^'c; ^1 -0fi4 THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETT November THE THERAPEUTICS RESPIRATORY PASSAGES PROSSER JAMES, M.D., LECTURER ON MATERIA MEDICA AND THERAPEUTICS AT THE LONDON HOSPITAL MEDICAL COLLEGE ; PHYSICIAN TO THE HOSPITAL FOR DISEASES OF THH THROAT AND CHEST; LATE PHYSICIAN TO THE NORTH LONDON CONSUMPTION HOSPITAL ; CONSULTING PHYSICIAN TO THE CHILDRENS' HOME INFIRMARY, VICTORIA PARK ; CORRESPONDING MEMBER OF THE ACADEMIES OF MEDICINE OF LYONS, MADBID, AND BARCELONA, ETC., ETC., ETC. NEW YORK WILLIAM WOOD & COMPANY 56 & 58 Lafayette Place 1884 Copyright, 1884, Bt WILLIAM WOOD & COMPAIfY TROWO PRINTING AND BOOKBINDING COMPANY, SEW YORK. Biomedical Library I40 PREFACE This book is not intended as a manual for students — it is lioped, in- deed, that senior students as well as practitioners may peruse it with profit — but it is mainly intended for those who have left the schools and entered upon the responsibilities of practice. Such readers, hav- ing no longer the fear of examiners before them, may be interested in points upon which they would not otherwise dare to spend their time. Xo doubt many faults will be found by critical readers, but not more than those of which the writer is sufficiently conscious. Some portions may be found too diffuse, others too condensed, and those who only refer to a question here and there may fail to see the con- nection between them, or perhaps to find that which they seek, Tliose who read the book through will not fail to discover the thread on which I have strung my beads — observe, I do not call them pearls. But as few may do this, it may not be amiss to say that there is a dis- tinct purpose in the work, and it is with " malice aforethought " that some portions have been so extended and others so contracted. Such as it is I commit this production to the candid consideration ^ . ■S: of my professional brethren, who have heretofore received my writings 'v. V with so much favor. rs, •^ Pkosser James, M.D. 3 Dean Stueet, Pakk Lane, London. October, 1884. 624331 CONTENTS. CHAPTER I. PAGE Introductory 1 CHAPTER n. Nutrition in Relation to Therapeutics 3 CHAPTER m. Respiration 14 CHAPTER IV. Food and Diet — The Proximate Principles of Foods— Food-stuffs. ... . 21 I. — Nitrogenous, Plastic or Albuminous Foods, 22 ; II. — Xon-Nitrogenous, 2'd ; III.— Inorganic Substances, 24 ; Nutritive Value of Foods, 26. CHAPTER V. Preparation of the Food-stuffs — Digestive Fluids 32 Saliva, 33 ; Gastric Juice, 34 ; Pancreatic Juice, 30 ; Bile, 37 ; Succus Enteri- cus, 38. CHAPTER VI. Variations in the Digestive Process 3!J A.— The Body, 40 ; B.— Aliment, 40. CHAPTER VII. Aliments as Remedies — Nutrients and Anai,eptics 44 Promoters of Construction, 45. VI CONTENTS. CHAPTER Vm. FAOE 1 KON 56 CHAPTER IX. Phosphorus and its Compounds C4 Free Phosphorus, 68 ; Hypophosphites, 73. CHAPTER X. Aids to Digestion 74 Stimulants to Digestion, 78. CHAPTER XI. Tr.anspusion 79 Injections into Serous Cavities, 82 ; Hypodermic Injections of Blood and Food, 83. CHAPTER XH. Water — Diluents — Beverages 85 Beverages, 89. CHAPTER Xin. Exercise and Rest 94 CHAPTER XIV. Alcohol ' 97 CHAPTER XV. Denutrients 107 Antiphlogistics, 107; Bleeding, 109; Counter-irritation, 117; Evacuants. 119 ; Mercury, 121 ; Diaphoretics, 133. CHAPTER XVI. Antipyretics 143 Cold, 145; Quinine, 157; The Salicyl Compounds: Salicin, Salicylic Acid, and the Salicylates, 166 ; Kairin, 171 ; Chinolin or Quinolin, 174 ; Eesor- ciu, 174 ; Veratria, 174 ; Digitalis, 175; Aconite, 177. CONTENTS. Vll CHAPTEE XVn. PA'K Neurotics 187 Narcotics, 187. CHAPTER XVm. Pneumatics 208 Expectorants, 213 ; General Expectorants, 222; Antiseptic and Disinfectant Pneumatics, 249 ; Antispasmodic Pneumatics, 255 ; Sedative and Anodyne Pneumatics, 262 ; Contra-Expectorants— Central Pneumatics, 263. CH^iPTER XIX. Topical Pneumatics 276 Methods of Inhaling, 282 ; Uses of Inhalations and other Topical Pneumat- ics, 294 ; Solids, 303. INDEX , 309 THERAPEUTICS RESPIRATORY PASSAGES. CHAPTER I. INTEODUCTOEY. The word therapeutics is often used in much too restricted a sense. It is derived from Oepairevoi, which is commonly translated, I cure, but which is susceptible of a far wider signification. It may be fairly ren- dered, I take care of, or render service to (the sick), and thus includes whatever relief to suffering or help to restoration may be conferred. Thus the therapeutist is the medical attendant, not the mere prescriber of more or less potent medicines. His materia medica includes all those materials which may be pressed into medical service. Thus it is as much his business to remove an accumulation of fluid from the pleura by means of the aspirator as to promote its absorption by the lymph- atics, and the instrument is as much within his use as a remedy as the administration of the often inefficient absorbents. To apply a bandage or a splint, nay, to fashion one from any material at hand is as much a therapeutical proceeding as to order a poultice or prescribe a narcotic. Nor is this a novel doctrine, for during the thirteen dark centuries which followed Galen every one admitted the importance of the "non- naturals," as they were called by the Peripatetics, and we know that long before him these subjects were ably treated by Hippocrates, to whom, indeed, Galen looked up with reverence, and whose method he did much to revive, avowedly taking him as his guide, although it must be admitted that he was sometimes led away by the unsubstantial specu- lations of the dogmatists who repudiated for empty hvpothesis the 1 2 THERAPEUTICS OF THE RESPIRATORY PASSAGES. solid result of the patient and attentive study of nature inculcated by the sage of Cos. These non-naturals are commonly defined as the prin- cipal things which do not enter into the composition of the body, but are nevertheless necessary to its existence. Galen called them the pro- catarctic causes, TrpoKarapKTtKos, principal, from -jvpo, and Kara and dpxofJiai, I befin. He considered that when well used and properly disposed thev contributed to the health, but otherwise to the derangement of the system. They are air, meat and drink, exercise and rest, sleep and wakino- retention and excretion, and the passions and affections of the mind. But lonf before the Hippocratic writings laid such broad foun- dations for Greek medicine the importance of such subjects had at- tracted the attention of the sages of earlier civilizations. Thus we find diet and reo-imen treated of in the oldest records of Hindoo medicine. These are written in the most ancient form of Sanscrit, and are be- lieved to extend from the third to the tenth century before the Chris- tian era. The Buddhists, too, have records of early thoughts on these subjects, on which even ancient Chinese literature is not destitute of ad- vice, overlaid though it undoubtedly is with accumulations of the strangest and most preposterous fancies. But it is not worth while to pursue this subject, for it is obvious that the effects of food, air, and other agencies would be observed by ever}' race quite as early as the influence of medicinal plants, and we know that the observation of such influences dates from the remotest times, while scarcely a savage tribe is known but possesses, either as a treasured secret or as a common belief, a con- viction of the value of some kind of herb or other substance for the re- lief of disease. CHAPTER II. NUTRITION IN RELATION TO THERAPEUTICS. The body may be regarded as an apparatus for the manifestation of energy, and it possesses the power of self-repair and self-adjustment. Growth, repair, and the production of energ\' constitute the work of the animal machine. All substances by means of which tlie body can main- tain its nutrition or either of the processes named may be called food or aliments {(dimentwn, food, nutriment, from alo, I nourish). Without a due supply of food nutrition fails, and the body can neither repair its waste nor develop energy. The action of the body on food may be said to be broadly one of oxidation. On the other hand, the result of vegetable life is deoxidation or reduction. The vegetable is an agent for transmuting- carbonic acid, water, and ammonia into other com- pounds, and, further, light and heat into chemical affinity. The work of the animal is to carry the vegetable material into higher structures, then to destroy these compounds and change their affinities into other manifestations of energy — ultimately into heat. Thus matter and force are alike ever moving in a circle. From the mineral kingdom the vege- table prepares compounds out of which the animal can construct its tissues, which having served their purpose in the body are oxidized and then returned to the inorganic world. As the production of energy is mainly, if not entirely dependent on oxidation, the atmospheric oxygen might perhaps be included in the above wide definition of food, but it is more conveniently considered further on, and moreover such a use of the term does not well accord with the idea universally entertained of food, which rather corresponds with the word aliment. Water, however, as the one necessary beverage, may very well be included. Medicines do not maintain nutrition ; sometimes they interfere with it, and are often said to be substances which act on unhealthy nutrition. Nevertheless no hard and fast line need be drawn. Thus we have analeptics (from avaXaiifiavu), I restore), which restore, and sometimes we speak of a class of nutrients. Poisons may either induce unhealthy or prevent healthy nutrition. But here again there is no sharp line Isetween medicines and poisons. Nature, indeed, does not rejoice in hard and fast lines, so that, useful as we find 4 THERAPEUTICS OF THE RESPIRATORY PASSAGES. them in classification, it is well to remember that this is founded on arti- ficial distinctions, and consists of groupings to aid the memory. There is philosophy in the popular proverb in its twofold reading : " What is one man's food is another man's physic," or " poison,'' as some people phrase it. Further, we may safely assert that food is, in numerous cases, the one medicine of prime value, as will appear if we bestow a little closer attention on nutrition. This process must consist of both waste and re- pair, and may therefore be looked at in this twofold aspect. It is neces- sary, first, for the aliment to be presented to the tissues in a condition in which it can be utilized, and then it must become incorporated with or assimilated by these tissues, while at the same time the worn out parti- cles must be removed. In lowly organisms like the amoeba the process seems tolerably simple : the jelly-like body simply flows around and en- closes such food as comes in its way; from this is dissolved apparently the soluble portion which thus unites with the jelly-like mass, and this in its turn extrudes the insoluble residue in a manner somewhat the reverse of that by which it surrounded the whole. But the higher we rise in the scale of animal life the more complex becomes the process, and the more its several stages are differentiated, and so we have to con- sider the nutrition of our own bodies through the process of digestion, absorption, assimilation, nutrition proper, or the renewal and waste of tissue, and elimination and excretion ; that is to say, it is essential for our food to undergo certain preliminary changes before it can be pre- sented to the tissues in such a form tliat they can act upon it or be acted upon by it. Some substances may be taken which are at once rejected by the digestive organs as useless or inconvenient, but with them others may be ingested which are of great value, and are therefore at once turned to account. The nutritious particles, then, are taken up, changed by diges- tion, absorbed by the alimentary canal, poured into the blood, of which they thus become a part, and are carried by the circulation to every portion of the body. From the blood are derived nutrient fluids which escape from the minutest vessels and continually bathe every particle of every tissue, and while thus bathed it would seem that each particle yields up to this bath whatever is useless or worn out, while at the same time all such effete material is replaced by the fresh contained in the bath. A double process is thus continually going on, waste and repair, and both are attended by the liberation of energy. On the one hand we have wear and tear, the vital machine, as we may sa}', is being con- stantly consumed in doing its own work: this is a sort of oxidation, a slow combustion in which the tissues are being burnt, and the residue of such combustion, the ashes, so to say, must be got rid of, and accord- ingly are thrown into the surrounding stream and returned to the blood, NUTRITION IN RELATION TO THERAPEUTICS. 5 which thus becomes a kind of sewer, and therefore in its turn has to be purified in order to fulfil its double office. Provision is accordingly made for removing these useless or worn-out products of combustion. On the other hand, to counteract this continual destruction, or wear and tear, we have an equally constant process of construction, or repair, un- interruptedly going on, so that as any used up product is thrown into the blood new material is taken from the same fluid to supply its place; all such new material, as we have seen, must be derived from the food. It is true we cannot observe the intimate molecular movements of nutrition as we watch the reactions of chemicals in the laboratory, but we can trace the aliment into the blood; this fluid finds its way to every part; we next trace the disappearance of certain nutrient ingredients, and then we find, not them, indeed, but the products of their combustion among the constituents of the excretions. And these continual changes, these marvellous metamorphoses are necessarily accompanied with the liberation of energy which ultimately manifests itself as heat. So long as all these changes continue we have life; the arrest of them all is death. In health they all go on harmoniously, there is a constant bal- ance, so to say, between destruction and construction. Let this balance be disturbed and disease in some form will result. That some disturb- ance may occur within certain limits without much injury is clear, espe- cially if only for a short period, but a prolonged disturbance, even if in so slight a degree as to be imperceptible, will in time inevitably make it- self manifest. To compensate for slight disturbance in one direction we have a sort of reserve: the body can lay by a store of material and force upon which it may draw when the aliment is insufficient, and to prevent the effects of temporary deprivation. Hence nutrition is often compared to banking. There is a balance, which may vary from time to time in amount, but we must pay in as well as draw out, or a time will come when our checks are valueless, and that time will depend on the amount of the balance and the demands made upon it. So, as we have said, the body is a sort of machine, an apparatus for the manifestation and employment of energy, every such manifestation being, of course, attended by wear and tear, but it possesses the power of self-repair, and the material for this purpose is obtained from the ali- ment. Life, then, may be said to consist in a series of perpetual changes in the tissues of the body, which in accordance with a physical law necessarily give rise to the liberation of energy, and these changes are of two kinds, destructive and constructive. If this be so, the greater or the more rapid the changes the more actual the life, and hence it has been plausibly argued that the more rapid the destruction of tissue, provided aliment be supplied for the construction of new, the greater will be the degree of health. With due limitations such a statement may be allowed to pass, but must not be accepted as certainly true to THERAPEUTICS OF THE RESPIRATORY PASSAGES. any extent and in all circumstances. We may, indeed, admit that work necessarily being attended by waste, increase of work should lead to more rapid waste, as it undoubtedly does, and this again to more rapid repair, more active life, greater health. This is so within certain limits, exercise is enjoyable, the waste caused by it is repaired quickly, energy is freely liberated, and bounding health with full joyous life results. But there is a point when fatigue comes on and we find that each indi- vidual machine, though all are constructed on the same lines, is specially adapted for its own work and its own rate of performing that work, however true it may be, that as a self-repairing, self-growing, self-ad- justing, and even self-improving machine, it may within certain limits attain toward the perfection of others. There is one more point. Strange as it may appear, when we view life from this standpoint it is closely related to death. We speak of the stoppage of the machine, but the analogy fails. Construction, repair ceases, but destruction goes on, or rather, after a pause a new mode of destruction begins. We have seen that all the waste is indeed only a sort of combustion or oxidation of our tissues. Well, after death, as we call it, these tissues decay, and what is that but oxidation ? We consign the no longer animate clay of our beloved ones to the grave, where it slowly moulders back to mother earth. The result would be the same if we adopted the plan of cremation, and burnt, that is, rapidly oxidized, their mortal remains. In either case the products of the oxida- tion of the body are the same — chiefly water, carbonic acid, ammonia, and salts; and these are the substances which during life result from the oxida- tion of the tissues and food which, as no longer serviceable, are excreted. So that as in life organic material is continually being oxidized and re- turned as waste to the inorganic kingdom, so in death the same result happens to all the body at once. The stages, indeed, tln-ough which the particles pass may vary, the rate of travelling may differ, the stopping- places may not be the same, but the ultimate goal, the end of the jour- ney is the same in death as in life. " So in the midst of life we are in death," as Luther said, whose phrase has been copied into our burial service. Had Watts a poetic prescience of this when he wrote : " The moment when our lives begin We all begin to die V " To return. For our present purpose we may regard healthy vital action, life, if you will, as a process of continual destruction on the one hand, counterbalanced by compensatory repair and construction on the other. But this normal condition may vary, and then we have disease. Alwaj'^s during life destruction is going on ; always, therefore, its products are accumulating and always must be cast off. Now it is easy to see how these actions may vary in rate or be otherwise imperfectly carried NUTKITIOJN' IlSr RELATION" TO THERAPEUTICS. 7 on, and that such interruptions or imperfections may occur in any of them. The rate of the destructive changes may be too slow or too fast, and in either case mischief will ensue. The work may be hindered, or even arrested at any point. The removal of the waste products may be slug- gish, and then accumulation may take place within the tissues, at the starting-point, or they may be poured into the blood and accumulate there from sluggishness in the organs of excretion. These products are for the most part highly injurious ; when carbonic acid is prevented from being thrown out by the lungs death soon occurs, as it also does, though less quickly, when either the skin or the kidneys cease to work. Then again the tissues may be imperfectly oxidized, in which case, instead of products precisely adapted for rapid removal, other intermediate com- pounds may be thrown into the blood — cinders, as it were, instead of ashes — and these may set up disease by their directly poisonous qualities, or by the difficulty experienced in removing them. Uric acid is such an inter- mediate compound, taking the place of the much more soluble urea, and the relation of gouty affections to the presence of that acid in the blood has been carefully investigated. The whole machinery of the body is ex- tremely delicate, precisely adapted to accomplish its ends, and when any part fails to efficiently perform its work, or when a foreign substance ill adapted to be utilized is present, we need not wonder that such a devia- tion from the conditions designed for its operations is so injurious when we see that a grain of sand in the oil with which a watch is lubricated may bring its movemeTit to a standstill. Further, even when elimination is equal to the task, it is easy to see that destruction may vary in rapidity. Such variation within moderate limits may occur in health, but if prolonged or excessive must give rise to disease. The body cannot work with tissues that need renewing, and therefore a certain rapidity of destruction and repair, or perhaps we should rather say renewal, is essential. Indeed, the more rapid the changes within a certain degree the more vigorous is the health, so that slowness of the process may leave imperfection in the organs. On the other hand, excessive rapidity of destruction is also dangerous. Tl)e power of repair is limited, and if destruction goes on so rapidly that repair cannot keep pace with it emaciation will take place. The body will indeed feed on itself, as we say, for a time, use up its stores which have been laid by, but when they come to an end it will then consume itself. This is not the ideal of health ; rather it constitutes one form of disease. The body wastes, though certain functions are going on actively, and unless in some way the balance can be redressed, the end of such life is inevitable. Now let us turn to the other side — construction or repair. This, like its opposite, may vary in rate or may be impeded or arrested, and that at any point. If the rate of construction more than keeps pace with wear 8 THERAPEUTICS OF THE KESPIRATORY PASSAGES. and tear some of the superfluous supply is rejected, cast out of the body as useless, but some of it may be utilized, stored up in the body, and thus we may have general increase of weight instead of emaciation, and this in some circumstances may go on to corpulency or obesity. The neces- sity for abundant supplies to produce increase of weight is well under- stood by feeders of stock. We have seen that repair is effected from ali- ment carefully prepared within the body itself — elaborated from the food- supply. Now this food-supply may be cut off from the outside, the body starved, as we say. So the processes of elaboration may be impaired or arrested, or the aliment, when duly prepared, may be prevented from reach- ing the tissues. In either of these cases the same result ensues — death by starvation. So, also, instead of absolute want of aliment there may be deficiency, when nutrition will flag ; or again, instead of insufficiency of nutrient material it may be of inferior quality, in which case other conse- quences are observed — those spoken of as malnutrition. The results of deficiency of nutrient material resemble those of excessive waste, for wear and tear is always going on in the living body, even in the most com- plete repose ; energy has to be employed and its liberation is attended by waste, oxidation, consumption of material. Merely to keep up the ani- mal heat a large consumption of fuel is necessary — indeed, most of the food of animals may be regarded as such fuel — so that insufficiency of this fuel leads to loss of power as well as to decrease of weight. It is in this way that absolute deprivation of food soon brings about death. Starvation has been carefully studied by Chossat.' From his experi- ments it would appear that death was greatly accelerated by a low tem- perature and delayed by warmth. Some of the animals, moreover, on approaching death were revived by the application of warmth and, being then supplied with food, recovered. On the other hand, a reduction of the external air hastened death, just as we know that exposure to cold in conjunction with deprivation of food is so much more rapidly fatal. In all cases there was a great loss of heat. At first the fall was slight and gradual, but later it became rapid, and when it reached twenty-nine or thirty degrees Fahrenheit below normal death always took place. The variations of temperature were, however, not confined to a regular progressive fall ; on the contrary, there were frequent rises and falls, both of them four times greater than the diurnal variations of health, presenting the phenomena of an extreme degree of hectic. Besides the temperature, the degree of emaciation served as an index to the approach of death, which always took place as soon as the loss of weight amounted to four-tenths of the normal, from which, perhaps, m'c may learn to measure the danger of progressive wasting. It seems as if the arrest of nutri- ment was at first partly compensated for by slower waste ; for example, ' Chossat : Recherclies experimentales sur I'inanition. Paris, 1843. NUTRITIOlSr IN RELATION TO THERAPEUTICS. 9 Chossat found frequently that constipation occurred, and this we should anticipate, but he reports that it was afterward sometimes replaced by a peculiar diarrhoea. Perhaps, however, we ought scarcely to denomi- nate as diarrhoea the evacuation of the grass-green dry faeces, or even the liquid saline matters he observed, especially as in most cases of per- sons who have been enclosed in mines, or otherwise accidentally deprived of food, the constipation seems frequently to have been nearly complete. So somnolency or stupidity may for a time mark the mental state, though later on convulsions or delirium may ensue, in either of which life may fail, or it may terminate in gradually increasing torpidity. It is in- teresting to note that nervous tissue — the highest, as we regard it — seems the last to fail, and after death was often found to have preserved its full weight, as if the highest function of animal life must be supplied at whatever cost to the members. We see, then, how the consequences of starvation naturally resemVjle those produced by the interrupted supply of food brought about by dis- ease. Stricture of the oesophagus, cancer of the stomach, pressure of a tumor on the thoracic duct alike interrupt the supply of aliment to the tissues, if more gradually yet no less certainly, and the results are the same, though the symptoms may vaiy. Tiie emaciation would alone be fatal, even if other complications did )iot arise to hasten death. In other cases where food is insufficient, where it is not properly digested, where assimilation in any of its stages fails, we have progressive emaciation, which will be fatal unless the obstacle to the flow of nutriment from the mouth to the tissues can be removed in time. Again, the aliment may be abundant but its quality unsuitable, in consequence of which the diges- tive organs, although active, may be unable to extract what is wanted for the system. Or the fault may be in some point of the digestion, or elab- oration of the aliment, so that only unsuitable material is presented to the tissues, which are thus starved, or half-starved, or ill-fed. If all the material accessible were to be unfit for use in a given tissue, and there- fore rejected, that tissue would be starved ; if the supply were too limited it would be half-starved or deprived of nutriment in proportion to the limitation ; if unsuitable aliment were taken to make the best of, then the tissue would deteriorate. Such products of imperfect elaboration as are rejected must be carried away by the blood in order to be got rid of by excretion. If they were to be retained in the blood its quality would be deteriorated ; and, indeed, they might act as powerful poisons, as we know that many used-up products do ; or again, they might set up disease in the organs on which was thrown the work of excreting them. What we have said of nutrition has been for the most part with ref- erence to the body as a whole, but very similar statements might be made as to each of its parts, and we may study the process as a local one with equal profit. Interrupt the blood-supply of a part and it perishes ; pre- 10 TnERAPEUTICS OF THE RESPIRATORY PASSAGES. vent the blood from leaving- it and the effects are also disastrous ; changes in the rate of circulation in parts are common enough in disease. But it is not necessary here to dwell further on interferences with local nu- trition. With regard to the function of aliment, though we have hitherto chiefly kept in view the maintenance of tissues and the repair of their wear and tear, we must not forget its work as a liberator of energy. This is manifested as movement, either muscular or molecular, as chem- ical or electrical action, and ultimately as heat. Indeed, the larger part of our food is required for keeping up the animal heat ; this explains why a fall of the temperature of the body so constantly attends starvation ; why when function is active there is increase of heat, and vice versa. Here it may be asked, Must, then, all food be converted into tissue before it can generate action ; may not energj' also arise from the trans- mutations of nutrient material dissolved in the blood, which may itself be regarded in many respects as a fluid tissue ? This question has given rise to much debate among chemists and physiologists, some holding one view and some the other. Liebig maintained that muscular force is alwaj^s obtained from the nitrogenous constituents of muscle. At one time, he regarded the action as a simple combustion, but later he modi- fied his view, supposing that the oxygen might not necessarily cause though it must take part in the action, and that no oxidation of nitro- genous material could occur until it had become organized tissue, so that all the energy of the animal machine must be derived from its own com- bustion. Others, however, hold that energy is liberated by the combus- tion of alimentary material, generally non-nitrogenous, in the blood, and it has been shown that for a short period great labor may be undergone on a non-nitrogenous diet, and that while there is always a relation be- tween the quantity of nitrogen ingested and excreted, nevertheless this last amount is not so related to the work of the body. Still, no manifestation of energy takes place without the participation in some manner of nitrogenous structures, which, if they do not carry on, at any rate appear to initiate the action. In this action the tissue is worn out. It has been shown by Pettenkofer and Voit that the tissue-changes de- termine the absorption of oxygen, its conversion into ozone, and its use in combustion ; so that its appropriation and use appears to be entirely dependent on the action of these tissues. Hitherto nothing has been said about the control exercised over nu- trition and other processes by the nervous system, because the points to be principally enforced are presented more simply by the omission ; and our readers as medical men will be able to supplement the sketch given. Whether great believers or not in the functions ascribed to trophic nerves, they will know well enough that every action of the organism is dominated by the nervous system ; and we may defer further considera- jSrUTIUTIOlS' IN KELATION TO THERAPEUTICS. 11 tioii of its influence over nutrition in its several stages with the remark that such influence may also be varied somewhat in health, much more in disease, and that the variations may appear as increase, decrease, or perversion of the normal action. Besides, we cannot undertake to give a complete dissertation on the physiology of nutrition ; but only to set forth what may seem necessary for the purpose in hand. Some readers, indeed, may already be impa- tiently asking. What has all this to do with therapeutics and more par- ticularly the therapeutics of respiratory diseases ? To them I reply, Much every way. In the first place, as already stated, food is pliysic, and what has been said as to nutrition goes far to show how and why. The balance between destructive and constructive tissue-chano^es beinff disturbed, it may often be restored by the proper use of aliments or nu- trients, or, as we call them in such case, analej)tics. So, too, it may happen that in opposite conditions the restriction of nutriment may suffice. In a third case, the impaired or perverted nutrition may be remedied by regulation of tlie diet. In all such cases alimentary substances constitute our materia medica and the principles of dietetics our therapeutics. It may be added that in few diseases are questions relating to nutrition of greater importance than in those that affect the respiratory organs. In the next place, articles which have little or no claim to be regarded as food, but which are commonly spoken of as medicines, are taken into the system by the same channels as food, and follow the same route to the inner arcana of the economy, and having produced their influence there are again carried out of the body by the same way, and are there- fore liable to be acted on by the same influences throughout that journey. The gastric juice, the liver, the pancreatic and intestinal juices may all modify our medicines or be modified by them. So, too, the blood may act upon them or be acted upon by them before they can reach the organs or tissues on which their influences are exerted. So, again, the several parts with which they come into contact — stomach, alimentary canal, etc. — before entering the system may be influenced by their local action. It is true that some of them are at once taken into the blood without suffering any change in the digestive organs ; others we delib- erately introduce into the cellular tissue, and so avoid the route by the alimentary canal ; others, again, we introduce into the lungs by inhala- tion, obtaining in this way, in some cases, invaluable local action, and in others exceedingly rapid effects on the whole system in consequence of their speedy absorption ; others, again, we direct immediately into the blood-stream through the veins. But the statement remains, that, what- ever the channel, it may or may not be locally affected by the medicine. In the former case the action may be reflected, so to say, and give rise to an indirect effect upon the system. From the air-passages, when ab- sorbed, medicines are taken up unchanged by the blood, but in the ali- 12 THERAPEUTICS OF THE RESPIRATORY PASSAGES. mentary canal tliey are liable to be acted upon by the digestive fluids. It is clear enough that the gastric juice may be reinforced by acids or neutralized by alkalies, but other changes are also important, though too generally neglected. Passing to the next stage, the effects of our remedies may be princi- pally manifested in the blood, which may be impoverished or enriched or otherwise changed by their action, as in the case of haematics (ai/za, blood), hjematinics on the one hand or spansemics (o-Travos, poor, and al/xa, blood) on the other. Having thus reached the circulation the medi- cines, either in their original form or changed by the blood, are carried by it to the various tissues, and may produce their principal effects on them, as for example neurotics (from vevpov a nerve), which act upon the nervous system. Or, again, they may influence the function of organs, such as the heart, on which cardiac stimulants or cardiac depressants pro- duce their effects, and of course through that the whole vascular system may in some cases be affected. Still later, having done certain work or liberated energy — either hastening, retarding, or otherwise changing the nutrition of the body or of some part of it, or of special tissues, or per- haps liaving influenced some special organ — such medicines, or " poisons," may be either deposited in the tissues or the viscera, or, as is much more frequently the case, may be raj^idly eliminated. In this last stage of their journey in and out of the system, during the very process of excre- tion they may affect considerably any parts through which they pass — again hastening, retarding, or interfering with the work of the excretory organs, most frequently the first, as we see in the extensive group of evacuants. The medicines we thus administer are very various in their nature and properties. Some are simple salts on which the body often appears to have little influence and which are quickly restored to the mineral kingdom. Others exercise much greater influence, often chiefly or en- tirely of a chemical kind, and after some changes are excreted in such compounds as might be anticipated. Others linger still longer in the system — if they do not become tissues, at least form some close union with them, and consequently have some claim to be regarded as supple- mentary food or a partially necessary aliment. Iron, for instance, must be supplied to the blood, which requires it for the production of haemo- globin. The amount required is usually obtained from the food, but some- times — perhaps from excessive waste, perhaps from deficient supply, perhaps in consequence of loss of blood or of some disturbance of the bal- ance not so easily traced — it is not present in sufficient quantity, and then the blood thus impoverished, so far as concerns one of its ingredients, fails to perform its work perfectly, and anaemia (from a, privative, al/xa, blood) is said to be present. This may often be removed by a suit- able diet, because the iron which the system lacks is present in appro- NUTRITION IN RELATION TO THERAPEUTICS. 13 priate food. So it may by fresh air, exercise, and other influences which stimulate oxidation, and in other cases by chalybeates (from Chalybs, XOi^v^, a name for the metal derived from the Chalybes, a people in Pon- tus, who used to work it), because they put within the system the miss- ing metal, which may thus far be considered an aliment. And so with regard to some other medicines. But further, not only may nutrition be modified, but all organs, all tissues, all fluids, perhaps all modes of energy developed within the body, may be influenced in some way by agents in- troduced or brought to bear upon it, and which therefore constitute our materia medica. CHAPTER III. EESPIRATION. We have seen how nutrition consists of a perpetual balance between destruction and construction. Tissue waste is incessantly going on, and new material is as constantly brought to take the place of the old, while the debris must as regularly be removed. The process is analogous to that of respiration. We inspire fresh air, we expire carbonic acid and some other material ; and this work, too, may be impeded or may be arrested, and that, also, in any part of its progress. The oxyg-en passes into the lungs, is taken up by the blood, is carried by the circulation to the tissues, where its work is done, is then returned as carbonic acid in the venous stream, brought back to the lung and expired into the atmosphere. If we cut off the supply of fresh air asphyxia is speedy, if we limit its quantity the process is slower, and it matters not whether the access of air be prevented by something external or within tlie body. Closure of the larynx or trachea by the intrusion of a foreign body is as fatal as hanging or enclosing an animal in a vessel containing no oxygen. Ob- struction of the bronchi or pulmonary cells by the products of disease may also asphyxiate. So, also, the atmosphere may be so contaminated as to be unfit for the purposes of respiration. Again, to prevent the ex- halation of the carbonic acid is just as fatal as to arrest the entrance of air, and such prevention may occur at any part of the journey. How often in respiratory diseases is the patient poisoned by the carbonic acid which he is unable to get rid of, asphyxiated by the product of his own function which the lungs fail to excrete. So, too, the rate of respiration, which varies somewhat in health, may in disease present great modifications. But we must examine the function of respiration a little more in detail. The first point is, that oxygen, being continually used in the tissues, must constantly be brought to them. This is accomplished by the circulation, which also takes away the carbonic acid and other refuse. The oxygen passes into the blood mainly by diffusion, by which process also carbonic acid passes from the tissues to the blood and from that to the air. Although a portion of the interchange between the body and the atmosphere takes place elsewhere the lungs are the chief organs of this process. Through the alternate inspiration and expiration a regular KESPIKATION. 15 ebb and flow of tidal air is established and the stationary air is renewed by diffusion from this. Tlie ordinary amount of air in the lungs of an adult after a full inspiration averages 330 cubic inches. Of this the tidal air, or that which is inspired and expired in every respiration, is estimated at only 30 cubic inches ; the complemental air, or that which can be inspired after an ordinary inspiration, 110 cubic inches ; the re- serve, or that w^hich can be expired after an ordinary expiration, and the residual, or that which remains after the fullest possible expiration, are each estimated at 100 cubic inches. What we call the vital capacity is the sum of the tidal, complemental, and reserve, that is to say, the total amount of air which can be given out by expiration after the fullest forci- ble inspiration. This in a man 5 feet 8 inches high, averages 230 cubic inches, and this is what we measure by the spirometer. Dr. John Hutchin- son showed (" Med. Chir. Trans.," 1858) that the vital capacity differs with the height, posture, weight, and age of the patient, but is much more modified by disease. Every additional inch of stature from five to six feet enables the patient to breathe eight cubic inches additional. As the move- ments of the thoracic walls are more free in the erect posture the vital capacity should be taken in that position. It increases from fifteen to thirty-five years of age and then diminishes to sixty-five. Usually it in- creases with the weight of the person. There is a g-reat diminution in almost all thoracic diseases, not only in tumors, abscesses, and effusions, which may be said to displace the air, but even in the early stage of phthisis, in which the respiration is evidently weakened. Instead of es- timating the air contained in the chest we may measure the movements of its walls. Sibson's chest-measurer registers the changes in tlie hori- zontal posture in the antero-posterior diameter of the chest ; Ransome's stethometer measures the movements of the walls in several diameters ; Riegel's, Marey's, and Burdon-Sanderson's ("Hbk. Phys.," p. 291) fur- nish graphic records. In ordinary inspiration the two principal means of enlarging the chest are the descent of the diaphragm and the elevation of the ribs ; expi- ration is mainly accomplished by elastic reaction. In labored inspiration all the muscles which can elevate the ribs, or which can contribute to the support of those which can, are brought into play ; and in labored expira- tion all those which can depress the ribs or press on the abdominal vis- cera or afford a fixed support to those which act in this way, are thrown into powerful action. The associated respiratory movements, both facial and glottic, may be observed even in tranquil respiration, but are greatly exaggerated in dyspnoea. In respiration the air loses four or five per cent, of oxygen but gains four per cent, of carbonic acid and becomes saturated with moisture. Haemoglobin is the purveyor of oxygen. This body, without any further change, takes up in the lungs oxygen, holding it loosely in combination 16 THERAPEUTICS OF THE EESPIRATORY PASSAGES. and may then be called oxyhsemoglobin, which is carried by the circulation to the tissues. These rob it of its surplus oxygen, and so it becomes a^aiu reduced to haemoglobin and must go back to the lungs to obtain a further supply of oxygen. The amount of change varies in different tissues, and, indeed, in the same tissues at different times, e.g., whether they are at work or at rest. It will be observed that we treat oxidation as taking place in the tissues, though it has sometimes been thought that part at least of the process was carried on in the blood, as if certain oxi- dizable substances were taken up into the blood and there oxidized. If such were the case, the chief oxidation would be in the blood, but all available evidence points to the conclusion that the locality of oxidation is the tissues. It is true that certain reducible substances may be detected in the blood, but only in too small quantity to be of any ac- count ; moreover, shed blood has no action on various substances which are unquestionably oxidized in the living body. Grape-sugar, for ex- ample, when added to blood is not oxidized, even though the mixture be kept at the temperature of the body ; and further, a slight excess of sugar in the system instead of being oxidized, is discharged unchanged. So too, pyrogallic acid passes through the system without change, although it is a very oxidizable body. Citric and other acids are scarcely at all oxidized in the body, and even when given in combination with alkaline bases are only partially oxidized. We conclude, then, that it is in the tissues that the change takes place, and this explains why certain diffusible substances which the tissues refuse to take up are removed by the secreting organs, whereas it would seem that they must be oxidized if that process took place to any considerable extent in the blood. The blood, then, by virtue of its corpuscles, these by virtue of their haemoglobin, takes up oxygen in the lungs, becomes, as we say, arterial, and goes as such to the tissues where the oxygen-tension is low. They therefore receive oxygen from the blood and store it up in some stable combination, leaving the haemoglobin reduced, that is, more or less of it, according to the activity of the tissue. As carbonic acid is continually produced in the tissues, its tension is always higher there than in the blood, and therefore it passes into the stream. Accordingly, the venous blood has not only its haemoglobin reduced but its carbonic acid tension increased, so that on reaching the lungs the gas streams through the vas- cular and alveolar walls till the tension without is equal to that within. Then the stationary air, having lost oxygen and gained carbonic acid, has a lower oxygen tension and a higher carbonic acid tension than the tidal air, in consequence of which rapid diffusion between these two takes place, so that at last the air issues from the body poor in oxygen but rich in carbonic acid. It is calculated that it requires from six to ten respirations to completely renew the air in the lungs. Variations in the atmospheric pressure necessarily produce important RESPIRATIOlSr. 17 effects. Living at the bottom of an atmospheric ocean some fifty miles deep, the normal pressure of nearly fifteen pounds to the square inch gives us thirty thousand to forty thousand pounds total pressure on the surface, according to the size of the person. This is at the sea-level. On lofty mountains it is considerably less and it diminishes rapidly in a bal- loon ascent. To gradual changes we can accommodate ourselves, but in mountaineering they are perceptible and, of course, aggravated by the necessary exertion. In ballooning the ascent is so sudden that very un- pleasant symptoms are often produced from the diminution of the press- ure. Thus the congestion of the capillaries of the skin and free mucous surface leads to sweating, mucous discharges, and sometimes hemor- rhages. The capillary resistance being lessened, the heart beats more fre- quently, and some dyspnoea is felt, the respirations are deeper but some- what irregular. Muscular weakness and exhaustion are also complained of, with either dyspnoea or oppression and constriction of the chest. Perhaps these symptoms are due to insufficient oxygen and imperfect elimination of carbonic acid. Vomiting is sometimes produced, which may, perhaps, be attributed to stimulation of the vagal centres in conse- quence of deficient oxygen. As the blood is drawn to the surface the brain has a less supply and this often leads to faintness. Diminished secretion of urine may be explained in the same manner. The effects of increased pressure may be seen in descending below the sea level, as in mines and in works carried on in an atmosphere of com- pressed air, as in the diving-bells or caissons for laying the foundations of bridges. In this case the skin becomes pale, perspiration is diminished, and the respirations are from two to four less in the minute ; inspiration is easier, but expiration is prolonged, and there is a distinct pause be- tween the movements ; the vital capacity increases, so does the secre- tion of the kidne3's ; muscular efforts are made with more energy and activity ; the heart, meeting with more resistance from the contraction of the cutaneous capillaries, beats slower, and the pulse-curve is lower ; there is a subjective sensation of warmth. Persons should not return suddenly to the normal pressure or the blood will be drawn to the surface, as if the body had been placed in a vacuum, and there will be hemorrhage from the nose, mouth, ears, etc., while the sudden removal of blood from the centres may bring on paralysis. The oxygenation of the blood may be impeded or totally arrested by various circumstances, as bv want of oxygen when an animal is placed in confined air, in a vacuum, in an atmosphere of nitrogen, or under water ; in the foetus from the separation of the placenta or pressure on the cord ; by interruption of the cutaneous respiration by varnishing the skin. We may also have closure of the air-passages, either partial or complete, tem- porary or permanent, as in strangulation, spasm of the glottis, pressure from without by tumors, accumulation within, as of mucus in the bronchi 18 THERAPEUTICS OF THE RESPIRATORY PASSAGES. or even hemorrhage. Then, again, we may have collapse of the lung from the entrance of air or liquid into the pleura, as in pneumo-thorax and pleuritic exudation. So, too, partial destruction of the lung, as in phthisis, or cessation of respiratory movement, or embolism of the pulmonary ar- tery will bring about the same condition. In a chamber of rarefied air an animal will die before the oxygen is exhausted, a result attributed by Hoppe-Seyler to the evolution of gas in the blood, which disturbs the circulation. In compressed air, the death is believed by Paul Bert to be due to the elimination of carbonic acid be- ing hindered. In the complete absence of oxygen, or when the gas is entirely pre- vented from reaching the alveoli, death speedily ensues. As the oxygen diminishes the carbonic acid increases, the accessory muscles of respira- tion are then called into action and the movements are deeper but slower. This degree of dyspnoea is a compensatory act, bringing in more oxygen when it can be obtained and ceasing on its arrival. A further want of oxygen sets up clonic convulsions — that is, spasms of all the muscles of the body. These seem to be due to stagnation of blood in the brain — venous blood, poor in oxygen, rich in carbonic acid — for they occur when arterial blood is prevented from going to the brain, as by ligature of the carotids and vertebrals, as well as when venous blood is prevented from returning, and also after hemorrhage. A further want of oxygen causes the centres to lose their irritability and asphyxia results. When there is a long-continued want of oxygen, but only of a mod- erate degree, there is an adjustment between the requirements and the supply, the functions associated with oxidation diminish, the tempera- ture is lower, the muscles are flaccid, the respiration is more rapid, the smaller arteries and capillaries relax, and the darker color of the imper- fectly arterialized blood is seen through the lips, mucous membranes, and portions of the skin. This is cyanosis. The supplementary respiration performed by the skin resembles in character that carried on in the lungs. In both we see a rich plexus of capillaries separated from the atmosphere by epithelial structure, but in the skin the latter is many times thicker than in the lungs, as we find the carbonic acid excreted through the cutaneous surface in much smaller amount than that removed by the pulmonary surface — the proportion be- ing as one to thirty-eight — but the water removed by the skin is about two pounds per day, double the amount which escapes in the form of vapor from the lungs. As respiration involves the continual co-ordinated acts of many mus- cles the nervous control of these movements demands attention. The harmony of their action is complete, and that in labored as well as in gentle breathing. Observation and experiment teach us that the co-ordi- nating impulses proceed from the medulla, and from a small point in the RESPIRATION. 