"''■^'•-•'.-.^•iwxa; ---■_:., .,.*-^----. ^^L^z^jmuVZiA. Ufe_ kMUMiH LIBRARY OF MEDICINE NLM001028658 ^ '" / REFERENCE-BOOK OF ' PRACTICAL THERAPEUTICS BY VARIOUS AUTHORS / Edited by FRANK P. FOSTER, M. D. editor of the new york medical journal and of poster's encyclopedic medical dictionary IN TWO VOLUMES VOL. I NEW YORK D. APPLETON AND COMPANY 1896 . W Be CF1541- s I8S7 ptU 8547 h^\ Copyright, 1896, By D. APPLETON AND COMPANY. PEEFACE. The leading idea in the preparation of this work has been to make it pre- eminently serviceable to the practising physician. It is not intended to take the place of treatises on materia medica or on pharmacy; hence, as regards the phys- ical properties of drugs, their mineralogical, chemical, botanical, or zoological relations, etc., the endeavour has been to set down only so much as is of direct bearing on the use of those drugs in medical practice or on the management of poisoning due to them. Even accounts of the physiological actions of drugs are condensed, for much of what the experimental pharmacologist justly looks upon as essential to the prosecution of his studies is useless and clogging superfluity to the physician in his daily work of treating the sick. For the same reason, profusion of references to literature has been avoided, although at the same time it is believed that due credit has been given as to sources of information. The " therapeutic nihilism " that but a few years ago was justly deplored by Professor Bartholow has been succeeded by a wave of over-activity for which it is not difficult to account. We have now to master the task of judiciously employ- ing remedial agencies many of which are new ; for this purpose we require the frequent appearance of trustworthy records of what has been accomplished with these novel agents, for in no other way can the individual practitioner keep pace with the progress of therapeutics. He who presents to the medical profession books purporting, as this one does, to contain only such positive statements about remedial agents as rest upon what seems to be a substantial basis—he who does that undertakes a work of no little responsibility. In the present instance the editor has been favoured with the collaboration of a number of writers whose teachings are known and respected. As this first volume goes to the press, it is with sorrow that he has to speak of the untimely death of two of them, the late Dr. Edward R. Palmer, of Louisville, and the late Dr. Benjamin F. Westbrook, of Brooklyn, both of whom had done important work on the book. In such a book as this, written by various authors, there is necessarily some overlapping in the treatment of certain topics ; that is to say, one author treats of a certain drug, but another, writing on a different theme, finds occasion to mention the drug assigned to the first one as a subject. If this resulted only in repetition, it might be considered a defect. But that is not the case; two or more writers on such a subject as therapeutics are not likely to inculcate exactly the same thing, except as to mere commonplaces. Indeed, the exposition of a topic by more than one author is recognised as one of the best ways for getting at the truth; the subject is treated of from more than one point of view, and additional light is thrown upon it. There are many drugs that it has not seemed necessary to mention in this iii iv PREFACE. book__some, because they have fallen into almost absolute disuse and are now of historical interest only; others, because they are used only in far distant coun- tries, often by peoples not more than semi-civilized, and are rarely if ever met with in the markets of Europe and North America; still others, because they have been so recently brought forward that too little is known of them to war- rant a writer in making definite statements concerning them. There is another class that may be called catchpenny products, put upon the market by persons of business enterprise without an excess of scrupulousness and wafted into a certain vogue—temporary and inglorious—by men who, while professing to write for the advancement of medicine, are really in the proprietors' pay, directly or indirectly. This class is to be carefully distinguished from those proprietary preparations that are really valuable, that are produced by careful and honourable makers, and that are in actual use by practitioners of high attainments and known pro- bity. Many of these preparations are used almost daily by every practising phy- sician, and there is hardly an issue of any of the most reputable medical journals in which more or less space is not devoted to them. They can not be ignored and they ought not to be. But there is a sort of neutral ground, so to speak, between these established proprietary preparations and those worthless and per- haps fraudulent productions to which allusion has been made. This neutral ground is occupied by products that have been but a short time in the market, and have not been subjected to sufficient investigation by competent persons to render it safe to make statements of any practical value with regard to them. Often it is impossible at first to tell whether they are in the hands of designing and untrustworthy men or whether their introduction proceeds from individuals of laudable intentions and possessed of the knowledge necessary to enable them to test new drugs adequately. It is an almost weekly occurrence for a new coal- tar derivative, for example, or an old compound under a new name, to be brought out as a remedy that, in the hands of some physician in a distant country, has, according to the early published accounts that reach us, produced wonderful results in the cure or mitigation of some disease; and these accounts almost always include an assurance that the drug is " non-poisonous." In short, the literature of that drug is in the florid stage ; it may take its place in the recog- nised materia medica; it may, " non-poisonous " as it has been proclaimed to be, shortly prove fatal when used in doses well within those employed by its intro- ducer, and come to be looked upon as too dangerous to be adopted ; or it may simply fall into disuse because further trial of it does not reveal to others the virtues ascribed to it by him who first brought it into notice. In this work the endeavour has been made to keep these considerations constantly in mind, and not to be hasty in promulgating statements that, although they appear well founded, may turn out to be erroneous. The editor's main work in the preparation of this book, besides that of plan- ning it and selecting the authors, has been to furnish the minor articles, together with some paragraphs or sections, distinguished by being inclosed in brackets, interpolated into the signed articles. These additional passages include sum- maries of observations that have appeared since the original articles were written. In his part of the work the editor has resorted freely to current literature, and he wishes to mention in particular the aid he has derived from the United States Dispensatory, from the National Dispensatory, from Eulenburg's Real-Encyclo- PREFACE. v pddie der gesammten Heilkunde and his Encyclopddische Jahrbilcher der ge- sammten Heilkunde, from Geissler and Moller's Real-Ency clop ddie der gesammten Pharmacie, from the Squibbs' Ephemeris of Materia Medica, etc., from Cerna's Notes on the Newer Remedies, from Bocquillon-Limousin's Formulaire des me- dicaments nouveaux, from Soulier's Memento formulaire des medicaments nou- veaux, and from Husemann's Handbuch der Arzuneimittellehre. Great care has been taken to make the Index of Diseases, etc., full and spe- cific ; and, notwithstanding the alphabetical arrangement of headings in the body of the work, it has been thought best to add an index of remedies, for the reason that drugs are often mentioned under other headings than their own names. New York, March 10, 1896. LIST OF CONTRIBUTORS TO VOLUME I. Joseph A. Andrews, M. D., Ophthalmic Sur- geon to the City Hospital, New York. Samuel Treat Armstrong, M. D., Ph. D., late Visiting Physician to the Harlem, Willard Parker, and Riverside Hospitals; ex-Passed Assistant Surgeon, U. S. Marine-Hospital Service, New York. Samuel M. Brickner, A. M., M. D., New York. Edward Bennet Bronson, M. D., Professor of Dermatology, New York Polyclinic; Visiting Physician to the City Hospital; Consulting Physician to the Babies' Hospital, New York. Henry H. Burchard, M. D., D. D. S., Lecturer on Dental Pathology and Therapeutics, Philadelphia Dental College, Philadelphia. G. Gordon Campbell, B. Sc, M. D., Demon- strator in Medicine, McGill University; As- sistant Physician to the Montreal General Hospital, Montreal. J. Leonard Corning, M. D., Neurologist to St. Francis Hospital (Jersey City) and St. Mary's Hospital (Jersey City), New York. Floyd M. Crandall, M. D., Adjunct Professor of Diseases of Children, New York Poly- clinic ; Consulting Physician to the Infants' and Children's Hospital, New York. Mary Gage Day, M. D., Wichita, Kansas. Charles Dennison, M. D., Emeritus Professor of Diseases of the Chest and of Climatology, College of Medicine of the University of Denver. George Dock, A. M., M. D., Professor of the Theory and Practice of Medicine and Clin- ical Medicine, University of Michigan, Ann Arbor. Jeremiah T. Eskridge, M. D., Professor of Nervous and Mental Diseases and Medical Jurisprudence, Colorado School of Medicine, Medical Department of the University of Colorado, Denver. Henry A. Griffin, M. D., Assistant Physician to the Roosevelt Hospital (out-patient de- partment) ; Attending Physician to the Ran- dall's Island Hospitals, New York. Lucien Howe, M. D., M. R. C. S. Eng., Clinical Professor of Ophthalmology, University of Buffalo, Medical Department, Buffalo. Charles Jewett, A. M., M. D., Sc. D., Profes- sor of Obstetrics and Diseases of Children, Long Island College Hospital; Obstetrician to the Long Island College Hospital; Con- sulting Obstetrician to the Kings County Hospital; Consulting Gynaecologist to the Bushwick Hospital, Brooklyn. Howard Lilienthal, M. D., Lecturer on Sur- gery, New York Polyclinic; Assistant At- tending Surgeon to Mt. Sinai Hospital, New York. Russell H. Nevins, M. D., Stamford, Connec- ticut. Austin O'Malley, M.D., Ph. D.. LL. D., late Medical Sanitary Inspector and Bacteriolo- gist of the District of Columbia, Washing- ton. William K. Otis, M. D., late Surgeon to the City Hospital, New York. Edward R. Palmer, M. D., late Professor of Physiology and Pathological Histology, Medical Department, University of Louis- ville ; ex-President of the American Associa- tion of Genito-urinary Surgeons, Louisville. Frederick Peterson, M. D., Chief of Clinic, Department of Neurology, Vanderbilt Clin- ic, College of Physicians and Surgeons (Medi- cal Department of Columbia University); Neurologist to the City Hospital; Patholo- gist to the New York City Insane Asylums, New York. Samuel 0. L. Potter, A. M., M. D., M. R. C. P., late Professor of the Practice of Medicine, Cooper Medical College : Visiting Physician to St. Luke's Hospital, San Francisco. Charles Rice, Ph. D., Phar. M., Bellevue Hos- pital, New York. Matthias Lanckton Foster, M. D., Assistant Surgeon to the Manhattan Eye and Ear Hospital. New York. Arpad G. Gerster, M. D., Visiting Surgeon to the Mt. Sinai and German Hospitals, New York. Vlll LIST OF CONTRIBUTORS TO VOLUME I. George H. Rohe, M. D., Professor of Materia Medica, Therapeutics, Hygiene, and Mental Diseases, College of Physicians and Sur- geons, Baltimore. D. E. Salmon, D. V. M., Chief of the Bureau of Animal Industry, United States Depart- ment of Agriculture, Washington. A. Alexander Smith, M. D., Professor of the Principles and Practice of Medicine and Clinical Medicine, Bellevue Hospital Medi- cal College, New York. Solomon Solis-Cohen, M. D., Professor of Clinical Medicine and Therapeutics, Phila- delphia Polyclinic; Lecturer on Clinical Medicine, Jefferson Medical College; Physi- cian to the Philadelphia and Rush Hospitals, etc., Philadelphia. Henry Ling Taylor, M. D., Assistant Physi- cian to the Hospital for the Ruptured and Crippled, and to the Vanderbilt Clinic, New York. Benjamin F. Westbrook, M. D., late Visiting Physician to St. Mary's Hospital and to the Methodist Episcopal Hospital, Brooklyn. James T. Whittaker, M. D., Professor of the Theory and Practice of Medicine, and Clin- ical Medicine, Medical College of Ohio, Cin- cinnati. John A. Wyeth, M. D., Professor of Surgery, New York Polyclinic; Visiting Surgeon to Mt. Sinai Hospital; Consulting Surgeon to St. Elizabeth's Hospital, New York. HAXDBOOK OF THERAPEUTICS. A. B. C. BALSAM ACETALDEHYDE A. B. C. BALSAM.—Unguentum elemi. A. B. C. OINTMENT or SALVE.—The unguentum flavum of the Ger. Ph., 1st ed. ABELMOSCHUS.—A genus of malva- ceous plants. Abelmoschus (or Hibiscus) es- culcntus furnishes okra pods, and demulcent poultices are made from the root. A paste and a syrup made from the seeds (which are distinguished from those of Abelmoschus moschattix, musk seeds, by being odourless and unstriped) are used like similar preparations of marsh mallow. ABIES.—A genus of the Coniferce (sub- order Abietiwa) including the fir trees. Abies balsamea furnishes Canada balsam. Abies communis (or excelsa), the Norway spruce, yields Burgundy pitch. Abies pectinafa (or picea), the European silver fir, furnishes Strass- burg turpentine. ABLUENTS.—See Detergents. ABORTIFACIENTS, ABORTIVES.— Certain drugs (chiefly ergot, tansy, and savin) are reputed to have the property of causing abortion. Their use for such a purpose has no place in medicine. ABRUS PRECATORIUS.—See Jequi- rity. ABSINTHIUM [U. S.].—Herba absin- thii, grande absinthe, aluyne (Fr. Cod.); the leaves and tops of Artemisia Absinthium, wormwood; a stomachic tonic, formerly used as an anthelminthic, now little used for any purpose. An infusion of an ounce in a pint of water may be drank freely. A volatile oil dis- tilled from the drug {oleum absinthii [Ger. Ph.], huile volatile d'absinthe [Fr. Cod.]) has been used internally as an antispasmodic, in doses of a drop or two, and locally as an analgetic. Tn large doses the oil produces epileptoid con- vulsions, coma, and death. ABSORBENTS are drugs which act by absorbing (sometimes by neutralizing) delete- rious gases or liquids, also those which pro- mote the absorption of exudates, etc. Cf. Antacids and Sorbefacients. ABSTERGENTS, ABSTERSIVES.— See Detergents. ACACIA [U. S.].—Gum arabic; the aca- cia7, gummi of the Br. and Austr. Ph's; the gummi arabicum of the Ger. Ph.; the gomme arabigne of the Fr. Cod.; a clear, whitish gum that exudes from various species of trees of the genus Acacia (of the Leguminosm, subor- der Mimoseai), especially Acacia Senegal. Gum arabic dissolves readily in cold water, and, so dissolved, is used as a demulcent. It has been considered somewhat nutritive. The mucilago acaci(P of the U. S. Ph. is a solution of 340 parts of gum arabic in enough water to make 1,000 parts by weight; this, mixed with three times its bulk of syrup, constitutes the syrupus acacia of the U. S. Ph. The mucilago acacim of the Br. Ph. is a solution of 2 parts of gum arabic in 3 of distilled water. A. C. E. MIXTURE.—A mixture of alco- hol, chloroform, and ether; so called from the initial letters of the names of its ingredients. In the United States, where such a mixture is much used as an anaesthetic, the proportions are generally 1 part of alcohol, 2 parts of chlo- roform, and 3 parts of ether, by bulk. It is esteemed safer than chloroform alone and more agreeable and speedy in its action than ether alone. The alcohol is added with the view of promoting the intimate blending of the chlo- roform and ether. ACETAL.—The acetals are formed by the action of an alcohol on a nascent aldehyde. Ordinary acetal, diethylacetal, CIIsCH(CaH60)a, is a thin, colourless, volatile liquid, of agreeable odour and taste, which contributes prominently to the flavour and bouquet of old wines. It dis- solves readily in all proportions in alcohol and in ether, and in eighteen times its volume of water. By oxidation, to which it is prone when exposed to the air, it is transformed into aldehyde, and then into acetic acid. Acetal is a hypnotic closely resembling chloral in its action, but much less powerful, regarded as especially suitable in cases of mental or emo- tional disturbance. The dose is from a drachm to a drachm and a half, in water or wine. Dimethylacetal, CI13CH(CH30)2, has the same medicinal properties, but is still feebler, so that the dose is twice as large as that of ordinary acetal. A mixture of two volumes of dimethylacetal with one volume of diethyl- acetal has been recommended as an anaesthetic less apt to enfeeble the heart than chloroform. Acetal may be detected in the breath for sev- eral hours after its administration. ACETALDEHYDE.—See Aldehyde. ACETANILIDE 2 ACETANILIDE, phenylacetamide, C6HB* NH.C2H3O, the acetanilidum of the pharma- copoeias, is known also under the proprietary name " antifebrine." It is an acetal derivative of aniline, and appears as white, shining, mi- caceous, crystalline laminae, or a crystalline powder, odourless, having a faintly burning taste, and permanent in the air. Should acet- anilide give a reddish-orange precipitate with sodium hypobromite, it contains aniline and should be rejected. Given to a healthy adult, in a dose of from 5 to 10 grains, it produces usually no effect. A repetition of the dose commonly results in somnolence, and at times malaise, a weaken- ing of cardiac force, and slight cyanosis, espe- cially of the face and extremities. In the ab- sence of fever no fall of temperature results. Given in the presence of pyrexia and in therapeutic doses there usually occurs a marked fall of temperature, which usually begins with- in one or two hours, soon reaches its maximum, and lasts even to eight or ten hours. Co- incident with the fall in temperature is a reduction of the pulse rate and force, with a disappearance of other febrile symptoms. Sweating frequently accompanies the fall in temperature, but is apt to be less than that caused by antipyrine. That the fall in tem- perature is not dependent upon the sweating is proved by the fact that the antipyretic effect of the drug is no less marked even in the absence of sweating. This action of acetani- lide in causing reduction of temperature is not thoroughly understood, but it is believed to act mainly by diminishing heat production, and also, though to a lesser degree, by in- creasing heat dissipation. Though a fall of temperature follows the administration of a therapeutic dose of the drug in the vast ma- jority of cases, the rule is not invariable, and an occasional failure of any antipyretic effect marks the capricious nature of acetanilide. While the antipyretic dose of acetanilide is usually about 4 grains, much larger doses have been given with no ill effect, even to 100 grains in twenty-four hours; moreover, a single dose of 1 drachm has been well borne by a healthy subject. Ill effects often follow the larger doses, however, and 10 grains is scarcely a safe dose for routine administra- tion ; indeed, serious symptoms are sometimes seen after an ordinary therapeutic dose, though in this respect the unreliability of acetanilide does not approach that of antipyrine. Of ad- verse symptoms following the administration of acetanilide, the most common is a slight cyanosis which in itself is seldom of gravity. Weakening of the cardiac force and of the ra- dial pulse is, however, a more serious occur- rence which not very uncommonly appears to some extent. The appearance of an eruption from the giving of acetanilide is exceedingly rare, though not unknown ; vomiting, too, may occur, but is comparatively rare. In a few cases collapse has been seen coincident with the fall in temperature, but it is by no means so com- mon as after the administration of antipyrine. Since acetanilide. is practically insoluble in wa- ter, it should be given in alcoholic solution or, better still, in powder, capsule, or tablet. Its therapeutic dose is from 2 to 8 grains. Poisoning by acetanilide is marked by pros- tration, cyanosis, sweating, cold extremities, shallow and feeble respiration, dilated pupils, and weak heart action, which may be rapid, slow, or irregular. Death takes place in fatal cases from cardiac paralysis. Unconsciousness may occur, but in many cases it is absent al- most to the time of death. The depression of the circulation following the administration of acetanilide is far more likely to occur if the patient remains in the erect attitude. It is far wiser, therefore, for him to lie down. The treatment in cases of poisoning is by active stimulation with the application of heat ex- ternally and the inhalation of oxygen. As a result of the continued administration of acetanilide, there may occur in man anaamia, with congestion of the liver, kidneys, and spleen. That such congestions will result in degenera- tion is probable, and experiments on animals show that the continued use of acetanilide in large doses is the direct cause of fatty degen- eration of the heart, liver, and kidneys. The therapeutic value of acetanilide depends upon its properties of reducing febrile tem- perature, preventing spasm, and relieving pain; and though for some time after its introduc- tion its antipyretic action was prominently con- sidered to the underrating and almost to the ignoring of its other powers, more extended use of the drug and more deliberate consideration have resulted in making known its other prop- erties, which are in reality the more valuable. The impression, unfortunately deep-rooted, that fever is an enemy to be met and vigor- ously attacked whensoever and wheresoever it makes its appearance, has been the cause of innumerable therapeutic blunders and of in- calculable harm. Unfortunate indeed was this belief previous to the introduction of the mod- ern antipyretic drugs, but with their appear- ance the situation became doubly serious, for there were then put into the hands of the prejudiced and the indiscreet the weapons wherewith the supposed enemy might be at- tacked, but weapons which, unwisely used, be- came the most dangerous of instruments. In their eagerness to drive away the fever many were quite regardless of the fact that a mod- erate rise of temperature lasting for a limited time was in itself comparatively harmless, and therefore they hastened to remove this eleva- tion of temperature by the administration of drugs which in themselves were not harmless, and thereby they substituted a frequently posi- tive harm for an often unimportant symptom. Among the drugs so misused was acetanilide, and, though probably the cause of less mischief than antipyrine, primarily because it is a less dangerous drug, but mainly because the previ- ous appearance of antipyrine had been produc- tive of the wisdom learned by experience, yet its indiscriminate use resulted not seldom" in repeated sweating and consequent exhaustion, cyanosis, enfeebled circulation, and, in some cases, collapse and death. The correction of these errors is due to three things: First, the introduction of hydrotherapy 3 ACETANILIDE into general use as a means of treating fever and its symptoms, whereby a reiativelv harm- less procedure was substituted for dangerous drugs; second, a realization of the dangerous properties possessed by the so-called antipy- retic drugs; and third, and more important than all, the appreciation that fever in itself is not necessarily a dangerous symptom unless excessive, and therefore does not call for re- moval unless it is an evident cause of harm. In typhoid fever acetanilide has been and still is much used, but its employment in this disease, except for the purpose of reducing temperature unusually and temporarily high, is not to be recommended, for the very nature of the disease, which is prolonged, exhausting, and generally adynamic, should prohibit the use of a drug which in continued employment constantly tends to the depression of the vital forces without possessing any compensating good effect on the disease process. Moreover, we have in our possession in hydrotherapy a means of treating the asthenic fevers which, so far from depressing and exhausting, is a stimu- lant and a tonic. In pulmonary phthisis acetanilide has been much employed to prevent the afternoon rise of temperature. For this purpose it has usu- ally been given in doses of from 2 to 4 grains, late each afternoon. That it does often prevent the occurrence of this rise of temperature is undoubtedly true, and by many this applica- tion of the drug is considered of great value; but the sweating so often resulting from the use of the drug is too great a price to pay for the slight benefit obtained in a disease where sweating and the exhaustion resulting from it are usually present and are among the worst of symptoms. Moreover, the tendency the drug has to cause cyanosis is especially prominent in phthisis. The objections to its use in typhoid fever apply with even more force to its use in phthisis, both from the longer course of the dis- ease and from its even more asthenic character. In epidemic influenza, on the other hand, its use is often of great value, less, however, on account of its antipyretic effect than on ac- count of its power to relieve the neuralgic pains which so often accompany grippe. The use of acetanilide as an antipyretic, then, should be confined to those fevers of a dynamic type in which the patient is otherwise strong, in which circulatory disease is absent, in which the temperature is high and from that height itself is obviously doing the pa- tient harm, and in which the duration of the disease is a limited one. In such cases and when a prompt reduction of temperature is of immediate importance, the occasional adminis- tration of acetanilide in doses of from 2 to 4 grains is often of great service. Its use in all adynamic conditions is, on the other hand, di- rectly contra-indicated, as tending to depress and to lower the strength and resisting power of the patient and potently to contribute to his exhaustion. By far the most valuable application of acet- anilide is in the relief of pain. Thus, in all febrile diseases associated with headache and body pains, as especially noted in epidemic in- fluenza, and where no contra-indication exists, its use is of great service. In ordinary headache, from whatever cause, it will generally relieve the pain, though, un- less the headache is of purely nervous origin, its action is seldom curative. In migraine it is frequently of service, and though many authorities hold it less valuable than antipyrine in the treatment of this con- dition, yet the far greater safety of its employ- ment, together with its general efficiency, ren- ders its use to be highly recommended. In neuritis it is one of the most valuable drugs we possess, and by many is regarded as almost a specific, so constant and so valuable is its action. This action is especially appar- ent in the treatment of sciatica, which mod- ern investigation has placed in the class of neuritis rather than in that of true neuralgia. Though its action in this obstinate affection can not be considered as constant, yet it fre- quently is of the greatest service, both reliev- ing and curing cases in which many other remedies have failed. In optic neuritis with pain it is said not only to relieve the pain, but to be the direct cause of lessening the inflammation which causes it. In neuralgia it probably has its most valu- able application, and though its employment here is to be regarded as symptomatic, so that other treatment appropriate to the cause of the pain must also be employed, yet its power to relieve is so marked and its action so prompt as to render it of the greatest usefulness. Though its use in neuralgia is in most cases merely symptomatic, yet this can not be said of all, for in some cases its action would seem to be directly curative, and especially in those due apparently to exposure to cold and to wet. In facial neuralgia particularly is its action seen at its best. In ordinary cases of neural- gia its dose should be from 3" to 5 grains three times a day. In myalgia, too, acetanilide is of great serv- ice, ranking with phenacetine and geisemium, and, from its greater safety, above antipyrine. Its action in such cases is usually prompt, both in relieving the pain and later in curing the disease. The appropriate dose for such cases is from 3 to 5 grains three times a day. In herpes zoster it promptly relieves the neuralgic pain associated with the condition, but upon the cutaneous eruption it exerts no influence. Its dose in such cases is the same as that employed for ordinary neuralgia. Gastralgia is at times benefited by the ad- ministration of acetanilide, but in such cases its action to relieve is not to be depended upon, and it does not exert any curative power upon the conditions causing the pain. The condition in which the action of acet- anilide is perhaps as valuable and as indispen- sable as in any other is seen in the lightning pains associated with locomotor ataxia. In relieving the suffering caused by these pains acetanilide is probably more reliable, safer, and more thoroughly efficient than any other drug we possess. In the crises of tabes, too, its action is often most beneficial, and the re- lief it affords most marked. ACETBROMANILIDE ACETYLTANNIN 4 In some cases of rheumatism, and especially in those in which pain is a marked feature, acetanilide acts not only to relieve the suffer- ing, but even to cure the disease. Indeed, at times it succeeds in curing cases of rheuma- tism in which the salicylates have failed to be of use, and though in no way a substitute for the salicylates, and, as a rule, showing its bene- fit in the rheumatic by relieving pain and low- ering temperature, yet its curative action is by no means to be forgotten or ignored. In such cases of rheumatism the proper dose is from 4 to 6 grains three times a day. The opinion held by many that acetanilide is inferior to antipyrine as an analgetic is probably true, though its inferiority is so slight as to be more than compensated for when we remember the marked advantages which it pos- sesses over antipyrine. Thus, the size of its dose, its freedom from taste, with the conse- quently greater ease of administration, are in marked, contrast with the properties possessed by antipyrine. Greater, however, than these and, even without them, sufficient to prove its superiority is its infinitely greater freedom from untoward effects. A marked advantage which acetanilide in common with others of its class possesses over other analgetics, and a consideration of the greatest importance when a drug is to be used with considerable frequency, is the absence of the danger of acquiring a habit from its use. Though the relief of neuralgic pain is the action by which acetanilide shows its most marked effectiveness, it is often of value, too, in conditions of spasm, tremor, and reflex ir- ritability, and though in almost all the condi- tions to be mentioned we have other drugs which possess more reliable and constant cura- tive properties, its use when a substitute is necessary will often prove of great value. Thus in some cases it will be of use in relieving the tremors associated with multiple sclerosis of the spinal cord. In chorea it not infrequently exerts a con- trolling influence over the muscular spasm, and, though by no means a specific like arsenic, and therefore not to be held as a substitute for that drug, it is at times a valuable adjuvant. Acetanilide has been recommended as an antispasmodic in asthma and in whooping- cough, and, though it occasionally exerts some slight beneficial effect in these conditions, its action is certainly neither constant nor relia- ble, and its use for such cases simply represents the constant endeavour of therapeutists to find satisfactory and reliable means by which to combat conditions unusually defiant of relief. Acetanilide has been largely used in the treatment of epilepsy, and though opinion is much divided and markedly contradictory as to its value in this condition, there seems to be no doubt that it does exert a controlling influence upon the attacks by no means incon- siderable. It has long been the effort of neu- rologists to find a means of treating epilepsy which would not be in itself of disadvantage and in certain ways of harm to the patient, as the bromides are. Such a place it was hoped that acetanilide would fill, but careful experi- ment and patient employment of the drug have utterly failed to demonstrate a usefulness in any way approaching that of the bromides. Some cases, indeed, are relieved, the attacks being made less frequent and less severe, but such action is relatively infrequent as com- pared with that of the bromides, and the benefi- cial effects of the drug can not be counted upon. It seems probable, however, that of epileptics those in whom plethora is present and those in whom the attacks are diurnal are the more benefited by the administration of acetanilide. Acetanilide has been given as a hcemostatic to check epistaxis and haemoptysis, but of such use the most that can be said is that it proba- bly does little harm. It has been suggested that acetanilide be used in lobar pneumonia, with the idea that in such cases it will not only act as an antipy- retic, but also have a specific and curative ac- tion upon the pathological condition. Of this suggestion little need be said, for of the value of acetanilide so employed all proof is want- ing. The use of acetanilide in lobar pneu- monia in the earliest period of the disease and in the presence of high temperature and sthenic symptoms is perhaps justified, though even at this time other procedures would ap- pear safer; but, apart from its failure of spe- cific action, it would certainly appear unwise to employ an antipyretic which clearly has a depressing effect upon the circulation in a self-limited disease in which the temperature is seldom a dangerous symptom, but in which circulatory failure is always to be feared and in fatal cases is the usual cause of death. As a local application acetanilide has been little used, and such use as it has had has not shown it to be possessed of qualities of any great value. As a dressing for chancre and chancroid it has proved disappointing and in no way comparable in effect to iodoform, iodol, or black wash.—Henry A. Griffin. ACETBROMANILIDE.—See Bromacet- ANILIDE. ACETIC ACID.—An organic acid, C4H602, which constitutes the acid principle of vine- gar. It is most commonly employed in the form of vinegar, which is one of the sources from which it is obtained, although the varie- ties derived from the oxidation of alcohol and from crude pyroligneous acid are more commonly met with. At moderately low tem- peratures the pure acid is crystalline, and at somewhat higher temperatures becomes a col- ourless, volatile liquid known as glacial acetic acid. Its poisonous effects are similar to those of most other acids, but much less marked, great irritation of the mucous membranes with which it may come in contact being the rule rather than corrosion or destruction of them. The symptoms observed in cases of poisoning, which, however, are very rare, are pain in the throat and stomach, nausea, vomiting, and purging. Alkalies and demulcents are the proper remedies to combat these conditions. A too prolonged use of the acid is followed by impairment of the digestion and by other ef- fects, which will be described under Vinegar. In cases of poisoning by the caustic alkalies the diluted acid can be used as an antidote with perfect safety, as the salts it forms with them are unirritating and, as a rule, cathartic. It combines with most of the bases to form the acetates—salts which are in most instances freely soluble in water and easily absorbed. The acetates of the alkaline bases are diuretic, slightly diaphoretic, refrigerant, and in con- siderable quantities cathartic. Like nearly all the combinations of the organic acids and the alkaline bases, they are converted into carbo- nates during the process of absorption, and hence render the fluids of the body more or less alkaline. The acid itself enjoys'this prop- erty to a slight degree on account of its com- bining with these bases within the body. The glacial acid, applied by means of a stick or a glass rod, is employed" to destroy warts, corns, condylomata, and fungous growths. The crys- talline form is rarely employed, except in the preparation of so-called "smelling salts," a favourite combination of this sort being one with potassium sulphate, from which the va- pours of acetic acid are slowly evolved. The in- halation of acetic-acid vapour will sometimes abort an incipient cold, relieve headache, and restore consciousness after fainting. The di- luted form is mildly astringent and haemo- static, relieves itching of all kinds, and is an agreeable addition to baths in hot weather. For the latter purpose aromatic vinegar is the form in which it is very generally employed, but caution must be observed that when me- tallic bath tubs are used the solution is not too strong and that none of it is allowed to re- main in the tub for any length of time, as it affects metals somewhat. The strong acetic acids of the different pharmacopoeias all con- tain about one third of the pure acid, and are rarely used except as caustics, as styptics, and in the treatment of ringworm and pityriasis. The dilute acid is somewhat stronger than or- dinary vinegar (the U. S. Ph. orders a six-per- cent, solution of the absolute acid), and may be substituted for it. Acetic acid or vinegar enters into a number of official preparations, in all of which the other ingredients are the active ones. See Chloraoetic Acid, Dichlor- acetic Acid, Trichloracetic Acid, and Vine- gar.—Russell H. Nevins. ACETIC ALDEHYDE.—See Aldehyde. ACETIC ETHER, the cether aceticus of the pharmacopoeias, ethyl acetate, CHsCO.OCa 116, is a colourless, transparent, fragrant liquid, of an acetous and burning taste, prepared by distilling together, according to the Br. Ph., 'S2i imp. fl. oz. of rectified spirit, 32J imp. fl. oz. of sulphuric acid, and 40 oz. (av.) of sodium acetate. The acid and the alcohol are mixed slowly, and the sodium acetate is added when the mixture has become cold; 45 imp. fl. oz. are distilled off, and the distillate is digested for three days in a stoppered bottle with 6 oz. (av.) of freshly dried potassium carbonate; the ethereal liquid is then separated and again dis- tilled until all but about 4 fl. oz. has passed over. The product is to be kept in well-stop- pered bottles in a cool place. It is inflam- ACETBROMANILIDE 5 ACETYLTANNIN mable, and mixes in all proportions with alco- hol and with ether. Acetic ether has been used as an anesthetic, but its action is feeble. As a stimulant and antispasmodic, it may be given in doses of from 5 to 20 drops, well di- luted with water, or inhaled, especially in cases of faintness or threatening collapse. It is also used externally, with friction, for the relief of rheumatic pains. ACETONE, pyroacetic ether or spirit, CH3. CO.CH3, is a colourless, inflammable liquid, of a fragrant, mintlike odour and a pungent, sweetish taste, prepared by the dry distillation of an acetate. It mixes readily with water, alcohol, ether, chloroform, or volatile or fixed oils. It is now little used in medicine, but was formerly given in gout, in pulmonary tuber- culosis, and as an anthelminthic. It is said to be feebly anaesthetic. ACETOPHENONE, phenylmethyl ketone, or hypnone, C6H6.CO.CH3, is prepared by the dry distillation of a mixture of calcium benzoate and acetate and subsequent fractional distilla- tion. It is a colourless, mobile, pungent liquid, of a disagreeable odour, insoluble in water, solu- ble in alcohol, ether, glycerin, or the essential oils. It is used as a hypnotic in doses of 1 to 5 minims, dissolved in oil and inclosed in capsules. ACETPHENETIDINE.—See Phenacet- INE. ACETUM.—Vinegar. The medicated vine- gars, aceta medicata, the acetoles of the French, are mostly made by macerating vegetable drugs (rarely animal or mineral substances) in vinegar or, better, in dilute acetic acid, percolating, expressing, and filtering. The more important of them will be mentioned in the article on Vinegar or under the names of drugs that appear in their titles. ACETUM PYROLIGNOSUM.—See Py- roligneous Acid. ACETYL ALDEHYDE.—See Aldehyde. ACETYLAMIDOBENZENE.— See Acetanilide. ACETYLAMIDOPHENOL.—A colour- less, amorphous substance, CibIIdNO*, but slightly soluble in water, but readily soluble in alcohol or strong acetic acid. It has been used as an antipyretic in capsules containing from 3 to 8 grains each. ACETYLAMIDOSALOL. — This com- pound, which crystallizes in brilliant lamellae, has been suggested as a substitute for salol, over which it is said to have the advantage of not being poisonous. It is but sparingly soluble in water, but dissolves freely in alcohol or benzene. ACETYLMETHYL.—See Acetone. ACETYLPHENYLHYDRAZINE. — See Hydracetin. ACETYLTANNIN, or tannigene, is de- scribed as a tannic-acid substitution product of hydroxyl acting somewhat less energetically as an astringent than tannin, but having the ad- vantage of remaining undissolved in the stom- ach and acting only on the intestine when ad- ministered by the mouth. ACHILLEA ACONITE 6' ACHILLEA.—Yarrow, a genus of the An- themidece. Achillea Millefolium (the entire plant) is mildly aromatic, astringent, tonic, and diaphoretic, and has been considered emmena- gogue. The dose of an infusion of 1 oz. in 1 pint of hot water is from 4 to 6 fl. oz. The expressed juice has been used in doses of from 1 to 2 fl. oz., three times a day. Achillein, a bitter "principle obtained from the plant, is said to have caused irregularity of the pulse. Achillea nobilis is sometimes used instead of Achillea Millefolium. ACIDS.—The acids whose action depends upon their inherent properties rather than those of the bases from which they are derived are the mineral acids, hydrochloric, nitric, ni- trous, nitrohydrochloric, sulphuric, and, to a certain extent, phosphoric, and the vegetable acids, acetic, citric, and tartaric. The mineral acids all have a strong affinity for water, and consequently are corrosive and destructive to animal tissues and are used as caustics, more especially nitric and sulphuric acids. (Cf. Caustics.) When freely diluted they relieve the itching of urticaria and other forms of pruritus, are astringent and hemo- static, diminish the amount of all normal and pathological acid secretions, and act as general stimulants of the skin and raw surfaces. When they are taken internally in a more or less con- centrated condition their effects upon the mu- cous membranes are escharotic. If after the taking of considerable amounts death does not occur shortly, the affected parts contract, caus- ing deformities of the mouth and strictures of the oesophagus and stomach. The members of this group which are most commonly the causes of accidental or intentional poisoning are ni- tric and sulphuric acids, on account of the ease with which they are obtained and their exten- sive uses in the arts. The local effects of these are easily to be distinguished by the yellowish stain upon the face or in the mouth left by nitric acid and the black, carbonized appear- ance caused by sulphuric acid. Whichever of the mineral acids may be the cause of poison- ing, the symptoms are practically the same, and so is the treatment. Severe burning pain in the mouth, throat, and stomach, nausea, vomiting (of blood in severe cases), colic, tym- panites, and diarrhoea are the most marked symptoms, due to the contact of the acid with the tissues. In addition, the effects upon the general system are profound, the action of the heart being depressed and the respiration hur- ried, and general collapse and coma occurring unless the destruction of the tissues has been sufficiently extended to be the direct cause of death. Without the assistance of collateral circumstances and the visible corrosive ac- tion of the acid there is little to distinguish these cases from poisoning by the caustic alka- lies or highly corrosive salts. Probably the most distinctive point of difference between poisoning by acids and that by alkalies is the slight effervescence caused by the vomited matters in the former case if they come in con- tact with a carbonate, and in some cases when they are ejected upon the earth. The chem- ical antidotes to all acids are the alkalies and their carbonates, of which magnesia is by far the best, on account of its great combining properties. The carbonates are not so desira- ble, as the distention caused by the carbonic- acid gas which they give off when in contact with acids may be sufficient to rupture the walls of the stomach or intestines, already weakened by the corrosive action of the acid, but, if nothing else is at hand, they must be used. The antidote most easily obtained is plaster from a wall, which can be easily de- tached and coarsely powdered. Soap may be used in an emergency, but is not very efficient. Whatever is used, it must be given promptly, but when a caustic alkali is employed care must be taken that an excess is not used, as the surplus over what is necessary to neutral- ize the acid will have a corrosive effect. Oil, milk, and eggs protect the unaffected tissues in a measure, and are to be freely given after the alkali. The constitutional symptoms are to be combated by opium, alcohol, the applica- tion of dry heat, etc. As a rule, it will be found necessary to administer by the rectum all medicines which can not be given hypo- dermically, and all forms of nutriment should be given in the same way until the most ac- tive symptoms have subsided. After the acute stage has been passed the treatment is to be conducted upon general principles. Treatment of the injuries caused by the contact of acids with the surface of the body does not differ from that appropriate in cases of burns, except that alkalies must be employed at once to neu- tralize the acid, and fatty matters applied around the injured parts to prevent an exten- sion of its action. The undiluted mineral acids are never used internally except as caustics in those cavities of the body readily accessible from the exte- rior. Diluted, they increase the secretion of all the mucous surfaces with which they may come in contact, and thus play an important part in allaying thirst, are astringent and haem- ostatic, and diminish the amount of free uric acid which may be present in the urine. When taken before eating or upon an empty stomach they diminish in a marked degree the acid secretion of the stomach, and, used at such times, are of great benefit in the treatment of acid dyspepsia, but, taken after eating, they simply add to the amount of free acid already present and aggravate the dyspepsia. Cholera germs are said to be destroyed by them, and they are added, more especially sulphuric acid, to drinking water during the prevalence of epidemics of Asiatic cholera. The effects upon the teeth when any form of acid is employed are disastrous unless precautions are observed to prevent its contact with them. The acids should be given through a glass tube bent in such a manner that it reaches far back upon the tongue, and after each dose it is wise to rinse out the mouth with a weak alkaline solution, none of which should be swallowed, as the desired effects of the acid might be counteracted. Of the vegetable acids, none except acetic are sufficiently strong to be of any value as escharotics, and in excessive doses they are 7 ACHILLEA ACONITE irritant rather than corrosive. Poisoning may be said never to occur, and the colic, etc., due to an overdose of any of these may be re- lieved by alkalies. Their internal effects are very similar to those of the mineral group, but they are less efficient, and are rarely employed like the latter. The salts which they form are, as a rule, freely soluble in the ordinary men- strua and readily absorbed. Their combinations with the alkalies are diuretic, diaphoretic, and in large doses cathartic, and, since during the process of absorption and assimilation they are converted into the carbonates, thev increase the alkalinity of all the fluids of "the body. Any one of either the mineral or vegetable acids may be used as the chemical antidote in cases of poisoning by alkalies, but the vege- table ones are rather better on account of the unirritating and cathartic properties of their alkaline salts.—Russell H. Nevins. ACONITE, the aconitum of the U. S. Ph., is the tuber of Aconitum napellus (monks- hood). The Ger. Ph. permits only the aconite roots (tubera aconiti) to be used in the prepara- tions it authorizes. The Br. Ph. and the Fr. Cod. employ both the root {radix) and the leaves {folia), however, and by the latter Aconitum ferox is recognised as well as Aconitum napel- lus. A remarkable resemblance exists between aconite root and that of horse-radish, a resem- blance which has often resulted in fatal poison- ing. The two roots may be distinguished by the fact that the horse-radish when scraped emits its peculiar odour, while aconite emits none. [Of the proximate principles of aconite, only aconitine is of therapeutic importance, and that will be the subject of the next article.] In the internal administration of aconite its effect is seen in producing at first a sense of tingling and prickling of the tongue, lips, and mouth, followed soon by a feeling of numb- ness of considerable duration, these sensations being due to a purely local action of the drug. After a variable period of time, usually not longer than half an hour, the general symp- toms, due to the absorption of the drug, make their appearance. A sense of numbness and partial anaesthesia of the face is experienced, and subsequently of the extremities, though it may be present throughout the body if the dose administered has been sufficiently large. The heart's action becomes reduced both in. force and in rapidity. The respiration is slowed, a sense of general relaxation is expe- rienced, the skin becomes moist and perspir- ing, the amount of urine is increased, and, if fever has been present, it is lowered. These symptoms mark the full therapeutic effect of the drug, the occurrence of manifestations more marked denoting poisoning. If a poisonous dose has been administered the symptoms make their appearance, as a rule, more promptly than after a therapeutic dose, the rapidity of their development gener- ally depending upon the size of the dose. Thus, following a dose of large size, poisoning may at times be recognised within five min- utes. The symptoms occurring after poison- ous doses are simply marked exaggerations of those produced by the therapeutic use of the drug. The same tingling is experienced in the mouth and throat and rapidly becomes numbness; with great rapidity the numbness spreads to the face, to the extremities, and then throughout the body, and may be so marked as to result in a condition of general cutaneous anaesthesia, though previous to this decided pain may be experienced, especially in the face. With the development of these dis- turbances of sensation the patient, experiences an overpowering weakness and relaxation, ul- timately amounting even to complete loss of the power of motion. The heart's action is decidedly reduced in rapidity and force, but later is generally rapid, feeble, and irregular. The pulse is exceedingly compressible, then rapid and running, later imperceptible. The respirations are at first slowed, then become shallow and laboured. The face is pinched, the eyes generally protrude, though sometimes they are sunken, and the pupils are dilated. The skin is pallid in the extreme, cold, and covered with moisture. The temperature falls decidedly. In some cases vomiting is present, and in some, too, spasmodic purging. Epi- leptoid convulsions may be seen, though their occurrence is not common. The mind usually remains entirely clear. Though aconite para- lyzes both respiration and circulation, death usually results from arrest of the heart in diastole, the fatal syncope in some cases hav- ing been determined by some exertion on the part of the patient. In the treatment of a condition so grave as aconite poisoning our whole endeavour must be toward stimulation and the prevention of syn- cope. For these purposes the patient is to be kept recumbent, and it is wise to elevate the foot of the bed or table on which he lies, that with the elevation of his extremities there may occur a determination of blood to the vital nervous centres. Warmth is to be applied to his extremities and surface generally by means of hot-water bottles and bags, cloths wrung out in hot water, hot bricks, etc. Stimulants should be administered freely, and, for the greater rapidity of action, are to be given by hypodermic injection. For this purpose the more diffusible stimulants are first to be em- ployed, especially ether, camphor, and ammo- nia in some form ; later alcohol, and then those drugs which, while more slowly absorbed, are yet of more prolonged action, especially atro- pine, strychnine, digitalis, and strophanthus. If the patient is not vomiting, stimulants may be given by the mouth, provided the condition is not so grave as to require the more rapidly acting hypodermic method, or provided the immediate danger has been relieved by that means. That emetics are not to be given it seems unnecessary to say, but the emptying of the stomach by the gastric siphon has been rec- ommended. Whether or not this is to be em- ployed will depend entirely upon the patient's circulatory condition. If the tube can be used before marked symptoms of cardiac weakness appear it should certainly be employed, and if the circulation can be sustained by stimula- tion its use is then indicated, but in using it ACONITE 8 great care must be exercised lest the procedure result in that cardiac weakening which it is the whole object of our treatment to prevent. Though the physiological action of aconite when given internally is not definitely estab- lished in many of its details, the following ex- planations are generally accepted: On the circulation aconite in therapeutic doses exercises a sedative effect, diminishing both the force and the rapidity of the heart's action and thereby lessening blood pressure. In poisonous doses this action is increased, and ultimately the heart is arrested in diastole. This depressing power upon the heart is sup- posed to depend upon the direct action of aconite upon the heart muscle. On the respiration aconite also exerts a de- pressing influence, slowing the respiration and diminishing its depth. It is, in poisonous doses, a paralyzer of respiration, both by an action upon the respiratory centre and by a direct effect upon the muscles of respiration. The temperature is reduced by aconite by means cf the increased heat radiation result- ing from the greater amount of blood con- tained within the relaxed capillaries of the skin as well as by evaporation resulting from the increased perspiration. Upon the nervous system aconite exerts an influence most marked. Its main action is upon the sensory nerves, whose end organs under its administration lose their functional activity. If large doses are administered this depression may extend to the nerve trunks, to the centres in the spinal cord, and even, ac- cording to some authors, to the perceptive centres in the brain. As a result of these ef- fects, reflex action is diminished. On the mo- tor nerves aconite acts only when given in poisonous doses. Then as a late symptom there may be motor paralysis as a result of a para- lyzing action upon the motor tract of the spinal cord and the motor nerves. The urine is increased by aconite, especially if there has previously been a febrile diminution. The skin shows the effect of aconite by a marked increase in the amount of perspiration. Doses of some size increase gastro-intestinal secretion, and, if gastric and intestinal irrita- bility is present, digestive disturbance with diarrhoea may result. Locally applied, aconite exerts a benumbing and local anaesthetic effect upon mucous mem- branes, and, after longer contact, upon the skin. These results occur from the specific effect of the drug upon the sensory end organs. In administering aconite by far the most valuable preparation, as well as the most re- liable, is the tincture. Of this, from 1 to 5 minims may be given, according to circum- stances. If the purpose in giving aconite is to produce its effects upon the sensory nerves the larger doses should be employed, and re- peated according to necessity, usually not of- tener than three or four times a day. If the object is to lessen the symptoms of the febrile state, then it is wiser to use the smaller dose, or, better yet, to give fractional doses (from i to \ a minim) of the tincture every quarter or half hour until the temperature falls, the cir- culatory excitement is lessened, and the skin becomes moist, or until the tongue and lips tingle. The doses may then be given at long- er intervals. In giving aconite it should be largely diluted (£ minim to a teaspoonful of water'is a sufficient dilution), on account of its decided local effect upon mucous membranes. From a therapeutic dose of aconite we expect to observe action in about half an hour, and this action, as a rule, lasts about three hours. The main indication for its administration is vascular excitement in the sthenic; its contra- indications are asthenia and adynamia, cardiac degeneration or dilatation, weak heart action from any cause, and gastro-intestinal irritation or inflammation. It is in no way a drug for use in coniinued fevers, and its prolonged use is not indicated save on the rarest occasions. Aconite has for a long time held a high place in the esteem of most practitioners, but opinion is by no means unanimous upon its worth, and by many its value is as severely questioned as 'it is by others highly estimated. Doubtless much of the adverse criticism is, as Edes points out, due to its burlesque employ- ment bv the homoeopathic school as well as to the natural tendency to rapid spontaneous cures in those affections in which aconite finds its commonest application. There seems to be no doubt, however, of the great value of the drug in certain conditions—conditions in which even the modern antipyretic drugs have failed beyond a certain point to replace it. Those fevers in children so commonly the result of exposure, often associated with in- flammations of the tonsils, pharynx, and bron- chi, and accompanied by marked circulatory excitement, constitute a set of affections in which aconite shows its greatest usefulness. In such cases the fractional doses, given as has already been described, soon result in a fall of temperature, circulatory sedation, the estab- lishment of perspiration, and amelioration of all accompanying symptoms. Yet its effective- ness is not confined to these diseases as seen in children, although from the relatively greater frequency of such disorders in early years its use in children is more common. In all in- flammatory febrile conditions, however, it is in the early and sthenic period that aconite is indicated, its later use in the absence of dy- namic conditions being as potent for harm as it is earlier for good. In the same way is aconite useful in coryza, acute otitis, quinsy, and asthma due to expo- sure. In croup, both catarrhal and spasmodic, it is exceedingly effective, relieving the dysp- noea of the latter usually within a few hours. In simple fever, febricula, or catarrhal fever, then, is the use of aconite as a febrifuge and sedative mainly to be recommended, and yet it may occasionally be well to use it for these purposes in other febrile disorders. Thus, while it should not be employed regularly in the continued fevers, its occasional use for hyper- pyrexia occurring in them and attended by vascular excitement is often most judicious. In scarlatina, measles, and erysipelas its oc- casional use in the presence of febrile and [ circulatory indications is often valuable in 9 ACONITE modifying the severity of the symptoms, re- ducing the temperature, and increasing the action of the kidneys and skin. It is to be recollected, however, that the effort to reduce temperatures persistently high by the use of aconite requires the employment of such doses as in themselves to constitute an element of great danger, even were such cases not more effectively relieved by other means. A class of diseases much benefited by the use of aconite in the early stages is seen in acute inflammations of the serous membranes. Thus meningitis, either cerebral, spinal, or the combination of both, seen in epidemic form may well be treated in its early stages by the small and frequently repeated doses of tinc- ture of aconite already mentioned. Acute pleu- risy, too, before the stage of exudation, is in like manner improved. Acute peritonitis, either pelvic or general, presents the same indications, and, though in general peritonitis the addition of opium in doses of considerable size is usually indicated, yet this in no way interferes with the gcod effect of the aconite. In pericarditis of acute type the aconite treatment of the early stages not only serves its usual purpose, but also has the additional and great value of con- tributing more directly to a curative result by its marked power of slowing the heart's action. In diseases of the respiratory organs aconite seems especially indicated from its sedative effect upon respiration, and, though in bron- chitis this effect is comparatively unimportant, in pneumonia it is a quality of the greatest value. In either lobar pneumonia or broncho- pneumonia in its earliest stages the greatest relief will often follow the administration of tincture of aconite in doses of 1 minim every hour until numbness of the lips and tongue occurs, after which its less frequent administra- tion will maintain the good effect. Indeed, there are those who administer aconite through- out the course of pneumonia, so firm a belief have they in its efficacy, in defiance of the fact that in all but the earlier stages of pneumonia it is circulatory slowing, strengthening, and stimulation that are needed, not the depres- sion and weakening of a heat whose very over- action shows its weakness. It has been taught that the fever of tuber- culosis is benefited by aconite given in doses of 1 minim of the tincture every hour till its effects are seen, and, though it is true that by this treatment the temperature may be re- duced, it is accomplished at the expense of undesirable sweating and the necessity of the continued administration of the drug in a dis- ease essentially asthenic in its nature. In acute articular rheumatism aconite will often be of service, and especially in those cases in which perspiration is absent and the skin hot and dry. In such cases it not only exerts to some extent its anaesthetic effect, but by a reduc- tion of temperature and a re-establishment of the functions of the skin often produces marked amelioration in the symptoms of the disease. Its action in muscular rheumatism, espe- cially if accompanied by fever, is similar and its effectiveness even more marked. In chronic rheumatism and in gout it is oc- casionally of service for its anaesthetic effect, but in chronic rheumatism it must be given with discrimination, lest by prolonged use it be the cause of untoward effects upon the cir- culation. To be effective in such cases it should be given in the form of the tincture in doses ot 1 minim every hour until some numbness of the lips and face or even of the extremities results, when this effect is to be continued by its less frequent administration. In neuralgia aconite has been much em- ployed, and is generally of great service from its benumbing effect upon the peripheral nerves, but it is in the so-called rheumatic neuralgia which follows exposure to cold and wet that it is most effective, and especially if the attack is accompanied by vascular excitement. From its efficiency in controlling and re- ducing the rate and force of an overacting heart, tincture of aconite will often be of serv- ice if given in doses of from 2 to 4 drops three times a day in exophthalmic goitre, pal- pitation from nervousness, and " smoker's heart." In hypertrophy of the heart without valvular disease it is also useful, and even if valvular disease is present it may be cautiously employed to control the overforcible action of excessive hypertrophy. If dilatation is pres- ent, however, or if the heart muscle is degen- erate, its use is absolutely contraindicated. In congestive dysmenorrhea aconite will often afford prompt relief, and in the sudden suppression of menstruation from exposure it is equally effective if given in small and re- peated doses to the extent of producing the full therapeutic effect. In the early stages of gonorrhea it may be given in doses of 1 drop of the tincture every hour till its usual effects are produced (Ringer). In such cases it appears to cause a lessening of the severity of the inflammation and to act distinctly in the prevention of chordee. In urethral'fever, too, it is said to be very effective. Aconite will generally be of beneifit in con- trolling the epistaxis of full-blooded people, and if given in fairly large doses may serve to relieve the vomiting of pregnancy, presumably by its action on the sensory nerves and its power to reduce reflex irritability. Aconite, by virtue of its action as a local anodyne and anaesthetic, is frequently of use in neuralgia. In such cases it may be applied in ointment (2 grains to 1 drachm) or lini- ment, or the tincture, alone or in combination with other remedies, may be painted over the painful area. Thus applied, a combination of equal parts of the tinctures of aconite and of gelsemium is often found of use. For vague rheumatic and neuralgic pains the addition of aconite to liniments will often add to their effectiveness. Local applications of tincture of aconite will also be found useful in relieving pruritus and the burning of chilblain. In toothache a few drops of tincture of aco- nite rubbed on the gum in the neighbourhood of the diseased tooth will frequently give relief, or it may be introduced into the carious tooth upon cotton. It is to be remembered in using aconite as a ACONITINE ACTIVE PRINCIPLES 10 local application that it is absorbed by the broken skin, and its employment under such circumstances is invariably to be accompanied by the greatest caution. Aconite as such is not employed in medi- cine. The extract {extractum aconiti [U. S. Ph.]) is made from powdered aconite by macer- ating it with alcohol, percolating, and evapo- rating. It is an extract of pilular consistence. The dose is from i to | grain. In the Br. Ph. extractum aconiti is directed to be made from the leaves. An extractum aconiti made from the root is authorized by the Ger. Ph. Its maximum single dose is fa of a grain. The Fr. Cod. authorizes extracts both of the root {extrait de racine (Vaconit) and of the leaves {extrait des feuilles d'aconit). The fluid ex- tract {extractum aconiti fluidum) is obtained from powdered aconite by macerating it with alcohol and water, percolating it, and diluting with alcohol and water to the required stand- ard. The dose is from 1 to 2 minims. The tincture {tinctura aconiti [U. S. Ph.]) is pre- pared from powdered aconite by macerating it with alcohol and water, percolating, and add- ing alcohol and water to the required standard. The dose is from 1 to 5 minims. The tinctura aconiti of the Br. Ph. is prepared from aconite root, and contains 54£ grains to 1 fl. oz. The Ger. Ph. authorizes a 10-per-cent. tincture made from the root, of which it gives the maximum dose as 8 grains. Tinctures of the root {teinlure de racine d'aconit) and of the leaves {teinture de feuilles d'aconit) are author- ized by the Fr. Cod. Fleming's tincture of aconite is a non-official preparation which is sometimes employed. It is much stronger than the official tincture, and its use is not to be recommended, both on ac- count of its unnecessarily great strength and from its offering no advantage over the official preparation. The alcoolature oVaconit of the Fr. Cod. is a preparation similar to the fluid extract of the U. S. Ph., made by macerating the bruised aco- nite in alcohol, with occasional agitation, for ten days, and then filtering with pressure. Two preparations are made thus—one from the leaves, the other from the root. The sirop d'aconit {syrupus de aconito [Fr. Cod.]), syrup of aconite, contains 25 parts of the alcoolature of aconite root and 975 of syrup. The aconite liniment {linimentum aconiti) of the Br. Ph. is made from 20 oz. of powdered aconite root, 1 oz. of camphor, and enough rectified spirits to make 30 fl. oz. To the names of aconite and its official prep- arations the word radix (signifying root) or its genitive, radicis, was formerly added as a means of distinguishing the preparations of the root from those of the leaves, which were at that time official. The leaves being no longer rec- ognised by the United States Pharmacopoeia, since in their action they have been found unre- liable, the use of the word radix has become un- necessary and superfluous.—Henry A. Griffin. ACONITINE, aconitina (Br. Ph.), or aco- nitinum (formerly also aconitia), is n&t official in the United States. The chemistry of Aconitum napellus is not yet well understood, but it is believed to con- tain several alkaloids, and among them aconi- tine and napelline (though by some napelline is believed to be merely a weaker form of aconitine), existing in combination with a pe- culiar acid known as aconitic acid. Though napelline has been used to some slight extent in medicine, aconitine is by far the most im- portant principle of the plant; on its presence depends the action of aconite itself. In aconite, aconitine is found both in an amorphous and in a crystalline form. The crystalline form appears as colourless, rhombic, tabular crystals, soluble in alcohol, chloroform, or ether, and but very slightly soluble in water. With acids aconitine forms crystalline salts. As has already been said, it is to the pres- ence of aconitine that aconite owes its activity, and according to the quantity of the aconitine contained in aconite root the preparations made from that root vary in potency, circumstances of growth and cultivation producing the great- est variation in strength. To these facts are due the diversities in power of the prepara- tions of aconite. With the exception of its vastly greater po- tency and activity, the action of aconitine is the same as has already been described in speaking of aconite. It is one of the most powerful and virulent poisons known, when pure even exceeding hydrocyanic acid in po- tency. Its action in poisonous doses is ex- ceedingly rapid, and if the drug is given by hypodermic injection it is said that it may re- sult fatally in less than a minute. Poisoning by aconitine is to be treated in the same man- ner as poisoning by aconite. The tremendous potency of aconitine would alone seem a sufficient argument against its internal use, especially when we consider that aconite itself is to be used in small doses and with great caution, together with the fact that the advantage of using aconitine rather than aconite is not apparent. But in addition to these objections to its internal use must be noted the great variation in the strength of the aconitines, according to their source of manufacture, and the consequent great danger of prescribing them. Thus, the ordinary com- mercial aconitine is merely a mixture of alka- loids, exceedingly impure and (yet more im- portant) subject to great variation in strength. The German aconitine, too, is very impure, as is the " impure English aconitine."' [The aconitine of the Br. Ph. is prepared by mixing any convenient amount of aconite root, in coarse powder, with twice its weight of rec- tified spirit, heating the mixture until it begins to boil, cooling and macerating for four davs; transferring the whole to a displacement ap- paratus and percolating, with the addition of more spirit as may be required, until the root is exhausted; recovering most of the alcohol by distillation and driving off the remainder of it over a water-bath; mixing the residual extract thoroughly with twice its weight of boiling distilled water, and, when it has cooled filtering through paper; adding a slight excess of solution of ammonia and heating gently 11 ACONITINE ACTIVE PRINCIPLES over a water-bath; separating the precipitate on a filter and drying it; macerating it, in coarse powder, in successive portions of pure ether, with frequent agitation; decanting and mixing the several products and distilling off the ether until the extract is dry; dissolving the dry extract in warm distilled water acid- ulated with sulphuric acid ; precipitating, after the solution has cooled, by the cautious addi- tion of solution of ammonia diluted with four times its bulk of distilled water; and washing the precipitate on a filter with a little cold dis- tilled water and drying it by slight pressure between layers of filtering paper and subse- quent exposure to air.] An English aconitine is prepared by Morson from the artificially cultivated root, and is said to be chemically pure. It is terribly power- ful, even r^ of a grain being said to cause numbness of the tongue. The aconitine of Merck is said to be reliable, but the prepara- tion most generally employed and the one of most constant strength, and hence most trust- worthy, is Duquesnel's. This is, strictly speak- ing, not aconitine, but a crystalline nitrate of aconitine, and, though from its virulence as a poison no form of aconitine is to be recom- mended for internal use, and ^ff of a grain of this preparation has been followed by alarm- ing results, yet, should the alkaloid be used, the crystalline aconitine of Duquesnel is the only form in which it should be employed. The internal use of aconitine is practically limited to two conditions—neuralgia and pneu- monia. In neuralgia, especially of the trigeminus. the aconitine of Duquesnel may be adminis- tered in the dose of from ^^ to ^^ of a grain, and repeated cautiously and very carefully increased. In such cases it is often, though by no means invariably, effective, but possesses no marked superiority over other means of treatment at our command. In pneumonia aconitine has recently been largely used in conjunction with digitaline and arsenate of strychnine, and the combination is at times referred to- by the name of " the trin- ity pill." Opinion is scarcely unanimous upon its efficiency in this disease, but in the pneu- monia accompanying influenza it appears to be unusually valuable. Delafield reports that in the cases with a disposition to general ve- nous congestion and failure of the heart's ac- tion he has obtained the best results by the combined use of J of a milligramme of digita- line. £ of a milligramme of aconitine and \ a milligramme of arsenate of strychnine, together with whisky. Even the local use of aconitine is not free from danger, and it should be employed most carefully, and never over a denuded surface. In the form of an ointment (2 grains to a drachm) or of a 2-per-cent. solution of the oleatc of aconitine in oil it will, if locally ap- plied, often afford marked relief in neuralgia. Similar preparations have been used for the relief of the pains of gout and chronic rheu- matism and myalgia, but have no advantage over the safer preparations of aconite. [The unguentum aconitine of the Br. Ph. is made by dissolving 8 grains of aconitine in £ fluid drachm of rectified spirit and mixing the solu- tion thoroughly with 1 oz. of benzoinated lard.] Pruritus has been benefited by its external ap- plication in ointment or solution, but other ap- plications are not only quite as effective, but decidedly safer, especially in the presence of the scratched skin, the usual accompaniment of pruritus.—Henry A. Griffin. ACORNS.—The fruit of various species of oak ; of the Austr. Ph. {semen quercus), that of Quercuspedunculata and Quercus sessi/iflora; of the Fr. Cod. {gland doux), that of Quercus ballota. The kernels contain nearly 40 per cent, of starch and nearly 10 per cent, of tannin, together with a fixed oil, an uncrys- tallizable sugar, quercite (a sugar resembling mannire), citric acid, and traces of an essential oil. The pharmacopoeias direct the kernels to be dried and roasted, whereby they lose about half their weight and their starch is partly converted into dextrin. In this condition the acorns are infused like coffee (1 to 2 drachms to the cup), and "acorn coffee " is employed as an easily digested nutrient and as a mild tonic and astringent. ACORUS CALAMUS.—See Calamus. ACTiEA RACEMOSA.—See Cimicifuga. ACTINOMERIS HELIANTHOIDES. —Diabetes weed, gravel weed, a North Ameri- can perennial herb of the Composite. Its root has been used in dropsy, chronic cystitis, and urinary lithiasis, in the form of an ethereal tincture (1 part of the root to 2 parts of nitrous ether), the dose of which is from 1 to 1^ drachm. ACTIVE PRINCIPLES. — Plants and animals are made up partly of mineral or in- organic material, among which it is customary to include water and simple or compound gases, but most largely of organic compounds, in which carbon is associated with hydrogen and oxygen, and frequently with other addi- tional elements, forming compounds which, when strongly heated, are more or less readily charred or decomposed. Proximate Principles.—These organic car- bon compounds which make up the larger pro- portion of an animal or plant are comprised under the general name proximate principles, because they are the first or proximate sub- stances which are obtained when an organic body is split up into its component parts by solvents or other agents which produce no al- teration in their nature. The art or process by which organic individuals are thus taken to pieces is called proximate analysis. The fur- ther reduction of these proximate principles to their elementary constituents, with the quali- tative and quantitative determination of the latter, is called ultimate analysis. Some of the substances now classed among the proximate principles were known and in common use, in a more or less pure form, for a long time before their chemical constitution was understood. The progress of chemical research, particularly during the last few dec- ades, has increased their number to such an extent that a mere enumeration of them, so far as known, would occupy many pages. ACTIVE PRINCIPLES 12 All proximate principles which exert any recognisable action upon the human or animal organism, beyond that of sustaining life by nourishment, are comprised under the term active principles. Since this work is designed to treat only of those agents which have been or are now used therapeutically, a large num- ber of proximate principles may here be left out of consideration altogether, either because they are not "active principles" in the true sense of the term (such, for instance, as the starches, sugars, albumins, etc.. which are rather articles of food), or because, although " active principles," they have been tested only experi- mentally, or else because nothing whatever is known "regarding their physiological effects or pharmacodynamic action. In order to afford a comprehensive view of the several kinds of active principles it will be well to enumerate and briefly characterize the various classes or groups of proximate princi- ples, and to mention under each group, where it may be found necessary, those which are therapeutic agents. Classification of Proximate Principles.