muco-purulent, and Thompson recommends the use of a solution of the strength of 1 grain to 4 ounces (0.05 : 128.0) of Avater, gradually increased to 2 grains to the ounce (0.1 : (32.0). Others, such as Gardner, Richardson, and Potter, recommend the use of stronger solutions, 5 grains to the ounce (0.35 : 32.0) of water, claiming that while these amounts may produce serious effects in some instances, they are very efficacious in obstinate cases. The* physician should have at hand a solution of common salt, Avhich he should inject into the bladder at once if the action of the silver solu- 476 DISEASES. tion is too painful or seems excessive. This treatment is only suited to the most chronic cases. The remaining remedies Avhich are employed internally in chronic cystitis are those Avhich are directed to the improvement of the mucous membrane of the bladder, and consist of buchu in the form of the fluid extract in the dose of £ to 1 drachm (2.0-4.0), well diluted; arbutin or ursin, 3 to 5 grains (0.25-0.35); or the fluid extract of uva ursi, dose 30 drops to 1 drachm (2.0-4.0). All of these are better fitted for the treatment of subacute than chronic cystitis, as they are not sufficiently active for the chronic forms. In cystitis of an advanced type, with great vesical atony, strych- nine is of service, and drop-doses of tincture of cantharides do great good. Turpentine may also be used with advantage in 5- to 20-drop (0.3-1.3) doses, as may also the oils of eucalyptus, sandal Avood, cubebs, and copaiba. All these measures are suitable for the treatment of cystitis in the male and female, but it is to be noted that injections into the female bladder are made much more readily than into that of the male, because of the shortness of the female urethra. In either case the operation is best performed by attaching a small funnel to a soft- rubber catheter and filling the bladder by raising the funnel full of water above the patient's belly. Creolin has been highly recom- mended by Parvin in the strength of from 1 to 2 per cent. Avith water. The irrigation is to be performed every tAventy-four hours. DIABETES INSIPIDUS. In diabetes insipidus the disorder exists simply as a profuse urinary flow dependent upon some disorder of the innervation of the kidney or upon atony or relaxation of this organ. This treatment consists in the use of astringents and tonics, and in some cases in the employ- ment of opium or belladonna, particularly if the over-secretion rests upon nervous irritability. Gallic acid may be used in 20-grain (1.3) poAvders three times a day, and the fluid extract or Avine of ergot is often of service given in the dose of 30 drops to a drachm (2.0-4.0) of the former or a wineglassful (32.0) of the latter. As tonics the sulphate of iron and strychnine are indicated. DIABETES MELLITUS. In the treatment of this affection it should be remembered that it is the result of disordered function, and is not a disease in itself, but a symptom of several disease-processes. For this reason a remedy which succeeds in one case may fail in another. The treatment of diabetes mellitus is dietetic and medicinal. The diet list should consist largely of meat, particularly of meat with some fat attached to it, as the fat, to some extent, takes the place of DIABETES MELLITUs. 477 starch in the nutrition of the body. The avoidance of starches of all kinds and the use of dry Avines or those containing little or no sugar are to be insisted upon. Beers and malt liquors must be forbidden. According to some authorities, the patient should be placed in bed and put on a purely milk diet, generally of skimmed milk, although buttermilk is better than any other form, OAving to its lactic acid and lack of sugar. Koumyss for the same reason is very valuable. The chief aim of the patient must be to avoid all substances Avhich can be readily converted into sugar by the organism. The folloAving list of foods and drinks may be taken, and the second list forbidden:1 Meats of all kinds (except liver), eggs, fish, cheese, butter, and cream; oyster-plant, asparagus (?), tomatoes, almonds, pecan nuts, butternuts, Avalnuts. and cocoanuts; string-beans, beet tops, radishes, mushrooms, lettuce and Avater-cress, caulifloAver, spinach, and onions. Celery and cucumbers may also be permitted. Of the foods and drinks to be avoided, Ave have all forms of sugar, all forms of starch, such as ordinary flour, cornmeal, arroAvroot, sago, tapioca, oatmeal, barley, carrots, beets, parsnips, pie-plant, peas and beans, chestnuts, and most of the fresh fruits, cider, beers, champagne, SAveet Avines, and honey. The treatment of diabetes by drugs is varied by the condition of the patient, the cause of his disease, and the quantity of sugar in the urine. While the drugs most commonly employed are used in many instances without any knoAvledge of Iioav they act, and have each of them a set of Avarm supporters among prominent authorities, much of the treatment must depend upon Avhether or not a rheumatic or gouty taint is the cause of the trouble, or Avhether it is due to high living, little exercise, and a plethoric, congested, overloaded system. In the first class of cases iodide of iiotassium and the salicylates will be most serviceable; in the second class, a restricted diet, moderate exercise, and purgation to relieve engorgement of the hepatic artery and veins may be needed. In the cases of gouty diabetes, Avhere relief does not follow the use of the iodides and colchicum, resort must be had to arsenic and lithium citrate or carbonate, a combination peculiarly adapted to such a condition, according to several authorities. Indeed, arsenic is a sheet-anchor Avith many practitioners in all forms of dia- betes, and should be given in fairly large, constantly-repeated doses for a long time. A very much larger body of medical men rely on opium or one of its alkaloids, such as morphine or codeine. The for- mer is used in the dose of £ to £ grain (0.015-0.03) three times a day; the latter, 1 to 5 grains (0.05-0.3) three times a day, and the Avriter has found them very useful. The morphine is much the most powerful for good, and patients who are diabetic must have large ascending doses, which they bear very well. The chloride of gold and sodium (-jijj- grain [0.006]) has been highly recommended by Bar- tholow, and ergot by Wood and DaCosta, In cases depending upon 1 It is worthy of note that certain persons may have a slight glycosuria without serious injury, who Avaste under a limited diet, requiring ordinary fare to support the body plus the diabetic drain. 478 DISEASES. rheumatism the use of salicylic acid is often of great value, the dose being 10 to 15 grains (0.65-1.0) three times a day. In cases of diabetes in Avhich diet Avill control the disease the best clinicians insist that drugs should be avoided, for Avhen opium or any of its alkaloids are used it is necessary to give rapidly-increasing doses, which finally become enormous, as much as 7 grains (0.6) of morphine a day being taken by some persons. Once having begun the use of drugs in severe cases, it is very dangerous to stop them, for clinical experience has shown that many of these patients Avaste rapidly and generally break doAvn Avhen this is done. In regard to the time of day at Avhich to give the morphine or codeine, it is gen- erally considered best about one hour after meals. Under the cir- cumstances the drugs seem to decrease diuresis more than if the dose precedes the meal; further than this, the stomach is not disordered. In some cases results Avill be obtained from opium Avhen its individual alkaloids fail. Careful observation of the patient should be carried out to determine the proper beginning and subsequent doses, and if at first the opiates fail to give relief, discouragement should not be felt. Jambul is a remedy Avhich has been Avidely used by clinicians for the relief of diabetes Avith such varying results that its position in therapeutics is uncertain. This is probably because it is effective in one form of diabetes and not in another, and Ave are unable to make the clinical distinction. Jambul is used in poAvder or the powder is placed in capsules or pills. The dose is 5 to 30 grains (0.3-2.0) once to thrice daily, and gradually increased. As much as an ounce (32.0) has been given in tAventy-four hours. This medicament is said to be advantageously combined with a pure meat diet in diabetic cases. The excessive thirst of diabetes can be best allayed by the use of acidulated water or alkaline Avaters containing non-purgative salts. It is useless to cut off the water-supply, to the production of great suffering, but the patient should use moderation in drinking so far as possible. The wasting coming on in diabetes is to be treated by careful diet, rest, and the supply of all the food Avhich the patient can digest. In many instances the amount of aliment ingested is extra- ordinarily large, while in others digestion is so impaired that food cannot be taken. If cachexia comes on, iron, strychnine, bitter tonics, the lacto- phosphates of lime and sodium, and astringents are to be used to sup- port the circulatory and nervous systems. Tea and coffee and all forms of food needing sAveetening may be rendered palatable by the use of saccharin or of glycerin. The former passes through thebody unchanged; the latter increases the glycogen in the liver, but checks the formation of sugar (Ransom). Unfortunately, we have no positive knoAvledge as to the minute and innermost causes of diabetes, nor the manner in Avhich the glyco- suria is brought about, and in consequence cannot explain the manner in which opium, codeine, or other drugs produce relief. Diabetic coma is a most dangerous complication of this disease, DIARRHCEA AND DYSENTERY. 479 and should be treated as actively as our knowledge of its cause per- mits. It is thought by some that the symptoms are entirely depend- ent upon the presence in the blood of oxybutyria acid, "and that hypodermoclysis or intravenous injection of normal saline solution (7 : 1000) should be resorted to. Stadelman insists upon the employ- ment intravenously of 150 ec. of normal salt solution to which 7.2 gm. of sodium carbonate and 4.6 gm. of sodium bicarbonate have been added. The injection is continued until the urine is alkaline. Unfortunately, the statistics of this method of treatment are only a little better than nil, as so far the mortality has been 10 out of 11 cases. Hypodermic injections of ether should be resorted to to sup- port the heart. DIARRHCEA AND DYSENTERY.1 Diarrhoea is a term loosely applied, Avith perfect correctness, to all forms of intestinal disturbance accompanied by the passage of liquid stools, and its meaning, "to run through," expresses the state it represents. The treatment of each form of diarrhoea depends upon its cause, and no case can be intelligently treated in Avhich the physician fails to recognize this aspect of the case. Diarrhoea is but a symptom, not a disease, and must be regarded solely as an evidence of intestinal disorder. While the same drugs are prescribed in many forms of the trouble, Ave may divide cases of diarrhoea into four classes, as folloAvs: (a) Those in Avhich the laxity is due to a catarrh, acute or chronic, of the intestinal mucous membranes, causing the passages to contain mucus; (b) those where, owing to disordered innervation, a profuse outpouring of liquid takes place from the blood-vessels into the intestinal lumen; (c) those in Avhich, OAving to disease, the glands fail to prepare juices to digest the food properly ; and, finally (d) those cases Avhere ulceration causes irritation and bloody purging. The treatment of the catarrhal form first named consists primarily in the regulation of the diet, Avhich should be made up chiefly of milk, boiled or predigested, or of milk whey, and in the administration of castor oil or other mild purge, such as sulphate of magnesium, to sweep out fermenting food and mucus. Enough laudanum should accompany this oil to prevent griping, and it is Avell to add bicarbon- ate of sodium, grains 20 to 30 (1.3—2.0) to the dose, both to aid the action of the oil and to render the boAvel alkaline in reaction (normal) instead of acid, as caused by the fermentation abnormally present. A mustard plaster or other counter-irritant should be applied to the abdomen. Often in the milder forms of mucous diarrhoea this is all that is needed, but more frequently it must be folloAved by the use of tonics and astringents, such as nitrate of silver and hyoscyamus, in the following pill: 1 The articles on Cholera, Cholera Morbus, and Cholera Infantum should be care- fully read in connection with this article. 480 DISEASES. R.—Argenti nitratis...........gr. ij (0.1). Extract, hyoscyami.........gr. v (0.3).—M. Ft. in pil. No. x. S.—One three times a day. Or, R.—Plumbi acetatis . Extract, opii . . Ft. in pil. No. x. S.—One three times a day If these stop the diarrhoea, yet there still seems to be a tendency for it to return or atony is present, we should use a pill containing the extract of chiretta or employ nitromuriatic acid, or, better still, nitric acid and cardamoms, because the constant tendency to relapse indicates a deficient secretive action on the part of the intestinal glands, which these remedies are prone to improve: R.—Acid, nitric, dil...........tX]\(4.0). Tr. cardamomi comp.........f^ij (64.0). Tr. gentian, comp..........f^ij (64.0).—M. S.—Dessertspoonful (8.0) every four hours. If the catarrhal state is persistent, no remedy compares to the chloride of ammonium, dose 5 grains (0.3) every four hours in liquorice and Avater. Where the catarrhal state is exceedingly chronic and obstinate it is well to employ 3- to 5-grain (0.15-0.3) doses of potas- sium iodide. If the pills already named do not control the diarrhoea, and the discharges are so profuse as to Aveaken the patient very greatly, the following prescription may be used to check the movements, but not to stop them completely: R.—Acid, sulph. aromat.........f^jss (6.0). Spt. chloroformi.......... f^ij (8.0). Tr. opii camphorat.........f^ij (64.0). Syr. zingiberis........q. s. ad f^iv (128.0).—M. S.—Dessertspoonful (8.0) every two hours. Or, R.—Tr. kino..............f£j (32.0). Tr. catechu comp..........f^j (32.0). Mistura? creta?...........f^iij (96.0). Aquae cinnamomi......q. s. ad fjvj (192.0).—M. S — Shake well before using. Tablespoonful (16.0) every three hours. In many cases where the condition of mucous diarrhoea becomes chronic it is necessary to resort to enteroclysis (Part III.) and the treatment needed in cases of chronic intestinal catarrh. (See Diar- rhoea, Chronic.) In the second form of diarrhoea named—that in which serous or watery purging is present—the treatment is radically different. In these cases the blood-vessels of the gut are relaxed and leaking, and must be contracted and made Avater-tight, This dilatation may result from fear ("nervous diarrhoea"), from exposure to cold, or from exhaustion, extreme heat, and irritant food. If from irritant foods, they are generally swept out in the first flush of liquid. gr. ij (0.1). gr. ij (O.l).-M. DIARRHOEA AND DYSENTERY. 481 The measures to be adopted consist in those directed to the con- traction of the dilated and relaxed blood-vessels and the restoration of the proper nerve-supply to the parts. As the splanchnic nerves are the vasomotor nerves of the intestine as Avell as the inhibitory nerves of peristalsis, it is evident that Ave must use drugs which will cause stimulation of these fibres, and the chief of these is found to be opium, Avhich diminishes intestinal peri- stalsis and secretion by just such an influence. In the same way small doses of volatile oils are of service, and camphor and spirit of chloroform may be used. As there is relaxation, astringents are indi- cated ; and as sulphuric acid is not only astringent, but eliminated by the loAver bowel, it is peculiarly seiwiceable. We find, therefore, that the folloAving prescription fulfils every indication: R.—Acid, sulph. aromat.........f^ss (16.0). Olei cajuputi...........gtt. xl (2.65). Ext. ha?matoxyli fi.........f£ij (8.0). Spt. chloroformi.........f^j (8.0). Syr. zingiberis.......q. s. ad f^iij (96.0).—M. S.—Teaspoonful (4.0) in Avater every two or three hours. If desired, kino or catechu may be used in lieu of the haematoxylon, or the oil of cloves substituted for that of cajuput. Camphor or pare- goric may also supplant these drugs. In some instances these attacks appear to depend upon hepatic disorder, and the only cure, aside from partial relief, is to be obtained by the use of 2 to 6 grains (0.1-0.35) of mercury Avith chalk (hydrar- gyrum cum creta) or calomel, gh^en in ^ to 4 grain (0.01-0.03) doses. What is said of intestinal disorder from lack of secretion under the head- ing of Cholera Infantum applies very forcibly to these cases, and diar- rhoea may persist for weeks, or only temporarily be held in check by the most powerful drugs, until the physician thoroughly flushes the intestine with bile by the use of podophyllin and calomel. Wood has highly recommended the use of a bismuth powder con- taining a drop or two of carbolic acid. The third class of cases seems, in many instances, to lie between those just spoken of and those in Avhich the Avriter has placed them ; they occur chiefly in children, and consist in the foetid, " mousv "- smelling stools of summer diarrhoea, with green, spinach-like masses of semi-digested food or distinct lientery. They may be due to defici- ent glandular action in any part of the alimentary canal, and are often cured by the use of pepsin and hydrochloric acid to aid the gastric processes. In other instances the duodenum is at fault, and should be stimulated by small doses of nitromuriatic acid, or by podo- phyllin in the dose of ^ to -fa of a grain (0.001-0.0015), with a little milk-sugar, or given in alcoholic solution. Similarly, ipecac in poAv- dered form may be used in the dose of J to 4; a grain (0.015-0.03) three times a day. In the case of children, Avho are often sufferers from rickets, phosphate of sodium, lime salts, and common salt should be freely given. For the purpose of establishing intestinal antisepsis, carbolic acid may be used, and naphthalin, thymol, and other drugs of this class 31 482 DISEASES. have been employed, particularly salicylic acid. None of them com- pare Avith carbolic acid, hoAvever, which should be used in 1-drop (0.05) doses on bismuth or in water. When the carbolic acid is given to a child, it is best prescribed in such a Avay that in each teaspoonful a half-drop is present. This teaspoonful of liquid should be placed in a tablespoonful of water. In other cases sulphocarbolate of zinc in the dose of from 1 to 4 grains (0.05-0.2) in powder or capsule is beneficial. Salol combined Avith chalk mixture may also be advan- tageously used. (See prescriptions under Salol.) Sometimes a good-sized, brisk purgative dose of calomel folloAved by a saline does good in these cases if they are strong enough to permit of its use. The regulation of the diet, Avhich should consist in sterilized milk or koumyss, the former being predigested, is of the greatest import- ance. Should the patient be a bottle-fed baby, the proportions of the milk, Avater, and cream placed in the bottle should be varied until a mixture is formed which is exactly fitted to the digestion of the case. The after-treatment consists in the use of tonics and a carefully regulated diet, which should be largely composed of milk and milk foods. The fourth type, generally known as dysentery, is due in some cases to hepatic trouble, in others to the drinking of impure water, and in the third place to exposure to heat and bad food. It is in most cases a very obstinate form of diarrhoea, requiring much skill and patience for its cure. In the chronic forms deep ulcers may exist; even in the milder cases a high inflammation is often present. In those cases Avhich are due to exposure to heat and hepatic trouble there are tAvo remedies Avhich are far above all others in value and should always be resorted to. The first of these is ipecac, the second is calomel. The ipecac should be used in a special manner to be effective (see Ipecac), and the calomel should be used in full purgative amounts, but is contraindicated if much Aveakness is present. If the passages are slimy and bloody, -^q of a grain (0.0003) of bichloride of mercury every hour or two is of service, and if much blood is present high rectal injections of the distilled extract of hama- melis and water half and half are of value. In some forms of dys- entery due to acute inflammation large enemata of iced Avater are of the greatest value. The Avater should be ice-cold, and at least a quart injected by hydrostatic pressure. This method can only be used in strong persons, and is very useful in that it also aids in reducing any fever Avhich may be present. The folloAving mixture may be injected into the bowel in place of cold Avater in feeble cases: R.—Sodii boratis............^j (4.0). Tinct. benzoin.............fgj (4.0). Spt. camphorse...........fgj (32.0). Aqua? ferventis...........Oij (1 litre).—M. If the ulcers are very old and chronic, nitrate-of-silver injections of the strength of 10 to 20 grains (0.65-1.3) to the pint (500 cc.) of water may be employed in large bulk, a salt solution being at hand DIARRHCEA. 483 for the destruction of the silver salt if the-action Avhich ensues is too severe. (For the manner in Avhich to use these intestinal irrigations see Cholera and Cholera Infantum, and the article on Enteroclysis in Part III.) Recently the injection of water or medicaments into the boAvel for the purpose of influencing the intestinal Avail has given way in the hands of prominent physicians to irrigation by means of an inlet and outlet tube. The inlet tube should be attached to a fountain syringe, and the outlet tube be long enough to reach to a vessel by the side of the bed and of sufficient calibre to carry off flaky mucus. In many cases of dysentery of a mild form rectal irrigation will suffice, but if the entire colon is involved larger injections are necessary. The irrigation should be continued until the returning fluid becomes perfectly clean and free from foreign particles. If the boAvel move- ments are very frequent, the injections may be made every three hours. Probably the best solution to employ for irrigation Avhere much mucus and pus is present is one composed of bichloride of mercury, 1 : 5000. AVhen this is used, a pure Avater injection or one of 1 : 30,000 should folloAv it, in order to prevent absorption of the mercury into the system. If for any reason the effect of the bichlor- ide is feared, boric acid may be used in the proportion of 1 drachm (4.0) to the pint (500 cc), or 15 grains (1.0) of sulphocarbolate of zinc added to 1 quart (1 litre) of hot water be injected. Tannic acid is an intestinal antiseptic, and can be employed in the strength of 1 drachm to the pint (4.0 : 500 cc.) for irrigation purposes. DIARRHCEA (CHRONIC).1 This is one of the most obstinate conditions Avhich the physician is called upon to treat. It may be due to nervous irritability of the boAvels, so that the entrance of food or drink sets up an excessive peristalsis Avhich so hurries the food and drink through the alimentary canal that digestion and absorption are only partly performed. Chronic diarrhoea may also be due to chronic intestinal catarrh, to ulcerations of the small or large bowels, as after typhoid fever, or to rectal dis- ease, AArhich reflexly causes hyperperistalsis. Fissure of the anus often causes persistent diarrhoea by reflex irritation. In those cases due to hyperperistalsis advantage is often gained by directing the patient to take as little liquid as possible, particularly at meals, and to avoid coffee or other stimulants to reflex activity. Highly-seasoned foods are also to be avoided. Meats should be preferred to vegetables, and an absolute peptonized milk diet may be ordered, the milk being given in tablespoonfuls every feAv'minutes, rather than in large amounts, at meal-times if the patient will remain in bed. Counter-irritation, con- stant and as severe as the patient can stand, should be used over the abdomen. Suppositories and rectal injections seldom benefit this class of cases, but a pill composed as folloAvs may be useful: 1 Read with this article those on Diarrhoea and Dysentery and Enteroclysis. 484 DISEASES. R.—Argent, nitrat.........gr. iv (0.2). Ext. hyoscyam........gr. x vel xxx (0.65-2.0). Ext. opii "..........gr. ij vel iv (0.1-0.2).—M. Ft. in pil. No. xx. S.—One one hour before a meal. In other instances some of the astringent prescriptions given under the article on Diarrhoea are better than the above. In the cases due to ulcers of the rectum injections of nitrate of silver 2 grains to the ounce (0.1 : 32.0) are of value, particularly if folloAved by a 5- or 10- grain iodoform suppository. Operative procedure against anal fissure will often cure a diarrhoea due to this cause. The cases due to intes- tinal catarrh are benefited by the use of full doses (5 to 20 grains [0.3-1.3]) of bicarbonate of sodium by the mouth and the use of iodoform suppositories, which not only relieve the rectal irritation nearly ahvays present, but exercise the peculiar effects of iodine upon the catarrhal process. In cases of so-called morning diarrhoea absti- nence from liquids before going to bed the night before and a very dry and small breakfast are to be strongly recommended, Avith rest in bed during the morning hours. DIPHTHERIA AND MEMBRANOUS CROUP. Diphtheria is at first a distinctly local disease, the membrane in the throat forming a nidus from Avhich the entire body ultimately becomes filled by the poison manufactured by the micro-organism peculiar to the malady. The author does not believe that membranous croup and diphtheria are distinct diseases, but regards one as the mild or undeveloped form of the other. As the treatment is identical, be the belief of the physician what it may, the case should always be considered as true diphtheria until it is proved to be some other disease. The treatment of the throat-changes before the membrane appears should consist in the use of sufficiently large doses of belladonna to impress the system, accompanied by painting the pharyngeal wall with a solution of chlorate of potassium of the strength of 15 grains (1.0) to the ounce, or, if this seems too strong, only 5 grains (0.3) to the ounce (32.0) may be employed. After the membrane is formed its dissolution may be carried on by the use of the atomizer spray with lime-water, or with lactic-acid solution of the strength of 30 grains (2.0) to the ounce (32.0), every hour. In other instances a solution of trypsin, one of the ferments of the pancreatic juice, may be used on a swab or by means of a spray to digest the membrane. Other cases do well when a solution of boric acid is applied dissolved in glycerin in a water-bath in the strength of 1 : 30. Still another solution, which may be used by means of a spray from an atomizer with great advantage, is made as folloAvs : R.—Sodii bicarbonatis 1 .. Sodii boratis }........aa gr. xx (1.3). Aquae...............f=;j (64.0).—M. S.—Use in atomizer. DIPHTHERIA AND MEMBRANOUS CROUP. 485 After the use of this solution there is often an expectoration of creamy mucus mixed Avith particles of false membrane. Of all the treatments Avhich are directed against the membrane, laden as it is Avith the micro-organisms of the disease, none compare, in the opinion of the author, to the peroxide of hydrogen. A cotton SAvab should be soaked Avith the strong undiluted 15-volume prepara- tion and pressed against the mucous membrane Avhich is diseased, or, if this cannot be done, a spray, from a glass atomizer, of the strength of 1: 4 of Avater may be employed. The effect is often extraordinary. After a feAv applications the false membrane appears to exist only in disorganized shreds. If the nasal chambers become affected, a solu- tion of the strength of from 1:12 or 1: 8 parts of peroxide of hydro- gen (15-volume) should be used in a spray or Avith a syringe, the child breathing through its mouth. This strength is quite sufficient in the nasal cavities, as the mucous membrane is delicate. The applications should be made as rapidly as the membrane forms. Another very useful application, Avhich is often more readily obtained than the peroxide of hydrogen, is tincture of the chloride of iron, undiluted. A cotton applicator is used as Avith the peroxide of hydrogen, but care must be taken that the cotton is not so fully soaked in the iron solution as to permit of drops falling into the larynx or on the teeth. Cohen states that in diphtheria the disengaging of sulphurous-acid fumes by the method usually carried out in the disinfection of rooms is a useful prophylactic measure against the contraction of the disease. Bv far the best thing for the physician to do to prevent or limit the formation of membrane in the earliest stages by internal medication con- sists in the judicious use of mercury. This is to be done by employing _1_ to 4; grain (0.006-0.03) of corrosive sublimate in divided doses in tAventy-four hours, or, in other Avords, by the administration of fa grain (0.0013) every hour, or by using calomel ^ to i grain (0.01-0.015) every hour until the evidences of the action of the mercury are shown bv the loose stools. It is said the stools following this use of corro- sive sublimate in diphtheria sometimes resemble " frog spaAvn "—that is. are frothy-looking. The object in using the mercury is to cause a lack of plasticity in the blood, so decreasing the exudation of fibrin. Having made this attempt, Avhich is only to be tried in sthenic cases, supportive measures are to be resorted to, and for this purpose tonics and stimulants Avith nourishing food are to be employed. Tincture of the chloride of iron, quinine, and strychnine are of service to keep the kidnevs active, to stimulate the heart and respiration, and to sup- port the vital forces. The tincture of iron is given internally by some physicians from the beginning to the end of the attack, but it certainly does the most good after the disease is thoroughly under Avay, and should be used in large quantity if great exhaustion and anaemia appear. The dose may be as much as 2 drops (0.1) every hour to a child of four years, or even more than this may be given Avell diluted. The food of a child during an attack of diphtheria should consist of pancreatized and sterilized milk. The object is to keep the bacil- 486 DISEASES. lus limited to the throat, yet with every drink of ordinary milk they are taken into the stomach in a culture medium. It is always best to use an antiseptic spray or swab before giving the sterilized milk, to render the mouth as far as possible antiseptic, and to avoid the gagging, which may result in vomiting, if the swab is used after tak- ing food. Another method Avhich is often of great value in the treatment of diphtheria is the use of turpentine, either by inhalation or by the stomach. Its use should follow the employment of the mercury should this drug fail to abort the formation of the exudate. All those Avho have given turpentine internally in diphtheria agree that the dose should be very much above that recommended in other dis- eases. Thus it is stated that from \ to 1 drachm should be given three times a day. The folloAving prescription may be employed: R.—Spt. terebinthina?..........f$ij (64.0). iEtheris fortior........; . . f^j (32.0). Alcohol............q. s. ad fgiv (128.0).—M. S.—Teaspoonful (4.0) three times a day in cold water. If the patient is old enough, the turpentine may be given in cap- sules, and folloAved at once by a drink of milk or water to prevent irritation of the stomach by the concentrated stimulant. Turpentine acts in these cases as a respiratory, cardiac, and gen- eral systemic stimulant, and at the same time as an antiseptic in the mouth, alimentary canal, and kidneys. It also acts as a diuretic and prevents renal torpidity, which is important, as the kidneys often do not eliminate the toxic materials generated by the micro-organisms Avith sufficient activity. The other method of using turpentine is by inhalation, and is highly recommended by J. LeAvis Smith. The following prescription is placed in Avater in the proportion of 2 tablespoonfuls (32.0) to a quart (1 litre), and this mixture is then placed on a gas or oil stove in a broad open vessel and alloAved to boil constantly. The air of the sick-room is soon laden with the vapor, which is not offensive. The prescription is as follows : R.—Acid, carbolici \ .. »-,. ,00/v. Olei eucalypti [.........aa f5) (32.0). Spt. terebinthina? ..........ff viij (256.0).—M. S.—Use as directed. Label: Poison if taken internally. Hundreds of other measures have been recommended and em- ployed, until almost eArery physician has his faA'orite method, but the treatments here given will be found advantageous in the majority of cases. When the glands of the neck threaten to suppurate, ice-bags should be applied to the throat and pieces of ice held constantly in the mouth, while the tincture of iron is pushed in as full amounts as possible. If suffocation is imminent, inhalations of oxygen are to be used and atropine or strychnine employed, although tracheotomy or intuba- tion may be necessary. Chlorate of potassium must never be given internally, as the kid- DROPSY. 487 neys are already severely inflamed, and this drug is not only useless when so given, but is in addition a renal irritant. Although the author has been criticised for this last statement, he is convinced of its truth; and that he is not in error is proved by the fact that no less eminent authorities than H. C. Wood and J. Lewis Smith agree with him. DROPSY. Dropsy is to be regarded as a symptom (not as a disease in itself) which may arise from many causes, such as cardiac, pulmonary, or renal diseases, or depend upon obstruction, from various causes, to the normal Aoav of the blood and lymph through the vessels and tissues. Its existence is dependent upon so many causes of a still more indirect nature that it is almost impossible to notice all of them, but the fol- loAving consideration of the subject will at least make clear some of the reasons for its occurrence and indicate the means which are to be taken for its relief. At the very start Ave are confronted by facts Avhich seem para- doxical, but which are in reality quite reconcilable. These are, that Ioav arterial pressure predisposes to dropsy, and that high venous pressure does likeAvise, or, in other Avords, that the cause of exudation on one side of the circulation is its prevention on the other. The explanation of these statements lies in a thorough under- standing of the physics of the circulatory system and its anatomical structure. It will be remembered that dropsical exudation takes place from the capillaries, and that the integrity of the Avails of the blood-vessels and lymphatics depends upon normal nutrition, or, in other words, upon a proper blood-supply. As a consequence, dropsy may be due to poorly-nourished vessels as much as to any other cause. Further than this, a watery state of the blood permits abnor- mal exudation. The force exercised upon the column of blood as it is driven out by the heart into the aorta may be considered as the chief support of the capillary circulation, so that if the heart be Aveak the pressure falls in the arteries, and in consequence the rapidity of flow is decreased in the capillaries, Avhile, on the other hand, an increased cardiac acth-ity hastens the capillary circulation. As the arterial pressure and force depend not only upon the heart-force, but also upon the tonicity of the arteries Avhich carry the blood-stream, it becomes evident that dilated arteries must loAver blood-pressure even if the heart be strong, although practically the heart and vasomotor system generally fail or increase in tone together. We find, there- fore, that a Aveak heart or a relaxed artery tends to cause stagnation of the blood in the capillaries, and, having found that such stagna- tion is productive of exudation, it is not hard to discover Avhy low arterial pressure is a cause of dropsy. Having shoAvn this to be true, let us turn to an explanation of the fact that a high pressure in the veins is productive of the same changes. 488 DISEASES. Here the normal pressure is almost nothing, being much less than in the arteries, and considerably less than in the capillaries. The result of this is, that in health the blood Hoavs rapidly from the high pressure of the artery to the low pressure of the vein, and passes through the small veins under a gradually decreasing pressure until it reaches the heart. Any obstruction to this venous Aoav must increase the venous pressure, and, the venous pressure being in- creased, the rapidity of Aoav through the capillaries must be decreased. The Avhole subject may be made more clear by the following example : Supposing that tAvo iron tubes are connected at one end by several lines of rubber tubes (the capillaries), and that water is floAving into the first tube, or the artery, under a pressure Avhich is represented by the figure 100, Avhile the resistance to the Aoav in the second tube, the vein, is represented by the figure 0. It at once becomes evident that the rapidity of the flow through the connecting rubber tubes will be very great, Avhereas if the pressure in the first or arterial tube is decreased to 50, the rapidity is decreased to one-half, or if the pressure in the second tube be increased to 50 instead of remaining at 0, the same changes -will occur; in either instance capillary flow is lessened and exudation is caused. This is the pathology of dropsy, and, having understood it, let us proceed to discover the causes of dropsy in various diseases. In cardiac disease it is due to a Aveak heart being unable to supply the arteries Avith enough blood to maintain the normal pressure, or to a damming-up of blood in the venous system as the result of the imperfect emptying of the cardiac cavities. In the first instance low arterial pressure produces dropsy ; in the second, high venous pressure has a similar effect.1 In renal troubles the dropsy depends more upon the lack of proper nutritive processes in the capillary Avails and upon changes in the blood-pressure than upon other causes. If the kidney is diseased, it may not be able to eliminate the proper quantity of liquids, Avhich accumulate and finally escape into the tissues, Avhile the same failure in renal function causes disease of the blood-paths themselves, and often produces cardiac complications. Hepatic troubles cause dropsy by producing pressure upon the large blood-vessels going to the liver, and, in consequence, the exudation is generally confined to the loAver limbs and abdomen. If the hepatic trouble be severe, some failure in the nutrition of the blood-vessels and changes in the quality of the blood may ensue. Pulmonary disease rarely causes dropsy unless the venous pressure is greatly increased and productive of cardiac dilatation, or, as in phthisis, where the changes in the nutrition of the body involve the blood-vessel Avails and the blood. Having spoken of these causes of dropsy, it remains for us to con- sider its treatment, Avhich may be divided into tAvo parts—namely, that directed to its removal Avhen once the liquid is poured out, and its relief or cure by direct attention to its causes. The means for the 1 For an explanation of these changes in the action of the muscle, valves, and car- diac action in heart disease see the article on Heart Disease. DROPSY. 489 removal of the fluid are suitable to all cases, be the cause Avhat it may, unless the dropsy be of renal origin. Whene\er an accumulation of liquid takes place in the tissues, drugs or measures must be resorted to Avhich will cause the emunctories of the body to get rid of it. In ascites, in particular, Ave may employ elaterium in the dose of ^ of a grain (0.01), or elaterin in the dose of fa of a grain (0.003). placed in the mouth and Avashed doAvn by a little Avater, or, if this is not used, the compound jalap poAvder may be resorted to in the dose of 20 to 30 grains (1.3-2.0), and to it may be added, to increase its efficiency, 10 grains (0.65) more of bitartrate of potassium than the official poAvder contains. These tAvo remedies are particularly ser- viceable in renal dropsies, since the elaterium is supposed to aid in the elimination of urea by the bowel, Avhile the cream of tartar in the jalap poAvder increases the action of the kidneys. The cream of tartar is not to be used in cases of acute nephritis. Compound extract of colocynth may be employed in the dose of 2 to 6 grains (0.1-0.3), according to the state and idiosyncrasy of the patient. All these remedies relieve dropsy by causing so great an outpour- ing of liquid from the blood-vessels of the intestine that the liquids in the tissues are taken up by the depleted blood-vessels to replace the loss through the action of the purgative. In other wTords, these purgatives render the alkalinity of the blood greater by concentra- tion, and absorption of fluid occurs by reason of the folloAving physio- logical and physical facts : As is Avell knoAvn to every physiologist, the passage through a blood-vessel of a salt solution of less than fa of 1 per cent, causes an abstraction of salts from the surrounding tissues by the circulating fluid, in order that the amount of salts in the vessels and tissues may be identical. At the same time the tissues become infiltrated with liquid. On the other hand, if the solution be stronger than the normal, the liquid leaves the tissues to enter the vessels, and the tissues in consequence shrink. When salines are given to relieve dropsy, they must be admin- istered in concentrated or saturated solution and on an empty stom- ach, total abstinence from the drinking of Avater being insisted upon until they have fully acted, for the reasons given in the last para- graph. For this reason they should be given an hour or so before breakfast. If these directions are not followed, this method of treat- ment is useless. The other means Avhich Ave possess for the removal of dropsy are bv Avay of the kidneys and skin. If the kidneys are hopelessly dis- eased, that pathAvay is almost useless, but if they are only passive or partly inactive, diuretics may be used to stimulate their secreting structure and to increase the leakage of liquid through them by increasing blood-pressure. Such patients should be placed almost entirely on a milk diet, and many of them Avill greatly improve under the use of buttermilk to the exclusion of other nourishment. If this cannot be taken, sugar of milk may be employed as an active diuretic. (See Sugar of Milk.) 490 DISEASES. Often the kidney will be found inactive, because, owing to conges- tion from cardiac trouble, it cannot act. Under these circumstances digitalis, in 5- or 10-drop (0.35-0.65) doses of the tincture, given three times a day, will be of value, and its efficacy will be increased by the addition of 1 drop (0.05) of the tincture of cantharides if the renal lesion is exceedingly chronic or mere torpidity exists. Digitalis and squill, in pill form, as follows, may be used: R.—Pulv. digital, fol...........gr. xx (1.3). Pulv. scilla?............gr. xx (1.3).—M. Ft. in pil. No. xx. S.—One every five hours. Or digitalis and calomel may be employed in pill form in renal and cardiac dropsies. Caffeine is also a useful diuretic, particularly in torpidity of the kidney, as it stimulates the secretory epithelium, thus eliminating urea and other effete matters, and increases the passage of liquids by the increased blood-pressure Avhich it produces. That a large amount of liquid may be gotten rid of through the skin under the influence of heat is Avell known. (See Heat.) In addition to external heat we may use pilocarpine by the. mouth or hypodermically in localized dropsies, to produce absorption and con- sequent elimination of liquid by sweating. No drug should ever be given hypodermically in dropsy of a general character, as it will not be absorbed from the Avater-soaked tissues Avith any rapidity, if at all. The hydrochlorate of pilocarpine may be given in the dose of ^ to i grain (0.01-0.015) by the mouth or | to £ (0.008-0.01) by the needle. This method of relieving dropsy is often very exhausting, and should be most carefully used if cardiac depression or weakness is present. If dropsy depends upon deficient cardiac action, digitalis Avill nearly always do good. (See Digitalis.) If this is not used, citrate of caf- feine will be found of service. Remembering that this form of dropsy is the result of failure on the part of the heart to do its work, we must use proper exercise, food, stimulants, and rest, combined with fresh air and avoidance of mental worry. An infusion of scoparius, 1 ounce (32.0) of the tops to a pint (500 cc.) of water, taken in twenty-four hours, may be of service, and strophanthus, sparteine, and adonidin may all be used if any one of the drugs fails which are commonly employed. In the ascites of hepatic cirrhosis and in localized effusions of a chronic type the best treatment for the removal of the liquid is the iodide of potassium or tapping with a trocar and canula, Avhich should be attached to an aspirating flask if the effusion be in the chest. Where the tenseness of the skin in the loAver extremities causes danger of local sloughs, some authors recommend small punctures for the escape of the liquid, the limbs being encased in sterilized absorb- ent cotton to absorb the liquid. (See Acupuncture.) D YSMENORRHCEA. 491 DYSENTERY. (See Diarrhoza.) DYSMENORRHCEA. The existence of dysnienorrhcea depends upon so many conditions that the treatment employed in one ease is seldom productive of suc- cess in the next. This is not the place for a consideration of the surgical measures adopted for the cure of this symptom, and only the medical treatment -will be spoken of. When dysmenorrhcea results from the taking of a cold, and is accompanied by uterine congestion and irritability, the folloAving measures are particularly valuable, and may do good in many cases depending upon other causes : The patient should take a hot sitz- bath, and immediately get into bed as soon as the buttocks are dried, being Avell covered while in the tub and afterAvard by a blanket. A turpentine stupe is now to be used (see Turpentine), and 10 grains (0.65) of Dover's powder to be administered, unless some idiosyncrasy toward opium is known to exist, when a half or a fourth of this amount mav be employed. Often when the attack is accompanied by constipation a ptirgati\~e dose of Epsom salts or aloes is of sendee in the congestive forms of the disorder. If the pain is persistent and severe, a belladonna suppository, of 4; grain of the extract, may be inserted into the rectum, or in other cases belladonna ointment smeared over the os uteri will be found of service. The latter method is generally impracticable and is rarely resorted to. Yerv commonly belladonna tincture, by the mouth, is of service in relaxing the spasm of the cervix and of the uterine fundus. Some practitioners resort to the use of opium at each epoch, and keep the patient partially narcotized until menstruation is passed. This is unjustifiable and born of ignorance and bad practice, since the physician is simply dodging the trouble and predisposing the patient to future attacks by reason of the constipation and the result- ing habit Avhich is almost sure to appear after the repeated employ- ment of opiates. When the dysmenorrhcea is due to obstruction of the cervical canal by organic changes or flexions, these conditions must, of course, be relieved before a cure can be expected, and the medical treatment can be directed only to the alleviation of the pain. Divulsions or sIoav or rapid cervical dilatation should be carried out by the use of instru- ments or tents. In neuralgic dysmenorrhcea, dependent rather upon nervous dis- order accompanying menstruation than upon menstruation itself, measures directed to the improvement of the nervous system and the nutrition of the patient are necessary. These cases generally occur in nervous, anaemic Avomen run doAvn by excessive dancing or other gayety or by the bearing and care of a large family of children. A course of strychnine or quinine and iron in small doses is often 492 DISEASES. beneficial in these cases, and horseback exercise betAveen the men- strual periods, out-of-door life, and avoidance of excessive dancing and exhausting exercise are to be ordered. Sometimes bathing the loins with alternate dashes of hot and cold water may do good in atonic patients. Cannabis indica and gelsemium are often of great service, both as cures and alleviators of the pain, and antipyrine, acetanilid, and similar drugs may be resorted to Avhile the attack lasts, if it be neuralgic. When the pain seems to be greater than the patient can bear, enough ether or bromide of ethyl should be given by the physician, by means of inhalation, to produce the primary stages of anaesthesia, but chloroform is not advisable, as the patient, if taught its value by the doctor, may resort to it Avithout advice and die from an overdose. DYSPEPSIA. (See Indigestion.) DYSPNCEA. Shortness of breath, or dyspnoea, arises from cardiac weakness, abnormal innervation resulting in cardiac palpitation, from the accu- mulation of fluids in the chest, from the involvement of the lungs by any disease-process in such a Avay that respiration becomes impaired, or it is produced by indigestion, or, finally, by the encroachment on the lungs or chest-Avails of tumors and growths. Each of these states must be removed to effect a cure, but it is only of the relief of the symptoms that Ave will speak. In old persons Avho suffer from dyspnoea the result of bronchor- rhcea, where a large amount of liquid fills the bronchial tubes and shortness of breath follows exertion, strychnine is the best remedy that Ave have. Its value depends upon its powerful influence over the respiratory centres, on Avhich it acts as a stimulant; and as these cases very commonly also have dilatation of the right side of the heart, with consequent cardiac enfeeblement, strychnine is of addi- tional service through its influence upon the circulation. These per- sons are not to be given opium or its alkaloids or any sedative drugs, as such medicines, while giving temporary relief from cough, only serve to depress the respiratory apparatus and cause an accumulation of liquid mucus in the chest as a result of the prevention of cough and lack of expectoration. The cases in Avhich opium or morphine do good are those in Avhich, through nervousness or functional nervous disorder, the respiratory cycle is imperfect, and, above all, in those instances where dyspnoea occurs as the result of cardiac disease. In these cases the attacks of oppression and suffocation can often be entirely set aside by the use of | to J grain (0.008-0.015) of mor- phine, given every night or at night and morning. If these doses fail, EARACHE. 493 larger ones may be cautiously used. Hyoscine, instead of causing sleep, nearly alAvays makes these cases worse. Sometimes a little carbonate of ammonium is useful as a respira- tory and cardiac stimulant in cases of dyspnoea. Dry cupping applied over the back of the chest may also be ser- viceable Avhen shortness of breath from cardiac or pulmonary trouble is present. In cases of dyspnoea due to emphysema and pulmonary inflamma- tion of a chronic type, or in those persons Avho take cold on the slightest exposure, particularly after attacks of asthma, arsenic is useful if continuously employed. If pleural effusion be present, relief of a positive and lasting nature can only be obtained through aspiration, or, in other words, by the operation knoAvn as thoracentesis. EARACHE. Earache may arise from a great number of causes, all of Avhich are, practically speaking, inflammatory. The pain may be the result of acute chronic inflammation of the middle ear, with a serous or purulent exudate, or to furunculosis of the external auditory canal. In other cases an eczema of this part is very painful. The treatment is systemic and local, the former being based on the general rules governing the management of inflammatory processes, the latter by the area involved and the cause of the trouble. In the general treat- ment a leech may be placed in front or behind the ear, and heat is to be applied to the head on the side affected in a dry form by means of a hot bottle or Avater-bag. Poultices, oil, and laudanum, and similar applications are not to be resorted to, as they may ultimately cause trouble and do not ahvays produce even temporary relief. Sometimes dropping a little water, as hot as can be borne, into the external auditory canal gives great relief if repeated as fast as the Avater cools. Cardiac sedatives are indicated, but quinine is distinctly contrain- dicated, as it tends to cause aural inflammation. If a cold in the head is present, and Avith it acute myringitis, it is important to establish a free opening through the nostrils, particularly if the middle ear is also involved, in order to clear the orifice of the Eustachian tube. This is to be accomplished by dropping into each nostril 1 to 3 drops (0.05-0.15) of a 4 per cent, solution of cocaine, and, as soon as the engorged mucous membrane is anaesthetic and shrunken, to use an atomizer with a fine spray attachment and the folloAving solution: R.—Acid, boric.............gr. x (0.65). Sodii chlorid............gr. xij (0.8). Sodii borat.............gr. x (0.65). Aq. rosa?..........q. s. ad f§iij (96.0).—M. S.—Use as a spray. This should be followed by a spray of menthol and albolene, 3 grains to the ounce (0.15 : 32.0), in order that the menthol may prolong the 494 DISEASES. effect of the cocaine and prevent secondary congestion. This is now to be folloAved by inflation of the Eustachian tube with a Politzer's air-bag. Only in most obstinately painful cases of acute middle-ear catarrh is paracentesis of the drum to be attempted. Should true septic otitis media develop and drainage of the middle ear become impos- sible through blocking of the Eustachian tube, then the doctor must very gently irrigate the external auditory canal wdth as hot water as can be borne, and render it entirely aseptic by insufflations of boric- acid poAvder. These injections should be frequently practised, and if the pain persists and the tympanic membrane is bulging, para- centesis must be performed in the most bulging part of the lower quadrant. After the paracentesis needle is AvithdraAvn the discharge should be alloAved to Aoav freely, and then boric acid be once more dusted into the ear and a piece of cotton inserted. In the case of eczema of the ear hot irrigation, followed by poAv- dered iodoform, is perhaps the best application for temporary treat- ment. In furunculosis of the ear hot irrigation and free incision, Avith iodoform dressing, are also useful. When foreign bodies cause the pain, they are best removed by repeated and gentle syringing with hot water. Forceps are danger- ous instruments in the hands of a novice treating the ear. In earache due to neuralgia a swab of chloroform may be applied in front and behind the ear. ECZEMA. This is probably the most common form of skin disease which the physician is called upon to treat, Avith the exception of acne. Dermatologists divide it into many forms and stages, but in this book a consideration of its forms is out of place, and only the treat- ment for its stages is proper. In the first place, it may be stated that the treatment is a quad- ruple one—namely, dietetic, hygienic, external, and internal. In regard to diet, the patient should be told to avoid salt foods, such as salt fish or pork and corned beef; greasy foods, such as bacon and fried dishes; pastry and cheese. Only moderate amounts of Avine and beer can be taken, and foods difficult of digestion are to be stricken off the bill of fare. In the way of hygienic measures, fresh air, the avoidance of seden- tary habits, horseback exercise, or Avalking are to be recommended. External treatment is the most important of the tAvo measures in Avhich drugs are employed, and its course is perhaps best described by taking a case of ordinary eczema as an example and treating it through its entire course. In the early stages of an acute eczema, Avhen the process is very active and the erythematous reddening of the beginning of the dis- ease is merging into the formation of vesicles or pustules, with the formation of large scabs, no application is better than oxide-of-zinc ointment, thoroughly applied night and morning. If the eczema be ECZEMA. 495 situated upon the scalp, the hair must be invariably clipped short or shaved off in such a Avay as to prevent the gluing of the hair into a mat by reason of the discharge. The ointment may be smeared over the part or applied on a piece of lint in a thick layer. Nearly always the ointment should be used in conjunction with black wash (calomel 1 drachm [4.0], lime-water 1 pint [500.0]), which should be applied tAvice a day, just before the zinc ointment is resorted to, by means of a swab or a sop, and alloAved to dry. In other cases the powdered oxide of zinc is dusted over the part if the discharge is very watery and profuse, or the following ointment, recommended by McCall Anderson, is very efficacious: R.—Bismuth, oxidi............gj (32.0). Acid, oleic, pur............Iviij (256.0). Cera? alba?..............liij (96.0). Petrolati..............|ix (288.0). Olei rosa?..............ni,v (0.3).—M. Ft. in unguent. S.—Apply to the part affected. As the quantities of this prescription are large, they may be reduced one-half for use in limited eczema. Where the proliferation of cells and the secretion are very profuse it may become necessary to remove the crusts before the local rem- edies can reach the skin, and for this purpose poultices may be used; or, if the disease be on the face, the parts should be anointed Avith olive oil, containing 1 or 2 drops of carbolic acid to the ounce (0.05- 0.1 : 32.0), to soften the crusts, Avhich are readily removed in a half-hour by the use of a little castile soap and Avater. The soap is not to be used if the inflammatory action is very angry-looking. Whenever itching is an annoying factor, the parts should be protected by lint smeared Avith some simple ointment, which may be carbolized both for its antiseptic and local anaesthetic effect. English and Amer- ican dermatologists use what is knoAvn as liquor carbonis detergens very largely in the acute stages of eczema as Avell as in other skin diseases. It should not be used pure, but diluted in such a way that for each 4 ounces (128.0) of Avater 2 drachms (8.0) of the pure liquor are present. Liquor carbonis detergens is made by taking 9 ounces (288.0) of tincture of soap-bark (quillaia-bark) and 4 ounces (128.0) of coal-tar, mixing and alloAving them to digest for eight days, after which the mixture is filtered and used. When the disease has passed from the acute, active inflammation of the first stage to the subacute form of the second stage of its exist- ence, applications of a mildly stimulant character are necessary. Before this the physician has endeavored to soothe the parts; now they must be excited to normal activity. For this purpose resorcin in the proportion of 2 to 30 grains to the ounce (0.1-2.0 : 32.0) of lard, according to the severity and induration of the lesion in the skin, should be used. Stehvagon recommends the folloAving: R.—Unguent, picis liq..........oj (4.0). Unguent, zinci oxidi ........gvij (28.0).—M. S.—Apply to the parts. 496 DISEASES. Where the disease is chronic and very persistent, but sluggish or atonic in its course, still more powerful remedies are necessary, such as salicylic acid, tar, or tincture of green soap used with hot water until the skin beneath is bared, dressing this by means of zinc oint- ment or resorcin ointment, 2 to 10 grains to the ounce (0.1-0.65 : 32.0), spread on a cloth. The salicylic acid should be used in the proportion of 30 to 60 grains to the ounce (2.0-4.0 : 32.0) of lard, while the tar is used in the form of the pure official tar ointment. In seborrhceic eczema, where the secretion is greasy and dry, and followed, if wrongly treated, by oozing and the pouring out of serum and the formation of cells which form crusts, the following prescrip- tion is of value: R.—Kesorcin...........gr. x vel xx (0.65-1.3). Pulv. amyli _ \ -- ;j (80)_ Unguent, zinci oxidi j J J Petrolati . .........gss (16.0).—M. g,—To be applied after removing the scabs by the use of a lotion composed of 1 part of bay rum and 3 parts of water. The internal treatment is directed to the cure of any disordered function Avhich is present, such as dyspepsia (see Indigestion), hepatic torpor, general debility, anaemia, scrofulosis, inanition, constipation, gouty diathesis, or renal insufficiency. The gastric disorder is to be relieved by the use of hydrochloric acid and pepsin; the hepatic tor- por by mercury, podophyllin, or, better still, by freshly-prepared undiluted nitro-hydrochloric acid added to Avater; the debility by tonics, such as cinchona, cod-liver oil, strychnine, and bitters; the anaemia by iron, and, if scrofulosis exists, by the syrup of the iodide of iron. Constipation is to be cured by the use of proper foods and laxatives, and the gouty tendency counteracted by the employment of lithium citrate and colchicum or potassium iodide. If the kidneys are at fault because of torpidity, the diuretic potassium salts, such as the citrate, are indicated. Arsenic is never to be used, except in those instances Avhere the skin is very dry, and AArhere, by improving digestion and through its alterative poAver, it does good. In the chronic forms of dry eczema or those depending upon some atonic state of the trophic nerves of the skin, arsenic is of great value in the form of Fowler's solution, or arsenous acid may be given. EMISSIONS. Seminal emissions occur as the result of sexual abuse, whereby a condition of hyperexcitation of the nervous cells in the spinal cord and the nerves of the genitalia is developed, or they are due to peripheral or centric irritations, Avhich reflexly irritate the genitalia or the nerves, and to a number of other similar causes. These emis- sions also occur with some periodicity in normal males who are con- tinent and chaste, and under these circumstances are not to be inter- fered Avith by treatment, unless the emissions become excessive. The former types are, however, proper for medical treatment, and ENDOCARDITIS. 497 their cure consists in the avoidance of unchaste literature and lasciv- ious thoughts during the waking hours, and the use of such spinal and cerebral sedatives that the centres governing the ejaculations of semen may be calmed, and so quiet a sleep produced that erotic dreams are avoided. The patient should sleep on a hard hair mattress, not be too heavily covered, and should avoid sleeping on his back, as this causes an undue blood-supply to the spinal centres, and consequent stimula- tion and ejaculations. Sometimes hard bodies, such as spools, are tied around the loins, so that lying on the back will cause so much discom- fort that the patient aAvakes and turns on his side. The drugs to be used are bromide of potassium or sodium in 20-grain (1.3) doses at bed- time, or chloral may be taken in the same amount. Hyoscine is cer- tainly of value in the dose of y^ grain (0.0006). Sometimes a warm sitz-bath or general bath before going to bed is of service. In other cases, where atony is the cause of the trouble, the physician should recommend cold sponging of the perineum and loins night and morning. In the cases in Avhich emissions come on as the result of continence, and become excessive, the remedies just named are to be tried, but really do not effect any permanent cure unless used until sexual power is seriously depressed, so that it has been the custom of many physi- cians to recommend "marriage," Avhich the patient may interpret in its legitimate light or not as he pleases. It is Avorthy of note that all irritations of the urinary bladder and other parts of the genito-urinary system should be removed, and it is often of value to administer citrate of potassium in 20-grain (1.3) doses, in Avater, three times a day, to render the urine non-irritating and alkaline. Stimulating foods and drinks are to be interdicted, and condiments, such as pepper and mustard, avoided. Sometimes, Avhen the emissions are caused by genital atony, strych- nine and arsenic are of very great sendee if given in full dose. In many of these cases it is the duty of the physician to treat the moral state of his patient as Avell as to give medicines. Many per- sons, believing that emissions are ahvays an evidence of disease, read books on such subjects Avhich are sold by quacks and soon find their way to the hands of these persons, or sensibly consult a regular physi- cian. Half the treatment in these instances consists in assuring the patient that he has nothing to Avorry about, and in making him feel that the physician is his friend and worthy of all confidence and complete belief. ENDOCARDITIS. Endocarditis occurs sometimes as a single manifestation of disease ; sometimes as a symptom, Avith many others, of some general tendency produced by a diathesis, such as gout and rheumatism or syphilis. Further than this, it may be acute, subacute, or chronic, and each one of its forms must be differently treated. It is hardly necessary to state that any diathetic taint should be 32 498 DISEASES. treated by antirheumatic or antilithic remedies, such as the iodides. The iodides are not, however, indicated if any rapid changes of a degenerative type are at work. In acute sthenic endocarditis, asso- ciated with great vascular disturbance and much cardiac embarrass- ment or irregularity, there is no remedy half so good in the early stages as full doses of tincture of aconite, 2 to 3 drops (0.1-0.15), given every hour until the physiological symptoms of its influence are felt, or, in its place, Avith equal efficacy may be employed the tincture of veratrum viride (2 to 3 drops [0.1-0.15]). At the same time cal- omel and opium may be used, the calomel for its antiphlogistic influ- ence, and the opium to control the purgative tendencies of the mer- curial. Thus we may use \ grain (0.015) of calomel every tAvo hours and y^y (0.006) of morphine. Leeches should be placed over the praecordium in a goodly number, and if these are not obtainable Avet cups are to be employed. In some cases it is Avise to apply an ice- bag over the heart. This depletion is only of service Avhen the dis- ease is seen early enough to make its abortion possible. As the disease progresses, if the physician fails to stop it, it will be found that the heart becomes somewhat labored in its action, irregular, and Aveak, and that its rhythm is seriously interfered with. At this time digitalis is of use in stimulating the depressed cardiac muscle and increasing its reflex activity, also steadying it through the pneumo- gastric irritation which it produces. Aconite and other depressants are contraindicated at this time. Absolute rest upon the back is to be insisted upon, and it is recommended, in those cases Avhere deposits of a calcareous nature are likely to occur in the valve, that the citrate or acetate of potassium be given or that citrate of lithium be employed. If the disease becomes ulcerative, supporting treatment, consisting chiefly in the use of good food and the tincture of the chloride of iron is of great value if the dose Avhich is given is large. EPILEPSY. The disease knoAvn as epilepsy is probably the most disheartening condition as to treatment that the physician has to deal Avith, since it often resists the influences of all the standard remedies, and drives the practitioner from drug to drug in the hope of finding one Avhich will be at least alleviating in its effects. For this reason the author has in this instance included the drugs Avhich are rarely used, as Avell as those generally recognized as useful in its treatment, in order that the physician may try every remedy of any possible value. It should be borne in mind that the treatment of epilepsy is as various as the disease is variable in its forms and phases, and should, in nearly all cases, resolve itself into tAvo or perhaps three divisions, consisting in the removal of any exciting cause, in the checking of the convulsive tendency already set up, and in the prevention of any further attacks by suitable drugs or other measures of relief. The treatment is governed largely by the cause, and is medicinal or operative according to the etiological factors at Avork. In simple EPILEPSY. 499 idiopathic epilepsy medicinal means must be folloAved, while in a case resulting from traumatism the depressed bone, abscess, or tumor must be removed, and in those due to reflex irritation the peripheral source of trouble must be sought out and relieved. So far as drugs are concerned, the most valuable remedy in use for the relief of epilepsy is bromide of potassium, although other forms of bromide salts are to be mentioned later on. This drug, however, is not a "cure-all," even in epilepsy, and reports are constantly made of cases Avhere it has failed ; but many cases prove that the remedy is undoubtedly responsible for a cure when it is pushed in a suitable manner, and in the vast majority of instances the seizures are so decreased, both in violence and fre- quency, that its use may be said to be indicated in every case of the disease. In a very small minority, however, it signally fails, and in a still smaller number of cases it is useless unless combined with some other drug Avhose power alone is very slight. Nevertheless, it is to be laid doAvn as a rule that the bromide treatment of epilepsy is, par excellence, the treatment to be employed on every occasion. There is no other drug knoAvn Avhich can be relied upon so absolutely, or Avhich is so poAverful in its action and devoid of marked toxic effect unless given in enormous doses. The doses to be used vary with the salt employed to a considerable extent, and depend upon the character of the disease and the tem- perament and physique of the patient. The greater the duration of the disease, the greater is the difficulty in effecting a cure, and the length of time Avhich the man has been epileptic should therefore be most carefully reckoned before the treatment begins. Further than this, the frequency and severity of the attacks are to be looked into, and these points are really more important than the actual duration of the ailment; since if a man has only one fit every six months for tAventy years his condition is far less serious than if he has a history of three or four fits a day for one year. Again, the character of the attack, as to its violence, may be the most important fact to be re- garded, for if it is violent enough to endanger life, remedies must be pushed even beyond the point of tolerance. The Avriter has heard a very celebrated physician cause much amusement among his auditors by detailing an instance of an epileptic who was getting Avell, and Avould have recovered if he had not died. His explanation Avas, that the man was syphilitic, and Avas receiving moderate doses of iodide and bromide of potassium, Avhich were sloAvly benefiting him, and Avould have cured him had not a single severe fit produced death in the mean Avhile. Another point to be considered is the condition of the digestion, Avhich the bromide of potassium is peculiarly liable to disorder, and Avhich is sometimes so disturbed as to necessitate the administration of the drug by the rectum in serious cases. Females generally require smaller doses than males, and children of both sexes do not require as large quantities as adults. The dose to be used in the beginning of the treatment in moderate cases is about 10 grains (0.65) thrice a day ; and Avhile this may seem a very small quantity, 500 DISEASES. it will be found that it can be rapidly increased in amount without causing the gastric distress produced by the sudden use of larger doses. Each day an additional 10 grains may be added, until at the end of a Aveek the patient is taking 80 grains (5.3) in each twenty- four hours. There are very few cases Avhich will not become com- pletely saturated Avith the drug if this is done, and there are very feAv in Avhich a more rapid arrival at bromism is needed. If, however, the patient has become able to stand large amounts by the prolonged use of the drug, the amount given is not to be governed by grains, but by physiological effects, and it may be pushed to any amount Avhich is borne without distress. In chronic epilepsy, too, Avith regularly recurring fits, the greatest good is obtained by pushing the drug in ascending doses for one Aveek, and then for the succeeding Aveek only enough is given to preserve the general effects of the medicament. By doing this the stomach gets a rest and the appetite is not greatly interfered Avith. Where the attacks occur only every two Aveeks, this is a particularly useful method for obvious reasons. As regards the time of day Avhen the drug is to be taken, there can be no doubt. Some Avriters have directed that it shall ahvays be taken before meals, but this is entirely lacking in advantage and decidedly fruitful of harm. Medicines which are given with the object of affecting the general system should be taken after meals, not before, and it is only when a local gastric effect is desired that we use them on an empty stomach, particularly when the substance is as irritant and depressing as potassium. If taken after meals the appetite is not decreased, but there are feAv Avho can take a dose of 10 or 20 grains (0.65-1.3) of bromide of potas- sium before breakfast Avithout suffering from indigestion. It has been held by some that the drug should be taken in minute doses, fre- quently repeated, in order to keep the patient constantly under its influence. This is an example of therapeutic ignorance, because bromides are sloAvly eliminated, and this frequent administration pos- sesses the disadvantages of being inconvenient, annoying, and apt to disorder the stomach. If the attacks have a distinct periodicity or can be foretold for as much as two hours beforehand, the remedy may be taken in a large dose only at this time, and but a feAv grains given in the intervals ; and if the attacks are severe, no one should hesitate to use large doses by the mouth and by the rectum on the day of the attack. A very important point to be borne in mind is that the drug often seems to have produced a complete cure, and this results in careless- ness in the regularity of administration. The patient should be impressed by the fact that every day passed Avithout a fit is a step foiAvard, and that every fit carries him many steps backAvard. He should also be made to use the drug, in moderation, for at least three years after all fits have ceased, and to watch after that time for the slightest sign of their return. The quantity taken each day should be gradually decreased, not suddenly stopped short. It is true also that if a recurrence of the fits takes place they yield to treatment very much more sloAvly than before. EPILEPSY. 501 Before passing on to the discussion of the other bromides, and the conditions produced by the excessive use of all of them, Ave may place our use of these compounds in epilepsy on a scientific footing. It is noAV generally recognized that the seizures knoAvn as epilepsy arise from the cells in the cerebral cortex, and there can be no doubt that the bromides act very powerfully upon the cerebrum in the higher animals, decreasing the irritability of the motor centres in these regions to a very great extent. Not only is this pointed to by clinical facts, but the well-known researches of Albertoni prove that such is their action beyond all doubt. This investigator found that the administration of a single dose of the bromide of potassium so lessened the excitability of the motor cells in the cortex cerebri that much stronger stimulation Avas necessary in order to cause response in the limbs than Avas normal, and that it Avas difficult to produce epileptic attacks by means of the electrical stimulation of the motor areas, even Avhen currents very much stronger than those which com- monly produce such a result' were used. He also found that this lessened irritability was increased still further if the drug Avas given for several days beforehand in such doses as thoroughly to impress the organism. It is therefore evident that the bromides act directly on the cortical areas, calming the tendency to explosions of nerve-force. The results of Seppilli have also confirmed those of Albertoni in every Avay. An enormous amount of research has also proved that the drug may be doubly useful in reflex epilepsies, not only by its action on the motor portion of the cortex, but by its influence on the afferent portion of the nervous system. The experiments of Eulenberg and Gutmann prove that the sen- sory paths in the spinal cord feel more powerfully than any other portion of the body the effects of the drug; for these investigators found that if they tied the blood-vessels supplying one limb of an animal, reflex action Avas abolished equally on both sides, proving that the loss of reflex action does not depend upon the action of the drug on the sensory nerve-trunks. That the loss of reflex activity is not due to an action on the motor portion of the cord is proved by the fact that voluntary motion is completely preserved. As these experiments have been confirmed by Lewisky, BartholoAv, Purser, the author, and Laborde, there can be no doubt of their truth ; and we can rest assured that not only does the drug prevent nervous dis- turbance in the cerebrum, but also that it prevents the peripheral irritation from traAdling up to the brain, there to produce morbid excitement. Apropos of the theory that epilepsy is due to vasomotor disturbance, Avhich is unfounded, it may also be added that the bromide of potas- sium was and is believed by some to effect a cure by producing a vaso- motor- spasm at the base of the brain, but there is no basis for this idea, even if the disease Avere due to vasomotor changes. Hammond and Amory have seen the circulation in the brain sloAved by the drug, and it has been claimed by Lewisky that if the toes of a frog be cut off, the blood Hoavs more sloAvly from them in the poisoned animal 502 DISEASES. than in the normal frog. None of these facts prove vasomotor action, but rather that there is a lessened circulation by reason of the cardiac depression produced by the potassium, for this element is known to have this influence. An important therapeutic point is to know how rapidly bromide of potassium is eliminated, so that Ave may knoAv hoAv frequently to give the drug. That it passes out of the body Avith only moderate speed is certain, for Rabuteau has noted its presence in the urine one month after the last dose, and Bill has found it in the same secretion two Aveeks after the use of the drug had ceased. Amory recovered, on the other hand, one-half the amount ingested in the first succeeding tAventy-four hours, and one-third in the second twenty-four -hours. It is evident, however, that it is eliminated so sloAvly that doses given three times a day make the patient ingest more than he eliminates. That bromide of potassium remains a long time in the system is proved by the fact that after repeated doses given to a healthy man marked somnolence persists for some days. There is one more point to Avhich attention must be called, and that is the fact that Avhen the bromides are taken for any length of time they produce bromism, Avhich in its moderate or severe forms produces a mental condition very closely allied to that seen in old, chronic epi- leptics. This condition of the mind should never be overlooked, and the ordinary mental changes of epilepsy are greatly increased by its constant and careless administration. The bromide salts of gold, iron, sodium, lithium, nickel, and ammonium have all been used in epilepsy Avith good results, but, except in certain instances, they fail to act as well as that of potas- sium, unless given in larger doses. There are several circumstances, hoAvever, under Avhich each one possesses marked advantages, and may suceed Avhere potassium has failed. In all cases of epilepsy complicated with anaemia the bromide of iron should be employed, but Avhere there is plethora it will generally increase the disease or do no good. When it acts after potassium fails the iron is of value, because of its tonic and nutritive effect. Bromide of sodium, Avhile someAvhat less powerful than potassium, is not by any means so apt to disorder the stomach, and is preferable in some cases on this account. It possesses no other advantages. The bromide of lithium has been highly recommended in intract- able cases by AY eir Mitchell, who even states that it may be given in one-half the dose of the potassium salt Avith equally good effects. The bromide of nickel cures some cases Avhere all other remedies fail, but this occurrence is rare. In a series of physiological experi- ments made by the writer some years since he found it virtually iden- tical Avith the potassium salt in its action, and it is useful in about the same doses and cases as is bromide of potassium. The bromide of ammonium is very irritant and disorders the stomach quite readily. It ought ahvays to be used, Avhen used at all, Avith some other drugs, the ammonium salt only acting as an adjuvant. EPILEPSY. 