19 medulla which we call the respiratory centre. The respiration goes on after the removal of the brain above the medulla and on section of the cord just below it, though the thoracic movements cease ; the centre con- tinues in action, for the facial and glottic movements continue, but these cease when the recurrent laryngeal nerves are divided. When that small portion of the medulla which Flourens called the nmud vital is destroyed, breathing ceases forever, though every other part of the ner- vous system be uninjured, and as the inhibitory vagus centre is gen- erally stimulated at the same time, the heart's beat is arrested and the animal killed. This noeud vital, then, we call the respiratory centre, and its rhythmic action is not merely reflex but automatic. Respiratory im- pulses start de novo from this centre, though their character may be altered by afferent impulses arriving at the moment when they are gen- erated. As the centre communicates with the lungs by the vagi no doubt afferent impulses started by any stimulus to their peripheral end- ings continually ascend and produce modifications, which changes have reference chiefly to the distribution in time of the efferent impulses. When the vagi are divided respiration becomes much slower, the pauses between inspiration and expiration being lengthened, but each respira- tion is fuller and deeper, so that the oxygen consumed and the carbonic acid lost in a given time are about the same, the loss in rate being made up in extent. Stimulation of the divided vagi by a gentle interrupted current quickens the respiration, and by careful management the natu- ral rhythm may be restored, but a too powerful current accelerates the breathing too much, and may throw the diaphragm into a tetanic condi- tion and bring about a standstill of respiration in the inspiratory phase. The respiration is also rendered slower by stimulating the central end of the superior laryngeal branch of the vagus, and that whether the trunk of the vagus (below the origin of that branch) be divided or not, and this stimulus may bring about a standstill in the phase of rest, that is in the normal expiratory phase. We conclude, therefore, that the superior laryngeal nerve contains fibres the stimulation of which inhibits the respiratory centre, while the main trunk of the vagus contains fibres the stimulation of which augments the action of that centre ; but as in some cases there is a retardation, we conclude further that the main trunk contains some inhibitory fibres, though the accelerating ones are much more numerous, and these accelerating fibres appear from the result of dividing them to be always at work. The rhythmic impulses of the res- piratory centre seem to be excited by the blood, or rat.her its condition : the more venous its character, the greater is the stimulus. The breath- ing becomes quicker and deeper whenever the arterialization is defect- ive. Greater activity in the tissues — loading up carbonic acid and using oxygen, as in muscular exertion — makes the respiration more active, as does any hindrance to air entering the lungs. In obstruction 20 THERAPEUTICS OF THE RESPIRATORY PASSAGES. to respiration, as the blood becomes more venous the nervous discharges of the centre are more vehement, and, so to say, overflow and set other muscles in action, and this may go on until the centre is exhausted. Instead of being too venous, the blood may be made less venous — as by breathing oxygen, or by forcible voluntary breathing, or by artificial res- piration vigorously carried on. Then, the blood having obtained all the oxygen it needs, the centre is no longer stimulated by a want of it, and respiration ceases until tissue-changes render the blood again venous. In such case the centre is at rest, and we have what many physiologists call " apnoea," following in this Rosenthal, who thus employed the word in 1864, but it must be remembered it had long before been in use for a different purpose, and is still applied by medical writers in its original sense. This physiological " apnoea," then, is the converse of dyspnoea, the centre resting when the blood is more arterialized, and being stimu- lated when it is more venous. The stimulus is the want of oxygen, not excess of carbonic acid, because dyspncea is produced in an atmosphere of nitrogen in which there is no impediment to the exit of carbonic acid, and that gas does not accumulate in the blood. So, too, breathing an atmosphere containing much carbonic acid, but at the same time more than the normal percentage of oxygen, does not produce true dyspnoea, but only narcotic poisoning. It may be admitted that the state of the blood may affect to some extent the peripheral ends of afferent iierves, and that impulses thus started — as, indeed, impulses started in any way — may contribute indirectly to the result ; but the effect is produced mainly by the direct action of the blood on the respiratory centre, for when the cord is cut below the medulla, and both vagi also divided, defective aera- tion still causes increased activity of the centre, as shown by the facial, respiratory movements. Again, if we cut off the blood-supply from the medulla by tying the vessels dyspnoea is produced, though the blood is not altered generally, but there is a deficiency of oxygen in that region with accumulation of carbonic acid. So, if the blood in the carotids be warmed the same effect follows, viz. : dyspnoea, the heated blood appar- ently hurrying on the activity of the cells, so that the normal supply does not suffice. We have spoken of the respiratory centre as a fact, but, though gen- erally admitted, its existence is strenuously denied by Brown-Sequard, who says he has seen respiration continue after removal of the supposed centres, and, indeed, of the whole medulla, and his statements have been corroborated by P. de Rokitansky, Langendorff, Nitschmann, and others. Not long ago Langendorff, as the result of a lengthy research, expressed himself as disposed to completely decentralize the respiratory motor im- pulses, but the most recent experimenter, Dr. Leon Fredericq {Archiv. fur Physiologic, 1883), finds himself compelled to admit the existence of a central organ for respiratory impulses in the medulla oblongata. CHAPTER IV. FOOD AOT) DIET— THE PROXIMATE PEINCIPLES OF FOODS— FOOD-STUFFS. As the one thing which is necessary to be supplied frequently, food should take a first place in therapeutics. There is no question about our power to regulate or to arrest the supply ; we can cut off all food for a time or we can diminish it. On the other hand, we can supply it more freely, but in this case we may not be able to assist its assimilation ; often appetite fails, and then we may feel that we are in the position of the man who took his horse to the brook but could not make him drink. The arrest of supply, a fast, is a most powerful therapeutic agent. Fur- ther, we can regulate diet in reference to its various ingredients ; we can exclude some constituents and introduce others. The substances we use as food are so numerous that to simplify their grouping we employ their proximate principles, which are either organic or inorganic — the latter class comprising water and salts. The organic elements of the food were divided by Liebig into two classes : I, Plastic, or proteinaceous, comprising nitrogenous substances, which he held were alone concerned in repair, growth, nervous and muscular energy. II. Elements of respiration, afterward better styled calorifacient prin- ciples, comprising the organic non-nitrogenous substances which he con- sidered were employed in heat production. No doubt a very direct relation exists between nitrogenous food and muscular work, but that it must be converted into tissue before it can liberate force has not yet been proved. It has, in fact, been shown that heavy labor can be undergone for a short period on a non-nitrogenous diet. Prout took milk as the type of a perfect food, and no one will deny that it is so for the young, who both subsist and grow upon it alone, and flourish best when nothing else is added to it. The ingredients of milk are : (a) nitrogenous ; (b) fatty ; (c) saccharine ; (d) mineral — and we cannot do much better than follow this classification with a little enlarge- ment. 22 THERAPEUTICS OF THE KESPIRATORY PASSAGES. I. — Nitrogenous, Plastic, oe Albuminous Foods. These are of two varieties : A. Substances containing nitrogen in the same proportion as albu* men, viz, : two of nitrogen to seven of carbon, nearly. These substances are sometimes called albuminates, and this group includes albumen, fibrin, syntonin, myosin, globulin, and casein, from the animal kingdom, with glutin and legumin from the vegetable. Their work is tissue repair, regulation of oxygen, absorption, and utilization ; under special circum- stances they may form fat and liberate energy. B. Substances containing nitrogen in the proportion of two to five and one-half of carbon, or four to eleven. This class comprises gelatin, chondrin, keratin, ossein, etc. These perform similar functions under particular circumstances, but far less perfectly. Some have doubted whether they possess any nutritive value at all. The experiments of Pettenkofer and Voit, of PIosz and Gyorgyai, Maly, Latschenberger, and others appear to indicate that the gelatinoids cannot replace the albu- minoids in the formation of tissues, although they may be perhaps sub- stituted for metabolism. Nitrogen is present in every tissue which can liberate any form of energy, and seems to be necessary for its manifestation, even if it only serves as an instrument. Nerves, muscles, gland-cells, the cells sus- pended in liquids, all are nitrogenous. So, too, are the digestive liquids ; the ferments contained in these liquids, ptyalin, pepsin, pancreatin, are nitrogenous — so are biliary compounds. Cut off the nitrogen from the food and function languishes, not at once, perhaps, but as soon as the store in the body is exhausted. We may add that the nitrogenous food- stuffs are not completely exhausted of their energy in the body ; the chief product of their combustion, urea, carrying away about one-seventh part of the potential energy. Voit's experiments seem to show that albumen is perhaps accumulated in the general fluids of the body, from which it is taken for the repair of the tissues as they may require it, and that this dissolved albumen is more easily metabolized than that which has become tissue. A full supply, perhaps an excess, of such dissolved albumen is essential to healthy functional activity ; but further excess is at once metabolized. Thus the excretion of nitrogen depends on the amount in the food and not on muscular exertion, as Liebig thought. In support of the more recent view, it may be remarked that the metabolism of albuminoids is never entirely suspended, nor is it increased by exer- cise, which, however, as previously proved by Dr. Edward Smith, enor- mously increases the excretion of urea. We pass on now to the next class. FOOD AND DIET. 23 II. — NoN-NlTBOGENOUS. These consist of hydrocarbons or fats and carbo-hydrates of starches and sugars, to which we may add vegetable acids and pectous substances. A. Fats or hydrocarbons are composed of carbon, hydrogen, and oxygen ; the oxygen being insufficient to combine with all the hydrogen in order to form water. The unoxidized hydrogen is in the proportion of about one to seven of the carbon. The fats are more energetic as calori- facients than the amyloids, about two and a half times as effectual, and they are also of value as nutrients, especially of the nervous system, and no doubt help in the production of energy. Perhaps, also, they assist disintegration. Fat is always present in the nerve-tubules and in the ganglionic centres. It is also of some use in digestion, perhaps aiding the solution of proteids ; further, it seems to assist in their conversion into tissue. Even artificial digestion is hastened by the presence of fat, and it has been proved experimentally that albuminous food deprived of all fat lies longer in the stomach. The power of the pancreatic fluid is largely expended in emulsifying fats, and chymification and absorption into the blood are thus secured. It would appear that the white corpus- cles get their first impulse from fat, which thus directly helps to make blood, and it seems to have something to do in cell development. If, then, fat promotes digestion, chymification, the absorption of nutrient fluids, and their transmutation into blood, or rather corpuscles ; and, fur- ther, seems to enter cells and take a part in the process by which the nu- trient juices derived from the blood become tissues, and afterward assists the disintegration and removal of used-up material, it is not surprising that a deficiency of this aliment should prove disastrous, and that in some diseases characterized by malnutrition, the administration of easily digestible fats should prove our most valuable therapeutical resource. Cod-liver oil is thus an important aliment as well as a medicine. B. Carbo-hydrates or amyloids may fairly be called hydrates of carbon, as their oxygen and hydrogen are in the proportion to form water. The proportion of water to carbon is about three to two. These substances are the starches and sugars. They are converted into fats by deoxidation and, as we have seen, they also give rise to energy and, of course, supply animal heat. Dextrin is included in this group, though the proportion of oxygen and hydrogen is not precisely the same. Cel- lulose, from its form and aggregation, is only adapted for animals with an appropriate digestive apparatus. As the amyloids are so closely related to the fats, it is natural to inquire whether the former can alto- gether replace the latter. Certainly not conveniently, and as a matter of taste alone the human race has always preferred to eat both. After long discussions it is now admitted that fat may be derived from carbo- 24 THERAPEUTICS OF THE EESPIRATORY PASSAGES. hydrates. A man's living on fat, free diet, proteids, amyloids, salts, and water being supplied, would seem to be a question of digestion, though a full experiment of this kind has not been made. He can exist for a time on proteids, fat, salts, and water — but health is not sustained on such diet, Parkes found in some experiments that when the health failed under certain dried foods, it was at once improved by the addition of fats and amyloids without nitrogen. It would seem that some fat may be obtained from albuminates, and in diabetes sugar seems sometimes also derived from them, but they cannot replace either sugar or starch, as the system would be injured by the excess of nitrogen introduced. We con- clude, then, that a due proportion of all classes is necessary for health. C. Vegetable Acids. — With these we may perhaps associate pectin and its allies. In this group the oxygen is more than enough to com- bine with all the hydrogen as water, except in acetic and lactic acids, in which there is no excess. They furnish but little energy in oxidation, but being converted into carbonates assist in maintaining the alkalinity of the blood. III. — Inorganic Substances. A. Salts are essential to health, they seem to be largely concerned in nutrition, facilitating the removal of effete matter as well as the entrance of nutrients. Perhaps they promote the transmutation of liquid colloid into solid tissues, as well as the converse solution of these. They seem to be concerned in digestion, absorption, assimilation, sanguinification, and tissue building ; later their presence promotes disintegration, secre- tion, and excretion. Proteids are incapable of osmosis, but the salts and diffusible acids aid in their conversion into peptones. An opposite effect may be produced in the alkaline blood and this again reversed in the acid tissues. As to disintegration, acid compounds are produced by oxidation, and they appear to give to the salts a solvent power on the debris. Salts have also been regarded as regulators of energy as well as nutrition, and some of them give solidity to bone, etc. A few words may be added respecting the several salts. Chloride of sodium is universally recognized as of great importance. The instinct of animals as well as of the human race shows its necessity. Feeding his victims on food deprived of salt was once one of " man's in- humanities to man." Almost everywhere, in all ages, among savages and civilized alike, salt has been regarded as an emblem of wisdom, riches, comfort, and even immortalitv. It forms about half the weight of the salines in the blood, but it does not enter into the tissues, appearing to act rather as a medium. We cannot much change the amount in the blood. Dilute solutions run off by the kidneys, concentrated ones by the bowels ; thus if we drink sea-water it is not absorbed. Most unorganized FOOD AND DIET. 25 and waste products of the body form crystallizable compounds with salt ; possibly this is why it seems to be concerned in both absorption and se- cretion. Phosphates. — Alkaline or basic phosphate of soda is always present in the blood, but acid phosphate of potash appears in the flesh ; their functions must be different, and in some degree opposed. The alkalinity of the blood keeps the fibrin and albumen in the liquid colloidal state. The basic phosphate of soda also absorbs carbonic acid, and is the chief agent for its removal, acting like an alkaline carbonate which is capable of replacing it in case of its insufficiency. In the herbivora the propor- tion of these two salts is the reverse of that found in the carnivora. In fact, we may say that whenever sodium phosphate is insufficient in quan- tity to carry away the carbonic acid it is supplemented by the alkaline carbonate, and where phosphoric acid is deficient it is replaced by car- bonic acid. The acid phosphate of potash in muscular substance re- verses the alkaline action of the blood, promoting the transudation of nutrient material as well as the solution of effete matter. Earthy phos- phates, especially the lime-salt, are present in all hard tissues, not only in the bones and teeth, but also in the flesh. Possibly their presence directly promotes solidification ; they appear to be agents in cell-growth. Lime is present in morbid growths and in rapidly growing cells in considerable amount. Weiske found that when calcium phosphate was excluded from the food of a goat its bones did not lose their lime ; but perhaps it was drawn from other parts, as nutrition was evidently interfered with, the animal becoming weak and dull. Phosphorus, like sulphur, is thought to enter the system with the albuminoids. Iron and manganese are both present in the blood. Iron in some form is further necessary for the coloring matter of muscle, and in some degree is found in almost all structures, just as it is in almost all foods. Manganese is the chief mineral of the corpuscles in white-blooded ani- mals as iron is in red-blooded. In haemoglobin and myochrome the iron is combined with albumen, or rather globulin. They absorb oxygen from the atmosphere, and give it up in the presence of reducing agents. The functions of the iron compound are therefore respiratory, they are pur- veyors of oxygen, taking it from the air in the lungs, carrying it thence over the whole body to be employed in oxidizing tissue. Dr. Edward Smith calculates that an adult man needs daily from 32 to 79 grains of phosphoric acid, from 51 to 175 grains of chlorine = 85 to 291 of table-salt, from 80 to 171 of soda, from 27 to 107 of potash, 2.3 to 6.3 of lime, from 2.5 to 3 of magnesia, which last is also an essential con- stituent of some tissues. It would seem that only a small proportion of these salts is stored up in the system, for Mr. Lawes found in fattening pigs that only twelve ounces out of eleven pounds present in the food were retained, and this amount was chiefly earthy phosphates. Generally 26 THERAPEUTICS OF THE RESPIRATORY PASSAGES. there is sufficient saline in our ordinary food and drink, except of sodium chloride, and to supply this table-salt must be added. B. Water is necessary in large quantities. It is present in every tissue, even the most solid, as the teeth ; it forms seventy-five per cent, of muscle, and about seventy per cent, of the entire weight of the body ; it constitutes 79.5 per cent, of the blood. Not less than about thirty pounds pass in and out of the alimentary canal by secretion and absorption. Bidder estimates that 28.6 pounds of chyle and lymph pass daily through the thoracic duct, a quantity equal to nearly one-fifth of the body weight. Barail reckoned that for a healthy adult the average amount introduced per day in the food and drink was two thousand grammes. Some water also appears to be formed in the body, but not more than perhaps three hundred grammes, many experiments and obser- vations showing an excess of two hundred to five hundred in the amount removed over that introduced. After forming part of the solids and fluids, it is discharged, according to the researches of Valentin, Labois- ier, Seguin, and others, by four channels, viz., twenty per cent, through the lungs, thirty per cent, through the skin, forty-six per cent, by the kidneys, and four per cent, through the bowels. The uses of water are obvious : it dissolves the food, carries it into the circulation, and dis- tributes it through the body ; it combines with all the tissues and lubri- cates every part ; it dissolves the waste and carries that away ; thus we see it is an active agent in absorption and secretion, in construction and destruction. Besides this, it regulates the temperature as it evaporates from the skin and lungs. Its quality is important ; it carries into the system minerals, as do the foods. It would not be advisable to abandon our ordinary drinking-water in favor of distilled ; in fact, as Letheby observed, " the water of a country may determine the diet of its inhab- itants." "The soft waters of the lakes of Scotland, for example, may have had something to do with the choice of brown meal, which contains so much saline matter ; and but for the calcareous waters of Ireland the potato could not have become a national food." Nevertheless there are times when we may be glad to place patients on distilled water, in order that it may carry off other salts from the body, as, for example, where there is a tendency to deposit calculi. So drinking largely on the one hand or a so-called dry diet on the other become important therapeutical measures. Nutritive Value of Foods. Animal and Vegetable Diet. — The amount of food required by the body varies with the work it has to do and other circumstances. Fur- ther, the proportions of the several classes best adapted varies with the kind of work required. . . FOOD AND DIET. The following table gives the amounts required : '2i Subsistence. Best. Standard. Hard work. Proteids Ounces. 2.0 0.5 12.0 0.5 Ounces. 2.5 1.0 12.0 0.5 Ounces. 4.31 3.53 11.71 1.70 Ounces. 6.0 to 7.0 Fats 3.5 to 4.5 Amyloids 16.0 to 18.0 Salt 1.2 to 1.5 Total water-free food. . . 15.0 16.0 21.25 26.7 to 31.0 The amount required for bare subsistence, that is for the maintenance of the internal work of the body only in a state of complete repose, is given in the first column. But as a man could probably not exist on that amount without loss of weight, we give in the next column the require- ments of ordinary rest, which presupposes that only gentle exertion should be undertaken, and is the minimum for an adult male weighing 150 pounds. This calculation is for water-free food, that is each constitu- ent is reckoned theoretically as water-free, but in what we term ordinary solid food there is from one hundred to one hundred and fifty per cent, water, so that thirty-two to forty ounces of such food would be required. For ordinary work a larger supply is needed and standard daily diets have been constructed, partly by calculation and partly by experiments. We give the mean of several such standard diets in our third column, but perhaps this should be a little more liberal. If we allow twenty-three ounces of water-free food for a man of 150 pounds, this gives 0.15 ounce for each pound, or nearly one-hundredth part of the weight of the body. This is dry food, and would correspond with fifty to sixty ounces of ordi- nary solid food, to which may be added the fifty to eighty ounces of water or other liquid taken, which would make a total supply of seventy to ninety ounces of fluid = 0.5 ounce for each pound of the body-weight. When working hard, men take much more food whenever they can get it, and for hard labor diet the greatest increase should be in the proteids and fat. Of the diets given, those most adapted for our patients would naturally be those for rest and ordinary work, but as some patients imagine they ought to consume large quantities, we have added a fourth column to our table, suitable for a person undergoing very laborious work; it gives the figures calculated by the late Dr. Parkes as sufficient for a soldier on service in the field.' Of course in acute cases the nature of the diet may have to be greatly changed — here we are only speaking of that which is required in health, as a basis for the consideration of what may be desirable in disease. The average proportion of the several classes, taking the mean of the figures given by Moleschott, Ranke, and Petten- 28 THERAPEUTICS OF THE RESPIRATORY PASSAGES. kofer and Voit, is for 100 of proteids, 83 fats, 273 amyloids, and 23 salts. As nutrition depends so largely on the chemical interchanges of nitro- gen and carbon, many calculations and experiments have been made as to the nutritive value of different foods. In the best diets the nitrogen should be in the proportion of one to fifteen of carbon. Tables based on the nitrogen alone lead to very unsatisfactory conclusions ; for instance, ham and red-herring would be, according to the amount of nitrogen con- tained, more than nine times as nutritious as human milk, both being cal- culated in the dry state. In framing, therefore, a table of alimentary equivalents we must consider all the constituents. The late Dr. Letheby constructed the following table showing the percentage, proportion of nitrogenous and carbonaceous matters, the latter being calculated as starch. The habits and instincts of the human race are in favor of a compara- tively rich nitrogenous diet, and the easiest to digest appears to be one containing meat ; for though the chemical composition of animal and vegetable albumen is nearly the same, and they serve similar purposes, the facility of digestion is not'to be overlooked. A judicious admixture of meat and vegetables is therefore generally recommended, though it is not to be denied that men can live in perfect health on vegetable food ; there are, indeed, races who do this. Some advocates of animal food, however, con- sider that the highest kind of work cannot be accomplished on such a diet, and Dr. Carpenter must perhaps be enumerated among these, for he sa^s : " And while, on the one hand, it may be freely conceded to the ad- vocates of ' vegetarianism ' that a well-selected vegetable diet is capable of producing (in the greater number of individuals) the highest jihi/sical development of which they are capable, it may, on the other hand, be af- firmed with equal certainty that the substitution of a moderate propor- tion of animal flesh is in no way injurious, while so far as our evidence at present extends, this seems rather to favor the highest mental devel- opment." Dr. Graily Hewitt, in his address at the British Medical As- sociation, assigned to a defective meat diet a large amount of " weakness " which he found prevalent and regarded as an antecedent of distinct dis- ease, and the Lancet recently stated that three- fourths of a pound of meat fairly represents the daily quantity which suffices to maintain an adult in health. Certainly many exceed this, taking meat two or three times a day, even when leading sedentary lives, but, as the same writer points out, sooner or later they pay the penalty. On the other hand, many — especi- ally women — reduce their meat to a minumum, scarcely taking an average day's allowance in a week, and it may easily be understood that they do not possess the same vigor as those who take more ; but the question naturally arises whether these persons are not underfed in other articles also, and that their weakness is due not so much to want of meat as to want of food. FOOD AND DIET. 29 Table of the Nutritive Values of Food (Dr. Letueby). Bread Wheat flour . . . . Barley meal. . . . Oat meal Rye meal Indian meal .. . . Rice Peas Arrowroot Potatoes Carrots Parsnips Turnips Sugar Treacle New milk Cream Skim milk Butter milk .... Cheddar cheese . Skim cheese . . . Lean beef Fat beef Lean mutton . . . Fat mutton .... Veal Fat pork Green bacon. . . . Dried bacon. . . . Ox liver Tripe Poultry White fish Eels Salmon Entire egg White of egg . . . Yolk of egg , . . . Butter and fats. Beer and porter. TOTAI, °i Total PEB CEST. PER CENT. u a; 1 a ■£ to 3 01 *2 a "a to a 0) tB . O on t- ? -A z w p it li O g til p 2 i ° < 37 8.1 47A 3.6 1.6 3.3 8.1 55.00 6.8 1.25 28.21 15 10.8 66 .3 4.2 3.0 1.7 10.8 75.50 7.0 1.66 38.57 15 6.369 .4 4.9 3.4 3.0 6.3 80.3012.8 0.97 36.61 15 13.6 58 .4 5.4 5.6 3.0 13.6 77.80 6.2 1.94 40.44 15 8.069 .5 3.7 3.0 1.8 8 78.30 9.8 1.33 38.48 11.164 .7 4 8.1 1.7 11,1 85.35 7.7 1.71 43.09 13 6.3 79 .1 0.4 0.7 0.5 6.3 81.35 12.9 0.97 39.03 10 23.0 55 .4 2.0 2.1 3.5 33.0 62.65 2.7 3.54 38.55 18 . ^ 82 .0 83.00 36.44 75 3.1 18 .8 3.2 6.3 6.7 2.1 22.50 10.7 31 10.98 83 1.3 8 .4 6.1 0.3 1.0 1.3 15.00 11.5 0.20 7.28 82 1.1 9 .6 5.8 0.5 1.0 1.1 16.65 15.1 0.17 7.91 91 1.3 5 .1 3.1 0.6 1.2 7.20 6.0 0.19 3.76 5 95.0 95.00 42.22 23 77.0 77.00 34.22 86 4.1 5.3 3.9 0.8 4.1 14.95 3.6 0.63 8.55 66 2.7 3.8 36.7 1.8 3.7 69.55 25.7 0.42 32.17 88 4.0 5.4 1.8 0.8 4.0 9.90 2.5 0.62 6.26 88 4.1 6.4 0.7 0.8 4.1 8.15 2.0 0.63 5.53 36 28.4 31.1 4.5 38.4 77.75 3.7 4.37 47.77 44 44.8 6.3 4.9 44,8 15.75 0.3 6.90 37.82 73 19.3 3.6 5.1 19.3 9.00 0.5 2.97 12 98 51 14 8 39.8 4.4 14.8 74.50 5.0 2.28 39.99 72 18.3 4.9 4.8 18,3 12.25 0.7 2.82 13.95 53 12.4 31.1 3.5 13.4 77.75 6.3 1.91 40.33 63 16.5 15.8 4.7 16.5 39.50 2.4 3.54 25.22 39 9.8 48.9 3.3 9,8 132.25 12.5 1.51 58.89 24 7.1 56.8 3.1 7.1 167.00 23.5 1.09 77.52 15 8.8 73.3 2.9 8.8183.85 20.8 1.36 85.53 74 18.9 4.1 3.0 18.9 10.25 0.6 2.91 13.34 68 13.2 16.4 2.4 13.3 41.00 3.1 3.04 24.36 74 21.0 3.8 1.2 21.0 9.50 0.4 3.23 13.99 78 18.1 3.9 1.0 18.1 7.35 0.4 2.79 11.64 75 19.9 13.8 1.3 9.9 34.50 3.5 1.53 19.93 77 16.1 5.5 1.4 16.1 13.75 0,8 3.48 13.60 74 14 10.5 1.5 14.0 36.25 1.9 2.16 18.18 78 20.4 1.6 20,4 3.14 9.49 53 16.0 30.7 1.3 16.0 76.75 4.8 2.46 41.55 15 . 83.0 2.0 207.50 92.22 91 0.1 i i.7 •• 0.2 0.1 8.70 87.0 0.02 3.92 ' The available carbon consists of all the carbon of the carbonaceous constituents of the food, and of the carbon of the nitrogenous after deducting the carbon of the urea which is excreted, 100 of dry nitrogenous matter yielding 31.23 urea. 30 THERAPEUTICS OF THE RESPIRATORY PASSAGES. The advocates of meat diet say that the carnivora are more active, or at any rate that they can respond to sudden calls for exertion more easily than the herbivora. But we must not be content to contrast the sudden spring of the tiger with the slow steady move of the domesticated cow. The antelope will start with amazing rapidity and keep up its run for a great distance. The high-bred hunter and the plodding donkey are both vegetable-feeders. The carnivora appear to be fiercer in their nature, but that would be almost necessary to enable them to seize their prey. It is said that the acorn-eating bears of India and America are mild and tractable, while the flesh-eating polar-bears are savage and untamable. Experiments have been made by feeding bears on different diet, and these point to the same conclusion, but allowance should be made for ani- mals kept in captivity. Men also seem to differ somewhat in their dis- position and powers of endurance according as they live on vegetable diet or partake of meat. Hindoo navvies employed in the boring of tunnels have felt driven to forsake their vegetable diet and live like their English fellow-laborers. Liebig attributed the Englishman's energy to the nature of his food, and says : " Compare the English statesman, who, in expounding his views or maintaining a debate in Parliament, delivers a speech lasting five hours or more, who at sixty years of age retains the capability of taking part in field sports, with the German philosopher, who at the same age keeps up with difficulty the remains of his power in order to be capable of work, while he becomes fatigued by a walk of a few hours." It is a flattering picture, and in the present day we may see a foremost statesman with physical energy enough to amuse a leisure hour by felling trees, but it is to be feared that the average Englishman will not be able by any diet to display an equal amount of physical and intel- lectual energy. Again, it may be remarked that not only sustained work but sudden putting forth of energy is seen in men by no means remarka- ble for their meat-eating. Some recent statistics seem to show that the English, after all, are not such large meat-eaters in comparison with other nations as has been generally thought. Even if they are, they are cer- tainly not more warlike nor more implacable than their neighbors ; in- deed, not a few are disposed to grumble at John Bull as having grown slow to take offence. It may, then, be doubted whether the deductions that have been made can be sustained. Certainly, the contrast with an ill-fed rice-eater should not be made, but with a well-fed vegetarian, who takes full supplies of corn and lentils as well as rice. The argument, from the degree of complication of the alimentary canal, seems rather to belong to the digestibility of the food. Further, it seems certain that different nitros^enous foods have varvinsf nutrient values. Fibrin and gelatin are not meat and cannot supply its place. Majendie found that dogs fed on raw meat alone for one hundred and twenty days retained their health, while three times the amount of isolated fibrin was insuffi- FOOD AND DIET. 31 cient to preserve life, though much gelatin and albumen were given at the same time. The glutinous materials of wheat and barley, though chemically nearly alike, are not of equal nutritive power. With regard to the non-nitrogenous foods, their varying value for nutrition depends largely on the digestibility. Starches seem to differ much in this, though all of them have to become sugar. Yet sugar will not completely replace starches in our food ; though perhaps this is partly a matter of taste, or it may very well be that cane-sugar may be less assimilable than that produced by the action of ptyalin on starch. As to hydrocarbons, animal fats are more easily digested than vegetable ; some with great flavor offend the palate or disagree with the stomach. Excess of any of the classes of food may pass through the alimentery canal undigested. CHAPTER y. PEEPAEATION OF THE FOOD-STUFFS— DIGESTrVTE FLUIDS. The digestibility of articles of food is closely related to their physical properties and these we may considerably modify by cooking. Dr. Beaumont's experiments on Alexis St. Martin will be remembered by our readers, and they certainly give some useful indications, but his tables have been so often quoted that it is unnecessary to repeat figures which may be so easily referred to. Moreover the variations in cooking intro- duce difficulties. It would be well if the light of science could be re- flected in the kitchen. Cooking may be compared to some of the opera- tions of pharmacy, and it is as important that food should be well cooked as that medicines should be accurately dispensed. It is obvious that the food should bear a certain relation to the pro- cesses by which its nutritious elements are to be extracted. We can- not feed on the proximate principles but must prepare them in our bod- ies. Milk is indeed a perfect food for the young, but adults seem to want something else. It may therefore be left to the edentulous race which some whimsical sophists anticipate will succeed us to prepare a fluid aliment for adults, as the present age has made artificial foods for those of its infants who are unhappily deprived of their mother's milk. The world seems content to employ its own digestive organs, and even those who are no gourmands seem to have no desire to renounce the pleasures of the table. Suitable food being then obtained, to what pro- cesses is it subjected ? Berzelius compared digestion to rinsing. The food is taken into and passed along the alimentary canal, being detained at intervals while various digestive liquids are poured upon it. By these the nutritious elements are dissolved out and carried into the system as the solvents thus loaded are reabsorbed. The amount of these digestive liquids is often unappreciated. According to the researches of Bernard, Bidder, and Schmidt no less than three gallons are secreted into and re- absorbed from the alimentary canal every twenty-four hours. The fol- lowing are the daily proportions of the several digestive fluids and of their chief constituents : PREPARATION OF THE FOOD-STUFFS. 33 Amounts of Digestive Fluids Secreted Daily, and the Proportions of their Chief Constituents. Solid matters. Active principles, lbs. grs. grs. Saliva 3.53 231 116 of ptyalin. Gastric juice 14.11 2,963 1,482 of pepsin. Pancreatic juice 0.44 309 39 of pancreatin. Bile 3.53 1,234 1,058 of organic ferment Succus intestinalis 0.44 46 28 of organic ferment. Total 22.05 4,783 2,723 of special solvents. These liquids are not merely solvents, but each possesses a power of changing the food by virtue of the peculiar ferment it contains. Each not only dissolves nutrient principles but transforms them. Saliva. This secretion is slightly alkaline. Except when fasting it contains only about one per cent, of solid matter, but half of that consists of the nitrogenous ferment called jOility. d. Liquid foods, such as milk, beef-tea, soups, broths, constitute the most nutritious group, being capable, when properly combined, of sup- porting the system. They have already been*sufficiently considered. e. Aerated drinks, water containing carbonic acid enough to render it effervescing, forming an agreeable cold drink, the gas acting as a stimulant to the stomach. f. Acidulous drinks, such as lemonade, etc., are often very grateful, and are believed to be refrigerant and somewhat astringent. They quench thirst, tend to check hemorrhage, restrain too copious perspira- tion, and to some degree abate hectic and other febrile states. Sub- acid fluids may to a considerable extent replace this group. g. Salines. — In one sense the previous group resembles this, since the acids appear in the blood in the form of salts. But there are differences in the therapeutical effects, partly due, perhaps, to differences in quan- tity. Some of the saline domestic remedies are but convenient modes of administering medicines, and now and then it is necessary to beware lest under the name of beverage, active medicines should be too freely con- sumed. h. Medicinal Beverages. — Some of the previous groups might be placed here, for both acids and salines are potent remedies, as, too, are alkalies and others which may conveniently be used as beverages. Soda 90 THERAPEUTICS OF THE RESPIRATORY PASSAGES. water and mineral waters to wit, but only with due regard to the condi- tion of the system. i. Fermented Beverages. — Their effects may be referred to the alcohol they contain. h. Tea and its Allies. — We come, at length, to those beverages which have obtained universal favor as ordinary articles of diet — tea, coffee, cocoa, mate or Paraguay tea, guarana, coca, or rather, as Chris- tison suggested, cuca, African kola nut, etc. These are mostly used as warm infusions, and are always recognized as possessing a decided influ- ence on the nervous system. These vegetables contain, first, a volatile oil, seldom amounting to one part in one hundred and fifty, but that is enough to impart the distinct aroma ; second, an astringent styptic acid, allied to tannin, which amounts to thirteen to eighteen per cent, in tea, but only about five per cent, in coffee ; third, a nitrogenous alkaloid, to which is attributed most of the effects ; this is called tliein, caffein, theo- bromine, according as it is obtained from tea, coffee, or cocoa ; but all are believed to be identical. The amount of alkaloid varies in the different substances. In coffee it averages 0.75 per cent., butPayen found as much as 1.7 per cent., though no one else has detected as much ; in tea it averages 1.8 to 2 per cent., but in some good specimens there is much more, Peligot once found 6.2 per cent., and Letheby found 4.94 per cent, in a sample of Himalayan tea ; in cocoa 1.2 to 1.5 per cent., and in the leaves of this plant 1.2 to 1.2G -p^v cent.; in mate 1,2, and in guarana the average is five per cent. The amount present, however, may not cor- respond with that extracted. Aubert found in a cup of coffee made with 16. G6 grammes, from 1.5 to 1.9 grain of caffein, and in a cup of tea made from five to six grammes of the leaf, about the same quantity of alkaloid. Cocoa may be regarded as a nutrient combined with the alka- loid, but coffee and tea are rather nerve-stimulants. The alkaloid cer- tainly seems to produce an agreeable excitation of the nervous system, without the subsequent depression which characterizes more powerful stimulants ; moreover, the effect is more prolonged. These facts ex- plain the high value so universally set on these beverages, as well as their occasional disagreement with a few individuals, some of whom, however, might very well partake of them if they would employ much weaker infusions. Liebig noticed that the alkaloid was related tokreatinin, and so com- pared tea and coffee to soups ; being related, further, to nervous tissue, it might be suggested that it would serve as a ready-prepared nerve-food. But it is not likely it enters into the formation of tissue. Perhaps, how- ever, it mav, on account of its near relation, serve as a kind of stimulus to change, as a true nerve-food would. Lehmann, in 1854, found coffee reduced the excretion of urea, and therefore he concluded that it retarded tissue change, and in this he seems to have been supported by WATER — DILUENTS BEVERAGES. 91 the experiments of Bocker and Hoppe. On the other hand, Volt found no such adulteration produced, and Dr. Squarey's numerous experiments do not support the alleged decrease. The evidence as to tea points to a slight decrease, but is not very satisfactory. Dr. Edward Smith (" Phil. Transactions," 185D) found that tea and coffee increased the car- bonic acid exhaled by the lungs, the quantity of air breathed being increased, the respirations being deeper and freer. This would indicate that they tend rather to increase than to retard tissue clianges. He says that " tea promotes all vital actions and increases the action of the skin," but seems to think that coffee diminishes perspiration. Probably both infusions, taken warm, promote perspiration, but tea more decidedly so, and coffee certainly seems rather to stimulate the kidneys. In pro- moting perspiration they would indirectly diminish the heat of the bodv. The alkaloid is not the sole active agent, for the volatile oil has been shown to produce similar symptoms. It causes wakefulness, abates* the feeling of languor, induces perspiration, and, according to Lehmann, lessens the excretion of urea. We may, perhaps, on the whole, conclude that tea and its allies do really retard tissue changes, and so diminish waste, while at the same time they certainly excite nervous action, and thereby render work easier, both physical and mental, but more especially the latter. To the cerebral excitement is due the wakefulness, the persistent thinking, and the feeling of cheerfulness and exaltation which are characteristic effects of even moderate quantities ; and poisonous doses expend their energy on the nervous system. If these beverages really retard tissue changes, we can understand why they are reputed to abate heat. It makes some difference whether they are taken warm or cold ; not that the temperature of the fluid itself would have much effect, but in tlie one case the sensation of coolness may be grateful, besides prodscing an effect through the nervous svstem, and in the other the promotion of evaporation by the skin and lungs in- creases the escape of heat. Are we then to regard such drinks as refrig-- erant, even when warm? Does the old nurse's tea really cool her as she says ? Is the febrile patient's cry that it cools him correct ; or is that idea only the expression of thirst, and the water, not the tea, the active agent? If so, may we not give the water and leave the additional ingre- dient to the patient's choice — tea or warm drinks, acid cool drinks, or fruits? Practically, we know that any refrigerant, we may say any pleasant tasting liquid, is grateful to a heated person, whether the heat be physiological or pathological. Thus we find in thirst with warmth of surface, produced by exercise, fluid is acceptable, and whether cold or warm is selected is often a matter of taste. In feverish conditions, no doubt, there is excessive production of heat, not merely deficient escape. Nevertheless, any increase in escape give proportionate relief, and drink- 92 THERAPEUTICS OF THE RESPIRATORY PASSAGES. ing liquids promotes this. The cool taste of the cold liquids is grateful in itself, while the warm beverages, perhaps, act by their indirect effect on the skin, for the simplest hot drinks will sometimes at once unlock, as it were, the sweat-glands, and so afford relief. This is particularly noticeable in affections of the air-passages, in which, even when acute and attended with fever, warm fluids are preferred and are most beneficial. Perhaps this may partly arise from the increased elimination of water through the respiratory mucous membrane. Cuca. — The leaves of the Erj'throxylon cuca have from time to time had ascribed to them very remarkable qualities. In 1609 Garcilasso de la Vega, described the use of them by the natives of Peru, as a means of preserving strength during fatiguing exercise and privation of food. Dr. Mantegazza, of Milan, whose charming travels in South America are pretty well known, observed that it increased the frequency of the pulse, produced a strong tendency to muscular action and great mental vigor. Dr. Von Tschudi partook of the leaves after the manner of the Indians, and found they prevented difficulty of breathing and fatigue in ascending the Andes, as well as enabled liim to pursue swift-footed game and to endure long abstinence from food. The Indians and Peruvians are said to run fifty miles a da}' without food or anything except their cuca. In 1876 Sir Robert Christison reported to the Royal Botanical Society of Edinburgh experiments on liiinself and students. The veteran professor havino- found that a fifteen mile walk without food or drink was sufficient to tire him, proceeded to walk sixteen miles in three stages. He chewed eighty grains during his second rest, and forty grains in the last stage ; all sense of weariness vanished and he reached home without any fatigue or uneasiness. Although no food had been taken for nine hours, neither hunger nor thirst was felt, but he did justice to his dinner, had a good night's sleep, and next morning was free from fatigue. On another occa- sion, after ascending three thousand feet of Ben Voirlich, fort}' grains were chewed, and all fatigue vanished, the descent was made with ease, another twenty grains being taken when half-way down. Neither food nor drink was taken from half past eight in the morning to six o'clock in the evening, yet neither hunger nor thirst was felt, no drowsiness was experienced in the evening, and after a good night's sleep he awoke readv for another day's exercise. He concludes that cuca removes and prevents fatigue, and suspends hunger and thirst without eventually af- fecting appetite or digestion. It seems to have no effect on the mental faculties except liberating them from the dulness and drowsiness which follow great bodily fatigue. We should, perhaps, remember that Sir Robert's splendid mind was associated with a body always remarkable for its activity and power of endurance, and young, if weakly, persons could not hope to cope with the aged but athletic professor. On the publication of his report a friend of mine took a twenty mile walk with WATER — DILUENTS BEVERAGES. 9o comfort and ease on sixty grains of cuca, and said he felt ready for an- other ; he took neither food nor drink from 8 a.m. to 4 p.m., and felt neither fatigue nor discomfort, in spite of inclement weather. Dr. Bur- ness, author of the " Specific Action of Drugs," undertook similar experi- ments with the same result, and he informed me that cuca produced a rise in the temperature ; not only when walking, when it might be at- tributed to the exercise, but also when in repose. In the last case there was a rise in half an hour after a dose from 98.0° to 99.3° F., and within the next half hour to 99.4° F., after which it again gradually fell. Mr. Dowdeswell reported in the Lancet, 187G, results of an opposite nature, and some others have failed to find cuca banish fatigue in the manner described by Christison. The leaves contain a crystallizable alkaloid sim- ilar to, if not identical with caffein, besides a volatile oil, a peculiar waxy body, and an astringent substance allied to tannin. From sixty to ninety grains is sufficient for one trial ; it is uncertain whether it retards tissue change, but it probably does, as it seems to diminish the excretion of urea, and in other respects resembles in its properties the other caffein- containing plants, but it does not seem to diminish perspiration nor to produce cerebral excitement, although this has sometimes occurred, and very large quantities have been followed by hallucination, Cucaine, the active alkaloid of cuca, has been given in one-eighth and one-seventh grain doses. In some respects it is said to resemble atropine. Dr. Aschenbrandt, during the manoeuvres of the Bavarian troops, tried it on the soldiers, and reports that one-seventh of a grain sufficed to remove fatigue, hunger, and thirst, so that the men could go for hours without food or drink. He considers it a nerve-food. His observations corrob- orate those of Dr. Amess, who experimented in 1880 with chloride of cucaine. CHAPTER XIII. EXERCISE AND REST. We have seen that exercise or work is a stimulus, just as aliment is, though acting- in a different way. This is most familiar in the muscular system. We can increase a muscle by exercising it and supplying the body with aliment, and indeed, under the influence of exercise, nutri- ment may be drawn from other parts to the muscles engaged. Labor which exercises many muscles requires a proportionate diet. On the other hand, daring rest in bed we need less food. A familiar instance of this is an accident, say a broken leg, which confines a healthy person to bed ; if he takes the same food as in active life febrile symptoms will set in. It would seem, then, that exercise would be a nutrient, or rather would promote nutrition, provided proportionate food be taken, other- wise it would act in a contrary way. The effect of exercise is perceived in all organs, but the expression is mostly used in reference to the loco- motor system. The muscles in contracting accelerate the flow of blood and so act on the circulation, which is also increased from the general effect. We have, therefore, increase of heat, more frequent pulse, fuller respiration, and increased secretion. Another more distant effect is the absorption of fat, whether from increased waste or from pressure exer- cised by the contracting muscle on the softer tissues. With the demand upon it the muscle grows, increases in volume, in firmness, in elasticity, acquires greater strength. As the muscular action is called forth by the nerves, they also are exercised. The oxidation of carbon and perhaps of nitroo-en is also increased by exercise, so is the elimination of water, as we see in the perspiration produced, so that the body contains less water after a spell of work unless this effect has been neutralized by the per- son drinking. In every organ there is more rapid circulation, more rapid flow of plasma, as well as more active absorption, that is to say, there is more waste and quicker repair. Thus the products of action are at once removed, instead of accumulating in the organs. Further, there is a greater escape of heat by the evaporation of the increased perspira- tion. We see, then, that nitrogen and carbon are required. If not sup- plied the absorption of oxygen and the molecular changes would be re- tarded, as would also the elimination of carbon. What we have said EXEKCISE AND REST. 95 applies to moderate exercise, immoderate work may produce exhaustion ; moreover, the muscles require periods of rest in which to store up the material which is metabolized during contraction. It would seem, too, that oxygen may be stored up during rest. Both the heart and the lungs should be sound, in order to secure a free blood-supply to the mus- cles, and the rapid interchange between oxygen and carbon without too much fatigue to those organs. All this shows us that under favorable circumstances moderate exercise, especially such as calls forth the ener- gies of large groups of muscles or many organs, is one of the best tonics, promoting nutrition and improving the health of the body ; especially is this the case with outdoor exercise. Sometimes, however, we are only able to employ passive exercise, and in other cases special gymnastics. Often instead of exercise rest is desirable, or even essential, and then, of course, we have the converse of some of the effects described, but not altogether, for rest again with proper food promotes nutrition by dimin- ishing waste. During sleep, for instance, there is slackened destructive metamorphosis, but repair is still going on, and this accounts for the res- toration of the wearied limbs. Children feel the want of sleep more than adults, partly because of their wonderful activity, still more because growth is so rapidly proceeding. But during rest not only is there this diminished molecular movement, but the respiration and circulation are slower, and the work of the organs less. As an example the heart beats less in the horizontal position, on assuming which in health a fall soon takes place of twelve beats per minute, or 17,280 in twenty-four hours ; in disease the fall may be twenty, thirty, or forty beats per minute. The consequences of such a difference may be traced throughout the body. Exercise and rest may alike be local or general, active or passive. A limb, a group of muscles, a single muscle, an organ, or other part may be subjected to the influence of either agent. When absolute repose cannot be had, relative rest may be procured. Wlien the work of an organ is intermittent, there is a period of repose between its efforts. Thus the heart rests during the pause between its contractions, and we are able to lengthen that pause, while increasing the force of the beat, and in tliis way the rest of the organ is increased ; as we have remarked, the recumbent posture greatly lessens the work of the heart, as it does also of the lungs. In respiratory diseases we cannot stop breathing, but we may regulate it by remedies. In chronic cases, fuller, deeper respira- tion takes place during exercise, which further secures other benefits, such as improved appetite and digestion, increased oxidation, and thereby augmented nutrition. But we more frequently need rest in diseases of these organs, and this is especially required in acute cases. Fever, of course, compels repose, as does often inflammation. In h.'emoptysis the first remedy is rest, and often this is the only remedy required. In in- 96 THERAPEUTICS OF THE RESPIRATORY PASSAGES. flammation of the air-passages, besides avoiding irritation by securing tliat only warm and perhaps moist air passes along them, we avoid the irritation which is so injurious, and, as far as we can, help them to rest. Thus in laryngitis we impose silence as far as we can, by forbidding speaking, that is, we give all the rest possible to the vocal organ. In bronchitis the same means are of no little assistance. In capillary bron- chitis we endeavor to attain the same result by an indirect method — such as relieving the oppressed heart, promoting the removal of secretion from the tubes, or arresting its outpour while maintaining the circulation. In pleurisy, besides rest in bed, we may bandage the chest or strap the af- fected side — a plan well reported of in acute general pleurisy, seen early, as well as when the disease is limited in area with little or no effusion. In pleuro-pneumonia caused by a fractured rib, the benefit of fixing the part is still more manifest, inasmuch as it prevents the repetition of the injury which would take place with every movement of the broken bones. In the intercurrent pleurisy of phthisis, and in the short cough and stitch so common at the commencement of that disease, temporary rest is also most beneficial, as it is in slight attacks of haemoptysis during the progress of phthisis, but care should be taken not to deprive the pa- tient too long of the general exercise of which he is in need, or the lungs of the free and full breathing which is so important. In advanced con- sumption cough and pain, of a most distressing kind, sometimes appear to be caused by adhesion of the pleural layers, and may be eased by such rest as may be secured by careful strapping. CHAPTER Xiy. ALCOHOL. We come now to a thorny subject, for alcohol has been alternately abused and neglected. Wine has been used as a medicine from the earliest times, and its history as a remedy shows a series of oscillations almost as remarkable as those exhibited in the history of depletion. As- clepiades pandered to the Roman taste for wine, not only by giving it at once after the evacuants he ordered, but prescribing it in excess sometimes, even to the extent of intoxication, under the pretence of thereby procuring sleep, while in other cases he also ordered it for the opposite purpose. Other charlatans at different times have abused the use of alcohol, and upheld their practice by equally inconsistent dogmas. Even able and .thoughtful physicians have sometimes been led away into excess or in- consistency in their use of this potent agent. It is perhaps curious to note that the most reckless prescribers of stimulants have often appeared to exhibit a touch of quackery in their conduct. Abuse of alcohol has naturaWy largely alternated with excess in the employment of depress- ants, especially venesection ; but we must leave these changes in medical opinion and practice until we come to the similar epochs which have marked the use of bleeding. Ts alcohol a nutrient ? Can it be regarded as a food ? It has been held that this may be the case, because the excretion of carbonic acid and urea are lessened under its use. But the experiments of Parkes and Wollowicz show that moderate quantities do not interfere with the metamorphoses of the nitrogenous tissues, while it is, to sa^^ the least, doubtful whether the exhalation of carbonic acid is, after all, decreased. Another reason has, however, been advanced for considering it a nutrient, viz. : that inasmuch as it is very easily oxidized, -it takes the place of ali- mentary material, which it thus spares, thereby permitting the accumula- tion of hydrocarbons in the system — that is to say it fattens. In the same way it would supply heat, its value for this purpose depending upon its ready combustibility; that is to say, it is preferred to other hy- drocarbons, and therefore oxidized, while they are left unattacked in its presence, so that it acts by sparing real nutrient material. But does it thus supply heat ? It is admitted on every hand that only small quan- 7 98 THERAPEUTICS OF THE RESPIRATORY PASSAGES. titles can do this, for larger amounts have been distinctly shown to reduce the temperature of the body. Binz attributes this effect to a paralyzing influence on the vaso-motor nerves, which results in a dilatation of the superficial vessels, by which more blood is brought to the surface and there cooled by radiation; at the same time there is a retardation of molecular change by a direct depressing influence on the cells, and of course a diminution of the heat which would be liberated by cell oxida- tion. It is, of course, by no means impossible that such opposite effects may be produced by different doses, but it may be observed that we are here considering quantities which fall short of intoxication, and the line which divides the one effect from the other seems to be much narrower than is generally supposed. In ordinary language a substance which, though it may be oxidized in minute quantities, yet in rather larger amounts depresses the tempera- ture and retards the activity of cells is scarcely entitled to be called a food, especially when it does not enter into the composition of tissues, but if it be shown to promote indirectly their repair or to reduce their waste it may be perhaps grouped conveniently among indirect nutrients. It is admitted that, at any rate, some of it undergoes change in the body, for when minute quantities only are taken it can scarcely be traced pass- ing out. What, then, becomes of it ? Our information here is rather de- ficient. Out of the body it is easily converted into acetic acid, and some* have supposed that such a change may be effected in the system ; in that case the acid would unite with the soda in the blood and the salt thus formed would become a carbonate, which would be excreted by the kid- neys in the same way as acetates are when taken into the stomach, but the effect woxild not be just the same, for in g'iving acetates by the mouth, we give the base as well as the acid, whereas, in the case supposed, acetic or carbonic acid formed from alcohol would have to obtain their alkalies from the system, and by uniting with them might thus increase instead of diminishing the natural acidity of the secretion. This would account for a slight increase of acidity which was observed by Parkes. Here, however, it must be observed that acetic acid has not been detected in the blood, nor, indeed, have other intermediate products of the combustion of alcohol. It has therefore been suggested that the oxidation is carried, so to say, at a single bound to its ultimate end, viz., the production of carbonic acid and water. In support of this view it is urged that before all the alcohol has escaped elimination ceases, or at any rate its presence cannot be detected. It is impossible to determine from the pulmonary exhalation the pro- portion which may have been oxidized, for the carbonic acid is not in- creased, indeed nearly all experiments point to the conclusion that it is rather decreased. Unless, therefore, some other substance which would yield carbonic acid is prevented from doing so, the alcohol cannot be con- ALCOHOL. 