— Proximate principles are most conveniently classed into the following groups: 1,Carbohy- drates ; 2, Tannins; 3, Glucosides; 4, Neutral Principles; 5, Alkaloids; 6, Organic Acids; 7, Colouring Matters; 8, Resins; 9, Fixed Oils and Fats; 10, Waxes; 11, Volatile Oils; 12, Camphors; 13, Miscellaneous Compounds ; 14, Protein Bodies; 15, Ferments. I. Carbohydrates.—In their widest sense car- bohydrates may be regarded as that class of organic bodies which constitute one of the first products of assimilation of the living plant by the interreaction of carbon and water. Accordingly they contain the elements carbon, hydrogen, and oxygen; and the two last- named elements are nearly always present in the same proportion as in water (rhamnose forms an exception, its composition being C6Hi205). This large group may be subdivided into three smaller groups, viz.: (a) Amyloids, comprising cellulose, starch, dextrin, inulin (the peculiar starch existing in many plants of the natural order Composite), etc.; (b) Sugars, such as glucose, hvvulose, lactose (milk sugar), maltose (malt sugar), saccharose (cane sugar), etc.; (c) Gums and Pectin Bodies, such as pec- tin, arabin, cerasin. bassorin, etc. Nearly all the bodies belonging to this group are more properly to be regarded as articles of food than as remedial agents. Nevertheless, some of them produce valuable curative effects, due in most cases to their blandness, neutrality, and demulcent, lubricating, or soothing action. II. Tannins.—A group of bodies containing only the elements carbon, hydrogen, and oxy- gen, in varying proportions, derived from vari- ous plants, and having the property of producing a blue or green colour with ferric salts. Most of them also have an astringent taste and form insoluble compounds with gelatin. Many crude drugs and preparations made from the latter owe their therapeutic effect to the presence of one or another of these tannins; thus, catechu to catechu-tannic acid or catechin. But there is only one of this group employed as a sub- stance by itself—namely, gallo-tannic acid, the ordinary tannic acid of the shops. Most'of the tannins partake of the nature of glucosides, since they can be split up into a sugar and one or more other bodies. III. Glucosides.—A group of bodies, mostly of a neutral character, which may be split up by the action of acids (also alkalies) into a sugar and one or more other bodies. Of the numerous glucosides thus far known only the following appear to deserve mention here: Adonidin, from Adonis vernalis L. Arbutin, from Arctostaphylos Uva-ursi (L.) Sprengel. . . Convallamarin, from Convallaria maiahs L. Digitalein, digitin, and digitonin, from Digi- talis purpurea L. (see below). Glycyrrhizin, from Glycyrrhiza glabra L. Salicin, from various species of Salix and Populus. Strophanthin, from Strophantus hispidus De Candolle, or more usually from S. Kombe Olivier. Concerning digitalein and the other bodies mentioned above in connection with it, much uncertainty exists as to their being true chem- ical individuals and as to their relation to each other. The crystallizable principles obtained from digitalis are mentioned under the next group. IV. Neutral Principles.—Among neutral or indifferent principles are classed a number of bodies of very varying composition and prop- erties, which are chiefly characterized by the absence of any acid or basic character, or of properties which would assign them to any of the other groups. Many cf these bodies pos- sess a decidedly bitter taste, and have, for this reason, also received the name " bitter princi- ples," or amaroids. Of this group the follow- ing are more or less in use as medicines: Anemonin, from Anemone Pulsatilla L., and some allied species. Cantharidin, from the blistering fly. Cotoin, from coto bark, derived from an unde- termined South American tree. Digitalin. The only substance which appears to deserve receiving this name as a definite chemical body is Schmiedeberg's digitalin. There are two crystalline " digitalins" in the market—one known as Nativelle's, which consists chiefly of Schmiedeberg's digitoxin. the other as Homolle's, which consists mostly of Schmiedeberg's digitalin. There is also an amorphous German digitalin, which is likewise a complex body. These several digi- talins differ greatly in strength and kind of action. Elaterin, from Ecballium Elaterium (L.) A. Richard. Kosin (or cussin, koussein), from Ilagenia abys- sinica (Bruce) Gmelin. Pierotoxin, from Anamirta paniculata Cole- brook e. Piperin. from several plants of the natural or- der Pi perace.ce-. Quassin, from I'icrama excelsa (Swartz) Lind- ley. Santonin, from Artemisia pavciflora, Weber. V. Alkaloids.—A large group of bodies hav- 13 ACTIVE PRINCIPLES ing basic properties, capable of forming crvs- tallizable salts with acids. All but three'of them contain oxygen, in addition to carbon, hydrogen, and nitrogen. The three which con- tain no oxygen (viz., coniine, nicotine, and sparteine) are volatile liquids. All the others are solids and not volatile in the ordinary sense of the term, though some of them may, with certain precautions, be partially sublimed. Nearly all of them are colourless, and may be obtained in a crystalline condition. All of them are odourless, and most of them have a more or less bitter taste. Some of them appear to exist uncombined in the plants, but most of them are combined with acids, chieflv organic. Formerly it was customary to include among alkaloids all basic bodies, whether derived from plants or from animals. At present the term is usually restricted to those which naturallv occur only in plants, or which have, at least, been first obtained from plants. The term "artificial alkaloid" is sometimes applied to secondary alkaloids derived from natural ones —for instance, to bodies like apomorphine, homatropine, or hydrastinine. The term " syn- thetic alkaloid " may be applied and should be restricted to alkaloids which occur in nature, but have been prepared synthetically. It should never be applied to basic bodies only obtained synthetically and not occurring in nature at all (such as kairine, thalline, antipy- rine, etc.). Alkaloids are distributed very irregularly through the vegetable kingdom. Some of the natural orders are quite rich in alkaloids (for instance, the Papaverace.ce, Pubiacee, Solan- acee, etc.), while others contain only a few or contain none at all. The latter appears to be the case with the Graminee, Labiate, and Composite. Nearly all plants which contain alkaloids are dicotyledonous. Of the monocotyledonous plants only the Liliacee appear to contain any {Colchicum, Asagrea, Veratrum). In acotyledonous plants they are very rare. Among the cryptogams alkaloids are found only in some of the fungi (muscarine) and club mosses (lycopodine); none at all occur in the seaweeds, lichens, mosses, and liverworts. A few alkaloids occur in more than one natural order (caffeine, berberine). Most of the other alkaloids are peculiar to certain nat- ural orders or members thereof. Very often there is more than one alkaloid in one or the same family or member. In some cases a large number occur side by side. The distribution of alkaloids through the several parts of a plant varies. Most of them occur in the parts latest in growth or having the most active circulation—that is, in the fruit and seeds, the roots, or leaves—but also in the bark, being formed in the cambium layer, and then stored in the dead bark. The following alkaloids are those which have been or are now more or less used thera- peutically: Aconitine (crystalline), from Aconitum Napel- lus L. Alstonine, from Alstonia scholaris R. Br. Aspidospermine. from Aspidosperma Quebra- cho-bianco Schlechtendal. Atropine, from Atropa Belladonna L. and Da- tura Stramonium L. Bebeerine, from Nectandra Rodiei Schomb. Berberine, from Berberis vulgaris L., Hydras- tis canadensis L., and many other plants. Brucine, from various species of Sirychnos. Caffeine (a feeble alkaloid forming unstable salts with acids), from coffee, tea, and gua- rana. Carpaine, from Carica Papaya L. Cinchonidine, \ from certain species of Cin- Cinchonine, j chona. Cocaine, from Erythroxylon Coca Lamarck. Codeine, from opium. Coniine, from Conium maculatum L. Cornutine (composition undetermined), from ergot. Curarine, from curare. Daturine, from Datura Stramonium L. Ac- cording to Ladenburg, this is a variable mixture of atropine and hyoscyamine. Duboisine, from Duboisia myoporoides R. Br. According to Ladenburg, this is identical with hyoscyamine. Emetine, from Cephaelis Ipecacuanha (Brotero) A. Richard. Ergotinine (composition undetermined), from ergot. Erythrophlceine, from Erythrophleum guin- eense Don. Eserine, same as physostigmine. Hydrastine, from J/ydrastis canadensis L. Hyoscine, from Jlyoscyamus niger L. Hyoscyamine, from Uyoscyamus niger L., Atropa Belladonna L., Datura Stramonium L., and Duboisia myoporoides R. Br. Morphine, "] Narceine, » Narcotine, \ from °Pmm- Papaverine, J Pelletierine (or punicine), from Punica Grana- tum L. Physostigmine (or eserine), from Physostigma venenosum Balfour. Pilocarpine, from several species of Pilocarpus. n,,,-!!; *ne' [ from various species of Cinchona. wll 111 111", \ Sanguinarine, from Sanguinaria canadensis L. Scopolamine, from Scopolia atropoides Schult. Sparteine, from Cytisus Scoparius (L.) Link. Strychnine, from various species of Strychnos. Theine, same as caffeine. Theobromine, from ITieobroma Cacao L. Tropacocaine, from a Javanese coca. Veratrine, from Asagrea officinalis (Schl. et Ch.) Lindley. This is not a single alkaloid, but a mixture of several. VI. Organic Acids.—Bodies having an acid character, forming salts with bases. The prin- cipal organic acids which come under consid- eration here are the following: Acetic, agaric (instead of " agaric acid," it is more usual to employ the term agaricin ; the substance is extracted from white agaric), benzoic, butyric, camphoric, citric, ergotinic (composition unde- termined), gallic, lactic, malic, meconic, oleic, oxalic, salicylic, succinic, and tartaric (tannic acid is classed under " Tannins "). VII. Colouring Matters.—A class of bodies of very varying properties, the nature of many ADANSONIA ADONIS 14 of which is not yet understood. Many of them will eventually find their proper place under other group heads. VIII.—Resins.—Resins, in the sense of prox- imate principles, do not comprise the ordinary commercial resins, such as shellac, damar, am- moniac, etc., ell of which are complex bodies, but the term is intended to apply to the sev- eral chemical individuals of a resinous charac- ter which exist in nature. Resin of jalap, resin of podophyllum (often called podophyl- lin), resin of scammony, etc., are also complex bodies and not proximate principles. IX. Fixed Oils and Fats.—These bodies prop- erly do not belong among the proximate principles, because they are not simple bodies, but compounds of the radicle glyceryl (C3H6) with various fatty acids, or rather their anhy- drides. When fixed oils or fats are decomposed by suitable means, the glyceryl separates, com- bines with some of the elements of water, and forms glycerin (C3H6(OH)3), while the fatty anhydride takes up the hydrogen left over from the decomposed water and produces the cor- responding fatty acid. Glycerin, therefore, is not a proximate principle, strictly speaking, because it does not exist as such in these bodies. When obtained by any process what- ever it is rather & product than an educt. It is, however, customary and convenient, when making a proximate analysis of a vegetable or animal substance, to report among the constit- uents " fixed oil" or " fat," if any has been found, because it is easy to isolate it in this form and to subject it to tests of identity. There is no sharp distinction between fixed oils and fats, so far as their physical character is concerned, their consistence (fluid or solid condition) at the ordinary temperature depend- ing upon their melting point, and this again upon the melting point of the fatty acid which they chiefly represent. X. Waxes.—These are likewise compound bodies, closely allied to fats, but containing no glyceryl. For convenience sake they are usu- ally classed among " proximate principles." XI. Volatile Oils.—A large group of bodies, mostly liquid at ordinary temperatures, with more or less odour, volatilizable with the vapour of boiling water, and usually extracted from plants in this manner. A few volatile oils, when thus extracted, are found to consist of only one constituent; but most of them are more or less complex bodies, which may be separated from each other by suitable means. If the single constituents can be separated from the oil without altering their nature, they must be regarded as the true proximate prin- ciples. For instance, by fractional distillation, safrol, a definite chemical individual, may be separated from oil of sassafras or from oil of camphor. Safrol, therefore, is a proximate principle, and it happens to be an active prin- ciple also (see under XIII). Oil of sweet birch {oleum befu/m, U. S. P.), on the other hand —which, by the way, constitutes the largest proportion of the commercial oil of winter- green—consists entirely of methyl salicylate, a compound body, which, when split up by appropriate agents, is converted into methylic alcohol and salicylic acid. Strictly speaking, even these are not its proximate principles, since they do not exist as free methylic alcohol and as free salicylic acid in the oil. When making a proximate analysis of a plant it is usual to report the " volatile oil" among its constituents, as if it were a proximate principle. The commonest constituents of volatile oils are terpenes (hydrocarbons) of the composi- tion Ci0H16. Some volatile oils consist entire- ly of terpenes. Others contain, besides, some oxygenated compounds. When exposed to cold, certain volatile oils separate into a solid portion, calted stearopten, and a liquid por- tion, elaeopten, Besides terpenes, some volatile oils contain phenols, ketones, aldehydes, com- pound ethers or esters, etc., which are prefera- bly put together in a group by themselves. XII. Camphors.—These are volatile aromatic bodies, solid at the ordinary temperature and closely related to the volatile oils, although they are, unlike many of the latter, homogene- ous individuals. It is customary in works on materia medica to make the term camphor embrace the stearoptens obtained from many essential oils, irrespective of their true chem- ical character. The only active principle prop- erly belonging here is the official camphor from Cinnamomum Camphora (L.) Nees et Eberm. XIII. Miscellaneous Compounds.—Since it is now known that many organic chemicals, not referable to the other groups here mentioned, occur as proximate principles in plants and animals, it seems best to place these all in one group, the single members of which may again be arranged in proper sections or sub-classes —for instance, phenols, ketones, etc. For our purposes it will be sufficient to establish the group at large, since the number of active principles belonging to it is not numerous. The following may be mentioned: Anethol (the essential constituent of oil of anise). Carvol (the essential constituent of oil of cara- way). Eucalyptol, or cineol, existing in the essential oils obtained from a variety of plants. Eugenol (the main constituent of oil of cloves, and also occurring in other oils). Guaiacol (the essential constituent of creosote from wood-tar). Menthol (the essential constituent of oil of peppermint; sometimes called peppermint- camphor). Safrol (obtained from oil of sassafras, or from oil of camphor). Thymol (from oil of thyme, and several other oils; sometimes called thyme-camphor). Apiol (not the green liquid extract commonly sold, but the colourless crystalline substance extracted from oil of parsley). XIV. Protein Bodies.—These constitute a class of substances otherwise known as albu- minoids, all containing nitrogen, and chiefly valuable as food. XV. Ferments. — The true ferment sub- stances, either vegetable or animal, have not as yet been isolated. Their presence is known only by their effects. They are contained in certain preparations sold in the market in a 15 ADANSONIA A DUN IS more or less concentrated form. From vege- ! table sources : papayotin (from the milk sap of Carica Papaya L.). From animal sources: pepsin, pancreatin (composed of trypsin, amy- lopsin, steapsin, and a ferment which coagu- lates milk). The Employment of Active Principles in Place of the Corresponding Crude Drugs.— Whenever it is known that the characteristic physiological and therapeutic effects of a plant are wholiy represented by the active principle which it contains, and when the latter is readily obtainable, it is self-evident that the employ- ment of the latter—a definite, homogeneous, readily identifiable body—will eliminate from the treatment of a case many of the factors of uncertainty which would be connected with the use of the drug itself, or with that of one of its common Galenical preparations, such as a tincture, fluid extract, etc., since these are loaded with inert matter. There can be no doubt that pilocarpine, for instance, can fully replace jaborandi; emetine, ipecac; physostigmine, Cal- abar bean ; sparteine, scoparius ; pelletierine, pomegranate bark ; and a suitable mixture of strychnine and brucine (about equal parts), nux vomica or ignatia; but this list could not be very much further extended at the present time. So far as cinchona is concerned, its principal alkaloid (quinine), and even some of the other alkaloids, can fully replace it so far as the treatment of intermittent fever is concerned. But cinchona contains small quantities of other constituents which appear to come into useful play when it is used as a simple tonic. Cocaine has certain decided effects and special uses. The drug it is derived from—coca leaves—possesses some valuable properties not referable to cocaine, though it is not yet clearly known to what they are due. None of the single constituents of opium fully represents it. In fact, most of them differ in'their action more or less from each other; and even an artificial mixture made up of the known constituents of opium in about their original proportion does not fully equal the effects of opium itself. None of the principles so far isolated from digitalis, nor any mixture of them, can fully replace the drug itself. These facts should be borne in mind to prevent disappointment when the re- sults expected from the use of an active prin- ciple are not realized. At the present time it is necessary to study each active principle by itself, and to remember its peculiar effects if they differ from that of the drug from which it is derived.—Charles Rice. ADANSONIA.—The bark of the baobab tree of Africa, the largest tree known, used as a febrifuge. An infusion of 1 oz. in 20 oz. of water may be taken in the course of a day. ADEPS.—See Fat, Lard, and Lanolin. ADJUVANTS are remedies or measures employed for the purpose of intensifying or furthering the action of drugs, etc., but which bv themselves have a somewhat different physi- ological effect. For example, perfect quiet is an adjuvant to anodynes, calomel and capsicum to quinine in malarial troubles, etc. The list might be extended indefinitely, but as the term is so nearly self-explanatory it is hardly neces- sary. [The adjuvant elixir of the Nat. Form., intended chiefly as a vehicle for acrid or dis- tasteful drugs, is a syrup of sweet-orange peel, wild cherry bark, Russian licorice, coriander seed, and caraway seed.]—R. H. Nevins. ADONIDIN.—The active principle of Ado- nis vernalis (see Adonis). ADONIS.—A ranunculaceous plant related to the genus Anemone, that grows wild in Eu- rope, Asia, and Africa. The species that have been employed in medicine are A. vernalis, A. capensis (seu vesicatoria), and A. cupani- ana. These seem to possess similar charac- teristics. When fresh, the plant ■ has acrid, irritant, caustic, and vesicating properties that disappear when it is dried. In Europe and Africa the bruised leaves of the fresh plant have been popularly used as a substitute for cantharides. Parkinson attributed to adonis lithontriptic properties. Pallas states that in Siberia A. vernalis is used as an abortifacient, and that in Russia it has been used as a household remedy for cardiac and renal dropsy. A. N. Bubnow reported in 1879 that an in- fusion of from f to 2 drachms of A. vernalis in 6 oz. of water possessed an action resembling that of digitalis, and that in some instances this drug had quieted the heart when digitalis had failed to do so. He made physiological experiments with an aqueous extract injected into the lymph sac of frogs, in doses varying from i of a drop to 6 drops, and found that it caused, proportionally to its dose, most ener- getic ventricular contractions, that eventually diminished, the ventricle remaining in systole for some seconds; the venous sinus and auri- cles distended and attempted to act, ineffectu- ally, until a few drops of blood penetrated into the ventricle, when it contracted spasmodically anew. In 1882 V. Cervello isolated from a precipitate produced by tannin a glucoside, adonidin. Adonidin is a clear, yellow powder that has a bitter taste ; it is insoluble in ether or chloroform, but is soluble in water and in alcohol. It is obtained from the leaves, rhi- zomes, and roots of A. vernalis or A. cupaniana, 10,000 parts of the plant furnishing about 2 parts of the glucoside. Huchard and Traversa found that the prin- cipal action of the infusion and of adonidin was on the cardio-vascular apparatus, regulat- ing and slowing the cardiac beats, increasing the apical shock, and diminishing the heart's dimensions. There were increased urinary ex- cretion, disappearance of dropsy or oedema, slowing and deepening of the respiration, and diminution of palpitation and dyspnoea. Both Huchard and Hare found that the in- creased arterial pressure was due to stimu- lation of the vaso-motor centres and to the increased cardiac force. In toxic doses it para- lyzes the peripheral extremities of the vagus, excites the accelerator system, and eventually produces paralysis of the cardio-motor nerves. Huchard recommended an infusion of 4 to 8 parts of the plant in 200 of water, to be taken three or four times a day. He administered ADRUE AGATHIN 16 the alcoholic tincture in doses of from $ to 1£ drachm. Adonidin may be given in doses of from -/j to £ of a grain, repeated two or three times a day if necessary. In large doses Hu- chard found that it caused vomiting or diar- rhoea. Either the infusion or the glucoside is useful in cases of uncompensated heart disease in which, in consequence of arrhythmia and in- sufficiency of the cardiac energy, grave circu- latory disorders exist. The drug has a marked diuretic action, in consequence of increased arterial pressure. With the diminution of oedema in dropsical patients there are de- creased body weight and greater comfort. Da Costa and Albertoni advise its adminis- tration in palpitation independent of cardiac lesion. H. C. Wood considers that it acts more promptly than digitalis, and, as it may be ad- ministered for months without any cumula- tive effect resulting, it is to be preferred to digitalis in those cases of mitral or aortic re- gurgitation in which the latter drug is not well tolerated. Where the drug is to be ad- ministered for a long time the use of the glu- coside is preferable to that of the infusion. Samuel T. Armstrong. ADRUE.—See Cyperus articulatus. 2EGLE MARMELOS.—See Bela fruit. AEROTHERAPEUTICS.—See Air, Com- pressed or Rarefied. AEROZOL.—A mixture of essential oils, chiefly oil of spruce, said to contain 25 per cent. of ozone by volume, to which is attributed any therapeutic value it may possess. iERUGO.—Verdigris, impure copper sub- acetate (see under Copper). .22SCULIN.—A glucoside found in the bark of the horse chestnut {^Esculus Hippocasta- num). It has been recommended as a substi- tute for quinine, and antiseptic properties have been attributed to it. ^THER.-See Ether. iETHER ANiESTHETICUS. — Aran's ether, a varying mixture of numerous chlor- ethers, formerly used as an anesthetic. Its action is similar to that of chloroform, over which it has no advantages, while its great tendency to undergo changes on keeping ren- ders it untrustworthy. iETHER CHLOROFORMIATUS.—A mixture of 1 part of chloroform and 9 parts of ether, recommended by Weigel as an anesthetic. iETHEROLEA.—Those of the elasosac- chara of which an ethereal oil is a constituent. AFFUSION.—Much confusion exists in the employment of the terms affusion and douche. To such an extent has this gone that the term affusion is now rarely employed, all methods and procedures by which water is forcibly projected against the body being described as douches. Strictly speaking, however, such a use of the word douche is incorrect, as includ- ing too much. Though in affusion nothing is requisite save that the liquid shall fall upon the body from a height, and the water may be cold, tepid, or hot, yet tepid affusions are rarely employed, and hot ones usually only in rapid alternation with cold ones, to pro- mote absorption of old inflammatory deposits, and to excite nerve action in hysterical con- ditions. Cold affusions (40° to 60° F.) are practically, then, both generally more useful and in more general use than any other forms. In fever Currie's method may find useful employment, but rather as a nerve tonic and exciter in asthenic conditions than for its antipyretic value. Even in this condition it is now seldom employed, and in the Brand method of cold bathing we find a more efficient and conven- ient means of meeting the indications. In one febrile condition, however, cold affusion is invaluable—namely, in insolation, or sunstroke. The patient suffering from sunstroke should be stripped of all his clothing and laid upon a table; he should be vigorously rubbed with ice, and from a watering pot or sprinkler held at a height of about six feet above his body ice water should be continuously let fall upon him. These procedures should be persisted in until the patient's rectal temperature has fallen to 101°; they are then to be discontinued, lest the fall of temperature which continues after the withdrawal of these means become too great, and collapse be thereby induced. In the greater number of cases these procedures are all that are required, even the necessity for stimu- lation generally not appearing, since the de- cidedly stimulant effect of cold water dropping forcibly and in fine streams upon the surface of the patient's body excites all the vital func- tions to activity, and renders the use of other therapeutic measures unnecessary. Should the temperature subsequently rise considerably, as is not infrequently the case, the application is to be repeated. The beneficial effect of the cold affusion used in cases of insolation is tru- ly wonderful, the circulation becoming more natural, the respiration growing deep, convul- sions and delirium ceasing, the temperature falling rapidly, coma disappearing, and the mind becoming clear. No other therapeutic procedure can in any way compare with this in the treatment of sunstroke, a fact that has again and again been demonstrated in the hos- pital services of large cities. In non-febrile conditions, too, the cold affu- sion is a useful application, but it is by no means to be used indiscriminately. If follow- ing its administration the respirations become deep, the pulse grows full and strong, the skin gets red and glowing, and the extremities are rendered warm—in short, if vigorous reaction takes place—then has affusion been wisely used. If, on the other hand, its employment results in pallor of the surface, cyanosis of the extremities, weakening of the circulation, and all the symptoms of depression, then is it by no means to be repeated, lest it work serious harm. From these facts, then, we may infer that the use of the cold affusion will usually be unwise in the very young, the aged, those whose vitality from any cause is notably low- ered, and those suffering from organic disease of the heart or blood-vessels. 17 ADRUE AGATHIN In coma, asphyxia, syncope, and narcotism cold affusion is often of great service, acting most vigorously to arouse and to restore the pa- tient. In frost bite it is frequently useful, restoring the circulation in the affected part. In chorea and allied spasmodic diseases the use of the cold affusion will in some cases serve to determine a healthier action in the disturbed nerves. As a refreshing and tonic agent in condi- tions of slight loss of vigour, as from overwork or overstudy, it is often of value. In hysterical manifestations the brief appli- cation of the cold affusion (or the cold douche) outranks all other therapeutic applications. To promote the absorption of chronic in- flammatory thickenings and deposits (espe- cially if rheumatic) cold affusions will often be of benefit, but it must be admitted that the rapid alternation of hot and cold water appli- cations, as in the Scotch douche, is generally more effective. As a corrector of functional disturbances in any part of the body when due to defective in- nervation, the cold affusion or the cold douche is one of the most valuable curative agents in our possession. The action of the cold affusion, then, is seen to depend in febrile conditions partly upon its antipyretic action, but in all conditions its greatest value lies in its great power to excite, stimulate, and restore defective and impaired innervation not dependent upon organic dis- ease. When the nervous condition is such that its application is followed by healthy re- action, its use is invariably for good; but when depression is its result, it is not only of no curative value, but most potent for harm. In applying the affusion, especially if the force is great, the stream large, or the temper- ature low, care must be exercised in directing it upon the head, the chest, or the abdomen. It is. therefore, wiser as well as more beneficial to allow the water to fall finely divided, as from the sprinkler, rather than in mass, as from a wide-mouthed vessel or a pipe. It is, moreover, better not to exceed either a fall of six feet or a temperature lower than 40° F. To quote the opinion of Bartholow, " no greater height than ten feet, and a column not larger than four inches, will be proper or safe under any circumstances."—Henry A. Griffin. AGARIC.—Under the name agaric three varieties of fungus have been used in medi- cine. Agaricus albus, purging agaric, Poly- porus officinalis. Boletus laricis, the agaric blanc of the Fr. Cod., is a fungus growing upon the European larch. Prepared for the market, it presents the appearance of yellow or white masses of a friable and spongy charac- ter. Its odour is heavy and sweetish, and its taste at first sweet, then acrid and nauseating. It was formerly used to some extent as a purgative, and for this purpose was given in doses of 10 grains. In this use it had nothing of value to recommend it, and it had the seri- ous disadvantage of frequently causing nausea. 3 In doses of 5 grains it has been much used, particularly in the southern parts of the United States, for the prevention of abnormal sweat- ing, especially the night-sweating of phthisis. Nausea frequently follows this dose also, and occasionally diarrhoea. Agaric as such is now little employed me- dicinally, though its active principle, agaricin, is in general use. Agaricin (agaric or agaricinic acid), Ci6HSo Os + hUO, is a white crystalline powder of slight solubility in water. It is extracted from Agaricus albus by the action of alcohol. Agaricin is mainly used to prevent the sweat- ing of phthisis and exhausting diseases, and thus employed is often of great value. For this purpose it is given in doses of from -■}■$ to £ a grain, usually in pill. It is exceedingly slow in its action, as much as from six to ten "hours being required for the production of its full effect. Nausea and diarrhoea at times follow its administration, but may be prevented by combining it with a little opium, preferably in the form of Dover's powder. Though it is occasionally given hypodermic- ally in doses of from tV to £ of a grain, its use thus is not to be recommended, owing to its irritating nature and its tendency to cause suppuration. Agaricin is occasionally used to diminish bronchial secretion, and sometimes to stop the flow of milk. Its effect in diminishing secretion is believed to depend upon its action on the terminal nerve fibres in the glands. Agaricus chirurgorum, Boletus igniamus, Polyporus fomentarius, touchwood, tinder, spunk, punk, the agaric de chene of the Fr. Cod., is a fungus growing upon the oak. Touchwood is a tough, porous, and spongy material which finds some application in sur- gery. Thus, its physical characters render it a hannostatic of some value. In haemorrhage of small amount, as from leech bites, agaric bound over the wound is often most efficient, and it has been highly recommended for use in plug- ging the nose for the relief of epistaxis. From its characteristic of burning slowly when ignited, touchwood was formerly in com- mon use as a moxa, and to render it more in- flammable it was often soaked in a solution of nitrate or of chlorate of potassium. Moxas having become practically obsolete, its use for this purpose is now very uncommon. Henry A. Griffin. AGARICUS MUSCARIUS.—See Mus- carine. AGATHIN.—This proprietary preparation is a compound allied to antipyrine. Chem- ically it is salicylaldehyde-a-methylphenyl- hydrazone. It is in the form of white scales, odourless and tasteless, insoluble in water, soluble in alcohol or ether. It was recently much vaunted as an analgetic, especially in neuralgia and rheumatism, for which pur- pose it was given in doses of from 4 to 8 grains three times a day, but it does not seem to offer any great advantage over the better- known analgetics. AGGLUTINANTS Allt, CONDENSED OR RAREFIED 18 AGGLUTINANTS are applications which serve to approximate and retain in position lacerated or incised tissues. Formerly a large number of substances were held in high repute for this purpose, but now the term is restricted to adhesive and court plasters, collodion, and all adhesive substances used in the dressing of wounds.—R. H. Nevins. AGRIMONY, the herb of Agrimonia Eupatoria, the aigremoine of the Fr. Cod., was formerly much used as an astringent and tonic, but it is now little used except for the preparation of domestic mouth washes and lotions. Internally the dose is from 1 to 2 drachms. AGROPYRUM REPENS.—See Triti- CUM REPENS. AILANTUS.—The bark and leaves of A. glandulosa, A. excelsa, and A. malabarica, the tree of heaven, Chinese sumach, simarubace- ous trees indigenous to India and China. It is chiefly used as an anthelminthic, especially against tapeworm, and is reputed less depress- ing than pomegranate. The dose of the bark or leaves is 8 grains, and that of a non-official fluid extract is from 15 to 30 grains. AIR, CONDENSED OR RAREFIED. —The density of air is measured by its pressure, or, to state the same fact in other words, air ex- erts in every direction a pressure proportional to its density. Upon this fact, together with the general physical laws that motion takes place in the direction of least resistance, and that action and reaction are equal and opposite, is based that portion of the art of pneumother- apy that deals with air modified in density.* In discussing this subject it is necessary not only to bear in mind the general physiology of respiration and circulation and the facts and laws of the mutual relations of these processes, but also to remember that the respiratory and circulatory mechanisms are commonly adjusted to the prevailing atmospheric pressure. The external surface of an ordinary human body being about sixteen square feet, the atmosphere presses thereon with a weight of about sixteen tons, which would " crush us to earth " were it not counterbalanced by an equal pressure act- ing upon the interior. Thus when the pres- sure of the air upon a part of the exterior is partially removed, as in cupping, that part is seen to be immediately forced outward, the motion being shared by both solids and fluids; but, the latter moving more readily than the former, a congestion of the part with blood is evident. Important modifications of physiological and pathological processes may therefore be brought about by modifying the pressure of the at- mosphere upon the body in genera], or upon a portion of the body, or differently upon dif- ferent portions of the body. Such modifica- tions of pressure are the mechanical effect of natural or artificial alterations in the density of the atmosphere. * For therapeutical purposes air may be modified not only in respect to its density, but likewise in re- spect to temperature, moisture, or chemical compo- sition. While for purposes of exact research an exact standard, taking account of corrections for temperature and moisture, is necessary, we may for practical purposes assume the ordi- nary mean barometric pressure at sea level, of 30 inches (7C0 millimetres) of mercury, repre- senting about 15 pounds to the square inch (1-033 kilogramme to the square centimetre) as that of an unaltered or standard atmosphere. Natural variations—that is to say, the ordinary barometric fluctuations—within a range of 2 inches of mercury may be disregarded. When, however, the mean barometric pressure at any locality in the temperate zones is con- stantly less than 28 inches of mercury, that lo- cality must be considered to fall within the category of those having naturally rarefied atmospheres. Naturally rarefied atmospheres exist at stations elevated above sea level, the pressure diminishing about 1 inch of mercury li pound to the square inch) for every 1,000 feet of elevation. From 2,000 to 3,000 feet is termed moderate altitude, 4,000 to 5,000 feet high altitude, more than 5,000 feet great alti- tude. The volume of a stated quantity of any gas being inversely as the pressure, in rarefied atmospheres the weight of the oxygen con- tained in a given volume of air is much dimin- ished. Thus, at the sea level, 1 cubic foot of dry air at 32° F. (0° C.) contains 130"4 grains of oxygen, while at an elevation of 5,000 feet the oxygen is reduced to 108*6 grains. In condensed atmospheres the oxygen is propor- tionately increased; at a pressure of li at- mosphere 1 cubic foot of dry air at 32° F. contains 195-6 grains of oxygen. Artificially modified atmospheres may be con- densed—that is, of increased or positive pres- sure ; or rarefied—that is, of diminished or negative pressure. Such modifications may be made to affect both and equally the respired air and the sur- rounding atmosphere, or one of these factors only, or both unequally. The former method, that in which the patient breathes air of the same (modified) density as that wherein he is immersed, is termed the method of absolute pressure, or the method of Tabarie. It em- braces the condensed-air bath and the rarefied- air bath. The latter group of modifications, those in which the patient breathes air differing in density from that wherein he is immersed, are included under the method of differential pressure, otherwise termed respiratory differ- entiation, or pneumatic differentiation, or the method of Hauke and Waldenburg. This method embraces a number of expedients (8) tabulated in the further course of this article. It is evident that, in so far as diminution of atmospheric pressure is concerned, the physio- logical and therapeutical effects of sojourn at altitudes are to be considered under the head of absolute pressure. Historically, however, it was not the obser- vation of the robust health and great thoracic development of mountaineers, or of the im- provement in health of invalids, and especially of poitrinaires, upon removal from lowlands to mountains, that led to the use of artificial- ly modified atmospheres in therapeutics; and AGGLUTINANTS 19 AIR, CONDENSED OR RAREFIED the artificial reproduction of the atmospheric pressure conditions of altitudes—that is to sav, the rarefied-air bath (or absolute negative pres- sure)—has not as vet been found of much im- portance. Paradoxical as it may seem, it is the condensed-air bath (or absolute positive pres- sure) that, intermittently used at low levels. best imitates the therapeutic effects of altitude ; and it was in fact through studies of the effects of condensed air upon vegetable and animal life, together with observations of the results upon men of descent in diving bells and into deep mines, that this important, but as yet imper- fectly appreciated, addition to the resources of medicine was made.* Tabarie made, a communication upon the subject to the Parisian Academy of Sciences in 1832, f and in 1853 Junod reported to the same body the results of his own experiments upon man. The first practical applications of the method in the treatment of disease seem to have been made in 1838, under the direction of Tabarie, by Pravaz and others. Tabarie's ap- paratus, upon the principle of which most sub- sequent ones have been modelled, consisted of a wrought-iron spheroidal chamber, large enough to accommodate a dozen persons, into which the external air was forced by a steam pump, and from which the air respired by patients was removed, the rate of efflux being made sufficiently less than the rate of afflux to se- cure any desired elevation of pressure within the chamber. Pneumatic chambers of variously modified construction have been erected and are in operation at many resorts on the Conti- nent of Europe.:): There is one at the Bromp- ton Hospital, London, but the writer knows of none in America. At each medical centre, however, there should be such a chamber (or a number of such chambers), under the care of an experienced physician, for the use of pa- tients referred by their medical attendants, the latter retaining proper control or oversight of the details of treatment in consultation with the specially expert physician in charge. * Absolute-Pressure Method. || — Without entering: into mechanical details, the general features of a pneumatic chamber may be de- scribed. The purpose of the apparatus is to immerse the patient for a certain time in air ol greater (or less) density than that to the ac- tion of which he is ordinarily exposed. The change of pressure must be brought about gradually, after the patient has entered the chamber; and after a certain length of expo- sure to the modified atmosphere the ordinary pressure must be gradually restored before the patient emerges. The apparatus consists, * Yule J. Solis-Cohen : Inhalation ; its Therapeutics and Practice, 2d ed., Philadelphia, 1876, p. 37. t Comptes, rendus t. vi, p. 890. i For a description of the different forms of pneu- matic chambers, see Oerlel, Hnndbuch der respira- torischen Therapie, Leipzig, 1882 ; English transla- tion, by Yeo, London, 1885. # There is at Brussels such an establishment, which owes its existence to the gratitude of a wealthy resi- dent of that city who recovered his health under pneumatic treatment at Montpellier. With this the writer has had no detailed personal experience, and he relies principally upon the writ- ings of von Vivenot, Oertel, and Hovent. therefore, of two essential parts: an air-tight chamber (usually of iron—in one instance, at least, of stone), and a pump or other mechan- ism by which air is forced into, or removed from, "the chamber. The chamber consists of a properly lighted and tastefully furnished room in which a patient or several patients may be seated, and a vestibule, or antecham- ber, in which changes of pressure may be ef- fected independently of the pressure in the main or respiration chamber. The object of this latter provision is to afford a means of exit or entrance to the physician or attendant without disturbing the pressure in the respira- tion chamber, and without subjecting the per- son entering or leaving to too sudden a change. Some chambers have a sort of double window by means of which books and other small ar- ticles may be passed in or out without disturb- ing the pressure. Electric bells and other means of calling instant attention are likewise provided. In addition there must be suitable devices for the removal of carbon dioxide and other products of respiration, and for the regu- lation of the temperature and the humidity of the air of the chamber. Provision can also be made for modifying the proportions of oxy- gen, nitrogen, or carbon dioxide, or for the impregnation of the incoming air or of the air of the chamber in any proportion desired with any gas, vapour, or volatile medicament, or any drug susceptible of nebulization. The various desiderata have been well accomplished by the chamber erected at Reichenhall by G. von Lie- big. It is figured in Yeo's translation of Oer- tel's Respiratory Therapeutics: London, Smith Elder & Co., 1885. It consists of three rooms of sheet iron, ar- ranged somewhat on the plan of a trefoil and communicating by means of an antechamber, the whole being inclosed by an outer iron wall with a door through which entrance is gained into the antechamber. The three other walls of the antechamber are formed by the walls of the three respiration chambers. Each room con- tains three windows of thick glass, and is 2'33 metres high and 2-04 metres in diameter. Its base is thus 3-267 square metres, and its capac- ity 7*612 cubic metres. Three persons can sit around a table in each of the chambers, and altogether nine persons can be accommodated in the apparatus. The antechamber has an average width of 1 metre and a depth of 1*3 metre, and is a little lower than the respiration chambers. Air is forced in by a pump which stands in another room and is operated by a steam engine. The air enters the antechamber on each side of the door, through two iron tubes, each 7 centimetres in diameter and 29 metres in length. To these tubes regulating cocks are attached. The wooden floor of the antechamber and the carpeted floors of two of the main chambers are perforated, and there is an orifice in the floor under the wall sepa- rating each of these main chambers from the antechamber. The air from the antechamber entering the chambers through these perfora- tions, the patient does not feel the shock of the pumping and the elevation is regulated more equably. Air escapes from the chambers 20 AIR, CONDENSED OR RAREFIED ! through orifices in the walls near the ceiling, closed by gratings, to which outlet pipes fur- nished with regulating cocks are attached. A mercury manometer with millimetre divisions for determining the air pressure in the chamber is placed outside near the door in communi- cation with the antechamber, while within, near the window of the respiration chamber, an August's psychrometer shows the tempera- ture and amount of moisture. The double- action air pump yields with every lift 27-3 metres of air and the piston makes about 140 excursions in the minute. An overplus of air, therefore, constantly streams into the cham- bers, and a uniform regulation is brought about by an assistant who stands in the ante- chamber and observes the manometer and the psychrometer. The pressure is increased not by arresting the efflux, but by increasing the afflux of air, in this way giving satisfactory ventilation. The pressure in the third chamber may be made lower than that of the other chambers by means of a stopcock cutting off a part of the air from entrance by way of a pipe leading from the antechamber. The temperature is regulated by cooling or warming the instream- ing air as it passes through the feeding pipes. At Brussels a different plan is adopted. By means of a specially constructed pump the same air is kept circulating through the res- piration chamber and a series of pipes com- municating with immense wash bottles, some containing alkaline solutions and others con- taining pure water, in order to remove the carbonic acid and other products of respira- tion. A gas engine furnishes the power. Other forms of apparatus have been devised not materially differing in essential principles from those described. In some, rarefaction of the air of the chamber can be effected by re- versing the action of the pump. The doors must be specially adjusted. Management of the Apparatus.—An experi- enced attendant famiiiar with the construction and the physical principles of the apparatus must always be at hand to observe and to regulate, according to the directions of the phy- sician, the conditions of pressure, temperature, moisture, etc. The physician in charge of the institution should always be within easy call. The preferable pressure varies with the indi- vidual case and with the nature of the disease for which the patient comes under treatment.* As a rule, an excess pressure of f to f of an at- mosphere (equal to 30 to 32-5 centimetres—12 to 12| inches—mercury) gives the best results. With weak patients, however, it is not safe to exceed £ of an atmosphere (15-2 centimetres—6 inches—of mercury)—at all events until the pa- tient has become habituated to the treatment and has shown signs of marked improvement. * Pressures are usually described in fractions of an atmosphere, and it must be remembered that the fig- ures given are to be added to or subtracted from the standard atmospheric pressure. Thus, when an ex- cess pressure of i atmosphere is mentioned, it means an absolute pressure of 1£ atmosphere, or 225 pounds to the square inch ; a negative pressure of J atmos- phere means an absolute pressure of J atmosphere, i. e., 12 pounds to the square inch. Very weak persons, especially those with febrile temperatures and much depressed in general condition by chronic exhausting disease, should not be subjected to pneumatic treatment. It could only hasten the end. Symptoms of fever in young and strong persons suffering with acute catarrhal inflammations of the respira- tory tract are not, however, considered to contra-indicate pneumatic treatment. The transition from ordinary pressure to an excess pressure previously determined should occupy, as a rule, about thirty minutes. When the excess pressure has reached the intended limit, it must be maintained unchanged for about an hour (or, in exceptional cases, two hours), and half an hour should again be consumed in gradual transition to the barometric figure. It has been given as a general rule that each transition period should occupy one minute for every centimetre of mercury measuring the increase of pressure, and that the period of unchanged pressure should be two minutes for each centimetre of mercury of excess pressure. Acute forms of disease, hyperaemias, and catarrhal inflammations usually require a shorter period of treatment than chronic cases. In the beginning of treatment the sittings should occur daily. After some weeks every two or three days may be sufficient. Some physicians make more or less prolonged inter- missions between successive series of daily sit- tings. Apart from recovery or improvement, the indications for ceasing pneumatic treat- ment or for intermitting it for a long time are the signs of excessive organic combustion—that is, fever, emaciation, excessive hunger (some- times followed by complete loss of appetite), marked lassitude, and muscular weakness. The physiological and therapeutical effects of the methods of the pneumatic chambers can be best studied after we have considered those of the Differential Pressure Method.—The cost of pneumatic chambers, their restriction to cer- tain resorts, and their inapplicability or ineffi- ciency in certain particulars have led to many endeavours to construct portable apparatus for pneumotherapy. The first practical appara- tus for inhalation of condensed air was made by Hauke, of Vienna, in 1870; and the same observer likewise devised a pneumatic cuirass and a pneumatic tub, by which the air about the chest or that about the entire body of the patient could be rarefied while the ordinary atmosphere was breathed. Hauke's apparatus has, however, only an historical interest, hav- ing been superseded by that of Waldenburg and others. Waldenburg's apparatus is simply a gasometer in which air is compressed or rare- fied by means of weights, and from which or into which the patient breathes. There are va- rious scales, gauges, and other attachments for purposes of exact observation. The air, taken from a proper source and filtered on its way to the gasometer, is conveyed to the patient by means of a rubber tube, and prevented from escaping by means of a mask of spun metal or of rubber edged with pneumatic rubber cush- ions, which is placed over the nose and mouth and correctly adjusted to the face. A two-way 21 AIR, CONDENSED OR RAREFIED stopcock of hard rubber, or a metallic arrange- ment modelled on the cornet-piston placed be- tween the supply tube and the mask, regulates the ingress and egress of air. The same ap- paratus may be used for both inspiration from and expiration into condensed or rarefied air, but it is best to have two cylinders for expira- tion, so that the air inhaled may run no risk of contamination. Weil and others have com- bined the two cylinders in one apparatus, and variously modified the details of construction. (See Oertel, op. cit.). Fraenkel has constructed an apparatus like an accordion, Biedert a large reversible bellows, Geigel and Mayr a water- engine bellows, Mathieu and others various forms of apparatus utilizing hydrostatic prin- ciples. The writer's apparatus (Fig. 1), de- Fig. 1.—The author's apparatus for inspiration scribed in 1884, is designed to furnish an in- strument as simple, but more cleanly, manage- able, and reliable than Fraenkel's or Biedert's, and at the same time less cumbersome and expensive than Waldenburg's or Geigel and Mayr's, and thus capable of being used by the patient at home. A further advantage that it offers over all instruments except that of Geigel and Mayr is its continuous action. As now im- proved, it consists of a small gasometer of zinc, the air chamber of which is 8 inches in diame- ter and 24 inches high, and a foot bellows such as is used by dentists. (For office use a pump. and for hospital work a special form of res- ervoir and pump with steam or electric mo- tor, is substituted. See N. Y. Mrd. Jour., Feb. 23, 1881).) Filtered air from out of doors is conveyed to .the bellows through a tube attached to a window board, and pres- sure is made by weights placed upon the air chamber. A second cylinder with suspended weights may be used for rarefied air, and a second bellows may be so combined with the first that one stroke of the foot operates both. (For details see N. Y. Med. Jour., Nov. 23, 1889). A further improvement contemplates a great reduction in size by surrounding one air chamber by another, instead of using two gasometers. In the physician's office and in hospitals the double apparatus is desirable; in the patient's residence the single cylinder of condensed air and expiration into rarefied air. for condensed air is usually sufficient. With all these forms of apparatus various attach- ments for medicating, warming, cooling, mois- tening, or drying the air can be utilized. Williams and Ketcham have devised an ap- paratus termed a " pneumatic cabinet." It is an air-tight metal chamber, just large enough to allow one patient to be comfortably seated therein; containing a glass window, through which the patient can be observed, and having an hermetically closing door. By means of a bellows attached to the instrument the air within it can be slightly condensed or rarefied, and a tube leading to the outer air is furnished AIR, CONDENSED OR RAREFIED 22 with a mouthpiece through which the patient inhales and exhales. The inspired air can be medicated or otherwise modified. The degree of pressure is shown by a mercury manometer. While theoretically this instrument may be used in various ways, in practice the air about the patient is usually rarefied by about -fa atmos- phere, and he thus inspires from and expires into relatively condensed air. Its effects will therefore be considered under the head of Con- tinuous respiration of condensed air (see page 25). It is at once much more expensive and considerably inferior in range of usefulness to the other forms of apparatus described. For special purposes a number of handy or pocket instruments have been described. Do- bell has devised an apparatus called a residual air pump. It consists of a mouthpiece with a valvular arrangement which allows freedom of expiration, but partially impedes inspiration, the nostrils being closed or unused during the process. It is intended for use in the treat- ment of emphysema. The writer has devised an apparatus which he has termed "the pneumatic resistance valves." It consists of a pair of small hollow, bipartite, metal cylinders (1 in. x2 in.), each containing an ebonite valve, the movement of which is resisted by a spiral spring, the ten- sion of the spring being regulated by turning 23 AIR, CONDENSED OR RAREFIED the perforated cap of the cylinder. Beneath the cylinders, and communicating with them through the valve seats, runs a metallic tube open at both extremities and attached at one extremity to a rubber tube, terminating in a hard-rubber mouthpiece. The patient inhales and exhales through the apparatus, occluding the anterior opening of the air tube during the phase of respiration to be affected. The respiratory current is then forced to pass through the cylinder. One valve is so ar- ranged as to impede the inspiratory current, the other to impede the expiratory current. Thus are obtained the effects of inspiration from rarefied air, and of expiration into con- densed air. The instrument is intended to be used as a means of regulated pulmonary gym- nastics. A scale of fractions of an atmosphere engraved upon the cylinder shows the degree of positive or negative pressure needed to over- come the resistance of the valve. In place of a spring, weights may be used to regulate the pressure. In such a case, a square opening of J-inch side will be most convenient. A sponge or cotton wad, on which a few drops of a vol- atile medicament are placed, may be inserted in the path of the incoming air. The cylinders can be used separately or to- gether, or either may be used in connection with a gasometer apparatus by inserting it into the proper part of the stopcock. Changes of intrathoracic air pressure can of course be obtained without any apparatus whatever. Thus if, while nostrils and mouth are closed, forced expansion of the chest is made (Muller's experiment), the air within the lungs will be rarefied ; or if after a full inspira- tion the glottis or the mouth and nostrils are closed and an effort is made to contract the chest (Valsalva's experiment), assisted perhaps by manual compression of the chest (Weber's experiment), or of the chest and abdomen (Gerhardt's experiment), the intrapulmonary air will be condensed. A less degree of con- densation may be caused by exhaling through but partially closed lips or by interrupting the expiration following a prolonged inspira- tion by slowly counting aloud (phonic expira- tion). It is obvious, however, that the effect of rarefaction can thus be produced only dur- ing a prolongation of the inspiratory phase of the respiratory act, while compression can be brought about only by a baffled or impeded expiration. The respiratory rhythm is com- pletely deranged, the mechanical force devel- oped and employed remains an unknown and variable quantity, and the disturbance of cir- culation is usually out of all proportion to the therapeutic value of the expedients. Metltod of employing the Portable Appa- ratus.—Atmospheric pressure upon the exteri- or surface of the body remaining unchanged, increase of pressure upon the surface of the air passages (pulmonary surface) may be ob- tained, first, by inspiration of condensed air: second, by expiration into condensed air. De- crease of pressure upon the pulmonary surface may be obtained, first, by inspiration of rare- fied air; second, by expiration into rarefied air. These procedures may be so combined as to maintain the increase or decrease during both phases of the respiratory act, or to allow of increase during one phase and decrease during the other. There are thus eight meth- ods of respiratory differentiation, which maybe tabulated as follows : Inspiration of 1. Condensed air 2. Condensed air 3. Condensed air 4. Rarefied air 5. Rarefied air 6. Rarefied air 7. Atmosphere 8. Atmosphere With expiration into Atmosphere. Condensed air. Rarefied air. Atmosphere. Rarefied air. Condensed air. Condensed air. Rarefied air. To carry out all these eight methods, two of Waldenburg's gasometers, or the writer's double gasometer and a pair of resistance valves, will suffice. The procedures numbered 1 and 3 are the most generally applicable. For the former a single gasometer of Waldenburg's or the writer's apparatus, for the latter a double gasometer is required. That numbered 2 is physically the equivalent of the method of the pneumatic cabinet of Williams. It is, in the writer's experience, of but limited applicability and inferior to the other methods. It requires two of Waldenburg's gasometers or one of the writer's gasometers and an expiration resistance valve. The procedures numbered respectively 4, 6, and 7 can be carried out with no other ap- paratus than the resistance valves. The proced- ure numbered 5 would require two cylinders of Waldenburg's or the writer's expiration gas- ometer, and an inspiration valve. It is of only theoretical importance. Procedure No. 8 re- quires a single cylinder of Waldenburg's or the writers expiration gasometer. The excess or negative pressures employed in the differential methods are much smaller than in the pneumatic chambers, varying from tV to -fa of an atmosphere. In negative pres- sure (rarefaction) fa atmosphere is rarely to be exceeded. In expiration into condensed air or against the resistance valve fa atmosphere should not be exceeded except with great caution. It is always wise to begin with the minimum pressure and increase as the patient's susceptibility is learned and his progress indi- cates. Patients use the apparatus at first for five minutes, later for thirty minutes at a time, and from one to four times a day. If weak they "may be seated, but it is better to stand. All constricting garments should be loosened. Inspiration should be as slow, expiration as prolonged as possible, the patient being en- couraged to increase the volume of air inhaled or exhaled at each respiration, as shown by the scale of cubic contents upon the air cylinder. The treatment should not be pushed to the point of fatigue. A rest of ten minutes before and after treatment, and sometimes an inter- ruption and rest of five or ten minutes during treatment, are advisable. The time thus con- sumed is a great drawback when the treatment must be carried out at the physician's office. For this reason it is preferable in cases of chronic disease, like pulmonary tuberculosis or AIR, CONDENSED OR RAREFIED 24 asthma, to have the patient purchase (or rent from the instrument maker) some form of ap- paratus that can be used at home after due in- struction has been given. The home apparatus has also the advantages of cheapness and of ap- plicability to cases of patients confined to the house or prevented by bad weather, distance, or other causes from visiting the physician s office. The physical effects of respiratory differen- tiation must be considered with reference, first, to respiration; second, to circulation. Motion of air and of blood takes place from the point of high pressure toward the point of low pressure. Increased pressure upon the pulmonary surface, therefore, favors the en- trance of air into the chest and the expansion of the lungs, and opposes the exit of air from the chest and the contraction of the lungs; thus it facilitates inspiration and impedes ex- piration. It tends to drive the blood out of the heart, out of the thorax, and toward the periphery. Decreased pressure upon the pul- monary surface facilitates expiration and im- pedes inspiration. It tends to drive the blood from the periphery toward the thorax and into the right heart. physiological and therapeutical action. Inspiration of Condensed Air.—The excess pressure employed varies from fa to -jy of an atmosphere (+ "9-5 to + 25 mm. Kg.). From 10 to 150 respirations may be made continuously, and the process repeated after a rest of 5 or 10 minutes. The patient, if able, should stand, with head erect and shoulders thrown well back. If necessary, the physician should aid inspiration by pressing the shoulders backward or assist expiration by compressing the chest. When it is desired to localize or locally in- crease the effect, the other portion of the chest may be strapped or its motion diminished by manual pressure or a suitable pad and brace. Respiration.—The muscular effort of inspi- ration is diminished and the alveoli are dilated to a greater extent than would be possible from unaided voluntary effort. There is increase in the quantity and in the penetrating power of the inspired air, therefore reopening of air cells disused from weakness or occluded by swelling of the bronchi, by pathological secre- tion, etc. There is increase in the volume, and in the weight per volume, of oxygen brought to and absorbed by the blood, a much greater area of blood surface being reached. The subsequent expiration is sometimes slightly retarded, though theoretically it should be easier in all cases. It is deeper than usual, the quantity of air expelled and of carbon di- oxide eliminated being increased. Tidal and complemental air are thus augmented, reserve air diminished, the first two quantities and a portion of the third quantity being added to form what is now virtually an increased vol- ume of tidal air, reaching 200 cubic inches or more. Diminished frequency of respiration, increased expansion, ventilation, and gaseous exchange are therefore the immediate effects; increased vital capacity the ultimate and per- manent result. In some cases the increase of chest measure is remarkable. It is not due to a pathological emphysema, as expiration can be perfectly performed. Circulation.—During inspiration there is an augmented centrifugal tendency of the blood current The ventricular systole is increased in force. Both arterial and pulmonic circula- tion are at first quickened, bringing more blood, therefore more corpuscles, more haamo- globin, in proportion to area, m contact with the increased quantity of inspired oxygen. The systemic vessels are filled, causing a rise of arterial blood pressure. The pulse becomes at first more rapid, afterward slower, lull, and hard The blood circulates more actively throughout the body, penetrating more read- ily into capillaries and lymph spaces, and being richer not onlv in oxygen but also in nutritive materials; for pressure upon the diaphragm transmitted to the abdominal viscera stimu- lates absorption of chyle, while heightened pressure and augmented quantity of blood in the viscera tend to stimulate functional activ- ity The waste products of metabolism are more thoroughly removed. Thus, increased ox- idation and tissue change increase appetite and improve nutrition; the increased alimentation is utilized; there is better combustion and elimination. The effect upon pathological conditions is due partly to the general effect upon respira- tion, circulation, and nutrition, and partly to local mechanical pressure. When pulmonary hyperemia exists it is relieved. The absorp- tion of inflammatory products is hastened. The general tone of the bronchial mucous membrane and the pulmonary tissue' is height- ened. Cough and expectoration are at first increased from dislodgment of accumulated materials, afterward diminished from relief to irritation and diminution of pathological secre- tions. Increased ingestion and assimilation repair pathological waste, and the increase in weight sometimes exceeds the previous record in good health. Toxic metabolins, whether autogenetic or heterogenetic, are destroyed and removed; useful metabolins are again formed. Thus fever is diminished, sleep is promoted, night sweating is often arrested, and haemop- tysis is sometimes checked. Expiration into condensed air impedes the act and requires greater muscular exertion. If this be sufficient to overcome the obstruction, the amount of air expelled is increased. Other- wise it becomes gradually diminished, and the subsequent inspirations are therefore rendered shallower. In other words, tidal air is at first increased, but soon diminished; residual air gradually encroaches upon reserve air, tidal air, and finally upon complemental air, the en- tire volume becoming practically stationary or residual. The excursions of the diaphragm and thoracic walls become less and less, but at the expense of the contraction, fixed expansion being finally maintained, and if the procedure be pushed to excess with too high a pressure, apnoea may result. Pulmonary ventilation is diminished and gaseous exchange is retarded, the absorption of oxygen by the haemoglobin being, however, facilitated, although the excre- tion of carbon dioxide is diminished. The 25 AIR, CONDENSED OR RAREFIED effect upon the circulation produced during I expiration is less relieved by subsequent in- spiration than in the converse case, and is thus an exaggeration of that described as the effect of inspiration of condensed air, being practi- cally the same as in Valsalva's experiment— depletion of the lungs and heart, overdisten- tion of the systemic vessels, especially the veins. The pulse may disappear from com- pression of the subclavian artery. Upon path- ological conditions, the pressure effects are similar to those already detailed. Continuous respiration of condensed air, therefore, greatly augments the distention of the thorax and of the lungs, maintaining the patency of the alveoli; and while it diminishes during treatment the volume of air exhaled, the result may nevertheless be properly stated as an increase in vital capacity. The ventila- tion of the lungs is diminished, but, on the whole, gaseous exchange appears to be slightly increased. There is constantly increasing in- terference with the dilatation of the heart, and an outward pressure replaces the normal tho- racic aspiration of the blood, thus blocking the systemic veins, while at the same time the arteries are distended. Arterial tension, in- creased at first, soon falls, and the pulse be- comes small, slow, and feeble. Inspiration of rarefied air, which should be conducted against a very small negative pres- sure, rarely exceeding -fa of an atmosphere, increases the muscular effort necessary to pro- duce expansion of the chest, and the volume of air needed to supply the proper weight of oxygen. If the requisite effort can be made, there is increase in the elastic tension of the lungs and in the volume of tidal air. If it can not be made, there is decrease in both these factors. The subsequent contraction of the chest is at first passively facilitated, after- ward impeded, from the resistance of the denser outer air. The muscular effort of this phase is thus also increased, and the frequency of respiration, at first heightened by the ex- citement of impediment, is finally diminished. Ventilation and gaseous exchange are, on the whole, increased, vital capacity is augmented, and the muscles of inspiration are strengthened. The blood tends at first to leave the periphery and accumulate within the thorax; but as there is more blood delivered to the left ven- tricle, and this can contract with sufficient force to overcome the higher peripheral pres- sure, the final result is a quickening of the cir- culation with an increase in the blood pressure and tension of the arteries. Expiration into rarefied air, conducted with a negative pressure of from fa to fa of an at- mosphere, facilitates the contraction of the thorax, exerting a moderate suction force, and greatly increasing the amount of air expelled from the lungs, thus facilitating the collapse of distended air vesicles. Subsequent inspira- tions are rendered easier and deeper, more oxvgen-bearing air enters the vesicles, ven- tilation and gaseous exchange are enormously increased, and the gain in vital capacity is very great. The circulatory effects are similar to those produced by inspiration of rarefied air, but more marked. They vary in different individuals, are evidently different in man and animals, and can be infiuenced by the manner of subsequent inspiration. While there are conflicting observations as to systemic blood pressure, there is agreement as to the tendency to pulmonary congestion and the facilitation of cardiac diastole. Inspiration of condensed air, with expira- tion into rarefied air, therefore increases the efficiency of both processes. The alternate expansion and contraction of the lung tissue stimulates its elasticity. Pulmonary ventila- tion, both as to interchange of gases and ex- pulsion of effete materials, is vastly augmented. The alternations of opposing circulatory effects relieve hyperemia wherever present, increase the activity and penetrating power of the blood current, and stimulate tissue change and nu- trition. Inspiration of rarefied air, with expiration into condensed air, increases the muscular ef- fort necessary to complete each act, prolongs the respiration, and retards expiration par- ticularly. The alternation of centripetal and centrifugal impetus increases the activity of circulation. Inspiration of rarefied air, with expiration into the same medium (continuous respiration of rarefied air), increases the muscular effort of inspiration, but hastens and facilitates expira- tion. The centripetal tendency of the blood is maintained during the entire act, and the heart's action is greatly diminished in force and increased in frequency, the general arterial pressure being much lowered. The effects of differential pressure being kept in mind, return may be made to the study of the method of absolute pressure. Physiological Effects of the Method of Absolute Pressure.—In this we deal not only with much greater pressures than in the differ- ential method, but with more complicated physical and physiological conditions. Some of these space permits us only to allude to. In a complete study there should be considered not alone the effects of pressure upon the various organs and their functions, but also the chem- ico-biological action of the air itself, a gas much richer in weight of oxygen (and other constitu- ents) per volume, and otherwise physically al- tered. Furthermore, the pressure effects have three distinct stages: 1, the stage of gradually increasing (or diminishing) pressure; 2, the stage of maintained pressure; 3, the stage of gradual restoration to standard pressure. In the first and third stages, therefore, are mani- fested certain differential effects, reversed in order and nature. Condensed Air.—On entering the chamber, the patient's lungs, bronchi, windpipe, larynx, pharynx, nasal passages, and Eustachian tubes contain air, and the stomach and intestines contain gases of the standard pressure. Not only will time be required to secure equaliza- tion, but, as the pressure constantly ascends, new occasion for equalization is continually made. To the sensations of the patient this is especially manifested in relation with the ear, the tympanic membrane being at first 26 AIR, CONDENSED OR RAREFIED pressed inward with the accompaniment of ringing noises, pain, and a sense of fulness and occlusion. Toward the end of the sitting, in the period of gradual return to standard at- mospheric density, the pressure conditions are reversed and the drumhead is now pressed out- ward, the sensations being like those first expe- rienced, but less in degree. When catarrhal swellings or other obstruc- tions exist they are much increased, and in some instances pain will forbid the employ- ment of full pressure, or alternate increase and diminution will be necessary. Usually, how- ever, adjustment occurs spontaneously or may be brought about by repeated motions of deg- lutition, or by Valsalva's experiment, or even by catheterism, if necessary. Normal hear- ing power is diminished in the pneumatic chamber, but deaf persons hear better in con- densed air than under ordinary conditions. The senses of touch, taste, and smell are ob- tunded. Articulation is impeded. The voice is raised in pitch and acquires a metallic clang. Respiration and Circulation.