503 Several clinicians have tried hydrobromic acid, but it is very much more apt to derange digestion and to produce vomiting than any of the salts. The dose of the dilute acid is 4 to 3 drachms (2.0-12.0) in a tumblerful of SAveetened Avater. The broniate of potassium has been used by Mitchell in doses of not more than 5 to 10 grains (0.3-0.65) Avith good results, but is more dangerous and scarcely of greater- value. There can be no doubt that in some instances Avhat is known as the mixed treatment is successful Avhen all else fails. This consists most commonly of a prescription in Avhich the bromides of potassium, sodium, and ammonium take part. Why this combination acts better than any one of the salts alone no one knoAvs, but it is certainly a clinical fact. In still other cases digitalis, when used along Avith one of the bro- mides, seems to produce favorable results. Indeed, digitalis has for years been used alone in epilepsy with fairly good results, and should ahvays be used in obstinate cases. In petit mal, where bromide of potassium Avhen used alone so often fails, it is useful, and several English Avriters. notably GoAvers, assert that its best effects are in cases of nocturnal epilepsy. Why this should be the case no one knows, and it Avould seem doubtful Avhether it does any more good in nocturnal attacks than in others. Indeed, it is difficult to understand hoAv digitalis can influence epilepsy at all, for its action on the nervous system is slight, save in toxic amounts, Avhen it lessens reflex action very markedly—first by stimulation of SetschenoAv's reflex inhibitory centre, and later by paralysis of the spinal cord. This latter action never occurs, of course, from a medicinal use ; but in medicinal doses it may, by acting on the inhibitory centre, allay convulsive tendencies. Probably its chief action is through its circulatory influence, and fur- ther study may sIioav it to be efficacious only in those cases Avhere a heart tonic is required. Another combination very much employed and lauded is bromide of potassium Avith belladonna, the mydriatic being almost useless alone, but of great antiquity in its use in epilepsy. Like the mix- ture of digitalis and bromide, it succeeds very frequently in petit mal, and, indeed, seems to be much more successful than the digitalis, but its mode of action is exceedingly doubtful. As the drug acts even more poAverfully upon the nervous system than upon the circulatory apparatus, it has been thought that its influence for good depended upon this effect, but the experiments of Seppilli contradict this belief, for he found that if atropine Avas given to an animal the surface of the cortex cerebri responded more readily than is normal to electrical stimulation. At one time it Avas held that belladonna acted on the spinal cord and peripheral nerves under such circumstances, but it should be remembered that Ave now knoAv that atropine is only of value in relax- ing spasm Avhen given in full dose, oftentimes .hypodermically, and that Albertoni has made a series of experiments to determine Avhether it irritates the motor centres of the cortex. In his hands repeated small doses or one large dose in no Avay retarded the convulsions com- 504 DISEASES. monly produced by stimulation of the brain. Both these investigators are therefore in accord. Under these circumstances it affects rather the motor nerve-endings than the central nervous apparatus. At the present time those Avho believe epilepsy to be dependent on cerebral vasomotor spasm rest the occasional good results obtained by the use of belladonna on its vasomotor influence; but there is a good reason for throwing this idea aside, even if the morbid process named Avas really present—namely, that the drug in ordinary medicinal doses raises arterial tension by stimulation of the vasomotor centre, while it loAvers blood-pressure only Avhen given in toxic amounts, and then by an action on the blood-vessel Avails. As long ago as the early part of this century cannabis indica came into notice in the treatment of epilepsy, and it is probably of greater value alone than when combined with any other drug, unless it be with the bromides. Although it is at present rarely so used, the author believes, from his own studies, that it is of value, for he found that it distinctly lessens reflex action and acts poAverfully upon the higher nervous centres in the brain. Its use and value in migraine are undeniably of the greatest importance, and epilepsy and migraine are often very closely allied. Celsemium semperdrens is an American plant whose praises have been Avidely heard in almost every disease. Its influence alone is Avorthless, for it possesses no power over the cerebral centres what- ever, but in combination Avith cannabis indica it makes a very useful remedy, and depresses the conducting power of the spinal cord, Avhile the cannabis indica in its turn quiets the cerebrum. The dose of the tincture is 20 drops (1.3), but it should be remembered that it is as poisonous as the cannabis indica is innocuous. Owing to the soporific influences exercised by opium it has been very frequently tried, with both success and failure as a result. It certainly has not taken any rank in the list of remedies, and is de- servedly lacking in professional favor. It increases reflex activity very commonly, and seems to affect the intellectual centres of the cere- brum rather than the motor portions, although Seppilli's experiments show it to exercise a decided depressant influence over these areas. Combined Avith gelsemium it may be employed, but only when nothing else is at hand or all other remedies have failed. If it is so employed, great care is to be used, and it should not be forgotten that both drugs kill by respiratory failure. When used in the 4' status epi- lepticus " it often does good in relieving the spasm, but it must be employed in large doses, and if the succeeding coma of epilepsy has added to it that of large doses of opium, death may ensue. The employment of zinc, in its various salts,' has been greatly recommended for many years, but has found little favor of late among the profession. It has been stated that it quiets the cerebral cortex, the medulla oblongata, and the spinal cord, and in this Avay cures the attacks. This is, however, merely clinical evidence, and has no ex- perimental proof to support it. Even its most sanguine supporters confess that the range of usefulness of zinc is generally in those cases where the bromides succeed, and agree that its poAvers are much infe- EPILEPSY. 505 rior to these compounds. The dose of the oxide is 3 to 7 grains (0.15-0.5) tAvice or thrice a day, and even in this amount it may cause nausea and vomiting. The citrate of zinc is more soluble, and is bet- ter borne by the digestive apparatus. Its influence over the disease is probably the same as that of the oxide, and this is also true of the lactate, Avhich was so largely used by Herpin, and Avhich is probably the best salt of zinc to employ. Nitrate of silver was brought into use long before the value of more recent drugs AA'as knoAvn. Every one is agreed that it is Avith- out power for good, save when it is used constantly for a long time. As the drug is eliminated very slowly, it rapidly accumulates in the body, and argyria soon comes on. It may be used, after all else fails, in doses of l to \ grain (0.01-0.15) thrice a day after meals, the mucous membrane of the inside of the lips and the conjunctiva being carefully Avatched for the early signs of chronic silver poisoning. We certainly have no knowledge as to its influence on the nervous sys- tem ; and if it acts at all, it must be by some alterative influences rather than by any other means. Nitroglycerin is to be employed in the treatment of petit mal, rather than haut mal, in the dose of 1 drop (0.05) of a 1 per cent. solution, once, tAvice, or three times a day. Our knowledge of its effects, so far as its curative influences are concerned, is very slight, but it seems to benefit some cases. Its action is very fleeting, and it influences the brain very little, except it be taken just before an attack is expected or when the cardiac action is defective. Its great lethal poAver should never be forgotton. The use of the nitrite of amyl is not for the purpose of directly curing the disease, but of warding off impending attacks, the warn- ing of Avhich is given by an aura of sIoav progression. It increases the severity of petit mal, but in epileptics Avho have a prolonged aura we may use nitrite-of-amyl pearls, Avhich consist in small glass beads containing a feAv drops of the drug. As the aura comes on the patient should break one of these in his handkerchief and inhale the drug, thereby putting aside the attack. The influence Avhich the drug exerts upon the brain is secondary rather than primary, and is probably dependent on its action on the blood or circulation. Its influence on the spinal cord and nerves is much more marked and direct, and it is most certainly a very powerful spinal depressant. As its influence over unstriated muscular- fibre is very great, it affects the vasomotor system very powerfully ; and those avIio think epilepsy is due to a vasomotor spasm at the base of the brain point to the effects of this drug as a proof of their hypothesis. Such reasoning is not, however, necessarily correct. Nitrite of amyl puts aside an attack by a sudden shock to the nerve-centres, Avhich diverts them, so to speak, from their intended discharge, very much as a ligature around the arm stops an aura. When Ave remember that the drug acts instantly and converts nearly all the oxygenating blood of the body into a non- oxygen-carrying fluid by reason of the methaemoglobin produced, the sudden change in the cerebral nutrition and state is easily understood. 506 DISEASES. In the treatment of the "status epilepticus " nitrite of amyl is of great value in stopping the seizures, and may be used under these circumstances in heroic amounts, applied to the nostrils at intervals. During the presence of the tonic spasm, if it be severe enough to stop respiration, it should be remembered that if the drug is not inhaled it is absolutely worthless. It is only Avhen respiration is being carried on that it can enter the lungs and do its Avork. As a general rule, the nitrite of ammonium or of sodium, both of Avhich are prolonged in their effects, should be used internally to sup- plement the nitrite of amyl. GoAvers states that nitrite of amyl does good in epilepsy by flood- ing the brain with arterial blood. Hoav such a statement can be made by any one is amazing. Of all the drugs in the world, nitrite of amyl produces exactly the opposite change. The use of anaesthetics during an attack of epilepsy is virtually useless, and in some cases dangerous, for ether is too slow in its effects, and may, by its irritant vapors, increase the tendency to laryngeal spasm or cause lung complications. Further than this, if uraemia is the cause of the fit—and this fact is unknoAvn in every case until the individual is carefully examined—the ether may increase the inflam- mation of the kidneys very seriously. Chloroform, though it acts much more rapidly, may cause sudden cardiac failure, and both drugs may increase the post-convulsive coma very greatly. In " status epilepticus " they may be used, as in such cases the convulsions must be stopped at all hazards, but the prefer- ence should be ahvays for amyl nitrite. The iodide of potassium is entirely useless in epilepsy unless the disease is due to syphilis, Avhen it is of the greatest service. Indeed, the bromide and all other drugs should be set aside Avhile this one is pushed to the utmost. As is Avell known, syphilitics usually bear the drug extremely well, and the author knows of one instance Avhere no less than 800 grains (53.0) were taken every twenty-four hours, with rapid improvement as a result. This point is strongly insisted upon by all therapeutists and syphilographers, notably among Avhom stands Fournier. Where the convulsions are due to the presence of a gumma, the iodide of potassium is, hoAvever, too slow in its action, and should be associated Avith mercury in order to break doAvn the groAvth without delay, lest a seizure cause death by glottic closure, producing asphyxia or some similar accident. Some difference of opinion exists as to the usefulness of iron in epilepsy. Several very eminent clinicians have asserted that it always makes the attack worse, and therefore does more harm than good. Like everything else, iron is no more to be given in every case than is a dose of oil; when there is plethora it is harmful, and when there are malnutrition and anaemia it does good. Over- the disease itself iron has really no effect at all, except through its action on the gen- eral system. Chloral hydrate is a remedy which has been only partly tried in epilepsy, and its usefulness is not as yet determined. It possesses the EPILEPSY. 507 marked disadvantage, as compared Avith the bromides, of being a very fatal poison, which is an important fact to be borne in mind by the physician Avhen giving it to a patient Avhose mind is already Aveak- ened by the disease or naturally stupid, and Avho may forget and take too much. Its physiological action indicates much more fully that it may be of value than does that of many other much more lauded rem- edies, since it exerts its chief influence on the motor pathways of the spinal cord and quiets the motor portion of the cerebral, cortex, and also produces sleep. Seppilli has proved this by direct experimenta- tion after the method employed by Albertoni. Its use, combined Avith one of the bromides, is often accompanied by the most desirable results, and it should be tried at all times unless some cardiac complication forbids it. It may disorder the stomach, and should, like the bromides, always be given Avell diluted and after meals. Of the more recent remedies, acetanilid certainly stands in the foremost rank, and bids fair in some instances to rival the bromides. Professor Germain-See. the author, and some others have reported cases Avhich obtained very marked relief from it, and more recent investigators have done likeAvise. The drug w ill be found to exert its chief benefits in chronic epilepsy. At least, if a child was brought to the author Avith a beginning epilepsy he would use the bromides, but, if the disease Avas chronic, acetanilid. Antipyrine has also been pushed forward as a remedy, and its physiological action on the nervous system is virtually identical with acetanilid. Antipyrine has been recommended by Lemoine in certain forms of epilepsy, but condemned in most cases. In those Avho suffer from menstrual epilepsy, so called, or in those in Avhom the attack is pro- duced reflexly by the presence of intestinal parasites, the drug does good. Lemoine also found it very useful in those cases which are asso- ciated Avith migraine. In these cases the results were better than with the bromides, but in the idiopathic simple varieties it was use- less. Mairet and Combemale have used the drug in the epileptiform mania with satisfactory results. In the epilepsy of childhood Solanum carolinense in the form of the fluid extract, in the dose of 2 to 15 minims (0.1-1 cc), is a useful drug. In children suffering from frequently recurring epileptic attacks the presence of worms should ahvays be looked for, and when they are found they should be expelled as'rapidly as possible. If they are the oxyuris vermiciilaris (seat-worms), the best remedy by far is the injection of a strong infusion of quassia of such a strength that there are 2 ounces (04.0) of quassia to each pint (500 cc.) of water. In girls, where the removal of the worms from the rectum is not followed by relief, a careful examination of the vagina should be made, and quassia employed in someAvhat weaker solution, as very commonly intense inflammation is there present, produced by migra- tory movements of rectal parasites. If the quassia is unobtainable in any case, a saturated solution of chloride of sodium may be employed. 508 DISEASES. The treatment of epilepsy by borax has not received very wide recognition. Perhaps the most" thorough studies of its effects have been those of Gowers in England and Folsom in America. It Avould seem that some cases which are obstinate under ordinary treatment are benefited by borax, but it is certainly not to be commonly employed. The dose generally given is about 15 grains (1.0). (See Borax.) Having spoken of the drugs which may be given to epileptics, attention may be drawn to those Avhich may not be used. There is a very large amount of reliable evidence, both experimental and clinical, that quinine should never been employed in these cases Avhen it can be avoided. Thus Seppilli in his researches found that it increased the irritability of the cerebral cortex, and Briquet has asserted that it is a direct cerebral stimulant. That toxic doses of quinine may provoke epileptiform convulsions has been proved by JakowboAvich, who has seen them occur in cinchonized dogs and other animals, and Brown-Sequard and Albertoni have noted that cinchonidine and quinine ahvays increase the number of attacks in epileptics. Salicylic acid, too, has an effect upon the brain very closely allied to that of quinine, and should ahvays be used with care in cases of epilepsy. Professor Germain-See has also pointed out that large doses of this drug produce violent epileptiform convulsions in the lower animals. Strychnine, Avhile its chief effect is to heighten the activity of the spinal cord, also, according to Seppilli, increases the irritability of the cortex, and should be employed only in peculiar cases. The same writer also found that absinthe and picrotoxin predispose to epileptic seizure by increasing the excitability of the motor zone of the cerebral cortex. Bleeding the patient in epilepsy, unless there is marked evidence of cerebral congestion, which is exceedingly rare, is harmful rather than of value. Orschansky found that removal of one-seventh of all the blood in the body by the femoral vein did not lessen the irritability of the cortex, and MinskoAvsky ligatured all the blood-vessels going to the brain without decreasing its excitability. We know also that cerebral anaemia produces epileptic attacks. A very important point, which is constantly brought before the physician who is treating epilepsy, is that of diet. Nearly every patient who suffers from this disease inquires what he shall eat. Very few researches of a thorough character have ever been carried out on a large scale to determine the things Avhich may or may not be in- gested. Of course, nearly every one of us knoAvs from our personal experience that red meats are hurtful, particularly in children. Curi- ously enough, the influence of diet in one research covering a number of cases of chronic epilepsy seemed to be of little moment. Thus, Merson examined 24 such cases, putting 12 of them on a purely vege- table, and 12 on a purely nitrogenous, diet. The result, after this study had been continued for tAvo months, was that the vegetarians had had a feAv less fits than the others, but the difference Avas so slight as to be of almost no Aveight in determining the question. Some EPISTANIS 509 authors at the present day believe this opinion as to the harmfulness of meats to be erroneous, and Goavcis is one of them. EPISTAXIS. Xose-bleed depends upon many causes, the chief of Avhich are traumatisms, plethora, and the presence of ulcerations in the nasal chambers. It also occurs as one of the prodromata of typhoid fever. Probably plethora is the most frequent cause of nose-bleed, and in most instances it is an attempt on the part of the system to rid itself of an excess of blood. Under these circumstances epistaxis is not dangerous, nor is it proper to arrest it unless it becomes exces- sive. Where it is excessive or must be controlled for any reason, the measures to be adopted are both medicinal and non-medicinal. If the person is full-blooded and strong, full doses of tincture of aconite or veratrum viride are useful, say 2 to 4 drops (0.1-0.2) of one of them, folloAved in a half-hour by a smaller dose, if necessary. The value of these drugs depends upon their power of loAvering blood- pressure, and in consequence decreasing the leakage from the break in the Avail of the blood-vessel. Some physicians have recommended ipecac in full nauseating doses to relax the arterial system. PoAvdered alum, pure or half and half Avith starch, or alum in solution, may be snuffed up the nostril, and tannic acid, in powder or in solution, may be used Avith advantage. If this does not control the hemorrhage, an atomized spray of Monsel's solution, in the strength of 30 drops to 4 ounces (2.0 : 12S.0) of Avater, may be of service. Ergot in the form of the fluid extract in the dose of 1 drachm (4.0) may be given, or its Avine in the dose of a wineglassful (32.0) employed. Sometimes, Avhen the oozing is slow, doses of turpentine taken internally, oil of erige- ron, or hamamelis, do good. As a household remedy vinegar may be injected into the nostrils, or lemon-juice may be employed in 'the same way. All these remedies act as styptics Avhen locally applied, by causing coagulation of the fibrin and the formation of a clot, Avhile the inter- nal remedies produce local contraction of the blood-vessels in the con- gested area, this area being more susceptible to the influence of these drugs than the rest of the vascular system. The non-medicinal measures to be employed if the bleeding is severe consist in plugging the anterior nares with pledgets of cotton or pieces of lint soaked in vinegar. If this does not control the hemorrhage, the posterior nares may also be closed by plugs, and compression of the facial artery of the same side as the bleeding nos- tril be made upon the superior maxilla near the nose, thus decreasing the blood-supply. The head must be kept raised, and the patient must not bend over a basin or Avear a tight collar. A piece^of bacon fat cut to fit and placed in the nostril may stop epistaxis Avhich has resisted all other measures. Sometimes, if the patient raises one or both hands high above the head, the hemorrhage ceases. This is due to the fact that the easiest 510 DISEASES. pathAvay for most of the blood is straight up the brachial arteries rather than through the tortuous vessels of the face. A hot foot- bath, by dilating the veins of the loAver extremities, draws away the blood from the face and is a useful measure. In other eases a hot- Avater bag applied over the dorsal vertebrae is efficacious, and some- times cold when so used is of service. A piece of ice pressed against the nose may prevent further hemorrhage by causing localized anaemia. Where the nasal hemorrhage results from traumatism Avith fracture of the bones, and great loss of blood ensues, ligation of the bleeding vessel or its supplying vessel should be, if possible, resorted to. ERYSIPELAS. This disease is noAV generally recognized as dependent for its existence upon a germ. The streptococcus of erysipelas is practi- cally identical Avith that of pus, and the disease is at first a distinctly local one. The changes Avhich have come fonvard in its treatment are chiefly the local measures, while those methods Avhich have been used internally for many years have suffered no alteration. Whether or not erysipelas is a local or systemic disease has little to do with the proper treatment. In any case it is an inflammation, and as such it must be treated. In its early manifestations and where some uncertainty may exist as to its true character aconite or vera- trum viride may be used in sthenic cases in Avhich the nervous and circulatory systems give eAridence of reflex irritation and the pulse is hard and full. These remedies are contraindicated if any tendency to Aveakness exists. DaCosta has recommended, and others have car- ried out Avith success, the practice of using pilocarpine in SAveating dose (| to 4; grain hypodermically) in these early stages. (See Pilo- carpus.) As Avith aconite and veratrum viride, it is to be remembered that this use of pilocarpine is not to be resorted to if debility exists. When the disease is too far advanced to be aborted, belladonna in the dose of 3 to 5 minims (0.2-0.35) of the tincture every four hours should be used. It may also be locally applied on lint Avith benefit, or belladonna ointment may be smeared on the skin. The internal treatment of erysipelas par excellence is the plentiful use of the tincture of the chloride of iron—20 to 30 drops (1.3-2.0), or even 40 drops (2.65), four times a day. The diet should be reg- ulated and the boAvels kept in good order, while any excessive febrile movements are to be treated by the use of antipyretic drugs, such as antipyrine—better still by cold bathing. Where the patient passes into the typhoid state supportive measures must be used and alcoholic stimulants added to the food, which should be predigested or prepared so as to be readily absorbed. During convalescence the use of tonics, both in the ferm of iron and of bitters, is particularly indicated if the recovery of strength is slow. The local treatment of erysipelas is very varied, but in the majority of cases resort need be had to but one or tAvo methods. FEET. 511 By far the best dressing for the general run of cases of erysipelas is a modification of that of Von Nussbaum, Avhich the author has tried in a number of cases with great success. The skin of the part involved is carefully cleansed Avith castile soap of the purest form, which is washed off by a 1 : 1000 solution of bichloride of mercury. The skin is dried with a soft towel, and a thick coating of ichthyol and vaseline or lanolin applied, the strength of this ointment being half and half. Over this is placed antiseptic gauze or sterilized absorbent cotton, and adhesive strips or a bandage is used to keep the dressing in place. Sometimes the ointment alone may be applied if the area is small. Under this treatment the results are'often extra- ordinary in all stages of the malady. Where ichthyol is not obtain- able, a thick coat of white-lead paint, as it is sold in cans before it is mixed with any thinning substance, will be found of service in an emergency. The plan recommended by Higginbottom, of applying nitrate of silver, is sometimes successful. It consists in the use of a solution of the strength of 80 grains to 4 drachms (5.3: 16.0) of distilled Avater, Avhich is thoroughly applied Avith a camel's-hair brush over the entire inflamed area and for a little space beyond. The application must be made twice or thrice to secure a good coating. This treat- ment will often arrest the inflammation and prevent its spread, but has caused sloughing. EXHAUSTION AND DEPRESSION. While the treatment of both these conditions is almost identical in some respects, it is. nevertheless, important that a clear idea of the difference between the two be clearly understood, if for no other reason than that the physician may recognize that exhaustion is a far more serious state than depression. It also requires more careful treatment. The man Avho is depressed retains in his body all the vital forces necessary for the maintenance of life, but they are tem- porarily in abeyance from some cause. As soon as the incubus is taken aAvay the system at once asserts itself and recovery takes place. This is not the case Avith a man suffering from exhaustion. In this patient every particle of his strength is sapped and lost. The man depressed is the giant lying unconscious from a bloAv on the head; the man exhausted is the same giant after a long attack of typhoid or other fever of a similar nature. The treatment of depression is stim- ulation; of exhaustion, hot only stimulation, but feeding and protec- tion from exposure. FEET SWOLLEN, TENDER, OR SWEATING. These comparatively simple yet annoying conditions are often brought before the physician for relief, and patients suffering from them will frequently be more grateful for skilful treatment than in the event of recovery from a severe illness. 512 DISEASES SAvelling of the feet occurs chiefly in two classes of cases, except- ing, of course, in dropsy, which makes a third class. These are old persons taking too little or too much exercise, and who may have gouty or rheumatic tendencies, and those who by constant standing or Avalking cause congestion of the lower extremities, chiefly by fatigue, or by wearing bad shoes, or by running over uneven ground, causing bruising. Where the swelling takes place in the first class, small doses Avhites "—consisting in a hypersecretion from those glands which pour out their contents into the vagina or the cervical canal of the uterus, or even into the cavity of this organ. It is a state dependent upon many causes for its existence, the chief of which is a condition of the system when it is " run doAvn " from any cause, Avith perverted functions of the glands or their sur- roundings. In some persons, Avho seem perfectly strong and well it Avould appear to be due to an effort of the system to overcome plethora. The character of the discharge varies Avith almost every case. In some instances it is thick and tenacious, in others so liquid as to trickle doAvn the limbs in a stream and greatly soil the clothing. In most of the latter cases catarrh of the Fallopian tubes or ovarian irri- tation and tenderness will be present. Where the secretion is very thick and tenacious it generally arises from the cervical canal, while that from disorder of the vaginal Avail alone, independent of other morbid conditions, may be either thick or thin. The treatment of these forms of leucorrhoea may be divided into two parts—one, that directed to the remedying of the morbid process through the use of drugs by the mouth; the other, by their employ- ment locally. It is needless to state that in that form dependent upon excessive lactation or other exhausting manner of life tonics of an active cha- racter are needed. As a general rule, anaemia will be present, and the folloAving pill will be found of service: R.—Acid, arsenosi...........gr. J- (0.016). Ferri redacti............gr. v (0.25). Quininae sulph............9j (1.3).—M. Ft. in pil. No. xx. S.—One pill three times a day, after meals, for an adult. Or, R.—Tr. ferri chloridi..........f^j.(4.0). Tr. cinchonae comp..........i%ij (64.0). Tr. gentian, comp.......q. s. ad fgiv (128.0).—M. S.—Dessertspoonful (8.0) three times a day, after meals.1 Sometimes small doses of the sulphate of iron are better for this purpose, OAving to its astringent properties, but when any prepara- tions of iron are used care must be taken that the bowels are kept active and that the stomach is not disordered. Associated with the use of these internal remedies should be a moderate amount of exer- cise and the avoidance of late hours and rich foods. 1 In both these prescriptions the small amount of iron and arsenic given will prob- ably be noted, but this is done advisedly, as iron and arsenic do as much good to the blood in small as in large amounts under most circumstances. (See Iron.) 576 DISEASES. The local applications Avhich are of value in these states consist in counter-irritation and vaginal injections or painting the mucous mem- brane of the parts from Avhich the discharge comesVith proper fluids. In the leucorrhoea dependent upon irritation of the ovaries Avith catarrh of the Fallopian tubes the use of small blisters formed by the employment of cantharidal collodion or a cantharidal plaster over the groin on either side is often accompanied by good results. At the same time the vaginal surfaces surrounding the cervix uteri may be painted Avith a mixture of iodine, carbolic acid, and chloral, such as is used by Dr. Goodell, as follows: R.—Iodi resublimat.........^iv (16.0). Acid, carbol. crystal. 1 -- z. roo n, Chloralis y } ■ ■ ■ • aa & (32.0). Rub the iodine and chloral in a glass mortar into a powder and add the carbolic acid. S.—Formula. To be used by the physician only. The folloAving pill may also be employed: R.—Hydrarg. chlor. corros. . . . . . gr. \ (0.03). Ft. in pil. No. xx. S.—One pill three times a day, after meals or a tablet triturate may be used instead of a pill. The remaining treatment of watery leucorrhoea consists in the use of astringent injections. A very cheap astringent injection is made by adding 1 ounce (32.0) of powdered white-oak bark to each pint (500 cc.) of water, or tannic acid and glycerin in the proportion of 1 ounce to 2 quarts (32.0 : 2 litres) of Avarm Avater. Ringer recom- mends the following: R.—Sodii bicarbonatis........3j (4.0). Tincturae belladonna? .......f^ij (8.0). Aquae.............Oj (500 cc.).—M. S.— Use as a vaginal wash. Where the discharge is foetid a solution of permanganate of potas- sium should be used as an injection in the strength of h, drachm to 1 pint (2.0 : 500 cc.) of water. In purulent vaginitis, specific or other- wise, the folloAving injection is serviceable: R.—Creolin.............f^ss vel fjij (2.0-8.0). Ext. hydrast. canaden. fl......f^ijss (10.0). Aquae............f|viij (256.0).—M. S— Add 2 tablespoonfuls to a pint (32.0 : 500 cc.) of hot water, and use as an injection. Sometimes a tampon thoroughly saturated Avith a poAvder of iodo- form and tannic acid, equal parts, and packed around a discharging uterine cervix, is of service. When using vaginal injections in females it is important to remem- ber that they should be in large quantities. Nothing is more antago- nistic to true asepsis than the usual manner in Avhich these applica- tions are made. Generally a pint of the solution is placed in a basin over which the Avoman squats, and by means of a syringe forces the LUMBAGO. 577 liquid into the vagina as fast as it runs out, thereby filling the syringe joints Avith the dissolved secretions, and returning to the vagina as soon as they Aoav away the impurities Avhich have left it. The only proper Avay to give such an injection is to have the solution in one basin, to the extent of 1 gallon (4 litres), Avhile the patient squats over a second basin, into Avhich the impure liquid may run. A very useful astringent injection may be made by ordering R— Zinc, sulphat............f,5j (4.0). Alumin. sulph...........f^j (4.0). Glycerini.............fgvj (192.0).—M. S.—A tablespoonful (16.0) to each quart (1 litre) of water. LID ABSCESSES. Lid abscesses are seen more frequently in children than adults, as the result of injury, the sequel of acute illness (epidemic influenza, pulmonary catarrhs, fever, etc.), or from local infection; under the latter circumstance they may assume a gangrenous type. The treat- ment is that for any form of abscess—poultices, preferably in the form of hot compresses, early incisions, antiseptic solutions, and tonics. LUMBAGO. This is a form of myalgia or muscular rheumatism of the muscles of the loins and small of the back, and is frequently the result of lifting heavy Aveights or it results from other strains. In many cases acupuncture is very useful, particularly if the trouble is bilateral. Sometimes after the employment of this measure the patient can straighten the back at once and retain that position. In other instances antipyrine or acetanilid, in 10- to 20-grain (0.65-1.3) doses of the former and 4- to 8-grain (0.2-0.6) doses of the latter, are of service, and iodide of potassium and salicylic acid are not to be for- gotten if the condition of the patient does not rapidly improve. Phenacetin and salol are also useful, combined or alone. A large hot poultice applied to the back is often efficacious in obstinate cases. Sometimes a hot foot-bath and a Dover's powder on going to bed Avill produce a cure, and ironing the back with an ordinary hot laundry iron at a proper heat, a piece of neAvspaper or cloth being placed over the skin under the iron, is very efficient. Counter-irritation in the shape of a blister, a mustard plaster, or capsicum draft will often give relief. Where these measures fail the reverse treatment may be tried, such as an ice-bag placed over the loins or an ether spray turned on the part until the skin is greatly blanched. MALARIAL FEVER. (See Intermittent and Remittext Fevers.) 37 578 DISEASES. MANIA (ACUTE). Space is Avanting to consider the thorough and complete treatment of mania as it comes to the neurologist. All that can be done here is to denote temporary measures suitable for cases Avhich are brief in their course. In those cases which occur after confinement and are not supposed to be based upon permanent trouble, cimicifuga racemosa is said to be very useful in the dose of 20 to 30 drops (1.3-2.0) of the fluid extract three times a day, while for the rapid quieting of the patient we may use hyoscine hydrobromate in the dose of -j-4^ grain (0.0006). In other instances, if the kidneys and heart are healthy, full doses of chloral may be used, and if an active preparation of cannabis indica can be had, at least 1 grain (0.05) of the solid extract or J to 1 drachm (2.0-4.0) of the tincture should be employed. Cannabis indica will be found particularly serviceable if 60 grains (4.0) of one of the bromides can be combined with it. Where a patient suffering from mania is so violent that nothing can be done Avith him, he should be held, and an emetic dose of fa grain (0.005) of apomorphine be given hypodermically to produce vom- iting and so relax the muscular system, or he may be tied or anaesthet- ized sufficiently to enable the physician to administer proper remedies. Sometimes full doses of morphine are needful, and in others a cold douche to the head while the body is in hot water is of service. MELANCHOLIA. This is not the place for the discussion of melancholia of so severe a form as to amount to insanity, since the treatment of this latter state is very various and largely depends upon the skill of trained physi- cians who are alienists. There is one form of melancholia, however, which may often be rapidly relieved by a simple measure. It is that dependent upon the condition of the system in which oxaluria is present. Whenever an individual complains of melancholia the urine should be examined, and if any oxalate crystals are found, undiluted, fresh nitromuriatic acid should be given in the dose of 5 drops (0.3) after each meal in a half-tumblerful or more of water. In order to guard against errors in diagnosis it is well to remember that pears, tomatoes, rhu- barb, and cabbage all cause oxalates to appear in the urine for a short period after their ingestion. MENINGITIS (ACUTE). Meningitis is to be treated as is any other form of acute inflamma- tion occurring in a sthenic or dynamic individual, and particularly does its treatment correspond to that of the other inflammations of large serous membranes, such as peritonitis or pleurisy. In the early stages the patient should receive sufficiently large MENINGITIS. 579 doses of aconite or veratrum viride to strongly impress the circulatory system. These drugs have the poAver of producing such dilatation of the blood-paths throughout the body that the congested or inflamed area is relieved of its excess of blood, because, the pressure being less elsewhere, the blood obeys the laAV that liquids ahvays try to escape from pressure, and so leaves the meninges of the brain for the vessels of the limbs and trunk. A good-sized blister should always be placed at the nape of the neck as a counter-irritant to prevent effusion. The proper dose of veratrum viride in the form of the tincture is 3 drops (0.15) every hour until the skin becomes moist or nausea is developed.1 The tincture of aconite is also useful in full dose. If great arterial excitement is present, venesection may be practised (see Bleeding), but veratrum viride and aconite are better remedies if they are at hand. Associated Avith these Iavo drugs we should em- ploy mercury and opium, the first for its antiphlogistic influence, the second for its poAver in allaying irritation. \ grain (0.016) of pow- dered opium and 4; grain (0.03) of calomel may be given every hour until the full effect of the opium or mercury is manifested. In some instances the deodorized tincture of opium (Tinetura opii deodorati) is better than the crude drug, in the dose of 2 to 5 drops (0.1-0.25) every one or tAvo hours. Sometimes belladonna is of great service, and this is particularly the case Avhere the drugs already named are contraindicated because of a condition of weakness or asthenia. In both conditions ergot is of value in allaying the congestion, but its period for exerting a favorable effect is not at the very first part of the attack, but a little later, when the stage of exudation is at hand. During the first acute stage an ice-bag should be applied to the head, both for its local influence and its antipyretic effect, and leeches may be put at the nape of the neck with advantage. As the disease adATances and the nervous disorders of the affection become marked, nervous sedatives are required to allay the twitchings, muscular spasms, or convulsions, and for this purpose no drugs are to be com- pared to chloral and the bromides. The doses to be used vary Avith the violence of the symptoms, but it may be stated that the chloral should rarely, if ever, be used in doses above 10 grains (0.65), and the bromides given in the dose of from 5 to 40 grains (0.3-2.65). If coma comes on, a large blister should be applied to the nape of the neck. Quinine has been recommended in meningitis, but it is absolutely contraindicated, as it predisposes to this condition. It may be em- ployed only in con\ralescence, and then used most carefully. The treatment of the second stage of meningitis must be neces- sarily supportive, owing to the reaction consequent upon great ner- vous and arterial excitement. Under these circumstances the use of opium is still indicated, because it allays nervous unrest and supports the system, partly by conserving the tissues and partly by inhibiting 1 It is to be remembered that veratrum viride often causes nausea, and even vomit- ing, in susceptible persons, and in consequence it should be carefully given in menin- gitis, lest if vomiting come on the disease be made worse. 580 DISEASES. the Avaste of nervous force apt to occur at this time. Alcohol should be given Avith the food if weakness is present, and a very simple milk diet insisted upon. MIGRAINE. (See Neuralgia.) MUSCLE VOLITANTES. Muscae volitantes is the name applied to the dark specks which patients frequently see floating across their fields of vision, especially if the eyes are directed toward a bright sky or a white page. Usually they indicate no disease of the vitreous humor, and the ophthalmo- scope fails to detect abnormal changes. They are attributed to tor- pidity of the liver by the laity. Muscae volitantes may indicate eye- strain, and if the refraction is abnormal this should be corrected; a mild course of alteratives is often a useful adjuvant. MYALGIA. Soreness of the muscles either on pressure or on movement may be dependent upon a number of causes, such as strains, bruises, rheu- matic taint, or inflammation due to cold. Here, as in many other states, the treatment is to be divided into the external and the inter- nal methods. Of the internal remedies, the best are the salicylates or the iodide of potassium if rheumatism be at the base of the trouble. On the other hand, if a bruise or cold be the cause the chloride of ammonium will be of service in 10- or 20-grain (0.65-1.3) doses given in a solution with extract of liquorice. (For prescription see Bronchitis.) Other remedies Avhich may be tried with a good chance of success are full doses of a good fluid extract of cimicifuga (20 drops to 1 drachm [1.3-4.0]) or the citrate or acetate of potassium in 20-grain (1.3) doses. The local medications are numerous, but only a few can be consid- ered as Avorthy of routine employment. The chief one is iodine, in the form of the pure ointment or diluted one-half Avith lard if the skin is easily irritated. Another method is to employ a liniment, well rubbed into the skin, made up as follows: R.—Tr. belladonna?............ fgj (4.0). Tr. aconiti..............f^i] (8.0). Tr. opii...............f^ij (8.0). Liniment, saponis.......q. s. ad f^vj (192.0).—M. S.—Poison. To be used externally and only as a liniment. Sometimes chloroform liniment is singularly successful, and poul- tices applied as hot as can be borne and covered by oil-silk and cotton to retain the heat are often of great value. Massage or good rubbing is also a sine qua non for the successful treatment of this state. NASAL CATARRH. 581 NASAL CATARRH (ATROPHIC). Synonym, Atrophic Rhinitis.—The atrophic or last stage of nasal catarrh, commonly known as dry catarrh, is a natural sequence of the stage of hypertrophy, although in exceptional instances the atrophic type has appeared at once. Increased vascularity and over- stimulation of the hypertrophic stage lead to increased functional activity, and finally to exhaustion and atrophy of the tissues involved. In atrophic nasal catarrh the nostrils are roomy and the mucous membrane red and shiny. The formation of connective tissue has, to a great degree, obliterated the delicate serous glands, and the dis- charge of mucus, no longer diluted, forms inspissated crusts, which adhere to the mucous membrane of the septum and turbinated bones. Areas of ulcerated or abraded membrane are disclosed upon removal of these adherent crusts. The turbinated bones are gradually absorbed and the secreting surface thereby much reduced. Sometimes the wasting is so great that the posterior Avail of the pharynx is clearly visible from the front. The inspissated secretion may make a cast of the nostril, and as fresh layers form underneath the oldest part is raised until the whole interior of the nostril becomes a mass of decomposition, giving rise to an overpowering stench. This form of catarrh causes loss of the sense of smell, and the odor is not recognized by the patient him- self. Ulceration or caries of the bony structure produces an odor even worse than the so-called ozasna. The pharynx suffers from the general wasting, and presents a dry, varnished appearance called pharyngitis sicca, which is rather a symptom of nasal atrophy than a separate disease of the pharynx. The indications are the removal of all accumulations in the nose and naso-pharynx and the healing of abraded or ulcerated surfaces. The earlv removal of dead bone is imperative, and Avhat secreting surface remains must be stimulated as far as possible, to compensate, in a measure, for the glands that are hopelessly destroyed. In other words, our efforts are directed toward producing a compensatory hyper- trophy of the glandular tissue that remains. Therefore Avith the use of antisepsis Ave combine alteratives and local stimulation. The nose should be thoroughly cleansed Avith an alkaline wash— Dobell's solution—Avarmed to increase its solvent poAver. To relieve the odor increase the amount of carbolic acid or substitute for it eucalyptol and thymol in the wash. Listerine contains both of these, and may be added to the wash. Its OA\n pungent odor masks some- what the offensive odor. Permanganate of potassium may be used in Aveak solutions, but it is painful except Avhen sensation is entirely lost. Peroxide of hydrogen is recommended, but the Avriter has had no experience in using it over such an extensive surface. The solutions are best applied by means of an atomizer or post- nasal syringe in the hands of the physician or by snuffing from the hand or cup. The odor, if due to decomposition, is much decreased as soon as 582 DISEASES. the passages are clear. The discharge must never be alloAved to reaccumulate or much time will be lost. Ulcerations require local stimulation by a strong solution of nitrate of silver or a superficial application of the flat surface of the galvano- cautery heated to a dull redness. Necrosed bone should be removed, and it is often found detached in the nostril. Local stimulants should be judiciously combined with alteratives. Powders of nitrate of silver in starch, varying in strength from 1 to 10 grains to 2| drachms (0.65-10.0) of the latter, may be blown into the nostrils by means of an insufflator. Cover gently the Avhole surface Avith a thin layer, and use it only of sufficient strength to be slightly felt. Nitrate of silver, in solution, 1 to 10 grains to 1 fluid- ounce (0.05-0.65 : 32.0), gives better results at other times when applied to the mucous membrane. Avoid over-stimulating, and so exhausting, the glands which it is wished to strengthen. The use of alteratives may alternate Avith the silver salt and iodide of potassium, and this may be done by using solutions of iodine and glycerin, as recommended for hypertrophic nasal catarrh. Tnternally, the physi- cian should employ iodide of potassium to increase nasal secretions and mucous-membrane stimulants and tonics. He should also pay attention to the activity of the skin. NASAL CATARRH (CHRONIC). Chronic nasal catarrh is essentially a disease of civilization, which may occur at any period of life, but more commonly develops from youth to early adult life. Although more prevalent among the upper classes, it is in the loAver ranks that it most frequently reaches its later stages and its worst forms. This does not result from lack of opportunity for treats ment, but from the ignorance or indifference Avhich this class shoAv to diseases while there is no suffering and no interference Avith business. Continued exposure to the action of irritants of various characters in the form of dust or particles floating in the air keeps the mucous membranes in a state of constant irritation. A low grade of inflam- mation is established, resulting in permanent thickening of the mucous membrane and of the submucous connective tissue, with dilatation or actual hypertrophy of the erectile tissue covering the turbinated bones. The swollen tissues obstruct the passage of air through the nostrils, and mouth-breathing results, with its train of symptoms. The most common cause of catarrh is found in repeated attacks of coryza, each attack increasing the thickening of the mucous mem- branes and narrowing the breathing-space. Nasal catarrh in its course passes through three stages or periods— namely, the stage of coryza or acute nasal catarrh, and the chronic stages, knoAvn as hypertrophic and atrophic nasal catarrh. Coryza, or cold in the head, is not strictly a stage of nasal ca- tarrh, but, as stated elseAvhere, is an acute inflammation of the nasal NASAL CATARRH. 583 mucous membranes, generally running a definite course and termi- nating in recovery in a Aveek or ten days. Its chief clinical import- ance, hoAvever, is derived from its tendency, Avhen the vitality is reduced or recovery is retarded, to pass into a chronic stage, which, to all intents, is identical Avith the hypertrophic stage of nasal catarrh. The line of demarkation is not clearly draAvn between these two dis- eases or stages, nor can Ave locate Avith absolute certainty the point where acute coryza becomes hypertrophic nasal catarrh. Atrophic nasal catarrh commonly develops from the hypertrophic stage, although occasionally the disease takes this form from the beginning. Its symptoms are essentially different from the other stages, being characterized by functional inactivity and derangement in place of the over-stimulation of the hypertrophic stage. Hypertrophic nasal catarrh commonly has its origin in a neglected cold in the head or in a series of colds occurring in rapid succession, keeping the nose in a congested state until the erectile tissue covering the turbinated bones loses in a measure its power of contracting, and, decreasing the calibre of the nostrils, becomes a source of permanent obstruction to breathing. As the disease increases there is increased susceptibility to cold. Slight exposure produces a stuffy feeling in the nose. The nostrils may become completely occluded; usually, hoAvever, only one side at a time is obstructed at first, the obstruction showing a tendency to change sides. This change is most noticeable in turning in bed, the lower side usually stopping, and on changing the position the obstruction is reArersed, the clearing being accompanied by a crack- ling sensation. A slight tickling cough and tendency to clear the throat in the mornings may result from irritation of the pharynx or larynx. The nasal obstruction, generally greatest at night, causes restless, troubled sleep, while the mouth-breathing leaves the tongue dry and coated in the morning. A dull, frontal headache, due to reflex irri- tation from intranasal pressure, is not uncommon. Unusual irrita- bility of the mucous membranes may result in frequent attacks of sneezing or in a free watery secretion, which is more active in cold weather, appearing as a drop of Avater, resembling a bead, at the end of the nostril, which may drip from the nose on leaning forward. In patients of a neurotic type attacks resembling acute coryza occur without a moment's Avarning, and subside as quickly as they come. The nose at such times becomes stopped up to an oppressive degree, with free secretion, with or Avithout violent sneezing. Such attacks are precipitated by exposure to a close or impure atmosphere or to dampness, especially at dusk Avhen the dew is fall- ing, or when the patient is fatigued. The voice becomes husky or altered in character from loss of nasal resonance. Catarrh of the middle ear is liable to occur. During the early stage of hypertrophic rhinitis, on inspection of the anterior nasal passages all the tissues appear red and highly vas- cular. Along the surface and margin of the lower, and perhaps the middle, turbinated bones the tissues are swollen and puffy, and in 584 DISEASES. severe cases these puffy bags adapt themselves to the shape of the nostril, completely closing the passage-Avay. They very rarely com- pletely close both sides, except during an acute attack of coryza. One or the other side, as a rule, remains open, with a tendency for the obstruction to reverse sides. The nervous impression produced by examination may cause temporary contraction and clearing of both sides, which, unfortunately, are soon as bad as ever. The swellings, as described elseAvhere, consist of cavernous blood- vessel tissue, Avhich has the property of filling with blood and erect- ing under stimulus. These SAvellings on the turbinated bones are known as hypertrophies, although at this stage they contain little hypertrophied tissue, but are, more strictly, bags of erectile tissue which have lost the power of contracting. They readily disappear upon pressure by means of a probe, but return at once Avhen the pressure is withdraAvn. Applications of cocaine (4 per cent, solution) produce some contraction, benumbing and blanching the tissues at the same time. The poAver cocaine possesses of contracting hypertrophied tissue is useful for purposes of diagnosis in hypertrophic nasal catarrh. By its use Ave may readily distinguish tumors or bony or cartilaginous groAvths from the erectile tissue. The long continuation of a Ioav grade of inflammation favors the formation of connective tissue and actual hypertrophy of the turbi- nated tissues, Avhich become larger and firmer, and do not completely disappear under pressure from a probe. At the same time a progress- ive increase in the nasal obstruction is observed. A rhinoscopic vieAv posteriorly reveals a similar state of affairs, and a hypertrophy developing on the middle or lower turbinated bone, rarely on the upper. At this position the hypertrophy appears as a round, globular tumor extending backAvard toAvard the vault of the pharynx. It is sometimes sessile, but often has a slight constriction at its attachment to the turbinated bone. It is occasionally pale and coA^ered Avith mucus—indeed, a collection of mucus may be mistaken for an hypertrophy. Cleansing the nose Avith a solution sprayed by means of an atomizer directed through the nose from the front, or by a post-nasal syringe from behind, clears the diagnosis. At other times a posterior hypertrophy becomes engorged with blood and presents a deep purple color, resembling in size and shape a red raspberry. Enlarged pharyngeal tonsils produce decided obstruction poste- riorly, and, by the secretion of large quantities of mucus cause a constant feeling of fulness, with a desire to "hawk " and spit. An enlarged pharyngeal tonsil is recognized as a soft, spongy mass in the vault of the pharynx. Occasionally it hangs doAvn in festoons which somewhat resemble stalactites hanging from the roof of a cave. Should one of these stalactites become eroded, it may cause frequent and alarming hemorrhages. Hypertrophy of the pharyngeal tonsil is more common in children than in adults, and frequently occurs in connection Avith hypertro- NASAL CATARRH 585 phied faucial tonsils or in conjunction Avith adenitis, or results from diphtheria or scarlet fever or as part of a strumous diathesis. Hypertrophied tonsil is a fruitful source of deafness in children, as it may become large enough to interfere Avith the passage of air through the Eustachian tube or cause extension of catarrh to the middle ear. When a child is too small to permit a rhinoscopic examination, the presence of an enlarged pharyngeal tonsil may be felt by introducing the index finger through the mouth up behind the soft palate, taking care that the finger is protected from the child's sharp teeth. It is Avell to educate the finger to recognize the size and shape of the naso-pharynx, although its introduction is a disagreeable per- formance, for it may aid materially in outlining the structure, con- sistency, or point of attachment of tumors projecting from the nose into this space, or even assist in engaging a large groAvth in the loop of wire from a snare introduced through the nose. The ear should be educated to recognize the different effects produced on the voice by obstructions in the front or back of the nose and to assist the eye in diagnosis. Occlusion of the nostrils, if Avell in front, gives a nasal sound to the voice from the pent-up vibrations in the nose and naso-pharynx. An obstruction at the back of the nose deadens the voice, interferes Avith its carrying power, and prevents the voice being heard at any distance from the speaker. The voice, to use a technical term, loses its timbre, and should it be used to any extent chronic laryngitis results. The extra pressure injures the larynx and tires the throat, Avithout increasing the carrying power. The pathological changes occurring in hypertrophic nasal catarrh do not differ materially from similar changes occurring in catarrhal inflammations elsewhere. In treating catarrh find the cause, and, if possible, remove it. Great assistance in this direction may .follow careful inquiry into the occupation and environment of the patient. The difference between nasal catarrh and simple catarrh occurring in other places is chiefly the result of location. The nasal mucous membranes are surrounded by bony walls Avhich limit the power of SAvelling to one direction—namely, toAvard the centre. This affects the main function of the nose, that of respiration, and obstructed respiration leads at once to a train of symptoms, not of catarrh, but of the results of catarrh. SAvelling of the turbinated tissue and nasal obstruction are early symptoms of hypertrophic nasal catarrh. The change in functional activity which is caused by obstruction to respiration, and the nervous irritation resulting from pressure, sooner or later produce permanent injury, either local or reflex. The first indications for treatment are the reduction of inflamma- tion and restoration of the breathing-space. As the chief function of the nose is respiratory, the re-establish- ment of free nasal respiration, combined with the liberal use of anti- septic washes, will lessen the inflammation and irritation and produce a healthier state of the secretions. 586 DISEASES. The writer places cleanliness at the head of the list of remedial measures. The alkaline wash recommended on page 472, sprayed into the nose by a hand atomizer or gently snuffed from the palm of the hand or from a small cup, gives good results. The hand Avarms the solution slightly, but Avhen snuffed from a cup the solution should be artificially Avarmed. This Avash may be used two or more times a day. The nasal douche should never be used Avhere there is nasal ob- struction, on account of the risk of forcing the solution into the Eustachian tube and causing catarrh of the middle ear. In addition to the antiseptic wash Avhere the mucous membrane is congested and irritable, the treatment recommended for coryza may be instituted for a few days with good results. A solution composed of equal parts of distilled extract of hamamelis and Avater or a dilute solution of hydrastis may be sprayed into the nose during the acute stage. A little later a spray of ferric alum, 5 grains to the ounce (0.3 : 32.0), may be applied carefully in an atomizer by the physician. It is not advisable to use alum in any considerable strength in the nose, as its continued use is liable to impair the sense of smell. The alterative and absorbent action of iodine makes it a valuable remedy for local application in chronic nasal catarrh. Combine it with glycerin in the strength of 6 or 8 grains to the ounce (0.35 : 32.0), with enough potassium iodide to make a solution. Apply this by means of a piece of absorbent cotton on the end of an applicator, along the floor of the nose, until it reaches the pharynx. It is need- less to say that such an application as this should be made with the utmost gentleness. The cotton should project beyond the probe, and care should be taken to avoid bruising the tissues. After the acute stage has subsided, as shown by the disappearance of the livid color and lessened sensibility, any remaining hypertro- phied tissue should be removed by a snare or the galvano-cautery. NEURALGIA. Like headache, neuralgia gives rise to most of the suffering expe- rienced by active persons who are not sick enough for bed and by those who are confined to bed by other diseases. It affects members of every walk of life, and may be so severe as entirely to incapacitate the most powerful of men. The causes of neuralgia are very various, but they may be briefly stated to depend chiefly upon malnutrition, over-Avork, nervous excite- ment with consequent reaction, and to reflex irritation from diseased organs, as in the case of supraorbital neuralgia from eye-strain or ovarian irritation from uterine inflammation. Nerves functionally diseased are always more or less active than normal; that is, hyper- excited or hypo-excited, above or beloAv par. In both cases they must be brought back to their normal tone by appropriate remedies, and these consist in nervous excitants and nervous sedatives. To give a nerve already depressed the additional depression of a bromide, NEURALGIA. 587 or a nerve excited the additional excitement of strychnine, would be absurd. From what has just been said it becomes evident that the physician must ahvays determine the condition of the system of his patient and the causes of that condition before administering remedies. The treatment of this disease from its curative standpoint may be divided into the use of tonics, nutritives, and palliatives. Where neuralgia is associated with anaemia no hope of permanent relief can be looked for unless iron and arsenic are used until the anaemia is cured, and it is often necessary to combine with these drugs the use of cod-liver oil and bitter tonics. These are the cases, too, in Avhich nux vomica and strychnine raise the depressed nerves to increased activity, and so bring relief. Hoav they do this is not known, but Ave know enough to recognize one or tAvo important facts. Strychnine is certainly a nervous stimulant, and is also a stimulant to the anterior columns of the spinal cord. It probably also acts upon the trophic centres in the anterior cornua of the spinal cord, and by stimulating these centres increases the nutrition of the trib- utary nerve-fibres. It is needless to state that the neuralgias of syphilis and scrofulosis are to be treated by the specific remedies directed to the cure of these affections, Avhile at the same time the various symptoms are carefully controlled by appropriate palliatives. When nervous exhaustion causes neuralgia, phosphorus is a useful remedy, particularly in those cases Avhich are convalescing from acute fevers. Sometimes malarial poisoning produces a violent form of supra- orbital pain knoAvn as "broAV ague," Avhich is to be relieved, not by ordinary remedies, but by large doses of quinine. The relief of the states producing neuralgia having been spoken of, it yet remains for us to consider the measures to be adopted for the cure of an attack. Fortunately, the recent advances of thera- peutic study have placed in our hands a large list of drugs not apt to produce a habit after prolonged use, comparatively safe though active, and not of disagreeable taste or evil general effect. By these terms the Avriter refers to antipyrine, acetanilid, and phenacetin, all of which possess Avonderful powTer in the alleviation of pain dependent upon true nervous involvement. In order to avoid failure in the use of these drugs in the relief of headache, we must always remember that their field of service is that of neuralgic pain, not other pains. Antipyrine is to be used in the dose of 5 to 20 grains (0.3-1.3) for ordinary neuralgia or the pain arising from the crisis of locomotor ataxia, acetanilid in the dose of 3 to 8 grains (0.18-0.5) for the same purposes, and phenacetin in the same amount as acetanilid. Upon these remedies, combined with caffeine and the bromides according to circumstances, Ave now depend, and the following pre- scriptions Avill be found of service: R.—Antipyrini............3j vel ^ij (4.0-8.0). Caffeinae citratis..........gr. xx (1.3).—M. Ft. in chart No. x. S.—One every thirty minutes till relieved. 588 DISEASES. The following may be of use also: R.—Antipvrini............3J vel ^ij (4.0-8.0). Potassii bromidi.........^iij (12.0).—M. Ft. in chart No. x. S.—One every thirty minutes till relieved. Or, when the caffeine in the first prescription causes nervousness, R.—Antipyrini............gj vel .^ij (4.0-8.0). Caffeina? citratis..........gr. x (0.65). Potassii bromidi.........3hj (12.0).—M. Ft. in chart No. x. S.—One as above. In any one of these prescriptions acetanilid or phenacetin may be substituted for the antipyrine. A very effective remedy in some cases of neuralgia of the fifth nerve is croton chloral in from 5- to 20-grain (0.3-1.3) doses in pills of 5 grains (0.3) each. In some cases of anaemic neuralgia of the head nitrite-of-amyl inhalations have proved useful, by reason of the cephalic flushing pro- duced by this drug. A very large number of local applications have been used with success in obstinate neuralgias and other cases not so difficult of cure. Cocaine cannot be applied, as it does not penetrate the skin, but relief can sometimes be obtained by the local use of the oleate of aconitine painted over the spot if it be limited in area. Much of this alkaloid cannot be applied, lest poisoning by absorption occur. Where the nerve is very superficial it can often be treated by cold with great success This is accomplished by freezing the parts Avith an ether or a rhigolene spray or by the application of a small package of finely-chopped ice and salt. Within the last few years the treat- ment of neuralgia by kataphoresis (see Part III.) has come into prom- inence, and consists in the use of some local anaesthetic, such as chlo- roform, which is applied over the part on a small piece of lint, and a galvanic current used through the pledget, Avhich is attached to the positive pole. Under these circumstances the anaesthetic passes through the skin and affects the nerve. A very useful local injection in localized neuralgia is 4/ to \ of a grain (0.016) of morphine, but the danger of beginning the morphine habit is to be remembered when treating chronic cases. Sometimes acupuncture (see Part III.) is of service, and the surgeon may be called upon to stretch the nerve or to do a neurectomy. There still remains to be considered a form of neuralgia generally known as migraine. This affection is very severe in its manifesta- tions, and is often most obstinate in yielding to treatment. Com- monly it is associated with eye-strain or cerebral disease or other sim- ilar cause, and these must be removed before a cure is entirely effected. The best treatment of most of these attacks is the use of 20 drops (1-3) of the tincture of cannabis indica every hour if a good preparation can be had, or by the use of \ to 4; grain (0.016-0.30) of the solid extract every tAvo hours, accompanied by 10 to 20 drops (0.65-1.3) of tincture of gelsemium. (See article on Headache.) OBESITY. 589 NIPPLES (SORE). Whenever the nipples become sore, so that it is impossible for the mother to alloAv the child to nurse, a solution of cocaine of the strength of 4 grains to the ounce (0.2 : 32.0) should be applied to the part, and Avashed off carefully just before the child sucks. Following the nursing, a solution of boric acid, of the strength of 20 grains to the ounce (1.3 : 32.0) of Avater or mucilage of acacia, may be used over the part, the nipple being thoroughly dried beforehand. Where the fissures are deep and sIoav to heal the tip of a stick of silver nitrate may be applied to them with advantage. Some practitioners employ tincture of benzoin over the inflamed part, and glycerite of tannin is often of value. Cleanliness, dryness, and care of the breast previous to parturition do much toAvard preventing the condition. Sometimes it is necessary to use a breast-pump or nipple-shield before a cure can be effected. OBESITY. Whenever an excess of fat accumulates in the body as part of its substance, various discomforts, both mental and physical, arise, and in addition the normal functions of all the parts are so disturbed or interfered Avith that the continuance of health is often impossible. In many cases the deposition of fat about the heart or betAveen its fibres results in serious symptoms; and breathlessness on exertion is produced by the obstruction which is offered to the free movements of the diaphragm by masses of omental fat, aided by the fact that the great weight and bulk of the body requires severe muscular effort. It is worthy of note, also, that a layer of fat over the body increases the vascular surface very greatly, and in consequence gives the heart the labor of supplying a larger number of blood-vessels. The causes of obesity are numerous. In many families there is an inherited tendency, while in others only certain individuals are affected. These persons are fat because their systems naturally tend to the de- posit of obese materials, in the same way that the members of one family have large bones, Avhile those of another have small bones. The etiology of obesity, outside of the causes just named, are very numerous, but the chief one is over-indulgence in food. Just at this point it is not out of place to state exactly Avhat over- indulgence in food means. Every individual is a law unto himself in regard to the amount of food which is consumed and ingested. One often sees large, poAverful, Aviry men, who eat little, sit beside others, not so poAverful or large, Avho eat excessively, and who appa- rently do not suffer from indigestion in consequence. Neither of these two groups becomes excessively fat, because one represents a grate Avhich burns its fuel so that there is no waste, while the other resem- bles a grate in Avhich there is ahvays a residue of unburnt coal, Avhich is cast out with the ashes as effete matter. As different engines of the same build require varying amounts of coal, so do different men 590 DISEASES. assimilate different amounts of food. No stated amount of food can be set doAvn as a man's daily portion until his case is carefully studied, but it is important to remember that the quantity of food is generally in direct ratio to the severity of the toil, and that a man Avho loafs about a club or "takes life easily " often eats more than a day-laborer—of far richer foods, too—and Avonders Avhy he gets stout. In nearly every case of obesity not dependent upon gross disorder of the trophic nerves over-indulgence in food is the cause. To some this may seem absurd, and the patient will say that he eats just enough to keep him from feeling empty betAveen meals; but this does not alter the case in the least. The proper amount of food for a man is not Avhat his appetite or gastric viscus calls for, but Avhat his sys- tem needs. To this further reference will be made Avhen considering the diet for obesity, found below. The very presence of fat aids in the deposition of it, for, by act- ing as a non-conducting pad all over the body, it prevents the dissi- pation of heat, and so decreases the combustion of those substances which, Avhen not used for the manufacture of heat, are deposited as fat. Again, we nearly ahvays find that obese persons take alcohol with their food, thereby increasing the fat in their bodies; for, find- ing that they cannot digest all the substances which greediness makes them SAvallow, they take alcohol to stimulate their digestive apparatus to increased efforts and assimilation. Further than this, alcohol adds force to the body, and preserves the tissues by substituting itself for food in the oxidizing processes. We find, therefore, that three great causes are active in producing corpulence in many cases—namely, heredity, over-indulgence in food, and lack of exercise, which is one of the means by Avhich over-indul- gence is produced; i. e. less exercise, less food needed, but often more eaten. The treatment of corpulence rests solely upon the conditions named. In all instances the diet is the important point for the bestowal of care. Beference has already been made to the fact that the needs of the system are the criterion by Avhich we judge the amount of food necessary to each case, not the sensations in the stomach. The use of coca by the natives of South America enables them to withstand hunger and privation, not because it gives tissue to the body, but because it paralyzes the sensory nerves in the stomach and relieves the sensation of hollowness or weakness which we are accustomed to overcome in this country, in the absence of food, by tightening our belts. Every one Avho has undergone severe mental or physical labor and missed a regular meal will remember that about the usual hour for the meal his sensation of emptiness may amount to nausea and distress, but the hour once passed he feels as strong as before until by prolonged toil he so exhausts his poAvers that the system forces him to eat, not so much from hunger as from exhaustion. To under- stand this clearly, we must recollect that the system keeps its shares of force in the same way as a careful speculator keeps his shares of stock—namely, one part in active use for speculation, the other half for reserve in case of need. In health the stomach begins to " feel OBESITY. 591 hungry " as soon as the speculative shares of force are nearly used, in order to cause the ingestion of more food and to preserve the " sinking fund " intact. It becomes evident, therefore, that the mere presence of hunger is purely a symptom, not an indication of the absolute necessity of food, for, if it were, the consumptive would be notorious for his appetite, instead of being noteworthy for his anorexia. The food of the patient suffering from obesity is to be cut down gradually, and the character of it arranged so that, though its bulk be great, its nutritive properties are small. Beef and other meats are concentrated foods containing much nourishment in a small space, while lettuce, spinach, cabbage, and nearly all vegetables, except roots or tubers, contain a large amount of fibre useless to the body. By the use of a carefully arranged vegetable diet in obesity we cut down the actual amount of food absorbed, and by its bulk keep the stomach so busy at sifting the nutritious from the non-nutritious mate- rials that hunger is not felt, because another meal-time is reached almost before the food of the first is assimilated. We find, therefore, that the diet for the reduction of corpulence should consist chiefly of bulky vegetables, but not too exclusively of any one article or set of articles. Heretofore it has been thought that proteids (meats, eggs, etc.) should be used to take the place of all hydrocarbons or carbohydrates (fats, starches, and sugars), but this is not physio- logically correct, as both forms of food are ahvays needed for health, and it has been found that proteids may be converted into fats in the body. The following bill of fare will be found of service in the treatment of obesity: Breakfast: One or two cups of coffee or tea, Avithout milk or sugar, but SAveetened with a fraction of a grain of saccharin. 3 ounces of toasted or ordinary white bread or 6 ounces of bran bread. Enough butter may be used to make the bread palatable—not more than 1 ounce. Sliced raw tomatoes Avith vinegar or cooked tomatoes without any sugar or fats. This diet may be varied by the use of salt or fresh fish either at breakfast or at dinner. Noon meal (dinner): One soup-plate of bouillon, consomm^, St. Julien, or other thin soup, or Liebig's or Johnston's beef essence, fol- lowed by one piece of the Avhite meat of any form of fowl or a small bird. Sometimes a small piece, the size of one's hand, of rare beef or mut- ton, but no fat, may be allowed, and this should be accompanied by string-beans, celery, stewed or raw, spinach, kale, cabbage, beans, asparagus, leeks, and young onions. Following this, lettuce with vinegar and a little olive oil (to make a French dressing), a cup of black coffee or one of tea, and a little acid fruit, such as some sour grapes, tamarinds, and sour oranges or lemons, may be taken, and followed by a cigar or cigarette. Supper should consist of one or two soft-boiled eggs, which may also be poached, but not fried, a few ounces of bran bread, some salad and fruit, and perhaps a glass or two of light, dry (not sweet) wine, if the patient is accustomed to its use. 592 DISEASES. Before going to bed, to avoid discomfort from a sensation of hun- ger during the night, the patient may take a meal of panada or soak Graham or bran crackers or biscuits in Avater and flavor the mass with salt and pepper. The reduction of diet is generally best accomplished slowly, and should be accompanied by measures devoted to the utilization of the fat present for the support of the body. Thus the patient should not be too heavily clad, either day or night, should resort to exercise, daily becoming more severe, and should drink freely of water, pro- Added that sweating is established sufficiently freely to prevent the accumulation of the liquid in the vessels and tissues. Very often a cold bath will, by its dissipation of heat, cause destruction of fat, which will be burnt up in the body in the manu- facture of heat-units to maintain the temperature; and if the patient is not too anaemic and stands this exposure to cold well, the bath should be repeated each day or a Turkish bath used instead. The bowels should be kept active by laxative fruits or purges, but if liquids taken in drink are not eliminated rapidly, saline purges are useful, since, if the blood-vessels are engorged, the circulation in the capillaries is slow and a deposit of fat is apt to result. Where proper exercise is impossible the rest cure, Avith massage, electricity, passive exertion, and an absolute skimmed-milk diet, may be resorted to, particularly in those persons known as "fat anaemics," who have not enough red corpuscles in their blood to carry sufficient oxygen to the tissues to complete oxidation. PERICARDITIS. Inflammation of the pericardial sac is a frequent occurrence and requires prompt treatment. If the case be sthenic and is seen early, five to ten leeches should be placed over the praecordium, and at the same time sufficiently large doses of veratrum viride or aconite resorted to to depress the circulation, and by the dilatation of the blood-vessels elseAvhere to draw off the blood from the inflamed area. To prevent the outpouring of a plastic exudate capable of undergoing organiza- tion and forming adhesions, calomel should be given in J-grain (0.03) doses every hour, combined Avith enough opium to prevent purgation. An ice-bag placed over the praecordium not only relieves, quiets the circulation, and reduces the temperature, but also acts favorably in modifying the severity of the inflammation. Where the case passes from the acute stage of inflammation to that in Avhich effusion takes place, the treatment changes at once, and becomes supportive if the system shoAvs signs of failure. The fric- tion-sounds of the first stage are now lost, and the heart-sounds may be feeble or muffled in tone by reason of the effusion present. Digi- talis, alcohol, or caffeine may be used if the heart shoAvs signs of fail- ure, but when digitalis is used its influence should be carefully watched, since the employment of this drug produces a very full diastole or dilatation of the ventricles, and these are already cramped for space PERITONITIS. 593 in Avhich to dilate by reason of the exudate Avhich has entered the pericardial sac. If the effusion is sufficient to endanger life, it should be tapped and aspirated away very gradually. Often it is best to use a long needle attached to a hypodermic syringe in order to be sure that there is fluid. The best place for making the puncture is the fourth or fifth intercostal space, one inch to the left of the edge of the sternum. Should pus be present, free drainage must be gradually established. In other instances, if the patient is strong, it is only necessary to administer hydragogue purges, such as jalap (20 grains [1.3] of the compound jalap powder), or elaterium ^ grain (0.01), or a saline purgative in concentrated form, before breakfast. Often a blister over the praecordium is of service. PERITONITIS (ACUTE). An inflammation of the peritoneum, as Avith any serous membrane, may be either sthenic and fibrinous or asthenic and serous. The same rules hold, therefore, in this case as in all forms of inflammation— namely, that circulatory depressants are only to be used in the first type, and folloAved, if needed, hx stimulants ; Avhereas in the asthenic class the use of stimulants is called for at once and depressants are contraindicated. For many years the profession have recognized opium and belladonna—particularly the former—as the most uni- versally applicable remedies and best curative drugs for cases of peritoneal inflammation, and Avhile a neAv method of treatment in this disease has arisen, it has only proved itself of value in a limited number of cases. Remembering constantly that peritonitis is an inflammation, the course of treatment to be pursued by the physician is by no means complicated. While the use of veratrum viride may be resorted to when the patient is strong and the pulse hard and tense, aconite may perhaps in such cases be better, for the double reason that vomiting is apt to occur of itself, and may be induced by the veratrum viride, Avhile aconite decidedly prevents any such tendencies. This is import- ant in vieAv of the fact that vomiting is ahvays to be avoided, lest the retching increase the peritoneal inflammation. If vomiting is present, this and the pain should be controlled by the use of large doses of opium and belladonna—say | grain (0.03) of the extract of each to an adult—and these should be accompanied by the applica- tion of leeches to the abdominal Avail in large numbers—from ten to thirty. If these cannot be had, a mustard plaster may be used. If the vomiting is too severe to permit of the administration of drugs by the mouth, they must be given by the rectum in \ a pint (250 cc.) of starch-water, laudanum and the tincture of belladonna being em- ployed in the proportion of 1 drachm (4.0) each. Opium can always be taken in full dose by those suffering severe pain, and it seems to be particularly Avell borne in peritonitis. The use of this drug in peritonitis, as with all other drugs in medicine, is not governed by the amount in grains Avhich has been used, but by 38 594 DISEASES. the effects Avhich it produces. There seems, too, to be some evidence that opium can be taken in full amounts without disagreeable results; and the same rule applies Avith equal effect to belladonna, it being given for the influence exerted and not according to the number of grains used. Both of these drugs, unlike depressants and stimulants, may be used in all forms of peritonitis and in all stages if called for, but the leeches and counter-irritation are limited in their use to the early periods of the attack. The use of calomel in peritonitis is highly praised by some and condemned by others, largely because its proper sphere is not recog- nized. Mercury does good only in the severe acute forms of peri- tonitis wThich arise from traumatism or other cause, and is to be used for the liquefaction or changing of a fibrinous exudate into a serous exudate incapable of undergoing organization. If, on the other hand, the peritonitis be tubercular or if it occurs in the course of some exhausting disease which has largely sapped the patient's strength, the use of mercury is exceedingly harmful and tends to increase the danger of a fatal result. The remaining directions Avhich the physician should give are, absolute rest, Avhich is nearly always adhered to voluntarily by the patient, owing to the pain, and the use of small quantities of pre- digested—that is, pancreatized—milk administered every feAv hours or every hour in small quantities. Often in peritonitis the inflammation extends to the boAvels, and paralysis of their muscular fibres occurs. As a result of this obsti- nate constipation ensues, which is not to be overcome by purges, Avhich if mild will not act, and if severe are dangerous, but by the use of belladonna and opium already spoken of. The rationale of this treatment is not far to seek in the light of our present physio- logical knowledge. Belladonna acts as an antispasmodic upon all unstriped muscular fibre, and in the large doses Avhich should be given in peritonitis depresses the peripheral ends of the splanchnic or inhib- itory intestinal nerves. In this way the muscular fibres Avhich are in spasm become relaxed so that peristaltic waves may freely move. The value of the opium, also, is apparent, for it allays irritation and prevents the reflex muscular spasm dependent upon the pain and inflammation. Obstinate constipation after the ingestion of irritant foods, such as putrid meat, will often be relieved by opium and belladonna as effectively as if the patient Avas purged by an ordinary purgative. Very frequently in acute peritonitis tympanites becomes not only a very painful, but even a dangerous symptom, the distention of the belly being very great. This may be much relieved by the employ- ment of turpentine stupes (see Turpentine), and in some cases by the rectal injection of milk of asafoetida, or, better still, turpentine J to 1 drachm (2.0-4.0), milk of asafoetida 3 ounces (96.0), and warm water 4 ounces (128.0). The thirst of the patient is often extreme, and should be relieved by small pieces of ice and small, but frequent, draughts of water. The old theory that this advice is wrong because of its producing PERITONITIS. 