99 verted into that gas. The difficulties attending the investigation into tlie elimination by the skin are very great ; we turn, therefore, to the kid- neys. When only small quantities of alcohol are taken it can scarcely be detected in the secretions when larger quantities are taken elimina- tion soon commences by the kidneys, as well as by the skin and lungs. So constantly is this the case that the late Dr. Anstie proposed to con- sider its appearance as a measure of the saturation of the system, or rather as a sign that as much had been absorbed as could possibly be oxidized. He found that about one and one-half fluid ounce always caused its appearance. Parkes and Wollowicz obtained this same result ; they found in a strong, healthy man, accustomed to take alcohol in mod- eration, when between one ounce and two ounces were given him some was at once thrown out unchanged by the kidneys, and at the same time some ill-effects began to manifest themselves, though only in a slight degree. The man lost his appetite, there was slight but distinct narcosis, increased rapidity in the heart's action, quite a rapid rise of temperature and greater dilatation of the small vessels. The sphygmograph confirmed the analyses, and these symptoms ard considered to mark the commencement of the poisonous effects. Here, then, we seem to be approaching a reply to the question, How much can be consumed in the body ? In a strono- man from one to one and one-half fluid ounce is the limit ; it is possible some persons might oxidize more, but the probability would be that a larger number might be unable to dispose of as much. After that limit has been passed the kidney begins to throw it out, and symptoms of incon- venience or of distress may be produced by its presence. Parkes made his experiments on strong, healthy men, and the deductions he drew were most moderate. We can scarcely go wrong in following so judicious an observer, his experiments are only likely to be corroborated, and until some flaw in them can be pointed out it seems reasonable to conclude that about one ounce of absolute alcohol should be considered the limit which ordinary men should not pass if they wish to avoid danger. Now, that ounce of alcohol is contained in about two ounces of brandy, or five ounces of sherry or other strong wines, or eight to ten ounces of weaker wines, such as hock and claret. If we take the outside quantity it would only allow us to increase these amounts by one-half, and then we should have arrived at the maximum which can be disposed of by strong men. Of course, in weakly or unhealthy men the figure should be reduced. In women, also, on account of the greater susceptibility of the nervous sys- tem, as well as for the less doses they require of all medicines, the amount should be less. In children the injurious effects of alcohol are more rapid in appearing and more severe in character, so that while it is almost universally allowed that they ought never to partake of it as a bevera£;-e, it should only be given as a medicine with extreme precaution. There is this to be said about the medicinal use of alcohol. We give 100 THERAPEUTICS OF THE RESPIRATORY PASSAGES. other remedies which are rapidly excreted and we often have to give them in such quantities as may for a time distress the secreting organ. This may be particularly observed in acute cases, and it may be that to pro- duce certain effects we might administer alcohol in doses which could not be oxidized. If we give it as an antipyretic, we must give enough to reduce the temperature, and that is more than the maximum which healthy men can dispose of in the system, and it is not alleged, so far as I remember, that larger quantities can be oxidized in disease. In chroTiic cases the use of alcohol presents a very different aspect. Here it approaches rather the dietetic employment, and consequently the quan- tity which the patient ought not to exceed should be rigidly kept within the limit of that which is likely to be oxidized in the system. For it should not be forgotten that the surplus is thrown out by the kidneys, not as so much useless, inoffensive matter, but these organs are irri- tated by the alcohol in its passage, and thus disease is produced. This has been denied, but although we may recognize certain pathological changes in the kidney as not necessarily induced by alcohol, yet statistics still show that drunkards are more liable than others to renal disease, some forms of which seem to be the consequences of alcoholic excess. But even this is not the most important. It is one of the less, for the alcohol in the system undoubtedly affects other tissues, in most of which fibroid or fatty degenerative changes are brought about by its agency. Fur- ther, these degenerations, though naturally looked for in drunkards, often appear in persons who consider themselves strictly moderate. And what else should be expected ? They habitually take only a little more than can be disposed of in the system ; the effect of the surplus must usually be present, just as when an occasional excess is taken its effects con- tinue until elimination is complete. So long as any surplus is in the svstem the spirit circulates in the blood, and the tissues are bathed in a fluid containing it. And here it is important to note that elimination is not so rapid as some have supposed. Subbotin found that it was not quite complete in twenty-four hours ; Perrin, Lallemand, and Duroy ob- served it to go on for thirty-two hours ; and Parkes and Wollowicz, after a large quantity of brandy, detected it on the fifth day, though exhalation by the lungs had ceased much earlier. This looks as if it might accumu- late in the body ; at any rate, it proves that the alcohol may remain in the system a considerable time after the period at which it has generally been supposed that elimination was completed, and when, accordingly, it has not usually been looked for. This may possibly help to account for some of the effects produced on tffe tissues. Some of these effects we proceed to note. On the mucous memhraiie it coagulates the albumen and corrugates the epithelium ; this it appears to do by absorbing water, and we may see the effect in the mouth. ALCOHOL. 101 In the stomach it produces a sensation of warmth or pain, according to the degree of dilution. It stimulates the mucous lining, and in small doses may thereby aid digestion, but in large quantities, or if not suf- ficiently diluted, it impairs that process, for it precipitates peptones and brings on congestion of the gastric mucous membrane. When this mem- brane is habitually subjected to such a congestive irritant the connective tissue between the glandules is increased and causes their disappearance, bringing about the chronic "catarrhal condition " of Dr. Wilson Fox. It diffuses easily into The IBlood. — Here it would seem the chemical changes are partially arrested. More fat accumulates, or at any rate becomes visible. Dr. B. W. Richardson says that the blood is deficient in oxygen when alcohol is present. This should diminish antiseptic resistance to disease. Dr. J. J. Ridge, who some time ago determined by experiment that alco- hol was injurious to growing cells, has lately made a more surprising an- nouncement. He says he has experimentally determined that alcohol, which in considerable quantity is admitted to be an antiseptic, is in very small proportions just the opposite, as he found minute quantities pro- mote the decomposition of both mineral and vegetable matter, bacteria flourishing and being propagated to a greater extent when a little alco- hol was added. As soon as the proportion of alcohol is less than one per cent, he found decomposition hastened instead of retarded by its presence. The heart and vessels receive the full force of the stimulus. At first the pulse is fuller and more frequent ; it is so far a stimulant according to the general notion, and this is confirmed by the sphygmograph. It quickens the systole and shortens the diastole or the period of repose, Parkes found that brandy or wine alike augmented the rapidity of the pulse about, thirteen per cent., at the same time increasing the force of the beat. The period of rest was shortened, so that the heart had more work and less repose. Now, such a stimulus as this would seem in one way to lessen the nutrition of the organ by an undue interference with its natural balance of exercise and rest ; for it is difficult to see how ex- cessive wear is to be compensated during diminished repair. The effect on the heart may be compared to that on the voluntary muscles, which alcohol certainly weakens, while it certainly interferes with their co-or- dinating power — doubtless through the nervous system. The arteries dilate more easily before the fiercer flow of the blood-stream as it is im- pelled by the excited heart, and the superficial vessels in their turn also di- late more fully, hence the familiar flushing of the skin. When this flush- ing becomes habitual the vessels become permanently dilated, and thus fix the mark of the evil habit upon the person in the turgescence of the capillaries and the altered condition of the skin, which gives to the individual the appearance of premature old age. Perhaps this yielding 102 THERAPEUTICS OF THE RESPIRATORY PASSAGES. of the vascular system may serve as a kind of safety-valve ; for other- wise the strong wave might rupture the vessels, or else, the force acting in the other direction, the heart might not be emptied by the contraction, and thus other inconveniences would arise. This would seem to indicate that when the arteries are rigid alcohol might be more dangerous, unless for some reason the heart did not react as usual under its influence. J^ervous System. — Perhaps the phenomena produced on the vascular system may be the indirect effects of the action on nervous tissue. Anstie and others have attributed them to the influence on the sympa- thetic, but others consider the vagus and the heart to be involved. On the cerebrum the first effect is exciting ; alcohol certainly increases the rapidity of the flow of ideas, but by no means the power of controlling or directing them. This faculty is, in fact, diminished ; close, concentrated attention is rendered difficult or impossible ; very soon, however, a nar- cotic or anaesthetic effect comes on, and then the rapidity of ideas or im- pressions is naturally lessened. Even when, as sometimes, the imagination seems to be stimulated, it becomes uncontrollable. As to the special senses, they scarcely seem to pass through the stage of excitement, but under quite small quantities their acuteness or their accuracy is lessened. From this deadening of the senses, as well as the muscular power, it would seem to interfere with the movements of nervous currents, and it has been conjectured that it may do this by entering into a temporary com- bination with nervous tissue. But can it do this ? and if so, would it be a nutrient or only a poison ? As to the first question we are in doubt. We know that considerable quantities have been found saturating, so to say, the brain, or bathing nervous tissue, but this certainly does not neces- sitate a combination, and out of the body the tissue may be steeped in the spirit, which hardens and preserves it but does not appear to combine with it. With regard to the second question, it can only be regarded as a nutrient if it combine with the tissue as a necessary ingredient, or as something assisting its formation or disintegration by the usual steps. If, by any combination it may be supposed to form, it hindered the usual constructive and destructive changes, and at the same time impaired or prevented its function, it would have no title for such reasons to be called nutrient, though it might fairly be termed poisonous. The Liver. — The degenerative changes produced on this organ are generally well known, but how much alcohol may be taken without setting them up we have no means of determining with any degree of certainty. Mespiratory System. — The muscles or nerves of respiration may be impaired or paralyzed, and death sometimes occurs in consequence. The carbonic acid and the watery vapor exhaled seems to be lessened, though different results have been observed in some of the experiments. Dr. E. Smith observed different effects with different kinds of spirits. It may be supposed that some variation might occur from the influence on diges- ALCOHOL. 103 tion or circulation, or from other circumstances. There is room, perhaps, for further investigation, but it seems pretty certain that if not much lessened the carbonic acid is certainly not usually increased. The bron- chial mucous membrane, and perhaps also the pulmonary tissue, must be injuriously affected by habitual excess of alcohol, and chronic bronchitis and lobar emphysema are among the penalties of heavy drinking. Cutaneous System. — It is often said that alcohol is a sudorific, and hot grog is a popular dose, but the effect of the hot water should not be over- looked. Dr. Edward Smith thought alcohol lessened the amount of per- spiration, but Weyrick found a large increase after all alcoholic beverages. No doubt the dilatation of the cutaneous vessels produced by alcohol tends to promote perspiration, but the effect is not such that it can be relied on as a diaphoretic ; indeed, when taken cold, it is much more likely to prove diuretic. As to the sudorific influence of hot grog, tea or any other hot beverage is equally efficacious and less likely to be injurious, while a dose of sweet spirits of nitre in hot water is a domestic diapho- retic of much greater value. Temperature. — The effect on temperature is less than might have been supposed from the vascular phenomena. Quite small doses do not affect the clinical thermometer. Experimenting on two healthy men, who were accustomed to take beer, and occasionally spirits, but who were strictly temperate, Parkes found neither a rise nor fall ; Mainzer ob- served a slight fall in one instance and none in another ; Obernier and Fokker also obtained no certain conclusions. But when larger doses are given there seems no doubt that the usual effect is to cause a fall. Binz, Ruge, Cuny-Bouvier, Richardson, Ringer, and Richards all seem to have met with this result. Lewis, Wood, and Reichert consider that the pro- duction and dissipation of heat are both increased, Parkes found a dif- ference in respect to the food, no effect being perceived when the alcohol was taken with a meal, but taken fasting a fall occurred. Ringer found in a boy, aged ten years, who had never in his life before tasted alcohol, a constant and decided reduction of temperature. We may, perhaps, then conclude that in health a moderate fall usually follows the dose of alcohol ; but no doubt this is much less, if at all perceptible in those ac- customed to its use. In old topers the temperature is unaffected even bv large quantities. Drs. Ringer and Richards once gave to an habitual drunkard twelve ounces of brandy in a single dose, which made him dead- drunk, but without the smallest reduction of the temperature. We come now to the therapeutic uses of alcohol. Twenty-five years ago it was prescribed by almost every house-surgeon, so freely as to seem almost routine practice, just as their predecessors, twenty-five years before them, had employed bleeding and depressants. At present a con- siderable reaction has occurred, and alcohol is much more cautiously pre- scribed. It is said to be stimukmt ; this term is indeed applied generally 104 THERAPEUTICS OF THE RESPIRATORY PASSAGES. to all intoxicating liquors, but we ought not to forget that it may just as properly be termed narcotic, for after the exhilarating influence it produces drowsiness and, in sufficient doses, coma. It has also been called anodyne and a^imsthetic, and undoubtedly it lessens the consciousness of pain by deadening the perceptive power. Does it promote nutrition if the amount given be within the limit which can be oxidized Avithin the sys- tem ? or does it, by hindering waste, merely cause an accumulation of useless effete material ? Opinions still differ on these points, but it seems clear that it can only be a nutrient indirectly, and to a very slight degree. Even so far as it is consumed, if it depress function, as it seems difficult to deny, would it not favor degeneration ? If so, that would surely counter- balance the assumed advantage of its liberating force. To check oxidation is not necessarily to promote nutrition ; to economize blood, or even tissue, may not be so desirable as to quicken their renewal. It has sometimes been given rather freely as an antipyretic, and we must admit that in the febrile state the effect is greater in this direction than in health. Binz and Bouvier produced septic fever in animals, and then reduced their temperature by alcohol. On the other hand, one of the men who was taking considerable doses in Dr. Parkes' experiments took cold, and his temperature rose in spite of the alcohol. Others have found that it cannot be relied upon to abate ordinary febrile excitement, though there are many records in which it has seemed to moderate septic fever. It would seem to act more powerfully on animals than on men, but perhaps this may be due to the influence of habit. We must conclude that a high temperature is not necessarily a contra-indication, though the pres- ence of arterial excitement and sthenic inflammation may be so regarded. Binz showed that it did not lower the temperature through the nervous system, so that the effect is probably due to its retarding metabolism. He gives it in order that it may be consumed, and so spare the tissues and supply animal heat. With such a view the amount administered surely ought not to exceed that which can thus be utilized, and yet it is too common for his followers to give much more. He says that small doses do not really stimulate, and compares them to small quantities of fuel laid upon a fire to prevent it going out. Exception might be taken to such comparisons, many of which have been introduced into discussions on this subject, but few, if any of which appear to me to have shed much light upon it. I have, therefore, in this chapter rigidly confined myself to a statement of some of the most important facts and the conclusions which seem to me to be fairly deduced from them. To obtain any con- siderable antipyretic effect it is necessary to employ large doses, so large as to be often dangerous, and therefore great caution is incumbent on all who use it for this purpose, and as the results are too slight in or- dinary pyrexia, it ought not to be resorted to unless other indications than fever are present. ALCOHOL. 105 As an illustration of its stimulant action, its effect in rousing the heart and circulation in syncope is familiar to all. It would probably have been much less familiar but for the fact that some form of wine or spirit is present in almost all households, and therefore in a case of faint- ing it is the most ready remedy. As an anaesthetic or anodyne it is sometimes resorted to in neuralgia and other painful affections, but the practice is dangerous whenever the pain is recurrent, inasmuch as it is likely to lead to a too frequent repetition, and so may induce habits of intemperance. This danger ought never to be forgotten in chronic dis- eases, especially as in them it is often administered in the shape of a beverage, and it is easy to understand that when it seems to afford relief it may be resorted to more frequently than at first intended, especially by those who may not be aware of the ease with which it becomes a snare. The more caution is required, inasmuch as, after all, we have more potent remedies of this kind which are not dangerous in this direction ; and if we had not, it would be better to endure the disease or to face death than to become the victim of intemperance. Among acute diseases, pneumonia has been largely treated with al- cohol. Indeed, this disease has been made the battle-ground between its advocates and opponents, just as it was in reference to bleeding. Now, however, it is generally admitted that simple pneumonia in healthy persons tends toward recovery, and therefore such a remedy should only be employed to meet certain conditions. As in all acute diseases with such a tendency, few would now resort to it during the early pro- gressive stage, but when only the results remain it is often employed with a view to restraining waste, or to being itself, as some still suppose, a substitute for food. In such cases it is generally combined with milk, or alternated with that and other aliments, and possibly much of its in- fluence may be due to its stimulating digestion, and facilitating the as- similation of the accompanying food. Wood, who is by no means averse to the use of alcohol, confines its use in acute pneumonia to cases " when so much consolidation has occurred as to render it doubtful whether the exuded matter can be removed," and then he thinks the demand for it may be " very great as a food and as an aider of digestion, and some- times as a stimulant." In phthisis, as a narcotic possessing some antipyretic action, it is sometimes given at night, but it should be combined with some form of food. Under its influence sometimes the patient sleeps better and the night-sweats diminish ; for this purpose but small doses are required, and perhaps they are chiefly useful in promoting digestion; and the same may be said as to very small doses given early in the morning in conjunction with aliment, such as the popular rum and milk. Whatever spirit be employed for this purpose, for others are just as efficient, and to many more pleasant than rum, the dose should only be enough to assist diges- 106 THERAPEUTICS OF THE RESPIEATORY PASSAGES. tion, and perhaps other aids to this process would be generally prefer- able. In chronic phthisis alcohol is sometimes prescribed at the same time as cod-liver oil, and by some under the impression that it will assist its digestion ; but from what has preceded it would appear that ether would be a more efficient adjunct. In the sleeplessness of old age a small dose at night often procures relief, and the night-cap, as this is called, is therefore popular ; but here again it should not be given without food, and ver}^ often nutriment alone will be equally, or even more effectual for the immediate purpose, and then, as every one will admit, should cer- tainly be preferred. The small dose of alcohol probably acts by stimu- lating the stomach, as well as by exciting the feeble circulation ; but in view of this latter action it is important that the arteries be sound. Where this is the case, stimulants of any kind may be given earlier in old age and feeble persons than in robust adults. The importance of giving food with the alcohol has several times been mentioned, and it is to be feared that much injury arises from the neglect of this precaution. Even in extreme prostration small quantities of milk and alcohol can be taken at frequent intervals, but unless strict injunctions be given to the attendants they are apt to separate the one from the other, and the result may be that while the patient gets the stimulus the due quantity of aliment is not taken. The wine or spirit is trusted to ; the heart responds for a time, but is not properly fed, and the consequences are necessarily disastrous. Patients who are strong enough to observe their regular meal-times should generally do so, as the stomach seems, from the force of habit, to work more easily in this way, and whatever stimulant be prescribed should be given with the food, unless urgent reasons exist for administering it at other times. Al- together, then, whether in acute or chronic disease, whenever stimulants are administered, it is an excellent rule to give them only in conjunction with some form of food. CHAPTER XY. DENUTEIENTS. Remedies which hasten destructive changes next demand attention. We have already seen that vpater and exercise may do this. Neverthe- less, they are indirectly promoters of construction unless taken in excess. It may further be said that some other agents more distinctly destructive may also be employed in such a manner as to become indirect nutrients — e.g., fasting, which arrests the supply jo^'O tern., and low diet, which restricts it, give time for the removal of waste, and perhaps at the same time arrest, or at least retard metabolism ; but when a new supply arrives its stimulus seems to provoke increased rapidity of construction, so that the loss is soon made up out of the fresh abundance. In the same way quickening excretion by evacuants, when carried far, causes waste; but a slight degree of the same process only stimulates to increased renewal. Further, the removal of the completely prepared nutrient fluid may act in a similar manner, e.g., sudden hemorrhage takes away the nutrient fluid ; but we see in accidents how rapidly loss of blood is made up for in liealthy persons, and so it often is in disease. That a moderate loss of blood may really stimulate to increased nutrition is a familiar fact to many farmers, who when they find their cattle slow to fatten will bleed them. It may be, then, that denutrients stimulate construction, but they are usually spoken of, in consequence of their more direct effects, as weakening, depressing, lowering, etc. For the present, then, we have to consider them under this aspect, whether they act by removing nutrient material or by quickening destructive metamorphoses, or both. One of the most important groups is Antiphlogistics, So named because they are employed in inflammation (avri, against, <^Aoyow, I inflame). This word, from the Latin inflammatio, itself derived from the verb inflammo, I set on fire, appears in almost the same form in all the languages of Latin origin. The German entzilndung has a similar meaning, which is also found in other Teutonic tongues. The idea of kindling or burning is also found in the words by which inflammation is 108 THERAPEUTICS OF THE RESPIRATORY PASSAGES. expressed in Hebrew, Sanscrit, Arabic, and perhaps other languages. Our word "fever," Latin febris, ivomfcrveo, I am hot, is also as widely distributed, for not only is it found in all the Latin languages, but the German fieber shows that it has spread to the Teutonic. The syno- nym, pyrexia, from the Greek Trup, fire, has a similar origin, and phleg. mon, (^Aeyo), and phlogosis, once in common use, expressed the same notion (<^Ao^, a flame). All these words have to do with the most strik- ing symptom of the process, and show that the preternatural heat or sensation of burning has in all ages attracted attention. Charaka divided remedies into those which increased or diminished internal fire, while Susruta divided them into those which increase the strength by evacuat- ing bad humors, and those which lower the exalted action of the humors. So extended, too, has been the idea of febrile action, that Hindu physi- cians say " that man is both born and dies in fevers (juvara) ; " while the Chinese do not seem to separate inflammation from fever, though they do distinguish several kinds of fever. The antiphlogistic diet and regimen has always implied a restriction of food and the imposition of rest. Everything supposed to increase heat has been banished, and the patient placed on the mildest farinaceous fluid food, and very little of it ; the beverages, also, have been simple diluents. At times such restrictions have been carried too far, and al- though judicious physicians have generally been found to inculcate the necessity of tempering the remedies to the patient, and even to the cause of the disease, there has very often been a danger of too strict adherence to the notion of combating inflammation by lowering measures. Of this a striking example was afforded when French physicians not only imposed their absolute diet, that is to say, denied their patients every- thing but pure water, but also practised bleeding and administered evacu- ants. But England was not much behind, for although there were always opponents to extremes of this kind, the general practice of the last generation was not inaptly described by the good and learned Dr. John Lettsom, in his rhyming pun on his own name. " When patients do to me apply, I physics [= purges], bleeds, and sweats 'em ; If after that they choose to die, What's thondon Pharmacopoeia, and is therefore three times the strength of our present British Pharmacopoeia. The latter authority gives the dose as five to fifteen minims, but I have already said this is much, too high. For general use T would recommend 186 THERAPEUTICS OF THE RESPIRATORY PASSAGES. only one to three as safer and equally efficient. Only occasionally need five be given at a dose. The United States Pharniacopceia tincture would be efficient in from one-fourth of a minim to one minim. The extract is not nearly so uniform in power. The pastilles I use contain one-half minim of tincture in each. The alkaloid, aconitia, is so powerful when pure that it is only adapted for external use. CHAPTER XYII. NEUROTICS. We pass now to remedies the chief value of which depends on their influence over the nervous system. The most striking group of these is that to which the term narcotics has been applied. In its widest sense this word may be used concerning- anything that causes sleep or stupor. It is perhaps as well restricted to those which positively stupefy, and then other words may be used to express other qualities which may be more or less possessed by narcotics. Thus we have soporifics and hypnotics which induce sleep ; sedatives which reduce excitement, and anodynes which relieve pain. Acro-narcotics have sometimes been grouped sepa- rately, cardiac and vascular sedatives and depresso-motors are terms which explain themselves, and sometimes neurotics used to produce a particular condition are named accordingly, as mydriatics, which dilate the pupils, and myotics, which contract them, and many other groups. A true sedative ought not to produce a previous stage of excitement, but the term is also loosely employed with reference to both soporific and anodyne qualities. KARCOTICS. Narcotics first cause excitement and then stupefy, just as we have seen alcohol does, but the period of excitement is shorter. They are, however, distinctly excitants, that is during the early stage of their op- eration, and they are therefore sometimes called stimulants ; indeed, we sometimes employ them for this very quality. The late Dr. Anstie held that the relief of pain was due to this stimulant action, and that in neu- ralgia stimulant not narcotic doses would suffice. So in prostration from fever and other acute diseases the stimulating influence of small doses of opium has sometimes been sought, and I think that the same effect may be obtained from other narcotics. We use narcotics for various pur- poses : first of all, to produce sleep or for their hypnotic quality; then to abate pain, for their anodyne influence, or to overcome spasm, when they become anti-spasmodics ; then to restrain secretion and sometimes hemorrhage, when they are astringents, or on the other hand to promote 188 THERAPEUTICS OF THE RESPIRATORY PASSAGES. secretion, as in the case of some sudorfics. Further, they are used to con- trol irritation and inflammation, when they may be called antiphlogistics ; and lastly, as we have said, they are often valuable stimulants. In refer- ence to respiration, some of the narcotics greatly retard it, and they are apt to interfere with expectoration and augment pulmonary congestion. Others, however, stimulate the respiratiory centre, instead of depressing it, and so quicken the breathing. The effect of these remedies varies greatly, according to the age, the idiosyncrasy and the habits of the pa- tient. The last point is of the highest importance, inasmuch as persons may so accustom themselves to the use of narcotics that ordinary doses take no effect. Opium. — Opium is the type of narcotics, and by far the most impor- tant of the class on account of the great range of its action. It has, in- deed, often been regarded as the most important of all medicines, and spoken of as " God's great gift to man." The effect of a single small dose is usually mild excitement together with a willingness for quietude and a tendency to dose, or to a dreamy state of semi-sleep, but with an effort tills gives way to a readiness to work. Movement is easy, fatigue is not felt, but in repose drowsiness comes on. The ideas flow fast, chas- ing each other in rapid succession, but are not so easily sustained. Pain, if present, is numbed or even subdued. Secretion is generally lessened, except that of the skin. Hence there is dryness of the mouth, nose, and fauces, no doubt of the entire respiratory mucous membrane, though later a secretion, but more viscid than usual, sets in. Sleep, when obtained, is often disturbed and dreamy, and the patient wakes up unrested, perhaps Avith nausea or at least a want of appetite, and a disposition to headache which sometimes becomes distressing. With a larger medicinal dose the excitement is more marked, but of briefer duration. At first the pulse and respiration are both quickened, but they soon beqpme slower, and the first stage gives way to the second, drowsiness is succeeded by sleep more or less profound, and on waking the uncomfortable condition is often still more marked. When a toxic dose is taken the preliminary excitement is scarcely perceived, but the patient is plunged rapidly into a comatose state, and lies unconscious, re- sembling a person intoxicated by alcohol or one suffering from congestion of the brain. The respiration is slow, deep, and stertorous, the pulse full and slow, though perhaps strong for a time — the pupils are contracted ; if roused the patient soon relapses into his unconscious state. At this stage death does not often take place, but unless relief be afforded, pros- tration soon comes on, the coma becomes complete, so that the patient cannot be roused, and the pupils are closely contracted, though on the approach of death they may dilate widely. The respiratory effects are feeble, slow, and imperfect, the pauses between them long, and at length they stop altogether, death occurring through failure of respiration ; the NEUROTICS. 189 pulse is no longer full and slow, but has become feeble and rapid, and it gets weaker and quicker ; the skin is cold and covered with clammy sweat ; the countenance cyanosed. Even yet it is possible for the patient to be saved, but recovery will be gradual. Sometimes toxic symptoms are set up by moderate doses, and occasionally after small medicinal doses in consequence of the idiosyncrasy of the individual, serious symptoms occur ; thus, within three minutes after a hypodermic injection of morphia profound coma has appeared. In other cases intense depression has fol- lowed a moderate dose ; in others vomiting takes the place of sleep or follows it, and very often severe dull headache with giddiness and a general aggravation of tlie unpleasant symptoms previously mentioned are produced. When these symptoms are not very distressing rest in the recumbent posture renders them bearable, but when they are severe antidotes should be administered. Cases have been recorded in which a single dose has produced struggling for breath or syncope and even death. Other cases have occurred in which opium has set up delirium or convulsions. A more frequent source of anxiety is very prolonged sleep. A case has been communicated to me in which after a hypoder- mic injection of morphia the patient slept on soundly for about thirty hours. More rarely there is either delirium or convulsion. Death mostly occurs from failure of respiration. This is due to a direct effect on the respiratory centre in the medulla, for in animals whose pneumogastrics had been cut Gscheidlen found the respiration was as much affected as when this had not been done. After death the bronchi present a highly congested appearance, and this congestion extends through the bronchial walls, the inner fibrous coat being specially af- fected. On the circulation opium produces a primary but transient ac- celeration of the pulse, which is followed by decrease in the rate with increase of its force and fulness, and to this succeeds either a gradual return to the natural condition or else as the patient loses strength the pulse again rises in rapidity. The slow full pulse of the second stage of poisoning appears to be due to the effect upon the inhibitory cardiac nerves, to which we may also ascribe the increase of the arterial pressure, for Gscheidlen found that morphia did not reduce the pulse after di- vision of the vagi and that if they were cut during the second stage of poisoning the operation produced an extraordinary rise in the rate of the pulse. Other experiments seem to show that the peripheral ends of the vagi are stimulated, as are also the inhibitory cerebral centres. The quick, feeble pulse of the third stage seems to be due to paralysis of the pe- ripheral vagi, for at that stage stimulation of the peripheral end of the divided nerve does not affect the heart. It is unnecessary for our present purpose to trace the physiological effect of opium in all the organs, nor need we pass in review the numer- ous uses to which it has been put in general therapeutics, but presuming 100 THERAPEUTICS OF THE RESPIRATORY PASSAGES. these to be familiar to the reader we shall content ourselves with men- tioning those points in relation to the respiratory passages which we are desirous of bringing before them.' Opium will often arrest an ordinary catarrh, so will a dose of morphia_ Christison believed that it would cut short tonsillitis in the early stage, and certainly many a sore throat in persons subject to quinsy has thus been arrested. In a common cold the coryza is often stopped by a single dose, and so it is in a feverish catarrh or influenza, though in the latter case the symptoms are apt to return as the influence of the medicine passes away, but a second dose will again hold them in check. If prop- erly combined with other remedies this will hasten recovery, or rather re- duce the length of the attack. There is another form of coryza which is also checked and very often completely stopped by a dose of opium or morphia, viz., that produced by iodide of potassium. Moreover, I have often witnessed the immediate relief of all the symptoms of iodism by a single dose of morphia. Dover's powder as a diaphoretic is a favorite form to employ in catarrhal cases and is certainly one of the most effi- cient. It is, however, rather bulky, and for a full dose a single pill is not sufficient ; generally I prefer morphia. Some add quinine to their opiate, but it is useless, unless a large dose be given, and a few small doses after the narcotic has done its work may be given with more advantage. Opiates are often useful in asthma. In some cases a hypodermic in- jection of morphia will at once cut short a most painful paroxysm ; on the other hand there are cases in which a single dose will bring on an attack. In the paroxysms of dyspnoea produced by emphysema consid- erable circumspection should be exercised in prescribing opiates, though they often afford great relief. In other neuroses of the respiratory or- gans opium may claim a place. In pertussis it is often used, and Cop- land thought that tinct. camph. comp. was the best form in which to prescribe it. In bronchitis opiates allay irritation and restrain secretion, hence they enter into so many cough medicines. It is often taught that they are contra-indicated in severe bronchial affections, and much care must certainlv be taken in prescribing them for old or weakly patients when the expectoration is copious and duskiness of the skin shows that ox- idation is deficient. In such a condition to produce narcosis is certainly dano-erous ; expectoration accumulates during the profound sleep and the patient may be, so to say, drowned in his own bronchial secretion . Nev- ' In this chapter the history is passed by in consequence of its extent. There lies be- fore me a list of upward of two hundred separate treatises on opium, to say nothing of morphia and other neurotics. It is impossible to analyze such a literature in the space at my disposal, and therefore scarcely any references will be given. It is hoped that the reader will be satisfied to have the subject treated as it presents itself from my own experience. NEUROTICS. 191 ertheless, even with rather free expectoration, with a violent cough and only slight rales and no sign of deficient oxidation, opiates may relieve the cough, and properly given they tend to diminish secretion. To nar- cotize by a large dose is one thing ; to give a few small doses, watching their effect, is another thing ; besides we can combine them with ammo- nium or other stimulants. It is the depressant influence on the respi- ratory centre which is to be feared, and to counteract this we must administer respiratory stimulants. The doses, too, must be carefully regu- lated if we would obtain the benefits of opium without its dangers. Even in old age and in infancy it may be made to yield some benefit if em- ployed with skill and caution. I have given it to a lady of eighty-four in severe bronchitis, but with alternate doses of ammonia, atropia, and strychnia, and a friend over ninety years always took it for every cold he caught. Hypodermic injection is not desirable in these cases, since the full effect of the dose is produced immediately. What is wanted is rather to obtain the effect of repeated minute doses, so as to stimulate as well as to compose, and the distress of the patient needs something frequently. This is one of the great uses of ether ; a few drops can be taken often and usually relieves the breathing. It is sometimes feared to give opium in the dry, hacking cough of pulmonary disease, but I find it often useful. AVhen these distressing coughs depend on morbid conditions of the throat, that part should be attended to ; even then morphia lozenges may be useful, but other more efficient topical remedies ought to be employed, such as vapors, sprays, paintings, and other applications. The larynx should be inspected and if necessary laryngoscopal medication brought into play. When a dia- phoretic is needed Dover's powder is suitable, but when the reverse is rather required atropia may be combined with morphia. This last combi- nation is often of the utmost value, and by a variation in the proportions we may accomolish very different results ; thus we may relieve the cough, perhaps the expectoration, and almost certainly the perspiration without at all depressing the respiratory centre. So, too, in bronchitis the secre- tion may be restrained and with it the cough when the respiration is not shallow nor the face blue, and in this case the relief thus produced may be permanent. In paroxysmal dyspnoea due to cardiac disease and preventing sleep morphia given hypodermically is often valuable. It is strongly recom- mended in such cases by Dr. Clifford Allbutt, who also employed it to assuage the pain of angina pectoris or that caused by intra-thoracic tu- mors. Of course cardiac dyspnoea arising from dropsy, etc., will not be relieved by this treatment, which is only adapted for paroxysmal, not permanent dyspnoea. It may be added that it need not be given every night, but once, twice, or thrice a week, according to the urgency of the dyspnoea. 192 THERAPEUTICS OF THE RESPIRATORY PASSAGES. In chronic plithisis it is difficult to exaggerate the relief that may be afforded by this remedy or to summarize the indications for its use. Sometimes the stimulant effect of opiates is a disadvantage. Graves tauo-ht us how this may be restrained by means of antimony, and the combination he suggested certainly enables us to extend the use of opium, tliough the discovery of other hypnotics has lessened the necessity for his combination. Aconite may be employed with a view of preventing the stimulant action, though it materially assists some of the other prop- erties. Frequently during a course of aconite I administer an occasional dose of morphia or opium, and find that it not only accomplishes the pur- pose for which it is given but renders the aconite more efficacious, while the latter so reacts that a smaller dose of the opiate suffices. We may also employ the bromides in conjunction with opium in such a way as to modify its action. Not that the two medicines should be taken together but administered at suitable intervals. The headache, sickness, and other disagreeable symptoms which are apt to follow a full opiate may be greatlv restrained, if not prevented, by bromide. Some persons for this purpose give a full dose with the opium ; I prefer a smaller quantity — a couple of moderate doses, preceding the opium, so that the patient may be under the influence of the bromide. When it is taken it will often prevent or shorten the stag-e of excitement, a good night's rest is thus secured, and the subsequent headache, etc., prevented. Should it not succeed in doing this, another small dose can then be taken. The hvpnotic effect of the opium is certainly increased by the bromide. My attention was first drawn to these reactions of the remedies on each other by observing the effects of morphia on patients who were taking a course of bromide. Chloral liydrate may also be made to modify the ef- fects of opium, e.g., a person under the influence of opium in the stage of excitement will drop off to sleep at once after a very small dose of chloral, and so several hours of repose may be gained. Very often, when persons accustomed to opiates were known to be kept awake by them for many hours together, have I cut short tliis dis'tressing sleepless- ness by five to ten grains of chloral hydrate. The action of belladonna in conjunction with opium is so important that it will be treated of further on, after treating of belladonna. Children bear opium very badly, so do the very old. A single drop of laudanum has proved fatal to a young child ; it should, therefore, only be given to children in exceptional cases and with the greatest caution, only in the liquid form. Morphia salts are distinguished therapeutically by what may be termed negative properties, as compared with opium, thus they are less constipating, less sudorific, less stimulating. Moreover, they produce less discomfort afterward. Of course we are speaking of ordinary doses, since naturally, weight for weight, the alkaloid is much more powejful NEUROTICS. 193 than the crude drug. The morphia salts do constipate, they are diapho- retic, and a stimulant stage usually precedes their narcotic action. These points may be observed after hypodermic injections, but in this case the effect on the alimentary canal may be less marked ; still, generally it may be observed. The neutral tartrate of morphia is sufficiently soluble in distilled water, and keeps sufficiently well to afford us a non-irritating and non-acid solution (introduced by Messrs. T. & A. Smith, of Edinburgh). Oodeia seems to be only a feeble hypnotic, but it is sometimes useful, when morphia disagrees, to allay cough. With regard to the other opium alkaloids the statements made are very conflicting. Belladonna and Atropia produce effects quite contrary to those caused by opium and morphia, nevertheless they are often used in combination, and sometimes are said to reinforce each other. So we may with advantage take them up here. Belladonna has, more or less, been known as a counter-poison to opium for some three centuries, but special attention has only been drawn to them since 18G2, when Dr. W. J. Norris wrote his paper in t\\e American Journal of the Medical Scie7ices. Dr. Hughes Bennett {^Brit. 3Ied. -T., 1874) experimented carefully with 'atropia and morphia, and concluded that the one is antagonistic to the other within a limited area, since which time these conclusions have been confirmed and frequently acted upon. Modern experience with the alkaloid shows the accuracy of earlier observations with the crude drugs, and atropia is undoubtedly a valuable counter-poison to morphia or opium, and, moreover, may be used, as alread\' stated, to prevent some of the disagreeable symptoms produced by opium. How, then, does it act ? By its effect on the respiratory centre of the medulla, for belladonna stimu- lates this important point while, as we have seen, opium depresses it. In this respect, therefore, the one is the physiological antagonist of the other. It is often urged that the antagonism is not complete, that in some respects the one reinforces the other. This may be admitted, but does not alter the fact that they largely oppose each other, and just as we understand more fully the exact area of their antagonism, so much the more certainly shall we be able to avail ourselves of this property. No one will now dispute that animals poisoned by morphia have been saved from death by the administration of atropia, and several patients have recovered from accidental opium poisoning under the f r-ee use of hy- podermic injections of atropia. We say the free use, but let it not be given recklessly, every dose should be watched. All depends on the res- piration ; a single large dose has been recommended, but this plan is not prudent ; it is easy to repeat a small one if necessary. It is true that a poisonous dose has been given at once and the patient has recovered from both poisons, but it would be safer to give less and repeat accord- ing to the effect ; we may thus keep always on the safe side. When the respiration beg-ins to fail, an injection of a fortieth or a twentieth of a 13 194 THERAPEUTICS OF THE KESPIRATORY PASSAGES. grain of atropia is enough ^^ro ton. if the function responds, if hot it can be repeated in a quarter of an hour. So, if it acts well but a relapse comes on another dose can be given. When the respiration has fallen to four, it may be doubled at once by an injection, which need not be re- peated until the breathing again grows less frequent, or unless there has been no improvement for a long period. In this cautious way a series of relapses may be met, and so tlie patient tided over the time while the morphia is being eliminated. Dr. Fothergill injected a grain of atropia at once, in a case of accidental poisoning — this was certainly not without risk. He would advise generally, of course after emptying the stomach, one-fourth or one-third of a grain " before respiration is gravely affected." He warns us that there is a difference of susceptibility in patients, which is true as far as doses of a seventy-fifth to a twenty-fifth are concerned, but in massive quantities this can scarcely count, and if it could, a patient is quite as likely to be unusually susceptible as the reverse. Whenever we come to doses that might prove fatal or dangerous, difference in the degree of susceptibility is inappreciable. It is rather the amount of opium still in the system that accounts for the tolerance of the counter- poison. The cardiac and vaso-motor actions of belladonna are no doubt of use in opium narcosis, but it is the respiratory stimulus on which we must depend. But we have anticipated, and may as well go back to the general effects of belladonna. In moderate doses, dryness of the mouth and throat with perhaps some disorder of the vision and dilated pupils may be produced. A larger quantity — a physiological dose will very decidedly disorder the vision and perhaps produce diplopia, fully dilate the pupils, and cause not only intense dryness in the throat, but distinct redness of the fauces; the pulse rises rather rapidly to 120 or more, and sometimes a scarlet flush comes over the face and neck and may travel over the whole body ; it does not present the punctuations of scarlet fever and is not followed by desqua- mation, except very rarely. It is sometimes said that the pulse falls be- fore the rise, if so, the fall must be very transient and is certainly not generally detectable; the medicine seems rather to produce a febrile state with very quick pulse, the beat of the heart being felt, and that un- pleasantly, the temples throbbing, and the hot dry skin and dry mouth and throat being very disagreeable. Often the intellect is not affected until quite late even by poisonous quantities, but confusion and giddi- ness are common symptoms, as are extreme restlessness and a staggering gait. Neither is drowsiness produced, but rather the reverse, although, of course, it may happen that a patient falls asleep because the poison has counteracted a cause of previous wakefulness. Later, delirium comes on, and this is often furious ; sometimes, too, convulsions may ensue ; when the delirium is not furious it is always wakeful — the patient sees visions and dreams dreams, in which he is entirely absorbed, so that his NEUROTICS. 195 attention cannot be drawn to the things around him ; the delirium may persist for a long time, but in the end it subsides into stupor, just as the convulsions when present pass into paralysis. If these late symptoms appear early, it may generally be concluded that a very large quantity of the poison has been taken. We do not see cyanosis or other sign of respiratory failure except at the very last, then no doubt the heart and respiration both usually fail. But we must consider these and some other systems separately. Circulatory System. — On the heart itself atropia acts as a direct de- pressant poison, but a large quantity must be present for such an effect to be apparent. On the cardiac-accelerator centres, or possibly on the nerves themselves, it acts as a stimulant, and unless in fatal doses it fails to destroy the excitability of these nerves. The ends of the vagus may be stimulated for a moment, but are quickly depressed, the pulse rapidly rising, and its rate cannot be reduced by faradization of the vagus. The vaso-motor system is also stimulated and the blood-pressure raised — at any rate so long as the doses are not excessive. Very large quantities depress the ganglia and even the cardiac muscle and the ventricle is found in diastole post-mortem. Respiratory System. — Belladonna increases the number and depth of the respiration and this it does by directly stimulating the centre in the medulla, for the acceleration takes place even though the vagi have been previously divided. Loss of power in the respiratory nerves may occur at the close, and the patient may die from asphyxia ; but this is probably not from failure of the centre, though some have conjectured that such failure occurs. It may be as well to mention that coincidentally with the stimulation of the centre there is perhaps depression of the bronchial ends of the vagus, lessening the tension of the muscular coat of the tubes and so facilitating the air-current, while at the same time there is depres- sion of the afferent branches of the vagus which tends to relieve cougli and dyspnoea by abating sensibility and reflex action. Nervous System. — Belladonna or its alkaloid is an excitant, a delir- iant, but not a hypnotic ; so, as to the brain, it opposes opium. True it sometimes is given to procure sleep, but it can only do so indirectly ; therefore, though it has been called a narcotic, and though coma comes on at the end in cases of poisoning, it scarcely deserves the name. In fact, in medicinal doses, it may be employed to remove or prevent the effects on the brain of morphia. By a careful graduation of the doses we may precisely antagonize the cerebral action of one of these medi- cines by the other. Dr. Fraser's experiments show that the action on the spinal centre is stimulant, although at first there is paralysis, because tlie function of the motor nerves is suspended. Lemattre, Meuriot, Be- zold, and Bloebaum have shown that in large doses atropia can suspend tlie excitability of the efferent or motor nerve fibres. Still the dose re- IDG THERAPEUTICS OF THE RESPIRATORY PASSAGES. quired to produce total suspension is so large that it may cause death before excitability is entirely lost. Both the nerve-trunk and the pe- ripheral intra-muscular terminations are affected, and no stage of pre- liminary excitement has ever been observed to precede the depression. This decided influence over the spinal nerves is important vpith regard to the therapeutical application of the remedy. 3Iuscular System. — The voluntary muscles appear to be unaffected and after death their contractility is unimpaired. On non-striated muscular fibre it is believed to exercise a paralyzing influence, to which is often re- ferred its effect on the intestine. It may, however, be doubted whether this is not rather due to depression of the splanchnics permitting increased peristalsis, and to increase secretion. It is also believed by many to act directly on the unstriped muscular fibres surrounding the arterioles, and perhaps also in other situations, as, e.g., in the bladder. Glandular System. — The secretion of the salivary and mucous glands is arrested in a most remarkable way by belladonna, which also suspends the secretion of the skin. As first shown by Schiff, section of the chorda tyinpani arrests the secretion of the submaxillary gland, after which gal- vanization of the peripheral end produces an increased flow of saliva. Keuchel found that when atropia was administered to an animal before cutting the chorda-tympani galvanization of the peripheral end was un- able to excite secretion, thus showing that the end of the nerve was par- alyzed by the poison. Belladonna checks the secretion of milk, and this property is occasionally taken advantage of in therapeutics. In small doses it is also diuretic, though there is a good deal of variation in this respect. Dr. J. Harley estimated that the water of the urine was doubled in amount, and his experiments indicate an increase in the solid constitu- ents, particularly phosphates and sulphates. After poisonous doses the secretion, though it may be increased at first, soon diminishes and event- ually may be suppressed. Meuriot found that the secretion rises and falls with the arterial pressure. Perhaps the diuretic effect of small doses may be produced by raising the tension in the glomeruli of the Malpig- hian bodies. Temperature. — Moderate doses produce a rise, toxic doses a fall ; probably these changes correspond with the rise and fall in the blood- pressure. No doubt the increased metabolism tends to increase the pro- duction of heat. Tlie Eye. — Belladonna produces characteristic effects on this organ. Applied locally or given internally it dilates the pupil. Locally it par- alyzes the peripheral ends of the ocular motor nerves, and perhaps also stimulates those of the sympathetic. When given internally it is carried in the blood to the eye, and there apparently acts in the same manner as if applied locally. Atropia is almost entirely eliminated by the kidney. It passes into NEUROTICS. 197 the urine quickly, and its effects therefore begin to decrease early. The production of a rash now and then suggests that possibly a portion may escape by the skin, but we have no proof that it does so. The urine of an atropinized animal dilates the pupil of another when applied locally, and there is little doubt that as a rule all medicinal doses pass out in the urine. Perhaps this accounts for some of the symptoms on the bladder which have been observed. Therapeutically belladonna or atropine has been employed (a) to re- lieve pain, (b) to relax spasm, (c) to stimulate the heart and respiration, (d) to arrest secretion. a. To relieve pain it is so vastly inferior to opium that we may say it is almost useless, though it has often been tried, and some still retain faith in its asserted anodyne qualities. We are speaking now of its in- ternal use. There is a good deal of evidence in favor of its local ap- plication. Trousseau administered in neuralgia one-fifth of a grain every hour until giddiness came on, and then lessened the dose, but kept up the medication for three days. Anstie, Mr. Ch. Hunter, and Bartholow say that when it does act in relieving pain the effect is more permanent than that of morphia. But all advocates of its use lament its uncertainty, which Mr. C Hunter finds very perplexing. It is the local application that is efficacious in this direction. No doubt internally and hypoder- mically in large doses it may affect the afferent nerves and so tend to assuage pain, while it may also modify the circulation in the part, and thus contribute to the relief of pain. This is why hypodermic injections for the relief of pain should be made as near as possible to the suffering point. But after all opium is the great anodyne and belladonna only exceptionally or indirectly useful for the purpose. b. As an antispasmodic belladonna is more effectual, and this to some extent accounts for the reputation it acquired as an anodyne. When colic, cramp, and other spasmodic affections are relieved, of course, the pain is removed. In spasm of the voluntary muscles produced by injury to a nerve atropine is effectual provided it be injected directly into the affected muscle, as practised by Dr. Weir Mitchell ; and then it doubt- less acts by paralyzing the end organs of the nerves. In this way, too, it may relieve rheumatic spasms. By the mouth it is ineffectual for these purposes, probably because we cannot administer large enough doses to enable a sufficient amount to circulate in the part. In the in- voluntary muscles it seems to be more powerful, but even here, when possible, the local use is the most effectual, but when we cannot avail ourselves of this, we may administer it by the mouth. The action on non-striated muscular fibres accounts for its repute in colic, laryn- gismus stridulus, asthma, pertussis, some forms of constipation, spasm of the sphincter, and, indeed, a number of spasmodic affections, in which it has been more or less successfully employed. 