—The cutane- ous surface and the parts immediately under- lying the lungs and upper air passages are at once influenced by the first increase of atmos- pheric density, and the effect becomes greater as the pressure rises. The blood is forced from the surface of the body; the lungs are expanded, and partially exsanguinated. In the deeper structures the effect takes place more slowly and only under steadily increasing com- pression of the overlying parts. Equalization occurs more readily, but more gradually, and the process will continue until there has been complete transfer of pressure from cell to cell, alike of soft and hard parts and fluids. The effects are therefore not limited to the duration of the disturbing influence, but will continue after the patient has emerged from the pneu- matic chamber. The intestinal gases, being slowly expelled, are condensed under the pressure exerted upon the abdominal superficies and from above by the diaphragm and expanded lung. Space will thus be given for pulmonary expansion. As the exchange of air between the lungs and the atmosphere takes place less rapidly than the increase of pressure of the air within the chamber, the air in the lungs remains al- ways of a less density than that of the external air. This difference of pressure permits the external air to find its way more readily into the minutest ramification of the pulmonary air tubes. After prolonged action of increasing pressure there will be a gradual equalization between the pressure upon various portions of the body and between that of the air and gases contained within the cavities of the body and that of the external atmosphere. The organ- ism will then accommodate itself to the pres- sure acting uniformly upon all its parts, and the effects will be constant. The lungs will therefore no longer expand beyond normal limits, pressure upon the thorax and within the lungs being now the same. As, however, the heart and vessels are di- minished in calibre and the diaphragm is de- pressed into the abdominal cavity, slight ex- pansion of lung tissue in the neighbourhood of these structures may take place. Thus, if the pressure continues to act steadily, enlargement of the total pulmonary volume not being pos- sible, compression of the tissue of the lung it- self must take place, proportioned to the degree of condensation of the air and the resistance of the various components of the pulmonary par- enchyma and intrathoracic structures in gen- eral, the most compressible being the elastic fibres, vessels, nerves, and glands. The lumen of the air vesicles is thus enlarged, and the lung contains a greater volume of air of greater density, but in nearly the same total space as normal. If the vessels are congested, they are thus emptied, and circulation is facilitated while metabolism is stimulated by the compression exerted upon the cells and fluids of glands, lymph spaces, and connective tissue. Pressure upon the heart, the aorta, the pulmonary ar- teries, both venas cavae, and the lymphatics causes a stimulation of absorption and out- flow, diminution and increasing consistence of their contents. Pressure upon these structures is always less than upon the lung, and while the circulation continues in both directions the tendency of fluids is increasingly from the lungs into the heart and thoracic vessels, and from these as well as from the external surface into the vessels of the deeper parts. Motion, however, must take place along the ramifica- tions of the arterio-capillary-venous canal, and in the general direction of its normal currents. Thus there is increased absorption and circu- lation through the lymphatic, venous, and ar- terial channels other than those of the lungs and the skin. As pressure is gradually lowered till it reaches the normal standard of the atmos- phere, a reverse process of equalization takes place. The surface of the body, the skin, and the lungs are again the first affected. Their vessels expand, the blood and lymph are invited thither from the deeper parts; the intestinal gases increase in volume; the dia- phragm recedes into the chest; the air passes from the alveoli into the bronchi, finally into the outer air; the compressed tissues of the lungs expand gradually and resume their nor- mal volume; the heart and thoracic vessels again fill with blood, but under conditions more favourable to function than those in exis- tence before the sitting. But as the intrapulmonary pressure will for some time remain greater than the external pressure the danger of rupture of the vessels from too sudden re-expansicn will be avoided. To summarize: In the condensed-air bath inspiration becomes easier, expiration more la- borious ; the respirations are increased in depth and diminished in frequency; the mobility of the thorax and the elasticity of the lung tissue are increased. These effects continuing after the sitting, the ultimate resu.t is a great gain in vital capacity. The dilatation of the heart is antagonized, but to a less degree than its con- tractions are aided. Relative blood pressure is lowered, so that the pulse becomes smaller 2r and slower, and the blood tends from the su- perficies, pulmonary and general, to the deeper parts and to those vessels contained in cavities with firm and unyielding walls. There are increased absorption of oxygen and increased tissue change, therefore increased nutrition and increased excretion. Upon the nervous system the effects are sedative and soporific. Concerning pathological conditions, cutaneous and pulmonary, it may be noted that hyper- aemia is opposed and resorption of effusions and inflammatory new formations favoured by mechanical compression, as well as by the in- creased oscillations of lymphatic and venous circulation and by the stimulation of absorb- ents and emunctories. Rarefied Air.—As the rarefied-air bath is not as yet employed to any extent in thera- peutics, it would be of merely theoretical in- terest to describe its physiological effects. In practice the effects of a rarefied atmosphere are usually secured by sending the patient to a mountain resort. Here, however, other fac- tors likewise come into play, and the subject is therefore more appropriately discussed under Climatic Treatment. The atmospheric influ- ence of altitude depends partly upon diminu- tion of pressure, partly upon the coldness and dryness of the air, and partly upon its lessened amount of oxygen. The patient is forced to expand his lungs more fully to appease the besoin de respirer, and this expansion, as well as the subsequent expiration, is more readily effected. Thus result great and permanent gains in vital capacity, as shown by remarka- ble increase in thoracic expansion. Patho- logical, especially catarrhal and infiltrative, processes are often checked and disused areas of lung cells are brought into active func- tion. The blood tends more readily to the surface of the skin and respiratory mucous membrane, and the heart beats more rapidly and is forced to harder labor. Thus at first unpleasant respiratory and circulatory symp- toms are experienced, even to epistaxis and haemoptysis in the healthy. These soon pass off, however, as the organism adjusts itself to the changed conditions, and the vigour and tone of the heart and vessels are increased. Haematosis and general nutritive processes are stimulated, excretion, is more complete, and there is a buoyancy of spirits of no mean value in treatment. Persons with weak hearts, of neurotic temperament, or advanced in years, can not bear more than moderate altitudes, and even these are contra-indicated in febrile cases, or in the presence of ulcerative pro- cesses in the larynx or bronchi. The princi- pal benefit of the rarefied air of altitude is in the prophylaxis against pulmonary tubercu- losis in young predisposed subjects, and in the treatment of the early stages of pulmonary tuberculosis in patients not presenting the contra-indications mentioned. Therapeutics.—The practice of pneumo- therapy closely follows physiological lines. The degree of usefulness of pneumatic expe- dients in any given instance will of course varv with the conditions of the case, and proper hygienic, dietetic, and medicinal meas- 7 AIR, CONDENSED OR RAREFIED ures must also be instituted. There are also important Contra-indications. — Persons over fifty years of age should not be subjected to the condensed (or rarefied) air bath or sojourn at altitudes of over 2,000 feet. Beyond this, the conditions forbidding pneumatic treatment by either method are much the same, but ap- ply with greater force to the absolute than to the differential procedures, and to high pres- sures than to low pressures. They are, in brief: Great weakness; exhaustion by long- continued disease; continuous high tempera- ture (101° F. or over); marked hectic; active inflammation; pulmonary softening in prog- ress ; advanced bronchiectasis; the presence in the bronchi or pulmonary cavities of large quantities of septic products that might be absorbed ; extensive excavation in one or both lungs, sufficient to give rise to danger of rup- ture, or of haemorrhage, or of generalization of infection ; general tuberculosis; atheromatous degeneration of vessels; severe haemorrhoids or a marked ha?morrhagic tendency of any kind; the apoplectic habitus; inflammations and congestions of the brain, spinal cord, ali- mentary canal, kidneys, ovaries, or uterus; car- diac weakness of marked degree, and especially degenerative myocarditis. In addition, the effects specially recom- mending certain expedients in certain affec- tions equally contra-indicate these expedients in affections of an opposite pathology. Therapy of the Absolute Method. — The range of usefulness of the condensed-air bath is limited, but within its range the pro- cedure is effective. Its action in diminishing hyperemia of the cutaneous and respiratory surface is utilized in the cure of chronic con- gestive and inflammatory conditions of these structures. In addition, it is employed with good effect in the treatment of catarrhal deaf- ness, in subacute nasal, laryngeal, pharyngeal, and bronchial catarrhs, and even in acute cases when not attended by high fever. It is said to cure whooping-cough in three or four weeks and to keep the patients fairly com- fortable during the progress of the disease. In pulmonary emphysema unaccompanied by cardiac lesion it often affords great relief, as likewise in bronchial asthma. In the latter affection it is alleged by some to be curative, and it is certainly a method of treatment superior to the use of any drug. It is also of advantage in promoting the absorption of pleuritic effusions and in convalescence after pleurisy and pneumonia when the lung is slow to re-expand and resume normal function. It is a prophylactic measure of great value against pulmonary tuberculosis. In the vari- ous catarrhal and other affections of the bron- chi and lungs preceding or associated with pulmonary tuberculosis it is one of the most potent agents for cure. In the early stage of pulmonary tuberculosis (stage of consolida- tion) it is frequently curative. It sometimes assists recovery from phthisis even after soften- ing and excavation have occurred, and is of benefit in all stages short of the last, when the conditions already noted as contra-indica- A JO WAN ALCOHOL 28 tions are present. Some observers commend it in certain cardiac lesions; others prohibit it in all. In the absence of personal experience, the writer can simply express a theoretical leaning toward the more cautious view. In anemas and in chlorosis the condensed-air bath is a decided stimulant to nutrition and hastens the beneficial action of iron or arsenic. In obesity it is of great service in promoting oxidation of superfluous fat. Therapy of Respiratory Differentiation.— An extended personal experience leads the writer to urge with emphasis the necessity for much greater resort to this method of treat- ment than physicians in general seem inclined to adopt. Inspiration of condensed air and expiration into rarefied air are the expedients most generally employed, singly or in combi- nation. Inspiration of condensed air is of benefit in dyspnea of almost any origin; in laryngeal and tracheal stenosis; in chronic bronchitis and bronchorrhea; in chronic broncho-pneu- monitis, especially in chronic broncho-pneu- monitis of the apex {apical catarrh) with beginning tuberculosis; in chronic interstitial pneumonitis; in convalescence from croupous or catarrhal pneumonia; in atelectasis; in chronic pleurisy with effusion ; in the dry pleu- risy of early tuberculosis of the lungs; in chronic pulmonary tuberculosis of any variety and at any stage short of general softening, with one or more large cavities, but par- ticularly in the early stages, when deficient respiration, impaired circulation, anaemia, and malnutritive dyspepsia in a predisposed sub- ject suggest tuberculosis even in the absence of pronounced physical signs or of bacilli in the sputa.* In these cases it should be recom- mended in preference to change of climate, except in the case of patients who need not consider expense. The good results of this procedure in pul- monary tuberculosis can not be too strongly emphasized. They result not alone from the primary effects already alluded to—the open- ing of disused or occluded air cells, with in- creased vital capacity, increased pulmonary ventilation, increased activity of circulation, absorption of inflammatory products, relief of congestion—but also secondarily from the in- creased appetite; relief of cough, with promo- tion of sleep; and the stimulus to local and general nutrition following the systematic pul- monary gymnastics necessitated. Recovery often takes place even in advanced cases, and in any case suitable for treatment comfort will be increased and life prolonged. In simple anemia, or chlorosis, without tuberculous ten- dency, the same good effects may be obtained. In asthma the inspiration of condensed air is also useful, but high pressures are necessary, and must be employed cautiously. In one case —that of a patient who was attacked in the * It may be remarked here that evidences of pul- monary impairment indistinguishable by the ordi- nary methods of physical exploration of the chest may sometimes be detected during inhalation of condensed air—a fact first published by Dr. J. Solis- (Johen. See N. Y. Med. Jour., October 18, 1884. writer's consulting room—the paroxysm was cut short by the employment of a pressure of one thirtieth of an atmosphere, steadily main- tained for nearly fifteen seconds, the expiratory act being held for the time in abeyance. This expedient, which probably overcomes spasm by a paralyzing effect upon the bronchial muscles, and by inducing fatigue of the diaphragm, was suggested by the experience of Dr. Monell,* who obtained relief in his own person by forced expiration, with his feet braced against the footboard of his bed, prolonged pause, forced inspiration, pause, and so on. In asthma and emphysema, however, better results are usually obtainable from expiration into rarefied air. In hemoptysis good results have been report- ed from the inspiration of condensed air and its equivalent—rarefaction of surrounding air in the Brooklyn pneumatic cabinet. Some authors, however, have considered a haemor- rhagic tendency as a contra-indication to the measure. When there is any weakness of the pulmonary vessels or any peripheral lesion of haemorrhagic tendency, or where it is inadvisa- ble to increase blood pressure in the brain or in the kidneys f or other abdominal viscera, the measure is undoubtedly dangerous. In two remarkable instances, elsewhere cited,! the writer has, however, been forced to credit it with a tendency to the relief of pulmonary haemorrhage ; and this seems to be due direct- ly to the relief of the conditions antecedent to haemorrhage—namely, pulmonary congestion —with perhaps an exaggerated stasis at one spot, from mechanical obstructions affecting that portion of the circulatory apparatus chiefly. Inspiration of condensed air is also recommended in mitral insufficiency and in stenosis and insufficiency of the aortic valves. It is theoretically indicated in dilated heart, and, used with caution, in lipocardiac asthma. The writer's experience with it in cardiac lesions is limited, but he has seen apparently good palliative results in a few cases of sim- ple dilatation and of mitral regurgitation of moderate severity, so that he is encouraged to extend its employment in cardiac thera- peutics. Expiration into rarefied air should be combined with the inspirations of condensed air, when it is desired to increase pulmonarv ventilation, circulatory activity, and gaseous exchange, or to get rid of obstructing, ac- cumulating, and decomposing matters in the bronchi or alveoli or in quiescent cavities. Thus, the combination is of signal utility in pulmonary tuberculosis, in bronchorrhcea, and in chronic pulmonary catarrh. Expiration into condensed air should be combined with the inspirations of condensed air when it is desired to relieve congestion or to stimulate absorption, or when increase of vital capacity is the principal object; tnus, in dilated heart, in mitral insufficiency, in consoli- * Med. Record, August 25, I860. Cited by J. Solis- Cohen, op. cit. t In one of the writer's cases albuminuria developed during treatment. This may have been merely a co- incidence, hut at the time it was considered more X Piula. Med. Times, February 6, 1886, p. 362 A JO WAN 29 ALCOHOL dation persisting after pneumonia, in chronic pleurisy with effusion, and in the after-treat- ment of cases in which pleural accumulations, serous or purulent, have been removed by as- piration or incision. Like the method of the pneumatic cabinet of Williams, this combina- tion (continuous respiration of condensed air) is highly recommended by many in the treat- ment of tuberculosis, for which purpose, how- ever, it is inferior to inspiration of condensed air with expiration into rarefied air. Alterna- tion of the combinations may be necessary in some instances. Expiration into condensed air is recom- mended in cases in which expiration is imper- fectly performed, as a means of strengthening the respiratory muscles. As practiced with the writer's expiration-resistance valve, it is of use in cases of convalescence from pulmonary tu- berculosis and in prophylaxis against the lat- ter affection. In a few early cases with good muscular power, it is of use in the treatment of pulmonary tuberculosis ; securing better ex- pansion of the lung by back-pressure. Expiration into rarefied air is of signal ad- vantage in emphysema and in asthma depend- ent upon emphysema. It is of some advantage in spasmodic asthma, of less advantage in bronchitic asthma, though of value in all, and in the latter variety may be usefully combined with inspiration of condensed air. Inspiration of rarefied air is at times a better combination in emphysema. Inspiration of rarefied air may also be em- ployed where it is desired to strengthen the muscles of inspiration by increased voluntary exercise, as in cases of contracted thorax, in prophylaxis against pulmonary tuberculosis and in the treatment of the earlier stages, and in convalescence after pleurisy or catarrhal pneumonia. In the latter instances it may be usefully alternated with inspiration of con- densed air. That forced voluntary respiration, however useful in suitable cases, can not replace pneu- matic treatment, either by the differential or by the absolute method, is evident from the mere statement of the mechanical and physiological effects as well as from the fact that many pa- tients are at first incapable of the necessary muscular exertion. As an adjunct or supple- ment to treatment by apparatus, or as a means of keeping up the good effects, it often serves excellently.—Solomon Solis-Cohex. A JO WAN.—See Am mi. ALANIN.—See Amidopropionic Acid. ALBUMEN.—The liquid white of hens' eggs, freed from yolk and membranous shreds, the ovi albumen of the Br. Ph. Besides its use as an article of food, white of eggs is em- ployed, spread on silk or goldbeater's skin, to make an adhesive plaster that only requires to be moistened when applied : as an antidote to certain corrosive poisons, notably corrosive sublimate and copper sulphate, with which it forms innocuous compounds ; and, coagulated by the addition of alum, as an astringent and cooling application in superficial inflamma- tions. Dried white of egg, albumen ovi sic- cum, albumen exsiccatum, is used largely in the arts, but the white of fresh eggs should alone be employed medicinally. ALBUMINATES.—Albumin (the proxi- mate principle, as distinguished from albu- men) forms with certain metals compounds, termed albuminates, which, especially those with iron and with mercury, have been used medicinally in preference to the true salts of those metals, on account of being unirritating and more readily absorbed. ALCOHOL.—Ordinary alcohol, the alcohol of the pharmacopoeias (the spiritus 1 ectificatus of the Br. Ph.), is one of a series of hydrocar- bonaceous compounds all of which have as their basis a radicle (or fundamental molecule), called ethyl, whose molecular structure is ex- pressed symbolically by the formula C2H6. By the addition of an atom each of hydrogen and oxygen, we get the combination CQH6HO, or, as it is, perhaps, more commonly written, Ca H60. Chemically it is a hydrate of ethyl, or hydrated oxide of ethyl, as some prefer to call it. To distinguish it from others of the group, particularly fusel oil (or amyl alcohol) and wood spirit (methyl alcohol), the common form, of which we are at present writing, is called ethyl alcohol. From the fact of its being obtained by dis- tillation and subsequent rectification or puri- fication from a mash of potatoes or grain or from wine lees, it is known in the Br. Ph. as spiritus rectificatus or spiritus vini rectificatus. Absolutely pure alcohol, absolute alcohol, the alcohol ethylicum of the Br. Ph., does not exist outside the chemical laboratories, as its extraor- dinary affinity for water is such that it in- evitably absorbs some of the latter from the atmosphere. What is known as strong alcohol contains 91 per cent, by weight of pure spirit (U. S. Ph.), and has a specific gravity of 0-820. The strong alcohol of the British and Prus- sian pharmacopoeias contains more water, their specific gravity being respectively 0830 and 0-834. It will be observed that, as alcohol is lighter than water, the specific gravity is always in- creased by its dilution. Dilute alcohol contains by weight 45-5 per cent, of pure spirit, with a specific gravity of 0-!)2S in the United States, while in England and the Continent it is a little stronger. As the processes of distillation and rectifica- tion are given in the dispensatories and va- rious works on practical chemistry, we omit them as of no immediate value to the practic- ing physician. Medicinal Applications of Alcohol.—Exter- nally alcohol may be used as a most valuable adjunct in the treatment of wounds, contu- sions, and sprains, as well as for inflammatory and other swellings. Its antiseptic influence is very considerable, as it is effectual for this purpose, according to Miquel,* in a 10-per- cent, solution—e. g„ in the case of whisky, about 1 part to 4 parts of water. It is also * Quoted by Sternberg, Harems System of Practical Therapeutics, Philadelphia, Lea Bros. & Co., 1891. p. 595. 30 ALCOHOL of use on account of its haemostatic properties. When a wound is already infected or, from its nature or cause, presents the liability to infec- tion, or if the question is not free from doubt, then a 50-per-cent. solution, such as is found in ordinary whiskies, may prove to be a very valuable lotion. This has indeed been used with great success in Scotland by Dr. Blair, in France by Susserot, and by others* But in the dressing of fresh wounds the weaker solution would be all that would be necessary. In fact, one of the most valuable as well as elegant dressings for wounds and granulating sores, though it is one greatly neglected at the present day, is the aromatic wine of the French Codex {Krauterwein G., Vinum aromaticum, U. S. Ph., Fr. Cod.), the vin aromatique. This may easily be prepared in any pharmacy, however small. We give the directions copied from the National Dispensa- tory of Stille and Maisch: " Lavender, 1 part (| oz. av.); origanum, 1 part (-J oz. av.); sage, 1 part {\ oz. av.); peppermint, 1 part (\ oz. av.); rosemary, 1 part (| oz. av.); wormwood, 1 part (| oz. av.); stronger white wine, a sufficient quantity to make 25 oz. av. Mix the solid ingredients and reduce them to a coarse powder. Moisten the powder with 1 oz. of the stronger white wine, pack it moderately in a conical glass percolator, and gradually pour enough stronger white wine upon it to make the filtered liquid weigh 25 oz. av., or about 24 fluidounces." As the stronger white wine has 20 to 22 per cent, of alcohol, it will be seen how, in connection with the essential oils of the aromatics, we shall have in this preparation a most valuable dressing. In the absence of the wine, alcohol diluted to one quarter its strength, or whisky to one half its strength, can be substituted for it without detriment to the compound, and in the absence of one or more of the aromatics their places may be filled by the addition of a larger quantity of one of the others. In snake bites or the bites and stings of poisonous insects alcohol, as strong as possible, combined with ammonia, is an exceedingly valuable, probably the most valuable, lotion to apply after the part has been well sucked and bled (especially in the case of snake bites as well as of all poisoned wounds). Besides its uses as an antiseptic and disinfectant, alcohol is of some value as an as- tringent, particularly after the opening of cavi- ties containing pus, blood, etc. [In the Kansas City Medical Index for April, 18(J4, Dr. A. J. Ochsner, of Chicago, reports the most gratifying results from the topical use of strong alcohol in nineteen successive cases of erysipelas, after the manner recommended by Behrend. The affected skin, together with the adjacent surface, is scrubbed very vigorously with strong alcohol three or four times a day. The severest cases were cured within five days*.] Alcohol forms one of the best of evaporat- ing lotions when diluted with 8 or 10 parts of water. Its efficacy for this purpose is greatly * Therapeutics, Mat. Med., and Toxic, H C Wood Philadelphia, Lippincott, 1870, p. 124; and numerous other authorities might be quoted. increased, however, by the addition of vinegar or acetic acid and the chloride of ammonium. A useful formula for the cooling of inflamed parts, such as strained and swollen joints, mus- cles, and tendons, phlegmons, erythema, ery- sipelas, and burns of the first degree, is the following: R Ammonii chloridi.......... 3 ij; Acidi acet. dil............. § j; Alcohol................... f ij; Aquae..................... Oj. M. By the addition of some perfume—e.g., eau de cologne or the extracts of Lubin and others—a most refreshing lotion may be made for use in cephalalgia or for toilet purposes, in the latter case omitting the chloride of ammonium. The external use of alcohol is also profitable in the case of fever patients. It cools the skin and aids in the removal of those effete sub- stances which are left upon it by the evapora- tion of the perspiration. With the addition of acetic acid, in about the proportion mentioned above, or of vinegar in three or four times that proportion, it checks, sometimes very remark- ably, the colliquative sweating of such patients. Where it is necessary, however, to thorough- ly cleanse the skin, a 10-per-cent. solution of alcohol with the bicarbonate of sodium—a heap- ing teaspoonful of the latter to half a pint of the solution—is most useful. By this means clean- liness of the skin may often be secured in cases occurring among the ignorant, who have a vio- lent prejudice against ordinary soap and water. A more homely use of alcohol externally is as an agent for the removal of resinous substances and such defilements of the skin as remain after the removal of various plasters. It is also of practical value in the thorough cleansing of the cuticle necessary to the effi- cient action of cantharides in many instances. For example, before painting cantharidal col- lodion on a part, where it is really important that the attempt at vesication should be suc- cessful, the preliminary cleansing of the skin with water, alcohol, and soda will be found to be a decided aid. And we may say further that as a preliminary to various hydriatric pro- cedures, especially "the various forms of the pack, and to fumigations with sulphur, mer- cury, etc., this thorough removal from the skin of foreign and effete matters which necessarily present a mechanical and sometimes a chem ical obstacle to absorption will enhance the ef- ficacy of the treatment. This is particularly true in the case of mercurial fumigations in the advanced stages of syphilis, and points to the great secret of success of treatment at some of the hot springs, where hot baths precede the mercurial or other inunctions. While thus cleansing and disinfecting the skin, alcohol has the further effect of increas- ing to some extent the compactness of its struc- ture. Whether this is a permanent change, or only apparent and due to contraction of the mistriped muscular fibres of the derma and of the vascular and other tissues contained in it, would be difficult to say. But it may safely be asserted that it does'condense and harden 31 ALCOHOL the epidermic layer, rendering the surface smooth and firm, increasing its resistance to the disintegrating action of friction, and di- minishing the sensibility of the nerve termina- tions. On account of this latter result it makes a very satisfactory application to those parts of the body which are covered by thin, delicate skin with an attenuated cuticle—e.g., the nip- ples, which, when irritated, sensitive to pres- sure, exroriated, or fissured, are wonderfully benefited by the use of diluted alcohol. Ulcers or aphthe of the throat and mouth are at times much benefited by applications of alcohol, the stronger the better. For this purpose it should be applied as we use the nitrate of silver, nitric acid, chromic acid, etc. A small pledget of cotton is wound on the end of a copper wire or a flexible probe which has previously been slightly notched with a knife so that the cotton can not come loose. Or, if the point to be reached is accessible with a straight probe, a small piece of wood, similarly notched, will answer the purpose. The cotton is then dipped into the alcohol for not more than one third, perhaps one quarter, of the length of the pledget, leaving the upper two thirds or three fourths dry, in order that the attraction of capillarity may constantly draw the medicament upward, and so prevent any dropping from the free extremity of our pro- bang. The end of the latter, which should cor- respond as nearly as may be to the size of the ulcer, is then laid upon the sore and held there gently for a few seconds, until coagulation at the surface occurs. If there is much secretion the sore should, of course, as a preliminary measure, be well cleansed and dried with clean absorbent cotton. Inhalations of alcohol are at times very use- ful therapeutic aids. It is well known that all the stimulant and narcotic effects of alcohol may be obtained in this way, under favourable influences. In large wholesale spirit ware- houses, when it becomes necessary to change quantities of wine or spirits from one kind of receptacle to another, the workers perceive in themselves very decided effects from the alco- holic vapours inhaled while they are at their work. Dr. H. C. Wood affirms that he has in- duced all the effects of alcoholic intoxication, even to the point of anaesthesia (alcoholic coma), and finally death, experimentally, by simple in- halation of its vapour,* which, of course, was greatly concentrated. Practical advantage may be taken of this fact in the treatment of shock, collapse, and the extreme asthenia accompany- ing many fevers and toxic conditions, more especially when the condition of the alimentary canal does not admit of the ingestion of suffi- cient quantities by the mouth, or of its rectal administration. To this purpose the ordinary steam atomizer is well adapted, or use may be made of one of the numerous hand-ball atom- izers. But it should not be forgotten in such cases that a 10-per-cent. solution is as strong as can well be borne for any length of time. In the absence of such apparatus the fumes can be generated by pouring alcohol, or some spirit, * Op. cit., p. 114. such as whisky, brandy, rum, or gin, into a ves- sel partly filled with hot water, and allowing the patient to inhale as much of it as possible. This is accomplished by throwing some very light fabric—e. g., a cambric handkerchief- over the vessel and the patient's head, taking care not to exclude the air entirely. [Interstitial injections of alcohol have been used in the palliative treatment of '• inopera- ble" cancer of the uterus. In the Nouvelles archives d'obstetrique et de gynecologie for Oc- tober, 1894, Professor Vulliet, of Geneva, makes a favourable report of his experience with this use of alcohol, and alludes to a previous pub- lication on the subject by a German physician. Professor Vulliet employs very strong alcohol, with strict antiseptic precautions. He thinks it acts by causing a local ischasmia.] The internal administration of alcohol is confined almost entirely to its diluted forms in those beverages Jong familiar to the human race, excepting the small amounts, compara- tively, which are present in tinctures, fluid ex- tracts, and other pharmaceutical preparations. It is, however, the practice, and at times a very useful one, in some hospitals and with some practitioners to make use of the pure alcohol in combination with various bitter tinctures and aromatics. This is done partly to secure accuracy of dosage, partly to avoid' the ill ef- fects of the more irritating ingredients of poor or bogus liquors, and often in private practice to avoid collision with the prejudices of the laity. It is also frequently an extremely use- ful device in dealing with patients in whom there is an unfortunate propensity to the abuse of alcoholic beverages. We have found, for instance, that in the treatment of convales- cents two-drachm to half-ounce doses of the tincture of calumba or quassia, re-enforced, if necessary, by the compound tincture of cin- chona, have a better tonic effect than the ordi- ary stimulant beverages, and can be much more safely administered. The dosage is accurate, and may be gradually reduced without leaving auy of the unfortunate desire for drink which occasionally, though, we believe, rarely, follows upon the use of stimulants in sickness. Our discussion of the constitutional effects of alcohol in health will be short, and simply de- signed to direct attention to those points which are of use to the practitioner when called upon to do his duty at the bedside. And, first, we must insist upon the qualitative difference be- tween the effects of small and those of large quantities, as many of the experimental obser- vations of physiologists and pharmacologists have been made with doses much larger than are ordinarily taken, except by inebriates. The objective results of the ingestion of al- cohol are of most importance to the physician, although the subjective effects are not to be ignored here any more than psychical condi- tions can, in any case, be disregarded by those who are responsible for the welfare of others. The latter, however, are simple, and, though most easily obtained from the testimony of the patient himself, are of such a nature that they reveal themselves to the eye of the practiced observer in so plain a manner that decep- ALCOHOL 32 tion is not easy. The sensations of warmth, well-being, and comfort following moderate doses are well known. When the amount is somewhat increased, so that the toxic effects be- gin to be apparent, the character of the sensa- tions experienced by the subject is dependent upon his temperament. The emotional indi- viduality is accentuated, and, a certain amount of anaesthesia preventing or lessening the con- trol of circumstances over the voluntary ideo- motor operations, the individual is prone to display what is called his " real character." As a matter of fact, however, he displays one side—the emotional—while the stronger, more rational, controlling, and correlating mechan- isms are in abeyance. When the dose is suffi- ciently large to inhibit that " self-control," so called, which consists in such correlation of ideas and actions as place one in harmony with the environing world, he is no more exhibiting his true character than is a person who is suf- fering from an attack of acute mania. Neither is he acting " like a beast," for animals conform their actions to their circumstances in such a way as to secure those adjustments which con- duce to comfort, the preservation of life, and the propagation of their kind. But the maniac, either from disease or from drink, does none of these things. In the case of the latter the al- cohol obtunds the processes of reasoning, and leaves only the lower reflex emotional phenom- ena. This fact it is important for the physi- cian to bear in mind. In addition to these subjective or psychical effects, there are others of more importance from a medical point of view. They are, after the exhibition of small or moderate quantities, first, slight quickening of the heart beat, re- laxation of the arteries, relaxation of the un- striped muscular fibres of the skin, and a more equable distribution of the blood throughout the body, so that if there has been some chill- ing of the surface it is again warm; if the ex- tremities were pale and cold, they resume their natural colour and temperature. And this slight surface relaxation favours withdrawal of blood from the muscles and nerve centres when these have been passively somewhat congested by overwork, relieving the sense of fatigue. It is not improbable that a certain tone is given to relaxed arterioles under such circumstances, which also favours the more rapid circulation of blood through the tired organs, the removal of effete matters, and resumption of their nor- mal chemical condition. As this is rest, small or moderate amounts of alcohol properly ad- ministered may fairly be said to rest the over- tired body. This, however, we regard as a matter not to be proclaimed from the house tops. It should be left to the determination of the physician, and when it is advisable to use alcoholic stimulants for this purpose it is un- doubtedly better to prescribe them disguised after some of the methods above given. At all events, the physician should in all such cases assume the authority of dictating the kind and quantity of stimulant taken, and the doses should be stated and at regular intervals. By pursuing this plan no medical man need ever incur the responsibility of having made an inebriate of any person, for it will not occur unless in the case of a born dipsomaniac. In addition to the effects already mentioned, moderate quantities of alcohol tend to increase perspiration, to augment the quantity of urine and of the secretions of the mucous glands throughout the alimentary tract, to improve the appetite where this is deficient, to quicken the special senses, and to overcome relaxation and meteorism of the intestine. These effects are more apparent in subjects in whom the vital actions alluded to are deficient—i. e., in the anaemic, the delicate, the overworked, and those upon whom the cares of life have borne too heavily. In individuals who are predis- posed to obesity, or especially plethora, doses which would be salutary in their effect upon others are apt to produce the phenomena of irritation characteristic of the action of larger amounts on the average man. So, too, the peculiarly unstable temperament commonly called the mercurial, which is characterized by rapid changes from emotional exaltation to depression and by an unusual suscepti- bility to external influences of all kinds, but particularly to psychical influences, renders those who are its subjects peculiarly vulnerable to alcohol. It should be administered to such persons with great caution, and the medical attendant should see that its use is gradually and completely discontinued before losing sight of the case. The uses of alcohol in disease are clearly in- dicated by the preceding short study of its physiological effects. It will be observed that nothing has been said of its effects upon the bodily temperature. The reason for this omis- sion is that in small or moderate quantities it has no appreciable effect upon the tempera- ture. When the dose is moderately large and the subject not accustomed to its use it may cause a slight elevation of temperature. And in cases of refrigeration, as after prolonged exposure to cold when the internal temperature has fallen to 97° F., 96° F., or even lower, it does undoubtedly help, through its action in restor- ing the equilibrium of the circulation and the activity of the cellular elements of the body, in bringing back the natural degree of heat. But when very large doses are given—say fl § iij or fl § iv of whisky or other spirit of proper strength—instead of causing an elevation, it brings about a positive diminution of tempera- ture. It is not, however, available for this purpose in fevers, or certainly to but a very slight extent, as the doses required would be but ill borne by most organisms. It has also been very satis- factorily proved by Arctic and other explorers —Rear Admiral A. II. Markham, Dr. Kane, Hall, Schwatka, and others—that alcohol is of little or no avail in preventing fatigue or the effects of long exposure to cold. And this is evident from what we have said as to its physi- ological action. But toward the end of the march, or when the exertion and exposure have terminated, it is of great value in moderate quantities as an aid in restoring the exhausted vitality—i. e.. in keeping up a proper circula- tion and distribution of blood and the activity 33 ALCOHOL of the cellular changes, until the exhausted tis- sues have been restored to their normal condi- tion. But even here, except for its quicker action, dependent upon its more rapid diffusi- bility, it is not superior to strong tea or coffee. Indeed, Dr. Kane,* a most reliable observer, and one the adequacy of whose experience will not be questioned, gives tea the first rank as a res- torative. Dr. Parkes,f too, who accompanied Stanley across Africa as surgeon to the expedi- tion, gives similar testimony. Probably one of the greatest of the advantages of tea and coffee lies in the absence of temptation to excess in their use—at least to such excess as to involve the dangerous and lamentable consequences of too free alcoholic indulgence. Still, as already said, where prompt and powerful results are demanded alcohol maintains its place. It is not quite so prompt to act as ammonia and the ethers, but much more persistent. This sub- ject will be again alluded to under the head of Cardiac Stimulants. Hence, in administering alcoholic stimulants to fever patients we ignore its influence upon the temperature, with the exception of one point, which should always be clearly borne in mind—viz., that if it irritates the stomach, in- terferes with digestion, or, in very susceptible or idiosyncratic persons, unduly stimulates the nerve centres, it may increase the fever. The special indications are great debility; rapid and small or irregular pulse; the nerv- ous adynamia known generally as the typhoid state, characterized by hebetude, indifference, jactitation, twitching of the muscles, the so- called subsultus, muttering delirium, coma vigil, or even a more active delirium when accompanied by signs of great weakness else- where, a dry or brown tongue, sordes, and perhaps even involuntary evacuations of urine or faeces. All these symptoms are so many sign-posts on the road to dissolution, and call for active stimulation to sustain the patient until the rallying point is reached. Such a symptom group as that just delineated never occurs except in case of profound toxaemia by one agent or another, or as a result of inanition or great exhaustion. The main differences between the symptom group of inanition and that of toxasmia are that in the latter the skin is dry and harsh, and the temperature is lower, even subnormal. In inanition the skin and breath become most horribly fetid, the odour somewhat resembling that of bromism. In this condition we have often found that the inhalation of the vapour of alcohol, as al- ready referred to, is a very valuable thera- peutic resource. Sometimes it is difficult to introduce a sufficiently large quantity by the mouth or rectum, and sometimes the alimen- tary canal will not tolerate enough to over- come the extreme weakness and ataxia (or want of co-ordinate operation of the various nervous mechanisms). It may, under such un- propitious circumstances, also be introduced hypodermically. But even when the injec- tions are thrown as deep as possible beneath * Arctic Explorations. t Experiences in Equatorial Africa, New York, 1891. the skin there is, with the trophic processes at so low an ebb, always danger of sloughing or the formation of abscesses. The latter may, to some extent, be avoided by first thoroughly cleansing the skin and then disinfecting the needle and syringe. For the latter purpose the author uses a strong solution of pure car- bolic acid (from 10 to 20 per cent.), afterward rinsing the apparatus thoroughly with boiled water. Usually, however, the exhibition of stimulants is begun long before the patient has sunk into this condition, and if great care is observed in dieting and the use of drugs, more especially if the temperature is kept with- in bounds, the stomach becomes accustomed to the reception of stimulants, and it will not be necessary to resort to such extraordinary measures. It is important, therefore, in treating feb- rile and inflammatory conditions, to watch carefully the pulse, eye, tongue, and general appearance of the patient, so as to begin the use of stimulants as soon as there is any sign of failure of the vital forces. In grave toxic conditions, such as poisoned wounds, no time should be lost, as, if the diagnosis is correct, we may rest assured that the sufferer will need all the aid we can give him from the very start. In the various neurotic affections alco- hol in some one of its numerous forms is capa- ble of giving prompt and very decided relief. I refer to neuralgia, asthma, spasmodic colic, etc. But while neuralgia and asthma are, as a rule, promptly relieved by alcohol. I do not by any means advise its employment as a rem- edy in these diseases. In fact, its use can not be too strongly deprecated. The disorders in question are essentially chronic in their na- ture and prone to frequent recurrence, and there is no class of affections in which the use of alcoholic stimulants is so fraught with the danger of the contraction of the terrible habit of inebriety, even in the case of the most con- scientious and well-meaning persons. If mat- ters are desperate and there seems to be no other means of relief, they should certainly be given under some of the disguises mentioned above, and their use entirely discontinued, as well as the chance of having prescriptions re- newed done away with, before the practitioner loses sight of the case. The same precautions shouldbe used when alcoholic beverages are employed in the treatment of atonic dyspepsia. For this condition, alcohol, administered di- rectly after meals or taken in the form of a light wine or malt liquor during the meals, is a most valuable remedy. But equally good results can be obtained by the use of a bitter tincture in pretty decided doses, either imme- diately before or directly after meals. For anorexia, when this is dependent upon debility or anaemia, without structural lesions of the stomach, a moderate dose of whisky or other strong spirit fifteen or twenty minutes before going to the table is one of the best temporary remedies. It may be given temporarily while we are wait- ing for the effect of whatever'tonic is prescribed. Employed in this way, it is quite manageable, and if* it is discontinued at the proper time ALCOHOL 34 no danger need be apprehended, provided, of course, there is no predisposition to inebriety, a point in regard to which the conscientious practitioner will always endeavour to inform himself. Alcohol is also a most valuable agent in the treatment of shock, whether arising from me- chanical or other violence or from great psy- chical disturbances, such as fright, sudden or, at times, prolonged grief and anxiety, or per- haps too sudden emotional exaltation. It is doubtful whether the last cause is operative on healthy organisms, though such a case can be imagined; but, as a rule, with, we think, few exceptions, dangerous nervous adynamia as a result of sudden emotional perturbation, if we except some extreme cases of fright, suggests some already existing cardiac or nervous weak- ness or disease. It should, at all events, be the rule of practice in all such cases to examine the patient thoroughly, and if there is any in- dication of such a weakness or disease we should not fail to administer stimulants and to con- tinue their use until we are perfectly satis- fied that the vital mechanism is again running smoothly, even though the symptoms are not alarming, for in such instances the heart may, unless properly sustained, grow progres- sively weaker, and sudden, fatal syncope super- vene, as in the accident called by surgeons " masked shock." The toxic effects of alcohol are acute and chronic. The milder acute toxic action is seen in those who have ingested too great a quantity, either through conviviality or by mistake. The action upon the alimentary canal reaches the point of intense irritation, with supersecretion of mucus, nausea, and vomiting. The renal irritation may be the cause of a greatly increased discharge of urine, or, if it is too intense, the swelling of the glomeruli may be so great as to impede the separation of water, or even lead to com- plete temporary suppression of the secretion. The blood being loaded with the products of an incomplete digestion, these are largely ex- creted by the kidneys in the forms of uric acid, oxalic acid, calcium oxalate, and urates, particularly the red urates; and, as a result of overstimulation of the nervous system and ex- cessive glandular activity, the triple phosphates appear, frequently in large quantities, with al- tered colouring matters, so that the large quan- tity of limpid urine directly accompanying the debauch is followed by lesser quantities of a highly coloured, strong-smelling secretion, com- posed as we have detailed above. More serious symptoms, sometimes even followed by death, occasionally result from the drinking of enor- mous quantities of spirits. The symptoms are those of violent irritation of the gastro-intesti- nal canal, while the cerebro-spinal excitation is so great as to lead to active convulsions, followed by coma. The treatment of ordinary drunkenness is, in the first place, thorough washing out of the stomach by emesis, usually best induced by the drinking of large quantities of warm water, complete rest, and the soothing effects of large doses of a bromide with large doses also of ammonia, either the acetate in the form of the liquor ammonii acetatis or the aromatic spirit. The cold pack is a very useful adjunct to the treatment. When convulsions and coma have been induced by an enormous dose, rectal injections of chloral, with the pack, and hypo- dermic injections of atropine, digitalis, and morphine, may be of use, though such cases are usually fatal. Chronic Alcoholism. — If the more pro- nounced stimulating and narcotic effects of alcohol are induced repeatedly and for a con- siderable length of time, varying, of course, with the varying constitutions, circumstances, and mode of life which characterize individ- uals, there results, finally, a peculiar patho- logical condition to which we apply the term chronic alcoholism. It is important that this condition of somatic disease should be distinguished from such psy- chical states as those indicated by the terms mania a potu and inebriety. Although alcoholic inebriety is, in its ter- minal stages, usually complicated by evident visceral changes, it is not necessarily so. It belongs to a distinct species, a type of disturb- ance affecting the higher centres, or those in which the nervous activities by which the ad- justment of the bodily functions to the changes in surrounding conditions is accomplished are translated into consciousness—the domain of the emotions, the intellect, and the will. Ine- briety is, essentially, a psychosis, as is mania a potu; but chronic alcoholism is a condition of disease brought on by repeated indulgence in alcohol excesses, which may be simply the result of recklessness or evil surroundings. It was formerly, in the United States and Great Britain, and is now in some countries, the custom, even in the best society, to drink to excess; and, no doubt, many who were not considered at all reckless or immoral acquired the lesions of chronic alcoholic intoxication. And the occurrence of inebriety at the present day is probably due to inherited tendencies ex- aggerated by a want of symmetry in the de- velopment of the cerebral mechanism, while simple drunkenness is the result of a careless or unprincipled yielding to a natural desire for stimulants and narcotics which seems to be common to all mankind, but which, fortunately, the vast majority of civilized men, at least, are able to control. The evil effects resulting from the frequent and prolonged use of alcohol in excessive quan- tities are observed in the digestive and respira- tory apparatus, the urinary organs, the nervous system, and the special senses. While it is convenient to describe the alterations in these various systems and apparatus separately, it is necessary also to point out their close relation- ship to each other, and the interactions which, in disease as in health, go to make up the sum of the phenomena presented for our study either by the individual parts or by parts as- sociated for the performance of special func- tions. Thus, in describing the changes in the digestive organs, we shall see that, in addition to the alterations of structure and function in those specialized tissues whose functions are ex- 3o ALCOHOL clusively digestive, there are also alterations in the other tissues which are included in the com- position of the organ as a whole ; and that the functional disturbances of at least two of these tissues—viz., the nervous and the vascular—are but the local manifestations of more extensive changes which are distributed throughout a great part, if not the whole, of the particular systems to which they belong. We allude to this fact because it is one which, if borne in mind, may help us to a clear con- ception of the complicated morbid conditions which are present in cases of well-developed chronic alcoholism—conditions to which too little attention is paid by the profession in general. The digestive apparatus is exceedingly com- plex, both in its anatomy and in its physiology, and the combination of its parts for the accom- plishment of one grand function does not re- move their liability to the pathological changes peculiar to their individual specific characters. The parts specially affected by alcohol are the mucous membranes, the glandular apparatus, the connective tissue, and the nervous mechan- ism. The muscular and serous coats of hollow organs (except the cardiac muscle, which is often found in a state of fatty degeneration with interstitial connective-tissue hyperplasia) and the lymphatic glands are not changed, anatomically at least. The changes observed after the frequent and prolonged use of alcoholics in excessive quanti- ties are such as would be expected to result from repeated irritation. The mucous mem- brane of the stomach and duodenum, but espe- cially the former, is thickened and congested, the slight tumefaction being due to dilatation of the capillaries and small veins, and to a sort of oedema resulting from the accumulation of blood and retardation of its current. The glands, mucous and peptic, are not much af- fected, except that the cells are somewhat swollen, and there are evidences of increased proliferation. The most important change is in the connective tissue, not only interstitial tissue, but also that which enters into the com- position of the walls of the veins and circum- venous lymphatics. This connective tissue is thickened by hy- pertrophic growth, and the process, extending through the portal into the hepatic system, gives rise to a chronic interstitial hepatitis. The liver thus becomes enlarged by increase in the bulk of its connective tissue and retarda- tion of the venous current. Later on, however, the neoplastic tissue, in compliance with the law of its growth, condenses and contracts upon the other histological elements, and, by so doing, brings about a diminution in the size and an increase of the specific gravity of the organ. The glandular hepatic cells at first are irritated, and there is supersecretion of bile, but later on, if the pressure of the newly formed connective tissue is considerable, there is more or less atrophy, with inability to adequately perform its function. The most important disturbances, however, are in the nervous system. Anatomically, it is not clearly made out to what extent there are actual alterations, but physiologically there is a very decided effect; and in the larger gan- glionic masses of the solar plexus connective- tissue thickening has been noted. It is in all probability to the deranged innervation that the other changes are due. Consequent on the exhaustion which follows overstimulation of the nervous system there is, in the abdominal viscera, great relaxation of the arterioles and venules with passive hyperemia and alterations of the secretions. This is very evident in the morning, when, the effect of the stimulation of the preceding day having dis- appeared, there is great relaxation with super- secretion, flatulence, and hyperesthesia. The first food taken is apt to be vomited, and it is only possible to retain the ingesta after enough alcohol has been taken to overcome the condi- tion. The brain, too, is in a similar condition, and there are vertigo, headache, depression of spirits, intellectual torpor, and a tremor due ap- parently to diminished activity of the muscular sense. The vomiting which occurs on assuming the upright posture is undoubtedly a result of insufficient force in the cerebral circulation. Finally, if the use of the stimulant is suddenly stopped, this nervous condition becomes so pronounced as to culminate in the well-known condition of alcoholic delirium, or delirium tremens. The same result may also come from such great excess that the nervous system loses its ability to respond, which condition is equivalent to that caused by ceasing to take it. Or the acme may be reached in the occurrence of such an exhaustion of the cerebro-spinal yaso-motor system that, the blood accumulat ing in the capillaries and small veins, its watery constituents pass out into the subarachnoid space and the contiguous lymphatic spaces so as to produce a true cerebral edema, or, as it is called in the hospitals, serous apoplexy. This is characterized by the sudden development of coma, usually associated with convulsions of a rather mild type—that is, with less violent mus- cular contractions than are seen in some other diseases—snoring, but rarely a typically ster- torous breathing; a pale, cold, and moist sur- face; a weak, irregular, and small pulse, usually quite rapid ; contracted or medium-sized pupils, which do not, so far as the writer has seen, vary in their dimensions; and, where it is possible to ascertain, no paralysis. The general appear- ance of the subject is suggestive of alcoholism. In the course of an alcoholic career there may be certain diseased states which are undoubted- ly symptomatic of it, but which occur in so small a proportion of cases that, unless the physician is aware of the tendency to them, and exercises due caution, he may fail to appreciate their significance. These complications &vepe- ripheral neuritis, or, as it was formerly called, alcoholic paralysis; insanity, which may be of either a maniacal or a melancholic nature, or, as a terminal condition, in rare cases, imbecil- ity, dementia, or irregular nervous symptoms caused by chronic leptomeningitis or pachy- meningitis in patches and giving rise to ad- hesion between the membranes or between the dura and the skull: and sometimes atrophy and hardening of the convolutions. These ALCOHOL 36 latter lesions can only be suspected, as there are no certain diagnostic symptoms. Pneu- monia of the asthenic variety is frequent and usually fatal. Chronic nephritis is very often met with, and it is, I think, caused by alcoholism in so far as the latter induces that disturbance of the vaso-motor system already described. It is not, however, probable that alcohol induces chronic Bright's disease unless there is a predisposition to it. But when the character of the tissues is such as to favour the development of chronic nephritis under the incidence of a suitable exciting cause, there can be no doubt that the excessive use of alcohol may be the means of initiating the disease; and I think it highly probable that its baleful influence is exerted indirectly through the agency of the solar and renal plexuses of the abdominal sympathetic. Through the nervous system, again, it is that the pneumonia of drunkards is caused. At least it is a fair inference that the effect of alcohol on the vaso-motor system and the trophic nerves is responsible for this asthenic inflam- mation of the lungs, which may perhaps be started by a cold; for, in addition to the results produced in the physiological laboratory by section of the pneumogastrics, we have the established clinical facts of the development of asthenic pneumonias under conditions of great debility and shock to the nervous system, such as fracture of the femur in old persons, the slower, destructive changes in diabetes, the pneumonia of diphtheria, etc. The vascular system suffers also, and not only in its capillary field, as already mentioned, but in the heart itself, which, greatly disturbed in its function as the immediate result of de- bauches, finally loses its muscular tonicity, and the walls become flabby, the cavities dilated, and the beat feeble, irregular, and inefficient. The diagnosis of chronic alcoholism under ordinary circumstances presents no difficulties to the experienced physician, at least none suf- ficiently great to require any discussion in this place. There are. however, certain circumstances or occasions when its distinction from other graver conditions is of the utmost importance. This is the case when alcoholic coma or se- rous apoplexy occurs, and especially when, as is not uncommon, there is no history, the patient being unconscious and, perhaps, found in this condition in the street. The diseases and in- juries with which it may be confounded are opium coma, cerebral apoplexy, uraemia, dia- betic coma, and fractures of the skull, espe- cially of the base, as fractures of the vault are usually accompanied by visible or palpable injuries to the soft parts. In the first place, we will say that the physician must not allow his judgment to be influenced by the fact that there is an alcoholic odour from the patient's breath. I have seen a most unfortunate result follow the neglect of this rule. Opium or morphine coma is usually readily distinguished by the pin-point pupils, the ex- traordinarily slow respiration, with rapid pulse, the well-marked lividity of the surface, and, when opium or its fluid preparations have been taken, the odour. In case of doubt the stomach- pump should, of course, be used. In apoplexy the respirations are, if anything, a little slow- er than normal, with stertor which is not an ordinary snore, for not only the palate, but all or many of the facial, buccal, and cervical mus- cles are paralyzed. The cheeks draw in, if the paralysis is profound, the tongue frequent- ly moves a little backward with the inspira- tion, the larynx is abnormally mobile, and the lips and cheeks puff out with a sort of blowing position and noise during expiration. The pulse is usually slow, full, and, almost without exception, irregular at some time during the stage of coma.* The heart sounds are loud and distinct if there is no degeneration. The general appearance of the patient is also a guide, sometimes a most important one, for it would be a remarkable experience to find a case of al- coholic coma which did not present the out- ward evidence of long-continued dissipation; while, on the other hand, though chronic alco- holism may be complicated by apoplexy, the great majority of the cases of the latter disease occur in persons who are not the victims of drunkenness. Uremic coma is above all other forms diffi- cult to distinguish from the coma of chronic alcoholism. The source of error lies in the fact (which has not, so far as I know, been noticed by the authors of systematic treatises on the subject) that the anatomical condition of the nerve centres is almost identical in the two dis- eases. Uraemia, to be sure, is a toxic condition, but the post-mortem appearances in cases where death has been preceded by convulsions and coma are such as to suggest the idea that the primary effects of the disease were upon the vaso-motor apparatus; and that, this apparatus being disordered, there ensued a dilatation of the capillaries, arterioles, and venules, with passive hyperemia, blood stasis, and transuda- tion of serum into the lymphatic spaces, cir- cumvascular, perineural, and pia-arachnoid. The nerve cells are in both diseases partially devitalized, first by the poison, and secondarily by lack of normal arterial blood, and, their re- flex activity being greatly reduced, they no longer receive or co-ordinate the impressions made by external forces on the peripheral nerve endings. When this failure of excita- bility reaches a point where that co-ordination of impressions from without and reproduced images of former mental states from within which is necessary for the production of ideas is lost, consciousness is abolished, and a state of stupor or coma supervenes. But. notwith- standing all this, it is. in most cases, possible to make a correct diagnosis. A careful review (comparison) of the symptom-complexes of urae- mia and alcoholic coma will show us that, while the resemblances between them are numerous and very distinct, there are also important dif- ferences of which some will always be present. * This statement will scarcely find support from the writers on the subject. I have, however, carefully ex- amined many cases, taking the pulse as often as'pos- sible, and have almost invariably found irregularity at some period. 37 ALCOHOL The ensemble of the symptoms is of great di- agnostic moment in these cases; for, while a person suffering from chronic alcoholism mav have nephritis, which, indeed, if it were typ- ically developed, would bring the case into "its own class, it would, when it was simply a com- plication, alter the symptomatology so little as not to attract attention, and we may therefore ignore it in preliminary examinations, such as are required on a person's admission into a hos- pital. If a person suffering from chronic alcoholism should become affected with a chronic nephritis of sufficient gravity to have the characteristic symptoms of that disease, the clinical aspect of the case would be changed by the addition of the following to the signs already presented : 1. Anasarca. Alcoholism alone may give rise to some oedema of the feet and ankles, and to a general puffiness, but it is not like the yel- lowish-white, tense oedema of dropsy, and it is not so extensive. 2. If the nephritis commences at an early enough period, before the nutrition of the body is too seriously damaged, the heart will be larger, the apex beat stronger, the ra- dial pulse larger and more tense. 3. In the condition supposed to be present at our exami- nation there will be, as a rule, more pulmonary oedema. 4. The urine, of which a little may almost always be obtained with a catheter, will be much more albuminous than in alcoholism alone. 5. There will be, as a rule, more con- vulsions. These points, derived from a study of the changes which might be expected if chronic nephritis were added to chronic alco- holism, are the diagnostic points of the two af- fections, and they may easily be recalled by reverting to this method of elucidating them. Diabetic coma is easily distinguished if the physician does not overlook the possibility of its occurrence. It is so rarely met with in gen- eral practice that there is a chance of its be- ing forgotten, and I have on one occasion seen such a case incorrectly diagnosticated by a skil- ful practitioner, who, never having seen dia- betic coma before, failed to consider it. In so far as alcoholic coma is concerned, the diagno- sis is very easily made. These are the points : 1. The patient is thin or shows evidences of be- ing in the course of emaciation, e. g., a loose and finely wrinkled skin. 2. The skin is dry, harsh, compact, clinging to the subjacent parts with lit- tle or no subcutaneous fat, or what there is de- void of succulence, the reverse of what we see in chronic alcoholism and chronic Bright's dis- ease. 3. The respiration is slightly increased in rapidity, is deep and laboured, yet there is an appearance of dyspnoea, sometimes marked cya- nosis. The pulse is very rapid and very feeble. 4. The examination of the urine is suggested by the peculiar ethereal odour of the breath, and the diagnosis is then certain. The diagnosis between alcoholism and frac- ture of the skull with compression of the brain, either by depressed bone or by effused blood, is of the greatest importance. The liability to error is greatest when the fracture is at the base of the cranium, as there is no external evidence of it unless the solution of continuity passes through the auditory por- ' tion of the temporal bone or through the eth- moid cribriform plate, allowing of the escape of the subarachnoid fluid. Of course, bleeding from the ears, deep-seated orbital effusions of blood, etc., are important symptoms in di- recting the surgeon's attention to the base of the skull. It is almost a daily occurrence in our large cities to have persons brought into the hospitals who have been seen to fall or been found lying in the street or other places, and, on examination, to find them comatose but without any mark of injury about the head. It has happened too often that such a person has been refused admission on the ground of drunkenness, and that he or she has, perhaps within a few hours, died in a cell, and the cor- oner's investigation has shown that there had been a fracture at the base of the cranium, with haemorrhage and, frequently, contusion of the cerebrum from the contre-coup. We will compare the symptoms, omitting the alco- holic odour of the breath, or, rather, mention- ing it in order to warn ambulance surgeons and others of the danger that lies in consider- ing it as a symptom of alcoholism, for that has been the cause of most of the terrible mistakes. We will suppose a case without any previous history, and we must here include the alcoholic coma that results acutely from the ingestion of an enormous quantity of the drug within a short space of time, as in a case seen by the writer in which the patient, a young man, on a wager, poured a pint of gin into his stomach at one draught. Within, probably, two or three minutes he fell to the floor comatose, and almost immediately was seized with violent tetanoid convulsions, which only ceased at his death, which occurred in a few hours. In fracture at the base of the cranium there is, as a rule, immediate unconsciousness from concussion. From this the patient may rally partially, so as to make some sign of intelli- gence, and then slowly relapse into a coma which is usually not so profound but that there will be some restlessness and occasionally great irritability. The breathing becomes noisy, each expiration being accompanied by a groan. Later, the stertorous breathing comes on. When the primary shock has passed away, the surface regains more than its natural heat, and. within a few hours, the temperature rises two or three degrees. The pulse is usually more rapid than in apoplexy, but of good volume and strength, until the '"' beginning of the end." It is, however, irregular; the more so, the greater the danger. Intermittency of the pulse is a gloomy prognostic. The breathing, at first superficial from the concussion, gradually deepens, not increasing much in rapidity. It is, however, very decep- tive in this respect, for the partial or complete paralysis of some of the muscles of inspiration —e. g., the diaphragm—throws on the other muscles the necessity of more vigorous contrac- tion, and gives the impression of laboured breathing. The pupils are not in either condi- tion affected in any way that is constant and typ- ical. If. however, they are unequal in size, as they frequently are in cerebral ha>morrhage, it is a strong point in favour of cerebral injur}- as ALDEHYDE ALIMENTATION 38 against the coma of either acute or chronic al- coholism. The mode of development of the coma is im- portant to the diagnostician. After an injury of the brain, from external violence or from apoplexy, when the shock has passed away, there is usually a gradual progression, from stupor or hebetude, from which the patient can be partially roused, to complete uncon- sciousness. The alcoholic coma is, or has been in every case that has come under my notice, fully de- veloped when the doctor first sees the patient. Such persons are not brought to the hospital or seen at their homes so soon as the subjects of injuries and apoplexies are; and it is prob- able that even when they are with their friends, who are accustomed to seeing them sleep heav- ily under the influence of drink, the more seri- ous condition is not immediately recognised. Besides these distinguishing signs, there are some which are of minor pathological import, but which are useful to the diagnostician. One of these is the condition of the tongue, which in an advanced case of alcoholism would be foul, but might remain comparatively clean for the first few hours after the receipt of a severe head injury. The personal appearance of the patient is also worth noting in cases of coma of which we can get no previous history. Chronic alcoholic conditions, for instance, are commonest in middle-aged men; and when they occur in women the evidences of debauch- ery are usually unmistakable. The majority of cases of fracture of the skull are seen in labouring men. The habit of drinking freely is very common among them ; and when at work, what with their soiled working clothes, sunburned faces, and general unkempt appearance, very little help comes from outward inspection. As a rule, however, if they are injured while at their work, they are accompanied by some of their fellow- labourers. But an acute clinical observer will, in most cases of chronic alcoholism in labouring men, be able to discern certain dif- ferences between the external appearance of them and of steady men. Though the colour of the skin may not differ materially in the two, it will be found that many of the small cutaneous veins of the heavy drinker are plainly visible—more so than would be accounted for by exposure. The muscles have not the same tone. There is usually more subcutaneous fat, and this is of a more oily character, while the increased and vitiated secretion of the sebaceous glands gives a greasy look and feel to the skin, and, besides, a peculiar greasy odour, which I have noticed even in men who were scrupulously clean. The eyelids are, as a rule, a little swollen, and their cutaneous covering exhibits an abnormally large number of fine wrinkles. We_ should never lose sight of the fact that chronic alcoholism and a fractured skull may coexist in the same person. We may say, finally, that it is the rule in all well-regulated hospitals—at least so far as my knowledge extends—in any case about which there is the least uncertainty, to give the patient the bene- fit of the doubt, and to adopt such treatment as would be proper in any event. Fortunately, this plan is practicable, as the central factor in each is an injury to and pressure upon the brain. The treatment of chronic alcoholism affords an excellent illustration of what is known as rational therapeutics, but, unfortunately, in cases which have advanced so far as to have well-marked visceral lesions there is little hope of success beyond some temporary mitigation of suffering, as the lesions are essentially de- generative. If the anatomical alterations in the viscera are not very far advanced, and not so exten- sive but that, if their progress can be stopped, there will remain enough of the specialized tissues to carry on their organic functions, it is possible to restore the bodily health—if not completely, at least sufficiently to enable the person to live a comfortable and moderately active life. The most important indication is to stop the taking of alcohol entirely and per- manently. Whether in a given case it is safe to stop it suddenly or not must be decided by the attendant. There are certain drugs which will assist very materially. The best are strychnine and the cinchona preparations. The following is a valuable combination: B Strychnin, sulphat.......gr. j; Tinct. cinchon. comp.....f § iij. M. Sig.: A teaspoonful every two hours. The alleged gold compounds have been greatly extolled of late, but I do not feel war- ranted in indorsing them as yet, as it requires long and careful clinical observation to estab- lish such allegations as are made for them. For the restoration of the nervous system, so far as that is possible, the salts of iron, zinc, and arsenic are very useful; and in many cases the bichloride of mercury may prove to be of service, particularly when the glandular appa- ratus, hepatic and peptic, is much deranged. To secure proper nutrition, which is the next step of importance, such light and wholesome diet must be prescribed as, in the judgment of the practitioner, is most suitable for the indi- vidual, and the directions for the feeding should be specific and written out by the attendant. In most cases liquid food is necessary at the beginning, but as soon as the stomach is capa- ble of retaining it we should give beef and mutton or lamb. If the gastric catarrh is rebellious it may be conquered bv lavage—a measure which in my hands has never failed. It is best in most cases to diminish the stimu- lant gradually, and aim at getting the patient up to the digestion of solids by the time the alcohol is omitted. Of almost as great importance is the procur- ing of sound sleep. To this end a warm bath at eventide, and twenty to thirty grains of sulpho- nal directly after it, will usually be successful. If a more powerful hypnotic is needed, at first a drachm of paraldehyde at bedtime, and repeated in an hour, is the best: B Paraldehyde 01. amygd. express., part. asqu. Sig.: Two teaspoonfuls at bedtime. 