595 vomiting is exploded. The vomiting is reflex, and the taking of water simply enables the patient to A'omit instead of retch. There is no reason for causing suffering by refusing liquid to cases of peritonitis, but of course the stomach must not be loaded with liquid, hot or cold. It is also a mistake to overcome restlessness by force. As Treves well says, the wretchedness of restlessness has a natural relief in little movements. Not content Avith having made a vast stride forward during the past few years, abdominal surgery brings Avith it not only new methods of treating diseases in this region by the knife, but also has given us a method of curing peritonitis by the use of saline purgatives which is certainly of the greatest value in those sudden inflammatory con- ditions Avhich occasionally spring into life after operations upon the abdominal area. It will be remembered that abdominal surgeons have been the chief advocates of this treatment for several years, and that the Avonderful results Avhich they have obtained, the reputation of the reporters, and the complete reversal of all our ideas concern- ing the treatment of the disease have called forth not only an enormous number of trials of the method in this country, but have also brought forth two opposing factions in the profession. The first of these is chiefly composed of surgeons; the second, of persons Avho in a long experience have reached good results by older methods, and who are generally physicians. The first class dogmatically assert that the physician should turn over every case of peritonitis to the surgeon to be opened, searched, and purged; the second class do not deny that saline purgatives do good in the hands of the surgeon, but are more conservative in their opinions concerning the general measures to be employed in all cases of peritonitis. Again, it would seem impossible at the present time to assert that peritonitis may be either idiopathic or traumatic without bringing upon one's head a storm of criticism; for on the one side Ave have a number of physicians who believe that peritonitis may arise without any direct exciting cause, and on the other hand an equally large body of observers who assert that it is essentially a secondary inflam- mation brought on by direct contiguity with an already inflamed tis- sue, or else that the inflammation is set up by the escape of foreign bodies into the peritoneal cavity, or by pathological changes occur- ring in organs normally situated in these regions, as, for example, fibroid enlargements of the uterus with impaction in the pelvis, or pyosalpinx. As it is absolutely impossible for either side at present to prove that their opponents are wrong, and as both sides are not to be doubted in the integrity of their observations, the unbiased judge can but come to the conclusion that, as yet, we have a right to believe that idio- pathic peritonitis may exist. If those observers are correct who believe that no peritonitis arises saA^e as the result of some one of these conditions, then the attempt on the part of the physician to treat such a case is criminal negligence, and as such cannot be too severely condemned; but too many cases of peritonitis are to-day Avalking examples of the value of the use of 596 DISEASES. opium to permit of any one asserting that this treatment is useless or that the knife of the surgeon is to be used in every case ; yet some of the more radical members of the profession Avould have us believe that the abdomen should be opened solely for the purpose of making a diagnosis, and that, this having been done and no intestinal compli- cations found, salines should be given. Whether the inflammation be idiopathic or not has little to do, hoAvever, Avith the methods which Ave are to resort to in the medical treatment of this condition. It cannot be gainsaid that the results obtained by surgeons in the use of saline purgatives have been start- lingly brilliant; neither can any one deny that their methods may sometimes be employed in medicine as avcII as in surgery; but there are several points to be recalled by both parties which Ave think so seriously modify the views of each as, after all, to unite them in a bond of unanimity. No one denies that the surgeon does rightly when he uses salines to prevent peritonitis after an operation; but the knowledge of the condition of the patient after he has been ope- rated upon by the surgeon, and that possessed by the physician when called to see a case of peritonitis, are radically different; for the sur- geon has a right to believe that the intestinal canal is patulous and devoid of impactions and intussusceptions, while the latter knoAvs not Avhether he has before him an inflammation of the peritoneum without intestinal involvement or inflammation dependent upon some abnormality in the primae viae. As a consequence it is perfectly proper for surgeons to administer salines, Avhich, to use their OA\n Avords, not only deplete the abdominal blood-vessels, but also by the increased peristaltic movements produced prevent adhesions; Avhile the physician in the case of peritonitis from perforation, impaction, or intussusception may do the patient an immense amount of harm by such a procedure long before it is possible to decide Avhat the cause of the trouble may be. It is evident, therefore, that the opium treatment must be adhered to, at least until the diagnosis is formed, unless at the very first sign of pain an exploratory incision is made, instead of using those remedies generally employed in ordinary attacks of abdominal discomfort; and it should not be forgotten that pain and tenderness with inflammation are the symptoms not only of peritonitis, after section, but also of many other states in the ordinary individual.1 It is also evident that other conditions may exist Avhich render the administration of purges unjustifiable, and in which the use of the knife by the surgeon is not to be thought of. It is undeniable that the surgeon should be summoned the moment a suspicion of threat- ened perforation arises, but in the case of a person in Avhom an enter- ritis has arisen locally by an old adhesion, increased peristaltic move- ment is equivalent to strapping the normal side of the chest in pleurisy with the object of giving the diseased side more exercise. Again, it is of the gravest importance that both the physician and surgeon should distinguish very clearly betAveen an inflammation of 1 These views of the writer have recently been strongly supported by two very thorough and thoughtful papers by Eichardson and Fitz of Boston. PERNICIOUS MALARIAL FEVER. 597 the peritoneum in a strong, healthy person and in one Avho is in a condition of vital depression or exhaustion from prolonged disease elseAvhere. Depletion by means of purges is, of course, in the first class as much indicated as the application of leeches or bleeding, but in the second class quite as strongly contraindicated. In the dynamic form of inflammation there is danger of adhesions being formed by reason of the fibrinous exudate throAvn out; in the adynamic condi- tion of inflammation there is already an enormous exudation of serum into the abdominal cavity which purges cannot remove until they have drained off a large amount of liquid from the blood. Again, there are some cases of peritonitis Avhich are ushered in by an acute paroxysm of pain, but Avhich do not continue during their Avhole course as dynamic cases, and in Avhich depletion at first results in exhaustion later on. Until the profession have employed these tAvo methods side by side, with an absolutely unbiased opinion, for a long period of time, the only proper conclusion to be reached seems to the Avriter to be this: namely, that in acute peritonitis, suddenly lighted up in a sur- gical case, and Avhich is recognized almost at the moment of its birth by the ever-Avatchful surgeon, Avho is on the lookout for it, salines may be given; Avhereas in the case which the physician rarely sees till hours have elapsed, and in Avhich grave doubt exists as to the cause of the trouble, opium and external methods of depletion must be resorted to. PERNICIOUS MALARIAL FEVER. This is one of the most acutely dangerous diseases knoAvn to man if it be fully developed, and requires the greatest activity and skill on the part of the physician, Avho may be called upon to treat a large number of widely varying symptoms, all of a pressing nature, at one and the same time. The chief indication is for the use of quinine in its most soluble forms, in solution and in large doses, Avhich may amount to 60 or 100 grains (4.0 or 7.0), by the mouth, by the bowel, and hypodermically. The manner in which quinine acts in malarial poisoning is noAV generally conceded to depend upon its influence over the malarial germ of Laveran, which has been so well studied in America by Osier and Councilman. All the students of the subject have found that at least some of these bodies are made inactive and disappear under the influence of the drug, and we have at last obtained a know- ledge as to the manner in which quinine does good. Avhich in its absence was a constant opprobrium to scientific medicine. The say- ing that "As soon as the physiologist and pathologist tell the thera- peutist Avhat disease is, the latter will tell how his remedies do good," is very well exemplified by the use of quinine in malaria and the present well-founded scientific reasons for its employment. (See Inter- mittent and Remittent Fevers.) 598 DISEASES. PLEURITIS, or PLEURISY. Under the consideration of Peritonitis the writer has already given so full an account of the treatment of acute inflammations affecting serous membranes or surfaces capable of throwing out a croupous or fibrinous exudate that it seems scarcely necessary to repeat the direc- tions here. It is to be remembered that an inflammation of the pleura is in many Avays identical with an inflammation anywhere. The treat- ment of this disease in its early stages is therefore identical Avith other inflammatory diseases, or, in other words, the use of venesection, or, better still, of tincture of veratrum viride or aconite to bleed the man into his OAvn blood-vessels, is to be resorted to. Along with these measures counter-irritation in the way of blisters or depletion by wet cups is in order; but dry cups are never to be used in pleurisy over the diseased area, since they may produce ecchymosis of the pleura by their suction exercised through the intercostal spaces. Where dry cups are used they should be employed at some distant spot, as over the skin of the back, Avhere the tissues are too dense to permit of pleural involvement by cupping. In cases which are very sthenic it is best to give calomel for its aplastic effect in order to prevent a fibrinous exudate. By this treatment nearly every case of pleuritis, if seen early enough, can be aborted. When the pain from the pleurisy is excessive and the movements of respiration greatly increase the discomfort, strapping the chest- Avall may be resorted to. This is done for the purpose of immobil- izing the chest. The straps should consist of adhesive plaster, two and a half inches wide and long enough to reach from the vertebrae to the sternum. They should be applied tightly during expiration, slightly overlapping one another at a right angle to the spine, and not in the line of the ribs. Both in pneumonia and pleurisy a poultice is often useful when applied to the chest, but, while this is efficient, it generally soils the clothes and slips down to the waist. A cotton jacket is much better. It consists of one or two thicknesses of carded cotton basted inside a thin undershirt, like a fur-lined coat. On the outside of the shirt oil-silk should be basted. By doing this we envelop the chest in a warm poultice, because the heat of the body keeps the cotton at the proper temperature, while the oil-silk, by preventing evaporation of the moisture exhaled from the skin, soon causes the cotton to be moist as well as warm. Poultices are for ever getting cold and boggy, and if not changed make the patient Avorse. If they are changed, there is danger of the patient taking cold: to avoid such an accident a fresh and hot poultice should ahvays be ready by the side of the nurse before the old one is taken off, so that as little exposure is suf- fered as possible. When the second stage of pleurisy, or the stage of effusion, is reached, other lines of treatment are needed. The cardiac sedatives have been stopped as soon as the quieting of the circulation, the lessen- ing of pain, and the absence of a friction-sound denote the passage of the case from the first stage to the second. If the pulse becomes weak PNEUMONIA. 599 and the system is depressed, stimulants in the form of alcohol or digi- talis are needed, and special care must be devoted to the condition of the exudation in the pleural space. If the effusion is sufficiently large to cause dyspnoea on exertion, and is not readily removed by the administration of salicylic acid in the dose of 1 to 2 drachms (4.0-8.0) a day, or saline purges given at the proper time in concen- trated form, or if it is not taken up by the vessels after jalap or elaterium is used, then resort must be had to aspiration of the liquid by the proper apparatus. The physical signs at this time, it will be remembered, consist in flatness on percussion over the lower portions of the chest, which area of flatness generally varies Avith the change in the position of the patient from the erect to the recumbent posi- tion, unless the effusion is sacculated. BloAving or bronchial breath- ing at the apex of the lung Avhen this organ is compressed upAvard by the fluid beneath it is often heard. If the effusion is on the right side, the apex-beat of the heart is apt to be displaced to the left. If it is on the left side, there is obliteration of Traube's semilunar space, which is a spot at about the level of the sixth and seventh ribs ante- riorly beloAv the nipple, Avhere there is usually a tympanitic note on percussion. During this stage of effusion blisters are often very use- ful in aiding in the absorption of the liquid which is present. PLEURODYNIA. This condition, being one of intercostal neuralgia, should be treated according to the directions given under the headings of Neuralgia and Counter-irritation. PNEUMONIA. It is of the greatest importance that the physician should employ drugs in this disease at the proper stage, in the proper dose, and Avith definite ends in view. In the beginning of a pneumonia of the croup- ous type the state of the patient is utterly different, as a rule, from that of an individual attacked by the catarrhal form of this disease. The first generally attacks a person possessing sufficient vitality and force to cause him to suffer an acute inflammation of the tissues involved. In other Avords, the balance of health being destroyed, systemic disturbance is far greater than if less vital force Avas mis- directed from its proper functions, and, as a consequence, high fever, with increased and excessive arterial tension, rapidly asserts itself, the changes in the circulatory system being produced both directly by the diseased processes and indirectly by the heat of the body act- ing as a stimulant to all its functions. In catarrhal pneumonia the systemic changes are, as a rule, somewhat different, since the patient is frequently already suffering from some predisposing disease, such as whooping cough, bronchitis, measles, or similar affections. If the patient is in good condition, the fever and circulatory excitement of 000 DISEASES. catarrhal pneumonia may be equal to that occurring in the croupous form ; but even if this be so, there will ahvays be found symptoms of lowered, vitality Avhich must modify the treatment in the early stages of the attack. For a clear and rational understanding of these con- ditions the reader should completely grasp the difference betAveen them, and under the title of Exhaustion and Depression the Avriter has already defined the differences between these states. It is important to emphasize that many diseases, taking pneumonia as an example, may be produced in two entirely different Avays or in two states of the system diametrically opposed to each other. On the one hand, Ave have a pneumonia attacking the lung of a strong and healthy individual Avho may be exposed to cold; on the other, a pneu- monia may attack an invalid recovering from typhoid fever or other exhausting disease, such as any one of the exanthems or phthisis. The question of the presence of pneumonia is, of course, to be decided, but the state of the system is to be the guide in the treatment. In the perfectly healthy man aa4io has pneumonia exposure to cold upsets the normal balance, and the full force /f his system runs riot and must be reduced to its proper level. In the weakly individual the curve of health has fallen below the normal line and must be raised until it is regained. In a sthenic pneumonia there are three stages of treat- ment: (1) The depressant or abortive stage, and, if this fails, (2) the supportive, folloAved finally by (3) measures for the relief of the recov- ering lung in convalescence. In asthenic adynamic pneumonia Ave must omit all depressant treatment and resort at once to the second or supportive measures. The remarks which immediately follow, it is to be remembered, have only to do with the so-called first stage in sthenic cases. If the patient shows symptoms of weakness, as evidenced by the pulse and other sign-boards of disease, the treatment is to be consid- ered as that of the second stage. It should be remembered, hoAvever, that the mere fact that either stage of the disease is in existence should only lead to a most thorough study of the indications present. Primary Stage.—The primary stage of pneumonia consists in an increase in the calibre of a number of the blood-vessels of the lung, so that congestion occurs, and, as a result, the blood stagnates and an exudation finally ensues. We have, therefore, a state of the vascular system in Avhich all the blood-vessels of the body are tense except those Avhich are relaxed by the inflammation in the lung, and the blood, floAving in the direction of least resistance, still further stag- nates in and engorges the diseased area. All this occurs in the first stage, and it is the object of the physician so to decrease the over- pressure in the general system that the blood will leave the lung in order to obey the laAV of resistance which has originally caused it to accumulate in this locality. In those instances Avhere the disease-process goes on still farther into Avhat is knoAvn as the second stage, or that of consolidation, the indications are at once reversed, and the change from the proper plan of treatment for the first stage to that necessary for the second may be PNEUMONIA. 601 required very promptly. The stagnation of the blood, combined Avith the pressure exerted by the rapidly-forming exudate, not only narrows the patulous vessels by its pressure, but so prevents the expansile movements of the lung that proper pulmonary circulation cannot occur. As a consequence the right side of the heart is distended at first, and exhausted finally by the resistance offered to the blood-stream which it is forced to propel, and is simultaneously fed by blood Avhich, by reason of the deficient respiration of the patient, is loaded with an excess of carbonic acid. Under these conditions the circulatory sys- tem must be so stimulated by the physician as to be able to overcome the obstruction. The methods Avhich may be resorted to during the primary stage are very numerous, but there are only tAvo Avhich can be recognized as of great value, while the other procedures are but subordinate measures. These tAvo measures are bleeding and the use of such drugs as our clinical and physiological knoAvledge tells us are proper. The discussion of bleeding as a therapeutic measure will be found in Part III., and it will readily be seen that the abstraction of blood from the entire system Avill rapidly relieve the diseased lung. The second, and by far the best method, is by the use of veratrum viride, aconite, or antimony, and perhaps several other drugs of the same class. In adults veratrum viride Avill be found far more useful than aconite, Avhile in most instances the reverse will hold true in children, in Avhom aconite ahvays exercises a much more wholesome influence than any other drug of this character. Supposing that the disease be in the adult, let us for the moment consider avIiv veratrum viride in this first stage is so useful a medicament. It Avill be remembered that the tAvo alkaloids of veratrum viride, jervine and veratroidine, possess different influences, and that betAveen them they fulfil every object which is sought after. According to the experiments of Wood, jervine is a most powerful vasomotor depressant, relaxing to a remark- able degree the Avails of the blood-vessels everyAvhere ; and not only does it do this, but at the same time it so quiets the heart by an action upon its muscle or ganglia as to reduce its force, thus preventing engorgement of the lung ; Avhile veratroidine by stimulating the inhib- itory nerves of the heart slows its beat, fills the ventricles by increas- ing their scope and the period of diastole, and allays excitement. Further recollection of physiological facts shoAvs us that the blood- vessels of the abdomen are capable of holding all the blood in the body, and into these will Aoav the major portion of the fluid Avhich is filling the pulmonary vessels, at once lowering blood-pressure very greatly everywhere, so that the lung is starved of blood Avithout dan- gerous engorgement taking place in the abdomen. The manner of using veratrum viride is a good example of the necessity of careful physical diagnosis and a clear idea of Avhat one is about to do. Used at the proper time and in the proper amount, it is most useful, but Avhen abused it is dangerous or disappointing according to the carelessness of the physician. The following case, briefly described, is in point: A. E----, aged twenty-five, brakeman, always strong and well, was much exposed to Avind and snow after 602 DISEASES. having been thrown into a profuse swreat by coupling a large number of cars. He had a severe chill in the evening, ushered in by a cough and followed by fever and a sense of oppression, Avith somewhat hur- ried breathing and pain in the side. At the time of admission into the author's wards, three hours after the chill, he had a temperature of 103° F., the eyes were bright, the expression of the face slightly anxious. Physical examination shoAved exaggerated breathing over the entire right side, Avhile at the base of the left lung posteriorly there were marked bronchial breathing and dulness on percussion. Fine rales could be heard now and then, but Avere not constant. The pulse was full and bounding. This man Avas at once given 3 drops (0.15) of the tincture of veratrum viride every two hours until such a time as he complained of faint nausea, and his pulse was found to be no longer rapid and bounding, but soft and sIoav, while the skin was moist and relaxed. The sense of oppression disappeared, the expres- sion of anxiety passed aAvay, no pain was felt in the chest, and the attack was aborted. The employment of veratrum viride in this instance took place at a period in which it was possible to quiet the inflammation by " bleed- ing the man into his OAvn vessels," or to reduce the hyperaemia and congestion. If veratrum viride had been used later, it would have done more harm than good, as Ave have already shoAvn Avhen discuss- ing the state of the inflamed part at the commencement of the second stage, for the heart Avould then be laboring to push blood past the con- solidated area, and the disease be fairly started or developed and beyond the stage in Avhich its abortion would be possible. The advantages of veratrum viride are its completeness and rapidity of action; the fact that it preserves in healthy blood-ves- sels the blood which may be needed in the struggle for life if the dis- ease is not aborted; and, lastly, its safety1 is a point largely in its favor. The use of aconite in pneumonia is of particular value in children, in whom the emetic effects of veratrum viride often prevent its being pushed to a sufficient degree to permit of an effect on the circulation. The indications for its employment are identical with those already named when speaking of the use of veratrum viride, and the only question which arises is as to whether its physiological action and clinical record justify its use. In reply to such a query the answer may be that it does act favorably in pneumonia, but that it is not as thorough in the case of adults as other drugs. The studies of Rirger, Achscharumow, Boehm, and Wartmann all prove that the drug is a distinct cardiac depressant, but there is no reliable evidence to prove that it exerts any vasomotor influence—the fall of arterial pressure, ac- cording to most writers, being produced only by the decreased action of the heart. On the other hand, there can be little doubt that clinically the arterial pressure is decreased by the drug. It at once becomes 1 Both veratroidine and a resin contained in veratrum viride are powerful emetics, so that upon the ingestion of a poisonous dose of the drug so much is generally vom- ited that recovery spontaneously occurs. The symptoms produced are said to yield to treatment with remarkable readiness. PNEUMONIA. 603 evident, hoAvever, that Avhile its influence is for good in pneumonia, it does not possess the scope of action Avhich makes it desirable in every case, and yet its powers of producing nervous quiet, allaying vomiting, or meeting some idiosyncrasy make it a drug always to be thought of in this disease. Antimony, although at one time used very largely in the treatment of pneumonia, has very properly ceased to be so commonly employed, chiefly for the reasons that it is a poison capable of producing decided morbid changes in the tissues, seeming to deprive them of their vital poAver for long periods of time, and that it often induces nausea of a distressing type, or even vomitino-, before it can be pushed to a sufficient degree to cause the desired cir- culatory depression. Next to veratrum viride, it holds a more useful position in extremely sthenic cases than any other drug, and may be used if the patient be unusually robust. Unlike aconite, Avhich ex- pends its chief action on the heart, this drug not only quiets and sIoavs the pulse by an action exerted directly upon the heart-muscle and its motor ganglia, but in addition markedly affects the vasomotor system, thereby aiding in causing the desired fall of arterial pressure. The proper dose of tartar emetic is fa grain (0.005), repeated every two hours until the skin shoAvs moisture, nausea asserts itself, or the pulse gives evidence of sufficient relaxation. Gelsemium has been highly recommended by Bartholow in the treatment of the early stages of pneumonia, but is certainly of very inferior influence, and is at the same time a dangerous drug. The use of chloral has been attempted, but its other powers so dominate its action on the circulation as to make it useless for the purpose before us. There can be little doubt of the value of pilocarpine in the very earliest stages of the malady. Given in full dose hypo- dermically, it will produce so profuse a SAveat and so great a lowering of arterial pressure as to relieve materially the congested lung. Its value, hoAvever, depends upon its very early employment, and it should not be used if any tendency to true consolidation has already asserted itself, as it is then useless, and capable of depressing the heart to a serious extent Avhen that organ is about to undergo a severe struggle because of the engorged lung. The application of cold to the chest in the early stages of pneu- monia has been resorted to very largely in Germany by Liebermeis- ter, Niemeyer, and others. It is said that the dyspnoea is decreased at once and the pain lessened. Bartol and Ziemssen speak of it highly in the croupous pneumonia of children, but the writer Avould fear to use it in any case unless the patient Avas above puberty and very strong. (See Cold.) If cold is used, it should be employed as an ice-poultice made of cracked ice and sawdust, mixed and seAved up tight in an oil-silk bag in such a Avay as to prevent the bed and clothes from becoming wet. (See Cold, Part III.) At this period, too, very distinct effects can be exercised over the blood-vessels of the lung by irritation of the skin, which results in the reflex influence already spoken of in the article Counter-irritation. The most active means of producing this counter-irritation is by 604 DISEASES. the use of the dry cup. The wet cup may be used to deplete or bleed the patient at the same time that it acts as a counter-irritant, but in many instances the dry cup will suffice. If the counter-irritation is to be thorough, the cups should be applied to the number of five or six, scattered over the area involved and a little to the sides of the diseased patch. In other instances aromatic spirit of ammonia or carbonate of ammonia may be used, or alcohol hot and concentrated, in the event of collapse. Mustard may be employed, and a turpentine stupe (see Turpen- tine) or Cayenne pepper can be used as a counter-irritant. The lat- ter is at once one of the most efficient and least dangerous irritants, as it produces much reddening and irritation, but does not destroy or burn the skin. In the beginning of a pneumonia a blister should be applied not immediately over the congestion, but a little to one side, as it may increase the congestion if placed over the diseased spot, When resolution begins, the blister may be placed over the exact spot involved, to aid reparative changes. The treatment of the second stage of pneumonia, when of a sthenic type, is much more difficult and hazardous than the treatment of the first stage. The question as to the line separating the first from the second stage must be clearly ansAvered in the physician's mind, and distinct indications must exist for the employment of measures suited to the disease at this period of its development. The physical signs in the chest are only of value as evidencing the progress of the local disease-process, and only indirectly indicate the use of a given line of treatment, while the state of the pulse, the color of the skin, more particularly of the face, the duskiness of the nails, along with the rhythm of the respirations, tell the physician how the patient is standing the strain. This is not the place to discuss the possible causes of death under these conditions, but to indicate clearly Avhat is to be done when the flagging to-and-fro pulse indicates arterial starvation, and the dusky skin and pulsating jugulars shoAV venous engorgement and distention of the right side of the heart. The employment of digitalis is here of the greatest service. It should be given in 10- to 15-drop doses of the tincture every eight hours, and be accompanied by from 5 to 10 drops of tincture of belladonna every four hours, or oftener as the case may require. In most instances it will be found that the belladonna is absolutely essential to control the leaking blood-vessels and to re-establish normal vaso- motor tone, which is very important to life. Should the digitalis fail and seem slow of action, then a more rapid drug must be used, and strychnine is the best in the dose of fa to fa grain every four hours. The most frequent cause of the failure of digitalis to do good at such times is the presence of high fever and a relaxed vasomotor system. If the digitalis is carelessly given and its effects are not watched, it may be found to produce so rapid and irregular a pulse at the wrist as to give one the impression that the heart needs still further doses of the drug; but if the ear be placed over the praecordium under PNEUMONIA. 605 such circumstances, the violent apex-beat, diffused thrill, and accen- tuated heart-sounds will shoAv that this viscus is over-stimulated, and that the drug should be Avithdrawn until some hours have elapsed, and its need is evidenced by a condition of real cardiac enfeeblement fol- loAving a stage of marked improvement due to the temporary with- drawal of the drug. Should collapse come on at any time in the course of pneumonia, strychnine in full doses (fa to fa grain [0.03-0.06]) should be given hypodermically, combined with y^- to fa-$ grain (0.0004-0.0006) of atropine. These drugs serve to stimulate the respiration and heart and improve vasomotor tone. The author cannot too urgently advise such treatment, as he believes it will save many lives. Sometimes in pneumonia, Avhen there is great duskiness of the skin and nails and auscultation reveals a laboring and apparently distended heart, fa-$ grain (0.0006) of nitroglycerin Avith or Avithout digitalis proves very useful. Having recommended these drugs in these states, let us study why they do good and the reasons for their use. According to a mass of experimental evidence, which by its very volume is incontestable, digitalis acts upon the heart-muscle as a most powerful stimulant, increasing the force of contraction in the cardiac walls and driving the contents of the ventricles out into the pulmonary artery and aorta, Avith an unmistakable increase in arterial tension. The experiments of Boehm show that the heart actually does more work under digi- talis ; and these studies have been confirmed by Williams. Frangois Frank agrees with Williams in the belief that this increased force is due to improved tone of the cardiac muscle. These facts indicate the raison d'etre of the use of digitalis in the second stage of pneumonia. since it enables the right side of the heart to send the venous blood to the general arterial system, thus preventing the over-distention of the right ventricle. When Ave remember, on the one hand, that all muscular fibres rapidly become paralyzed by over-distention, and, on the other, that digitalis produces a systolic contraction of extreme completeness, we can readily see hoAv, by the entire emptying of the ventricle at each contraction, distention from gradual accumulation is impossible. It seems probable, too, that the pneumogastric nerves are the trophic nerves of the heart, and that in consequence its nour- ishment is improved by their stimulation by the digitalis. (See articles on Heart Disease and Digitalis.) There are other reasons, hoAvever, which are only second to those just named, Avhy digitalis should be used at this time. The heart-beat under its influence is greatly sloAved, and by means of this sloAving the patient becomes a cool-headed man instead of a flurried, nervous, irri- table invalid. By its very slowing the heart finds time to carry out all its functions regularly and with "all its might;" it does not exhaust itself by fruitless effort, and accomplishes far more than Avhen it is irregular and uncertain as to whether it is to contract or expand. That digi- talis slows the pulse by a stimulation of the pneumogastric nerves has been proved beyond all doubt, and the remembrance of the fact that these nerves are respiratory in function as Avell as cardiac clearly 606 DISEASES. indicates the value of this influence. They supply motor fibres to the muscular coats of the entire bronchial system, the tonicity of Avhich is most important for the well-being of the lung, since by this means the quantity of air admitted to the vesicles is equalized and the excessive use of the healthy vesicles prevented. Longet asserts that the "lung tonus" during increased tension (which is present during pneumonia) depends solely upon these muscles and their proper nerve- supply. These assertions are once more supported by the experi- ments of Graham BroAvn and Roy, which prove that the vagal fila- ments are to the lung and its air-streams what the vasomotor nerves are to the circulatory system, dilating or contracting the bronchial tubes as may be necessary. Digitalis by stimulating them increases their tone and supports them Avhen strained. The assertion of Schiff, that the vagus is the vasomotor nerve of the lungs, is only partly true, and is so doubtful as to preA^ent any value being derived from this fact, so far as the blood-supply is concerned. Another way in which digitalis does good is often overlooked. The respiratory centre is governed solely by the condition of the blood. If this fluid be overladen with carbon dioxide, it sends out more impulses and rids itself of the gas by the increased respiratory effort, or, if an excess of oxygen is present, it sends out fewer impulses until the normal balance is restored. If, however, the carbon dioxide is not rapidly eliminated, the combined effects of the gas and effort speedily decrease the respiratory activity. It is also to be remembered that Marckwald has proved that the pneumogastric nerves are the regulators of the impulses sent out by the respiratory centre, so that a perfect rhythm is obtained. The asphyxia due to the laming of a lung by pneumonia increases the number of respiratory efforts, and in consequence the labor of the vagus is increased. Very commonly we see cases of pneumonia in which the breathing is hobbling, with a distinctly altered rhythm—now fast, now slow; now full, now deep. In these the breathing becomes regular and quiet after digitalis is used in the proper amount—a result often accorded to the cardiac influence of the drug, but largely due to its effects on the respiratory portion of the vagus nerves. The same advantages are gained by a regulated respiratory effort on the part of the lungs as are obtained in the case of the steadied heart. In those cases where digitalis is pushed too far, these favorable effects are replaced by the most unfavorable conditions, as has already been described in the discussion of the action of this drug in heart disease. Here, as elseAvhere, over-stimulation is as bad as lack of proper tone. Strychnine is used to carry out an object supplementary to that of digitalis, for it has been proved to be one of the most reliable and powerful stimulants upon the respiratory centres that we have, and they are apt to be exhausted by rapid breathing. It also prevents general nervous depression, and aids in the maintenance of a circu- latory balance by its stimulating effect on the vasomotor system and heart-muscle. PNEUMONIA. 607 In many cases the heart seems strong enough, but the blood-ves- sels relaxed and the pulse compressible. Atropine or belladonna, Avhen used at this time, stimulates the vasomotor system and dries the leaking skin. The employment of alcohol in the second stage of pneumonia is based upon the same principle as is the use of digitalis. It is inferior to the latter drug, because it stimulates the heart and increases its force, but does not afford it the nutrition that digitalis can give it. That is to say, it stimulates and causes the expenditure of all the power the heart is capable of, but does not replace the tissue destroyed by the effort. Further than this, it possesses the disadvantage of act- ing for a comparatively short time, dose for dose, and tending to cause cerebral excitement or heaviness if it is pushed to the point of stimu- lation required by the circulatory condition. In persons addicted to the excessive use of alcohol it either fails to act, produces effects con- trary to those desired, or actually aids the disease-process. The danger of the patient forming the alcoholic habit is also to be remem- bered. In children, hoAvever, alcohol and ammonia act, as a rule, better than does digitalis. Having detailed this treatment of the second stage, that for the third stage is to be considered. For the thorough understanding of this Ave should remember that this stage consists in the breaking doAvn or resolution of the exudations and in their absorption and expulsion from the chest. At this time the entire diseased area is crowded with secretions Avhich have been formed, dead epithelial cells, and all the morbid sub- stances Avhich have accumulated. The local surfaces are depressed by the reaction following upon the excitement of inflammation, and their tone is below par. The object of the physician must be to stimulate these areas so that they may throw off the old and take on a new functional activity, and for this purpose remedies are to be used which ,Avill soften deposits and stimulate depressed vesicles and bronchial tubes. By far the most valuable class of drugs to be here employed are those Avhich Avill increase the secretion from mucous membranes with- out acting as cardiac depressants. Antimony is a remarkable drug for the production of a large secretion, but is often too depressing to the heart after the prolonged strain to Avhich it has been subjected. Under the article on Bronchitis the action of these drugs will be found more thoroughly explained, but it will suffice to point out, at this time, the method of their administration. First and foremost stands the chloride of ammonium, a drug whose elimination takes place largely through the lungs, and Avhich acts most happily in aiding in the loosening of the cough and secretions. Its only disadvantage is its salty taste, Avhich in many cases renders it disagreeable to the patient, Avhile its irritant properties may disorder the action of the stomach, although if this organ is depressed and atonic this drug often improves its condition. This drug may be given in compressed pills, or, what is far better, in such a mixture as here folloAvs: 608 DISEASES. J, R.—Ammonii chloridi............,^ij (8.0). l£ Extract, glycyrrhizae fl.........^ij (8.0). Aquae dest..............; fgiij (96.0).—M. S.—Teaspoonful (4.0) in water every four hours during the day. If the cough be in excess of the expectoration—that is, if the cough often fails to bring up phlegm and is due to tickling or irrita- tion—it may be relieved by the addition of a little morphine to this mixture, as follows : R.—Morphinae sulph.........gr. j vel gr. ij (0.05-0.1). Ammonii chloridi.......^ij (8.0). Extract, glycyrrhizae fl......£iv (16.0). Aquae dest...........^vj (192.0).—M. S.—Dessertspoonful (8.0) every four hours. If much more morphine than this is used, it will tend to stop secretion. When the chloride of ammonium fails to act favorably, the car- bonate may be called into use for its local and circulatory action, and, in addition, the bromide of ammonium may be employed to allay the cough if morphine cannot be used. The folloAving prescription is valuable: R.—Ammonii chloridi....... Ammonii bromidi....... Ammonii carbonat....... Extract, glycyrrhizae fl..... Aquae dest........... S.—Dessertspoonful (8.0) every four hours (For other remedies for this stage see Bronchitis.) So far, the treatment given has dealt Avith a routine case: let us suppose that things run less smoothly and complications arise. It will be impossible, in a book on Therapeutics, to explain the causes of all the dangers Avhich may present themselves. One of the most serious of them is an increase in the area of the consolidation or its development elsewhere, or, in other Avords, a second attack super- imposed on the first. The treatment of this most dangerous state of affairs requires the greatest care, skill, and intelligence, and con- sists primarily, not in the use of cardiac sedatives, but in the admin- istration of digitalis and stimulants, in order to drive out the blood from the new congestion or to enable the system to bear the strain. A blister or dry or Avet cup thoroughly applied a little to one side of the spot involved may aid in the removal of the congestion, and the application of mustard plasters to the feet is indicated, or a turpentine stupe may be applied to the entire chest. The use of expectorants stimulating to the lungs is to be stopped at once, and nourishment given in small amounts, carefully prepared and frequently adminis- tered. It is to be remembered, hoAvever, that, above all things, the physician must use his judgment, and if he finds that sufficient strength yet remains to his patient for the second attack to partake of a dynamic or sthenic character similar to that of the first, he must use bleeding, leeching, cupping, or cardiac sedatives. If the consolidation be very widespread in any case, the entire heart becomes strained by the venous congestion and arterial tension 3J (4-0). 33 (4-0). 3J (4-0). 3»j (12-0- f^vj (192.0).—M. PRURITUS. 609 due to the partial asphyxia, Avhile there is also danger of death from lack of oxidizing space for the blood. No better treatment exists, under these circumstances, than the inhalation of oxygen, either almost pure or mixed with air. By this means even a small patch of lung offers sufficient oxygen to the blood to cause its necessary oxidation. This gas may be obtained in small cylinders, Avhich, by compression of the gas, hold forty gallons, at several large establish- ments, notably at the offices of the S. S. White Dental Company, Avhich has agencies in all the large cities of the United States, or it may be made by the physician himself in the folloAving manner: Take 4 ounces of chlorate of potassium—which must not contain a single chip or piece of organic matter—and add to it an equal quan- tity of peroxide of manganese. These should be placed in a retort or strong flask, and an alcohol-lamp placed under it. The gas as it is generated escapes through a tube, Avhich should pass into a large jar of water, so that the gas, as it bubbles up, may become cooled and purified; a second tube may noAV lead the gas to an inhaler over the patient's mouth. It should be remembered, hoAvever, that chlorate of potassium may explode if contaminated by the smallest piece of organic matter.1 The period in the treatment of pneumonia Avhen simple poultices do the greatest service, and the only time when they are to be employed, for valid reasons, is during the second and third stages of the disease, when clinical experience shoAvs that they are of value in aid- ing in the production of resolution and in loosening the cough. How they act, except by increasing the external warmth and moisture of the parts, we do not knoAv, unless by the production of some reflex influence exerted upon the lungs from the skin by means of the nerves. Unless the attendant is unusually intelligent and Avell trained, the common poultice does more harm than good, because it is allowed to get cold or the patient is chilled Avhen it is changed. The proper application is the cotton and oiled-silk jacket, particularly in young and restless children. The remarks AA'hich have just been made deal entirely Avith simple poultices, and not Avith those possessing drugs in their mass, such as those agents belonging to the counter-irritant group of drugs. By far the most commonly used substance under these circumstances is mustard, and its addition to the mass at once alloAvs this method of treatment to be employed in the first as Avell as in the later stages. PRURITUS. Itching of the skin or mucous membranes about the openings of the body is a very common state, and while it may be dependent upon local causes, such as lice or fleas, it more commonly is due to some systemic condition, such as debility, diabetes, gout, or renal disease, or other similar causes. The treatment consists, first, in the removal 1 Several firms manufacture small yet complete forms of apparatus for the man- ufacture and clinical application of oxygen. The cost varies from ?25 to §50. 39 610 DISEASES. of the cause, and, next, in the local treatment of the condition. There is generally no redness or eruption, except that due to scratching. Internally, arsenic, quinine, bitter tonics, coddiver oil, alkaline diuretics, or mineral waters are useful in debilitated cases, and an avoidance of condiments, such as mustard or pepper, is needful if the disease affects the mouth of the urethra or vagina. The local treatment of pruritus consists in the use of lotions, salves, or ointments made up of various constituents, a number of which are capable of acting as local anaesthetics. Very often, bathing the parts with 1 drachm of bicarbonate of sodium or of borax to a pint of cold water gives relief temporarily, or the following formulae will be of service: R,-Acidi carbolici.........f& vel f^y (4.0-8.0). Aquae dest......• . . q. s. ad Oj (500 cc.).—M. S.—Apply as a lotion several times a day. Or, R.—Liquor carbon, detergen.1 .... f^ij (8.0). Aquae ..........q. s. ad Oj (500 cc.).—M. S.—Apply as a lotion. Or an ointment made as follows is serviceable: R.—Acidi carbolici.........gtt. v vel xx (0.3-1.3). Adipis benzoinatus.......§j (32.0). Petrolati ...........3J (4.0).—M. S.—Apply as an ointment. In other cases 10 to 20 minims (0.65-1.3) of chloroform may be used in place of the carbolic acid. Cocaine may be painted over the parts, but it should rarely be used in ointment, as fats prevent its acting effectively. It should also be remembered that the anal and vaginal mucous membranes are so thick that strong solutions of cocaine are necessary to produce anaesthesia, and that the effects of cocaine are only temporary. Where the itching is very obstinate the parts may be painted with a solution of nitrate of silver of the strength of 20 grains to the ounce (1.3 : 32.0) of Avater, cocaine having been previously applied to relieve the pain of the application. (See article on Cold.) Brinton has highly recommended powdered teucrium scordium in the dose of 20 grains (1.3) three times a day. PUERPERAL DISEASES. The diseases of the puerperium may be divided into two broad classes—infectious and non-infectious. The first class should be further subdivided into (1) those infectious diseases in which the point of infection has been someAvhere along the parturient tract, and (2) those in Avhich the infecting poison has entered the body by some other channel. Under sub-heading 1 come all those diseased 1 For method of preparing this liquor see article on Eczema. PUERPERAL DISEASES. 611 conditions grouped together under the very inadequate generic terms ;t puerperal fever," "puerperal septicaemia," "puerperal infection," and the like, none of which truly express the condition present. If it is necessary in medical nomenclature to have a single term Avhich shall denote infection of the genitalia after delivery, a Avoid should be coined strictly limited in sense to mean the pathological conditions which result from the activity of pathogenic microbes along the Avhole genital tract. This classification is necessary for a clear and system- atic description of the treatment of diseases in the puerperal state. The Treatment of Infection along the Geenital Tract after Labor.—' By far the most common form of infection along the genital tract after labor is the absorption of ptomaines from the infection and decomposition of membranes, fragments of placenta, or blood within the uterus. This condition will be found in more than 75 per cent. of all cases in which infection occurs. Therefore, in any case after labor in Avhich there is fever that cannot be explained by some evi- dent cause independent of the genitalia, it is safe to assume ptomaine poisoning and to act accordingly. The indications are plain: to destroy the microbes, and thus at once stop the manufacture of their poisonous products, and, if necessary, to remove their habitat. The writer's routine application of this principle in practice is as folloAvs: If the temperature after delivery remains over 100° F. for tAventy-four hours without evident cause independent of the genitalia, he washes out the uterine cavity Avith at least 1 quart (1 litre) either of bichloride-of-mercury solution, 1: 2000, or a 2 per cent, solution of creolin. The former is more convenient in private practice, be- cause the tablets of corrosive sublimate can be easily carried about in one's instrument-bag. To ensure the entrance of the antiseptic fluid to the fundus and its free exit from the cervical canal an intra-uterine catheter is desirable. Of all those upon the market, the best is that manufactured by hentz, an instrument-maker of Philadelphia. If, hoAvever, the cervical canal is patulous, as it usually is after labor, a hard-rubber catheter attached to a Davidson's or fountain syringe answers the purpose perfectly. In the majority of cases this treatment will bring the temperature down to normal Avithin twenty-four hours. If fever does not disap- pear Avithin this time or perhaps rises even higher, the second indica- tion must be met. The infected albuminous substance within the uterine cavity must be removed in order to deprive the micro- organisms of their feeding-ground. This is best accomplished by the use of the curette and the placental forceps, care being taken in the employment of the former instrument to guard the uterine Avail itself from the slightest injury; for not only can the uterine muscle be per- forated by a curette in clumsy hands, but slight wounds of the uterine substance with this instrument may be enough to inoculate the gen- eral system Avith the germs Avhose activity has been confined before to the uterine caA-ity. The writer's manner of employing this plan of treatment after labor is as follows: The anterior lip of the cervix is seized with a double tenaculum 612 DISEASES. and pulled gently dowmvard; a cleansing uterine douche is then given in order to disinfect the field of operation; next the curette is inserted to the fundus, and the Avhole interior of the uterus is carefully gone over Avith the instrument, first the fundus and then each of the four sides ; then the curette is turned Avith the scraping surface upward and Avithdrawn from the cervical canal, a finger in the vagina meet- ing its tip as it emerges in order to help extract any substances which may be caught by and entangled in it. Next the placental forceps is inserted, and an effort made to grasp any material lying loose Avithin the cavity or still attached to the uterine Avails. It is usually best to repeat each of these manoeuvres several times until nothing more can be brought aAvay except a little clear blood. Then the uterine cavity is again thoroughly washed out. The writer has many temperature charts in his possession which show the success of this treatment when simple uterine irrigation has failed. Occasionally it is necessary to repeat the irrigation, and even the curetting, for several successive days. If, as rarely happens, this treatment should prove unsuccessful and the temperature should remain elevated in spite of irrigation and the use of the curette and placental forceps, one must assume either that general systemic infec- tion has occurred, or at least that an inflammatory action has begun in the uterine walls or within the tract of the tubes. One of the earliest, surest signs of systemic invasion is the appearance of peritonitis. In such a case the only available treatment is to support the body- cells in the combat which they must Avage with the invading micro- organisms. This is best accomplished by the administration of as large a quantity of nutriment as the patient can stand Avithout rebel- lion of the stomach or boAvels, and the exhibition of a large quantity of alcoholic stimulant. Cases of this sort not infrequently require more than a pint of Avhiskey or brandy in the twenty-four hours. Occasionally measures will be required to reduce an exaggerated ele- vation of the temperature, but this is best avoided as long as possible, for antipyretic treatment is usually depressing and ill suited to the patient's adynamic condition. With this plan of treatment about three-quarters of the cases of general septic infection after labor will recover. There may be some in Avhich metastasis to important organs occurs so early as to render all treatment of no avail. There will be others in Avhich the peri- toneum is early infected, and in which the septic peritonitis develops rapidly and to an extensive degree. It is in such cases that laparot- omy and evacuation of the septic matter, usually pus, within the peri- toneum will occasionally save life. The physician must guard him- self, however, from the disposition which is 'prevalent at this day to operate too early and unnecessarily. After operation, drainage of" the peritoneal cavity is an essential feature of the treatment, even although the evidence of suppuration Avithin the cavity is slight. The writer has in mind a case in Avhich an operation was performed ten days post-partum for septic peritonitis: a very small quantity of purulent PUERPERAL DISEASES 613 lymph Avas found upon one ovary, Avhich Avas greatly enlarged and contained a small quantity of sero-pus. The ovary Avas removed and the abdomen closed Avithout drainage, as there Avas no other evidence of suppuration Avithin it. Thirty-'six hours later the patient died, and the peritoneal caA-ity Avas found filled Avith pus Avhich had accu- mulated in that short space of time. In the early stages of the peritoneal infection, if the subject is vigorous, not exhausted by a prolonged labor or other depressing causes, the administration' of saline ourgatives in concentrated solution will often effect brilliant results. The waiter's custom is to give a dessertspoonful of a concentrated solution of Epsom salts every fifteen minutes until free evacuation of the boAvels is secured. He has seen the temperature reduced by this plan of treatment from 104° F. to normal in the course of tAvelve hours, and Avith the reduction of temperature all the symptoms of peritonitis, Avhich Avere Avell marked, entirely disappeared. In the treatment of microbic acthdty along the parturient tract after labor it should never be forgotten that the point by Avhich the microbes invade the system may be anyAvhere from the fundus of the uterus to the parturient outlet; therefore the practitioner should never neglect to examine carefully all the loAver parturient tract, in order to detect, if possible, an ulcerated surface covered by diphtheritic membrane, Avhich if overlooked might be the entrance-point for a fatal infection. These unhealthy surfaces are best detected by the use of a cylindrical speculum of clouded glass introduced so that the cervix appears Avithin its inner end, and then withdrawn, so that the vaginal mucous membrane as it prolapses into the end of the speculum may be examined, and treated if necessary throughout its whole extent. If an unhealthy, ulcerated wound is thus discovered, the Avriter's practice is to apply to it a solu- tion of nitrate of silver 40 or 60 grains to the ounce (2.65 : 32.0). In the vast majority of cases this application will promote an exfolia- tion of the unhealthy membrane and the appearance of healthy gran- ulation tissue Avithin a feAV days. It may, in some cases, be necessary to employ a stronger applica- tion, as the solution of chloride of zinc, but the Avriter has not been driven to its use. The most common point of infection outside the parturient tract after labor is some portion of the urinary apparatus, almost invariably the bladder. The process of parturition necessarily diminishes the vitality of the vesical mucous membrane cells by the pressure and stretching to Avhich they are subjected. After labor, therefore, they are not in a condition to resist the attacks of micro- organisms should these in any Avay gain access to the vesical cavity. Most commonly microbes are introduced into the bladder by a cath- eter. This, hoAvever, is not necessary, as it has been plainly demon- strated that they can wander from the vaginal canal through the urethra into the bladder without the intervention of an instrument Avhich Avould directly carry them into the vesical cavity and deposit them in that situation. Once arrived within the bladder, the microbes attack the depressed bladder-cells, and very often gain a lodgment in the vesical mucous membrane. This is manifested by the usual 614 DISEASES. symptoms of septic cystitis—fever, pus in the urine, pain on pressure over the hypogastrium, and pain and difficulty in micturition. The duration of these symptoms is, as a rule, not very long. The fever subsides and the symptoms of cystitis disappear. After an interval of some days, however, there is again a sharp outbreak of fever, with pain in the region of the kidneys and the reappearance of pus, or at least of numerous microbes, in the urine. This indicates a septic infection of the pelves of the kidneys after the micro-organisms have migrated along the ureters. During their migration their presence has not been manifested by any symptoms. In the majority of cases even the symptoms of pyelitis will disappear after a time, and the patient Avill make a good recovery; but in a certain proportion there is a systemic infection by the direct passage of microbes or their products from the kidneys into the blood. There may be an extensive suppuration of the kidneys and surrounding tissue, with fatal results, or, as the writer has seen in several cases, the symptoms of general systemic infection become so grave as for a long time to threaten the patient's life. In the worse cases of bladder infection the mucous lining sloughs, peritonitis develops, and the patient dies before the disease has time to spread to the kidneys. The practitioner, bearing in mind the serious consequences of sep- tic cystitis after labor, should ahvays be on the watch for it, and should adopt an energetic treatment immediately upon its discovery. A thorough disinfection of the bladder will remove all present symp- toms, and prevent the occurrence of grave and possibly fatal after- complications. To accomplish this purpose the writer employs a \ of 1 per cent, solution of creolin. One injection of a quart of this solution through a tAvo-way catheter is usually sufficient. Occasion- ally it is necessary to repeat it or to folloAv it by several injections of boric-acid solution. In susceptible individuals creolin causes too much pain to be employed. A 1 : 8000 bichloride-of-mercury solu- tion may be substituted for it, or in mild cases a solution of boric acid alone will be sufficient. If, in spite of all precautions, infection of the kidneys should ensue, a vigorously stimulating and supportive plan of treatment affords the only hope of success. If extensive suppuration occurs in the kidneys, all treatment will of course be useless. Perhaps the most uncommon point of septic infection after labor is the rectum. The writer has, however, seen one fatal case of this sort—from the use, no doubt, of a dirty syringe-nozzle in the hands of a careless nurse. It Avould be difficult, or perhaps impossible, to diagnosticate such a case until after death, and therefore treatment directed toward this form of infection will usually not be adopted. Next in frequency to the parturient tract and the urinary system as a region of infection after labor come the breasts. Infection of the nipples, and a consequent mammary inflammation or suppuration, is one of the most troublesome minor complications that the obstetrician is called upon to treat. By careful preparation of the nipple during the last month of pregnancy, and by extreme care to secure perfect cleanliness during the period of lactation, infection of the breasts can PUERPERAL DISEASES. 615 almost surely be avoided. If it occurs, the first effort should be to limit its extent and degree, and to prevent, if possible, suppuration. The best means to accomplish this end are derivation of the blood from the mammary glands by an active purge, compression of the gland-substance, and support of the breasts by a suitable mammary binder. To these should be added, in the acute stage of inflammation, fomentations of very hot Avater, and, later, the application of cloths Avrung out in lead-Avater and laudanum, reneAved every three hours. Unless the infection has been of a virulent nature and the amount of infective material large, this plan of treatment will almost surely dissipate the inflammation and prevent suppuration. The other infectious fevers of the puerperal state include the in- fectious diseases which can, under any circumstances, attack the adult female, and their treatment differs in no respect during the puer- perium from that adopted under ordinary circumstances, unless there should be developed some local complications. Non-infectious Diseases of the Puerperium. Anomalies of Involution.—Superinvolution, an exaggeration of that process by Avhich the uterus is reduced to its normal size after labor, only manifests itself, as a rule, after the puerperal state is com- pleted, and therefore its treatment need not be further considered. Subinvolution, an arrested or retarded return of the uterus to its normal condition and dimensions after labor, is one of the commonest complications with Avhich the obstetrician has to deal in the manage- ment of the puerperium. The cause of subinvolution is ahvays a local one. General conditions, as acute fevers and so on, have no influence whatever upon the process of involution unless they are accompanied by some local complication. There are two causes which prevent the involution of the uterus Avhich must be borne in mind Avhen one is called upon to treat this condition. The involution may be prevented, on the one hand, by anything Avhich calls an excessive amount of blood to the uterine body, as, for instance, small fibroids within its Avails or hypertrophied deciduous membrane remaining adherent to its inner surface. On the other hand, subinvolution may be the result of mechanical obstruc- tion to the contraction of the uterine walls and the reduction of the cavity of the uterus to the normal size. As an example of this we have a retained placenta or a submucous fibroid or adhesions dragging the uterus out of place and preventing its contraction, or, most com- monly perhaps, an over-distended bladder and rectum. In those conditions Avhich result in a hyperaemia of the uterus the cause of an excessive blood-supply must be sought out and removed before one can remedy the subinvolution. If small fibroids can be detected, the administration of quinine, ergot, and strychnine in pill form has been found most useful. If practical, a faradic current may be employed in addition to medica- tion. If there is an hypertrophied endometrium retained withm the 616 DISEASES. uterus, a curette will most quickly and effectually hasten involution. In cases of heart disease in which the blood-current is sluggish and dammed back into the large veins of the trunk digitalis will be the most effective remedy to overcome the subinvolution. There may be an active hyperaemia associated with inflammatory action, either in the uterine wall or upon its peritoneal covering or in its annexa; in this case the inflammation must be overcome by disinfection, the use of purgatives, and. possibly, the local application of hot Avater, before involution can be secured. When there is mechanical obstruction to the return of the Avomb to its normal dimensions, the hindrance must of course be removed before one can expect a good result from treat- ment. In the case of retained adherent placenta every effort must be made to remove the placental tissue. In the case of submucous fibroids their removal must be attempted if there is any hope of safely accomplishing it. There is no case of labor which does not leave behind, in the par- turient tract, some injury to the maternal structures. Usually these are slight in degree, manifesting no symptoms and healing spontane- ously. Occasionally the injury done results in fistula communicating with the bladder or rectum, in deep granulating wounds in the vagina, or in ulcerated sores. In the case of fistula a cure can sometimes be effected without operative interference by touching up the edges of the fistulous tract with nitric acid, in order to excite an outpouring of granulation tissue in the hope that it may plug up the opening. In deep tears, Avhich have not been primarily united, application of a solution of nitrate of silver will hasten the cure and prevent infection of the wounded surface. If ulceration occurs, the ulcerated spots are to be carefully watched and treated in the same manner. Hemorrhages from the birth-canal after labor depend upon a num- ber of well-knoAvn causes, which must be sought out and corrected before the bleeding will cease. Most frequently the cause of a hem- orrhage Avill be found in retained placental fragments in utero, which must be removed. Not infrequently displacements of the uterus will be found as a cause, and correction of the displacement will stop the bleeding. In interstitial bleeding after labor, resulting in haematoma, care must be taken to preserve the parts in as aseptic a condition as pos- sible, Avhile an attempt is made to limit the bleeding by the applica- tion of direct cold, preferably by means of a Barnes bag dilated Avith ice-Avater, which must be removed from time to time in order to allow the lochia to escape. After rupture or incision of these blood-tumors the cavity left behind must be carefully disinfected Avith the bichlo- ride-of-mercury solution or creolin, and, if necessary to control further bleeding, Avell packed Avith iodoform gauze. Of all forms of bleeding, that Avhich occurs directly after labor in consequence of inertia uteri, knoAvn as post-partum hemorrhage, is the most frequent, the most alarming and dangerous in its manifesta- tions and consequences. No one should attend a case of obstetrics without having in mind a clearly-defined programme to be put in PUERPERAL DISEASES. 617 immediate execution Avhen called upon to deal Avith this frequent and dangerous complication. There are tAvo indications to be met: First, to control the hemorrhage, and, second, to treat the after-condition. The first indication is met by the folloAving plan of treatment: External stimulation of the uterus by kneading and rubbing through abdominal Avails, as is practised in Crede's method of expressing the placenta. Next carry the other hand into the uterus and remove any blood- clots, pieces of placenta, or membrane that may be found there, so that the internal surface of the uterine Avails is irritated by the move- ments of the operator's fingers. Next apply a small piece of ice upon the abdomen externally, and carry another piece the size of a hen's egg into the uterine cavity. The use of cold must not be persisted in for more than a minute at most, for its ultimate action is depressing and relaxing. Next soak a clean linen handkerchief in vinegar, carry it up to the fundus, and squeeze it out so that the vinegar shall run doAvn over the uterine surface. Next, hot Avater at a temperature of 116° or 120° F. should be injected into the uterine cavity. If one happens to have the necessary appliances at hand (a small Gaiffe battery, Avhich can be carried in an ordinary instrument-bag), a strong faradic current can be applied to the uterine muscle. Finally, as a last resort, the uterine cavity may be packed with long strips of iodoform gauze in the manner suggested by Diihrssen and carried out by a number of observers Avith gratifying success. Drugs, as the styptic salts of iron, and especially Monsel's solu- tion, have been recommended from time to time as intra-uterine appli- cations in the case of post-partum hemorrhage, but they are dangerous, for the coagulation produced by them may extend far into the uterine vessels, and the clots must be broken up by putrefaction, exposing the patient to the danger of septic poisoning. This programme is to be carried out in the order given: if the milder measures suffice, of course the more radical plans of treatment will not be employed. Excessive hemorrhage (post-partum) from lacerations along the genital canal can be controlled by well-placed sutures. Bearing in mind this plan of treatment, it is almost inconceivable that an intelligent and skilful practitioner should lose a case of post- partum hemorrhage. The physician should give ergot in full dose by the mouth and, if need be, hypodermically. Treatment of the After-condition.—While the physician is busy controlling the hemorrhage the nurse should administer a hypodermic injection of ether if symptoms of shock or collapse are manifested. After the bleeding has ceased it is Avell to administer an enema of a pint of hot water, Avhich maintains the patient's temperature, relieves the shock, and by its irritation promotes contraction of the uterine muscle. This should be succeeded by small doses of hot, strong brandy-and-Avater, and a little warm milk if the stomach will retain 618 DISEASES. it. As soon as reaction is Avell established a half-pint (250 cc.) of hot beef-tea should be administered, and a hypodermic of ^ grain (0.008) of morphine given in order to secure quiet and rest and to get the stimulant qualities Avhich this drug undoubtedly possesses. Occasionally measures must be adopted to retain enough blood within the large vessels and in the heart to prevent excessive cerebral anaemia or cardiac failure. This is best done by auto-transfusion; that is, by bandaging the extremities from beloAv upward, in order to secure as large a quantity of blood as possible Avithin the vessels of the trunk and brain. Actual transfusion of a T67-of-l-per-cent. solution of com- mon salt into the blood-vessels is required Avhen there are profound exhaustion and depression after hemorrhage. It has been demon- strated that it is not necessary to throw this solution directly into the blood-vessels, as interstitial injection seems to ansAver the pur- pose equally Avell. The milk secretion during the puerperal state presents abnormal- ities Avhich call for treatment. One may have to deal Avith anomalies of quantity or quality. The most frequent anomaly of quantity in milk secretion is unfortunately one of defect. Insufficient milk-supply depends on a number of causes. Perhaps the most frequent is a lack of development of the glandular tissue, and in this form of insufficient milk secretion no treatment can be of avail. When the lack of milk is due to some intercurrent affection in the puerperal state the treatment must be directed toward this complication before the milk-supply can be re-established in normal quantity. It may be the consequence of hemorrhages or of diarrhoea, or the result of an acute febrile attack during lactation, or of inflammation Avithin the gland itself. Serious organic disease may also be a cause, and insufficient nourishment must be held accountable in some cases. Profound emotions exert an extraordinary influence upon lactation in altering both the quantity and the quality of the milk. It has long been supposed that the return of menstruation has a disastrous influence upon milk secretion. This, hoAvever, has been definitely disproved by careful observations recently conducted in Austria. The return of normal menstruation without complications has no apparent influence, as a rule, upon the quantity or quality of the woman's milk. In all the temporary diseases interfering with milk secretion described above it should be borne in mind that on the dis- appearance of the abnormal general or local condition milk secretion can be successfully re-established, even though it be absent for days or weeks. Electricity has been much vaunted of late as a remedy for insufficient lactation. It may be applicable in cases of torpidity of the mammary gland or in those cases Avhere lactation has been suppressed on the birth of a first child, and where the mammary gland, therefore, does not respond readily to the stimulus of subse- quent births. This remedy will, however, often prove ineffective and disappointing. Instances of excessive milk secretion are not infrequently met with. In the milder and simpler forms they can be managed by regulation of the diet and free purgation. Galactorrhcea, a constant flow of PUERPERAL DISEASES. 619 milk from the breasts, is one of the most stubborn forms of excessive milk secretion. Tavo measures can usually be relied on to give relief: firm compression of the mammary gland Avith the application of bella- donna ointment, or the administration internally of iodide of potas- sium. In some cases of this character milk secretion stops sponta- neously Avith the return of menstruation, and in a certain proportion of cases a treatment to secure a discharge of blood from the uterus has been successful in stopping the Aoav of milk. Success has been obtained Avith Simpson's plan of introducing a piece of caustic Avithin the uterus in order to bring back the menstrual Aoav. Warm douches have been used successfully for this purpose. Electricity has been recommended to secure the proper contraction of the sphincter muscles of the lactiferous ducts, but as this is usually a result, and not a cause, of the galactorrhoea, the use of electricity must prove in the vast majority of cases ineffective. The long-continued administration of ergot has been Avarmly recommended. The remedy should be tried, for its use seems rational. Chloral has been shoAvn to be very effective in diminishing the quantity of milk. This drug, therefore, is worthy of trial. It has recently been declared that antipyrine, in 2J-grain (0.12) doses three times a day, will diminish milk secretion. The drug, however, has not been tested often enough to demonstrate its power. Quantitative anomalies in the milk secretion must often depend upon an ill-regulated diet. A fatty diet will diminish the quantity of milk; a vegetable diet will diminish the casein, and fat Avill increase the sugar; a diet rich in meat, especially if reinforced with alcoholic stimulants, will increase the fat and casein, but vyill diminish the sugar. If the mother's milk is evidently disagreeing Avith the nursing infant, a chemical analysis of it should be made, and on the result rules regulating the diet should be adopted. The most common mistake in practice is to over-feed a nursing woman, espe- cially Avith a milk diet, with the idea which prevails extensively among the laity that the cow's milk poured into the stomach appears again in the mammary gland. It is usually sufficient for a nursing Ayonian to observe the ordinary diet which agrees Avith her under all circum- stances, with the addition perhaps of a half-pint of milk midAvay betAveen the morning and mid-day and mid-day and evening meals. Occasionally a Avineglassful of malt at the mid-day and evening meals is a useful addition to the diet, and in anaemic patients the addition to the malt of 5 grains (0.3) of pyrophosphate of iron will be an advantage. There is found in every pregnant Avoman some alteration in the constitution of the blood, which consists, roughly speaking, of a dimi- nution of the red blood-corpuscles and of the albumin and the iron in the blood, with an increase in the white blood-corpuscles and the watery element. In some cases this change is much exaggerated, until an intense degree of anaemia appears in the puerperal state Avhich, in its severity, will simulate pernicious anaemia or some fatal form of blood disease. The anaemia of puerperal women, however, even in exaggerated cases, usually yields to treatment in a most gratifying manner. After the prolonged use of Blaud's pills the 620 DISEASES. writer has seen the blood-corpuscles rise from less than three to nearly four and a half millions, and the haemoglobin increase from 40 to 75 per cent, in a few Aveeks. In some cases arsenic alone suc- ceeds where iron fails completely. Eclampsia. To treat eclampsia intelligently and successfully it is necessary to understand its etiology as fully as modern knoAvledge permits. Al- though the subject needs more Hght from future investigations, enough is noAV known to justify the following statement: 1. The cell-activity of mother and foetus produces excrementitious substances which will surely prove virulently poisonous to the whole organism unless they are voided or made harmless by the excretory organs.1 2. The organs in the childbearing woman are often inadequate to the disposal of effete material from the maternal and foetal bodies. 3. Consequently, poisons, of a nature not yet demonstrated, are stored up in the maternal blood until, by cumulative action, their presence is manifested in the eclamptic seizure and other symptoms. 4. The convulsions are probably the result of an acute cerebral anaemia brought about by violent contraction of the arterioles, pos- sibly by direct irritation of the brain-substance. As a result of intense muscular action the circulation is interfered with, and blood is determined to non-muscular regions, as the brain, lungs, kidneys, etc., to such a degree that the congestion of these parts become dan- gerous, leading to apoplexy in the brain, oedema in the lungs, and often a complete abrogation of renal function. The indications for treatment in convulsive seizures of this nature are plain: First, to attack the fons et origo mali, and to eliminate the poisons from the blood as quickly and in as large quantities as possible. Second, to diminish nervous sensibility and lessen muscular poAver, in order to reduce the convulsions in vehemence, duration, and fre- quency. Third, if convulsions occur during labor, to save the infant without adding to the risk of the mother. Fourth, to guard the woman from injury during the attack. The first indication is met by venesection, diaphoresis, and cathar- sis. By the first, one eliminates a certain quantity of poison along with the blood and relaxes the muscles. If there is sharp post- partum hemorrhage, or if the patient is from any cause weak and anaemic, bloodletting is not called for. In the ordinary case, how- ever, Avith full pulse, congested head, the veins standing out upon the neck and face, venesection is an undoubted advantage. While the median basilic of one or both arms is being opened some croton oil should be sent for, and 2 drops (0.1) mixed Avith SAveet oil may be placed upon the tongue. Directions should at the same time be given to wring out three or, better, four old blankets in boiling water; these are to be wrapped around the legs, trunk, and arms, and Avell covered 1 Harold C. Ernst, American System of Obstetrics, vol. ii. p. 431. REMITTENT FEVER. 