198 THERAPEUTICS OF THE RESPIRATORY PASSAGES. c. As a respiratory and cardiac stimulant, belladonna is of much more importance. In full therapeutical doses atropine increases the frequency and force of the pulse, raises the temperature, and otherwise acts so as to produce a febrile condition, while, as we have already shown, it stimulates respiration. It may be employed simply as a cardiac stim- ulus. Graves recognized its value in typhus fever ; it has often been em- ployed in scarlet fever, erysipelas, etc. It has been used to rouse the heart in the collapse of cholera. Professor Schafer advises a dose to be administered before the administration of chloroform as a preventive of cardiac failure. But we should remember that later on large doses ex- haust the irritability of the cardiac ganglia. It is, then, as a respiratory stimulus that it is most valuable, acting directly on the centre. Its greatest use is when respiration is failing-, as, for instance, in opium-poi- soning. The stimulating effect on the respiratory centre may be com- pared to that of ammonia, but we must remember that the latter promotes bronchial secretion, quite an opposite effect to that of belladonna. The two, however, may often be given with advantage at the same time ; thus, in bronchitis, when respiration is failing and the pulse feeble, even though rapid, with deficient oxidation, we may often tide over the danger by persistently stimulating the centre. Our predecessors relied on car- bonate of ammonia, calling it a stimulating expectorant. We may give it just as they did, but reinforce it by a dose of atropine whenever its effect seems insufficient. Dr. Fraser found atropine at once restored the respiration in poisoning by calabar bean, and the antagonism to opium in this respect is well established. Besides the stimulating effect on the centre, there is a depressant influence on the periphery, which is doubtless of importance when the remedy is used in I'espiratory diseases ; thus the depression of the afferent branches of the vagus in the bronchi would diminish reflex action as well as sensibility, and so tend to relieve cough and dyspnoea, while the depression of the bronchial termini of the vagus would reduce the tension of the muscular coat and so facilitate the air-current. d. Atropia paralyzes the extreme branches of the chorda tympani ; possibly, also, it acts on the gland-cells and also on a centre for sweat, if such a centre exist. We find the secretion of the mammary, sudoriparous, and salivary glands are all diminished or suspended under its influence. It will arrest excessive salivation from almost any cause ; thus it will sus- pend mercurial ptyalism, and it will neutralize the effect of pilocarpine. It will check local sweats when used locally, and administered by the stomach or h3^podermically it will control general sweats, even those produced by exercise or the Turkish bath. In the colliquative sweats of l^hthisis, Dr. Costa stated (Phil. 3fed. Times) in 1871 that a seventy- fifth of a grain at bedtime would prove an efficient remedy, and his ob- servation has since been abundantly confirmed. NEUROTICS. 199 In diseases of the respiratory passages the uses of belladonna are numerous and important ; in inflammation or congestion of the mucous lining attended with abundant secretion the indication for its use is dis- tinct. Whether the nose, the fauces, the larynx, or bronchi be affected chiefly, a few doses will restore the normal circulation, and restrain the excessive secretion. In influenza or in catarrhal fever a large portion of the respiratory mucous tract is involved, and the general depression is often very marked ; here, then, we have indications for the use of bella- donna, which it is to be feared are often overlooked. It will relieve the intense depression by restoring the circulation, while it acts favorably on the inflamed membrane, in the stage, that is, of secretion: when the mem- brane is dry it will not be appropriate. When catarrh affects the nose only, or the nose and fauces, or perhaps the conjunctivas, belladonna should be useful, for it dries the Schneiderian membrane and conjunctivne, as well as the mouth, the fauces, and tonsils. In laryngeal catarrh, it is not so useful, perhaps, because here secretion is not so abundant, and vet in some cases of functional aphonia it exercises a favorable influence. In a couple of hours after a full dose the sensation of dryness passes away ; a viscid secretion now appears and renders the mouth and throat clammy, while the tongue is covered with a white fur. If the secretion should be still too abundant, the dose may be repeated. It will be ob- served that in these cases, when not too severe, a single dose may suffice, but many prefer to give minute doses, say a drop or two of tinct. belladonnas every hour until the patient is atropinized. When this plan is adopted it is desirable that the first dose or two should be larger than the succeeding ones. Here I would also remark that the indications from the state of the membrane point also to opium, wliich is an invalu- able remedy in these cases, and may be advantageously combined with atropine, which reinforces the effect on the membrane, while it counter- acts the depressing influence on the centre, and the opium in its turn frequently prevents the drying action of the belladonna on the skin and even secures a gentle perspiration. The modifying influence of one drug- over another may often be secured in this way. A further example is afforded by aconite, which may be given at the same time as belladonna, whenever there is much feverishness ; the aconite allays the fever, re- strains or prevents the stimulating effects of the atropine on the circula- tion, and promotes perspiration, while the atropia may be thus compelled, as it were, to expend its energies on the mucous membrane. In asthma belladonna relieves both cough and dyspnoea, as it does also the paroxysms of dyspnoea which occur in emphysema, but for these purposes full doses have to be given ; Hyde Salter found this and gave ten minims of tinct. belladonnae every two or three hours until a distinct effect was produced, and if the patient prove insusceptible still larger doses may be required, e.g., half a drachm as a single dose to arrest or 200 THERAPEUTICS OF THE KESPIRATOEY PASSAGES. avert a paroxysm. As soon as distinct symptoms are produced the dose may be diminished, and if the paroxysms usually last long it is better to give divided doses. When a full dose is needed, I prefer the hypodermic method. Possibly some of the larger doses that have been required "were in consequence of the tincture not being good ; of course the alkaloid is more certain, but a well-prepared tincture is also efficient, or the succus may be preferred. The remedy is only useful where the symptoms indi- cate the necessity of its effects. Thus a moist skin, abundant expecto- ration, and quiet pulse are in its favor, but feverishness, with scanty ex- pectoration, contra-indicate it. Fumigation by belladonna leaves dipped in a solution of nitre and dried, is sometimes preferred ; these prepared leaves are burned in a close room and the patient breathes the fumes. Trousseau used cigarettes made of the leaves of belladonna, hyoscyamus, and stramonium moistened with a solution of opium. When the par- oxysms of asthma come on pretty regularly in the morning a dose of atropia taken at bedtime will sometimes prevent the expected attack. In laryngismus, in pertussis, and in any neurosis of the respiratory system, we may be glad to avail ourselves of the properties of bella- donna. Its antispasmodic effect is here again to be considered, and as in asthma full doses are required, that is to say, to obtain good results, we must produce the physiological effects, though as soon as they are manifested the dose should be lessened. Children are more insusceptible to the action than adults, so that as much as ten minims of the tincture may have to be given every hour to a child of one or two years old, and even that may not dilate the pupil. The cases in which it is most effect- ual are those in which the bronchial secretion is considerable. It is dis- favored by some when bronchitis is present, but this is probably because it has been given during the febrile stage ; it is most effectual when pyrexia has completely subsided, about the third week, when it will be found to exercise considerable influence over the paroxysms. It is true that their violence should be abating about this period, but with every allowance for that it must be admitted that belladonna exercises a favorable influ- ence, and so it will at an earlier date when the cough is even more con- vulsive, provided the bronchial secretion be free and the fever not con- siderable, or be restrained by other remedies given concurrently. In diphtheria belladonna may be administered, either with a view of supporting the respiration or of restraining exudation. As it suspends secretion in the fauces, it has been assumed that if given in time it may prevent the formation of the false membranes. As diphtheria is an ex- ceedingly depressing disease, it may be safely employed in the hope that it may do this, as if not, its influence will be favorable in supporting the circulation. At a late stage it may be used to stimulate the respiratory centre, and can be given hypodermically when ammonia cannot be taken. In the night sweats of phthisis atropia is almost certain to maintain NEUROTICS. 201 its reputation. It seldom fails to arrest this distressing symptom, and the dose required for this purpose is usually so small that no inconven- ience is to be apprehended. Moreover, it does not require to be long continued. One small dose at bedtime will often suspend the sweats for several nights. Sometimes it requires to be given for two or three nights in succession, and then no more may be needed for some time. The y-|"„ grain will often suffice, sometimes even less, but at others -^j or -g^y may be required. Belladonna with Opium. — We have seen that in some instances opium and belladonna neutralize each other, as also do their alkaloids, morphia and atropia. These opposing actions are so important that it is desirable to consider them further. We may utilize the two remedies at the same time, giving them in combination or alternately with each other, especially in painfnl neuroses. Opium will cut short asthma or catarrh ; so will belladonna. Opium produces certain unpleasant symp- toms, belladonna prevents most of these. From an early period the op- posite effects upon the pupil could not be overlooked. Morphia and atropia are often combined in hypodermic injections ; these same alka- loids may also be administered by the mouth. Morphia produces less disagreeable effects than opium, and we may further reduce the unpleas- ant action by adding atropine. When we only want the good effect of opium or morphia, we can often neutralize the evil consequences by the addition of a suitable dose of atropia. The antagonism between the two agents is not universal, that is, does not cover the whole field of action, but the area over which it exists is exceedingly favorable for our therapeutical efforts. In some points there is no antagonism ; for in- stance, atropia does not prevent the relief of pain by opium ; indeed, many have supposed that it rather assists the anodyne action. Erlen- meyer says that the antagonism is complete in regard to the action on the brain, so that when the two remedies are given together no coma re- sults ; but on the sensory nerves there is no antagonism, and accord- ingly he combines them for the relief of pain. Bartholow holds that the anodyne effect of opium is even assisted by atropia. On the other hand, the existence of the antagonism has been denied by Brown-Sequard and Dr. John Harley. The latter has criticised the recorded cases of opium poisoning which have been treated by atropia with considerable ingenu- ity, but has scarcely succeeded in reversing the general judgment. The Edinburgh committee presided over by Dr. Hughes Bennett reported that : (1) sulphate of atropia is within a limited range physiologically antagonistic to meconate of morphia ; (2) meconate of morphia does not act antidotally after a large dose of atropia, thus, while atropia is an antidote to morphia, morphia is not an antidote to atropia ; (3) meconate of morphia does not antagonize the effect of atropia on the branches of the vagi supplying the heart. From this it may be concluded that 202 THERAPEUTICS OF THE RESPIRATORY PASSAGES. atropia is of more value to correct the action of morphia than the reverse, and this coincides witli our clinical experience ; but there are cases in which morphia may with advantage be made the corrective of a full medicinal dose of atropia. Therapeutically the question of dose is of most importance, and it varies with reg-ard to each remedy in different individuals ; considerable experience is therefore required to obtain the best results. If one-fif- tieth grain of atropia will stop certain effects of a quarter grain of mor- phia it is by no means certain that one-hundredth grain will serve to correct one-eighth. Indeed the presumption might rather be the other way. Both alkaloids affect the brain, but differently ; it has been said that when they are combined the sleep is longer, and some assert that atropia prevents the insomnia of morphia, that is, shortens the stage of excitement. My experience is rather the reverse of this, which certainly might be anticipated from the physiological effect of atropia, which it- self produces excitement, and so, a prio)'i, might be expected to increase the excitement of opium. It is possible that the atropia may tend to prolong the sleep induced by morphia, but it is very difficult to judge. It may reinforce the anodyne property, but in the small dose required the amount which could obtain local access to the painful part must be infinitely small, and we have seen that any anodyne quality depends on this local access. Morphia is our sure anodyne, and we only add the atropia to enable the patient to tolerate it, or to prevent the inconven- iences to which it may give rise. Nausea, vomiting, headache, constipa- tion, syncope, all the ^in of disagreeable symptoms which so often follow the opiate may be prevented by a properly graduated quantity of atropia added to the morphia, and this whether taken by the stomach or injected under the skin. It is said that the illusions produced by bella- donna are prevented by opium and the sleep is more rational, but we hardly give doses of atropia which produce illusions. Morphia depresses, atropia stimulates the heart. A very minute amount of atropia will pre- vent morphia from contracting the pupil. Morphia lessens, atropia aug- ments the secretion of the kidneys ; on the skin the action is just the reverse, morphia promoting, atropia arresting perspiration ; both reme- dies arrest the secretion along the respiratory tract ; morphia retards, atropia increases peristaltic movements, and the same may be said of their action on the intestinal secretion. Above all, opiates depress, but belladonna stimulates the respiratory centre. It will now be seen how often the one may be made to supplement the other, and that their coun- ter-influences are of special value in respiratory diseases, particularly catarrhal affections and neuroses. As an average it takes from -^-^ to j^ of a grain of atropia to neutral- ize the effect of a quarter grain of morphia, but much less doses may suffice to secure the freedom from inconvenience which is desired. Bar- NEUROTICS. 203 tholow recommends -j-|-^ or ^^^ grain of atropia to a quarter and half a grain of morphia. I have usually found a larger proportion of atropia necessary. In giving atropia by the mouth, the dose being so small and the drug powerful, it seems best to give it in liquid form, the liquor atropiie sulphatis affords a convenient dose of one to two minims {j^ to g^ij), and this combines well with liquor morphije. Sometimes it is desira- ble to administer aconite at the same time, for the sake of its febrifuge property and to restrain the action of the atropia on the heart. Other Antagonisms. — Medicines may be partially antidotal or antag- onistic, that is they may counteract each other in some respects but not in others, and we may call them antagonistic, well knowing that the area over which they thus act is limited. Still their counteraction is extremely interesting and important, and may even suggest to us how medicines may antagonize diseases. It seems idle to deny the antagonism because it is not complete ; should we not relieve some of the effects of a poison, even although others might be beyond our control? Atropia and Physostigrna. — Kleinvachter and Bourneville recorded cases in which they observed an antagonism between these drugs. Bar- tholow received the prize of the American Medical Association for an essay on the subject in 18G8, and the following year Dr. Fraser brought before the Edinburgh Royal Society some account of his researches, in which he has shown the area over which this antagonism exists. He showed that atropia averted the effects of a lethal dose and therefore is the antidote for calabar-bean. From one-fiftieth to one-thirtieth grain should be injected under the skin, and repeated at intervals until the pupils dilate and the bronchial secretion is checked. This leads us to observe that calabar-bean immensely increases the secretion of the lach- rymal, salivary, bronchial, and intestinal glands, while atropia controls these effects and establishes its own, just as it counteracts the contract- ion of the pupils and dilates them. Some other opposite effects have been demonstrated chiefly by Dr. Fraser, thus " physostigma increases the excitability of the vagi nerves, while atropia diminishes or suspends this excitability ; physostigma diminishes the arterial blood-pressure, while atropia increases it." It is remarkable that a minute dose of atropia which is insufficient to produce an appreciable effect will suffice to avert many of the effects of physostigma. Although atropia ma}- prevent death from calabar-bean, the converse of this fact has not yet been dem- onstrated. The committee of the British Medical Association reports that sulphate of atropia antagonizes to a slight extent the fatal action of calabar- bean, but that the area is more limited than indicated by Dr. Fraser. Atropia and Pilocarpine. — Jaborandi excites perspiration and sali- vation. Applied to the eye it contracts the pupil, it retards the heart and afterward arrests it in diastole. These effects are the opposite of those of atropia, which is able to control them so that a hypodermic in- 204 TUERAPEUTICS OF THE RESPIRATORY PASSAGES. jection of oiie-liiuidredth of a grain will at once check the action of a dose of jaborandi or pilocarpine. Atropia and Bromal. — In reference to the bronchial membrane it is interesting to observe that these two oppose each other. Bromal kills by producing extreme excess of the bronchial and salivary secretions, by which the animal is choked ; atropia arrests th esesecretioiis, and so far is antidotal, but of course bromal is no antidote to atropia, as this latter does not destroy life by its action on these glands. Atrojjuiand 2Iuscarin. — Schmiedeberg showed the antagonism of these substances on the heart. Dr. Lauder Brunton has enlai-ged this area by showing that the dyspnosa caused by muscarin appears to be due to power- ful contraction of the pulmonar}"- vessels, blanching the lungs. The right heart is distended owing to the condition of the pulmonary vessels. Now atropia at once removes the spasm of the vessels and sets the loaded right heart free, thus completely removing the dyspnoea. Muscarin also stimu- lates the termini of the chorda tympani and so salivates, it also excites per- spiration, in both these respects being opposed by atropia. It appears, however, to dilate the pupil, though in most other respects it antagonizes atropia. Muscarin seems to act on the heart by stimulating the intracardiac inhibitory apparatus, much in the same wa}' as pilocarpine probably acts. Atropia and Prussic Acid. — Preyer says that atropia paralyzes the peripheral branches of tlie vagus and in this way prevents hydrocyanic acid from arresting the contractions of the heart. If so, it would be an antidote to that poison, which, however, produces death so rapidly that there is seldom time for treatment of any kind. Atropia and Aconite. — Atropia given with aconite, or a little before it, antagonizes the action on the heart, but when delayed for about a quarter of an hour after a lethal dose is unable to prevent death. As before remarked, we rnay avail ourselves of this antagonism when employ- ing therapeutical doses; thus it often happens that the general effects of aconite ai-e most desirable and may be obtained by its regular adminis- tration every few hours, while an occasional dose of atropia may be ad- visable for the sake of its effects on the mucous membrane. On the other hand, when regular doses of atropia are required, it may be desirable to counteract some of its effects by aconite. Some of these antagonisms are not easy to understand and show that the action is more complex than has been supposed. It is not a single effect which expresses the properties of a medicine, although its thera- peutical value may depend on that one. Atropia, as we have seen, an- tagonizes the effect on the heart of pilocarpine, muscarin, and aconite, though both poison and counter-poison seem to paralyze the excito-motor and muscular substance. Further, pilocarpine antagonizes the effect on the heart of muscarin, and yet both seem to act in precisely the same manner. Moreover, atropia, which we have seen antagonizes so many NEUROTICS. 205 poisons, does not prevent the effect of digitalis nor of veratria on the frog's heart. Though digitalin antagonizes niuscarin, pilocarpine, aco- nite, and atropia, Dr. Ringer has suggested " that these antagonisms iriav be due to chemical displacements." Before leaving' this subject it may be remarked that some other an- tagonisms are of special interest, and progress is being made in their study. Caffeine and morphia are distinctly antagonistic, and guaranine modifies the action of morphia, but not very markedly. Calabar-bean, as we have seen, provokes the bronchial secretion, and its action is greatly modified by chloral hydrate, which in some cases has prevented death after a lethal dose, but it must be given before the full action of the phy- sostigma is produced. The chloral depresses the respiration and para- lyzes the centre, as well as the circulation, in which it appears rather likely to reinforce the effect of the calabar-bean, for that certainly de- presses the respiratory centre. Physostigma has also been given in strychnia poisoning, as well as in tetanus, but has scarcely answered the expectations formed of it, and the same may be said as to its antidotal power toward atropia and chloral ; in fact, the chief use at present of calabar-bean or its alkaloid, eserin, is for local use in diseases of the eye. Strychnia prevents some of the effects of aconite, but the reverse does not seem to hold good, strychnia is also to some extent counteracted by the bromides and by chloral hydrate, which have been employed with some success as antidotes. It is obvious that the more completely we understand the mode of action of any of these powerful remedies, the more likely we are to be able to influence that action whether by count- eracting or preventing it, or by increasing or reinforcing it, or otherwise modifying it. A knowledge, too, of the area of the antagonisms between them helps us in arranging suitable combinations ; thus, though a simple prescription may often be best and it is certainly desirable to cultivate simplicity in prescribing, it very often occurs that great benefit may be obtained by suitable additions to the chief remedy. Further, we may modify the action of our remedies by giving others before, with, or after them, we may administer variously acting agents alternately between each other. To modify opium we g"ive with it belladonna ; to stimulate the respiratory centre we give belladonna, or atropia alone, and we may reinforce its action by alternating it with ammonia or ether ; and furthermore, while pushing these remedies we may obtain the effect of morphia on the mucous membrane by a small dose at bedtime, its depressant effect on the centre being neu- tralized by the other medicines. These delicate alkaloids are easily de- stroyed, caustic alkalies decompose them, even lime-water destroys atropia so much that Dr. J. Harley proposed it as an antidote in bella- donna poisoning. It is usually better to give these powerful alkaloids in a fluid form unless great reliance can be placed on the preparation. 206 THERAPEUTICS OF THE RESPIRATORY PASSAGES. Atropia in combination with morphia is often given as a pill. Atropia alone lias the disadvantage that a solution does not keep well, and should therefore be freshly prepared. The gelatine disks, however, prepared by Savory & Moore, keep perfectly ; they are always ready for hypoder- mic injection, and are equally available for administration by the stomach, as a disk can be washed down with a little water without tasting. Hyoscyami'S and Stramonium. — These two remedies may be re- garded as allies of belladonna, in fact, daturia and hj'oscyamia were for some time regarded as identical with atropia, but some differences have been established, and other very similar alkaloids have been obtained from the solanacea. The alkaloids have been used for subcutaneous in- jection as anodynes, but are not superior to atropia, and very inferior to morphia. Hyoscyamine has also been employed for the secondary seda- tive effect on the cerebrum in maniacal excitement. The herbs hyoscya- mus and stramonium seem both to be more decidedly hypnotic than belladonna, and hyoscyamus has a special repute as an anodyne, and its secondary or soothing effect comes on earlier and is more marked ; hence, perhaps, its reputation for producing sleep and relieving pain. Moreover, hyoscyamus seems to exercise a special influence on the mucous mem- branes. Thus the respiratory, the gastric and the intestinal lining are all soothed by it, as is also that of the bladder. In these cases it has also been given with alkalies, and even with liquor potassse, but it has been shown that this decomposes it. Its somewhat laxative and ano- dyne influence on the bowels makes it a valuable adjuvant to aperients. All the preparations of stramonium have obtained considerable repute as antispasmodics in asthma, and their use has been extended to cases of laryngeal cough. A favorite method of employing stramonium is by fumigation or inhalation. A popular plan is to smoke it like tobacco, and smokers mix tobacco with it ; this, however, is not to be recommended, as it is desirable to draw the fumes of the stramonium into the bronchi, where its local action is believed to be considerable in relaxing spasm, and so relieving the dyspnoea, whereas the fumes of tobacco irritate rather than soothe. Twenty grains of the dried leaves or ten of tlie powdered root may be smoked at a time, the fumes being inhaled, or any other convenient method of inhaling the fumes may be employed. It will be seen that it is in pure nervous asthma that it is indicated ; in the dyspnoea of heart disease, or that caused by structural changes in the lungs, it is useless. Sometimes it fails in asthma, but in other cases it is very successful, the cause of this difference not having been ascertained. Stramonium seems to be more directly depressant to the nerves of the bronchi than belladonna, and thus, perhaps, may be considered as to some extent a respiratory sedative, especially as regards its local action.' Given internally, the extract is more powerful and the dose accordingly smaller. Datura tatula, an allied plant of more robust growth belong- NEUROTICS. 207 ing to the stramonium genus, has been introduced of late years, as a sub- stitute for the older remedy, and as often succeeding when that fails ; it may be used in the form of cigars, cigarettes, fumigations, etc., in the same manner as stramonium. An extract and tincture are also made. Daturia extracted from it is more powerful than atropia, from which its salts differ somewhat in solubility and in crj'stalline form. The dose is yicr ^° e'o ^^ ^ grain, but it should be employed with great caution ; the five-thousandth of a grain applied locally affects the pupils. Camphor. — Camphor excites the cerebrum and produces a kind of intoxication, evidently exercising a considerable influence on the nervous system. It is eliminated by the skin and the bronchial mucous mem- brane. It is, therefore, natural to employ it in respiratory diseases, in which, indeed, it has long enjoyed a popular reputation. In acute catarrh, inhaled or used as a snuff, it is a popular remedy, and in Jiay fever as much may be said. Some authorities have recommended it in whooping-cough and other spasmodic affections, others look upon it rather as a stimulant or perhaps expectorant, giving it in combination with ammooia in chronic bronchitis, capillary bronchitis, and in emphysema. Its action in respiratory diseases seems to be not dissimilar to that of turpentine, to which it presents other analogies ; for instance, it is anti- septic, antispasmodic, etc. The late Dr. Copland attributed to it spe- cial value in bronchitis and asthma ; he combined it with ammonia as an appropriate stimulant when expectoration was arrested from want of power ; when expectorants were admissible he often added it to them, as he did to diuretics, opium, and other remedies. He declared that " in nearly all stages of bronchitis, camphor is a most valuable medicine," and added, " its virtues have been singlarly overlooked by the writers on this disease," and further pointed out that when exhaustion and difficulty of expectoration become urgent, " it is one of the most valuable remedies we possess." But in spite of this opinion of a most able observer, the remedy has not been extensively used for these purposes, except by a small number of physicians, who have satisfied themselves of its value. Though camphor has been in tolerably common use for some two hundred and fifty years, during which it has given rise to a very considerable lit- erature, and been recommended for all sorts of diseases, from a common cold to cholera, its exact medicinal value has scarcely yet been fully as- certained, and it is perhaps most frequently employed, rather as an ad- juvant than for other purposes. As an antispasmodic it is not unfre- quently combined with musk and other powerful nervines. Camphor forms some very curious compounds with chloral, thymol, phenol, etc., most of which possess distinctly anodyne properties. Cam- phor-monobromide is sedative and antispasmodic, as well as hypnotic, and from Bouneville's researches appears also to depress the circulation and lower temperature. CHAPTER XYIII. PNEUMATICS. This term (TrvevfiaTLKd, from ttvcw, I breathe) was employed by Pereira to signify therapeutical agents which acted by their influence over respi- ration and calorification. He included those which affected the respira- tory muscles, the mucous membrane, the breathing, and the calorific func- tion. In reference to the muscles, something has already been said in tlie chapter on Neurotics ; thus the efficacy of stramonium and other medi- cines in relieving spasm of the bronchial muscular fibres has been pointed out, and it may be stated that other medicines possess similar or opposite properties. As to those medicines which Pereira considered diminished want of breath, and which he termed " torporifics," these also are for the most part neurotics. Some of them have been supposed to produce a condition analogous to the physiological states of hibernation, ordinary sleep, asphyxia, or syncope, but most of them may be classed as narcot- ics, and several are distinct depressants of the respiratory centre. So again, substances >yhich influence animal heat have been considered ajnongst refrigerants and antipyretics on the one hand and stimulants and neurotics on the other ; the calefacients of Pereira being in reality excit- ants or respiratory stimulants, i.e., accelerators of circulation and respira- tion. This leaves us only those substances which act on the mucous membrane and an immense number of which are commonly spoken of as expectorants. It will, however, be necessary to extend our view beyond this, and we must therefore rearrange our pneumatics. If whatever affects the respiratory system directly or indirectly were to be included among pneumatics the word might as well have been em- ployed as the title to this volume, since it only professedly includes re- spiratory therapeutics. Many, perhaps, would object as it is to some of the agents we have included, but surely those which only indirectly af- fect the respiration ought not to be overlooked as remedies for disorders of that function, while other functions are so closely related to it as con- stantly to claim attention. Nutrition, therefore, and everything affecting it are of equal importance in diseases of the respiratory and other systems, while in consequence of the intimate association between respiration and circulation derangement of the one almost invariably produces disorder PNEUxMATICS. 209 of the other. We may, then, employ the word pneumatics for all those substances which influence directly or indirectly the respiratory system ; or rather, we apply it to these substances whenever they are used for this purpose, since almost all of them possess other properties for which they may be even more frequently employed. Some of these pneumatics have consequently been considered elsewhere, and it will not be essential to repeat what has been said concerning them, it being a matter of con- . venience to consider the various actions of a remedy in connection with each other. Plenty of remedies enter into more than one group in every classification, and so in this ; our pneumatics, therefore, will include those which act more or less directly on some portion of the respiratory organs or influence distinctly their function. Regarding respiration as a provision for interchange between the at- mosphere and the blood, we find that the function may be greatly affected by changes in the quality of the air. Thus variations in its temperature and in the amount of moisture it contains affect every portion of the membrane over which it passes in its passage toward the blood, and may even affect the pulmonary cells and the circulating fluid itself. So well known is the effect of unusual cold that catarrh is continually ascribed to it, but dampness is equally injurious, and the two combined are still more likely to give rise to affections of the respiratory tract. So disease of any portion of the mucous membrane extending from the lips and nose to the extreme ramifications of the air-passages, and even catarrhal jmeumonia may be produced by cold and damp. The opposite condition of warmth and moisture is soothing and sorhetimes Ave endeavor to maintain it by regulating the atmosphere of the room or by providing a warm stream of air through inhalers or respirators. Variations in the pressure of the atmosphere also exercise consider- able influence. As previously stated, the diminished pressure on lofty mountains increases the frequency and depth of the respirations as well as the vascularity of the lung, and thus accounts for the tendency to hemoptysis observed under such circumstances. In descending mines an opposite condition obtains, and sometimes we may produce a some- what similar influence by causing the patient to breathe compressed air. Deficiency in the quantity of air available for respiration may also take place, or the supply may be interrupted for a brief period, or it may be replaced by a respirable gas like nitrous oxide. Increase of the sup- ply may be produced by resorting to pressure, or an excessive proportion of oxygen may be provided. Then, again, the amount of air at the dis- posal of a patient remaining the same, more or less may be actually used according to the activity of the respiration, and this we may sometimes vary by regulation of his exercise and rest. So in disease, when one por- tion of the lung is rendered useless we see the remainder working harder in order to make up for the deficiency thus occasioned. 14 -10 TnELlAPEUTICS OF THE RESPIIIATORY PASSAGES. The chemical quality of tlie air may be altered. This may occur from defect of oxyg-en as well as from the presence of impurities. Some- times tlie attempt has been made to increase tlie amount of oxygen, but without much success ; at other times inhalations of oxyg-en, or of this o-as mixed in various proportions with air for short periods at a time have been prescribed. A resort to mountain air, or to the seaside, or an ocean voyao-e is a more usual method of improving the quality of the air breathed. The variations in the air, which we have already noticed, go far to make up the complex influence of climate. But this subject, im- portant as it is in reference to respiratory therapeutics, is too extensive to be included in the present chapter and will therefore be postponed. The circumstances relating to the blood and general circulation have already been consideredj but we must not quite pass over the vascular supply of tlie bronchi and lungs. The circulation through the bronchial vessels may be stimulated or depressed by agents which act upon the general circulation, as well as by remedies which possess a topical action, thus exercise, evacuants, some respiratory stimulants and expectorants may notably stimulate the bronchial circulation, while depressants and some Other remedies produce an opposite effect. So the pulmonary cir- culation may be modified by the systemic, and therefore whatever acts on the latter affects the former ; besides which a direct influence on the less- er circulation may be produced by these agents. Muscarin appears to possess a very direct action, powerfully contracting the pulmonary* ves- sels. The muscular system must not be overlooked. The muscles of respi- ration, as we have seen, may be affected by various agencies within our control ; but it is the muscular coat of the bronchi and perhaps also the diaphragm wjiich we most frequently seek to affect by medicines. Inas- much as spasm of the bronchial fibres gives rise to most distressing symp- toms, substances which control this condition, whether acting directly or indirectly, are sometimes grouped together as antispasmodics. Many of these are depressants of the respiratory nervous apparatus ; others, acting perhaps through the same channels, are grouped as narcotics. Sometimes expectorants become antispasmodics by relieving the vessels and there- by causing a free flow into the tubes, when after the secretion is coughed up the spasm suVjsides. In the same way the removal of mucus by emetics produces subsidence of the spasm, and the act of vomiting, as is well known, greatly relaxes muscular fibres. With regard to the nervous system, we have already considered several stimulants and sedatives of the respiratory and cardiac centres, and we may add that other agents of tliis kind are within our grasp. Of these, ammonia and str3'^chnia are important as stimulants, while chlo- ral, the bromides, conium, etc., may be added to the depressants we have had occasion to describe. Afferent sensory nerves from all parts convey p:s"eumatics. 211 impulses to the medulla and produce impressions on the centre which in- fluence reflexly the respiratory movements. But impulses from the re- spiratory organs themselves are more important, inasmuch as they are di- rect. Now the entire surface of the air-passages is abundantly supplied by the vagi, which are the special afferent respiratory nerves, B}^ them impressions are constantly being collected and conveyed to the centre, and when such impressions are unusually powerful they may overflow, so to say, and thus affect other centres. They may even reach the convolu- tions, when they will be perceived as sensations referred more or less distinctly to the respiratory organs. We may thus have undefined, un- easy sensations, or a degree of irritation, or oppression and distress, or, again, distinct pain. Further, motor filaments of the vagi rise in the centre and are distributed to the bronchial muscles and so regulate their contraction, thus controlling the calibre of the tubes. In this way the bronchi are completely under the control of the medulla, and moreover the very impulses which originate in the air-passages conveyed to the centre react through it on tlie passages themselves. Now the afferent respiratory nerves may be stimulated on the one hand, as, e.g., bv cold air, irritating gases, or certain medicines which determine to the respira- tory tract. On the other hand, they may be depressed, as by warmth and moisture as well as by remedies acting more or less directly upon them, and some of which deserve to be called respiratory anodynes, from the soothing influence which they exercise and the manner in which thev re- strain uneasy sensations and relieve pain. Indirect influences traiismitted through other nerves also readilv affect the respiratory centre, and may therefore be employed to act upon it. Everyone knows how readily it is stimulated through the fifth bv irritat- ing the nostrils, or by the sudden application of cold to the forehead. In the same way it may be influenced through the olfactory, optic, and auditory nerves by strong odors, intense light, and loud sounds, as it also may through the cutaneous nerves, as from counter-irritants. On the other hand, sedative influences may be transmitted from the surface, as in warm baths, general or local, fomentations, poultices, and anodyne local applications. We have now to add that efferent nervous impulses may be also more or less modified by our remedies, e.g., strychnia stimu- lates the spinal centres of tlie respiratory muscles as well as the periph- eral nerves, perhaps both directly and indirectly, and electricity may be called in as an immediate stimulant. On the other hand, opium seems to be a depressant of the entire efferent tract, while calabar-bean depresses the spinal centres and conium expends its energy chiefly on the motor nerves. The glandular system of the respiratory tract is also within the reach of our remedies, and that not only as a whole but in some of its parts. So that the secretion from the nose, throat, larynx, trachea, and bronchi 212 THERAPEUTICS OF THE RESPIRATORY PASSAGES. mav be changed in quantity or quality, and this alteration may affect a small portion or the whole of the membrane. The glands may be stimu- lated bv ammonia, sulphur, iodine, most of the expectorants, and by some remedies which perhaps act topically, being excreted through the mem- brane. Their action may be restrained by belladonna, opium, and per- haps astringents. Cold and heat, warmth and moisture, or other local remedies also influence the secretion directly, while other remedies act upon it either through the circulation or the nervous system, some of these being irritating, others soothing. We are now prepared to consider the various effects produced upon the air-passages by the remedies at our command. It will be observed that their action is often very complex, though sometimes it is simple and perhaps direct. So many substances and of such opposite qualities have been supposed to act upon the secretion, or to affect its production that no little confusion has been introduced. Excess of secretion is so obvious a symptom that it must have attracted attention from the earli- est times. Many substances were believed to be capable of increasing it, but only a few were supposed to possess the power of restraining it, and accordingly medicines of most opposite qualities have been grouped to- gether as expectorants. If the origin of the word {ex pectore) justified the usage, we might perhaps apply it to whatever affects the sputa, or that which is brought np from the chest, though originally it was no doubt intended for whatever increased the secretion. Such increase might, however, only be apparent, the removal of a larger quantity not necessarily implying greater activity of production. Like other func- tions, that of the respiratory membrane may be increased, decreased, or altered. No doubt it is most frequently increased, and as this constitutes the most obvious and the most frequent symptom of disease, agents which could promote it seem to have received the most attention. It is per- haps due to the notion which so unfortunately prevailed for a long time, as to the value of evacuants, that this idea of promoting secretion was allowed to put into the shade the equally important subject of the possi- bility of restraining it. Still, it is curious that those who could see the desirability of restraining mucous diarrhcea should consider that an an- alogous discharge from the respiratory tract should be promoted rather than restrained. It was, perhaps, a happy thing that some so-called ex- pectorants really acted by diminishing and altering the sputa, rather than by stimulating its production. Here, perhaps, it is but fair to admit that some early writers ' were conscious of the evils that might arise from the indiscriminate use of expectorants. ' Ludolf, J. : De iisu et abusu medicamentonim Expectorantium. 1723. Buechner, A. E. : De incongruo Expectorantium iisu frequent! morborum pectora- lium causa. 1756. PNEUMATICS. 213 Here we may pause to refei- to certain remedies which act locally on small portions of the aerian inembranes. These are first of all errhines (from eV, in, ptV, nose), which are introduced into the nostrils for tlie pur- pose of increasing the nasal discharge. Many of them are taken as snuffs ; some act merely mechanically, but others are distinct irritants to the mucous membrane. Various acrid powders have been used for this purpose, but liquids and vapors may be also employed. It will be ob- served that all are stimulants to tlie secretion and we have no name for substances possessing opposite qualities. But we perhaps oftener use such as tend to restrain secretion, and which possess emollient, soothing, or astringent properties. Some internal remedies promote the nasal se- cretion, but are not called errhines, as they are not applied locally. Other internal medicines restrain this secretion. Absorption readily takes place from the healthy pituitary membrane. Sternutatories {sternutatoria, from sternuo, I sneeze), or ptarmics as they are also called (from Trratpw, I sneeze), also stimulate this membrane, but these terms are employed for medicines which are applied locally in order to produce sneezing but not to bring on a discharge, though it is obvious that such a stimulant will tempo- rarily increase both the nasal mucus and the tears. Cough medicines, sometimes called bechics ((3rjxtKd, from (3i^i, a cough), are not used to stimu- late, but rather to soothe the throat and larynx : they comprise a num- ber of emollients and demulcents supposed to act locally during the act of swallowing and to sheathe the surface from irritants. Various forms of linctus, lozenges, and similar remedies are given with this intention, and sometimes small quantities of expectorants or narcotics are added, to which is due, perhaps, the most important part of the effect. Direct local applications can be made to the larynx by means of the laryngoscope, information concerning which will be found in the author's " Laryngos- copy." Passing further down the respiratory tree we come to medicines acting upon the lower portion of the membrane, and first of all Expectorants. In a wide sense this term is frequently applied to whatever facilitates the evacuation of the bronchial secretion, as well as to whatever increases its flow, and this whether directly or indirectly. It will be observed that there is a great difference in these two actions. In each case more phlegm is raised, but in the one that is only because the removal is effected of that which is already there, while in the other case there is the additional outpouring of fresh secretion. Now the natural method of evacuating bronchial mucus is by coughing, so that whatever excites this action assists the process. An irritating gas or any other local stimulant to the respiratory membrane may thus be said to be expecto- rant. In health, although moisture is continually exhaling from the pul- 214 THERAPEUTICS OF THE RESPIKATOKY PASSAGES. monaiy surface, very little is condensed into liquid and retained in the passages ; only enough to maintain the moisture of the membrane, and in combination with the products of the gland to form a sufficiently tena- cious secretion to cover the surface and entangle such particles as may be inspired and thus enable them to be coughed up. Small pellets or larger glutinous masses are thus frequently brought up by persons who have been exposed to dust, etc. In perfect health a resident in a pure atmosphere, i.e., in a good climate, might perhaps scarcely ever cough up such masses, but in towns it is not uncommon for these pellets to be extruded nearly every morning, and in densely populated cities like Lon- don and Manchester, where much coal is burnt, the sooty particles taken in give rise to a black phlegm, which is coughed up more or less regu- larly. When the membrane has become relaxed, perhaps from the re- currence of catarrh, a secretion of this kind may become habitual. In disease the cough may be weak and insufficient to accomplish the in- creased labor, and it may then happen that it is desirable to excite the muscular action by appropriate stimuli, or it may be necessary to act upon the membrane and the muscles engaged indirectly through the ner- vous system ; stimulants of the respiratory centre may be called for. But in other cases it may be possible to so sustain and strengthen the system as to give the patient more power to cough ; nutrients and ton- ics may perhaps do this. But a cough may be incessant and yet ineffectual, and in such cases it may be necessary to employ remedies to restrain it. These act on the mucous membrane or on the nervous system, and periiaps on the pro- cess of secretion. The irritability of the pulmonary surface needs to be soothed while the vagi are controlled, and it may be that depressants of the centre are also required. When there is no secretion to be raised, it may even be desirable to employ such expectorants as provoke the secer- nent action, concurrently with sedatives. When the troublesome but useless cough is kept up by disease at some small point in the larynx, that must be treated by local applications, not by expectorants, which are equally useless in the cough caused by elongated uvula. Other hindrances may occur to the evacuation of bronchial secretion, the tubes may be in a state of spasm, preventing the removal and interfer- ing with the respiration. When the accumulation is considerable and the spasm intense an emetic will sometimes relieve the distress. The act of vomiting produces relaxation of the muscular system and at the same time greatly aids mechanically in clearing the tubes. In other cases antispas- modics will bring about the relaxation of the bronchial muscles. De- pressants of the nervous system also do this, whether of the centre or periphery. Narcotics are sometimes employed for this purpose, but in full doses are not without danger. We may next direct our attention to the accumulated secretion. We PNEUMATICS. 215 may act upon this with a view to vary its quality or quantity. As to its consistency, when, as often happens, it is thick and tenacious, and there- fore difficult to raise, we may endeavor to liquefy it in order to make it easier to g'et up, i.e., we may try to dilute it. This we may do iirst of all bv inhalations of steam, which may also be laden with other vapors or by atomized liquids containing chemical substances in solution, such as certain salines which are believed to assist in attenuating the sputa. But we should not forget that these vapors and sprays act upon the mucous membrane as well as its secretions, and absorption may even take place. We may also act upon the secretion through the system, by the internal administration of medicines. Iodide of potassium is a powerful atten- uant, which also increases the quantity of the secretion, as does, perhaps, chloride of ammonium, but it is not unlikely that they do not merely di- lute it but distinctly alter its character. Alkalies used to be considered as liquefying the sputa, but recent experiments throw some doubt on their action. Of course, whatever increases the quantity of the secretion tends to attenuate it. Another group of remedies which facilitate ex- pectoration may produce an opposite effect, thickening' the secretion. When there is a large quantity of thin, watery mucus it may be more difficult to raise than if it possessed more tenaciousness. In such cases whatever thickens it in a moderate degree may expedite its exit. Pure, dry air, even if cold, will do this, and a dry climate may be most desirable. Certain vapors and sprays may also be employed to act on the membrane and internally the administration of astringents or of opium may accom- plish the end. Of course, whatever checks the act of secretion tends to thicken the sputa. Other changes in quality may also be brought about. Essential oils and other substances which impart their odor to the breath alter the secretion. Some not only add their own odor but deodorize the sputa, are, in fact, disinfectant or antiseptic expectorants, and they are the more entitled to the name, inasmuch as most of them stimulate excretion. We come now to those expectorants which affect the quantity of sputa secreted. These also are of two kinds, those which stimulate the secernent function and those which restrain it. The first are sometimes classed with eliminants, and, indeed, have been employed with an idea of relieving the system by increasing the discharge. Such a notion is, how- ever, obsolete ; they may act by directly irritating the mucous membrane, as when ammonia and other stimulants are inhaled. Others are intro- duced through the system, and being brought to the pulmonary surface may act upon the vessels there, causing them to unload themselves ; or they may stimulate the glands to increased action ; or, again, they may stimulate the nerves ; or, once more, circulating in the blood may directly influence the centre. Many of these true expectorants are unquestion- ably eliminated through the respii'atory mucous membrane, and it is natural to seek there the explanation of their action. Many of them are 21G THERAPEUTICS OF THE RESPIRATORY PASSAGES. very volatile, and it would appear that this quality facilitates their ex- cretion through the aerian membrane. It is, indeed, a general rule that the more volatile a substance the more easily it escapes from the lungs. The respiratory membrane is in truth especially adapted for the inter- change between the air and gaseous substances of the blood, so that we mio-ht anticipate that volatile substances would here find a natural out- let, and this, in fact, they do. When they are present in too great a quantity to escape l)y this route the excess not unfrequently passes off by the skin, this being also adapted for the removal of vaporous sub- stances which' may be compared with the insensible perspiration. It is true that some medicines of this kind seem to be attracted to the lungs almost exclusively, while others are determined toward the skin ; but often the one appears to supplement the other, though in other cases there is rather a determination toward other mucous membranes than toward the cutaneous surface. We have said that these volatile sub- stances are excreted through the lungs, and there exercise their influence where they not only affect the quantity but alter the quality of the se- cretion, and may, perhaps, replace the deteriorated phlegm by a more healthy flow, thus being, as is sometimes said, alterative. Some have doubted whether the effect is produced in consequence of elimination through the bronchial membrane or glands. In '• Neligan's Medicines," edited by Macnamara, this question is raised, and it is said that it is perhaps only the odorous principle which escapes through this channel. To this it may be replied, very likely, but in such case it is perhaps this very principle to which the medicinal virtues belong. Further, the elim- ination by this channel, not only of volatile but of other expectorants, has at length been ascertained by experiment. Remedies which diminish the quantity of the secretion are directly antagonistic to the true expectorant which we have just considered, but some of the former have often been grouped with the latter. When the expectoration is very profuse, its evacuation may be rendered easier by restraining secretion, and so we have remedies which might be termed " paradoxical expectorants," if we admit them to be expectorants at all. When they diminish the quantity they mostly render the phlegm thicker and more tenacious. They may act directly on the mucous membrane or its glands ; others act only through the nervous system, either on the periphery, as some neurotics, or on the centre, as narcotics ; others con- tract the vessels as astringents ; and it may happen that some first of all stimulate the vessels to pour out an increased quantity of liquid, by which they are relieved, and afterward on their contracting the second- ary effect is produced. Finally, it is not impossible that some may act indirectly by altering the quality of the blood, for in recent experiments a solution of soda injected into the circulation was followed by arrest of bronchial secretion. PNEUMATICS. 