39 ALDEHYDE ALIMENTATION Another very important measure is a change of air and surroundings. Of course the subse- quent abstention from alcoholic drinks must be accomplished through the patient's own volition; but he can be assisted by proper treatment and encouragement. I have found, too, in many instances that the mixture of strychnine and tincture of Peru- vian bark—the formula for which I have given above—is so good a substitute for the alcoholic liquors to which these patients are accustomed that while taking it they have very little if any craving for strong drink. Of the different forms in which alcohol can be administered something has already been said. It will suffice to add that the so-called spirits—viz., whisky, brandy, rum, gin, and ar- rack—contain about 50 per cent, of alcohol. The heavy wines—port and sherry—contain about 20 per cent., but are usually too sweet for administration to sick people. When '• dry," however—i. e., free or nearly free from sugar—they are frequently useful, particularly with convalescents and debilitated persons. The light table wines—claret. Burgundy, Hock, and the Rhine wines—have from 5 to 10 per cent, alcohol in their composition ; but many of the Rhine wines, on account of the oxalic acid which they contain, are not at all suited to those who have any tendency to the oxalic diathesis. Malt liquors—viz., ale, stout, and beer—are especially tonic in their effects, and the diastase which is usually present in them aids the digestion of starchy foods. For this reason, probably, they have a tendency to pro- duce obesity. The stronger ales and stout or porter contain from 12 to 15 per cent, of alco- hol, while the lighter beers have only 3 or 5 per cent. The smaller percentage of alcohol in the latter and in the light wines causes them to ferment when exposed to the air in warm weather or warm rooms, so that great care should be taken to see that they are perfectly clear before they are given to the sick person. The slightest turbidity is sufficient to condemn them. When decanted and held toward the light they should be as clear as water, other- wise the torula has already begun to grow in them, and they are unfit to drink. To the final question, 7s alcohol a food? we must, in the present state of physiological sci- ence, answer unqualifiedly in the affirmative. Those physiological chemists who have suc- ceeded in recovering pure alcohol from the blood, secretions, or exhalations of men or animals to whom it has been given have never recovered but a small percentage of it. It also unquestionably retards the waste of tissue, and this directly apart from its action upon the nervous system. This does not, however, in any way detract from the dangers of its con- sumption, though justifying still further its employment in disease.—B. F. Westbrook. ALDEHYDE.—The aldehydes (dehydro- genated alcohols) are alcohols deprived of two atoms of hydrogen in the molecule. Ordinary aldehyde is acetic aldehyde, C2H40, a very volatile, pungent, transparant liquid, readily oxidizing into acetic acid. It mixes in all proportions with water, alcohol, or ether. Employed in a 15-per-cent. alcoholic solution, it is a remarkably potent antiseptic. Cf. Par- aldehyde. ALDEHYDUM TRICHLORATUM.— See Chloral. ALDER.—See Alnls. ALEMBROTH.—Salalembroth,chlorideof ammonium and mercury, (NII4)2HgCl4-|-2HaO, has been recommended by Sir Joseph Lister as a substitute for corrosive sublimate in antisep- tic dressings. It is readily soluble in water, and is not so violent a poison as corrosive sublimate. It is used in a 1-per-cent. solution. ALETRIS.—The rhizome of Aletris fari- nosa (star-grass, colic-root, etc.), a haemodora- ceous plant, is a bitter tonic, and, in large doses, emetic and cathartic. It has been said to be efficient as an emmenagogue and as a remedy for dysmenorrhcea, but there is a lack of careful observations to justify the state- ment. The dose is 10 grains of the pow?der, a tablespoonful of an infusion of 1 ounce of the rhizome in 1 quart of water, or 10 minims of a fluid extract (the extractum aletridis fluidum of the Nat. Form.). ALEXINS are certain products obtained from cultures of pathogenic micro-organisms. They seem to confer upon an organism into which they are injected immunity against the diseases caused by the micro-organisms from which they were originally obtained. Tuber- culocidin is an example. ALEXIPHARMACS.—See Antidotes. ALIMENTATION.—Diet appeals to the physician in a twofold aspect—as a means of nutrition, and as a therapeutic agent. He gives instructions regarding the diet of pneu- monia and scarlet fever for the purpose simply of maintaining the nutrition of his patient. He prescribes certain diet in scurvy and dia- betes with the additional object of aiding in the cure of the disease. In the present article the subject of diet in health and disease is alone considered. Food as a therapeutic agent is considered in the article on Dietetic Treat- ment. Closely allied to these two subjects is that of Foods, and to the article thus entitled the reader is also referred. The daily amount of food required by the average human being has been determined by various observers. The results of their inves- tigations are of great value in determining the amount of food necessary for the main- tenance of large bodies of men. While the average amount necessary to sustain life and maintain health may be determined by investi- gations of this character, it is folly to attempt to feed the individual according to set rules re- garding the percentages of the various proxi- mate principles. Numerous factors must be considered in each individual case. The most important of these are age, climate, season, oc- cupation, and idiosyncrasy. Age is a most im- portant factor, and will be discussed at greater length hereafter. Climate and season have a marked influence not only upon the character of the food, but upon the amount ingested. In ALIMENTATION 40 cold climates fats and meats are largely used; in hot climates the use of fruits and vegetables predominates. Occupation is another element of the greatest importance. A change in oc- cupation and surroundings is frequently not properly considered. The country boy who eats fat pork and indigestible pastry with im- punity on the farm, becomes, if transplanted to the city, a dyspeptic on a much more digesti- ble diet. The labourer requires more food than the student, and entirely different food. Idiosyncrasy must explain many peculiarities both in the character of food desired and in the amount consumed. Some people are ha- bitually hearty eaters and consume enormous amounts of food without digestive disturb- ance. Others are habitually small eaters and maintain perfect health upon a surprisingly small quantity of food. This is especially noticeable in children. The physician is not infrequently consulted by an anxious mother who fears that her child, who is apparently in perfect health, is not eating sufficiently. Overfeeding is perhaps the most common error made in diet. It is almost universal among young children who are artificially fed, being far more common than the opposite ex- treme of underfeeding. Overeating probably accounts for more dyspepsia than the eating of improper articles of diet does. The theory, however, that a person should stop eating before the hunger is appeased is not worthy of serious consideration. Among infants over- feeding leads to indigestion, flatulence, colic, diarrhoea, and malnutrition. Among adults it produces constipation and dyspepsia with all its attending woes. Insufficient diet, though comparatively less common, causes very decided symptoms. Acute starvation is characterized by a feeling of hun- ger and intestinal uneasiness, which soon changes to actual pain. The various secretions are diminished, especially those of the intes- tinal canal, and constipation becomes pro- nounced. Digestion, when food is taken, is imperfect. The respiratory movements are diminished, the blood is diminished in amount and loses its power of coagulation, and a tend- ency to extravasation is developed ; the urine decreases in amount, and the urea is dimin- ished in quantity. The temperature, which at first may be elevated, falls below the normal. Vertigo develops, and the mental faculties become deranged. The fat disappears and the muscles themselves diminish. A loss of 40 per cent, of the average weight has been ob- served in persons who have recovered. Acute starvation in infants during the first few days of life is probably not very uncommon. It is marked by restlessness and a high temperature, which falls as soon as the child receives proper nourishment. Fever in a very young infant, unless clearly explained by other causes, is very suggestive of starvation. Investigation may show that a child who is supposed to be nurs- ing properly is getting practically no nourish- ment from the breast. Insufficient nourishment not infrequently causes peculiar and obscure symptoms. It is sometimes seen among children who are fed upon condensed milk. As a rule, this article of diet is diluted far too much, the fat being espe- cially deficient. These children are anaemic, rhachitic, and always restless and troublesome. They suffer from indigestion and malnutri- tion, and perhaps from athrepsia. Alcoholic drinkers are frequently found in a state of actual starvation. The excessive use of alco- hol destroys the appetite for food. It is the rule to find that those patients who have been drinking heavily have been without food for days or even weeks. Proper nourishment is one of the most important elements in the treatment of these cases. Symptoms result- ing from insufficient food are frequently seen among over-worked women whose chief diet consists of tea and bread or cake. They suffer from a condition to which the term starvation dyspepsia has been very appropriately applied. Many cases of anaemia among women are due in large measure to a diet which contains an insufficient quantity of nourishing food. The amount of food ingested may be sufficient, but it is so innutritious, if not actually indigesti- ble, that the woman suffers, in fact, from a mild form of starvation. Hard-working stu- dents not infrequently suffer from the same condition. Closely allied to deficient feeding is a diet consisting exclusively of a few articles of food. The teeth, the digestive organs, and the diges- tive secretions all point to the fact that man is an omnivorous animal. If too much reliance is placed on a single article of diet, deca- dence is certain to follow. This has been frequently observed in Ireland during times of distress, when the people have lived very largely upon potatoes. Such large quanti- ties of the given articles must be ingested to satisfy hunger that the digestive organs are overtaxed and are unable to perform their functions properly. Alimentation in Health.—A diet suitable for the adult must possess the proper propor- tions of the proximate principles in digestible form. It must be adapted to the habits of the individual, and must vary with the season and occupation. The relation between carbon and nitrogen in ordinary food should be six- teen and six tenths to one. The proportions of these elements in proteids is three and five tenths to one. In an exclusive diet of lean meat, over six pounds of beef would be re- quired to furnish the proper amount of car- bon. This would contain an excessive amount of nitrogen, which would disturb the digestion and place a great burden upon the kidneys. An exclusive diet of carbohydrates in the form of cereals, to supply the needed amount of nitrogen, would furnish twice the necessary amount of carbon. In an exclusive vegetable diet the proteid is so diluted by insoluble cellu- lose and unnecessary starch that large volumes must be taken to obtain the required amount of nitrogen. The hydrocarbons and fats oxidize much more readily than the proteids. They have therefore been termed proteid-sparing foods, as they protect the proteids from oxidation and preserve them for other purposes. The carbohy- 41 ALIMENTATION drates and fat can replace each other to a cer- tain extent. They are both produced in the body, from the proteids. This does not occur, however, when sufficient fat is present in the food. Fat is formed in the body in three ways: It may be formed from fat taken as food; it may be formed from the carbohydrates; it may be formed from the proteids of the tis- sues. This last process is due to retrograde metamorphosis, and is a step in the degenera- tion of tissue. These facts are additional proof of the necessity of a properly mixed diet. The following table, approved by Playfair, Petten- kofer, Parkes, and others, shows the amount of proximate principles required by the adult in the following conditions: SUBSTANCES GIVEN DAILY. Subsistence. 20 oz. 0-5 " 12-0 " 0-5 " Ordinary labour. 4 5 OZ. 35 " 14-0 " 10 " Active labour. 6 5oz. 40 " 170 " Fais............... Carbohydrates........ Total.............. 15-0 oz. 23 0 oz. 28-8 oz. Translated into the terms of ordinary foods, the daily supply for an adult doing ordinary work is as follows: 1. Bread............................... 18 ounces. 2. Butter................................ 1 3. Milk.................................. 4 4. Bacon................................ 2 " 5. Potatoes ............................ 8 " 6. Cabbage............................. 6 " 7. Cheese............................... 3£ " 8. Sugar................................ 3£ " 9. Salt.................................. i " 10. Water, alone and in tea, coffee, beer. 66± " The amount of dry substance in this diet is 1 lb. 5f oz., though the total weight is 6 lbs. 14^ oz. Porter advises the following diet, which he believes yields the largest heat pro- duction, and also supplies the full quota of the various proximate principles: Wheat bread, 7 oz.; eggs, 3-j^j oz.; milk, 24 oz.; meat, 14 oz. Practically, the diet of any given individual is determined largely by his education, his so- cial standing, and the habits of those by whom he is surrounded. Times and method of taking food, both important factors in maintaining healthy digestion, are dependent chiefly upon custom and habit. Regular intervals between meals are important, but no rule can be given as to the proper time for taking the heartiest meal. In warm climates but little food is taken during the heated part of the day, the heartiest meal being eaten late. In large cities the same custom is adopted from necessity or convenience. While there are objections to eating a hearty meal late in the day, there are certain marked advantages in not loading the stomach during the hours of active labour and business. Most of these matters are beyond the control of the physician and sanitarian. The importance of proper cooking can hardly be overestimated. Prevailing methods of cook- ing have a vast influence upon the welfare of a nation. Although the chief object of cook- ing is to increase the digestibility of food, it would be an error to suppose that this was the only object. The most skilful cooking does not accomplish this in all cases, but bad cook- ing has a powerful influence in rendering food unfit for use. Raw pork digests in three hours, while roast pork requires over five hours. Boiled potatoes require three hours, while roast potatoes are digested in two. The chief effect of cooking upon vegetable foods is the breaking up of the starch grains, which in the raw state are uninfluenced by the digestive juices. Cooking converts the insoluble colla- gen of animal foods into soluble gelatin, and disintegrates the connective tissue. This ac- tion on the connective tissue is of great im- portance and counterbalances the fact that the proteids are often rendered more insoluble. There is a tendency to prescribe foods contain- ing a carbohydrate or proteid without regard to their digestibility. If the proteid is so changed by cooking as to render absorption impossible, it is equivalent to omitting it from the diet entirely. Frying is probably the most deleterious method of cooking, as it saturates the article with oil, thus effectually preventing any digestion in the stomach. This may be, to a large degree, obviated by dipping the article to be fried in egg albumen and submit- ting it at first to a high degree of heat. The albumen is quickly coagulated, thus prevent- ing saturation with oil. In roasting, baking, boiling, and frying, it is important that the temperature during the first few minutes should be at least 212 F. If the temperature is then reduced to 160° F., the juices of the interior portions of the meat remain largely uncoagulated and far more digestible and pal- atable. The same is true of boiling, except where broth or soup is to be made. It is im- portant that meat should be thoroughly cooked to destroy the parasites with which it is liable to be infested. It should be raised to a tem- perature of at least 160° F. Meat of a blood- red colour has not, as a rule, been raised to this temperature, and is not wholly safe. Any food, whether animal or vegetable, which is open to the suspicion of being infested by parasites should be subjected to a temperature of at least 212° F. Alimentation in Disease.—Artificial Di- gestion.—In conditions of great debility the digestive organs are sometimes incapable of properly disposing of even the most digestible food. This is of frequent occurrence not only during the course of acute disease, but also during convalescence. A condition of weak- ened digestion is sometimes seen among in- fants, even when they are not suffering from actual digestive disorders or other disease. The necessity for predigested food in such cases is frequently very great. To Dr. Roberts, of Manchester, we owe a method of peptoniz- ing food which is extremely efficacious. Al- though the term "peptonizing," which has been applied to this method, is a misnomer, it has obtained a firm foothold and is univer- sally employed. It consists in digesting milk, gruel, or meat by the use of extract of pancreas rendered alkaline by bicarbonate of sodium. It was formerly difficult to obtain these diges- tive ferments in proper condition. Being of animal origin, they rapidly decomposed. They 42 ALISMA ALKALIES - can now be obtained at most pharmacies in satisfactory condition. The most reliable and convenient method of performing this process is by means of the so-called peptonizing tubes. Sufficient extract of pancreas and bicarbonate of sodium to digest one pint of milk are placed in each tube. The tubes are tightly closed with corks covered with wax, so that the con- tents remain unchanged almost indefinitely. Each tube contains five grains of extract of pancreas and fifteen grains of bicarbonate of sodium. The following is the ordinary method of preparing peptonized milk: Into a clean quart bottle put the powder contained in one of the peptonizing tubes and a teacupful of cold water; shake, then add a pint of fresh cold milk, and shake the mixture again. Place the bottle in water as hot as can be borne by the hand without discomfort and allow it to remain from five to twenty minutes. Put the bottle on ice at once to check further digestion. 'The degree of digestion is very simply regulated by the length of time that the milk is kept warm. If this process is car- ried too far the milk is rendered bitter and unpleasant to the taste. To avoid the bitter taste, the milk may be prepared quite satis- factorily by the cold process. The water, milk, and powder are mixed as in the ordi- nary process, and the bottle, instead of being placed in the warm-water bath, is placed di- rectly in contact with ice. The taste of the milk thus prepared is not changed. Milk may be completely peptonized by allowing the bottle to remain in the hot water for two hours. It may then be heated to boiling and strained. This so completely converts the casein to soluble peptone that the milk does not curdle upon the addition of an acid. This form of food is most valuable in many condi- tions. The unpleasant taste is the chief dis- advantage. This may be overcome for many patients by the addition of lemon juice and su^ar to form a milk lemonade. The different effervescent mineral waters, with or without an acid, sometimes render it palatable. In many cases of delirium or partial unconsciousness, or for rectal feeding, the taste is not objectionable. Peptonized milk punch maybe made as follows: Take a goblet about one third full of cracked ice, pour on it a tablespoonful of St. Croix rum, with a dash of Curacoa or other liqueur that is agreeable to the taste. Then fill the glass with peptonized milk, sweetened if de- sired, stir well, and grate a little nutmeg on top. Peptonized gruel is made by combining half a pint of hot gruel with an equal quan- tity of fresh cold milk. Mix and strain into a bottle and add the contents of a peptonizing tube. Allow it to stand in a warm place for twenty minutes, then place it on ice. The bit- ter taste of the milk is almost completely cov- ered in this mixture. The gruel may be made from arrowroot, barley, flour, oatmeal, or maize meal. The farinaceous materials should be boiled with water until the starch grains are completely broken up and incorporated with the water. Peptonized beef may be made as follows: Take a quarter of a pound of finely minced, raw lean beef and half a pint of cold water. Mix in a saucepan, and cook over a gentle fire, stirring constantly until it has boiled a few minutes. Then pour off the liquor for future use, and beat or rub the meat to a paste, and put it into a clean fruit jar with half a pint of cold water and the liquor poured from the meat. Add twenty grains of extract of pancreas and fifteen grains of bi- carbonate of sodium. Shake all well together and keep in a warm place, at about 110° F., for three hours, stirring or shaking occasionally; then boil quickly. It may then be strained or clarified with white of egg. Season to taste with salt and pepper. For most cases it will not be required 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 will be in very fine particles and diffused in an almost impal- pable condition. Junket is a very delicate preparation of milk for the sick and conva- lescent. It is made as follows: Take half a pint of fresh milk, heated lukewarm, add a teaspoonful of essence of pepsin or liquid ren- net, and stir just enough to mix. Pour into custard cups and let it stand until firmly curdled. It may be served plain or with sugar and grated nutmeg. It may be seasoned with fruit extracts or wine. An egg beaten to a froth and sweetened with two teaspoonfuls of sugar may previously be added to the half pint of milk, forming a highly nutritious jelly. Whey is made by curdling warm milk as above directed, then beating up with a fork until the curd is finely divided, and straining out the whey. It is a fluid food peculiarly useful in many ailments, and always valuable as a means of variety in diet for the sick. It is frequently resorted to as a food for infants to tide over periods of indigestion and diarrhoea. Rectal Alimentation.—It is frequently neces- sary to maintain nutrition by means of nutri- ent enemata. It is often advisable or necessary to give the stomach absolute rest. Feeding by the rectum in such cases becomes a most impor- tant procedure. Absorption from the rectum is fairly active, but no digestion takes place in that organ. It is sometimes so irritable that feeding by this method is impracticable. This is especially true in infants and chil- dren. This irritability can be overcome in some cases by the addition of small amounts of opium or chloral to the enema. The amount of fluid employed should not be large. Four ounces is as much as will be tolerated by most persons. Others will retain six or even eight ounces. The temperature of the enema should be raised to about 100° F. It should not be repeated more frequently than once in four hours. If irritation occurs, the time should be extended to six or eight hours, or the injec- tions should be omitted entirely for twelve or eighteen hours. When it is desired to employ this method for more than one or two days, daily irrigation of the rectum with warm water to which a little borax has been added will do much to allay the irritability. It, will also wash away masses of unabsorbed residue, which do much to prevent the continuance of the injections. The injection may be given ALISMA 43 ALKALIES with the ordinary bulb syringe, but a six-ounce barrel syringe, designed for this purpose, is preferable. With care and patience rectal ali- mentation may be successfully continued for weeks, or even months in some cases; in others, in spite of every precaution, it becomes impos- sible. As a rule, nutrition can not be main- tained by rectal alimentation for more than two or three weeks. The best material for this purpose, in most cases, is completely peptonized milk. Whisky may be added if a stimulant is required, and also opium, chloral, and other drugs when in- dicated. An egg thoroughly beaten may be added to each enema. Beef tea has been suc- cessfully employed for twenty-eight days. If for any reason milk is contra-indicated or if a change is desired, defibrinated blood may be employed. The blood must be defibrinated at the moment it is drawn by stirring it with a bundle of twigs. The chief objection to blood is that in most cases the stools become very offensive and a fetid odour is more or less constantly present. Bovinine sometimes forms a valuable addition to the ordinary enema. A good meat injection consists of five ounces of finely scraped meat, which is rendered still finer by chopping. It is then mixed with three ounces of warm water in which extract of pancreas and bicarbonate of sodium have been dissolved. It is allowed to stand for an hour, and is injected through a wide-mouthed syringe. An enema of beef extract not strictly for nutritive purposes is now sometimes used by surgeons to overcome shock. Six or eight ounces of warm beef tea made from Liebig's extract, rendered a little salty, are injected, together with a little whisky. This has a de- cided effect in overcoming shock during or im- mediately following an operation. It is much more effective than an injection of stimulants alone. This is due either to more rapid ab- sorption or to the stimulating effect of the beef extract. Peptonized suppositories composed of meat and milk may be used for alimentary pur- poses. They are fairly effective for short periods of time, but their use can not be long continued. Forced Feeding.—It sometimes becomes necessary in cases of insanity to introduce food into the stomach by force. In serious injuries and operations about the throat the same method of feeding may be required when rec- tal feeding is contra-indicated. In cases of this character a catheter or long rubber tube may readily be passed through the nose to the oesophagus, and thus into the stomach, through which aliment may be introduced. The term " forced feeding" is also used in another and quite different sense. [Compare the article on Gavage.] As proposed by Debove, it is a meth- od of treating phthisis and other wasting dis- eases. It is known that the power of digestion does not depend upon appetite. The peculiar fact has been demonstrated that a stomach that has rejected all food taken by the mouth will retain without difficulty considerable quantities introduced by means of a tube. A special tube has been devised for this purpose. It consists of a long flexible rubber tube, expanded at one end into a funnel. A mark is placed on the tube to show the distance to which it should be introduced. It is lubricated with vaseline, having been first washed with a warm antiseptic solution. The patient sits erect or lies on a couch with the head extended and the mouth open. The tube is passed through the mouth into the pharynx, being carried well back to the posterior wall to avoid the epiglottis. As it passes into the oesophagus gagging occurs, which is so great in some cases as to prohibit its use. In other cases it disap- pears after the tube has been used a few times, and many patients permit its introduction without hesitation. The material most employed for this pur- pose is known as Debove''s powder. It consists of very finely minced meat which has been dried in the oven at a temperature of 230° F. This meat when desiccated is reduced to a very fine powder having a reddish colour and the taste of roasted beef. It mixes readily with milk, broth, or gruel. An ounce is ad- ministered at first, but the amount may be rapidly increased to three or four ounces. The nutrient value of this powder is four times as great as that of fresh beef. The re- sults of treating phthisis by forced feeding are reported as extremely good. It is very doubt- ful, however, whether methods of this char- acter are to be commended except in extreme cases. It sometimes happens that infants ill with serious acute diseases absolutely refuse all nourishment and stimulants. The effort to compel the child to take milk in small quanti- ties results in the waste of a vast amount of strength, while little is accomplished. With the ordinary apparatus employed for stomach washing, several ounces of food may be quickly and easily introduced into the stomach. With children as with adults, food thus introduced is rarely vomited. Completely peptonized milk is the food employed, the quantity being larger than that given by the mouth. The process may be repeated once in four or five hours. This system of gavage has been for some time satisfactorily employed in the New York Infant Asylum in extreme cases of diph- theria, pneumonia, and gastro-intestinal dis- ease.—Floyd M. Craxdall. ALISMA.—A genus of the alismaceous family of the Helobie. Alisma Plantago, the water plantain, was formerly credited with various medicinal virtues, even that of curing rabies. It is now occasionally given for some supposed remedial action in lithiasis and other irritative affections of the urinary passages. The dose of the leaves, in powder, is 1 drachm; that of the root, \ drachm. The fresh leaves are acrid and stimulating, and have been used as a vulnerary. The plant contains an acrid resin known as alismin. ALKALIES.—Calcium, lithium, magnesi- um, potassium, and sodium are the bases cer- tain compounds of which are included in this class. Those most commonly used are the I ALKALOIDS ALMONDS 44 oxides and hydrated oxides and carbonates, but to them may be added the salts formed with acetic, citric, and tartaric acids, which, though not alkaline in reaction, become con- verted, after absorption, into the carbonates, and have a true alkaline effect upon the secre- tions of the body. In making use of the term alkali these latter salts will be excepted unless otherwise mentioned. On account of the great affinity for water and high diffusibilityOf the oxides and hy- drated oxides of calcium, potassium, and sodi- um, they are caustic and corrosive, and, if taken in sufficient quantities, are highly poi- sonous, causing deep erosions of the portions of the alimentary canal with which they may come in contact. The carbonates of potassi- um and sodium possess this property in a slight degree, and in large quantities cause de- cided irritation of the gastro-intestinal canal, while the same salts of calcium and magnesi- um are bland and unirritating. The salts of the organic acids in large doses may set up gastro-enteritis. Dilute acids, both mineral and organic, are the chemical antidotes in cases of poisoning, and to them should be add- ed oily or fatty bodies and demulcent drinks, to prevent further action of the poisons as far as possible. In addition to the local effect, a weakened action of the heart, coldness of the surface of the body, collapse, and coma may supervene, not as the result of shock, but be- cause of the physiological action of the alka- lies. These complications must be combated by stimulants, hot applications to the surface, and opium. In case of poisoning by acids or mineral salts the alkalies are the chemical antidotes, neutralizing the first and reducing the latter to the insoluble oxides. The absorption of alkaloids is somewhat retarded by them, but they are not to be regarded as being the only reliance in poisoning by those substances. Caustic lime, potassa, and soda are largely used, either by themselves or in combination with other bodies, for the destruction of mor- bid growths, as applications to unhealthy raw surfaces, and for the opening of abscesses where the use of the knife is not advisable or desira- ble (cf. Caustics). If the administration of this class of bodies is too prolonged it will give rise to a true cachexia, resembling scurvy, in which there may be paleness, general emaciation, soft and spongy gums, and passive haemorrhages from the different mucous surfaces. This condi- tion is promptly relieved by ceasing to give the medicine and by the use of the vegeta- ble acids, together with tonics, iron, and cod- liver oil. If the latter is given concomitantly with an alkali it will in a great measure pre- vent the occurrence of this cachexia-. When taken into the system all the. alkaline salts promote destructive metamorphosis, and hence in small doses are regarded as alteratives, and are also slight cardiac sedatives, espe- cially the carbonates of potassium and so- dium. Their most marked effects, however, are the diminution of normal or pathological alkaline secretions, the increase of acid secre- tions, and the neutralization of undue acidity of the blood, urine, and other secretions of the body. When they come in contact with a surface from which there is a normal or abnormal alkaline secretion, they diminish its quantity to a marked degree. On account of this property, weak solutions are beneficial in the moist stage of eczema and in leucorrhcea depending upon a diseased state of the cervix uteri. If it is desired to increase the amount of the gastric juice in cases where its secre- tion is scanty, as in atonic dyspepsia, alkalies given before" eating will have the desired ef- fect, provided there is no marked atrophy of the gastric glands. For this purpose they are best given combined with a bitter tonic. If administered after eating, the alkali will neu- tralize the acid of the gastric juice and retard the process of digestion. Neglect of these precautions leads in many cases to failure to relieve and brings great reproach upon the medical attendant. On the other hand, if there is an excess of the gastric juice or acid fermentation exists in the stomach, alkalies given after eating will be of benefit, but they act simply as palliatives and a permanent cure can not be expected by their use alone. (Cf. Acids.) Used for these last purposes, the car- bonates are, as a rule, the least eligible salts when any amount of flatus exists, as the car- bonic dioxide given off during their decompo- sition only aggravates the distress caused by large amounts of gas in the stomach. Diar- rhea with acid, fluid, irritating stools is easily cured by moderate doses, especially of the car- bonates. As a rule, the urine is rendered alkaline un- der their use, particularly when the carbon- ates, acetates, citrates, or tartrates are the salts selected; free uric acid is converted into soluble urates, and often uric-acid calculi are resolved. All conditions in which there is a considerable amount of free uric acid present in the urine are benefited by the use of alka- lies, especially in children in whom there is painful micturition due to the irritation of the urethra by the sharp angles of the uric- acid crystals. In this connection it is to be borne in mind that if the carbonates are used they must be given on an empty stomach, as when taken during digestion they render the urine acid. Cystitis with alkaline decomposi- tion of the urine is a condition aggravated by their use, as the greater the alkalinity of the urine, the more energetic is its decomposition. On the other hand, in cystitis without decom- position, strangury, gonorrhea, and all condi- tions in which it is desirable to render the urine, as unirritating as possible, their use is strongly indicated, and the salts of the or- ganic acids are to be preferred. Alkaline baths render the urine alkaline and act as mild irritants of the skin. The desquamation of measles and scarlet fever is hastened and the danger of spreading the contagion lessened by these baths or by sponging with weak solu- tions. Where the skin is thick and tough, as on the hands and feet, much stronger solu- tions can be used, such as the tincture of green soap, and in some cases the soap itself. All ALKALOIDS 45 ALMUNDS dry and scaly eruptions are, as a rule, bene- fited by such baths, to which, in case they prove irritating, bran or some other demulcent should be added. The itching of lichen and of urticaria is generally relieved by alkaline baths or applications, as also the pain from the bites or stings of poisonous insects. A poul- tice of hard-wood ashes often aborts phlegmo- nous inflammations, such as boils, whitlows, and felons, on account of the considerable amount of soda and potash they contain. Painting the affected surface with a strong so- lution of potash is sometimes effectual in these cases. The alkaline carbonates are reputed to have the power of diluting the blood, and on that account of doing good to intemperate eat- ers and drinkers with sluggish livers and in cases of hepatic and splenic dropsy. When a somewhat prolonged course of treatment is desirable in such cases it is best carried out at one or another of the alkaline mineral springs, as the change of scene and the improved hy- gienic surroundings aid greatly. The indi- viduals who receive the greatest benefit are the sedentary and plethoric and those who have resided in hot climates, and the condi- tions in which these waters are used with the best results are lithiasis, chronic gastroduo- denal catarrh, jaundice, engorgement of the hepatic and portal circulations, cirrhosis of the liver, gout, rheumatism, hepatic diabetes, atonic dyspepsia, and the disorders brought on by excesses in eating and drinking. In the treatment of acute rheumatism, to ob- tain the best results the alkalinization of the fluids of the body must be obtained as speedi- ly as possible, the only precaution necessary being the avoidance of irritation of the stom- ach and intestines by too large doses. Under this treatment cardiac and arthritic complica- tions rarely occur, and, if they do, are usually not so apt to lead to serious trouble. As the effect upon the heart is slightly sedative, alka- lies are especially useful when any cardiac com- plication is suspected or expected. When this variety of treatment was first instituted 30- grain doses of potassium bicarbonate were given until defervescence or an amelioration of the pain occurred, but at the present time 1£ oz. of the same salt is administered in equally divided doses during the first twenty- four hours ; as soon as alkalinity of the urine is established the quantity is diminished by one half, and as the, pain and fever subside a further diminution of the dose is made until just sufficient to maintain the alkaline state of the urine is given. After the subsidence of the most acute symptoms from 10 to 20 grains of quinine sulphate are given every twenty- four hours. If constipation exists it must be relieved by cathartics. The addition of a drachm of lemon juice to each dose of the pot- ash salt renders it more agreeable to take, and will also have a gentle laxative effect upon the bowels. It is to be noted that this method is more applicable to cases occurring in the plethoric and vigorous than in the anaemic and delicate. Sodium bicarbonate may be substi- tuted if the potash is not obtainable, but is not so effective. Other uses of the alkalies will be more fully treated of under special heads. See Calcium, Lithium, Magnesium, Potassium, and Sodium.—R. H. Nevins. ALKALOIDS.—The vegetable alkaloids, which are the only ones used in medicine, are proximate principles that combine with acids to form salts. They are found in a great number of plants, sometimes more than one in the same plant, and they usually constitute the active medicinal principle (cf. Active Prin- ciples). On account of their more or less com- plete insolubility in water, the uncombined alkaloids are little used, being replaced by their more soluble salts. ALKANET, formerly used medicinally, is now employed only as a colouring ingredient in pharmaceutical preparations. ALLAMANDA CATHARTICA is an apocynaceous plant found in Guiana and Brazil. Its juice is milky and acts in small doses, from 8 to 10 drops, as a hydragogue cathartic. An extract made from the bark is also used as a cathartic, in doses of from 1 to 2 grains; but the best preparation is said to be an infusion of 2k drachms of the leaves in a quart of water. ALLSPICE.—See Pimenta. ALLTL.—A radicle, CSH6, found in com- bination in the oils of garlic and mustard. For allyl tribromide see Tribromhydrin. ALMONDS.—The seed of Amygdalus com- munis, a tree indigenous to Asia Minor and Africa, and cultivated in the southern parts of Europe and the United States. The kernel of the almond seed is either sweet or bitter, and the varieties can be distinguished by their taste. The almond was a highly esteemed medica- ment in the Hippocratic and Galenical eras, being used in emulsion in pulmonary affec- tions, in leucorrhcea, in menstrual disorders, and as a diuretic. The composition of both varieties is virtually the same except that the bitter almond con- tains amygdalin, which was the first gluco- side discovered (1830). They contain a fixed oil, gum, sugar, and emulsin. Amygdalin, which is also contained in the leaves, seed, or bark of other trees than the almond, is a white substance in the form of transparent prismatic crystals, odourless, but with a bitter taste; it is soluble in water and in alcohol. When, in a watery solution, it is brought in contact with emulsin, an albuminous principle contained in both varieties of almonds, it is decomposed, and forms hydrocyanic and formic acids and a colourless, thin, volatile oil that has a peculiar odour and a burning taste. By itself, amygda- lin is without effect upon the organism, 60 grains at a dose being innocuous. But if food containing emulsin has been taken, the amyg- dalin decomposes, and Liebig has shown that 17 grains of amygdalin will yield a grain of hydrocyanic acid. An emulsion of sweet almonds is made by triturating \ oz. of freshly blanched almonds with i oz. of gum arabic, 2 drachms of sugar, and | pint of distilled water. This is not only ALNUS ALOES 46 an excellent demulcent in acute laryngeal and bronchial affections, in gastro-enteritis, and in cystitis or urethritis, but also nutritious and sedative. It may be administered ad libitum. The Ger. Ph. gives a compound emulsion of almonds made with 4 parts of sweet almonds, 1 part of hyoseyamus seed, and 64 parts of diluted bitter-almond water, which are made into an emulsion, and 6 parts of white sugar and 1 part of calcined magnesia are added. The hyoseyamus seeds make this an efficient bronchial sedative. The Pr. Cod. orders a white linctus, made by triturating 30 parts of sweet and 2 parts of bitter blanched almonds, with 20 parts of sugar and 120 parts of water; the emulsion is strained, and again triturated with 10 parts of sugar and -J- part of powdered tragacanth, and finally 10 parts of orange- flower water are added. The small amount of hydrocyanic acid contained in this linctus has but a slight action in bronchial irritation. A syrup of almonds is made by triturating 140 parts of sweet and 40 parts of bitter blanched almonds with 100 parts of sugar and 30 parts of water until a smooth paste is made; this is mixed with 100 parts of orange-flower water and 200 parts of water, and strained with strong expression ; 100 parts of water are added to the residue, and it is again expressed. In the strained liquid 100 parts of sugar are dis- solved without heat, and enough water is added to make 1,000 parts. This syrup is an agree- able menstruum for diuretic or expectorant mixtures. In the Ger. Ph. a similar syrup is directed to be prepared by emulsifying 50 parts of sweet and 10 parts of bitter blanched almonds with 120 parts of water; 200 parts of sugar are added to 130 parts of the strained emulsion, and after boiling the mixture 10 parts of orange-flower water are added and the whole is mixed with 340 parts of syrup. A bland and agreeable fixed oil of almonds is expressed from sweet almonds. It was formerly used to allay cough and bronchial irritation in doses of from 1 oz. to 9 oz. Ex- ternally it is employed where an unirritating oil is required, as in the desquamation of scarlatina. From bitter almonds the oil of bitter al- monds may be prepared by pressing the kernels between warm plates, macerating the cake with water, digesting the mixture, and then distilling the oil, 100 parts of which should contain nearly 13 parts of anhydrous hydro- cyanic acid. This oil would be one of the best forms in which to administer hydrocyanic acid if its percentage of the acid was constant, and it could be used wherever the latter medicament was indicated. The dose is from J to 1 drop. A spirit or essence of bitter almonds is pre- pared by dissolving 10 parts of oil of bitter almonds in 800 parts of alcohol and adding enough water to make 1,000 parts. It may prove to be a more convenient preparation for administering the oil. The dose is ± to 1 tea- spoonful. Bitter-almond water is prepared by agitating 1 part of oil of bitter almonds with 991) parts of water, and filtering the mixture. This preparation is unreliable because the oil con- tains a variable amount of hydrocyanic acid. The Ger. Ph. provides that 12 parts of bitter almonds, freed from oil by a cold press, shall be mixed with 80 parts of water and 1 part of al- cohol and allowed to stand for twelve hours in a well-covered retort; 11 parts of this are dis- tilled off into a cool receiver containing 1 part of alcohol. The distillate is assayed for the amount of hydrocyanic acid, and it is diluted with a mixture of 1 part of alcohol with 5 parts of water, so that 1 part of hydrocyanic acid will be contained in 1,000 parts of bitter- almond water. The various preparations of bitter almond are employed in cases in which hydrocyanic acid is indicated. (See Hydrocyanic Acid.) The Index Catalogue of the Library of the Surgeon General's Office mentions reports of thirty-nine cases of poisoning by bitter-almond preparations. Of these, the oil caused 28, the spirit 4, the almonds themselves 4, the water 2, and the emulsion 1. Almond bread is made with sweet-almond meal, and is used as a substitute for wheat bread for diabetics.—S. T. Armstrong. ALNUS.—A genus of the Cupulifere, sub- family Betulacee. Alnus glutinosa, alder, was formerly official, and is used as an astringent, tonic, and diaphoretic. The bark, leaves, and young twigs are the parts employed. The bark contains alnein, which is highly astringent and has been recommended as a substitute for cate- chu. The fresh leaves have been used topically as an antigalactic. The dose of the powdered bark is 10 grains. ALOES.—Though three varieties of aloes have been and are frequently used medicinally, the U. S. and Br. Ph's recognise but two, Aloe barbadensis and Aloe socotrina. The Ger. Ph. recognises as official only Aloe capensis (cape aloes), the inspissated juice of the leaves of several species of Aloe coming from the Cape of Good Hope. The Fr. Cod. recognises as official aloes du Cap (cape aloes) and aloes des Barbades (Bar- badoes aloes). Aloe barbadensis (Barbadoes aloes, Curacoa aloes), is the inspissated juice of the leaves of Aloe vera and comes " in hard masses, orange brown, opaque, translucent on the edges; frac- ture waxy or resinous, somewhat conchoidal; odour saffronlike ; taste strongly bitter " (U. S. Ph.). Aloe socotrina (Socotrine aloes) is the inspis- sated juice of the leaves of Aloe Perryi, and comes "in hard masses, occasionally soft in the interior, opaque, yellowish-brown, orange- brown, or dark ruby-red, not greenish, translu- cent on the edges ; fracture resinous, somewhat conchoidal. When breathed upon, it emits a fragrant, saffronlike odour. Taste peculiar strongly bitter " (U. S. Ph.). Aloe barbadensis or aloe socotrina may be employed in doses of from 1 to 5 grains'as a laxative, or in doses of from 10 to 20 grains as a purgative, but 20 grains is to be considered a large dose. Owing to the impurities contained in commercial aloes, the purified aloes is in- variably to be preferred for administration. 47 ALNUS ALOES Decoctum aloes compositum (Br. Ph.), com- pound decoction of aloes, contains 4 grains of extract of Socotrine aloes in a fl. oz. The dose is from $ to 2 fl. oz. Enema aloes (Br. Ph.) consists of 4 grains of aloes, 1| of potassium carbonate, and 1 fl. oz. of mucilage of starch. Extractum aloes (U. S. Ph.), aqueous extract of aloes, formerly known as extractum aloes aquosum, is made from aloe socotrina. Its dose is from ^ to 5 grains. The Br. Ph. gives an extractum aloes barba- densis and an extractum aloes socotrine, the dose of each of which is from 2 to 6 grains. The Ger. Ph. also gives an extractum aloes made from cape aloes. Aloes purijicata (U. S. Ph.), purified aloes, is obtained from Socotrine aloes by a process of melting, the addition of alcohol, and strain- ing, followed by evaporation and cooling. " The product is in irregular, brittle pieces of a dull- brown or reddish-brown colour and having the peculiar, aromatic odour of Socotrine aloes. It is almost entirely soluble in alcohol" (U. S. Ph.). The dose is from 1 to 5 grains. For a purga- tive effect, 10 grains may be employed. It is directed by the U. S. Ph. "that those of the fol- lowing preparations of aloes that are given in that work be compounded from aloe purificata. Pilule aloes (U. S. Ph.), pills of aloes, contain 2 grains each of purified aloes and soap in each pill. One or two pills may be taken at a dose. Pilula aloes socotrina' (Br. Ph.), a pill mass of Socotrine aloes, consists of 16 parts of So- cotrine aloes, 8 each of hard soap and confec- tion of roses, and 1 fl. part of volatile oil of nutmeg. The dose is from 5 to 10 grains. Pilula aloes barbadensis (Br. Ph.) is a simi- lar mass made with Barbadoes aloes and with oil of caraway instead of oil of nutmeg. The dose is the same. The pilules d'aloes simples, pilule cum aloe, of the Fr. Cod., contain each 1-J- grain of pow- dered aloes. The pilules d'aloes et de savon, pilule cum aloe et sapone of the Fr. Cod., contain 1| each of aloes and soap in a pill. Pilule aloes et asafefidm (U. S. Ph.), pills of aloes and asafcetida, contain purified (Soco- trine) aloes, asafcetida, and soap, of each In- grain in each pill. The analogous preparation, pilula aloes et asafetide of the Br. Ph., is made from Socotrine aloes and contains also confection of roses. The dose of the U. S. preparation is one or two pills; that of the British, from 5 to 10 grains. Pilule aloes et ferri (U. S. Ph.), pills of aloes and iron, contain purified aloes, dried sulphate of iron, and aromatic powder, of each 1 grain in each pill. The dose is one or two pills. Pilula aloes et ferri (Br. Ph.) consists of 1^ part of sulphate of iron, 2 parts of Barbadoes aloes, 3 of compound powder of cinnamon, and 4 of confection of roses. The dose is from 5 to 10 grains. The pilule aloeficm ferrate of the Ger. Ph. correspond with the pilula* aloes et ferri of the U. S. Ph., and contain equal parts of dried sul- phate of iron and aloes. Pilule aloes et mastiches (U. S. Ph.), pills of aloes and mastic, or the " Lady Webster dinner pills," contain .purified aloes 2 grains, mastic and red rose, of each about \ grain in each pill. The dose is one or two pills. Pilule aloes et myrrhce (U. S. Ph.), pills of aloes and myrrh, contain 2 grains of purified aloes, about 1 grain of myrrh, and about $ grain of aromatic powder in each pill. The dose is one or two pills. The pilula aloes et myrrhe of the Br. Ph. contains 2 parts of Socotrine aloes, 1 part of myrrh, j part each of saffron and treacle, and a sufficiency of glycerin. The dose is from 5 to 10 grains. The pilules d'aloes et de gomme gutte of the Fr. Cod., pills of aloes and gamboge, contain 1£ grain each of aloes and gamboge, with a small quantity of oil of anise as a flavouring agent and corrigent. Tinctura aloes (U. S. Ph.) contains 10 per cent, of purified aloes. The dose is from 1 to 3 drachms. Tinctura aloes (Br. Ph.) contains 11 grains of Socotrine aloes to 1 fl. oz. The dose is from 1 to 2 fl. drachms. The teinture d'aloes of the Fr. Cod. is a 20- per-cent. tincture. The tinctura aloes of the Ger. Ph. is made with 1 part of aloes to 5 parts of alcohol. The tinctura aloe's composifa of the Ger. Ph., occasionally referred to as " elixir ad longam vitam," contains 6 parts of aloes, 1 part each of rhubarb, gentian, zedoary, and saffron, and 200 parts of diluted alcohol. The teinture d'aloes composee, tinctura de aloe composifa, of the Fr. Cod., is at times re- ferred to as " elixir de tongue vie." Its composi- tion, like its name, is similar to that of the compound tincture of the Ger. Ph. It con- tains 2 per cent, of aloes. Tinctura aloes et myrrhe (U. S. Ph.), tinc- ture of aloes and myrrh, elixir proprietatis, contains 10 per cent, each of purified aloes and myrrh. The dose is from 1 to 2 drachms. The wine of aloes {vinum aloes) of the Br. Ph. is made with 1| oz. of Socotrine aloes, 80 grains each of bruised cardamom seeds and coarsely powdered ginger, and 2 pints of sherry. The dose is from 1 to 2 fl. drachms. The suppositoires d'aloes {suppositoria cum aloe) of the Fr. Cod., aloes suppositories, con- tain each about 8 grains of finely powdered aloes. Given by the mouth, aloes, by virtue of its bitter taste, acts upon the stomach as a simple bitter and stomachic, increasing the appetite and promoting gastric digestion. Upon the liver it acts as a true cholagogue, promoting the flow of bile and rendering it more watery. The chief and most important action of aloes is seen in the large intestine, where it acts by increasing peristaltic action. Only in large purgative doses (20 grains) does it increase in- testinal secretion ; consequently the ordinary laxative dose of from 2 to 5 grains is followed by solid or pultaceous movements. This laxative dose may be accompanied in its action by some tormina. For the prevention of this an anti- spasmodic, especially belladonna, is often used ALOIN ALTERANTS 48 in combination. The larger purgative doses may cause rectal tenesmus, heat, fulness, marked symptoms of irritation, and even rectal catarrh. And thus, though in aloes we have one of the most useful of laxatives, its use as a purga- tive is not to be recommended, since we have at hand so many drugs that are its superiors both in producing purgation and in freedom from untoward effect. In all doses aloes has a marked tendency to produce an increase of blood in the pelvic vis- cera, which, following the larger doses, may be- come pathological. From this action increased menstruation is often seen, and in the pregnant state abortion is not impossible. Frequency of micturition may also occur, and in some cases sexual excitement. Applied to an open wound or a denuded sur- face, aloes is absorbed into the blood and exerts its usual action upon the large intestine in pro- ducing purgation. Given to a nursing mother, it will appear in the milk and produce purga- tion of the infant. Aloes is a laxative of exceedingly slow action, ten to twelve hours usually being required for its effect. Thus it is usually to be given at bed- time, and, though a saline laxative given from six to eight hours after the administration of aloes well enhances its effect, it is to be em- ployed usually uncombined with other laxa- tives. Though seldom used in combination with other laxatives, aloes is quite as rarely used alone, for the addition of other remedies, not laxative, is usually advisable not only to correct its tendency to cause griping, but also both to enhance its action and more particularly to cor- rect and to relieve those conditions of local or general atony and debility in which aloes finds its most useful application. As correctors of its tendency to gripe, belladonna and hyoseya- mus are in general use, and as adjuvants to its action or remedies for the conditions in which it is employed, strychnine, nux vomica, asa- fcetida, mastic, iron, and myrrh. A pill in general use and one most valuable for the relief of constipation, the result of atony of the large intestine, is one containing £ grain each of extract of nux vomica and extract of bella- donna and 2 grains of purified aloes. Aloes, on account of its disagreeable taste, is almost invariably given in pill. The contra-indications to the use of aloes will have been inferred from what has already been said. They are active abdominal or pelvic inflammation, pregnancy, genito-urinary dis- ease, and haamorrhoids if due to pelvic con- gestion. Moreover, its administration for the constipation of the plethoric is unwise. Though the applications of aloes are some- what varied, they, most of them, have as their basis the relief of constipation and its attend- ant ills, both pelvic and general, the result of atony of the colon and rectum. Thus, by far the commonest and most useful service it renders is in the relief of habitual constipation. For this purpose it is one of the most valuable drugs in our possession, and has the special merit, of not requiring increase in dose as time progresses; and, though its use alone in such con- ditions may result in atony worse than before, yet if it is properly combined with the dietetic, hygienic, and medicinal remedies indicated in such cases for the permanent cure of the con- dition on which the atony depends, its dose may be steadily diminished until, cure result- ing, the drug becomes no longer necessary. In such cases, too, it has the additional value of acting as a stomachic and thus relieving the gastric feebleness or even dyspepsia so often found in cases of subacute or chronic constipa- tion. For this purpose only the smaller laxa- tive doses are indicated, and they are more wisely given in pill. In the constipation occurring in the weak and anaamic and in those of sedentary habits its use is most effective and it is to be given in connection with tonics and regulation of habits. Its employment with iron is in such cases very desirable, the aloes not only relieving the con- stipation incident to the disease, but prevent- ing that resulting from the use of the iron. For such patients the pill of aloes and iron may be used, though it is perhaps more ad- visable to employ the iron in the usual way— namely, given after each meal, while the aloes is given in pill form and upon going to bed. In habitual constipation it has been sug- gested that aloes be given in combination with strychnine and belladonna in suppository, but, while when thus given it is certainly active, the method is neither so thorough and con- venient nor so rational as the administration by mouth. When enemata are employed for constipation the addition of tincture of aloes and myrrh (about 2 drachms) to the ordinary quantity of soapsuds is undoubtedly a means of increasing the activity and thoroughness of the enema. In cases of intestinal indigestion resulting from the production of an insufficient quantity of bile and accompanied by dyspeptic symptoms with constipation, flatulence, dulness, drowsi- ness, and mental depression—those symptoms so carelessly classed under the name '"bilious" —the use of aloes (especially in the form of the dinner pill, given in dose of one after each meal) is highly to be recommended. If flatu- lence is a prominent symptom the pill of aloes and asafcetida is probably the more effective form of administration. In a similar way the constipation of hypo- chondriasis and melancholia receives marked benefit and relief. In anemia associated with constipation and accompanied by hysterical manifestations the pill of aloes and asafcetida (from three to six a day) is highly recommended. As an anihelminthic. and especially for the expulsion of ascarides, aloes is often of service. For this purpose the pill of aloes is generally employed. In hemorrhoids aloes is by many supposed to be productive of harm, and," while* it is doubt- less true that if associated with active inflam- matory conditions or pelvic congestions thev would probably be aggravated, it is not to be doubted that in the absence of these conditions the drug is a most effective remedy in the cure of hiemorrhoids. It is certainly true, more- 49 ALOIN ALTERANTS over, that the vast majority of cases of haemor- rhoids are dependent upon passive congestion the result of constipation and deficient bile secretion, and in such cases aloes is directly in- dicated. Failure of relief in such cases "may indeed occur, or even fancied aggravation, but it is much more reasonable to attribute the failure of success to the constipation for which tiie aloes was given rather than to the aloes it- self. In causing piles, of which it has been ac- cused, it certainly, if given in laxative doses, has no effect. In atony of the sexual apparatus in women. as manifested in amenorrhea or even in mon- orrhagia, the pill of aloes is of great service, and perhaps even of greater value is the pill of aloes and myrrh. Indeed, in amenorrhcea from this cause the pill of aloes and myrrh is by many regarded as a specific, and is" to be given for several days preceding the period of expected menstruation. Should the amenor- rhoea be dependent upon amemia, as is so often the case, the pill of aloes and iron is to be pre- ferred. The action of aloes in these cases has been supposed by some to be that of correcting the constipation generally present, but it seems more likely to lie in a stimulant effect directly exerted upon the endometrium. Aloes has been recommended as a derivative in cerebral disorders, but where depletion is desired its use, even in purgative doses, is only irrational and useless. Aloes is occasionally used in simple catarrhal jaundice, and, while no doubt it is of service in this condition, we certainly have in our posses- sion remedies of much greater usefulness. In gonorrhea cures have been said to result from the administration of aloes in doses of from 2 to 3 grains, in pill, three times a day, but it would seem that the patients must have re- covered rather in spite of the medication than on account of it, for in genito-urinary inflam- mations the use of aloes is not to be recom- mended. Tincture of aloes, diluted with an equal quantity of water or more, has been rec- ommended as an injection in the later stages of gonorrhoea. Locally, aloes in the' form of a glycerole (made by evaporating the tincture and adding glycerin to it) may be advantageously applied to cracks and fissures in mucous membranes and to bedsores.—Henry A. Griffin. ALOIN.—Aloin is official in the U. S. and Br. Ph's under the name of aloinum, and is '• a neutral principle obtained from several va- rieties of aloes, chiefly Barbadoes aloes (yielding barbaloin), and Socotra or Zanzibar aloes (yield- ing socaloin), differing more or less in chemical composition and physical properties accord- ing to the source from which it is derived." It appears in " minute acicular crystals, or a microcrystalline powder, varying in colour from yellow to yellowish brown, odourless or possess- ing a slight odour of aloes, of a characteristic, bitter taste, and permanent in the air " (U. S. Ph.). The dose is from fa grain to 2 grains. The uses of aloin differ in no marked way from those of aloes, and its title to superiority rests rather on its smaller dose and its sup- 5 posedly Jess marked tendency to produce irri- tation and pelvic congestion than is seen from the use of aloes. As valuable combinations for laxative effect the following may be suggested: R Aloini.................... gr. } ; Ext. belladon.............. gr. £; Strychnin, sulph...........gr. -fa. M. Ft. pil. No. 1. 6 Aloini.................... gr. fa; Resin, podophylli.......... gr. fa; Ext. belladon.............. gr. fa; Ext. nuc. void............. gr. fa. M. Ft. pil. No. 1. 5 Aloini.................... gr. fa; Ferri sulph. exsicc......... gr. j. M. Ft. pil. No. 1. Henry A. Griffin. ALPHA - NAPHTHOL. — See under Naphthol. ALPHOL is a preparation obtained by heating together sodium salicylate, sodium alpha-naphtholate, and phosphorus oxychlo- ride, freeing the product from sodium chloride and sodium phosphate by treatment with water, and purifying by repeated crystalliza- tion from alcohol. Its therapeutic properties closely resemble those of salol. It is used as an antiseptic and antineuralgic, and is said to have given excellent results in gonorrheal cystitis and in acute articular rheumatism. It is given in doses of from 7 to 15 grains or more, in capsules. ALSTONIA.—A genus of apocynaceous trees of the East Indies. Alstonia scholaris furnishes Dita bark, and Alstonia constricta yields a bark having similar, if not indentical, medicinal properties, and known as Australian fever bark. The bark of these trees is astrin- gent, tonic, and antiperiodic. It contains the alkaloids alstonidine and alstonine. Alstonia scholaris is official in the Fr. Cod. under the name ecorce de Dita, and a tincture (made by macerating 1 part of the bark in alcohol, per- colating, expressing, filtering, and adding enough more alcohol to make 5 parts of prod- uct) is used in France in daily amounts of from 1 to 2 drachms. ALTERANTS, or ALTERATIVES, are remedies or measures which produce an al- teration in the morbid processes of the tis- sues and tend to" restore them to their normal state without their exact mode of action being known. They assist nutrition, enrich the blood, increase or decrease its plasticity, add to the number of the red corpuscles, improve the vital functions, aid in the absorption of exudations, and counteract the various toxa?mic conditions, such as the malarial, syphilitic, tuberculous, and those due to chronic poisoning by metals. If their use is carried to an extreme* the nu- tritive and vital functions, instead of being improved, may be perverted. The action of astringents, etc., upon unhealthy surfaces has sometimes been termed alterative. The term is one which is going out of use rapidly, and as our knowledge of the actions of drugs in- creases it will probably be cast aside entirely. ALTH^A ALVELOZ 50 The principal drugs, etc., included under this head are arsenic, iodine and its salts, iodoform, iodol, mercury, cod-liver oil, phosphorus a,nd its compounds', sarsaparilla, guaiacum, electrici- ty in its various forms, and massage. R. 11. Nevins. ALTHiEA.—See Marsh Mallow. ALUM.—Alums are double sulphates of the alkaline metals and the higher sulphates of the aluminum or the iron group. In phar- macy the name has been indifferently applied to aluminum and potassium sulphate, A12K2 (S04)4-r24II20 (potassium or potash alum) and to aluminum and ammonium sulphate Ala(NH4)a(S04)4 + 24HaO (ammonium or am- monia alum). The former alone is official in the U. S. and Ger. Ph's; both salts are official in the Br. Ph. Alum occurs as large, colourless, octaedral crystals, or crystalline fragments, having a sweetish and strongly astringent taste. It is soluble in water and in warm glycerin, but in- soluble in alcohol. It is obtained from alum shale, or by means of the direct combination of its constituents. One hundred parts of alum placed in a shal- low porcelain capsule so as to form a thin layer, heated over a sand bath until it liquefies, and stirred constantly until the aqueous vapour ceases to be disengaged, will give fifty-five parts of a dry white mass called exsiccated alum or burnt alum. Externally, alum exercises no action on nor- mal skin, but on a moist mucous membrane it produces whitening of the part and con- traction of the fibres and blood-vessels. It coagulates the albumin in the discharges from ulcers, etc., and at the same time exercises an astringent action on the tissues, decreasing secretion and causing contraction of the capil- laries. Internally, it produces vomiting in large doses, and is irritant and purgative; in small doses it is an astringent for the stomach and intestines. As an emetic, it has been used in cases of croup, in doses of a drachm, re- peated every fifteen minutes until vomiting occurs. In such doses, it is well to dissolve it in syrup. Externally, it is used as a mild caustic to destroy exuberant granulations. In small discs, containing ?\o of a grain each, it is applied to the eye in granular lids, or a cone of alum, mounted in a wooden case, is applied to the granulating surface. One part each of alum, copper sulphate, and potassium nitrate, with -fo part of camphor, are fused together and run into a mould, forming an aluminate of copper; this is used as a stronger stimulant to granu- lating surfaces. A solution of from 2 to 5 grains to the ounce may be used as a collyrium. A favourite application to granulation tissue formerly was alum curd, made by mixing powdered alum and the white of egg. It forms a cataplasm that has been recommended for chilblains. Alum finely powdered or in solution has been used as a styptic, especially in hemor- rhages from mucous membranes. In colliquative sweats, sponging the body with alum water, or giving a bath in an alum solution, has been recommended to restore the tone to the skin. In diphtheria and croup insufflation of pow- dered alum, or nasal and faucial irrigation with an alum solution, has been highly recom- mended. In catarrhal affections of the mucous mem- branes a solution of from 5 to 30 grains of alum to the ounce of water will reduce the dis- charge. The late Sir Morell Mackenzie recommended powdered alum applied by means of a pharyn- geal spatula as a most effective application for enlarged tonsils. The administration of alum in lead colic, in amounts of from 60 to 120 grains a day, has caused a marked amelioration in the symp- toms and relieved the constipation. It has been recommended in dysentery and in diarrhea, in pills in amounts of from 5 to 30 grains a day, but it is inferior to enterocly- sis and diet for the relief of these diseases. Alum whey, prepared by boiling 2 drachms of powdered alum with a pint of milk and straining, given in wineglassful doses or less, has been administered in diabetes (successfully and unsuccessfully), in the diarrhea of typhoid fever, in chronic bronchitis, and in whooping cough to restrict the secretion of mucus. A glycerin of alum is official in the Br. Ph. One ounce of powdered alum is stirred and heated with 5 fl. oz. of glycerin. This has the astringency of the glycerite of tannin, but is more irritating than the latter, and, unlike it, does not stain linen. Dr. C. H. R. Harrison has proposed a " tan- nate of alum " for the treatment of obstinate gonorrhea and gleet. He injects it, in the strength of 5 grains to 1 oz. of water, several times daily.—S. T. Armstrong. ALUMINIUM,OR ALUMINUM, AND ITS SALTS.—Aluminum is a bluish-white metal that, while hard, is malleable and ductile, very light and sonorous, and a good conductor of electricity. It is unaffected by air or oxy- gen, but combines directly with boron, bromine, chlorine, iodine, and silicon. Hydrochloric acid, as a gas or in solution, attacks it with the evolution of hydrogen and the formation of aluminum chloride. It dissolves in alkaline solutions with the formation of aluminates. It is exceedingly abundant in clav as a silicate, and by several patented or secret processes it is obtained therefrom. The only report of its internal administration is that of A. Joux, who, in 1856, administered the powdered metal in doses of 3 grains six times a day, and applied it externally in an ointment of a strength of 1 to 25, in a case of recurrent cancer of the spermatic cord. No benefit resulted from its use. It is used in the manufacture of the han- dles of surgical instruments, and, on account of its lightness, it is an excellent material for per- manent splints, such as those used in chronic diseases of the vertebra. [Aluminum borofannate occurs in the form of pearly scales crystallized from a solution prepared by saturating with freshly preeipi- 0 1 ALT ILEA ALVELOZ tated and well-washed alumina a solution of 2 parts of formic acid and 1 part of boric acid in 6 or 7 parts of water. It is said by J. Mar- tenson to be mildly antiseptic and astringent {Pharm. Jour, and Trans., Dec. 1,1894, p. 433)]. Aluminum hydrate. Al2rla06, is prepared by decomposing a solution of an aluminum salt by an alkali or alkaline carbonate. It is a light, white, amorphous powder, odourless and taste- less, insoluble in water, but soluble in acids and in fixed alkalies. It is feebly astringent, and has been used externally in skin diseases. Aluminum sulphate, A12(S04)3, is obtained by dissolving aluminum hydrate in sulphuric acid or by heating clay with sulphuric acid. It crystallizes, with difficulty, in thin flexible plates ; it is soluble in water, but insoluble in al- cohol ; it has a sweetish and afterward astrin- gent taste. Injected into the blood, it produces strong contraction in the pulmonary and sys- temic capillaries. It has been used, in satu- rated solutions, as an antiseptic in diseases of the nose, throat, vagina, and uterus. In weak- er solutions it is used as a lotion for ulcers and tor fetid vaginal discharges. Mentel published, in 1857, a formula for a benzoinated solution of aluminum, prepared by dissolving 1,000 parts of pure aluminum sul- phate in 2,000 parts of water. This solution was saturated with recently prepared gelati- nous aluminum hydrate. To the solution 100 parts of bruised amygdaloidal benzoin were added, the mixture was kept at a temperature of from 140° to 176° F., with agitation from time to time, and evaporated until the density- was 1-26 at 59° F., when it was filtered and cooled. It was used in fetid leucorrhea. The Ger. Ph. provides for a solution of acetate of aluminum {liquor aluminii acrtici). It is made by dissolving 300 parts of aluminum sulphate in 800 of water and 360 of acetic acid, and gradually adding 130 of precipitated cal- cium carbonate triturated in 200 of water. The mixture is allowed to stand for twenty- four hours, and is then strained and filtered. It is used in a 24-per-cent. solution as a disin- fecting wash in wounds and chronic granulat- ing surfaces, and as an injection in gonorrhoea. Gauze impregnated with a 5-per-cent. solution is used as a surgical dressing. There is a non-official German preparation, liquor aluminii acetici glycerinatus, consisting of a mixture of 84 parts of the solution of acetate of aluminum, 4 parts of dilute acetic acid, and 12 parts of glycerin. It is used as a local antiseptic. Aluminum chloride, A12C16, is prepared by passing chlorine gas over a mixture of alumi- num oxide and carbon heated to redness, or by heating clay in a mixture of gaseous hydro- chloric acid and vapour of carbon disulphide. It crystallizes in colourless, hexagonal prisms that are fusible, volatile, deliquescent, and very soluble in water and in alcohol. Gowers states that in doses of from 2 to 4 grains sev- eral times a day he has found it of distinct ad- vantage in relieving the pain of tabes dorsalis. A solution of aluminum chloride is prepared by the double decomposition of aluminum sulphate and barium chloride. It is a straw- coloured, inodorous liquid that has an astrin- gent taste and an acid reaction. It possesses strong antiseptic properties. A weaker solu- tion, of darker colour on account of the pres- ence of iron perchloride, is prepared by the double decomposition of aluminum sulphate and calcium chloride: it is sold under the proprietary name of chloralum. An Italian pharmacist, G. Tarozzi. has made a sulphophenate of aluminum and potassium by the decomposition of sulphophenate of ba- rium with potash alum. It occurs in unctuous, hygrometric crystals that have a pronounced styptic taste and the odour of phenic acid. It is a hemostatic, and has been used as a disin- fectant for various suppurating surfaces. Dr. W. C. Wade reported in 1888 that he had employed as antiseptics the sesquisulphite and the persulphite of aluminum. The for- mer is made by adding a solution of 10 parts of potash alum to 8 of sodium sulphite, and care- fully washing and drying the precipitate. It is an insoluble white powder. The persulphite is made by adding sulphuric acid to the un- dried sesquisulphite, making a solution and crystallizing it without heat; it is soluble. No dangerous effects followed the administra- tion of either of these salts in doses of 30 grains. S. T. Armstrong. ALUMNOL.—This substance, thought to be an aluminum naphtholsulphonate, is a whitish powder, but slightly if at all hygro- scopic, freely soluble in cold water and still more freely in hot water, moderately soluble in glycerin, sparingly soluble in alcohol, and insoluble in ether. It was discovered by Fi- lehne and introduced intodermatological prac- tice by the German physicians as an astringent and antiseptic. Although it forms a pre- cipitate with albumin, the precipitate is soluble in an excess of albumin, so that an abun- dant morbid secretion does not prevent it from reaching the underlying diseased surface. A 1-per-cent. solution has been used with advan- tage as an injection in gonorrhea, and a 10- per-cent. solution for the irrigation of wounds and abscesses, as a dressing lor venereal sores and other ulcers, and as an application in va- rious superficial inflammatory and parasitic skin diseases, such as moist eczema, psoriasis, acne, urticaria, and favus. A 4-per-cent. solution has been found effective in checking lacrymation and epiphora. Owing to its un- irritating quality and its solubility in puru- lent discharges, it may be used by insufflation of the powder in situations, such as the middle ear, where most other astringents used in that manner would clog the perforation of the drum membrane. ALVELOZ.—The milky juice, leite d'alve- loz, of this South American plant (supposed to be Euphorbia heterodoxa), preserved for transportation by the addition of salicylic acid, is of a syrupy consistence, soluble in ether and in chloroform, and miscible with fixed oils. It is a powerful irritant and mild caustic, said to produce profuse suppuration when applied to raw surfaces, and to have proved very bene- ficial as an application to cancerous and syphi- AMANITA MUSCARIA AMMONIA 52 litic ulcers. A resin, obtained by precipitating the juice with water, has been used in the form of a3-per-cent. ointment made with vaseline. AMANITA MUSCARIA.—See under Agaric AMANITINE.—See Muscarine. AMARA.—See Bitters. AMBER.