621 over with one or more dry blankets. The sweating thus induced is profuse. An ice-bag must be put to the head to prevent over-con- gestion of the brain. In this Avay one eliminates the cause of eclamp- tic convulsions as quickly and thoroughly as possible from the blood, directly and indirectly through the skin and bowels. The latter may be acted upon by \ grain of elaterium rubbed up in butter, or by compound jalap poAvder and calomel, instead of resorting to the croton oil. Pilocarpine seemed at one time an ideal remedy to secure diaph- oresis in eclamptic cases, but it has lately fallen into Avell-deserved disrepute. It much increases the danger of pulmonary oedema, and is too profound a depressant. It is no longer employed by experienced and educated obstetricians. The second indication is best met by an anaesthetic. Usually the convulsion first shoAvs its approach in the eyes: these should be closely watched, so that on the first symptom of the oncoming attack chloroform may be at once administered and pushed as rapidly as possible. Ether is inadmissible in these cases, for it is sIoav of action, congests the brain, and irritates the kidneys. Just before the Avoman is wrapped in blankets 1 drachm (4.0) each of chloral and bromide of potassium in starch-water should be injected into the rectum. This may be repeated in an hour if necessary. Morphine, veratrum viride, and inhalations of nitrite of amyl have their enthusiastic advocates in this connection. They may be held in reserve in case the plan of treatment described needs reinforce- ment. If convulsions come on during labor, the child should be rapidly extracted as soon as the os is Avell dilated, but not before, because efforts to dilate the os would be very apt to increase the convulsions, and Avould attract the physician's attention from the Avoman's most threatening danger. Moreover, the os dilates naturally Avith unusual rapidity during eclampsia. The only injury to be feared during eclamptic attacks is Avounds of the tongue from the teeth. This can be prevented by inserting betAveen the teeth a brush-handle wrapped in a handkerchief or by drawing a towel into the mouth like a bit. Well-meaning but igno- rant bystanders will sometimes throw themselves upon an eclamptic patient to restrain her convulsions by force. This should be forbidden. REMITTENT FEVER. This is sometimes called bilious fever by reason of the violent bilious vomiting and jaundice Avhich often accompany it. It separates itself from intermittent fever by the fact that the patient's condition, chiefly as regards temperature, does not have normal intervals, but has periods of only temporary improvement, or, in other words, the disease remits. For the proper treatment of this fever, three things must be borne in mind: 1. It is more dangerous than intermittent fever; 2. It is dangerous in the hot stage, not in the cold stage; 3. The patient, not having periods for complete or partial recovery, rapidly loses 622 DISEASES. strength. The safety of the patient depends upon the use of large doses of quinine to cut short the pyrexial stage, the doses used being from 20 to 30 grains (1.3-2.0), preceded by a good-sized purgative dose of calomel, say 3 to 4 grains (0.15-0.2). If vomiting is too vio- lent to permit of the retention of the quinine, it must be used by the rectum and hypodermically, and the stomach and intestines be swept out by the use of divided doses of Seidlitz poAvder or citrate or sul- phate of magnesium. If purgatives are used, they should precede the quinine by twenty minutes, as otherAvise the latter drug is swept out into the bowels, where it is rendered useless by reason of its pre- cipitation by the alkaline juices there present. Many clinicians claim that remittent fever is chiefly benefited by quinine during the remis- sion, and cinchonism during the pyrexial stage undoubtedly increases the discomfort of the patient. If pyrexia is excessive, relief must be sought in the cold pack and antipyrine. The best treatment of the vomiting is the use of small doses of morphine, or 3- to 5-drop (0.15-0.3) doses of the spirit of chloro- form in from 30 drops to 1 drachm (2.0-4.0) of cherry-laurel water. Aconite may also be used if the patient is strong enough. (See Vomiting.) If the belly is tender, a turpentine stupe should be applied. (See Turpentine.) If intestinal hemorrhages occur, gallic and tannic acids or Mon- sel's salt, in the dose of 3 grains (0.15) in hard pills, may be used, and cold cloths be placed over the belly. (See Hemorrhage.) If haematuria appears, quinine must be avoided unless the neces- sity for its employment is absolute because of the frequent recur- rence of paroxysms. Quinine in some cases increases the haema- turia. (See Collective Investigation by author in Therapeutic Gf-azette, July, 1892.) The treatment of convalescence consists in the use of tonics, such as quassia, calumba, gentian, Huxham's tincture, arsenic, and purga- tives when needed, Avith attention to the kidneys, the potassium salts being employed to keep these organs active. (See Intermittent Fever.) RETINITIS. Retinitis, or inflammation of the retina, often associated with cho- roiditis, is commonly the result of several constitutional diseases: Bright's disease, diabetes, syphilis, etc. In some cases no cause can be found. The general remedies must be directed according to the supposed cause, and the eyes must be protected from light and all close work avoided. Very distinct retinal irritation may be caused by eye-strain, which is to be relieved by the prolonged use of atro- pine and dark glasses, and later suitable lenses for the correction of any existing error in refraction. RHEUMATISM. 623 RHEUMATISM (ACUTE ARTICULAR). No better example of the fact that therapeutics is in advance of pathology can be adduced than the disease knoAvn as rheumatism. The therapeutist cannot tell hoAv he cures the condition designated by this name, simply because the pathologist cannot tell what the cause of the disease is, and Avhen this information is forthcoming from the one side, an explanation will be immediately given by the other. This being the case, Ave must devote ourselves to the study of pure empiricism, and not to logical pharmacology. The treatment of acute articular rheumatism is divided into that portion devoted to the cure of the disease-process, and that directed to the relief of the pain and of the local manifestations of the disease. When an acute attack of rheumatism comes on, it is nearly always accompanied by a high temperature, a bounding pulse, and all the evidences of active systemic disturbance accompanying inflammatory outbreaks, Avhich, in this particular instance, involve the joints. We may therefore use at such times the remedies which Ave have learned are best able to combat inflammation—namely, aconite and veratrum viride. So powerful are these drugs in the early stages of acute rheumatism that some persons have believed them to be possessed of a specific antirheumatic poAver. This is, hoAvever, highly unlikely, as they act no better here than in other inflammatory conditions else- where. The proper manner in Avhich to use the tincture of aconite under these circumstances, in a strong, healthy individual, is to administer 3 drops (0.15) at once in a little Avater, and folloAv it by a teaspoonful of a mixture containing 5 drops (0.3) of tincture of aconite and 2 ounces (64.0) of water, every half-hour until perspiration on the skin betokens circulatory depression through the action of the drug. If this is not used, veratrum viride in the same proportions may be gh-en. The advantages of this treatment are numerous; first, it allays the fever; second, it quiets nervous excitability; third, it tends to prevent permanent changes in the joints which are involved; and, last of all, it aids in the production of a sweat. Whenever these drugs are employed the patient must be strong and hearty, not debil- itated or Aveak, and it is to be noted that this treatment is not to be resorted to carelessly. Finally, care is to be taken that the symp- toms of depression from the drug and the disease combined do not become too severe. Where great exhaustion is primarily present or ensues upon the use of depressant drugs, alcoholic stimulants are particularly needed. Simultaneously with these internal measures a solution of bicar- bonate of sodium, 20 grains to the ounce (1.3 : 32.0), may be applied to the joints involved, by means of lint Avet with this solution, with relief to the sense of heat or burning, or ice-cold compresses may be tried. In other cases relief may be obtained by applying hot cloths saturated with the so-called Fuller's lotion—namely, carbonate of sodium 6 drachms (24.0), laudanum 10 ounces (320.0), glycerin 2 624 DISEASES. ounces (64.0), and water 9 ounces (288.0). Sometimes great relief is obtained by fixation of the joints by means of splints. A most valuable application to the inflamed joints of rheumatism, either during the acute stage or afterward when they remain swollen and enlarged, is: R.—Ichthyol............3iv vel gj (16.0-32.0). Adipis............ gij (64.0).—M. S.—Kub in well and apply about the inflamed part on lint. In other cases the acute stages of the inflammation may be com- bated with advantage, particularly where there is gastric disorder, by the local application of salicylic acid made into an ointment with an animal fat, not vaseline or glycerin, as it is not absorbed Avhen so mixed. According to Bourget, this treatment is best suited to blondes and young persons, as absorption is more rapid in this class of patients. The following salve may be prescribed: R— Acid, salicylic.............3J (4.0). Ol. terebinthin............. n\,xxx (2.0). Lanolin...........■ ■ ■ • • S (32.0).—M. High fever is to be controlled by the same measures as the high fever of any other disease—by antipyretics, by the cold pack, cold bath, or sponging with tepid or cold Avater. Immediately after the system has been thoroughly impressed by cardiac sedatives—or at once and in their place if the case is not seen at first or is Aveak—the physician should resort to one of three remedies—namely, salicylic acid or its salts, antipyrine, or acetanilid. The general opinion of the profession seems to be that these three remedies stand in the order here placed in regard to their efficiency, but it is also true that one will often succeed when the other fails, and it is worthy of note that success or failure generally asserts itself rapidly; that is, the drug used gives relief in twenty-four or seventy- two hours or fails altogether. It is most important to remember that salicylic acid only protects the cardiac valves and the entire endocardium from the ravages of the disease by shortening the attack, and not by any direct influence, and in addition that this acid, by reason of the profuse sweats often produced by it and its tendency to cause cardiac depression, must be watched lest it act unfavorably on the general systemic state. Taking up salicylic acid first, we find that its proper use is often misunderstood, and that it fails because of this fact. Whenever acute articular rheumatism appears the salicylic acid should be pushed in the same way that Ave use quinine on the advent of a malarial parox- ysm—namely, in full dose. It is useless to give salicylates in 5- or 10-grain (0.3-0.65) doses three times a day; they must be given in 20-grain (1.3) doses, morn- ing, noon, and night, or oftener, or not at all. If the sweats are too severe or the stomach rebels, they may be stopped, but not decreased in amount unless for good reason. Further than this, if salicylic acid is used for two or three days in this way, and produces evidences of cinchonism, yet fails to alter materially the course or RHEUMATISM. 625 severity of the trouble, it should be withdrawn, as it will rarely if ever do any good after this time. A very efficient substitute for salicylic acid is the oil of gaultheria (wintergreen), which contains about' 90 per cent, of salicylate of methyl. The dose should be 10 to 20 drops (0.65-1.3) oil a tea- spoonful of sugar or in capsule or emulsion three times a day, after meals. Antipyrine and acetanilid may both be considered together, since their action is identical in rheumatism. The author believes that antipyrine, while often relieving the pain more than the acetanilid, nevertheless does not act so favorably in decreasing the duration of the disease. The dose of the first should be 5 to 10 grains (0.3-0.65) three times a day; of the second, 4 to 8 grains (0.2-0.6) at the same intervals. The studies of Guttmann Avith acetanilid in a very large number of cases of rheumatism, embracing all its forms, both chronic and acute, have given most encouraging results, and the author has seen the drug act most happily in cases Avhich had refused to yield to the iodides and salicylates, although all of these cases Avere of the severe acute form, suffering intense pain from the articular inflamma- tion, but devoid of any cardiac complications. It at once becomes evident that a drug such as antipyrine or acetanilid may do good in a case of rheumatism in three entirely separate and distinct Avays, any one of Avhich may be active at once or all active together, hand in hand, in the improvement of the patient's state. Any substance pos- sessing strong antipyretic power must be of value under such circum- stances, because of the lowering of the fever Avhich folloAvs its admin- istration, Avith the resulting quieting of an excited system, and in putting aside the delirium associated Avith a condition of hyperpy- rexia. Not only does such a drug act favorably in this manner, but the analgesic effects of such a substance must exert a poAverful influ- ence for good. By benumbing the sensibility of'the patient to the excruciating pain consequent upon movement, and so putting aside the nervous Avear and tear of sleeplessness and suffering, the patient's state must be improved, or at least not groAV Avorse from the exhaus- tion of the long hours of agony. Further than this, it would seem probable that acetanilid possesses a direct antirheumatic influence, allaying the disease-processes even in those forms Avhere, pain being largely absent, the improvement must be real and not apparent. The intention of the author is not to extol the value of acetanilid and antipyrine in rheumatism to the exclusion of other means of re- lief, nor to recommend their use before the more thoroughly tried sali- cylates and iodides, but to draAv to their standard a certain number of cases Avhich persistently resist treatment of the ordinary stamp, and Avhich put the physician to his wit's end for a change of treatment at least promising some chance of relief. Many of the readers of this book have doubtless seen such cases, and many of them must have learned by sad experience that acute articular rheumatism is in many cases bound to run a course of so many Aveeks or days, do Avhat Ave will. Under these circumstances nothing acts further than a pal- 40 626 DISEASES. liative, and the patient and his friends become impatient for a change. The author has found that acetanilid in such cases Avill often relieve the pain, and so permit a refreshing sleep, in doses of from 4 to 8 grains (0.2-0.6) three times a day, and that these amounts do not cause the excessive sweating which the necessarily large doses of salicylate are sure to produce—SAveats Avhich leave the patient often- times almost dyspnoeic from very weakness. Whether this temporary relief produces such changes in the system as to permit of a better battle against the disease, or whether it actually counteracts the rheu- matic poison, we knoAv not; but Ave do know that after the use of ace- tanilid the relief is not only temporary, but often permanent, and that a very distinct step in advance is made toward the close of the attack if any influence at all is felt. The following prescription, which is of additional value because the caffeine supports the heart and increases urinary secretion, is recommended: R.—Acetanilid............. Caffein............... Camphor, monobromat........ Ft. in capsul. vel pil. No. xx. S.—One every three hours or three times a day Phenacetin is often very useful when used in rheumatism, partic- ularly if combined with salol. Passing from what may be appropriately called the coal-tar treat- ment of rheumatism, because all the drugs so far named for internal use have such a source, Ave come to a list of remedies heretofore largely used in rheumatism in place of the newer compounds, but which are not so commonly employed to-day. These remedies act, as a rule, in the subacute forms of rheumatism or in the cases Avhere the first group fail because the disease is obsti- nate. Of these the chief is the iodide of potassium, followed by the acetate, bicarbonate, and citrate of potassium. If the iodide is used, the following prescription is of service: R— Potassii iodidi ...•■•.......gj (32.0). Syr. sarsaparilla? comp. ........fgvj (192.0).—M. S.—Dessertspoonful (8.0) three times a day, after meals. In other cases it is best, because of the disagreeable taste of the iodide, to give it in sugar-coated pill or in tablet form, but care should be taken that milk or Avater is taken at the same time to prevent gastric irritation. Or, if preferred, 20 to 30 grains (1.3-2.0) of the bicarbonate of potassium may be taken every four or five hours in water flavored Avith cinnamon for the sake of the taste, or the citrate of potassium, Avhich is more agreeable, may be taken in equal amount. Sometimes a little colchicum added to the prescription given above may be useful if the case is very obstinate, as follows: R— Potassii iodidi.......,?j vel |ij (32.0-64.0). Vini colchici radieis.....f£ij vel f.^ss (8.0-16.0). Syr. sarsaparilla? comp. . q. s. ad fgvj vel f|xij (192.0-384.0).—M. S.—Dessertspoonful (8.0) three times a day, after meals. gr. xl (2.6). gr. xx (1.3). gr. xx (1.3).—M. RHEUMATISM. 627 Haig has proved that in rheumatism there is retention of uric acid, and that the use of alkalies and the salicylates at once causes this sub- stance to be changed into a soluble form ready for elimination. The other drugs used in acute rheumatism are numerous, but only a feAv of them deserve attention here. There is abundant evidence on record that full doses (10 to 30 drops [0.65-2.0]), of the fluid extract of cimicifuga if given every five hours will decrease the red- ness and pain of the joints and shorten the attack in some cases. Again, certain species of rhus, as rhus toxicodendron, are useful if fresh preparations are at hand. The dose of rhus toxicodendron is fa to 1 drop (0.006-0.05) of a tincture made by adding 1 part of the fresh leaves of poison-ivy to 2 parts of alcohol, this dose being taken three times a day. Where the pain seems particularly severe at night this drug is very valuable, according to many careful students of therapeutics. Nearly every case of acute rheumatism will do better if a strong mixture of lemon- or lime-juice and Avater be taken daily in large quantities. The local remedies in rheumatism are chiefly counter-irritants and sedatives. Thus, small or large blisters applied around an inflamed joint after the general systemic excitement is passed may be of great value in restoring the suppleness of the joint and in aiding in the absorption of the effusion. The remaining local treatment consists in thoroughly painting the inflamed parts Avith tincture of iodine if blis- ters are not used, and in the application of veratrine ointment or iodine ointment around the joint. (See Areratrina.) Salol, Avhich is dissolved and absorbed solely in the intestine through the action of the juices there present, has been used in the place of salicylic acid with success; but it is Avorthy of note that, as it contains 40 per cent, of carbolic acid in addition to the salicylic acid, its use in very large amounts is dangerous. (See Salol and Salophen.) RHEUMATISM (CHRONIC). Chronic rheumatism is one of the most difficult and obstinate dis- eases Avith Avhich we have to deal. In some cases the acute form just considered merges sloAvly into the chronic form, or, in other instances, the disease gradually comes on, increasing, it may be, by exacerba- tions or by gradual progression. The treatment of chronic rheuma- tism is someAvhat different from that of the more acute forms, and approaches that of gout in some of its therapeutical indications. In other Avords, the salicylates are not so useful in these cases as are the iodides and colchicum, so that in the majority of instances the pre- scription of iodide, sarsaparilla, and colchicum given in the article on Acute Rheumatism is indicated. When anaemia or weakness is pres- ent, cod-liver oil is often of great service, and it is Avorthy of note that this useful nutritive remedy Avas first brought into therapeutics by the fishwives of Holland, Avho found it useful in the attacks of rheu- matism to which their husbands were subjected through exposure. 628 DISEASES. When the oil is thoroughly rubbed into chronically-inflamed joints it is almost as useful as Avhen taken internally. The same forms of severe counter-irritation are not so useful in chronic rheumatism as in acute rheumatism, but a very valuable therapeutic measure in these cases is the use of the Russian or Turk- ish bath or an improvised sweat by means of a lamp and a blanket. (See Heat, and Cold.) Liniments are always called for, for two reasons: First, they relieve pain and do good to the parts, if not from their medicinal properties at least by the rubbing which accom- panies their application; second, because they give the patient some- thing to do or to have done, and therefore impress him with the object-lesson that his attendants are attendant and alive to his suffer- ing and need of sympathy and care. Among the loAver classes the belief in liniments is very widespread, and their use will often instil into the minds of the friends a far greater confidence than the most logical of treatments with the lini- ment left out of the list of remedial measures. The following liniments Avill be found very useful under these circumstances: R— Tr. aconiti...........f^ij (8.0). Tr. opii............f*j (32.0). Olei terebinthina?........f|j vel fgij (32.0-64.0). Linimenti saponis . . . . q. s. ad f^viij (256.0).—M. S.—Poison. Use as a liniment three times a day. Or, R.—Aqua? ammonia? fort.......f^iv (16.0). Olei cajuputi........fzj (4.0). Tr. belladonna?.........f^j vel f^ij (32.0-64.0). Linimenti camphora? . q. s. ad f^viij (256.0).—M. S.—Poison. Use as a liniment. Or, R.—Tr. opii "| Tr. aconit. I.....aa fgiv (16.0). Aqua? ammon. fort. J Linimenti chloroformi.....f^vj (192.0).—M. S.—Poison. Use as a liniment to chronically-inflamed muscles or joints. In other instances the greatest relief is obtained by employing the folloAving ointment of veratrine: R-—Veratrina?...........gr. xxx (1.6). Hydrargyri iodidi flav......%j (4.0). Petrolati...........'Jij (64.0).—M. S.—Use as an ointment over the joints. This ointment ought not to be widely distributed, and the pulse and respiration should be Avatched, as the veratrine may be absorbed and depression of a severe character set in. For the reduction of enlargements of the joints due to the dis- ease, and accompanied in some cases by pain, the folloAving ointment is serviceable: R.—Unguent, iodi.........gj (32.0). Adipis............3iv vel |j (16.0-32.0).—M. S.—Apply locally. RICKETS. 629 Or, still better, R.—Ichthyol.............^iv to ^j (16.0-32.0). Adipis............3J (32.0).—M. S.—Kub into the joints thoroughly. Ichthyol is certainly the most efficient remedy that we have for the enlarged and painful joints. The employment of red flannel over inflamed joints is no better than the use of Avhite flannel, and it is never beneficially "medi- cated," as claimed in the stores. The only advantage of red flannel is that, as it is dyed, the avooI is often better for not being thoroughly bleached, and is in larger amount for this reason. The disadvantages of red flannel are that it stains the clothes and the possibility of its producing irritation of the skin or even systemic effects of an eAdl character. RICKETS. Rickets may be defined as a state of the body of an infant or child in which there is a deficiency of the normal salts of the bones and tissues, Avith corresponding enlargement of the animal portion of the bone, or, in other words, the cartilaginous parts. Generally the term is applied solely to designate bony troubles, but every practising physician sees cases where the manifestations of rickets are empha- sized in gastro-intestinal disorders rather than in bony deformities. The chief cause of rickets in children, aside from the presence of any disease, such as scrofulosis, is inanition ; that is, non-nutrition of a specialized form, or, in other words, bone-salts starvation. This may occur after or before birth, and it is quite common to see children, born of mothers ill-fed or whose assimilation of salts is defective, Avith soft bones or a distinct tendency to rickety development. The treatment of rickets is therefore largely dietetic and devoted to the improvement of the food and digestion. No part of the body fails in force more than the digestive apparatus in the presence of this disease, probably because the alkalinity of the blood is altered, and partly because the stomach cannot secrete properly-formed juices from imperfectly-nourished glands. The medicines to be used in rickets are general tonics, digestive tonics and stimulants, and bone tonics and stimulants, such as salts of lime and phosphorus. The general tonics are quinine, cod-liver oil, nux vomica, and iron, Avhile the digestive tonics are the simple bitters, physostigma, and mineral acids. The bone tonics and stim- ulants are lime salts, phosphorus, and phosphate of zinc. Tonic treatment is best carried out in young children by the admin- istration of quinine in the form of quinine chocolates or by the use of strychnine in the dose of ^u to ^ of a grain (0.0003-0.0006) in sugar-coated pink granules. Arsenite of copper in the dose of Y^o of a grain (0.0006) in tablet triturate three times a day is also useful: 630 DISEASES. A very useful preparation is the following: R.—Olei morrhua?............f^vj (24.0). Syr. calcis lactophosphat.l .....aa f5iij (96.0).—M. Liquor calcis J ^ J S.—.] to 1 teaspoonful (2.0-4.0) two or three times a day. Shake thoroughly. Nux vomica is so bitter as to be difficult of administration to young children, and when given only 1 to 4; of a drop (0.008-0.016) of the tincture should be used, three times a day. Where a distinct scrofulous tendency exists and anaemia is present small doses of the syrup of the iodide of iron are of service, and fa to 1 drop (0.006-0.05) may be given three or four times a day to a child of six months or a year, thus: Or, R.—Syrupi ferri iodidi......gtt. iij vel xxiv (0.15-1.5). Aqua? dest.......q. s. ad fgiij (96.0).—M. S.—Teaspoonful (4.0) every four or five hours during the day. R.—Syrupi ferri iodidi..........gtt. v vel xx (0.3-1.3). Syrupi............q. s. ad fgiij (96.0).—M. -Teaspoonful (4.0) three times a day, after meals. Here, again, arsenite of copper is a particularly valuable remedy. The salts of lime and sodium are of direct benefit to the bones, forming by their presence in health a large proportion of the osseous system, and therefore they may be considered as foods rather than drugs. Very often their administration to nursing mothers or preg- nant women saves the maternal teeth from caries and preserves the general health of the mother and child. The following prescription may be used: R.—Syrupi calcis lactophosphatis......f§iv (128.0). S.—2 to 1 teaspoonful (2.0-4.0) three times a day, after meals. The reasons for the use of phosphorus are clear, from what has been said of that drug Avhen speaking of it elsewhere in this book, as it acts as a direct and powerful stimulant of bone-growth. Phosphorus is best given to children in the form of very small sugar-coated pills (fas gr. [0.0003]), such as are put up in the form known as "• pink granules " by manufacturing chemists. Phosphate of lime and phosphate of sodium are valuable remedies in rhachitis. They are never to be used in large doses, because they will not be assimilated and will only disorder the stomach. The proper dose of each is 1 to 2 grains (0.05-0.1), placed in the milk, where their presence will not be noted. The ventilation of the rooms where a child prone to rickets is kept should be excellent, not too hot or cold and free from draughts. A cool sponge-bath is useful at night if the patient is strong enough, or a good rubbing with salt and whiskey, 1 drachm (4.0) of salt to a pint of whiskey, is of still greater service. Special attention should be paid to the development of the mus- cles by massage and passive movements, as these parts are always Aveak. Walking must not be allowed too early, as it may cause bony deformities. SCARLET FEVER. 631 SCARLET FEVER. This disease, the most frequently fatal of all the exanthematous diseases of childhood, requires the greatest care in its treatment. Complications constantly arise requiring skill on the part of the attendant, and it is upon his success in treating these outbreaks, as well as in the general direction of the case, that the life of the patient chiefly depends. It has been claimed by certain practitioners that one or tAvo remedies Avhich they have used act as abortifacients of the attack, decreasing its severity, duration, and the probability of complications. Thus, one European physician has used salicylates with Avonderful results, if his claims are true, for he found them to prevent all complications and even to remove them Avhen present. He gives, throughout the entire attack and for some days after defer- vescence has ensued, the following: R.—Sodii salicylat.............gr. xlviij (3.0). Aqua? dest'illat......... . . . fsjij (8.0). Syr. aurantii..........q. s. ad f^iij (96.0).—M. S.—Teaspoonful (4.0) every hour during the day and every two or three hours at night, in a little water. In this country Wilson has employed chloral throughout the entire attack, Avith asserted good results, in the folloAving manner; but in our opinion Wilson's method is not the best for most cases, unless the nervous manifestations are very marked, Avhen the chloral treat- ment is of great value. The plan is as folloAvs: " As soon as the patient is suspected or knoAvn to be developing scarlatina, a laxative dose of calomel, pro- portionate to the age and general condition, is administered. Shortly thereafter chloral is given in moderate doses, at intervals of tAvo or three hours or longer, throughout the attack. The dose varies Avith the age of the child; the frequency of its administration depends largely upon its effect. To infants of tAvo or three years a dose of from 1 to 2 grains (0.05-0.1) may be given, the dosage being grad- ually increased Avith older children, that for adolescents reaching 5 grains (0.3). The tranquillizing and sleep-producing effects of the drug are, in most instances, promptly realized, the patient falling into a condition of quietude, instead of the restlessness and jactitation Avhich are so distressing in the well-developed forms of the disease. "The repetition of the dose should not be more frequent than is necessary to maintain this condition of quietude—a condition from Avhich the patient may be easily aroused, and into Avhich he quickly relapses when left undisturbed. It is neither necessary nor desirable to push the drug to the establishment of a deeper sleep. Profound narcotism is, of course, to be avoided. The patient may thus be kept in a condition of light repose throughout the Avhole duration of the fever. By this means not only is there obtained relief from the restlessness and distress of the active period of disease, but much wear and tear of the nervous system and some exhaustion from mus- cular effort are prevented. Delirium is controlled; the itching and burning of the skin, due to the eruption, are allayed; in a word, the 632 DISEASES. greater number of the distressing symptoms of the disease are favor- ably influenced by the cautious and prolonged administration of chloral hydrate in efficient doses." As a rule, the drug is easy of administration and Avell borne by the stomach. Its acrid after-taste is best masked by its administra- tion in Aubergier's syrup of lactucarium, diluted, thus : R.—Chloralis. ... .......gr. xxx (2.0). Syrup, lactucarii (Aubergier) j _ f?gs ye, f~ (16i0_32.o)._M. AQU86 J S.—A teaspoonful (4.0) in iced Avater every two, three, or four hours. " The administration of nourishment immediately after the medi- cine is desirable. The sleep-inducing properties of the drug manifest themselves rapidly, but are not prolonged; therefore its repetition at intervals of two or three hours is called for." From the very beginning of an attack to its end unless diabetes comes on, the child should be supplied Avith plenty of pure water, and, if possible, this Avater should be obtained from a spring contain- ing a low percentage of solids, as Poland water, Avhich is Avidely sold throughout this country. If this is impossible, then Vichy Avater may be employed, or it may be used by obtaining the granulated Vichy salts sold by most large drug firms, and adding this in small amounts to pure filtered or distilled water. This makes an effervescing draught Avhich may be taken while bubbling or not as the child desires. The object of this treatment is to flush out the kidneys, and to so dilute the effete matters generated in the body by the fever and the germs of the disease that they lose, to a great extent at least, their poison- ous and irritating poAvers. In other cases a prescription containing SAveet spirit of nitre and citrate of potassium proves useful, as follows: R— Spt. a?ther. nitros........ . . . f Sj (32.0). Potassii citratis............^ij (8.0). Aqua?.............q. s. ad f^vj (192.0).—M. S.—Teaspoonful (4.0) every two hours if the urine is high-colored. The convulsions Avhich sometimes usher in an attack are to be treated by 5-grain (0.3) doses of chloral and 10 to 20 grains (0.65-1.3) of bromide of sodium for a child of five to eight years. The convul- sions of the advanced stages are often uraemic, and must be treated appropriately. The further treatment of the disease rests upon the symptoms alone. We cannot cure the patient by the use of remedies, but we can do much toAvard making the pathAvay to health smooth and free from pitfalls and obstructions. Probably the most common complications calling for treatment, Avhen the kidneys have been treated in the way just spoken of, are high temperature or fever, and sore throat or angina. The fever is to be controlled in these cases in precisely the same Avay that it is in all other conditions in which it is present. It is best to attempt to keep it down beloAv 101°, or at least beloAv 102° F., by tepid spong- ing, Avhich also allays the itching of the skin, or, if the fever still SCARLET FEVER. 633 rises, by the use of colder water, or even the cold pack if the parents Avill allow it. Generally the popular fear that the application of cold to the surface will drive the eruption "inward" is so strong as to make the cold pack objectionable in the eyes of the friends; but if the temperature reaches 105° F., the physician must assert the fallacy of this belief and insist on its use. (See Cold, Part III.) If sup- pression of the rash does occur, we must use the Avet pack. (See Heat, Part III.) Antipyrine and acetanilid, to be sure, may both be used, but it is worthy of note that each of these may produce collapse or other complication if large doses are necessitated by an obstinately high temperature. If these complications ensue, alcohol will be indi- cated. Quinine has been highly recommended as an antipyretic in scarlet fever, but it is of little value in the majority of cases, simply disordering the stomach and irritating the kidneys if used in doses large enough to be effective. Where the head seems to be particu- larly hot and the fever is high, an ice-bag or a head-coil of rubber tubing is to be employed, and through the latter Avater may be circu- lated at Avhatever temperature is thought best. (See Cold, Part III.) The treatment of the sore throat of scarlet fever is an important part of the care of the child in many cases. Small pellets of ice may be held in the mouth and an ice-bag applied to the outside of the throat. This is done by finely breaking up some ice and placing it in a thin india-rubber bag about the neck, the surface of the bag being covered by a cloth to prevent too rapid melting of the ice and the wetting of the clothes by the condensation of moisture on the surface of the bag. This treatment should be used during the entire attack if needed, and the contents of the bag reneAved as often as the Avater becomes at all Avarm from the heat of the body. By this means the redness of the fauces and the SAvelling of the glands of the neck are prevented or relieved. Chlorate of potassium may be used in a spray or on a swab, but never internally, OAving to its irri- tant effects upon the kidneys and stomach and its general influence on the blood. In some cases where the eruption fades or is never very prominent it is of the greatest importance that it be made active. Under these circumstances the child may be placed in the Avarm Avet pack, and, if the head is very hot, cold applied to the vertex and throat Avhile the body is enveloped in the blanket. (See Heat.) This often brings out in an hour or two a bright scarlet rash, and the child falls asleep and wakes up free from delirium and high fever. The itching and burning of the skin in many cases of scarlet fever are annoying symptoms, and they may become really dangerous. The author has recently carried out a series of experiments shoAving that fever of high degree can be brought on solely through nervous irri- tation, thus explaining a fact long Avell known to clinicians—namely, that the relief of this dermal irritation in'scarlet fever may be fol- loAved by a fall of temperature. To relieve this symptom it will often be found advisable to cover the entire skin Avith a thin layer of vase- line or cosmoline or benzoated lard, or, in other cases, as an antisep- tic and local anaesthetic, carbolized oil may be applied (2 drops of 634 DISEASES. carbolic acid to each 2 ounces [0.1 : 64.0] of olive oil). In other cases almond oil may be used. If nephritis comes on and is a pressing condition, the greatest care is necessary, and the object of the physician must be to make the skin, disabled as it is, carry out a sufficiently active eliminative function to relieve the kidneys of any strain, to remove dropsy, and to aid in the removal of effete matter by producing catharsis. These effects are best attained by the use of pilocarpine: 4y grain (0.01) by the mouth for a child of ten years, or fa grain (0.006) hypodermi- cally. If cardiac Aveakness exists, this drug cannot be given, and we are forced to the use of from 5 to 10 grains (0.3-0.65) of compound jalap powder to a child of ten or tAvelve years, to Avhich should be added 10 grains (0.65) of bitartrate of potassium to increase its efficiency. SAveating may also be produced by the employment of heat obtained by the use of bottles of hot water or hot bricks placed about the patient, Avho is first Avrapped in blankets, so that the bottles cannot burn the skin, and so arranged that SAveating will come on. The thermometer must be placed in the mouth to foretell any danger from heat-stroke if the sweat should fail to appear. In such cases the hot pack is of great value. (See Heat.) The after-treatment of scarlet fever during convalescence consists in the use of Basham's mixture or the tincture of the.chloride of iron and in the employment of simple bitters, strychnine, or quinine. Fresh air, sea-air or mountain-air is useful, Avhile cold or exposure to cold air or draughts is to be carefully guarded against. SCIATICA. Sciatica is an exceedingly obstinate affection, in the majority of cases resisting the best treatment for Aveeks. It seems to be due to rheumatic taint in the majority of instances, and may sometimes be cured by the remedies used and described under the heading of Acute or Chronic Rheumatism. In other instances it is due to injury or jarring of the nerve, as by heavy persons stepping off from a high step to the hard ground. Thus the most obstinate case ever seen by the writer Avas one in Avhich a stout man weighing about tAvo hundred and fifty pounds acted as "coupler" on a SAvitching engine, and, though Avonderfully agile for his weight, provoked the disease in the leg on Avhich he ahvays first struck the ground Avhen jumping from the platform of the moving locomotive. The treatment for all cases is both internal and external. The internal treatment may be the same as that already described under Acute or Chronic Rheumatism, or in other instances consists in the use of large doses of bitartrate or citrate of potassium, 40 grains (3.0) three times a day, in plenty of Avater to aid in the maintenance of free kidney action. At the same time the amount of coffee and tea should be cut (Ioavii as much as possible, and lemonade, strongly acid, be taken freely during the day. If the pain is very excessive, morphine should be given, or antipyrine or acetanilid may be used. SCROFULOSIS. 635 The local treatment of sciatica is quite various. One of the favor- ite methods is to inject deeply into the flesh, just over or about the exit of the nerve from the pelvis, 10 to 20 minims (0.65-1.3) of chlo- roform, or instead of the chloroform £ to i grain (0.01-0.016) of mor- phine, in 30 minims (2.0) of water which has first been distilled and sterilized, may be used with equally good results and less danger of sloughing. Other physicians prefer acupuncture, the needle being driven down until the sheath of the nerve is punctured. Still another useful method is to take a strong glass rod with a round, smooth end, and, after anointing the skin over the course of the nerve with a little ichthyol ointment or lard, to pass the end of the rod back and forth over the tender area, using as much pressure as can be borne. By this means massage or pressure on the nerve is accomplished. In other cases the daily use of an ether or rhigolene spray over the part is effective, or kataphoresis may be resorted to. In still others, from two to four large Avet or dry cups, preferably the wet, may be placed along the course of the sciatic nerve Avith great advantage. Glundrum has employed Avet cupping over the course of the dis- eased nerve to the number of 5 to 10 cups, with very extraordinary results. The liniments recommended in chronic rheumatism may be tried, and cod-liver oil is of service in obstinate cases. Sometimes nerve- stretching must be performed before a cure is effected. SCLERITIS. Scleritis, or inflammation of the sclera, consists in a bluish-red, someA\'hat elevated patch, Avith implication of the overlying episcleral tissue (episcleritis). In the earlier stages pain and photophobia, if present, require atropine and boric acid and compresses of hot water; later, the infiltration may be subdued with yelloAAr-oxide-of-mercury ointment, associated with massage. If the disease spread and impli- cate the cornea and iris, the treatment useful in ordinary iritis is in- dicated. In stubborn episcleritis, without iritis, Avhich does not yield to these measures, eserine, usually accompanied by pilocarpine sweats, should be tried, and even the actual cautery has been recommended. The disease in many instances is associated Avith rheumatism, syphilis, scrofula, anaemia, and menstrual disorders: these must ahvays receive the needed constitutional treatment, especially if iritis or keratitis ensue. Scleritis is a disease hard to eradicate and subject to frequent relapses. SCROFULOSIS. Scrofulosis is to be treated by hygienic measures rather than drugs—fresh air, residence by the seaside, proper out-door exercise, massage, and dietetics, all of which take precedence of medicines. If these necessary adjuncts to a cure are obtainable, the prognosis is fair, to say the least, and the following drugs may be used, all of 636 DISEASES. them being devoted to the improvement of the general health, and not to any direct influence over the scrofulous tendency in itself. It is hardly necessary to state that cod-liver oil (or its supposed active principles combined under the name of morrhuol) is perhaps the best remedy of all. The oil should be given in emulsion, being first pan- creatized and so prepared as to be somewhat palatable by the addition of flavoring substances if the child is old enough to appreciate such flavors. In young children, while distaste to the oil is often shown at first, a liking for it rapidly develops, so that the writer has seen chil- dren cry for it when the oil was discontinued. It is nearly ahvays best to combine the lactophosphates or the hypophosphites Avith the oil when it is given in these cases. Whenever anaemia is present, syrup of the iodide of iron is useful in from 1- to 10-drop (0.05-0.65) doses, according to the age of the child, as follows: R.—Syrupi ferri iodidi..........f^ss vel f^ij (2.0-8.0). Aqua? dest...........q. s. ad fjiij (96.0).—M. S.—Teaspoonful (4.0) in water three times a day, after meals, to a child of one year. In these same cases fa grain (0.001) of arsenous acid or jfa grain (0.0006) of corrosive sublimate may he given to a child of three or four years, in the form of tablet triturates, or the following pre- scriptions may be used : R.—Liquor potassii arsenitis........tt\,xvj (1.0). Aqua? destillat.............f|ij (64.0).—M. S.—Teaspoonful (4.0) three times a day, after food. Or, R.—Hydrarg. chlor. corros. . . gr. TV vel gr. ^ (0.006-0.012). Aqua? destillat.......fjij (64.0).—M. S.—Teaspoonful (4.0) every five hours, after food. The use of the iodides is generally contraindicated in those cases where softening and breaking down of the glands are going on rap- idly. In their place we may employ the phosphates of lime or sodium in from 1- to 2-grain (0.05-0.1) doses several times a day, and if sup- puration is active the sulphurate of calcium, given by placing 1 grain (0.05) of it in half a tumblerful of water and giving a teaspoonful hourly. This mixture should be made fresh every day to prevent its becoming oxidized. Where enlargement of the cervical glands takes place, iodine ointment, diluted, one-half of lard, should be well rubbed into the part twice daily, but stopped at once if any signs of softening or fluctuation appear or if the skin becomes reddened. Where these enlargements are persistent, ichthyol ointment is to be rubbed in, using the following formula: R— Ichthyol...............^j vel ij (4.0-8.0). Adipis..............33 (32.0).—M. S.—Apply locally. If this is not followed by a cure, the glands should be excised or scraped and the cavity packed with iodoform, as in the majority of cases these enlargements will be found to be distinctly tuberculous. (See Adenitis.) SHOCK. 637 SCURVY. Scorbutus is caused so frequently by dietetic laAvlessness, and its cure is so completely dependent upon the use of proper foods, that almost no drugs are to be employed in its treatment. The avoidance of all salt meats, or, more important still, the avoidance of those foods, be they Avhat they may, Avhich have caused the disease in a given case, is to be practised. The only remedies particularly indicated are lemon-juice or lime- juice or citric acid, the latter being far less valuable in all cases than the juice of the fresh fruit. Where lemon-juice causes indigestion this effect may be avoided by boiling the lemonade and alloAving it to cool. The boiling precipitates certain poisonous and irritating albu- minoids, and the supernatant liquid Avhen taken aAvay is devoid of any evil influence, and may be cooled and SAveetened to suit the taste of the individual concerned. Arsenic and iron are of service in most cases, and rest and quiet are to be insisted upon. SHOCK. The medical treatment of shock is very important, and the life of the patient depends upon the care exercised by the attendant; but before describing the treatment it is in place to consider the causes of the con- dition and the state of the injured person, so that Ave may understand the methods indicated. Every physiologist recognizes the fact that the body, particularly in its most vital parts, is controlled by inhibi- tory and accelerator nerves or nerve-cells, which govern the functions of all organs. Normally these two forces of inhibition and acceleration act in such away as to be perfectly balanced, but abnormally they may either of them become excesshre and overcome the other. Further than this, Ave must remember that all conditions of great functional activity are ultimately followed by a reaction Avhich amounts to depression or exhaustion. Shock consists in an over-stimulation of the inhibitory apparatus Avhich governs the heart and respiration, ultimately folloAved by ex- haustion of inhibition, so that the pulse and breathing become rapid and shallow instead of sIoav. Various degrees of shock can be readily recognized, and the severity of the condition ahvays depends upon the constitution of the individual. Every one has heard a nervous Avoman say, "You frightened me so that my heart stood still," and again, a moment later, " Just feel hoAv fast my heart is beating :" and Ave all of us knoAV how any severe and sudden shock causes these changes to appear in the pulse to some degree. The same mechanism is the cause of shock in railavay or other injuries, only it is much more severe, owing to the actual injury received and its accompany- ing terrors. Many of the readers of this book probably knoAv that a violent bloAv upon the belly-wall just over the solar plexus Avill cause death even in so large an animal as the ox, and every boy has had the "breath knocked out of him " by a blow in this region. 638 DISEASES. This period of inhibitory excitement speedily gives place to inhib- itory exhaustion, and Ave have a rapid pulse from inhibitory palsy, while through the palsy of the vasomotor system the blood-vessels are relaxed and the normal resistance to the heart is taken away. The heat beats wildly and fast for the same reason that a locomotive's Avheels fly round Avhen the track is slippery—or, in other words, nor- mal resistance is lost. The capillaries in the second stage of shock are dilated, and the skin is relaxed, moist, and cold from excessive dissipation of heat. This is the more prolonged stage of the tAvo, but they both need active treatment. The patient will rarely be seen in the first stage of shock, simply because by the time the physician reaches him the second stage av ill have come on. In either event the principal things to be done are the administration of fa to fa grain (0.001-0.0012) of sulphate or atropine hypodermically, and the application of external heat to main- tain the bodily temperature, the fall of Avhich is a factor of great importance, but generally overlooked in attending to an operation or other measures of relief. The use of atropine is peculiarly a triumph of experimental therapeutics and rests upon logical deduction. It will be remembered that atropine in full dose acts as a depressant to the vagus nerve, and, as this nerve is over-active in the first stage, the drug acts as a sedative to it. This is, however, a comparatively un- important fact, for it is another action of atropine which makes it valuable. If the Aragus be very much stimulated, a safe dose of atro- pine cannot quiet it, but in the second stage, which we most com- monly have to treat, a safe dose does not act so much upon the vagus as upon the vasomotor system, and by preventing the dilatation of the blood-vessels of the body thereby provides blood-paths of normal tone and tenseness, Avhich do not hold all the blood in stagnant pools where it is not needed, but carry it to the brain and vital parts. Digitalis is a useful adjuvant to atropine in the second stage of shock because of its powerful vasomotor and cardiac influence. 20 drops (1.3) of the tincture of digitalis should be given hypodermically, and repeated in an hour if the pulse does not shoAv the influence of the drug at the end of that time. The application of heat in the form of hot-Avater cans, hot bricks or bottles, must not be forgotten, care being taken that the patient is not burned. (See article on Heat, Part III.) In many cases of surgical shock hypodermoclysis of hot saline solutions is of the greatest value, particularly if much blood has been lost. (See Hypodermoclysis, Part III.) SMALLPOX. The treatment of smallpox is not specific, simply because it is one of those diseases which run a given course and Avhich we cannot abort. We can only treat the various symptoms Avhich present them- selves, and by the modification of these manifestations prevent com- SMALLPOX. 639 plications and sequelae to some extent. The fever is to be treated as is any fever of this class. Often it can be allayed by a mixture con- taining tincture of aconite, spirit of nitre, and spirit of Mindererus (liquor ammonii acetatis), Avhile the headache or backache may be controlled by antipyrine or acetanilid. Mustard plasters are not to be used for the backache, as the dermal irritation Avill increase the eruption. Insomnia and restlessness, if excessive, are to be quieted by the bromides or chloral, care being taken that the doses of the latter are not large enough to depress the heart. It must be remem- bered that the time of onset of the secondary fever, the eighth day, is one of grave import to the patient. Before its arrival the treat- ment of the case must be so managed that strength is saved for this strain, and tincture of the chloride of iron, in 5- to 10- (0.3-0.65) or even 20-drop (1.3) doses, may be resorted to to give strength to the patient and to affect specifically the pyaemic fever. The pulse should be Avatched, and if it flags brandy and Avhiskey should be freely but Avisely used. At the same time nourishment in the shape of eggnog, milk punch, or beef tea should be pushed as freely as the digestion will allow. The peripheral irritation and itching of the eruption are a cause of the fever in part, and produce much unrest and nervous irritability. The condition of the skin is, therefore, to be looked after, and the pit- ting prevented, if possible, by every means in our power, particular care being taken to prevent its appearing on the face. One of the means which has been recommended to prevent pitting is the use of flexible collodion, and another application is glycerite of starch or simple cerate applied in a heavy coating. Some physicians recommend inserting the tip of a nitrate-of-silver stick into each vesicle as it rup- tures, to prevent pitting. All of these measures are futile in most cases, and the use of collodion is probably harmful in some instances. The best application to use is made up of 4 parts of salicylic acid to 100 parts of vaseline or cold cream. Sometimes, anointing the entire body with sweet oil slightly carbolized (1 : 100) is useful to check irritation. If the mouth is sore, a mouth-wash of chlorate of potassium and water may be used, flavored with a little tincture of myrrh. Disinfection, good ventilation, and the avoidance of much light are necessary. STINGS AND BITES. The stings of nearly all small animals depend for their activity upon formic acid, and are to be relieved by the use of dilute alkaline liquids, or, better still, by the application of ammonia, or, instead, an application of ordinary or flexible collodion may be made, which is improved in its action bv the addition of 1 part of mercury bichlo- ride to 1000 of the collodion, or, if preferred, salicylic acid may be added in the proportion of 5 grains to the ounce (0.3 : 32.0). Some- times a solution of carbolic acid, 1: 100 or 1: 50, when sponged over 640 DISEASES. the parts exposed, not only relieves the itching of mosquito-bites, but keeps aAvay the mosquitoes. In other instances the stings are relieved and cooled by the use of dilute or pure vinegar. In snake-bite the best treatment is that introduced by Weir Mitchell and Reichert—namely, the local application of perman- ganate of potassium to the part, which should be thoroughly filled Avith the drug, and full doses given hypodermically about the wound, the salt being diluted three-fourths with Avater and followed by full doses of alcohol by the mouth. The secret of successful treatment consists, however, in the use of a ligature or a cleansing of the wound as soon after its reception as possible, thereby preventing the absorp- tion of the poison. STOMATITIS. This annoying affection is most commonly seen in children, and is characterized by the appearance on the tip and sides of the tongue, lips, and lining membrane of the mouth of small spots Avhich some- times have a reddened zone around them, and Avhich result in minute or large ulcers. The best treatment, if the kidneys are not acutely inflamed, is the use of the folloAving prescription, Avhich largely depends for its value upon the potassium salt used: R.—Potassii chlorat...........3J (4.0). Tinct. myrrh............gtt xx (1.3). Elixir calisaya?...........fgiij (96.0). —M. S.—Teaspoonful in water every four hours. As the chlorate of potassium is eliminated Avith the saliva, it not only does good Avhen taken into the mouth, but is active all the time that it is being eliminated. If the stomach is disordered, the same preparation may be used as a mouth-wash. Often constipation will exist, and it should be removed by salines or by rhubarb in the form of the aromatic syrup. Another remedy Avhich is very efficient in stomatitis is borax, used as a mouth-Avash, in the strength of 10 to 15 grains to 1 ounce (0.65-1.0 : 32.0) of water and honey, as follows: R.—Sodii boratis ...........gr. xxx (2.0). Mel. purificati...........f^iij (12.0). Aqua?............q. s. ad fgiij (96.0).—M. S.—To be used on a swab or as a mouth-wash every four hours. This also may be used internally in adults. In many cases peroxide of hydrogen in the proportion of 1 ounce (32.0) of a 15-volume solution to 8 ounces (256.0) of Avater proves a valuable mouth-wash. If the liver is at fault and is torpid, nitromuriatic acid is useful, and Avhen the spots do not readily yield to treatment they may be touched with the tip of a stick of silver nitrate, which treatment, while it is momentarily painful, is very efficacious. Nearly ahvays with this disease in childhood there is considerable SUNSTROKE. 641 fever, vomiting, and wakefulness at night, Avith fretfulness and crying during the day, and total refusal of food, not because hunger is absent, but because the food hurts the mouth and is rejected with a cry of pain as soon as it touches the lips. The food should be very soft milk toast for older children, or milk Avith lime-water in it in large amount for infants fed by the bottle. If a child at the breast be attacked, the mother's nipple should be carefully Avashed with boric- acid solution after each nursing. A warm foot-bath at night is often necessary to produce rest, and 10 drops (0.65) of sweet spirit of nitre thoroughly diluted may be given with advantage to a child of one or Iavo years. If the irritability of the nervous system is excessive, bromide of sodium or potassium in the dose of from 1 to 10 grains (0.05-0.65), according to age, three times a day, is of service, and may be added to the mixtures already named, or, better still, given alone, Avell diluted Avith syrup and Avater. After the attack tonics and a carefully selected diet are generally necessary. STYES. Styes consist in a localized inflammation of one of the glands in the margin of the lid or the surrounding connective tissue. Before suppuration is established abortive treatment may be practised by an inunction with a salve of the red or yelloAv oxide of mercury (8 grains to 1 drachm [0.6 : 4.0]), by painting the surface with an ethereal solution of collodion, or, according to Abadie, by the application of a saturated solution of boric acid. Pain may be alleviated Avith hot compresses (water 110° F.), frequently changed, and as soon as pus appears incision is necessary. Associated conjunctivitis requires a boric-acid solution for its relief. It should be remembered that styes indicate ill health, that tonics are indicated, and that they most fre- quently appear in the subjects of refractive error. When they tend to come in crops the internal use of sulphurate of calcium has been recommended. SUNSTROKE. Sunstroke—or, more correctly speaking, heat-stroke—is an affec- tion produced by exposure of the body to any form of high tempera- ture, Avhether the source of heat be the sun, a furnace, or the radiation of heat from the earth. For this reason the condition may occur as readily at midnight as at mid-day. Heat-stroke is to be divided into two classes, in one of Avhich excessive exposure to heat upsets the balance of the thermal mechanism of the body, so that fever comes on (thermic fever); in the other the temperature is lowered .and forms the condition knoAvn as heat- exhaustion. The condition of thermic fever is very frequently seen, Avhile heat- exhaustion is rare. The danger of thermic fever is that the excessive heat may cause 41 642 DISEASES. coagulation of the myosin in the heart-muscle and of the protoplasm in the brain, and cause death, or that the same result may be reached by paralysis of respiration. The danger of heat-exhaustion is that death may ensue from col- lapse due to a general failure of vital power and the chilling of the body. In heat-exhaustion, too, the vascular system is greatly relaxed and depressed, and the circulation is at its lowest ebb. The treatment of these two states is, of course, radically different. When a patient has thermic fever and is brought under the care of the physician, the first thing to be done is to loosen the clothing—if possible, remove it—at the same time applying cold to the body, and particularly to the abdomen, back, and chest. Better still, the man should be stripped, laid upon a bed, which must be covered with a rubber blanket, and ice-Avater be applied to the body by means of a sponge, or a piece of ice may be laid on the belly, while another piece is rubbed over the rest of the body. While this is being done the surface of the patient's body must be thoroughly and briskly rubbed in order to bring the hot blood to the cooled surface. Care should be taken that the temperature, when it once begins to fall, does not drop suddenly below the normal and cause collapse. If the clinical thermometer in the mouth or rectum shows that the temperature has fallen to 100.5° F. or 101° F., the cold application should be stopped, and the patient allowed to lie on the bed covered with a thin sheet only. The bodily temperature must be constantly • watched, as it Avill probably bound up again in a few minutes, and require the application of more cold, used with the same care. This second rise is due either to the disorder of the nervous mechanism of heat-production and dissipation, or to the fact that, while the surface of the body is cooled by the ice, the innermost viscera are still in high fever and rapidly heat the surface as soon as the ice is taken aAvay. Antipyretics have been found to be almost useless in the hyperpyrexia of sunstroke, and at their best are not to be relied upon. After the fever has been reduced permanently the danger is not all passed, and it is the greatest mistake to discharge a patient as cured at this time. After two or three days it is very common for a menin- gitis to develop, accompanied, it may be, by little or no fever, but characterized by violent darting headache, which is made worse on lying down or on sudden movement. The treatment of this state must be bold, and venesection is the only safe method of obtaining relief, although vascular sedatives, such as veratrum viride, may be employed. The bleeding should be copious enough to impress the circulatory system to some degree, and may be done by opening any of the prominent veins in the arm. (See Venesection.) Sometimes a violent attack of epistaxis saves the man's life, when it Avould have been lost through the ignorance of his attendant. If life is preserved without vascular depletion, secondary changes in the brain may ensue and produce hemianopsia, optic atrophy, imbecility, or insanity. Quinine, salicylic acid, and similar substances are all contraindicated under these circumstances, because of the congestion of the meninges to Avhich they predispose by their physiological effcts. SYPHILIS. 643 The treatment of heat-exhaustion consists in the use of heat instead of cold, in order to restore the bodily temperature. Just here, hoAv- ever, must be uttered a Avord of warning—namely, that the mere fact that the skin is cold does not prove the case to be one of heat-exhaus- tion, since a rectal thermometer may show the central or real tem- perature of the body to be in a condition of hyperpyrexia. Of course such a case should not receive hot, but cold, rectal injections if the symptoms require it. The bodily heat in heat-exhaustion is to be raised by placing the patient in a bath at 105° to 110° F., or by the use of hot bricks or bottles, care being taken that they do not burn the patient. The bodily temperature should also be Avatched, lest the other extreme of heat be reached. Cases of heat-exhaustion are not so apt to have meningitis as are cases of sunstroke, but they are generally slow to conA'alesce, and require tonics and careful watching for a long time. Indeed, in many instances the system seems to receive a shock from which it takes several weeks or months or recover. SYPHILIS. In so far as the choice of drugs is concerned, the treatment of syphilis is exceedingly simple: iodine, iodide of potassium, and mer- cury practically represent the only remedial agents which are Avell ' proved to possess the poAver of distinctly counteracting the effects of the disease. In regard to the method of administration and the period of the disease in Avhich any or all of these drugs can be given to the best advantage there is a Avide diversity of opinion. Following the teach- ing of Fournier, in this country the practice generally obtains of administering mercury on the appearance of the first symptoms of the secondary stage of syphilis; this drug is continued for from tAvelve to eighteen months, and is then followed by a course of iodide of potassium continued for from six to twelve months. If after the suspension of this treatment for six months no manifestations of dis- ease appear, the patient is regarded as cured. Should the disease again break out, the iodides are administered in increasing doses, sup- plemented by the addition of mercury if necessary. Against this treatment, however, there have been many and vigor- ous protests. Every syphilographer knows that the disease is fre- quently self-limited. Zeissl states that a large number of cases prog- ress to spontaneous cure, and that the secondary eruption in such cases disappears in from tAvo to eight months, after which time the patient is perfectly Avell, recidivity being far less common than when mercury has been employed in the early stages of the disease. The treatment by iodides, he thinks, should be commended chiefly after the expectant plan : their effect is not so rapid as is that of mercury; they are suitable, hoAvever, to all stages of the disease. When the symptoms become so urgent that it is no longer safe to depend upon 644 DISEASES. iodides, mercurial inunctions should be employed, the dosage of the drug being regulated by its effect upon the symptoms, in all cases the minimum quantity necessary to accomplish the result being admin- istered. We have, then, three methods of treatment proposed, each advo- cated by a formidable array of authorities: 1. The expectant treatment. 2. The treatment by iodides, folloAved, if necessary, by mercury. 3. The continued treatment, beginning with mercury and ending with iodides or the combination of the two drugs. By the expectant treatment is implied abstinence from all medica- tion intended to directly counteract the syphilitic virus: if possible the patient should lead an active, out-of-door life, the diet should be most carefully regulated, and the treatment should be purely symp- tomatic, tonics being administered when required, the sore throat being combated by astringent gargles, particularly those containing chlorate of potassium or malic acid, together wdth direct local appli- cations, while the eruption on the exposed parts of the body is con- trolled by the application of heat. Even in the mildest cases there is nothing to be said in favor of this treatment. Where the primary lesion is large and persistent; Avhere the period of secondary incuba- tion is less than seven weeks ; Avhere the papular eruption is uni- versal, is confluent, and is accompanied by the simultaneous appear- ance of mucous patches; where the lymphatic enlargement is very marked and persistent; and where the disease attacks a depraved con- stitution,—the expectant plan offers little hope of accomplishing a cure. Here the second and third methods of treatment are absolutely indicated. By the second plan of treatment the iodides are administered, not immediately on the appearance of the secondary eruption, but after this has run a course of several weeks and is steadily increasing in severity. The iodide of potassium is chosen by preference, beginning Avith the administration of 5 grains (0.3) three times a day, and in- creasing steadily 5 grains (0.3) a day until either the constitutional effects of the drug are manifested or the symptoms are favorably influenced. Should iodism appear, the dose is cut doAvn one-half and continued for one or two Aveeks, after Avhich, if the syphilitic lesions are not favorably modified, inunctions of mercury are employed, a drachm (4.0) of mercurial ointment being rubbed in every other day. The iodide should be continued for from six to twelve months after the disappearance of all symptoms, relapses being combated by tem- porarily increasing the dose and by a course of mercurial inunctions. If after the suspension of the treatment the patient remains free from all manifestations of syphilis for tAvo years, he can be fairly considered as cured. By the third method of treatment—and this is the method most commonly accepted in practice—the patient is placed upon mercury the moment the early secondary symptoms denote that the primary- sore was surely syphilitic. Many surgeons begin this treatment from the time that the inguinal glands on both sides become characteristic SYPHILIS. 645 in shape and size. Others Avait until there is general lymphatic involvement, Avhile others believe that the mercury should not be administered until roseola appears. In regard to the particular preparations of mercury to be em- ployed, the protiodide, blue mass, bichloride, and mercury Avith chalk represent the forms usually employed Avhen the drug is administered by the stomach. Of these the protiodide is to be preferred, and the effort of the surgeon is directed first toAvard determining what is termed the " tonic " dose. With this end in vieAv, £ grain (0.016) of the protiodide of mercury is given, in pill form, three times a day, and every second day this quantity is increased by one pill, the patient being meanAvhile carefully Avatched. The drug usually manifests its physiological effects by griping pains accompanied by tAvo or more Avatery passages from the boAvels, or by foetid breath and slight ten- derness of the gums. The quantity taken to produce this effect represents the extreme limit to which it is safe to push the drug. If this dose is continued or increased, the characteristic symptoms of mercuric saturation appear. When the surgeon has determined the limit to which the drug can be safely pushed, this dose is cut down one-half, and in the absence of further complications the patient is directed to continue Avith this dose for eighteen months. If during this time local symptoms appear Avhich show that the disease is not thoroughly under control, the mercury must again be pushed to the full dose, being reduced to the tonic dose as soon as the disappearance of specific lesions permits of this. Where comparatively small doses of the protiodide produce pain and purging, opium may be added; in this case the breath and the mouth will show Avhen the full effect of the medicine is obtained. Manifestations of the disease occurring during mercuric treatment must receive local treatment. The surface eruption is combated by mercuric ointments and washes and by the application of heat. (See Heat.) Mucous patches in the mouth are quickly healed by applications of solid nitrate of silver or sulphate of copper, 20 per cent, chromic-acid solution, or the acid nitrate of mercury. AVhen these patches occur about the genitals, Avashing with 1 : 2000 bichloride solution and dusting Avith calomel and bismuth will be found satisfactory. Alopecia is combated by shampooing and by the application of strong stimulating lotions containing croton oil or tincture of cantharides. The intense cephalalgia is combated by ^-grain (0.010) doses of calomel, repeated overy two hours. The periostitis yields most read- ily to gentle, long-continued mercuric inunction, supplemented by the application of pressure bandages. When the integrity of any vital organ is threatened there should be no hesitation in pushing the mercury treatment, and in supple- menting it, if favorable results do not folloAv promptly, by large doses of iodide of potassium. After the first eighteen months iodide of potassium is generally indicated. This is commonly given together with the mercury, con- stituting the mixed treatment. The following formula, or one similar to it, may be employed: 646 DISEASES. R.—Potassii iodidi.........3ij vel .^iv (8.0-16.0). Hydrarg. chlor. corros......gr. ss (0.03). Syrup, aurant. cort......f,lj (32.0). Aqua?..........q.s. adf^ij (64.0).—M. S.—Teaspoonful (4.0) three times a day. When this prescription is put up a precipitate is formed and then dissolved. This mixture, or iodide of potassium Avithout the mercury, admin- istered in 5- to 10-grain (0.3-0.65) doses three times a day, is given for from six to twelve months longer. When the iodide is given alone it is most conveniently administered in the form of a saturated solu- tion. Of this a drop contains a grain of the salt. Milk seems to have the poAver of completely disguising the disagreeable taste of the drug. Thereafter, specific treatment is stopped, unless symptoms arise, in which case it should be reneAved and should be continued for many months. The protiodide is usually preferred, because the symptoms of its constitutional effect are manifest at first by looseness of the boAvels, and because in practice it has been found one of the most satisfactory of all preparations. Where this form of mercury is not Avell borne the physician should at once employ some other salt; the bichloride, in ^-grain (0.005) doses three times a day, is efficacious. Blue mass will often act favorably when other preparations cannot be tolerated. Its combination Avith iron is desirable, and the folloAving formula rep- resents one of the most valuable of the antisyphilitic pills: R.—Mass. hydrargyri..........gr. xxx (2.0). Pulv. ferri chloridi.........gr. xv (1.0).—M. Ft. in pil. No. xii. S.—One three times a day. Where mercury cannot be administered by the mouth it may be given by means of vapor-baths, by inunctions, and by hypodermic injections. The vapor-baths are useful Avhen it is desired to promptly cure eruptions on the surface of the body or Avhen it is most import- ant to bring the disease quickly under the influence of mercury. They are readily administered, the only apparatus required being an alcohol lamp and a plate in Avhich the mercuric preparation can be volatilized. The patient is seated in a chair entirely naked; several blankets are Avrapped around his neck, and beneath the tent thus formed a large vessel of steaming water is placed. When the skin is thoroughly softened J drachm (2.0) of calomel is sublimed by means of the lamp. These baths may be repeated every night until the mercuric foetor of the breath is observed or until the specific symptoms disappear. (See articles on Mercury and on Heat.) Inunction represents the most efficient Avay of administering the mercuric treatment. When the stomach is intolerant of drugs, or when, administered by the mouth in full doses, they do not favorably modify the symptoms, inunctions are indicated. The patient is instructed to take a Avarm bath, and the mercury is then Avell rubbed in over the inner surface of the forearm and arm and along the side of the chest for fifteen minutes. Either the oleate of mercury, 10 SYPHILIS. 647 per cent., or the ordinary mercury ointment is commonly employed; the former is more cleanly, but less efficient. The rubbings should be done by the patient, should be made over a large surface of the body, and should be performed thoroughly; 1 drachm (4.0) of blue ointment is rubbed in daily. A shirt kept for this purpose is then put on next to the skin, and the ordinary clothing is worn over this. The next night the opposite arm and side of the body are utilized as the seat of inunction; the folloAving night the right groin and the inner surface of the right thigh and leg; next, the same regions of the opposite side of the body; finally, the anterior surface of the chest and abdomen. In this way irritation of the skin is avoided. Where it is impossible to employ the inunctions in this Avay, another means of causing absorption of mercury through the skin, suggested by Sturgis, will be found satisfactory: After a thorough soaking of the patient's feet in hot Avater, from J to 1 drachm (2.0-4.0) of a 20 per cent, oleate of mercury is rubbed vigorously into the sole of one foot; the next night the sole of the other foot is treated in the same way. The patient is directed to wear, night and day, a pair of avooI- len socks: these are not changed for one Aveek. Mercury may be taken by the mouth at the same time inunctions are employed Avhen it is desired to influence the system quickly. In the late periods of the disease very striking effects are often obtained by supplementing the iodide treatment by a course of twelve to eighteen inunctions. The hypodermic administration of mercury is in this country lim- ited to those feAv cases Avhich do not seem to respond to the drug Avhen given by the mouth or by inunction. Although many prepara- tions of mercury have been lauded as most efficacious Avhen used hypo- dermically, the best formula seems to be that recommended by Hebra. This consists of a solution of 1 per cent, of bichloride of mercury in a 6 per cent, sodium-chloride solution; the resulting mixture is per- fectly clear and is readily prepared. If it becomes turbid it should be throAvn away. Most rigid antiseptic precautions must be observed, as abscess-formation is not uncommon. One injection is given daily, from ^ to 4; grain (0.01-0.02) of the sublimate being administered. The nates are selected as the seat of the injection, the solution being driven Avell into the muscles of each side every other day. Twenty injections are usually sufficient to cause the disappearance of all symp- toms. The employment of the insoluble preparations of mercury, particularly of calomel, gives much pain, frequently causes abscess, and is at times attended by a continuous absorption which may pro- duce severe and even fatal ptyalism. The ulcerations often found as tertiary manifestations of syphilis are treated according to general surgical principles. The local application of mercuric preparations is of less service than during the existence of the secondary lesions. Iodoform is peculiarly ser- viceable. The tonic and general treatment of syphilitic cases must not be forgotten; fresh air, exercise, bathing, careful diet, regular living, all must be enjoined. Moreover, in certain cases where there is marked anaemia or physical Aveakness cod-liver oil, stimulants in moderation, 648 DISEASES. compound syrup of the hypophosphites, and other tonic and nutritive courses of treatment must be carefully administered. Although the treatment of an ordinary case of syphilis is simple and satisfactory in its results, it must be remembered that there are malignant forms of the disease, attacking by preference feeble and cachectic individuals, running a rapid and virulent course, unchecked, nay aggravated, by specific treatment, and responding feebly, if at all, to the most careful hygienic and tonic regimen. In such cases a strong extract of sarsaparilla is sometimes of service. TETANUS. The treatment of tetanus is quite independent of its causation, so far at least as drugs are concerned, and is virtually identical with that of Strychnine Poisoning, to Avhich the reader is referred. It is stated that FoAvler's solution acts almost as a specific in some cases. (See Nux Vomica.) TONSILLITIS. Inflammation of the tonsils occurs in three forms: superficial tonsillitis, in Avhich the mucous membrane covering the tonsils becomes inflamed through extension of a pharyngitis; follicular tonsillitis, in which the follicles are chiefly involved and pour out an excessive secretion; and, finally, true tonsillitis, in Avhich the gland itself suffers from severe, widespread inflammation phlegmonous in type. In all these forms the treatment to be instituted at the beginning is practically identical. The boAvels should be opened by a saline pur- gative, which in some cases should be preceded by small doses of calomel, the diet should be liquid and nutritious, and a fever and diuretic mixture should be given freely as follows: R.—Tine, aconiti.........TT\,xij vel xxiv (1.0-1.6). Spt. a?theris nitros.......fSj (32.0). Liq. potassii citratis . . . q. s. ad fgiij (96.0).—M. S.—Dessertspoonful every three hours. Locally, a solution of nitrate of silver, 60 grains to the ounce (4.0 : 32.0), should be applied Avith a camel's-hair brush or Avith a cotton applicator. Externally, an ice-bag should be applied about the throat, and as soon as the purgative has acted and the fever is reduced by the mixture just given, full doses of the tincture of the chloride of iron should be administered (20 drops [1.3] every three or four hours), in plenty of water, which preferably should be Vichy or one of the good lithia Avaters. In inflammatory involvement of the entire tonsil active scarifica- tion in the early stages may be of service in limiting the severity of - the attack. In some instances hot fomentations about the neck and hot gargles seem to be more beneficial than the use of ice. Often a TUBERCULOSIS. 649 mild antiseptic gargle of carbolic acid (1 : 100 of water) will relieve the pain and the fcetor of the breath. Finally, it should be remembered that rheumatic persons suffer severely at times from tonsillitis, and the best remedies for this form of tonsillitis are the salicylates or guaiac. TUBERCULOSIS. Under this head will be considered pulmonary tuberculosis as a type of all forms of this morbid process. Its treatment may be placed in two lines—the first devoted to the cure of the disposition or inclination toAvard the disease or the abortion of its early stages; the second directed to the improA-ement of the patient's condition, so that his progress through the disease may be made as comfortable as possible. Before doing this, however, it is proper to state that pro- phylaxis, or true prevention, is the object really to be sought after, although it is certainly true that many cases of early tuberculosis are curable. Recent studies have shown most conclusively that tubercu- losis is capable of being transmitted from man to man if air laden with the bacilli is breathed, and if the lungs are in a fit state of depressed vitality, from any cause, to afford a favorable field for the growth of the germ and the development of its poison. Cases of pulmonary consumption folloAv, rudely speaking, three well-defined lines. A very early stage sometimes comes to the care of the physician, and it is that in which the folloAving history is given or a similar story is elicited. A patient, previously strong and Well or of poor health, as the case may be, begins to lose Advacity. Life becomes a burden and exercise is distasteful. A slight daily chill, in morning or evening, and fever develop, and the physician Avho is care- less treats the case as one of mild malarial poisoning. Careful exam- ination, hoAvever, will show an area in the lung, generally near the apex on one or both sides, where slight prolongation of expiration with a harsh inspiratory sound is heard, and Avnere percussion will give impaired resonance or dulness. In other words, the first stage of phthisis is present, and the physician must resort at once to those active measures for the patient's relief Avhich will be considered in a moment. In another form a chill, a SAveat, a loss of flesh and vigor, w ith, more prominent than all, a hard cough, sudden in its onset and rap- idly becoming excessive with profuse expectoration, are the dominant symptoms. The Avasting is extraordinary, the SAveats are constant, and death may come in a few weeks. This is the form known as "galloping consumption." The third variety is ushered in by a gradual loss of vigor or a sen- sation of being a little unAvell, or is brought before the patient's mind by a sudden acute hemorrhage, or several hemorrhages rapidly suc- ceeding one another. This variety passes along its course more or less rapidly. Sometimes death soon ensues from a fatal hemorrhage; in other cases the disease keeps on for months and the case dies from exhaustion. 