217 Here it may be convenient to consider the most recent researches into the phenomena of the secretion of mucus and the clianges which may be effected by medicines. Professor Rossbach reported {Berl. klin. JVoch.), in 1882, the results of a series of experiments, mostly on cats, which have since been confirmed by Petronne [Lo Sperimentale, 1883). The method of procedure was to open the trachea and watch the ap- pearance of the mucus which in the normal state covers the membrane. This they found was only a thin layer, which persisted even when large quantities of air passed over it. When the mucus was gently removed with blotting-paper the layer reformed within a minute or two, but the collection was never so great as to run into drops or to flow down. From this it would appear that the secretion is not continually going on, but that whenever it is reduced in quantity by evaporation a fresh outflow is produced to compensate for the loss. It is probable that the consti- tution of the mucus is not uniform, but that the portion last exuded is more watery and alkaline and therefore adapted to hold the mucin in solution. According to Rossbach's experiments no nervous current, or only a feeble one, is transmitted from the centre to the glands of the air- passages, for the secretion continues in its usual manner after section of the laryngo-tracheal nerves. But vaso-motor fibres seem to reach the laryngeal lining, as the secretion appears to have some connection with the vascularity of the membrane. Rossbach next observed the effects of temperature, by applying hot poultices and ice-bags to the animal's body. Within half a minute of the application of ice the whole mucous surface of the larynx and trachea was blanched from the complete contraction of the blood-vessels, but in from one to two minutes this passed away and was succeeded by a bluish red tinge, while such quantities of mucus were secreted as to freely flow down. On the removal of the ice and replacing the poultice the color instantly changed to deep red. Fresh applications of ice again set up vascular spasm, but more slowly and to a lesser degree. These phenomena Rossbach considered direct reflexes. Equally interesting results followed the application of medicinal sub- stances. No effect was observed from a weak solution of carbonate of soda when inhaled, but the application of weak ammonia or vinegar, by painting the membrane, caused intense hyperaemia and increased secretion. Astringents applied in the same way produced an opacity of the epithe- lium, so that deeper changes could not be observed, together with com- plete arrest of the secretion. Air saturated with turpentine blown upon the membrane caused gradual diminution, and finally arrest of the secre- tion, which, however, returned when the irritant was removed. A watery solution of turpentine increased the secretion, but at the same time diminished the vascularity of the membrane. From this it would appear that turpentine is a true expectorant, though at the same time it 218 THERAPEUTICS OF THE RESPIRATORY PASSAGES. removes congestion and would account for the value which has been placed upon it by some clinical observers. Other true expectorants, so far as these experiments go, are emetia, apomorphia, and pilocarpine ; but neither of these affected the vascularity of the membrane. It will be observed that clinical experience confirms these results, especially as regards emetia ; pilocarpine is not well adapted as an expectorant on ac- count of its effect on the salivary glands, nor unless a powerful sudorific should be at the same time desired, but apomorphia is easily tolerated and does not often disturb the appetite or cause nausea, points which my clinical experience confirm. The antagonists of these expectorants, atropia and its allies, were also shown to produce the effects which had been ascertained by observation ; thus, the membrane could be completely dried by the application of atropia, but at the same time the vascularity was increased. In the same way morphia diminishes but does not arrest the bronchial secretion as atropia does. The combinations of morphia and atropia recommended in our chapter on Neurotics are thus shown bj' experiment to possess the qualities there stated, and, as we have said, these experiments have been repeated with similar results. Petronne agrees with Rossbach that aniigmia of the membrane and atony of the glands is brought about by the effect of soda on the vaso- motor and secretory nerves, when that alkali is injected into the blood, but a considerable quantity of the carbonate had to be emj^loyed. An experiment of this kind is certainly not so satisfactory as the others we have named, it seems to show, indeed, that great excess of soda in the blood may hinder, or even arrest the tracheal secretion, but those who have been accustomed to employ it with an opposite intention may reply that they only use small doses, or else local applications, by means of an atomized solution. Perhaps the use of such sprays by attenuating the secretion may render it more easy to expel. Inhalations of ammonia or of vinegar are considered by Petronne as rational in chronic dry catarrh, but, of course, as inadmissible in acute cases. When the membrane was bathed with these liquids it caused extensive hyperaemia and much secre- tion. Astringents within four to six minutes he found produced great pallor of the membrane. His observations with nitrate of silver on the tracheal membrane of rabbits, guinea-pigs, and dogs are interesting : he used a solution up to four per cent., which dried the epithelium and com- pletely arrested secretion, but he was able to satisfy himself that there was no diminution in the vascularity. On the other hand, in the phar- ynx and the nasal cavity the four per cent, solution produced a consider- erable excess in the secretion of the mucous glands in these regions, but in the larynx the same solution in the course of half an hour pro- duced dryness ; hence, inhalations of tannin or alum may be used as astringents, but applications of nitrate of silver will differ in their effects PNEUMATICS. 219 according to the part of the menibrane to which they are applied. A spray of spirits of turpentine on a small portion of membrane diminished and soon arrested secretion, but a watery solution, one or two per cent., gave rise to hyper-secretiou and vascular depletion, thus completely con- hrming- Rossbach's statements. This property of calling forth secretion and at the same time producing anaemia of the membrane is as important as it is interesting-, and enables us to understand the favorable influence of terebinthinate sprays and vapors in chronic catarrh and thickening of the membrane. With apomorphia, pilocarpine, and emetia, experimenting upon dogs and cats, he produced swelling of the tracheal membrane with a glandular condition, and so much secretion in the respiratory tract that crepitant rales were heard all over the chest, and section of the nerves did not prevent these phenomena. He considers that pilocarpine pro- duces secretory troubles through the whole system and should therefore be used with caution, but like the other expectorant alkaloids may be useful in dry catarrh and croup. As to their antagonists, atropia and morphia, he entirely confirms Rossbach. Atropia completely checks the secretion in forty or fifty minutes, but increases the vascularity, and as section of the laryngo-tracheal nerve does not prevent the phenomena the action of the alkaloid may be exerted upon the mucus-forming cells and the terminal nerve-filaments. The preceding account of Rossbach's and Petronne's experiments upon animals may perhaps be appropriately followed by a briefer state- ment of some of my researches on the subject of exriectorants. It may be stated at the outset that my experience very largely corroborates their statements, though some differences may yet have to be accounted for. My observations have been made upon patients chiefly with the aid of the laryngoscope, but in the pharynx and nostrils this is unnecessary. In all cases, however, reflected light has been employed. The parts have been painted with solutions in some cases, in others they have been treated with vapors and atomized sprays. Comparing- the results, I have not been able to satisfy myself as to the effect of soda, partly, perhaps, because the solution was not of the same strength. I have never regarded this bicarbonate as specially expectorant, whether employed locally or administered internally. Potash, however, promotes secretion, and is therefore a useful ingredient in expectorant mixtures ; not only the bicarbonate, but the citrate, and I think also the nitrate, possesses this property. Some of the salts of lithia are also endowed with similar virtues : under the influence of these salts the secretion becomes thinner and more abundant, while congestion abates. But the most remarkable salt in this respect is iodide of potassium, the action of which, when taken internally, is obvious in the nasal passages, the pharynx, and larynx. Further, by auscultation, it may be demonstrated to act also on the bronchial membrane. When the system is saturated and severe 220 THERAPEUTICS OF THE RESPIRATORY PASSAGES. iodism produced, it is perfectly true that a state of congestion may be set up, but at an earlier stage, or rather under the influence of small quantities, or when solutions are painted on the part, or sprays inhaled, there is seen rather the exudation of a considerable quantity of thin, watery mucus, with no increase of vascularity, and sometimes even a little pallor. This salt is therefore expectorant, promoting the bronchial secretion, as also may be incidentally remarked it does that of the sali- vary fflands. As to such irritants as ammonia and acetic acid, I can en- tirely confirm the statements quoted. So I can for the most part what has been said of astringents, but these agents differ somewliat atnong themselves, some do not appear to produce the oj^acity described by Rossbach, unless the solutions are very concentrated, and all of them may be so diluted as to prevent this result and yet retain their power to di- minish secretion and vascular fulness. I have applied tannin to the mem- brane of the larynx, in both weak and highly concentrated solutions, with the result of reducing vascularity and secretion. In the pharynx the effect is much less obvious ; in the nasal passages it is more marked, and this and other weak astringents may be applied in the same manner and the effect observed with the rhinoscope. As a rule it may be stated that only weak solutions should be experimented with in this region. The result of applying nitrate of silver with a brush differs very greatly in different parts, as well as in different proportions. I have employed the nitrate in solutions varying from one grain to sixty in the ounce, in a few instances one hundred and twenty grains, and various proportions between. These concentrated solutions are of course caustic. Milder ones produce opacity of the membrane and arrest secretion ; still weaker solu- tions, and sometimes very weak ones, produce in the larynx a sensation of drvness, which arises from diminished secretions as well as a diminu- tion of vascular fulness. In the nasal cavity and in the pharynx, per- haps as a secondary effect, congestion follows the application of ten to twenty grain solutions, accompanied by hyper-secretion, and this even when the application is confined to a small area. Pilocarpine and emetia internally are decided expectorants, but the former is not well adapted to be used for this purpose in ordinary cases, though the latter may be made to replace ipecacuanha. I have no con- clusive experiments as to the local application of pilocarpine, but as to ipecacuanha and its alkaloid can confirm their expectorant qualities. On the other hand, apomorphia I have tried locally with very decided re- sults, as well as administered it internally. It produces a considerable in- crease in the secretion, with little if any diminution of vascularity, and is, therefore, an excellent simple expectorant, and may also be given as such internally in very small doses. For the last two or three years, in conse- quence of the result of experiments, I have been using apomorphia as a spray to relieve preternatural dryness and irritability of the larynx, and PNEUMATICS. 221 can recommend it for this purpose. In a case in which incessant cough had been a most serious complication for many weeks, exhausting the patient — a phthisical one — and defeating all the efforts of the medical at- tendants, a spray of apomorphia produced more relief than any other remedy, local or general, and in distinctly laryngeal cough, with a pre- ternaturally dry membrane, even when congestion was present, the local use of this alkaloid has been of great service, apparently by provoking a fresh flow of thin, unirritating mucus. The power of apomorphia to produce considerable bronchial secretion, when given internally, has been con- firmed by Jiirgensen and Wertner, who have given it in bronchitis, pneu- monia, and oedema of the lungs, with good results. With atropia my results are exactly antagonistic to those observed with apomorphia. It is very easy to check, and even to arrest the se- cretion by means of atropia ; it acts as promptly and certainly on the laryn- geal membrane as it does in arresting salivation. In from half to three- quarters of an hour the membrane may be dried and rendered hyperremic. This may be effected by a hypodermic injection or by a local application ; it is obvious that the latter should be made with considerable circumspec- tion, on account of the potency of this alkaloid. It would not do to paint the ordinary solution with a laryngeal brush. Morphia, though less powerful and perhaps less rapid, also diminishes the secretion, but it does not in ordinary quantities cause hyperjemia ; it is difficult to completely arrest secretion by opiates. With regard to the combined action of morphia and atropia, it is scarcely necessary to add anything to the statements which I have advanced in the sections on opium and bella- donna in a former chapter. [Vide Neurotics.) It is commonly said that expectorants are rather uncertain in their action. This is not surprising if we are to include among them all the groups we have described, and then regard them all as acting in the same way, or look upon the respiratory surface as a medium for the action of evacuants. This membrane ought not to be regarded as an emunctory, and it is fortunate that the notion of evacuating by all channels has pretty well passed away. Nevertheless, we observe that gases which are ordi- narily eliminated by the bowels do sometimes escape through the respira- tory membrane and taint the breath, and so it is not surprising that other substances finding their way into the blood should be removed by this channel, though at other times they are eliminated by the skin or kid- neys. The uncertainty complained of will, to a considerable extent, dis- appear if we are sufficiently exact in the selection of our expectorants and other pneumatics according to the precise effects we are desirous of producing. Even then, however, it is not to be denied that a great ele- ment of uncertainty does exist, which is chiefly due to the difficulty we experience in coping with the many grave results which are produced by diseases of the respiratory organs. 222 THERAPEUTICS OF THE EESPIRATORY PASSAGES. Expectorants, and indeed all the pneumatics, may be conveniently di- vided into two groups : 1, those which are applied locally to the mucous membrane, that is, which are inhaled as gases, fumes, vapors, or spravs, or which are brought into contact with accessible portions of the membrane as in the case of gargles, lozenges, and topical medication by manipula- tive proceedings ; 2, those which are administered through the system, and which may be called, therefore, general expectorants. No doubt, as we have seen, many of these act topically, being brought to the part through the circulation and there excreted, at any rate in part. But being present in the blood, other effects in the system may also be pro- duced. Moreover, the several members of the group act through differ- ent channels, some on blood-vessels, others on the nerve-supply, others on the glands of the membrane, others circulating in the blood find access to the medulla and act upon that, and others may perhaps produce their effect by acting on the blood-plasma or the red corpuscles. The influence of some narcotics is very general ; thus opium not only restrains secre- tion and affects the entire respiratory nervous apparatus, but has so great an influence on the nervous system of the whole body as to make its in- fluence exceedingly complex and, so to say, universal. So we find other general expectorants exercising such important influence on the circula- tion that their effects are felt throughout the system, whether as stimu- lants or depressants. We propose now to rearrange in a few useful groups the principal respiratory remedies — pneumatics — with brief comments on some of the more important, a method which it is hoped will economize space. We will begin with GENERAL EXPECTORANTS. These augment the amount of secretion poured into the respiratory passages by stimulating the activity of the secernent function. Their effects upon the general system are so diverse and so considerable, espe- cially upon the circulation, that they may be divided into groups according to their general effects, which, as it happens, to a larg-e extent correspond with their local action. Three groups may thus be arranged ; 1, De- pressants ; 2, stimulants ; 3, alterants. 1. Depressant Expectorants. — -The most important of these are the nauseants, which have already been described in connection with emetics, as in large doses they produce vomiting. Antimony and ipecac- uanha act directly and indirectly as expectorants, as we have seen they do as emetics and nauseants. They hold an almost unique place as de- pressant expectorants, greatly reducing the circulation, and so are of more use in febrile cases. It has sometimes been thought that the expecto- rant action is only produced as a result of the nausea, but emetia has been PNEUMATICS. 223 detected In the secretion, and as well as antimony is doubtless partly- eliminated through the respiratory membrane and may therefore act upon it locally, at the same time the centre is depressed as well as the circula- tion. Moreover, an expectorant action can be produced in doses which are insufficient to excite nausea. Anyone with large experience of these medicines, and especially of antimony, can confirm this statement. (See Nauseants ) Apomorphia, though a prompt emetic, and chiefly employed for that purpose, also possesses expectorant properties. It is, however, scarcely a depressant, except through the vomiting it produces. It does not seem to depress the circulation as a necessary part of its own influence, for in emetic doses the pulse may rise on the approach of nausea and reach its highest point just before vomiting begins, falling between the acts of vomiting-. Tlie blood-pressure, too, is not lessened by its action. Further, it stimulates the respiratory centre, and thus, as shown by Dr. Gee ' and by Siebert,'' greatly accelerates the respiration. From these observations, which have been fully confirmed by Quehl,^ Riegel and Boehm,^ Bour- geois,^ Dujardin-Beaumetz," Budin and Coyne,' Brunton {^Practitioner), and others, it would seem that in itself it is hardly entitled to be called a depressant expectorant, but neither can it be, perhaps, considered stimu- lant, at any rate in expectorant doses. Large quantities or repeated doses may set up prostration with depression of the respiratory centre, causing slow and shallow respirations, and, as Harnack ' proved, death from their gradual secession ; there may then be a rise in the pulse-rate and a fall of temperature of, according to Ziolkowski,^ one-tenth to half a de- gree C, though Bourgeois maintains that it has no effect on the temper- ature, and Moerz " observed a rise of one-fifth during the act of vomiting. After section of the vagi the respiration is more accelerated, so the effect appears to be due to the action on the centre. Carville mentions a case in which three-tenths of a grain caused prostration and collapse in an adult ( Gaz. Heh., 1874); another is reported by Prevost {JMedical Record, 1875), in which a smaller dose produced serious collapse. In children, Harnack* found this condition easily produced, butLoeb [Schmidt'' s Jahrb.) ' Gee, S. : Clinical Society's Transactions. 1869. ' Siebert, V. : Untersuchungen iiber die pliysiologisclien Wirkungen des Apomor- phins. 1871. ' Qnehl, Max : Ucber die pliysiologisclien Wirkungen des Apomorphins. 1872. * Riegel and Boelim : Deutsclies Arcliiv fiir klin. Med. 1872. * Bourgeois, J. B. V. : De rapomorpliine Reclierclies cliniques sur uii nouvel emetique. 1874. ^ Dujardin-Beaumetz : Note sur Paction tlierapeutique de I'Apomorpliine. 1874. ■' Budin and Coyne : Sur certains effets de I'Apomorpliine. 1875. 8 Harnack : Archiv. exp. Path. u. Ther. , Bd. ii. ' Ziolkowski : Apomorpliin. 1872. '" Moerz, A. : Prager Vierteljalir. 1872. 224 THERAPEUTICS OF THE RESPIRATORY PASSAGES. injected 0.002 grain under the skin of an infant thirteen months old suf- fering from capillary bronchitis ; it produced free vomiting, by which the child was much exhausted. Occasionally without causing vomiting apo- morphia has produced unpleasant and even alarming symptoms. Some- times these appear to have been due to the use of a solution which had become green, a change it soon undergoes. It is therefore desirable to use only fresh solutions. Lobelia and tobacco are both powerful depressant expectorants. They kill by depressing the respiratory centre. The active principles, lobelin and nicotin, are very powerful depressing and irritating poisons. They are quickly eliminated, chiefly through the kidneys. Both medi- cines have been said to be expectorant, but are not much used as such. Lobelia is reputed to possess a considerable power over spasm of the bronchial muscles, and for this reason is esteemed by some physicians, who give from ten to twenty drops of the tincture every quarter of an hour until nausea is produced, in order to arrest paroxysms of asthma. Others give as much as a drachm, and repeat it in two hours if no relief follow. But these large doses sometimes produce alarming collapse, and their effect must be closely watched. Ten minims of the ethereal tincture may be added to expectorant mixtures when there is a ten- dency to bronchial spasm. Lobelia is a powerful irritant of the stomach and bowels, and has been sometimes popularly used, probably on this account, but it has given rise to a number of fatal results. Even under medical supervision grave symptoms have frequently arisen, especially in weakly or young patients. Indeed, it ought not to be given to chil- dren, and altogether is not a remedy in which I have much confidence. 2. Stimulant Expectorants. — These include {ci) substances which act directly on the membrane, those (i) which stimulate the centre, and (c) those Avhich, though exercising an influence over the respiratory or- gans, excite the circulation. Sometimes general stimulants become ex- pectorants, as by sustaining the system for a time they either promote the bronchial secretion, or, more important still, in the cases in which they are required, enable the patient to expel it. Hot beverages and liquid nutrients assist in fulfilling these indications. In other instances exercise and gymnastics are anpropriate. Alcohol, ether, essential oils, terebinthinates, and oleo-resins find their place here. Stimulants of the centre, like belladonna and strychnia may also be used with a view to sustaining respiration and assisting the removal of the sputa. Ammonia and its carbonate are powerful general stimulants with expectorant properties, operating on the central nervous system and es- pecially stimulating the respiratory and cardiac centres. As a volatile stimulant ammonia may be supposed to determine toward the respira- tory membrane, but it appears to be oxidized in the system, at least a portion of it, and to escape, as shown by Bence-Jones (" Phil. Trans.," PlfEUMATICS. 225 1851) by the kidneys. A small quantity injected into the blood of an animal greatly accelerates the respiration. Not only does section of the vagi fail to prevent this, but the change from the slow, deep breathing of divided vagi to the extremely rapid breathing of ammonia-poisoning is most remarkable. The increase in the pulse is chiefly due to the effect on the cardiac centre, though it also exercises a powerful but evanescent stimulant action on the heart. On injection into the veins Lange found a momentary fall of arterial pressure, followed by an enormous sudden rise, corresponding with the increase of the pulse-rate, and which by other experiments {Archiv f. exper. Path. u. T/ier.) he showed to be due to an effect upon the heart itself, or on the peripheral vaso-motor nerves, or on the muscular fibres in the coats of the arteries. In poison- ous quantities Funke found the heart was quickly paralyzed [PJiueger^s Archiv). Felz and Ritter {Jahr. de VAnatomle et de la Phys., 1874) ob- served that the red corpuscles were injured in a dog killed by ammonia. As an expectorant the carbonate is generally employed, and is appropri- ate in feeble patients when the secretion is tenacious and difficult to raise. By sustaining the centre it improves the coughing power, and enables the patient to get rid of the accumulation. It is therefore in the bronchitis of old and weakly people, in pneumonia when the heart is failing, or when it occurs in the course of typhoid, that it is most ap- propriate. In short, it is as a general stimulant, with a very special action on the respiratory centre, as well as on the circulation, that it is most valuable. That it also does affect the bronchial membrane seems to be shown by the fact that in some instances of death by poisoning this membrane has been found intensely congested. It is often added to other expectorants, such as senega, in order to increase their effects. Compare its action with other respiratory stimulants. Scilla. — Hippocrates employed squill (o-KiXAa) for various purposes, and Pliny describes (lib. xix., cap. 30) two sorts, and mentions that Pythagoras had written a treatise on the medicinal virtues of squill and invented the acetmn. Durastantes ' extolled this preparation in 1567, Alberti ^ and Schuize ' recommend it in asthma, and Brichenden * says that in his time it was used in both asthma and dropsy. Its action as a diuretic was discussed by Cullen ^ and Home," while Vogt ' contrasted it ' Durastantes, J. M. : Libri duo Medici, i., De Aceti Scillini compositione mirificis, ob saiiitatem ac vitam duitissime producendam viribus, ac congruo usu. 15C7. 2 Alberti, M. : De Sqnilla. 1722. ^ Schiilze, J. H. : Disp. sistens aegrotum Asthmaticum nsu radicis Scillae sublevatum. 3737. Also, Examen chemicum radicis Scillge mariiiEe. 1739. * Brichenden, J. : De radice Scillse. 1759. * Cullen, W. : Treatise Materia Medica. 1789. * Home : Clinical Experiments. 1783. ' Vogt : Lehrb. d. Pharmakodyn. 1828. 15 226 THERAPEUTICS OF THE RESPIRATORY PASSAGES. with digitalis. The diuretic effect was naturally noticed before the ex- pectorant, but the latter has been well established. It was also early recognized that scilla is very irritant, full doses causing nausea, vomiting, and perhaps purging. In toxic quantities inflammation and even gan- grene of the stomach and intestines have been seen and strangury and convulsions have occurred. Scilla is a powerful stimulant of the mucous membrane, we may per- haps say of all the mucous membranes, but it exercises a special influence on the bronchial surface, where scillain has been shown to be eliminated. It is further entitled to a place among the stimulant expectorants as it possesses a very decided action on the heart, in respect to which, as well as to its diuretic qualities, it may be compared to digitalis, with which, indeed, it is very often advantageously combined. The force of the car- diac contraction is increased by this medicine, but not the frequency, which is rather retarded. At the same time contraction of the periph- eral vessel is produced, with a rise in the blood-pressure. This is followed by relaxation, which mostly begins in the renal arterioles, and thus ac- counts for the diuretic action. Squill increases both the secretion and the vascularity of the bronchial membrane ; it is therefore contra-indi- cated in acute cases. Active congestion of this membrane becomes acute inflammation under the influence of scilla. It is true that in strong per- sons it may seem to do good, for by increasing the amount of secretion and at the same time rendering it thinner this remedy may facilitate its expulsion and so give rise to a deceptive appearance of relief, while it is in reality aggravating the disease. But in chronic cases with some pas- sive congestion it may be very appropriate. In relaxed conditions of the membrane, in leuco-phlegmatic constitutions, and in aged or debilitated patients, when the expectoration is viscid and raised with difficulty, pro- vided the skin be cool, soft, and moist, and the pulse sloWj soft, or weak, the best effect may be obtained. If the right heart should be at the same time secondarily affected, the remedy will l)e still more applicable, as it will act favorably in sustaining the circulation. But if the pulse be hard and quick, and the expectoration purulent, there is considerable risk of its doing mischief. It is quite possible that in such a case it may indi- rectly benefit a strong patient, by exciting a profuse secretion and thereby unloading the capillaries. In doubtful cases it may be combined with antimony or with refrigerants ; but when these are required it is usually too soon to begin squills. The rule is, in acute inflammations it is not to be given — nor is any stimulant expectorant. Ipecacuanha, it is true, has a stimulating influence on the membrane, in increasing and liquefying the secretion, but in the doses usually prescribed the irritation is not great and the other qualities of this drug make it a depressant expectorant. Scilla is apt to derange digestion, and may therefore be inadmissible when otherwise indicated lest it should interfere with nutrition. In such PNEUMATICS. 227 cases combinations with ammonia, belladonna, or carminatives may be em- ployed, or these and other remedies substituted, with perhaps minute doses of ipecacuanha, reserving the squill for a later period. Senega was introduced as a remedy for the bites of snakes and other venomous creatures by Dr. Tennent,' a Scotch physician, residing in Pennsylvania in 1738, and soon after we find from C. Linnaeus ° that it had been employed in fevers and inflammations, and he considered it diuretic. By 1782 Hellmuth ' was able to collect remarks from various writers as to its use in pleurisy, pneumonia, hydrothorax, asthma, rheu- matism, dropsy, etc.; it was considered to promote most of the secre- tions, and therefore was employed in numerous diseases. But it has failed to maintain its reputation, except in bronchial affections, and in these it is still confidently prescribed. Sundelin * took twenty grains of the powder every two hours for three doses ; he found it greatly irri- tated the back of the tongue and throat and increased the flow of saliva. A little later it caused burning at the epigastrium, nausea, and vomiting, as well as griping pains and watery purging. The gastric uneasiness with loss of appetite lasted three days. The skin was rendered warmer and moister, and diuresis, with a feeling of heat in the urinary passages was produced. Larger doses caused violent vomiting and purging, with giddiness and anxiety. It appears to excite the vascular system, and to stimulate all the mucous membranes ; but its chief value is for its effect on the respiratory membrane. Its irritant quality has caused the pow- der to be used as an errhine, but it is internally that it is chiefly em- ployed. It promotes the secretion of the bronchial membrane, and ren- ders it less tenacious. It is believed to stimulate the circulation in that membrane, as well as the nerves, so that it assists the expulsion of the sputa, and is therefore a valuable stimulating expectorant, acting in both ways. Senega also acts upon the heart in the same way as squill and foxglove, diminishing the frequency, but not the force of the beat ; prob- ably, also, it affects the circulation, and through this may be diuretic. It contains saponin, which has some analogies with digitonin, and may be perhaps identical with it. This active principle is locally very irri- tating and affects the whole circulatory and nervous systems ; it is ex- creted by the bronchial membrane (which perhaps explains the expec- torant action of senega) as well as by the skin and kidneys, both of which it stimulates to increased action. As a diuretic it increases the amount of the solid constituents of the urine as well as the water. So powerful a stimulant to the respiratory membrane is to be avoided ' Tennent, J.: On the Rattle-snake Root. 1738. Also, Epistle to Dr. Mead con- cerning the Efficacy of the Seneca Snake Root. 1743. ^Linnaeus, C. : Radix Senega. 1749. " Hellmnth, L. C: De radice Senega. 1783. ^ Sundelin : Handb. d. spec. Heilmittell. 228 THERAPEUTICS OF THE RESPIRATORY PASSAGES. in acute inflammatory conditions. It may even be capable of convert- ing congestion into inflammation. In pneumonia and piitiiisis it is also as a rule too stimulating. As it irritates the stomach and bowels, it is desirable to avoid it where the digestion is easily disordered and when there is a danger of impairing nutrition. Moreover, most persons con- sider it nauseous, so much so that many decline to take it. Its greatest value is in chronic bronchitis, in debilitated constitutions, and when am- monia is called for. The infusion then forms a good vehicle for car- bonate of ammonia. Some persons venture to give it before the febrile stage has completely passed by, but most observers admit that it is much better at a later period. Some have so much faith in its specific action on the membrane, that in order to obtain that at an earlier period, i.e., before they would venture to give it alone, they give with it, or at the same time, small doses of antimony. This, of course, increases the tendency to vomiting which is produced by the senega, and it would be more rational and more in accordance with the knowledge we have ob- tained of its action to postpone its use until antimony becomes no longer appropriate. Turpentine. — Several terebinthinates have been employed from an early period, though it is not easy to identify the particular plants spo- ken of by ancient writers. Probably the pistachia terebinthus is the terebinthus of the ancients (the T€p/i,iV^o9 of Dioscorides and Theo- phrastus). Oil of turpentine is a powerful stimulant to the various mucous membranes, and also to muscular fibre ; it is largely excreted by the lungs and kidneys, perhaps also to some extent by the intestines. Some of it passes out through the skin, and an eruption is occasionally produced by it ; it is extremely irritant to the kidneys, which fact pre- vents its being used when otherwise it is indicated ; but it has been em- ployed in many very different diseases. It is a depressant of the ner- vous system, an effect which begins to manifest itself as soon as the reflex stimulant influence has been produced. A full dose produces, after" preliminary excitement, dulness, drowsiness, and unsteady gait, and a larger quantity, coma. At the same time the heart is interfered with, and the blood-pressure falls. These facts may perhaps explain the re- markable power of turpentine to arrest haemoptysis, and other forms of internal hemorrhage ; a full dose sometimes acting like a charm, when all astringents have failed. This effect may perhaps be partly due to an effect upon the vessels. In the bronchial walls it appears to affect the vascular supply, and also the muscular fibres. It must also be a disin- fectant to the sputa, and for this reason is useful in chronic bronchitis, bronchiectasis, and pulmonary gangrene. Locally we know that the fumes of terebinthinates and allied substances have long been found to exercise an important influence on the respiratory membrane. This local influence is no doubt e.\ercised upon the capillaries, glands, and nerves of PNEUMATICS. 229 the membrane during the exhalation of the remedy, which imparts its own odor to the breath. The inconvenience attending the administration of oil of turpentine is derived not from its effect on the gastro-pulmonary membrane, but on the o-enito-urinary tract, to which it determines, and also on the kidneys, which it greatly irritates, even small quantities often giving rise to lum- bar pain, diminution or sometimes suppression of urine, strangurj'', and haematuria. Although, therefore, it has been used as a diuretic, and is generally speaking antispasmodic, any excess in the dose produces oppo- site effects, and it is often necessary to omit its use on account of renal irritation. Besides these symptoms toxic doses often, but not invariably, occasion vomiting and purging. The giddiness and intoxication which succeed the preliminary, no doubt largely reflex, excitement rapidly pass into a state of extreme depression. Complete unconsciousness comes on in some cases with dilated pupils, the pulse becomes rapid and weak, and the respiratory centre fails. At a very early period the effect on the renal organs was observed, Ranchin,* in 1640, having given us an ac- count of the violet odor imparted to the urine by the remedy, and Wil- helmi ' gives an account of its use in diseases of this membrane and com- pares it with balsams. Durand ' a century afterward recommended it in biliary calculi. During the present century the properties of the medicine have been more carefully studied and its position among thera- peutic agents determined. AH the turpentines properly so called are odorous exudations from the stems of trees belonging to the coniferas ; some, as frankincense, are solid, others, like Canada balsam, liquid ; all of them are mixtures in va- rious proportions of volatile oils and resins, these can be separated by distillation. Thus pure oil of turpentine, sometimes improperly called spirit or essence of turpentine, is the volatile oil obtained from various species of pinus by distillation from the crude exudation, the solid resin being left. When freshly distilled the pure oil is colorless and limpid, but on exposure to the air it absorbs oxygen, gets yellowish and thicker, and a resin is produced. Moreover, it converts part of the oxygen into ozone, for which reason it is employed in the guaiacum process for de- tecting blood. The oil is very slightly soluble in water and less soluble in alcohol than most volatile oil, it is, however, readily taken up by ether ; in its turn it dissolves fixed oils and fats, resins, india-rubber, etc. Prepared from different sources it behaves differently toward polarized ' Ranchin, P. : Traite curieux sur I'odeiir de la violette que les Terebinthines don- nent aux urines. 1640. ^ Wilhelmi, J. : De Terebinthina. 1699. ^ Durand, J. P. : Observations sur I'efficacite d'un melange d'Ether sulfurique el d'Huile volatile de Terebeutliiue dans les Coliques Hepatiques produites pars des pierres biliares, 1790. 280 THERAPEUTICS OF THE RESPIRATORY PASSAGES. light, but commercial samples often consist of a mixture of several oils. Pure oil = C,o Hj^ and is therefore isomeric with many other essential oils, and is resolvable into terebine, cymene, a campiioraceous body, col- ophene, etc. We have dwelt thus particularly on its properties on ac- count of its intimate relations with other essential oils and allied reme- dies, some of which we will now notice. Firwood oil, obtained from the pinus sylvestris, may be regarded as identical with common turpentine, but rather less disagreeable in flavor. Essential oils are rather complex compounds, possessing powerful odors of very various kinds, many of which are greatly esteemed for their agreeable flavor and fragrance. They contain campliors, turpenes, resins, etc., and are allied to balsams and gum resins on tlie one side and to carbolic, benzoic, and cinnamic acids on the other. Many of them at a low temperature separate into a solid camphor-like body called stearop- tene (o-rcap, fat, tttt^vos, volatile), and the pure fluid hydro-carbon eloeop- tene (c'Aatov, oil, ttttjvos). We may make three groups : (a) Pure hydro- carbons or non-oxygenated turpenes, isomeric with oil of turpentine, C,„ Hjg, examples of this group are oil of junij)er, lavender, peppermint, cloves, and several others ; ip) oxygenated, of which cinnamon, caraway, etc., furnish examples ; (c) those which contain besides C and H a pro- portion of S, whether with or without N, these are marked by their pow- erful and often fetid odor, as in the case of oils of mustard, horseradish, and assafoetida. Essential oils are partly excreted by the pulmonary mucous mem- brane and stimulate it in a manner resembling turpentine and camphor, and may therefore sometimes be substituted as more agreeable medicines. As we have seen, they differ considerably among themselves in fragrancy, flavor, and other qualities. And so they do in their therapeutical value, but they may all be regarded as weakly antiseptics, as stimulants, and antispasmodics, and inasmuch as they are eliminated to some extent through the bronchial membrane, claim to be regarded as expectorants. Many of them, however, exert their principal effect on the alimentary membrane, exciting the nerves of taste and smell, promoting the flow of saliva, stimulating the stomach, and increasing appetite ; they are there- fore commonly called carminatives and stomachics. The muscular coat is also stimulated, and the consequent contractions expel flatus and re- move the pain caused by distention ; they are therefore in a sense anti- spasmodic. This stimulating influence extends along the intestines and some of them are highly prized in colic and as corrigents of purgatives. They enter the blood and directl}' excite the whole nervous system, though perhaps some of their stimulating influence may be regarded as reflex. The pulse rises in force and frequency ; under their influence the blood-pressure is also raised, but these remedies are not often given in doses sufficient to affect the circulation or to be much felt through the PNEUMATICS. 231 general nervous system. They are excreted by all the mucous membranes, chiefly through the kidneys and bronchial membrane, upon which, as we have said, they may exercise their special effect while being eliminated. Oil of eucalyptus, which has lately been so largely used, is antiseptic, and being excreted by the kidneys and lungs imparts its odor to their excretions, disinfecting them and at the same time stimulating the mu- cous surface ; it has therefore been freely used in cystitis and pyelitis on the one hand, and on the other much more freely in bronchitis, asthma, and other respiratory affections. Oil of anise has generally been held to determine toward the respiratory membranes, while the mints, cloves, pigments, caraway, coriander, etc., most affect the alimentary membrane, and juniper is a diuretic and is identical with turpentine in its composition and specific gravity, and resembles it in imparting a violet odor to the urine. Garlic, onions, leeks, and other strong-smelling vege- table substances employed in cookery, owe their qualities to their essen- tial oil, and have long had a popular reputation as expectorants in chronic catarrh. In some districts raw onions are eaten by elderly sufferers from bronchitis, under the belief that they help their winter cough, and with the same view leeks and garlic are freely used in their diet. Camphor may be regarded as an oxidized product of an essential oil, or a stearopten ; its formula is C,„H,gO, and it has so distinct an effect on the bronchial mucous membrane, through which it is eliminated un- changed, that it has long enjoyed a popular reputation in catarrh and other affections, the powder being even used as snuff. In moderate quantities it does not give its odor to the breath, and it is not eliminated as such, but in a changed condition through the kidneys. It is somewhat antiseptic and generally regarded as a diffusible stimulant and antispas- modic. In ordinary doses it is rapidly absorbed and apparently rapidly decomposed, and does not produce a great effect, but in full doses its chief action is on the brain, where it may produce giddiness, drowsiness, and a species of intoxication. ( Cf. Neurotics.) Oil of camphor is a hy- drocarbon C,„Hj5, isomeric with oil of turpentine, and possessing in a high degree the odor and other qualities of camphor. Canada balsam is the turpentine which exudes from the balm of Gilead fir — abies balsamea. It has sometimes been given internally, for the same purposes as ordinary turpentine, and is believed to be less irri- tating. It is not a true balsam, but yields a volatile oil on distillation. Fine specimens are sometimes sold as balm of Gilead, which, however, is the product the balsamodendron opobalsamum. Other turpentines have also been used, and they all possess, though in different degrees, similar qualities. Iialsam.s. — The true balsams are the fragrant, resinous substances which contain benzoic or cinnamic acids, and all of them have some claim to be considered expectorants. In the Pharmacopoeia we have four true bal- 232 THERAPEUTICS OF THE RESPIRATORY PASSAGES. sams, viz. : benzoin, storax, and the balsams of Peru and Tolu, Copaiba is not a balsam, but an oleo-resin, as is Canada balsam. lialsam of Peru, though a stimulating tonic and expectorant, is not much used internally in the present day. Like its allies it may be considered antiseptic, it seems also to be a nervous sedative. lialsam of Tolu possesses similar qualities, but its flavor is much more agreeable, and consequently it re- tains its place as a valued ingredient of cough-mixtures, though in the quantities in vehich it is mostly employed it is more a flavoring ingredi- ent than an active therapeutical agent. At one time the use of balsams and other somewhat stimulating substances was almost universal, but now they have become unduly neglected, and certainly in chronic bron- chitis, winter cough, and any old standing affections of the respiratory membrane, and in bronchitic asthma they deserve attention. They began to be neglected from the time when Dr. Fothergill ' pointed out the evils that might follow their indiscriminate use, about one hundred years ago. But Trousseau and Pidoux" have expressed considerable confidence in them as remedies in chronic bronchial catarrh, though in the present day it is their local use which is most trusted. Benzoin is not named by ancient writers in such a way as to enable us to identify it, but it must have been known at an early period, and has long been used in incense. It seems to have been confounded with other bal- sams, all of which were believed to exercise considerable influence and were highly valued as medicines. In 1530 Perez^ wrote a treatise upon their use. In 1592 Alpinus^ distinguished some of them, and in 1597 Guibert^ pointed out the distinction between benzoin and myrrh. Eenzoin is the most irritating of the balsams, therefore the most likely to derange the digestion ; its effect on the respiratory mucous membrane resembles that of the others, but it is more stimulating and therefore should be avoided where there is any degree of irritation. In chronic cases, in leuco-phlegmatic constitutions it may be employed. Benzoic acid has also been used internally for this as well as other pur- poses, as well as topically. Storax was well known to the ancients ; it is mentioned by Hippocrates, Theophrastus, Dioscorides, and later on by Galen, under the name (TTvpa^, and Pliny calls it styrax. The source of this and some other drugs related to it have been carefully investigated by the late Daniel Hanbury," whose papers on such subjects are full of ' Fothergill, John : Works, edited by Lettsom. 1783. ^ Trousseau et Pidoux : Traite de thorapeutique. Third edit. 1874. ^ Perez. G. : De Balsamo, j de sus utilidades para les enfermedades del cuerpo humano 1.530. * Alpinus, Prosper : De Balsamo Dialogiis ; in quo verissima balsami plantse, Opo- balsami, Carpobalsami et Xylobalsami, cognitio elucesoit. 1.592. * Guibert, N. : De Balsamo ejnsque lachryma quod Opobalsataum dicitur. 1603. * Hanburj, Daniel, F.R.S. : Science Papers. 1876. PNEUMATICS. 233 information and interest. The therapeutical use of styrax is the same as the other balsams. Gum Eesins. — Olibanum and myrrh are both of great interest on ac- count of their long history and the immense value at one time attached to them. Olibanum, the Lebonah of the Jews, the Luban of the Arabs, the Xt)3ai/os and Xt/Javwros of the Greeks, was doubtless the frankincense of the ancients. It is mentioned in the book of Exodus (xxx., 34). It contains a volatile oil besides gum and resin. It was long regarded as most useful in chronic mucous discharges, particularly those of the respi- ratory membrane, and was also employed in other chest affections, even in hfemoptysis ; it may be regarded as a stimulating expectorant and is most efficacious as a fumigation. Myrrh was a most important article of commerce at the very dawn of history, the company of Ishmaelites who bought Joseph from his brethren " came from Gilead with their camels bearing spicery and balm and myrrh, going to carry it down to Egypt " (Genesis xxxvii., 25). Its Hebrew name is mahr ("''?), most likely in allusion to its bitter taste ; the Greeks called it cryaupra, and in the ^olic dialect fxvppa. Hippocrates valued it in several diseases and Dioscorides described several kinds. But, notwithstanding the early period at which the product was known and its importance as an article of commerce, we had no accurate account of the tree which produces it until quite modern times. An interesting account of this investigation has also been given by Hanbury.' Guibert " distinguished it from benzoin, for Haller, speaking of his work, says, " Agit de myrrha, de vino myrrhato, de benzoino ; negat pocula myrrhina facta fuisse ex benzoino, et benzoina myrrha differre do- cet." In the next century Polisius ' collected a curious account of the uses of this drug and the numerous formulte in which it was employed, an example followed by an English writer* at the commencement of the present century. Myrrh promotes the appetite and is considered as a good stomachic. Like the other remedies to which it is related it appears to be eliminated by the mucous membranes, upon which it acts as a moderate stimulus. In large doses it may irritate the stomach and cause a degree of pyrexia with a full pulse and a feeling of warmth in the respiratory passages, but it does not appear to possess to any extent the nervine and anti- spasmodic properties of the fetid gum-resins, such as assafoetida, galba- num, etc. It is, however, considered more distinctly tonic, in which it is ' Hanbury, D. : Op. cit. ^ Guibert, N. : Assertio de murrhinis, sive de iis qufe murrhino nomine exprimun- tur, adversiis quosdam de iis minus recte disserentes. 1597. ^ Polisius, G. S. : Myrrhologia seu myrrhae disquisitio curiosa. 1688. ■* Stackhouse, J. : Extracts from Modern Authors respecting the Balsam and Myrrh Tress. 1815. 234 THERAPEUTICS OF THE EESPIRATORY PASSAGES. distinguished from the balsams. In chronic bronchitis it may therefore be useful. It has been lauded in phthisis, in which it was supposed to check purulent expectoration, but it is more likely to prove injurious in this disease, at any rate in large doses. It has been much employed in gar- gles and mouth-washes ; it may be considered somewhat antiseptic. Halm of Gilead, the balm of the Old Testament, the BaXcra/Aov of the Greeks, also called balm of Mecca, once so highly valued, is now sel- dom employed in Europe, but in Asia still retains its reputation both as a medicine and a perfume. It contains a volatile oil and its properties are closely allied to the terebinthinates. Hdelliwn is the name applied to two gum-resins, one of them proba- ably the bdellium of the Bible, also called Indian bdellium, or false myrrh, the other called African bdellium ; the former is the more fragrant and resembles myrrh, the latter contains a volatile oil. Neither are now much use^. Ammoniacum still retains considerable repute as a stimulant expecto- rant, and in this respect is perhaps overrated, being scarcely superior to several of the almost obsolete gum-resins and interior to the fetid ones. Two kinds have been described, and that used by the Greeks, a./i,/iwvta/coi/, differs from the article now in use. Pliny says it grew near the temple of Jupiter Amnion, to which the name has been traced, but others think it quite as likely that it is only a corruption of armeniacum, having been probably imported through Armenia. From Abu Mansur Mowafik ben Ali ' we learn that it was found in Persia as early as the tenth century. It is mentioned by various writers, Greek and Roman, from the first to the thirteenth century, as an incense or fumigation, thymiama and suffi- men. Ammoniacum is decidedly a local irritant, and large doses are there- fore apt to disturb the stomach. It appears to be eliminated by the mucous membranes, upon which it acts as a stimulant. It contains a small quantity of volatile oil, which probably escapes through the lungs and accounts for its stimulant action on the respiratory membrane. The irritation of the skin produced by the plaster would seem to be due to the resin. In the small doses usually given it can hardly be considered to have much action on the system, but full doses are apt to cause vomit- ing and purging by their local irritating action. In chronic bronchial catarrh and in asthma, and in some cases of emphysema if there is a good deal of secretion from a relaxed condition of the membrane, it sometimes appears to be useful, though Trousseau and Pidoux [op. cit.) took it in doses of two drachms without producing anv effect, local or general. It is certainly less efficacious than the fetid gum resins. Cullen "^ preferred ' Liber Fundamentoriim Pharmacol ogiae. 1055. 2 Cullen, W. : First Lines of the Practice of Physic. 1784. Fourth ed. PNEUMATICS. 235 assafoetida as an expectorant, and when any antispasmodic influence is desired it would be well to combine it with one of its more disagreeable allies. These /etid gum resins have held a distinct place in materia medica from the earliest times, and are still valued as possessing very distinct properties, dependent, probably, for the most part on the essential oil which can be obtained by distillation. In spite of what we consider their extremely disagreeable odor they have been and are prized in the East for this very property, and have sometimes been employed among us in cookery, though only in the most minute quantities. The most impor- tant and the strongest is assafoetida. Although undoubtedly used by the ancients the history is not very clear, on account of the confusion between it and the succus cyreniacus. It seems as if it had been introduced as a substitute for the cyrenian juice, probably from Persia, the word assa corresponding with laser, pointing to that source, but Myrepsus,' who lived about 1227, speaks of dcra<^iriSa. Assafoetida is a nervine stimulant, antispasmodic, and may be re- garded also as expectorant. In truth all these fetid gums might very well be grouped together as antispasmodic expectorants. Some have called it disinfectant, as such it would be a good illustration of a more powerful odor overpowering a weaker one, and so obtaining the credit of destroying it. It is readily absorbed and is eliminated through all the secretions, charging them with its disagreeable smell. It exercises a de- cidedly stimulant influence on the mucous membranes, particularly the bronchial, through which a considerable portion of the essential oil es- capes. So completely does it pervade the system that the pus of super- ficial ulcers has been observed to smell strongly of the drug. .Joerg ^ found that in doses of twenty grains assafoetida caused in healthy per- sons irritation of the stomach and bowels, with increase of the secretion of the alimentary membrane and of the fceces. The bronchial secretion was also increased, the respiration quickened, and together with this the pulse rose, the animal heat seemed augmented, and perspiration was pro- moted. These and other excitant effects were verified on nine healthy persons, the dose in no case exceeding twenty grains. Nevertheless Trousseau and Pidoux swallowed half an ounce for a dose, with no other effect, they tell us, than having to live for two days in an atmosphere more horribly fetid than the drug itself. It is said that the perspiration of Asiatics who use assafoetida daily is verv fetid, a circumstance alluded to by Aristophanes,' but probably it is the breath which is more tainted and distributes the odor round the person, though there is little doubt that ' Myrepsus, N. : Antidotarius, cap. xxvii., cited by Alston, Materia Medica, vide Sprengel's Hist. * Joerg : Vide Wibmer. Werk. d. Arzneim. u. Gifte. ^ Aristophanes : Equites, act ii. , scene 4. 236 THERAPEUTICS OF THE KESPIRATORY PASSAGES. the skin also excretes some. As a stimulant and antispasmodic expec- torant assafcetida is well adapted to relieve chronic bronchial disease, at- tended with dyspnoea and wheezing, especially in old and weakly persons where the disease is of long standing, and where the dyspnoea is some- what paroxysmal. Another class of cases in which it often produces bene- fit is recurrent bronchial catarrh, attended with wasting, in young women who seem predisposed to phthisis and in whom debility and amenorrhoea cause anxiety. It is scarcely as an expectorant, however, that in such cases it is most useful, for under its influence the bronchial secretion often diminishes ; but there is no doubt that the effect on the bronchial membrane is favorable, it may almost be called soothing, and the other Avell-known properties of the drug indicate its use. Combinations with ammonia, where a more stimulating influence is needed, are most valu- able and should be used when the circulation is languid. In pure spas- modic asthma, assafoetida is uncertain. Cullen,' who placed great reli- ance on the drug in other diseases, found it of no benefit in this, and his opinion is indorsed by Pereira." Still it may often be advantageously taken in combination with other remedies between the paroxysms, with a view of giving tone to the respiratory system, especially when attacks are provoked by damp. It is more useful still in bronchitic asthma. In laryngismus and in whooping-cough it has been very strongly recom- mended both by Millar ' and Kopp,^ but I cannot report much in its favor, and it is difficult to persuade children to take it. Galbanum. — The next most important of the fetid gum-resins is mentioned among sweet spices in the book of Exodus (xxx., 34). It was used by Hippocrates and other Greeks. Dioscorides spoke of -^aXjiavy] as the produce of fxerwTnov, which grew in Syria. Its physiological and thera- peutical properties resemble those of assafoetida, and it may be ranked between that drug and ammoniacum, but as it yields more essential oil than either it has been supposed to be more excitant to the circulation. Clini- cal observation does not support this idea, and it may be that the oil, though greater in quantity, is of a less powerful kind. It is decidedly less antispasmodic and probably less expectorant, and for the most part only employed in combination with its more powerful ally. Similar observations may be made respecting Saga2yennm, the o-aya- TTtyjv^v of Hippocrates and Dioscorides, the sacopenium of Pliny, which, so far as the respiratory membrane is concerned, may be ranked between assafoetida and galbanum, though it may be remembered that it acts more decidedly on the alimentary mucous membrane, and has therefore been ' Cullen, W. : Treatise on Materia Medica. 1789. *Pereira, J. : Elements of Materia Medica and Therapeutics. 1853. ^Millar, J. : Observations on the Astlima and the Whooping-cough. 1769. *Kupp: London Medical Gazette, vol. i. PNEUMATICS. 