—A fossil resin, the succinum of the Fr. Cod., that is found on the southern shores of the Baltic Sea, and also in fossil beds in the interior of Europe, Asia, and North America. It occurs in yellow, red, or white masses, clear or opaque, that are quite brittle. It is insoluble in water, and only partly solu- ble in alcohol or ether, but dissolves freely in chloroform. When rubbed briskly itQ becomes negatively electric. It melts at 550° F., and in burning emits an agreeable aroma. Dry distillation of amber yields succinic acid {q. v.) and oil of amber. The latter is a yel- lowish, transparent liquid having a peculiar pungent odour, and a hot, acrid taste. Amber itself is not used medicinally, but it is a popular superstition in some parts of the world that wearing a necklace of amber beads will prevent diphtheria and control functional convulsive diseases. The oil of amber {oleum succini), which is often adulterated with kerosene or turpentine oil, is an irritant when applied externally. Given internally, it has been credited with stimulant and antispasmodic properties, and it has been administered in the treatment of gout and rheumatism. In large doses it has been taken to produce criminal abortion. It has been recommended in whooping-cough and in infantile convulsions, and in the latter affection it is also applied externally along the spine. Formerly the oil was official in the U. S. and Ger. Ph's, but on account of its insignifi- cant therapeutic properties it has been omit- ted from the last editions of these works. The dose of the oil is from 5 to 15 drops, in a cap- sule.—S. T. Armstrong. AMBLOTICS.—See Abortifacients. AMBROSIA.—Two species of this genus of senecionideous plants—Ambrosia frifida and Ambrosia artemisifolia, ragweed, hogweed— are esteemed in the Southern States to be tonic and astringent and especially to act effectively in checking epistaxis, the nasal passages being plugged with the leaves. The pollen is thought to be one of the chief ex- citants of so-called hay-fever. Ambrosia may be given freely in infusion or decoction of from 10 to 15 parts in 500 of water. AME.-A Japanese preparation of malt, said to be more readily digested than most products of the sort. AMIDOBENZENE.—See Aniline. AMIDOPROPIONIC ACID, or alanin, CIl3.CIl(NH2).COJI, is a sweetish, crystalline substance obtained by the prolonged heating of aldehyde-ammonia with hydrocyanic and hydrochloric acids. Its compound with mer- cury, amidopropionate or alaninaie of mer- cury, is a crystalline powder soluble in 3 parts of water. It is an eligible mercurial for sub- cutaneous use, as it does not cause irritation at the site of the injection. In the treatment of syphilis it may be used in daily amounts of from -fa to 4 of a grain. AMMI, or ajowan (the ammi officinal of the Fr. Cod.), is the fruit of Ptychotis Ajowan and of various other allied Oriental umbellifer- ous plants. It is a carminative ranking with anise. A volatile oil distilled from it, which smells like thyme, is given in doses of from 1 to 3 drops, on sugar. AMMONIA. — A transparent colourless gas, NH3, that has an acrid taste, an extremely pungent smell, and an intensely alkaline reac- tion. It may be prepared by the union of nascent hydrogen with nitrogen, or by the spontaneous or artificial decomposition of organic matter containing nitrogen, or by heat- ing a mixture of dry slaked lime with ammo- nium chloride, or by heating a solution of ammonium hydrate. The gas liquefies at —40° F., forming a colourless, mobile fluid used in making artificial ice. It is very solu- ble in water, 1 volume of the latter, at 59° F., dissolving 727 volumes of ammonia. Physiological Action.—It diminishes the excitability of the muscular system and less- ens its capacity for work; it increases the functional activity of the spinal cord; it stimu- lates the vaso-motor centres, and thus raises the blood-pressure; it stimulates the vagus and the respiratory centres, but when inhaled it may arrest respiratory movements by irri- tating the nasal branches of the fifth nerve. In moderate doses it increases blood-pressure and diminishes secretion, thus acting as a stimulating expectorant. By its stimulating action on the vaso-motor centre, and its action on the heart, like that of alcohol, it is a most important cardiac stimulant, though in toxic doses it produces cardiac paralysis that is pre- ceded by violent convulsions, respiratory dis- turbances, and lowering of the temperature. In man slight traces of free ammonia are found in the urine, the quantity being in- creased when putrefaction sets in. Ammonia water {aqua ammonie [\J. S. Ph.], liquor ammonie [Br. Ph.], liquor ammonii caustici [Ger. Ph.]) is an aqueous solution con- taining 10 per cent, by weight of the gas. It is a colourless liquid, transparent, and possessed of the odour and taste of the gas. It has a lower freezing point than distilled water. A stronger ammonia water {aqua ammonie. fortior [U. S. Ph.], liquor ammonie fortior [Br. Ph.]) is made that contains according to the U. S. Ph. 28 per cent., according to the Br. Ph. 32-5 per cent., of the gas. The vapour of ammonia water, when in- haled, stimulates the nasal branches of the fifth nerve, thus reflexly exciting the vaso- motor centre and consequently raising the blood-pressure, and so relieves syncope or shock. Such inhalations may bo administered in opi- um narcosis or in cardiac, depression caused by sedatives, but, if too strong a solution is used or the inhalations are continuous or too prolonged, they may cause inflammation of the 53 AMANITA MUSCARIA AMMONIA air-passages. Externally, it is a counter-irri- tant, acting as a rubefacient when confined in contact with the skin; either alone or in the form of a liniment, it may be used locally for neuralgia or rheumatism. It may be ap- plied pure, by means of a compress or on a bit of absorbent cotton placed in a shallow recep- tacle, like a watch-glass, which is to be held firmly against the part, so as to prevent evapo- ration, to produce vesication. It has been ap- plied to insect-bites and stings to neutralize the acid poison. In large doses ammonia water is a violent cor- rosive poison, and the fumes may cause suffo- cation during swallowing by gaining access to the air-passages. When it has been swallowed accidentally, either vinegar or lemon juice should be administered at once as an antidote. It may be injected hypodermically in a di- lution of 1 part to 3 parts of water into the puncture made by a snake-bite, and in the same strength it may be administered intra- venously to prevent collapse. In collapse or heart failure due to other causes, from 10 to 60 drops of ammonia water, diluted with from 1 to 8 drachms of sterilized distilled water, may be injected into a vein with great benefit. Ammonia water or some of its preparations may be used to stimulate the gastric secretion, especially in patients in whom it is undesira- ble to lessen urinary acidity. It is often use- ful in those forms of gastric fermentation in which the stomach is distended with gas. In gastric superacidity from 1 to 5 drops of the ammonia water, taken in a small quantity of water, will neutralize the acid. The aromatic spirit of ammonia is a more tasteful remedy for the latter condition, and its administration is also indicated in that form of headache caused by gastro-intestinal indigestion. In acute alcoholism or alcoholic narcosis, after gastric lavage or emesis produced by apomor- phine, 10 drops of diluted ammonia water may be administered per os every half hour to avert the toxic effects of the alcohol. In such conditions it may also be appropriately given intravenously. Sir B. W." Richardson has called attention to the antiseptic action of ammonia water, and Dr. Gottbrecht has confirmed that report by bacteriological investigations, finding that ani- mal matter placed in a 5-per-cent. solution of ammonia was free from putrescence after near- ly two years. Ammonia water is used in the preparation of ammonia, or volatile, liniment {linimentum ammonie [U S. Ph., Br. Ph.], linimentum am- moniatum, sen ammoniacale, sen volatile [Ger. Ph.]) by being mixed and agitated with the following ingredients: Ammonia water.......... Alcohol................... Cotton-seed oil (olive oil. Br. Ph., Ger. Ph.)....... Poppy oil................ Sweet-almond oil......... u. s. Br. Ger. Parts c. <-. by vol. Parts. 3.--0 1 1 50 600 3 3 1 Grammes. 1U It is a stimulating application for local pain. In France and Germany camphorated am- monia liniment {linimentum ammoniato-cam- phoratum) is official. It is prepared by mix- ing and agitating. • Ger. Fr. 3 parts. 1 part. 1 " 90 grammes. 10 " Linimentum ammoniato-phosphoratum is a non-official German preparation consisting of phosphorated oil. 25 parts ; ammonia water, 8 parts; turpentine oil, 1 part. Linimentum saponato-ammoniatum is an- other unofficial German preparation consisting of 1 part of brown soap dissolved in 30 parts of water and 10 parts of alcohol, and mixed with 15 parts of ammonia water. The stronger water is used to prepare spirit of ammonia (spiritus ammonie [U. S. Ph.], liquor ammonii caustici sj)irituosus [Ger. Ph.]), an alcoholic solution containing 10 per cent, by weight of the gas. It is a colourless liquid having an alcoholic and ammoniacal odour. It is rarely used internally. Spirit of ammonia may be used in place of the aromatic spirit, in doses of from 5 to 30 drops. It is sometimes useful in post-febrile asthenic conditions. An aromatic spirit of ammonia {spiritus ammonie aromaticus [U. S. Ph., Br. Ph.]) con- tains the following ingredients: U. s. Br. Ammonium carbonate Ammonia water...... Stronger ammonia wa- 34 grammes. 90 c. c. 4 oz. 8 fl. oz. 10 c. c. 1 " 1 " 700 " 1.000 " 6i fl. drachms. Oil of lavender flowers Oil of nutmeg......... Alcohol............... 41 fl drachms. 0 pints. Distilled water, enough 3 " Its dose is from 20 to GO drops, in water. The Br. Ph. prescribes a fetid spirit of am- monia that is prepared by macerating 1| oz. of asafcetida in 2 fl. oz. of alcohol for twenty- four hours, when the spirit is distilled off and the product mixed with 2 parts of the stronger water of ammonia, and then enough alcohol added to make 1 pint. The fetid spirit of ammonia may be administered in hysterical conditions and in gastro-neuroses, as well as in other states in which asafcetida is indicated. The dose is from 15 to 60 minims, in water. The Ger. Ph. orders an anisated spirit of ammonia {liquor ammonii anisatus) that is a mixture of 5 parts of ammonia water with a solution of 1 part of oil of anise in 24 parts of alcohol. There is an unofficial German preparation, liquor ammonii aromatico-ethereus, consisting of a mixture of 4 parts of liquor ammonii vinosus, and 1 part each of aromatic tincture and spiritus adherens. It is used as a car- minative in doses of from 15 to 20 drops. The liquor ammonii vinosus is a mixture of 1 part of ammonia water with 2 parts of alcohoL AMMONIAC AMMONIUM CARBONATE 54 Any of the preparations of ammonia water are useful to stimulate the intestine, and to facilitate the expulsion of gas in flatulence. Thev will be found to be serviceable in the flatulence and colic of children. S. T. Armstrong. AMMONIAC, the ammoniacum of the pharmacopoeias (the gomme ammoniaque of the Fr. Cod.), is a gum-resin that exudes from the trunk of a Persian umbelliferous tree, Do- rema Ammoniacum, at points where it has been punctured by beetles. It is soluble in alcohol, and forms a milky emulsion {lac am- moniaci) when triturated with water. Am- moniac is used internally as a stimulating expectorant, in doses of from 10 to 30 grains, in powder, pill, or emulsion. Ammoniac emul- sion is official in several pharmacopoeias. The emulsum ammoniaci of the U. S. Ph. contains 1 oz. and 180 grains of ammoniacum in 33 fl. oz. and 6^ fl. drachms of the mixture; the mistura ammoniaci of the Br. Ph., 1 oz. of the gum in 64 fl. oz. of water. Ammoniac is in some repute as a resolvent, and figures in vari- ous compound plasters, notably the emplastrum ammoniaci cum hydrargyro. AMMONIUM.—Compounds of ammonium are formed when ammonia gas and an acid gas come together without the liberation of hydro- gen, or by the direct union of a diatomic an- hydride with dry ammonia. When heated to redness they are volatilized without leaving any residue, unless the acid is not volatile. In man, small quantities of ammonia gas are found in the putrefactive processes that occur in the alimentary canal, but it soon enters into combinations to form salts or organic com- pounds. Of the ammonium salts, minute traces of ammonium chloride are found in the urine, as is the case with ammonium urate and ammo- nio-magnesic phosphate. Ammonium carbon- ate is formed from urea in decomposing urine. Physiological Action.—While the action of ammonium is materially modified by the acid radicle with which it is combined, all its salts have an action on the spinal cord, the motor nerves, and the muscles, some salts affecting the cord first, others the motor nerves. For example, toxic doses of the bromide produce hyperesthesia with atonic spasm that eventu- ally passes into tetanus; ammonium chloride will produce tetanus; ammonium iodide pro- duces progressive paralysis, the brain appar- ently being affected before the spinal cord, but there is no tetanus; ammonium phosphate pro- duces paralysis without convulsions; ammo- nium sulphate produces symptoms similar to those caused by the bromide, but rarely is tet- anus present. Dr. T. Lauder Brunton aptly suggests that these salts form a series at one end of which the members stimulate the spinal cord, and have no marked paralyzing action on the mo- tor nerves, while those at the other end have no marked stimulating action on the cord, but paralyze both it and the motor nerves. Many of these salts stimulate the vaso-motor centres. The chloride and the carbonate of ammo- nium have been found to increase glycogenesis, and both the phosphate and the benzoate are powerful hepatic stimulants, increasing the se- cretion of bile. In the articles which immediately follow, only those ammonium salts will be treated of that owe their medicinal properties mainly or largely to the base; for the others, see under Arsenic, Benzoic Acid, Bromine, Iodine, Phos- phorus, Valerian, etc.—S. T. Armstrong. AMMONIUM ACETATE, (NII4)C2H302, is formed by saturating acetic acid with am- monia gas or with ammonium carbonate. It is a white, odourless, soluble substance that crystallizes in large needles. It is rarely used in the natural state. Solution of ammonium acetate, spirit of Min- dererus {liquor ammonii acetatis [U. S. Ph., Br. Ph.], liquor ammonii acetici [Ger. Ph.]), is made by adding 5 parts of translucent pure ammo- nium carbonate to 100 parts of diluted acetic acid and stirring gradually until dissolved. The British preparation is made by mixing 1 fluid part of the liquor ammonii acetatis for- tior (Br. Ph.) and 5 fluid parts of water. In the Ger. Ph. the solution of ammonium acetate is prepared by mixing and heating in a porcelain vessel 10 parts of ammonia water with 12 parts of acetic acid; this is neutralized with ammonia water, filtered, and water added to bring the specific gravity to 1-032. It is a clear liquid, of a mildly saline taste and acid reaction. It should be freshly prepared, be- cause its acid becomes decomposed and ammo- nium carbonate is generated. It is used as a diaphoretic and diuretic, and Ringer thinks its action is increased by combination with other remedies of the same class; both Hare and Wood regard it as very feeble in its action. It is frequently used in febrile and inflammatory affections, such as the exanthemata, acute ca- tarrh, influenza, and infantile coryza, and in headache consequent upon gastric derange- ment. Dr. George Harley recommends it in large doses in cases of delirium due to " bilious- ness." Dr. A. T. Thompson has applied it lo- cally in porrigo of the scalp, and it has been used as a lotion in sprains, bruises, and gland- ular enlargements. It is a mild diuretic and does not irritate the kidneys, but increases both the water and the solids excreted. The dose is from 1 to 8 drachms, in water, repeated every three or four hours. The British pharmacopoeia provides a strong solution of ammonium acetate {liquor ammonii acetatis fnrtior) that is prepared by gradually adding 17^ oz. of crushed ammonium carbonate to 45 oz. of acetic acid, then adding more acid until a neutral liquid results, and'finally add- ing sufficient distilled water to yield 3 pints of product. The dose of this solu'tion is from 25 to 75 minims, but its principal use is in the preparation of solution of acetate of ammo- nium.—S. T. Armstrong. AMMONIUM BIBORATE. — See Am- moxhm Borate. AMMONIUM BICARBONATE, (NH4) IlCOa, is produced by exposing powdered offi- cial a.mmoniuni carbonate to the air. or by heating its solution, or by keeping it under a AMMONIAC 55 AMMONIUM CARBONATE bell glass over sulphuric acid and slaked lime, I or by treating 1 part of the carbonate with 2 parts of water. All these processes decom- pose the carbonate into the bicarbonate, car- bon dioxide, and ammonia. The bicarbonate is a white powder that has no ammoniacal odour when dry, and possesses a cooling, saline taste. It is soluble in water in the proportion 1 to 8. It has a less caustic taste than the carbonate and is more palatable, being espe- cially adapted for effervescing draughts. It may be used as an antacid instead of sodium bicarbonate. The dose is from 3 to 10 grains. S. T. Armstrong. AMMONIUM BORATE, 2(NH4HB204) 3H20, is formed by dissolving boric acid in ammonia water and heating until the am- monia excess evaporates. It occurs in semi- transparent crystals having an alkaline taste and reaction. It is soluble in water. It is said to be efficacious in cystic catarrh, especially that associated with calculus, and in renal colic, uric acid and earthy phosphates appear- ing in the urine in great quantities. The dose is from 10 to 20 grains, every hour. Professor Lashkevich reported in 1887 that he had found this salt of great value in the treatment of phthisis. It decreases expectora- tion and diminishes pyrexia. The dose is 5 grains, three times a day, with codeine or some other sedative.'—S. T. Armstrong. AMMONIUM CARBAZOTATE, am- monium picronitricum, picrate of ammonium, C6IIs(NT( )2)3( )N 113, is a compound of ammonium and picric acid. Internally, it diminishes the strength of the pulse, and in large doses brings on heaviness and causes cephalalgia or even delirium. It is eliminated by the kidneys. In its physiological action it closely resembles quinine. Dr. Dujardin-Beaumetz states that it is very efficacious in intermittent fever. The suppression of the paroxysms may be ob- tained, he says, by the use of from £ to § of a grain daily, and no bad effects are produced. Mr. H.'M Clark (Lancet, 1887. i, p. 366) states that he used this drug during four years and a half in 10,000 cases of malarial disease of an intermittent type, and in 9 cases only did it fail to cure. He gave it in doses of from \ to 1£ grain four or five times a day. in pill. He states that it is useless in remittent fever. In therapeutic doses it produces no unpleasant effect—headache, deafness, tinni- tus, gastric disturbance, or nausea. On account of its explosive effect it should be dispensed with caution. No report regarding its efficacy has been made since the custom of confirming the diag- nosis of paludal fevers by searching for the Hematozoon of Laveran has prevailed. S. T. Armstrong. AMMONIUM CARBONATE, or sesqui- carbonate, ammonii carbonas (U S. Ph., Br. Ph.), ammonium carbonicum (Ger. Ph.), sal volatile. Preston salts, (NII4)4Ha(COs^. is pre- pared by heating a mixture of ammonium chloride and calcium carbonate and condens- ing the product. Ammonium sulphate may be substituted for the chloride. Ammonium I carbonate occurs in white, translucent masses that become opaque and friable on exposure to air. It has a pungent odour, a sharp taste, and an acid reaction. As it occurs in commerce it consists of am- monium bicarbonate (acid carbonate) and car- bamate. It is soluble in cold water, but is decomposed by hot water with the elimination of ammonia and carbonic-acid gas. When it is added to alcohol the carbamate is dissolved, leaving ammonium bicarbonate. It volatilizes on being heated. Ammonium carbonate neutralizes the gas- tric acids and is a useful antacid, but, ad- ministered in large doses, it is incompletely neutralized, and it may so stimulate the gas- tric mucous membrane that vomiting will be produced. It possesses in a lesser degree the stimulating properties of ammonia, and its use is indicated where an ammonium salt is to be administered continuously. It excites the action of the skin, kidneys, and bronchial glands. Rohmann found that it increased the forma- tion of glycogen; this is not considered the result of its alkalinity, because sodium car- bonate will not act in this manner, but it is believed that ammonia and a carbohydrate entering the liver together may form a new compound that will split into glycogen and a nitrogenous product, such as urea. Schroder's recent experiments indicate that ammonium carbonate is one of the urea pre- cursors. After nephrectomy in a dog there is a fourfold urea increase, but blood mixed with ammonium carbonate and passed through the excised kidney or through the lower-limb muscles shows no urea increase, while if the mixture is passed through the liver there is an increased quantity of urea, although blood so passed without this ammonium salt shows slight, if any. increase of urea. The adminis- tration of ammonium salts with the food in- creases the excretion of urea. Pathologically, these conclusions are supported by the fact that in hepatic cirrhosis, in which the liver-cells are partly destroyed by the connective-tissue pro- liferation, urea in the urine is diminished while ammonia is increased. Ammonium carbonate is an irritant when administered internally in large doses, and ad- vantage is taken of this fact when an expec- torant re-enforced by an emetic is desired in severe cases of chronic bronchitis in which there are pronounced dyspnoea, feeble circula- tion, and great depression in consequence of the tubes being choked with mucus. In such asthenic patients this salt is preferable to ipecac or squill, which may be indicated in a sthenic bronchial inflammation. In doses of from 5 to 8 grains, in an aro- matic water or bitter infusion, it stimulates the secretion of gastric juice, and may be ad- ministered in atonic dyspej/sia. flatulence, and colic due to the latter. In such conditions the aromatic spirit of ammonia or the spirit of Mindererus may be substituted for the car- bonate. Dr. Hope has stated that in those forms of asthma associated with cardiac disorders great AMMONIUM CHLORIDE AMMONIUM SUCCINATE 56 benefit is derived from this salt in doses of from 10 to 15 grains, six or eight times a day. The principal use of this salt is as a stimu- lant expectorant in chronic bronchitis and in pneumonia. Dr. H. C. Wood considers it the best preparation for use in typhoid pneumonia. It should be given in doses of from 5 to 10 grains pro re nata. Dr. George Harley, having observed that am- monium carbonate administered in large doses to pigs caused leanness and great muscular hardness, was led to administer the salt in cases of fatty liver, in doses of from 5 to 10 grains, thrice a day. This, with a regulated diet of lean animal food, daily exercise, and sulphate of sodium before breakfast, will often cause a rapid diminution in the size of the liver. Dr. Basham has used it in diabetes mellitus, in an effervescing draught, as follows: B Ammon. carb., Amnion, phosphat., Sodii bicarb..........aa gr. x; Tinct. zingib........... gtt. x; This is to be taken with a tablespoonful of fresh lemon juice, twice daily. It is said to relieve thirst, diminish the quantity of urine, and decrease the proportion of sugar excreted. It has been used in chorea and hysteria with satisfactory results, and Dr. Anstie main- tained that if it was administered before an expected attack of epilepsy the paroxysm would be averted. It has had popularity in the treatment of scarlatina, in doses of from 2 to 6 grains, in cinnamon water or milk, every one or two hours, but it is not apparent what specific ac- tion it can exercise on that disease. Several physicians have recommended its use in the treatment of rubeola, urticaria, ro- seola, and erythema, but. unless these diseases are accompanied by deficient urea excretion that is corrected by the ammonium salt, the advantage of its use is questionable. Dr. Beale has found the salt very useful in cystinuria. Experiments made by Dr. Gottbrecht have shown that ammonium carbonate retards pu- trefaction according to the concentration of the solution employed; a 1-per-cent. solution retarded it until the third day, and a 10-per- cent, solution until about the sixtieth day. A 5-per-cent. solution added to infected gelatin stopped, and a 2-|-per-cent. solution hindered, the liquefaction of the gelatin. Ammonium carbonate is used in the prepa- ration of aromatic spirit of ammonia (see Am- monia) and of liquor ammonii acetatis (see Ammonium Acetate). Ammonium carbonicum pyro-oleosum (Ger. Ph.), sal volatile cornu cervi, is a compound of 32 parts of ammonium carbonate with 1 part of ethereal animal oil. It is a light-yellow powder that turns brown on exposure to" light. It combines in its effects the antispasmodic action of the animal oil and the stimulating action of ammonium. It may be used in hys- terical conditions. The dose is from 3 to 8 drops. The preparation must be kept from the light in well-stopped bottles. Liquor ammonii carbpnici pyro-oleosi (Ger. Ph.), spiritus cornu cervi, is prepared by dissolving 1 part of ammonium carbonicum pyro-oleosum in 5 parts of distilled water and filtering. The dose is from 15 to 40 drops. Liquor ammonii carbonici (Ger. Ph.) is a filtered solution of 1 part of ammonium car- bonate in 5 parts of distilled water. S. T. Armstrong. AMMONIUM CHLORIDE, ammonii chloridum (U. S. Ph., Br. Ph.), ammonium chloratum (Ger. Ph.), sal ammoniac, NH4C1, is obtained from the ammoniacal water of gas works. It occurs in tough, translucent, fibrous, inodorous masses, salty in taste, soluble in wa- ter and in rectified spirit, volatile without fusion or decomposition. In pharmacy it is used for generating ammonia gas in preparing aqua ammoniae. In frequent small doses ammonium chloride causes discomfort and heat in the stomach, di- aphoresis, diuresis, and increased secretion of mucus from the gastro-intestinal tract. In large doses, in animals, it produces pain, ex- citement, collapse, convulsions, and death. It has no effect upon the bile secretion of dogs. In man, as much as two ounces have been taken with no other ill effects than colicky pains and some diarrhoea. Ordinarily, in man, it pro- duces a notable increase in all the solids of the urine, except the uric acid, which is slightly diminished, while the urea is decidedly in- creased. Dr. H. C. Wood does not consider that in ordinary doses this salt has any decided influ- ence upon the circulation. Analyses and clin- ical experience have shown that the continued administration of the salt does impoverish the blood of its solid constituents. The salt acts especially on the mucous membranes. It is chiefly eliminated in the urine, unchanged. It is most useful in the treatment of acute and chronic bronchitis, but is administered in the former condition only after active inflam- matory action has been modified. In dcses of from 5 to 20 grains it increases the mucous secretion and facilitates expectoration. It has been administered in intermittent fever, but there is no positive evidence that it is of the slightest value in the treatment of that disease. It has been a favourite remedy for gastric and intestinal catarrhs, especially in children, given in doses of from 2 to 10 grains, with extract of licorice. It is a widely employed remedy in hepatic inflammations. Dr. Charles Murchison considering that it holds a pre-eminent place. It has proved to be of great value in relieving hepatic congestion, as well as in treating func- tional hepatic, derangement associated' with hthemia. Its diaphoretic and diuretic actions are influential in relieving the portal circula- tion and allaying pain. Dr. Harley does not consider that it is an antiphlogistic in conges- tion, as it seems to be a stimulant to both the circulatory and nervous systems, and he agrees with Dr. William Stewart, who first called at- tention to its use in this condition, that a dry, AMMONIUM CHLORIDE 57 AMMONIUM SUCCINATE hot skin contra-indicates its administration. In the early stage of hepatic abscess large doses of ammonium chloride stimulate the ab- sorbents of the liver, and thus tend to avert suppurative degeneration of the liver tissue. For these hepatic affections it may be pre- scribed in conjunction with either alkalies or mineral acids, and should be given in doses of from 20 to-30 grains, three or four times a day. A number of observers have recommended its employment in cases of amyloid liver in doses of from 60 to 100 grains; but a rigid diet should be enforced at the same time. In facial, intercostal, and ovarian neuralgias, in doses of 30 grains from three to four times a day, it has proved of service, but if the pain is not diminished after four doses the use of it should be discontinued and some other treat- ment instituted. The indications for its use are empirical rather than scientific. It has been recommended for headache, amenorrhea, dropsy, hemorrhages, senile gangrene, whoop- ing-cough, and myalgia, but it is inferior to many other remedies for these conditions. Inhalations of ammonium-chloride vapour are very useful in coryza and injlammations of the pharynx, larynx, and bronchi. There are a number of inhalers made for the purpose, all of them based on the fundamental principle of mixing the fumes of hydrochloric acid and ammonia water. Ammonium-chloride troches, trochischi am- monii chloridi (U. S. Ph.), are prepared by rub- bing together until thoroughly mixed, finely powdered ammonium chloride, 10 grammes (about 150 grains); extract of glycyrrhiza, 25 grammes (about 375 grains); tragacanth, 2 grammes (about 30 grains); sugar, 50 grammes (about 750 grains); and adding enough syrup of Tolu to make a mass to be divided into 100 troches. These troches are used in pharyngitis, laryngitis, and subacute bronchitis. Compressed tablets consisting of 5 grains each are much used for catarrhal affections. S. T. Armstrong. AMMONIUM CITRATE, (NI14)SC6E50„ is obtained by dissolving citric acid in ammonia water, or in water containing ammonium car- bonate. In Germany it has been administered in diseases of the bladder in doses of from 15 to 45 grains several times a day. A strong solution of citrate of ammonium, liquor ammonii cifrafis fortior (Br. Ph.). is made by neutralizing 12 oz. of citric acid with 11 fl. oz. (or a sufficiency) of strong solution of ammonia, and adding enough distilled water to make a pint of product. This solution, di- luted with four times its bulk of distilled water, constitutes liquor ammonii citratis (Br. Ph.). The dose of the stronger solution is from 30 to 90 drops, and that of the weaker from 2 to 6 fl. drachms. The solutions are clear, colourless, and saline in taste. Their ac- tion is similar to that of the solution of am- monium acetate.—S. T. Armstrong. AMMONIUM EMBELATE, ammonium embelicum, C8III8COONlI4, occurs as large, needle-shaped crystals of a foxy-red hue. It is precipitated from an alcoholic solution of embelic acid mixed with an excess of strong ammonia water. This salt, which is tasteless, is said to be an effective teniafuge in doses of from 3 to 6 grains, acting where the ordinary tamiacides have failed. It is given in honey, and the dose is preceded and followed by one of castor oil.—S. T. Armstrong. AMMONIUM FLUORIDE, ammonii fluoridum, NH4F, is prepared by saturating a solution of hydrofluoric acid with ammonia and allowing the mixture to evaporate over quicklime. It crystallizes in colorless hex- agonal prisms that dissolve readily in water. It must be kept in gutta-percha or wax-lined bottles. Dr. J. Lucas has prepared a liquor ammonii fluoridi, of the strength of 4 grains to 1 oz. of water. This solution has been used to diminish the size of hypertrophied spleens, in doses increasing from 5 to 20 drops, in water, after each meal. It has been recommended as an inhalation in phthisis in a 2-to-l,000 solu- tion.—S. T. Armstrong. AMMONIUM FORMATE, ammonii formas, ammonium formic.icum NH4CH02, is obtained by neutralizing formic acid with am- monia and evaporating the solution until crys- tallization occurs. It has a pungent taste. It is eliminated, unchanged, in the urine. It has been administered for reflex paralysis and for muscular paresis due to disuse, in patients in whom there is no active inflammation or irri- tation of the nervous centres. Its value is questionable. The dose is 5 grains, once or twice a day.—S. T. Armstrong. AMMONIUM HYDROSULPHIDE, NH41 IS, is formed, in solution, by saturating a caustic solution of ammonia with sulphuretted hydrogen, or, anhydrous, by mixing equal vol- umes of dry ammonia gas and dry sulphuretted hydrogen. It is a colourless, transparent, vola- tile salt. There is a German preparation, solu- tion of ammonium sulphydrate, liquor ammonii hydrosulfurati, seu hydrothionici, that is made by passing a current of sulphuretted-hydrogen gas through a mixture of 30 parts of flowers of sulphur and 180 parts of caustic ammonia solution. It has been used for catarrhal and rheumatic diseases and for diabetes. The dose is from 6 to 15 drops, in water or milk. In doses of from 5 to 6 drops it has been used for dysuria.—S. T. Armstrong. AMMONIUM NITRATE, ammonii ni- tras (U S. Ph.. Br. Ph.), ammonium nitricum, NlI4N03, is prepared by neutralizing nitric acid with ammonium hydrate or carbonate. It is odourless and deliquescent, and has a sharp bitter taste and a neutral reaction. It is used in the preparation of nitrous-oxide gas ; heated to 320° F., it is resolved into this gas and water. S. T. Armstrong. AMMONIUM PHOSPHATE.—See un- der Phosphorus. AMMONIUM PICRATE.—See Ammoni- um Carbazotate. AMMONIUM SALICYLATE.—See un- der Salicylic Acid. AMMONIUM SUCCINATE, ammonii succinas, ammonii succinicum, C4H4(XH4)a04, AMMONIUM SULPHATE AMYL NITRITE 58 is prepared by supersaturating succinic acid with ammonia. It has been used in the treat- ment of delirium tremens, in doses of from 5 to 10 grains, three times a day. Solution of ammonium succinate {liquor am- monii succinici, ammoniacum succinicum so- lutum, liquor cornu cervi succinatus, spiritus cornu cervi succinatus) is a German prepara- tion made by dissolving 1 part of succinic acid in 8 parts of warm water, and neutralizing the solution with a sufficient quantity of pyro- oleous ammonium carbonate. After standing for twenty-four hours the solution is filtered. It has a brownish colour. It has been recom- mended in the treatment of convulsive, and hysterical disorders, and in asthmatic and rheumatic conditions. The dose is from 10 to 20 drops. With it is prepared an ethereal solution of ammonium succinate (liquor ammonii succinici ethereus, liquor antispasticus), made by mix- ing equal parts of the solution of ammonium succinate and spiritus ethereus (Ger. Ph.). It is sold under the name of Eller's drops {liquor antarthriticus Elleri), and is given for the con- vulsive disorders of children, in doses of 20 drops. From the first-mentioned solution pyro-oleous ammonium succinate {ammonium succinicum pyro-oleosum) may be obtained. It is not now used medicinally. S. T. Armstrong. AMMONIUM SULPHATE, ammonii sulphas, ammonium sulfuricum, (NH4)2S04, is prepared by collecting the distillate from a mixture of ammoniacal-gas liquor and lime in sulphuric acid. It forms anhydrous, soluble, rhombic crystals. It has been used as a stimu- lant in doses of from 15 to 30 grains, but it is inferior to other ammonium salts. S. T. Armstrong. AMMONIUM SULPHICHTHYOL ATE.—See Iciithyol. AMMONIUM SULPHYDRATE.—See Ammonium IIydrosulphide. AMMONIUM TETRETHYLATE, NEt4OlI, is obtained by decomposing ammo- nium iodide with silver nitrate or its sulphate with baryta. It occurs in slender crystals that are alkaline, bitter, and deliquescent. Mr. T. A. Edison, in experimenting with uric-acid solvents, found that this salt was most effica- cious in dissolving that acid or a deposit of sodium urate removed from a joint. Dr. F. Peterson found that 10 drops of a 3-per-cent. solution, injected into an animal's ear, or 15 drops of such a solution, given per os, pro- duced no bad results. The writer once under- took an investigation of its therapeutic effects. There was no marked increase of urea excre- tion following its administration by the mouth in patients suffering with acute articular rheu- matism. There did not seem to be any specfiic influence exercised on the course of the disease. It was given in doses of from 10 to 20 drops of a 10-per-cent. solution. In one patient, to whom it was administered hypodermically, there followed at a late period a necrobiosis of the subcutaneous tissue wherever an injection had been made. A sterilized syringe was used, and abscess following hypodermic injections of usual hospital solutions was unknown. No opportunity offered to use it in gouty deposits, where, if it is not decomposed in the stomach, it may exercise some curative influence. S. T. Armstrong. AMMONIUM URATE, ammonii uras, NH4C6H3N403, is formed by digesting uric acid in ammonia solution or by adding am- monium chloride to a solution of urates. It is a white, amorphous salt that dissolves with difficulty. It has been applied in an ointment, in the strength of 20 grains to 1 oz., in eczema and other skin diseases. Its therapeutic value is slight, if it has any.—S. T. Armstrong. AMPLOSIA.—This name has been given to the expressed juice of grapes bottled with- out having been allowed to ferment. Its use has been recommended as a. substitute for the " grape cure." The fermentation is checked by the addition of benzoic acid, but apparently not wholly prevented, for the liquid has been found to contain an infinitesimal amount of alcohol. AMYGDALA, AMYGDALIN, AMYG- DALUS.—See under Almonds. AMYLiETHER NITROSUS. — See Amyl nitrite. AMYL ALCOHOL, CsHnOH, a promi- nent constituent of fusel oil, especially that obtained from potato spirit, was formerly offi- cial on account of its being used in the manu- facture of valerianic acid, amyl nitrite, and some other products. It is still employed in medico-legal investigations to extract alka- loids, especially morphine, from watery liquids. It is an active poison, producing muscular rigidity followed by complete relaxation and coma. AMYLAMINE CHLORIDE, or hydro- chloride, Nria.C5Hn.IICl. has been found to reduce the pulse and temperature when given in daily amounts of from 7 to 15 grains. Its use in practice is not to be recommended. AMYL CHLORIDE.— Chloramvl, pentyl chloride, C5II,,C1, a colourless liquid," of agree- able odour, prepared by the action of hydro- chloric acid on alcohol heated in a retort to 230° F. It is an anirsthetic, but is slow in its action and in the subsidence of the ames- thesia. AMYLENE, C»H10, a derivative of fer- mentation amyl alcohol, is a mobile liquid of a garlicky odour. It was formerly used as an anesthetic, but was found to be more danger- ous than the ana'sthetics in common use. AMYLENE HYDRATE, (CH3)2.C2H6. C.OII, tertiary amyl alcohol, the ami/lenum hyd rat urn of the Ger. Ph., is a colourless, vola- tile liquid of a eamphoraceous and peppermint- like odour. It has been used as an anesthetic, and is considered a comparatively safe one, but is employed principally- as a pure hypnotic, ranging in potency between chloral 'hydrate and paraldehyde. It has the advantage over chloral of not increasing nitrogenous waste in cases of its repeated administration for a con- 59 siderable period of time. It dissolves in 8 parts of water and in all proportions in alcohol. It should be kept in well-stopped bottles and away from the light. The dose is from 15 to 60 grains, and not more than 120 grains should be given in twenty-four hours. It should be taken well diluted with water or wine. AMYL HYDRIDE.— Pentane, C5H„, be- longing to the paraffin series, a colourless liquid, of a slight but disagreeable odour, said to be of the least density of all known liquids. It is a potent anesthetic, said to act without causing irritation or dyspncea. Until further observation has established its manageability, its use is not to be recommended. AMYL IODIDE.—A colourless, pungent liquid, C6IIi,I, turning brown on exposure to light, prepared by the action of amyl alcohol on iodine in the presence of phosphorus. It was found by Richardson to have anesthetic properties. AMYL NITRITE, or amylonitrous ether, the amyl ni.tris of the U. S. and Br. Ph's, the amylium nitrosum of the Ger. and Austr. Ph's, C6Hii.O.NO, is prepared by the action of 1 part of strong nitric acid on 2 parts of rectified fusel oil. Although it was discovered as early as 1844. it was not brought to the notice of the profession until 1865, when Dr. (now Sir) B. W. Richardson, of London, called attention to it. It is an oily, yellowish, inflammable, and very volatile liquid, with a fruity odour very much resembling that of ripe pears. It is rapidly decomposed by coming in contact with water, and nitrous acid is set free ; but when it is taken by the stomach it is probably not destroyed be- fore absorption takes place, although Dr. D. J. Leech (Croonian Lectures, Brit. Med. Jour., June 24. 1893) says: "From the comparatively slight effects produced by the nitrite of amyl when taken into the stomach, I am inclined to think but little is absorbed." It is rapidly ab- sorbed in an undecomposed state when inhaled, and its effects when administered by the lungs are prompt and decided. The most pronounced symptoms caused by inhaling several drops of amyl nitrite are a sudden and intense fulness of the head, which, if the dose is large, amounts to severe pain, especially in the frontal region, flushing of the face, increased frequency and depth of respira- tion, and exceedingly rapid and irritable action of the heart, without, apparently, much increase in the strength of the cardiac systole. If the dose is sufficiently large to produce the lethal effects of the medicament the face becomes ex- tremely pale, the pupils dilate, great muscular relaxation results, the pulse is weak, rapid, and scarcely perceptible, and respiration is irregu- lar, slow, and shallow. Cases of convulsions, or muscular twitching of the face, very infre- quently observed after inhalations of large doses of amyl nitrite, are probably due to as- phyxia rather than to the direct influence of the drug on the brain. When lethal doses of amyl nitrite are taken the arterial blood as- sumes an appearance similar to that of the venous, and before death the blood is choco- late-brown in colour. AMMONIUM SULPHATE ) AMYL NITRITE The Circulation. — The condition of the heart, pulse, and capillaries indicates the pro- found influence of nitrite of amyl on the cir- culation. When this drug is administered, especially by inhalation, in five- or ten-drop doses, the heart's action is suddenly increased several beats a minute. One of the most im- portant questions in relation to the use of amyl nitrite in certain cardiac disorders and de- pressed conditions is. whether this agent, either directly or indirectly, is a cardiac stimulant, or whether it simply acts as an indirect cardiac accelerator by reason of its depressing influence on the cardiac inhibitory nerves. Professor Reichert, of the University of Pennsylvania (A'. Y. Med. Jour., July, 1881), as a result of his experiments with the drug on animals, ex- presses the view that in small doses it acts primarily as a stimulant to the heart. Most observers, however, hold the opinion that there is no positive evidence to prove that amyl nitrite is a cardiac stimulant. While this agent is not a direct cardiac stimulant, yet by its in- fluence in depressing the inhibitory nerves of the heart it enables this organ to do more work in a given time, and in this manner it may be said to be an indirect cardiac stimulant. With this, as with all other agents which increase the heart's action by depressing one portion of the nervous system, the stimulant effect is transient, and, if large doses are employed, or the use of the medicament is continued for a considerable length of time, it becomes a cardiac depressant. In a few cases irregular action of the heart has been observed after inha- lation of nitrite of amyl. The pulse is greatly increased in frequency, and the arterial pres- sure is lessened almost from the first. As the strength of the cardiac systole undergoes but little change when medicinal doses are admin- istered, it is evident that the lessened arterial pressure is not cardiac in nature. The dilata- tion of the capillaries which occurs from amyl nitrite is the cause of the decreased arterial pressure. This view is abundantly substan- tiated by numerous observers and physiological experimenters. Some have attributed the capil- lary dilatation to the influence of the drug on the central nervous system, but the majority of those who have conducted scientific experi- ments on lower animals to determine this point are convinced that the capillary dilatation is mainly peripheric and due to paralysis of the muscular coat of the arterioles. Undoubtedly Dr. H. C. Wood is correct in stating: " It is, however, very probable, from the general sed- ative effect of the drug upon the motor centres, that it acts also upon the vaso-motor centres; and when the local flushings caused by small doses of the poison are borne in mind, this probability is greatly enhanced." The Nervous System.—Amyl nitrite acts on the nerve centres and nerves as a depressant, affecting principally motor conduction and re- flex activity, especially in the spinal cord. The functions of the muscles and motor nerves are depressed, but to a lesser degree than those of the cord. The effects of the drug on the spinal cord have been determined principally by ex- periments on lower animals. Other symptoms AMYL NITRITE 60 than spinal are so prominent in man after in- haling the nitrite of amyl that it is almost impossible to determine satisfactorily the ef- fects on the functions of the cord. It is prob- able that cerebral function is depressed by this agent, but to a lesser extent than the spinal. Nearly all writers are agreed that nitrite of amyl has no direct analgetic effect, and the pain, especially cardiac, neuralgic, and cephalic, which is sometimes promptly relieved by in- haling a few drops of it, is influenced by the direct effects of the drug on the arterioles. A considerable part of the ultimate depress- ing effects of the drug under consideration is due to its influence on the blood. These con- sist mainly of lessened power of oxidation of the haemoglobin of the blood-corpuscles and impaired vitality and vitalizing influence of the blood. It is important to bear in mind that the arterioles of the lungs dilate from the effects of nitrite of amyl, as it enables us to appreciate the prompt relief afforded by its inhalation in certain cases of angina pectoris and in cases of cardiac dyspncea. Under such circumstances the sudden dilatation of the pul- monary capillaries relieves the distended cavi- ties of the heart. The Urine.—Several observers have detected sugar in the urine after giving large doses of amyl nitrite, but it does not seem to produce this result in man when given in medicinal doses. The drug has the effect of temporarily increasing the flow of urine. The Temperature.—There may be a tem- porary slight rise of the heat of the mouth and surface of the body after administering nitrite of amyl, but the rectal temperature is said to be diminished from the first. The ultimate effects of the drug in decided doses are to lessen heat production and lower the tempera- ture of the entire body. These results take place in the febrile as well as in the normal condition, and are probably due to dilatation of the cutaneous capillaries, thus exposing the blood to the cooling effects of the atmosphere, with impaired hamiic respiration and lessened metabolic processes. Dose and Administration.—The average dose of amyl nitrite is from 3 to 5 minims. Much larger doses have been given without untoward results. A dessertspoonful has been swallowed and the patient has recovered, although emetics were employed. Leech (Croonian Lectures, Brit. Med. Jour., July, 1893) mentions a pa- tient suffering from phthisis who inhaled 7 drachms of the drug and succumbed to its influence. Two drachms have been given hy- podermically to a patient with cholera in the course of an hour and thirty-six minutes with- out serious symptoms (H. C. Wood's Thera- peutics, etc., sixth edition, p. 389). The best method of administration seems to bo by in- halation. The drug acts more promptly when given in this manner than when taken'by the mouth. When the medicine is administered by an attendant a few drops may be placed on the handkerchief and held near the nose until the face begins to flush or the patient experi- ences a full sensation in the head. When the patient is allowed to carry the drug and inhale it at will, it is safer to use the pearls, little hollow balls made of thin glass, containing 2 or more drops of amyl nitrite. These balls can readily be crushed between the folds of the handkerchief. If it is desirable to administer it by the mouth, Wood recommends dropping 2 or 3 minims on a lump of sugar and causing it to be taken instantly. As water changes it so rapidly, it is probable that little of the amyl nitrite is absorbed unchanged when it is given in an aqueous menstruum. Therapeutics.—From a knowledge of the physiological effects of nitrite of amyl it would seem to be indicated in various cardiac, pulmonary, and nervous disorders attended by angeiospasm and increased blood pressure. Angina pectoris is the most conspicuous affec- tion of the heart for which the drug has been used. Two of the most obtrusive symptoms of angina pectoris are cardiac distress, with various radiating neuralgic pains, and in- creased blood-pressure. There is a difference of opinion as to whether the increased blood- pressure is the cause of the cardiac distress. Undoubtedly the disease has numerous causes, but the paroxysms of pain are usually attended with increased" blood-pressure. It is this latter condition which the inhalation of nitrite of amyl often relieves so promptly, and with it the pain and distress which are so intolerable to the unhappy sufferer. That the drug does not act directly as an analgetic in these cases is evident from the fact that large doses of morphine fail to relieve the pain in some pa- tients whose pain is almost instantly allayed by inhaling a few drops of nitrite of amyl. In some cases of angina pectoris the drug under discussion affords little or no relief, but we are not in a position to determine without trial in what class of cases it may be adminis- tered with benefit and in which it is better to refrain from giving the medicament. In the early stage of the disease, no matter what the pathological lesion may be, amvl nitrite is likely to afford partial or entire "relief. The shorter the paroxysms the greater the proba- bility that they will yield to the inhalations. In a few instances when 3 or 5 drops have failed, 8 or 10 have been attended with decided benefit. As a rule, if small doses give no re- lief, larger ones will probably fail. Leech's summary of the use of the nitrite in angina pectoris {Brit. Med. Jour., July 15. 1893, p. 109) may be quoted with advantage:" Of late isobutyl nitrite has been employed occasionally as a substitute for amyl nitrite. Cash finds isobutyl and secondary" propyl nitrites some- what more active in reducing "tension than the amyl compound. It has appeared to me, too, that isobutyl nitrite more certainly relieves anginal pain than does official amyl nitrite. "The inhalation of amyl nitrite sometimes fails to relieve the pain of angina pectoris; this failure may arise from several causes: "(1) The paroxysms may be due to neural- gia of local origin, or the pain may be re- flected or hysterical, and circulatory changes may take but little part in its production. In such conditions nitrite inhalations can do no harm, yet they may fail to relieve pain. 61 AMYL NITRITE " (2) In some cases the nitrite does not re- move pain because of the short duration of its action. It does not break the spell of the ves- sel contraction. There may be relief, but it is not complete, and when in a minute or two the effect of the drug passes off the wave of con- traction returns and with it the pain. "(3) Some are curiously insusceptible to the influence of amyl nitrite. In such people full inhalations may succeed when slight ones fail, though this is not very common. If a certain measure of success is" not obtained with ordi- nary inhalation, it is not often that a more copious use of amyl nitrite completely removes anginal pain. "(4) Lastly, in very advanced cases, where the attacks of pain continue long, amvl nitrite may entirely fail to relieve the pain, though in an earlier stage it proved useful for this pur- pose." In many cases of cardiac dyspnea inhala- tions of amyl nitrite afford prompt, although usually only temporary, relief of the patient's most distressing symptom. The question will naturally arise, Will not an agent which causes so great an increase in the heart's action be attended with danger in fatty heart, or in cases of long-standing dilatation, attended with degeneration of the muscular fibres? All are agreed that large doses of nitrite of amyl might prove dangerous and should be avoided in such cases. Many have employed the drug in small doses for the relief of car- diac distress in cases of fatty and dilated heart, and have afforded their patients speedy respite from suffering without observing any untoward results. In such cases the safe rule would seem to be to use the medicament in the smallest possible dose that should be found to relieve the distressing symptoms, and if 3 or 5 minims inhaled were not attended with any benefit, it should not be pushed further. The agent under discussion has been of service in relieving pain in aortic insufficiency with ex- cessive hypertrophy and severe frontal head- ache (Wood). Striimpell has not been able to obtain much help from it in cardiac dyspncea due to valvular lesion and dropsy. As amyl nitrite seems to be a very feeble cardiac stimu- lant, if at all a direct one, we should not expect much aid from its inhalation in syncope and cardiac failure, such as may result from the use of anaesthetics, from shock, etc., yet numer- ous cases of cardiac failure during anaesthesia, especially from chloroform, have been reported, in which imminent death is believed to have been averted by the timely inhalation of a few drops of this agent. Dr. Edward Rice {Lancet, Sept. 19, 1891) reports such a case. It may be that the sudden dilatation of the pulmonary capillaries in such cases relieves the heart, but further than this we are not in a position to give a satisfactory reason for its beneficial effects in such cases. Amyl nitrite has been used by a number of physicians for the relief of the paroxysms of dyspnea due to asthma and bronchitis, but, as might be expected, its influence is of too short a duration to afford more than temporary ame- lioration. In cases of nervous asthma in which the paroxysms come on at a certain time dur- ing the night, a few drops of amyl nitrite in- haled at the beginning of the paroxysm may cut it short. As a rule, the other nitrites, espe- cially the nitrite of sodium, nitrite of ethyl, and nitroglycerin, have a more decided influ- ence in the relief of the dyspnoea of asthma, as they are more permanent in their action. The inhalation of amyl nitrite affords prompt relief from uremic dyspnea in some cases, but its effects are so transient that it is at best only palliative, and in the majority of cases of this kind its use leads to disappointment. Bals and Broglio (Bull, med., May 30. 1888) recom- mend the tertiary nitrite of amyl, as its action is more marked and more lasting: it does not produce heat, tension, and throbbing of the head; it can be inhaled without inconvenience or danger in relatively large doses (80 to 100 drops daily), and it acts as a hypnotic. {Ann. of the Univ. Med. Sci., 1889, vol. v, 110.) In epilepsy, amyl nitrite, if inhaled during the aura, may avert an impending seizure, and it has been employed with good effect in the status epileptic us, in which convulsions follow one another in rapid succession. The effect of the drug is too transient to be of any service in breaking up the habit. Puerperal convul- sions at times seem to yield to this agent, but its tendency to relax the muscular contraction of the womb, and thus to favour uterine haemor- rhage, has deterred obstetricians from its use. Hysterical paroxysms have apparently been cut short by repeated inhalations of nitrite of amyl, and a like result has followed its admin- istration in catalepsy and hystero-epilepsy. It seems to be worthy of a more extended use in hysteria than the majority of physicians here- tofore have accorded to it. While the course of tetanus is too long for us to expect a decided curative effect from inhalations of nitrite of amyl, yet its influence in depressing the excit- ability of the spinal cord and in relieving par- oxysms of dyspncea makes it air agent of great value to meet the emergencies in this troublesome disease. By its timely adminis- tration severe paroxysms of muscular spasm can be prevented while the patient is being fed. and at times death may be averted by re- laxing the tonically contracted respiratory muscles. The favourable results following its administration in tetanus certainly justify its use in this disease. Migraine attended with angeiospasm, and headache due to anemia of the brain are favourably affected by the inhala- tion of amyl nitrite. This agent has been used in cerebral anemia, but it is evident that it can have only a temporary effect. Striimpell recommends amyl nitrite in trigeminal neu- ralgia, but does not seem to have much con- fidence in its use in this trouble. Dr. Alfred L. Loomis advises the employment of amyl nitrite in the vertigo of seasickness, and recom- mends its inhalation on the first appearance of nausea (Practical Medicine, p. 1079). Nu- merous observers have given the drug under consideration in various reflex vaso-motor dis- turbances, and especially those connected with the climacteric and menstrual periods. It is said to have afforded relief in these cases from AMYLONITROUS ETHER ANESTHETICS 62 depressed mental conditions, cold hands and feet, peculiar flushings, hysterical manifesta- tions, and, at times, pain. From the powerful influence of amyl nitrite in promptly dilating the capillaries we should expect good effects from its use in the stages of asphyxia and syncope in Raynaud's disease. I am not aware that it has been used in this affection. Dr. Alexander P. Rudsky {Ann. of the Univ. Med. Sci., 1891, vol. v, 102) describes an in- teresting case of cocaine poisoning in which nitrite of amyl proved to be a successful anti- dote. Several similar cases have since been reported. Professor H. C. Wood advises in- halations of amyl nitrite to lessen the spinal reflexes in strychnine poisoning, and gives re- sults of experiments in which the administra- tion of twice the ordinary fatal dose of strych- nine was followed by recovery when this drug was employed as the sole antidote. J. T. Eskridge. AMYLONITROUS ETHER.—See Amyl Nitrite. AMYLUM.—See Starch. AMYL VALERIANATE, CsHn.O.CaH, 0 + CioH2002, is an ethereal liquid of an agree- able apple-like odour. It has been recommended in hepatic and nephritic colic, also as & calmative and antispasmodic, and for the relief of mi- graine and neuralgia. It has recently been employed by Dr. Blanc {Brit. Med. Jour.; Med. Record, Nov. 17, 1894, p. 623) not only for the relief of attacks of hepatic colic, but also to prevent their recurrence, which it is thought to do by virtue of a solvent action on the concre- tions of cholesterin. Dr. Blanc has found it use- ful also in muscular rheumatism, in spasmodic dysmenorrhea, and in hysterical paroxysms. The dose is 1-J- grain, in a capsule, and five or six doses may be taken in the course of twenty- four hours. ANACARDIUM OCCIDENTALS— See Cashew nut. ANACYCLUS.—See Pyrethrum. ANiESTHETICS are agents that for the time being annul or deaden sensitiveness to pain. When they affect the entire organism pro- foundly they also cause total loss of conscious- ness, complete relaxation of the voluntary muscles, and other phenomena to be mentioned further on. The condition thus produced is known as general anaesthesia; local anaesthesia is insensibility of a part, due to the topical action of an anaesthetic agent. In a certain sense all anaesthetics are thought to be local in their action ; anaesthesia is held to be produced, not by the effect of the anaesthetic agent upon particular organs of the central nervous sys- tem, but by its actual presence in all the tissues, whither it is carried by the blood. There are many drugs that, if given in doses large enough to prove fatal, lead to a state of profound unconsciousness and insensibility, but only as one of the manifestations of their deadly action; we reckon as anesthetics, how- ever, only those agents that give rise to anaes- thesia regularly and without notable danger. The number of these is now considerable, al- though it was not until the nineteenth cen- tury was well advanced that such an agent as an efficient and manageable anaesthetic was known. It is true that the ancients are cred- ited with having made use of various drugs that may have mitigated the pain of a surgical operation in some faint degree, but (except by employing exceedingly dangerous doses of narcotics or possibly, as has been surmised, inducing asphyxia with carbonic-acid gas set free from the "stone of Memphis") we may be sure that they never succeeded in effect- ing any close approach to what a modern surgeon would look upon as satisfactory anaes- thesia. No better did the moderns succeed until the fifth decade of the present century, within which brief period of time the three great anaesthetics — nitrous oxide, sulphuric ether, and chloroform—were made known to the world. It is said, indeed, that so long ago as in 1799 Sir Humphry Davy became aware that something more than exhilaration could be produced by the inhalation of nitrous oxide —a degree of insensibility to pain—but he did not carry his observations so far as to enable him to see that " laughing-gas " could be made available as an anaesthetic; that discovery was reserved for Horace Wells, a dentist, of Hart- ford, Connecticut, who in 1844 began to use the gas to prevent pain in the extraction of teeth. He had been led to try it by having observed that some of the persons to whom it was administered at public exhibitions given by G. Q. Colton, an itinerant lecturer, became insensible to blows, etc., that would ordinarily give rise to pain. Wells continued to use the gas in his dental practice, and made a praise- worthy effort to demonstrate to the medical profession its availability as a surgical anaes- thetic in an operating theatre in Boston. Un- fortunately, there was some fault in its prepa- ration or administration on that occasion, and it failed to produce the desired effect; conse- quently its use as an anaesthetic was soon for- gotten, but only to be revived on a grand scale twenty years later. In 1846 another dentist (afterward a physi- cian), William T. G. Morton, of Boston, suc- ceeded in showing, in the same operating thea- tre, that of the Massachusetts General Hospital, that inhalation of the vapour of sulphuric ether was capable of producing entire insensibility to the pain of a surgical operation. For sev- eral years before, Morton had occasionally taken part in those curious gatherings of frolicsome young students of medicine, pharmacy, and dentistry that took place here and there at various times, at which ether vapour was in- haled for the purposes of exhilaration and merriment. It was reflection on these experi- ences, together with vague hints that he had been able to pick up from chemists—notably Dr. Charles T. Jackson, of Boston—that led Morton to try ether as an anaesthetic. Opinions are divided as to who should be credited with the honour of having first dis- covered the anaesthetic property of ether, for a number of physicians had experimented with it, and, in particular, it is well established that Dr. Crawford W. Long, of Jefferson, Geor- / AMYLONITROUS ETHER 63 ANAESTHETICS gia, used ether as an anaesthetic in surgery as early as in 1842. Morton's demonstration, nevertheless, was incontestably the event that proclaimed the practicability of surgical anaes- thesia, which immediately became general the world over. In the following year, however, it was made known, chiefly by" the efforts of Dr. (afterward Sir) James Y. Simpson, of Edinburgh, that chloroform was an efficient anaesthetic. It was at once recognised that chloroform had the advantages of being speed- ier in its action and much more agreeable to the patient; consequently it soon came into common use in Europe, almost to the exclusion of other anaesthetics. In most parts of the United States, however, ether has always held its place as the leading anaesthetic, and "for the last few years there have been growing indi- cations that European surgeons were coming to realize that supreme advantage of ether— safety. Absolute safety, it is true, there is not in the use of any anaesthetic; so profound a perturbation of the processes of life as the total abolition of all sensation can not be brought about without some little risk. It is our plain duty, therefore, always to employ the anaes- thetic that experience has shown to be the least dangerous, unless in an individual instance there is some special reason to choose some other. The question, as between chloroform and ether—and that is practically the whole question—will be treated more fully in the article on Ether. All the drugs that act as general anaesthet- ics are either gases or highly volatile liquids; there are, however, certain agencies, such as hypnotism and rapid breathing, that are pro- cesses, not substances. Hypnotic anaesthesia will be considered in the article on Hypnotism. A few years ago some experiments made in Philadelphia went to show that brief anaes- thesia could be induced by causing the patient to lie on his side, with his eyes bandaged so as to withdraw his attention from the sur- roundings, and getting him to breathe at the rate of about a hundred times a minute for from two to five minutes. Professor Henry M. Lyman, of Chicago, in his admirable mono- graph on Artificial Anesthesia and Anesthet- ics (New York, 1881), explains the anaesthesia thus induced as perhaps partly or in some in- stances one of the phenomena of the apnoea that results from surcharging the blood with oxygen, and as partly or in other instances a feature of incipient asphyxia resulting from overdistention of the veins produced by the " puffing" expiration which is one of the ele- ments in the process. It is doubtful if this method of anaesthetization has anything to recommend it save as an expedient in case none other is practicable. General anaesthesia is almost always in- duced by causing the patient to inhale the aiucsthetic gas or vapour, but it is possible to accomplish the object in some other way. as was shown by the practice of rectal etherization that came into vogue a few years ago and was largely resorted to for a brief period, during which it caused death in a number of instances, so that it soon came to be abandoned. In this method of anaesthetization the vapour of ether, hastened in its evolution by the application of heat to the vessel holding the liquid, was conveyed into the rectum. The process was for a time thought to be particularly advantageous in cases in which there were special reasons for sparing the patient the irritation' of the air- passages that attends the inhalation of the vapour of ether. In the fatal cases intense hy- peraemia of the rectum and of the adjoining portion of the colon was found post mortem. When the vapour of ether or chloroform is inhaled, if the inhalation is conducted prop- erly, anaesthesia comes on gradually, but is sometimes preceded by various unpleasant phenomena, such as a choking sensation and coughing, due to the pungency of the vapour; the delirium of incipient anaesthesia, some- times inducing the patient to attempt acts of violence or otherwise misbehave, but quite in- voluntarily ; transitory convulsive movements; and vomiting. Finally the individual has the appearance of a person in deep sleep, and, if the anaesthetization is carried to a profound degree, resembles one in a state of coma, snor- ing heavily and with the muscles utterly limp. Ordinarily, full surgical anaesthesia need not be carried to this extreme. Among the early phenomena of anaesthetiza- tion with ether is a condition termed primary anesthesia. It is an anaesthesia that lasts for a few seconds only, but long enough to serve the purpose when only a puncture or a single rapid incision is to be made, as in opening an abscess. The way to take advantage of this primary anaesthesia was thus described by the late Dr. Gaspar Griswold {New York Med. Jour., xxxiii, 1881, p. 572): "The operator stands with his knife ready; the patient is told to hold one hand raised above his head, and is given some ether to inhale. As the critical moment is reached, the patient becomes temporarily un- conscious, and allows his hand to fall. The in- cision is then made at once. The return to consciousness is complete in a few minutes, and is attended with no nausea or other dis- comfort." Vomiting is a troublesome and often danger- ous occurrence that may take place at almost any period of the process of anaesthetization— troublesome in that it hinders further proced- ures for the time being; dangerous from the tendency of the vomited matter to drop into the larynx and cause either immediate suffo- cation or remote bronchitis. Often has it been necessary to perform tracheotomy for the re- moval of a piece of undigested meat that had thus found its way into the air-passages. Vom- iting may usually be prevented by instructing the patient to abstain from taking food for several hours before the time set for the op- eration, but he should not be told to do so for so many hours as to weaken him by lack of needed nourishment; this is a matter for judg- ment and discrimination. As a patient emerges from the anaesthetic state, especially if he has been long subjected to it, he is at first dazed, and is apt to suffer with headache and nausea. The complete return to the condition he was in before the anaesthetization often requires ANAESTHETICS 64 several hours for its accomplishment. During all this time he should be watched carefully. As a rule, women and children are more readily anaesthetized than men; they require less of the anaesthetic. Occasionally an indi- vidual well-nigh proof against anaesthesia is encountered, but, if the ether or chloroform is pure and its administration well managed, suc- cess is always the result. There are few per- sons whom it is not safe to anaesthetize, but a patient's condition should, when practicable, be carefully examined before a decision is made as to the time and method of anaestheti- zation. If the person is subject to fainting attacks or the victim of serious pulmonary or cardiac disease or of any grade of Bright's dis- ease, general anaesthetics should be avoided if possible, or used with the greatest caution. In an article published in the Deutsche medicin- ische Wochenschrift (summarized in the Thera- peutic Gazette for December, 1894), Dr. Baxer shows that it is dangerous to anaesthetize dia- betics with chloroform, even if the diabetes is not pronounced. They recover from the anaes- thesia, but fatal coma is prone to occur within a few days, preceded by indifference, stupor, and confusion. Fortunately, local anaesthesia is now so readily produced under a wide range of conditions that there are few instances in which a general anaesthetic is indispensable, although for most major operations it is to be preferred in the absence of any special contra- indication. The danger attaching to the use of approved anaesthetics is very small; small as it is, how- ever, we should strive to reduce it to the mini- mum, and the work of anaesthetization should never, if it is possible to avoid it, be intrusted to a tyro. The anaesthetizer should give his attention exclusively to his own work, never allowing himself to get so interested in what the operator is doing as to lose sight for a mo- ment of the patient's behaviour under the ac- tion of the anaesthetic. Such a spectacle as that of an etherizer craning over toward the field of operation, and even resting his elbows on the patient's chest in boorish forget fulness, thus materially hampering respiration, is re- volting, and yet the writer has witnessed it in the operating theatre of a hospital of great renown. Whoever could be guilty of such conduct is not only grossly incompetent to administer an anaesthetic, but really unfit to practise medicine. The anaesthetizer should endeavour to induce anaesthesia gradually, with as little discomfort to the patient as possible. The particular procedures in the induction of anaesthesia will be given in the articles on the individual anaesthetics. It is quite necessary to know when the patient is sufficiently anaesthetized to admit of the operation being begun, for, if an inci- sion is made while he is still capable of feeling the pain of it, the unexpected impression made on the nervous system may, says Dr. Lyman, be severe enough to cause sudden death. A ready test is that of raising the patient's arm and letting it fall to the table; if it falls limp and lifeless, the anaesthesia is sufficiently pro- found. The test of touching the ocular con- junctiva with the tip of the finger is fallacious, for to some persons such an impression is not ordinarily painful; moreover, it involves taking an unwarranted liberty with a helpless person. When full anaesthesia has been produced, the anaesthetizer should thereafter administer just so much of the anaesthetic as may be necessary to maintain anaesthesia of the degree required, and no more, and he should continue the admin- istration by adding small quantities of the anaes- thetic to the cone or napkin frequently, rather than by allowing the patient almost to emerge from the anaesthesia and then flooding him with more of the vapour. He should take care that at all times the patient has plenty of air to breathe, laden with no more of the anaes- thetic vapour than is necessary; to no degree should asphyxiation play a part in the induc- tion of anaesthesia. From the very beginning of the process the pulse and the breathing should be watched closely, also the condition of the skin ; copious perspiration accompanied by heavy, stertorous breathing calls for a tem- porary suspension of the inhalation. A for- tiori, at the least sign of real danger, whether from failure of the respiration or weakening of the heart's action, the inhalation should be stopped, and measures at once resorted to for warding off a catastrophe. In cases of threat- ened failure of the breathing, it usually suffices to sprinkle a little cold water on the chest and to endeavour to evoke spontaneous respiratory movements by alternate compression of the lower part of the chest and pressure upon the epigastrium. If these measures do not suc- ceed promptly, the patient should be suspended with the head down, and then systematic meas- ures to set up artificial respiration resorted to, including insufflation through a tracheal tube. The expedient of seizing the tongue with a tenaculum and drawing it forward is of some value, and should be adopted especially when the body is suspended. This procedure is re- sorted to simply to establish and maintain patency of the rima glottidis; it must not be confounded with Laborde's method, to be de- scribed in the next paragraph. In the year 1894 Dr. J. V. Laborde, director of physiological experiments to the Paris Fac- ulty of Medicine, published a work entitled Le Traitement physioloqique de la mort: les fractions rhythmees de la langue. The some- what startling first term of this title—the physiological treatment of death—was really meant to apply to the management of sus- pended animation, the resuscitation of the asphyxiated, by means of rhythmical tractions of the tongue. M. Laborde tells us that he had frequently succeeded in restoring animation to asphyxiated animals in his laboratory, and that at length it happened to him to be called upon in the case of a person who had been asphyxiated by submersion, and for whose res- toration all known measures other than that of rhythmical tractions of the tongue had proved ineffectual. With his method he succeeded in bringing back the manifestations of life, and in his book he recounts a considerable number of cases in which it has been employed success- fully. These were cases (one) of a foreign body 65 ANAESTHETICS in the larynx, of asphyxia neonatorum, or of asphyxia from submersion, from an electrical shock, from tetanus, or from the inhalation of sewer air or the vapour of chloroform. Up to the time at which the book was published not a case of failure had occurred, and the proce- dure was taken up enthusiastically, with the result that in the course of a few" months it had been resorted to successfully in a great number of instances. It consists in seizing the tongue with a forceps, with a hook, or with the fingers guarded with a handkerchief, and pulling upon it regularly and with a rate of frequency corresponding' roughly to the normal rate of respiration—from eighteen to twenty-five times a minute. M. Laborde ex- plains the reviving effect of these rhythmical tractions by supposing that the throat reflexes are among the last to be destroyed in cases of asphyxia, and that the irritation of pulling upon the tongue is conveyed by the superior laryngeal, the glosso-pharyngeal, and the lin- gual nerves to the respiratory centre in the medulla oblongata, whence a motor impulse in response is sent by the phrenic nerve and by the nerves going to the thoracic and facial re- spiratory muscles. The procedure, he thinks, is preponderatingly, if not solely, a stimulus of respiration, with little if any primary effect on the heart, for he has found it unavailing after division of the phrenic nerves. Whether or not we can accept this explanation without reserve, it is to be conceded that M. Laborde has added materially to the stock of resources we can draw upon in the endeavour to resusci- tate asphyxiated persons, and rhythmical trac- tions of the tongue should be resorted to, it may be said, in all cases of asphyxia from ana'sthetization. provided other measures are not neglected. It will not do to depend upon this one procedure to the neglect of others; the patient should be placed in such an atti- tude (on the side) that liquids may flow from the mouth freely, the mouth itself should be freed at once with the finger or a sponge pro- bang of the vomited matter or thick, frothy mucus that may be obstructing the entrance to the air-passages, and the well-known means of artificial respiration employed conjointly with the tongue-pulling. According to Hare (Am. Pract. and News, Nov. 3, 1894, p. 357), artificial respiration should be preceded by extension of the neck and tilting of the head forward, which can readily be carried out with the fingers behind the head and the thumbs resting against the angles of the lower jaw. This procedure causes the epi- glottis to rise. If a faradaic apparatus is at hand, the efforts at artificial respiration may be assisted by rhythmical faradization of the right phrenic nerve, one electrode being placed just at the outer side of the carotid artery above the clavicle and the other on the right side of the chest, in the sixth intercostal space, and the current, which should not be a strong one, allowed to flow only during those artificial respiratory movements that are designed to excite inspiration. Any form of electrization of the pncumogastric nerve must be avoided; otherwise, if the heart is still acting, its action will be stopped at once. Random applications of electricity not only involve the waste of pre- cious time, but may actually prove detrimen- tal. Whatever measures are resorted to must be continued patiently and unremittingly until the patient either breathes regularly or is dead beyond peradventure. For his own protection, a physician should avoid the administration of a general anaes- thetic without the presence of a third person to guard against credence being given to any charge of misconduct to which the patient may subsequently subject him. Such charges —generally of taking liberties with the per- son, if not of actual rape—have often been made, and they are not necessarily malicious, but may be founded on the remembrance of a vivid hallucination occurring as one of the phenomena of incomplete anaesthesia. In such cases the accuser's manifest sincerity gives her a great advantage in court. Now and then the question comes up in court as to the possibility of inducing anaesthesia in a sleeping person without waking him. Such an- a'sthetization with chloroform has been shown to be possible, but its success in the hands of a person unaccustomed to the process is exceed- ingly improbable, and surely would never take place in the dramatic way that newspaper-writ- ers are fond of depicting, by the thrusting of a sponge drenched with chloroform close before the victim's nose, with the effect of producing anaesthesia instantly. When criminal anaes- thetization is charged, evidence of the most minute character should be brought forward before the charge can be held to be proved. Ordinarily, ana'sthetics are used to prevent the pain of a surgical operation, but it is not alone the avoidance of suffering that they ac- complish—they lessen the shock of a severe operation, guard against involuntary move- ments on the part of the patient that might seriously interfere with the surgeon's pro- cedures, and relieve the operator from the horrible consciousness that he is inflicting pain, and so leave him free to do whatever seems best for the patient, without regard to the amount of cutting, tearing, stretching, saw- ing, crushing, etc., that may have to be done. Quite apart from the domain of operative sur- gery, moreover, general anaesthetics have a wide range of usefulness. Especially are they of un- speakable service in midwifery. To render the pains of childbirth bearable is so easy and so free from danger that, in the absence of a par- ticular contraindication, any parturient woman who calls for an anaesthetic should be allowed to have it. The inhalation of a very little chloroform vapour as each pain comes on will answer the purpose, although at hardly any time will the patient's consciousness be fully lost. When, however, it becomes necessary to perform one of the major obstetrical opera- tions, the use of chloroform should be aban- doned, and that of ether substituted for it. General anaesthesia is often resorted to for the purpose of securing relaxation of the volun- tary muscles, in order to facilitate the reduc- j tion of a dislocated bone, also to enable the ANAGALLIS ANALGETICS 66 physician to explore the abdominal and pelvic contents more thoroughly than he could other- wise without inflicting unbearable suffering and evoking embarrassing spasmodic muscular action. It is useful also as a means of detect- ing the feigning or the involuntary simulation of'disease. In certain convulsive diseases, nota- bly puerperal convulsions, anaesthetics are serv- iceable. " Mixed Anesthesia."