650 DISEASES. Last of all, the fourth class is made up of persons Avho gradually pass from bad to Avorse: First, they "catch a cold," Avhich hangs on longer than it ought, and, as soon as they are Avell, this is followed by another one, which is found more difficult to cure, until finally there is always a cough. Soon Avasting comes on, strength is lost, and a long period of months or years ensues during which the progress of the case is now sIoav, now fast, the condition now better, now worse, until death ensues from wasting, pneumonia, or some other com- plication. These forms and stages have been roughly outlined, so that a dis- cussion of their treatment might be taken up Avith a clear idea of what is to be done. When a patient exhibits those physical signs Avhich have been given as evidences of the early beginnings of phthisis, the physician should institute certain hygienic and medicinal measures. If the individual be earning a livelihood by following some confining occu- pation, this occupation must be given up and one undertaken Avhich is carried on in the open air and yet not accompanied by too great exposure. Even if exposure is incurred, it is better than the occu- pation previously folloAved: thus, if the patient be a bookkeeper, a printer, or a bookbinder, or a clerk kept much at a desk in an ill- ventilated room, a few wettings in the rain will do little or no harm if properly treated by the wearing of flannel shirts, which, when wet, are changed as soon as labor ceases, as under these circumstances the danger of catching cold is at a minimum. (See Part III., article on Climate.) The medicinal measures to be carried out in all cases of phthisis, except that known as the galloping form, are not numerous if Ave confine ourselves to the modes possessing any real value. For many years cod-liver oil has been sadly abused in the management of these cases, and has been given at all stages, OAving to ignorance of its proper use as a general rule. The Avriter believes that the folloAving rules are never to be departed from: 1. Never use cod-liver oil where the disease has passed the primary stages of thickening of the lung and roughening of the respiratory sounds, unless fibroid changes are going on and the changes are very slow indeed. 2. The use of cod-liver oil when rapid degenerative changes are occurring in the lung is distinctly harmful, as it is not of any1 service, disorders the digestion, and destroys the appetite. When the oil'is used it should be given as directed in the article on Cod-liver Oil. A remedy of some value as a curative and of great value as a palliative is creosote, first introduced by Bouchard some thirteen years ago, but only recently widely employed. Many cures have been claimed from its use in the early stages of phthisis, and it has been highly lauded by a number of European clinicians. In the author's experience it is merely a palliative to the cough and general discomfort, particularly when the disease is fully established, and the opinion expressed by Striimpell expresses so well the thought which TUBERCULOSIS. 651 the author was about to Avrite Avhen he read Striimpell's article that his words are here given: " Taking it all in all, Ave'find that creosote, even in large doses, has no injurious effect on tuberculosis. At times Ave notice an apparently favorable symptomatic effect. We failed, however, to observe any real influence exerted by creosote on the progress of the disease." On the other hand, the relief of some distressing symptoms pro- duced by creosote is never to be underrated. (See Creosote.) When creosote is used internally it may be given in the following formula: R.—Creosoti (beechwood)......gtt. xxxij vel f^j (4.0). Tr. gentian..........fxj (4.0). Alcoholis...........fgj (32.0). Yin. alba? . ._......q. s. ad f^iv (128.0).—M. S.—Teaspoonful (4.0), in water or wine, three times a day. Better still, order in ascending doses (1 minim extra each dose) in milk or wine. Often a 1-drop (0.05) dose three times a day may be increased to 5 drops (0.3) in the same period Avith advantage, and if given in ascending doses the author has frequently had patients take as much as 90 minims (6.0) a day. Sometimes 1 or 2 drops (0.1) in capsules are as useful as the formula just named. (For methods of administra- tion see Creosote.) Creosote may also be inhaled in the spray from a steam atomizer or by means of an inspirator fitted over the nose and mouth and made of perforated zinc Avith a sponge at the edge to hold the drug. A very good method is to Avet the sponge Avith creosote, alcohol, and water, equal parts, or to use the creosote alone if coughing is not too seA^ere. Another useful mixture consists of equal parts of tere- bene, iodide of ethyl, and chloroform. This last mixture is most useful Avhen the secretion is tough and tenacious, and should not be used in the presence of acute irritation due to inflammation. Such inhalers are very cheap, not easily broken, and readily Avorn. If the cough* in phthisis is excessive, a little spirit of chloroform placed on the sponge of the inhaler will often relieve it, or a mixture of morphine and Avild-cherry bark may be given as folloAvs: R.—Morphina? sulph. ......gr.j vel ij (0.05-0.1). Syr. pruni Virginiana?......fjfiij (96.0).—M. S.—Teaspoonful (4.0) every three hours. Or the following: R— Potassii cyanidi ........gr. j vel ij (0.05-0.1). Morphina? sulph.........gr. j velij (0.05 0.1). Syr. pruni Virginiana?......fjiij (96.0).—M. S.—Teaspoonful (4.0) every four hours. In still other cases 2 to 10 minims (0.1-0.65) of a good fluid extract of cannabis indica, or | to i grain (0.008-0.016) of the solid extract, will act with surprising benefit and stop the cough. Very often during the course of phthisis localized spots of pleu- ritic inflammation arise. Without the occurrence of any exposure 652 DISEASES. the patient Avill remark, " Doctor, I think I have taken a little more cold, and I have a stitch here in the chest." The best treatment is to apply a small blister or to paint the spot Avith iodine. (For the treatment of Haemoptysis see Hemorrhage.) Laryngeal phthisis, one of the most serious complications of this disease, is best prevented by ordering the patient to inhale the steam arising from boiling; Avater Avhich contains corrosive sublimate in the -r proportion of 1: 10,000. If a proper watch is kept for evidences of a general mercurial effect, and this measure stopped at once Avhen tenderness of the gums appears, no danger exists. Before the inhala- tion takes place a spray of cocaine (4 per cent, solution) should be thoroughly used. The treatment of laryngeal phthisis itself is various. The best method is that in which lactic acid is used. By the aid of a laryn- geal mirror and a cotton applicator a 10 per cent, solution of lactic acid is applied to the spots Avhich are involved. As this is generally quite painful, cocaine solution should first be used. Gradually the strength of the lactic-acid solution should be increased to 60 per cent. if the Aveaker solutions do not check the disease. Very valuable results have been obtained by this method. The second method in point of value is that of iodoform insuffla- tions. A poAvder of iodoform alone is too light for satisfactory pro- pulsion into the larynx, and poAvdered talc should be added to it in small amount, as may also fa grain (0.004) of morphine to each drachm (4.0) of iodoform. The odor is generally disagreeable to the patient, but if a cocaine spray be first employed and the operator is skilful, very little coughing is produced. As iodoform is a local anaesthetic, it relieves the pain in the larynx, acts as an antiseptic and alterative, and is peculiarly obnoxious to the bacillus tuber- culosis. When the night-sweats are very violent, hypodermic injections of atropine in the dose of fa to fa grain (0.001-0.0012) are useful in some cases, and the efficiency of this treatment may be increased by the use of an alum sponge-bath at bedtime. A solution of alum, 10 to 20 grains to the ounce (0.65-1.3 : 32.0), may be sponged over the body, or sulphuric acid may be added to water in the proportion of 1 drachm to the pint (4.0 : 500 cc), and used in the same way as the alum solution. Sulphuric acid is often given internally with advantage in these cases of sweating. Small doses of pilocarpine amounting to fa grain (0.003), given from one to tAvo hours before the SAveat is expected, are sometimes potent for good. The means by which this result is brought about are not far to seek. The drug in any dose causes great stim- ulation of the peripheral ends of the nerves supplying the sweat- glands. In many instances we find excessive secretion dependent upon depression of function, as in a serous diarrhoea or a local SAveat- ing of the feet. These states pass away just as soon as the parts regain their normal tone through proper treatment. The night-sweats of phthisis are sometimes improved by pilocarpine, because this drug in all doses stimulates the sweat-glands. In large doses this stimula- TYPHOID FEVER. 653 tion amounts to free diaphoresis; but in the minute doses, such as fa to 2V 0I" a g1-{»n (0.0016-0.003), the stimulation just balances the de- pression and a normal tone is acquired. While it is true that pilocar- pine and atropine are physiological antagonists, it will be found prac- tically beneficial to prescribe small doses of both in such cases as refuse to respond to either one alone, as by their antagonism they prevent over-action on other parts of the body, and both act in harmony in so influencing the SAveat-glands as to be of service to the patient. Camphoric acid in 20- to 30-grain (1.3-2.0) doses is the best remedy and is invaluable in treating night-SAveats. TYPHOID FEVER. Any attempt to review the treatment of the disease knoAvn as typhoid fever would be absolutely impossible, OAving to the very numerous theories and practices put forward by Ararious clinicians. What is said under the general heading of Fever and under the con- sideration of Cold, and also under Antipyrine and Acetanilid, gives sufficient information as to the treatment of febrile movements, and the care of the patient beyond this point in nearly all cases depends upon the severity of the attack. Before going further, however, the Avriter desires to insist very strongly upon one fact—namely, that a case of typhoid fever is not curable in any degree. No remedy yet found, except it act through the prevention of complications, can shorten its course. We can only guide the patient safely to health when the storm of disease comes on, and we cannot stop the storm. Not only should the facts of the last paragraph be carefully borne in mind, but the physician must remember that he is treating an exhausting disease—not a disease Avhich runs a violent course for a feAv days and strands the patient sick and weak, but convalescent, upon the shores of health, but one in Avhich, after sapping the strength for Aveeks, some sudden intercurrent malady or accident may ensue which will speedily kill him if every possible grain of strength is not preserved for the struggle. The physician should always put every case in Avhich there is a suspicion of typhoid fever to bed at once, and keep the patient there till the disease has passed or fails to appear. Every muscular movement unnecessarily made is a waste of force, and, in consequence, everything should be done for the patient, and not by him. A bed-pan should always be employed, the patient not being allowed to sit erect upon a commode. Remembering, too, the force consumed in difficult digestion, the food should be liquid, free from fat, and consist solely, if not entirely, of milk, and during convalescence of an egg or a little arroAvroot or corn-starch. Not only is this recommendation practically correct at the bedside, but it is Avell based on scientific fact, for Brieger has shown that typhoid bacilli do not readily reproduce themselves and their poisons in peptone and Avell-digested milk, but do so very actively in meat-broths or jelly which has not been acted upon by the digestive juices. He has also 654 DISEASES. found that these bacilli generate two poisons, one of which causes, when given to animals, salivation, paralysis, and diarrhoea, the other violent and exhausting diarrhoea alone. Milk diet is therefore evi- dently better than broth diet in typhoid fever, and avc once more are able to explain an empirical fact by a scientific discovery. Another reason for using liquid instead of solid foods, beyond the difficulty of digestion, is the fact that these solids may irritate or perforate the ulcers in the small intestines. Alcohol may be used in all stages as a stimulant, as a giver of force to the system, and as an aid to digestion. A very large part of the profession believe that the mere presence of an abnormally high temperature contraindicates the use of alcohol. Mere high tempera- ture does not do so, hoAvever, and it seems probable that many deaths have resulted from putting into practice such a belief. High tem- perature of a sthenic type, Avith a full, tense, bounding pulse and all the signs of a disease attacking one in the full vigor of life, of course precludes its use; but in the high temperature of advanced typhoid, with the marked asthenia often present in that stage, alco- hol should be given constantly in large amount. Under these cir- cumstances the tissues Avhich the man can afford to lose are gone, and much of the vital portion of his system is greatly encroached upon: the alcohol yields force to the body, and is burnt up in great part, keeping the flagging heart pumping the tides of blood through the lungs and systemic circulation, when otherwise the very cardiac depression Avould produce hypostatic congestion, if not more wide- spread circulatory failure. A no less useful and valuable result obtained by the use of alcohol in the early stages of exhaustive fevers is the part that it plays in aid- ing digestion. The writer has elseAvhere denned the difference be- tween the influence of alcohol in the artificial digestion of the test- tube and that occurring in the stomach. No one doubts that alcohol added to a small amount of gastric juice in the test-tube retards or prevents its action; but evidence is abundant to prove that the inges- tion of this drug produces by its stimulating and irritant action a very decided increase in the quantity of gastric juice secreted over and above the amount normally present. Aside from experimental evi- dence, every-day experience has taught the gourmand that alcohol, in a fairly concentrated form, enables him to digest an amount of food Avhich under ordinary circumstances would remain unchanged in his stomach. The importance of aiding the flagging powers of the stomach is not generally recognized; but if one remembers the fact that at one time during the course of a severe attack of typhoid an occasion must come Avhen a struggle betAveen the few remaining grains of strength and the disease results in death or in recovery, its importance becomes evident. By the ingestion and digestion of more food early in the attack a larger amount of vital force remains for use at a crisis, and the chances of a recovery, to say the least, are increased. Alcohol may therefore be used all through the ordinary exhausting fevers— for the purpose in the first stage of aiding digestion, and in the later TYPHOID FEVER. 655 stages of supporting the system ; but the physician ought not to use it as a routine measure in every case Avithout a rational idea of Avhy he does so. In those cases in which a temporary loss of heart-power is due to hemorrhage or to some sudden severe depression alcohol is one of the remedies to be .employed—in a hot and concentrated form. That alcohol may be misused and cause great harm is of course knoAvn to every practitioner of medicine. So long as it reduces the temperature and lowers the rate of the pulse, causes a moist skin and tongue, and quiets nervous tAvitchings, it does good, and only up to this point is it to be employed. If its administration is pushed after this, the tendency to adynamia becomes, under the over-use of the drug, one of dynamia ; the pulse is no longer soft, but comes in angry, bounding beats ; the nervous symptoms change from Ioav, weak, mut- tering delirium, Avith subsultus tendinum, to wild, incoherent callings and strong tossings to and fro; and by and by, Avhen the influence of the alcohol begins to decrease, and even before this time, the system has put forth the strength of days in a feAv hours, and the man, having no reserve strength, is dead. The treatment Avhich has been used by the author in his Avards at the Jefferson Medical College Hospital and St. Agnes's Hospital have given him results which the application of other methods have failed to give, and is as folloAvs: As soon as the patient enters the house he is Avashed or bathed and placed in bed, and required to remain there. He is assured that the more quietly he lies the more mild and safe Avill be the course of his attack, and is made to use a bed-pan and urinal, and never allowed to get up. He is also given 5 drops (0.3) of dilute hydrochloric acid in a Avineglass (32.0) of water every four hours, or, if the boAvels are not active, nitromuriatic acid is substituted therefor, care being taken to employ 1, 2. or 3 drops of the strong, freshly-mixed orange-colored acid according to the degree of coating of the tongue. The diet is strictly a milk diet—namely, a quart to a quart and a half (1 to IJ litres) a day, with a little salt to flavor it, as already described in the article on Indigestion. In some cases koumyss acts very much better than milk. Sometimes, if vomiting is threatened, lime-water is added or the milk is peptonized, or beef-tea is temporarily employed. In other instances the milk agrees with the patient if it is partly diluted with plain soda or Apollinaris Avater. For the dry and sordes-covered tongue a mouth-Avash of glycerin and water, half and half, to Avhich may be added a little lemon-juice, is used. If constipation is very obstinate and continues over tAvo davs, an injection is employed, and if this, after being used tAvice, fails to act, a dose of calomel, \ grain (0.001) every fifteen minutes till a grain has been taken, is prescribed, and, if no movement occurs in tAvelve hours, is folloAved by 4 an ounce of sulphate of magnesium, or, best of all, a teaspoonful of liquorice powder is given. When diarrhoea becomes troublesome, over four or five passages a day, the following will be of service: 656 DISEASES. R— Acid, sulph. aromat...........f^ij (8.0). Extract. ha?matoxyli fl.........f^iij (12.0). Syr. zingiberis............f^iij (96.0).—M. S,—Teaspoonful (4.0) in water every hour until relieved. Just so soon as any evidences of tympanites or much meteorism come on turpentine is given, as follows: R .—01. terebinthina?...........f^ij (8.0). Syr. acacia?...........q. s. ad fjiij (96.0).—M. Ft. in emulsio. S.—Teaspoonful (4.0) three times a day. At the same time it is well to employ a turpentine stupe over the abdomen. (See Turpentine.) Where the tympanites is excessive it may be relieved by an injection made up as follows: R— 01. terebinthina?............f^j to ij (4.0-8.0). 01. oliva?...............fgiv (128.0). Mist, asafoetida?............Oj (500 cc.).—M. S.—Use as an injection. Shake well before using. In the later stages of typhoid fever, as convalescence is approached, turpentine is invaluable, as it causes rapid healing of the intestinal ulcers and stops diarrhoea, preventing relapses through the absorption of poisonous materials from the unhealed intestinal lesions. For many days after the patient begs hard for solid food it should not be allowed, for he will ask for it long before he should have it, but if the temperature remains normal for five days, very soft-boiled rice may be used in broth. Sometimes curds and Avhey make a pleas- ant change in the diet. The complications of typhoid fever of the most serious import are hemorrhage from the bowel, pneumonia and pleurisy, and perforation of the gut. The hemorrhage from the bowel may be stopped as indicated under that heading (Hemorrhage), and the pneumonia or pleurisy should be treated as are these diseases when free from complications; but it is to be remembered that this is an asthenic or adynamic case, which must not be bled or depressed, but stimulated. When perforation of the intestine appears, large doses of morphine should be given to relieve pain, prevent collapse, and allay irritation. Warm applica- tions should be used over the belly and down the limbs, and stim- ulants given if needed. Probably in the future surgery will add another triumph to the art by devising some fairly safe plan of ope- rative interference in this accident, which, if left alone, is very often fatal. The method of cold bathing introduced by Brand has given such wonderful results in the treatment of typhoid fever, and has been so thoroughly tried, both in this country and abroad, that its application should be well understood and practised whenever it is possible to do so. The method consists in immersing the patient every three hours in a bath at a temperature of 85° F., or as Ioav as 75° F. if neces- sary, and allowing him to remain in the water until the temperature falls to 100.5° or 101°, the bath being used Avith the frequency named URMMIA. 657 as long as the temperature is above 102°. Before entering the bath it is Avell to give the patient 4 to 1 ounce (16.0-32.0) of Avhiskev in a little milk or Avater, to prevent any depression from his being moved into the tub. The patient will generally complain bitterly of the cold, particularly at first, and will also appear someAvhat blue and chilly after the bath, but these signs are not to alarm the physician unless there is prolonged and persistent coldness, Avhen hot bottles should be applied to the feet and in some eases a little whiskey or brandy admin- istered. When the bath is given, cold should be applied to the vertex to prevent a congestion of the head, Avhich, of course, is not under Avater. The patient should either be immeised or the directions given in Part III. in regard to the use of the cold pack be folloAved. The bath ought ahvays to be near the bed, and a sufficient number of assistants should be present to lift the patient Avithout his putting forth any exertion Avhatever, as this consumes his strength, Avhich must be preserved with the greatest care. During the time the patient is in the bath the nurse should rub the surface of the body briskly in order to bring the blood to the surface and prevent congestions in internal organs. In cases where the patient objects so strongly to the cold bath that the physician cannot resort to it, it is sometimes possible to have the objections removed by putting the patient in the water at 95° F., and cooling the bath by the gradual addition of cold Avater to 75° F. It is said that pneumonia, intestinal hemorrhage, menstruation, nephritis, and cardiac complications are none of them contraindica- tions to this method of Brand, but the author Avould not resort to it if any of these conditions Avere actively present. One fact more should be stated—namely, that this method, Avhile not Avholly doing aAvay Avith all other treatment, generally makes other measures unnecessary, although it is, of course, advisable to move the boAvels every feAv days, if constipation be present, by injections, and to peptonize the milk if the digestion is faulty. The advantages gained by Brand's method are a mortality very much less than that of any other knoAvn method, the absence of high fever, the avoidance of disagreeable complications of all kinds, and the production of a rapid convalescence. UREMIA. The treatment of this dangerous manifestation of renal disease is often futile, but always to be resorted to with the recollection that wonderful recoveries sometimes occur under judicious management. It matters little whether the onset of the symptoms has been gradual or instantaneous : in either event the prime endeavor must be to rid the system of the poison which is threatening life. This can only be accomplished by aiding its elimination through the bowels, skin, and kidnevs. The second indication is to support the vital organs until the emunctories have had time to act. Often this second indi- cation w ill be more pressing than the first, and the physician will 42 658 DISEASES. have to give stimulants at once. The third indication is to arrest any convulsive seizures. The methods to be resorted to for the elimination of the uraemic poison are external and internal, externally the hot pack being resorted to to increase the activity of the skin. (See Heat in Part III.) Internally we give elaterium or elaterin in the dose of 4y grain (0.01) or fa grain (0.004), respectively, for the induction of Avatery purg- ing, Avhich at once aids elimination through the bowel and relieves dropsy if present. The elaterin should be dissolved in a few drops of alcohol or in whiskey. The medication directed to increased action of the skin should consist of small doses, hypodermically—say i- grain (0.01)—of hydrochlorate of pilocarpine, but this is contraindicated unless the heart is believed to be strong and acting properly. If dropsy is present, the drug will have to be given by the mouth, as it will not be absorbed from the boggy subcutaneous tissues. Pilocarpine will also tend to increase the activity of the kidneys, and in addition to this influence on the renal structure Ave may use caffeine in the dose of 2 grains (0.1) every four hours for three doses, to stimulate the renal epithelium still remaining healthy to greater effort. For the support of the heart and respiratory function we employ strychnine hypodermically or by the mouth in the dose of 2V to fa grain (0.003-0.006), and folloAv it by the more poAverful stimulant digitalis in the form of the tincture in the dose of 20 drops (1.3). The convulsions, if present or threatened, are to be combated by the use of an enema of 20 grains of chloral (1.3) and 60 grains (4.0) of bromide of sodium in 3 ounces (96.0) of starch-Avater, and the hot pack will also be of \ralue, not only to produce saveating, but for its sedative influence on the venous system. Should the convulsive tend- encies be marked, chloroform inhalations may be employed until the chloral or bromide can be absorbed. According to Peabody and Kinnicutt, urethan is extraordinarily efficacious in uraemic convulsions, and they advise that the dose be very large, as much as 6 to 7 drachms (24.0-28.0) in twenty-four hours. It is said to lack the irritating properties of chloral, and to be lacking in dangerous effects on the heart. The drug may be given hypodermically or by the rectum, dis- solved in water. Tavo other remedial measures should be resorted to in cases of uraemia for the relief of all the symptoms—namely, full venesection and hypodermoclysis. (See Part III.) Venesection is only contrain- dicated in the feeble. As much as 1 to 2 pints (4> to 1 litre) may be Avithdrawn from a vein in the arm. After the bloodletting or during its progress hypodermoclysis may be performed or a saline solution transfused into the vein. (See Transfusion.) Often deep insensibility is speedily removed by venesection, which should be regarded as the sheet-anchor of treatment in those cases with a high blood-pressure. VITREOUS DISEASES. Vitreous opacities may be either dust-like, flaky, or dense and membranous. They impair vision in proportion to their number and VOMITING. 659 density, and are to be detected with the ophthalmoscope. Patients detect them as floating dark spots in their field of vision, because the opacities cast a shadoAv upon the retina. If vitreous disease is syphilitic, the usual remedies are indicated. Hypodermic injections of pilocarpine act favorably, and in the earlier stages of the inflam- mations of the retina, choroid, iris, and ciliary body, upon Avhich the opacities depend, leeches should be applied to the temple. Gal- vanism has been recommended. VOMITING. Vomiting is of course a symptom, not a disease, and arises from a large number of causes, some of which are very unimportant, others very serious. The most common cause is probably lack of proper digestion, with all that this implies; that is, gastro-intestinal irrita- tion and perversion of normal function. Additional causes are cer- ebral hemorrhage, tubercular meningitis, cerebritis, uraemia, or dis- eases of the middle lobe of the cerebellum, all of which conditions cause irritation of the vomiting centre. All these states may be considered as lesions of a centric charac- ter which directly or indirectly cause the vomiting centre to send out impulses. On the other hand, it is worthy of note that under certain circumstances vomiting may be reflex and dependent upon irritation of the nerves of the stomach or elseAvhere Avhich conveA- impulses to the muscles whose activity results in vomiting. These conditions are well represented by the vomiting which comes on in incarcerated hernia, or in pregnancy, or in that occurring during the passage of renal or hepatic calculi, or in indigestion. It is important to bear in mind that peripheral vomiting due to disorder of the gastric walls may be dependent upon tAvo con- ditions. The mucous membrane and its nerves may be over- excitable or they may be depressed. For this reason we shall find that tAvo modes of treatment are necessary Avhen this subject is considered below. The mechanism of vomiting consists in the closure of the pyloric sphincter, the contraction of the gastric muscles from the pylorus to the cardia, and at the same time, and more important than these movements, the contraction of the supplementary respiratory and abdominal muscles, which so compress the stomach as to drive out its contents through the open oesophagus. The violence of the muscular contractions in the abdominal Avails is greatest when the stomach is partly empty, and gives rise to the pain and exhaustion accompanying the condition knoAvn as retching. The practical point to be learned from this is that vomiting is ahvays easier Avhen the stomach is full; so if an emetic is given on an empty stomach, as the popular expres- sion runs, a large amount of liquid should precede or accompany it if possible. Dogs vomit easily because of the development of the gas- tric muscles, but they render the effort easier by filling the stomach Avith air, and so completely fill the viscus that its walls can contract on a resisting mass. 660 DISEASES. Having described the mode and causes of vomiting, it still remains for us to consider its treatment. It is needless to remark that the vomiting of cerebral disease is very intractable, and that very active agents must be used to stop it. Probably the vomiting folloAving etherization is ceutiic, and should be treated, as should all forms of obstinate emesis, by the injection into the rectum of 40 grains (2.05) of sodium or potassium bromide and 20 drops of laudanum in 4 to S ounces (128.0-256.0) of water. If this does not stop the vomiting, a second injection may be given one hour after the first. When vomiting seems to be due to hyperexcitability of the gastric mucous membrane, so that very small amounts of food when swalloAved are at once rejected, local anaesthetics and depressants are needed, the chief of these being cocaine and aconite. Both of these drugs, hoAv- ever, have disadvantages, because in effective dose their general phys- iological action may be very severe and almost poison the patient. When given to act as antiemetics, these drugs do so by acting as local anaesthetics, or, in other Avords, by paralyzing the peripheral sensory nerves. Cocaine should be given in the dose of 2 to 3 drops (0.1- 0.15) of a 4 per cent. Avatery solution every fifteen minutes until 10 drops (0.65) are taken. The aconite should be used in the form of the tincture, the patient being placed flat on the back, so as to Avith- stand the ensuing cardiac depression with the least inconvenience, and 2 to 5 drops (0.1-0.3) of the drug given in a little Avater every thirty minutes until the rapidly Aveakening pulse forbids its further use. This drug may be resorted to in all forms of vomiting due to irritability of the stomach, but it is contraindicated in cases of debil- ity or Aveakness. Aconite is generally to be preferred to cocaine. Sometimes a prescription of the following character is of service, the bismuth acting as a coating to the walls of the stomach, protect- ing and soothing them : R.—Bismuthi subnitrat........giij (12.0). Tr. aconiti..........gr. xx vel xxx (1.3-2.0).—M. Ft. chart. No. x. S.—One powder every half-hour. This prescription is very useful if the vomiting becomes excessive and is due to acidity or fermentation. In other cases of the same type the following is useful, and is to be preferred if, owing to active fermentation, the vomiting is ex- cessive (the creosote or carbolic acid being a local anaesthetic and antiseptic) : R.—Acid, carbolic, vel creosoti (beechwood) . gtt. x vel xx (0.65-1.3). Bismuthi subnitratis.........giij (12.0).—M. Ft. in chart. No. x. S.—One powder every hour. In other cases 1 drop of tincture of iodine and 1 drop of carbolic- acid in a couple of drachms of water will act very well. Sometimes pure chloroform in 1- or 2-drop (0.05-0.1) doses, in a little water, does good; and dilute hydrocyanic acid, in the dose of 2 VOMITING. 661 to 6 drops (0.1-0.4) is also of value in like instances, given in a tablespoonful (16.0) of Avater. In other instances small repeated doses of nitroglycerin do good unless the vomiting complicates peritonitis or pregnancy. Probably this good effect is due to its depressant effect on the peripheral pneu- mogastric nerves, so decreasing gastric reflex activity. The treatment of a case of vomiting dependent rather upon de- pression and debility of the stomach than upon irritation is directed to the administration of gastric and, it may be, systemic stimulants. The chief of the gastric stimulants is ipecac in small doses, and it it is this employment of a drug generally resorted to for the produc- tion of emesis by physicians Avhich has caused homoeopaths to claim that the regular school obey the law of similia shnilibus curautur and infinitesimal doses. The claim only holds good on its face, for we do not use an infinitesimal dose, and obey no laAA% but rrse common sense. Ipecac is an irritant, even to the skin, and it is partly by its irritant effects that it causes vomiting by exciting the stomach to a point over and above its normal condition. In the vomiting depending upon gastric debility and depression small doses of ipecac do good, because they irritate the stomach sufficiently to restore its normal tone with- out going to the other extreme of hyperexcitation. Under these cir- cumstances a drop dose of the wine of ipecac, or 4 of a grain (0.016) of the poAvdered ipecac, every hour, is of the greatest value, often succeeding after all other remedies have failed. In other instances tincture of nux vomica, given in 4- to 1-drop (0.025-0.05) doses, is useful as follows : R.—Tinct. nueis vomicae.......gtt. iv vel viij (0.25-0.5). Aqua? cinnamomi........fjj (32.0).—M. S.—Teaspoonful (4.0) every half-hour or hour. In the nausea and vomiting folloAving an alcoholic debauch \ to 1 drop (0.025-0.05) of Fowler's solution every tAvo hours, or before food, often gives relief, and it may be used in some cases in place of the nux vomica and ipecac. Another useful measure for the cure of alcoholic nausea is the use of full doses of hydrochloric acid, 5, 10, or 15 drops (0.3-0.65-1.0) of the dilute acid in half a tumblerful of water, repeated every two hours. In all cases of persistent vomiting counter-irritation should be applied over the stomach in the form of a mustard plaster, or, if preferred, an ice-bag may be applied to the nape of the neck, the lumbar spine, or the epigastrium. The food given in cases of vomiting should be especially prepared. It is always best to use peptonized milk, made by using the pepton- izing materials sold by all the large drug firms of reliability. (See article on Diet, Part III.) Lime-water should always be put in the milk if it is not peptonized; the amount usually employed is per- fectly useless, because of its smallness: at least 2 to 3 tablespoonfuls (32.0-48.0) should be placed in each glass of milk. Another point of importance is the quantity of liquid taken. As fast as the patient vomits he is often fed with glasses full of liquid 662 DISEASES. by well-meaning friends. Instead of this, he should have only 1 or 2 teaspoonfuls (4.0-8.0) of milk every hour, half-hour, or fifteen min- utes, for it is better for him to retain a drachm than to take a quart and vomit it. Where vomiting is absolutely persistent enemata previously partly or entirely digested must be resorted to. WHOOPING COUGH. The remedies recommended for this disease are almost as numer- ous as the members of the medical profession, and every one of them is worthless so far as a cure is concerned. Probably the very best drug of all in the majority of cases is antipyrine. Given in the dose of 4; to 3 grains (0.025-0.15) every five hours according to the age of the child, it will nearly ahvays decrease the number of paroxysms, but not the severity of each individual attack. Where the child will submit to it there is little doubt that quinine in a very fine spray will be of service in many cases, and it is very useful, when so used, as a prophylactic in other children of the family Avho it is feared will be attacked by the same disease. The strength of the solution to be employed should be about 1 grain (0.05) to the ounce of water. There is no doubt that carburetted hydrogen as inhaled at gas- Avorks is useful as a curative measure in cases of Avhooping cough. A very useful remedy in some cases is belladonna in the form of the tincture, in the dose of \ drop (0.025) twice a day to a child of one or two years. Where great vascular engorgement ensues upon a severe coughing spell vascular sedatives are of service ; that is, in those cases in which hemorrhages from the nose, ears, and mouth take place veratrum viride or aconite may be used, unless the disease has already so exhausted the child that stimulants are needed, and cardiac sedatives are contraindicated by the degree of adynamia present. The reason for this lies in the following facts : The vascu- lar tension consequent upon the obstruction of respiration causes a rise of blood-pressure from asphyxia, and the hemorrhages or the conjunctival ecchymoses are due to rupture of the small blood-vessels under the increased strain. By loAvering vascular tension Ave prevent so great a spasm of the blood-vessels and avoid vascular rupture or distention. Where paroxysms come on so rapidly as really to interfere seri- ously Avith respiration, the child should take a whiff of chloroform poured over the parent's hand, and so relax the spasm, while in other instances nitrite of amyl is equally serviceable. Only 2 to 3 drops of the nitrite of amyl should be used at a time, and this fact must be impressed upon the parents. Benzine has been found useful in certain cases of Avhooping cough. It should be lightly sprinkled about the room or on the bed-clothing. In France it has been used internally in the dose of 10 to 15 drops (0.6-1.0) for this affection. This is scarcely to be recommended. WORMS. 663 Bromoform renders good service in some cases. (See article for prescription.) The vomiting following the cough may be ovevcome by using such minute amounts of milk as to enable nutrition to go on Avithout at any time overloading the stomach, as, for example, a teaspoonful (4.0) after each paroxysm of cough. Often it will be found possible to modify the severity and frequency of the attacks by keeping the patient under a bronchitis tent or by keeping the air of the room moistened by steam. (See Bronchitis.) WORMS. Intestinal parasites may be said to be represented by the Ascaris lumbricoides. or round-worm; the Taenia solium, Taenia media canellata, and the Bothriocephalus latus, or tape-worms ; and, finally, by the Oxyuris vermicularis, sometimes called seat-, pin-, or thread- worm. The round-Avorm and tape-worm are to be attacked by Avay of the patient's mouth, the seat-A\orm by Avay of the anal opening; but before mentioning the drugs to be employed it is necessary to insist upon one or tAvo important points, disregard of which will result in failure in treatment. Whenever a round- or tape-Avorm is to be attacked, the patient must be starved for at least twelve to tAventy-four hours, in order that no food in the intestinal tract may protect the Avorm from the action of the drug. During this time a little milk may be taken, and after a night of fasting, before breakfast, the anthelmintic must be SAval- lowed. Further than this, nearly all of these drugs must be followed by purges in order to dislodge the intruder Avhile he is paralyzed and has lost his hold; and in many instances it is well to have a basin of salt and water ready, so that Avhen a passage occurs a rectal injection may be given to Avash out any segments of the Avorm Avhich remain behind in the rectum. In the treatment of thread-Avorms it is necessary to fill the boAvel thoroughly with soap and water to dislodge the faecal matter and expose the Avorms in the folds of the mucous membrane. The drugs Avhich are used against the round-worm are: Spigelia in the form of the fluid extract, dose 1 drachm (4.0) to a child of two or three years, or 2 drachms (8.0) to an adult, or, better still, the fluid extract of spigelia and senna, dose 2 to 3 drachms (S.0-12.0), given in divided doses, to a child; oil of chenopodium, dose 5 to 20 drops (0.3-1.3) on sugar; santonin, dose 4, to \ grain (0.016-0.025) to a child, in the form of troche, made by using the crystals, or as much as 2 to 4 grains (0.1-0.2) to an adult. (See Santonin.) Brayera, or kooso, is given for the removal of the same worm in the form of an infusion, which is made by adding | ounce (16.0) of the poAvdered leaves to 1 pint (500 cc.) of Avater and mucilage of acacia, one-half of each. This may be taken at one dose, or the fluid extract may be given in the dose of 4; ounce (16.0) to an adult. 664 DISEASES. Koosin may be given in 40-grain (2.05) doses in capsule to adults. but it should not be used against Avorms in pregnant Avomen, as it may cause abortion. Unless the spigelia is used with senna, it should always be folloAved after from tAvo to four hours by a full dose of castor oil or a saline purgative to SAveep out the Avorm, and the same rule applies to all the drugs mentioned above. The most efficient remedy against the tape-A\orm is pelletierine, the active principle of pomegranate, dose 1 to 2 grains (0.05—0.1) in capsules; or pepo, or pumpkin-seeds (2 ounces [64.0]), may be resorted to Avhen deprived of their outer coating and rubbed into a paste Avith sugar. Almost, if not quite, as valuable a remedy is male fern, or Filix mas, or, as it is officially called, Aspidium. Used in the form of the oleoresin (Oleoresina Aspidii), in the dose of J to 1 drachm (2.0-4.0) to an adult, it should be folloAved in three or four hours by a calomel purge, aided by a saline. Either the calomel or the increased amount of bile Avhich is present is apparently peculiarly abhorrent to the tape-worm, and its free excretion should folloAv the use of all the drugs just named. Aspidium should not be folloAved by castor or other oils, as they increase the absorbability of the drug, and so tend to develop poisonous symptoms. By far the most useful remedy for seat-Avorms is quassia used by injection. 1 to 2 ounces (32.0-64.0) of powdered quassia or quassia chips may be made into a decoction Avith a pint (500 cc.) of Avater, and half of this injected into the rectum after it has been well cleansed with soap and Avater. The quassia injection should be retained in the boAvel for some minutes, and in children this may be accomplished by pressing upon the anal opening the ball of the thumb covered by a pad formed from a small folded towel. If this treatment fails to bring aAvay all the worms in three or four trials, either there are none present or the bowel is not thoroughly invaded by the injection. In some cases the Avorms infest the colon, and large injections sent high up into the boAvel are necessary. DOSES OF MEDICINES. dr. = drachm ; fl. dr. = fluidrachm; fl. oz. = fluidounce; gr. = grain ; gm. — gramme; min. — minim : oz. = ounce. Remedy. Acetanilid....... Acetophenone .... Acetphenetidin..... Acetum lobelia?..... opii......... sanguinaria^..... scillse....... Acid, acetic, diluted . . . arsenous....... solution of (Ph. U. S.) benzoic....... boric........ carbolic....... chrysophanic..... citric ....... fluoric, dilute..... gallic........ hydriodic, dilute . . . hydrobromic, dilute ■ . hydrochloric..... dilute....... hydrocyanic, dilute . . lactic........ nitric ........ dilute....... nitrohydrochloric . . phosphoric, dilute. . . picric ....... polygalic....... salicylic....... sulphuric...... aromatic...... dilute....... sulphurous ...... tannic........ tartaric ...... valerianic...... Aconite, abstract of . . . leaves, extract of . . . fluid extract of . . . tincture of..... root, extract of ... . fluid extract of • • ■ tincture of..... Aconitine....... Adonidin....... JEther. See Ether. Apothecaries' Weights and Measures. 1-8 gr. 5-20 min. 2-5 gr. 15-30 min. 5-10 min. 15-30 min. 10-30 min. 1-2 fl. dr. 1— 1 or 60 2 J Sr- 2-8 min. 5-15 gr. 5-10 gr. £-1 gr; j-5 min. 5-20 gr. 10-20 min. 3-15 gr. h fl. dr. i-2 fl. dr. 2-5 min. 10-20 min. 2-5 min. 1-3 dr. 2-5 min. 10-25 min. 2-5 min. 5-25 min. 1-5 gr. H gr- 5-15 gr. 2-5 min. 5-20 min. 5-20 min. i-1 fl. dr. 2-10 gr. 10-30 gr. 3-4 min. i-lgr- i-i gr; 1-5 min. 10-15 min. 4-i gr; \-\ min. 1-3 min. 1-1 err ToTi 3THJ 6r- tW gr- Metric System. 0.06 0.3 0.12 1.0 0.3 1.0 0.6 4.0- 0.001- 0.12 0.3 0.3 0.03 0.008 0.3 0.6 0.2 2. 2.0 0.1: 0.6 0.12 4.0 0.12 0.6 0.12 0.3 0.06 0.015 0.3 0.12 0.3 0.3 O.lt 0.6 0.2 O.Oli 0.015 0.06 0.6 0.01 0.03 0.06 0.00015 0.005 -0.5 gm. -1.25 gm. -0.3 gm. -2.0 gm. -0.6 gm. -2.0 gm. -1.8 gm. -8.0 gm. -0.003 gm. -0.5 gm. -1.0 gm. -0.6 gm. -0.06 gm. -0.3 gm. -1.25 gm. -1.2 gm. -1.0 gm. .0 gm. -8.0 gm. :-<).;! gm. -1.2 gm. -0 3 gm. -12.0 gm. -0.3 gm. -1.5 gm. -0.3 gm. -1.5 gm. -0.3 gm. -0.06 gm. -1 gm 1-0.3 gm. -1.2 gm. -1.2 gm. ;-4 gm. 0.6 gm. -2 gm. -0.25 gm. -0.03 gm. -0.03 gm. ;-0.3 gm. I—1.0 gm. -0.016 gm. 1-0.06 gm. 1-0.18 gm. 1-0.0002 gm. -0.01 gm. 665 666 DOSES OF MEDICINES. Remedy. Aga-riein.............. Aloes .......■..... extract of............ and myrrh, tincture of....... tincture of............ watery extract.......... wine of............. Aloin............... Alumen.............. (as emetic)............ Aluminium hydrate......... Ammonia, aromatic spirit...... solution of acetate of....... spirit of............. water of............. Ammoniacum........... mixture ............. Ammonium benzoate........ bromide............. carbonate............ chloride............ iodide.............. phosphate............ picrate .............. sulphate............. valerianate............. Amygdala amara, water of...... Amyl nitrite............ by inhalation.......... Amylene hydrate.......... Amylum iodatum.......... Angelica-root, fluid extract...... Angustura-bark........... Anise, oil of............ .spirit of............. Anthemis............. extract............. fluid extract........... Antimonial powder......... Antimony oxide.......... oxysulphuret........... and potassium tartrate, as diaphoretic as emetic........... sulphide............. sulphurated........... sulphuret............ wine of ............. Antipyrine............. Apiol............... Apocynin............. Apocynum cannabinum....... fluid extract of......... Apomorphine hydrochlorate..... Aralia hispida, fluid extract of ... . nudicaulis, fluid extract of..... racemosa, fluid extract of..... spinosa, fluid extract of...... Arbutin.............. Areca, fluid extract of........ Argentum and compounds. See Silver. Arnica-flowers, extract of...... Apothecaries' Weights and Measures. Metric System. tW gr-2-6 gr. 2-6 gr. 0.005-0.015 gm. 0.1-0.35 gm. 0.1-0.35 gm. 1 -2 fl. dr. 4.0-8.0 gm. 1-2 fl. dr. 4.0-8.0 gm. 1-2 gr. 0.03-0.12 gm. 1-2 fl. dr. 4.0-8.0 gm. 1-3 gr. 5-10 gr. 0.06-0.18 gm. 0.3-0.6 gm. 30 gr.-l dr. 5-15 gr. 30 min.-l fl. dr. 2.0-4.0 gm. 0.3-1.0 gm. 2-4 gm. 1-2 fl. dr. 5-15 min. 4-8 gm. 0.6-1.0 gm. 2-6 gr. 10-30 gr. 1-1 oz. 10-20 gr. 10-30 gr. 3-10 gr. 5-10 gr. 3-5 gr. 0.1-0.35 gm. 0.6-2 gm. 16-32 gm. 0.6-1.2 gm. 0.6-2 gm. 0.18-0.6 gm. 0.3-0.6 gm. 0.18-0.3 gm. 10-20 gr. 3-10 gr. 2-8 gr. 1-2 fl. dr. 0.6-1.2 gm. 0.016-0.03 gm. 0.18-0.6 gm. 0.12-0.48 gm. 4.0-8.0 gm. 2-3 min. 0.12-0.18 gm. 3-5 min. 0.18-0.3 gm. 10-30 min. 0.6-2.0 gm. 5-30 gr. 0.3-2.0 gm. 30-60 min. 2.0-4.0 gm. 10-30 gr. 1-5 min. 0.6-2.0 gm. 0.06-0.3 gm. 1-2 fl. dr. 4.0-8.0 gm. 1-1 dr. 2-4 gm. 2-10 gr. 0.12-0.6 gm. 30-60 min. 2.0-4.0 gm. 1-3 gr. 2-3 gr. *-2 gr. 0.06-0.18 gm. 0.12-0.18 gm. 0.03-0.12 gm. T6~2 gr. i-1 gr-1-2 gr. 1-2 gr. 1-2 gr. 0.004-0.03 gm. 0.03-0.06 gm. 0.03-0.12 gm. 0.06-0.12 gm. 0.03-0.12 gm. 10 min.-l 11. dr. 0.6-4 gm. 5-15 gr. 0.3-1.0 gm. 2-5 gr. i-2 gr. 10-20 gr. 0.12-0.3 gm. 0.03-0.12 gm. 0.6-1.2 gm. 10-30 min. 0.6-2.0 gm. tV-tV gr-30-60 min. 0.004-0.006 gm. 2.0-4.0 gm. 30-60 min. 2.0-4.0 gm. 30-60 min. L'.0-4.0 gm. 30-60 min. 2.0-4.0 gm. 1-10 gr. 0.06-0.6 gm. 30-60 min. 2.0-4.0 gm. 2-5 gr. 0.12-0.3 gm. DOSES OF MEDICINES. 667 Remedy. Arnica-flowers, fluid extract of..... root, extract of.......... fluid extract of.......... tincture of............ Aromatic powder........... Arsenate of sodium, solution of..... Arsenic. See Acid, arsenous. bromide.............. iodide............... and mercury iodide, solution of (Dono- van's solution) ......... Arsenite of potassium, solution of (Fowler's solution)............ Asafoetida............... mixture of ............. tincture............... Asdepias incarnata, fluid extract of . . . Syriaca, fluid extract of........ tuberosa .............. Aspidium, fluid extract of....... oleo-resin of............. Aspidosperma, abstract of....... fluid extract of............ Atropine sulphate........... Aurantii cortex, fluid extract of..... Azedarach, fluid extract of....... Balsam of Gurjun........... of Tolu............... Baptisia, extract of........... fluid extract of........... Baptisine............... Belladonna, abstract of......... alcoholic extract of.......... leaves, fluid extract of........ tincture of............ root, extract of........... fluid extract of........... Benzanilide.............. Benzoin, compound tincture of..... tincture of............. Benzol ................ Berberina............... sulphate . . ............ Eerberis aquifolium, fluid extract of . . . vulgaris, fluid extract of....... Bismuth and ammonium, citrate of ... . citrate ............... salicylate.............. subcarbonate ............ subnitrate.............. tannate............... valerianate............. Boldo, fluid extract of......... oil of................ tincture of............. Brayera................ fluid extract of............ infusion of............. Bromal................ Bromoform............ Brucina................ Apothecaries' Weights and Measures. 5-15 gr. 2-5 gr. 5-15 gr. 10-20 gr. 10-30 gr. 3-5 min. 1-4 min. 1__1 „r T6 s gr- 5-10 min. 2-5 min. 5-20 gr. 4-1 fl. oz. 30 min.-l fl. dr. 15-30 min. 15-30 min. 15-30 min. 1-2 fl. dr. 30 min.-l fl. dr. 5-20 gr. 15-30 min. TT0-4 o gr- 15 min.-2 fl. dr. 15-60 min. 20-30 min. 10-30 min. 2-10 gr. 10-30 min. 2-5 gr. 2-H gr- 3-6 min. 10-20 min. I—1 or s^¥ gr; 1-2 min. 1-5 gr. 30 min.-l fl. dr. i-1 fl. dr. 5-10 min. 3-10 gr. 3-10 gr. 15-30 min. 15-30 min. 1-10 gr. 3-15 gr. 5-15 gr. 5-20 gr. 5-20 gr. 5-30 gr. 1-3 gr. 5-15 min. 5 min. 8 min. 2-3 dr. J-l fl. oz. 4-8 oz. 2-3 gr. 5-10 min. 3 2_T6 gr- Metric System. 0.3-1.0 gm. 0.12-0.3 gm. 0.3-1.0 gm. 0.6-1.2 mg. 0.6-2.0 gm. 0.18-0.3 gm. 0.06-0.024 gm. 0.004-0.008 gm. 0.3-0.6 gm. 0.12-0.3 gm. 0.3-1.2 gm. 15-30 gm. 2-4 gm. 1.0-2.0 gm. 1.0-2.0 gm. 1.0-2.0 gm. 4.0-8.0 gm. 2.0-4.0 gm. 0.3-1.2 gm. 1.0-2.0 gm. 0.0005-0.0015 gm. 1.0-8.0 gm. 1.0-4.0 gm. 1.2-2.0 gm. 0.6-2.0 gm. 0.12-0.6 gm. 0.6-2.0 gm. 0.12-0.3 gm. 0.03-0.1 gm. 0.016-0.03 gm. 0.18-0.36 gm. 0.6-1.2 gm. 0.008-0.016 gm. 0.06-0.12 gm. 0.06-0.3 gm. 2.0-4.0 gm. 2 0-4.0 gm. 0.3-0.6 gm. 0.18-0.6 gm. 0.18-0.6 gm. 1.0-2.0 gm. 1.0-2.0 gm. 0.06-0.6 gm. 0.18-1.0 gm. 0.3-1.0 gm. 0.3-1.2 gm. 0.3-1.2 gm. 0.3-2.0 gm. 0.06-0.18 gm. 0.3-1.0 gm. 0.3 gm. 0.5 gm. 8.0-12.0 gm. 15.0-30.0 gm. 118.0-236.0 gm. 0.12-0.2 gm. 0.3-0.6 gm. 0.002-0.004 gm. 668 DOSES OF MEDICINES. Bryonia, fluid extract of...... tincture of........... Buchu, fluid extract of . %...... Buckthorn, fluid extract of..... Cactus grandiflora, fluid extract of . . "Caffeine.............. citrate of............ Cajeput, oil of.......... Calamus, fluid extract of...... Calcium benzoate....... . bromide............ carbonate............ chloride............ hypophosphite.......... iodide............. lactophosphate, syrup of..... phosphate............ sulphide............ Calendula, fluid extract of...... tincture of........... Calomel. See Mercury, mild chloride of. Calumba, extract of. ........ fluid extract of.......... tincture of............ Calx chlorata........... sulphurata........... Camphor............. bromide............ monobromated.......... spirit of........... water.............. Camphoric acid.......... Cannabin tannate......... Cannabis Americana, fluid extract of . Indica, abstract of........ extract of........... fluid extract of......... tincture of.......... Cantharides............ tincture of........... Capsicum............. fluid extract of.......... oleoresin of........... tincture of........... Caraway, oil of. .......... Carbon bisulphide......... Cardamom, compound tincture of . . fluid extract of.......... tincture of........... Caryophyllus, oil of . . •...... Cascara sagrada.......... extract of............ fluid extract of.......... Cascarilla............. fluid extract of.......... Cassia fistula, pulp of........ Castanea vesca, fluid extract of. . . . Castor.............. tincture of............ Cataria, fluid extract of....... Catechu.............. Dose. Apothecaries' Weights and Measures. 15-60 min. 15-30 min. 4-1 fl. dr. 15-30 min. 5-10 min. 2-5 gr. 2-5 gr. 5-20 min. 15-60 min. 10 gr. 10-20 gr. 15-30 gr. 5-10 gr. 10-30 gr. 1-3 gr. 1-2 fl. dr. 15-30 gr. 1-1 or r 2 gr- 15-60 min. 15-30 min. 3-10 gr. 15-60 min. 1-4 fl. dr. 2-5 gr. 1-1 gr. 2-10 gr. 2-5 gr. 2-5 gr. 5-30 min. 4-2 fl. oz. 15-30 gr. 5-10 gr. 3-15 min. 1-3 gr. |-1 gr. 3-6 min. 5-20 min. 1-1 gr; 2-5 min. 1-2 gr. 4~1 min. \-\ min. 5-20 min. 1-5 min. 4-1 min. 1-2 fl. dr. 15-45 min. 1-2 fl. dr. 1-5 min. 2-8 gr. 2-8 gr. 10-30 min. 20-30 gr. 1-2 fl. dr. 1-2 dr. 4-1 fl. dr. 10-30 gr. 2-4 fl. dr. 15 min.-l fl. dr. 10-30 gr. Metric System. 1.0-4.0 gm. 1.0-2.0 gm. 2.0-4.0 gm. 1.0-2.0 gm. 0.3-0.6 gm. 0.12-0.3 gm. 0.12-0.3 gm. 0.3-1.2 gm. 1.0-4.0 gm. 0.6 gm. 0.6-1.2 gm. 1.0-2.0 gm. 0.3-0.6 gm. 0.6-2.0 gm. 0.06-0.18" gm. 4.0-8.0 gm. 1.0-2.0 gm. 0.012-0.03 gm. 1.0-4.0 gm. 1.0-2.0 gm. -0.6 gm. -4.0 gm. -16.0 gm. -0.3 gm. -0.06 gm. -0.6 gm. -0.3 gm. -0.3 gm. -2.0 gm. -64.0 gm. -2.0 gm. -0.6 gm. -1.0 gm. -0.18 gm. -0.06 gm. -0 36 gm. -1.2 gm. -0.06 gm. -0.3 gm. -0.12 gm. -0.06 gm. -0.06 gm. -1.2 gm. -0.3 gm. -0.06 gm. -8.0 gm. -3.0 gm. -8.0 gm. -0.3 gm. -0.5 gm. -0.5 gm. -2.0 gm. 2.0 gm. -8.0 gm. -8.0 gm. -4.0 gm. -2.0 gm. -16.0 gm. -4.0 gm. -2.0 gm. 0.18- 1.0 4.0 0.12- 0.016- 0.12 0.12- 0.12 0.3 16.0 1.0 0.3- 0.18 0.06- 0.015- 0.18- 0.3- 0.03- 0.12 0.03 0.03 0.015 0.3- 0.06- 0.03 4.0 1.0 4.0 0.06 0.12 0.12 0.6 1.2 4.0 4.0 2.0 0.6 8.0 1.0 0.6 DOSES OF MEDICINES. 669 Remedy. Catechu, compound tincture of... . fluid extract of.......... Caulophyllin........... Caulophyllum, infusion of...... Cava-cava ............. Cerium nitrate.......... oxalate............. Chalk, compound powder of..... mixture ............. prepared ............ Chamomile, oil of......... Charcoal, animal, purified...... Chelidonium majus......... extract of............ fluid extract of.......... Chenopodium, oil of........ Cherry-laurel water........ Chimaphila, fluid extract of..... Chinoidin............. Chionanthus, fluid extract of ... . Chiretta, fluid extract of...... tincture of............ Chloral hydrate.......... Chloralamide........... Chlorine-water........... Chloroform, mixture of....... purified............. spirit of............. Chrysarobin............ Cimicifuga, fluid extract of..... tincture of............ Cinchona-bark........... aromatic fluid extract of..... compound tincture of....... extract of............ fluid extract of.......... tincture of............ Cinchonia sulphate . . ...... Cinchonidia or Cinchonidine sulphate Cinchonine sulphate........ Cinnamon............. oil of.............. spirit of............. tincture of............ Cloves. See Caryophyllus. Coca, fluid extract of........ leaves of............ Cocaine............ . . Cocculus, fluid extract of...... tincture of............ Codeine or Codeia......... Colchicine............. Colchicum, acetic extract of..... root.............. extract of........... fluid extract of......... wine of ............ seed............. fluid extract of........ tincture of........... wine of ............ Dose. Apothecaries' Weights and Measures. 4- 10 i ? l 10- 1 1 10 1 15 5- 10 i 2 5 15 4- 5 1 10 30 i 15 5 15 1- 1 5 10 min. 5 10 10 gr', 30 1 10 10 1 10 10 10 5 1 o- -2 fl. dr. -30 min. 4gr- -2 oz. -30 gr. -2 gr. -2 gr. -30 gr. -2 fl. oz. -30 gr. -15 min. -30 gr. -1 dr. "10 gr. -30 min. -8 min. -30 min. -2 fl. dr. -30 gr. -60 min. -1 fl. dr. -60 min. -20 gr. -30 gr. -4 fl. dr. -4 fl. dr. -10 min. -1 fl. dr. -20 gr. -30 min. -1 fl. dr. -1 dr. -60 min. -2 fl. dr. -30 gr. -30 min. -2 fl. dr. -20 gr. -30 gr. -30 gr. -20 gr. -5 min. 20 min. 2 fl. dr. 20 min.-l fl. dr. 1-1 dr. 1-1 gr. 1-3 min. 2-10 min. 1-2 gr. 1 - 1 or TB(T 7o" gr- ? t. gr- 2-5 gr. \r\ gr: 2-5 min. 10-20 min. 2-10 gr. 2-8 min. 10-30 min. 20-40 min. Metric System. 2.0-8.0 gm. 0.6-2.0 gm. 0.015-0.03 gm. 16.0-64.0 gm. 0.6-2.0 gm. 0.06-0.12 gm. 0.06-0.12 gm. 0.6-2.0 gm. 32-64 gm. 1.0-2.0 gm. 0.3-1.0 gm. 0.6-2.0 gm. 2.0-4.0 gm. 0.3-0.6 gm. 1.0-2.0 gm. 0.24-0.5 gm. 0.3-2.0 gm. 4.0-8.0 gm. 0.6-2.0 gm. 2.0-4.0 gm. 2.0-4.0 gm. 1.0-4.0 gm. 0.3-1.2 gm. 1.0-2.0 gm. 4.0-15.0 gm. 4.0-15.0 gm. 0.3-0.6 gm. 0.6-4.0 gm. 0.3-1.2 gm. 0.6-2.0 gm. 2.0-4.0 gm. 0.6-4.0 gm. 2.0-4.0 gm. 4.0-8.0 gm. 0.6-2.0 mg. 0.6-2.0 gm. 8.0-15.0 gm. 0.6-1.2 gm. 0.6-2.0 gm. 0.6-2.0 gm. 0.3-1.2 gm. 0.06-0.3 gm. 0.3-1.2 gm. 2.0-8.0 gm. 1.2 2.0- 0.03 0.06 0.12 0.06 0.0012 0.015 0.12 0.015 0.12 0.6 0.12- 0.12 0.6 1.2 -4.0 gm -4.0 gm -0.06 gm -0.2 gm -0.6 gm -0.12 gm. -0.0006 gm. -0.03 gm. -0.3 gm. -0.03 gm. -0.3 gm. -1.2 gm. -0.6 gm. -0.5 gm. -2.0 gm. -2.4 gm. 670 DOSES OF MEDICINES. Colocynth .......... compound extract of..... extract of.......... Colocynthidine........ Colocynthin.......... Condurango, fluid extract of . . . Coniine .... ....... hydrochlorate........ Conium, abstract of....... fluid extract of........ fruit, alcoholic extract of . - . fluid extract of....... tincture of........ leaves, extract of....... fluid extract of....... Convallamarin......... Convallaria, extract of..... fluid extract of........ Copaiba............ oil of............ oleo-resin of......... Copper, acetate........ ammoniated......... sulphate, astringent, tonic . . . emetic....... Coptis, fluid extract of..... Corrosive sublimate. See Mercury. Corydalis, fluid extract of ... . Coto............. fluid extract of........ tincture of......... Cotoin............ Cotton-root bark. See Gossypium. Creasote............ water............ Creolin............ Croton-chloral hydrate..... Croton oil........... Cubebs ........... , fluid extract of........ oil of............ oleoresin of......... tincture of......... Curare............ Curarin............ Cypripedium......... fluid extract of........ Damiana, fluid extract of ... . tincture........... Daturine........... Delphinium, fluid extract of . . . Digitaline........... Digitalis, abstract of...... extract of.......... fluid extract of........ infusion of......... powder of leaves of...... tincture of.......... Dioscorea, fluid extract of . . . . Dita, fluid extract of......■ Dogwood, bark of root..... Dose. Apothecaries' Weights and Measures. 2-8 gr. 5-10 gr. 2-5 gr. tW gr- Wgr. 10-30 min. 1-1 err K si gr- 1 - 1 or 6? 3 2" gr- 1-2 gr. 5 min. 1-1 gr; 1-2 min. 10-20 min. 1-2 gr. 1-3 min. 2-2gr._ 2-10 min. 15-30 min. 20 min,-l fl. dr. 10-20 min. 2-10 gr. i-igr- *-l gr- \~\ gr- 5gr. 30-60 min. 15-30 min. 1-2 gr. 5-15 min. 2-10 min. 1 -1 7 CONJUNCTIVA (HEMORRHAGE BENEATH), 467 Boric-acid or cocaine wash, when conjunc- tival irritation exists, 467 710 INDEX OF DISEASES AND REMEDIES. Massage of globe through closed lid, to aid absorption of blood, 467 CONJUNCTIVA (XEROSIS OF), 467 Glycerin, almond oil, cod-liver oil, or weak alkaline washes, 467 CONJUNCTIVITIS (CHRONIC), 465 Boric acid, wash (gr. 10 to the ounce [0.65 : 32.0]), cocaine, gr. 2 (0.1), may be added if there is no corneal ulcer; for this condition salt, gr. 4 to the ounce (0.3 : 32.0), may be substituted, 465 Copper, crystal, or a solution (gr. 1 to 3 to the ounce [0.05-0.15 : 32.0]), applied to diseased spot, if subacute, 169 Correction of refraction error, if it be pres- ent, 465 Lapis divinis, 465 Tannin and glycerin (gr. 10 to the ounce [0.65 : 32.0]), as an application, 465 Yellow oxide of mercury, salve, or alum crystal, useful application, 465 Zinc oxide, in powder or the sulphate in the form of a wash, 285, 336 CONJUNCTIVITIS (DIPHTHERITIC), 467 Atropine instilled, 469 Boric-acid or bichloride solution, frequently applied in early stages, 467 Cade, oil of (strength 1 to 10), 467 Citric-acid ointment or lemon-juice, locally applied, 467 Hot compresses, 467 Quinine, solution (gr. 3 to the ounce [0.15 : 32.0]), 467 Silver nitrate, same as in purulent conjunc- tivitis, 467 Sulphur, insufflations, 467 CONJUNCTIVITIS (FOLLICULAR), 466 Alum, crystal applied locally if due to atro- pine instillations, 466 Astringent and antiseptic lotions, 466 Calomel, as a dusting-powder, alone or with bismuth, aristol, or iodoform, 466 Copper sulphate, as an ointment (gr. £ to the drachm [0.3:4.0]), 466 CONJUNCTIVITIS (GRANULAR), 466 Atropine, instillations, iu acute forms, 466 Boric acid or salicylic acid, solution, as a wash in acute forms, 466 Boroglyceride (20 to 50 per cent.), applied to chronic granulations, 466 Carbolic acid, applied pure, to chronic granulations; excess removed with water, 466 Copper sulphate, crystal, applied to chronic granulations, 466 Corrosive sublimate, solution (1 : 200 or 1 : 500), applied every second day in chronic forms, preceded by cocaine; eyes also being irrigated thrice daily with solution (1 : 7000), 466 Crushing granulations, often satisfactory, 466 Excision of granulations when isolated, 466 Glycerole of tannin, applied to chronic granulations, 466 Jequirity, rarely used, 467 Leeches, to temple, to reduce inflammation in acute stage, 406 Liquor potassa, beta-naphthol, iodoform, aristol in powder or salve, yellow-oxide ointment, calomel, or hydrastine may be tried, 466 Scarification, not advisable, 466 Silver nitrate, stick or solution (gr. 10 to the ounce [0.65 : 32.0]), applied daily, if there is discharge; neutralize excess with salt solution, 466 Yellow oxide of mercury, ointment, with lard equal parts, in chronic types, 257 CONJUNCTIVITIS (LACHRYMAL), 465 Treatment same as for chronic type. CONJUNCTIVITIS (MUCO-PURULENT). Treatment same as for purulent type. CONJUNCTIVITIS (PURULENT), 464 Atropine or eserine, if corneal ulcer ap- pears, 465 Bichloride of mercury (1: 8000), or boric acid (saturated solution), as a wash, used hourly, 464, 465 Hot compress, in lieu of cold, if vitality of cornea is threatened, 464 Iced compress, in early stage, to reduce in- flammation, 464 Leeching, useful if inflammation is high, contraindicated in infants, 465 Permanganate of potassium, aqua chlorini, sulphocarbolic-acid solution, alum sul- phate, zinc sulphate, creolin (1 per cent.), or iodoform ointment may be tried, 465 Peroxide of hydrogen useful as a cleansiug agent, 465 Pyoktanin, not satisfactory, 465 Silver nitrate, stick or solution (gr. 10 to the ounce [0.65 : 32.0]), touched to lids after cleansed of pus, excess neutralized with salt solution; 2 per cent, solution dropped in new-born infant's eyes to prevent, 464 Sozoiodol (2 : 30), 330 CONJUNCTIVITIS (SIMPLE), 463 Alum curd or solution (gr. 4 to 8 to the ounce [0.25-0.6 : 32.0]), or application of stick, if there is chronic tendency, 464 Atropine usually unnecessary unless cor- neal ulcer is present, 463 Boric acid, lotion (gr. 10 to the ounce [0.65 : 32.0]), 463 Cold compress, dipped in water, and hama- melis (equal parts), to allay inflamma- tion, 463 Creolin solution (1 per cent.), 463 Eye-wash, to allay irritation, prescription for, 94 Mercury, bichloride solution (1:10,000], if discharge is great, 463 Peroxide of hydrogen, 463 Poultices and bandages contraindicated, 463 Pyoktanin (1:1000), 463 Silver nitrate, solution (gr. 2 to 5 to the ounce [0.1-0.3 : 32.0]). if there is muco- purulent discharge. If discharge is ex- INDEX OF DISEASES AND REMEDIES. 711 cessive employ gr. 10 to the ounce (0.65: 32.0]), and neutralize excess with salt solution or wash with tepid water, 463 Smoked glasses, 463 Sodium biborate, gr. 4 to 8 to §j (0.3 to 0.5: 32.0), 463 Tauuin and glycerin (gr. 10 to the ounce [0.65 : 32.0]), or alum crystal if there is a chronic tendency, 464 Zinc sulphate, solution (gr. 1 to 2 to the ounce [0.05-01 : 32.0]), alone or with boric acid, if there is chronic tendency, 463 CONSTIPATION, 466 Aloes and podophyllin, with other drugs, useful for temporary use; contraindi- cated for continued use; prescription for, 470 Alum, useful in some cases, 58 Belladonna, 88 Cascara sagrada, the best curative agent, dose gtt. 10 to 20 (0.65-1.3) of fluid ex- tract or drachm 1 (4.0) to 6 (24.0) of cordial, 470 Castor oil, following acute disease in chil- dren, ultimately harmful in all cases, 470 Colocynth, jalap, or senna, not to be used constantly, 470 Enemata, as a routine treatment harmful, 471 Glycerin, suppositories or enemata, often used, 471 Gymnastic movements, horseback riding, or massage, with regulated diet, 469 Hunyadi, Carlsbad, or Friedrichshall wa- ters, rarely of value, 470 Leptandra, fluid extract of, in intestinal atony, 238 Magnesium sulphate by the mouth or by enema, 243 Manna, as a laxative fruit for adults, or drachms 1 to 2 (4.0-8.0) to bottle of milk, for infants ; harmful if long continued, 470 Mercury as an habitual purgative harmful, 470 Opium, 471 Oxygen-water, before retiring, in constipa- tion due to intestinal atony, 285 Phosphate of sodium, useful in rickety children, gr. 2 to 4 (0.1-0.2) in bottle of milk ; or adults, gr. 30 to 60, 470 Rhubarb, usually harmful, in some cases in children useful, 470 Salines, simply to unload bowels, not as a routine treatment, 470 Seidlitz powder, 324 Soap suppositories, useful in children, 326 Stillingia, recommended, when habitual; prescription for, 333 Sulphur, especially valuable if hemorrhoids are present, 339 Tobacco, sometimes used, 471 CONVULSIONS. Allium, as a poultice over spine or feet in infantile spinal or cerebral convulsions, 54 Amyl nitrite, 65 Chloral with bromide, in infants; also useful alone iu uramic and puerperal convulsions, if no acute renal trouble exists, 130 CORNS. Fowler's solution, locally applied, 79 Salicylic acid, the best application, formula for, 472 Silver nitrate, solution (gr. 60 to the ounce [4.0 : 32.0]), applied to soft corns every four or five days, 473 CORYZA, 472 Aconite, useful in early stages, 47 Allium, efficient though disagreeable, in persistent colds, as a poultice to breast or in emulsion or boiled iu milk, for children, 53 Arsenic, taken for months, often cures per- sistent colds, 78 Antipyrine in 2 to 4 per cent, solution as a spray, followed by alboline spray, 473 Bromides useful in headache, 473 Camphor, as a snuff, or inhalation of spirit or fumes, when sneezing and lachryma- tion are excessive, 110 Cocaine, a few minims of a 4 per cent, solu- tion dropped into nostril, followed by lotion (see prescription) with atomizer or cocaine (1 part ), morphine (1 part), and bismuth (7 parts) as a snuff, 472 Cubebs, as a snuff during stage of secretion, 173 Glycerin, applied alone by brush or spray, often of service, 194 Hot mustard foot-bath with hot draught or Dover's powder, followed by rest in bed, may relieve, 473 Menthol, very useful, 290 Prescription for wash, 472 Quinine, internally, combined with chloride of ammonium, useful after secretion is established, 473 Sweet spirit of nitre, 243 COUGH. Acacia, as a mucilaginous drink with flax- seed and liquorice, to loosen hacking cough, 39 Almonds, essential oil, in emulsion, as a de- mulcent in cough of phthisis, 54 Belladonna, the best remedy in nervous cough, 86 Cannabis indica, a useful adjunct to cough mixtures, 112 Chloroform, useful, added to cough mixtures for irritant cough, 145 Flaxseed tea, alone or with paregoric, a useful demulcent in excessive cough, 191 Gelsemium, 193 Hydrocyanic acid, highly recommended, prescription for, 206 Hyoscyamus, 207 Iodine, as a paint over supraclavicular spaces, in irritative cough, 216 Ipecac, in spray, useful in chronic winter cough, 222 Morphine in wild-cherry syrup, useful in irritative cough and when cough is 1E8 AND REMEDIES. 712 INDEX OF DISEAS greater than necessary to expel mucus, 280 Paregoric (1 drachm [4.0]) in hot water, from which the steam is inhaled, useful in irritative form of cough, 280 Sandalwood oil for excessive cough follow- ing influenza, 319 CRAMPS. Belladonna, internally or locally as a lini- ment, 86 Chlorodyne, for stomach cramp, 136 Ginger, especially useful in menstrual cramp due to cold, 195. (See Dysmenor- rhea.) CROUP (MEMBRANOUS). (See Diphtheria.) CROUP (SPASMODIC), 473 Aconite, useful, 47 Amyl nitrite, inhalations, if paroxysm is severe, 473 Antimonial wine, drachm 1, to cause vom- iting if paroxysm is severe, 474 Belladonna, bromides, chloral, or opium in small doses at bedtime, as a preventive, 473 Bromides and lactucarium, 473 Cold cloth around neck, and child placed at once in hot bath, air of room being moistened by steam, 473 Menthol, useful, 473 Prophylactic measures, 473 Sanguinaria, as an emetic, unfavorable, 320 Spongio-piline or flannel, wet with hot water, applied to neck and covered with oiled silk or cotton, 437 CYSTITIS (ACUTE), 474 Aconite in full dose, with sweet spirit of nitre and potassium citrate if there is fever ; prescription for, 474 Belladonna, alone or with aconite, espe- cially useful if due to cold; dose gtt. 5 to 10 (0.3-0.65) thrice daily, 474 Boric acid, to render urine acid, 93 Cannabis indica, preferable to opium for relieving pain, 474 Creolin, as a vesical wash (1 to 2 per cent. solution) in cystitis of women, 172 Flaxseed tea, as a demulcent, 191 Hot compress over bladder, should not con- tain irritants, 474 Hot sitz-bath and enemata, to relieve bear- ing-down pain, 474 Hygienic measures, 474 Laudanum, gtt. 30 (2.0), to starch-water, oz. 2 (64.0), in enema, to relieve bearing- down pain, 474 Leeches to perineum or cups to sacrum, 474 Opium, belladonna, or iodoform supposi- tory, to allay bearing-down pain, 474 Quinine, contraindicated, 475 Salines, in early stage to evacuate bowel, 475 Salol, gr. 10 (0.65) thrice daily if inflamma- tion becomes purulent, 475 CYSTITIS (CHRONIC), 475 Arbutin, gr. 3 to 5 (0.15-0.3), or fluid extract of buchu or uva ursi, i to li drachms (2.0-4.0), to improve vesical mucous membrane when inflammation is of sub- acute type, 476 Benzoic or boric acid, gr. 5 to 10 (0.3-0.65) in pill, to render urine alkaline, 475 Creolin solution (1 to 2 per cent.) as a vesi- cal douche, 476 Grindelia, as a vesical stimulant, 198 Mercury, bichloride solution (1:10,000), a's an injection to cleanse bladder, 475 Opium suppositories, gr. i to i (0.016-0.03), very useful, 280 Potassium salts, except bitartrate, to ren- der urine alkaline when mucus is ex- cessive, 475 Turpentine, oil of sandalwood, cubeb, or copaiba, useful when vesical atony is great, 476 Silver nitrate, solution (gr. 1 to oz. 4 [0.05 : 128.0], increased gradually to gr. 2 to oz. 1 [0.1 : 32.0]), as an injection when discharge is muco-purulent, followed by salt solution if pain is sevare, 475 Strychnine and cantharides, when vesical atony is great, 476 DEBILITY. Arsenic, with bitter tonics, very useful, 78 Calomel, in debility of children, often re- lie\as, 253 Eupatorium, a good tonic, 189 Lime salts, 106 Phosphorus, of service in sexual debility, 297 DELIRIUM TREMENS. Chloral, of great service used cautiously, 130 Croton oil, 172 Hops, 203 Hyoscine, in insomnia, 209 Monobromated camphor, when nervous twitching is troublesome, 111 Valerian with morphine, frequently used, 352 DIABETES INSIPIDUS, 476 Arsenic, 79 Belladonna or opium, if due to nervous irritability, 476 Carbonate or citrate of lithium, gr. 10 (0.65), with sodium arsenite, gr. fa (0.002), val- uable in gouty types, 240 Ergot, 476 Gallic acid, alone or with opium, one of the best remedies, 476 Rhus aromatica, highly recommended, 310 Strychnine and sulphate of iron, as tonics, 476 DIABETES MELLITUS, 476 Acidulated water or non-purgative alkaline water, to allay thirst, 478 Almond bread, as a food for diabetics, 54, 411 Alum, 58 Bran bread, 411 Carbonate of sodium, by injection in dia- betic coma, 479 Chloride of gold and sodium, gr. fa (0.006), recommended, 474 INDEX OF DISEASES AND REMEDIES. 713 Codeine, in ascending doses, beginning gr. 1 to 5 (0.05-0.25), thrice daily, 160 Colchicum and iodides, in gouty types, 477 Diet, 476 Ergot, highly recommended, 477 Ether, hypodermically, to support heart in diabetic coma, 479 Gallic acid, with opium, one of the best remedies, 192 Glycerin or saccharin, as sweetening agents to replace sugar, 477 Iodol, gr. 2 to 6 (0.1-0.3), thrice daily, rec- ommended, 221 Iron, lacto-phosphates of lime and sodium, strychnine and astringents, if cachexia comes on, 478 Jumbul, gr. 5 to 30 (0.3-2.0), once to thrice daily, said to be very useful in some cases, 476 Lime-water, 103 Lithium carbonate or citrate, with arsenic, very useful, if due to gout, 477 Morphine, very useful in ascending doses, 477 Opium, gr. i to i (0.016-0.03), thrice daily, largely used, 477 Purgatives, restricted diet, and exercise, if due to high living and sedentary habits, 477 Salicylates and iodide of potassium, if due to rheumatic or gouty taint, 477 Soya bran bread, 330 DIARRH02A, 479 Ammonium chloride, gr. 5 (0.3) every four hours, best remedy in persistent catar- rhal states, 460 Arsenic, 79 Belladonna, may be used in serous type, 87 Bichloride of mercury, gr. ^ (0.0006) hourly, if stools be slimy and bloody, 482 Bismuth, with carbolic acid, gtt. 1 or 2 (0.05-0.1) highly recommended in se- rous and summer diarrhreas, 481 Cajuput, gtt. 10 to 20 (0.65-1.3) in serous forms, 104 Calomel, followed by a saline, useful in sthenic cases of summer diarrhoea, 481 Calumba, in summer and serous diarrhaas, prescription for, 107 Camphor, useful in serous but never in mu- cous types, 109 Carbolic acid, especially useful as an intes- tinal antiseptic, 4n2 Castor oil, with laudanum and sodium bi- carbonate, to unload bowel and render it alkaline, 479 Catechu, alone or with opium, in serous types, prescription for, 126 Chalk mixture, with kino and catechu, in serous diarrhaas, prescription for, 105 Charcoal, useful in acid and fermentative types, 121 Chirata, nitro-muriatic acid, or, better still, nitric acid and cardamoms, in mucous type, prescription for, 460 Chlorodyne, largely used in serous types, 136 Chloroform, with astringents and opium, very useful after removal of irritant cause, 146 Cinnamon, as a stimulant, in serous types, 154 Cloves, 156 Copper sulphate, gr. i (0.016) with opium, gr. 1 (0.06) in pill, or in enema, (gr. 5 to 20 to the ounce [0.3-1.3 : 32.0]), if due to ulceration, 169 Diet, for summer diarrhea, 482 Ergot, sometimes useful in serous types, 181 Gallic acid, 192 Geranium, 1 or 2 roots, boiled in pint of milk, of great service in infantile types, 195 Ginger, a good addition to diarrhaa mix- tures, 195 Hamatoxylon, useful in children, because of agreeable taste, 200 Hope's camphor mixture, in serous and choleraic types, 204 Ipecac, gr. i to i (0.016-0.03), thrice daily, useful in summer diarrhaa of children, 481 Kino powder, formula for, 480 Krameria, useful in serous types, 232 Lead acetate, with opium and camphor, in serous type, prescription for, 236, 460 Mercury, with chalk or calomel, in hepatic disorder, 481 Morphine, gr. fa to fa (0.0008-0.0012), hypo- dermically, often checks summer diar- rhaa in children, 281 Mustard plaster, or other counter-irritants, to abdomen, 479 Naphthalin, 481 Nitrate of silver and hyoscyamus, or lead acetate and opium, in mucous diarrhaa, prescription for, 479 Nitro-muriatic acid, or podophyllin, gr. fa to fa (0.0012-0.0016), in summer diar- rhaa, if duodenum is at fault, 481 Nutmeg, useful in prescriptions for serous types, 272 Pepsin with hydrochloric acid, in summer diarrhaa, if gastric digestion is deficient, 481 Phosphate of sodium, lime salts, and com- mon salt in summer types, if rickets is present, 481 Potassium iodide, gr. 3 to 5 (0.15-0.3), if catarrhal state is obstinate, 480 Raspberry-leaves, used in domestic medi- cine, 311 Rhubarb, often useful, preceding direct treatment in summer diarrhaa, 310 Sulphocarbolate of zinc, 2 grains every three hours; of service in summer diar- rhaa, 482 Salol combined with chalk mixture, 482 Sulphuric acid, especially valuable in serous types, prescription for, 480, 481 Tannic acid, in atonic or serous types, 344 Tar mixture, highly recommended in ob- stinate types, formula for, 304 Thymol, naphthalin, and especially sali- cylic acid, useful as intestinal antisep- tics, in summer diarrhaa, 481 Zinc oxide, in summer types, prescription for, 284 Zinc sulphate, 2-grain (0.1) pills, especially useful with opium, or podophyllin, gr. fa (0.001), in serous types, 336 ES AND REMEDIES. 714 INDEX OF DIARRHOZA (CHRONIC), 483 Bismuthi et ammonii citras, in chronic se- rous types, 91 Diet, 483 Iron sulphate, gr. 5 (0.3) in pill, in chronic types, 229 Nitric acid, Avith a bitter tonic, useful in green diarrhaa of children ; combined with Fairchild's essence of pepsin, re- lieves chronic types in children, 267 Operative procedures when due to lesions of the rectum, 484 Silver nitrate in pill form, or in other cases rectal injections of this drug, gr. 2 to^j (0.1 : 32.0), followed by iodoform sup- pository, of greatest benefit, 484 Sodium bicarbonate, gr. 5 to 20 (0.3-1.3), and iodoform suppositories, by their combined action, give great relief, 484 DIPHTHERIA, 484 Aconite, in early stages, 47 Belladonna, internally, accompanied by po- tassium chlorate, as a paint (5 to 15 grains to the ounce [0.3-1.0 : 32.0]), to pharyngeal walls before membrane forms, 484 Boric acid with glycerin (1: 30), locally ap- plied, to remove membranes, 484 Carbolic acid (1:100) in form of spray or gargle, 120 Chlorate of potassium contraindicated as an internal remedy, 486 Corrosive sublimate or calomel, gr. fa (0.0012) hourly, or gr. £ to J, respect- ively, followed by supportive measures, the best means to prevent or limit exu- dation, used only in sthenic cases, 485 Iodine, inhalations, 218 Iron, tincture of chloride, externally and internally, and ice held in mouth and applied to glands, if suppuration threat- ens, 485 Lime-water, or lactic-acid solution (gr. 30 to the ounce [2.0 : 32.0]), in spray, to aid solution of membrane, 484 Monsel's solution, as a topical application, valuable, 228 Oxygen inhalations, atropine, and strych- nine, and finally intubation or tracheot- omy, if suffocation threatens, 486 Peroxide of hydrogen, applied on swab or spray to remove false membrane, 485 Potassium chlorate, applied on swab, dan- gerous internally, 133 Potassium permanganate, solution (gr. 20 to the pint [1.3 : 500 cc]), applied as a swab or as a gargle, 291 Prescription for wash, 484 Sulphurous-acid fumes as a prophylactic, 485 Tonics, such as quinine, strychnine, and chloride of iron, as supportive measures, 485 Trypsin, applied by swab or spray, to di- gest membrane, 484 Turpentine, 30 minims (2.0), with spirit of ether, three times a day, or by inhala- tion, 486 DROPSY, 487 Acupuncture, less favorable than incisions, only to be resorted to after other rem- edies fail, 490 Adonidin, sparteine, or strophanthus, if other drugs fail, 490 Aspiration, in local effusions or dropsy of hepatic cirrhosis, 490 Caffeine, in torpidity of kidneys, 490 Calomel and digitalis, in renal and cardiac types, 490 Colocynth, compound extract of, gr. 2 to 6 (0.1-0.3), 489 Copaiba, of service in slow renal types, 168 Digitalis, gtt. 5 to 10 (0.3-0.65), with can- tharides, gtt. 1 (0.05), thrice daily, in renal torpidity due to heart trouble, 490 Elaterium, especially useful in renal dropsy, 489 Jalap, compound powder of, gr. 20 to 30 (1.3-2.0), with potassium bitartrate, gr. 10 (0.65), added, especially serviceable in renal dropsy, 489 Magnesium sulphate, in concentrated solu- tion, before breakfast, 489 Milk diet, very useful, 489 Pilocarpine, useful in localized dropsy, con- traindicated in cardiac types, 490 Potassium iodide, in hepatic cirrhosis and localized effusions, to remove liquid, 490 Scoparius, infusion, may be used, 490 Senega, rarely of value, 324 Squill with digitalis, prescription for, 332, 490 Sugar of milk, useful as a diuretic, 489 Tapping in ascites, the best method, 493 DYSENTERY, 482 Alum, internally, 58 Bichloride of mercury, gr. T^ (0.0006) (or gr. \ [0.025] in water 5 ounces [160.0]), teaspoonful hourly till relieved, 482 Bichloride of mercury, injections (1: 5000), followed by solution (1: 3000) topre\ant toxic effect, by absorption, 483 Boracic acid, 3j to Oj (4.0 : 500 cc), or sul- phocarbolate of zinc, gr. 15 to 1 quart (1.0 :1000 cc), very useful as rectal in- jection, 483 Calomel, in purgative dose, contraindicated if weakness exists, 482 Continuous irrigation with two-way tube, of great value, 483 Copaiba, 168 Ergot, useful in bloody stools, 181 Hamamelis, injections, if much blood is present, 482 Ice-water, injections, if due to inflamma- tion, used only in strong persons, 482 Ipecac, best remedy in acute dysentery, 222 Lead acetate, with opium and camphor, pre- scription for, 236 Nitro-hydrochloric acid, if due to defective action of secretory glands, 270 Prescription for enema, 482 Silver nitrate, rectal injections (gr. 10 to 20 to the pint [0.6-1.3:500 cc.]), if ulcers are chronic; followed by salt solution if action is too severe, 482 Tannic acid (3j [4.0] to water Oj [500cc.]), in the form of intestinal irrigation, 483 INDEX OF DISEASES AND REMEDIES. 