237 used as a warm aperient in constipation with flatulence. The essential oil has a strong odor resembling garlic, and a bitter garlicky taste, which is shared by the resin. Opoponax was also employed by the Greek fathers of medicine, who mention, some three and others four, kinds under the names Trai/a/ccs and oTTOTTavo^. Dioscorides, who describes three kinds of the gum-resin, gives a good account of opoponax {oiroirava^), wlrich he tells us was procured from the Trdi/aKcs rjpdKXaov. In composition this resembles the preceding gum-resins and is most like ammoniacum in its properties ; it may often be advantageously combined with this, and though excluded from the British Pharmacopoeia, perhaps deserves a place as much as a number of other little used substances. The essential oil is eliminated through the lungs and acts on the bronchial membrane, stimulating it to increased secretion but not often appearing to irritate. Eleini, apparently a word of Ethiopian origin, is probably derived from several of the terebinthaceae, and its effects are similar to other tere- binthinates, but it is abandoned to external use. The ointment is some- times called the balm of Arcaeus, being a substitute for an ointment in- troduced by that writer.' Copaiba has sometimes been employed in bronchial affections, instead of some of the other oleo-resins, and Armstrong,'' Halle, Bretonneau,^ Bayle,^ and others have recommended it, but it has no superiority to the other substances, is extremely disagreeable to take, sometimes gives rise to severe gastric irritation, and on account of its associations and of its affecting the bronchial less distinctly than the urinary passages is better abandoned to the treatment of diseases of the latter. Mastich, obtained from the Island of Scio, also contains a volatile oil, and so possesses in some degree the properties of the terebinthinates. Highly prized for centuries, it was used by Hippocrates, who also employed the leaves of the tree a")^vov, as well as the resin, and an oil obtained from the fruit. It is scarcely ever now used in medicine, though it so long enjoyed a high reputation, and should have some power in chronic affections of the mucous membranes. Inula Helenium, the kXiviov of Hippocrates and Dioscorides, our ele- campane, is an aromatic tonic as well as an expectorant, also somewhat diaphoretic. Thus it seems to promote the secretion of most mucous membranes and of the skin. In large doses it is sufficiently irritating to cause nausea and vomiting. Its action resembles that of senega, but it is milder, and as it has had some repute as a tonic in dyspepsia it may ' Arcaeus : De recta Curand. Vulner. Ratione. 1658. ■^ Armstrong, J. : On the Efficacy of Copaiba in Inflammation of Mucous Membranes. 1823. ^ Bretonneau ; Memoire sur la diphtherite. * Bayle, A. L. J. : Bibl. de Therapeutique. 1838. 238 THERAPEUTICS OF THE KESPIRATORY PASSAGES. be presumed tliat it is less likely to irritate the stomach than senega, and is certainly less nauseous. It is in rather chronic bronchial affections with profuse secretion, in the absence of pyrexia, that it is most likely to be useful. The name inulin has been sometimes applied to a substance resembling starch obtained from Helenium, but which its discoverer, Rose, called alantin. The active principle seems rather to reside in a camphor- aceous body, which has been* called alantol, or alant camphor, somewhat resembling- menthol in taste ^nd smell. Larix. — This interesting tree has again been brought somewhat into notice after having suffered a long eclipse. From it is obtained Venice turpentine, to which wonderful virtues were long attributed, and which has lately acquired a sudden but ephemeral notoriety. Orenburgh gum and manna de Brian9on were also the products of the larch. Dr. Frizel, of Dublin, introduced the inner bark, in 1858, as a somewhat stimulant medicine, possessing also astringent properties, with a special action on mucous membranes, especially the bronchial, and a tincture of this bark has found its way into the Pharmacopoeia, and is often used to check profuse expectoration in chronic bronchitis. It has also been used in haemoptysis and other hemorrhages. Dr. Stenhouse obtained from the bark a volatile active principle, which he could not find in other pines, and which he called larixinic acid, on account of its reaction, but which some have termed larixin, an inconvenient name, as it may be confused with another body to be named just now. The common larch is also the source of a fungus, which for a long period was highly valued, the agar- icus laricis, or boletus laricis, or boletus officinalis, boletus purgans, polyporus laricis vel officinalis, as it was variously called. This fungus was known to the ancients, Dioscorides describing it under the name AyaptKov, while in the East it is now known as ayapiKov ToXevKov and Karpav fxavTupi, It may still be found at herbalists', under the name of agaric, female agaric, white agaric, or larch agaric. The active principle has been referred to the resin, but Martins ' isolated a white amorphous bitter- tasting powder which he termed laricin. The resin certainly possesses irritant qualities and is purgative. The powder of agaric is a local irritant, causing watering of the e3'es, sneezing, cough, etc., when applied to the nostrils. Swallowed, it acts as an emetic and a purgative, causing con- siderable nausea and griping, but its most important use was to arrest colliquative sweating in phthisis. De Haen recommended it for this purpose, and Bisson ' and many others' reported favorably of it, includ- ' Vide Bncliner's Repertoriuin, 1846. ^Bisson : Metnoire sur I'emploie de I'Agaric blanc contreles sueurs dans ]a plitliis'a pulmonaire. 1832. ^ Vide Rubel, J. : De Agarico offlcinali. 1778. Jacquin: Diss, de Agarico officinali. 1778. Murray, J. A. : Apparatus Medicaminum, tarn simplicium quam compositorum. 1776-90. PNEUMATICS. 239 ing Andral, who, however, afterward abandoned it as of little use. Tlie dose of agaric was from three grains to eight, at bedtime, to restrain sweating, and from one-half a drachm to a drachm as a cathartic. Tar and its derivatives are all more or less stimulant expectorants, but as they are more frequently used in respiratory diseases for their antiseptic qualities, they will be considered with other antiseptics in a separate group. 3. Alterant Expectorants. — These are chiefly alkaline, saline, or antiseptic. They promote the secretion of the bronchial membrane, but with little or no irritant effect, and may even rather depress than excite the circulation. Alkalies. — Something has already been said respecting recent experi- ments, which tend to throw doubt on the long-acknowledged power of alkaline carbonates to promote bronchial secretion and to render it less viscid. It had long been considered certain that these carbonates were partially eliminated by the bronchial membrane, but the experiments alluded to cast doubt upon this. It must be remembered, however, that the injection of a large quantity of soda into the blood is a very different thing from the administration of moderate medicinal quantities. Then it may be remarked that soda is a natural constituent of the blood, and a few grains more or less would scarcely make much difference by the mere fact of their presence. Clinical observation leads me to regard soda as very inferior to potash as an agent for attenuating the sputa, and might almost induce me to admit that it is powerless to do so. But the local effect on some mucous membranes resembles that of potash, though it is less marked, and we have Virchow's authority for stating that soda stim- ulates the movements of the cilia, and sometimes restores them after they have ceased. Then again it can scarcely be forgotten that mucin, which is readily precipitated by acids, dissolves freely in alkaline fluids. Even the precipitated form of mucin is easily redissolved by alkalies. The application of a solution of a potassium salt to the mucous mem- brane of the mouth increases the flow of saliva and even causes an opac- ity in the fluid which has been conjectured to arise from alteration of the secreting cells ; but irritation of the sympathetic nerve-filaments of the submaxillary gland will give rise to the same appearance. The question is, whether the bronchial membrane is affected in the same way. That some potash salts affect the mucous tissue is undeniable from their action on the bowels. Further, their effect in the mouth and phar3mx confirms the general observation that they really increase the bronchial secretion and render it more fluid, while they perhaps increase the activity of the cilia as well as the glands. Gubler conjectured that potash antagonizes soda in the blood and in respiratory combustion, inasmuch as it is found normally in the red corpuscles. Chlorate of potash has enjoyed a considerable reputation, though 240 THERAPEUTICS OF THE RESPIRATORY PASSAGES. partly on grounds for wliich there is no foundation. It has been largely used in croup and diphtheria, but does not deserve confidence. It could not be expected to sufficiently liquefy the exudation. It will, however, sometimes cause a degree of salivation, and in bronchitis, when the ex- pectoration is viscid and scanty, it seems to give relief by promoting the flow of the secretion and rendering it more watery, so that it may be termed, perhaps, an alterant expectorant. Dr. liaborde ' says that it both modifies and dilutes the expectoration in acute and chronic bronchitis, and Dr. Sedgwick ^ considers it useful in catarrh. Koehler ' had long be- fore employed it in phthisis, but without obtaining any benefit, though Dr. Fountain ■* at a later period endeavored to revive its use under the notion that it would act as a liberator of oxygen in the system. This idea unfortunately seems to have prevailed for a considerable time after it was shown that the chlorate is eliminated unchanged by the kidneys. Wohler ^ as early as 1824 reported that the chlorate among other salts passed off unchanged in the urine, and his observation has been fully confirmed ; nevertheless, the idea continues from time to time to crop up. It was entertained as recently as 1871 by Baudrimont," and has several times since been, complacently stated by contributors to the medical journals, but though this hypothesis must be abandoned, it does not fol- low that in some way the chlorate may not be of some service, as we know that other salines are. That it may affect mucous membranes is natural to suppose, since, as shown by Isambert,' it escapes in all the se- cretions, but its chief value is undoubtedly as a local remed}'. Dr. Harkin ^ reported that it improved the color and strength of some phthisi- cal patients, and lessened cough and diarrhoea. The late Dr. Symonds* seems to have thought that it could promote the healing of a cavity. Dr. Spender '° expresses a regret that its value in phthisis is not better ' Laborde, J. V. : De la valeur du Chlorate de Potasse dans le traitement des Glngivites Clironiqnes, etc. 1858. Also, Laborde, J. V. : Etude comparative de Tac- tion pliysiologique des Chlorates de Potasse et de Sonde, des Bromnres de Potassium et de Sodium. Deductions relatives a I'emploi therapeutique compare de ces sub- stances 1875. ^ Sedgwick, L. : Britisli Medical Journal, 1873. ' Koehler : Lancet, 1886-37. '• Fountain, E. J. : On the Treatment of Phthisis by the Chlorates of Potash, with Observations on Oxygen as a Therapeutic Agent. 1860. 'Wohler: Zeitschrift f . Physiologie, 1824. * Baudrimont, E. : Eeeherches sur Taction intime des substances qui aident a la decomposition dii Chlorate de Potasse pour en degager Toxygene. 1871. ' Isambert, E. : Etudes chimiques, physiologiques, et cliniques, sur Temploi thera- peutique du Chlorate de Potasse, spccialement dans les Affections Diphtheritiques. 1856. * Harkin : Dublin Medical Quarterly Journal, 1861. ' Symonds : British Medical Journal, 1868. "Spender: Brit, and For. Med.-Chirur. Rev., 1873. PNEUMATICS. 241 known, and M. Gimbert * endeavors to show that in certain forms of this disease it is of considerable value. On the other hand Dr. Cotton, in his trials at the Brompton Hospital, could trace no definite effects to the remedv, though sometimes it improved the condition of cachetic patients, while Dr. Austin Flint'' found benefit in only one out of fourteen cases. We may perhaps be permitted to infer from this discordant evidence that like other salines it is only useful in those conditions of the sys- tem which indicate this class of remedies, and this is the conclusion to which my own experience points. That in considerable doses it affects mucous membranes there can be little doubt, and the way in which it does this is probably by a local effect while being eliminated, and certainly its great power as a topical application in aphtha and other affections of these membranes is not to be denied, and gives it a place in therapeutics quite distinct from other potash salts. It may also be here observed that the chlorate is destitute of the powerful cardiac depressant action pos- sessed by the nitrate. With regard to the other salts both of soda and potash the statements already made will suffice. Ammotiiuin Chloride. — The early history of this salt, as it is often told, may after all be only a fable, for sal ammoniac, which is said to derive its name from Ammonia, the name of a district of Libya where stood the oracle of .lupiter Ammon, though mentioned by various writers, may have been only rock-salt. Besides, this district has been said to have obtained its name from the nature of the soil (a/Ajaos, sand), and after all the name may have been derived from a/xfiwi, a word of Egyptian origin. Herod- otus, it is true, mentions sal ammoniac (aX? d/x,/xa)via(cds) as found in this locality, but perhaps the name was applied to some other salt. Dr. Royle ' has remarked that the Hindoos must have been acquainted with sal ammoniac ever since they burnt bricks, as they now do with the ma- nure of animals, for some of it usually crystallizes at one end of the kiln. Moreover, they seem to have found out how to make the carbonate from it, and from them the Arabians probably learned the process. Geber * knew the method of purifying it by sublimation. Muys ^ recommended it in doses of one to two drachms in interniittents, and it became rather largely used for various purposes. The older writers thought that chloride of ammonium acted as a seda- tive to the heart, and at the same time quickened the capillary circula- tion. They also observed that it increased secretion, especially from the mucous membranes, and attributed to it the power of promoting absorp- ' Gimbert : De I'emploi du Chlorate du Potasse dans certaines formes de la Phthisie Pulmonaire. 1872. - Austin Flint: American Journal Medical Sciences, 1861. ' Royle : Antiquity of Hindu Medicine. 1837. * Geber: The Works of Geber. London, 1678. 'MuTS, W. G. : De Salis Ammoniaci Proeclaro ad Febres Intermittentes usu. 1716. 16 242 THERAPEUTICS OF THE RESPIRATORY PASSAGES. tion, though in a less degree than mercury. It was also said to impover- ish the blood, but in ordinary doses no impairment of the plasticity will be noticed, and no distinct effect on the circulation, though it has been shown that after poisonous doses administered to animals, the blood con- tained less solids than normally, Rabuteau ' has shown that it probably passes off by all the secretions. He found it speedily in the saliva, but the major portion is removed through the kidneys, and he was able to recover from the urine nearly the whole amount which had been taken. It nota- bly increased the amount of urea, and Bocker " found that it increased all the solids of the urine except uric acid, which was slightly diminished. In Germany sal ammoniac has been largely prescribed for gastric catarrh. In England it is chiefly used as a remedy for chronic bronchitis, and sometimes for acute catarrh ; but it is scarcely appropriate in the early stage of the latter, or when there is decided pyrexia. Perhaps its most appropriate use is after the more active symptoms have subsided, but be- fore a stimulant expectorant seems called for. Dr. Patton commends it {Practitioner, vol. vi.) in the later stages of pneumonia. Some writers seem to have supposed that it is decomposed in the system, ammonia being liberated and acting as a stimulant, but there is no foundation for the idea, and even large doses have no exciting effect. Dr. Copeland recommended it in passive hemorrhages, and Dr. Warburfcon Begbie has used it for this purpose with success {Lancet, 1875). The late Dr. Bei- gel {Lancet, 1867) arranged an apparatus for the inhalation of freshly formed chloride, and Liebermann has reported favorably of a similar ap- paratus of Loewin's {Bull, de Therap., 1873). Sulphur has been known from the earliest ages, it is mentioned in the Book of Genesis (xvi., 24) and in Homer's Jliad (lib. xvi.) as well as other ancient writers. It passes into the secretions and may be con- sidered a mild stimulus of the skin and mucous membranes, particularly the broncliial, but in large doses it acts on the intestinal lining. Among other uses it has accordingly been employed in chronic catarrh, asthma, bronchitis, croup, diphtheria, and pneumonia. Buchheim and some others doubt whether it really increases the bronchial and cutaneous secretions, but it is difficult to shut our eyes to the fact ; there is a difference of opinion at to the renal secretion. There is a vast amount of experience as to its favorable influence in respiratory diseases. It was a recognized remedy among the ancients. Galen sent consumptives to breathe the sulphurous vapors at Etna. It acquired the name of Pectoral Balsam. Dr. Graves and many others expressed confidence in its favorable influ- ence over the respiratory membrane, and Duclos' advocates the continued 'Rabuteau: L'Union Medicale, 1871. - Bocker, F. W. : Beitrage zur Heilkunde. 1849. »Duclos: Bull, de Therap., 1861. PISTEUMATICS. 243 use in asthma of small doses. Biiiz ' suggests tiiat the bronchial nerves may be soothed by the direct action of sulphuretted hydrogen, as it is excreted through the membrane. Many mineral waters of considerable repute in the treatment of respiratory diseases are supposed to owe their virtues to the sulphides they contain.'^ The local use of sulphur will be considered further on. Iodine is the most remarkable of all the alterative expectorants. As the element was only discovered in 1811 and introduced a few years later by Coindet ' into therapeutics we may regard it as a conquest of the present century, but before this remedies containing iodine were in use ; such, for instance, as burnt sponge, which for a long time enjoyed a con- siderable reputation. Iodine is also present in many mineral waters. Indeed, it is rather widely distributed in small quantities in both the or- ganic and inorganic kingdoms, as may be seen by reference to Sarphati's " list of substances containing it. Of course a medicine so potent and, as shown by Coindet and later by Lugol,^ of special value in scrofula, was sure to be employed in phthisis and other diseases of the respiratory or- gans and to give rise to a very considerable literature which we have not space to examine.^ Topically iodine is an irritant, and the vapor when inhaled strongly stimulates the respiratory membrane. It has been employed at times ex- tensively for this purpose, either alone or in combination with other stimulants or with anodynes. Camphor sprinkled with the tincture and inhaled is a jDopular remedy for coryza ; so is a combination of iodine with carbolic acid. Combina- tions with kreasote, ether, chloroform, etc., have their uses, but it should be remembered whenever these inhalations are employed, the iodine may enter the system and produce its characteristic effects. Conversely we may administer it or the salts by the stomach for the purpose of influenc- ing the respiratory membrane. Iodine is quickly taken into the blood, probably as iodide of sodium or perhaps as an albuminate ; it passes rapidly to all the tissues, particu- larly to the lymphatic glands and secreting surfaces ; but only scantily to the nervous centres. It would appear, therefore, as if it must increase ' Binz : Elements of Therapeutics. ^Ticliborne and Prosser James: Mineral Waters of Europe. 1883. ^ Coindet, C. W. : Biblioth. Univ. de Geneve, vol. xvi. ; also Observations on the Re- markable Effects of Iodine. Trans, by Dr J. R. Johnson. 1821. ■* Sarphati, S. E. : Commentatio de Iodic. 1835. " Lugol, J. G. A. : Memoires, snr Tiode, etc. 1829-1831. Also trans, by O'Shaugh- nessy, with appendix, 1831. " For early literature see Bayle's Bibl. de Ther. , 1828. For later references to 1854 see Titon, H. A. : Recherches sur I'absorption et la valeur therapeutique des prepara- tions lodees. 1854. 244 THERAPEUTICS OF THE RESPIRATORY PASSAGES. tissue metamorphosis, but in medicinal quantities loss of weight is quite exceptional, and it does not appear to increase the excretion of urea. It has been conjectured that it may act on the blood-plasma, rather than the tissues, or that it may spare the liver, which would account for these results. They may, however, be partially due to the rapidity with which the medicine is eliminated. It is found very soon after it has been taken in the mucous secretions. It appears also, though later, in the perspira- tion, bile, and even the milk. It seems, in fact, rapidly to pervade the system and to be as rapidly excreted in all directions, but the major part is removed by the kidneys, though it can scarcely be termed a diuretic, and it is found in the secretions chiefly as iodide of sodium, but a portion of this salt is decomposed, and hence the free element exercises its local ac- tion. Pereira observed that the pocket-handkerchiefs of iodized patients had a distinct odor of the element. The j^rominent symptoms of iodism show the eflPect on the respiratory membrane, on the whole of which it acts powerfully. Tlie nasal pas- sages are perhaps the first to be affected, but the conjunct! vre and the frontal sinuses speedily participate, and thus we have sneezing, profuse coryza, and watering of the eyes, with often distention of the brow and severe headache. Often the patient complains that he has caught a vio- lent cold and the watery discharge from the eyes and nose saturates his handkerchiefs. The effect on the buccal and faucial membrane is also obvious in the coated tongue, flow of mucus, swelling and redness of the gums, palate, and tliroat. Salivation shows the stimulant action on the glands and even when this is not prominent, the continual taste of the medicine proves that it is being secreted in the saliva. The effect on the pharynx and larynx gives rise to irritation in the throat, a sensa- tion of heat, and eough ; the burning and rawness extend along the tra- chea and over the chest. Further, that the bronchial membrane is also en- gaged is shown by the coughing up of a frothy mucus or a larger quantity of a more liquid secretion, according to the degree of iodism, and on aus- cultation moist rales indicate the extra fluid in the tubes. Thus through- out the respiratory membrane a considerable degree of congestion is pro- duced ; but at an earlier stage, or in the milder cases, there is less active congestion, and the membrane may only pour out a quantity of thin, watery mucus, with scarcely any increase of vascularity. Such effects would seem to indicate that the preparations of iodine in appropriate doses must be regarded as true expectorants. When the secretion is deficient, the membrane dry, and perhaps swollen, the cough painful, frequent, or constant, and yet useless, nothing, or very little being raised, iodide of potassium will bring on a secretion of thin mucus, and so re-establish a moist condition of the membrane, thereby relieving the irritation, and at the same time unload the vessels and remove the swell- ing. Why, then, should it not be more often employed in this condition ? PNEUMATICS. 245 Another kind of case in which it may be used may be named, when the tubes are not dry, but contain an increased quantity of mucus, but that so tenacious as to be with difficulty removed, being brought up as " stringy " phlegm with no little difficulty ; sometimes it seems to plug some of the tubes. In these cases the cough is troublesome, but ineffect- ual, and whatever will liquefy or dilute the secretion will give relief. Iodide of potassium causes an extra flow of thin mucus, and is also be- lieved to exercise an attenuant effect on the secretion already in the tubes, but, whether it does this or not, the extra flow dilutes what is al- ready there, and, even if the thick phlegm will not mix with or dissolve in the new watery outflow, it will at least float in it and be loosened from the walls of the tubes by it, and so be more easily coughed up. Iodine has also been said to be an antispasmodic expectorant, but if so, it would for the most part be by an indirect influence. Free secretion of itself naturally tends to remove tenacious phlegm, or foreign bodies, as well as to relieve engorged vessels, and so far to relax spasm set up by such influences. The inhalation of ethyl-iodide, however, will often rapidly relax the spasm of asthma, and recently Prof. Germain See has employed with considerable success sprays of iodide of potassium for the same purpose. It seems to me probable that the action in the last case is, as stated, indirect, but with regard to the vapor of ethyl-iodide the effect is too rapid to be thus accounted for. We have no proof that iodine depresses the respiratory centre ; its action on the mucous membrane is therefore not to be referred to the nervous system ; and though there are many other uses for this remedy which have almost overshadowed its expectorant properties, these last can scarcely be considered as the least valuable. Very curious differences in the susceptibility of patients to the influ- ence of iodine may be constantly observed. Some are so extremely sus- ceptible that minute doses at once produce iodism, and others are so easily affected by it that it is extremely disagreeable to them. In some this idiosyncrasy shows itself in salivation, in others in coryza. Some- times there is only a moderate salivation, the fluid being impregnated with the taste of the iodide as it is being continually eliminated, so that all the food tastes of the salt, to the great disgust of the patient, and the digestion is apt to be deranged. To many persons this taste is ex- ceedingly repugnant. When the respiratory membrane is affected, the patient seems to catch cold, sneezing being early followed by free secre- tion. Occasionally the catarrh is so easily induced that we cannot use the remedy, but usually it can be restrained or arrested. A dose of morphia will generally accomplish this, and sometimes very small quan- tities of an opiate given with the iodide enable the patient to tolerate it. In mild cases a single dose of morphia arrests the coryza, and prevents the development of worse symptoms. The antagonism of these two 246 THERAPEUTICS OF THE RESPIRATOKY PASSAGES. medicines, so far as the mucous membrane is concerned, is fairly com- plete, but we must not forget that opium affects the centre and it is often undesirable to give it. Belladonna is also to the same extent an- tagonistic to iodine. Possessing a very special influence on the salivary glands, it is perhaps preferable where they are chiefly excited, but ex- perience satisfies me that it also antagonizes the effect of iodides on the pituitary, faucial, laryngeal, tracheal, and bronchial lining. I have used atropia to restrain and arrest the effects of the iodides in these situations with great success, especially where opium was contra-indicated or un- desirable, but much more frequently I rely upon morphia. There is an opposite condition to the extreme susceptibility noticed above. Some patients seem almost insusceptible to the action of iodine ; and others, to whom it is given in large quantities with great benefit for various purposes, never experience any irritation of the respiratory pas- sages. This seems to me specially the case when large doses of iodide are required. In syphilis I have administered very large doses for long periods, and that, too, when the fauces and larynx have been seriously diseased, without exciting irritation of the membrane. Such cases are, indeed, of daily occurrence, and yet out of numerous instances of iodism I have met with few in syphilitics. It would be interesting to learn whether this is the general experience. The uses of iodine in respiratory diseases may be deduced from its action. In bronchitis it is only admissible as a promoter of secretion in the manner already explained. Where the expectoration is thin and easily coughed up, the iodides are useless, if not contra-indicated. In asthma. Trousseau and Jaccoud both found it useful, and long before it had been used by Horace Green, and it also constituted the chief ingre- dient of a once popular quack remedy. Dr. Salter sometimes obtained benefit from full doses. Dr. C. J. B. Williams employed it in combina- tion w'ith carbonate and stramonium {3Ied. Times, 187:2). Dr. Reed employed liquor iodi in constitutional dry asthma, when the paroxysms came on without obvious cause [Med. Record, 1879), and during the last few years M. See has reported {La France Med.) a number of cases at all ages, in which he has given doses of twenty to forty-five grains, daily reducing the dose as the improvement continued. Often he found the breathing become easy in an hour or two after such a dose given during the paroxysm. He has also employed with great benefit sprays contain- ing the iodide. There seems to me no doubt that the remedy is often very beneficial, especially in those cases in which the paroxysms are ex- cited by cold, or whenever they are relieved on the appearance of secre- tion. It is the power to excite this secretion that is probably the key to the use of the iodide in asthma. It may also be added that in gouty and rheumatic patients its influence is favorable. So potent a medicine was sure to be tried in phthisis, and at first PNE-UMATICS. 247 there were not wanting observers who hoj^ed that a curative agent had been discovered, among whom may be mentioned Bardsley/ Gairdner,' Scudamore/ Clarke,* and others. It must, however, be confessed that disappointment aveaited them. At the Brompton Hospital the experi- ence of Dr. Cotton {Med. 71mes, 1859) was not favorable ; weight was seldom gained, dyspepsia was often produced, and a wasting increased. Others have observed irritation and even haemoptysis follow the use of this remedy. But in certain cases of pneumonic phthisis, carefully used for a short time, it may possibly be beneficial, and in strumous constitu- tions, where there is a fear of the development of tubercle, it may per- haps be used with advantage, but any attempt to produce a distinct im- pression on the respiratory organs may excite local irritation and aggravate febi'ile excitement. Even the local use by inhalations of the vapor of iodine, valuable as it often is, requires to be prescribed with considerable circumspection, and the effect should always be watched. It is quite possible for iodism to be induced by such inhalation. I have known these phenomena brought on by the accidental inhalation of the vapor during the preparation of compounds of iodine, as well as by the exposure of the element with the intention of its becoming evaporated as a method of its administration. It is in laryngeal phthisis that the local effect of the vapor is most useful, indeed in extensive pulmonary disease it has not yet accomplished much, and Pereira declared he had never seen it do any good. In pneumonia, when consolidation has continued for a considerable period, small doses of iodide of potassium will sometimes set up the pro- cess of absorption. Some physicians have employed the iodide at an earlier stage. Dr. Gualdi treated thirty-nine cases from the beginning with frequent doses of iodide of potassium, and obtained excellent re- sults ; two only died, and one of these from a complication at the outset. In all cases the expectoration from being tenacious and viscid became on the second day fluid, resembling bloody serum, the fever ceased and with it the exhaustion, though the state of the lungs was not improved. The appetite of the convalescents was greatly increased. Dr. Gualdi found the treatment succeed better in young persons than adults, and urges ' Bardsley, J. L. : Hospital Facts and Observations. On Iodine, etc. 1830. ■ Gairdner, W. : Essay on the Effects of Iodine on the Hnman Constitution, witli Practical Observations on its Use in the Cure of Bronchocele, Scrofula, and Tuberculous Diseases of the Chest and Abdomen. 1824. ' Scudamore, Sir C. : Cases illustrating the Remedial Power of the Inhalation of Iodine and Conium in Tubercular Phthisis and various Disordered States of the Lungs and Air-passages. 1834. "• Clarke, Sir A. : On the Exhibition of Iodine in Tubercular Consumption and other Diseases of the Chest, and in the Treatment of Scrofulous, Cancerous, and Cutaneous Diseases, etc, 1845. 248 THERAPEUTICS OF THE RESPIRATORY PASSAGES. that the remedy should be given at the commencement of the disease. In croup and diphtheria the iodides have been employed with a view of separating the false membrane by causing a profuse flow of watery se- cretion. Iodoform differs so much from the other preparations as to require a few words to itself. It does not seem to irritate the mucous membranes like the other preparations, so that iodism very seldom follows its use, and it is well tolerated by the stomach. It is rapidly absorbed. Hogyes ' says the first step is its solution in such fatty matter as it may meet with, this solution being in turn decomposed by albumen, as a compound of which it enters the blood. The iodine is eliminated in combination with sodium in the same manner as when taken in other forms, but some iodoform seems to escape from the skin, or in the breath, for a person who has taken it for some time evolves the characteristic odor. Con- sidering its chemical relations with chloroform it was conjectured that it might be anaesthetic, and locally it seems to possess this property. Maitre pointed out {^Bouchardaff s Annales, 1857) that its application relieved pain, and examined its action on the nervous system, respecting which experimenters are not agreed. He compared it to alcohol, and in some instances it seems to narcotize, as shown by McKendrick [Edin. Med. Journ., 1874) and again by Hogyes {3Ied. Record, 1879). I have em- ployed it largely internally, though not as an expectorant, and the effect on the mucous membrane seems but slight, yet the other medicinal effects of iodine may be obtained from this preparation. I compared it with others in a paper read at the Medical Society of London, in 1871 {Med- ical Press, 1871-72), and have continued to use it largely ever since {Brit. Med. Jour., 1878). Of late it has been employed with a view to an antiseptic action, especially in Italy.'' Dr. Dreschfeld introduced it into this country in 1882, as likely to be of service in phthisis, and Dr. A. Ransome read a paper on it at the British Medical Association, in 1883. He gave it in doses of 1^ grain three times a day, and found that it disturbed the digestion, whereupon, on the suggestion of Dr. March, he added two grains of croton-chloral-hydrate. He used at the same time inhalations and had the patients weighed before and after treatment. He attributes to iodoform " some slight improvement, even in cases in which it was manifestly hopeless to expect a cure," and thinks that " in the earlier stages of the disease, it is decidedly worthy of further trial." I have very seldom found such doses interfere with digestion, I have often given three grains three times a day for weeks to- gether without the slightest inconvenience. A combination with an equal quantity of storax greatly controls the disagreeable odor ; but ' Hogyes ; Archiv f. exper. Path, und Pharm. -Lo Sperimeutale, 1883, and Anuali Univers. di Med. e Chir., 1883. PNEUMATICS. 249 when the system becomes saturated, so to say, with the medicine, tiie patient begins to feel the inconvenience of continually perceiving the smell. Antiseptic and Disinfectant Pneumatics. We have already had occasion to speak of antiseptics, when treating of antipyretics, and perhaps it would be as well to recur to the subject here, inasmuch as the pneumatics of which we are about to speak are such as are supposed to act through the system. The idea of disinfec- tion is by no means modern. Homer speaks of sulphur as a disinfect- ant, and the preservative power of salt and of vinegar was known at an early age. Even the word antiseptic is by no means so modern as some have supposed, and it was preceded by antiloimic (avrt, and Xoi/aos, pestilence), a term which was applied to any substance supposed to pre- vent infection from the plague or other pestilence. We have seen that Pringle ' used the word antiseptic in the title of his paper, and he was soon followed by MacBride.^ In 1767 the Dijon Academy of Science offered a prize for an essay on antiseptics, and two years afterward three of the essays ' submitted were publislied. The same year Godwin * produced his " Septicologie," and soon after Alexander,^ Brownrigg," and Henry ' published English essays on the subject. Cartheuser * and Callisen" followed in Latin, Bucholz '" in Ger- man, and a little later Mugis " and Grewe '^ in Latin. Nearly fifty years then elapsed before Kaiser'^ published his experiments on the compara- tive antiseptic power of several agents. Nearly forty years more before Lister began what may be considered the modern antiseptic system in surgery, for an exposition of which we must refer to his contributions ' Pringle, J. : Op. cit. ^ MacBride, D. : Experimental Essays. 1764. ' Boisseau, B. C. , Bordenave, S., et Godart, J. : Dissertations sur les Antiseptiques, qui concoururent pour le Prix propose par I'Academie des Sciences de Dijon en 1767- 1769. * Godwin, J. : Septicologie, ou Dissertation sur les Antiseptiques. 17G9. 'Alexander, W. Experimental Essays : On Antiseptics, etc., 1770. ^Brownrigg, W. : On the Means of Preventing the Communication of Pestilential Contagion, and of Eradicating it in Infected Places. 1771. ' Henry, S. : On Antiseptic Substances. 1773. ^Cartheuser, J. F.: De remediis Antisepticis. 1774. 8 Callisen, H. : De Antisepticis. 1775. '" Bucholz, C. F. : Chym Versuche iiber einige der neuesten einheimischen antisep- tichen Substanzen. 1776. " Mugis, P. N. : De antisepticis proprie dictis. 1781. " Grewe, T. : De putridine et Antisepticis. 1782. '^ Kaiser, J. : Experimenta ad Comparandam vim Antisepticam Aceti, Nitri, Salis communis, et Chloreti calcis instituta. 1831. 250 THERAPEUTICS OF THE RESPIRATORY PASSAGES. and those of his followers in the various journals since 18G9. Dr. San- som's ' able treatise refers to the medical as well as t-he surgical uses of antiseptics. In diseases of the respiratory organs we may select a remedy which is believed to possess antiseptic powers fortwo purposes : first, tliat when it is excreted through the bronchial membrane it may disinfect the sputa ; second, in the hope that it may prove destructive to the organ- isms supposed to be present in the body. With regard to the first indi- cation, we have seen that a number of expectorants may act in this man- ner, but the use of antiseptic inhalations would seem to be more eflScacious. As to the second point, the whole theory of the parasitic origin of disease is involved. This theory is undoubtedly a fascinating one, admitting the presence of an organism to be the cause of a disease, the business of the therapeutist would be to search for a remedy which would be poisonous to the parasite but not to the patient. In quinine, as we have seen, these requisites appear to meet. Minute quantities are fatal to whole colonies of putrefactive organisms, and very large quanti- ties can be taken into the human body, and will linger in the system for a considerable period. If, therefore, a disease be caused by an organism to which quinine is fatal, its administration will effect a cure, provided no irreparable injury has been inflicted. It is believed by many that the virtues of quinine really depend on this property. Unfortunately it is powerless over some other organisms, and we have to search for more potent poisons. Buchner denies the value of antiseptic treatment, and seems to think that it is impossible to satisfactorily carry it out, at any rate with the agents now at our disposal. Koch has shown that corrosive sublimate is fatal to the bacteria of anthrax in the proportion of one part to two hun- dred thousand. To reach this proportion in the mass of a man's blood would require doses of two-fifths of a grain. Such proportionate doses have been injected into the veins of animals by Binz, without killing them, and he seems to think that it would not be impossible to employ this remedy in man, but Buchner [Centralb. f. Jclhi. 3Iecl., 1883) re- marks that the sublimate combines with the all)umen of the blood, and that the resultant albuminate, thougli remaining in solution, is less dif- fusible, less capable of osmosis, and therefore less likely to be equally distributed through the tissues, while it is at the same time less poison- ous. He found double the quantity of albuminate of mercury to that of the sublimate was required to destroy the bacteria, and he calculates that for quinine to act as an antiseptic it would have to be given in * Sansoin, A. E. : The Antiseptic System : A Treatise on Carbolic Acid and its Compounds. A Theory and Practice of Disinfection, and the Practical Application of Antiseptics, especially in Medicine and Surgery. 1871. PNEUMATICS. 251 three-ounce doses, but he admits that there is probably some relation be- tween the value of a remedy in disease and its power of destroying micro-organisms outside the body, but what that relation is remains to be proved. Different micro-organisms vary greatly in the effects they produce, and it has been stated rather confidently that perfectly healthy tissues harbor germs. The recent researches of Hauser and Zahn discounte- nance this idea. Hauser {Centralb. f. die 3Ied.-Wissensch., 1884) re- moved entire organs and parts of tissues by heated instruments from animals just killed to^ super-heated glass vessels, plugging the mouths with cotton-wool. He kept the vessels in a moist chamber, at a temper- ature of 30° C. Zahn ( Yirchoid^s Archives, 1884) employed the blood of healthy animals, collecting it with full precautions in tubes previously filled with oxygen, hydrogen, and carbonic acid, so as to exclude atmo- spheric air. The tubes were kept sealed at a temperature of 37° to 38° C. for months without any sign of putrefaction. We have seen that some organisms are destroyed by quinine. Kru- kenberg' found some which were killed by one in one hundred thou- sand. Others, however, require one in twenty thousand, and others may resist a stronger solution. Then we must remember that what one para- siticide fails to effect may be accomplished by another, and so when organisms resist one influence, we must seek for something that will be noxious to them. Perhaps the bacterium subtile is the most difficult to destroy. It will resist boiling for an hour. Yet M. Schnetzler has this year reported to the Paris Academy that it is easily killed by formic acid. To a drop of water teeming with these bacteria he adds a drop of liquid containing one-thousandth part of formic acid, and says that the effect is such that the liquid may be introduced into the digestive tract with im- punity. If this be confirmed, the fact may probably be turned to practi- cal account in preventing, if not in curing, disease. Experiments with tubercular sputa seem to show that it possesses great power of resistance to our ordinary antiseptics. Falk announced that its virulence was de- stroyed by putrefaction, but this has not been confirmed, and the bacilli have been found in putrefying sputa. Baumgarten thought the viru- lence of tubercular material was diminished by putrefaction. Parrot and Martin {Eev. de Med., 1883) found that the infective power was not de- stroyed by corrosive sublimate solution of one in one thousand ; bro- mine, one in one thousand ; salicylic acid, one in five hundred ; carbolic acid, one in twenty. But a temperature of 100° to 120° C. was sufficient. Recently Dr. Niepel {La France Med., 1884) has stated that sulphuretted hydrogen destroys the infective property. Professor J. Sormani, of Pavia, brought before the late Hygienic Congress at the Hague (August, ' Krukenberg : Vergleicliemd. riij'siologische Studien. 1880. 252 THERAPEUTICS OF THE RESPIRATORY PASSAGES. 1884), the results of numerous experiments as to the possibility of de- stroying the tubercle bacillus. The following are his conclusions : 1. The bacilli of tuberculosis were generally very diflficult to destroy ; dry- ness, exposure to oxygen, putrefaction, and most disinfectants failed to produce any effect. 2. A temperature of 100° 0. only killed the bacilli after at least five minutes of ebullition. 3. The artificial digestion of bacilli showed that they were the last of all living organisms to be de- stroyed by the gastric juices or hydrochloric acid. A very active digest- ion is necessary to kill this microbe. A healthy man may destroy the bacilli in his stomach, but an infant or an adult with his digestive facul- ties impaired would easily allow the germ to pass the stomach intact, and retain its virulence in the intestinal tube. This determined enteric ulcerations, etc. 4. The bacillus of tuberculosis can be preserved intact for a whole year when mixed with water. It is probable, though not proved, that it has retained its virulence during that time. Thus drink- ing-water may become the means of propagating tuberculosis. It is probable that contaminated linen retains its virulence for five or six months. 5. Alcohol does not destroy the germ ; hard drinkers often suffer from tuberculosis. G. Cod-liver oil, ozone, oxygenated preparations, and other similar remedies, have no effect in killing the bacillus, nor are benzoate of soda, salicylate of soda, sulphate of zinc and carbolic acid, iodide of silver, bromide, camphor, etc., of much greater use. They in- jure, perhaps, but do not absolutely destroy the bacillus, at least not in the doses that can be taken without danger. 7. A more decisive action may be attributed to creasote, eucalyptol, pure carbolic acid, the naph- thols, and bichloride of mercury. 8. For disinfecting spittoons, a car- bolic acid solution of five per cent, is thought sufficient, and Dr. Sor- mani asserts that the breath never contains any bacillus. He also suggested that oil of turpentine or eucalyptus should be diffused in liouses as an agent for the destruction of this bacillus. Although it may seem that if we could saturate the system with- out inconvenience with a substance fatal to microbes, we should thus be able to effect an immediate cure of diseases dependent upon them, it does not necessarily follow that less active parasiticides are useless. It is easy to imagine that a small quantity of an antiseptic, though insufficient to kill, may cause inconvenience to parasites, especially if such antiseptic should be excreted through an organ in which they have effected a lodgement. Moreover, it may well be that such an antiseptic might im- prove the condition of that organ, and thereby render it a less suitable nidus for the microbe. And again, it is possible that a substance in the process of elimination from the body, either by decomposition or other- wise, may be more noxious to micro-organisms than when employed in a culture-fluid. The conditions, in fact, in the living body differ greatly from those in the laboratory, otherwise we should only have to collect PNEUMATICS. 258 the organisms and destroy them. It must, too, be freely admitted that the reactions of the system, provoked by the parasites, form no incon- siderable proportion of the phenomenon. Nevertheless, they scarcely account for the whole, and while freely admitting all that is to be said in favor of the nervous theory, we are scarcely in a position to deny the reasonableness of the antizymotic explanation. Antiseptic pneumatics belong to several groups. Some of them have an expectorant action and may be called properly enough antiseptic ex- pectorants. But there are others of which the modus operandi is not so clear, and there are some general antiseptics which are useful in respira- torv diseases, but are not expectorant at all, and perliaps possess even opposite properties, e.g., tonic antiseptics, such as quinia, etc. That the antiseptic or disinfectant action is exercised on the sjjuta is reason- able enouo-h to suppose when the remedy is excreted by the bronchial mucous membrane, and we have seen that several such true expectorants are calculated to act in this manner, but there is no doubt also an action on the mucous membrane itself. Thus an alterative expectorant may be antiseptic and quite a number of stimulant expectorants are antiseptics, such as essential oils, the balsams, the camphors, and the turpenes. Eu- calyptus, which has been lately so much employed, may be classed among these. Cubeb contains an essential oil, and as this is perhaps eliminated partlv bv the bronchial membrane, it would seem more adapted for dis- eases of this tissue than the crude piper. But the value of this medicine has been much exaggerated of late years. Other essential oils are nicer and better. Tar and its derivatives may be mentioned here, though in the pres- ent day thevare more used as local antiseptics. Tar is the iriTTa of Theo- phrastus, the kcovos or TrtWa vypa. of Dioscorides, t\\Q pix liquida of Pliny. In the middle of the last century it was suddenly brought into vogue by Bishop Berkeley,' the great philosopher, who seems to have thought that he had discovered a panacea in tar-water, and whose book on the subject gave rise to a great number of pamphlets for and against the use of the remedy, one of them quaintly entitled " Cure for the Epidemical Madness of Drinking Tar-water." Nevertheless the good bishop and learned phi- losopher returned to the charge, professed unbounded belief in his pana- cea, and no doubt thought that he was serving his fellow-creatures in making known his favorite remedy. It soon, however, fell into disuse, though it has at times been revived. It is still occasionally prescribed in catarrhal affections and in phthisis, and indeed of late years an attempt has been made to introduce special preparations of tar into use. Dr. ' Berkeley, G. (Bishop of Cloyne) : Siris : A Chain of Philosophical Reflections and Inquiries respecting the Virtues of Tar Water, etc. 1744. Also, Two Letters on the Usefulness of Tar Water in the Plague. 1747. Also, Further Thoughts on Tar Water. 1752. 254 THERAPEUTICS OF THE RESPIRATORY PASSAGES. Dunglison ' reported considerable benefit in clironie bronchitis ; he di- rected one ounce of tar to be digested in two pints of water for a week and strained ; of this he gave from eight to twelve ounces daily mixed with milk. The inhalation of tar vapors is more rational and often of service. The discovery of Creasotc by Reichenbach," who named it from Kpeas, flesh, and o-w^o), I preserve, led to the disuse of the crude remedy and the substitution of the supposed active principle, both for internal use and for inhalations. It seems, however, that creasote is not a simple body but a rather valuable compound containing a good deal of creasol, and there is little doubt that very impure preparations have found their way into the market. As tar was displaced by creasote so this in its turn has been largely superseded by carbolic acid and its compounds, as have also some old preparations of soot, pyroligneous acid, rag oil, paper oil, animal oil, mummy, and other obsolete medicaments. Creasote, liowever, has been largely employed internally, and EUiotson,' Miquet,* and Sir John Cor- mack ^ have written in its favor, while it still maintains a place as a valu- able inhalation. Carbolic acid, though chiefly obtaitied from coal-tar, is produced in small quantities during the distillation of benzoin and some other gum-resins, and is also said to be found in the urine of man, and some animals. In the Italian war of liberation, in 1859, some of the French surgeons used a powder containing coal tar and lime as an appli- cation to wounds. In 18G3 Dr. Lemaire discussed Pasteur's germ theory, in a volume on carbolic acid.° He had previously published a work on coal-tar.' He recommended the new product as an antiseptic application in wounds, injuries, and diseases, and advised its internal use in diseases due to infective poisons. A couple of j-ears later, M. Boboeuf * addressed the Academy of Paris on the value of phenol and the history of its use. ' Dunglison : Practice of Medicine. 1844. ' Reichenbach, C. von. : Das Kreosot, in chemischer, physischer, und medicinischer Beziehung, etc. 1833. 3 EUiotson, J. : Med. Cliir. Trans. 1835. * Miquet, E. : Recherches cliimiqnes et medicales de creosote. 1834. * Cormack, J. Rose : A Treatise on the Chemical, Medical, and Physiological Prop- erties of Creosote, illustrated by Experiments on the Lower Animals, etc. Harveian Prize. 1836. ^ Lemaire, J. : De I'Acide Pheniq\ie, de son action sur les vegetaiix, les animaux, les ferments, les renins, les virus, les miasmes, et de ses applications a Thygiene, etc. 1863. ■' Lemaire, J. : Du coal-tar saponifie, disinfectant energique arretant les fermen- tations ; de ses applications a I'hygiene, a la therapeutique, a I'histoire naturelle. 1860. ** Boboeuf, P. A. F. : Memoire adresse a TAcad. des Sciences sur I'acide Phenique, etc. ; Proprietc s du Phenol Sodique, etc. 1865. PNEUMATICS. 255 About the same time M. Declat ' wrote on the subject and he has since contributed a number of papers respecting- it. In England, Dr. Turner, of Manchester, communicated a paper to the British Association in 18G3, in which he recommended carbolic acid as antiseptic and astringent in mu- cous discharges, etc. Dr. Grace Calvert about this time took up the study of the acid as a disinfectant. In 1867, Lister began that system- atic use of antiseptic dressings which has been so fully developed. ANTisrASMODic Pnkumatics. The ancients were well acquainted with a number of our antispas- modics and formed a tolerably clear estimate of their virtues. Early in the last century Bauer ^ turned Ins attention to the general antispasmod- ics, and soon after the middle the Dijon Academy awarded a prize to Godart ^ for an essay on the subject, and perhaps to the interest thus ex- cited we owe Nonne's * work, which appeared soon after. At the begin- ning of this century a brief account of antispasmodics was published by Sproede/ and nearly thirty 3'^ears later a short treatise by Salinger." Of course, during this period, as previously, these medicines continued to be largely employed. The word was applied in a wide sense and many remedies were included in it which we now classify in a different manner. Tliose antispasmodics which are employed in respiratory diseases, whether alone or in combination with pneumatics, furnish an interesting and important group, and although they might be otherwise classed, bringing them together under this head affords an opportunity of com- paring their actions with advantage. In considering expectorants we have seen that many of them possess antispasmodic properties. They may therefore be called, as indeed they frequently are, antispasmodic ex- pectorants. On the other hand, some antispasmodics, though given in re- spiratory diseases, are not expectorant at all, but restrain rather than pro- mote the secretion of the bronchial membrane. It is therefore better to use the word pneumatics, in grouping them, rather than expectorant, which has too often been erroneously applied. Whatever produces relaxation of muscular fibre may seem to be en- titled to the name antispasmodic, whether the action be local or general. The inhalation of steam, therefore, might be included, or the use of vapor baths, or other baths, or any method of applying heat ; but at present ' Declat, G. : Nouvelles applications de I'acide phenique en medicine et en ch.irur- gie aux affections occasionni'es par les micropliytes, les microzoaires, etc. 1865. ' Bauer, C. H. : De specificis antispasmodlcis. 1704. ^ Godart, G. L. : Sur les Antispasmodiques proprement dits. 1765. * Nonne, J. P. : De Antispasmodicorum modo agendi et usii. 1769. ^ Sproede, J. G. L. : De medicamentis antispasmodicis. 1800. * Salinger, L. : De Antispasmodicorum differentia. 1829. 256 THERAPEUTICS OF THE RESPIRATORY PASSAGES. we are rather concerned with those remedies which when introduced into the system produce their effect. Among the expectorants which are also antispasmodic, we have seen that emetics and the nauseants possess this property in a high degree ; though they are not often used on this account. As the act of vomiting produces intense muscular relaxation, it may sometimes be provoked for this purpose when the need is urgent. The sensation of nausea is also attended by relaxation, so that the nause- ants are antispasmodic, but the influence in this case takes more time to produce and generally lasts longer. The antesthetics, which are very powerful antispasmodics, have largely superseded the use of nauseants for the purpose of relaxing muscles. The majority of our group of stimulant expectorants are to some ex- tent antispasmodic, tluis the essential oils, the oleo-resins, and the gum- resins may be so termed. Assafoetida, galbanum, and other odoriferous remedies have been known from very early times to possess the properties we call antispasmodic, and their effect on the bronchial membrane has already been explained. Directly opposed to these are some of the de- pressant expectorants, of which lobelia and tobacco are examples. They have both been used to relax spasm, though neither perhaps is entitled to much confidence, and should only be used with caution. Next come a number of neurotics which have been considered antispasmodic : opium, belladonna, hyoscyamus, stramonium, datura, etc., are used as antispas- modic-pneumatics. Their special uses depend chiefly upon their action on the nervous system ; conium acts chiefly on the motor nerves. Then we have seen that nitrate of potash and iodide may sometimes serve as antispasmodics, and so indirectly may anything which causes a free se- cretion of mucus and so relieves the vessels, the effect being to remove the cause of the spasm. Ipecacuanha and senega sometimes effect this. All depressants of the respiratory centre may serve as antispasmodics. Opium takes a chief place here, though it also acts over a more extended area ; so alcohol, ether, and chloroform depress this centre and under cer- tain circumstances are antispasmodic pneumatics, though we can obtain from them the stimulant action, giving them only in small quantities. The bromides also depress the centre, and when the system becomes af- fected by them have considerable power over spasm. This is well seen in some cases of asthma and of laryngismus. Chloral, again, is a depress- ant of the centre which may also produce similar effect. Then we have other nerve-depressants, which become antispasmodic by an action on the nervo-muscular apparatus rather than on the centre. It will thus be seen that the antispasmodic pneumatics differ greatly among each other. A few words may be added respecting one or two members of the group, which have not been previously considered. Amyl nitrite, CjH,,NO„ is mostly used as an inhalation, being only .seldom given internally ; but we may employ it so in doses of one-half a PNEUMATICS. 