—This term is applied to the conjoint use of a narcotic and an anaes- thetic. It has been found that the hypodermic injection of a very small dose of morphine about half an hour before the inhalation of chloroform is to be begun shortens the stage of excitement and renders it practicable to maintain the required degree of anaesthesia with less chloroform than would otherwise be needed. The administration of a small dose of atropine before giving chloroform by inhala- tion conduces to the patient's safety, for atro- pine is a stimulant of the respiratory centre. In the case of ether the preliminary use of morphine has not generally been found advan- tageous, but rather the reverse, for it prolongs the stage of excitement, increases the frequency of vomiting, and retards the recovery of con- sciousness. However, the use of a hypoder- mic injection of morphine as ether anaesthesia passes off, to lull pain that may be expected to come on, is commonly practised, and is to be recommended. The administration of chloral before that of ether has been found little less unpleasant than that of morphine. Local anaesthesia, in the therapeutical sense, is induced anaesthesia limited to a par- ticular part. In many cases it is-to be pre- ferred to general anaesthesia, because it is generally less unpleasant and less dangerous to the patient. Often, however, it is prejudicial to the vitality of the tissues involved in the operation, or tends to shrink or exsanguinate them and then set up a secondary hyperaemia of them, whereby haemorrhage is favoured; more- over, in the case of almost any grave surgical procedure it is to the patient's interest that he should not be conscious of what is being done. On the whole, it will generally be found wise to resort to general anaesthesia in performing major operations, unless there is some special reason for not doing so. Local anaesthesia is brought about by freezing the part by causing a fine spray of some very volatile liquid, such as rhigolene or ether, to play upon it, or by the instillation or injection of an anaesthetic drug, notably cocaine. (See Cocaine, Ether, and Rhigolene.) ANAGALLIS.—The flowering herb of Anagallis arvensis, pimpernel, herbaanagalli- dis. was formerly used in infusion as a remedy for rabies and various other diseases. It is said to contain a digestive ferment. ANAGYRINE, C,4TI18N202, is an alkaloid obtained from the seeds of Auagyris fcetida, a papilionaceous plant of the group Poda/i/riee. It is an active poison, paralyzing the function of respiration. ANALEPTICS are tonic and restorative remedies. ANALGENE, or orthoethoxyanamonoben- zoylamidoquinoline, NHOOC6H5tI, is a syn- thetical derivative of quinoline occurring as a white, crystalline powder insoluble in water, but readily soluble in hot alcohol and dissolv- ing sparingly in cold alcohol. As first pre- pared, it contained acetyl, but the substitution of benzoyl for that radicle has been found to heighten its therapeutical action decidedly. It is used as a remedy for neuralgia, rheuma- tism, and spasmodic asthma. The dose is from 7 to 15 grains, which may be repeated in two hours if necessary. It is said that anal- gene sometimes imparts a cherry-red colour to the urine, but that this is of no pathological significance. ANALGESICS.—See Analgetics. ANALGESINE.—See Antipyrine. ANALGETICS are agents that give re- lief from pain, and include the anodynes and most of the antineuralgics. All anodynes are antineuralgics, but such antineuralgics as arsenic, iron, strychnine, quinine, and the nutrient agents, foremost among which is cod-liver oil, are not anodynes. Pain is the conscious recognition of an irritation in some portion of the nervous system, and is due to disease or perverted conditions which affect nerve tissue directly or indirectly. Anodynes are simply pain-relievers, and are given to less- en the normal or heightened sensibility of a part; while antineuralgics are made to include these, they also comprise remedies which are supposed to aid in removing dyscrasic blood states which are not infrequently the cause of the pain. It is probable that all the analgetics might be included under the antineuralgics, but, as custom favours it and it seems conven- ient, a short space will be devoted to ano- dynes. Anodynes.—The most powerful and cer- tain are opium and some of its derivatives, morphine and codeine. Were it not for the unpleasant effects in many persons following the use of opium, and the danger of estab- lishing the drug habit, we should rarely have occasion to resort to other remedies for the di- rect relief of pain. Since, however, the direct effects of opium on some are more distressing than the pain which it has been given to re- lieve, and the danger of creating a craving for opium is always great in persons who are, or become, tolerant of its effects, it often de- volves upon us to resort to other agents, either alone or in combination with it. Anodynes should be employed with judgment and "cau- tion. If possible, the patient should never know what he is taking, and it should be impossible to have the prescription for an anodyne renewed without the knowledge and consent of the physician. A combination of two or more of these agents prevents the pa- tient from becoming accustomed to the sole influence of either. When anodynes have to be continued for a considerable length of time, one drug should be substituted for another every few days. In treating the hysterical and the neurotic the physician should always be on his guard lest the d'rug habit be established. 67 ANAGALLIS ANALGETICS Opium and its Derivatives.—In all cases of sudden, violent, and acute pain, such as at- tends an attack of cholera morbus, a severe surgical injury, or a paroxysm of suffering so common in certain lesions of the nerves and central nervous system, nothing takes the place of one of the salts of morphine, preferably the sulphate, administered hypodermically in doses varying from eight milligrammes (\ of a grain) to two centigrammes (j of a grain), or even more, according to the severity of the pain. Hysterical paroxysms should not be relieved by opium in any form, as a rule. It is better to Jet the patient endure some suffering until relief is obtained by other, slower and safer, measures, lest the habit of resorting to opium on every occasion confirm the patient in in- validism, and establish the drug habit. The pain caused by acute inflammation of the serous membranes, especially of the abdomen, chest, and joints, is often relievable only by opium in some form. For the relief of angina pectoris, a hypodermic injection of morphine is often resorted to, and not infrequently with good effect, but it is just here that acute pain may at times be promptly relieved by an agent that has no direct analgetic properties. Amyl nitrite, early in the disease, if the patient is al- lowed to inhale from 4 to 8 drops, affords relief almost instantaneously, even when morphine has failed. Pain as a result of enteritis, exces- sive intestinal peristalsis, or tenesmus, yields promptly to opium, and in tenesmus camphor is an excellent adjuvant. Comparatively small doses of opium in combination with other agents not infrequently act better in relieving continuous pain than large doses when given alone. This is seen especially in cases of in- flammation of the sciatic nerve, where 1| cen- tigramme (i of a grain) of morphine with £ of a milligramme (fa of a grain) of atropine will often give relief for twenty-four hours or lon- ger; but if morphine is injected alone, several injections are required' to produce the same effect. Opium acts well in combination with cannabis indica or belladonna in relieving pain, of uterine or ovarian origin. While we should not administer opium if one of the other anodynes will give the necessary relief, when we are compelled to give it. the smallest possible dose should be used, except for the relief of severe pain, especially of traumatic origin, when the quantity should be sufficient to afford prompt relief. When opium is admin- istered by the mouth, old opium pills will often he followed by less disagreeable effects than morphine or the other preparations of opium. In the early stages of meningitis the hypoder- mic use of" morphine promptly relieves pain and allays restlessness, and apparently has no bad effects upon the morbid process. Codeine.—There are two preparations of co- deine, the sulphate and the phosphate. The latter, on account of its ready solubility in water (about 1 to 4 parts), is preferred for hy- podermic administration; 0-061 gramme (1 grain) of codeine is equivalent to about 0-0103 gramme (,'; of a grain) of morphine. Codeine is less likely than morphine to disorder the stomach, constipate the bowels, and produce disagreeable itching of the skin, but it is not entirely free from these unpleasant effects, and it is a much less reliable agent for the relief of pain. In the chronic inflammatory and de- generative diseases of the nervous system, in which anodynes have to be employed over long periods, codeine, especially if combined with cannabis indica and phenacetine, may obviate the use of morphine. Cannabis indica.—When this is given alone it has, as a' rule, very feeble anodyne proper- ties, except in pain of ovarian or uterine ori- gin and in many cases of nervous and reflex headaches. To relieve pain with cannabis in- dica, it must be given in sufficiently large doses to produce the physiological effects of the drug. Obstacles to the use of this agent are the "difficulties heretofore experienced in obtaining reliable preparations of uniform strength and the unpleasant, though harmless, sensations experienced from its use. The most reliable of the solid extracts that I have used is the one made by Hering, of England. The dose of this varies from 0008 gramme (-J- of a grain) to 0-016 gramme (i of a grain), and even the smaller dose will be found to produce de- cided physiological effects in some persons. The extracts made by most American manu- facturers may be given in doses varying from 0-016 gramme (J of a grain) to 0-066 gramme (1 grain), or even more. Next to the extract made by Hering, the " normal liquid " made by Parke, Davis, & Co. seems to be the most certain in its strength. This may be given in doses varying from 0-185 gramme (3 minims) to 0-616 gramme (10 minims). Cannabis in- dica given in capsules with acetanilide or phenacetine, citrate of caffeine, and monobro- minated camphor aids in relieving pains from most of the chronic nervous disorders for which morphine has been commonly used. Anesthetics.—Ether or chloroform promptly relieves pain and relaxes muscular spasm. They are indicated when immediate relief from pain and an antispasmodic are demanded. The suffering caused by renal and hepatic colic is almost immediately relieved by these agents. Belladonna.—This remedy for the relief of severe pain, unless the suffering is due to spasm of involuntary muscles, when used alone, is almost valueless. Its best effects for the re- lief of pain are obtained when it is employed in connection with morphine. A small quan- tity of atropine added to morphine greatly aids in relieving the pain of lead, hepatic, and renal colic and spasmodic dysmenorrhea. When it is remembered that belladonna relieves pain largely by relaxing muscular spasm, espe- cially of the involuntary muscles, the indica- tions for its use as an anodyne will be appre- ciated. This agent has been employed for the relief of pain caused by spasm of the voluntary muscles, but to have much effect under such circumstances it must be injected directly into the affected muscles. Belladonna seems to prolong the anodyne effect of the morphine, and a prolonged relief from pain may be ob- tained by injecting morphine and belladonna ! into inflamed muscles and into or around in- flamed nerves. For the relief of pain from ANAPHRODISIACS ANATRIPTICS 68 spasm of the muscular fibres of the intestines, belladonna is administered by the mouth, and for this purpose the tincture, from 0-308 to 0-924 gramme (5 to 15 minims), the alcoholic extract, 0-008 to 0-032 gramme (\ to \ a grain), or the fluid extract of the root, 0-0616 to 0-123 gramme (1 to 2 minims), may be used; For hypodermic administration, sulphate of atro- pine is the most eligible preparation in a dose of from 0-0006 to 0-001 gramme (jfa, to fa of a grain). Antipyrine, in doses varying from 0-66 to 1-33 gramme (10 to 20 grains); phenacetine, in doses of from 0-20 to 1-33 gramme (3 to 5 grains); exalgine, in doses of from 0-133 to .0-266 gramme (2 to 4 grains); acetanilide, in doses of from 0-20 to 0-33 gramme (3 to 5 grains); asaprol, in doses of from 0-20 to 0-33 gramme (3 to 5 grains); salol, in doses of from 0-33 to 0-66 gramme ( 5 to 10 grains), and some other agents of this group, given every two, three, or four hours, according to the urgency of the case, are capable of relieving pain. All except antipyrine are best administered in capsules or in pill form. On account of their antiseptic properties, these remedies are effi- cient in relieving headache caused by the prod- ucts of fermentation of the gastro-intestinal canal. Antineuralgics.—In referring to neuralgia in this connection the so-called idiopathic form is meant. Neuralgia proper is due to per- verted nutrition and reflex or direct irritation. The perverted nutrition may be caused by altered blood states or temporary or perma- nent increased or decreased blood supply to a part. Mechanical or chemical irritants may give rise to direct or reflex pains or to both. In selecting a line of treatment for any form of neuralgia the cause must be searched for and removed if possible. The Choice of Antineuralgics for Neuralgia due to Altered Blood States.—The condition of the blood may be due to anaemia or to toxic agents, such as alcohol, lead, malarial poison, and various toxines. The toxic irritants must be removed by appropriate agents, and the blood must be improved by hygienic measures, nourishment, and remedies that have a tonic action. Physical rest, sometimes absolute rest in bed, is often of the greatest advantage, but this depends upon the character of the anaemia,. Blood-corpuscles are able to absorb and carry oxygen in proportion to their richness in haemo- globin, and if this is reduced to a greater ex- tent than the corpuscles, physical rest becomes of the first importance. Under such circum- stances rest should be secured even at the loss of abundance of fresh air, which is of less im- portance. It is well known that muscular ex- ertion uses up oxygen: and if the corpuscles are poor in haemoglobin, the tissues suffer in their nutrition, and the organic functions, such as digestion, respiration, and circulation, are imperfectly performed. In most forms of anae- mia except the pernicious variety the haemo- globin is deficient, and rest is frequently of marked benefit in the treatment. On the other hand, the blood-corpuscles sometimes contain from 25 to 50 per cent, more haemoglobin than normal in pernicious anaemia, so that in neural- gia from this form of anaemia a slight amount of exercise is beneficial. Exercise in modera- tion should only be denied to neuralgics whose nervous disturbance is due to well-marked non- pernicious anaemia. Fresh air is an aid to tis- sue metamorphosis, and should be sought for neuralgics, but not at the expense of needed rest. An abundance of easily digested, nutri- tious, and appetizing food should be insisted upon, and the best is animal food. Cod-liver oil is an excellent agent in the treatment of those forms of neuralgia which are due to im- paired nutrition. Hydrotherapy, massage, and sometimes electricity are excellent aids in im- proving nutrition and in overcoming a neu- ralgic diathesis. The antineuralgic remedies that have a tonic action are arsenic, iron, quinine, strychnine or nux vomica, the zinc salts, especially the phos- phide and valerianate, and free phosphorus. Arsenic and iron are the most useful of the remedies just mentioned in neuralgia due to anaemia. It is well in most instances to give iron and arsenic at the same time. The form in which iron is administered matters but little if it does not disarrange the digestive organs. Lactate and pyrophosphate of iron are two ex- cellent preparations which may be adminis- tered in capsules in 0-324-gramme (5 grain-) doses thrice daily to persons who are unable to tolerate the tincture of the chloride or the other astringent forms of the metal. For the pro- longed administration of arsenic Fowler's so- lution, in 0-123-gramme (2-minim) doses thrice daily after meals, is one of the most convenient methods of giving it. Quinine in non-malarial cases is an excellent antineuralgic in anaemic persons, and need'not be given in more than 0-130-gramme (2-grain) doses thrice daily. Strychnine or nux vomica forms part of most prescriptions for the relief of patients suffering from neuralgia caused by impaired nutrition. Either is an efficient agent. Phosphide of zinc is an excellent tonic, and mav be given in capsules in doses varying from 0-004 to 0-208 gramme (fa to | of a grain) thrice daily after meals. Valerianate of zinc docs not seem to be a very reliable tonic in neuralgia, but has been more effectual as a sedative in cases attended with considerable emotional disturb- ance. Free phosphorus, dose 0-0006 gramme (tott of a grain), has been extensively used in neuralgia, but it is only occasionally that it seems to do much good. Special Agents in the Treatment of Neural- gia due to Altered Blood States other than Simple Anemia.—Neuralgia caused by chronic malarial disease is best treated by a few anti- periodic doses of quinine, then by quinine in tonic (loses in combination with iron and arsenic. Of late I have had success in treat- ing neuralgic pains of chronic malarial orit/in by methylene blue in doses varying from 0-016 to 0-048 gramme (± to } of a grain) in a cap- sule with powdered nutmeg three or four times daily. In small doses it rarely disorders the stomach if given with nutmeg. It discolours the urine and sometimes causes vesical and urethral irritation if the doses are very lar"-e 69 ANAPHRODISIAf'S ANATRIPTIL'S and continued for some time. In neuralgia caused by syphilis, potassium iodide and mer- cury are specifics. In neuralgia due to lead, potassium iodide and bromide apparently act better than the iodide alone in getting rid of the lead deposited in the tissues. Neuralgia from chronic alcoholism is always associated with ana'inia. Besides withdrawing alcohol, those agents must be employed that have been recommended in ana'inia, Choice of Remedies in Neuralgia due to In- creased or Lessened Blood Supply to the Part affected.—Increased vascularity may be tem- porary or constant. The cause may be reflex, local, or genera], giving rise to vaso-motor dis- turbances which result in dilatation of the arterioles. If possible, the cause should be re- moved. The bromides have a good influence in congestive neuralgias, especially affecting the head (probably the cerebral dura), but aconite, and its active principle, aconitine, are more efficient and reliable. Duquesnel's prepa- ration of aconitine may be given in doses varying from 0-0003 to 0-0006 gramme (-pfa to T(',tj of a grain) every two hours with decided benefit in this form of neuralgia affecting the fifth cranial nerve. Gelsemium is often an efficient agent in trigeminal and ovarian neu- ralgias. The fluid extract may be given in doses varying from 0-135 to 0-308 gramme (3 to 5 minims) every two hours till the physio- logical effect of the medicine is experienced or the pain is relieved. The tincture is of about one third the strength of the fluid extract. As the strength of different official prepara- tions of gelsemium varies greatly, it is safer to begin with the smaller dose and gradually in- crease until the desired effect is obtained. In neuralgia due to deficient blood in a part, nerve and cardiac stimulants, such as sulph uric el her, valerian, nitroglycerin, amyl nitrite, or small quantities of alcohol, are useful. In some cases of neuralgic headache, attended with insufficient blood in the brain, amyl nitrite or nitroglycerin affords prompt relief. Unless pain is relieved by these agents with a few doses, it is not likely that a further trial of them will be beneficial. When the neuralgia is due to certain diatheses, such as rheumatism and gout, appropriate remedies must be given for these conditions. Sometimes neuralgia caused by the presence of an irritant, such as a diseased tooth, remains after the offending body has been removed. Under such circum- stances the neuralgic habit must be broken up by sedatives, anodynes, and tonic agents. 'Agents for the Immediate Relief of Neu- ralgic Pain.—Some of the remedies already mentioned afford prompt ease. Among these maybe instanced amyl nitrite and nitroglyc- erin. Opium and its preparations—cocaine, cannabis indica, belladonna, croton- chloral, antipyrine, phenacetine, acetanilide, exalgine, asaprol, salol, mefhylal, and chloride of methyl —have been used by the mouth, and a number of them hypodermically, for the pain of neu- ralgia. Opium and its preparations afford almost immediate relief from suffering, but they should never be resorted to in neuralgia if it is possible to do without them. When they are employed, it is safer to use them with other remedies. For hypodermic use morphine and atropine form the best combination. Hy- drochloride of cocaine injected at the seat of pain. 0*016 gramme (i of a grain), often affords great relief. On account of the danger of the cocaine habit, it is not a remedy to be trifled with. Cannabis indica in full doses, especially when combined with acetanilide or phenace- tine, is a safe remedy. It alone acts excellently in relieving headache in the neurasthenic. To break up the headache, habit in these cases it is often necessary to keep up a gentle physio- logical effect of the medicine for several days. Belladonna is not a reliable anodyne in neu- ralgia, but at times it acts well when combined with other anodynes. Butylchloral hydrate (croton - chloral), in 0-324 -gramme (5-grain) doses every half hour, administered in syrup, often gives relief in trigeminal neuralgia. If the pain is not greatly lessened by the time four or five doses have been given, it is probable that further trial will be useless. Antipyrine, phenacetine, and acetanilide are useful remedies for the relief of neuralgic pains, but it is not well to rely upon them to the exclusion of other agents with which it is advantageous to give them. The most use- ful of them are cannabis indica, codeine, and belladonna. Caffeine citrate prevents depres- sion from the steady use of such depressing agents as antipyrine, phenacetine, and acet- anilide, and monobrominated camphor seems to increase their power in relieving pain. I must confess that I have been disappointed in the use of exalgine. It may have been that the preparations were not pure. I have had no experience in the use of methylal, so highly spoken of by some for neuralgia in superficial nerves. It may be administered by the mouth or hypodermically in 0-32-1- to 1-gramme (5- to 15-grain) doses. Debove has praised chloride of methyl as an analgetic in sciatica, lumbago, and trigeminal neuralgia. It is applied in the form of a spray to the skin over the affected nerves. I have employed the method first practised in th.s country by Dr. Frederick Peterson, of New York, with the effect of promptly relieving pain in the trigeminal nerve. It consists in using a solution of cocaine, morphine, or some other analgetic agent in a properly constructed electrode which is attached to the positive pole of a galvanic bat- tery and applied over the affected nerve. The negative electrode, if the trigeminal nerve is the seat of the pain, is applied at the back of the neck. Five or ten milliamperes will be found sufficient for the strength of the current, although Peterson recommends a much greater strength. [See under Electricity.] Several external applications, such as camphor-chloral (equal parts of each rubbed together), veratrine ointment, heat, cold, mustard paste, and blisters have been used with success in certain forms of neuralgia.—J. T. Eskridge. AN APHRODISIACS. — See Antaphro- DISIACS. ANATRIPTICS.—Medicinal preparations designed for use by inunction. ANDA OIL „n ANIMAL EXTRACTS AND JUICES 70 ANDA OIL.—An oil (oleum ande) said to be obtained from the fruit of Johannesia prin- ceps, a South American tree of the Euphorbia- cee, and to have the medicinal properties of castor oil without its disagreeable odour. The dose is one fourth that of castor oil. An alka- loid, Johannesine, has been found in the oil. ANDIRA.—A tropical genus of papiliona- ceous trees. The wood of Audira Araroba con- tains Goa powder. Andira anthelminthica is a Brazilian species the fruit of which is used as an anthelminthic. Andira bark, cortex an- dire, is thought to be derived chiefly from Andira (Geoffrea) inermis and Andira retusa. It is a violent emeto-cathartic. In doses of from 5 to 20 grains, it is used for the expulsion of lumbricoid worms. The dose of a non-offi- cial fluid extract used in France is from 15 to 30 grains. ANDROGRAPHIS PANICULATA, Justicia paniculata, is an acanthaceous annual found in India, Ceylon, and Cochin-China. The bark is official in the Ph. of India as an- drographis cortex. It is a stomachic tonic re- sembling chiretta, for which it is sometimes substituted. An infusion is made with 5 parts of the bark and 100 of boiling water. ANDROPOGON.—A genus of grasses, mostly tropical. Andropogon pachnodes is of- ficial in the Ph. of India, also Andropogon citratus. From the leaves of these and other species several varieties of aromatic oil, the oleum andropogi citrati of the Ph. of India, are distilled. The oil is used as a carminative and as a stimulating embrocation. ANEMONE PRATENSIS, ANEMONE PULSATILLA.—See Pulsatilla. ANEMONIN, C15H]206, a camphor-like crystallizable substance found in Anemone pra- tensis and in several allied plants, is a violent poison. It has been used in dysmenorrhea in doses of from 0-015 to 0077 of a grain. ANETHUM FCENICULUM.—See Dill. ANGEIONEUROSINE. — See Nitro- glycerin. ANGELICA.—Several species of this genus of umbelliferous plants were formerly recog- nized in the pharmacopoeias, and Angelica Archangelica (angelique officinale), garden an- gelica, still figures in the Fr. Cod. The root and the fruit are tonic and provocative of ap- petite. ANGINE.—Crude wool-fat. ANGOSTURA, ANGUSTURA. — See CUSPARIA. ANHALONIUM LEWINII, a Mexican cactaceous plant, now referred to the genus Mamillaria, is the source of " muscale buttons." It contains an alkaloid, anhalonine, which has been found to act as a tetanizing poison. ANHYDROSULPHAMINEBENZOIC ACID.—See Saccharin. ANIDROTICS.—See Antiiidrotics. ANILINE, (^II6.NII2 + 2II2(), called also phenylamine and amidobenzene, was first ob- tained by the distillation of certain indigoes, but is now one of the coal-tar products. It is a colourless, aromatic liquid, of an acrid, burn- ing taste, soluble in 31 parts of water and in all proportions in alcohol, ether, or oils. It is an alkaloid, forming crystallizable salts with acids. It is an irritant poison, and continued exposure to it leads to muscular weakness, a leaden or bluish discoloration of the skin and nails, vari- ous cutaneous eruptions, and mental disorders. It has been used medicinally in daily amounts of from 0-77 of a grain to 2-31 grains, in water acidulated with sulphuric acid, chiefly in chorea and epilepsy, but its employment as a drug is open to the objection that it is apt to give rise to unpleasant effects, and its remedial efficiency does not seem to be such as to warrant its use. Several of its derivatives, however, have come into extensive use. Aniline Camphorate, (C6H7N)2CioH1604, has recently been employed by Tomaselli as an antispasmodic. It is a white or reddish crystal- line substance obtained by dissolving 50 parts of camphoric acid in 150 parts of absolute al- cohol, and adding 56 parts (or enough to make a neutral solution) of aniline. The crystals are obtained by evaporating this solution. They are soluble in water, glycerin, alcohol, or ether. Glycerin dissolves one tenth of its weight of the salt, and a 10-per-cent. glycerin solution will bear dilution with an equal bulk of water without becoming turbid. From 8 to 12 grains of aniline camphorate may be given in the course of twenty-four hours. ANIMAL EXTRACTS AND JUICES. —The time has not yet arrived to pass final judgment on the value of most of the animal extracts as therapeutic agents. Some, most prominent among which is the thyreoid extract, will find a permanent place in therapeutics, while others, probably the non-glandular ex- tracts, may share the fate of so many quasi- therapeutic agents which have flourished one day and been forgotten the next. From time immemorial there has lingered a vague and indefinite belief in the efficacy of animal substances in the cure of disease. Ancient pharmacy was filled with vile and disgusting compounds made from the excreta or bodies of animals, fish, reptiles, or insects. According to the Medical Press (1889), Horace, in one of his odes, pays his respects to the invigorating influence of the animal ex- tracts and beseeches the witch Canidia to re- veal to him the secret of the draught which she prepared at night by crushing in a mortar pieces of flesh torn from" the most fiery horses of Rome, and the patricians, says the Latin poet, used this mysterious liquid with great confidence. (Medical Record, July 20, 1889 p. 70.) y "Dr. Archie Stockwell, in the Therapeutic Gazette for January, 1890, wrote an elaborate historical and critical article regarding the tes- ticular secretion in therapeutics. According to this author, Paracelsus anticipated Brown- Soquard, for out of the spcrma hominis he made his homunculus, and asserted that 'it was good against the imbecility of the instru- ments of generation.' In the Ilortulus genialis of Baricellus, Genoa, 1620, is found a receipt for sexual rejuvenescence the principal ingre- dient of which is the testicle of the wild boar, and a parallel prescription is offered in a work by Elzen Blaze one hundred and twenty years later. During the seventeenth century repro- ductive products as obtained from mammals, birds, and fishes still enjoyed an enviable repu- tation as cerebro-spinal and genital excitants; they were occasionally endowed with specific attributes in diseases of mucous membranes or those due to nervous derangements, such as ' the falling sickness,' chorea, and neurasthenias. They were, however, more generally employed to restore sexual vigour and increase virility, and found a prominent place in the London Pharmacopoeia as issued by the Royal College of Physicians in 1076, and also in" Salomon's New London Dispensatory of 1684. In the eighteenth century most animal remedies were dropped from the Pharmacopoeia, and the tes- ticles among them." (Ibid., Feb. 15, 1890, p. 186.) It is quite evident, from a study of the mode of preparation and administration of the animal substances employed in medicine prior to a re- cent date, that they were unattended with any beneficial effect beyond the psychical, and that they held a place in the pharmacopoeias only on account of the superstition and mysticism which dominated medicine for a number of centuries. To the eminent investigator Brown-Sequard is due the credit of directing the medical pro- fession to the study of the animal extracts and juices as therapeutic agents. Regardless of the value that we may attach to the importance of his investigations and discoveries in animal therapeutics, we should not hesitate to accord to him scientific enthusiasm, indomitable per- severance, and honesty of purpose, notwith- standing that by reason of advancing years he was inadvertently led to attach an undue im- portance to his orchitic fluid. Much of the odium and ridicule which have deservedly been heaped upon some of the preposterous allega- tions for the testicular fluid have been due more to the blind enthusiasm of many of Brown-Sequard's followers than to the direct statements of the eminent physiological inves- tigator himself, although, in candour, we must admit that in his review On a New Therapeu- tic Method Consisting in the Use of Organic Liquids extracted from the Glands and Other Organs (British Medical Journal, June 3 and 10, 1893) he accepted the unwarranted state- ments of others as proof of the marvellous in- fluence of the orchitic fluid in the cure of certain organic diseases of the spinal cord. In 1869, at the Paris School of Medicine, Brown-Sequard delivered several lectures the principal object of which was to establish the fact that all glands, with or without excretory ducts, gave to the blood by an internal secre- tion principles which were of great importance if not necessary. He endeavoured to show this to be the case for the kidneys, the suprarenal capsules, and the sexual glands. In 1875 he reinvestigated this subject at Nahant (near Boston), and professed to have confirmed the ANDA OTL 1 ANIMAL EXTRACTS AND JUICES correctness of the views which he had ad- vanced in 1809. He says: " I thought that if we could safely introduce the principle of the internal secretion of a gland taken from a liv- ing animal into the blood of men suffering from the lack of that secretion, important therapeutic effects would thereby be obtained. In February, 1889. in a paper deposited at the Biological Society, I stated that I had found that means, and it consisted in injecting under the skin the liquid extract we can get easily from glands by pressure, with the addition of a little water. Since then, with the help of my assistant, Professor d'Arsonval, I have pushed matters considerably forward, and I have espe- cially tried to prove that not only glands, but all tissues, have, besides their influence on blood resulting from the interchange of nutri- tion, an internal secretion." (British Medical Journal, June 3, 1893.) As many of the unpleasant results following hypodermic injections of animal liquids seem to be due to the presence of septic material in the fluid, it is of the first importance that every necessary precaution to procure thoroughly sterilized extracts should be taken. The mode of preparation of all organic extracts given by Brown-Sequard, from a paper by d'Arsonval (British Medical Journal, June 3, 1893), is probably the best, and I shall reproduce it here with the illustration which accompanies the description. " We procure the testicles" (these glands are only mentioned for example, as Brown-Sequard states that the same procedure is followed in the preparation of all the animal extracts for hypodermic administration) " of bulls at the slaughter house. Just after the killing of the animal a ligature is placed as high as possible on the whole mass of the spermatic cord, so as to get at least a certain amount of the blood contained in the veins. When the organs reach the laboratory their coverings are at once re- moved with scissors sterilized by heat. The or- gans are then washed in Van Swieten's liquor " (corrosive sublimate 1 part to water 1,000 parts), " and afterward in recently boiled water. That being done, each of the organs is cut in four or five slices, which, with the piece of cord, are placed in a glass vase, in which is thrown, for each kilogramme" (about 22 pounds) "of the organs used, 1 litre " (about a quart) " of gly- cerin marking 30 degrees. The vase is covered, but it is essential during the next twenty-four hours to turn over a good many times the slices and other pieces of organs. At the end of that period an addition of 500 cubic centi- metres " (a pint) " of freshly boiled water, con- taining 25 grammes of pure chloride of sodium, is made. The liquid so obtained is made to pass through a paper filter (we use the syrup gray filter No. 8 of the Laurient series). Be- fore doing this, however, we hardly need to say that the paper filter and the glass funnel in which it is placed must be thoroughly washed with boiling water. The filtered liquid is slightly rose-coloured. To hasten the filtration it is well to raise the temperature of the glyc- erin solution to 40° C." (104° F.); "the vis- cosity is thereby suppressed. ANIMAL EXTRACTS AND JUICES 72 " Of the various means we have made use of to obtain a liquid absolutely free from microbes or other dangerous pieces of solid matter, the most important is the one we will now de- scribe. The sterilizing d'Arsonval filter, repre- sented in the annexed figure, is composed of a metallic hollow cylinder, which receives and keeps immovable the thick steel bottle, B, filled with liquid carbonic acid; a metallic tube, F F, which has borne the weight of 200 atmospheres; a metallic stopper screwed on the lower extremity of this tube, and carrying the filtration bougie, b. This bougie is of a which is surrounded by a manometer gradu- ated up to 100 atmospheres, and carries also a screwing top, which allows the escape of the accumulated carbonic gas when this is needed. An adjoining lateral tube, E, serves for com- munication between the sterilizing filter and the liquid carbonic acid contained in the steel bottle, B. A stopper, R, with a steel point, put in action by a key, C, gives the pos- sibility of establishing or stopping communica- tion between the two tubes B and FF, so that the pressure against the liquid which is to be filtered may be gradual. The two tubes or two apparatuses form a whole, fixed on a wooden tablet, s, which is screwed firmly on a table. To sterilize the glyceric liquid it is first thrown into the tube F F ; then, after having screwed solidly the superior stopper on which is the manometer, M, and having turned to the end of the closing screws, Uand V', the tap, B, of the steel bottle, B, is opened. The carbonic acid enters rapidly into the tube F F, and presses over the liquid. A pressure of 50 to 60 atmospheres is maintained for about an hour, during which all the microbes that may be present are crushed and killed. The pres- sure may be increased, notably if the appara- tus is submitted to a temperature of 40° C. (104° F.). Neither the albuminoids nor the soluble ferments are in the least altered, as has been ascertained with pancreas and yeast. When the sterilization is considered sufficient (from half to one hour for tissues of a healthy animal), the tap, V, is opened, and the liquid filters rapidly through the bougie, b, after hav- ing been submitted to two sterilizations, the first one by C02 under pressure, the second by the filtration." There are several methods of preparing some of the animal extracts, but the one adopted by Brown-Sequard is probably the most reliable. It has the disadvantage that the extracts should be used soon after they are made, as thev begin to deteriorate within a few days. Extracts whose efficacy is not destroyed or greatly im- paired by the digestive fluids mav be made dry, and then can be kept for a considerable length of time. The dry thyreoid extract is the prin- cipal one on the market to-dav. The Colum- bia Chemical Company, of Washington, D. C, makes liquid preparations of most of the glands, and of many of the other tissues of the body, and states that they mav be kept without fear of deterioration for any reasonable length of time. My experience with this company's prep- arations is not sufficient to enable me to draw just comparisons between them and those made according to the d'Arsonval method at the Pas- teur Institute, of New York. The question is often asked, Is there any therapeutic value in the animal extracts and juices f Some have painted in glowing terms alleged results from their use, which, to say the least, are marvellous, while others, many with- out giving them a trial, and some without ex- tended experience in their use, have denounced most of them in unmeasured terms. When we come calmly to review the literature of the whole subject we are forced to the conviction that all the animal extracts, when injected hypodermically, exert some influence on the organism. The fault seems to have been due to two causes: A number have exhibited too great eagerness in reporting experiments and too great enthusiasm in detailing real or sup- posed results; while others, disregarding ail facts, have refused to investigate or be con- vinced. The unpleasant effects of the testicu- lar juice on epileptics, and the brilliant results obtained from the use of the thyreoid gland, or an extract made from it, in myxcedema and other diseases, to say nothing of serum therapv. etc., should, in view of the fact that ordinary"thera- peutic measures are so unsatisfactory in dealing with many diseases for the treatment of which great pretensions are made by some for animal extracts, determine us to wait carefully results which competent and reliable observers"seem to obtain from the use of various animal sub- stances. We are not asked, or even expected, to accept theories. That every non-glandular organ of the body possesses an active principle which, when administered hypodermically, is capable of exerting a special influence in dis- ease of that tissue or organ from which the liquid is extracted, is too chimerical, it seems to me, to deserve serious coiLsideration. Such substances, when introduced in a concentrated form into the subcutaneous tissues, may act as tonics or stimulants to the nervous system; they may, inherently or by virtue of some leu- comaine which may develop, possess some anti- toxine influence, and thus result in destroying or neutralizing toxines which may be the direct cause of the disease for which the extracts are being used. There are, no doubt, other ways by which these animal agents may act in neu- tralizing the effects of disease. If we are to make advance in this line of therapeutics we must first accept facts and patiently wait for satisfactory explanations, which may or may not come. Before considering the individual animal ex- tracts, it may not be amiss at this time to say a few words in regard to their administration and the precautions necessary to observe when the hypodermic method is employed. It seems to be "conceded that the vast majority of the animal extracts of the glands or other tissues from which the extracts are derived, when taken into the stomach, have their active prin- ciple destroyed by the digestive ferments. We know that the toxic principles of woorara and serpent's venom are neutralized by the digest- ive agents. Numerous observers find an excep- tion to this general rule in the thyreoid gland, whose therapeutic powers are nearly as great when it is administered by the mouth as when it is given subcutaneously. According to Dr. C. Macalister, the thymus gland and the me- dulla of bone do not lose their therapeutic ef- fects when administered by the mouth. Most of the extracts of animal matter, as now made, contain considerable glycerin, and are too irri- tating for hypodermic use in their pure state. The syringe which is employed when admin- istering these extracts should be large enough to hold about three or four times as much as is necessary for a dose. After the requisite quan- tity of the extract has been drawn into the 3 ANIMAL EXTRACTS AND JUICES syringe the instrument should be completely- filled with freshly boiled water and shaken to allow the fluids to mix thoroughly. Thorough aseptic precautions should be observed in giv- ing the injection. The part into which the needle is to be thrust should be well washed with soap and water, and afterward with a corrosive-sublimate solution. The needle and syringe should be rendered aseptic by immers- ing them in boiling water just before using them, and it is a good plan to clean them again by the same means immediately after giving the injection. It is probable that the unpleas- ant local effects following the injection of the animal extracts, such as great pain, inflamma- tion, and sometimes abscess, have been due to septic material in the liquid or to microbes carried into the tissues from the septic skin on the needle of the syringe. Those who have been most careful in obtaining thoroughly ster- ilized animal extracts and have employed every aseptic precaution in introducing them have had no abscesses to report from this treatment. As many object to the hypodermic injections of the animal extracts on account of the pain that not infrequently follows their use in this manner, the mucous surfaces of the rectum and mouth may be made use of with advantage for those extracts whose active principle is de- stroyed by the digestive ferments. When the mouth is used, about twice the usual quantity for subcutaneous injection should be dropped on the tongue, and the patient requested not to swallow for half an hour. When the rectum is the method of administration, about twice the dose given by the mouth should be given in an ounce or two of water. There will not be much difficulty in retaining the rectal injection and getting it absorbed if the lower bowel has been previously cleared by an enema and the patient remains in the recumbent posture for half an hour after receiving the extract, Rectal diges- tion is so feeble that it is probable that the liquid will be absorbed without undergoing much change. Orchitic or Testicular Liquid.—On June 1, 1889, at the Societe de biologie, Brown- Sequard made his first communication on the orchitic liquid. Within a short time he pre- sented several reports to the society on the use of this liquid, a full account of which is found in the Lancet of July 20, 1889. As a result of a few injections in his own person the eminent physiologist maintained that his mental and physical vigour, and his power of endurance without the accustomed fatigue, were increased. Before the use of the injections a half hour's work in the standing posture in his laboratory exhausted him. After the second injection he was able to work for two or three hours with- out any feeling of exhaustion, the dynamometer showed increased power of the muscles, con- stipation and paresis of the bladder were re- lieved, and, while before the treatment he had felt unusually feeble for his age (seventy-one years), after the use of the orchitic liquid he experienced a vigour that he had known thirty years before. The sexual passion and appetite were said to be increased. Following Brown- Soquard's early communications on the influ- 74 ANIMAL EXTRACTS AND JUICES ence of the orchitic fluid injected into the sub- cutaneous tissue, a number of medical men, both in Europe and in America, reported the results of their experience with the liquid in question, and some of them alleged greater effects than the illustrious physiologist had thought possible, while the more conservative had obtained either negative results—barring accidents, such as pain, inflammation, or ab- scesses at the seat of the injection—or, at most, only temporary stimulation of the nervo-vas- cular system in persons who were in feeble health. Results were so contradictory in the experience of different observers that the mar- vellous statements of some served to bring the agent into disfavour. Had it not been for the brilliant experience on the functions of the thyreoid gland by Schiff, von Eiselberg, Bircher, and Victor Ilorsley, it is probable that to-day the Brown-Sequard treatment would be sim- ply a matter of history. Locomotor Ataxia.—In 1892 Professor Brown- Sequard and Professor d'Arsonval agreed to fur- nish all kinds of animal extracts that might be asked for by physicians, on the condition that the histories of the cases, with the results of treatment, should be sent to them. More than twelve hundred physicians availed them- selves of this generous offer, and as a result Brown-Sequard and d'Arsonval received re- ports of over sixteen hundred cases that had been treated by the orchitic liquid. Among these cases there were three hundred and forty- two of locomotor ataxia in which the diagnosis seemed to be reliable. Of this number, three hundred and fourteen were reported improved or cured. Dr. Depoux, who seemed to have been the first to use the orchitic fluid in loco- motor ataxia, reported five complete cures, six cases of progressive amelioration, and two fail- ures, out of thirteen cases treated. Dr. Gilbert, a physician of Havre, treated two cases, with a cure in each. Victoroff, of Moscow, treated seven cases, with a result of five either cured or greatly ameliorated. Brown-Sequard states: " The various other kinds of sclerosis of the cord give a proportion of 85 per cent, of cures or ameliorations, while ataxy gives about 90 per cent." (British Medical Journal, June 10, 1893). It is due to Brown-Sequard to state that he adds: " We reserve the question of cure of organic diseases. All that we have just stated applies to the cessation of morbid manifestations." One case of locomotor ataxia treated by means of the orchitic fluid by Dr. Depoux, of Paris, and one by Dr. Gilbert, of Havre, certainly showed remarkable improve- ment, which was maintained when the report was made, nearly a year after the treatment had been discontinued. In none of the cases of locomotor ataxia treated by means of the orchitic fluid have the knee jerks returned, so far as I have been able to learn. Depoux's patient received, from August 6 to 10, 1892, 2 cubic centimetres of the orchitic liquid each day hypodermically; from August 30th to September 10th, 6 cubic centimetres daily. Improvement at this time was quite marked. He was next subjected to treatment on Novem- ber 15th, and from this date to the 21th he re- ceived each day 12 cubic centimetres of the fluid, when he considered himself practically cured. Dr. Gilbert's patient was subjected to two series of injections of the extract of bull's testicles, at a month's interval. Each series consisted of twelve injections, three being given a day. In" the New York Therapeutic Review, vol. ii, No. 2, Dr. Paul Gibier reports four cases of locomotor ataxia treated by injections of or- chitic fluid and nervous matter. All the pa- tients showed improvement in general health. Besides this, in one case an old perforating ulcer of the sole of the right foot healed in a few days; in the second the bladder regained its power, constipation disappeared, and walk- ing became better; in the third, after fifteen injections, an increasing weakness lessened, standing became possible with the eyes closed, and diplopia disappeared; in the fourth, se- vere pains were relieved, sensation was very much improved, and walking became much better. Others have reported great improve- ment in locomotor ataxia from the use of hypodermic injections of the orchitic fluid. Owspenski, of St. Petersburg, reported twen- ty-nine cured or markedly improved out of thirty-six treated (Year-Book of Treatment, 1893, p. 92). My personal experience with the use of the orchitic fluid in the treatment of locomotor ataxia has been limited. I have not been able to obtain any material made ac- cording to the d'Arsonval method. I have used the preparation made by the Columbia Chemical Company and a preparation at one time made by Parke, Davis, & Co., but from neither have I seen any permanent results. In two cases of locomotor ataxia, as nearly alike as it was possible to get them, to one patient 1 gave the liquid preparation said to be made from the testicles of animals, and to the other nothing of special importance was given. Be- yond a sense of excitement experienced for a few minutes, and sometimes for an hour or more, by the one to whom the testicular juice was given, I was unable to detect any differ- ence in the daily condition of each "patient, and at the end of two months, if I had not known, I should have been unable to say to which the orchitic fluid had been given. The test to which I have put the liquid in question has not been a satisfactory one, and I should wish to employ the preparation made at the Pasteur Institute in New York before speaking definitely of its effects. It does seem, however, that if the testicles possess any agent of a tonic or antitoxine effect, this m'ight be obtained by rectal feeding with the freshly ex- pressed juice from the glands. Unless "some such method of administering the active prin- ciple of the glands is found feasible, it is going to be impossible to give patients who live at a considerable distance from large cities the benefit of the treatment, on account both of the expense and of the impossibility of using the material in a fresh state. Tuberculosis.—The conservative element of the medical profession was unprepared for the virtues alleged by a number of physicians for the orchitic fluid in the treatment of tubercu- 73 ANIMAL EXTRACTS AND JUICES losis. Brown-Sequard, after speaking of the effects of the testicular fluid in locomotor ataxia and cancer, says: "There is no other serious affection of any kind which has not given us a good proportion of cases of consid- erable amelioration. I will only say that the favourable results obtained in the treatment of pulmonary tuberculosis in the Hotel-Dieu Hos- pital, of Paris, by Drs. Dumontpallier and Va- riot, and at the Charite Hospital by Professor Cornil and Dr. Henoque, and also at Lille by Professor Lemoine, have been confirmed by more than sixty medical practitioners of Paris or of the French provinces." Dr. D. Uspenski, in a lecture before the Russian Society of Pub- lic Hygiene (Epitome of the British Medical Journal. Jan. 10, 1891), stated that he had tried this "emulsion" on eighteen patients in all stages of tuberculosis. Two acute cases had been given up. In one, that of a lad of eight- een, in which all other measures had failed, the appetite and general condition were great- ly improved after three injections, and after six the patient was able to leave his bed and walk about his room. Under continued treat- ment, strength and weight increased, temper- ature gradually fell, night sweats ceased, and the patient could take a long walk. Fifteen injections were given between the beginning of May and June 15th. The treatment was stopped and the patient continued to gain strength and weight through the summer, the increase in weight being from 122^ to 148i pounds. The lung mischief came to a stand- still. In another man, aged twenty-eight, fever and profuse sweating were associated with bac- illary phthisis of both apices. After the sixth in- jection the appetite improved, after the twelfth the patient was able to leave his bed, and after the eighteenth the temperature became normal. There was, however, no increase in weight and the lung condition was not improved. In chronic cases the injections acted more rap- idly ; in twelve such, marked general improve- ment, with reduction of fever and lessening of night sweats, occurred after from two to four injections. Nine, or at most twelve, injections usually suffice, he says. The bacilli do not dis- appear entirely, but diminish in proportion to the extent to which the diseased process re- cedes. The author considers that Brown-Se- quard's fluid has a markedly beneficial effect on the general health in all cases of phthisis. On the other hand. Dr. M. K. Zienier (ibid., 1891, vol. ii, sec. 125) employed the testicular fluid in five cases of phthisis, and, after giv- ing the remedy a fair trial, saw no permanent benefit .and abandoned the treatment. A number of others have used injections of the orchitic fluid in the treatment of' tubercu- losis ; some have praised and some have con- demned it. The most sanguine seem to be able to allege for it nothing more than a tonic influence. How much of this is due to expec- tancy and the mental impression made upon the patient, and how much to the efficacy of the injections themselves, time and further experience must decide. Cancer.—It seems strange that the orchitic fluid should have been tried in this disease, but it has, and marked systemic improvement, to say the least, has apparently followed its use. Brown-Sequard states : " To our utter surprise, an organic affection which we did not believe could be ameliorated is. on the con- trary, the one of all kinds of disease which has given the largest proportion of ameliorations ; that affection is cancer when located super- ficially. We knew in April last " (1892) " the effects of treatment in one hundred and three cases. If we put aside six cases in which death was impending, and was only delayed by treat- ment, there w;rs considerable amelioration in the ninety-seven other cases. It consisted in the healing of ulcers, the cessation of pain, of insomnia, of haemorrhage, of all appearances of cachexia, and of every other, except the pres- ence of the tumour." " In the New York Thera- peutic Review, vol. ii, No. 2. p. 19, Paul Gibier reports two cases of cancer treated by the or- chitic fluid, with marked improvement of the general health in both. Dr. Labrosse, of Al- giers, has observed great improvement in the general health of his patients suffering from cancer on resorting to the Brown-Sequard method of treatment. Scepticism is excusable. Leprosy and Skin Diseases.—Brown-Sequard observed ulcers heal in leprosy on the adminis- tration of the orchitic fluid. In the British Medical Journal, August 26, 1893. p. 474, oc- curs the following suggestive paragraph : " Dr. Symons Eccles cited a case of long-standing psoriasis in which injections of von Poehl's spermin appeared to be attended by marked amelioration, the severity and spread of the dis- ease being distinctly checked. If von Poehl was correct in attributing the therapeutic value of spermin to its action as an oxidizing agent, it might be that all the animal extracts now employed depended on the existence of an oxidizing ferment in them. The influence of spermin on the leucomaine tide was very marked, and he hoped that observations on this point in regard to thyreoid and other extracts would he forthcoming." Diabetes Mellitus.—Brown-Sequard gave the preference to the orchitic fluid over the pan- creatic extract in the treatment of diabetes mellitus. Paul Gibier has treated two cases of this disease with alternate injections of nervous matter (from the cortex of the sheep's brain), the pancreatic, and the orchitic extracts. In the first there was no diminution of the quan- tity of sugar excreted, although the general health of the patient improved. Chorea.—Brown-Sequard, commenting upon the orchitic liquid being more effectual in the treatment ol organic disease of the nervous system than in the pure neuroses, remarks: '• Chorea, however, forms an exception, as dem- onstrated by the success obtained by Professors Oilier and Tissier and a great many other prac- titioners." Deydier reported in Lyon 'medical, April, 1892, five cases of severe chorea treated and cured by the orchitic fluid after other means, including antipyrine, had failed. In the first, several injections were required ; in the second, forty ; in the third, eleven ; in the fourth, eighteen ; in the fifth, thirteen. (New York Therapeutic Review, vol. i, No. 4, p. 102.) ANIMAL EXTRACTS AND JUICES 76 Colrat (Lyon medical, March 26 and April 16, 1893) has treated several cases of chorea with the orchitic fluid. One patient who had been affected with the disease for six weeks and was still unable to be out of bed, although he had been treated with antipyrine, was able to sit up after the first injection and to walk about a week later. Of two others, one required five, and the second six weeks' treatment. It does not seem that much can be alleged for the orchitic fluid in any of Colrat's cases, except possibly the first, and in this the cure was so sudden that it makes one suspicious of hysteria. Epilepsy.—The consensus of opinion seems to be that the orchitic fluid increases the se- verity and number of the attacks in epilepsy. Paul Gibier has reported a number treated by injections of the orchitic fluid, and in each there was an increase of the severity of the malady. Fere, one of the ablest of the French neurologists, at the solicitation of d'Arsonval, gave the orchitic fluid a thorough trial in epilepsy at the Bicetre Hospital, Paris. His report was made to the Societe de biologie in 1893, just four years after Brown-Sequard an- nounced the wonderful effects of this fluid, and in no uncertain language he gave his un- qualified disapproval of this method of treat- ing epilepsy. In no case was a favourable result observed, but, on the contrary, the in- jections seemed to act as a depressant. Dr. Bourneville and Dr. Paul Cornet (Progres medical, Dee. 9 and 16, 1893) reported thirty cases of epilepsy treated by subcutaneous in- jections of testicular juice, and in none was there any marked improvement. Only twenty- eight of the thirty remained sufficiently long under treatment to test this method fairly, and in eight there was a slight diminution in the number of seizures, while in twenty there was a decided increase in the number of spells. (Journal of Nervous and Mental Disease, July, 1894, p. 479.) Neurasthenia.—Nearly every one who has experimented with the orchitic fluid has given it a trial in this troublesome affection. A few have reported excellent results. In America, Paul Gibier and Hammond are quite sanguine of its beneficial and permanent effects in the neurasthenic. Both of these writers seem to prefer the combined or alternate injections of testicular fluid and nervous matter (cortex of sheep's brain). It does seem that if the or- chitic fluid has a decided tonic effect it ought to be indicated in neurasthenia. I have tried Breparations formerly manufactured by Parke, •avis, & Co., and those manufactured by the Columbia Chemical Company, but, besides a slight and temporary stimulating effect, which patients have frequently described as a sense of flushing, I have been unable to observe any result from the treatment.* Persons suffering from nocturnal emissions, impotence, debility, or premature senility, and children afflicted with nocturnal incontinence * Since this paragraph was written I have tried the orchitic and brain extracts obtained from the Pasteur Institute, of New York, in one case of neurasthenia with apparently negative results. of urine, have been treated with injections of orchitic fluid with apparent benefit. We must, however, have a more extended trial with this agent in these cases before definite conclusions can be drawn. Patients with hysteria, hystero-epilepsy, and contractures have been benefited by the use of the orchitic liquid, but it is in these cases that suggestion has its most potent influence. Dr. W. D. Waterhouse (British Medical Journal, Jan. 30,1892, p. 229) has reported: "A woman, aged seventy-seven, who suffered from rigidity and contraction of the left arm following an attack of apoplexy five years before. The rigid- ity almost at once relaxed, and she has been able to use the hand and arm ever since, now six months." He gave brief accounts of two other cases, one of which was evidently organic disease of the cord. Both patients recovered under hypodermic treatment with the orchitic fluid. We often forget that many patients with undoubted organic trouble become decidedly hysterical, and that the most obtrusive symp- toms are of the latter nature. Charcot showed that these persons might be greatly benefited by suggestion. Administration and Dose.—The preparation made according to the d'Arsonval method acts more readily and effectually when given sub- cutaneously, but for the nervous and timid, to whom hypodermic injections are objectionable, considerable effect may be obtained by dropping the liquid, about twice the quantity used in the subcutaneous method, on the tongue and re- questing the patient not to swallow for half an hour, so that it may be absorbed from the mouth without coming in contact with the fluids of the stomach. I have over and over again tested this method of administration, and patients have told me that the sensations were about the same as when the medicine was given them under the skin. The effects are not quite so prompt or decided, but often more prolonged. I must repeat what I have ex- pressed before, that, if the testicles are found to be an aid in the treatment of disease, rectal administration of the juice of the crushed glands will be found to be the most popular, especially by physicians living at considerable distances from large cities, unless it is posi- tively demonstrated that the fluid may be kept for several weeks without deteriorating. The daily dose of the preparation made according to the d'Arsonval method varies, when given subcutaneously, from 1 to 3 cubic centimetres (from 16 to 48 minims). It is a glycerin prepa- ration and should be diluted with two or three parts of water, to prevent irritation. The dose by the mouth, the liquid being allowed to be absorbed without reaching the stomach, should be at least twice that given by the. subcutane- ous method, and the dose by the rectum twice that given by the mouth. When the glycerin extract is given by the rectum the precaution must be taken to mix with it one or two ounces of water to prevent its irritating the bowel. Thyreoid Extract.—The thyreoid extract has proved to be of so much importance as a therapeutic agent, especially in mvxcedema, that a short account of its history inay be of ANIMAL EXTRACTS AND JUICES interest. It had been known for some time that total destruction of the thyreoid gland would cause a peculiar cachexia, known as cachexia strumipriva, and that this condition was the more marked the younger the subject in which the gland was totally destroyed, when Schiff found in the dog that transplantation (intraperitoneally) of the healthy gland shortly after the operation of thyreoidectomy was suf- ficient to protect the animals from" the fatal cachexia. Later, von Eiselberg conducted elaborate experiments, and found that if the transplanted gland underwent atrophy and de- generation the usual cachexia supervened, but if it became vascularized and resumed its func- tion, no cachexia occurred. In 1883 Bircher reported his experiments in the transplantation of the thyreoid for the treatment of cachexia strumipriva, or acute myxoedema (Yolkraann's Sammlung klin. Vortrdge, No. 357). Kocher tried thyreoid grafting in 1883, but the gland atrophied. He performed the operation five times, and one patient improved. Victor Ilors- ley, without being aware of Bircher's experi- ments with the thyreoid in acute myxoedema, suggested the treatment of ordinary myxoedema by means of transplanting the thyreoid gland from the sheep. Lannelongue, Merklen, Wal- ther, Bettencourt, and Serrano performed the operation in cases of myxoedema and sporadic cretinism (British. Medical Journal, Feb. 8, 1890, and Jan. 30 and Feb. 6, 1892). Betten- court and Serrano, in 1890, placed half of a sheep's thyreoid beneath the skin in the thy- reoid region of a patient suffering from myx- edema. Improvement began in twenty-four hours, and soon the red corpuscles increased to normal, speech improved, perspiration returned, and the menstrual flow, which usually had lasted three weeks, ceased in four days. On account of the improvement in the case just mentioned being manifest on the day after the operation, Vessale reasoned that it could not be due to the gland becoming vascularized and functionally active, but it must be owing to the absorption of the juice of the transplanted gland, and he therefore made intravenous injections of the thyreoid extract of a dog into a dog after thyreoidectomy with beneficial results. G. R, Murray (British Medical Journal, 1891, vol. ii, p. 797) reported results of his treatment of a case of myxoedema by means of subcutaneous injec- tions of the thyreoid extract of a sheep. The improvement in this case was well marked. The disadvantages of having to inject animal extracts under the skin are apparent, especially when it is not always possible for physicians residing at long distances from cities to obtain fresh extracts without a great deal of trouble. The credit of having first begun the adminis- tration of the thyreoid extract by the mouth for the treatment of myxoedema seems to be due to Professor Ilowitz, of Copenhagen. In March. 1892, he treated a woman suffering from myxtrdema with pies made of calf's thy- reoid. The improvement was prompt and de- cided. On June 2. 1892. Dr. E. L. Fox, of Plymouth, England, without any knowledge apparently of Professor Howitz's trial with the thyreoid gland, directedapatientofhissuffering I from myxoedema how to prepare a glycerin ex- | tract of half a sheep's thyreoid, somewhat after | the manner that Dr. Murray had recommended. She was to take one half of this quantity an hour before breakfast and the remainder an hour before supper, and to continue doing so twice a week. Improvement in this case was pronounced, and perceptible soon after the treatment was begun. Curiously, Dr. Hector W. G. Mackenzie, of London, in apparent igno- rance of the administration of the thyreoid gland by the mouth by Howitz and Fox. on July 27, 1S92, began the treatment of a case of myxoedema of several years' standing by ad- ministering in one day two pounded sheep's thyreoids. The next "day two drachms of a glycerin extract were given. During the last two years several manufacturing chemists, both in Europe and in America, have placed upon the market tabloids and dried extracts of sheep's thyreoid which may be kept for an in- definite time and are apparently as effectual in the treatment of myxoedema and other affec- tions for which the thyreoid gland has been employed as the fresh juice of the gland. But little is known of the effects of the ad- ministration of the thyreoid gland or its ex- tract to persons in health (British Medical Journal, Dec. 9, 1893, p. 12(17). Most of our knowledge of the influence exerted by the thyreoid gland comes from observing the ef- fects following thyreoidectomy, the conditions accompanying deficient functional power of the thyreoid gland, and the changes that take place on administering the gland to persons whose thyreoid gland is absent or defective. Victor Horsley (British Medical Journal, Jan. 30 and Feb. (>, 1S92), in his masterly re- view of the function of the thyreoid gland, divides the symptoms following thyreoidectomy into neurotic, myxcedematous, and cretinic, these taking place in the order named. Fol- lowing thyreoidectomy the symptoms are acute and profound and soon result in death, espe- cially in young subjects. In disease of the thyreoid the symptoms come on gradually, and a condition known as myxoedema takes place. Through the loss of the modifying effects of the secretion of the thyreoid gland on the blood, the central nervous system and the nu- tritive functions are affected in disease of this gland. We seem to be justified in concluding that insufficient thyreoid secretion causes a de- generation in the nerve elements of the central nervous system, especially in the cortex of the brain and in the centres of the medulla; marked changes in the blood, probably from toxaemic influences ; and pronounced nutritive changes, best observed in the subcutaneous tissue, where a substance called mucin is often depos- ited. The skin is greatly altered, and it be- comes rough, coarse, dry, and inelastic. The hair turns gray and falls out. In acute myx- oedema following thyreoidectomy the tem- perature may rise several degrees, while in the chronic form it is not infrequently below nor- mal. Owing to the deposit of mucin in the subcutaneous tissue, the emaciation which would otherwise be well marked is not ob- served. Haemorrhages, probably due to blood ANIMAL EXTRACTS AND JUICES 78 changes, frequently take place from the mu- cous surfaces of the body. Owing to the profound disturbances which follow extirpation or disease of the thyreoid gland, the gland or an extract made from it has been tried in several diseases. Myxedema.—The positive beneficial results of the use of the thyreoid gland or its extract in the treatment of myxoedema are too numer- ous and the failures too few for us to hesitate to employ this agent in combating a hitherto irremediable disease. Before the days of the use of the thyreoid extract or thyreoid feeding all that the best clinicians had to offer for the comfort of those suffering from myxoedema was protection of the patient from cold. In the Medical Record, October 7,1893, Dr. Francis P. Kinnicutt, of New York, tabulated eleven cases of myxoedema treated by thyreoid graft- ing, with improvement in six and failure in five; and fifty-one cases treated by thyreoid injections or feeding, with improvement in forty-seven, no result in two, and failure on the part of the writer to report the result in two. I have since enlarged this list to one hundred and sixteen cases, with absolute fail- ure to secure improvement in only three cases, leaving one hundred and thirteen out of one hundred and sixteen improved. Reports vary in regard to the degree of improvement. Some give the results as cures, while others say great improvement, the patient considering herself well, and a few record slight improve- ment. Where the condition of the thyreoid gland is such that its functional activity is permanently below the requirements of health, a permanent cure of myxoedema by the use of thyreoid feeding or injection is out of the ques- tion. We may conceive it possible, and even probable, that a condition of myxoedema may develop from impaired function of the thy- reoid gland, and that this function, in the ab- sence of organic change in the gland, may be re-established under the stimulus of thyreoid ingestion, while the myxcedematous condition is disappearing. The cases of myxoedema re- ported cured from the thyreoid treatment are comparatively few in number, and it is prob- able that sufficient time had not elapsed when the reports were made to justify such a con- clusion. Experience seems to teach that cases of myxoedema relieved by the thyreoid treat- ment will relapse when the treatment is dis- continued, so that to insure the best results it is probable that the treatment will have to be continued in a modified form throughout the patient's life. Improvement manifests itself within from a few days to a week or two after beginning the treatment, and continues for several months. It consists in increase of muscular strength, loss of weight, with a re- turn of the natural appearance of the face and extremities, improvement of the voice, a fresh growth of hair in bald places, desquamation of the dry epidermis, with apparently normal cu- taneous nutrition, a rise of temperature to nor- mal, increased force ami frequency of the heart's action, return of the blood to a normal condition, and brightening of the intellectual faculties, with improved mental vigour. The unpleasant effects of the thyreoid treat- ment—such as headache, lassitude, nausea, ver- tigo, and sharp increase of temperature, with rapid pulse, so frequently observed by many —may be greatly modified, if not "entirely avoided, by gauging the dose according to the tolerance of the patient. Some patients com- plain of pain in the limbs while taking the thyreoid extract. Cretinism and Infantile Myxedema.