715 DYSMENORRHEA, 491 Amyl nitrite, often relieves, 65 Antipyrine or acetanilid, in neuralgic at- tacks, in other cases of doubtful value, 492 Belladonna, suppository, gr. \ (0.03) of ex- tract, or ointment applied to os; tinc- ture, internally, useful to relax spasm, 491 Camphor with acetanilid, in pill, useful iu nervous cases, 109 Cannabis indica and gelsemium, often of service, 492 Epsom salts or aloes, if constipation is present, 491 Hot sitz-bath, followed by turpentine stupe, and Dover's powder, gr. 10 (0.65), often relieves, 491 Iron, strychnine, and quinine, as tonics, with rest and horseback riding for anae- mic and run-down patients, 491 Opium, to relieve spasm and pain, contra- indicated, 491 Piseidia erythrina, extract, in the dose of from \ to 2 fluidrachms (2.0-8.0), 303 Potassium bromide, 97 Water, cold and hot, alternately dashed over loins in atonic cases, 492 DYSPEPSIA. (See Indigestion.) Arsenic, useful in atonic types associated with chronic diarrhaa, 78 Bismuth, when due to acid fermentation, 91 Hydrastis, as an antiseptic and curative agent in chronic types, 205 Hydrochloric acid, if gastric secretion is deficient, 205 Lavage in fermentative dyspepsia, 392 Nitric acid with bitter tonics often relieves intestinal types, 267 Oxygen-water, often useful in chronic types, 265 Permanganate of potassium, 291 Quassia, useful, if not due to gastritis, 307 Serpentaria, as a tonic in atonic types, 326 Strontium bromide, in painful dyspepsia, 334 Terebene, useful as an antiseptic in fer- mentative dyspepsia, 345 DYSPNffiA, 492 Ammonium carbonate, as a respiratory and cardiac stimulant, 493 Arsenic, continuously employed, useful in emphysema and chronic pulmonary in- flammation, 493 Dry cupping over back, when due to car- diac or pulmonary trouble, 493 Hvoscine, contraindicated, 493 Morphine, gr. \ to \ (0.008-0.016), night and morning, often cures, when due to nervous or cardiac disorders, 492 Opium, if due to nervous disorders, 492 Strychnine, in idiopathic types and when due to bronchorrhaa in old peoile, 492 Thoracentesis, if there is pleural iffusion, 493 EARACHE, 493 Cardiac sedatives, 493 Chloroform, on swab, behind and in front of ear in otalgia, 494 Cocaine, gtt. 1 to 3 (0.5-0.15), dropped into nostril, followed by spray if mucous membrane is engorged, 493 Heat, dry, applied to head on affected side, 493 Inflation of Eustachian tube with Politzer's air-bag, 4!»4 Leeching behind ear, to relieve pain, 493 Menthol and albolene spray, following co- caine, 492 Poultices, oil, and laudanum, contraindi- cated, 493 Puncture of tympanum, if it bulge, fol- lowed by careful cleansing and insuffla- tion of boric acid, 494 Saline solution, in fine spray, if cold in head is present, 493 Water, hot as can be borne, dropped into ear gives great relief, 493 EAR (DISEASES OF). Glycerin, useful to soften impacted ceru- men, 197 Potassium permanganate, solution, useful in otitis media, 291 ECLAMPSIA, 620 Chloral and bromide, each 1 drachm (4.0), by rectum, before applying hot pack, 621 Chloroform, pushed rapidly as possible, at onset of attack, 621 Elaterium, gr. \ (0.016), rubbed up with butter, or compound jalap powder and calomel, may be substituted for croton oil, 621 Ether, as an anasthetic, contraindicated, 621 Extraction of child rapidly as possible, if attack comes on during labor, 621 Ice-bag to head while in warm pack, 621 Morphine, veratrum viride, and amyl ni- trite, may be held in reserve, to be used if necessary, 621 Pilocarpine, contraindicated, 621 Venesection, hot wet pack, and croton oil, gtt. 2 (0.1), with sweet oil on tongue, to eliminate poison, 620 Veratrum viride in full doses, 355 ECZEMA, 494 Arsenic, only when skin is very dry, 496 Bismuth subgallate in weeping eczema, 92 Cantharis, internally in small doses, 115 Carbolic-acid ointment (minims 10 [0.65] to cerate 1 ounce [32.0]), to prevent itch- ing, 120, 494 Dermatol in weeping eczema, 92 Green soap, as a detergent stimulating ap- plication, 327 Hygienic measures and diet, 494 Ice-water injections, highly recommended in eczema of anal margin, 373 Ichthyol ointment, highly recommended, 2li Internal treatment, 496 Iron, syrup of iodide, in young children with anamia and debility, 227 Kaolin as a dusting-powder, 232 716 INDEX OF DISEASES AND REMEDIES. Lead, dilute solution of subacetate, a useful lotion, 237 Liquor carbonas detergens, in acute cases, 495 Mc( 'all Anderson's ointment, 494 Ointments, prescriptions for, 284, 309, 495 Poultices, or olive oil with carbolic acid (gtt. 1 to 2 to the ounce [0.05-0.1: 32.0]), followed by soap and water, necessary in some cases to soften scales, before use of ointment, 495 Prescription for, 296 Prescription of iodol, as an ointment, about nose and lip, 221 Resorcin ointment (gr. 2 to 30 to the ounce [0.1-2.0:32.0]), locally applied iu sub- acute types; in chronic form, ointment (gr. 2 to 10 to the ounce [0.1-0.65 : 32.0]), 495, 496 Salicylic-acid ointment (gr. 30 to 60 [2.0- 4.0] to lard 1 ounce [32.0]), in chronic or weeping types, 496 Starch poultice in crusty eczema, 333 Sulphides, bath of, often beneficial, 337 Tar ointment, in chronic forms, 496 Thiol, as a dusting-powder, preceded by an antiseptic wash, especially suited to moist eczema, 347 Zinc carbonate, as a protective powder in weeping eczema, 123 Zinc oxide, as a dusting-powder or oint- ment in early stages, applied directly or on lint, generally preceded by black wash, 494 EMISSIONS, 496 Bromide of sodium or potassium, gr. 20 (1.3), at bedtime, valuable in spinal irri- tability, 497 Chloral, gr. 20 (1.3), at bedtime, 497 Cold douches to perineum and scrotum, 497 Hygienic measures, 497 Hyoscine, gr. TJ5 (0.0006), of great value, 497 Potassium citrate, gr. 20 (1.3), thrice daily, to render urine non-irritating, 497 Strychnine and arsenic, in full dose, of great service in genital atony, 497 Warm bath before retiring, often useful, 497 EMPHYSEMA OF LUNGS. Cod-liver oil, useful, 161 Ethyl iodide, 188 Euphorbia pilulifera, \ to 1 drachm (2.0- 4.0) of the fluid extract, 190 Iodide of potassium, 213 Physostigma, aids in expelling mucus, 298 Strychnine, 275 EMPYEMA. Iodine, gr. 6 (0.4); potassium iodide, gr. 6 (0.4); water, 1 pint (500 cc), as an irri- gating fluid, used daily, 217 ENDOCARDITIS, 498 Aconite, tincture of, gtt. 2 to 3 (0.1-0.15), hourly, in early stage of acute sthenic types, 498 Antirlieumatics, antilithics, or iodides, if due to diathetic taint, 498 Calomel, gr. \ (0.016), with morphine, gr. fa (0.006), eAary two hours, in early stages, 498 Digitalis, to strengthen heart in later stages, 498 Ice-bag over pracordium, 498 Iron, tincture of chloride, associated with supportive treatment, in purulent types, 498 Leeches or wet cups, in early stages, to abort, 498 Lithium citrate or acetate, or citrate of po- tassium, to prevent calcareous deposit in valves, 498 Mercury, in full dose, in sthenic cases, 250 Veratrum viride, used for same purposes as aconite, 498 ENTERITIS. (See Dysentery and DIARRHCEA.) EPIDIDYMITIS, 533 Heat, moisture, and pressure, in later stages, to relieve induration, 534 Horand-Langlebert's dressing, 534 Ice-bags, 534 Iodide of potassium, gr. 10 to 20 (0.65-1.3), thrice daily, to remove induration, 534 Iodine, painted over scrotum, said to be beneficial, 534 Mercury and belladonna ointments, equal parts, or iodine, gr. 4 (0.25), with lano- lin, ounce 1 (32.0), locally applied, to relieve induration, 534 Punctures, useful to relieve tension and al- leviate pain, 534 Rest in bed, elevation of pelvis and testi- cles, cessation of local gonorrhaal treat- ment, and administering treatment for acute inflammation, 534 Silver nitrate, solution, painted over scro- tum, in early stage, may relieve, 534 Strapping and suspending testicle, to re- duce inflammation, 534 EPILEPSY, 498 Acetanilid, 43 Ammonium or sodium nitrite, used to sup- plement amyl nitrite, 506 Amyl nitrite, inhalations, when aura is per- ceived and also in status epilepticus to relax spasm, 505 Anasthetics contraindicated in all cases ex- cept status epilepticus, when chloroform may be used to control attack, 506 Antifebrin and antipyrine, especially use- ful in chronic cases when bromides fail, 507 Belladonna, with bromides, recommended, 503 Bleeding, harmful, except in marked cere- bral congestion, 508 Borax, of doubtful value, 508 Bromate of potassium, 503 Bromide of ammonium, should be used with other drugs, 502 calcium. 99 gold, 99 iron, when anamia is present, 502 lithium, highly recommended in some cases, 502 nickel, 502 INDEX OF DISEASES AND REMEDIES. 717 Bromide of potassium, the most reliable, in ascending dose, 500 sodium, not so apt to disorder stomach, 502 Cannabis indica, 504 Chloral, alone or with bromides, well di- luted, after meals, used with care, 506 Diet, 508 Digitalis, with bromides, useful in some cases. 503 Gelsemium, with cannabis indica, often of value, 504 Hydrobromic acid, liable to derange diges- tion, 503 Iodide of potassium, useless except in syphilitics, 506 Mercury, instead of potassium iodide, when due to gumma, 506 Mixed treatment, 500 Monobromated camphor, 111 Nitro-glycerin, useful in some cases of petit mal, 505 Opium with gelsemium, only to be used when other remedies fail, 504 Potassium nitrite, 268 Quassia injections, when due to worms; if not obtainable, sodium chloride solution may be used, 507 Quinine and salicylic acid, contraindicated, 508 Silver nitrate, may be tried when other remedies fail, 505 Solanum carolinense, fluid extract of, 2 to 15 minims (0.1-1 cc), thrice daily, in the epilepsy of childhood, 507 Strontium bromide, 334 Strychnine, contraindicated, except in rare cases, 506 Zinc salts, seldom used of late, 504 EPISTAXIS, 509 Acetanilid has been recommended, 43 Acetic acid, locally applied, to arrest, 44 Aconite or veratrum viride, tincture, gtt. 2 to 4 (0.1-0.2), in sthenic cases, followed in thirty minutes by smaller doses, if necessary, 47, 509 Alum powder, pure or half-and-half with starch, as a snuff, 509 Bacon fat inserted as a plug in nostril, may arrest, 509 Compression of facial artery may be neces- sary, 509 Ergot, turpentine, hamamelis, or oil of erig- eron, internally, in slow oozing, 509 Hot foot-bath, or hot- or cold-water bags applied to dorsal vertebra, may arrest, 510 Ice applied to nose, may arrest, 510 Ipecac, in nauseating doses, recommended, 509 Mousel's solution, in spray (gtt. 30 to 4 ounces [2.0-126.0]), only to be tried when other remedies fail; very disagree- able, 509 Plugging anterior and posterior nares, if necessary, with cotton or lint soaked in vinegar, 509 Tannic acid, in powder or solution, snutt'ed up nostril, 509 Vinegar or lemon-juice injected into nos- tril, 509 EPITHELIOMA. Acid nitrate of mercury, applied to part with glass rod, 256 Arsenous acid and gum acacia (of each 1 ounce [32.0], to water 5 fluidrachms [20.0]), locally applied, 79 ERYSIPELAS, 510 Alcoholic stimulants if patient passes into typhoid state, 510 Antipyrine, to control fever, 510 Belladonna, tincture, internally, minims 4 to 5 (0.2-0.25), every four hours, and lo- cally applied on lint or ointment smeared over part, 510 Bitters and iron, during convalescence, as tonics, 510 Boric acid, as a lotion, 93 Ichthyol ointment and vaseline, half and half, locally applied, preceded by wash- ing with castile soap, followed by bi- chloride solution (1:1000), 511 Iodine, tincture, painted around inflamed edges, to arrest, 217 Iron, tincture of chloride, gtt 20 to 40 (1.3-2.6), thrice daily, best internal treatment, 510 Pilocarpine, gr. J to £ (0.008-0.01), hypo- dermically, contraindicated in debility; also injected around borders of inflam- mation in some cases, to arrest, 510 Silver nitrate, solution (gr. 80 to the \ ounce [5.0 : 16.0]), applied twice or thrice, to arrest, 511 Veratrum viride or aconite, in early stages of sthenic cases, 510 White-lead paint, locally applied, when ichthyol is not at hand, 511 EXHAUSTION AND DEPRESSION. Stimulants, 511 EXOPHTHALMIC GOITRE. Belladonna relieves some cases, 87 Sparteine, 323 EYELID (ECCHYMOSIS OF). Alum, curd or solution, to prevent discol- oration, 57 FAINTING. Alcohol, 50 FEET (SWOLLEN, TENDER, OR SWEATING), 511 Arsenic, gr. fa to fa (0.001-0.0015), in swell- ing of old persons, 512 Borax, stockings soaked in saturated solu- tion and dried, each day, when sweat- ing is excessive, 512 Carbonate of calcium, precipitated, locally applied to sweating feet, 105 Cotton, instead of woollen stockings, may aid cure, 512 Hamamelis, distilled, or fluid extract, drachm \ to 1 (2.0-4.0) of former, or gtt. 10 to 20 (0.65-1.3) of latter, 512 Lead plaster and linseed oil, equal parts, applied on linen to feet, every third day, for sweating, 237 Prescription for dusting-powder, 512 Rest, absolute, of feet, may be necessary in swollen feet, 512 718 INDEX OF DISEASES AND REMEDIES. Salicylic acid and borax, equal parts, in water and glycerin, best application to sweating and tender feet, 512 FELON. Bread-crumbs saturated with liquor plumbi subacetatis, as a poultice, to abort, 237 Silver nitrate, solution, applied early, to abort, 265 FEVER, 512 Acetanilid, 42 Aconite, the best depressant for sthenic types in children, 47 Alcohol, as a systemic support and stimu- lant in low fevers, 50 Antipyretics, useful in most sthenic fevers, often fail in thermic fever, 516, 517 Antipyrine, 72 Brand's method, 656 Cold applications and baths, 516 Cold packs and baths, in asthenic types, to be relied on first; if impracticable, then antipyretics, 517 Digitalis, in small dose, valuable in ex- hausting fevers, 177 Musk, by rectal injections, valuable in low stages, 261 Neutral mixture, useful as a febrifuge, es- pecially iu children, 155 Phenacetin, 292 FIBROIDS. Ergot, used as an expulsive and curative remedy, 181 FLATULENCE. Aromatic powder, 154 Asafatida, 81 Camphor, 109 Capsicum, prevents formation of gas, 116 Chloroform, gtt. 1 to 2 (0.05-0.1), or spirit, gtt. 10 to 20 (0.65-1.3), will relieve, 145 Cloves, a useful tonic and stimulant, 156 Hoffmann's anodyne, the best carminative, 202 Pepper, 288 Peppermint, 288 Potassium permanganate, 291 Turpentine, prescriptions for, 351 FRECKLES AND CHLOASMA, 518 Almonds, emulsion of, supposed to be of value, 54 Boric acid, saturated solution, applied same as corrosive sublimate wash, 518 Corrosive sublimate (gr. 1 to 4 to the ounce [0.05-0.25 : 32.0]), applied night and morning until irritation appears, then stop for some days and again renew. 518 Lactic acid (gr. 10 to the drachm [0.65 : 4.0]) applied same as corrosive sublimate, 518 Prescription for chloasma of pregnancy, 284 Prescriptions for, 518 FURUNCLES. (See Boils.) GALACTORRHEA, 618 Antipyrine, gr. 2-V (0.125), thrice daily, said to decrease secretion, 619 Caustic, introduced into uterus, successful in some cases by inducing menstrual flow, 619 Chloral should be tried, 619 Compression of gland with applications of belladonna ointment and potassium iodide internally, usually relieves, 619 Diet, 619 Electricity, generally ineffective, 619 Ergot, long continued, highly recom- mended, 619 Malt, wine-glassful at midday and evening meals, useful addition to diet; pyro- phosphate of iron, gr. 5 (0.3), in addi- tion, if anamia is present, 619 Warm douches, 619 GANGRENE. Bromine, as an escharotic in hospital gan- grene, 100 Carbolic acid, spray (gtt. 5 to 10 to the ounce [0.3-0.65 : 32.0]), useful in pul- monary gangrene, 47 Nitric acid, to destroy tissue, 267 GASTRALGIA, 518 Acetanilid, 42 Alum, 58 Arsenic with iron, the most reliable rem- edy, prescription for, 519 Bismuth and pepsin, 1 to IJ hours after meals, to prevent pain, 519 Bromide of strontium, a valuable new rem- edy, 519 Bromides or valerian, alternated with other treatment, if case is neurotic, 519 Cod-liver oil in emulsion with hypophos- phites, occasionally better than arsenic and iron, 519 Counter-irritation and a vigorous revulsive, especially useful in hysteria, 519 Cyanide of potassium, dilute hydrocyanic acid or chloroform as a substitute for bismuth, if it favors constipation, 519 Diet and hygiene, 519 Emesis and purgation, when due to indi- gestible food, 519 Hot applications, stimulating infusions, hot brandy or whiskey or laudanum, gtt. 30 (2.0) to 60 (4.0), during acute stage, 519 Hydrocyanic acid, useful in nervous types, 206 Massage, enemata, diet, or suppositories of gluten, glycerin, or soap, to overcome constipation, 519 Menthol, 289 Nitro-glycerin, 268 Potassium nitrite, gr. 4 to 5, 268 Prescriptions for, 519, 520 Salicylic acid, used in paroxysmal forms, 315 GASTRIC CATARRH (ACUTE), 520 Ammonium muriate, useful in subacute forms in children, 63 Diet, principal point in treatment, 520 Effervescing draughts, useful in convales- cence, 520 Emetic, mild, to dislodge fermenting mass, if present, 520 Ice, to quench thirst, if anorexia is great, 520 INDEX OF DISEASES AND REMEDIES. 719 Iron, if anamia exists, 520 Milk, with large percentage of lime-water, 520 Pepsin and hydrochloric acid, 521 Salicylic acid, valuable in vomiting, 315 Salt, in moderation with food, 521 Seidlitz powder, one-fourth of one powder every fifteen minutes, to settle stomach and remove fermenting mucus, 520 Sodium bicarbonate with gentian, useful in convalescence and in children, 520 Spice poultice to relieve epigastric distress, 520 Tartar emetic, given early, in acute attack of children, may abort, 69 GASTRIC CATARRH (CHRONIC), 519 Apomorphine, as an emetic, to throw off mucus, 75 Bismuth subnitrate, added to prescription, if hyperacidity exists, 519 Cascara sagrada, if constipation exists, 519 Diet, such as koumyss, light broths, and matzoon, 519 Silver nitrate and hyoscyamus, along with counter-irritation and regulated diet, prescription for, 520 GASTRIC DILATATION, 522 Cod-liver oil, by stomach or inunction, if due to rhachitts, 52 Diet, 522 Enemas, nutrient, often useful, especially in older children, 523 Faradization of gastric walls recently in- troduced, 523 Gentian and calumba, useful as tonics, 523 Iodide of iron, syrup of, lacto-phosphates of lime, or phosphate of sodium, in stru- mous diathesis, 522 Lavage. 522 Physostigma, tincture, gtt. 5 to 10 (0.3-0.65), or extract, gr. $ to \ (0.008-0.016), to im- prove muscular coats, 523 GASTRIC ULCER, 523 Bismuth and sodium bicarbonate, as an as- tringent and sedative, and to these may be added morphine or codeine for pain, 524 Carlsbad salts, magnesium sulphate, or so- dium phosphate, for relief of constipa- tion, 525 Cocaine, gr. \, alone or combined with bis- muth, to control vomiting, 525 Counter-irritation, mild, continuous, over belly, to relieve pain, 524 Creosote or carbolic acid, for vomiting, 525 Diet and hygiene, 524 Monsel's solution, cold compresses, or tur- pentine, may be given to check hamat- emesis. 525 Prescription for, 488 Morphine for pain or collapse following perforation, 525 Resorcin useful in some cases, 309 Silver nitrate with hyoscyamus, opium, or belladonna in pill, half to one hour be- fore meals, 524 Spice plaster, useful as a mild continuous counter-irritant, 524 Stimulants, cardiac, guardedly adminis- tered, external heat and rubbing, in col- lapse following hemorrhage or perfora- tion, 525 GASTRITIS (ACUTE), 525 Belladonna, internally, and flaxseed poul- tice over epigastrium and chest, if col- lapse threatens, 525 Bismuth, as an astringent and sedative, 91 Flaxseed tea, a useful demulcent, 191 Mucilaginous drinks and albuminous sub- stances freely given, 525 Oils, to prevent spread of inflammation, 525 Opium, in fluid form, to relieve pain and irritation, 525 Warm water, internally, or stomach-pump, to unload stomach at onset, 525 GASTRO-ENTERITIS, 526 Castor oil or magnesium sulphate, to sweep out poison, 526 Morphine, hypodermically, to allay pain, followed or preceded by mild, rapidly acting emetic, if irritating substance re- mains, 526 Opium and sulphuric acid, with hot appli- cations or plasters to belly, to control ir- ritation and diarrhaa, 526 GASTRO-INTESTINAL CATARRH. Carlsbad, Vichy, or other alkaline mineral water of purgative powers, often useful, 397 Diet for seven-year-old child, 408 Garlic, as a poultice to belly almost equal to spice poultice, 54 Hydrastis, especially useful if due to alco- holism, 204 Sanguinaria, of service if jaundice is pres^ ent, 320 Sodium bicarbonate, 10 to 20 grains, 90 Tar, in 2-gr. (0.1) pills, 324 GIDDINESS. Cod-liver oil with quinine, valuable in old age, 161 Ergot and bromides useful, 181 GLANDS (DISEASED). Ammoniac plaster, as a stimulant to en- larged glands, 61 Ammonium iodide and glycerin (gr. 30 to the ounce [2.0 : 32.0]), locally applied to enlarged tonsils, 63 Carbolic acid (2 per cent, solution), injected into glands threatening suppuration, 120 Carbon bisulphide, in enlarged glands, 122 Cod-liver oil, in lymphatic enlargements, 161 Ichthyol ointment, valuable as an inunc- tion in lymphatic enlargements, 211 Iodine, the best remedy for enlargements, 216 Mercury ointment as an inunction in en- larged glands, 256 GLAUCOMA, 527 Atropine, contraindicated, 527 1ES AND REMEDIES. 720 INDEX OF Eserine (gr. 1 to 2 to the ounce [0.05-0.1- 32.0]), or pilocarpine nitrate (gr. 2 to 4 to the ounce), dropped into eye if opera- tion is delayed, 527 Hot compresses, leeches, and opiates to re- lieve pain, 527 Iridectomy, the only curative treatment, 527 GLEET. Bichloride of mercury, injection (gr. I to water ounces 6 [0.025 : 192.0]), eAary three or four hours, 251 Cantharidal collodion, applied to under surface of penis, or perineum, 377 Cantharides, 115 Gurjun oil, 200 Turpentine, internally. 351 Uva ursi, 352 GOITRE. (See Bronchocele.) GONORRHOEA (ACUTE), 527 Aconite, gtt. 2 (0.1), every two or three hours, if inflammation is high, 529 Almond emulsion, diminishes burning on urination. 54 Benzoic acid, with cannabis indica, useful in later stages, 90 Bicarbonate of sodium or potassium citrate, gr. 10 (0.65), after meals, increasing, if necessary ; relieves ardor urina, 529 Cannabis indica, often used instead of co- paiba and cubebs, 113 Cinnamon oil, by injection or spray, 154 Cocaine, solution (4 percent.), instilled into urethra before urination, diminishes ardor urina, 529 Copaiba, to relieve ardor urina and stimu- late mucous membrane in later stage, 168 Cubebs, useful in later stage, 173 Diet aud hygiene, 530 Erigeron oil, occasionally used instead of copaiba and cubebs, 182 Eucalyptus, valuable in subacute stages, 188 Gurjun oil, of value in place of copaiba and cubebs, 200 Hot sitz-bath, prolonged, and hot-water in- jections, useful in females, 535 Hydrastis, one of the best remedies, locally and internally in later stages; also as a vaginal wash for females, 204 Lead acetate, injection, gr. 1 to 8 to the ounce (0.05-0.6 : 32.0), 237 Lead-water and laudanum, or alcohol and water, applied on a cloth to penis, dur- ing inflammation, 528 Mercury bichloride (1:20,000 or 1: 40,000), in large quantities to flush urethra : in females, 2 pints of solution (1 : 4000), thrice daily, to irrigate vagina, 527, 535 Opium or belladonna, hypodermically or in suppository, to control pain in posterior urethritis, at same time discontinuing active treatment, and observing strict hygiene and diet, 530 Prescription for infusion, 204 Prescriptions for injection for posterior ure- thritis, 531 Quereus alba, injections, useful in females, 308 Salol, cubebs, and copaiba, prescription for, 529 Silver nitrate, injections (gr. 2 to 4 to the ounce [0.1-0.2 : 32.0]), useful in subacute stage; in females, gr. 4 to 60 to the ounce (0.2-4.0 : 32.0), painted over va- gina, followed by astringent cotton tam- pon, 266, 535 Urinating with penis in hot water, to re- lieve ardor urina, 529 Warm baths, lasting one-half to two hours, useful in early stage, 530 White's prescription for, 528 Zinc acetate, injection, gr. 1 to 20 to ounce (0.05-1.3 : 32.0) of rose-water, 44 Zinc chloride, injection (gr. 1 to 2 to the ounce [0.05-0.1: 32.0]), occasionally used in second stage, 134 Zinc sulphate, weak solution, as an astrin- gent injection, 338 GONORRHOEA (CHRONIC), 531 Copper sulphate or silver nitrate, solution as an application, after dilatation, to focus of inflammation, 531 Dilatation, if stricture exists, 531 Prescriptions for, 531 Pressure and use of cold, often valuable, 532 Sandalwood oil, to stimulate depraved mu- cous membrane, 319 Silver nitrate, solution, if discharge per- sists after dilatation; also in posterior urethritis, 531 Uva ursi, 352 GOUT, 535 Antipyrine, said to have a specific effect, 72 Baths of sulphides, 337 Blisters, flying, short distance from in- flamed joint, every few days, 537 Chloral, in insomnia, 537 Chloroform liniment, applied over affected part, 146 Cod-liver oil, 537 Colchicum, wine of the root, gtt. 20 (1.3), increasing by gtt. 1 (0.05) every four hours, until symptoms are relieved or appear toxic, in acute types, 536 Collodion, not more than one or two coats ; also useful with iodine, 536 Diet, 537 Fowler's solution, gtt. 3 (0.15) in water, a standard remedy in subacute and chronic types, 537 Iodide of iron, syrup of, and cod-liver oil if auamia is present, 537 Iodide of potassium, to relieve night pains ; also with colchicum, in chronic gout, 536 Iodine, ointment or tincture, locally ap- plied to chronic gouty joints, 537 Leeches or venesection, contraindicated, 536 Lithium carbonate or citrate (gr. 5 to 10 to the ounce [0.3-0.65:32.0]), locally ap- plied to dissolve deposit around joints, 537 Morphine, hypodermically, near painful spot to relieve acute pain, 536 INDEX OF DISEASES AND REMEDIES. 721 Peppermint oil, locally applied, 536 Potassium bromide, the best remedy for in- somnia, 537 Sodium bicarbonate and linseed oil (1: 9), locally applied to joints, 536 Stimulants, ether hypodermically, opium except in brain or kidney disturbances; diuretic and alkaline driuks and coun- ter-irritation, in retrocedent gout, 537 Water, distilled or medicinal, in large amounts, 537 GRANULAR LIDS. (See Conjunctivitis, Granular.) GRAVES'S DISEASE. (See Exophthal- mic Goitre.) GRIPING. Allspice or ginger, to prevent griping of purgatives, 55, 195 GROWTHS (PATHOLOGICAL). Caustic potash or soda, occasionally used, to destroy, 127 Chromic acid, as a caustic, to growths on skin or mucous membranes, 146 Lime, as an escharotic on hairy growths, 107 GUMS (DISEASES OF). Burnt alum, useful applied to swollen gums, 58 Catechu, as a mouth-wash, for spongy gums, 126 Cocaine, locally applied, in soreness and tenderness of gums, 158 Iodine, solution (gr. 1 to the ounce [0.05 : 32.0]), locally applied, followed by rins- ing mouth, when gums are retracted, 217 Myrrh, tincture, locally applied, to spongy or tender gums, 262 HiEMATEMESIS, 540 Ergot, hamamelis, or ipecac, in slow bleed- ing, 540 Ice, cracked, swallowed frequently, accom- panied by Monsel's solution, gtt. 3 (0.15) in a half-tumblerful of water, every fifteen minutes, 540 Iron, tincture of chloride, or turpentine, internally, if passive, 540 Lead acetate with morphine or opium, gr. 2 to 3 (0.1-0.15), in pill, 540 Monsel's salt, gr. 2 to 3 (0.1-0.15), in pill, 540 Silver nitrate, gr. \ (0.015) in pill, in slow bleeding, 540 Tannic acid, gr. 20 (1.3), to drachm of water; must not be given with Monsel's solution, 540 HEMATURIA, 542 Alum, gr. 2 to 3 (0.1-0.15) to water, 1 ounce (32.0), injected into bladder, if alarming, 542 Camphor, gr. 10 to 20 (0.6-1.3), in divided doses, in pill, 542 Cannabis indica, useful in some cases, 542 Ergot, 542 Erigeron, 542 Gallic acid, gr. 20 (1.3), very valuable, 542 46 Hamamelis, injected daily into bladder, 542 Hyposulphite of sodium, 10 to 30 grs. (0.65- 2.0), if due to malaria, 543 Prescription for, 542 Quiuine, if due to malaria, 543 Rhus aromatica, 310 Styptic injections, should only be used when bleeding is alarming, 542 Turpentine, 542 HEMOPTYSIS, 540 Acetanilid, has been recommended, 43 Aconite, to prevent pneumonia following, contraindicated in exhaustion, 540 Alum, solution (gr. 20 to the ounce [1.3: 32.0]), in fine spray, 58 Chloral and bromides, to allay nervous ex- citement, 540 Ergot, fluid extract, 1 to 1£ drachms (4.0- 6.0), internally, 539 Gallic acid, gr. 20 to the ounce (1.3 : 32.0) of water, when ergot is not at hand, 539 Hamamelis, 201 Ice or dry cup over bleeding spot, 540 Ipecac, in small doses, very effective, 222 Morphine, hypodermically, to allay ner- vousness, 540 Tannic acid, Monsel's solution, or alum, used in spray, as styptics, prescriptions for, 539 HAY FEVER. Arsenic, 79 Cocaine, with bismuth and morphine, as a snuff, 158 Resorcin, solution 2 per cent., in spray, 309 Terpine hydrate, in full dose, 346 HEADACHE, 545 Belladonna, valuable in young people, 87 Caffeine, with antipyrine or sodium bro- mide, in nervous headache, 545 Capsicum plaster, to nape of neck, 117 Cimicifuga, if due to eye-strain, 148 Colchicum, in gouty headache, 546 Croton chloral, if due to eye-strain or asso- ciated with sick stomach, 172 Cup, to nape of neck, in congestion, 545 Ergot, if due to congestion, 181 Eucalyptus, 188 Gelsemium, if due to nervous troubles or eye-strain, 193 Hydrobromic acid, if due to eye-strain in nervous women, 100 Ice-bag, applied to head, or leeches behind ears, in severe cases, 545 Liquor magnesii citratis, in sick headache, 242 Magnesium carbonate, gr. 5 to 60 (0.3-4.0), in sick headache due to gastric acidity, 242 Mustard foot-bath and plaster to nape of neck, in congestion, 545 Nux vomica, gtt. 1 (0.05) every five or ten minutes till 10 drops (0.65) are taken, in sick headache, 275 Oxygen-water, 285 Phenacetin, if due to eye-strain or neural- gia, 293 722 INDEX OF DISEASES AND REMEDIES. Potassium bromide, 96 Prescriptions for, 546 Salicylic acid or iodide or acetate of potas- sium, if due to gout, 546 Sodium bicarbonate, as an antacid in sick headache, 90 Strychnine or nux vomica, if due to eye- strain, 545 HEART DISEASE, 546 Aconite or veratrum viride, often useful in palpitation and hypertrophy, 550 Adonidine, often of service when digitalis fails, 48, 549 Ammonia and ether, followed by digitalis and alcohol, in heart failure, 550 Amyl nitrite, in single whiffs, often relieves cardiac failure, 65 Barium chloride, in heart failure, 84 Belladonna, when arhythmia is present, 550 Cactus grandiflorus, useful in valvular dis- ease with incompetency, 103 Camphor, in palpitation, 109 Cimicifuga, as a tonic in fatty and irritable heart when digitalis fails, 148 Convallaria majalis, in cardiac arhythmia, 167 Diet and exercise, in fatty degeneration, when fat is deposited between muscular fibres, 551 Digestive remedies, in palpitation due to indigestion, 550 Digitalis, to be tried in all heart troubles, except in simple or compensatory hyper- trophy, 547 Hoffmann's anodyne, very useful in palpi- tation due to indigestion or tobacco, 202 Iron, in palpitation due to anamia, 550 Nux vomica, in palpitation, as a stimulant, 550 Opium, if dyspnaa prevents sleep, 281 Sparteine, in arhythmia or palpitation, also as a substitute for digitalis, if it fails, 549 Strophanthus, may be tried if digitalis fails, 549 Veratrine ointment, recommended, applied to chest in some cases of palpitation, 549 HEMORRHAGE, 537 Alum, a useful styptic, applied to bleeding vessel, 57 Arnica, 76 Compress, soaked in antiseptic liquid or filled with antiseptic powder, preferable to styptics, 538 Hypodermoclysis, 390 Ligation preferable to styptics, when appli- cable, 538 Oil of erigeron, 182 Packing of astringents, if bleeding point cannot be reached by compression, or for ligation, 538 Tannic acid, 344 Transfusion, 392 HEMORRHAGE, INTESTINAL, 541. (See also Hemorrhage.) Enemas, styptic, for hemorrhage from rec- tum or colon; alum (gr. 10 to the ounce [0.65 : 32.0]), copper (gr. 5 to the ounce [0.3 : 32.0]), Monsel's solution (dr. 1 to 2 ounces [4.0 : 64.0]), Monsel's salt (gr. 10 to the ounce, or drachm I [2.0] to water 2 ounces [64.0]), chlorate of pot- ash (gr. 10 to 25 to the ounce [0.6-1.0 : 32.0]), and tannic acid (gr. 20 to ounce [1.3 : 32.0] of glycerin and water), 541 Ergot, 541 Ice, by mouth, and Monsel's salt, gr. 3 (0.15), in hard pill, every half-hour or oftener, 541 Ice-water injections in bloody purging of dysentery, 542 Lead acetate and camphor, in pill, of ser- vice in some cases, 541 Monsel's solution not advisable, 228 Sulphuric acid, gtt. 5 to 10 (0.3-0.65) in water, 541 Tannic acid, in solution or pill, when Mon- sel's salt is not at hand, 541 Turpentine, in capsule or emulsion, when bleeding is not active, 541 HEMORRHOIDS, 543 Aloes, 543 Carbolic or acetic acid, locally applied, 544 Carlsbad salts, taken before breakfast to cause evacuation, 544 Cold-water injections in the morning, re- lieve congestion and cause easy evacua- tion, 544 Ergot, sometimes useful in bleeding piles, 181 Gallic acid and ointment of stramonium, equal parts, 192 Gallic acid and opium, ointment, prescrip- tion for, 544 Hamamelis, internally or as a lotion or in- jection, 544 Iodoform suppository, if ulceration is pres- ent, 221 Nitric acid, lightly touched to one or two points, 267, 544 Potassium chlorate, with laudanum, as an injection, 134 Quereus alba, as an astringent wash, 308 Rhubarb-root, gr. 10 to 20 (0.6-1.3), chewed before retiring, to relieve constipation, 544 Stillingia, prescription for, 333 Sulphur, to produce soft passages, 339 Tannic acid, suppositories in bleeding piles, 344 Tobacco, contraindicated, 349 Wool tampons, 544 HEPATIC ABSCESS, 552 Active treatment for dysentery, if present, 553 Ammonium muriate, thought to be of value, 63 Aspiration, when pus forms, 552 Diet, 553 Quinine, after abscess develops, 553 HEPATIC CIRRHOSIS. Ammonium chloride, 63 Iodoform, highly recommended, 220 INDEX OF DISEASES AND REMEDIES. 723 Potassium iodide, often useful in early stages, 213 HEPATITIS (ACUTE), 552 Aconite, in early stages, 552 Ammonium muriate, has been recom- mended, 69 Cantharidal blister, small, over right hypo- chondrium ; if impracticable, use mus- tard plaster, 552 Hot cloths, over counter-irritant, may re- lieve pain aud aid in formation of blis- ter, 552 Saline purgatives, preceded by calomel, gr. 1 (0.05), in divided doses, if constipation exists, 552 Sweet spirit of nitre with potassium citrate, or diuretic waters, to regulate kidneys, 552 Veratrum viride, rarely used, 552 HEPATITIS (CHRONIC AND SUBACUTE), 553 Antisyphilitic treatment, if due to syph- ilis, 553 Aspiration, frequently repeated, may effect a cure, 553 Nitro-muriatic acid, internally and exter- nally, most useful remedy, 553 Potassium iodide, useful in all cases, 553 HERNIA. Chloroform, inhalations, to relax muscles during reduction, 145 HICCOUGH, 554 Belladonna, 67 Camphor, spirit of, dose 1 drachm, 554 Capsicum, tincture, gtt. 2 to 3 (0.1-0.15), Chloral, 131 Chloroform, 554 Ether, inhaled or sprayed on epigastrium, 554 Hoffmann's anodyne, especially valuable, 554 Musk, gr. 10 (0.65), given by rectum, valu- able in all cases, especially in typhoid fever, 554 Nux vomica, accompanied by mineral acids, if due to indigestion, 554 Oil of amber, gtt. 5 to 10 (0.3-0.65), in cap- sule, one of the best remedies, 554 Pilocarpine hydrochlorate, hypodermically, if due to uramia, 554 Valerian, tincture of, dose 1 drachm (4.0), 554 HOARSENESS. Sulphides or sulphur-water, if due to cold or speaking, 337 HYDROCELE. Iodine, injections, after evacuation of the sac, the best curative remedy, 217 HYDROCEPHALUS. Potassium iodide, to cause absorption of fluids, 213 HYSTERIA. Calcium bromide, 99 Hops, as a nervous sedative, 203 Monobromated camphor, to produce sleep, 111 Oil of amber, 58 "Pill of three valerianates," recommended, 353 Potassium bromide, 96 Valerian, 352 Valerianate of ammonium, 63 IMPOTENCE. Cannabis indica, with strychnine, nux vomica, or ergot, if no organic trouble exists, 113 Cantharis, with nux vomica and iron, may restore sexual power if loss is due to excess, 115 Cold douche to perineum and testicles, in atonic types, 374 Gold, chloride of, and sodium, gr. ^j (0.003), 197 INCONTINENCE OF URINE, 554 Antiseptic fluids, to cleanse bladder, in paralysis, 556 Arsenic, with nux vomica, in weakness of spinal centres, prescription for, 555 Belladonna, if due to vesical spasm, 555 Buchu, with sweet spirit of nitre, valuable in some cases, 102 Cantharides, gtt. 1 (0.05), with alkaline diuretics, thrice daily, in adults, 114, 556 Catheterization, in retention or paralysis, 556 Circumcision, if prepuce is redundant, re- lieves some cases, 555 Diuretic waters, used for years, necessary in some cases, 556 Fowler's solution, gtt. I to 1 (0.025-0.05), in chronic types due to atony, 555 Hyoscyamus, if due to irritable bladder, 209 Rhus aromatica, in incontinence of chil- dren, due to atony, 310 Santonin, often valuable when other rem- edies fail, 320 Sweet spirit of nitre and potassium citrate, if urine is dark and concentrated, pre- scription for, 555 INDIGESTION (GASTRIC AND INTES- TINAL), 556 Alcohol, in adynamic types. 556 Ammonia, if due to large amounts of lac- tic and butyric acids, 559 Asafatida, useful in indigestion associated with flatulence in old age, 81, 560 Bitter tonics, useful in atony, contraindi- cated in gastric irritation, formula for, 556 Bromide of strontium, recommended by See, 334 Chiretta, 128 Chloroform, gtt. xx (1.3), often of great value, 561 Creosote, 1 to 2 minims (0.05-0.1), very use- ful after meals, 559 Diet, 556 Gold, chloride of, and sodium, when epi- gastric pain is present, 197 724 INDEX OF DISEASES AND REMEDIES. Hydrochloric acid in gastric forms, or com- bined with cardamoms, in intestinal in- digestion, 205 Leptandra, of great value in intestinal types, prescription for, 238 Nitric acid, if sour regurgitation is present, after meals, 267, 560 Nitro-hydrochioric acid, valuable in many cases, 269 Pancreatin, with sodium bicarbonate and alkaline mineral waters, in intestinal types, 560 Pepsin and hydrochloric acid, if due to de- ficient secretion, 558 Podophyllin or mercury, in lientery, 560 Prescription for torpid liver of indigestion, 560 Prescriptions for flatulence of intestinal indigestion, 559 Salol, 559 Salt, in increased amounts, if gastric diges- tion is imperfect, 558 Serpentaria, as a tonic, 386 Strychnine, quinine, and nux vomica, use- ful tonics, prescriptions for, 557 Yellow oxide of mercury, gr. fa or fa, in trituration, if there is foul belching or ill-smelling stools, 257 INFLAMMATION. Cannabis indica, valuable in chronic types, 112 Cocaine, in acute types, prescription for, 157 Hop poultice, 203 Liquor plumbi subacetatis, useful as a top- ical application, 236 Opium, 280 Veratrum viride, 355 INFLUENZA, 561 Aconite, sweet spirit of nitre, and citrate of potassium in combination, valuable in early stage, 562 Antipyrine, phenacetin, and acetanilid should only be used in small dose to allay pain, 561 Belladonna, combined with strychnine, if there be vasomotor paresis, 565 Bromides, if cough be excessive, 565 Cannabis indica, often valuable if pushed, for irritative cough, 565 Chloral, chloralamid, or sulphonal, for in- somnia, 565 Cold bath, preferable to antipyretics for re- duction of temperature, 562 Cup, contraindicated, 563 Ergot, cannabis indica, with bromides, often relieve vertigo, 565 Salol and phenacetin, valuable in combi- nation, to allay irritation and pain, 562 Sandalwood oil, for excessive cough, 319 Steam inhalations, laden with vaporized drugs, for cough, 564 Strychnine, preferable to digitalis if there be tendency to collapse, 563 INSANITY. (See Mania, Acute.) INSOMNIA, 566 Amylene hydrate, useless if due to pain, 567 Bath, cold, in cerebral anamia, hot in ner- vous irritability, 371 Bromide of potassium with Fowler's solu- tion, in nervous females, prescription for, 566 Cannabis indica, prescription for, 113 Chloral, useful if not due to pain, prescrip- tion for, 566 Chloralamide, gr. 15 to 60 (1.0-4.0), in wine or capsule, in nervous insomnia, 567 Chloralose, 2 to 8 grains (0.1-0.5), in cap- sule, 132 Croton chloral, preferable to chloral, if due to pain, 172 Duboisine more useful than hyoscine, 178 Hop pillow, 203 Hot-water bags to feet and cold to head, if due to cerebral hyperamia, 567 Hyoscine, gr. TJff to fa (0.0006-0.0008), by mouth, or gr. x\v to T$ff (0.0004-0.0006), hypodermically, in mania or hysteria, 566 Hypnal, useful in insomnia due to pain, 210, 567 Morphine with chloral, if due to pain, pre- scription for, 566 Opium, only to be used in pain, 279 Paraldehyde, 287, 567 Potassium bromide, in nervousness and overwork, 97 Somnal, minims 10 to 40, in liquorice and water, 567 Sulphonal, prescription for, may be given in hot water, 567 Tetronal, useful, 349 Trional, in 15-grain (1.0) doses, 349 Valerian, in nervousness, 352 INTERMITTENT FEVER, 567 Alcohol, contraindicated, during chill, 569 Anasthetization, has been employed to put off paroxysm, 569 Antipyrine, if fever is excessive, 569 Arsenic, in intervals between attacks, as an antiperiodic, 568 Calomel, gr. i to \ (0.011-0.01), every fif- teen minutes until 1 grain is taken, four or five hours before quinine, if con- stipation is present, 568 Chloroform inhalations, preceded by lauda- num, by mouth or rectum, or morphine, gr. \, with atropine, gr. fa (0.001), hypo- dermically, if death threatens during chill, 569 Cool drinks and sponging, in fevered stage, 569 Digitalis, to relieve internal congestion during chill, 568 Ice-pack, if fever is long continued and ex- cessive, 569 Ipecac or zinc sulphate, as an emetic, if chill follows full meal, 568 Methylene blue, 1 to 4 grains (0.05-0.2), 259 Phenocoll, sometimes useful, 294 Podophyllin, gr. fa to \ (0.006-0.007), pre- ceding quinine, if constipation is pres- ent, 568 Potassium or sodium nitrite, gr. 10 (0.65), have been employed to put off attack, 569 INDEX OF DISEASES AND REMEDIES. 725 Quinine, as a prophylactic and antiperiodic, INTERTRIGO. (See Chapping.) INTESTINAL CATARRH. Ammonium chloride, useful in subacute types, 63 Chlorate of potassium, injections (gr. 20 to the ounce [1.3:32.0]), in acute rectal catarrh, 134 Iodide of potassium, if ammonium chloride fails to relieve, 213 Leptandra, fluid extract, dose 20 minims to 1 drachm (1.3-4.0), 238 Salol, 318 INVOLUTION (ANOMALIES OF), 615 Cannabis indica, of great value in subinvo- lution, 113 Curette, in subinvolution due to retention of hypertrophic endometrium, 616 Digitalis, in subinvolution due to sluggish circulation, 616 Ergot, quinine, and strychnine, in pill, if due to fibroids, 615 Purgatives, disinfectants, and possibly hot water locally applied, if due to inflam- mation, 616 Removal of placenta, if adherent, 616 IRITIS, 569 Atropine, the best local remedy, 569 Counter-irritation, 570 Daturine, scopolamine, or duboisine, when atropine cannot be used, 569 Iced compress, in early stage of traumatic iritis, 570 Iodide of potassium, alone or with mercury bichloride, following mercurial impres- sion in syphilitics, 570 Leeches and dry heat or hot fomentations, to relieve pain, 570 Mercury, preferably by inunction, if due to syphilis, 570 Morphine, if pain is severe, 570 Paracentesis, 570 Pilocarpine, internally if vitreous becomes opaque, also in gonorrhaal types, 570 Salicylic acid or oil of gaultheria, followed later by potassium iodide, in rheumatic iritis, 570 Saline laxatives, during course of disease, followed by iron, after cessation of specific treatment, 570 Turpentine accompanied by potassium iodide, in plastic iritis, following second- ary syphilis, 570 Zollicoffer's mixture, useful in chronic types, 570 ITCH. (See Scabies.) JAUNDICE. Calomel, gr. % (0.01), every half-hour till gr. i (0.025) is taken, if due to cold, 253 " Carbolic acid, gr. 10 (0.65), with water and glycerin, each 2 drachms (4.0) locally applied in itching of jaundice, 120 Citric acid, 156 Hydrastis, useful in subacute types, 204 Iodoform, highly recommended, 220 Leptandra, fluid extract, dose 30 minims to 1 drachm (2.0-4.0), 238 Manganese sulphate, may be tried in mala- rial types, 243 Pilocarpine, useful unless due to malignant disease, 301 Salol, said to be of value, 318 JOINTS (ENLARGED). Ammoniac plaster, a useful stimulant, 64 KELOID. Ichthyol ointment, 211 KERATITIS (INTERSTITIAL), 571 Antiseptic lotions, in marked ciliary con- gestion, 571 Antisyphilitic treatment, if due to syphilis, 571 Atropine, in ciliary congestion, to prevent iritis, 571 Creolin, 172 Leeches, to temple to relieve pain, if pa- tient is not too young for bleeding, 571 Thymol iodide, as a dusting powder, 348 KERATITIS (PHLYCTENULAR), 571 Atropine, to relieve pain, 571 Boric acid, solution, to relieve congestion, 571 Cocaine, not advisable in photophobia, 572 Cold-water douche on closed eyelid, to re- lieve photophobia, 572 Dark glasses, to protect eyes, 571 Tonics and alteratives, with strict hygiene and regulated diet, associated with local treatment, 572 Yellow oxide of mercury, ointment, or calo- mel as a dusting powder to hasten cica- trization, contraindicated if iodine is being given, 571 KERATITIS (SUPPURATING), 572 Antiseptic lotions, to limit sloughing, 572 Cautery, actual, best means of preventing perforation, 572 Curetting floor of ulcer, if perforation threatens, 572 Eserine or atropine, instilled into eye, to limit sloughing, 572 Hot compresses, 572 Massage of cornea and introduction of yel- low-oxide ointment, to remove scars of ulcers, 572 Pressure bandage, if perforation threatens, 572 LACHRYMAL ABSCESS, 573 Blue pyoktanin (1 : 1000), injected through external opening if there is puiulent discharge, 573 IRRITABILITY. Almonds, as a drink in irritability of intes- tines and air-passages, 54 Cantharis, recommended in irritable blad- der of women and children, 114 Cimicifuga, in uterine irritability, 148 Hops, in vesical irritability, 203 Petrolatum, as a soothing agent in gastro- intestinal types, 291 Potassium bromide, in irritability of phar- ynx, 96 726 INDEX OF DISEASES AND REMEDIES. Division of canaliculi and washing out sac with antiseptic fluids, and insertion of probes into ducts after inflammation subsides, to restore patulency, 573 Hot compresses, composed of lead-water and laudanum, to relieve pain, 573 Puncture of abscess, if rupture threatens, LARYNGISMUS STRIDULUS. Amyl nitrite, 65 Belladonna, 87 Bromide of potassium, 97 Gelsemium, 193 LARYNGITIS (ACUTE), 573 Abstinence from talking, with bland and unirritating but nutritious diet during attack, 575 Aconite, to control fever, 574 Antipyrine, as a spray, 73 Bromides, useful in full doses, 60 to 120 grains (4.0-8.0) a day, 97, 574 Calomel, small and repeated doses, fol- lowed by saline purges, along with hot mustard foot-bath and demulcent drinks, 574 Dover's powder, if necessary, to give rest, 279 Iodine, painted over throat, useful on third or fourth day, 574 Oil of amber and olive oil, half and half, well rubbed into the skin of the neck and chest, 574 Silver nitrate, 265 Steam inhalations, charged with benzoin, often advantageous to add menthol, 573 LEUCORRHOZA, 575 Alum, gr. 10 to 20 to the ounce (0.65-1.3 : 32.0), as a vaginal wash, 58 Ammonio-ferric alum, gr. 2 to 5 (0.1-0.25), in atonic types, 224 Belladonna, gr. 1 to 2 (0.05-0.1), with tan- nic acid, gr. 6 to 8 (0.5), applied on cot- ton, in disease of uterine cervix, 87 Cantharidal collodion, applied over groins to produce blister, in catarrh of Fallo- pian tubes or ovarian irritation, 576 Goodell's prescription for, 576 Hot sitz-bath, or vaginal injections of hot water, if due to uterine congestion, 386 Hydrastis, injections, if due to relaxed va- gina, 204, 576 Iron, with touics, if due to excessive lacta- tion or exhausting life, prescriptions for, 575 Myrrh, if due to uterine trouble, 262 Potassium permanganate (drachm £ [2.0], to water 1 pint [500 cc.]), as an injection, if discharge is foetid, 576 Prescription for injection, 576 Ringer's prescription for wash, 576 Tampon, saturated with iodoform and tan- nic acid, equal parts, sometimes of ser- vice, 576 White-oak bark (ounce 1 [32.0] to water 1 pint [500 cc]), or tannic acid and glyce- rin (ounce 1 [32.0] to 2 quarts [2 litres] of water), as an injection, 576 LICHEN. Arsenic, usually cures, 78 Bath of sulphides, often beneficial, 337 Cantharides, 115 LID ABSCESS, 577 Treatment, same as for other abscesses, 577 LITHEMIA. (See Gout.) LOCOMOTOR ATAXIA. Acetanilid, 42 Antipyrine, 73 Potassium bromide, to prevent laryngeal crises, 97 Suspension, 401 LUMBAGO, 577 Acupuncture, often relieves, especially if pain is bilateral, 577 Antifebriu, dose, gr. 4 to 8 (0.2-0.6), 577 Antipyrine, dose, gr. 10 to 20 (0.65-1.3), 577 Chloroform liniment, 164 Cod-liver oil, 161 Foot-bath and Dover's powder, before re- tiring, often relieves, 577 Ice-bag or ether spray to loins, if hot ap- plications fail, 577 Ironing back with laundry iron, skin being protected by cloth or paper, very effi- cient, 577 Monobromated camphor, with other drugs, very useful, 111 Mustard or capsicum plaster or blister, over painful spot, may relieve, 577 Phenacetin and salol, of each 5 grains (0.3), 577 Potassium iodide or salicylic acid, if recov- ery is slow, 577 Poultice, a large hot, to lumbar region, use- ful in obstinate cases, 577 Turpentine, gtt. 20 (1.3), said to be useful, 351 LUPUS. Acid nitrate of mercury, 256 Europhen, in ointment or powder, 190 Ichthyol ointment, 211 Iodine, as a paint, to retard spread, 217 MALARIAL FEVER. (See Intermittent and Remittent Fevers.) Antipyrine, 73 Arsenic, as a cure and prophylactic, 7.8 Eucalyptus, instead of quinine, when it cannot be borne, 188 Gelsemium, of doubtful value, 193 Gentian, in malaria associated with dys- pepsia, 194 Hydrastis, said to be antimalarial, 204 Methylene blue, 1-4 grains (0.05-0.2), 253 Phenocoll, useful in some cases, 294 Pilocarpine, may be used to abort, 300 Quinine, the best remedy as a prophylactic and a cure, 150 MANIA (ACUTE), 376 Anasthetics, or apomorphine in emetic dose, to relax muscular system, if pa- tient is very violent, so that other rem- edies may be administered, 578 Bromide of potassium, as a soporific, 97 Cannabis indica, with large dose of bro- mides, particularly serviceable, 578 INDEX OF DISEASES AND REMEDIES. 727 Chloral, in full doses, if kidneys are healthy, 578 Cimicifuga, fluid extract, gtt. 20 to 30 (1.3- 2.0), thrice daily, in cases occurring after confinement not due to permanent causes, 578 Cold douche to head while body is im- mersed iu hot water, often of service, Duboisine, for insomnia, 178 Hyoscine hydrobromate, gr. TJff (0.0006), when necessary to quiet patient quickly, 578 Morphine, in full dose, may be required to quiet patient, 578 MARASMUS. Cod-liver oil inunctions, one of the best remedies, 161 MASTITIS. (See Breast, Inflamed.) MELANCHOLIA, 578 Nitro-muriatic acid, gtt. 5 (0.3), in water after meals, if associated with oxaluria, 57S Phosphorus, useful in some cases due to overwork, 297 MENINGITIS (ACUTE), 576 Aconite or veratrum viride, in early stages to depress circulation, 579 Alcohol, given with food in second stage, if there be asthenia, 580 Belladonna, often useful, especially when opium and calomel are contraindicated, 579 Blister to nape of neck, in early stage, to prevent effusion ; also in comatose state, 579 Bromides and chloral, best agents to allay nervous symptoms, 579 Calomel, gr. £ (0.025), with opium, gr. I (0.012), every half-hour, in early stage, until effect is manifested ; the deodor- ized tincture, gtt. 2 to 5 (0.1-0.3), every two hours, or less, preferable to powder of opium in some cases, 579 Ergot, in stage of exudation, 579 Ice-bag to head, in early stage, 579 Leeches to nape of neck, in early stage, 579 Milk diet, in second stage, 580 Opium, useful in second stage, 579 Quinine, contraindicated in acute stage, 579 Venesection in early stage of sthenic cases, if aconite or veratrum viride is not at hand, 579 MENINGITIS (CHRONIC). Phosphorus, 297 MENOPAUSE. Bromide of potassium, in nervous disor- ders, 96 Cannabis indica, alone or with aloes and iron, if anamia or constipation exist, in headaches of the menopause, 113 Eau de Cologne, saturated writh camphor, locally applied in headache or drowsi- ness, 110 l Valerianate of ammonium, in nervous dis- orders, 63 MENORRHAGIA AND METRORRHAGIA, 538 Bromide of potassium or sodium, gr. 10, once or twice daily, if bleeding is irreg- ular, 97, 538 Cannabis indica, recommended, 538 Cinnamon oil, drachm £ (2.0), when erig- eron is not at hand, in oozing flow, 538 Dry cups, over sacrum, if due to conges- tion, 539 Ergot, fluid extract, gtt. 10 to 60 (0.65-4.0), best remedy in active bleeding, 538 Erigeron, oil of, minims 3 to 5 (0.15-0.3), in capsule or emulsion, the best remedy for oozing, 538 Hamamelis, distilled extract, drachm 1 (4.0), thrice daily, in irregular bleeding, 538 Monsel's solution (50 per cent.) full strength locally applied, if due to polypus, 228 Rhus aromatica, highly recommended in menorrhagia, 310 Rue, in atonic menorrhagia, 312 Savine, oil of, gtt. 5 to 10 (0.3-0.65), in cap- sule or emulsion, every three or four hours, as a tonic in menorrhagia, 322 Turpentine, often of value, 351 MIGRAINE, 588 Amyl nitrite, 65 Bromide of potassium, with caffeine, almost a specific, if due to eye-strain, 97 Cannabis indica, tincture, gtt. 20 (1.3), hourly, or extract, gr. \ to f (0.01-0.015), every two hours, best treatment, 588 Croton chloral, very efficient, especially if fifth nerve is involved, 172 Gelsemium, with cannabis indica, to abort. 193, 588 Salicylic acid, of great service, in rheu- matic types, 314 MILK DEFICIENCY, 618 Electricity, 618 Treatment for intercurrent affection, if due to that cause, 618 MORPHIOMANIA. (See Poisoning from Opium, Chronic.) Bromide of potassium, 97 Phosphorus, of service in sequela of mor- phiomania, 297 MUCOUS MEMBRANES (DISEASES OF). Acacia, as a mucilaginous drink in irrita- tion and inflammation of upper air- passages, 39 Bismuth, as an astringent, to inflamed membranes, 91 Flaxseed, as a soothing demulcent, 191 Glycerole of aloes, locally applied to fis- sures, valuable, 56 Opium, suppositories, gr. \ (0.012), useful in rectal inflammation, if not an acute catarrh, 280 Pareira, useful in chronic genito-urinary inflammation, 287 Terebene, useful in subacute and chronic genito-urinary iuflammation, instead of sandalwood or copaiba, 345 728 INDEX OF DISEASES AND REMEDIES. Zinc sulphate, weak solution, as an astrin- gent, 336 MUSCJE VOLITANTES, 580 Alteratives and correction of anomalies of refraction, 580 MUSCULAR STIFFNESS. Hot laundry iron passed over part, skin being protected by layers of paper or cloth, often relieves, 386 MYALGIA, 580 Ammonium chloride, if due to cold or bruises, 580 Camphor liniment, 110 Chloroform liniment, 580 Cimicifuga, fluid extract, gtt. 20 to 1 drachm (1.3-4.0), 580 Clove oil, added to liniment, as a counter- irritant, 156 Iodide of potassium or salicylates, if due to rheumatism, 580 Iodine ointment, pure or diluted with lard, 580 Massage or good rubbing, very necessary, 580 Potassium acetate or citrate, gr. 20 (1.3), may be tried, 580 Poultices, hot as can be borne, 580 Prescription for liniment, 580 NASAL CATARRH (ATROPHIC), 581 Dobell's solution, as a cleansing wash ; car- bolic acid may be increased, or thymol and eucalyptus substituted for it, to re- lieve odor, 581 Galvano-cautery, or strong silver-nitrate solution, if ulcerations are present, 582 Hydrogen peroxide, 581 Iodine and glycerin (gr. 6 to 8 to the ounce [0.4-0.6 : 32.0]), with potassium iodide sufficient to make solution, valuable, locally applied, 582 Listerine, may be added to Dobell's solu- tion, to relieve odor, 581 Potassium iodide, internally, tonics and stimulants to mucous membrane and attention to actiAdty of skin, 582 Potassium permanganate, useful; painful if sensation is not entirely lost, 581 Removal of necrosed bone, 582 Silver nitrate and starch (gr. 1 to 10 [0.05] to drachms 2J [10.0]), as an insufflation powder, or solution (gr. 1 to 10 to the ounce [0.05-0.65 : 32.0]), better, in some cases, locally applied, 585 NASAL CATARRH (CHRONIC), 582 Ferric alum (gr. 5 to the ounce), useful, in spray, in later stage, 586 Galvano-cautery or snare, to remove hy- pertrophic tissue remaining after acute stage, 586 Hydrastis, dilute solution, or distilled ex- tract of hamamelis and water, equal parts, useful in spray, in acute stage, 586 Iodine and glycerin (gr. 6 to 8 to the ounce [0.4-0.6 : 32.0]), with potassium iodide, sufficient to make solution, locally ap- plied, 586 Prescription for alkaline wash, 472 NAUSEA. (See Vomiting.) Hoffmann's anodyne, when due to excessive use of tobacco, 202 Hydrocyanic acid, dilute, gtt. 20 (1.3), in water, often useful, 206 Lime-water, 108 NEPHRITIS. (See Bright's Disease.) NERVOUSNESS. Camphor, as a sedative, 109 Hops, as a sedative, 203 Musk, useful in nervous excitement and collapse ; only to be used through crisis, 261 Phosphorus, in nervous debility and ex- haustion, 297 " Pill of three valerianates," highly recom- mended, 353 Rest-cure very useful where nervousness is due to exhaustion, 294 Strychnine, in functional nervous atony or depression, 274 Sumbul, prescription for, 342 Sweet spirit of nitre, in nervous excitement of fever and other nervous states of in- fancy, 343 Valerian, alone or with other drugs, 352 NEURALGIA, 586 Acetanilid, useful, especially with mono- bromated camphor, 42 Aconite ointment (gr. 2 to the drachm [0.1: 4.0]), or oleate of aconitine (gr. 2 [0.1] to sweet oil 100), useful applied over painful spot, if limited in area ; if not, contraindicated, 588 Acupuncture, nerve-stretching, or neurec- tomy necessary in some cases, 588 Amyl nitrite, inhalations, when due to anamia, 588 Antipyrine, gr. 5 to 20 (0.3-1.3), very use- ful, 587 Belladonna, 87 Bromide of potassium with caffeine, almost a specific, 587 Camphor liniment, locally applied, to re- lieve pain, 110 Chloralamide, 132 Chloroform liniment, as a local anasthetic, 146 Cimicifuga, especially useful in ovarian types, 148 Cod-liver oil, 161 Croton chloral, gr. 5 to 20 (0.3-1.3), in 5- grain pills, often effective in brow neur- algia, 588 Freezing parts with ether or rhigolene spray, or by small package of ice and salt, suc- cessful if nerve is superficial, 588 Hydrocyanic acid, useful in intestinal neur- algia, 203 Iodide of potassium, may be tried in rheu- matic neuralgia, 213 Iron and arsenic, in anamia, often neces- sary to associate with them bitter tonics and cod-liver oil, 587 Kataphoresis, 392, 588 Morphine, gr. \ to \ (0.013), injected into painful spot, if localized; not advisable in chronic cases, 588 INDEX OF DISEASES AND REMEDIES. 729 Muriate of ammonium, useful in ovarian types, 63 Mustard plaster, as a counter-irritant, 261 Nux vomica or strychnine, if nerve is de- pressed by anamia, 587 Peppermint oil, locally applied on cloth over painful spot, 289 Phenacetin, gr. 3 to 8 (0.15-0.6), very use- ful, 587 Phosphorus, if due to nervous exhaustion, 297 Prescription for, 293 Prescriptions containing antipyrine with bromides and caffeine, 566 Quinine, if due to malaria, 587 Rest-cure very useful in exhausted patients, 366 Specific remedies, if due to scrofulosis or syphilis, 567 Turkish bath, may relieve, if due to rheu- matism or gout, 368 Veratrine ointment, locally applied over neuralgic nerve, 354 NIGHT-SCREAMING. Bromide of potassium, 97 NIGHT-SWEATS. Acetic acid, as a lotion, diluted one-half, 44 Agariciu, of doubtful value, 48 Alum dissolved in water or alcohol, efficient application for sponging, 57 Belladonna, best remedy, S7 Camphoric acid, the best of all remedies, 111 Ergot, 161 Gallic acid, 192 Pilocarpine, gr. fa (0.003) hypodermically, two hours before sweat, often useful, even when atropine fails, 301 Sulphuric acid, with belladonna or mor- phine, often useful, 341 Zinc oxide, prescription for, 285 NIPPLES (SORE), 589 Benzoin, tincture,- locally applied, 569 Boric acid (gr. 20 to the ounce [1.3 : 32.0]), or mucilage of acacia, applied after nursing, nipple being dried beforehand, 5-9 Breast-pump or nipple-shield may be neces- sary to effect cure, 589 Cocaine (gr. 4 to the ounce [0.2 : 32.0]), ap- plied and washed off before nursing, if breast is very painful, 589 Ichthyol, wrhen indurated, 211 Silver-nitrate stick touched to fissure, if deep and slow to heal, 569 Tannin, glycerite of, locally applied, 589 NYMPHOMANIA. Bromide of potassium, of great service, 97 OBESITY, 589 Acetic acid, harmful, 44 Cold bath, 592 Diet, 591 Laxative fruits and purges, to regulate bowels, 592 ' Massage, passive movements, absolute skimmed-milk diet, and electricity, if exercise is impracticable, 592 Potassium permanganate, 291 Saline purges, if liquid taken in drink is not rapidly eliminated, 592 Turkish bath, 592 OPHTHALMIA. (See Conjunctivitis.) OPIUM HABIT. (See Poisoning from Opium, Chronic.) ORCHITIS. (See Epididymitis.) OSTEOMALACIA. Phosphorus, 297 OTORRHEA. Creolin, solution (1:500), used with syringe, 172 OVARIAN TUMOR. Iodine, 217 OZ.ENA. Prescription for insufflation powder, 250 PARALYSIS AGITANS. Cannabis indica, to quiet tremors, 112 Chloral, of great service, 131 PARASITES. Bichloride of mercury (gr. 2 [0.1] to water oz. 1 [32.0]), applied thrice daily in para- sitic skin diseases, 252 Chrysarobin, gr. \ (0.008), internally, or the ointment, with benzoated lard (1 : 4 or 5), locally applied, in parasitic skin diseases; must not be used on face, 147 Hyposulphite of sodium, 1 drachm to the ounce (4.0 : 32.0), for parasitic skin dis- ease, 329 Mercurial ointment, useful to destroy pe- diculus pubis or other parasites, 256 Pyrogallol, 30 grains to ounce, for parasitic skin disease or psoriasis, 307 Volatile or fixed oils, useful to destroy, 256 PARTURITION. Castor oil, to relieve constipation, 125 Chloral, if rigidity of os exists, 131 Cimicifuga, 146 Quinine, as a stimulant to uterus, 150 PEMPHIGUS. Arsenic, 78 PERICARDITIS, 592 Aconite, to allay inflammation and quiet heart, 47 Alcohol, digitalis, or caffeine, if heart shows signs of failure, 592 Aspiration, gradual, if exudation endangers life, 593 Blister, over pracordium, often useful, 693 Calomel, gr. £ (0.025), with opium, hourly, to prevent exudation, 592 Ice-bag over the pracordium, very useful, 369 Iodide of potassium, to aid in absorption of fluid, 213 Jalap, compound powder of, gr. 20 (1.3) ; or elaterium, gr. $ (0.011); or saline purga- tive, before breakfast, useful in sthenic cases, to remove effusion, 593 730 INDEX OF DISEASES AND REMEDIES. Leeches, 5 to 10, over pracordium, accom- panied by large dose of veratrum viride, iu early stage of sthenic cases, 592 Opium, to allay inflammation, 280 PERITONITIS (ACUTE), 593 Aconite, preferable to veratrum viride, to depress circulation, 593 Belladonna and opium, by mouth; if im- possible, by rectum, to relieve vomiting and pain ; also useful in obstinate con- stipation, due to intestinal paralysis, 593 Leeches, 10 to 30, or mustard plaster to ab- domen, accompanied by opium and bel- ladonna, given as above, to relieve pain and vomiting in early stage, 593 Mercury, useful only in severe acute forms due to traumatism or other causes, 594 Pancreatinized milk, frequently given dur- ing attack, also enjoining absolute rest, 594 Saline treatment, 595 Turpentine stupes, or turpentine, drachm 1 (4.0) ; milk of asafatida, oz. 3 (96.0); and water, oz. 4 (128.0), as an enema, if tympanites is present, 594 Venesection, valuable in early stage, if case is sthenic, 405 Veratrum viride, inferior to aconite, in early stage, 593 PERNICIOUS MALARIAL FEVER, 597 Quinine, large doses, iu solution, by mouth, rectum, or hypodermically, 597 PHARYNGITIS. Antipyrine in 4 per cent, spray, 74 Cocaine, gives temporary relief; after-effects bad, 158 Cubebs, troches of, used in chronic types, 173 Monsel's solution, pure or diluted one-half with glycerin, applied on pledget of cot- ton or camel's-hair brush, 228 Peroxide of hydrogen, 208 Salol, in 5-gr. (0.3) doses, 318 Silver-nitrate solution, in varying strength, locally applied, 265 . PHTHISIS. (See Tuberculosis.) PLEURITIS, or PLEURISY, 598 Aconite or veratrum viride, preferable to venesection, in early stage, 598 Aspiration, when hydragogue purges fail to remove effusion, 598 Blisters, useful in early stage ; also during stage of effusion, 598, 599 Calomel, in sthenic cases, to prevent exuda- tion, 594 Cantharidal blister, two inches below axilla, aids absorption of effusion, 377 Cotton jacket, 598 Digitalis or alcohol, if pulse weakens in second stage, 599 Dry cup. contraindicated over diseased area, may be employed OAar back, 598 Elaterium or jalap, useful to remove eflu- sion, 598 Gelsemium, 193 Ice-poultice or jacket, used with success in sthenic cases, 369 Iodide of potassium, used in chronic stage, to aid absorption, 213 Iodine, locally applied, to abort, and aid absorption of fluid, 217 Poultices, 599 Salicylates, very useful for the removal of effusion, 599 Saline purges, in second stage, to remove effusion, 599 Strapping chest, if respiratory movements are very painful, 598 Wet cups, useful in early stage, over in- flamed spot, 598 PLEURODYNIA. (See Neuralgia.) PNEUMONIA, 599 Aconite, preferable to veratrum viride, in early stage, in children, 601 Alcohol, inferior to digitalis, as a cardiac stimulant in the second stage in adults, but better than in children, 607 Ammonia useful for adults and children, 604 Ammonium chloride, as an expectorant in third stage, 607 Antimony, should only be used in sthenic cases, 607 Antipyrine, of great value if fever is ex- cessive, 72 Belladonna, very useful if there are evi- dences of collapse, 87 Blisters, applied to one side of congested spot, in first stage; immediately over spot in stage of resolution, 604-608 Cardiac stimulants, if secondary attack is superimposed on first, 608 Cayenne pepper, a valuable counter-irri- tant, 604 Chloral, not advisable, 603 Cotton jacket, 609 Cups, dry and wet, iu first stage ; also in secondary attack superimposed on first, 604 Digitalis, tincture, gtt. 5 to 15 (0.3-0.9), every four hours, accompanied by bella- donna, gtt. 5 to 10 (0.3-0.6), carefully watched, in second stage, 604 Ethyl iodide, causes resolution, 188 Expectorants, must be stopped, if secondary attack is superimposed on first, 608 Gelsemium, not advisable, 603 Ice-poultice or jacket, highly recommended in first stage of sthenic cases, 369, 603 Leeching, bleeding, cupping, or cardiac sedatives, in sthenic cases, if secondary attack is superimposed or. first, 608 Mustard plaster, to chest in first stage; to feet in secondary attack superimposed on first, 604 Nitro-glycerin in second stage when nails are dusky, 605 Oxygen inhalations, if asphyxia threatens, 609 Phosphorus, 297 Pilocarpine, hypodermically, only to be used in earliest stage, 603 Poultices, useful in second and third stages, 609 Prescriptions, containing ammonium chlo- ride, to loosen cough of second stage, 608 INDEX OF DISEASES AND REMEDIES. 731 Quinine, gr. 2 (0.1), thrice daily, in sup- pository, in lobar pneumonia of children, 151 Strychnine as a respiratory and circulatory stimulant in second stage, 605 Turpentine stupe, in first stage; also in secondary attack superimposed on first, 604, 608 Venesection, in early stage of sthenic cases, cardiac depressants preferable, 405, 601 Veratrum viride, preferable to aconite, in early stage, in adults, 601 POISONING FROM— Acetanilid. Supportive measures, stimulants, external heat, belladonna to maintain blood-pres- sure, strychnine to counteract respira- tory failure, and oxygen inhalations to overcome cyanosis, 42 Acetate of Zinc. Treatment same as for gastro-enteritis, 526 Acetic Acid. Large amounts of milk, alkaline liquids, and general treatment for gastro-enteri- tis, 44 Aconite. Keep patient in prone position with feet higher than head. Hot applications; emetics contraindicated; evacuate stom- ach by siphon or stomach-pump. Ether hypodermically, followed by alcohol, and this by digitalis. Artificial respiration and amyl nitrite, a few whiffs, no more, if heart fails, 46 Alcohol (Acute). External heat, digitalis and strychnine hy- podermically, in coma, if heart fails. Belladonna, if skin is relaxed and clammy, and counter-irritation to nape of neck, for brain symptoms. After- treatment, ammonia, spices, spirit of Mindererus; emollients in gastritis. Ice, aconite, or ipecac in minute dose, and counter-irritation for vomiting. Jalap, gr. 40 (2.6), elaterium, gr. i (0.011), or calomel and salines, as purgatives, 50 Alcohol (Chronic). Withdrawal of drug, at once or gradually. Highly seasoned broths, predigested foods, and morphine or coca, in small dose, if weakness is marked. Capsicum prescriptions (pages 51, 116), 51 Antimony. Large doses of tannic acid, external heat, alcohol, digitalis, and opium hypoderm- ically, if respiration is not too feeble. Prone position, the patient vomiting into towels. Stomach-pump, if vomit- ing is absent, 68 Antipyrine. Maintain bodily heat, stimulants, atropine, and oxygen inhalations, if cyanosis is alarming, 72 Arsenic (Acute and Chronic). Stomach-pump, external heat, stimulants, and the chemical antidote, hydrated sesquioxide of iron and magnesia. Mag- nesia also useful by itself. Opium should follow antidote, to allay pain, also large draughts of water to flush kidneys aud dilute poison. For chronic poisoning, iodide of potassium, tonics, electricity, and out-of-door life, 81 Carbolic Acid. Soluble sulphates, as Epsom or Glauber salts, warm mucilaginous drinks, hot applications to extremities, digitalis, strychnine, and counter-irritation over abdomen. Emetics and stomach-pump should be used if possible, 119 Carbon Bisulphide. Potassium bromide and chloral, if convul- sive disorders exist, and circulatory stimulants if heart failure threatens, 122 Chloral. External heat, emetics in early and stom- ach-pump in later stages. Strychnine or atropine to stimulate respiration. Digitalis, preceded by ether, ammonia, brandy, or whiskey. Prone position, feet being elevated, 130 Chloroform. Artificial respiration, ether and hot brandy hypodermically. Poles of battery with rapidly interrupted current swept over body, not over diaphragm or phrenic nerve. Place patient with head down- ward. Atropine, strychnine, and digi- talis to stimulate heart and respiration, 140 Colchicum. Tannic acid, emetics, and stomach-pump. Opium to relieve pain, and oils to soothe inflamed mucous membranes. Atropine and stimulants if collapse comes on, 163 Conium. Emetics or stomach-pump, strychnine as a nervous and respiratory stimulant, ex- ternal heat and cardiac stimulants, if circulation fails, 167 Copper. Yellow prussiate of potassium, sweet oil, white of egg; followed instantly by emetics or stomach-pump. If emesis or purgation is present, emetics are contra- indicated ; instead, mustard plaster over abdomen and opium internally are to be employed, 169 Corrosive Sublimate. Large amounts of white of egg, followed by stomach-pump, external heat, stimu- lants, 250 Croton Oil. Treatment same as for gastro-enteritis, 526 Digitalis. Tannic acid as a chemical antidote, emetics or stomach-pump, external heat to abdo- men and aconite as a physiological anti- dote. Maintain horizontal position, 177 1ES AND REMEDIES. 732 INDEX OF DISEAS Elaterium. Treatment same as for gastro-enteritis, 526 Ether. Artificial respiration, lowering head if face is pale; strychnine, atropine, and digi- talis hypodermically, or intravenous in- jection of ammonia to stimulate heart and respiration ; frictions and hot appli- cations ; ether dashed on chest and ab- domen, 184 Gelsemium. Emetics and stomach-pump, digitalis, atro- pine, and ammonia as cardiac stimu- lants.; external heat, strychnine, and atropine for respiratory centre, 194 Iodine. Emetics or stomach-pump, large amounts of starch, hot applicaiions, and hypo- dermic injections of alcohol, ammonia, atropine, digitalis, or strychnine, 215 Lead (Acute). Epsom or Glauber salts, in large amounts; emetics or stomach-pump, if vomiting produced by the drug has not cleared stomach of all poison. Hot applications and opium to relieve pain, 233 Lead (Chronic). Jalap and calomel with opium or alum, gr. 2 (0.1), in full dose, valuable in lead colic Blister to back of neck, revul- sives and pilocarpine in cerebral inflam- mation. Iodide of potassium to elimi- nate lead. Strychnine in progressive paralysis. Electricity and baths of sul- phuret of potassium, to restore lost function, 234 Mineral Acids. Alkalies, such as magnesium, lime, white- wash, and soap as antidotes; white of egg, external heat, oils, and opium, to relieve irritation. Monsel's Solution. Soap, 228 Nitrate of Silver (Acute). Common salt as the chemical antidote, opium and oils to allay irritation, also large amounts of milk and soap and water, 264 Nitrate of Silver (Chronic). Iodide of potassium, to aid in eliminating poison, 264 Nux Vomica and Alkaloids. Inhalations of amyl nitrite, to prevent con- vulsive tendencies, at the same time use stomach-pump. Tannic acid followed by physiological antidotes, potassium bromide, gr. 60 (2.0), with chloral, gr. 20 (1.3). If convulsions prevent swal- lowing, chloroform patient carefully and give antidotes by rectum in starch- water. Amyl nitrite, hypodermically, if relaxation does not occur, 273 Opium (Acute). Emetics or stomach-pump, tannic acid, black coffee, electricity, and other meas- ures to keep patient awake. Atropine or strychnine, hypodermically, if res- piration fails. Alcohol, ammonia, and external heat. Artificial respiration may be necessary, 277 Opium (Chronic). Decrease a sixth or fourth of customary amount each twenty-four hours. Co- caine not advisable as a substitute, as the cocaine-habit may be established. Digitalis if heart fails, 278 Phosphorus. Sulphate of copper as the chemical anti- dote ; acts as an emetic if given in ex- cess, 296 Physostigma. Atropine as a physiological antidote, exter- nal heat, and cardiac and respiratory stimulants, 298 Scammony. Treatment same as for gastro-enteritis, 526 Strychnine. (See Nux Vomica.) Tobacco. Strychnine, cardiac stimulants, external heat, and atropine, 349 Veratrum Viride. Prone position, head higher than feet; atro- pine, strychnine, external heat, and cardiac stimulants, 355 POST-PARTUM HEMORRHAGE, 616 Auto-transfusion, or actual transfusion of weak salt solution, necessary in some cases, 618 Beef-tea, £ pint (250 cc), and morphine, gr. I (0.01) hypodermically, after reac- tion is established, 618 Enema, of hot water, 1 pint (500 cc), after cessation of bleeding, 617 Ergot, as a cure and prophylactic, 617 Ether, hypodermically, if symptoms of shock are manifested, followed by small doses of hot, strong brandy and water, and warm milk, 617 Hirst's method of controlling, 616 Suture, if due to laceration, 617 PRIAPISM. Hops, 203 PROLAPSUS ANI AND RECTI. Injection of cold or hot water, often re- lieves, 373 PROSTATITIS. Cold-water injections and perineal douches, 373 Local treatment to prostatic urethra, and use of cold steel sounds in chronic types, 533 Perineal incision, to evacuate pus, if ab- scess forms, 533 INDEX OF DISEASES AND REMEDIES. 733 Rest in bed, regulation of bowels, leeches to perineum, medication to render urine alkaline, and morphine hypodermically or in suppository, 533 Soft catheter, allowed to remain in bladder, if retention of urine is persistent, 533 PR0STAT0RRH02A. Cantharides, 115 PRURIGO. Cantharides, 115 PRURITUS, 609 Alum solution as a wash in pruritus vulva, 58 Arsenic, quinine, bitter tonics, cod-liver oil, alkaline diuretics or mineral waters in debility, and avoidance of condi- ments if mouth of vagina or urethra is affected, 610 Calomel and lard (1 drachm to the ounce [4.0 : 32.0]), locally applied, 254 Cocaine, relieAas temporarily, 610 Cold douche and injections highly recom- mended in pruritus ani and vulva, 374 Goulard's extract, dilute, useful in pruritus pudendi, 237 Hydrocyanic acid, locally applied, prescrip- tion for, 207 Prescriptions for lotions and ointments, 610 Salicylic acid, prescription for, 315 Silver nitrate (gr. 20 to the ounce [1.3; 32.0]), locally applied, preceded by co- caine, if itching is intense; a 4- to 6- grain (0.2-0.3) solution may relieve itch- ing of pruritus pudendi, ani, and vulva, 266, 610 Sodium bicarbonate or borax (1 drachm to the pint [4.0 : 500 cc]), as a wash, re- lieves temporarily, 610 Teucrium scordium, highly recommended bv Brinton, 610 Tobacco, 349 PSORIASIS. Anthrarobin, 66 Aristol, 348 Arsenic, 79 Baths of sulphides, very useful, 337 Chrysarobin, gr. £ internally, or the oint- ment with benzoated lard (1 to 4 or 5) locally applied, face excepted, 147 Gallic acid, ointment, 192 Prescription for application, 147 Pyrogallol, 30 grains to ounce (2.0 : 32.0) of lard, 307 Resorcin, prescription for, 309 Tar, locally applied, 304 Thymol iodide, 347 PTYALISM. Alum, applied on swab, in mercurial ptyal- ism, 58 Belladonna, in idiopathic or mercurial types, 87 PUERPERAL DISEASES, 610 (For treatment, see special titles.) PUERPERAL FEVER, 611 Antipyretics, best abstained from as long as possible, 612 Bichlorate of mercury (1 : 2000), or creolin (2 per cent.), solutions, as antiseptic in- jections, 611 Boric acid, creolin (2 per cent.), or bichlo- ride (1 : 8000), solutions, as injections into bladder, to prevent septic cystitis, 614 Curette or placental forceps, to remove membranes if fever continues after an- tiseptic injections, 611 Epsom salts, concentrated solution, 2 drachms (8.0) every fifteen minutes, if peritonitis develops, 613 Laparotomy, occasionally saves life, if sep- tic peritonitis develops, 612 Nutriment in large amounts and alcoholic stimulants, if symptoms of systemic in- vasion arise, 612 Silver nitrate (gr. 40 to 60 to the ounce [2.0-4.0 : 32.0]), locally applied to un- healthy ulcerated wounds; zinc-chlo- ride solution may be necessary, 613 Veratrum viride, 355 PURPURA HEMORRHAGICA. Turpentine, 351 PYELITIS. Buchu, in chronic types, 102 Cantharides, 114 Copaiba, 168 Juniper, as a tonic in chronic types, 231 Uva ursi, 352 QUINSY. Aconite, in early stage, 47 Salicylic acid, gr. 3 (0.15), hourly, acts as a specific, especially if due to rheumatism, 315 REMITTENT FEVER, 621 Antipyrine, or cold pack, if fever is exces- sive, 622 Eupatorium, 189 Monsel's salt, gallic or tannic acid inter- nally, if intestinal hemorrhage occurs, 622 Morphine, spirit of chloroform, or aconite, in sthenic cases, to control vomiting, 622 Phenocoll, in 5 to 8 grains (0.3-0.6), 294 Quinine, gr. 20 to 30 (1.3-2.0), preceded by calomel, gr. 3 to 4 (0.15-0.2); if not re- tained, administer by rectum, or hypo- dermically, with divided doses of Seid- litz powder by mouth, 622 Tonics, potassium salts, to regulate kidneys, and purgatives, if necessary, during convalescence, 622 Turpentine stupe, if belly is tender, 622 RETINITIS, 622 Atropine, dark glasses, and later suitable lenses, if due to eye-strain, 622 RHEUMATISM (ACUTE ARTICULAR), 623 Acetanilid, relieves pain and fever, 43,625 Acetate of potassium, 43 Aconite, or veratrum viride, useful at onset of inflammation in sthenic cases, 623 Alcohol, in depression, 623 734 INDEX OF DISEASES AND REMEDIES. Ammonium bromide, 62 Antipyrine, gr. 10 to 20 (0.65-1.3), or anti- febrin, gr. 4 to 8 (0.2-0.4), often very valuable, 625 Benzoic acid, drachm 2 to 3, daily, said to be a specific, 90 Bicarbonate or citrate of potassium, gr. 20 to 30 (1.3-2.0), in water, every five hours, in obstinate cases, 626 Blisters over joints, useful after systemic disturbance is past, 627 Camphor liniment, 110 Capsicum plaster, 117 Cimicifuga, shortens attack and relieves pain in some cases, 622 Colchicum, prescription for, 626 Cold pack, if fever threatens life, 624 Fuller's lotion, applied on hot cloths to joints, 623 Ice-cold compress, may relieve inflamed joints, 623 Ichthyol, ointment, valuable applied to joints, prescription for, 624 Iodine, ointment or tincture, painted over parts, 627 Lemon- or lime-juice, or citric acid, bene- ficial in nearly all cases, 627 Oil of gaultheria, useful as a substitute for salicylic acid, 625 Phenacetin, alone or with salol, 626 Potassium iodide, useful in subacute or ob- stinate types, prescription for, 626 Potassium nitrate, 263 Rhus toxicodendron, especially useful for night pains, 627 Salicylic acid, gr. 20 (1.3) thrice daily; if untoward symptoms arise must be stopped, 624 Salicylic acid, applied to joints in a salve when stomach is irritable, 624 Salol, useful as a substitute for salicylic acid ; dangerous in large doses, 617 Sodium bicarbonate (gr. 20 to the ounce [1.3 : 32.0]), applied on lint to inflamed joints, 623 Splints for fixation of limbs, may relieve greatlv, 624 Sulphur, 339 Veratrine ointment, useful locally, applied to joints, 627 RHEUMATISM (CHRONIC), 627 Arsenic, useful in some cases, 79 Baths of sulphides, often useful, 337 Cimicifuga, sometimes relieves, 148 Citrate of potassium or sodium, gr. 30 to 60 (2.0-4.0), before retiring, 314 Cod-liver oil. internally, in weakness or anamia, also useful rubbed into joints, 627 Ichthyol, the best remedy for joints, 629 Iodine, locally applied, 628 Liniments, prescriptions for, 628 Ointments, prescriptions for, 628 Potassium iodide, colchicum, and sarsa- parilla, usually indicated ; see prescrip- tion, 627 Turkish or Russian baths, very valuable, 628 Veratrine ointment, gives greatest relief in some cases, prescription for, 628 RHEUMATISM (MUSCULAR). Burgundy pitch, a mild local remedy, 303 Dover's powder, in conjunction with hot drinks and hot foot-bath, often cures, 281 Mustard, as a counter-irritant, 261 Veratrine ointment, locally applied, 354 RHINITIS. Creolin (1: 1000), as a nasal douche, 172 Fluid cosmoline, in spray, 291 Potassium permanganate, solution, in fatid rhinitis, 291 RICKETS, 629 Arsenite of copper, 629 Cinchona, for child of one year or more, prescription for, 630 Cod-liver oil, prescription for, 630 Cool sponging or rubbing with salt and whiskey (1 drachm to the pint [4.0 : 500 cc]), useful at night, 630 Iodide of iron, syrup of, if scrofulous tend- ency or anamia exists, prescriptions for, 630 Lime salts, phosphorus, zinc phosphate, as bone tonics, 629 Massage and passive movements, 630 Mineral acids, physostigma, and simple bitters, as digestive tonics, 629 Nux vomica, rarely given because of bitter- ness, 630 Phosphate of lime or sodium, gr. 1 to 2 (0.05-0.1), in child's milk, 630 Phosphorus (gr. T^ff [0.0006]), in sugar- coated pill, 630 Quinine, cod-liver oil, nux vomica, and iron as general tonics, 629 Sodium and lime salts, useful in nursing and pregnant women, 630 RINGWORM. (See Tinea Circinata.) SATYRIASIS. Potassium bromide, one of the best rem- edies, 97 SCABIES. Sulphur, the best remedy, 340 SCARLET FEVER, 631 Aconite, harmful, 47 Alcohol, indicated in collapse, 632 Antipyrine or acetanilid, may produce col- lapse in large doses, 633 Bromide of sodium, with chloral, useful when convulsion ushers in attack, 632 Carbolic acid (gtt. 2 [0.1] to olive oil oz. 2 [64.0]), beuzoated lard, vaseline, cosmo- line, or almond oil, useful, locally ap- plied, to allay itching, 633 Chloral, very useful, prescription for, 632 Chlorate of potassium, locally applied, by spray or swab, in sore throat, 633 Cold sponging, useful; pack must be em- ployed if fever is excessive, 633 Ice, applied externally and held in moufh, to prevent swelling of throat, 633 Ice-bag or rubber head-coil to head, if very hot, 633 Jalap, compound powder, with potassium bitartrate, or hot dry applications, to produce sweat, in nephritis, 634 INDEX OF DISEASE Juniper, in later stages, if there is renal atony,231 Pilocarpine, best agent to produce sweating in nephritis; contraindicated if heart is weak, 634 Potassium citrate and sweet spirit of nitre, prescription for, 632 Quinine, unsuccessful in most cases, 633 Salicylic acid, highly recommended, pre- scription for, 631 Strychnine, iron, simple bitters, quinine, or Basham's mixture, in convalescence, 634 Warm wet pack, useful to bring out rash, 633 Water, pure, such as Vichy or Poland, in large amounts, 632 SCIATICA, 634 Acetanilid and antipyrine, may prove use ful, 634 Acupuncture, recommended, 635 Cod-liver oil, of service in obstinate cases, 635 Chloroform, deeply injected over exit of nerve, a favorite remedy, 635 Ether or rhigolene, sprayed on part, often effective, 635 Kataphoresis, may be tried, 635 Liniments for rheumatism may be tried, 635 Massage of nerve with glass rod, 635 Morphine, injected over course of nerve, 634 Nerve-stretching, necessary in some cases, 635 Potassium bitartrate or citrate, gr. 40 (2.6), thrice daily, in plenty of water, to reg- ulate kidneys, 634 Potassium iodide, 213 Remedies for rheumatism, often relieve, 635 Salicylic acid, 314 Sulphur, 339 Wet cups, highly beneficial over course of nerve, 635 SCLERITIS, 635 Atropine, boric acid, aud hot-water com- presses, to control pain in early stage, 635 Eserine, with pilocarpine sweats or cautery, in stubborn episcleritis without iritis, 635 Yellow-oxide ointment, associated with massage, to subdue infiltration, 635 SCLEROSIS. Antipyrine, 73 Nitrate of silver, 265 SCROFULOSIS, 635 Arsenic or corrosive sublimate, useful if anamia is present, prescriptions for, 636 Calcium chloride, 105 Cod-liver oil, the best remedy, 636 Diet and exercise, 635 Europhen in scrofuloderm, 190 Excision, or scraping gland, and packing with iodoform gauze, if other treat- ments fail, 636 ■S AND REMEDIES. 