257 minim to one minim. Discovered by Balard in 1844 {Annales de CJiimie et de Phys. xii.), the attention of physiologists was directed to it by Guthrie in 1859, and in 1865 Dr. B. W. Richardson reported on its physi- ological action to the British Association for the Advancement of Science. Dr. Lauder Brunton then took up the subject, and in 18G7 suggested to the Clinical Society the use of amyl in angina pectoris, basing his rec- ommendation on its physiological properties. This valuable deduction has been fully coJifirmed by clinical experience, and affords us a brilliant illustration of the success of theory applied to therapeutics. In 1868 Dr. Arthur Gamgee communicated to the Royal Society the result of an elab- orate investigation into the effect of the nitrite on the blood ("Philosoph- ical Trans.," 1868). In 1871 the Warren Prize was awarded to Dr. H. C. Wood for his memoir on the subject, which was published the same year {American Journ. Med. Sciences, 1871). Amyl nitrite is remarkable for the rapidity of its effect on the circu- lation. A short inhalation will bring on immediately palpitation with fulness and throbbing of the head, flushing of the face and neck, quickly extending to the trunk, tingling of the surface, and perhaps giddiness. Another inspiration or two, and j^ulsation of the carotids with great rest- lessness, disturbance of vision, depression, and cold sweats follow, with generally cold extremities, headache, and some confusion, but no loss of consciousness. It will be seen that the chief effect is on the circulation, two very distinct actions being observed ; one acceleration of the cardiac beat, the other dilatation of the peripheral vessels. The pulse is immedi- ately increased in frequency, and the blood-pressure is simultaneously greatly diminished. Different explanations have been offered of these remarkable effects, but the great point is the sudden fall of blood-press- ure, so that the resistance to the left ventricle is taken off, its contrac- tions being more frequent, though they can scarcely be more powerful ; thus the heart has less work to do and there is more power to do it — that is to say, in a given time the number of contractions is increased. The vascular relaxation has been referred to an actioi\ on the vaso-motor nerves and muscular coat of the arterioles, or, on the other hand, to an effect on the centre in the medulla. It really appears to be peripheral, not central, for both Brunton and Wood found that it occurred after the vessels had been separated from the centres by section of the cord, show- ing that the sudden fall is produced by a direct paralyzing action of the remedy exercised upon the coats of the arterioles. The local action of amyl upon muscular tissue confirms this view. The quick beat may per- liaps be partly due to depression of the cardiac centre or of the peripheral cardiac vagus. The nitrite, however exhibited, greatly reduces the temperature, both in health and in a febrile condition ; this effect seems to be due to a direct check to the tissue metamorphoses. Wood has shown that it is associ- 17 258 THERAPEUTICS OF THE RESPIRATORY PASSAGES. ated with diminished excretion of carbonic acid. It is independent of the nerve-centres, for it occurs after section of the cord, and even after death in those cases in which the temperature remains high or rises. Outside the body the nitrite has a remarkable influence over oxidation — for ex- ample, a few drops introduced into a jar of glowing phospliorus will extinguish it. Possibly within the body a similar effect is produced, though not so complete, or instant death would ensue. Diminution, not total arrest of oxidation probably occurs. All highly organized tissues lose power in the presence of amyl. Muscles, nerves, and nerve-centres all have their functions restrained or suppressed by contact with it ; but if the contact be only brief the}' recover their power, so that the poison does not destroy the vitality of the tissues. Nitrite of amyl is very rapidly taken up by the blood, on which it ex- ercises a remarkable influence, greatly interfering with the function of the red corpuscles. Under its influence, both the arterial and venous blood assume a chocolate hue, the cause of which has been carefully investi- gated by Dr. Gamgee, who finds that the nitrite unites with ox3'h.iemo- globin to form a compound which is in its turn easily broken up by am- monia, and by reducing agents. He found, too, that blood to which the nitrite had been added failed to take np an appreciable quantity of oxygen* Still the corpuscles retain in some degree their power of giving up ozone to substances having an affinity for it. Thus their respirator}' function is not abolished, though it is greatly interfered with. The poison is elim- inated by the kidneys and in poisonous doses gives rise to g-lycosuria, a phenomenon first observed by J. A. Koffmann {Reicherfs Archives, 1872) when experimenting on rabbits. At the same time the amount of urine is increased. Perhaps disturbances of pressure in the kidneys and liver may account for these symptoms. The most important use of nitrite of amyl is in angina pectoris, but in other cases of cardiac failure, as for instance in chloroform narcosis, it has sometimes been successful. Whenever it is essential to lower the blood- pressure rapidlv it may be effected by amyl. Its action also naturally indicates it as likely to relieve asthma as well as other forms of spasm. As soon as Dr. Brunton brought it forward for angina, I began to use it to relieve spasm of the bronchial tubes, and obtained excellent results. I have seen a single whiff from a bottle containing a few minims put an end to a severe paroxysm of asthma, but sometimes the dyspnoea returns rather soon. We mav then repeat the inhalation with due care, but it is not desirable for the patient to become habituated to the remedy. It seems almost necessary to intrust him with it, and the relief is so rapid and sometimes so complete and lasts so long that there is some danger of his resorting to it too freely. It is when the dyspnoea is accompanied with pallor of the face that this remedy may be tried ; when the superficial , vessels are already relaxed it is inappropriate. The patient should also PNEUMATICS. 259 be instructed to leave off inhaling the moment he feels the flushing begin, as the effect will continue and even increase for a short time after this. Dr. Kitchin {Amer. Jour. Med. Sci., 1873) has used it in acute bronchitis as well as asthma, but I should scarcely resort to it unless distressino^ spasm were present. In emphysema and cardiac dyspnoea it is not so successful, and, indeed, in heart disease it should only be resorted to with considerable circum- spection. It is, as already stated, to take off blood-pressure and arrest spasm that it is chiefly indicated, though it has naturally been tried in many diseases, and a good epitome of experience concerning it will be found in Dr. Pick's pamphlet.^ Kitro-ghjcerine has been revived by Dr. Murrell ^ as a substitute for amylnitrite in the treatment of angina pectoris, and it mav also be used as an antispasmodic in asthma, whooping-cough, etc. Its effects come on more slowly but last longer. Many years ago it was introduced by Mr. Field {3Ied. Times, 1858) as a very powerful remedy, giving rise to a sensation of fulness in the neck and head, some confusion, noises in the ears, etc., followed by headache. And he strongly recommended it in neuralgia and spasmodic diseases. His statements were confirmed by my late brother, Mr. Augustus James, then a student at University Col- lege, by Drs. Thorowgood, Brady, and others. But Drs. G. Ilarley and Fuller took much larger quantities without any effect, and their state- ments no doubt largely contributed to the remedy falling into neglect. It seemed obvious to me at the time that there were considerable differ- ences in the susceptibility of individuals to the influence of nitro-glycer- ine. My brother was affected severely for a considerable time by a dose taken in my presence from the same bottle out of which I took an equal quantity, but in my case the effects passed off in a few minutes, while he was affected in the maimer he has described {]\Iedical Times, 1858). The average dose is one minim of a one per cent, solution, wliich may be taken in water, or on a lump of sugar, or in tablets as made ])y Martin- dale. It acts on the blood like nitrite of amyl, paralyzes muscle, and de- stroys the reflex function of the cord, causing death by asphyxia. Nitrite of sodium has also been found to produce effects similar to those caused by nitrite of amyl. On the heart and vessels, as well as on the blood, the action seems to be precisely similar, but it is less sudden and less energetic ; on the other hand, it lasts longer. Dr. Ralfe brought it before the Medical Chirurgical Society, and described the toxic symp- toms to which doses then thought small had given rise. Dr. Ramskill corroborated this, and it has been shown that when it began to be used impure specimens were employed, and the dose therefore of the pure ' Pick, R. : Ueber das Amylnitrit und seine therapeiitische Anwendung. 1874. ** Murrell, William : Nitro-glycerine as a remedy for angina pectoris. 1882. 260 THERAPEUTICS OF THE RESPIRATORY PASSAGES. nitrite, now readily obtained, is much smaller than was supposed. Drs. Reichert and Matthew Hay have shown that pure nitrite of sodium or of potassium will act like the nitrite of amyl {Practitioner, 1883). Gamgee has shown that the nitrites act on the blood in the same way as the amyl compound, and Drs. Ringer and Murrell have experimented {Lancet, 1883) on the relative activity of nitrites and nitrates on animals, and employed full doses, producing unpleasant symptoms on patients. When used it would be desirable to begin with smaller doses than have been recommended, say two to three grains. Of course, the alkaline nitrites are less diffusible than the amyl, take longer time to be absorbed, and it would appear that they are more depressant to the central nervous system, while they also act on the peripheral nerves and the muscles, not only through the centre but by local access through the circulation. Ethyl-iodide or hydriodic-ether, C^H^I, is sometimes inhaled as an antispasmodic in asthma when the expectoration is scanty and tenacious. It must be regarded as a stimulant to the air-passages, and of course it introduces iodine into the system very rapidly. It can scarcely be re- garded as anaesthetic. Occasionally the relief it gives in spasmodic asthma is almost instantaneous. Ether and Chloroform. — Without producing any anesthesia small quantities of ether or chloroform when inhaled often act at once on the respiratory passages and arrest spasm. Even spasm of the glottis may be stayed by a whiff of chloroform, so may the asthmatic paroxysm ; so again may a useless, dry, persistent spasmodic cough, whether arising from irritation in the respiratory passages or in the nervous system. Yet these vapors unless largely diluted are A'ery irritant. The use of chloro- form liniment is sufficient to show this, or a small quantity on cotton "wool with a covering to confine the vapor will be found an active rubi- facient and even vesicant. The irritating effect of the vapor of ether on the respiratory membrane is manifest when it is given as an anaesthetic ; cough is set up almost always and very often some blood-stained mucus is brought up. The reason we do not see this in using chloroform is probably because so much smaller a proportion of the vapor is employed, from three to four per cent, being sufficient, and we give ether in as con- centrated a form as we can. Dr. Snow ' stated that air at 80° F. satu- rated with ether contained about seventy-one per cent, of the vapor. In practice we scarcely reach this degree of concentration, but the nearer it is approached the more rapidly anfesthesia is produced. How is the antispasmodic action of chloroform and ether produced ? In larger doses we know that the respiration and circulation are both more frequent at first ; but very soon the cardiac and respiratory centres ' Snow, J. : On Chloroform and other Anfesthetics, their Action and Administra- tion. 1858. PNEUMATICS. 261 become depressed, the pulse falls in frequency and power, and the breath- ing becomes slow, heavy, and stertorous. Although, therefore, these vapors may act upon the respiratory nerves, it is to the centre we must look for the chief explanation. Ether depresses the circulation less than chloroform ; the heart beats after respiration has been arrested by ether, which is one reason of its greater safety ; at the same time the respira- tory centre is less depressed, though we must not forget that it is a de- pressant eventually. The stage of stimulation is, however, much lono-er with ether than chloroform and the anaesthesia is briefer and not so deep. Comparatively, therefore, ether is sometimes spoken of as a stimulant and chloroform as a narcotic. Each possesses both properties, as we have explained in regard to other narcotics, but the exciting stage of chloro- form quickly passes into narcosis, while the primary effect of ether is more protracted and more decided. Both ether and chloroform are antispasmodics when administered in- ternally. The former is the more generally used for this purpose, being more exciting and commonly regarded as a powerful diffusible stimulant. They are both carminatives. As soon as they are taken into the stomach they stimulate the circulation and the nerve-supply of that organ, and act reflexly on the heart and respiratory system. At the same time a portion is at once absorbed and taken by the circulation to the nervous centres, where the first effect is excitant. By careful dosage we mav contrive to confine the action to this stage, giving only enough to pro- duce excitement and taking care not to repeat the dose until time has been given for the effect to pass off, so as to prevent accumulation. This is what we want when we give these medicines for their antispasmodic effect. This is obtained in the stage of stimulus without any perceptible degree of narcotism being necessary. Chloroform is much more pleasant to take, but more decidedly narcotic. Hence, ether, the more stimulant and the more diffusible and so the more evanescent in its action, main- tains the first place as an antispasmodic, but by careful dosage — and this is all in all — spirit or tincture of chloroform may very often take its place and in some cases seems to be preferable. It is perhaps better suited to gastro-intestinal affections, while ether is far superior in spasm of the respiratory system. Ether may be given in capsules or pearls, or the spirit of ether may be used, but the compound spirit, the old Hoffmann's anodyne, is more decidedly antispasmodic. Acetic ether has been intro- duced as more agreeable in taste and odor and therefore more appropri- ate as a carminative. Other anaesthetics naturally possess antispasmodic properties, but as they are not used for this purpose need not detain us. Quebracho. — This bark has been lately introduced as a remedy for dyspnoea, and is said to be especially useful in emphysema ; it may, there- fore, perhaps, be called antispasmodic ; but both the bark and the alka- 262 THERAPEUTICS OF THE RESPIRATORY PASSAGES. loid, aspidospennia, reduce the frequency of the respiration as well as the heart's action and a'pparently tlie temperature, probably by operating through the centre. It has, however, sometimes been said that quebracho stimulates the respiratory system. Manifestly further information is needed as to its precise action, which is probably rather complex, as que- brachin and four other alkaloidal substances have been described as con- tained in it besides aspidospermin. The dose of this last is given as a quarter to half a grain. A tincture of the bark, one in five of proof spirit, is also used in doses of five to sixty minims ; the drug appears, however, to be uncertain in its action, and when given should be care- fully watched. Probably it will be found that its proper place is among the central depressants, though it may possess a preliminary stimulating action. Sedative and Anodyne Pneumatics. These have naturally been named in the other groups, but may be considered together for a moment as substances the use of which is in- dicated for the purpose of removing pain or uneasy sensations in the respiratory organs, and for restraining their excessive action, whether that be represented by spasm, cough, or other symptom. It is obvious that whatever dulls the perceptive faculties will seem to relieve pain or uneasiness. The sedative or anodyne action may therefore be cerebral, annulling consciousness, as in the case of anjesthetics, or diminishing- it, as by narcotics. So it is also clear that whatever interrupts the con- veyance of sensation from the periphery to the centre will appear to be sedative or anodyne. Consequently the depressants of the respiratory branches of the vagi, which, as we have seen, are antispasmodic, are naturally anodj'iies to the respiratory organs. Further, whatever re- lieves the mucous membrane or other tissue, and restores healthy breath- ing, may claim to be an anodyne pneumatic ; therefore, moisture and warmth, when the membrane is swollen and dry, are remedies of this kind, so that fomentations and hot applications acting reflexly may give relief ; but inhalations of warm vapor, bringing the remedy in contact with the surface are much more effectual. But we are concerned here with general rather than topical remedies. Sometimes expectorants alone are effectual, inasmuch as they cure the disease ; but very often they are not required, or their action needs modification ; therefore, combinations with opiates or other neurotics may be resorted to, or a dose of the neu- rotic may be required at long intervals, while small quantities of the expectorant are given more frequently. We may Use for this purpose the stimulant depressant or alterant expectorants, according to circum- stances, combining them with various neurotics, of which opium is per- haps the most frequently employed. But belladonna deserves very often PNEUMATICS. 26S the preference. As these neurotics both restrain secretion, they may be thought to be therapeutically incompatible with expectorants, but prac- tically this is not the case, and often the greatest advantages are obtained by the judicious combination of differently acting medicines. Nowhere is this more decidedly the case than in diseases of the respiratory organs. And the combinations of the various pneumatics appropriate to individ^ ual cases afford ample scope for the exercise of the therapeutical knowl- edge and skill of the physician. In other cases our anodynes may re- quire to be contra-expectorant, or we may turn from this class entirely and employ agents which act directly on the centre. CONTRA-EXPECTORANTS. These are medicines which diminish the sputa by restraining the secernent function : they therefore antagonize expectorants. Most of them have been considered among other groups. Thus we have seen that some of the antispasmodics restrain secretion, though others produce a freer flow of mucus. So, too, some of the sedatives and anodyne pneu- matics restrain secretion and antagonize the expectorants ; besides these, neurotics diminish the bronchial mucus ; thus, both opium and bella- donna do this, though their action on the nerve-centre is precisely oppo- site. We now come to quite a different class of remedies, which restrain secretion whether by a local action or administered through the system. Astringents, among which may be included certain acids, are distinct contra-expectorants, as they tend to diminish the amount of secretion, and though their action is not so manifest on the bronchial membrane as on other surfaces, it must still be admitted to exist and may sometimes be utilized. Some of our most valued tonics possess astringent properties, and where an astringent seems to be required in bronchial affections, a tonic of this character, particularly an acid one, will very often accom- plish all that we require. When the use of an astringent becomes urgent to restrain bleeding instead of secretion, it may be necessary to resort to the most powerful members of the class, but generally in such cases astringents alone are not to be relied upon, although they often assist such powerful agents as complete rest and other appropriate measures. Central Pneumatics. These are such remedies as produce their effects by a direct action on the respiratory centre. Such action may be of two kinds, either stimu- lant or depressant; the first giving rise to more active respiratory move- ments, the other retarding them. This may seem to be a sufficiently broad line of distinction between tiie two groups, but if we try to tabu- 264 THERAPEUTICS OF THE KESPIRATORY PASSAGES. late the central pneumatics we shall find that some of them almost claim a place in each. Tims most of the depressants of the centi'e cause at first some excitement, if only very brief, as if the first impression on a nerve or organ excited a reaction in the part affected. ^Ve have seen such an effect in cliloroform, ether, alcohol, and the narcotics general! v, which appear to excite before they depress, the duration of the exciting- stage rather than its intensity furnishing the most important distinction between them. Camphor has often been spoken of as both a stimulant and a depressant to the nervous system. So far as the respiratory centre is concerned, it seems at first to excite, but the depressant action soon comes on. Then stimulants of the cardiac centre, many of which act also on the respiratory, may be employed for the latter effect, and we must remember that excitement of tlie circulation would usually be accom- panied by more rapid breathing, whether the stimulus directly affected the respiratory centre or not. Moreover, cardiac stimulants, as we have seen, are mostly followed by a stage of depression, and we have to vary our mode of using them according to the effect we are desirous of pro- ducing. Opium — wliich, as we have seen, distinctly depresses the respiratory centre — has a full preliminary excitant action on the circulation, or pos- sibly at first a slight stimulating effect on the respiratory centre, so slight as to be disguised by the circulatory excitement, and so brief that it is to be regarded as a characteristic depressant pneumatic. So it has been said that such potent depressants as prussic acid, tobacco, and calabar bean exhibit a slight but evanescent stimulating effect, which is soon quenched in the profound depression. A similar course of events may be observed in respect to the action on mucous membrane, those which in- crease secretion and even depress the circulation being found to produce a preliminary ephemeral stimulation. Even antimony and ipecacuanha are said to act in tiiis way, both on the centre and the periphery, but the excitement is so slight that it can seldom be detected, and can never be reckoned on, unless it is to be maintained that the promotion of secre- tion is to be considered as necessarily stimulating. In the same way it is to be observed that our most valued stimulants of the respiratory centre tend to terminate in a stage of depression, or if the expression be preferred, of exhaustion. Thus, belladonna in too large quantities and its allies, hyoscyamus, stramonium, and datuia, may finally depress, thougli in therapeutic doses the real value is the powerful stimulant action on the centre, which sometimes enables us to maintain the failing respiratiori. The difficulty of strictly classifying these central pneumatics will now be apparent, but we shall take the ordinary chief therapeutical action, and disregard so far the minor or subsidiary effects, and first of all we will consider PNEUMATICS. 265 1. Stimulants of the Respiratory Centre. — Arnmonia is perhaps the most important of these. It is the most commonly used medicine for this jaurpose, and may be confidently relied upon to produce a rapid ef- fect on the centre, the circulation being- at the same time powerfully stimulated. As we have seen, it is also an expectorant, promoting the secretion within the tubes, its action on the centre increasing- the cough- ing power and sustaining the breathing, while, of course, the general stimulant action is also produced. JBellado)i7ia and Atropia. — This remedy, too, we have previously con- sidered at length, and need now say but a few words respecting its ac- tion on the centre. It is a most valuable stimulant, the next perhaps to ammonia, if not its equal, for sustaining- the failing respiration ; the action is rapid, beginning- almost immediately, and soon passing- off, so that small doses can be repeated. The pupil is not a sufficient guide, nor is dryness of the throat, nor dimness of vision ; these are symptoms caused by full doses and are somewhat uncertain. The patient should be watched and a small dose will generally cause flushing, which is a sufficient indication of the effect. The breathing will then become deeper, and when it again fails a dose may be repeated. It will be remembered that atropia also restrains the secretion and tends to dry the membrane, in this respect being contra-expectorant and opposing anunonia ; at the same time it reinforces the drying action of opium, though it antagonizes that medi- cine in other directions, as we have already shown at length in our chajj- ter on neurotics. N'ux Vomica and Strychnia. — The medulla is very powerfully stimu- lated by this remedy. The vaso-motor, the cardiac, and the respiratory centres all experience its influence ; some of the effects are partially masked by the powerful stimulation of the cord, which in toxic doses ex- alts the reflex excitability of the motor dentres to so great an extent. The frequency and depth of the respirations are increased by therapeuti- cal doses, as shown both by experiment and observation. Prokop Roki- tanski found [Oesterreich Med. Jahrb., 1874) that strychnia caused the respiratory movements to reappear after they had been abolished by section of the cord. Dr. Milner Fothergill found that strychnia success- fully antagonized lethal doses of aconitia, and he brought it forward at the International Medical Congress in London, in 1881, as an expectorant acting through the centre. Dr. Lauder Brunton has employed it to check the night-sweats of phthisis, thinking that when the centre becomes ex- hausted the accumulation of carbonic acid, being no longer sufficient to rouse the centre, excites the sweat-glands. He therefore gave strychnia to increase the excitability of the centre and so lead to more perfect res- piration. His clinical results (" St. Bartholomew's Hospital Reports ") seem to support his view. Dr. Thorowgood has also used this remedy in em- barrassed respiration, and I can fully confirm its value as a stimulant of 2(3G THERAPEUTICS OF THE RESPIRATORY PASSAGES. tlie centre. We must remember, however, that it excites the other centres. Dr. Fotliergill also suggested to the Congress tliat strychnia should be employed to meet the disturbance in the respiration sometimes caused bv digitalis ; and when disease in the lungs or air-passages co- exists with impairment of the heart's power, he would combine strychnia with diii'italis in their treatment. For this purpose I use tincture of digi- talis with tincture of nux vomica. In other instances, where a decided expectorant is required, the tincture may be added to the mixture of senega and ammonia ; when the senega is not tolerated serpentary is a useful adjunct. Quinine and other tonics I also often employ in conjunc- tion with nux vomica. As a respiratory stimulant in bronchitis, emphy- sema, asthma, and phthisis, whenever it is desirable to increase the action of the centre, I regard strychnia as a most valuable remedy, and inasmuch as it also acts on the cardiac centre, it is at the same time a tonic to the heart, the ganglia of which it also rouses, while it favorably influences the vessels through the vaso-motor centre, by which the arterial pressure is raised. It seems, therefore, appropriate in cardiac dilatation accom- panied by diminished vascular tension. I usually select strychnia in preference to atropine when a more pro- loiio-ed effect is required and when the need for sustaining the centre is nc ": so urgent. The remedy takes a longer time to produce its effect. It is, indeed, absorbed quickly enough, but we give it in doses which have to be repeated several times before a full action is established ; it is eliminated rather slowly. It seems, therefore, suited for keeping up a moderate degree of stimulation for a considerable period. It also affects the circulation less than belladonna. AVhen the necessity for a respira- tory stimulant is urgent, I use atropia or belladonna ; the effect of this is much more rapid, almost immediate ; but it is also less permanent. I have also used the two alkaloids alternately, giving doses of atropia from time to time to maintain the failing movements while the less frequent doses of strychnia were gradually accumulating. I would not hesitate to produce rather quickly the physiological effect of strychnia, if it seemed to be needed ; but this is seldom the case in my experience, for atropia may be confidently resorted to in urgent cases, and may be alter- nated with ammonia. I have therefore come to regard strychnia as better in less urgent or more chronic cases, and would plead for its more frequent use in chronic bronchitis and emphysema. The use of strychnia in the paralysis that sometimes follows diphtheria in some cases of laryngeal paralysis, and for other purposes, need scarcely detain us. 2. Depressants of the Respiratory Centre. — Some of these stimulants, as already pointed out, may at a late stage act as depressants, but we may pass them by. The nauseants, especially antimony and ipecacuanha, are decided de- PNEUMATICS. 267 pressants of the centre, so much so as at times to be contra-indicated when otherwise they might be useful. Lobelia and tobacco are both powerful depressants, but have been fully considered in a previous article. Opium is the most constantly useful of the respiratory depressants ; we have seen how it enters into a considerable number of our groups, and although it affects the entire nervous system — we might almost say the entire organism — we must never forget the special depressant action on the respiratory centre as a most important element in its use as a pneumatic. Paralysis of this centre is the cause of death in opium-poi- soning, and its depressing influence in therapeutical doses comes on at an early period. We have seen, too, how it restrains bronchial secretion, blunts the sensations, impairs the action of the vagi, and lowers the pul- monary circulation as well as the general blood-pressure. Thus the en- tire effect on the respiratory organs is very depressing-, though its im- mense value must be recognized in restraining cough, spasm, dyspnoea, expectoration, and even vascular excitement and hajmoptysis. Some of the undesirable or dangerous effects may also be modified or prevented by the simultaneous administration of other remedies acting as antago- nists to it over a portion of its area of operation. Combinations, too, with synergists instead of with antagonists, as well as with various other pneumatics, may also render the greatest service. Further, the adminis- tration of other medicines, even such as scarcely claim to be considered pneumatics, may in their turn advantageously affect the narcotic ; and again, an occasional opiate miiy be ventured upon under circumstances when its action on the centre might suggest that it would be scarcely appropriate. The action of opium itself is very complex, and he will prove himself the most skilful therapeutist who, whether by judicious combinations or alternations with other medicines, or by the most careful dosage, is able to obtain the greatest benefit for his patient. Chloral. — Chloral acts first on the brain, but larger doses soon in- volve the medullary centres, which are much depressed. The heart is weakened partly through the centre, but a full dose is a direct cardiac poison, retarding and enfeebling the beat by diminishing the excitability of the intrinsic ganglia, and in toxic doses the ventricle is arrested in diastole. The blood-pressure likewise falls, apparently from a direct ac- tion on the vascular walls as well as on the vaso-motor centre, which is depressed. Thus there is altogether a very considerable weakening of the circulation, tending toward its arrest, while at the same time the respiratory centre is deeply depressed and the breathing rendered slower and feebler, a little later irregular and shallow, and ultimately it is com- pletely arrested. These effects have been observed after section of the vagi, and so must be attributed to the influence on the centre. There is a remarkable fall in the temperature. 268 THERAPEUTICS OF THE RESPIRATORY PASSAGES. In spite of its powerful effect chloral has been used to restrain spasm, cough, and dyspnoea, but it very frequently fails to do so, and alto- gether in respiratory diseases it is much less useful than opium, though it is probably more risky, and when there is any fear of the centre becom- ing exhausted it is very dangerous. Moreover, large doses seem to favor congestion of the lungs and air-passages. In acute inflammation of these parts it is, therefore, to be avoided. It is useless as an anodyne and not much use as an antispasmodic ; though it has sometimes relieved asthma, it more frequently fails. In whooping-cough and laryngismus it is perhaps more successful when given in small doses two or three times a day, but even in these cases it is inferior to the bromides, and should for the most part be reserved as a hypnotic, for which purpose it is in- valuable. Bromides depress the respiratory centre, and to tliis influence is per- haps due their effect in relieving spasmodic diseases of the respiratory system. But tlie depression is by no means confined to this part ; the other centres in tlie medulla are also affected and probably all parts of the nervous system, though much of the influence on the brain is to be traced to the effect on the cerebral circulation. Tlie depression of the cardiac centre is not very marked ; true, the heart is weakened and re- tarded by the medicine, but this appears to be largely due to direct ac- tion on the nervo-muscular substance rather than on the centre, which explains the value of the remedy in certain nervous disorders of the heart. The tension seems to be reduced, but the effect on the vessels is hardly settled. The temperature is usually somewhat lowered. The bromides are absorbed readily and elimination begins at once through the saliva and urine. The salt usually passes away unchanged ; the largest portion leaves the system during the first day, but as Clarke and Amory ' have shown, elimination goes on longer ; on the second day, after a single large dose, the amount removed is much less than on the first, and the reduction goes on until elimination is complete. Namias reported ( Gazette Sebdom., 1868) that when bromide had been taken for a considerable period its excretion might not be complete for fourteen days. Disease of the kidney renders the process slower, and Dr. Lees mentioned to the Pathological Society (" Trans.," 1877) a case in which it vpas found four weeks after the medicine was discontinued. Rabuteau, operating upon large quantities of urine, found a salt of bromine at such a distance of time that he came to regard it as a natural constituent {Gazette Hehdoni., 1868) of the body. Armory found that a single dose was removed almost entirely in one day, but some of it often re- mained until the second day. After continuous doses it lingered longer ' Clarke, Edward H., Amory, Robert: The Physiological and Therapeutical Action of Bromide of Potassium and Bromide of Ammonium. 1873. PNEUMATICS. 269 in the system. Namias found i^Comptes Rendus, tome Ixx.) bromide of potassium in all the fluids as well as in the brain, lungs, liver, and other viscera of a man who had died while taking a course of that medicine. Some elimination has been supposed to go on upon the mucous mem- branes, and Voison {Bull. gen. de Therap.^ Ixxi.) has stated that the breath has a strong odor of bromine after the continued use of the salt, so that he supposed it might be decomposed to some extent in the res- piratory passages, and the volatile element escape, and he and others ob- served that hoarseness, cough, and laryngeal and bronchial irritation sometimes followed the use of the drug. But Amory and Clarke con- clude {pp. cU.) that it is not eliminated by the breath, and regard the odor observed by M. Voisin as one which is produced equally by other salts of potassium, after the use of which they say a fetid smell is often given o£E and a disagreeable taste experienced by the patient. Eche- verria ' noticed that this odor occurred earlier and to a greater degree in persons who did not attend rigidly to the cleanliness of the teeth ; a similar effect is observed in persons who have a habit of biting and chew- ing up portions of the lining of the mouth and lips. The laryngeal symptoms observed are generally attributed to impurities in the medi- cine ; a very small contamination with iodate will bring on catarrhal symp- toms. The skin assists in the elimination on the second day, and the eruptions so well known to occasionally follow the use of bromides may perhaps be due to a local action. The effect on the circulation is less marked than on tlie nervous system, but must not be forgotten as an im- portant element in the action. It will be observed that the action of the bromides is rather slow, compared with the iodides ; or again, compared with chloral the effect is slower but more protracted, so that in so far as the respiratory system is concerned, chloral and the bromides are to each other as depressants of the centre much the same as belladonna and strychnia are to each other as stimulants ; and here is one danger of chloral and the great recommenda- tion of the bromides. We do not really want to suddenly depress the cen- tre in the manner in which it is so often most urgent to suddenly stimu- late it. Therefore, the quick-acting stimulant is often called for, but the quick-acting depressant is rather to be avoided when possible, though the slower and less intense depressant action of the bromides may not be in- jurious ; in some instances it is manifestly desirable, and constantly it is allowable in order to secure the other remarkably valuable effects on the nervous system. The bromides are useful in spasmodic respiratory disorders ; they sometimes relieve laryngismus and prevent the recurrence of the par- oxysms, and thus enable the tonic and hygienic measures so often neces- ' Echeverria, Gonzalez : On Epilepsy. 270 THERAPEUTICS OF THE RESPIRATORY PASSAGES. sary to be brought into play. In whooping-cough the value of the bromides was pointed out by Gibb ' and corroborated by Dr. G. Harley {^Lancet, 1863). In asthma the bromides have been freely emploved, both during the paroxysm and the interval ; more successfully in the latter case. Professor See {Bull, de Theraj)., 1865) found that it de- layed the attacks, as did Dr. Warburton Begbie {Edin. Med. Joitrncd, 1866), and M. Saison published a remarkable case in which, after full doses for a fortnight, no further paroxysms occurred ("Du Bromaure," These, 1868). The same author recommended this remedy in recurrent tonsillitis, .but it appears to have little influence, and would probably only be of use to persons in whom it was otherwise indicated. ' In phthi- sis it. is sometimes useful in relieving spasmodic laryngeal cough, though it very often fails to do so, and is not appropriate where there is much ansBmia or depression. In this disease, also, it will restrain dysphagia when that assumes a spasmodic character and there is a good deal of irritation but no severe disease in the larynx. Of course it would only aggravate this symptom if it arose from any degree of paresis. In diphtheria these salts have been taken internally and used locally, with the addition occasionally of some pure bromine. The records are not very encouraging. In resorting to the bromides in respiratory diseases, they may often be advantageously given in combination, or alternately with other reme- dies, partly for the purpose of reinforcing their action, as by chloral, cannabis, opium, aconite, etc.; but more frequently with.a view of modi- fving the effect or preventing disagreeable consequences. The antago- nism of strychnia to the bromides Avas observed by Saison, and has since been confirmed. He examined post mortem the spinal centres, after using the two medicines, and found that after bromides the capillaries were scarcely visible, but after strychnia they were intensely congested. As the effect of strychnia on the brain is so much less than on the cords, we may partially neutralize the spinal action of bromides without inter- fering much with their cerebral influence, and this is occasionalh' an ad- vantage. Combinations with opium are also sometimes of service. Da Costa {Amer. Jour. Med. Sciences, 1871) has shown that it is easy to correct the disagreeable action of opium by preceding it Avith a dose of bromide, and that with no loss, but rather with a gain in the hypnotic effect. So arsenic is sometimes given simultaneously to prevent or re- move the cutaneous complication set up by bromides. Dr. Bill in a very interesting article holds that chloride of sodium {Amer. Jour. Med. Sciences, 1868) is in some degree antagonistic to bromide of potassium. Atropia and ergot are both partially antagonistic, but both also may at times be advantageously combined with bromide. In some cases expec- ' Gibb, G. D. : Treatise on Whooping-cough. 1854. PNEUMATICS. 271 torants and other pneumatics are advantageously given, while the system is kept more or less under the influence of bromide. The potassium salt is most commonly used. The ammonium salt has been freely employed, and seems of late to grow in favor, but it is the more nauseous of the two, and seems also to be more irritatino- to mucous membranes, for which reason it is perhaps less appropriate when there is much bronchial irritation. It has also been thought to be more evanescent. Brown-Sequard ' found that the union of the two salts in- creased the sedative action of the dose. The bromide of sodium is less depressing, less likely to irritate mucous membranes, and rather less disagreeable in taste. As in other instances, I have been led to prefer the sodium salt ; the dose is a little less, as, weight for weight, it con- tains more bromine. Bromide of lithium is still more powerful, contain- ing about ninety-two per cent, of bromine against seventy-eight of the sodium salt and sixty-six of the potassium. I have found a smaller dose, that is to say, a dose proportionate to these figures, thoroughly effectual, less disagreeable to take, and sometimes successful when the other salts fail. Probably absorption, and perhaps elimination, may be a little more rapid, for sleep comes on more quickly after the lithium salt. It may be preferred in gouty and rheumatic constitutions. Dr. Weir Mitchell speaks as favorably (Amer. Jour. Med. -Sci., 1870) of the hypnotic qualities of this preparation. JBromide of calcium is another active salt. It has not come much into favor, perhaps because it is rather unstable, but it has a value of its own. Hammond has found it succeed after the potassium has failed, and I would once more urge the more frequent use of this and other calcium salts. Charcot has recom- mended {Brit. Med. fTour., 1877) hromide of zinc, and some other metallic bromides have been employed, so have combinations with quinine and other organic bases ; while hydrohromic acid has been supposed to produce many of the effects of the alkaline bromides with- out causing so much depression, but it is more frequently used, merely to prevent quininism than to produce the effects of bromine. Prussic Acid. — The dilute hydrocyanic acid of the pharmacopcBias, United States and British, contains only two per cent, of this powerful poison, which is absorbed with great rapidity and produces its deadly ef- fects most swiftly. It changes the red corpuscles and converts the venous blood to a bright arterial color which speedilv turns black. The first change seems to check the function of the corpuscles, the second to de- stroy them, reduction of oxyhsemoglobin being effected and cyanohfemo- globin formed. This body, discovered by Hoppe-Seyler, has no ozon- izing power, at the same time some cyano-oxyhfemoglobin seems also to ' Brown-Scqiiard : Lectures on the Diagnosis and Treatment of Functional Xervous Affections. 272 THERAPEUTICS OF THE RESPIRATOKY PASSAGES. be formed, hut these changes which liave been well studied out of the body, and which no doubt occur in cases of poisoning, do not altogether account for the therapeutical effects which appear to be largely produced by an action on the nervous tissues, all of which are greatly depressed. As soon as ever the poison is taken tlie respirator}'^ centre feels the im- pulse, and after a momentary excitement is greatly depressed, so that the respiration falls, dyspncea ensues, and asphyxia follows. It has been held that at the same time the respiratory nerves are dejoressed and re- flex respiratory acts arrested, especially when the poison is inhaled, but Preyer ' says that after division of the vagi letlial doses did not kill, though Boehm and Knie {Arcliiv f. exper. Path. u. Tlierap.) found that section of the vagus had no influence on the respiratory action of the poison. The vaso-motor centre is affected like the respiratory ; so also is the cardiac, but this in a much less degree, so that the heart continues to beat for some time after respiration has ceased. A full medicinal dose may cause giddiness, disturbed breathing, and syncope ; this effect may be so rapid as to cause great alarm. No doubt great differences in the preparation have occurred, and it is unfortunate that in dealing Avith so powerful a medicine more than one preparation should have been in common use. The so-called Scheele's acid was much stronger than that of the Pharmacopoeia, and also somewhat uncertain in its strength. It is, therefore, a source of regret" that a few physicians should still insist on using it. The officinal acid is strong enough for all therapeutical purposes, and a dose of one to three minims need not be exceeded. The dose given by the British Pharmacopoeia is much too high ; indeed, it may be said to be quite double Avhat it ouglit to be. The British Pharmacopoeia gives two to eight minims, but very few people happily will prescribe this maximum. K case has been communicated to me in which a patient, after four minims, fell down in a state of breath- lessness, which was at first thought by friends to be fainting, but the great dyspnoea, constriction of the chest, confusion and giddiness with- out loss of consciousness, convinced them that the medicine just swal- lowed was the cause of the symptoms, and they sent for the gentleman who had prescribed it in the greatest alarm. As he happened to be near he arrived in time to see the effect, which left a severe headache and sense of prostration for several hours. Admitting that there may have been some unusual susceptibility in this case, considering that many other persons who have taken a less dose have experienced headache and other unpleasant symptoms, my contention seems reasonable that the officinal dose is too large. Moreover, as the effect of the medicine in small doses is very evanescent, it can be repeated every two or three ' Preyer, W. : Die Blausaure. 1870. PNEUxMATICS. 273 hours, and in most of the cases in which it is likely to prove useful small and frequent doses will be found most desirable. In my experience two or three minims always suffice, and more frequently one to two. The chief use of hydrocyanic acid is to allay troublesome spasmodic cough in phthisis, asthma, and whooping-cough. It probably acts botli on the centre and on the peripheral nerves ; by this latter action it also arrests vomiting, for which it is often employed, and this also makes it specially useful in some cases of phthisis. We know that locally it allays irritation, as we sometimes see on the skin, and perhaps this is why the inhalation of the vapor is occasionally so effectual. The high value placed on this remedy by Majendie ' is not easy to account for, in view of tlie disappointment to wiiich it constantly gives rise. The still more extravagant praises of Dr. Granville,' who seemed to think it could cure advanced phthisis, did not perhaps exercise the influence of the eminent physiologist's confidence. Dr. Elliotson ' defined its sphere in dyspepsia. Dr. Roe* had much confidence in its value in simple, uncom- plicated cases of whooping-cough, but gave it in doses which Sir T. Wat- son in his lectures pronounced "gigantic." Still Dr. West^ admits it sometimes "exerts a magical influence," and Dr. Atlee [Ai/i. J. Med. S.) gives a favorable report based on two hundred cases. Dr. Lonsdale made some interesting experiments {Ediii. M. and S. J., 1838) and Dr. Nun- neley contributed others ("Trans. Prov. Med. and S. Ass.," 1847). The more recent researches have already been cited, and a review of the whole evidence will, I think, confirm my estimate of its therapeutical value. Cherry-laurel is only of use for the prussic acid it contains, and being of uncertain strength is best avoided. Its introduction into the British Pharmacopoeia is greatly to be regretted. Cyanide of potassium produces the same effects as hydrocyanic acid. Five grains have several times proved fatal, and it is not improb- able that half that quantity will cause death. The medicinal dose would be a tenth to an eighth of a grain. Cyanide of zinc has also been em- ployed, and is included in the French Codex ; dose, one-fourth of a grain. Some other cyanides have been used, but not as substitutes for the acid. Physostigma, after a very brief stimulation, powerfully depresses the respiratory centre, death being due to failure of the respiration. It has ' Majendie, F. : Reclierclies pliysio'ogiques et cliniqnes siir I'emploie de I'acide Prussiqiie, etc. 1819. - Granville, A. B. : Internal Use of Hydrocyanic Acid in Pulmonary Complaints, etc. 1819. 'Elliotson, J. : Cases Illustrative of the Efficacy of Hydrocyanic or Prussic Acid, etc. 1820. ^Roe, Gr. Hamilton : Treatise on Whooping-cough. 1838. * West, Charles : Lectures on Diseases of Infancy and Childhood. 1854. 18 274 THERAPEUTICS OF THE EESPIRATORT PASSAGES. been used in several spasmodic affections. Subbotin speaks well of it (Archiv f. klin. Med., 18G9) in clironic bronchial catarrh, attended with dyspncjea. We have already mentioned its antagonism to atropia. It can scarcely be said at present to have obtained a position as a respira- tory remedy. Aco7iite and veratria, although they depress the respiratory centre, are employed rather for their effects on the circulation, which have already been considered. A similar observation may be made as to gel- semium. Conium may be mentioned here, and has been used more or less from the time when Socrates drained the fatal cup presented by the Athen- ians, But although the ancients employed it as a medicine, it fell into disuse until Baron Stoerck ' revived it in a treatise of nearly three hun- dred and fifty pages, which he followed by a second smaller work and be- sides that a '• supplement," all three of which were in a short time trans- lated into English. No one can doubt that Stoerck's statements are highly colored, as indeed his contemporaries asserted, but the interest he excited secured a long trial for the drug, and a very considerable litera- ture accumulated concerning it, of which Bayle has furnished us("Biblio- theque de Therapeutique," 1835) an excellent summar}-. Sir Charles Scudarnore added conium to his iodine inhalations ; and in our own time Dr. J. Harley ^ has carefully studied its action and shown how it may be intensified by opium. A further important study of the subject has been made by Martin-Damourette and Pelvette.^ Conia or cotiine seems to have been discovered by Brandes and Gie- secke in 1826, and was isolated by Geiger in 1831, but the first important examination of its properties was by Professor R. Christison ("Trans. Royal Soc. Edinburgh," 1836). It appears that the herb contains also an essential oil which is not poisonous, and a crystalline base, couhydrin, which is less poisonous than conia. This last is a yellowish, strong-smell- ing, oily liquid, more soluble in cold than hot water, very unstable, very ])oisonous, and when locally applied an irritant. It may be dissolved in alcohol, and it forms salts which are more manageable than the alka- loid. Conia is readily taken into the system, where it has been supposed to be destroyed, but Zaleski and Draggendorff have detected it in the urine, and Orfila found some in the spleen, kidneys, and lungs of animals poisoned by it. Perhaps on account of its volatility it may easil}' escape ' Stoerck, A. : Libellns quo demonstratur Cicutara non solum uso interne tutissimo- exhiberi sed et esse simnl remedium valde utile in miiltis morbis. 1760-1. Also, Li- bellns secnndns qno confirmatur, Cicntam usu interno ti;tissime adhiberi, etc. 1761. Also, Snpplenientum necessarinm de Cicuta. 1761. - Harley, John : The Old Vegetable Neurotics. 1869. ^ Martin-Damonrette et Pelvette : Etude de physiologie experimentale et th6ra- peiitique sur la CiguG et son Alcaloide. 1871. PNEUMATICS. 275 in the breath. Its chief action is on the motor nerves, paralysis taking place first in the extremities and proceeding upward. In the end the respiratory centre as well as the nerves are paralyzed, and death ensues from asphyxia. But it is not so entirely without effect on sensory nerves as has often been said. Gubler {^Bull. de TTierap., 1875) found that it numbed cutaneous sensibility, and Lautenbach i^Phil. 3Ied. Times, \o\. v.) declares that it greatly impairs the functions of the peripheral afferent nerves. It is not a hypnotic or a narcotic, as was once supposed, and its great use is to restrain excitement of the motor system. Conia locally applied is extremely irritant, and probably fatal to the more highly organized tissues. Christison {loc. cit.) proved this in regard to muscular fibre, and yet we use it as a sooth nig inhalation. When mixed with hot water it rises with the vapor, but curiously enough its own boiling point, unmixed, is much higher than that of water. It would appear that in ordinary inhalations the vapor is so diluted that it no longer irritates the mucous membrane, and some local effect is exercised on the nerves ; at the same time, by its central action it tends to relieve spasm. The British Pharmacopoeia vapor is a bad preparation ; in fact, we have been very unfortunate in our officinal preparations of hemlock ; the extract is very often useless, and the mixture of it with liquor po- tasses a method of dissipating the small amount of alkaloid that may be present in a superior specimen. The best way is to employ the succus, the only useful preparation in the British Pharmacopoeia, and the alkali ought to be added at the time of use, so that what conia separates may be inhaled. Moreover, an alkaline carbonate is best. This vapor, care- fully prepared, I have found very soothing in laryngeal phthisis and some other diseases. Internally the succus may be used in whooping- cough and other spasmodic affections ; it must be continued until the physiological effects are manifest. The new United States Pharmaco- poeia has an abstract and a fluid extract, but I have not yet fully tried them. Perhaps a salt of the alkaloid will in time become more frequently used. CHAPTER XIX. TOPICAL PNEUMATICS. The attempt to introduce vapors or fumes into the air-passages dates from the most remote antiquity, and the attempt to vary the conditions of the atmosphere must be quite as ancient. It could not but be that the pernicious effects of fogs should be noticed at the earliest period, and that men should not only avoid as far as they could what seemed injuri- ous, but should Avhen ill attempt to subject themselves to opposite con- ditions. The breathing of various emanations from the earth, especially in the neighborhood of volcanoes, was probably also resorted to in the earliest ages, just as other natural agents were employed, either accident- ally or from superstition ; and plants which were not found to be edible have been used as medicines by most uncivilized tribes. Fumigations with cyphi (ki)^i) entered into the practice of the ancient Egyptians, these cyphi being, according to Dioscorides, a mixture of various drugs, and as the Egyptians had made great advances in the use of spices, balms, and other odorous medicines, it is probable that these entered largely into their cyphi. As soon as men began to use warm baths, indeed, as soon as they made water hot, they would become ac- quainted with its vapor, and probably notice the soothing effect of breath- ing steam, and endeavor to turn it to useful account. The early Greeks were well acquainted with the use of inhalations and fumigations, and handed their knowledge down to the Romans, from whom the Arabian school obtained it. Then it may, perhaps, be said that wherever incense was burned in religious ceremonies the effect of breathing it must have been noticed, and to it would probably be as- cribed the greatest benefit both curative and preventive. Homer men- tions fumigations with sulphur (" Iliad," xvi., 228, and " Odyssey," xxii., 481). Hippocrates frequently recommends the inhalation of vapors and fumes of various balsamic and resinous substances, and on his authority these remedies long held a high place in the practice of his successors. He even describes an apparatus for the purpose, consisting of a sauce- pan with a hole in the lid through which a reed was passed. As the vapor escaped it was inhaled through the open mouth, wet sponges being employed to prevent scalding the lips. The works of Hippocrates fur- TOPICAL PNEUMATICS. 277 ther show his knowledge of the effects of air and the use of change of climate. Galen's genius and erudition are only equalled by his practical sense and observation, and we know the reliance he placed on this class of remedy. A little later flourished Ccelius Aurelianus, the only Roman methodist whose works have descended to us, and though this sect re- jected previous opinions, and ridiculed the Hippocratic system, terming it a " meditation on death," we find this author ' recommended inhala- tions and fumigations. Pliny had already recorded (" Hist. Nat.") that in his time diseases of the lungs were believed to be benefited by a resi- dence among pine-trees, so that the inhalations could pass into the air- passages, and Celsus (" De Medicina ") recommended sea voyages to consumptives. As the Arabians took their inspiration from Hippocrates and Galen, they handed down this method of treatment, extending it by the numerous medicines and compounds which they added to the recognized materia medica. During the dark ages, when the incubus of an apostate church weighed down the nations of Europe, medicine largely passed into the hands of a corrupt priesthood, many of whom were vicious, many ignorant, and not a few both. But while they lost many other valuable remedies and re- placed them by superstitious observances, they recognized the value of fumigation, though they may have attributed its use to religious obser- vances. On the revival of learning, men turned back with impatience to the writings of the Greeks, and soon the spirit of inquiry in various de- partments added to what had been previously known. In the sixteenth, seventeenth^ and eighteenth centuries a large number of writers recom- mended frankincense, myrrh, amber, camphor, styrax, assafcetida, cloves, sulphur, the balsams, and, indeed, all strongly odorous fumes and vapors as a method of applying remedies directly to the bronchial membrane. Benedict in his " Theatrum Tabidorum " recommended this method of treating consumption, and Boerhaave in his "Materia Medica" furnished a number of formulre for such fumigations. Dr. Mead recommended fumes produced by throwing the medicament on hot coals to be inhaled through a tube, and regretted the undeserved neglect into which this plan had fallen in his day, and bore testimony to the signal service he had obtained from balsamic fumes thus employed. Alberti ^ described the use of vari- ous inhalations and Buxtorf ^ and Caccialupi* wrote treatises on the subject. Toward the close of the last century a series of brilliant discoveries directed attention to the elastic gases. It is true that hydrogen had ' Aurelianus, Caelius: De morbis Chvon. , lib. iii., c. 4. ' Alberti, M. : Dissertatio de spirandi difficultate. 