—Sev- eral cases of this variety of myxoedema have been successfully treated by means of the thy- reoid extract. One of Osier's cases, reported in abstract in the Medical Record, July 21, 1894, p. 85, was that of a boy aged four years and eight months. In the early part of the treatment he took one quarter of the thyreoid gland of a sheep each twenty-four hours ; later the gland was given him in a desiccated form. In fourteen months the boy grew four inches, an unusual increase. At the time of the re- port he walked and ran about, and had gained so much mentally that few would think him "queer." The myxcedematous appearance was all gone. Numerous other cases of cretin- ism or infantile myxoedema have been treated by means of the thyreoid extract and feeding, and with equally good results. As this is the only agent that apparently does any good in this form of myxoedema, it should receive a thorough trial in every case, but we must be prepared for less uniformly successful results in infantile than in adult myxoedema. Here, too, as in the adult form, the treatment must be continued from time to time during the life of the patient. If thyreoid grafting should prove to be satisfactory, 'it will be the most de- sirable method by which to combat infantile myxoedema. Exophthalmic Goitre.—In the British Medi- cal Journal for 1893, vol. ii, p. 1192, Owen, of Manchester, reported a case of exophthalmic goitre treated by thyreoid feeding with benefit. The case has been quoted by numerous Eng- lish and American writers as an example of the good effect of the thyreoid treatment in exophthalmic goitre, a condition supposed to be the opposite to what is found in myxoe- dema. Numerous trials of thyreoid feeding have been made since in exophthalmic goitre, but so far I have been unable to find another favourable report.* Dr. Hector W. G. Macken- zie (British Medical, Journal, July 21, 1894, p. 157) states: "The case" (Mr. Owen's) -'was one in which a man was said to have had, by mis- take, a quarter of a pound of thyreoid "gland for two'days running. As the weight of an individual gland is onlv about 90 grains,! it seemed to me that possibly a mistake had arisen on the ] art of the butcher, and that the pa- tient had not had thyreoid gland at all. On my writing to Mr. Owen, he very kindly rein- vestigated the subject, and found that, at any * Voisin reports a ease of exophthalmic goitre in which benefit followed the use of thyreoid sland, and Brims reports twelve eases of goitre of the paren- chymatous variety, in nine of wliieh the patients were cured or improved by the administration of thyreoid S I'll1' ■ (',/''/"'"' X<-"-s, Dec. H, IS!)I, p (580 ) .i, + Th'« estimate is too light for the weight of a sheep s thyreoid gland. 9 ANIMAL EXTRACTS AND JUICES rate in the first instance, it was not thyreoid gland that the patient had had." Experience seems to justify the conclusion that thyreoid feeding in exophthalmic goitre is not bene- ficial, but, on the contrary, according to some observers, it increases the unpleasant symp- toms of the disease. Skin Diseases.—To Byrom Bramwell is due the credit of having first used thyreoid feeding for the cure of certain diseases of the skin. It does not seem to have been a chance experi- ment with him, but, to use his own words in his first communication on the subject (British Medical Journal, 1893, vol. ii, p. 933): " I was led to treat cases of psoriasis by thyreoid feed- ing not merely as a matter of chance, but in consequence of observing the very definite effects which the remedy produces on the nu- trition of the skin in cases of myxoedema and sporadic cretinism." He began treatment with the thyreoid extract in his first case of psoriasis on February 4, 1893, and within six days decided improvement had taken place. By May 3d the eruption had entirely disappeared. Two months after treatment was discontinued the eruption began to reappear. The treat- ment of two other cases reported by Bramwell in the same communication was equally suc- cessful. Dr. Arthur T. Davies, following the suggestion of Bramwell, soon after the latter's early experience with thyreoid feeding for cer- tain diseases of the skin, reported four cases— two of psoriasis, one of ichthyosis, and one of chronic eczema—which had been greatly bene- fited by the administration of thyreoid tab- loids. The case of ichthyosis and one of the cases of psoriasis were entirely cured by means of the tabloids ; the other two cases were con- siderably improved. After the results of Bramwell's experience with thyreoid feeding in certain skin diseases were made known, numerous trials were made with various prep- arations of sheep's thyreoid for the relief of chronic and more or less intractable skin af- fections, and for a time it seemed that a great advance had been achieved in the manage- ment of these diseases ; but, if we are to be guided by further observations and riper ex- perience, hopes have been raised which are destined to disappointment. At the meeting of the American Dermatological Association held in Washington in May, 1894, Dr. George Thomas Jackson, of New York, in his paper on thyreoid feeding in diseases of the skin, stated that he had treated three cases of xeroderma, one of ichthyosis, and one of dermatitis exfoli- ativa with the powder of desiccated thyreoid in gelatin capsules. Four of the patients had experienced unpleasant symptoms from the use of the thyreoid preparation. There had been some improvement in the condition of the skin, but no cures. Including the author's five cases. there had been reported up to May 1, 1894. thirty-eight cases of skin diseases treated by thyreoid feeding, with eleven cured, fourteen improved, and thirteen unchanged. In the discussion which followed the read- ing of Dr. Jackson's paper. Dr. Hartzell and Dr. St el wagon reported negative results, and Dr. Hyde gave his experience with the use of thyreoid feeding in ten cases of psoriasis, in which two of the patients had shown decided improvement, two had been made very ill. and the six others had derived no benefit. It seemed to be the prevailing opinion of the members of the association that we had little to hope for from the use of the thyreoid gland in the treatment of skin diseases. At the same meeting Dr. Corbett stated that the English physicians were about ready to give up the use of this new remedy in cutaneous diseases, with the exception of lupus vulgaris, where, it was thought, benefit was derived from its use. Insanity.—Thyreoid feeding has been recom- mended in various forms of insanity attended with depression, and especially in melancholia. I am not aware that it has had an extended trial in any cases of mental disease except when associated with myxcedema. Here, as a rule, the menial symptoms improve with the physical, but Dr. F. ('. Shattuck, of Boston, reports a case in which melancholia developed during the thyreoid treatment. It should be remembered, however, that in this case there was no improvement in the myxcedematous condition except in the nutrition of the skin. Syphilis.—In the British Medical Journal, December 2. 1893, p. 1192, there is found un- der the head of Kye-Piece: "Is there any existing record of cases where thyreoid extract proved beneficial and curative in patients suf- fering from obstinate secondary and tertiary syphilides { I have noticed that marked desqua- mation and a healthy action of the skin was induced by this treatment. A case of very severe rupia, with extensive ulcerations of the legs and scalp, which resisted all unknown remedies, has commenced to improve." Other cases are referred to in the same note, and in all the ulcers had shown a tendency to heal (commencing on the third day) when the pa- tient was placed upon the use of thyreoid ex- tract. Ten grains of the powdered extract of the gland, given in the form of tabloids, were administered thrice daily. Dr. J. Duncan Menzies {British Medical Journal, July 7, 1894, p. 12) reports four cases of "■malignant Indian" syphilis treated by thyreoid extract, with apparently decided benefit. The author thinks that the administration of thyreoid gland alone in syphilitic subjects is attended with good results, and adds: "I am inclined to regard the remedy as a powerful skin tonic and adjuvant to the mercurial and alterative treatment of syphilis." Obesity.—A properly constructed dietary with regulated exercise is undoubtedly the best and safest means of reducing superfluous fat. and in many cases this is all that is re- quired. Dr. N. E. Yorke-Davies believes that " in certain conditions of the blood, as where it does not seem to have the power of oxidizing the waste of the system, they" (the tabloids of thyreoid extract) "are a valuable adjunct."' Certainly his tables show a very much more rapid reduction of weight when the thyreoid extract was administered in connection with a regulated dietary than when the latter alono constituted the treatment. ANIMAL EXTRACTS AND JUICES 80 On account of the increased metabolism and the improved condition of the blood following the ingestion of the thyreoid gland, especially in myxoedema, the thyreoid extract has been suggested as an aid in the treatment of ane- mia. The analogy between the thyreoid gland and the pituitary body, and the frequency of disease of the latter in acromegaly, is probably the reason why some have suggested the use of thyreoid feeding in this disease. Dose and Administration.—Since it seems to be pretty well established that the active principle of the thyreoid gland is not destroyed by the juices of the stomach, there is no occa- sion for administering the glycerin extract hypodermically. Probably the best, and cer- tainly the most available, preparation of the thyreoid gland is the dried extract, which may be given in the form of tabloids or in gelatin capsules. The dose to begin with should be small—2 or 3 grains thrice daily, and gradu- ally increased to 5 or 10 grains, as the toler- ance of the patient and the demands of the case seem to indicate. Pancreatic Extract.—The earliest refer- ence that I find advocating the use of pan- creatic juice in pancreatic diabetes is one made by Dr. R. Mansell-Jones, of Brighton, in which he suggests that it might be used with benefit in these cases, as the pancreas is often disor- dered in this affection. Dr. Neville Wood (British Medical Journal, Jan. 14, 1893, p. 64) reports two cases of diabetes treated with- out success by the pancreatic extract. Dr. Hector W. G. Mackenzie (ibid., p. 63) reports two cases of diabetes treated by | fl. oz. of liquor pancreaticus administered thrice daily, immediately after meals, with some apparent benefit to the strength and general health of the patient, but the quantity of the sugar was not affected. In the two cases of diabetes treated by Paul Gibier by alternate injections of pancreatic extract and nervous matter, in one there was no effect on the quantity of sugar eliminated, and in the second the sugar disappeared and the patient was much im- proved (New York Therapeutic Review, vol. ii, No. 1, p. 20). W. Hale White, as a result of treating two cases of diabetes mellitus by means of raw pancreas and liquor pancreaticus hypodermically, expresses a doubt whether the disease can be modified by this means (British Medical Journal, March 4,1893). In the same journal for March 18, 1893, W. Knowsley Sibly says that he thinks he has produced some benefit in diabetes mellitus by feeding his patients on raw pancreas, and in the issue of June 17, 1893, W. A. Willis reports a case of diabetes mellitus treated with raw pancreas, in which there was little or no improvement, Several others have tried the pancreatic treat- ment for this disease, usually, however, with indifferent results. Nervous Substance.—Constantin Paul (Bull, de I'Academ. de med., 1893, No. 17, p. 445), W. A. Hammond (New York Medical Journal, Jan. 28, 1893, p. 93), Marechal (Pres.se medicate beige, May 8, 1892), Babes (Dtsch. med. Woch., July 28, 1893), Dana (Boston Med. and Surg. Journal, May 18, 1893), Paul Gibier (New York Therapeutic Gazette, vol. ii, No. 2), and others have employed preparations made from the spinal cord and brain cortex, usually of the sheep, in the treatment of various forms of functional and organic nervous disorders. According to most of the observers mentioned, glycerin extract of nervous matter, introduced hypodermically, acts as a stimulant in exciting the heart to increased vigour in contracting and in improving the condition of the digestive apparatus, resulting in improved nervous tone and relief of insomnia. Constantin Paul em- ployed brain extract in fifty-three cases of neurasthenia, with alleged improvement in all except those in which the patient was suffer- ing from hysteria, melancholia, or hypochon- driasis. The most marked beneficial effects were noticed in the digestive functions, in ability to sleep, and in the patients' becoming amenable to other forms of treatment from which they had failed to derive any apparent benefit before beginning the hypodermic ad- ministration of nervous matter. Hammond records similar results. Babes and Paul Gibier report decided effects from the hypodermic use of brain and cord substance in epilepsy. Babes alleges cures of cases of epilepsy from this treat- ment, while Gibier is modest enough to record improvement only. Dana urges a more ex- tended trial with the animal extracts of nor- mal tissues and organs, and with ferments and blood serum, apparently more on account of the effect of these substances on toxic agents which may be causing irritation than on any supposition of the animal substances' having any direct curative action on the diseased pro- cesses. He relates a case of bulbar paralysis apparently cured and six cases of tabes dorsu- alis treated with brain extract, with improve- ment in two, which improvement was not manifest while injections of water were being given, but became apparent soon after brain extract was substituted for the water. Paul Gibier has used the brain and cord extracts quite extensively, and reports good results from this new treatment. It is premature to pass judgment on this plan of treatment. Most of us are prejudiced against it, but we should wait for more ex- tended observations before condemning it. The difficulty of obtaining suitable prepara- tions and the inconvenience of using the ex- tracts hypodermically are obstacles to their general use. If they "are beneficial on account of their _ antitoxic properties, it is probable that the juices of the stomach and small intes- tines will destroy these, but they have been used with apparent benefit by the "lower bowel, and preparations for this mode of administra- tion can be made by any one with ease. Dose and Ad mi n'i stmt ion.—Babes took nor- mal brain and spinal cord and made them into an emulsion with broth in the proportion of 1 part of nerve tissue to 5 parts of broth, and of this he injected from 4 to 5 c. c. (60 to 75 minims) into the abdominal wall or the flank five or six times a week in epileptics and four or five times in neurasthenics. If hypodermic injections are used, it is better that they should 81 ANIMAL EXTRACTS AND JUICES be made of known strength in the d'Arsonval apparatus, and of this glycerin extract from 2 to 3 c. c. (30 to 45 minims) may be used daily or several times a week. If the" rectum is the channel of administration, the bowel should be thoroughly cleansed, and an extract made from the brain or cord by means of water with the addition of a little glycerin, which has been allowed to stand for a few hours, or, better, one or two days in a cool place, then filtered through paper, may be thrown well up into the rectum. Spleen extract has been recommended to be used hypodermically in leucocythaemia, en- larged spleen, and Jlodgkin's disease; supra- renal-capsule extract in Addison's disease ; pituitary-body extract in acromegaly ; thy- mus extract in cases in which the thyreoid extract is indicated ; kidney extract in cases of deficient action of the kidneys; bone-mar- row extract in anemia; and muscle ex- tract in muscular dystrophies; but no definite and positive results have been reported from their use, with the possible exception of the extract of bone marrow. Extract of Bone Marrow.—Dr. J. Dixon Mann (Lancet, March 10, 1894. p. 599) states that he has seen good results follow the inges- tion of bone marrow by the stomach in cases of anemia and of oligemia due to loss of blood from such causes as placenta pnevia, haemorrhoids, and wounds. As the bones of young animals are the richest in red marrow, he thinks these are preferable. His method of preparing and giving the marrow is as follows : "To prepare the extract the heads of the long bones, obtained from recently killed animals, with other portions of bone which contain red marrow, are broken into small pieces and di- gested in glycerin with frequent agitation. When the extraction is complete—several days being required—the extract is filtered off and is ready for use. It is red or reddish brown in colour and is devoid of any unpleasant taste or odour. It may be given in teaspoonful doses once or twice a day either out of the spoon or spread between thin pieces of bread." Tuberculin.—On November 14, 1890, Koch announced in the Deutsche medicinische Wochenschrift (Epitome of the British Medi- cal Journal of the same date) a remedy for tuberculosis. It was a brownish, transparent liquid which, according to the author, did not readily decompose. At that time Koch stated that his researches were not completed, and he was therefore, not prepared to make known the origin and mode of preparation of the remedy. When this liquid was injected into a healthy person, decided reaction followed, attended by pain in the limbs, fatigue, cough, dyspnoea, and rise of the body heat, but it was found that a dose sufficiently small to be scarcely appreciated by a healthy person gave rise to pronounced symptoms in tuberculous subjects, with a rise of temperature far in excess of that which fol- lowed a larger dose administered to a person in health. The local effect on lupus, tubercu- lar diseased glands, joints, etc.. was decided. On account of the greater reaction which fol- lowed the administration of the remedy to tuberculous subjects, it was early recognised that in this liquid we had a means of diag- nosticating tuberculosis in doubtful cases in the lower animals. An influence was exerted upon lupus and tuberculosis, and a large num- ber of physicians were eager to try the new remedy. On January 15,1891 (ibid.), Koch announced that the new remedy was a glycerin extract of a pure cultivation of tubercle bacillus. We are told that the active principle was extracted from the bacilli by a forty- to fifty-per-cent. solution of glycerin. Reports of thousands of cases of tuberculosis treated with Koch's tuber- culin were soon forthcoming, with results vary- ing from cures to death. In the Year-Book of Treatment (1892. p. 55) 1,191 cases of various forms of tuberculosis treated with tuberculin were recorded, with eleven cures-»-certainly a small percentage of cures had they been left without any treatment, especially when we take into consideration that 242 of the pa- tients were in the early stage of pulmonary tuberculosis. A number of excellent and con- scientious observers were able to report many cases which had seemed to be decidedly bene- fited by the tuberculin treatment, but it be- came apparent that much harm was resulting from the extensive use of tuberculin. In many cases the reaction following the intro- duction of the agent resulted in speedy death, while in others the treatment seemed to cause the spread of tubercular processes to other portions of the body. On October 22,1891 (ibid.). Koch, in a com- munication, gave the results of experiments with a purified form of tuberculin, the dose of which, according to Ehrlich (Lancet, 1891, vol. ii, p. 917), varies from 0-l to 0-5 milligramme, although where hectic exists only from 3 to 5 decimilligrammes several times daily are rec- ommended. Ehrlich maintains that the meth- od of treatment first adopted was wrong in that the doses were too large, so that violent reaction and depression of the recuperative powers of the tissues resulted. In a report issued from the Brompton Con- sumption Hospital (Lancet, 1892, vol. i, p. 41) it is stated " that the tuberculin did not fa- vourably influence the course of the disease in the majority of cases, that in some the effects were detrimental, and that even in the sta- tionary and improved cases it was difficult to ascribe any distinct improvement to the injections." After a careful study of the reported results obtained by the use of tuberculin in tubercu- losis, one is forced to the conviction that its beneficial influence, at best, is never very pronounced, and that, unless the remedy is employed with considerable judgment and dis- cretion, harm may follow its use. The uniformly favourable influence of tuber- culin on lupus observed on the first employment of this agent raised hopes which have been disappointing, as the disease is found to recur in many cases after the use of the injections is stopped, and sometimes it has returned with increased virulence. ANIMAL EXTRACTS AND JUICES Bose.-The dose to begin with should not exceed 0-1 milligramme, and this should be in- creased by 01 milligramme at each aJm s tration until 1 milligramme is reached, w I, n the dose may be increased more rapidh. ine precaution observed by Dr. Karl yon Ruck of Asheville, N. C, is not to repeat the use of the remedy until twenty-four hours have elapsed after all signs of irritation from the previous dose have subsided. The dose must be cau- tiously increased as the tolerance ot the patient is established. . , Rabies treated with Spinal-cord Emul- sion.—On July 4, 1885, Pasteur began a se- ries of inoculations on the person ot Joseph Meister, employing spinal-cord emulsions pre- pared from animals which had succumbed to rabies. During 1884, Pasteur had demon- strated that it was possible to modify rabies in the lower animals by means of inoculation. By methods suggested and practised by Pas- teur the virus of rabies may be attenuated or intensified. The longer the medulla taken from an animal dead of rabies is allowed to dry, the more attenuated the virus becomes, so that medullary substance that is allowed to dry for fourteen days loses much of its viru- lence. Intensified virus of rabies may be ob- tained by a series of inoculations from animal to animal. An emulsion of the medulla taken from an animal dead from " street" rabies is placed under the cerebral dura of a living ani- mal, which soon dies from the disease, and from this animal the medulla is injected into a second animal, in which the disease develops more rapidly, runs a shorter course, and shows greater malignancy than in the first. By- means of repeated animal-to-animal inocula- tion the virus soon becomes so intensified as to give rise to " paralytic rabies." In employing inoculation for the preven- tion of hydrophobia in a man bitten by a rabid animal, Pasteur begins by injecting an emulsion from a spinal cord fourteen days old (dried), and on each subsequent day an emulsion from the cord dried one day less than that used on the previous day. until the virus is reached only two or three days re- moved from the strength of ordinary " street" rabies. It seems to bo conceded by the ma- jority of experimenters with rabies that the disease can be prevented in the lower animals and in man by using the Pasteur method of inoculation soon after the subject is bitten by a rabid animal. It must be remembered that some contend that it is possible to communi- cate hydrophobia by inoculation with the at- tenuated virus. Statistics of the Pasteur Institute of Paris from 1880 (the time of its foundation) to 1S92, inclusive, show 12,782 persons treated, with 08 deaths, making the death rate 052 per cent. It is stated that the great majority of persons who have been treated at the Paris Pasteur Institute were bitten by dogs which have been examined by veterinary surgeons and recognised as rabid (A'. )'. Therapeutic Gazelle, vol. i. p. 93). In 1892. 104 persons were treated for the prevention of hydrophobia in the New York Pasteur Institute. Forty- seven of these had been bitten by animals whose rabies was assured by experimentation or by the death of persons or animals bitten by them ; 42 were persons wounded by animals whose rabietic condition had been recognised by clinical or veterinary examination ; and 15 were persons injured by animals whose disease was only suspected. No deaths are reported among the 104 persons thus treated. Inoculation against Rabies by the Method, of Tizzoni and Centanni.—Tiz- zoni and Centanni (British Medical Journal, 1893, March 11, p. 516) profess to have extract- ed from the central nervous system of rabid animals a principle for inoculation against rabies. With this substance they succeeded in every case in rendering rabbits proof against even subdural infection. They propose to communicate hereafter the method by which the principle is obtained. The virus is ex- tracted from the central nervous system of a rabbit which has died from the effects of the intensified virus (virus fixe), although they state that the virus taken from a rabbit of the first generation has given positive restdts. The material is a watery liquid of a very light straw-colour, readily absorbed, and 10 c.c. rep- resent about 1 gramme of the nervous tissue. It has the advantage over the antirabietic virus of Pasteur that it is without any harmful ac- tion, local or general, and will not communi- cate hydrophobia. Fourteen animals were treated: Three re- ceived 40, 30, and 25 c. c. of the solution re- spectively, in divided daily doses extending over a period of fourteen days. Eight animals were treated for eight davs, and received 30, 30, 20, 15, 15, 10/ and 7c. c, distributed in daily doses: one was treated for five days and was given 20 c. c. in five equal doses each day; one was given 20 c. c. at one dose. All were inoculated with the virus (injected under the cerebral dura) of "street" rabies on the day after the final "vaccination," and at the same time six healthy animals not "vaccinated"^ were inoculated with the same virus of "street" rabies. The results were as follows: The six "control" animals died between the fifteenth and twenty-first day after infection; twelve of the " vaccinated '"' animals were living and healthy five months later; and the two re- maining animals died. The one that had re- ceived only 7 c. c. during a period of eight days died "on the fifteenth day. and the one that had been given 10 c. c. in the same length of time died on the twenty-second day. For curative effects the" treatment by "vac- cination" must be begun not later than the fourth day after infection has taken place; the sooner the treatment is instituted after- infection the greater the probability of a cure; and the dose must be larger for curative than for preventive " vaccination." For the former purpose not less than 40 c. c. should be em- ployed for a rabbit, given in divided daily doses extending over a period of from six to eight days, and for the latter 15 c. c. should be the minimum quantity. Cholera Inoculation.—To Dr. Jaime Fer- ran, of Banelona, is due the credit of first 83 ANIMAL EXTRACTS AND JUICES introducing a method of anticholeraic inocu- lation. It was found that by this method an animal might be rendered proof against hypo- dermic injections of cholera virus, yet that it would succumb when the poison was injected into the intestinal canal, and, further, that there was danger of spreading the cholera poison. Dr. Ilaffkine's method of "vaccina- tion" against cholera seems to be superior to Ferran's in every respect, and the one intro- duced by Klemperer has apparent advantages over Ilaffkine's. Haffkine renders the system tolerant of chol- era poison by injecting attenuated cultures, pre- pared by growing them in media aerated by air at a temperature of 39° C. [102-2 F.], and then employs an intensified or exalted culture made by carrying the poison from animal to animal until its virulence is many times stronger than that of ordinary Asiatic cholera. One objection to this method of anticholeraic inoculation is the reaction which sometimes follows its use. Klein (British Medical Journal, .Alar. 25. 1893, p. 632), endeavours to show that Haffkine only uses the intercellular poison developed from cholera culture, and not the true toxine of the comma bacillus. Haffkine is at present (July, 1894) in India, employing his method of anti- choleraic "vaccination," and in the British Medical Journal for July 7,1894, p. 25, we find a report of forty-eight persons, belonging to four families, of whom twenty-one were "vac- cinated" against cholera, and twenty-seven were not. Of the "unvaccinated," seven, or 33-3 per cent., suffered from cholera, while none of the twenty-seven "vaccinated" were at- tacked. (See also Boston Medical and Surgical Journal, Aug. 23,1894, p. 201.) Serum Therapy in Cholera.—Klemperer conferred immunity on guinea-pigs by accus- toming them to the living, dead, or attenuated virus, which he administered either subcutane- ously or by the stomach, having first rendered the gastric secretion alkaline. In contradis- tinction to Haffkine, he always used bouillon cultures from twenty-four hours to three days old, which presumably contain the specific toxine. The animals were refractory against any form of inoculation—intraperitoneal, gas- tric, or subcutaneous—after such treatment, and their serum was subsequently highly pro- tective. To man he gives subcutaneous injections of bouillon cultures, from twenty-four hours to three days old, which have been kept heated for two hours to 70° 0. [158 F.]. The initial dose is 04 c. c, the maximum 1 c. c. He gives alto- gether about 3-5 c. c, divided into from six to eight doses, administered in from ten to twelve days. The general and local reaction is said to be insignificant. Three days after giving the last injection he tested the " immunizing " power of the blood serum of man by injecting it into a guinea-pig, which was found to be resistant against large doses of virulent cholera bacilli. He succeeded in rendering his own blood serum strongly protective by taking into his stomach large quantities of warmed cultures of cholera bacilli, having first rendered the contents of the stomach alkaline. Serum Therapy in Diphtheria.—Behr- ing, Wernicke, Kossel, Kitasato, and others have experimented with an antitoxine to the poison of diphtheria, but as yet results do not seem to be satisfactory. The sheep has been employed, and serum in large quantities is thus obtained. George F. Still (British Medical Journal, July 28, 1894. p. 180) reports one case treated by Schering's antitoxine. The case seemed very grave and tracheotomy appeared to be necessary, but, on giving 11 minims of the antitoxine hypodermically, the improve- ment was prompt and decided. The next day 8 minims were given, and the child was soon out of danger. The thirty cases of diphtheria treated by Behring and the eleven by Kossel by means of " normal diphtherial therapeutic serum" do not give any gratifying results. (Year-Book of Treatment, 1894, p." 190.) Still more recent reports from Berlin phy- sicians on the treatment of diphtheria with "immunizing" blood serum are more encour- aging. The Medical Record for September 1, 1894, quotes from the Berlin correspondent of the Journal of the American Medical Associa- tion the statement that Professor Ehrlich, Pro- fessor Kossel, and Dr. Wasserman, of Berlin, have published a paper on the application of a curative serum invented by Professor Behr- ing, an assistant of Professor Koch's. Behring had undertaken to confer on animals immun- ity from the diphtheritic poison, and then to get a serum from the blood of those animals by which he hoped to protect human beings against the results of diphtheria, as well as to cure the disease when already developed in an individual. Ehrlich, Kossel, and Wasserman have followed Behring in his experiments, and they always intended to use the results of their experiments for curative purposes. They ex- perimented on goats. Two hundred and twenty patients with diphtheria were treated with the serum. Of these there were cured 168, or 70-4 per cent.; 52 died. Tracheotomy was per- formed on 67 patients, of whom 30 died ; the rest recovered. But a true insight into the curative effects of the injections is gathered, says the correspondent, only by grouping the diseased persons according to the time that had elapsed between the infection and the be- ginning of the treatment. He then gives the following table: DURATION OF DISEASE AT TIME OF BEGINNING! THE TREATMENT. Third day.. Fourth day Fifth day. 29 (8 tracheotomies) 39 (14 tracheotomies) 23 (10 tracheotomies) 64 (7 tracheotomies) 25 (7 tracheotomies) 30 (10 tracheotomies) 13 (4 tracheotomies) 2 (2 tracheotomies) 4 (1 tracheotomy) 9 (4 tracheotomies) 10 (6 tracheotomies) 100 1)7 50-5 ANISE ANTACIDS 84 The foregoing shows the importance of in- stituting the antitoxine treatment of diphtheria early in the disease, when the best effects are accomplished by its use. In the Boston Med- ical and Surgical Journal for August 30,1894, p. 225, Dr. Cyrus Edson, of the New York City Health Department, speaks enthusiastically of the efficacy of the antitoxine treatment of diph- theria, and says that, on the strength of the testimony of Dr. Hermann M. Biggs, chief of the bacteriological bureau of the department, who had spent nine months in Berlin in study- ing the treatment, he has decided to ask from the authorities "an appropriation of $30,000 for the establishment of an experimental sta- tion for the manufacture and dissemination of the antitoxine." * [See the articles on Anti- toxines and on Serum Therapy, and, for Klebs's treatment of diphtheria, the article on Antidiphtherine.] Serum Therapy in Tetanus.—The bacil- lus of tetanus was first discovered by Nicolaier. Rosenbach, a few months later, obtained a like germ from the secretions of a wound of a pa- tient suffering from tetanus. Kitasato, a Jap- anese student in Koch's laboratory, isolated the germ, and by inoculating this in pure culture produced the disease in animals, and estab- lished the identity of the Nicolaier soil bacil- lus with that of Rosenbach taken from the wound of a person suffering from tetanus. To Behring and Kitasato is due the credit of first demonstrating that animals can be rendered proof against tetanus. The serum of animals thus rendered insusceptible to the poison possesses a strong antitoxine effect on the poison of tetanus, so that one part of such serum will destroy thirty parts of the poison. Roux and Vaillard, whose investigations with the blood serum on the poison of tetanus, both in the lower animals and in man, carried on in the Pasteur Institute in Paris, enable them to speak with some authority, profess to be able to preserve the serum indefinitely after it has been dried in vacuo, by keeping it dry. On using it, six parts of distilled water are added to dissolve it. Both man and the lower animals can be ren- dered proof against tetanus, but, while the im- munity sets in within a few hours after the first injection, it is uncertain how long it may last. In the treatment of tetanus in man, the sooner the antitoxine serum is administered after the disease becomes apparent the more probably will success be obtained, but even then the action of the serum is not so certain as when it is given before symptoms are ap- parent. It has been suggested by Roux and * Since this paragraph was written the results of numerous trials with the antitoxine of diphtheria have become familiar to all who have interested themselves in this subject. The demand for large quantities of serum from animals rendered proof against diphtheria has led to the selection of the horse for this purpose. It requires several months1 treatment of the horse, by injecting from 20 to 30 c. c. of a culture of the toxine of diphtheria three or four times a week, before the serum possesses sufficient antitoxine power to be trustworthy in the treatment of diphtheria in the human subject. It takes, too, about a month to prepare the toxine culture which is to be used on the horse. Vaillard that small doses might be admin- istered as a preventive of the disease in persons suffering from wounds likely to be followed by tetanus. According to the investigators just mentioned, the blood of an average-sized man may be rendered antitoxic by injecting from 100 to 150 c. c. of prepared serum. For the treatment of tetanus they recom- mend the following: " Excision of the wound and injection at once of 100 c. c. of active serum ; next day and the following day repeat the injection of 100 c. c, and continue it daily so long as any symptoms last" (Year-Book of Treatment, 1894, p. 447). It must be borne in mind, however, that the antitoxine serum, while it neutralizes the poison in the blood, does not destroy the germs at the original seat of the disease, and, unless this source of rein- fection can be removed, the disease may at any time return. To guard against such unto- ward results, it has been proposed to keep up the antitoxine injections for ten or twelve days after all symptoms of the disease have sub- sided. It is well known that, while certain animals and fowls are refractory to tetanus, their blood serum will not destroy the toxine of tetanus, but that after injecting pure cultures of tetanus poison into such naturally refractory animals, their blood serum acquires strong antitoxine powers against tetanus, and may then be used to render other animals proof against the dis- ease. The blood serum of artificially protected animals is capable of destroying the toxine of tetanus. Serum Therapy in Hydrophobia. — Babes, of Bucharest (Lancet, 1891), experi- mented with the blood serum of dogs rendered proof against hydrophobia. Spinal-cord emul- sion does not seem to give the usual protection against hydrophobia to those bitten by rabid wolves, and Babes used antitoxine blood serum on twenty-seven dogs thus bitten, with the result that three died, two having symptoms of the disease before the injections were begun, and twenty-four recovered. It would seem from these experiments that it is possible for blood serum to protect in certain cases when spinal-cord emulsion is powerless. Tizzoni and Schwarz conclude (Riforma medica, 1891) " that the serum of 'vaccinated' rabbits can destroy the activity of the virus of rabies, retaining the power for some days if kept at a low temperature. Besides this, it distinctly confers immunity not only against subcutaneous, but also against intravenous and subdural inoculations." The experiments on dogs were less satisfactory. (Annual of the Universal Medical Sciences, 1892, vol iii M-5.) ' Serum Therapy in Typhoid Fever.— Chantemesse and Widell (abstract in New York Therapeutic Gazette) found it a comparatively easy matter to protect rabbits against typhoid fever, and to stop the disease in infected ani- mals with the serum taken from animals thus treated, yet when the same treatment was ap- plied to man, except for a slight lowering of the temperature, the disease ran its usual course. ANISE 85 ANTACIDS Serum Therapy in Tuberculosis.—The experiments of Semmola with the serum of the dog in the treatment of tuberculous disease have not been very gratifying, while C. Richet and Roger seem to think the local trouble and the general health were improved and the vir- ulence of the bacilli was lessened. Dogs are refractory to aviary tuberculosis, but not to human tuberculosis. Hericourt has demon- strated the fact that, if dogs are " vaccinated " with a culture of aviary tuberculosis, they be- come proof against human tuberculosis, and their blood serum then possesses an antitoxic power against the human form. Serum Therapy in Syphilis.—Fenlard has employed bichloride of mercury dissolved in the serum of the dog in the proportion of 1 to 2,000, and of this he gives three or four tea- spoonfuls in milk, but the reports do not show results to commend this method of treatment. The sheep and calf are said to be refractory to the poison of syphilis. Tommasoli and Pelliz- zari have treated syphilitic subjects with in- jections of the blood serum of these animals, using from 4 to 8 c. c, and profess to have been able to cure the secondary syphilitic manifestations in a fortnight in every in- stance. They encourage the hope that in serum therapy we shall ultimately find a sure cure for syphilis. Serum Therapy in Influenza.—The ex- periments of Bruscheltini on animals are in- teresting. With a culture made with the microbe of this disease he conferred immunity against influenza, and found that the serum from "immunized" animals possessed marked curative properties. Should these results be verified, this method of treatment of influenza in the lower animals alone will prove of ines- timable value to stock-raisers. Serum Therapy in Anthrax.—To Ogata and Jasuhara, of Tokio, seems to be due the credit of having discovered that the blood serum of an animal rendered proof against anthrax possesses properties antitoxic to the bacilli of anthrax. Emmerich (Munch, med. Woch., July 10, 1894; Epitome of British Medical Journal, July 28, 1894) relates some interesting results in serum therapy in the treatment of anthrax. Serum Therapy in Pneumonia.—During 1893 II. Andeond, Klemperer, Foa, Scaria, Janson, Netter. and Patella made known the results of numerous experiments with serum therapy in pneumonia (Year-Book of Treat- ment, 1894, pp. 41, 42), but we must wait for further developments before much advance in the treatment of pneumonia by this method over older ones can be accepted. Great care is necessary in the preparation of the serum, so that every step of the procedure may be thoroughly aseptic. When the ani- mal's blood-vessels are sufficiently large, a ster- ilized pipette is inserted into one of them, and after the desired quantity of blood is collected the pipette is sealed by heat. The serum is allowed to separate from the coagulum at a low temperature, when microscopical exami- nations and culture tests are made to insure freedom from all infecting germs. When the animal's blood-vessels from which it is desired to obtain blood are too small to allow of the insertion of a pipette into them, the blood is allowed to flow into a sterilized vessel. After the serum has separated, it is sterilized, pref- erably by the d'Arsonval apparatus. Serum therapy has received so much atten- tion from able experimental investigators dur- ing the past few years, and the principles on which it is based seem so logical and scientific, with the promise of practical results, that it is with regret I am compelled to devote so small a space to it. [For further consideration of this subject, see the articles on Antitoxines and on Serum Therapy.]—J. T. Eskridge. ANISE, ANISEED, anisum (U. S. Ph.), anisi fructus (Br. Ph), fructus anisi (Ger. Ph.), is the dried fruit of Pimpinella Anisum. It is a stimulant stomachic by virtue of its volatile oil, the oleum anisi of the pharmacopoeias. The aqua anisi of the U. S. Ph. is made by triturating 2 c. c. of oil of anise with 4 grammes of precipitated calcium phosphate, gradually adding 1,000 c. c. of distilled water, and filtering; that of the Br. Ph., by distilling 1 gallon from a mixture of 1 lb. of bruised anise fruit and 2 gallons of water. From a tablespoonful to a wineglassful of this prepa- ration may be given at a dose. The dose of oil of anise is from 2 to 6 drops on sugar, or well diluted with water. The spiritus anisi of the U. S. Ph. is made by mixing 1 part by bulk of oil of anise and 9 parts of deodorized alcohol. The dose of this preparation, com- monly called essence of anise, is from 10 to 30 drops. The teinture d'anis of the Fr. Cod. is made by macerating 1 part of anise fruit in 5 parts of alcohol for ten days, with occa- sional agitation, expressing, and filtering. The dose is from 5 to 15 drops, on sugar. An ex- temporaneous hot infusion of anise, prepared by steeping from 2 to 10 parts of anise fruit in 1,000 of boiling water, may be taken freely in attacks of colic. Star anise, anisum stellatum, is the fruit of Illicium anisatum (see Illi- cium). ANNIDALIN.—Iodized phenol, C6HsTsO, a proprietary amorphous, violet-red powder obtained by the action of iodine on phenol in the presence of an alkali. It is odourless, in- soluble in water, but readily soluble in ether, benzene, or chloroform. It has been used as a substitute for iodoform. ANODYNES.—See Analgetics. ANODYNINE.—See Antipyrine. ANTACIDINE.—Calcium saccharate. ANTACIDS are remedies used to neutralize an excess of acidity in the secretions of the alimentary canal or to check acid fermentation of the food. As commonly understood, they consist of the alkaline bases and their carbon- ates and oxides. Wood charcoal is sometimes included in this class on account of its prop- erty of absorbing large volumes of gases. The antacids most commonly used are so- dium bicarbonate, lime water, and the oxides and carbonates of magnesium. A very popular proprietary preparation consists of from 3 to ANTAGONISTS 86 5 grains of sodium bicarbonate, 1 to 2 grains of ammonium carbonate, and a small amount of oil of peppermint, compressed into tab- lets of varying size known as " soda-mints." The effect of this class of remedies is simply to neutralize temporarily the acidity present in the alimentary canal," but their continued use for this purpose is not desirable, as they soon aggravate the condition they are intended to benefit. The states in which they are indi- cated are pyrosis with acid eructations, aph- thous sore mouth, colic, and acid diarrhea, and they are best administered after eating, in combination with carbonic-acid water. (Cf. Alkalies.)—Russell II. Nevins. ANTAGONISTS are agents which, in their physiological action, oppose each other or op- pose disease, and may be employed against each other, or against diseases, to counteract their effects upon the living organism. Such agents have been designated physiological anti- dotes by some writers. They are either sub- stances or measures, and may be subdivided into (a) toxicological antagonists and (b) thera- peutical antagonists, according as they are employed against each other or against dis- ease. The substances employed as antagonists are generally the active principles of plants, a few being chemicals (such as oxygen and chlo- ral), or animal products (such as vaccine, tu- berculin, etc.), while the antagonistic measures include all such procedures as artificial respira- tion, faradization of the respiratory muscles, constant motion or absolute repose, heat, cold, douching, etc. Antidotes, on the other hand, are agents which alter the chemical or physical charac- ters of poisons and thereby prevent their toxic action upon living animal tissues. (See under Antidotes.) Antidotal action takes place in the alimentary canal or in the respiratory pas- sages before the absorption of the poison, and is available against mineral as well as vegetable poisons, but not against poisons which have been administered hypodermically. Antago- nism takes place in the blood and tissues after absorption of both the poison and the antago- nist, it is available against poisons administered hypodermically, as well as by other channels, and, so far as drugs are concerned, it is appli- cable chiefly to vegetable poisons or to those which produce their effects after absorption. Thus, for poisoning by digitalis the antidote is tannic acid, which forms with the active toxic principle of the drug a chemical com- pound (tannate) which is almost insoluble and therefore comparatively innocuous. But, as it is not entirely inert, an antidotal measure— viz., evacuation of the stomach—must be em- ployed, by the administration of zinc sulphate or any other emetic, or by the use of a stom- ach-pump. If, however, the patient is not seen until a dangerous quantity of the poison has been absorbed, antidotes will be of no service except against such portion of the drug as is still in the stomach, and the following antagonists should be employed to counteract the effects of what has been absorbed—viz., aconite or morphine against the cardiac ac- tion, the former for the effects of large doses, the latter for those of the long-continued use of the drug. Saponin and senegin are the most complete antagonists against digitalis, their counteraction extending throughout nearly its entire range of action. Alcohol is also indicated as a cardiac stimulant, and among the antagonistic measures the recum- bent posture is one of prime importance, by reason of the liability to sudden cessation of the lowered cardiac action on the patient's assum- ing the erect posture. In most cases of poisoning by vegetable principles absorption has proceeded so far be- fore professional assistance is obtained that antidotes are of no value, and reliance can be placed only upon the physiological antagonists and such antagonistic measures as may sup- port vitality until the poison can be eliminated by the excretory organs of the body. There may be an exception in the case of morphine, which, after making the round of the circula- tion, constantly returns in part to the stomach until it is eliminated, so that the ingestion of potassium-permanganate solution from time to time may have a continuous antidotal action on such portion of the poison as may have been absorbed. Physiological antagonism means a bal- ance of opposed actions on particular organs or tissues, which actions (or derangements) may be excited by medicinal agents and measures or by disease. Their antagonism may extend throughout the whole or the greater part of their range of action, or, as is usually the case, be limited to a few points thereof. There are no instances in which the antagonism of two drugs is absolutely complete along their whole line of action. In a few it is nearly so, as with morphine and atropine (except as to narco- sis), digitalis and saponin, and atropine and muscarine, the latter being considered the most complete known. In most cases the an- tagonism extends only to certain definite spheres of action, and the antagonists may be synergists to each other in other spheres, as in the narcosis produced by both morphine and atropine. It may be local, affecting a single organ or function, or may extend to a group of organs, to several associated functions, or over the distribution of the nerves proceeding from a certain nerve-trunk (such as the vagus) or nerve-centre. Again, antagonism implies a balance of functional disturbance, not an al- teration of structure. Drugs are rarely antagonistic to each other in the same degree, but, by reason of differ- ences in their mode and time of action, the action of one preponderates over that of the other, so that the latter will not counteract the former to the extent of averting a fatal result, though in the reverse order their counterac- tion may be most satisfactory. For example, while chloral is the antagonist to strychnine, opposing the spinal action of the latter drug, the reverse is true to a very limited extent; and, while atropine may prevent death from a lethal dose of aconitine, morphine, or bromal hydrate, no one of these three will do so in atropine poisoning. 87 ANTAGONISTS Two mutually antagonistic principles may exist in the same plant, such as the alkaloids pilocarpine and jaborine in pilocarpus, and the glucoside constituents of digitalis, one of which, digitonin, antagonizes the actions of the three others, digitalin, digitoxin, and dig- italein. Toxicological antagonism is a very old idea in medicine. Mithridates the Great, of Pontus (B. c. 164-'24), and other monarchs of the heathen world occupied themselves with the study of poisons and their antidotes and antagonists, established botanical gardens for the purpose of their investigation, and gave their names to what were supposed to be uni- versal preventives against the results of poi- soning. Mithridatics and alexipharmacs were the names of such, and they were in use to the period of the Middle Ages. In the sixteenth century Prosper held that theriaca (opium) was an antagonist to all poisons. From 1570 to 1677 many observations were made and published on the treatment of belladonna poisoning by opium, and in 1810 the same matter was made the subject of an inaugural thesis by Lipp. The scientific investigation of drug action and antagonism was not possible until the discovery and isolation of the alka- loids, but followed immediately thereon, and was begun in 1809 by Magendie upon the upas poison (nux vomica) and its newly discovered alkaloid, strychnine. In 18G9 Schmiedeberg and Koppe made their researches on muscarine and atropine, and Liebreich discovered chloral and proved the antagonism of strychnine against its action, the converse of which was shown by Bennett in 1875. In 1870 Frazer published his investigations upon atropine and physostigma, and Preyer his on the antagonis- tic influence of atropine and hydrocyanic acid on respiration. In 1875 a committee of the British Medical Association made an extended investigation and report on the antagonism of several drugs, which was supplemented by the work of Vulpian on atropine and pilocarpine in the same year, that of Fothergill (1876-'78) on aconite, atropine, and digitalis, and that of Huseman. in 1877, on the antagonisms of chloral. Much good work has also been done in England by Brunton and Ringer, and in the United States by Wood and Bartholow, on the same lines. The name of Brunton is unalterably associated with the antagonism between amyl nitrite and the spasmodic parox- ysm of angina pectoris, a discovery in thera- peutic antagonism which was made by him through the exercise of purely scientific rea- soning. Bartholow has collected a list of 120 cases of poisoning by opium and belladonna, each treated with the other as an antagonist, in which 15 proved fatal, or 12-5 per cent. The most important instances of drug an- tagonism, so far as elucidated, are set forth in the following synopsis, in which the active principles of plants are designated rather than the plants containing them, except in a few instances: Atropine and morphine are antagonistic in their action on respiration, atropine stimu- lating, morphine depressing it, and this is the most valuable point in their antagonism : on the pupil, atropine dilating it by stimulation of the sympathetic and paralyzing the motor oculi, morphine contracting it by stimulating the motor oculi, the action of atropine pre- ponderating and lasting much longer ; on the heart, atropine quickening it, morphine slow- ing it, the action of atropine preponderating ; on arterial tension, atropine raising it, mor- phine depressing it after a brief rise; on the kidneys, atropine promoting, morphine de- creasing the renal activity; on the brain, in medicinal doses, atropine exciting, causing ac- tive congestion, insomnia, hallucinations, and busy delirium, morphine depressing (except in small doses), causing passive congestion and correcting the cerebral symptoms produced by atropine, both producing coma and narcotism when used in excessive doses; as to general symptoms, atropine correcting the coldness, sweating, cerebral nausea, etc., produced by morphine. Morphine kills by causing failure of respira- tion ; atropine counteracts this tendency and tends to maintain the activity of the respiratory function. Atropine proves fatal by exhausting the irritability of the cardiac motor ganglia, the vasomotor system, and the respiratory centre through overstimulation: morphine, by less- ening the work of the heart and lungs, opposes these effects. Atropine and muscarine present the most complete instance of physiological antagonism. On the brain, atropine causes hyperaemia and active delirium, muscarine produces anaemia and intoxication ; on the pupil, atropine dilates and muscarine contracts it; on salivation, atro- pine arrests it. and muscarine promotes it; on the heart, atropine quickens and restores its action when arrested by muscarine, which slows and stops it in diastole; on respiration, atro- pine stimulates and muscarine paralyzes it. Atropine and pilocarpine present one of the most exact cases of antagonism. On the eye, atropine dilates the pupil, paralyzes the accommodation, and renders the subject pres- byopic, while pilocarpine contracts the pupil, causes spasm of accommodation, and approxi- mates the near and far points of vision ; on secretion, especially of the sweat and saliva, atropine arrests and pilocarpine promotes it; on the heart, atropine stimulates and pilo- carpine slows and enfeebles it; on the arterial tension, atropine raises and pilocarpine de- presses it. Atropine and physostigmine (eserine), on the pupil, respiration, and secretion. The antagonism of atropine against physostigmine acts within narrow limits, but sufficiently to be of use in poisoning by physostigmine, the converse being doubtful. Atropine and quinine.—On the heart, atropine stimulates and restores action arrest- ed by quinine, which stops it in diastole; on the arteries, atropine dilates and quinine con- tracts them ; on blood-pressure, atropine re- tards and quinine raises it, as observed in frogs and rabbits. Atropine and bromal hydrate.—On the blood-vessels, which atropine contracts (?) and ANTAGONISTS 88 bromal dilates by paralysis of the sympathetic; on salivation, atropine arresting and bromal promoting it. Atropine may save life after a lethal dose of bromal, but the reverse is not true. Atropine and chloral.—On the brain, atro- pine excites it, causing hyperemia, while chloral is hypnotic, producing anaemia; on the spinal cord, atropine exalts reflex excitability and causes a tetanizing action, while chloral sus- pends the reflexes and causes spinal paralysis; on respiration, atropine stimulates and chloral depresses it; on the vaso-motor centre, atropine stimulates and chloral depresses it. Atropine is antagonistic to chloral in much greater de- gree than chloral is to atropine. Both produce motor paralysis. Atropine and aconitine.—On the heart and respiration, which are stimulated by atro- pine and depressed by aconitine. Atropine and phytolaccine.—On the heart, which phytolaccine arrests in diastole by paralysis of its motor ganglia and muscle, while atropine stimulates the accelerator nerves and the motor ganglia; on sensation, phytolaccine lessens it; on the spinal cord, phytolaccine paralyzes it; on respiration, which phytolac- cine depresses. Atropine antagonizes all these effects. (Observed in twenty experiments on animals by Bartholow.) Chloral and picrotoxin.—On the brain and spinal cord they are antagonistic, includ- ing the reflex, motor, and sensory functions of the cord, but not on the heart and respiration, which both drugs paralyze. Chloral and heat.—Dr. Lauder Brunton found that an animal kept wrapped in cotton- wool might recover from a dose of chloral suf- ficient to kill it if exposed to the cooling action of the air. Digitalis and aconite have an antagonism limited to their action on the heart, which, when paralyzed and distended by aconite, recovers its contractile power slowly under digitalis. The reverse action is not so marked. These drugs have widely different rates of diffusion and elimination, and digitalis, being the slower, must be given from five to nine hours before aconite for them to exhibit their antagonistic action. (Observed on frogs and rabbits by Fothergill.) Digitalis and muscarine or aconitine, on the heart, digitalis stimulating inhibition, and thus paralyzing it, muscarine restoring cardiac movements by relaxing the grip of in- hibition. (Boehm.) Digitalis and saponin or senegin.—Sap- onin or senegin arrests the heart in diastole, while digitalis stimulates contraction. The heart, if arrested by saponin or senegin, is re- stored to action by digitalis, and vice versa. (KShler.) Morphine and aconite, on the heart and respiration, which morphine stimulates and aconite depresses. Morphine has repeatedly saved life in cases of poisoning by aconite. Morphine and caffeine (also cocaine, theine, and guaranine) are antagonistic on the spinal cord, the heart, and sensation, but synergistic on the brain and the vaso-motor system. Strong infusion of coffee is an em- pirical antagonist to the effects of morphine poisoning. Morphine and chloroform or ether are synergistic as to anaesthesia, but antagonize each other in their action on the heart and respiration, morphine stimulating and sup- porting them and chloroform and ether de- pressing them. The combined use of morphine with chloroform or ether for anaesthesia is safer than the use of these anaesthetics alone. (Bernard.) Opium and gelsemium.—Opium, in ordi- nary medicinal doses, antagonizes gelsemium, which acts like Veratrum viride (see below). Opium has saved life in several cases of poison- ing with gelsemium. Opium and Veratrum viride, the for- mer in medicinal (not toxic) doses.—On the heart and respiration, opium maintains, while veratrum depresses the heart and paralyzes respiration; on the vaso-motor system, opium stimulates it, raising arterial tension, and vera- trum depresses it, lowering arterial tension ; on the body temperature, opium raises and sus- tains it, and veratrum lowers it; on secretion, opium diminishes it, and veratrum increases it; on the brain, opium stimulates it, and ve- ratrum produces anaemia; on the spinal cord, opium stimulates and veratrum depresses the motor functions. These agents have high rank as mutual antagonists in efficiency, extent of range, and vice-versa action. In several cases of poisoning with opium life has been saved by veratrum (Bartholow). Strychnine and aconitine.—Strychnine has a stimulating and aconitine a paralyzing action on the muscles of respiration. A* leth- al dose of aconitine is entirely overcome by strychnine in twice the lethal dose. (Ob- served on animals by Fothergill.) Strychnine and amyl nitrite.—On res- piration, strychnine stimulates the muscles, and amyl nitrite paralyzes them; on the spinal cord, strychnine stimulates the reflex function, and amyl nitrite suspends it; on the heart, strychnine decreases its action, and amyl nitrite increases it greatly; on arterial tension, strychnine stimulates it, and amyl nitrite de- presses it greatly. Strychnine and chloral.—On respira- tion, strychnine stimulates the centre, pro- ducing tetanic fixation of the muscles, while chloral depresses the centre and removes te- tanic fixation; on the spinal cord, strychnine exalts the reflex and motor functions, while chloral suspends both; on the circulation, strychnine stimulates the vaso-motor centre, and chloral depresses it; on the brain, strych- nine increases the circulation, while chl'oral causes cerebral anaemia. Chloral is more decidedly antagonistic to strychnine than strychnine is to chloral. The antagonistic quantities are ^ of a grain of strychnine and lo grains of chloral. Seven cases of strychnine poisoning treated with chloral, all successfully, have been recorded (Bartholow). Strychnine and chloroform or ether.— hither given by inhalation in poisoning with strychnine has proved successful in ten report- 89 ANTAGONISTS ed cases (Bartholow). Anaesthetics suspend the exalted sensibility and reflex excitement due to the action of strychnine, and maintain functions which would otherwise be exhausted by overstimulation. Conversely, strychnine in the dose of fa of a grain, hypodermically, antagonizes the cardiac and respiratory de- pression produced by these agents, though atropine will do so more quickly. Strychnine and nicotine are antago- nistic in their action on the spinal cord and the respiratory muscles. Nicotine was pro- posed as an antagonist to strychnine in cases of poisoning by Haughton, of" Dublin, in 1862, but has been superseded by chloral. Strych- nine is antagonistic to and curative of the effects of nicotine on the heart and vision, caused by excessive tobacco smoking. Viscum album (mistletoe) is a cardiac tonic, exalts the vascular tension, and di- minishes sensation. Its antagonists are the cardiac and respiratory depressants, especially aconite and veratrum viride (Bartholow). The following table, modified from Brunton, gives the antagonistic poisons, also their mu- tual antagonistic and lethal doses, in grains to the pound weight of the animal: ANTAGONISTS. LETHAL DOSE. ANTAGO-NISTIC DOSE. I. II. I. II. I. 11. 5S5 7 7 7 7 7 7 5B5 1 lis SffB "3" H 7 "a 1 IBS sis 1 IB 7 1? 7 1 TETF bJb SB 3 i 1? ? T5E " " hydrocyanic acid. " " jaborandi........ " " muscarine........ " " morphine........ " " pilocarpine....... " " phvtolaccine " " physostigmine ... Bromal hydrate and atropine .. " " physostigmine.... Chloroform and amyl nitrite... 3BB " " muscarine....... Gelsemium and opium......... " atropine....... B 3 i 3 7 " '' chloroform...... Muscarine and atropine........ " " veratrum viride Under the titles of the various poisons, Opium, Nux Vomica, etc., throughout the book, the antidotes and antagonists for each are treated of, together with such antidotal and antagonistic measures as are most suitable. Therapeutical antagonists include all agents or measures which counteract the ef- fects of particular diseases, and may be em- ployed against them in accordance with the law of contraries. This was laid down by Hippocrates in several aphorisms, notably that in which it is stated that " Some diseases are cured by contraries, some by similars"; also by Fernel (sixteenth century) in a treatise on the maxim "Every disease must be com- bated by contrary remedies." The antagonism between medicinal agents and disease has been recognised empirically from the earliest historical times, but was im- possible of scientific elucidation until, with the discovery of the active principles of plants, the systematic study of their physiological effects began, early in the present century. The pio- neers in this field were Magendie, who investi- gated the action of strychnine in 1809, and suggested its use against paralysis, and Fou- quier, who first actually employed it in ac- cordance with Magendie's deductions. Among later investigations, the most brilliant is that of Brunton upon the antagonism of amyl nitrite to the paroxysms of angina pectoris, already mentioned. The most important instances of the treat- ment of disease by drugs having actions an- tagonistic to their effects are as follows: Strychnine against the functional paralyses, such as diphtheritic and reflex paralyses, asthma from paralysis of the diaphragm, and depression of respiration. Antispasmodics, such as chloroform, chloral, tobacco, the bro- mides, physostigma, and gelsemium, against the spasmodic neuroses, such as tetanus, epi- leptoid convulsions, spasmodic coughs, hic- cough, laryngismus stridulus, etc. Amyl nitrite for the paroxysms of angina pectoris and epilepsy. Chloral, cimicifuga, conium, and morphine against chorea. Analgetics—such as aconite, gelsemium, and morphine—and anaes- thetics, against pain ; analgetics by interrupt- ing transmission of the sensation to the centre, and anaesthetics by preventing its realization by the consciousness. Hypnotics, such as chloral, against insomnia and acute mania. Gelsemium, conium, hyoscyamine, and du- boisine against acute mania, with illusions, hallucinations, and great motor activity. Morphine against melancholia. Aconite, veratrum, and the bromides against acute cerebral congestion of an active form; and digitalis, ergot, barium, and quinine against the passive form. Cerebral excitants, such as strychnine, atropine, and quinine, against cere- bral anemia. Digitalis and ergot against exophthalmia. Atropine against weakness of the heart from depression of its accelerator apparatus; digitalis for a weak, quick heart, due to relaxed inhibition. Ergot against aneurism and hemorrhage. Digitalis, verat- rum, the bromides, opium, etc., against metrorrhagia, menorrhagia, and other forms of hemorrhage. Atropine and strychnine against dyspnea. Atropine and morphine against diarrhea and dysentery. Belladonna, nux vomica, and physostigma against consti- pation from intestinal torpor and deficient secretion. Atropine against sweating, lacta- tion, and salivation. Digitalis and squill against renal inactivity. Ergot against poly- uria. Quinine, morphine, digitalis, aconite, the salicylates, resorcin, and other antipyretics against fever and inflammation. Morbific products of disease or bacterial life, ANTAPHR0D1STACS ANTASTHMATICS 90 obtained by cultivation on living tissue and other media, were introduced by Jenner, Pas- teur, and Koch, and are successfully employed as antagonists against variola, hydrophobia, and tuberculosis. They can only be referred to in this place, as their use forms a special system of treatment. " Animal products have been employed as antagonists to diseases, such as that from the thyreoid gland for myxoedema and testicular extract against disorders of senility; but the results thus far obtained are not sufficiently definite to admit of dogmatic teaching thereon. Samuel 0. L. Potter. ANT APHRODISIACS.—In the satyria- sis, priapism, and nymphomania due to insan- ity, idiocy, leprosy, and disorders or injuries of the central nervous system, probably all methods will fail of more than slight or tem- porary success, but where these elements are absent a greater or lesser degree of relief can be obtained, provided the patient will co-operate. The treatment consists largely in the use of moral measures. No matter what may be the apparent causes of these conditions, certain procedures are necessary in every case. These consist in the removal of every possible kind of irritation, no matter how slight, of the geni- to-urinary tract and the genital organs. The diet should consist as largely as possible of non- nitrogenous articles, alcoholic liquors and all condiments except salt being interdicted ; the rectum should be kept free from any over- accumulations of faecal matters; the urine should be rendered alkaline, as an acid urine always acts as an irritant of the urethra and increases its vascularity; intestinal worms, if they exist, should be expelled: and all local causes of irritation, such as eruptive disorders of the genitals in either sex and phimosis, paraphimosis, adherent prepuce, irritable ure- thra, etc., in the male, should be corrected by appropriate treatment. The clothing should be arranged so as to cause as little irritation of the genitals as possible, and the patient made to sleep on his or her side on a hard bed with just sufficient clothing to insure comfort, the foot of the bed, in bad cases, being at least a foot higher than the head, thus relieving or pre- venting pelvic congestion; and the sleeper should be roused at an early hour in the morn- ing. As a precaution against young children acquiring the habit of self-abuse, it is desirable to begin as early as possible with them in the practice of sleeping with the arms outside of the bedclothes. By tying a towel around a person's body, with the knot behind, about on a level with the last dorsal vertebra, the habit of sleeping on the back may easily be broken up, as the instant the person turns over on to his back the knot will cause suffi- cient uneasiness or pain to rouse him. As a distended bladder causes erections in the male, it must be emptied before going to bed and early in the morning, or sometimes in the mid- dle of the night, the patient being wakened for the purpose. In aggravated cases, due either to serious disease of the central nervous system or to the use of articles irritating to the genito-urinary tract, such as cantharides, it mav be necessary to apply ice to the genitals until'the irritation has somewhat subsided. This same method is entirely applicable in the treatment of painful chordee. It should be hardly necessary to state that all exciting in- fluences, such as that of libidinous literature and pictures and association with loose wom- en, must be removed. In men in whom a not excessive sexual erethism exists the con- stant association with virtuous women is an advantage. In the young a certain amount of physical restraint may be advisable, but as a rule such measures as'inflbulation and the at- taching of the prepuce to the thigh by means of a silver wire have not been attended with much success. In spermatorrhea and im- moderate nocturnal emissions what is known as a spermatorrhoea ring will often lend aid to the patient in his desire to gain relief. This consists of a soft rubber ring in the inner cir- cumference of which is concealed a sharp me- tallic point, so that when it is slipped over the flaccid penis it is not noticeable. When, how- ever, an erection takes place the point presses into the penis and causes sufficient pain to wake the person, who can then make water, apply ice, or do whatever his own experience has taught him is best. A somewhat similar device is arranged to sound an electric bell upon the occurrence of erections during the night, but is rather complicated and has never met with much success. Daily cold baths and frequent affusions upon the genitals are valuable aids to whatever treatment may be undertaken. In aggravated conditions of nymphomania the propriety of ablation of the clitoris and labia minora may be considered, but such an operation is rarely allowable un- less there seems to be no hope of success by less severe methods and when life or reason is threatened. One point which must not be overlooked in such cases is that of the condi- tion of the ovaries, for in many instances their prolapse or morbid condition excites a most exaggerated sexual appetite. Their removal or restoration to their normal condition will, as a rule, relieve the other symptoms. The drugs which are most likely to be of use in the states just mentioned are camphor, its mono- bromide, the bromides of the alkaline bases, lupulin, conium, belladonna, and digitalis. Camphor, to be of any value, must be given in large doses; the bromides are best associated with camphor water, and such a mixture is practically identical with the monobromide. Veratrum viride and all nauseating drugs are used with some degree of success in the treat- ment of chordee. Malt liquors, on account of the hops they contain, are slightly antaphrodisi- ac, and tobacco has a feeble effect in the same direction, so that it is not advisable to suspend their use when aphrodisiac conditions are being combated. Lactucarium is credited with some antaphrodisiac virtues, but they are so slight as to be almost valueless. Belladonna is more especially indicated when there is priapism or an irritable bladder.