735 Ichthyol ointment, useful, rubbed into per- sistent enlargements, prescription for, 636 Iodine ointment and lard, equal parts, rubbed into glands, stopping at first sign of reddening or fluctuation, 636 Iron, syrup of the iodide in anamia, pre- scription for, 636 Lactophosphates, or hypophosphates, with cod-liver oil, useful in young children, 636 Phosphate of sodium or lime, if glands are breaking down, 636 Sulphurate of calcium, if suppuration is active, 636 Thiol, recommended in scrofulous skin dis- eases, 347 SCURVY, 637 Arsenic and iron, of service in most cases, 637 Citric acid, if lemon-juice is not obtainable, 637 Diet, 637 Lemon- or lime-juice, particularly indi- cated, 637 SEA-SICKNESS. Bromides, the best prophylactics, 97 Nitrite of amyl, 58 SEAT-WORMS. (See Worms.) SHOCK, 637 Alcohol, 50 Atropine, gr. fa to fa (0.001), hypodermi- cally, with hot applications, very useful in first or second stage, 638 Digitalis, valuable as an adjuvant to atro- pine, 638 Heat, external, very useful, 638 Hypodermoclysis, useful, 638 SKIN DISEASES. Arsenic, in dry, scaly types, 78 Cod-liver oil, in strumous types, 161 Copper sulphate gr. fa (0.005), thrice daily, if arsenic is not well borne, 169 Corrosive sublimate, oz. £ (16.0), and am- monium chloride, oz. 1 (32.0), useful, added to bath in syphiloderm, 251 Hydrocyanic acid, in itching types, pre- scription for, 207 Ointment of yellow oxide and lard, in equal parts, a useful application, 257 Petrolatum, as an emollient dressing, 291 Tar and suet, equal parts, locally applied except on face, 304 Unguentum hydrargyri ammoniati, 250 Zinc-oxide ointment, 284 SMALLPOX, 638 Aconite, with spirits of nitre and Min- dererus, useful as a fever mixture, 639 Antipyrine or acetanilid, to control head- ache and backache, 639 Brandy and whiskey, if pulse fails, 639 Bromides and chloral, in insomnia; latteT used carefully, 639 Carbolic acid and sweet oil (1 : 100), as an ointment to check irritation, 639 Chlorate of potassium with tincture of myrrh, as a mouth-wash, 639 736 INDEX OF DISEASES AND REMEDIES. Flexible collodion, glycerite of starch, or simple cerate, locally applied, to prevent itching, 639 Iron, tincture of the chloride, to give strength and act as a specific, 639 Salicylic acid and vaseline, or cold cream (4 : 100), best local application, 639 Silver nitrate, locally applied, to prevent pitting, 639 SORDES. Glycerin and water, equal parts, useful as a mouth-wash, 197 SORES. Black wash, useful for syphilitic sores, 252 Camphor, locally applied, as a stimulant in indolent sores, 109 Charcoal, applied to old sores, as a deodor- ant and antiseptic, 121 Cold cream, as an emollient dressing, 311 Iodoform, gr. 20, with oil of eucalyptus, oz. £ (16.0), or iodoform, oz. £ (16.0), camphor, gr. 75 (5.0), and essence of roses, gtt. 2 (0.1), as a dressing for syph- ilitic sores, 220 Petrolatum, as an emollient dressing, 291 Potassium permanganate (gr. 60 to the pint [4.0 : 500 cc]), as a wash, 291 Quereus alba, powdered, as a poultice, to check discharge, 308 Red or yellow oxide of mercury, with chalk, equal parts, a good dressing for syphilitic sores, 257 Salicylic acid, ointment, 2 per cent, for sores from riding in a saddle, 315 Sulphuric acid, sometimes used as an es- charotic in venereal sores, 341 Zinc-oxide ointment, 284 SORE THROAT. Aconite, in early stage, 47 Alum (gr. 20 to the ounce [1.3 : 32.0]), lo- cally applied on swab, 57 Belladonna, of greatest service in some cases, 88 Capsicum, tincture of, and glycerin, equal parts, locally applied on a swab, 116 Carbolic acid (1:100), in spray, in ulcerated types, 120 Catechu, as a gargle or in troches, 126 Copper sulphate (gr. 4 to the ounce [0.2 : 32.0]), often of service in relaxed sore throat, 169 Hydrogen peroxide (2 per. cent, strength), in spray, in fatid types, 208 Kino, as a gargle, 232 Myrrh, tincture of, diluted one-half, as a gargle, in ulcerated types, 262 Quereus alba, useful as a gargle, 308 Quinine (gr 1 to 2 to the ounce [0.05-0.1 : 32.0]), in spray, in fatid sore throat, 152 Rhus glabra, with glycerin and water, use- ful as a gargle, 311 SPASMS. Belladonna, useful in urethral, anal, and vesical spasms, 87 Cannabis indica, useful in vesical spasm, 112 Conium, useful, if due to irritation of nerve-trunk, 166 Ether, inhalation, relieves local spasms, 186 Nitrite of amyl, of service to relax, 65 SPERMATORRHEA. (See Emissions.) SPRAINS, 639 Arnica, 76 Camphor liniment, 110 Cold applications, useful in sprained ankle, 367 Hot foot-bath, prolonged for hours, very useful in sprained ankle, 386 Ichthyol ointment, well rubbed in, very useful, 211 Lead-water and laudanum, 236 Soap liniment, 327 Soap plaster, used as a support to sprained joints, 327 Turpentine liniment, 352 STINGS AND BITES, 639 Ammonia or alkaline liquids, locally ap- plied to neutralize poison, 639 Carbolic acid (1 : 50 or 100), sponged over part, useful in mosquito-bites, 639 Corrosive sublimate, with flexible collodion (1 : 1000), painted over part; salicylic acid a useful addition, 639 Ligature, or cleansing of wound, at once, to prevent absorption in snake-bite, 640 Potassium permanganate, applied and in- jected around snake-bite, followed by alcohol in full dose, 640 Vinegar, dilute or pure, locally applied, often relieves insect-bites, 640 STOMATITIS, 640 Borax, as a mouth-wash, prescription for, 640 Bromide of potassium or sodium, gr. 1 to 3 (0.05-0.15), thrice daily, when nervous irritability is excessive, 641 Carbolic acid, as a mouth-wash, 120 Cocaine, locally applied, if spot is to be cauterized, 158 Nitrate of silver, stick touched to sore spots when they fail to yield to other treat- ment, 640 Nitric acid, gtt. 3 (0.15), in water, taken through tube, 267 Nitro-muriatic acid, indicated when he- patic torpor exists, 640 Peroxide of hydrogen, 640 Potassium chlorate, prescription for, 640 Salicylic acid (1 : 250), as a mouth-wash, after blisters have broken, to allay pain, 315 Salines or rhubarb, if constipation exists, 640 Sozoiodol (5 per cent, solution), locally ap- plied, 330 Sweet spirit of nitre, 10 drops (0.65), well diluted, to a one- or two-year-old child, and a Avarm foot-bath, before retiring, to produce rest, 641 Thymol, prescription for, 347 Tonics and careful diet after the attack, 641 INDEX OF DISEASES AND REMEDIES. 737 STYES, 641 Boric acid (saturated solution), collodion (ethereal solution), or red or yellow ox- ide of mercury salve (gr. 8 [0.6] to the drachm [4.0]), locally applied, to abort, 641 Calcium sulphurate, if they tend to return, 641 Hot compresses, to alleviate pain, 641 Incision, as soon as pus forms, 641 Tonics, if general health is poor, 641 SUBINVOLUTION OF UTERUS. (See In- volution, Anomalies of.) SUNBURN. Almonds, in emulsion, 54 SUNSTROKE, 641 Antipyretics, almost useless, 642 Hot baths (105° to 110° F.), or hot bottles or bricks, in heat exhaustion, 643 Ice, application to chest, back, and abdo- men, as quickly as possible, in thermic fever, 642 Salicylic acid, quinine, and similar drugs contraindicated, 642 Tonics, during convalescence in heat ex- haustion, 642 Venesection, best treatment, if meningitis threatens, after thermic fever, 642 Veratrum viride may be used if meningi- tis threatens, 642 SYNCOPE. Ammonia, if due to shock or indigestion, 60 SYNOVITIS. Carbolic acid (2 per cent, strength), as an injection in chronic types, 120 Counter-irritation, 377 SYPHILIS, 643 Bismuth and calomel, as a dusting-powder, or bichloride solution (1 : 2000), locally applied to mucous patches about geni- talia, 645 Calomel, gr. \ (0.011), every two hours, for cephalalgia, 645 Cod-liver oil, useful in advanced cases, 647 Expectant plan of treatment, 644 Hypodermic injections of mercury, 647 Iodides, followed if necessary by mercury, recommended by some, 644 Iodoform, gr. 1 to 5 (0.05-0.25), internally in tertiary stage, and the ointment ap- plied to ulcers, very useful, 220, 647 Mercury, at beginning of secondary stage, followed later by the iodides, the most commonly accepted treatment, 644 Mercury, by fumigation, general and local, 246 ' Mercury, with chalk, chiefly employed in infantile syphilis, 255 Mixed treatment, 646 Ointments and washes of mercury, and hot applications, to combat surface erup- tions, 645 Prescription for blue mass and iron, 646 Prescription for potassium iodide and mer- cury, to be used after first eighteen months, 646 Pressure bandage and mercurial inunctions for periostitis, 645 Russian baths, highly recommended, 390 Sarsaparilla, a useful adjunct to potassium iodide, 321, 648 Shampooing and local application of croton oil or cantharides, as a lotion, to com- bat alopecia, 645 Silver nitrate, copper sulphate, chromic acid, solution (20 per cent.), or acid ni- trate of mercury, locally applied to mu- cous patches in mouth, 645 Stillingia, used as an aid to other drugs, 333 Thiol, iu syphilides, 347 Tonic and general treatment, 647 Vapor baths, hypodermic injections, or in- unctions, useful modes of applying mer- cury, if it cannot be taken by mouth, 646 SYSTEMIC STRAIN. Opium, useful in prolonged physical strain, 281 Quinine, gr. 2 to 4 (0.1-0.2), useful to pre- vent exhaustion following physical and mental strain, 151 TABES DORSALIS. (See Locomotor Ataxia.) Chloralamide, 132 TAPE-WORM. (See Worms.) TEETHING. Bromide of potassium, to prevent convul- sions, 97 TETANUS. (See Poisoning from Strychnine.) Amyl nitrite, to relieve and prevent, 65 Chloral and bromide of potassium, by mouth or rectum, 130 Fowler's solution, said to be almost specific in some cases, 648 Physostigma, of moderate A'alue, 298 TINEA CAPITIS. Lime-water, locally applied, 108 TINEA CIRCINATA. Borax, strong solution, locally applied, 93 Iodine, applied with camel's-hair brush, 217 Turpentine, useful, applied with a brush, 252 TINEA TARSI. Copper, crystal, or weak solution, applied to diseased eyelid, 169 TINEA TONSURANS. Borax, strong solution, locally applied, 93 Iodine, applied with camel's-hair brush, 217 Oil of cajuput, applied pure, 104 TOE-NAIL (INGROWING). Absorbent cotton, soaked in strong alum solution, and inserted under nail, 58 Liquor potassa, to soften nail prior to pack- ing Avith cotton or partial evulsion, 239 47 738 INDEX OF DISEASES AND REMEDIES. TONSILLITIS, 648 Alum stick, deeply applied, 58 Carbolic acid, solution (1 : 100), as an anti- septic gargle, relieves pain and fator, 649 Glycerin and tincture of capsicum, equal parts, applied by swab, 197 Hydrogen peroxide (2 per cent, strength), in spray, in ulcerative types, 208 Ice-bag to throat and pieces of ice in mouth, also internally in full doses, 648 Iron, tincture of the chloride, locally ap- plied, 648 Monsel's solution, pure, applied with cam- el's-hair brush, 228 Nitrate of silver, applied locally, 648 Salicylates, are valuable in rheumatic cases, 649 TOOTHACHE. Creosote, applied on cotton, often relieves, 170 Oil of cloves, inserted into cavity on cot- ton, 156 Oil of peppermint, applied on cotton, 289 TORPOR. Ammonium chloride, in hepatic torpor, 63 Euonymus, in mild hepatic torpor, 189 Lactophosphates and hypophosphites, use- ful in hepatic torpor, 106 Nitro-hydrochloric acid, in torpor of liver, 270 Oxygen-water, after meals, useful in sys- temic torpor, 285 Potassium acetate, exceedingly useful in hepatic torpor, 43 Russian and Turkish baths, useful in tor- pidity of skin and kidneys, 388 Saline purgative, followed by fever mixture of aconite, sweet spirit of nitre, and po- tassium citrate, 646 Taraxacum, in hepatic torpor, 345 TORTICOLLIS. Belladonna, injected into muscle, 87 Gelsemium, 193 TREMOR. Hyoscine, 210 Sparteine, 324 TUBERCULOSIS, 649 Acetanilid, generally acts unfavorably, 42 Almonds, essential oil of, recommended in cough, 54 Alum (gr. 10 to 20 to the ounce [0.65-1.3 : 32.0]), or sulphuric acid (1 drachm to the pint [4.0 : 500 cc]), useful, sponged over body iu night-sweats, 652 Antipyrine, harmful, 72 Arsenic, in phthisical tendencies, 78 Atropine, gr. fa to fa, hypodermically, in excessive night-sweats, 652 Blister, small, useful over new pleuritic spots, 652 Camphoric acid, gr. 20 to 30 (1.3-2.0), in- valuable, 653 Cannabis indica, 112, 651 Carbolic acid (gtt. 5 to 15 to the ounce [0.3- 1.0 : 32.0]), in spray, 120 Chloroform, spirit of, used by inhaler, often relieves cough, 651 Climatic treatment, 399 Codeine, recommended in excessive cough, 160 Cod-liver oil, rules for its use, 650 Creosote, internally, in spray or by inhaler, often relieves cough and discomfort; contraindicated if fever and harnoptysis are present; prescription for, 650 Glycerin and water, equal parts, with lem- ou-juice, useful as a mouth-wash, 197 Hydrogen peroxide (2 per cent, strength), in fine spray in laryngeal phthisis, 208 Inhalations of steam from corrosive-subli- mate solution (1 : 10,000), stopping at first sign of mercurial effects, in laryn- geal phthisis; precede inhalation with cocaine spray (4 per cent, solution), 652 Iodine, useful, painted over new pleuritic spots, also useful in chronic cases as an inhalation, 217, 652 Iodoform with small amount of powdered talc and a little morphine, useful when puffed into the larynx in laryngeal tu- berculosis, 652 Iodoform emulsion (10 per cent.), useful in tubercular abscess, 220 Lactic-acid applications (10 to 60 per cent. solution), in laryngeal tuberculosis, using cocaine spray first to relieve pain, 652 Lactophosphates and hypophosphites, use- ful in some cases, 106 Morphine and wild-cherry bark, in cough, prescription for, 651 Opium, may be given in last stage, to re- lieve pain and discomfort, 281 Oxygen, inhalations in dyspnaa, 285 Pilocarpine, gr. fa (0.003), one to two hours before sweat, sometimes arrests; if it or atropine fails alone, give them together, 652 Potassium cyanide, in excessive cough, pre- scription for, 174, 651 Silver nitrate (gr. £ to 2 to the ounce [0.05- 0.1 : 32.0]), in spray, may be tried in laryngeal types, 265 Strychnine, in dyspnaa, 275 Sulphuric acid, internally, may relieve night-sweats, 652 TYPHOID FEVER, 653. (See Fever.) Acetanilid, generally acts unfavorably, 42 Alcohol, useful throughout course of dis- ease, 654 Asafatida, by rectal injections, in tympa- nites, 82 Brand's method of cold bathing, 656 Calomel, gr. £ (0.011), every fifteen min- utes, till gr. 1 (0.05) is taken, followed by magnesium sulphate, £ ounce (16.0), if constipation lasts two days, 655 Enemas, to be tried first, if constipation lasts over two days, 655 Glycerin and water, equal parts, with a little lemon-juice, as a mouth-wash, if sordes are present, 655 Hydrochloric acid, dilute, gtt. 5 (0.3), every few hours, or, if bowels are inactive, ni- tro-hydrochloric acid, gtt. 3 (0.15), 655 INDEX OF DISEASES AND REMEDIES. 739 Lime-water added to milk, if vomiting threatens, 655 Liquorice powder, drachm 1 (4.0), if con- stipation lasts over two days, 655 Morphine in large dose, if perforation oc- curs, 656 Phosphorus, if nervous system is affected, 297 Prescription for diarrhaa, 656 Quinine inferior to new antipyretics, 151 Rest and diet, 653 Silver nitrate, gr. \ to } (0.011-0.015), high- ly recommended, 265 Sulphocarbolate of zinc, useful, 337 Turpentine, in the form of stupes, enemata, or by mouth, in tympanites, also useful in later stage, to relieve diarrhaa, heal ulcers, and prevent relapse, 656 (For remedies for complications—intesti- nal hemorrhage, pneumonia, and pleurisy —see their titles.) ULCERS. Alcohol, a useful local application, 50 Aristol, 348 Benzoate of bismuth, as a dressing for in- doleut or sloughing ulcers, 89 Burnt alum, as a dressing for old ulcers, 58 Caustic potash, as an escharotic for exu- berant ulcers, 127 Chimaphila, said to be of service in stru- mous ulcers, 128 Copper, in solid or powder form, locally applied to indolent ulcers, 169 Creolin, solution (1 : 100), as a douche for nasal ulcers, 172 Europhen, iu 10 per cent, ointment, in leg ulcers, 190 Gallic-acid ointment, in actively discharg- ing ulcers, 192 Hamamelis, locally applied on a cloth, re- lieves leg ulcers, 201 Hot pack to increase activity of skin, 658 Hydrogen peroxide, a useful application, 2( >8 Lime, as an escharotic in old ulcers, 107 Nitric acid, as a caustic for phagedenic ulcers, or a solution (gtt. 5 to 30 to the ounce [0.3-2.0 : 32.0]), locally applied to indolent types, 267 Ointment of lead carbonate, as a dressing, 236 Potassium permanganate (gr. 60 to the pint [4.0 : 500 cc.]), as an antiseptic wash, 291 Precipitated carbonate of calcium, as a dry dressing, 105 Silver nitrate, in hard pills, for intestinal ulcers, and by injections for rectal and cacal ulcers, 264 Sulphuric acid, sometimes used as an es- charotic in slow ulcers, 341 URiEMIA, 657 Bromides for convulsions, 658 Chloral and chloroform for convulsions, Elaterium, thought to aid elimination of poison by the bowel, 179, 658 Hypodermoclysis, 658 Pilocarpine, a most efficient remedy, 301, 658 Strychnine, followed by digitalis, for heart failure, 658 Urethan for convulsions, in large doses, 658 Venesection, very useful, 658 URIC-ACID DIATHESIS. Acetate of potassium, 44 Lime-water, 107 Piperazine in the dose of 15 grains (1.0) a day in 1 pint (500 cc.) of water, 302 Prescription for prevention of formation of calculi, 94 URTICARIA. Ichthyol, ointment, highly recommended, 211 UVULA (RELAXED). Capsicum, tincture of, and glycerin, equal parts, as a gargle, 116 Kino, as a gargle, 23l VARICOCELE. Cold water, applied by bidet, highly recom- mended, 374 VARICOSE VEINS. Barium chloride, internally and locally ap- plied, said to be of value, 83 Hamamelis, useful internally or injected into part, 201 VITREOUS DISEASES, 658 Antisyphilitic treatment, if due to syph- ilis, 659 Galvanism, 659 Leeches, in early stage, if due to inflam- mation, 659 Pilocarpine, hypodermically, 659 VOMITING, 659 Bismuth and aconite may be of service, prescription for, 660 Bromide of sodium or potassium, with lauda- num, as a rectal injection in obstinate cases, prescription for, 98, 660 Calomel, 254 Carbolic acid, with bismuth, useful in acid- ity and fermentation, prescription for, 660 Chloroform, gtt. 1 to 2 (0.05-0.1), in water, 660 Cloves, oil of, sometimes controls, 156 Cocaine or aconite, if due to hyperexcita- bility of stomach, 660 Enemas, partially digested, if vomiting is incoercible, 662 Fowler's solution, gtt. £ to 1 (0.025-0.05), every two hours, useful in nausea fol- lowing debauch, also in other cases, instead of ipecac or nux vomica, 661 Hydrochloric acid, gtt. 5 to 15 (0.3-1.0), in water, every two hours, in alcoholic nausea, 661 Hydrocyanic acid, dilute, gtt. 2 to 6 (0.1- 0.3), in water, 95, 660 Ice-bag, to nape of neck, lumbar region, or epigastrium, 661 Iodine and carbolic acid, gtt. 1 (0.05) of each in gij (8.0) of water, 660 Ipecac, in small doses, if due to gastric de- pression, 661 740 INDEX OF DISEASES AND REMEDIES. Lime-water, added to milk, may relieve nausea, 661 Mustard plaster, over stomach, useful iu all cases, 661 Nitro-glycerin, very useful in some cases, 661 Nux vomica, if due to gastric depression, prescription for, 661 Oxygen-water, of great service, 285 Peptonized milk, best food, 661 Podophyllin, useful in gastric depression and hepatic torpor, 305 Seidlitz powder, often settles stomach, if due to constipation, 324 VOMITING OF PREGNANCY. Aconite, as a nervous sedative, 47 Arsenic, may be tried, 79 Bromide of potassium, as an effervescing draught, or with opium by enema, pre- scriptions for, 98 Cerium oxalate, gr. 2 to 5 (0.1-0.25), in pill, every four or five hours, 127 Cocaine, useful to decrease irritability, 158 Iodine, tincture of, largely used of late with good results, 218 Ipecac wine, gtt. 1 (0.05), or powder, gr. 2 (0.1), useful in some cases, 222 Menthol, very useful, 289 WARTS. Acetic and salicylic acids combined, 44 Chromic acid (gr. 100 to the ounce [6.5 : 32.0]), locally applied, to remove, 146 Fowler's solution, locally applied, 80 Glacial acetic acid, useful to remove, 44 Nitric acid, as a caustic, 267 Trichloracetic acid, useful, 349 WHITE SWELLING. Iodine, 217 WHOOPING COUGH, 662 Aconite or veratrum viride, if vascular en- gorgement is excessive, 662 Amber, oil of, 58 Amyl nitrite, when paroxysms interfere with respiration, 662 Antipyrine, gr. £ to 3 (0.025-0.15), every five hours, probably the best remedy, 662 Belladonna, tincture of, gtt. £ (0.025), thrice daily, to child of one or two years, 662 Benzine, 662 Bromoform, prescription for, 100, 663 Bronchitis tent, to modify severity of at- tacks, 663 Cannabis indica, sometimes of service, 113 Carburetted hydrogen, 662 Chloral, 131 Chloride of gold and sodium has been rec- ommended, 197 Chloroform, a few whiffs, if paroxysms in- terfere with respiration, 663 • Gelsemium, 193 Hyoscyamus, probably better than bella- donna, 209 Milk, in small amounts, may overcome vomiting following paroxysms, 663 Monobromated camphor, 111 Prescription for, 285 Quinine (gr. 1 to the ounce [0.05 : 32.0]), in spray, useful, also of service in ex- posed children as a prophylactic, 151 Resorcin, gtt. 10 (0.65), of a 2 per cent, so- lution, internally, or, better, iu spray, 308 Silver nitrate (gr. £ to 1 to the ounce [0.025- 0.05 : 32.0]), in spray, used when stom- ach is empty, 264 WORMS, 663 Aspidium, very efficient against tape-worm, prescription for, 83 Azedarach, a useful remedy against round- worms, 83 Brayera, as an infusion, or fluid extract, against round-worms, 663 Calomel, should follow or precede all drugs used for tape-worm, 664 Castor oil, or a saline purgative, should fol- low remedies for round-wTorms, 664 Chenopodium, oil of, gtt. 5 to 20 (0.3-1.3), on sugar, to remove round-worms, 663 Chloroform, should not be used against tape-worm, 146 Kamala, drachms 1 to 2 (4.0-8.0), in syrup, against tape-worm, 232 Koosin, gr. 40 (2.6), to adult, against round- worms, contraindicated in pregnant women, 664 Pelletierine, gr. 1 to 2 (0.05-0.1), in capsule, best remedy against tape-worm, 664 Pepo, ounce 2 (64.0), in confection, against tape-worm, 664 Quassia injections, preceded by soap and water, most useful remedy against seat- worms, 307 Rue, should not be used against round- worms, 312 Rules for diet preceding taniacides, 663 Salicylic acid, gr. 8 (0.6), hourly, till gr. 40 (2.6) are taken, against round-worms, or as an injection against seat-worms, prescription for, 315 Santonin, gr. i to £ (0.016-0.03), in troches, for child, against round-worms, 663 Spigelia, alone, or, better, with senna, to remove round-worms, 663 Turpentine and castor oil, equal parts, efficient, but somewhat dangerous, against tape-worm, 351 WOUNDS. Collodion, as an air-tight dressing for small wounds, 164 Potassium permanganate (gr. 20 to 60 to the pint [1.3-4.0 : 500 cc]), as an anti- septic wash, 291 Sozoiodol, as an antiseptic and disinfectant in diseased wounds, 330 LEA BROTHERS & GO'S CLASSIFIED CATALOGUE OF Medical m Surgical ;I Publications. a a> j]N ASKING the attention of the profession to the works advertised in the follow- 0< . V ing pages, the publishers would state that no pains are spared to secure a qj fq continuance of the confidence earned for the publications of the house G> ft +Ji —' by their careful selection and accuracy and finish of execution. ® ^ The printed prices are those at which books can generally be supplied by booksellers . '"* *-J throughout the United States, who can readily procure for their customers any works not ^>+jj kept in stock. 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J ,oe/- a/wu/n. £'-£ g THE HEDICAL NEWS VISITING LIST (4 styles, see page 3), $125. §5 8, +j CO With either or both above periodicals, in advance, 75c * «^ 5 THE YEAR-BOOK OF TREATMENT (see page 16), $1.50. With either < O — JOURNAL or NEWS, or both, 75c Or JOURNAL, NEWS, VIS- ITING LIST AND YEAR=BOOK, in all $10.75. for $8.50 in advance. Practical Medical Periodicals. Subscription Price Reduced to $4.00 Per Annum. THE MEDICAL NEWS. Y KEEPING closely in touch with the needs of the active practitioner,^ The News has achieved a reputation for utility so extensive as to render practicable its reduction in price from five to Four Dollars per annum. It is now by far the cheapest as well as the best large weekly medical journal published in America. Employing all the recognized resources of modern journalism, such as the cable telegraph, resident correspondents, special reporters, etc., The News supplies in the 28 quarto pages of each issue the latest and best information on subjects of importance and value to practitioners in aU branches of medicine. The foremost writers, teachers and practitioners of the day furnish original articles, clinical lectures and notes (Continued on next page.) 2 Medical Periodicals, Visiting List, Ledger. THE HEDICAL NEWS===Continued. on practical advances; the latest methods in leading hospitals are constantly reported; a condensed summary of progress is gleaned each week from a large exchange list, com- prising the best journals at home and abroad; a special department is assigned to abstracts requiring full treatment for proper presentation; editorial articles are secured from writers able to deal instructively with questions of the day; books are carefully reviewed; society proceedings are represented by the pith alone; regular correspondence is furnished from important medical centres, and minor matters of interest are grouped each week under news items. In a word The Medical News is a crisp, fresh, weekly professional newspaper and as such occupies a well-marked sphere of usefulness, distinct from and complementary to the ideal monthly magazine, The American Journal of the Medical Sciences.______________________ The American Journal i Published Monthly of the i at $4.00 Medical Sciences ♦ The American Journal entered with 1894 upon its seventy-fifth year, still main- taining the foremost place among the medical magazines of the world. ^ A vigorous existence during two and a half generations of men amply proves that it has always adapted itself to meet fully the requirements of the time. 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Subscribers can obtain, at the close of each volume, cloth covers for The Journal (one annually), and for The News (one annually), free by mail, by remitting Ten Cents for The Journal cover, and Fifteen Cents for The News cover. The Medical News Visiting List for 1894 Is published in four styles, Weekly (dated for 30 patients); Monthly (undated, for 120 patients per month) ; Perpetual (undated, for 30 patients weekly per year); and Per- petual (undated, for 60 patients weekly per year). The 60-patient Perpetual consists of 256 pages of assorted blanks. The first three styles contain 32 pages of important data and 176 pages of assorted blanks. Each style is in one wallet-shaped book, leather- bound, with pocket, pencil, rubber, and catheter-scale. Price, each, $1.25. This list is all that could be desired. It con- tains a vast amount of useful information, especi- ally for emergencies, and gives good tables of doses and therapeutics.—Canadian Practitioner. Its compactness and simplicity are such as to indicate that the highest point of perfection has been reached in works of this class.— University Medical Magazine. The new issue maintains its previous reputation. ; adapts itself to every style of book-keeping; there is space for all kinds of professional records; it is furnished with a ready reference thumb-letter index, and has a most valuable text.—Medical Record. For convenience and elegance it is not surpass- able.—Obstetric Gazette. SPECIAL COMBINATIONS WITH THE VISITING LIST, see p. 1. JgyThe safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned; where these are not accessible, remittances for subscriptions may be sent at the risk of the publishers by forwarding in registered letters addressed to the Publishers (see below). The Medical News Physicians' Ledger. 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D., Professor Pathology and Practice of Medicine, Medical Department, Univer- sity City of New York, New York. It seems to me entirely satisfactory for the pur- pose for which it is intended. From J. C. Wilson, M. D., Professor of Medicine, Jefferson Medical College, Philadelphia. It appears to be well suited to the purposes of the medical student, being simple as regards deri- vations and pronunciation, explicit yet sufficiently comprehensive in definitions, and thoroughly up to the times. From James T. Whittaker, M. D., Professor Theory and Practice of Medicine, Medical College of Ohio, Cincinnati, O. I find it admirably adapted to the wants of stu- dents, and thoroughly modern in every particular in which I have taken occasion to consult it. I shall certainly recommend it to my class. THE STUDENTS' QUIZ SERIES. ANEW Series of Manuals, comprising all departments of medical science and practice, and prepared to meet the needs of students and practitioners. Written by promi- nent medical teachers and specialists in New York, these volumes may be trusted as authoritative and abreast of the day. Cast in the form of suggestive questions, and concise and clear answers, the text will impress vividly upon the reader's memory the salient points of his subject. To the student these volumes will be of the utmost service in pre- paring for examinations, and tbey will also be of great use to the practitioner in recalling forgotten details, and in gaining the latest knowledge, whether in theory or in the actual treatment of disease. Illustrations have been inserted wherever advisable. Bound in limp cloth, and in size suitable for the hand and pocket, these volumes are assured of enormous popularity, and are accordingly placed at an exceedingly low price in com- parison with their value. For details of subjects and prices see below. ANATOMY (Double Number) — By Feed J. Brockway, M. D., Assistant Demonstrator of Anatomy, College of Physicians and Surgeons, New York, and A. O'Malley, M.D., Instructor in Surgery, New York Polyclinic. $1.75. PHYSIOLOC Y—By F. A. Manning, M. D., Attending Surgeon, Manhattan Hosp.,N.Y. $1. CHEMISTRY AND PHYSICS—By Joseph . Steuthers, Ph. B., Columbia College School of Mines, N.Y., and D. W. Ward, Ph. B., Columbia College School of Mines, N. Y., and Chas. H. Willmarth, M. S., N. Y. $1. HISTOLOCY, PATHOLOCY AND BAC- TERIOLOCY—By Bennett S. Beach, M. D., Lecturer on Histology, Pathology and Bacte- riology, New York Polyclinic. SI. MATERIA MEDICA AND THERAPEU- TICS—By L. F. Warnee, M. D., Attending Phvsician.St. Bartholomew's Disp., N.Y. $1. PRACTICE OF MEDICINE, INCLUDINC NERVOUS DISEASES—By EdwinT.Dou- bleday, M.D., Member N.Y. Pathological Soci- ety, and J. D. Naoel, M.D., Member N. Y. County Medical Association. SI. SURCERY (Double Number)—By Bern B. Gal- latoet, M. D., Visiting Surgeon Bellevue Hospital, N.Y., and Charles Dixon Jones, M. D., Assistant Surgeon Out-Patient Department, Presbyterian Hospital, N. Y. S1.75.__________ CENITO - URINARY AND VENEREAL DISEASES—By Charles H. Chetwood, M.D., Visiting Surgeon, Demilt Dispensary, Dep. of Surg, and Gen.-Urin. Dls., New York. SI. DISEASES OF THE SKIN—By Charles C. Ransom, M. D., Assistant Dermatologist, Van- derbilt Clinic, New York. $1. DISEASES OF THE EYE, EAR, THROAT AND NOSE—By Frank E. Miller, M.D., Throat Surgeon, Vanderbilt Clinic, New York, James P. McEvoy, M.D., Throat Surgeon, Belle- vue Hosp., Out-Patient Dep., New York, and J. E. Weeks, M. D., Lect. on Ophthal. and Otol., Bellevue Hosp., Med. Col., N. Y. 81. OBSTETRICS—By Charles W. Hayt, M.D., House Physician, Nursery and Child's Hospi- tal, New York. $1. CYN ECOLOGY— By G. W. Beatenahl, M. D., Assistant in Gynecology, Vanderbilt Clinic, New York, and Sinclair Tousey, M. D., Assist- ant Surgeon, Out-Patient Department, Roose- velt Hospital, New York. $1. DISEASES OF CHI LDREN-ByC. A. Rhodes, M. D., Instructor in Diseases of Children, New York Post-Graduate Medical College. 81. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 4 Dictionaries. NEW (21st) EDITION. THOROUGHLY REVISED. JUST READY. Dunglison's Dictionary OF MEDICAL SCIENCE. With the Pronunciation. Accentuation and Derivation of the Terms. Containing a full Explanation of the various Subjects and Terms of Anatomy, Physiology, Medical Chemistry, Pharmacology, Pharmacy, Therapeutics, Medicine, Hygiene, Dietet- ics, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology, Obstetrics, Pediatrics," Medical Jurisprudence and Dentistry, etc., etc. By Robley Dunglison, M. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Phila- delphia. New (21st) edition, thoroughly revised and greatly enlarged. With the Pro- nunciation, Accentuation and Derivation of the Terms, by Richabd J. Dunglison, A.M., M.D. In one very large and handsome royal octavo volume of 1191 pages. Cloth, $7.00; leather, raised bands, $8.00. Thumb-letter Index for quick use, 75 cents extra. THIS great medical dictionary, which has been for more than two generations the standard of the English-speaking race, is now issued in a thoroughly revised and greatly enlarged and improved edition. The new words and phrases aggregate by actual count over 44,000. Though the new edition contains far more matter than its predecessor, the whble is accommodated within a volume convenient for the hand. The revision has not only covered every word, but it has resulted in a number of important new features designed to confer on the work the utmost usefulness, and to make it answer the most advanced demands of the times. Pronunciation has been introduced throughout by means of a simple and obvious system of phonetic spelling. At a glance the proper sound of a word is clearly indicated, and thus a most important desideratum is supplied. Derivation affords the utmost aid in recollecting the meanings of words, and gives the power of analyzing and understanding those which are unfamiliar. It is indicated in the simplest manner. Greek words are spelled with English letters, and thus placed at the command of those unfamiliar with the Greek alphabet. Definitions, the essence of a dictionary, are clear and full, a characteristic in which this work has always been preeminent. In this edition much explanatory and encyclopedic matter has been added, especially upon subjects of practical importance. Thus under the various diseases will be found their symptoms, treatment, etc.; under drugs their doses and effects, etc., etc. A vast amount of information has been clearly and conveniently condensed into tables in the alphabet. In a word, Dunglison's Medical Dictionary, in its remodelled and enlarged shape, is equal to all that the student and practitioner can expect from such a work. The new " Dunglison" is new indeed. The vast amount of new matter and the thoroughness with which the work has been brought down to date cannot fail to strike even the least observant reader. The immense advances made in all branches of medical science here find represen- tation. A prominent and very useful feature of the old book is retained and amplified in this—we mean the tables, which recur with great fre- quency and represent a vast amount of condensed information. In respect to accuracy the book quite equals and usually surpasses any of its contempo- raries that we are acquainted with. The new "Dunglison" has been brought down to date, so as to represent adequately the latest advances in medical science.— The American Journal of the Medical Sciences, January, 1894. The subjects and terms contained in this edition, over and above those In the last, amount by actual count to forty-four thousand. We notice that a system of pronunciation has for the first time been introduced into the work—a valuable ad- dition, we think. So fully have derivations and definitions been considered, and so great is the amount of practical matter, such as symptoms,. treatment and prognosis of many of the diseases described, that the volume is entitled to be called an encyclopedia rather than a dictionary. The reviser has elaborated the fundamental purpose of the distinguished author, "to make ;the work not a mere lexicon of terms, but to afford under each a condensed view of its various medical re- lations, and thus to render the work an epitome of the existing conditions of medical science."—The Brooklyn Medical Journal, June, 1894. It has been the standard of reference for medical scholars for over a half-century. The twenty-first edition comes to us thoroughly re- vised and greatly enlarged, with new features treating of pronunciation, accentuation and deri- vation of terms. Covering the entire field of medicine, surgery and the collateral sciences, its range of usefulness can scarcely be measured. Perhaps the most valuable feature in the present work is the addition of a vast amount of praeticajt matter. The type is commendably clear. We predict for the book another term of usefulness. —Medical Record, February 24,1894. The National Medical Dictionary, Including English, French, German, Italian and Latin Technical Terms used in Medicine and the Collateral Sciences, and a Series of Tables of Useful Data. By John S. Billings, M. D., LL. D., Edin. and Harv., D. C. L., Oxon., member of the National Academy of Sciences, Surgeon (J. S. A., etc. In two very handsome royal octavo volumes containing 1574 pages, with two colored plates. Per volume—cloth, $6.00: leather, $7.00; half morocco, marbled edges, $8.50. Subscription only. Address the publishers. The work is remarkable for its fulness. It pres- ents to the English reader a thoroughly scientific mode of acquiring a rich vocabulary and offers an accurate and ready means of reference in consult- ing works in any of the three modern continental languages which are richest in medical literature. Apart from the boundless stores of information which may be gained by the study of a good diction- ary, one is enabled by the work under notice to read intelligently any technical treatise in any of the four chief modern languages. There cannot be two opinions as to the great value of this dictionary as a book of ready reference for all sorts and condi- tions of medical men.—London Lancet, Apr., '90. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Anatomy, Dictionary. NEW (THIRTEENTH) EDITION. JUST READY. GRAYS ANATOMY IN COLORS OR IN BLACK. Anatomy, Descriptive and Surgical, BY HENRY GRAY, P. R. S., lecturer on anatomy at st. georqe's hospital, london. Edited by T. PICKEEING PICK, F. E. C. S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of Surgeons of England. , A new American from the thirteenth enlarged and improved London edition. In one imperial octavo volume of 1118 pages, with 636 large and elaborate engravings on wood. Price, with illustrations in colors, cloth, $7 ; leather, $8. Price, with illustrations in black, cloth, $6; leather, $7. SINCE 1857 Gray's Anatomy has been the standard work used by students of medicine and practitioners in all English-speaking races. So preeminent has it been among the many works on the subject that thirteen editions have been M?qU]lre meet the aemand- This opportunity for frequent revisions has been fully utilized and the work has thus been subjected to the careful scrutiny of many of the most distinguished anatomists of a generation, whereby a degree of completeness and ac- curacy has been secured which is not attainable in any other way. In no former revision has so much care been exercised as in the present to provide for the student all the assistance that a text-book can furnish. The engravings have always formed a distin- guishing feature of this work, and in the present edition the series has been enriched and rendered complete by the addition of many new ones. The large scale on which the illustrations are drawn and the clearness of the execution render them of unequalled value in affording a grasp of the complex details of the subject. As heretofore the name of each part is printed upon it, thus conveying to the eye at once the position, extent and relations of each organ, vessel, muscle, bone or nerve with a clearness impossible when figures or lines of reference are employed. Distinctive colors have been utilized to give additional prominence to the attachments of muscles, the veins, arteries and nerves. For the sake of those who prefer not to pay the slight increase in cost necessitated by the use of colors, the volume is published also in black alone. The illustrations thus constitute a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room. Combining as it does a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers a more extended range of subjects than is customary in the ordinary text-books. It not only answers every need of the student in laying the groundwork of a thorough medical education, but owing to its application of anatomical details to the practice of medicine and surgery, it also furnishes an admirable work of reference for the active practitioner. itself a complete atlas of anatomy. Dear to so We always had a kindly regard for the illustra- tions in Gray, where each organ, tissue, artery, and nerve bear their respective names, and in this edi- tion color has been worked to advantage in bring- ing out the relationship of vessel and nerve. Of late years, many worKs on anatomy have been intro- duced to the profession, but as a reference book for the practical everyday physician, and as a text-book for the student, we think it will be difficult to sup- plant Gray.—Buffalo Med. and Surg. Jour., Jan., 1894. No book deals with the complex subject so sys- tematically, or presents the material in a way better fitted for the student to memorize.—Inter- national Medical Magazine, Dec. 1893. It embraces the whole of human anatomy, and it particularly dwells on the practical or applied part of the subject, so that it forms a most useful. intelligible and practical treatise for the student and general practitioner.—Dublin Journal of Medi- cal Science, December, 1893. In modern times no book on any medical sub- ject has held the position of a standard so long as Gray's Anatomy. For logical arrangement, clear, terse, pointed, and yet full description, it is the peer of any work on any scientific subject. A pioneer in helpful drawings, it is still in the van and leads in every improvement. Indeed, it is of many thousands for old and helpful associations, it will be no hard task for Gray to remain in the lead so long as it shall find revisers comparable in aptitude to the present editor. The physician or student who requires but one work on anatomy will not need to ask which, nor will those who will have more than one need to ask which one to add. The work is admitted to be easily first on anatomy in any language.—The American Practitioner and News, June, 1894. Gray's has been the unvarying standard for anatomical study by the vast majority of English- speaking medical students for so long that it would seem an anomaly to see a student acquire such knowledge from some other source.—Medi- cal Fortnightly, February, 1894. Few treatises can claim such a record of endur- ance of usefulness. To say that it still maintains its reputation is to give it the highest compliment within the range of the critic's privilege. It has grown and strengthened with the advancements and requirements of the modern knowledge of anatomy, enlarging its scope for newer adapta- tions in surgery and physiology.—Medical Record, March 3,1894. HOBLYN'S DICTIONARY OF MEDICINE. A Dictionary of the Terms Used in Medicine and the Collateral Sciences. By Richard D. Hobltn, M. D. In one large royal 12mo. volume of 520 double- columned pages. Cloth, $1.50; leather, $2.00. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 6 Anatomy, Physiology. HUMAN MONSTROSITIES BY BARTON C. HIRST, M. D., and GEORGE A. PIERSOL, M.D. Professor of Obstetrics in the University Professor of Anatomy and Embryology of Pennsylvania. in the University of Pennsylvania. Magnificent folio, containing 220 pages of text, illustrated with engravings, and 39 full-page, photographic plates from nature. In four parts, price, each, $5. Complete work just ready. Limited edition, for sale by subscription only. Address the Publishers. We have before us the fourth and last part of the latest and best work on human monstrosi- ties. This completes one of the masterpieces of American medical literature. Typographically and from an artistic standpoint, the work is un- exceptionable. In this last and final volume is presented the most complete bibliography of teratological literature extant. No library will be complete without this magnificent work.—Jour- nal of the American Medical Asso., May 6,1893. Altogether, Human Monstrosities is a satisfactory production. It will take its place as a standard work on teratology in medical libraries, and it must always retain the honor of being the first of its kind written in the English language.— The British Medical Journal, May 27,1893. This work promises to be one for which a place must be found in the library of every anatomist, pathologist, obstetrician and teratologist. It is the joint production of an obstetrician, and an embry- ologist, and histologist, and this fact makes it certain that both the obstetric and anatomical sides of the subject will be fully represented and described. The book promises to be one of the greatest value to the English-speaking medical world.—Edinburgh Medical Journal, April, 1892. Allen's System of Human Anatomy. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. By Harrison Allen, M. D., Professor of Physiology in the University of Pennsylvania. With an Introductory Section on Histology by E. O. Shakespeare, M. D., Ophthalmologist to the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 illustrations on 109 full page lithographic plates, many of which are in colors, and 241 engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50; also bound in one volume, cloth, $23.00; very handsome half Eussia, raised bands and open back, $25.00. For sale by subscription only. Address the Publishers. Holden's Landmarks, Medical and Surgical. Landmarks, Medical and Surgical. By Luther Holden, F. E. C. S., Surgeon to St. Bartholomew's Hospital, London. Second American from the third and revised English ed., with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in the Penna. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00. Clarke & Lockwood's Dissector's Manual. The Dissector's Manual. By W. B. Clarke, F. E. C. S., and C. B. Lock- wood, F. E. C. S., Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. Messrs.Clarke and Lockwood have written a book that can hardly be rivalled as a practical aid to the dissector. Their purpose,which is "how to de- scribe the best way to display the anatomical structure," has been fully attained. They excel in a lucidity of demonstration and graphic terseness of expression, which only a long training and intimate association with students could have fiven. With such a guide as this, accompanied y so attractive a commentary as Treves' Surgical Applied Anatomy (same series), no student could fail to be deeply and absorbingly interested in the study of anatomy.—New Orleans Medical and Sur- gical Journal, April ,1884. Treves' Surgical Applied Anatomy. Surgical Applied Anatomy. By Frederick Treves, F. E. C. S., Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. In one pocket- size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, p. 30. Bellamy's Surgical Anatomy. The Student's Guide to Surgical Anatomy: Being a Description of the most Important Surgical Eegions of the Human Body, and intended as an Introduction to Operative Surgery. By Edward Bellamy, F. E. C. S., Senior Assistant-Surgeon to the Charing-Cross Hospital. In one 12mo. vol. of 300 pages, with 50 illus. Cloth, $2.25. Wilson's Human Anatomy. A System of Human Anatomy, General and Special. By Erasmus Wilson, F. E. S. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00; leather, $5.00. HARTSHORNE'S handbook of anatomy AND PHYSIOLOGY. Second edition, revised. 12mo., 310 pages, 220 woodcuts. Cloth, $1.76. HORNER'S SPECIAL ANATOMY AND HISTOL- OGY. Eighth edition. In two octavo volumes of 1007 rageo, with 320 woodcuts. Cloth. $6.00. CLELAND'S DIRECTORY FOR THE DISSEC- TION OF THE HUMAN BODY. 12mo., 178 pp Cloth, $1.25. F Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Physics, Physiology, Anatomy, Chemistry. 7 Draper's Medical Physics. Medical Physics. A Text-book for Students and Practitioners of Medicine. By John C. Draper, M. D., LL. D., Prof, of Chemistry in the Univ. of the City of New 1 ork. In one octavo vol. of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. No man in America was better fitted than Dr. Draper for the task he undertook and he has pro- vided the student and practitioner of medicine with a volume at once readable and thorough. Even to the student who has some knowledge of physics this book is useful, as it shows him its applications to the profession that he has chosen. Dr. Draper, as an old teacher, knew well the diffi- culties to be encountered in bringing his subject within the grasp of the average student, and that he has succeeded so well proves once more that the man to write for and examine students is the one who has taught and is teaching them. The book is well printed and fully illustrated, and in every way deserves grateful recognition.—The Montreal Medical Journal, July, 1890. Reichert's Physiology.—Preparing. A Text-Book on Physiology. By Edward T. Eeichert, M. D., Professor of Physiology in the University of Pennsylvania, Philadelphia. In one very handsome octavo volume of 800 pages, fully illustrated. Power's Human Physiology.—Second Edition. Human Physiology. By Henry Power, M. B., F. E. C. S., Examiner in Physiology, Eoyal College of Surgeons of England. Second edition. In one 12mo. vol. of 509 pp., with 68 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 30. Robertson's Physiological Physics. Physiological Physics. By J. McGregor Eobertson, M.A., M. B., Muirhead Demonstrator of Physiology, University of Glasgow. In one 12mo. volume of 537 pages, with 219 illus. Limp cloth, $2. See Students' Series of Manuals, page 30. The title of this work sufficiently explains the I ments. It will be found of great value to the nature of its contents. It is designed as a man- practitioner. It is a carefully prepared book of ual for the student of medicine, an auxiliary to reference, concise and accurate, and as such we histext-bookinphysiology.anditwouldbeparticu- heartily recommend it.—Journal of the American larly useful as a guide to his laboratory experi- | Medical Association, Dec. 6,1884. Dalton on the Circulation of the Blood. Doctrines of the Circulation of the Blood. A History of Physio- logical Opinion and Discovery in regard to the Circulation of the Blood. By John C. Dalton, M. D., Professor Emeritus of Physiology in the College of Physicians and Sur- geons, New York. In one handsome 12mo. volume of 293 pages. Cloth, $2. Dr. Dalton's work is the fruit of the deep research of a cultured mind, and to the busy practitioner it cannot fail to be a source of instruction. It will inspire him with a feeling of gratitude and admir- ation for those plodding workers of olden times, who laid the foundation of the magnificent temple of medical science as it now stands.—New Orleans Medical and Surgical Journal, Aug. 1885. Bell's Comparative Anatomy and Physiology. Comparative Anatomy and Physiology. By F. Jeffrey Bell, M. A., Professor of Comparative Anatomy at King's College, London. In one 12mo. vol. of 561 pages, with 229 illustrations. Limp cloth, $2. See Students' Series of Manuals, page 30. The manual is preeminently a student's book— clear and simple in language and arrangement. It is well and abundantly illustrated, and is read- able and interesting. On the whole we consider it the best work in existence in the English language to place in the hands of the medical student.—Bristol Medico-Chirurgical Journal, Mar. 1886. Ellis' Demonstrations of Anatomy.—Eighth Edition. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy in University College, London. From the eighth and revised London edition. In one very handsome octavo volume of 716 pages, with 249 illus. Cloth, $4.25; leather, $5.25. Roberts' Compend of Anatomy. The Compend of Anatomy. For use in the dissecting-room and in pre- paring for examinations. By John B. Eoberts, A. M., M. D., Lecturer in Anatomy in the University of Pennsylvania. In one 16mo. vol. of 196 pages. Limp cloth, 75 cents. WOHLER'S OUTLINES OF ORGANIC CHEM- ISTRY. Edited by Fittio. Translated by Ira Remsen, M. D , Ph. D. In one 12mo. volume of LEHMAN'S MANUAL OF CHEMICAL PHYS- IOLOGY. In one octavo volume of 327 pages, with 41 illustrations. Cloth, $2.25. CARPENTER'S HUMAN PHYSIOLOGY. Edited bv Henry Poweb. In one octavo volume. CARPENTER'S PRIZE ESSAY ON THE USE AND Abuse of Alcoholic Liquors in Health and Dis- ease. With explanations of scientific words. Small 12mo. 178 pages. Cloth, 60 cents. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 8 Physiology—(Continued), Chemistry. Foster's Physiology.—New (5th) American Ed. Just Ready. Text-Book of Physiology. By Michael Foster, M. D., F. E. S., Prelec- tor in Physiology and Fellow of Trinity College, Cambridge, England. New (fifth) and enlarged American from the fifth and revised English edition, with notes and additions. Intone handsome octavo vol. of 1083 pages, with 316 illus. Cloth, $4.50; leather, $5.50. has escaped his painstaking attention. The details receive the fullest consideration. The additions which have been made to this last edition are caused by an effort to explain more fully and at greater length what seemed to be the most funda- mental and important topics. The publishers have subjected it to the searching revision of one of the foremost American professors of physio- logy. We have nothing but words of the highest praise for the classical and thorough manner in which the work is written, as well as for the liber- ality of the publishers for selling such a large work, and one which must necessarily be very costly to produce, for an extremely moderate price.—The Canada Medical Record, March, 1894. This is the standard work on physiology, bein most thorough and complete in all branches and details; moreover it contains considerable mate- rial which has never before been presented to the medical public. Evidence of its success is shown in the fact that it is now in its fifth English and fifth American edition. In its high character, in the care which is shown in the statements and their verification, and in Its thorough dealing with physiological and histological problems, it is far ahead of any book of the class yet issued.—The Medical Age, December 26,1893. One cannot read a single chapter without being impressed with the care that the author has be- stowed upon it. Apparently nothing that is known up to the present year concerning vital processes Dalton's Physiology.—Seventh Edition. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. By John C. Dalton, M. D., Professor of Physiology in the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beau- tiful engravings on wood. Cloth, $5.00; leather, $6.00. From the first appearance of the book it has been a favorite, owing as well to the author's renown as an oral teacher as to the charm of simplicity with which, as a writer, he always succeeds in investing even intricate subjects. It must be gratifying to him to observe the fre- quency with which his work, written for students and practitioners, is quoted by other writers on physiology. This fact attests its value, and, in great measure, its originality. It now needs no such seal of approbation, however, for the thou- sands who have studied it in its various editions have never been In any doubt as to its sterling worth.—N. Y. Medical Journal, Oct. 1882. Professor Dalton's well-known and deservedly- appreciated work has long passed the stage at which it could be reviewed in the ordinary sense. The work is eminently one for the medical prac- titioner, since it treats most fully of those branches of physiology which have a direct bearing on the diagnosis and treatment of disease. The work is one which we can highly recommend to all our readers.—Dublin Journal of Medical Science, Feb.'83. Chapman's Human Physiology. A Treatise on Human Physiology. By Henry C. Chapman, M. D., Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. In one octavo volume of 925 pages, with 605 engravings. Cloth, $5.50; leather, $6.50. It represents very fully the existing state of physiology. The present work has a special value to the student and practitioner as devoted more to the practical application of well-known truths which the advance of science has given to the profession in this department, which may be con- sidered the foundation of rational medicine.—Buf- falo Medical and Surgical Journal, Dec. 1887. Matters which have a practical bearing on the practice of medicine are lucidly expressed; tech- nical matters are given in minute detail; elabo- rate directions are stated for the guidance of stu- dents in the laboratory. In every respect the work fulfils its promise, whether as a complete treatise for the student or for the physician; for the former it is so complete that he need look no farther, and the latter will find entertainment and instruction in an admirable book of reference.— North Carolina Medical Journal, Nov. 1887. Schofield's Elementary Physiology. Elementary Physiology for Students. By Alfred T. Schofield, M. D., Late House Physician London Hospital. In one 12mo. volume of 380 pages, with 227 engravings and 2 colored plates containing 30 figures. Cloth, $2.00. Frankland & Japp's Inorganic Chemistry. Inorganic Chemistry. By E. Frankland, D. C. L., F. E. S., Professor of Chemistry in the Normal School of Science, London., and F. E. Japp, F. I. C, Assistant Professor of Chemistry in the Normal School of Science, London. In one handsome octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. Clowes' Qualitative Analysis.—Third Edition. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. By Frank Clowes, D. Sc, London, Senior Science-Master at the High School, Newcastle-under-Lyme, etc. Third American from the fourth and revised English edition. In one 12mo. vol. of 387 pages, with 55 illus. Cloth, $2.50. CLASSEN'S ELEMENTARY QUANTITATIVE ANALYSIS. Translated, with notes and addi- tions, by Edgar F. Smith, Ph. D., Assistant Pro- fessor of Chemistry in the Towne Scientific School, University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, 82.00. Lea Brothers d Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Chemistry—(Continued). 9 Simon's Chemistry.—New (4th) Edition. Manual of Chemistry. A Guide to Lectures and Laboratory work for Begin- ners in Chemistry. A Text-book, speciallv adapted for Students of Pharmacy and Medi- C1,n-S-, By W. Simon, Ph. D., M. D., Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland Col- lege of Pharmacy. New (4th) edition. In one 8vo. vol. of 490 pp., with 44 woodcuts and 7 colored plates illustrating 56 of the most important chemical tests. Cloth, $3.25, A work which rapidly passes to its fourth edition needs no further proof of having achieved a suc- cess. In the present case the claims to favor are obvious. Emanating from an experienced teacher of medical and pharmaceutical students the vol- ume is closely adapted to their needs. This is shown not only by the careful selection and clear presentation of its subject matter, but by the colored plates of reactions, which form a unique feature. Every teacher will appreciate the saving of his own time, and the advantages accruing to the student from a permanent and accurate stan- dard of comparison for tests depending on colors, and frequently upon their changes. To the prac- titioner, who is likely to be confronted at any "time with important pathological or toxicological ques- tions to be answered by the test-tube, the volume will be of the utmost value. Such it has proved in the past, and the author has accordingly been enabled, through frequent and thorough revisions to keep his work constantly in touch with the progress of its science and the best methods of its presentation.—Kansas City Medical Index, May, 1893. Fownes' Chemistry.—Twelfth Edition. A Manual of Elementary Chemistry; Theoretical and Practical. By George Fownes, Ph. D. Embodying Watts' Physical and Inorganic Chemistry. New American, from the twelfth English edition. In one large royal 12mo. volume of 1061 pages, with 168 engravings and a colored plate. Cloth, $2.75; leather, $3.25. Fownes' Chemistry has been a standard text- book upon chemistry for many years. Its merits are very fully known by chemists and physicians everywhere in this country and in England. As the science has advanced by the making of new discoveries, the work has been revised so as to keep it abreast of the times. It has steadily maintained its position as a text-book with medi- cal students. In this work are treated fully: Heat, Light and Electricity, including Magnetism. The influence exerted by these forces in chemical action upon health and disease, etc., is of the most important kind, and should be familiar to every medical practitioner. We can commend the work as one of the very best text-books upon chemistry extant.—Cincinnati Med. News, Oct. '86. Attfield's Chemistry.—Twelfth Edition. Chemistry, General, Medical and Pharmaceutical; Including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., Ph. D., F. I. C, F. E. S., etc., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. A new American, from the twelfth English edition, specially revised by the Author for America. In one handsome royal 12mo. volume of 782 pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. Attfield's Chemistry is the most popular book among students of medicine and pharmacy. This popularity rests upon real merits. Attfield's work combines in the happiest manner a clear exposi- tion of the theory of chemistry with the practical application of this knowledge to the everyday dealings of the physician and pharmacist. His book is precisely what the title claims for it. The admirable arrangement of the text enables a reader to get a good idea of chemistry without the aid of experiments, and again it is a good laboratory guide, and finally it contains such a mass of well-arranged information that it will al- ways serve as a handy book of reference. He does not allow any unutilizable knowledge to slip into his book; his long years of experience have produced a work which is both scientific and practical, and which shuts out everything in the nature of a superfluity, and therein lies the secret of its success. This last edition shows the marks of the latest progress made in chemistry and chem- ical teaching.—New Orleans Medical and Surgical Journal, Nov. 1889. Bloxam's Chemistry.—Fifth Edition. Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professor of Chemistry in King's College, London. New American from the fifth London edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $2.00; leather, $3.00. Comment from us on this standard work is al- most superfluous. It differs widely in scope and aim from that of Attfield, and in its way is equally beyond criticism. It adopts the most direct meth- ods in stating the principles, hypotheses and facts of the science. Its language is so terse and lucid, and its arrangement of matter so logical in se- quence that the student never has occasion to complain that chemistry is a hard study. Much attention is paid to experimental illustrations of chemical principles and phenomena, and the mode of conducting these experiments. The book maintains the position it has always held as one of the best manuals of general chemistry rn the Eng- lish language.—Detroit Lancet, Feb. 1884. Luff's Manual of Chemistry.—Just Ready. A Manual of Chemistry. For the use of students of medicine. By Arthur P Luff M. D. B. Sc., Lecturer on Medical Jurisprudence and Toxicological Chemistry, St Mary's Hospital Medical School, London. In one 12mo. vol. of 522 pages, with 36 engravings. Cloth, $2.00. See Students' Series of Manuals, page 30. Greene's Medical Chemistry. A Manual of Medical Chemistry. For the use of Students. By William H Greene M. D., Demonstrator of Chemistry in the Medical Department of the Uni- versity of Pennsylvania. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 10 Chemistry—(Continued), Pharmacy. Vaughan & Novy on Ptomaines and Leucomaines — 2d Edition. Ptomaines, Leucomaines and Bacterial Proteids; or the Chemi- cal Factors in the Causation of Disease. By Victor C. Vaughan; Ph. D., M. D., Professor of Physiological and Pathological Chemistry, and Associate Professor of Therapeutics and Materia Medica in the University of Michigan, and Frederick G. Now, M. D., Instructor in Hygiene and Physiological Chemistry in the University of Michigan. New (second) edition. In one handsome 12mo. vol. of 389 pages. Cloth, $2.25. This book is one that is of the greatest import- ance, and the modern physician who accepts bacterial pathology cannot have a complete knowledge of this subject unless he has carefully perused it. To the toxicologist the subject is alike of great import, as well as to the hygienist and sanitarian. It contains information which is not easily obtained elsewhere, and which is of a kind that no medical thinker should be without.—The American Journal of the Medical Sciences, April, 1892. Remsen's Theoretical Chemistry.—New (4th) Edition. Principles of Theoretical Chemistry, with special reference to the Con- stitution of Chemical Compounds. By Ira Eemsen, M. D., Ph. D., Professor of Chem- istry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edi- tion. In one handsome royal 12mo. volume of 325 pages. Cloth, $2.00. The fourth edition of Professor Remsen's well- known book comes again, enlarged and revised. Each edition has enhanced its value. We may say without hesitation that it is a standard work on the theory of chemistry, not excelled and scarcely equalled by any other in any language. Its trans- lation into German and Italian speaks for its ex- alted position and the esteem in which it is held by the most prominent chemists. We claim for this little work a leading place in the chemical literature of this country.—The American Journal of the Medical Sciences, July, 1893. Charles' Physiological and Pathological Chemistry. The Elements of Physiological and Pathological Chemistry. A Handbook for Medical Students and Practitioners. Containing a general account of Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the methods for pre- paring or separating their chief constituents, as also for their examination in detail, and an outline syllabus of a practical course of instruction for students. By T. Cranstoun Charles, M. D., F. E. S.^ M. S., formerly Assistant Professor and Demonstrator of Chem- istry and Chemical Physics, Queen's College, Belfast. In one handsome octavo volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. Dr. Charles is fully impressed with the impor- tance and practical reach of his subject, and he has treated it in a competent and instructive man- ner. We cannot recommend a better book than the present. In fact, it fills a gap in medical text- books, and that is a thing which can rarely be said nowadays. Dr. Charles has devoted much space to the elucidation ot urinary mysteries. He does this with much detail, and yet in a practical and intelligible manner. In fact, the author has filled his book with many practical hints.—Medical Rec- ord, December 20,1884. Hoffmann and Powers' Medicinal Analysis. A Manual of Chemical Analysis, as applied to the Examination of Medi- cinal Chemicals and their Preparations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceu- tical and Medical Students. By Frederick Hoffmann, A. M., Ph. D., Public Analyst to the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem- istry in the Philadelphia College of Pharmacy. Third edition, entirely rewritten and much enlarged. In one octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. Parrish's Pharmacy.—Fifth Edition. A Treatise on Pharmacy: Designed as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. By Edward Parrish, late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustrations. Cloth, $5.00; leather, $6.00. ________________________ Caspari's Pharmacy.—Preparing. A Text-Book on Pharmacy, for Students and Pharmacists. By Charles Caspari, Jr., Ph. G., Professor of the Theory and Practice of Pharmacy in the Maryland College of Pharmacy, Joint Editor of The National Dispensatory of 1894. In one very handsome octavo volume, richly illustrated. Ralfe's Clinical Chemistry. Clinical Chemistry. By Charles H. Ealfe, M. D., F. E. C. P., Assistant Physician at the London Hospital. In one pocket-size 12mo. volume of 314 pages, with 16 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Pharmacy, flateria fledica, Therapeutics. 11 JUST READY—NEW AND THOROUGHLY REVISED EDITION. The National Dispensatory. . Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi- cines^ including those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. By Alfred bTiLLE, M. D., LL.D., Professor Emeritus of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania, John M. Maisch, Phar. D., late Professor of Materia Medica and Botany in Philadelphia College of Pharmacy, Secretary to the American Pharmaceutical Association, Charles Caspari, Jr., Ph. G, Professor Su n r^?7^n *xe Maryland College of Pharmacy, Baltimore, and Henry C. C Maisch, Ph. G., Ph. D. New (fifth) edition, thoroughly revised in accordance with the new U. S. Pharmacopoeia (Seventh Decennial Eevision, 1894). In one magnificent imperial octavo volume of 1910 pages, with 320 engravings. Cloth, $7.25, leather, $8.00. With Eeadr Eeference Thumb-letter Index, cloth, $7.75; leather, $8.50. ON the first appearance of The National Dispensatory fifteen years ago it was at once recognized by the pharmaceutical and medical professions as satisfying the need for a work affording all necessary information upon its subject, with authoritative accuracy, and with a completeness and convenience attainable only by the exclusion of obsolete matter. Its success in filling this want is fully attested by the rapid demand for five editions, and the opportunity thus afforded has been well used in successive revisions, each placing it abreast of the day and maintaining the characteristics which had won for it a leading position. Of all its issues the present embodies the results of the most exhaustive revision. The sweeping changes in the new United States Pharmacopoeia are thoroughly incorpor- ated, with official authorization of the Committee of Eevision, and full use has been made of aH valuable material in the latest issues of foreign Pharmacopoeias. The volume is accordingly rich in pharmaceutical and chemical information, with data, formulas, tables, etc., gathered from all official sources, but this constitutes only a single department of its usefulness. As an encyclopaedia of the latest and best therapeutical knowledge it deals not only with all official drugs, but also with all the new synthetic remedies of value and with the unofficial preparations now so largely in use. Pharmacists will appreciate its systematic descriptions of the materia medica, its clear explanations of chemical and pharmaceutical processes and tests, and its illustrations of important drugs and of the most improved apparatus. Physicians will readily perceive the indispensable assistance offered by its authoritative statements as to the efficacy of drugs in the light of the most recent medical advances. Arranged alphabetically in the text, this information is placed most suggestively at command by the recommendations grouped under the various Diseases in the Therapeutical Index. Together with the General Index this covers more than one hundred treble-columned pages containing 25,000 references. The immensity of detail compiised in this single volume of 1900 pages is thus most forcibly indicated. Though the present edition contains far more matter than its predecessor it is maintained at the same price in view of the ever-increasing demand. Weights and Measures are given in both Ordinary and Metric Systems. In brief the new edition of The National Dispensatory is presented to the medict*. and pharmaceutical professions as the equivalent of a whole library of pharmaceutical and therapeutic information; it is the standard of accuracy, the embodiment of completeness without inconvenient bulk, and a marvel of cheapness owing to the widespread demand for it as the authority. The careful examination of this large volume will strike the reader with surprise at the great number of new articles added, and the amount of useful and accurate information regarding their properties, methods of preparation and therapeu- tical effects. The large number of new articles containing all the latest synthetic remedies and unofficial remedies, compass the entire range of available information in the line of the work. A number of very complete tables together with all the official re-agents and solutions for qualitative and quantitative tests, appear in the appendix. Altogether this work maintains its previous high reputation for accuracy, practical usefulness and encyclopaedic scope, and is indispensable alike to the pharmacist and physician. Every druggist knows of it and uses it, and almost every physi- cian properly consults it when desirous of settling all doubtful questions regarding the properties, preparation and uses of drugs.—Medical Record, April 7,1894. . „. . T'he descriptions of materia medica are clear, thorough and systematic, as are also the explana- tions of chemical and pharmaceutical processes and tests. The therapeutical portion has been re- vised with equal care and the statements of the action and uses have been arranged not only alphabetically under the various drugs, but for practical medical usefulness have also been placed at the instant command of those seeking infor- mation in the treatment of special diseases by being arranged under the various diseases in a therapeutical index. The readiness with which any of the vast amount of information contained in this work is made available is indicated by the twenty-five thousand references in the two in- dexes at the end of the volume.—Boston Medical and Surgical Journal, April, 1894. It is the official guide for the medical and phar- maceutical professions.—Buffalo Medical and Sur- gical Journal, March, 1894. The book is recommended most highly as a book of reference for the physician and is invalu- able to the druggist in his every-day work.—The Therapeutic Gazette, March, 1894. This edition of the Dispensatory should be recog- nized as a national standard.—The North American Practitioner, March, 1894. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 12 Therapeutics, flateria fledica—(Continued). A System of Practical Therapeutics BY AHERICAN AND FOREIGN AUTHORS. Edited by HOBART AHORY HARE, H. D. Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. In a series of contributions by seventy-eight eminent authorities. In three large octavo volumes of 3544 pages, with 434 illustrations. Price, per volume: Cloth, $5.00; leather, $6.00; half Eussia, $7.00. For sale by subscription only. Address the Publishers. Full prospectus free to any address on application. The various divisions have been elaborated by men selected in view of their special fitness. In every case there is to be found a clear and concise description of the disease under consideration, corresponding with the most recent and well- established views of the subject, embracing appo- site pictorial illustrations where these are neces- sary. In treating of the employment of remedies and therapeutical measures, the writers have been singularly happy in giving in a definite way the exact methods employed and the results ob- tained, both by themselves and others, so that one might venture with confidence to use remedies with which he was previously entirely unfamiliar. The practitioner could hardly desire a book on practical therapeutics which he could consult with more interest and profit.— The North American Practitioner, September, 1892. The scope of this work is beyond that of any previous one on the subject. The goal, after all, is the treatment of disease, and a work which con- tributes to its successful management is to be looked upon as of vast use to humanity. It can- not be denied that therapeutic resources, whether the treatment be confined to the mere administra- tion of drugs, or allowed its more extended appli- cation to the management of disease, have so greatly multiplied within the last few years as to render previous treatises of little value. Herein will be found the great value of flare's encyclo- pedic work, which groups together within a single series of volumes the most modern methods known in the management of disease, and espe- cially deals with important subjects comprehen- sively, which could not be done in a more limited treatise. We cannot commend Hare's System of Practical Therapeutics too highly; it stands out first and foremost as a work to be consulted by authors, teachers, and physicians, throughout the world.—Buffalo Med. and Surg. Jour., Aug. 1892. Hare's Text-Book of Practical Therapeutics.—Third Edition. A Text-Book of Practical Therapeutics; With Especial Eeference to the Application of Eemedial Measures to Disease and their Employment upon a Eational Basis. By Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; Sec. of Convention for Eevision of U. S. Pharmacopoeia of 1890. With special chapters by Drs. G. E. de Schweinitz, Edward Martin, J. Howard Eeeves and Barton C. Hirst. New (3d) and revised edition. In one octavo volume of 689 pages. Cloth, $3.75; leather, $4.75. The student of other works, has often, indeed, very often, longed for less of the abstract materia medica and more of the practical application of drugs to disease. In this work that want is filled. The drugs are arranged alphabetically, which enables one to find any name quickly, and. with the excellent index at the end of the volume, naught is left to be desired in the way of quick reference. Each drug, including all the newer remedies which have been proved to possess true merit, is considered in a rational and scientific manner. This work also presents us with nearly 250 pages of practical therapeutics, as applied to the individual diseases. The subjects are arranged alphabetically. It is in the chapter on Diseases that the student finds the rationale of therapeutics. This section is properly the com- plement of the former, in which each drug was presented with notes as to its usefulness in numer- ous diseases, while in the latter each disease is considered very fully from a therapeutical stand- point, the applications and special indications of the different remedies in the different phases of that particular affection being given. It is not a wonder that this work was quickly adopted by many colleges as a text-book and so liberally pur chased as to necessitate the publication of a third edition within two years. The student will find its pages filled with the choicest of therapeutical lore, systematically arranged and clearly and forci- bly presented ; the practitioner will appreciate its rationality and its general utility as an elbow con- sultant. It contains, without question, the best exposition of modern therapeutics of any text- book with which we are acquainted.—The Chicago Clinical Review, March, 1893. Maisch's Materia Medica.—Fifth Edition. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the Use of Students, Druggists, Pharmacists and Physicians. By John M. Maisch, Phar. D., Prof, of Materia Medica and Botany in the Philadelphia College of Pharmacy. New (fifth) edition, thoroughly revised. In one very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth, $3.00 This is an excellent manual of organic materia medica, as are all the works that emanate from the skilful pen of such a successful teacher as John M. Maisch. The book speaks for itself in the most forcible language. In the edition before us which is the fifth one published within the comparatively short space of eight years (and this is the best proof of the great value of the work and the just favor with which it has been received and accepted), the original contents have been thor- oughly revised and much good and new matter has been incorporated. We have nothing but praise for Professor Maisch's work. It presents no weak point, even for the most severe critic. The book fully sustains the wide and well-earned reputa- tion of its popular author. In the special line of work of which it treats it is fully up to the most recent observations and investigations. After a careful perusal of the book, we do not hesitate to recommend Maisch's Manual of Organic Materia Medica as one of the best, if not the best work on the subject thus far published. Its usefulness cannot well be dispensed with, and students, drug- gists, pharmacists and physicians should all pos- sess a copy of such a valuable book.—Medical News, December 31,1892. Edes' Therapeutics and Materia Medica. * CTA Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. By Eobert T. Edes, M.D., Jackson Professor of Clinical Medicine in Harvard University. Octavo, 544 pp. Cloth, $3.50; leather, $4.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Practice of fledicine. 13 Flint's Practice of Medicine.—Sixth Edition. <• *u "^ TE68^86 on tne Principles and Practice of Medicine. Designed tor the use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., ±Tolessor of the Principles and Practice of Medicine, and of Clinical Medicine in Belle- vue Hospital Medical College, N. Y. Sixth edition, thoroughly revised and rewritten 7, tne Author assisted by William H. Welch, M.D., Professor of Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D.,LL. D., Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one verj _ volume of 1160 pages, with illustrations. No text-book on the principles and practice of medicine has ever met in this country with such general approval by medical students and practi- tioners as the work of Professor Flint. In all the medical colleges of the United States it is the fa- vorite work upon Practice; and, as we have stated before in alluding to it, there is no other medical work that can be so generally found in the libra- ries of physicians. In every state and territory of this vast country the book that will be most likely to be found in the office of a medical man, whether very handsome octavo Cloth, $5.50; leather, $6.50. in city, town, village, or at some cross-roads, is Flint's Practice. We make this statement to a considerable extent from personal observation, and it is the testimony also of others. An examina- tion shows that very considerable changes have been made in the sixth edition. The work may un- doubtedly be regarded as fairly representing the present state of the science of medicine, and as reflecting the views of those who exemplify in their practice the present stage of progress of med- ical art.—Cincinnati Medical Newt, Oct. 1886. Hartshorne's Essentials of Practice.—Fifth Edition. Essentials of the Principles and Practice of Medicine. A Handbook for Students and Practitioners. By Henry Hartshorne, M. D., LL. D., lately Professor of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and rewritten. In one 12mo. vol. of 669 pages, with 144 illus. Cloth, $2.75; half leather, $3. Farquharson's Therapeutics and Materia Medica.—4th Ed. A Guide to Therapeutics and Materia Medica. By Eobert Far- quharson, M. D., F. E. C. P., LL. D., Lecturer on Materia Medica at St. Mary's Hospi- tal Medical School, London. Fourth American, from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Pro- fessor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chi- rurgical College of Philadelphia. In one handsome 12mo. vol. of 581 pp. Cloth, $2.50. copceias, as well as considering all non-official but important new drugs, it becomes in fact a miniature dispensatory.—Pacific Medical Journal, June, 1889. It may correctly be regarded as the most modern rork of its kind. It is concise, yet complete. Containing an account of all remedies that have It is concise, yet complete int of all remedies that have a place in the British and United States Pharma Brace's Materia Medica and Therapeutics.—Fourth Edition. Materia Medica and Therapeutics. An Introduction to Eational Treat- ment. By J. Mitchell Bruce, M. D., F. E. C. P., Physician and Lecturer on Materia Medica and Therapeutics at Charing-Cross Hospital, London. Fifth edition. In one 12mo. volume of 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 30. The pharmacology and therapeutics of each drug are given with great fulness, and th e indications for its rational employment in the practical treatment of disease are pointed out. The Materia Medica proper contains all that is necessary for a medical student to know at the present day. The third part of the book contains an outline of general therapeutics, each of the symptoms of the body being taken in turn, and the methods of treat- ment illustrated. A lengthy notice of a book so Well known is unnecessary.