—Russell H. Nevins. ANTARTHRITICS are remedies against gout. See the articles on Alkalies. Antir- rheumatics, Colchicum, Guaiacum, Lithium, 91 Piperazixe, Potassium iodide, and Salicylic acid. ANT APHRODISIACS ANTASTHMAT1CS cone were of such dimensions that the angle of its apex was a right angle, it would increase in size from above downward at the same rate as that at which a pencil of light does—viz., in direct proportion to the square of the dis- tance. The surface illuminated at the distance of 100 miles from the sun is a hundred times that at 10 miles, though the distance is only ten times as great. This simple illustration may be useful to those whose mathematics is rusty. If the area of the trachea is a square inch, the alveolar surface would be, say, 150 square inches. But, in fact, the rate of expan- sion is far greater than that. In true asthma the calibre of the bronchial tubes is lessened, either by contraction of their muscular coats or by swelling of the mucous membrane and submucous tissues. At the same time there is a secretion of viscid mucus which, clinging to the surface and being raised from it to some extent by the current of air, increases the obstruction. In the larynx and trachea—probably in the larger bronchi also—there is no appreciable diminution of capacity. As a result of these conditions the normal equilibrium between the influx and efflux of air is disturbed. While the inspired air flows easily from the narrow apex of the cone into its broad base, the outflow from the larger into the smaller space is not so free. This begets a tendency to the accumulation of air in the alveolar cavities. I am personally persuaded that the time- honoured theory of the production of asthma by spasm of the circular muscular fibres of the bronchial tubes is not correct: but that the expiratory dyspncea results from a vaso-motor aberration involving dilatation of the blood- vessels of the mucous membrane, swelling and diminution or even obliteration of the lumina of the tubes, and accumulation of viscid mucus. Be this as it may, we have two pretty definite indications for the general treatment of asth- ma. One is the evident necessity of some action upon the nervous system. The agents used for this purpose are classed under the head of antispasmodics, though the exact nature of their action is not thoroughly under- stood, inasmuch as they are known to relieve abnormal conditions which do not correspond to our ideas of spasm. It is quite possible that the vaso-motor changes, some of which are characterized by contraction and others by dilatation of the smaller blood-vessels, are all in reality due to similar reactive changes in the ganglion-cells, and may all be modified or controlled by agents which inaugurate the activity of these central nervous elements. There appears to me to be no valid objection to the theory that such drugs as diminish the constricting operation of certain parts of the vaso-motor system may. under different circumstances, also arrest the dilating function. The second indication is to modify in some way the secretion of adhesive mucus, which has* in all probability more to do with the causation of asthma "than the other factors mentioned. ANTASTHMATICS are substances and agents which prevent, diminish, or abolish asthma. To complete the definition it is ne- cessary to state the exact meaning of the word asthma as 1 here employ it. It is a term which, like many another one, has been used rather indiscriminately by medical writers, some limiting it to the indication of spasmodic dyspnoea ; some extending its connotation so as to include any attack of dyspncea. subject- ive or objective, which is of rapid development, without a distinct pulmonary lesion as its basis, and which subsides without any marked altera- tion in the condition of the respiratory appa- ratus; while almost all authors use it as a convenient term whose significance varies, and is at any particular time qualified by the sub- ject upon which they are writing. For general therapeutical purposes I shall de- fine asthma as a derangement of the function of respiration characterized by dyspncea which is not due to any diminution of the respiratory surface or to pulmonary congestion. In other words, there is no hindrance to the diffusion of gases between the blood and the air, save in so far as the accumulation of car- bonic oxide (C02) in the residual air increases the tension and makes the interchange less rapid. That is, however, a factor of no prac- tical importance, as the slight difference be- tween the rapidity with which the carbonic oxide (or acid) of the blood and the oxygen in the air effect their exchange of places under the fluctuating tensions which correspond to the phases of respiration would cause varia- tions in the ha?mogiobin so small that they might be ignored. In ordinary breathing in the human subject the air loses only about 5 per cent, by volume of its oxvgen. The meaning of this proposi- tion is that if a certain quantity—say 100 cubic inches—of atmospheric air is drawn into the respiratory passages in a given inspiratory act, it will be found that the same volume of air taken from what is exhaled during the expira- tion immediately following has a different composition. It has now about 5 per cent, (or 5 cubic inches) less oxygen, and about 4-5 per cent, of it is carbonic oxide. But the air which remains in the bronchial tubes and the alveoli of the lungs has a com- position which is much more constant—indeed, it can vary but little when the body is quies- cent, for this residual stratum of air stands as a medium between the gases of the respiratory capillary system and the tidal drift of the at- mospheric sea as it ebbs and flows in the tubu- lar channels. By this means the rate of diffusion is maintained at the same ratio, ex- cepting as it is influenced by the blood-pres- sure and, to a very slight degree, by the fluctuation of the bodily temperature. The volume of air contained in the respira- tory system, from the rima glottidis above to the" alveoli below, may be presented to the im- agination as a cone the angle of whose vertical section is more than a right angle. If the ANTASTHMATICS 92 Antasthmatics, then, will be such agents as have a sedative effect on the vaso-motor nerv- ous system, and such as have the power of changing the secretion of viscid mucus into the secretion of thin, non-adhesive mucus. Inasmuch as the disturbance may be second- ary, we have also to deal with a third problem —viz., that of ascertaining and removing the cause of these troubles. Most of the cases of asthma are of reflex origin. The primary irritation is in the lungs themselves, in the larynx, in the naso-pharynx, in the nasal passages," in the tympanic region, in the circulatory apparatus, or in the digestive organs. When not of reflex origin, asthma is almost always caused either by a neurotic condition associated with epilepsy, hysteria, or some other grave dyscrasia, or by renal disease. Though the list of causes is long, the dis- tinction is seldom difficult. The examination is made in accordance with the principles stated. First, is it a case of asthma? This is easily determined by ascertaining that the dyspncea is due to interference mainly with the expiration; that the breathing is slow as compared with the intensity of the dyspnea ; * that there are sibilant and sonorous rales in- dicative of but little moisture ; and that there is no evidence of disease in the pulmonary parenchyma, except, it may be, emphysema. This being determined, an investigation of the upper air-passages, inquiry into the con- dition of the digestion, and a careful scrutiny of the personal history will enable one to state the nature of the case with much certainty. In cases of neurotic inheritance it is impor- tant to search for a zone, as the neurologists say of epilepsy, or region from which the in- itial reflex may come. We are now able to classify the antasthmatic resources as follows: 1. Means of combating the constitutional predisposition. 2. Means of overcoming the (so-called) spasmodic con- dition. 3. Whatever will do away with the source of a reflex irritation. The constitutional predisposition is, as the expression indicates, something inherent in the individual which can seldom be eradicated entirely, but must be combated, as I have said. In some instances, where the physician has the opportunity of beginning his treatment while the subject is still young—in infancy or childhood—and where, as the confidential and trusted adviser of the family, he is able to insist on a rational course of physical educa- tion, it is possible to influence the development of the organism in such a manner as to guide it slowly and steadily into the path of normal existence. We can always count on a " power which makes for (physiological) righteousness " —viz., the tendency of organized bodies to grow toward the anatomical and physiological type of their species, and, where there is some in- herited deviation from that type, we may by * It is not always or usually slower than normal respiration, as might be inferred from the statements of some authors—e. a.. Riegel—but it is much slower than would be expected where one is so short of breath. This is always the case in labored breathing. judicious management enable the individual organism to overcome the evil tendency and to grow toward the average ancestral form. This is quite apparent in cases of genu varum, in which, as is well known, careful attention to health and avoidance of undue strain on the legs are usually sufficient to enable them, as the child develops, to assume the normal structure. Less apparently, but no less cer- tainly, may an analogous result be accom- plished in dealing with congenital or early acquired abnormities of the nervous, respira- tory, and vascular systems. And nowhere is the opportunity of the family physician to do good more evident, or the result of his efforts more satisfactory, than in this particular de- partment of practice. The scope of this work does not allow me to do more than to indicate this very important division of the therapeutics of asthma. The remedial agents for this predisposition are, aside from hygienic measures, tonics, al- teratives, and the drugs which act especially as calmatives and roborants of the nervous system. The means of combating the so-called spas- modic condition are physical and chemical. Physical Means.—Regulation of tempera- ture is one of the most important. The asth- matic, like all other nervous people, is very sensitive to changes of temperature. His room should be moderately warm—should have a temperature which is so regulated that he is not conscious of any sensation of heat or cold. From 60° to 65° F. will usually answer. The bedclothing should be very light, so as to pre- clude any feeling of oppression. It is often better to have him wear a full suit of light un- derclothing,* to which I have frequently and with great satisfaction made the addition of a light pair of socks basted on to the drawers. This allows of free motion without danger from uncovering the feet. In cool weather it is better to have a fire in the room and the windows open to secure free ventilation. Another physical influence of great value— one which I have not seen suggested by any author—is elastic compression of the chest. For this purpose I use a Martin pure rubber bandage, applied so as to make the slightest pressure compatible with its retention. In winding it about the chest it is stretched bare- ly enough to have it tighten itself and cling to the surface. This will assist the expira- tory efforts, prevent the excessive distention which usually occurs, and materially lessen the dyspncea, which is largely due to inability to expel the normal amount of tidal air. It should not cause distress—at most a little discomfort —and should be used at first for five or ten minutes every hour. If well borne it may be kept on for half an hour, but the physician * It is always better to have asthmatics, as well as those suffering from other chronic pulmonary dis- eases, wear light underclothing. They always per- spire easily, and as our houses are almost as warm in winter as in summer, heavy underclothing keeps the skin continually moist when they are indoors, and they catch cold when they go out. It is better to make changes in the outer garments to suit the tem- perature of the air. 93 ANTASTHMATICS should watch it himself until he is satisfied as to the best arrangement. A similar effect may be obtained by causing the patient to exhale into rarefied air. In this operation the pressure upon the surface of the body is greater than that within the respira- tory passages, and, as a necessary consequence of this, the expulsion of air from the bronchial tubes is more easily accomplished. It is pos- sible, of course, by this measure to put such a suction on the air contained in the lungs as to draw it all out, and produce a complete col- lapse—a return to the foetal condition. But, unfortunately, in exhaling into a cham- ber containing rarefied air, the air in the re- spiratory passages and that in the chamber are mixed, and the pressure in the bronchi and alveoli sinks until it is the same as that in the apparatus. In other words, it acts exactly like a cupping glass, and if not managed with the greatest skill the operation involves great dan- ger of haemorrhage. Electrical stimulation of the contractile tis- sues is not feasible. The current can not be applied to a given portion of the nervous tis- sues exclusive of all the other portions. The result of my own efforts in this direction has been that when the current was strong enough to have an appreciable effect, it sus- pended respiration entirely, so that I was abundantly satisfied with the resumption of breathing when I removed the electrodes, which was done without standing on the order of their going. The chemical means are numerous, and some of them are valuable. They may be divided into two classes: 1. Those which act immedi- ately and are used to break up a paroxysm. 2. Those which are slower in manifesting their effect, and which are employed between the paroxysms, their use being continued over a long space of time, with the intent of overcom- ing the conditions which constitute the predis- position. I must, at the beginning of the discussion of these measures, call attention to the fact, sometimes overlooked by practitioners in their anxiety to relieve the sufferings of one who is evidently in the most dreadful torture, that asthma is essentially a chronic disease—a chronic neurosis—and that it, like all diseases of its class, presents the danger of the forma- tion of some habit of inebriety. The very drugs which most quickly and cer- tainly give relief—viz., alcohol, chloral, and opium—are the most deadly of narcotics, ruin- ing the health, annihilating the moral force, and blasting the hopes of those who are un- fortunate enough to fall under their terrible influence. For immediate relief the following remedies are useful: Morphine.—The hypodermic injection of morphine will seldom or never fail to give im- mediate relief, sometimes complete, sometimes partial, its extent depending on the amount administered, and also obviously on the sus- ceptibility of the patient. Morphine, or any opium preparation, may be given by the stom- ach, and, if it is retained, it will be effectual, | but not to the same degree as when it is in- jected hypodermically, because its absorption is gradual and it does not, at any given mo- ment, exert the same intensity of action. If the absorption is very slow, the effects, while they are prolonged over a greater period of time, may never be intense enough to give any notable mitigation of the suffering. In asthma, as in cases of severe pain, the dose of morphine may safely be made rather larger than under ordinary circumstances. As a rule, with adults, it is safe to begin with 10 minims of Magendie's solution (2 grains to 1 drachm of water). This should be given only when the attack is very severe, when the patient has not previously used the drug, so as to be in danger of becoming wed- ded to its use, or when it is of importance on account of danger from exhaustion or of the necessity of producing a strong moral effect, to make a speedy and certain impression upon the disease. If the urgency is not great it is better to administer the opiate by the stomach, and by all means to keep the patient in ignorance of the nature of what he is taking, as thereby one retains control and secures the sufferer against the danger of incurring a disease far worse than asthma. For internal administration the best opiates are codeine (\ to \ a grain), morphine bi- meconate dof agrain), vinum opii (\Q to 15 min- ims), acetum opii (5 to 10 minims), and Squibb's liquor opii compositus (10 to 15 minims). The strength of the last-named preparation is about the same as that of laudanum in so far as it is an opiate; but the chloroform and ether which enter into its composition augment its power as a sedative of the nervous system. In fact, they not only add their own specific influence, but, by their quality of stimulants to the vascular and glandular tissues at the point of contact, they facilitate, or rather has- ten, the absorption of the substances with which they are combined. A still better formula, and one which I have used in many cases with few disappointments, is the following: R Morphin. sulphat......... gr. j ; Spir. ammon. aromat...... f 3 ij ; Spir. chloroformi......... f 3 j; Aquae................... 3 v. M. A drachm of this mixture, containing £ of a grain of morphine, 15 minims of aromatic spirit of ammonia, and ?-£ minims of spirit of chloroform, will serve to relieve the dyspnoea in most cases, at least to the extent of allow- ing the patient to sleep, and to sleep quietly enough to get considerable rest. Such a for- mula may be used as a basis upon which to construct individual prescriptions to meet the requirements of particular cases. For instance, if the mucous secretion of the bronchial tubes is particularly adhesive, the addition of 10 or 15 grains of iodide of ammonium to the ounce may suffice for its correction. Or, in mam- cases, especially if we have cause to suspect the existence of an excessive susceptibility to 1 iodine, 5-, or even 10-minim doses of wine of ANTASTHMATICS 94 antimony will be still better. Or, if it is known or suspected that the patient in hand is unduly nauseated by morphine, it may be replaced by codeine, which, while equally effectual in its proper dose, has not the same tendency to produce nausea. The spirit of chloroform also may sometimes be very ad- vantageously replaced by Hoffmann's anodyne (spiritus etheris compositus), the dose of which is much larger and the taste more disagree- able, but which has the advantage of being safe when given in large doses. Our original formula is, perhaps, improved by being put into the following shape: B Codein. sulphat.......... gr. ij; Vini antimonii.......... ill xl; Spir. ammon. aromat.....f 3 j ; Spir. aether, comp........ f 3 iv - vj; Aq. menthoe pip.......ad f § ij. M. The dilution of the ammonia and Hoffmann's anodyne has raised the dose to two teaspoonfuls instead of one. It is scarcely necessary to note that there must be further dilution at the time of administration. Chloral hydrate.—This is next in impor- tance to morphine as a means of prompt relief in violent attacks of asthma. We can not speak too frequently or too earnestly of the paramount necessity of extraordinary caution in the administration of these powerful nar- cotics in such diseases as asthma, which involve the cerebro-spinal system and are essentially chronic in their course. Every physician knows what the danger is, but it is, nevertheless, one of those dangers which come to be underesti- mated if one has been so fortunate as to have escaped. Chloral hydrate is very speedy in its action, and seldom fails to arrest the asthmatic par- oxysm. The dose for an adult whose heart is sound is 15 or 20 grains. For children the dose may be large in proportion to their ages. The existence of cardiac valvular disease is not to be considered prohibitory of the thera- peutic use of chloral hydrate if the lesion is moderate, if the compensatory hypertrophy is sufficient to carry on the circulatory operations, and if the subject is not too greatly debilitated, particularly as regards the nervous system. The greatest danger from the use of chloral hydrate is that, if continued for too long a time, it induces a peculiar cachectic state, characterized by anaemia, failure of digestion, chronic gastric or gastro-intestinal catarrh, a pasty, opaque skin, and an eruption of acne, pustular and tubercular, accompanied by ocu- lar and palpebral conjunctivitis. There are besides great general debility, anorexia, an- aphrodisia, and profound psychical depression. While the continuous use of chloral hydrate can be more easily and safely stopped than that of opium, chloral is more serious in its effects upon the organism, and should never be used except as a temporary resource in very severe attacks ; and, if possible, the patient should be kept in ignorance of the nature of the remedy.* * It would also be well not to combine it with celery to mitigate its unpleasant taste, as the writer knows The dose of chloral alone, as said above, is 20 grains. It is often better to divide this into 5-grain doses, with 10 or 15 grains of bromide of po- tassium or of sodium, and give this every hour in solution with water and syrup of Tolu. If further means of disguising the taste are ad- visable, 10 or 20 drops of camphorated tinc- ture of opium with each dose will be found very effectual. Sulphuric ether is another extremely useful agent for the immediate control of an asth- matic paroxysm. It may be given in ^-drachm to drachm doses every half hour. It is usually given on sugar, and washed down quickly with water. Its volatilization by the heat of the body gives rise to a peculiar sensation of dis- tention in the oesophagus, but that soon dis- appears. Spirit of chloroform (spiritus chloroformi, U. S. Ph., Br. Ph.), or chloric ether, contains, according to the U. S. Pharmacopoeia, 1 part of chloroform to 9 parts of alcohol, and is of twice the strength of the same compound in the British Pharmacopoeia. It mixes very well with water, and the addition of a little Tolu or acacia sufficiently mollifies its irritating effects. The irritation, however, subsides very quick- ly, leaving only an agreeable sensation of warmth diffused through the precordial and epigastric regions. Spirit of chloroform has an additional advantage in its power to pre- vent the nauseating effects of other drugs. For this reason it may at times be advantage- ously combined with morphine or any other opiate. Hoffmann's anodyne, compound spirit of ether, is similar in its action to sulphuric ether and spirit of chloroform. The ethereal oil which it contains, in the proportion of 3 per cent., probably augments its calmative influ- ence upon the nervous system. Unless it is combined with other remedies of the same class, the dose for an adult should be at least a drachm, and this should be repeated every hour until it becomes evident either that it is controlling the asthmatic paroxysm or that it is ineffectual. It should be diluted with from five to ten times its bulk of water. The bromides of potassium, sodium, and am- monium, while not so rapid in their action as those already mentioned, are very useful as aids in subduing the asthmatic paroxysm. A large proportion of the cases of asthma are not so severe but that they may be impressed by these agents if given in full doses. The bromides, like chloral, if given for too long a time, produce a cachectic condition most painful in its manifestations and deplorable in its results. But it is perfectly safe to give a few large doses which may so obtund the re- flex excitability of the nervous system as to terminate the attack of asthma and to lessen the chance of its recurrence. The bromides are especially valuable on ac- of at least one proprietary nostrum which is flavoured with celery, and there might be a suggestion to try some such miserable thing. J 95 ANT ASTHMATICS count of the peculiarity that, when once their influence is established", the induced state may be kept up by the administration of compara- tively small quantities, which may be con- tinued almost indefinitely if there is no constitutional abhorrence of the drug. They should, however, be associated with some tonic, such as strychnine, iron, or arsenic, to assure the safety of the patient from the dystrophia which is so constant a result of their'adminis- tration. A prescription that has been effica- cious in quite a number of cases is about as follows. I must, however, remind the reader that the formulae given in this article, as in all the others furnished by me, are proposed as bases for the construction of prescriptions to suit individual patients, for we do not expect a set recipe to suit all cases that have the same name applied to them. Physiology is not so exact a science as to admit of that kind of prescribing: B Codein................. gr. iv ; Sodii bromid............ 3 ij; Tinct. belladon......... f 3 iv ; Tinct. nuc. vomic....... f 3 iij; Spir. aether, comp. ... ad f % iij. S.: A teaspoonful once in two hours. If the dyspnoea is not very severe, it may not be necessary to use any more potent reme- dy than this. But, in order to inaugurate the remedial influence, if I may be permitted the expression, one should, at the outset, adminis- ter the doses very frequently. ()(' any one of the bromides, 20 grains should be given at least every two hours, or, better still. 10 grains every hour, for six or eight hours, after which the frequency may be less- ened one half, this modus continuing for twenty-four hours, after which time there may be a reduction of the dose to two thirds of its original size, and, if the symptoms warrant it, after forty-eight hours more there may be a still further reduction. I am convinced, how- ever, that it is better to give smaller doses at more frequent intervals than larger ones with the intervention of longer periods. This plan commends itself for three reasons : In the first place, it has been testified by observers of great acuteness and clinical skill that this is really true. Secondly, by giving 10 grains every hour instead of 20 grains every two hours, its influence is kept at a degree of intensity which fluctuates less than under the other system. Thirdly, it may often be the case that a larger quantity of the drug may be used in a given time. The nauseating expectorants—such as ipe- cacuanha, squill, and lobelia—are useful to some extent, but are too depressing and de- range the digestion. In case of emergency, other drugs not being at hand, should some member of this class ap- pear to be indicated, it is better to employ the tartrate of antimony and potassium, in doses of from ^0- to fa of a grain, every two hours, and its efficacy will be greatly enhanced by the addition of a minute dose of calomel—e.g., fa of a grain; a small dose of opium, say from to { a grain; and 5 grains of sodium bicar- bonate : B Antim. et potass, tart. ... gr. ij ; Hydrargyri chlor. mit.... gr. j; Pulv. opii .............. gr. ij-vj; Sodii bicarbonatis........ 3 jss. M. et in chart. No. xx div. One of these powders every two hours, or perhaps a little more frequently at the begin- ning, with an occasional saline if necessary, will often give more brilliant effects than some of the more recent and extensively advertised drugs. Quebracho and Grindelia robusta, in their fluid extracts, have not attained the reputa- tion which was expected at the time of their introduction. The nitrate and hydrochloride of pilocarpine, by their powerful effect upon the vascular and glandular systems, are sometimes very valuable aids in the treatment of asthma. But the un- certainty of the action of jaborandi and the salts of its alkaloid, pilocarpine, makes it a very disappointing remedy. Amyl nitrite sometimes gives temporary re- lief, which is very pleasing to the patient be- cause of its rapidity. But it is uncertain, very evanescent in its action, and gives rise to such disagreeable sensations in the head that it at- tains to no popularity. Nitroglycerin, in doses of from Tfg- to fa of a grain, acts somewhat more steadily than the nitrite of amyl, but has the same faults. A solution is kept in the larger apothecaries' shops of 1 part of nitroglycerin in 99 parts of alcohol. It is known as glonoin. The dose is 1 or 2 drops. These drugs are usually thought to be somewhat dangerous, but I have not been able to confirm this idea. In fact, my friend, Dr. Edward R. Squibb, the great chemical manufacturer, has related to me an exciting incident in which a large bottle of amyl nitrite standing on his desk was upset and broken and its contents were instantly diffused in all di- rections. He experienced no ill effects what- ever, nothing more than the usual flushing of the skin and some transient vertigo. Iodide of ethyl, inhaled in quantities of from 5 to 10 drops, or even more, brings prompt relief to some, though the relief is not very enduring. It is, however, quite agreeable, and is often of great value in heading off an at- tack. Inhalation of Oxygen.—This is a method mentioned only to condemn it. Oxygen has been thoroughly investigated and has been as thoroughly condemned or has found as few supporters as any agent ever recommended for the treatment of asthma. As was stated at the beginning of this arti- cle, asthma is not characterized by a diminu- tion of the respiratory area, excepting only in so far as the viscid mucus is concerned. The inspired air, in ordinary breathing, loses only 5 per cent, of its oxygen, and its detention in the bronchial tubes simply gives time for a greater diffusion to take place. The cyanosis is due to failure of blood to pass through the pulmonary capillaries with sufficient rapidity. ANTATROPHICS ANTEMETICS 96 Compressed air, while favouring diffusion, distends the lungs. Besides, it requires too much apparatus, and may do harm unless the practitioner has very carefully studied the physical relations involved. Even so good a man as the late Dr. Geddings, writing m I ep- per's System, speaks so loosely about W alden- burg's portable apparatus and the pneumatic cabinet, meaning apparently by the latter the cabinet of Dr. Williams, that one not familiar with these devices might be led into dangerous error by his remarks. Between the pressure change in Williams's instrument and that in the older" cabinets there is a difference equal to 1 to 240. . i Alkalies.—Whoever has acquired much ex- perience in the treatment of asthma must have noticed that the paroxysms are associated almost invariably with a vitiated urinary se- cretion, characterized by great concentration, hyperacidity, and the presence of both urates and phosphates in exceptionally large quanti- ties. Calcium oxalate is also found in many cases in such abundance that the crystals are encountered in large numbers in every micro- scopic field. Indeed, cases are met with which defy all our efforts until we take measures to relieve this hyperacidity, which, as we know, is not confined to the urine, but is a constitu- tional condition. I have succeeded in relieving, and finally practically curing one of the worst cases of asthma that I have ever seen. But no prog- ress whatever was made until I finally thought it worth while to try the alkaline treatment for rheumatism, and the paroxysm was almost gone by the time the urine had become con- tinuously alkaline. The most feasible course is to provide the patient with some blue litmus paper and direct him to test it at every evacu- ation of the bladder. The bits of paper should be saved on a card, with the time of the test noted, so that the physician can trace the course of the reaction. As a rule, the urine should be rendered continuously alkaline, i. e., the paper should be unchanged—blue at every urination. When this is accomplished it will be found in almost all cases that the dyspncea is greatly reduced or even absent, while the bronchial mucus has become quite liquid and easily expelled by the cough. Remedies for the Constitutional Predisposi- tion.—1. Such systematic and properly selected and supervised exercise as can be expected to bring the vital organs to their proper degree of functional activity. 2. Hi/drotherapeutic Measures.—It is not safe to bring these into the treatment unless the physician himself has considerable practical knowledge of the subject, and is satisfied that the directions will be properly executed. Diet.—This is a very important means of in- fluencing the constitufional condition of the patient. It is especially valuable in those not yet matured, say under thirty years old. After that period it is still capable of rendering great assistance, although its regulation as to quality, quantity, and ingestion is much more difficult than with the younger subjects. In the latter, success or failure in attaining results rests upon the respective moral qualities of parent and child, and upon the family discipline. If the evidence makes the prospect of the carrying out of the details of our instructions doubtful, it is far better to make no attempt in that direction. . Climatic Influences.—These consist in the general changes in the organic functions which frequently result from change of residence; local modifications in the breathing apparatus by change of locality—e. g., from coast to in- terior, from one altitude to another, from a cold to a warm or torrid region, etc., and the remarkable impressions which at times are made upon the nervous system by very decided changes in altitude, in atmospheric pressure, and in relative humidity; the character of the soil; the prevalence of "certain winds; the di- urnal, menstrual, and annual variations of temperature. As a rule, slight altitudes or sea-level positions, moderate variability of temperature, and a moderate but well-marked changeableness of the relative humidity are most favourable to nervous stability. The coast, also, is, with the average constitution, better than inland regions. Habits of Life.—This is the most important item on this Ust, excepting altitude. Great altitudes are well known to have certain evil effects on the nervous system which I can not here explain. But the mode of life, social and domestic, the occupation of the individual, and the habits, as the word is generally under- stood, have a most important influence on the existence or non-existence of the physiological deviations which predispose to asthma. This is as true of children as of adults, for children also have their bad habits, which are, at times, fully as injurious as those of their elders. The two most important classes of bad habits are those which injure the respiratory tract and those which injure the nervous sys- tem. The physician who attends the case is the one best qualified to give the directions in all these matters, but they should be explicit and should be written down. It is a fact that directions which are written or printed are much more likely to be observed—ten times as much so as verbal instructions. Medicinal Agents.—The medicinal agents which may be considered useful in combating the pathological states or conditions that pre- dispose to asthma are not numerous if we limit our enumeration to those whose utility is established or, at least, acknowledged by so many as to give them a strong claim on clin- icians for further trial. Arsenic.—This is used in most of its official forms, some alleging a higher degree of effi- ciency for one, some for another. Probably the different compounds, both chemical and pharmaceutical, act differently upon different individuals. It is, again, not at all improbable that such other important modifications of en- vironment as are produced by climate, mode of life, endemic diseases, etc., influence the ac- tion of these compounds, sometimes favour- ably toward one, and again toward another. Age, sex, and hereditary and acquired traits 97 ANTATROPIIICS ANTEMETICS may all have their influence. Even the skill which an individual physician acquires in the management of a particular drug is well known to have the effect of making him more successful with it than another practitioner, who, however, obtains equally good results from the use of some other. 1 shall not, there- fore, attempt any analysis of reports, but name the drugs and, if necessary, state mv own views in regard to their respective merits" Liquor potass ii arsenitis (Fowler's solution). —This seems to me to be the best of all the preparations of arsenic for the purpose of modifying, by prolonged use, the nutrition of the cerebro-spinal nervous system, the vaso- motor mechanism, and the splanchnic ganglia and plexuses. Fowler's solution has a great advantage in the fact that it has been well known and extensively used by the profession for so many years that its therapeutic effects are very thoroughly understood. Arsenious acid is, therapeutically, about the equivalent of Fowler's solution, but is not so eligible for administration, particularly to children. It does not enter well into liquid preparations, and, as the dose for a child be- tween five and ten years old is only from y^ to -rta of a grain, there is great uncertainty— unless we are sure of the apothecary's skill and conscientiousness—as to whether the drug is so equally distributed in powders or a pill mass as to be present in exactly the same quantity in each dose. Fowler's solution, on the other hand, having a potency equivalent to 1 per cent, of arsenious acid, is easily and safely dispensed in very minute doses. It is not, in the opinion of the writer, proper to prescribe this powerful solution en masse, and allow the patient or anybody else to drop it from a bottle. Bottles of Fowler's solution, tincture of aconite, etc., should never be in the hands of non-professional persons. . Bromide of arsenic.—This preparation has no demonstrated advantages over those already named ; certainly it is not so useful as they are for our present purpose. It deliquesces, and, when dissolved in water, it decomposes with the formation of an oxide of arsenic (As203). Chloride of arsenic.—This compound is chemically entirely analogous to the bromide. There are solutions of both of them, now offi- cial, which have the same strength (1 to 100) as that of Fowler's solution, but neither of which is constituted as its name implies, for both the chloride and the bromide are decom- posed by water. They have no advantages. Donovan's solution (the liquor arsenici et hydrargyri iodidi) is better by far than the two last named. It is more of a tonic than the others are, and more useful on account of the mercury, which acts well on the gland- ular apparatus and is an alterative of much value. Potassium iodide.—This is a remedy which is, for the prompt relief which it gives, even to the extent of arresting prolonged paroxysms— i. e., when they last twenty-four hours, and after a few days of preventing their recur- rence, sometimes even forbidding the occur- rence of a second attack after the one which suggests its exhibition—the most useful of all our therapeutic resources in asthma. There are few physicians who would not, if given their choice of but one remedy for asth- ma, select potassium iodide. The dose is 5 grains every two or three hours, increased slowly to 10 grains at the same intervals. Its combination with potas- sium bromide often increases its efficacy, but the bromide should not be used for more than two or three days—certainly not more than a week. Sodium iodide is almost as good as potassium iodide, and may be combined with sodium bro- mide and with sodium bicarbonate, especially where acidity prevails. Oil of pine needles, or pine leaves (oleum pini foliorum).—This preparation has not had a very extensive use hitherto, but my friend Dr. W. E. Griffiths reports personally the most gratifying results from its administration in doses of from 4 to 6 drops every three hours. He gives it on sugar. The relief—which comes after a few doses, and culminates, in a few days, in the disappearance of all signs of the disease —is probably caused by its action on the gland- ular apparatus of the respiratory tract and di- gestive system. Terebene is quite similar in its action to the pine-needle oil. The dose is the same, or a trifle larger, and it is administered in the same way. Tonics of all kinds are useful adjuncts in the treatment of the predisposition to asthma. The selection of the best one for use in a given case must be determined by the one who has the patient under his care. It is, of course, necessary, in order to get the best results, to change the tonic occasionally. The remedies mentioned above apply to the treatment of those who are under the influence of predisposing causes. Benjamin F. Westbrook. ANTATROPHICS are medicines and arti- cles of food that are supposed to be efficacious in promoting nutrition, such as cod-liver oil. They include some of the reconstituents, such as calcium phosphate and iron. ANTEMETICS, or gastric sedatives, are those procedures and drugs by which vomiting is prevented or combated. The means em ployed to relieve vomiting are exceedingly numerous, and especially in those obstinate conditions, the vomiting of seasickness and the vomiting of pregnancy, the vast number of drugs and pro- cedures which have been employed testifies to the uncertain action of antemetics as a class. Yet, while there is no drug or procedure which will in every case give relief, and therefore there is no specific for vomiting, there are many remedies which, used with judgment and discrimination, are highly efficacious as gastric sedatives. Antemetics may be held to act either by a quieting action upon the vomiting centre, in which case they are said to act as general ant- emetics, this class including quiet, posture, opium, morphine, bromides, hydrocyanic acid, and possibly creosote ; or by a sedative power 8 ANTEMETICS 98 exerted upon the gastric mucosa, in which case they are referred to as local antemetics and include a vast number of drugs and foods, among them peptonized milk, alkalies, cocaine, iodine, calomel, cerium oxalate, carbolic acid, ipecac, and alcohol. A consideration of the means used to check vomiting requires much more than a mere study of the antemetic drugs, and in rest, pos- ture, food, and counter-irritants we find means of the greatest importance and usefulness. Posture is indeed invaluable in checking vomiting, and often will alone suffice to ac- complish that end, and, even if it is not efficient to that degree, yet as an adjuvant to other treatment it is of the greatest service. The patient should be placed in the horizontal pos- ture and upon his back, and, that his comfort may be the greater, in all conditions associated with nausea and depression his clothing should be loose and light. The room should be kept cool and the air pure, for heated and impure air provokes nausea. Quiet, too, should be insisted upon not only on the part of the patient, but in the room generally, and especially is this true in the vomiting of nervous origin and in neurotic subjects. A darkened room will act like quiet in diminishing nervous excitement, and so de- creasing the tendency to emesis. External applications are often of great value in preventing and checking vomiting, and of these none is so reliable and effectual as a mustard plaster. This, if applied to the epi- gastrium and kept there as long as practicable, will often succeed in allaying nausea and vomit- ing without the employment of other means. The strength of the mustard plaster must de- pend upon the activity and violence of the gas- tric symptoms ; one made in the proportion of 1 part of mustard to 4 parts of flour is usually regarded as the extreme of strength, while those of less strength (even 1 to 10) are often effective in less active disturbance, and have the advantage of more prolonged action, since they may longer be retained in position. The ice-bag may be applied to check vomiting, either to the nape of the neck, to the lumbar region, or to the epigastrium. Though it has its advocates, it is but slightly effective, save in the vomiting associated with hysteria, and in no way generally to be compared with the mustard paste in effectiveness. Emetics are often decidedly indicated in nau- sea and vomiting, and, though themselves pro- ducing vomiting, it is true, yet they act as antemetics by removing from the stomach those undigested substances which are frequently the cause of the disturbance, and thus directly promote gastric quiet. Thus, in the nausea and vomiting which often follow the eating of indigestible food the administration of zinc sulphate, copper sulphate, or ipecac, or, if haste is an object, the subcutaneous admin- istration of apomorphine. will act most effi- ciently to relieve. Of similar action and even greater effectiveness is lavage. Though in the vomiting of acute gastric in- flammation (where from the brevity of the at- tack starvation is scarcely possible) it is wiser to withhold all food and to restrict the amount of drink so far as is possible, limiting it to small quantities of cracked ice or extremely cold water, especially carbonated water, taken in small amount; yet there are many conditions in which food must be given notwithstanding the vomiting, and in some of the modifications of milk and in the use of milk as a vehicle for antemetic drugs we have valuable means of treating vomiting. In all cases where milk is thus given it is, however, to be administered at first in small doses, usually of about 1 drachm, and only with the improvement in the patient's condition is the amount to be increased. Peptonized milk may be given in such con- ditions, and is often well borne, but it must not be forgotten that, if the peptonizing pro- cess has been carried to completeness, or even to a considerable extent, a bitter taste is ac- quired by the milk which in itself may be suf- ficient to cause vomiting. Peptonized foods other than milk, too, may be given, such as gruels, soups, etc., but they are neither so nu- tritious nor so effective as milk, and are only indicated where variety is an object, and there- fore not in vomiting of limited duration. Milk, indeed, may be given in its natural state if the attack is not severe and if the milk is exceed- ingly cold. Taken in small quantities, it will often be well borne. A mixture of milk and Vichy water is yet better borne, for, in addi- tion to the dilution of the milk, there is the antemetic action of the carbonic acid contained in the effervescent water. Milk may be given containing lime water in quantity varying from one eighth the amount of milk to an equal quantity, and this is often better borne than any other food, the effect being due not only to the dilution of the milk, but to the sedative properties of the alkali. One of the most effective ways of giving milk in cases of this kind is to add to each glass of milk 5 grains of cerium oxalate and 10 grains of sodium bicarbonate. This, given in small doses, as above described, is one of the most trustworthy and effective measures in such cases, the cerium oxalate and the bicar- bonate of sodium exerting marked power as antemetics. The fermented milks—koumiss, matzoon, and kephir—are excellent antemetic foods in cer- tain cases, though by no means always well borne. They are usually not liked by patients at first, but with a little use they are"generally tolerated, and often exceedingly well liked, the preference of some patients being for koumiss, and that of others for matzoon. Kephir, though an excellent preparation, is comparatively sel- dom used. The antemetic properties of these fermented milks lie in the alcohol they contain as well as in the carbonic acid, and as controll- ers of vomiting they may be compared to cham- pagne, over which they have the additional advantage of possessing the food value of milk. In considering the antemetic drugs, no sat- isfactory order or classification is possible, and in properties as well as effectiveness they mani- fest the greatest variations. Carbonic-acid gasy as administered in car- 99 ANTEMETICS bonated waters, is in some cases effective the water being given in small amounts and as cold as possible. Alcohol may be efficient, and, given in the form of iced chauipagne, is doubly so from the presence of the carbonic-acid gas. The cham- pagne should, however, invariably be " dry " ; sweet wines but increase the vomiting. Thus employed, champagne is specially indicated in the vomiting of seasickness and acute febrile disease. Chloroform, in doses of from 1 to 2 drops in water, will at times relieve, and in seasickness it is thought to have a special value. This is, however, to be doubted, like the efficacy of al- most all remedies recommended for this obsti- nate and defiant affection. Ether, too, may be employed in small doses, and acts presumably by a stimulant effect upon the gastric mucous membrane when it is in an atonic condition. It is at times serviceable, but generally not to be depended on. Opium may be given to relieve nausea and vomiting, and exerts this power by a quieting influence upon the vomiting centre, a fact which renders it possible to administer it by the rectum as well as by the mouth. Indeed, in this respect opium has a marked advantage over the majority of antemetics, since when it is thus administered there is no necessity of disturbing a stomach already too much dis- turbed. Opium as such, though antemetic at first, often seems to be productive subsequently of nausea, and even vomiting, conditions which are less frequently seen if morphine is the form of opiate used, and particularly if it is given hypodermically, but which even then are by no means of very uncommon occurrence. The bromides are at times exceedingly useful in relieving the vomiting due to cerebral disease or that resulting from a reflex cause, as well as from neurotic disturbances in general. For seasickness, too, they have been much em- ployed as prophylactics, considerable doses of a bromide being given for about two days pre- ceding the day of sailing, under the impression that this would diminish the nervous irritabil- ity upon which seasickness was supposed to depend. Though by many the bromides have been thought effective when so used, they are utterly untrustworthy, and quite as likely to cause digestive disturbance as to prevent it. The recently introduced strontium bromide is thought to be more effective than the other bromides as an antemetic, and certainly does appear to act well in vomiting of nervous ori- gin, though its use has not yet been sufficient to enable us to consider its value fully determined. Chloral hydrate has been used in cases simi- lar to those in which the bromides are used, but generally its effectiveness is not great. As ipecac in large doses is emetic, so in small doses is it antemetic; for, in vomiting due to nervous disturbance, and particularly in that obstinate condition the vomiting of pregnancy, the administration of drop doses of wine of ipecac will at times be exceedingly efficient. Arsenic is often serviceable in vomiting, especially when due to gastric irritation and gastric ulcer. It is preferably given in the form of Fowler's solution, in doses of \ a minim or 1 minim, in water. Tincture of iodine, in minute doses, may be tried, and will at times work well. In the vomiting of pregnancy, where drug after drug is tried and discarded, it will sometimes act when all others have failed. Dilute hydrocyanic acid is a gastric seda- tive of considerable value, its antemetic power being exerted especially in vomiting of nervous origin. Calomel will often relieve gastric irritability, if given in small and repeated doses, and partic- ularly when the irritability is associated with intestinal disturbance. In all such cases, un- less purgation is specially contra-indicated, calomel should be tried, and it will generally be of service. Bismuth subnitrate is efficient in some cases, especially where gastric irritation or inflam- mation is present. The alkalies are generally more valuable in vomiting associated with hyperacidity, decom- position, and fermentation, and in such cases sodium bicarbonate or lime water may be given in milk, or magnesia may be employed. Cerium oxalate is generally very efficient in gastric disturbance and ranks high among ant- emetics. The usual method of administration has already been described. Sulphonal may be used to check vomiting, and seems at times of some value. The usual method of administration is by the addition of from 3 to 5 grains of sulphonal to a glass of milk and the giving of the milk as is done when it is associated with cerium oxalate. Pepsin and ingluvin are at times given as antemetics, but they are of comparatively little value. Cocaine is very effective in vomiting, acting locally upon the gastric mucosa to diminish its excitability. Its dose for such purpose is usually fa of a grain. Though this dose is minute, the peculiar susceptibility of many persons to cocaine must not be forgotten. Carbolic acid is often valuable as a gastric sedative, acting partly to diminish the irritabil- ity of the gastric nerves and partly as an anti- septic, and, though creosote has been thought to have some effect in quieting the vomiting centre, or, in other words, to act as a general antemetic, it is probable that its efficiency is due to an action similar to that of carbolic acid. In some few cases where other drugs have failed atropine or belladonna will be efficient, but they are scarcely to be used save as sub- stitutes, other drugs being generally more re- liable. In the vomiting of chronic gastric disease astringents are sometimes of service, especially small doses of alum or of nitrate of silver. Nux vomica, in small doses, too, will fre- quently be of benefit in the vomiting associated with gastric atony. Seasickness has been attacked by so great a variety of drugs and with such poor success that it seems hardly necessary to speak of drugs so used, but among them amyl nitrite and nitroglycerin have in some cases been thought beneficial. ANTENNARIA ANTHELMINTICS 100 [In the Lancet for April 21, 1894, Dr. M. Charteris, of the University of Glasgow, gives extracts from reports made to him by thirty ship surgeons as to the utility of " chlorobrom " as a remedy for seasickness. He summarizes as follows: " 1. In long sea voyages no prophy- lactic benefit can be secured by the use of chlorobrom unless for two nights before em- barkation the passenger pays due attention to the stomach and bowels by taking a cholagogue pill. Further, in the case of a person who dreads a voyage a dose of the solution should be taken. 2. The diet on board ship should be ' spare and dry.' Soup, pastry, and sweets should be especially avoided, and no full meal should be indulged in. A hypnotic dose (one tablespoonful and a half for a male, and one tablespoonful for a female) should be taken for three nights. 3. In short voyages, when the steamer leaves, perhaps, at 10 p. m., the pas- senger should immediately retire to rest, and take one of the doses mentioned. 4. In a shorter passage across the Channel a teaspoon- ful should be taken before going on board. 5. By following these directions immunity from seasickness is obtained in the great ma- jority of cases, but if they be not followed it is to be remembered that chlorobrom has no ef- fect in arresting an outburst of vomiting. If it is given in a teaspoonful dose every ten minutes until a tablespoonful and a half or a tablespoonful have been taken, it will almost invariably check retching and depression."] Aconite, in small doses of the tincture, has been employed as a gastric sedative in vomiting due to excitability of the gastric nerves. Thus used, it often appears to act well,-a result ex- plained by its usual benumbing effect upon the endings of sensory nerves when directly applied. Resorcin has been used as a gastric sedative in conditions associated with fermentation, but, though theoretically it may here act as an antiseptic, it certainly does not usually have much effect as an antemetic. The simple bitters will often check vomit- ing, especially that due to the prolonged abuse of alcohol, most typically seen in the " morning vomiting " of drunkards. For this, calumba, gentian, and serpentaria are often employed. In such cases, however, a more decided effect is produced by their combination with an aromatic, which by stimulating the atonic mu- cosa will generally relieve the vomiting. The aromatics generally so employed are cinnamon, capsicum, and ginger. Salicylic acid and its salts are at times serv- iceable, but, though they act thus by virtue of their antiseptic powers, and hence particularly in conditions of gastric fermentation, it must not be forgotten that in their prolonged use or in large doses the salicylates, as well as the acid itself, are decidedly irritating to the stom- ach, and thus at times productive of vomiting. That vomiting is frequently associated with intestinal disturbance is well known, and in that occurring with simple constipation there is nothing more effective than a promptly act- ing saline cathartic, preferably, on account of its effervescence, Seidlitz powder. If the in- testinal disturbance producing this vomiting is due to sluggish hepatic action, however, a more decided effect will follow the use of podophyllin. Oxygen water has, in many cases of gastric disturbance, appeared to act as an excellent antemetic. Oil of cajuput and oil of cloves, too, are at times effective, but they are by no means to be regarded as constant in their action. In some cases the mineral acids have seemed effective, and hydrochloric acid has been partic- ularly recommended in the treatment of the nausea and vomiting due to alcoholic overin- dulgence. Though it is usual to administer the drugs of which I have spoken by the mouth, in spite of the gastric disturbance, and though the vast majority of them must be so used, since their action is solely a local one upon the stomach, yet there are those whose action is general, or at least follows absorption, and, if we prefer, they may be introduced otherwise than by the mouth. Thus, opium and the bromides may be administered by the rectum and morphine hypodermically. Indeed, the hypodermic administration of morphine is ap- parently the best means of combating vomit- ing as such of which we are possessed, and, though it may subsequently be followed by some gastric disturbance, this is only occasion- ally seen, so that, if vomiting must be stopped promptly and no contra-indication to its use exists, morphine thus employed is our most trustworthy drug for the purpose; indeed, by some it is considered almost a specific. In the vomiting of uremia, the treatment of uraemia alone will prove effective, and perhaps hot-air baths are the most striking in their results. In spite of all treatment, it not infrequently happens that vomiting will persist, and under these circumstances we are often not justified in giving anything by the mouth. It is there- fore frequently necessary to abstain from the introduction of food, drink, or drug into the stomach, but, leaving that organ entirely un- employed and, so far as may be, at rest, to sup- port and nourish and treat"the patient by the employment of nutrient and medicinal ene- mata.—Henry A. Griffin. ANTENNARIA—See Gnaphalium. ANTEPILEPTICS.—Drugs capable of curing epilepsy are not known. Certain reme- dial measures that are not drugs seem in some instances to accomplish a cure; for the most part they are operative procedures designed to rid the organism of a source of persistent irri- tation, such as a narrow or adherent prepuce. Medicines that are considered palliative, di- minishing the frequency and intensity of the paroxysms, are numerous. The brom'ides are the chief of this class of remedies, and the reader is referred to the article on them, and for the others to the articles on the individual remedies, as referred to in the Index of Dis- eases, etc., under the word Epilepsy. ANTEROTICS.—See Antaphrodisiacs. 10 ANTHELMINTHICS.—This class of remedies may be conveniently divided into the vermicides, which have a toxic influence upon intestinal worms, and the vermifuges, which simply expel them living. The ta-uie, on account of their firm attach- ment to the walls of the intestine and the large amount of mucus which envelops the attached portion, are by far the most difficult variety of intestinal parasites to dislodge. There is scarcely any pathological condition of such relatively slight importance in which failure to relieve so often results, and for which such an endless variety of remedies has been proposed. That any one of several taeniacides or tamiafuges will either destroy a teenia or expel it in a living state is an unquestioned fact; and whenever failure results the blame is to be laid, not upon the particular remedy selected, but upon the neglect to observe proper precau- tions in its administration. Whatever is used, it is essential that it should come in free con- tact with the animal, especially the attached portion, or " head," as it is conventionally but incorrectly termed. To render this possible, a careful preparatory treatment is of the greatest importance, and in the large majority of cases absolutely neces- sary. The object of this preparation is to re- move as far as possible the accumulated mucus and fa?cal matters so as to allow the remedy to come in contact with the worm. To prove effectual, the preparatory treatment must be- gin at least a week before it is expected to use the medicine, and in some cases in which the digestion is decidedly perturbed a fortnight is none too long for preparation. The first point to be looked after is the di- gestion, which if disordered must be rendered as nearly normal as possible by the use of bit- ter tonics, mineral acids, pepsin, etc. Absin- thium is probably the best tonic, as it seems to possess some anthelminthic properties. Every morning a free movement of the bowels must be obtained by the use of cathartics. The salines and the alkaline cathartic mineral wa- ters are the most suitable. For three days prior to the use of the anthel- minthic catharsis should be quite free and the diet restricted to such articles as leave little residue to be disposed of by the intestines. Bread and milk are the popular foods for this time, and are the most appropriate. They need not be used to the exclusion of all other articles, if they are not agreeable to the indi- vidual, but soups, rice, and similar foods may be substituted. By the laity salted meats and fish are highly esteemed in this connection, and they are often useful, if readily digested, not on account of their being: obnoxious to the taenia, but because of the specific action of the salt they contain in rendering the intestinal mucus less tenacious. This property is possessed by all chlorides, and consequently the administration of from 10 to 15 grains of ammonium chloride three times a day constitutes a useful adjunct to the pre- paratory treatment. If, however, a mineral water containing chlorides, such as the Fried- ric/ishall, has been used for its cathartic effect, ANTENNARIA 1 ANTHELMINTHICS the ammonium chloride may be omitted. Dur- ing the last twenty-four hours no food except milk or clear soup is admissible, and these only in the smallest quantities consistent with the comfort of the individual. Although it is de- sirable to have the intestines as empty as pos- sible, care must be taken not to lower the person's strength so as to render the retention of the anthelminthic doubtful. The morning is the best time for the dose to be taken, and on an empty stomach ; and, un- less catharsis follows in the course of three or four hours after its administration, a cathartic is to be given. This should be as active as the strength or age of the person will warrant, as strong peristaltic action of the intestines as- sists in the dislodgment of the parasite, and may by itself have that effect. Gamboge is a very good cathartic, especially for children. As nausea almost always follows the admin- istration of tamiacides, and in fact is one of the most serious obstacles in the way of their effectiveness, it must be combated by the re- cumbent posture, hot water to the abdomen, small doses of potassium bromide, etc. Some- times, if the patient is a heavy sleeper, it is a good plan to rouse him at a very early hour, and after giving the medicine allow him to sleep for several hours. As soon as any inclination to have a move- ment of the bowels is shown the person should sit on a vessel containing water and remain there, if possible, until the entire animal is ex- pelled. In this way traction upon it is avoided, and it is usually possible to obtain the entire worm. Sitting in a bath tub full of water is advised by some, but this seems hardly neces- sary, is decidedly unpleasant to the patient, and is calculated to prejudice the mind against a second attempt if it should become necessary. The excreta must be examined carefully to as- certain the absence or presence of the " head." This is most easily done by collecting them on a sieve and allowing a gentle current of water to pass through. If the " head" should not be found, it is more than probable that the treat- ment has failed, although in a certain number of cases the detachment of the worm close to the " head " has been followed by its death. Whether a second attempt should follow immediately after the failure of one is a ques- tion which must be decided in each case. It is safe to say, however, that a delay of at least a fortnight should follow unless the individual concerned is very strong and not unduly weakened by the treatment. In most cases it is best to delay until the fully developed seg- ments are again visible in the faeces. Often the period of convalescence from an attack of gas- tro-enteritis, to which the victims of tapeworm are very liable, is an excellent opportunity to administer an anthelminthic without any pre- paratory treatment, and in some cases where several attempts have failed by reason of the inability of the person to retain the medicine it furnishes the only chance of success. The plan here advised for what is usually regarded as being of no great importance may seem unnecessarily elaborate, but, as under such conditions success is nearly certain, it is un- ANTHEMIS ANTIARIS 102 doubtedly best to adopt it. Failure to relieve a person of a tapeworm is sure to bring re- proach upon the medical attendant, and, more- over, a second attempt is much more apt to fail than an initial one, especially'in children, in whom the knowledge that the preparatory treatment is to be followed by a nauseous dose is almost sure to interfere with its retention when it is given. Occasionally infants who are given raw meat become affected with tapeworm, and in such cases treatment must be deferred until the child is at least a year old. When, for that or any other reason, it seems best to postpone treatment for a while, it is a good plan to give small doses of oil of turpen- tine from time to time. This will cause the detachment of a large number of the segments, and no more will escape until they have reached the proper stage of development, which usually will be several days. In this way one of the most unpleasant features of helminthiasis will be prevented. As might be expected, in a condition which through neglect or carelessness is so often treated unsuccessfully, the remedies which have been suggested are almost without num- ber, but only a few of them are of the slightest value. Aspidium, pomegranate root or its ac- tive principle pelletierine, and the crushed seeds of the common pumpkin are the ones most com- monly used. There is little occasion to choose from them. Pelletierine, on account of the relatively small dose needed, is perhaps the best, but, unfortu- nately, its high price prevents its use except by those in good circumstances. Pumpkin seeds seem to be the least apt to excite nausea, and on that account may be the most desirable in some cases. Oil of turpentine is probably the surest taeniacide we have, but its use is unsafe on account of the excessive dose required. Powdered anthracite coal (see Anthracite) has been used with success in some instances. Kousso, mucuna, areca nut and its alkaloid arecine, and powdered tin have been recom- mended, but present no advantages over the remedies mentioned previously, and are rarely used. Papain and papoid, on account of their solvent effect upon albuminoid bodies, have been suggested with the idea of digesting the worm, as it were, but their use has not proved very satisfactory. For ascarides vermiculares, or threadworms, the treatment is usually local, as they rarely extend beyond the ileo-caecal valve. Enemata containing common salt, carbolic acid, quassia, or aloes are most commonly used, and are entirely satisfactory. There is no particular advantage in one over another, and whichever is most convenient may be employed. No fixed rule as to the strength of these enemata can be laid down. The only thing to be avoided is irritation of the rectum by too highly con- centrated solutions. In fact, complete relief is often obtained by simple cold-water enemata. Immediately before the use of the enema the perineal region, also in the female the external genitals, must be sponged with a one-per-cent. aqueous solution of carbolic acid, to prevent the lodgment of the worms after they have been removed from the rectum. No prepara- tory treatment beyond the thorough emptying of the rectum by a cathartic is needed. If there is reason to suspect the presence of the worms high up in the colon, in the small intestines, or in the stomach, a dose of santonin or kamala and calomel should be given, and as soon as it has acted the enema should follow. When the Ascaris lumbricoides, or round worm, exists, it; is wise to restrict the diet for forty-eight hours to bread and milk and clear soups, and to evacuate the intestines thorough- ly by saline cathartics before the use of an anthelminthic. Santonin is the one usually given, being preferable to mucuna, fluid ex- tract of spigelia, oil of chenopodium, and ka- mala. These latter are effectual enough, but are more bulky and less easily administered. The santonin is best given at night, together with calomel in an ordinary cathartic dose, and followed in the morning by a saline. Russell H. Nevins. ANTHEMIS.—See Chamomile. ANTHIDROTICS are substances that di- minish the secretion of sweat. The morbid and excessive sweating which calls for their use is sometimes associated as a symptom with some special disease, when interference may or may not be desirable, and sometimes, in the ab- sence of any obvious assignable cause, it is what is termed " idiopathic." It may also be either general or confined to a limited area. Though the pathology of hyperidrosis is often vague, certain facts more or less well estab- lished furnish indications for the use of spe- cial remedies. For example, it is known that when the influence of the sympathetic is with- drawn from any region—as, for instance, when the supplying nerve is divided—sweating of the part supplied results. Dilatation of the blood- vessels and hyperaemia of the sweat glands have this effect. Certain actions exerted upon the nervous centres of secretion in the spinal cord, whether through high temperature, a toxic agent, or excessive venosity of the blood, will cause sweating. Anthidrotics may often be rationally employed to meet such indications, though as frequently perhaps they are used, or have been discovered at least, empirically. Some act generally or upon the nerve centres, others locally or at the periphery—i. e., direct- ly upon the perspiratory apparatus. Where nerve debility exists vaso-motor stimulants are indicated, such as nux vomica, strychnine, ergot, and zinc oxide. The beneficial effect of quinine in the night sweats of phthisis has been attributed to its action in reducing the high temperature. But an indication for quite another class of remedies in phthisical sweats has been found, through partly theo- retical reasoning, in a condition of excessive venosity of the blood, suggesting agents that stimulate the nerve centre of respiration. It is argued by Brunton that in cases of pul- monary phthisis the respiratory centre, through excessive stimulation attended with the pro- longed coughing of the daytime, becomes com- paratively insensitive at night during sleep, 103 ANTHEMIS ANTIAR1S permitting of an accumulation of unaerated venous blood which in a normal state would be dispelled by increased respiration and which finally acts as an irritant upon the secretory centres of the cord with the result of causing an excessive secretion of sweat. On this sup- position, therefore, the chief indication is for agents that act as stimulants to the respiratory centre—such as picrotoxin, pilocarpus (which, though ordinarily a sudorific, here acts in the contrary way through its stimulation of the respiratory centre rather than the secretory), ipecacuanha or Dover's powder (to which what was said of pilocarpus also applies), strychnine or nux vomica, muscarine, and belladonna. Belladonna, as well as its alkaloids, atropine and duboisine, however, has another action which is exerted peripherally in paralyzing or obtunding the ends of the secretory nerves, and this is perhaps its most important action as an anthidrotic. It makes it a remedy which is ef- fective not only when used internally, but also as a topical agent in the form of a liniment or lotion, particularly in cases of partial or re- gional sweating. Agaricus and agaricin are said to act in the same way as belladonna and atropine. The employment of mineral acids in hyperidrosis has been explained on the general principle that acids tend to diminish the acid secretions, while alkalies lessen the secretions that are alkaline. Of the value of these acids there is no question, whatever be the amount of truth in the principle as stated. A similar explanation may apply to local ap- plications of vinegar, which have a good effect often in profuse sweating. A remedy very strongly advocated by Crocker, more particu- larly in cases of partial hyperidrosis, is sulphur. A level teaspoonful of precipitated sulphur is given in milk twice a day as the usual dose, or where it purges it is combined with a little cinnamon and powdered chalk. No explana- tion is given of its action. It is known that sulphur given internally is eliminated in the form of sulphuretted hydrogen through the skin sufficiently, often, to blacken any silver worn upon the person. It might therefore more easily account for an effect upon offen- sive sweat (bromidrosis) than upon the profuse secretion. In many of the cases of partial hyperidrosis, especially affecting the feet and axillae, the sweating is offensive, constituting bromidrosis,and the treatment must be directed to the latter condition as well as the former. Boric acid in powder or lotion, sometimes combined with salicylic acid or with perman- ganate of potassium (1 per cent, in lotion), is a good remedy for this. The boric acid may be dusted over the articles of clothing worn next the skin, or the latter (the stockings, for exam- ple) may be prepared before they are worn by soaking them in a saturated solution of the boric acid and then allowing them to dry. Another very efficacious remedy for bromidro- sis of the feet is chromic acid in a 5- to 10-per- cent, solution applied once in from two to four weeks. Hebra used diachylon ointment, which was changed twice every day for two weeks, and required the patient to be kept quiet or in bed. These topical remedies all have a modi- fying action upon the epidermis and upon the sweat follicles as well. It would be well to use such internal remedies as seem appropriate at the same time, more particularly such as stimulate the sympathetic, and perhaps the sulphur treatment of Crocker.—E. B. Bronson. ANTHRACITE.—Teaspoonful doses of anthracite coal, free from slate or pyrites, re- duced to granules of about the size of No. 9 bird shot, have sometimes been used to expel tapeworms. It is supposed to act mechanically, dislodg- ing the worm in its passage along the alimen- tary canal. It should not be given to the very young or to the weak, as it excites a consider- able amount of intestinal irritation. The same preparatory treatment advised under the article Anthelminthics must be adopted. Unless there is intolerance of other more approved remedies or nothing else is at hand, the use of coal is hardly to be com- mended.—Russell H. Nevins. ANTHRAROBIN, C14H10O3, is an odour- less, yellowish-white, granular powder, a reduc- tion product of alizarin, of flavopurpurin, and of anthrapurpurin. In 1888 it was introduced into dermatological practice by Liebermann, of Berlin, as an advantageous substitute for chrysarobin. It has been found to be much less irritating than that substance. It is prac- tically insoluble in water and in dilute acids, but dissolves readily in dilute alkaline solu- tions; in such solutions, however, it is prone to oxidation, whereby it is converted back into alizarin, the colour changing from a golden brown to green, blue, and finally violet. An- thrarobin is soluble also in alcohol, in glycerin, and in a solution of borax. Behrend has found it very useful in psoriasis, ringworm, and ery- thrasma, in the form of an alcoholic or glycerin solution or that of an ointment, in the propor- tion of from 10 to 20 parts of the drug to 80 of the excipient. Its action is somewhat slower than that of chrysarobin, but it has the great advantages of being non-poisonous and of not irritating the skin to which it is applied. ANTHYDROPICS are remedies that tend to promote the absorption of dropsical effu- sions. They are evacuants, including the ca- thartics, diuretics, and diaphoretics. ANTHYDROPIN.—See under Blatta. ANTHYSTERICS are remedies that are supposed to mitigate or cut short the parox- ysms of hysteria. So far as drugs are con- cerned, the chief anthysterics are castoreum, asafcetida, valerian, camphor, and sumbul. Systematic writers class anthysterics as a divi- sion of the antispasmodics. ANTIARIS.—The Antiaris toxicariais an artocarpaceous tree, belonging to the group Ulmacee, that grows in Java and the neigh- bouring islands, and that has been known to the English-speaking world as the upas tree. The name of the tree is taken from the Javan- ese, antsjar, and Leschenault de Latour first described it under the present botanical name. The tree exhales a toxic principle that af- fects some individuals, and perhaps birds and ANTIBACTERID ANTIBLENNORRHAGICS 104 animals, and that has originated the story that birds flying over the tree or animals approach- ing it closely fall dead in consequence of this miasm. All parts of the tree contain a poisonous principle, but a juice is collected by incising the bark, that is known as the upas antiar, a Malayan term signifying vegetable poison. From 100 parts of this juice there may be ob- tained about 38 parts of a brownish-red, waxy, resinous substance that has an acrid bitter taste. This resin is used as an arrow-poison by the natives of the islands. From this resin Pelletier and Caventou isolated a toxic princi- ple antiarin, and Bettink isolated two other substances, epain and toxicarine. Antiarin is a neutral substance that crystal- lizes in brilliant scales, is soluble in water and in alcohol, but is very slightly soluble in ether or benzene. Boiling antiarin in dilute acids converts it into antiarrhetin and sugar. An- tiarrhetin occurs in feathery crystals that are soluble in alcohol, ether, benzene, or petroleum ether. One sixth of a grain of upas antiar, intro- duced within the veins of an animal, produces a very rapid elevation of arterial pressure that persists for some time and disappears slowly as the poison is eliminated. Maurice Doyon's experiments show that the upas acts on the vaso-motor centres of the medulla oblongata, and that death is due to arrest of- the heart in consequence of the direct action of the upas on the cardiac muscle, though in some in- stances death is caused by bulbar action. Toxic doses of upas or of antiarin produce convulsions, vomiting, voiding of urine and faeces, irregular respiration, cardiac irregular- ity, and speedy death. Administered medicinally, it has caused violent vomiting and tenesmus. It has no therapeutic use at present.—S. T. Armstrong. ANTIBACTERID is a German patented antiseptic said to be made by melting together 350 parts of borax and 200 of glucose, with the addition of a little water, and adding 125 parts of boric acid. ANTIBAKTERIKON is a German pro- prietary preparation said to contain ozone and to have been devised as a prophylactic of all infectious diseases. It is probably of little if any value. ANTIBLENNORRHAGICS.—With all the great good that has come and is yet to come to modern medicine because of modern science, nomenclature will probably remain as it is to-day, irrelevant and untrustworthy. The term blennorrhagia is from the_ Greek $\ei/va, mucus, and p-fiyvu