—Med. Chronicle, May, 1891. COHEN'S HANDBOOK OF APPLIED THERA- PEUTICS. Being a Study of Principles Applic- able and an Exposition of Methods Employed in the Management of the Sick. By Solomon Solis Cohen, M D., Professor of Clinical Medi- cine and Applied Therapeutics in the Philadel- phia Polyclinic. In one large 12mo. volume, with illustrations. Prepnring. REYNOLDS' 8YSTEM OF MEDICINE. Edited by J. Russell Reynolds, M. D., Professor of the Principles and Practice of Med. in University College, London. With notes and additions by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. Three octavo volumes, containing 3056 double- columned pages, with 317 illustrations. Price per volume, cloth, $5.00; sheep, $6.00; half Russia, $6.50. Subtcription only. ____ WATSON'S LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. From the fifth English edition. Edited with additions, and 190 illustrations, by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In two large octavo volumes of 1840 pages. Cloth, $9.(K); leather, $11.00. FLINT'S PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY AND TREATMENT OF DISEASES OF THE HEART. Second re- vised and enlarged edition. In one octavo vol- ume of 550 pages, with a plate. Cloth, 84. FLINT ON PHTHISIS: ITS MORBID ANAT- OMY, ETIOLOGY, SYMPTOMATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREATMENT AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. FLINT'S ESSAYS ON CONSERVATIVE MEDI- CINE AND KINDRED TOPICS. In one very handsome royal 12mo. volume of 210 pages. Cloth, $1.38. LYONS' TREATISE ON FEVER. In one 8vo. volume of 354 pages. Cloth, $2.25. HUDSON'S LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2.50. LA ROCHE ON YELLOW FEVER, in its Histori- cal, Pathological, Etiological and Therapeutical Relations. Two octavo vols., 1468 pp. Cloth, $7.00. BRUNTON'S PHARMACOLOGY, THERAPEU- TICS AND MATERIA MEDICA. Octavo, 1305 pages, 230 illustrations. HERMANN'S EXPERIMENTAL PHARMACOL- OGY. A Handbook of Methods for Determining the Physiological Action of Drugs. Translated, with the Author's permission, and with exten- sive additions, by R. M. Smith, M. D. 12mo., 199 pagns, with 32 illustrations. Cloth, $1.50. STILLE'S THERAPEUTICS AND MATERIA MEDICA. A Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, re- vised and enlarged. In two octavo volumes, con- taining 1936 pages. Cloth, $10.00; leath er, $12.00. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 14 Prac. of fledicine, Treatment, Digestive Syst. Lyman's Practice of Medicine. The Principles and Practice of Medicine. For the Use of Medical Students and Practitioners. By Henry M. Lyman, M. D., Professor of the Principles and Practice of Medicine, Eush Medical College, Chicago. In one very handsome octavo volume of 925 pages, with 170 illustrations. Cloth, $4.75; leather, $5.75. This is an excellent treatise on the practice of medicine, written by one who is not only familiar with his subject, but who has also learned through practical experience in teaching, what are the needs of the student, and how to present the facts to his mind in the most readily assimilable form. Although the book contains over nine hundred pages, there has been no space wasted by useless historical essays, prolonged discussions on de- batable topics, or " padding " of any kind. Each subject is taken up in order, treated clearly but briefly, and dismissed when all has been said that need be said in order to give the reader a clean- cut picture of the disease under discussion. The reader is not confused by having presented to him a variety of different methods of treatment, among which he is left to choose the one most easy of exe- cution, but the author describes the one which is, In his judgment, the best. This is as it should be. What the student should be taught is the one most approved method of treatment. We have spoken of the work as one for the student, and this because the author occupies so prominent a position as a teacher, but we would not be under- stood that it is adapted only for students. There is many a practitioner of ten years' or more stand- ing, who has been unable to follow the constant advances made in medical science, to whom this work will be of great use. He will find here each subject presented in its latest aspect, and only such theories mentioned as have been generally accepted by the highest authorities. The practi- cal and busy man who wants to ascertain in a short time all the necessary facts concerning the pathology or treatment of any disease, will find here a safe and convenient guide.—Medical Rec- ord, October 22,1892. The Year-Book of Treatment for 1894.—Just Ready. A Comprehensive and Critical Review for Practitioners of Medi- cine and Surgery. In one 12mo. vol. of 501 pages. Cloth, $1.50. **# For special commutations with periodicals see pages 1 and 2. enough to secure them. It is the very book the This is the tenth year of this valuable work, which comes to hand with unerring regularity. It would be difficult indeed to imagine a book more nearly suited to the every-day needs of the medical practitioner or writer than this. The contributors to this volume are among the most prominent and well-known writers and teachers of the day, and their articles and opinions will be appreciated By all who are fortunate and wise busy practitioner needs. He can find anything pertaining to any subject in a moment's time, and he may rest assured that it is the most modern and reliable view now accepted. It, year by year, keeps him apprised of important advances in all branches of medicine, and presents them in a well-condensed and classified form.—The Char- lotte Medical Journal, April, 1894. The Year-Books of Treatment for 1891, 1892 and 1893. 12mos., 485 pages. Cloth, $1.50 each. The Year-Books of Treatment for 1886 and 1887. Similar to above. 12mos., 320-341 pages. Cloth, $1.25 each. A System of Practical Medicine. BY AMERICAN AUTHORS. Edited by WILLIAM PEPPER, M. D., LL. D., PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. Price per volume, cloth, $5; leather, $6; half Russia, $7. Subscription only. * * The greatest distinctively American work on the practice of medicine, and, indeed, the super- lative adjective would not be inappropriate were even all other productions placed in comparison. An examination of the five volumes is sufficient to convince one of the magnitude of the enter- prise, and of the success which has attended its fulfilment.— The Medical Age, July 26,1886. The feeling of proud satisfaction with which the American profession sees this, its representative system of practical medicine issued to the medi- cal world, is fully justified by the character of the work. The entire caste of the system is in keep- ing with the best thoughts of the leaders and fol- lowers of our home school of medicine, and the combination of the scientific study of disease and the practical application of exact and experimen- tal knowledge to the treatment of human mal- adies, makes every one of us share in the pride that has welcomed Dr. Pepper's labors. Sheared of the prolixity that wearies the readers of the German school, the articles glean these same fields for all that is valuable. It is the outcome of American brains, and is marked throughout by much of the sturdy independence of thought and originality that is a national characteristic. Yet no- where is there lack of study of the most advanced views of the day.—N. C. Med. Jour., Sept. 1886. Habershon on the Abdomen. On the Diseases of the Abdomen; Comprising those of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. By S. O. Habershon, M. D., Senior Physician to and late Lecturer on Principles and Prac- tice of Medicine at Guy's Hospital, London. Second American from third enlarged and revised English edition. In one handsome octavo vol. of 554 pages, with illus. Cloth, $3.50. This valuable treatise on diseases of the stomach rectum. A fair proportion of each chapter is and abdomen will be found a cyclopaedia of infor- devoted to symptoms, pathology, and therapeutics mation, systematically arranged, on all diseases of —New York Medical Journal, April. 1879 the alimentary tract, from the mouth to the Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Practice of fledicine, Diagnosis, Heart. 15 Musser's Medical Diagnosis.—Just Ready. A Practical Treatise on Medical Diagnosis For the Use of Students and Practitioners. By John H. Musser, M. D., Assistant Professor of Clinical Medicine, University of Pennsylvania, Philadelphia. In one very handsome octavo volume of 873 pages, with 162 illustrations. Cloth, $5; leather, $6. mended alike for its logical arrangement, accurate observation and clearness of expression. The chapter on bacteriology is especially commenda- ble, because it contains everything practically necessary for clinical work.—Med. iJec.Apr. 21,'94. The book should receive a hearty reception from students and medical men; it contains much in- formation essential to good, scientific medical work. It is with pleasure that we can state that The aim of the author has been to make the work eminently practical. Dr. Musser has succeeded in bringing together a large and valuable collection of clinical data drawn from his own extended experience and from exhaustive literary research, and has presented them in an unusually clear and concise manner. In brief, the book is thoroughly modern, readable and in- structive, and, we believe, superior to any work of the kind before the profession.— University Medical Magnzine, March, 1894. Modern methods of medical teaching and study have rendered treatises like the present an abso- lute necessity. The present work is to be com- the work has been adopted as a text-book at the Johns Hopkins Medical School and Harvard Uni- versity, and that it has met with marked approval in other teaching centres.—International Medical Magazine, April, 1894. Flint on Auscultation and Percussion.—Fifth Edition. A. Manual of Auscultation and Percussion; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D., LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi- cal College, New York. Fifth edition. Edited by James C. Wilson, M. D., Lecturer on Physical Diagnosis in the Jefferson Medical College, Philadelphia. In one hand- some royal 12mo. volume of 274 pages, with 12 illustrations. Cloth, $1.75. Whitla's Dictionary of Treatment. A Dictionary of Treatment; or Therapeutic Index, including Medical and Surgical Therapeutics. By William Whitla, M. D., Professor of Materia Medica and Therapeutics in the Queen's College, Belfast. Eevised and adapted to the United States Pharmacopoeia. In one square, octavo vol. of 917 pp. Cloth, $4.00 ___ * i i i • i • •___ *____J!..'_______J IL«. .-,,-,,-.>-, ™rt»- nKnAlUinnaw Twrill An/1 lit if a-VQ/lfltr t.tlJ We have already dictionaries of medicine and dictionaries of surgery; Dr. Whitla now provides us with a dictionaryof treatment. And reference to the volume shows that it really is what it professes to be. The several diseased condi- tions are arranged in alphabetical order, and the methods—medical, surgical, dietetic, and climatic—by which they may be met, considered. On every page we find clear and detailed direc- tions for treatment supported by the author's personal authority and experience whilst the recommendations of other competent observers are also critically examined. The book abounds with useful, practical hints and suggestions, and the younger practitioner will find in it exactly the help he so often needs in the treatment both of those who are ill, and those who are ailing. At the same time the most experienced members of the profession may usefully consult its pages for the purpose of learning what is really trustworthy in the later therapeutic developments. The Diction- ary is, in short, the recorded experience of a prac- tical scientific therapeutist, who has carefully studied diseases and disorders at the bed-side and in the consulting-room, and has earnestly ad- dressed himself to the cure and relief of his patients.—The Glasgow Medical Journal, April, 1892. Fothergill's Handbook of Treatment.—Third Edition. The Practitioner's Handbook of Treatment; Or, The Principles of Therapeutics. By J. Milner Fothergill, M. D., Edin., M. E. C. P., Lond., Physician to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. volume of 661 pages. Cloth, $3.75; leather, $4.75 This is a wonderful book. If there be such a thing as "medicine made easy," this is the work to accomplish this result.—To. Med. Month.. June, 87. To have a description of the normal physiologi- cal processes of an organ and of the methods ol treatment of its morbid conditions brought together in a single chapter, and the relations between the two clearly stated, cannot fail to prove a great convenience to many thoughtful but busy physicians. The practical value of the volume is greatly increased by the introduction of many prescriptions. That the profession appreciates fch ' ' chat the author has undertaken an important work and has accomplished it is shown by the demand for this third edition.—N. ¥. Med. Jour., June 11,'87. Broadbent on the Pulse. The Pulse By W. H. Broadbent, M. D., F. E. C. P., Physician to and Lecturer on Medicine at St. Mary's Hospital, London. In one 12mo. volume of 312 pages. Cloth, $1.75. See Series of Clinical Manuals, page 30 TANNER'S MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. Third American from the second London edition. Revised and enlarged by Tilbury Fox, M. D. In one 12mo. volume of 362 pp. with illus. Cloth, $l-50- DAVIS? CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES. By NS. Davis mTd: Edited by Fbank H. Davis M D. Second ArUtinn l2mo. 287 pages. Cloth, 81.75. __ TODD'S CLINICAL LECTURES *ON CERTAIN ACUTE DISEASES. In one octavo volume of Pl'TNT'S^PRACTiciL- TREATISE ON THE PHYSICAL EXPLORATION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AH- FECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. STURGE8' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome 12mo. volume of 127 pages. Cloth, 81.25. WALSHE ON THE DISEASES OF THE HEABd AND GREAT VESSELS. Third American edi- tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. HOLLAND'S MEDICAL NOTES AND REFLEO TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 16 Practice, Electricity, Cholera, Food, Hygiene. Yeo's Medical Treatment. A Manual of Medical Treatment or Clinical Therapeutics. By I. Burney Yeo, M. D., F. E. C. P., Prof, of Clinical Therapeutics in King's Coll., London. In two 12mo. volumes containing 1275 pages, with illustrations. Cloth, $5.50. cussion of the best methods of carrying out these indications. Each section contains a number of prescriptions which the author has found most useful, and at the end of every chapter is added a selection of formula? from the writings of various well-known physicians. The work is exceedingly practical, and the details of the various methods of treatment are always given. Full directions are given with regard to diet, mode of life, and gen This work is devoted entirely to the treatment of disease, being the first we have ever seen of the kind. Only so much of the pathology and etiol- ogy of disease is introduced as is necessary to ar- rive at the rational indications, without which the administration of a drug can hardly be called scientific. Half a dozen choice formulae by lead- ing physicians are appended to each chapter. The index is so arranged that one can find disease and the various remedies at a glance. Without exaggeration, we can say that one could hardly read anything affording at the same time so much pleasure and profit as this elegantly written and beautifully printed book.—The Canada Medical Record, November, 1893. In Dr. Yeo's book the study of the treatment of disease is approached, not from the side of the drug or remedy as in works on therapeutics, but "from the side of the disease." The various dis- eases are grouped together, a short account is given of the clinical history, course and pathology of each, and from a consideration thereof, indications for treatment are arrived at; then follows a full dis- eral treatment, which are often as important as the treatment by drugs.—Med. Chronicle, January, 1894. The discussion of the different ailments has a distinctly practical turn toward the main purpose of the book. Standard formula? are introduced from eminent practitioners, and all the drugs of recognized value are grouped in the order of their importance. The dosage receives careful atten- tion, which is a feature that cannot be too highly commended. It cannot fail to be an exceedingly useful, suggestive and instructive work to the physician who wishes to be well up in the present advanced and scientific therapeutics of the day.— Medical Record, November 25,1893. Yeo on Food in Health and Disease. Pood in Health and Disease. By I. Burney Yeo, M. D., F. E. C. P., Professor of Clinical Therapeutics in King's College, London. In one 12mo. volume of 590 pages. Cloth, $2.00. See Series of Clinical Manuals, page 30. Dr.Yeo supplies in a compact form nearly all that the practitioner requires to know on the subject of diet. The work is divided into two parts—food in health and food in disease. Dr. Yeo has gathered together from all quarters an immense amount of nseful information within a comparatively small compass, and he has arranged and digested his materials with skill for the use of the practitioner. We have seldom seen a book which more thor- oughly realizes the object for which it was written than this little work of Dr. Yeo.—British Medical Journal, Feb. 8,1890. Bartholow on Electricity in Medicine and Surgery.—3d Ed. / Medical Electricity. A Practical Treatise on the Applications of Electricity to Medicine and Surgery. By Eoberts Bartholow, A. M., M. D., LL. D., Emeritus Pro- fessor of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila- delphia, etc. Third edition. In one octavo volume of 308 pp., with 110 illus. Cloth, $2.50. Bartholow on Cholera.—Just Ready. Cholera: Its Causes, Symptoms, Pathology and Treatment. By Eoberts Bartholow, M. D., LL. D., Emeritus Professor of Materia Medica, General Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia. In one 12mo. volume of 127 pages, with 9 illustrations. Cloth, $1.25. The most scientific work on cholera extant. Broad yet comprehensive, concise but explicit, it treats the subject in a way to invite but little criti- cism. The most valuable chapter is the one on treatment, which, considering the author's thera- peutical experience, and the great improvements made in practice, is indeed, a contribution to medical literature worthy of more than passing notice — The Medical Fortnightly, July 15.1893. The author has sought to make a practical book in the smallest compass. The symptoms and pathology of the disease are described separ- ately in a brief and comprehensive manner. The final chapter, on the treatment of cholera, gives the prophylactic measures, including quarantine and the latest therapeutical methods in vogue in India, Europe and America. The volume is writ- ten in the author's usual pleasant style, and will satisfy the desire of any one that wishes to obtain the most recent information on the subject.—The New York Medical Journal, July 29,1893. Richardson's Preventive Medicine. Preventive Medicine. By B. W. Eichardson, M. D., LL. D., F. E. S., Fel- low of the Eoyal Coll. of Phys., London. In one 8vo. vol. ol 729 pp. Cloth, $4; leather, $5. ~ ' scholarly; the discussion of the question of disease There is perhaps no similar work written for the general public that contains such a complete, reliable and instructive collection of data upon the diseases common to the race, their origins, causes, and the measures for their prevention. The descriptions of diseases are clear, chaste and is comprehensive, masterly and fully abreast with the latest and best knowledge on the subject, and the preventive measures advised are accurate, explicit and reliable.—TheAmerican Journal of the Medical Sciences, April, 1884. SCHREIBER'S MANUAL OF TREATMENT BY MASSAGE AND METHODICAL MUSCLE EX- ERCISE. Translated by Walter Mendelson, M. D., of New York. In one 8vo. volume of 274 pp., with 117 engravings. CHAMBERS' MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand some octavo volume of 302 pp. Cloth, 82.76. STILLE ON CHOLERA: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treatment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one octavo volume of 238 pages. Cloth, $2.00. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Throat, Nose, Lungs, Hind, Nerves. 17 Seiler on the Throat and Nose.—New (4th) Edition. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. By Carl Seiler, M. D., Lecturer on Laryngoscopy in the University of Pennsylvania. New (4th) edition. In one handsome 12mo. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25. This little book is eminently practical, and will prove of interest not only to the specialist, but to the general practitioner as well. It deals with the subject in a clear and distinct manner, and the text is copiously illustrated with diagrams and colored plates. So little attention is paid ordi- narily to the examination of the larynx that the need of such a book has long been felt. By con- sulting its pages anyone can learn the necessary manipulations, and, by a little practice, soon be- come expeit in the use of the laryngeal mirror, a method of examination too often neglected. The anatomy of the larynx is explained with especial care, and the operative procedures for various diseases of the throat, tonsils, etc., are carefully explained. Approved methods of treatment are dealt with in a very satisfactory way, and all the most useful remedial agents are described.— International Medical Magazine, November, 1893. As a guide to the practitioner and a text-book for the student, it is unexcelled, being plain, ac- curate, comprehensive and pleasantly written.— Atlanta Medical and Surgical Journal, August, 1893. It is needless to say that it is brought up to date in the fullest possible sense of the term. Rarely has any treatise on any specialty met with a more cordial reception than the one under consider- ation. A most generous recognition is given to the work of American laryngologists. The main feature of the present edition has been the ex- pansion of that portion which deals with the diseases of the nose. The author is to be com- mended on the excellence of his work, and con- gratulated that a new edition has been so speedily called for.—Medical Record, November 25,1893. Browne on the Throat and Nose.—New (4th) Edition. The Throat and Nose and Their Diseases. By Lennox Browne, F. E. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. Fourth and enlarged edition. In one imperial octavo volume of 751 pages, with 120 illustrations in color, and 235 engravings on wood. Cloth, $6.50 Although quite complete enough for the use of specialists, it is at the same time so clear as to be of daily value to the general practitioner, who will find at the end of the volume a number of well- tried formulas most in vogue at the London hos- pitals for diseases of the throat.—The Canada Medical Record, November, 1893. It is an admirable presentation of its subject in the light of the large clinical experience of a care- ful observer. It is a book that no specialist can afford not to have, and that the general physician can rely upon as a safe guide and practical adviser. —The Medical News, Oct. 14,1893. Tuke on the Influence of the Mind on the Body. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. By Daniel Hack Tuke, M. D., Joint Author of the Manual of Psychological Medicine, etc. New edition. Thoroughly revised and rewritten. In one 8vo. volume of 467 pages, with 2 colored plates. Cloth, $3 00. It is impossible to peruse these interesting chap- ters without being convinced of the author's per- fect sincerity, impartiality, and thorough mental grasp. Dr. Tuke has exhibited the requisite amount of scientific address on all occasions, and the more intricate the phenomena the more firmly has he adhered to a physiological and rational method of interpretation. Guided by an enlight- ened deduction, the author has reclaimed for science a most interesting domain in psychology. previously abandoned to charlatans and empirics. This book, well conceived and well written, must commend itself to every thoughtful understand- ing.—New York Medical Journal, September 6,1884. Clouston on Mental Diseases. Clinical Lectures on Mental Diseases. By Thomas S. Clouston, M D. Lecturer on Mental Diseases in the University of Edinburgh. With an Appen- dix containing an Abstract of the Statutes of the United States and of the Several States and Territories relating to the Custody of the Insane. By Charles F. Folsom, M D Ass't Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one octavo volume of 541 pages, with eight lithographic plates, four of which are colored. Cloth, $4. ~Or Folsom's Abstract also separate, in one 8vo. vol. of 108 pages. Cloth $1.50. . ', • . . ..- - j:----.„ ~~a „o0oo arc and descriptions given as to the practical man- agement and care of the cases. We can heartily recommend it to the student and busy general practitioner. Dr. Folsom's work greatly increases the value of Dr. Clouston's book for the American practitioner.—Archives of Medicine, June, 1884. The descriptions of the diseases and cases are simple and practical, but true; and one sees as he reads that they are given by one perfectly familiar from daily observation with the cases and diseases he is speaking of. One feature of the book which commends it highly, and which is not to be found in any other work on mental diseases, is the hints Playfair on Nerve Prostration and Hysteria. Tbfi Svatematic Treatment of Nerve Prostration and Hysteria. ByW.S.PLlYElSrTD.^F^aP. In one 12mo. volume of 97 pages. Cloth, $1.00. BROWNE ON KOCH'S REMEDY IN RELATION TO THROAT CONSUMPTION. In one octavo volume of 121 pages, with 45 illustrations 4 of nrViif.h are colored and 17 charts. Cloth, $1.50. FULLER ON DISEASES OF THE LUNGS AND AHWPASSAGES. Their Pathology, Physical Di- aenosis Symptoms and Treatment. From the second anTrevised English edition In one octavo volume of 475 pages. Cloth, $3.50. BLADE ON DIPHTHERIA; Its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Second and revised edition. In one 12mo. vol., 158 pp. Cloth, $1.25. SMITH ON CONSUMPTION; its Early and Reme- diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 pages. Cloth, $3.00. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. With an analysis of one thousand cases to exemplify its duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 18 Nervous and flental Diseases, Histology. Gray on Nervous and Mental Diseases. A Practical Treatise on Nervous and Mental Diseases. By Landon Carter Gray, M. D., Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. In one very handsome octavo volume of 681 pages, with 168 illustrations. Cloth, $4.50; leather, $5.50. A book that will be welcomed by the many who desire a modern text-book on nervous diseases that is comprehensive and practical, and especial- ly full in the details of the treatment of these affections that are so often matters of perplexity to the general practitioner. It will be found, on this account, to sneet the wants of a large number perhaps better than would another equally meri torious text-book less full in this regard. Dr. Gray states in his preface, and it is evident to anyone perusing the work, that" especial care has been taken to make the therapeutical suggestions suf- ficiently detailed and prtcise to cover the varying stages, symptoms and complications of disease, as wen as to follow the important indications afford- ed by differential diagnosis," and that "only that knowledge has been admitted to these pages which has stood the test of experience." Its style is clear and very readable, and the illustrations are numerous and excellent. A glossary of special terms is appended which will be found useful by the student. While it is intended as a text-book, not assuming any special knowledge on the part of its readers, the volume is full of valuable orig- inal matter that renders it a desirable addition to the library of the specialist in nervous and mental diseases.—American Jour, of Mental Sci. Feb., 1893. None but one of the foremost neurologists in this country could have succeeded in condensing within less than seven hundred pages a text-book on nervous and mental diseases. But the author's long experience as a teacher and his wide range of information regarding the literature of his subject have enabled him to discriminate nicely as to what knowledge is most needed by the stu- dent and practitioner. We wish that every medi- cal college could have inscribed on its walls the following: "Medical nihilism is an error of youth and a confession of impotence, for Nature rarely afflicts man beyond the hope of relief. The therapeutist has enormous resources." Too often the instructor informs his pupils with exceeding care of the aetiology, pathology, and diagnosis of disease, and then says that it is incurable; he makes no effort to teach them what to do to allevi- ate, and Dr. Gray's optimism is in refreshing con- trast to such instruction.—New York Medical Jour- nal, March, 1894. Ross on Diseases of the Nervous System. A Handbook on Diseases of the Nervous System. By James Koss, M. D., F. B. C. P., LL. D., Senior Assistant Physician to the Manchester Eoyal Infirmary. In one octavo vol. of 725 pages, with 184 illus. Cloth, $4.50; leather, $5.50. This admirable work is intended for students of medicine and for such medical men as have no time for lengthy treatises. In the present instance the duty of arranging the vast store of material at the disposal of the author, and of abridging the de- scription of the different aspects of nervous dis- eases, has been performed with singular skill, and the result is a concise and philosophical guide to the department of medicine of which it treats. Dr. Ross holds such a high scientific position that any writings which bear his name are naturally expected to have the impress of a powerful intel- lect. In every part this handbook merits the highest praise, and will no doubt be found of the greatest value to the student as well as to the prac- titioner.—Edinburgh Medical Journal, Jan. 1887. Hamilton on Nervous Diseases.—Second Edition. Nervous Diseases; Their Description and Treatment. By Allen McLane Hamilton, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, Blackwell's Island, N.Y. Second edition, thoroughly revised ana rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4.00. Savage on Insanity and Allied Neuroses. Insanity and Allied Neuroses, Practical and Clinical. By George H. Savage, M. D., Lecturer on Mental Diseases at Guy's Hospital, London. In one 12mo. vol. of 551 pp., with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, p. 30. Klein's Histology.—Fourth Edition. Elements of Histology. By E. Klein, M. D., F. E. S., Joint Lecturer on General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, London. Fourth edition. In one 12mo. volume ol 376 pages, with 194 illus. Limp cloth, $1.75. See Students' Series of Manuals, page 30. The large number of editions through which Dr. Klein's little handbook of histology has run since its first appearance in 1883 is ample evidence that it is appreciated by the medical student and that it supplies a definite want. The clear and concise manner in which it is written, the absence of debatable matter, of conflicting views, added to the convenient size of the book and its moderate price, will account for its undoubted success.—Medical Chronicle, Feb., 1890. Schafer's Histology.—Third Edition. The Essentials of Histology. By Edward A. Schafer, F. E. S., Jodrell Professor of Physiology in University College, London. New (third) edition. In one octavo volume of 311 pages, with 325 illustrations. Cloth, $3.00. BLANDFORD ON INSANITY AND ITS TREAT- MENT. Lectures on the Treatment, Medical and Legal, of Insane Patients. In one very handsome octavo volume. JONES' CLINICAL OBSERVATIONS ON FUNC- TIONAL NERVOUS DISORDERS. Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25. PEPPER'S SURGICAL PATHOLOGY. In one pockel/size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, 82.00 See Students' Series of Manuals, page 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Pathology, Histology, Bacteriology. 19 Gibbes' Practical Pathology and Morbid Histology. Practical Pathology and Morbid Histology. By Heneage Gibbes, M. D., Professor of Pathology in the University of Michigan, Medical Department. In one very handsome 8vo. vol. of 314 pp., with 60 illus., mostly photographic. Cloth, $2.75. This is, in part, an expansion of the little work published by the author some years ago, and his acknowledged skill as a practical microscopist will give weight to his instructions. Indeed, in ful- ness of directions as to the modes of investigating morbid tissues the book leaves little to be desired. The work is throughout profusely illustrated with reproductions of micro-photographs. We may say that the practical histologist will gain much useful information from the book.—The London Lancet, January 23,1892. The student of morbid histology and bacteri- ology has at his hand, in this neat volume of some three hundred pages, a most excellent guide and one which, unless he be a very advanced student, he cannot afford to be without. The work is divided into four parts, the first, that of practical pathology, containing clear and precise directions in histological technique, showing how to prepare the tissues for examination, cut, stain and mount sections, etc. The second part deals with bacteri- ology, with the different forms of cultivation, microscopic examinations of the bacteria, etc. The third part, which comprises more than half the book, treats of morbid histology. This part is illustrated with a great number of beautiful photo micrographs in which the microscopic field is reproduced with a distinctness that is really remarkable. The fourth part contains some very practical instruction on photography with the microscope. Works like this of Dr. Gibbes will soon popularize histology among the profession at large, whereas it is now to a large number of physicians almost a sealed book.—Medical Record, Oct. 17,1891. Abbott's Bacteriology. The Principles of Bacteriology: a Practical Manual for Students and Physicians. By A. C. Abbott, M. D., First Assistant, Laboratory of Hygiene, University of Pennsylvania, Philadelphia. In one 12mo. vol. of 259 pp., with 32 illus. Cloth, $2.00. To a person desiring to learn the technique of bacteriological work, we cannot recommend any work which will be more suitable than the one before us. Dr. Abbott has shown great judg- ment in the selection and arrangement of his material. The student who follows it closely will be in a condition to carry forward the work for himself. Medical practitioners generally co uld read the work with profit, especially the chapters on sterilization and disinfection, and those on tuberculosis and diphtheria in the second part.— The Canadian Practitioner, Nov. 1,1892. Senn's Surgical Bacteriology.—Second Edition. Surgical Bacteriology. By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Eush Medical College, Chicago. New (second) edition. In one handsome octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. The book is really a systematic collection in the most concise form of such results as are published in current medical literature by the ablest workers in this field of surgical progress; and to these are added the author's own views and the results of his clinical experience and original investigations. The book is valuable to the student, but its chief value lies in the fact that such a compilation makes it possible for the busy practitioner, whose time for reading is limited and whose sources of information are often few, to become conversant with the most modern and advanced ideas in sur- gical pathology, which have "laid the foundation for the wonderful achievements of modern sur- gery."—Annals of Surgery, March, 1892. Green's Pathology and Morbid Anatomy.—Seventh Edition. Pathology and Morbid Anatomy. By T. Henry Green, M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. Sixth American from the seventh and revised English edition. Octavo, 539 pages, with 167 engravings. Cloth, $2.75. The Pathology and Morbid Anatomy of Dr. Green is too well known by members of the medi- cal profession to need any commendation. There is scarcely an intelligent physician anywhere who has not the work in his library, for it is almost an essential. In fact it is better adapted to the wants of general practitioners than any work of the kind with which we are acquainted. The works of German authors upon pathology, which have been translated into English, are too abstruse for the physician. Dr. Green's work precisely meets his wishes. The cuts exhibit the appearances of pathological structures just as they are seen through the microscope. The fact that it is so generally employed as a text-book by medical stu- dents is evidence that we have not spoken too much in its favor.—Cincinnati Medical News, Oct. 1889. Payne's General Pathology. A Manual of General Pathology. Designed as an Introduction to the Practice of Medicine. By Joseph F. Payne, M. D., F. E. C. P., Senior Assistant Physi- cian and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Octavo of 524 pages, with 152 illustrations and a colored plate. Cloth, $3.50. Coats' Treatise on Pathology. A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Patholo- gist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50; leather, $6.50. MAHfpal students as well as physicians, who manner, the changes from a normal condition - effected in structures by disease, and points out the characteristics of various morbid agencies. so that they can be easily recognized. But, not limited to morbid anatomy, it explains fully how the functions of organs are disturbed by abnormal conditions.—Cincinnati Medical News, Oct. 1883. desire a work for study or reference, that treats the subjects in the various departments in a very thorough manner, but without prolixity, will cer- tainly give this one the preference to any with which we are acquainted. It sets forth the most recent discoveries, exhibits, in an interesting Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 20 Surgery. Ashhurst's Surgery.—New (6th) Edition. Just Ready. The Principles and Practice of Surgery. By John Ashhurst, Jr. M. D., Professor of Surgery and Clinical Surgery in the Univ. of Penna., Surgeon to the Penna. Hospital, Philadelphia. New (6th) edition, enlarged and thoroughly revised. Octavo, 1161 pages, 656 engravings and a colored plate. Cloth, $6.00; leather, $7.00. Ashhurst's Surgery maintains in its sixth edition the high standard of excellence which has always been its characteristic. The author has so thor- oughly revised his work that the most recent appliances and methods in surgery are mentioned. Dr. Ashhurst's well-known, comprehensive, and yet concise treatment of the various subjects is even more marked in this than in the previous editions. A great deal of new matter has been ad ded without making the volume unwieldy. Con- densation and elimination have been most skil- fully done where necessary.—The Chicago Medical Recorder, January, 1894. The author has been before the surgical world so long and is so versatile and resourceful that his several editions are rapidly taken up and others follow in equally prompt measures of time. Ashhurst has taken great pains to render this sixth edition fully equal to the demands of the present, and has constructed it on lines which merit a con tinuance of the confidence of the profes- sion. In this edition he has incorporated an ac- count of the more important recent observations in surgical science, as well as such novelties in sur- gical practice as meritthe classification of improve- ments. Dr. Charles B. Nancrede, of Ann Arbor, has contributed a new chapter on surgical bacteri- ology ; Dr. Barton C. Hirst has revised the sections on gynecological subjects; and Drs. George E. de Schweinitz and B. Alexander Randall have re- vised the chapters on diseases of the eye and ear. Those surgeons who possess earlier editions of Ashhurst's treatise will make haste to obtain this new one, and those who are not familiar with the work will necessarily add it to their libraries. Surgical science is so varied and extensive in its application, that one must needs have at hand all the contemporary authors extant in order to keep pace intelligently with its progress.—Buffalo Medi- cal and Surgical Journal, March, 1894. Roberts' Modern Surgery. The Principles and Practice of Modern Surgery. For the use of Stu- dents and Practitioners of Medicine and Surgery. By John B. Eoberts, M. D., Prof, of Anatomy and Surgery in the Philadelphia Polyclinic. Prof, of Surgery in the Woman's Medical College of Pennsylvania. Lecturer in Anatomy in the Univ. of Penna. Octavo, 780 pages, 501 illustrations. Cloth, $4.50; leather, $5.50. vanced doctrines and methods of practice of the present day. Its general arrangement follows This work is a very comprehensive manual upon general surgery, and will doubtless meet with a favorable reception by the profession. It has a thoroughly practical character, the subjects are treated with rare judgment, its conclusions are in accord with those of the leading practitioners of the art, and its literature is fully up to all the ad- this rule, and the author in his desire to be con- cise and practical is at times almost dogmatic, but this is entirely excusable considering the admira- ble manner in which he has thus increased the usefulness of his work.—Med. Rec, Jan. 17, 1891. Druitt's Modern Surgery.—Twelfth Edition. Manual of Modern Surgery. By Eobert Drtjitt, M. E. C. S. Twelfth edition, thoroughly revised by Stanley Boyd, M.B., B. S., F. E. C. S. In one 8vo. volume of 965 pages, with 373 illustrations. Cloth, $4.00; leather, $5.00. Voung's Orthopaedic Surgery.—Ready in a few days. A Manual of Orthopaedic Surgery, for Students and Practi- tioners. By James K. Yotjng, M. D., Instructor in Orthopaedic Surgery, University of Pennsylvania, Philadelphia. In one octavo volume of about 475 pp., with about 285 illus. The correction of deformities constitutes so large and important a department of surgery that it cannot be adequately dealt with except in a special treatise. The able author of this forthcoming work has provided a guide which in clearness of text and richness and beauty of illustration will leave nothing to be desired. The afflictions therein treated are unfortunately frequent in every community, and the work is therefore one which will be of the utmost value to the general practitioner, the surgeon and like- wise the orthopaedist. Sutton on Tumors, Innocent and Malignant.—Just Ready. Tumors, Innocent and Malignant. Their Clinical Features and Ap- propriate Treatment. By J. Bland Sutton, F. E. C. S., Assistant Surgeon to the Mid- dlesex Hospital, London. In one very handsome octavo volume of 526 pages, with 250 engravings and 9 full page plates. Cloth, $4.50. Sutton has without doubt written the best general work on tumors which has yet appeared in the English language. His classification is a most excellent one, and his clinical descriptions are clear-cut and sharp. Throughout the work comparative anatomy is brought into play as well as embryology, and the usefulness of these com- parisons is at once apparent to the reader. His views on cancer are such as will immediately appeal to a rational mind. The large number of illustrations is of the greatest help, being well made and judiciously chosen in every instance. We urge all of our readers to get this splendid book.—The St. Louis Med. and Surg. Jl., April, 1894. BUTLIN ON DISEASES OF THE TONGUE. By Henry T. Butlin, F. R. C. S., Assistant Surgeon to St. Bartholomew's Hospital, London. In one 12mo. volume of 456 pages, with 8 colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clin- ical Manuals, page 30. GOULD'S ELEMENTS OF SURGICAL DIAG- NOSIS. By A. Pearce Gould, M. S., M. B., F. R. C S., Assistant Surgeon to Middlesex Hos- pital, London. In one pocket-size 12mo. volume of 589 pages. Cloth, 82.00. See Students' Series of Manuals, page 30. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D. In one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. GANT'S STUDENT'S SURGERY. By Frederick James Gant, F. R. C. S. Square octavo, 848 pages, 159 engravings. Cloth, $3.75. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Surgery—(Continued). 21 Wharton's Minor Surgery and Bandaging—2d Ed. Just Ready. Minor Surgery and Bandaging. By Henry E. Wharton, M. D., Demonstrator of Surgery in the University of Pennsylvania. In one 12mo. volume of 529 pages, with 416 engravings, many being photographic. Cloth, $3.00. It is but little more than two years ago that we published a review notice of Wharton's first edition. At that time, we remarked that the book was one of the very best treatises on minor sur- gery that had been published, that it ought to be adopted as a text-book on the subjects of which it treats, and that it contained more practical sur- §ery within its limits and boundaries than any ook of its kind we had ever seen. What was true of the first edition may be, with propriety repeated and accentuated in regard to this second" and revised edition. Its illustrations are to be specially commended, particularly those that re- late to bandaging, most of which have been taken from photographs of applied bandages in the several localities of the body. The author has thoroughly revised that portion of the work relating to the aseptic and antiseptic methods of wound treatment, than which there is no more important subject in the whole domain of sur- fery. Much new matter has been added, which rings it abreast of the very latest knowledge on the subjects of which it treats.—Buffalo Medical and Surgical Journal, January, 1894. Treves' Operative Surgery.—Two Volumes. A Manual of Operative Surgery. By Frederick Treves, F.E.C. S., Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes containing 1550 pages, with 422 engravings Mr. Treves in this admirable manual of opera- tive surgery has in each instance practically assumed that operation has been decided upon and has then proceeded to give the various opera- tive methods which may De employed, with a criticism of their comparative value and a detailed and careful description of each particular stage of their performance. Especial attention has been paid to the preparatory treatment of the patient and to the details of the after treatment of the case, and this is one of the most distinctive among the many excellent features of the book. We have no hesitation in declaring it the best work on the subject in the English language, and indeed, in many respects, the best in any language. It can- Complete work, cloth, $9.00; leather, $11.00. not fail to be of the greatest use both to practical surgeons and to those general practitioners who, owing to their isolation or to other ciroumstances, are forced to do much of theirown operative work. We feel called upon to recommend the book so strongly for the excellent judgment displayed in the arduous task of selecting from among the thousands of varying procedures those most worthy of description; for the way in which the still more difficult task of choosing among the best of those has been accomplished; and for the simple, clear, straightforward manner in which the information thus gathered from all surgical literature has been conveyed to the reader.— Annals of Surgery, March, 1892. In Treves' Student's Handbook of Surgical Operations. square 12mo. volume of 508 pages, with 94 illustrations. Cloth, $2.50. A Manual of Surgery. In Treatises by Various Authors, edited by Fred- erick Treves, F. E. C. S. In three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per set, cloth, $6.00. See Students' Series of Manuals, page 30. We have here the opinions of thirty-three authors, in an encyclopaedic form for easy and ready reference. The three volumes embrace every variety of surgical affections likely to be met with, the paragraphs are short and pithy, and the salient points and the beginnings of new sub- jects are always printed in extra-heavy type, so that a person may find whatever information he may be in need of at a moment's glance.—Cin- cinnati Lancet-Clinic, August 21,1886. Treves on Intestinal Obstruction. In one 12mo. volume of 522 pages, with 60 illus. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 30. Erichsen's Science and Art of Surgery.—Eighth Edition. The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Diseases and Operations. By John E. Erichsen, F. E. S., F. E. C. S., Professor of Sur- gery in University College, London, etc. From the eighth and enlarged English edition. In two large 8vo. vols, of 2316 pp., with 984 engravings on wood. Cloth, $9; leather, $11. of the former edition has been dropped and no discovery, device or improvement which has marked the progress of surgery during the last decade has been omitted. The illustrations are For many years this classic work has been made by preference of teachers the principal text-book on surgery for medical students, while through translations into the leading continental languages it may be said to guide the surgical teachings of the civilized world. No excellence many and executed in the highest style of art. —Louisville Medical News, Feb. 14,1885. Bryant's Practice of Surgery.—Fourth Edition. The Practice of Surgery. By Thomas Bryant, F. E. C. S., Surgeon and Lecturer on Surgery at Guy's Hospital, London. Fourth American from the fourth and revised English edition. In one large and very handsome imperial octavo volume of 1040 pages, with 727 illustrations. Cloth, $6.50; leather, $7.50. The present edition is a thorough revision of those which preceded it, with much new matter added. Almost every topic in surgery is pre- sented in such a form as to enable the busy practitioner to review any subject in every-day practice in a short time. In short, the work is eminently clear, logical and practical.—Chicago Med. Jour, and Examiner, Apr. 1886. MILLER'S PRACTICE OF SURGERY. Fourth and revised American edition. In one large 8vo. vol of 682 pp.. with 364 illustrations. Cloth, $3.75. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh ed., In one Rvo vol of 638 paees. with 340 illus. Cloth, $3.76. HOLMES' SYSTEM OF SURGERY. THEORET- ICAL AND PRACTICAL. By Various Authors. Edited by Timothy Holmes, M. A. American edi- tion, revised and re-edited by John H. Packard, M. D. Three large octavo volumes, 3137 pages, 979 illustrations on wood and 13 lithographic plates. Per set. cloth, 518.00; leather, $21.00. Subscription only. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia 22 Surgery—(Continued), Fractures, Dislocations. Smith's Operative Surgery.—Revised Edition. The Principles and Practice of Operative Surgery. By Stephen Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. Second and thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00, This excellent and very valuable book is one of the most satisfactory works on modern operative surgery yet published. The book is a compendium for the modern surgeon. The present edition is much enlarged, and the text has been thoroughly revised, so as to give the most improved methods in aseptic surgery, and the latest instruments known for operative work. It can be truly said that as ahandbook for the student, acompanion for the surgeon, and even as a book of reference for the physician not especially engaged in the practice of surgery, this volume will long hold a most conspicuous place, and seldom will its readers, no- matter how unusual the subject, consult its pages in vain. Its compact form, excellent print, num- erous illustrations, and especially its decidedly practical character, all combine to commend it.— Boston Medical and Surgical Journal, May 10,1888. Holmes' Treatise on Surgery.—Fifth Edition. A Treatise on Surgery; Its Principles and Practice. By Timothy Holmes, M. A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. From the fifth English edition, edited by T. Pickering Pick, F. E. C. S. In one octavo volume of 997 pages, with 428 illustrations. Cloth, $6.00; leather, $7.00. To the younger members of the profession and to others not acquainted with the book and its merits, we take pleasure in recommending it as a surgery complete, thorough, well-written, fully illustrated, modern, a work sufficiently volumi- nous for the surgeon specialist, adequately concise for the general practitioner, teaching those things that are necessary to be known for the successful prosecution of the surgeon's career, imparting nothing that in our present knowledge is consid- ered unsafe, unscientific or inexpedient.—Pacific Medical Journal, July, 1889. Hamilton on Fractures and Dislocations.—Eighth Edition. A Practical Treatise on Fractures and Dislocations. By Frank H. Hamilton, M. D., LL. D., Surgeon to Bellevue Hospital, New York. New (8th) edi- tion, revised and edited by Stephen Smith, M. D., Prof, of Clinical Surgery in Univ. of City of N. Y. In one octavo volume of 832 pp., with 507 illus. Cloth, $5.50; leather, $6.50. Its numerous editions are convincing proof if any is needed, of its value and popularity. It is pre- eminently the authority on fractures and disloca- tions, and universally quoted as such. In the new edition it has lost none of its former worth. The additions it has received by its recent revision make it a work thoroughly in accordance with modern practice, theoretically, mechanically, aseptically. The task of writing a complete treatise on a sub- ject of such magnitude is no easy one. Dr. Smith has aimed to make the present volume a correct exponent of our knowledge of this department of surgery. The more one reads the more one is impressed with its completeness. The work has been accomplished, and has been done clearly, concisely, excellently well.—Boston Medical and Surgical Journal, May 26,1892. Stimson's Operative Surgery.—Second Edition. A Manual of Operative Surgery. By Lewis A. Stimson, B. A., M. D., Professor of Clinical Surgery in the University of the City of New York. Second edi- tion. In one royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. the antiseptic system, and has added an account The author knows the difficult art of condensa- tion. Thus the manual serves as a work of reference, and at the same time as a handy guide. It teaches what it professes, the steps of operations. In this edition Dr. Stimson has sought to indicate the changes that have been effected in operative methods and procedures by of many new operations and variations in the steps of older operations. We do not desire to- extol this manual above many excellent standard British publications of the same class, still we be- lieve that it contains much that is worthy of imi- tation.—British Medical Journal, Jan. 22,1887. Stimson on Fractures and Dislocations. A Treatise on Fractures and Dislocations. By Lewis A. Stimson, M. D. In two handsome octavo volumes. Vol. I., Fractures, 582 pages, 360 illustra- tions. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, cloth, $5.50; leather, $7.50. Either volume separately, cloth, $3.00; leather, $4.00. The appearance of the second volume marks the completion of the author's original plan of prepar- ing a work which should present in the fullest manner all that is known on the cognate subjects of Fractures and Dislocations. The volume on Fractures assumed at once the position of authority on the subject, and its companion on Dislocations will no doubt be similarly received. This volume exhibits the surgery of Dislocations as it is taught and practised by the most eminent surgeons of the present time. Containing the results of such ex- tended researches it must for a long time be re- garded as an authority on all subjects pertaining to dislocations. Every practitioner of surgery will feel it incumbent on him to have it for constant reference.—Cincinnati Medical News, May, 1888. Pick on Fractures and Dislocations. Fractures and Dislocations. By T. Pickering Pick, F. E. C. S., Sur- geon to and Lecturer on Surgery at St. George's Hospital, London. In one 12mo. vol. of 530 pp., with 93 illus. Limp cloth, $2.00. See Series of Clinical Manuals, page 30. Marsh on the Joints. Diseases of the Joints. By Howard Marsh, F. E. C. S., Senior Assistant Surgeon to St. Bartholomew's Hospital, London. In one 12mo. volume of 468 pages, with 64 woodcuts and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Ophthalmology. 23 Norris & Oliver's Ophthalmology. A Text-Book of Ophthalmology. By William F. Norris, M. D., Professor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, M. D., Surgeon to Wills' Eye Hospital, Philadelphia. In one very handsome octavo vol. of 641 pages, with 357 engravings and 5 colored plates. Cloth, $5; leather, "*" This is the first text-book of diseases of the eye, written by American authors for American col- leges and students. Every method of ocular pre- cision that can be of any clinical advantage to the every-day student and the scientific observer is offered to the reader. Rules and procedures for the ordinary methods of examination of the ex- ternal appearances of the eye, for ophthalmoscopy, and for the application of the fundus-reflex tests, are made so plain and so evident, even to the most careless reader, that any student can easily understand and employ them. It is succinct in recital, practical in its teachings, judicious in the selection of material and conservative, yet radical when necessary. In treatment it can be accepted as from the voice and the pen of a respected and recognized authority. The illustrations, many of which are original, far outnumber those of its contemporaries, whilst the high grade and un- biased opinions of the teachings serve to give it a rank superior to any would-be competitor. Won- derfully cheap in price, beautifully printed and exquisitely illustrated, the mechanical make-up of the book is all that can be desired. After most conscientious and painstaking perusal of the work, we unreservedly endorse it as the best, the safest and the most comprehensive volume upon the subject that has ever been offered to the American medical public. We sincerely hope that it may find its way into the list of text-books of every English-speaking college of medicine.— Annals of Ophthalmology and Otology, Oct. 1893. Berry on the Eye.—New (2d) Edition. Diseases Of the Eye. A Practical Treatise for Students of Ophthalmology. By George A. Berry, M. B., F. E. C. S., Ed., Ophthalmic Surgeon, Edinburgh Eoyal Infirmary. New (second) edition. In one octavo volume of 750 pages, with 197 illustra- tions, mostly lithographic. Cloth, $8.00. This is by far the best work upon its theme in the English language that we have seen, for the diction is pure and clear, and besides, the beauti- ful illustrations of normal and diseased conditions make it a valuable addition to the library of all practitioners, general as well as special. We have never seen more real delineation of disease, the coloring is perfect, and each illustration is an "object-lesson." We cannot but reiterate what we said at the beginning, that we have had great pleas- ure in the perusal of this work, and great profit, and that we consider it the best on the subject in the English language to-day, not only for its diction but for its instructive illustrations.—The American Journal of the Medical Sciences, August, 1893. Juler's Ophthalmic Science and Practice.—New (2d) Edition. A Handbook of Ophthalmic Science anc? Practice. By Henry E. Juler, F. E. C. S., Senior Assistant Surgeon, Eoyal Westminster Ophthalmic Hospital; Late Clinical Assistant, Moorfields, London. New (2d) edition. Handsome 8vo. volume of 561 pages, with 201 woodcuts, 17 colored plates, selections from Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $5.50; leather, $6.50. The continuous approval manifested towards this work testifies to the success with which the author has produced concise descriptions and typical illustrations of all the important affections of the eye. The volume is particularly rich in matter of practical value. The sections devoted to treatment are singularly full, and at the same time concise, and couched in language that cannot fail to be understood.—The Medical Age, Nov. 10, 1893. Nettleship on the Eye.—Fifth Edition. Diseases of the Eye. By Edward Nettleship, F. E. C. S., Ophthalmic Surgeon at St. Thomas' Hospital, London. Surgeon to the Eoyal London (Moorfields) Ophthalmic Hospital. Fourth American from the fifth English edition, thor- oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College Philadelphia. In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test-types and formulae, and a colored plate. Cloth, $2.00. This is a well-known and a valuable work. It was primarilv intended for the use of students, and supplies" their needs admirably, but it is as useful for the practitioner, or indeed more so. it does not presuppose the large amount of recondite knowledge to be present which seems to be as- sumed in some of our larger works, is not tedious from over-conciseness, and yet covers the more important parts of clinical ophthalmology.—New York Medical Journal, December 13,1890. Carter & Frost's Ophthalmic Surgery. Ophthalmic Surgery. By E. Brijdenell Carter, F. EC. S., Lecturer on Ophthalmic Surgery at St. George's Hospital, London, aud W. Adams Frost, F.E C.S., Joint Lecturer on Ophthalmic Surgery at St George's Hospital, London In one 12mo. volume of 559 pages, with 91 woodcuts, color-blindness test, test-types and dots and appen- dix of formulae Cloth, $2.25. See Series of Clinical Manuals, page 30. THE URINARY ORGANS. THOMPSON ON Lectures on Diseases or tne unumj V'.s""": By Sir Henry Thompson, Professor of Clinical ?nr^erv in University College Hospital, London. THOMPSON POgN9' Ve^aVToLOGY' £g T TUP ATMENT OF STRICTURE OF THE T7RETHRA AND URINARY FISTULA. From the third English edition. In one octavo volume of 359 pages, with 47 engravings and 3 plates. Cloth, 83.50. BASHAM ON RENAL DISEASES: A Clinical Guide to their Diagnosis and Treatment. 12mo. 304 pages, with 21 Illustrations. Cloth, $2.00. WELLS ON THE EYE. In one octavo volume. LAURENCE AND MOON'S HANDY BOOK OF OPHTHALMIC SURGERY, for the use of Prac- titioners. Second edition. In one octavo vol- ume of 227 pages, with 66 illus. Cloth, 82.75. LAWSON ON INJURIES TO THE EYE, ORBIT AND EYELIDS: Their Immediate and Remote Effects. In one octavo volume of 404 pages, with 92 illustrations. Cloth, $3.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. 24 Otology, Urinary & Renal Dis., Dentistry. Politzer on Diseases of the Ear.—New Edition. Just Ready. A Text-Book of Diseases of the Ear and Adjacent Organs. By Dr. Adam Politzer, Imperial-Eoyal Professor of Aural Therapeutics in the Univer- sity of Vienna, Chief of the Imperial-Eoyal University Clinic for Diseases of the Ear in the General Hospital, Vienna. Translated into English from the third and revised German edition, by Oscar Dodd, M. D., Clinical Instructor in Diseases of the Eye and Ear, College of Physicians and Surgeons, Chicago. Edited by Sir William Dalby, F. E. C. S., M. B., Consulting Aural Surgeon to St. George's Hospital, London. In one large octavo volume of 748 pages, with 330 illustrations. Cloth, $5.50. This standard treatise, by a recognized German authority, will be eagerly welcomed by those English readers unacquainted with the work in the original. Politzer's views on otological sub- jects are those of an advanced yet conservative surgeon. His advice is that of a careful observer of vast and varied experience. The illustrations accompanying the text are good.—Medical Record, April 21, 1894. Field's Manual of Diseases of the Ear.—Just Ready. A Manual of Diseases of the Ear. By George P. Field, M. E. C. S, Aural Surgeon and Lecturer on Aural Surgery in St Mary's Hospital Medical School, London. In one octavo of 391 pp., with 73 engravings and 21 colored plates. Cloth, $3.75. The author's views are so plainly and forcibly expressed that the student and general practi- tioner of medicine cannot afford to be without their teaching and careful guidance if they would do the justice to their patients that the present advanced state of otology demands. Within the covers of this book will be found information suf- ficient to supply the needs of the student and practitioner of general medicine in practical mat- ters pertaining to diseases of the ear.—The Thera- peutic Gazette, January 15,1894. Burnett on the Ear.—Second Edition. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. By Charles H. Burnett, A. M., M. D., Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society. Second edition. In one handsome octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00; leather, $5.00. Roberts on Urinary and Renal Diseases.—Fourth Edition. A Practical Treatise on Urinary and Renal Diseases, including Urinary Deposits. By Sir William Eoberts, M. D., Lecturer on Medicine in the Manchester School of Medicine, etc. Fourth American from the fourth London edi- tion. In one handsome octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. It may be said to be the best book in print on the subject of which it treats.—The American Journal of the Medical Sciences, Jan. 1886. It is an unrivalled exposition of everything which relates directly or indirectly to the diagno- sis, prognosis and treatment of urinary diseases, and possesses a completeness not found else- where in our language in its account of the differ- ent affections.— Manchester Med. Chron., July, '85. Purdy on Bright's Disease and Allied Affections. Bright's Disease and Allied Affections of the Kidneys. By Charles W. Purdy, M. D., Professor of Genito-Urinary and Eenal Diseases in the Chi- cago Polyclinic. In one octavo vol. of 288 pages, with illustrations. Cloth, $2.00. On treatment the writer is particularly strong, I items which are all important to the general prac- steering clear of generalities, and seldom omit- titioner.—The Manchester Medical Chronicle, Oct. ting, what text-books usually do, the unimportant | 1886. The American System of Dentistry. In Treatises by Various Authors. Edited by Wilbur F. Litch, M.D., D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6; leather, $7 ; half Morocco, gilt torj, $8. For sale by subscription only. doubtless it is), to mark an epoch in the history of dentistry. Dentists will be satisfied with it and proud of it—they must. It is sure to be precisely what the student needs to put him and keep him in the right track, while the profession at large will receive incalculable benefit from it.—Odonto- graphy Journal, Jan. 1887. As an encyclopaedia of Dentistry it has no su perior. It should form a part of every dentist's library, as the information it contains is of the greatest value to all engaged in the practice of dentistry.—American Jour. Dent. Sci., Sept. 1886. A grand system, big enough and good enough and handsome enough for a monument (which Coleman's Dental Surgery.—American Edition. A Manual of Dental Surgery and Pathology. By Alfred Coleman L. E. C. P., F. E. C. S., Exam. L. D. S., Lecturer on Dental Surgery at St. Bartholomew's Hospital, London. Thoroughly revised and adapted to the use of American Students, by by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology in the Philadel- phia Dental College. Octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. MORRIS ON SURGICAL DISEASES OF THE KIDNEY. By Henry Morris, F. R. C. S., Surgeon to Middlesex Hospital, London. 12mo., 554 pp., with 40 woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, p. 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Impotence, Sterility, Venereal, Skin. 25 Gross on Impotence, Sterility, etc.—Fourth Edition. orders ofS?!SS treatise on Impotence, Sterility, and Allied Dis- LL D ProfSS.5SeTaS.ex.U?1 0rgans. By Samuel w/gboss, A.M., M. D., MedicalSw/pff Jnncrples of Surgery and of Clinical Surgery in the Jefferson Medical College of Philadelphia. Fourth edition, thoroughly revised by F. E. Sturgis, S Y Poft Cr,A uTTt °f *£e Genito-Urinary Organs and of Venereal Diseases, ^Thr^eStgnsof llttfor^r^ JZ^±^^{ ™ W. ** 18 Ulmu Cloth, $1,50: Three editions of Professor Gross' valuable book have been exhausted, and still the demand U unapplied. Dr. Sturgis has revised m™ added to the previous editions, and the new one appears more complete and more valuable than before EX ™I?rt«»t M>.d generally misunderstood su£ jects are treated-impotence, sterility, spermator- rhoea, and prostatorrhcea. The book is a practical one and in addition to the scientific and very in- teresting discussions on etiology, symptoms, etc., there are lines of treatment laid down that any practitioner can follow and which have met with success in the hands of author and editor.—Medi- cal Record, Feb. 25,1891. Taylor on Venereal Diseases.—Sixth Edition. Preparing. ™»„na ~fThe ??tho}PSy and Treatment of Venereal Diseases. Including the results of recent investigations upon the subject. By Eobert W. Taylor, A. M., M. D, Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons New lork. Being the sixth edition of Bumstead and Taylor, rewritten by Dr. Taylor! Large 8vo volume, about 900 pages, with about 150 engravings, as well as numerous chromo-lithographs. In active preparation. A notice of the previous edition is appended. It is a splendid record of honest labor, wide research, just comparison, careful scrutiny and original experience, which will always be held as a high credit to American medical literature. This is not only the best work in the English language upon the subjects of which it treats, but also one which has no equal in other tongues for its clear, comprehensive and practical handling of its themes.—Am. Jour, of the Med. Sciences, Jan. 1884. Culver & Hayden's Manual of Venereal Diseases. A Manual of Venereal Diseases. By Everett M. Culver, M. D., Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James E. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur- geons, New York. In one 12mo. volume of 289 pages, with 33 illus. Cloth, $1.75 This book is a practical treatise, presenting in a condensed form the essential features of our pres- ent knowledge of the three venereal diseases, syphilis, chancroid and gonorrhea. We have ex- amined this work carefully and have come to the conclusion that it is the most concise, direct and able treatise that has appeared on the subject of venereal diseases for the general practitioner to adopt as a guide. The general practitioner needs a few simple, concise and clearly presented laws, in the execution of which he cannot fail either to cure or prevent the ravages of the maladies in question and their direful results.—Buffalo Medical and Surgical Journal, May, 1892. Cornil on Syphilis. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. By V. Cornll, Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hos- pital. Specially revised by the Author, and translated with notes and additions by J. Henry C. Slmes, M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. William White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one handsome octavo volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. Hutchinson on Syphilis. Syphilis. By Jonathan Hutchinson, F. E. S., F. E. C. S., Consulting Sur- geon to the London Hospital. In one 12mo. volume of 542 pages, with 8 chromo- lithographs. Cloth, $2.25. See -Series of Clinical Manuals, page 30. Hardaway's Manual of Skin Diseases. Manual Of Skin Diseases. With Special Eeference to Diagnosis and Treat- ment. For the use of Students and General Practitioners. By W. A. Hardaway, M. D., Professor of Skin Diseases in the Missouri Medical College. 12mo., 440 pp. Cloth, $3.00. Dr. Hardaway's large experience as a teacher and writer has admirably fitted him for the diffi- cult task of preparing a book which, while suffi- ciently elementary for the student is yet suffi- ciently thorough and comprehensive to serve as a book of reference for the general practitioner. It GROSS' PRACTICAL TREATISE ON THE DIS- EASES, INJURIES AND MALFORMATIONS OF THE URINARY BLADDER, THE PROS- TATE GLAND AND THE URETHRA. By Samuel D. Gross, M.D., LL.D., D.C.L., etc. Third edition, thoroughly revised by Samtjel W. Gross, M. D. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. FOX'S EPITOME OF SKIN DISEASES. WITH FORMULA. Third edition, revised and en- larged. In one 12mo. vol. of 238 pp. Cloth, $1.25. HILLIER'S HANDBOOK OF SKIN DISEASES; for Students and Practitioners. Second Ameri- embraces all essential points connected with the diagnosis and treatment of diseases of the skin, and we have no hesitation in commending it as the best manual that has yet appeared in this department of medicine.—Journal of Cutaneous and Genito- Urinary Diseases. can edition. In one 12mo. volume of 353 pages, with plates. Cloth, 82.25. HILL ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. LEE'S LECTURES ON SYPHILIS AND SOME FORMS OF LOCAL DISEASE AFFECTING THE ORGANS OF GENERATION. In one 8vo. volume of 24R pages. Cloth. $2.25. WILSON'S STUDENT'S BOOK OF CUTANEOUS MEDICINE AND DISEASES OF THE SKIN. In one handsome small octavo volume of 535 pages. Cloth, $3.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. 26 Venereal and Skin Diseases. Hyde on the Skin.—New (3d) Edition. Just Ready. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. By J. Nevins Hyde, A. M., M. D., Professor of Dermatology and V en- ereal Diseases in Eush Medical College, Chicago. Third edition. In one octavo volume of 802 pages, with 9 colored plates and 108 engravings. Cloth, $5.00; leather, $6.00. The third edition, just issued, fulfils all the ex- the book one to be warmly recommended.—Bos- ton Medical and Surgical Journal, June, 1894. The qualities that have contributed so much to its previous popularity still remain. The chief of these unquestionably are the standpoint of prac- tical medicine from which it speaks and its wealth of therapeutical information. The writer knows no book in which one can seek more satisfactorily for information as to how to manage his patients with skin diseases. The present edition may be commended as being an exposition of the subject fully up to the present state of our knowledge. —The Chicago Clinical Review, April, 1894. pectations warranted by the great accumulation of dermatological material since the earlier editions were Drought out, and puts this work at the head of the modern American treatises on skin diseases. The author has introduced thirty- five new diseases in this edition. He is especially to be congratulated on his chapter on tuberculosis. Five plates and twenty-two woodcuts, all of great excellence, have been added to the illustrations. The excellence of the chapters on treatment, to- gether with the care that has been bestowed on subjects that have acquired new interest, make Taylor's Clinical Atlas of Venereal and Skin Diseases. A Clinical Atlas of Venereal and Skin Diseases: Including Diag- nosis, Prognosis and Treatment. By Eobert W. Taylor, A. M., M. D., Clinical Pro- fessor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York; In eight large folio parts, and comprising 58 beautifully colored plates with 213 figures, and 431 pages of text with 85 engravings. Price per part, $2.50. Bound in one volume, half Eussia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen plates sent on receipt of 10 cents. A full prospectus sent to any address on application. It would be hard to use words which would per spicuously enough convey to the reader the great value of this Clinical Atlas. This Atlas is more complete even than an ordinary course of clinical lectures, for in no one college or hospital course is it at all probable that all of the diseases herein represented would be seen. It is also more ser- viceable to the majority of students than attend- ance upon clinical lectures, for most of the students who sit on remote seats in the lecture hall cannot see the subject as well as the office student can examine these true-to-life chromo-lith- ographs. Comparing the text to a lecturer, it is more satisfactory in exactness and fulness than he would be likely to be in lecturing over a single case. Indeed, this Atlas is invaluable to the gen- eral practitioner, for it enables the eye of the physician to make diagnosis of a given case of skin manifestation by comparing the case with the picture in the Atlas, where will be found also the text of diagnosis, pathology, and full sections on treatment.— Virginia Medical Monthly,Dec. 1889. Jackson's Ready-Reference Handbook of Skin Diseases. The Ready-Reference Handbook of Diseases of the Skin. By George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College of the New York Infirmary. In one 12mo. volume of 544 pages, with 50 illustrations and a colored plate. Cloth, $2.75. Intended to serve as a reference book for the 1 ment." It treats in alphabetical order of the dis- general practitioner, "no attempt has been made eases of the skin and their management. This to discuss debatable questions," and "hence pa- book seems to us the best of its class that has thology and etiology do not receive as full consid- yet appeared.—Boston Medical and Surgical Jour- eration as symptomatology, diagnosis and treat- | nal, May 18,1893. Morris on the Skin.—Just Ready. Diseases of the Skin. An Outline of the Principles and Practice of Der- matology. By Malcolm Morris, F. E. C. S., Surgeon to the Skin Department, St. Mary's Hospital, London. In one Bquare octavo volume of 572 pages, with 19 chromo-lithographic figures and 17 engravings. Cloth, $3.50. This admirable manual, written as it evidently is by a keen, clever specialist of exceptionally wide experience, most satisfactorily meets the requirements of the American practitioner of medicine, in that it gives him a clear, comprehen- sive picture of every skin-affection, and formu- lates lor him a system of therapeutics in the follow- ing of which he can feel well assured of obtaining the best results.—The Therapeutic Gazette, March, 1894. Pye-Smith on Diseases of the Skin. A Handbook of Diseases of the Skin. By P. H. Pye-Smith, M. D., F. E. S., Physician to Guy's Hospital, London. In one octavo volume of 407 pages, with 26 illustrations, 18 of which are colored. Cloth, $2.00. It is a plain, practical treatise on dermatology, written for the student and general practitioner by a general practitioner of broad experience in the special subject of which he writes. He simpli- fies the nomenclature, and succeeds in removing much of the difficulty. After reviewing the recent advances made in this department of medicine. he pays a merited compliment to the "important contributions made by the newest school of dermatology, that of America."—Pittsburg Medical Review, June, 1893. Jamieson on Diseases of the Skin.—Third Edition. Diseases of the Skin. A Manual for Students and Practitioners. By W. Allan Jamieson, M. D., Lecturer on Diseases of the Skin, School of Medicine, Edin- burgh. Third edition, revised and enlarged. In one octavo volume of 656 pages, with woodcut and 9 double-page chromo-lithographic illustrations. Cloth, $6.00 The scope of the work is essentially clinical, lit tie reference being made to pathology or dispuled theories. Almost every subject is followed by illustrative cases. The pages are filled with inter- est to all those occupied with skin diseases. The general practitioner will find the book of great value in matters of diagnosis and treatment. The latter is quite up to date, and the formulae have been selected with care.—Medical Record, April 9 1892. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Diseases of Women. 27 The American Systems of Gynecology and Obstetrics. Systems of Gynecology and Obstetrics, in Treatises by American Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics and Gynecology in the Medical Department of the University of Buffalo; and Obstet- rics edited by Barton Cooke Hirst, M. D, Associate Professor of Obstetrics in the University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- taining 3612 pages, 1092 engravings and 8 plates. Complete work now ready. Per vol- ume: Cloth, $5.00; leather, $6.00; half Eussia, $7.00. For sale by subscription only. Address the Publishers. Full descriptive circular free on application. These volumes are the contributions of the most eminent gentlemen of this country in these de- partments of the profession. Each contributor pre- sents a monograph upon his special topic, so that everything in the way of history, theory, methods, and results is presented to our fullest need. As a work of general reference, it will be found remarka- bly full and instructive in every direction of inquiry.—The Obstetric Gazette, September, 1889. One is at a loss to know what to say of this vol- ume, for fear that just and merited praise maybe mistaken for flattery. The papers of Drs. Engel- mann, Martin, Hirst, Jaggard and Reeve are incom- parably beyond anything that can be found in obstetrical works.—Journal of the American Medical Association, Sept. 8,1888. In our notice of the "System of Practical Medi- cine by American Authors," we made the follow- ing statement:—" It is a work of which the pro- fession in this country can feel proud. Written exclusively by American physicians who are ac- quainted with all the varieties of climate in the United States, the character of the soil, the man- ners and customs of the people, etc., it is pecul- iarly adapted to the wants of American practition- ers of medicine, and it seems to us that every one of them would desire to have it." Every word thus expressed in regard to the "American Sys- tem of Practical Medicine" is applicable to the "System of Gynecology by American Authors." It, like the other, has been written exclusively by American physicians who are acquainted with all the characteristics of American people, who are well informed in regard to the peculiarities of American women, their manners, customs, modes of living, etc. As every practising physician is called upon to treat diseases of females, and as they constitute a class to which the family phy- sician must give attention, and cannot pass over to a specialist, we do not know of a work in any department of medicine that we should so strongly recommend medical men generally purchasing.— Cincinnati Med. News, July, 1887. Emmet's Gynaecology.—Third Edition. The Principles and Practice of Gynaecology; For the use of Students and Practitioners of Medicine. By Thomas Addis Emmet, M. D., LL. D., Surgeon to the Woman's Hospital, New York, etc. Third edition, thoroughly revised. In one large and very handsome 8vo. vol. of 880 pp., with 150 illus. Cloth, $5; leather, $6. We are in doubt whether to congratulate the the privilege thus offered them of perusing the author more than the profession upon the appear- views and practice of the author. His earnestness ance of the third edition of this well-known work, of purpose and conscientiousness are manifest. Embodying, as it does, the life-long experience of He gives not only his individual experience but one who has conspicuously distinguished himself endeavors to represent the actual state of gynse- as a bold and successful operator, and who has cological science and art.—British Medical Jour- devoted so much attention to the specialty, we nal, May 16,1885. feel sure the profession will not fail to appreciate Tait's Diseases of Women and Abdominal Surgery. Diseases of Women and Abdominal Surgery. By Lawson Tait, F.E. C. S., Professor of Gynaecology in Queen's College, Birmingham, late President of the British Gynecological Society, Fellow American Gynaecological Society. In two octavo vols. Vol. I., 554 pp., 62 engravings and 3 plates. Cloth, $3. Vol. II., preparing. Much of the text is abundantly illustrated r C^^ i ivnoiivn SNiDiasw do Aavaan IVNOIIVN few i ^F> f <;* feM i NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDI snidiqsw do Aavaan ivnoiivn snidiqsw do Aavaan tvnc MEDICINE NATIONAL LIBRARY OF MEDICINE IVNOIIVN 3NIDI0SW dO Aavaan IVNOIIVN W7 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MED a. 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