1726. ^ Buxtorf, J. R. : De inhalatione. 1758. ^ Caccialupi, A. : De usn et prsestantia Halituum, Vaporum, Suffituumque in morbis respiratiouis organa obsidentibus. 1795. 278 THERAPEUTICS OF THE RESPIRATORY PASSAGES. been discovered a little earlier, namely, in 176G, by Cavendish (" Phil, Trans.," 17GG), but it was not till 1774 that Priestley' announced the discovery of oxygen, and Scheele that of chlorine, while two years later Priestley discovered nitrous oxide, Tliis gas received its name of nitrous oxide from Sir Humphry Davy,^ whose remarkable researches respecting it have a special interest, inasmuch as he foreshadowed the use of anaesthetics in surgery. Dr. Beddoes ^ took up the subject of elastic gases and their use in medicine with great energy, and had the advan- tage of Sir H, Davy's assistance. He tried the various gases in a great number of diseases, and recorded their effects with care. He was fol- lowed by Hill,'' Cavallo,* and others, and in another work he " himself recommended the inhalations of In'drogen mixed with air as a remedy for consumption, on the assumption that in that disease there was ex- cessive oxygenation. He prescribed inhalations for about fifteen min- utes at a time, to be used several times a day. About this time the value of acids, chlorate of potash, and other substances containing a con- siderable proportion of oxygen was often attributed to that element be- ing liberated in the system, as it was not till sometime later that Wohler and Stehberger {ZeitscJirift f. PJtys., 18'34) showed that these med- icines were eliminated unchanged. Under the influence of the impetus thus given to the inhalation of gases, even carbonic acid mixed with air was freeh' tried again ; for it had been previously employed by Percival,' who considered that it ameli- orated the febrile symptoms of phthisis, in wiiich he was confirmed by Hulme,* Beddoes,^ Cavallo," and some others. The lat^ observers thought that it lessened the stimulation of oxygen, which they considered excessive in consumption, and that it also relieved hectic and expectora- tion. Brera " recorded some important observations respecting this gas, which was also tried by Priestley,'^ who, however, turned his attention to ' Priestley, J. : Experiments and Observations on Different Kinds of Air. 3 vols. 1775-77. ■"'Davy, Sir Humphry: Researches Chemical and Philosophical chiefly concerning Nitrons Oxide. 1800. ^Beddoes, T. , and Watts, J. : On the Medicinal Use and Production of Factitious Airs. 1796. * Hill, D. : Practical Observations on the Use of Oxygen or Vital Air in the Cure of Diseases. 1800. * Cavallo, T. : On the Medicinal Properties of Factitious Airs ; with Ajipendix on Blood. 1798. * Beddoes, T. : On a New Method of Treating Pulmonary Consumption. ^ Percival, T. : Essays, Medical and Experimental. 3 vols. 1773-76. ^ Hulme, N. : Easy Remedy for the Relief of Stone, Gravel, Scurvy, Gout, etc. 1778. 9 Beddoes: Op. cit. i" Cavallo : Op. cit. "Brera, V. L. : Osservazioni e sperienze suU' uso delle Aere Mefitiche inspirate nella Tisi Pulmonare. 1796. '- Priestley, J.: Directions for Impregnating Water with Fixed Air. 1773. TOPICAL PjSTEUMATICS. 279 its use in solution in water. lu the hands of Miihry ' inlialations of carbonic acid entirely failed to relieve consumption. Although carbonic acid continued to be used in a number of diseases, we cannot affect sur- prise that it could not maintain the position which these writers assign to it. It may be stated, however, that it can be used when mixed with air more easily than might be supposed, and it is sometimes resorted to at Ems, St. Moritz, and other places in the present day. The good ef- fect believed to arise from sleeping in cow-houses and stables was also supposed to depend on the carbonic acid in the air, but perhaps, if it ex- isted, it was rather due to the warmth and moisture present. It has also often been remarked that asthmatics sometimes breathe easier in the close air of large towns, than in the country, and this also has been attributed to the carbonic acid ; but it may quite as likely depend on some other condition, and it is by no means a general rule. Tlie relief sometimes afforded to asthmatics by the fumes of nitre papers has also been attrib- uted to the same agency. At the opening of the present century AYard ° collected a number of observations on inhalations, and Zallony ^ employed them freelv, while Dr. Paris ■* advised the evaporation of water in the rooms of his patients during tlie prevalence of dry east winds, as well as other modes of inhalation. A little later than this Sir Alexander Crichton ^ turned back to tar vapor, as an inhalation in phthisis, in which he was followed by Lazzaretto," and Hufeland.' About this time, also. Dr. Forbes [Med. and Phys. Journ., 1822) and Pagenstecher {HufelaiuVs Journal, 1827) advocated the use of inhalations of tar, which continued to hold their ground until quite recently, Sales-Girons ■* recommending them, in addi- tion to the pulverized liquids with which his name is so honorably con- nected, and some others, especially in France, employing them at the present time. But this use of the fumes of tar was largely superseded by creasote, as recommended by its discoverer, Reichenbach, whose re- searches excited no little attention. Elliotson at once employed creasote inhalations in phthisis, as did Miquet and Cormack. The writings of these four authors have already been cited in the article on creasote, and ' Miihry, G. F.: De Aeris fixis iuspirati usu in Flithisi Puluaouali. 1796. 2 Ward, G.: De Medicina Pueumatica. 1800. 3 Zallony : Trait j de Tasthme. 1809. * Paris, J. A. : Pharmacologia. 1812. Ninth edition, 1843. 5 Crichton, Sir A. : Acconnt of some Experiments made with the Vapor of Boiling Tar in the Cure of Pulmonary Consumption. 1817. ^Lazzaretto, E. : Practical Hints on the Natnre and Cure of Consnmption, with Cases in Proof of the Beneficial Effects of Inhaling the Fumes of Pitch, as a Powerful Auxiliary to other Treatment. 1818. ' Hiifeland, C. W. : System der Pract. Heilkunde. 3 vols. 1818-28. ^ Sales-Girons : Traitement de la Phthisic pulmonaire par I'iuhalation des liquides pulverises et par les fumigations de goudrou. 1860. 280 THERAPEUTICS OF THE RESPIRATORY PASSAGES. may be supplemented by Frueh's ' work. These inhalations are still used, and often render good service in various affections of the respira- tory passages. Creasote has, however, fallen into comparative neglect since the introduction of carbolic acid, which is now so extensively emploved. To return. Murray ^ and Scudamore ^ turned to iodine in the hope that its vapor might prove to be an effectual remedy in phthisis and other respiratory diseases. They were gratified with the results obtained, and it is not surprising that their expressions of confidence are somewhat exaggerated and scarcely supported by their cases. Those of Dr. Bards- ley * certainly inspire more confidence. The use of iodine inhalations became gradually extended, and their value in some conditions of the air-passages is now generally acknowledged ; though we no longer enter- tain the hope that this or any other agent will prove a panacea. While so much attention was being directed to the inhalation of vapors and gases it was not likely that chlorine would be overlooked, and accordingly we find that this powerful irritating and suffocating gas, when adequately diluted, was tried as an inhalation. Gannal ^ gives an account of eight cases of consumption in which diluted chlorine appeared to him to alleviate the symptoms and prolong life. Jn one case recovery was said to have taken place, but then the only proof of the existence of tubercle was the presence of general symptoms. Elliotson " and other physicians also employed these inhalations in various diseases, and with somewhat conflicting results. At the present time we employ the vapor chlori as a stimulant and disinfectant inhalation in bronchiectasis, ad- vanced phthisis, and in gangrene of the lungs. The air of bleaching- w^orks is believed by many residing near them to be effectual in the cure of chronic coughs, and they sometimes resort to these works for that pur- pose; and it has been reported that the bleachers, although they may suffer from the emanations of chlorine, are jjarticularly free from con- sumption. We have already seen that sulphur fumigations have been employed from time immemorial; we need not, therefore, dwell on them specifically, but pass on to the more general subject of the various kinds of inhala- tions. Many of these are described by Maddock,' and about the same ^ Frueli, G. : Ueber die Anwendung desKreaosots in der Pneumophthisis. Ib36. ^ Murray, James : On the Influence of Heat and Humidity ; with Practical Obser- vations on the Inhalation of Iodine and Various Vapors iu Consumption, Catarrh, Croup. Asthma, and other Diseases. 1829. ^ Scudamore, Sir Charles : Op cit. ^ Bardsley, J. L. : Hospital Facts and Observations. On Iodine, etc. 1830. * Gannal, J. X. : Du Chlore emiiloye comme rem'de contra la Phthisie Pulmonaire. 1830. 6 Elliotson : Op. cit. ' Maddock, A. B. : Cases of Piilmonary Consumption, Bronchitis, Asthma, Chronic Cough, and Various Diseases of the Lungs, Air-passages, Throat, and Heart Success- fully Treated by Medicated Inhalations. 1837. TOPICAL PNEUMATICS. 281 time Dr. Coxe ' urged their curative power. A little later than this a very remarkable impulse to the study of inhalation was given by its applica- tion for the purpose of producing anaesthesia during the performance of surgical operations, the year 1847 being remarkable for the appearance of between thirty and forty pamphlets respecting the new discovery, and the next year being almost as fruitful. Somewhat later Sylvestri ^ gave a full account of the subject of inhalation and Desruez ^ published his practical guide to this method of treatment. At many continental spas inhalation-rooms were i^rovided in which the steam of the mineral waters was employed, but of course it was felt that none of the mineral constituents were present, and ordinary water might have been employed for the same purpose. The idea of atomiz- ing the mineral waters seems to have originated, or at any rate to have been first carried into effect by Auphan at Euzet-les-Bains in ISiO ; he projected a jet of the mineral water on the wall of the inhaling-room Avith sufficient for^e to break it up into a spray, which was inhaled by his patients. This method was adopted at several spas. But at length Sales-Girons constructed a portable apparatus for atomizing fluids, and brouo-ht it before the Academv of Medicine of Paris in 1858. This was undoubtedly an epoch in the history of inhalations, and the gTcatest interest was excited. It was not, however, till 1862 that the committee of the Academy appointed to investigate the new method brought in its report, and during the interval prolonged discussion had taken place as to whether the spray penetrated deeply into the air-passages. Tlie report stated that it was proved that both the water and the mineral constituents employed penetrated not only to the bronchi but even to the air-cells ; and this report was founded on extensive independent experiments and was almost unanimously adopted by the Academy. The conclusions and practice of Sales-Girons,^ who has been called the Father of Atomization, thus received the highest authority aTid rapidly spread over the civilized world. Demarquay ^ vvas one of the earliest to adopt it, and to prove independently that tlie atomized liquids rapidly pass into the respiratory passages. ' Coxe, E. J. : Practical Treatise on Medical Inlialation and its Curative Powers in Bronchitis, Consumption, and other Diseases of the Respiratory Organs. 1841. '-' Sylvestri, G. : La Pneumojatria ossia I'arte di curare le malattie coi medicamenti sotto forma gazosa, giusta le expeiienze di rinomati medici antichi e moderni. 1851. " Desriiez, J. M. R. : Inspirations Pulmonaires ou Fumigations internes ; guide pratique de la methode thorapeutique. 1854. •* Sales-Girons : Therapeutique Respiratoire : Traite th'oriqiie et pratique des Sal- les de Respiration nouvelles (a I'eau minorale pulvcrisoe) dans les etablissements thermaux pour le traitement des maladies de poitrine. 1858. ^Demarquay : Memoire sur la p='netration des Liquides Pulverises dans les voies, respiratolres et leur application au traitement des maladies des yeux, du pharynx, et du larynx. 1862. 282 THERAPEUTICS OF THE EESPIKATORY PASSAGES. It seems surprising that this should have been doubted, considering that solid particles are constantly introduced in the cases of workmen engaged in certain trades and give rise to serious diseases, e.g., miner's lung, and grinder's disease. Dr. Bergson simplified the apparatus by employing a pair of tubes fixed at right angles, one descending, vertically into the liquid to be atomized, the other for driving the air through. Siegle substituted steam for the bellows, and Dr. Beigel added a screen, for which a tube is sometimes substituted, to direct the spray into the mouth. Methods of I^'haling. When we wish only to change the conditions under wliich respiration is carried on, we may to some extent do this by change of air or change of climate, and instances have already been mentioned in which patients have been sent to localities where they could breathe certain emanations from the earth or air laden with artificial impurities. The atmosphere of gas-works, bleaching-works, stables, and other places has often been resorted to by the public. Attempts have also been made to change the air in a patient's room. The most familiar instances is wlieu we add moisture and raise tlie tem- perature. In addition to this, the liberation of elastic gases has also been tried ; thus oxygen has been set free in the room in the hope thereby of providing an atmosphere in which respiration should be carried on more efficiently. On the other hand, hydrogen and even carbonic acid have been set free with a view of restraining oxidation. This method is difficult to manage, ventilation is essential, the diffusion of gases rapid, and we have no mode of measuring in what degree such a plan can op- erate in an ordinary room. Of course, in specialise constructed chambers this process might be carried out for short periods, but for a longer time the necessity of ventilation defeats our efforts. The liberation of irritating gases, such as chlorine or sulphurous acid, is easy enough, as very small quantities speedily make their presence known, and only such small quantities can be tolerated. The fumes ob- tained from burning nitre papers are rapidly diffused through the apart- ment, and can be approximately measured by using definite sizes of paper saturated in solutions of known strength. The amount of sulphurous acid liberated may be regulated by burning a known weight of sulphur. Pas- tilles of definite strength can be made for this purpose. The fumes of tar may be obtained by boiling, or by simply stirring with a hot poker. Turpentine, by reason of its volatility only requires to be sprinkled about a room to secure a portion of the vapor being perceptible in the air for a considerable period, and it can easily be removed. A solution of carbolic acid may be employed in the same way, but it is less volatile. TOPICAL PNEUMATICS. 283 and when we wish to secure its full effect it is necessary either to vapor- ize it or to distribute the solution over a considerable surface, which may be accomplished by dipping towels or sheets in a solution of known strength and suspending them as curtains by the doors, and if necessary by the windows or any other openings, so that the entering air must traverse them. This has been done lately at the Victoria Park Hos- pital, and Dr. Heron calculates {^Lancet, September 6, 1884) that patients in the inhalation-room pass seven cubic feet of carbolic vapor through their lungs in twenty-four hours. But for a room to be permanently used in this manner, special provision ought to be made for ventilation. Even when a room is only used for a short time, it is not an easy matter to keep up a definite supply of the substance with which the air is to be laden. Dr. Hassall has constructed a special inhalation-chamber at San Remo, in which he has endeavored to accomplish this {Lancet, 1884). But it is often inconvenient, or even impossible to resort to a special chamber, Fig. 1 — Bumstead's Vaporizer. and therefore various modes of evaporating carbolic acid and other sub- stances are employed. Such a vaporizer as is here shown will very quickly fill an ordinary room with the vapor of carbolic acid, eucalyptus, or other volatile antiseptics, and it will keep on evolving small quantities for about three hours without needing a fresh supply. For this purpose the little lamp has only to be trimmed with oil, taking care that the wick is short, as a very small flame is suflicient. Indeed, in the absence of a lamp an ordinary night-light will give off sufficient heat, and too much will be produced if the lamp be filled with spirit or petroleum. Iodine gives off its vapor at a low temperature, and a little of the ele- ment may be placed in a watch-glass, and this floated on a saucer of hot water. Balsamic substances maybe thrown upon live coals or heated over a lamp. In order to diffuse an increased amount of moisture through the air 2S-i TIIKUAPEUTICS OF THE RESPIRATORY PASSAGES. a saucer containing water is often placed on a stove when that method of warming is employed. For an open fire or gas-stove an ordinary croup kettle, which has a long tube to project into the room, may be used. For the same purpose, as well as to permeate the apartment either with aqueous vapor alone or combined with carbolic acid, a steam-draught inhaler may be employed. In these cases a supply of steam is diffused through the air ; but sometimes instead of vaporizing the water we may simply atomize it, and in this case it carries with it particles of such solids as it may contain in solution. In this way attempts have been made by employing salt to Fia. 2. — Croup Kettle. Fig. 3. — Steam-clraiight Inhaler. fill the patient's room .with a kind of artificial sea air. Any of the larger sized spray-producers will answer for this purpose. When we do not desire to charge the air with the remedy, but only to supply such an amount as the patient can use for a short time, we have to resort to inhalers. For the elastic gases a very simple apparatus will suffice ; but Earth's oxygen inhaler is the most convenient, and this gas may be produced condensed in strong metallic bottles, from which a given quantity can be let into the inhaler as required. Limosin had an apparatus made to lib- orate the oxygen at the time of use, and Robbins also contrived an in- haler for this purpose, but I have always used the condensed oxygen. For nitrous oxide Earth's apparatus is also excellent. TOPICAL PNEUMATICS. 285 For iodine Nelson's inhaler can be used, but it is better to have one of glass, such as is here figured, wliich will also serve for chlorine. For steam inhalations a very simple plan is to breathe through a large Fio. 4. — Iodine Inhaler. cup sponge which has been dipped in hot water and rapidly squeezed. Children willingly do this. A less efficacious method is to lean over a jug or basin, half filled with hot water. In this case the patient should not envelop the head in a towel, as many often do, for this is likely to produce flushing and headache ; it is easy to arrange a towel around the brim of a jug so as to enclose only the mouth and nose. A simple dou- Fl".. S.^Double-valved Inhaler. ble-valved inhaler is more convenient than the domestic jug and very often necessary. When the patient cannot sit up a long elastic tube is necessary, as in 286 THERAPEUTICS OF THE EESPIKATORY PASSAGES. Hunter's iiilialer (see Fig. G), an improvement on which is Maw's double- valved, which provides a separate channel for the expired air. In Hunter's inhaler the air is made to traverse the water. Bullock's liospital inhaler, and Martindale's portable one are both cheap and ef- fective. Fig. 6. — Hunter's Inhaler. The eclectic, which professes to combine the excellencies of several inhalers, is much more expensive, and some patients consider it cum- brous, but it is very comjDlete. For any patient who can sit up Lee's steam-draught inhaler (Fig. 3) is the least troublesome. It brings a full stream of vapor out at the end of the tube at a temperature fit for breathing, so that no suction is re- quired, and no effort on the part of the patient, who simply sits with his Fig. 7. — Martindale's Portable Inhaler. mouth near the opening and breathes in the ordinary way. This in- haler is also well adapted for carbolic acid, as Dr. Lee has shown that this vapor is given off with the steam in a constant proportion. For the inhalation of atomized fluids or sprays a different method is adopted. A pair of Bergson's tubes constitutes the most important TOPICAL PNEUMATICS. 287 part of the atomizer. They may be made of metal, and with a hino-e, so as to be easily carried about, as seen in Fig, 9, but they are more fre- FiG. 8.— The Eclectic Inhaler. quently made of glass. One of the tubes descends vertically into the bottle containing the liquid for atomization, and a rush of air or steam Fig 9. — Bergson's Portable Tubes. through the horizontal tube exhausts its fellow, when the fluid rises and is sent forward in a fine spray, as seen in the following engraving of Bergson's instrument. Pia. 10.— Bergson's Atomizer, 288 THERAPEUTICS OF THE RESPIRATORY PASSAGES. The bottle being held in one hand, the bellows can be worked with the other, or an assistant may do this. Wintrich modified the form of the tubes so that they might be introduced into the mouth, and the spray thus prevented from being projected upon the face. Fig. 11. — Wintrich's Atomizer. Schnitzler's apparatus is constructed on the same plan with a vul- canite tube protecting the fine points. Newman's instrument with glass tubes is very much cheaper and quite as effectual. But the cheapest of all, which I have used for many years, and which I have named the '* Simple Atomizer," is constructed somewhat differently. The tubes are placed parallel to each other, and the distal end of the upper one is formed into a cup which holds enough liquid for each occasion ; the fluid finds its way by gravity to the point, and the Fio. 12. — Schnitzler's Atomizer. air is blown through the lower tube by the ordinary double bellows ; the bottle is thus dispensed with, and the apparatus simplified. The tubes can be held far enough in the mouth to prevent the spray spreading over the face. This simple atomizer I introduced to the London Medical TOPICAL PNEUMATICS 289 Society many years ago, but a very similar form seems also to have been used by Dr. Rumbold, and also by Dr. Solis-Cohen. A somewhat modified form with a larger cup has also been made. Fig. 13. — Newman's Atomizer. Instead of the hand-bellows, Dr. Siegle employed steam as the motive power, and the patent which he took out having now expired, steam atomizers are made of various shapes, and at greatly reduced prices. Fig. 10 shows his instrument. Fig. 14. — Simple Atomizer. Another apparatus constructed on the same principle, with the addi- tion of a tube to convey the spray to the mouth, is represented in Fig. 17. 19 290 THERAPEUTICS OF THE RESPIEATORY PASSAGES. To these may be added, when price is not an object, Codman & Shurt- leff's Complete Steam Atomizer (Fig. 18), which I have used with satis- faction. All these methods of employing inhalations only permit us to carry our remedies into the air-passages for a short period, at a sitting. ■In 1 Fig. 15. — Simple Atomizer, Large Size. order to prolong the application, or rather to extend it over a long pe- riod, we have to resort to respirators ; but here another principle is in- volved. In using them we dispense with the steam, but we filter the air which the patient breathes, and not only so, but we warm it as the stream of expired air imparts its heat to the respirator, which gives it up again to the inspired current. A simple woollen respirator may easily be knitted of some such pattern as shown in Fig. 19 ; and if the upper end be left open, cotton-wool soaked in antiseptics can be introduced. Or any Fig. 16.— Siegle's Atomizer. of the small respirators sold in shops may be employed, but by far the best is Jeffreys', in which the air traverses carefully arranged strands of gold wire, which takes and gives back the heat from the breath most readily, and maintains a current of air of uniform temperature. In order to raise the temperature still more, Dr. Seaton has proposed [Lancet, TOPICAL PNEUMATICS. 291 1884) to utilize the body heat, by compelling the air to pass through a tube applied to the surface, but this would seem almost necessarily to in- FiG. 17. — Atomizer with Tube. volve greater labor in breathing, and Jeffreys' respirators have been found to regulate the temperature without much inconvenience. Nevertheless, Fig. 18. — The Complete Atomizer. the objection to all respirators is that they may to some extent impede the breathing. Dr. Ramadge, however, deliberately impeded the expira- FiG. 10. — Knitted Respirator. tion by inserting a graduated valve for the purpose, and he attached more importance to the alteration of pressure thus brought about, than to the inhalations which he also prescribed. The following engraving 292 THERAPEUTICS OF THE RESPIRATORY PASSAGES. shows a combined inhaler-respirator, but quite as frequently, a small tube onl}"^ is used, with the necessary valves, so as to compel the patient to ex- pire slowly, leaving" the resoiratioii free. Respirators are also used in order to charge the air inspired with anti- septic vapors, and this method of treatment has received a great im- petus from Koch's discovery of bacilli in tubercle. If we can secure a ])ortion of the medicament passing into the air-passages, it is easy to sup- pose that it may produce a favorable influence, even although it is unable Fig 20. — Inhaler-Respirator. to destroy bacilli or to repair organic mischief in the lungs. We are not, therefore, shut up to the theory that only germicides can be useful in this way. Dr. Coghill's antiseptic respirator has been largely tried, and he reports [Brit. Med. Journ., 1881) very favorable results from its use. Some modifications of his original form have been made by Dr. Hunter Mackenzie, whose instrument has the disadvantage of being much heavier; and by Dr. Roberts, but they all very much resemble Fig. 21. Dr. Hassall has investigated the question how far the antiseptic sub- stances usually employed can be recovered from the sponge or cotton- wool with which these inhalers are charged. He found [Lancet^ 1883) that after one or two hours' inhalation he was able to recover more than four-fifths of the creasote, carbolic acid, or thymol which had been placed in the respirator, from which he concludes that most of the oral and oro- nasal inhalers are of little use, and he has devised others in which the antiseptic substance is distributed over a much larger extent of surface. TOPICAL PNEUMATICS. 2^3 Our view of the value of antiseptic respirators must depend somewhat on the intention with which we use them. If we wish merely to intro- duce a certain amount of vapor into the respiratory passages this can be accomplished by very simple means. A glass tube containing some of the substance on cotton-wool or sponge will answer the purpose, and such a simple tube packed with blotting-paper has lately been sold as the " patent pocket inhaler," though why it should be patented must be a mystery to those who have used it many years before ; perhaps the pat- entee relies upon the shape of his blotting-paper. A vapor may be intro- duced either through the nose or mouth, and a Frankfort physician a few years ago contrived the simplest possible nasal inhaler, the advan- tage of which he held to be its invisibility. It was, in fact, a small cellu- loid tube, which was to be passed into the nostril and then a piece of Fig. 21.— The Antiseptic Respirator. cotton-wool charged with the antiseptic introduced, the tube merely serving to protect the lining of the nostril. Dr. Ward Cousins has lately proposed {Lancet, 1884) a somewhat larger tube, the end of which can be placed either in the nostril or mouth and supported by a wire which sus- pends the inhaler and compresses the nose. He considers it useful not only for introducing antiseptic vapor but as a mechanical method of sus- taining forced inspiration. Dr. Burney Yeo recommends a small respira- tor of perforated zinc {Brit. Med. Joiirn., 1884). If we wish to compel a patient to breathe a pure atmosphere and at- tempt to attain this end by means of a respirator, it is obvious that an oro-nasal one would be preferable and that it must be such an one as does not impede respiration, since it would have to be constantly worn. On the other hand, if the object were only to kill bacilli believed to be pres- ent, it would be necessary for the antiseptic to be sufficiently noxious to these organisms and yet not poisonous to the patient, and if such a o-ermicide could be found it need only be breathed for a sufficient time to 294: THERAPEUTICS OF THE EESPIRATORY PASSAGES. accomplish this object. Again, if we only wish to act upon the respira- tory membrane or the lungs in the same way as when we employ steam inhalations, then it would suffice for the respirator to be charged with a volatile medicament of such a strength as should be found sufficient, and for the instrument to be worn for a short time at suitable intervals. Fur- ther, if we abandon these efforts and revert to the use of respirators for the purpose of partially filtering and warming the air, then the instru- ment must be regarded rather in the light of protective clothing and the times at which it is worn regulated accordingly. Even in this case it is most important that the respirator should not impede inspiration, or the patient will soon give up its use. Heavy instruments are apt to cause a feeling of oppression, even when sufficient provision is made for the pass- age of air, a point often overlooked. Those which press closely on the face are found to be very irksome, and it is essential that a patient should be able to take sufficient exercise without experiencing any difficulty or oppression of his breathing. It seems obvious, therefore, that the sim- pler and lighter the instrument the better. Those which are complex and cumbrous are sure to be discarded. Uses of Inhalations and Other Topical Pneumatics. Though we have considered inhalations as topical remedies for the entire respiratory passages, it must not be forgotten that the absorptive power of the membrane is such that many of them become the most po- tent and rapid of general remedies. It is, therefore, only as a matter of convenience that they have been included in this chaptei'. The anaes- thetics and nitrite of amyl are examples of this. Then, again, the inhala- tion of oxygen can only be regarded as a general, not a local remedy. But in most other cases the topical effect is so important as to obtain the first consideration. Steam inhalations may be considered first. The contact of simple watery vapor with inflamed mucous membrane is so grateful as to de- serve to be called anodyne. It cuts short the congestive stage of catarrh by supplying moisture, and so relieving the dryness, heat, and oppres- sion, and at a later stage it dilutes and assists the removal of the secre- tion. In acute bronchitis the inhalation of steam is often of the greatest service, and the vapor may be made the purveyor of other volatile reme- dies, either anodyne or stimulant. Much of the good effect of many in- halations may be traced to the influence of the steam. In croup and diphtheria, great good arises from keeping the atmosphere of the sick- room saturated with steam. In the first edition of my " Sore Throat " I insisted on the value of a more thorough and systematic use of steam in these diseases, and have been advocating it ever since. During the last TOPICAL PNEUMATICS. 295 few years it has also been recommended by Oertel and other German writers. Any volatile substance can be easily employed in the form of inhala- tion, and those herbs, the therapeutic value of which depends on an aro- matic volatile principle, are often thus used ; or this principle is previ- ously extracted, as in the case of essential oils. The soothing properties of steam are often increased by employing hops — the vapor of the freshly-made infusion being charged with the sedative properties of the plant ; the oil of hops is too irritating to substitute for the crude drug. Chamomile flowers may be used in the same way. Another aromatic sedative is obtained by putting a teaspoonful of tinct. benz. comp. into the inhaler, with a pint of hot water. Vapor conise is more distinctly sedative — its efficacy depending on the conia being set free by the alkali, for which reason it should be added at the time. The succus conii is to be preferred to the extract, as previously pointed out. The vapor acidi hydrocyanici is employed with cold water, but may be ranked among sedatives. The volatile parts of opium can be utilized by putting the tincture or the solid drug in the inhaler with hot water. Ether and chloroform may be used with water at a low temperature. Conium or opium, in combination with chloroform and similar compound inhala- tions will often prove of service when a simple one fails. It is, however, obvious that very volatile substances may be as well administered with- out the medium of water. A very simple inhaler, or a little cotton-wool in a cone of paper, will suffice for chloroform, ether, and nitrite of amyl. Besides anodyne inhalations, those possessing stimulant properties are most important. In the British Pharmacopoeia there are only three — vapor chlori, creasoti, and iodi. The mode of using differs in each case, while each vapor is a special stimulant. For vapor chlori cold water is used ; for vapor iodi the water is heated after the addition of the tincture, but the other plan is quite effectual. Camphor is a good stimulant for inhalation. Ten drops of the spirit may be put into the inhaler to begin with : it is better to dilute it with more spirit. Cam- phor is also a very useful addition to many other inhalations. In like manner most of the essential oils can be used as stimulants. They can be dissolved in spirit or diffused through water by means of magnesia, or powdered silex, in the manner often resorted to for making medicinal waters. The oils of aniseed, cajeput, cloves, cinnamon, marjoram, myrtle, rosemary, and others are adapted for this purpose. Ammonia is a gen- eral stimulant often resorted to, and may be utilized for its local effect. When the effect of steam is not needed, we may try the plan recom- mended by the late Dr. J. A. Symonds,' viz.: inhaling solutions of balsams in ether, or pyro-acetic spirit from an ordinary wide-mouthed ' British Medical Journal, 1868. 296 THERAPEUTICS OF THE RESPIRATORY PASSAGES. bottle, the warmth of the hand holdidg it being quite sufficient to vola- tilize the liquid. I prefer ether to the pyro-acetic spirit. Spirit of chloroform may also be used by this method. Half an ounce of benzoic acid in an ounce of ether forms a standard solution, to which two drachms of balsam of Peru, or of Tolu, or of any similar substance, may be added. Turpentine has also been used in this way, but might then be made the menstruum. Other rather volatile drugs, such as creasote, carbolic acid, iodine, the essential oils, etc., can, if desired, be employed in this manner without steam, but very often the warm vapor is an important element in the treatment. Sometimes warm inhalations are not desirable. We can then use sprays or atomized fluids. Sprays are generally useful when it is an ad- vantage to administer the inhalations at a low temperature ; while for warm applications I mostly resort to the mode of inhaling steam impreg- nated with the remedy. It is usually advisable to administer astringent sprays cold, though, of course, they may be used warm. Anodynes are applicable either w'ay, but more frequently should be taken warm. After warm inhalations it is often desirable for the patient not to go into the open air, or into a cold room ; but the cold spray is the best possible preparation for such sudden changes of temperature. The remedies most commonly used in the atomizer are solutions of metal- lic salts. As astringents, sulphate and chloride of zinc, alum, perchloride of iron, and sulphate of iron. The strength of the solutions of these salts may vary from two to ten grains in the ounce, or more, according to circumstances. Permanganate of potash, one to five grains per ounce, is disinfectant and stimulant, and in some cases exercises a most happy influence on mucous membranes. In other cases calx chlorata, two to five grains, is preferable ; or we may use the liq. calcis chlorate, or the Hq. sodae chlor., ten to sixty minims, or liq. chlori., two to thirty min- ims per ounce. Carbolic acid, one to five grains, is a good stimulant, particularly when the membrane is unusually dry. This remedy is also much used as an antiseptic and disinfectant in various conditions of the membrane. A much weaker solution thus is required, for this also ex- ercises a soothing influence in cases of great irritability. It is not to be forgotten that carbolic acid is readily absorbed by mucous membranes. Lactic acid has been strongly recommended as a solvent of the false membrane of diphtheria. About half a drachm in the ounce will be strong enough generally, but I have had occasion to use it much more concentrated. Nitrate of alumina (two to five grains) was tried by the late Dr. Beigel,' who also used many other substances, including acetate of lead, chloride of sodium, and even cod-liver oil. I have used chloride of aluminium rather freely as an astringent. ' On luLalation. London, 1866. TOPICAL PNEUMATICS. 297 As an anaesthetic bromide of potassium has been used, ten to fifteen grains ; but weaker solutions are serviceable for other purposes. Solu- tions of the alkaline carbonates and tlieir salts form a very useful series. Thus, the carbonates of soda, potash, or lithia may be tried, two to ten grains. Muriate of ammonia, eight to fifteen, is reputed to possess pecul- iar effects on the faucial membrane. The local influence of chlorate of potash, now fully recognized, may be obtained in this way, two to ten grains. A number of mineral waters are also used as sprays. Those containing sulphur, or chloride of sodium are most in repute. Corrosive sublimate is sometimes used in specific cases, but such remedies should only be used with circumspection. Demarquay recommends glycerine to soothe an irritated pharynx, and the late Dr. Scott Alison employed this fluid in laryngitis and tracheitis. Laudanum and solution of the salts of morphia can be used in the form of spray, five minims to twenty at a time, properly diluted ; so can the tinctures of h_yoscyamus, conium, belladonna, etc. In asthma, success seems to have followed Fowler's solution, five minims at a time, adminis- tered in this manner. Recently Professor See has recommended sprays of iodide of potassium in this disease. Other uses for "this drug will occur to the reader, and solutions of iodine have also been used. Sprays of vin. ipecac, have of late years come into use and sometimes seem very efficient, but to many patients they are extremely disagreeable. Sul- phurous acid is generally prescribed too diluted. It may be employed pure, as advised by Dewar * and Pairman,'' or it may be diluted with one, two, or three parts of water. It should be recently prepared. Tan- nin, as an astringent, varies much in the dose, and is often given too weak to be effectual. According to the effect required the strength may vary from a single grain per ounce to fifteen or more. Iodoform has been used as a spray as well as in other modes. Profes- sor Sormani contrived a special apparatus for the purpose of experiment- ing upon animals, and by means of compressed air he forced an ethereal solution of iodoform deep into the lungs, in order to determine its power as an antiparasitic in phthisis. That the remedy was thus carried into the air-cells he proved experimentally ; he has also reported three cases of phthisis treated by iodoform sprays. The patients gained in weight and some of the symptoms were relieved but the expectoration continued to contain bacilli, though their number diminished. The expectoration in- jected into guinea-pigs was still infective, but seemed to be rather less virulent. Other attempts are being made to bring antiseptics to bear in the treatment of lung diseases by inhalation. 1 On the Application of Sulphurous Acid to the Prevention and Cure of Conta- gious Diseases. 1867. 2 The Great Sulphur Cure brought to the Test. 1868. 298 THERAPEUTICS OF THE RESPIRATORY PASSAGES. So far we have been considering those topical remedies which oper- ate on the whole of the respiratory passages at once. It may, of course, be desirable, even for a disease which only involves a portion of the mu- cous membrane, to subject it all to the action of remedies ; but there are other cases in wiiich we may wish to restrict the extent of the applica- tion. And then, again, there are remedies which only affect a small por- tion of the surface, and some of which we must now notice. Sprays may very easily be localized and for this reason may claim a place between vapors and liquids ; but enough has been said about them and we pass on to the latter, beginning with Gargles. — This form of local remedy is very ancient and was freely used by Hippocrates. It is still popular, though considerable discussion has at times taken place as to its value. While some physicians have almost excluded gargles from their practice, others have relied upon them to a great extent. The former have maintained that they never come in contact with more than the anterior surface of the velum and uvula, and perhaps a portion of the tonsils. The latter have endeavored to show that they penetrate much farther. Even were the first allegation correct there would still be a use for gargles, but it is now generally abandoned. These diverse views have no doubt partly depended on the inclusion of several distinct acts in the term gargling. A mere mouth-wash may be so employed that the anterior surface of the velum is subjected to its influence. The word gargling, however, is generally understood to imply that the air is to be expelled through the liquid with sufficient force to make the bubbling ' noise which many seem to consider so essential to the process. But a moment's thought will suffice to show that the liquid may be permitted to remain in the position it occupies as long as the breath can be held and, further, that expiration may be carried on so gently as to prevent any bubbling noise being heard. If now any at- tempt be made either to swallow or to inspire to a very slight degree, the liquid may pass farther and yet be arrested before it sets up any spasmodic action. The act of gargling may be well studied in conjunc- tion with that of swallowing, and the reader will no doubt be aware of the diversities of opinion that have prevailed respecting the physiology of deglutition. We all know that soft bodies produce little irritation in the larynx compared with hard ones, though, as previously pointed out, a drop or two of liquid coming unexpectedly on certain parts may at once set up spasm. It is believed by many that the use of the epiglottis in closing the air- ' Gargle and gurgle were originally the same word — both forms are derived from the Latin c/urgulio, throat, and this doubtless from the older Greek, yapyapfwv. The reduplicated syllable gargar also appears with the same meaning in Hebrew and other oriental languages. TOPICAL PNEUMATICS. 299 passage during deglutition has been somewhat exaggerated. Certainly I have met with many cases in which great destruction of the epiglottis had occurred — some in which it had been entirely destroyed — without the power of swallowing being greatly affected. On the other hand, we con- stantly see swelling and ulceration of the epiglottis associated with pain and difficulty in deglutition. M. Krishaber having masticated and insalivated a little bread crumb, pushed it with his finger over the edge of the epiglottis, and then by an inspiration drew it into the air-passage, expelling it again by a sudden forcible expiration. M. Guinier, of Montpellier,' had previously ob- served on himself, by means of the mirror, that such a morsel of soft bread could come upon the closed glottis without causing any uneasiness. The last-named author subsequently attained such command over the parts as to let liquids enter the larynx, and founded upon his experience the plan of laryngeal gargling." "We must remember, however, that the presence of the mirror in the throat during an effort to swallow com- pletely changes the conditions to be studied. In the natural act of deg- lutition there can be little doubt that the air-passage is generally closed. The impossibility of breathing during that act, and the spasm excited by the entrance of small quantities of the food or drink, seem to show this. Besides, if we eat any substance that will impart a distinct color to the membrane over which it passes, and then practise autolaryngoscopy, we find that it discolors the anterior surface of the epiglottis, but not the posterior, still less the mucous membrane of the vestibule of the larynx. From w'hat has preceded it will be readily understood that the act of gargling may varv very much with the individual. Accordingly, we find tiiat some persons never learn to gargle properly, while others achieve what at first seems impossible. Singers generally acquire considerable control over the parts, while those who have never learned to gargle sometimes find it no easy task. The majority of patients, in point of fact, require some instruction respecting the end to be attained. In using a mouth-wash the velum and uvula descend so as to cut off all communi- cation with the pharynx. In gargling, as frequently understood, the re- sult may be almost the same, the liquid coming in contact with the ante- rior surface of the velum and uvula only. If, however, the patient should now raise the velum, as many can do, some of the liquid will flow into the pharynx. There it produces a desire to swallow, and unless the patient can control this some of it will pass into the oesophagus and stomach. Some persons, however, instead of yielding to the desire to swallow, sud- denly jerk the head forward, and a quick, forcible expiration taking place ' Noiivelles Experiences sur la Deglutition faites au moyen *de 1' Auto-Laryngo- scope (L' Union Med., 1865). * Etude du Gargarism Laryngien. Paris, ISfiS. 300 THERAPEUTICS OP THE RESPIRATOKY PASSAGES. at the same rnotnent the liquid is expelled through the nose. "What they do involuntarily can be accomplished by others deliberately and without inconvenience. In persons possessing this control over the parts we may often obtain good results from a natural nasal douche thus employed. Is is by no means so easy to let the liquid enter the larynx, and, in spite of persistent efforts, many will totally fail in the attempt. Of course, the glottis must be kept closed if the fluid is to rest upon it, and therefore the duration can only be while the patient can hold his breath. M. Guinier, wlio has demonstrated his method with the laryngoscope, says that the head should not be thrown back, as the less it is raised the less urgent is the desire to swallow. He also advises that the mouth should not be quite closed. With these precautions he takes the liquid into the mouth, brings forward the lower jaw, and closes the glottis by the uncompleted act of emitting a vowel sound. The velum in this dis- position of the parts is raised, and the base of the tongue perhaps falls a little, so that the liquid finds its way into the larynx, where, if the patient can completely control the sensibility, it may remain as long as the breath is held. The slightest attempt to inspire will bring on spasmodic cough. Only the few can expect to attain success in this method, and its use is therefore very restricted, especially when we remember that there are other modes of applying liquids to the laryngeal mucous membrane. In gargling it is more important to manage the respiration than deg- lutition. If compelled to swallow, the patient merely receives a little of the fluid in his stomach, and, unless the gargle should contain some nox- ious ingredient, there is an end of the incident. On the other hand, en- trance of the fluid into the air-passages may give rise to severe lar^'ngeal spasm. Astringents, disinfectants, and antiseptics are the remedies most fre- quently required in this form, but anodynes may be utilized in the same wav. One of the best gargles is a solution of alum, the strength of which may be vai'ied according to the effect required. Chloride or nitrate of aluminium may be employed for the same purposes. For a powerful astringent tannin may also be used — one or two drachms in half a pint of water, to which a drachm of rectified spirit or an ounce of g-lycerine has been added. Borax and chlorate of potash are also useful as both gargles and mouth-washes. The former is slightly alkaline as well as astringent ; the latter possesses special value in an aphthous condition of the buccal and faucial mucous membrane, and is often advantageously combined with decoction of bark. As a disinfecting wash and gargle Condy's fluid is the best, but chlorated gargles are also valuable. Carbolic acid is a good stimulant to the pharyngeal mucous membrane, but its flavor is very disagreeable to some patients. Weak gargles of carbolic acid are not merely slight stimulants, but exercise a soothing influence over irri- table mucous membrane. The sulpho-carbolates are also useful. I have TOPICAL PNEUMATICS. ;^oi had excellent results from lactic acid, both as a gargle and in the form of spray. Three or four drachms or more may be diluted with eight or ten ounces of water. This remedy is of special value in diphtheria. The lactates and lime-water are also used in the same disease. Mineral acids ought not to be employed as gargles, as they destroy the patient's teeth, and less injurious substances are equally or more efficacious. It is obvious that it is not desirable to order gargles for children who have not learned to use them, or for per- sons whose fauces are so inflamed as to make all movements of these parts pain- ful. Gargles are usually employed cold, but occasionally — especially when ano- dyne — they are ordered warm. The nasal douche may be mentioned here, inasmuch as it is in one sense sup- plementary to gargling. By it the fluid is brought into contact with a portion of raucous membrane which, in the major- ity of persons, is otherwise inaccessible to local treatment such as the patient can *''°- 22.-Siphon Douche, employ. I usually recommend the simple siphon douche, Fig. 22. The nasal douche is, of course, most serviceable when the disease is located in the posterior nares,' but is also of value in some laryngeal cases. The liquids most serviceable for the nasal douche are weak saline and alkaline solutions. Half a drachm of carbonate of soda in a pint of water is one of the best forms, being both safer and more agreeable than the chloride of sodium so often prescribed. By this the mucous mem- brane may always be thoroughly freed from the discharges, and thus prepq*ed for other remedies. Astringents may be afterward resorted to in many cases, the chlorides of aluminium, zinc, and iron being employed in very small quantity. The sulpho-carbolate of zinc is a good astrin- gent. The permanganates are still more useful, possessing local action and being deodorizers. Chloride of lime I have also found very valu- able. Carbolic acid has also most valuable properties and is a recognized disinfectant. The nasal douche should be used tepid at first in all cases. Occasionally it may be desirable to decrease the temperature, especially when astringents are employed, A temperature of 85° Fahr. may then be employed, and gradually reduced to 75°, or even 70°. Very rarely do we descend to the ordinary cold water. The patient should breathe ' See the author's paper on Ozsena, read before the Medical ^Society of London, October 20, 1871 (Medical Press and Circular, December 6, 1871). Reference may al- so be made to the author's contribution to the same journal on Syphilitic Diseases of the Throat (January 10 and February 28, 1872). 302 THERAPEUTICS OF THE RESPIRATORY PASSAGES. quietly and restrain any movement of deglutition, in order that the Eustachian tubes may remain closed. It can no longer be doubted that in using a nasal douche the accidental entrance of fluid into the ear has given rise to serious results. It is not necessary to have much pressure — just enough to cause the fluid to flow through the nares will sufTice, and this will be produced with the siphon douche, when the vessel is not raised much above the patient's head. It is a good plan for the patient at first to hold it himself — he will scarcely then be able to lift it too high. The soda solution above named is the best for removing hardened secretions. I have also found it less irritant than the salt solution so constantly used, and Weber-Liel ' has shown that it is less likely to injure the ear — a conclusion ^uite in accordance with my experience. A weak saline produces less stuffiness than pure water. In using astrin- gents care should be observed to use them Aveak enough. Half a grain per ounce of sulphate or acetate of zinc is quite enough. More is apt to give rise to headache, local irritation, and other unpleasantness. Alum is said to have impaired the function of smell. The douche should be used once or twice a day — seldom oftener, but it is necessary in many cases to continue it for a long time. Irrigations. — I have designed tubes with perforated extremities, by means of which the nasal passage can be carefully irrigated by the physi- cian, both from the front and back. In this way we may apply fluid remedies which should not be entrusted to the patient. Syringes and atomizers constructed for the purpose can also be used to convey medicated fluids to the nasal passages. Besides these methods we may sometimes avail ourselves of the more primitive plan of snuffing up the liquid by a series of sudden short inspirations. Fluids may thus be taken up from the hollow of the hand or from a convenient vessel. Some persons acquire a trick of this kind, and call it " drinking through the nose." The Pharyngeal Douche and Irrigator. — It is easy to direct a stream of liquid on the posterior wall of the pharynx. For this purpose I have arranged mouth-pieces which can be used in place of the nose-piece of the nasal douche. Some patients learn to employ this method themselves. The liquids are such as have been recommended for the nasal douche, and for gargles, but their strength should be between these two. My phar3'ngeal irrigator^ like its nasal fellow, consists of a properly shaped silver tube perforated at the extremity by numerous minute holes, so that the liquid can be projected in a fine shower by means of a small Higginson's syringe attached to it. The atomizer may be resorted to when it is desirable to break up the fluid into a fine spra}^, but both the pharj'ngeal and nasal irrigators will often be found of service. ' Berliner klin. Woch., April 1, 1878. TOPICAL PNEUMATICS. 303 Linctus. — In order to somewhat prolong the local action of medicines which are to be swallowed they may be rendered thicker and more glu- tinous by sugar and other additions. We then have the linctus, loch or lohoch, called also eclegma, eclectos, ecleitos, elegma, and illinctus — va- rious terms derived from €KXei;^w. Various syrups and mucilages may be used for the same qualities, or may enter into the composition of the linctus. Glycerine, from its slowness to evaporate, may be used to attain the same end, and is, indeed, rather too popular, for since the glycerine of tannin and borax were introduced to the Pharmacopoeia their use has become quite an abuse. ' Solids. As sprays take an intermediate place between vapors and liquids so between these and solids we might place confections or electuaries, in which we have a tenacious semi-solid substance, which may be slowly dissolved in the mouth, and thus the local action of its ingredients pro- longed ; though these preparations are also used as vehicles for system- ic remedies. In confectio opii the galena, mithridate, philonium, and theriaca of antique pharmacy survive. Lozenges, being completely solid, are slower of solution, and there- fore enable the medicament to exercise a much more prolonged influ- ence in the mouth and fauces, and have always been popular remedies. The Greek hypoglottides are represented in our lozenges. Although the London and Dublin Pharmacopoeias omitted them, the Edinburgh re- tained them, and the British has restored them. In doing so, however, the lozenge has been made as much use of as a vehicle as for local ef- fects. Thus some officinal lozenges (as morphia and iron) are chiefly to be regarded as dosed, general remedies, though others (as tannin and chlorate of potash) are valuable for their topical influence. It is obvi- ous that the two qualities may often be combined. For special topical use lozenges should possess the following quali- ties : 1. They should dissolve slowly in the mouth, so that the resulting solution of the medicament may remain as long as possible in contact with the mucous membrane. 2, They should possess a certain degree of soft- ness, so as not to hurt the diseased surface mechanically. 3. For the same reason their shape should be without corners. 4. Their flavor should be agreeable, or as little distasteful as possible. 5. They should keep without change for an indefinite period, as they cannot be advan- tageously made in small quantities. The lozenges of the British Pharmacopoeia are most defective, on ac- count of their hardness. They irritate the mucous surface ; and the sharp corners of some shapes in common use, or of the broken pieces of others, may enlarge ulcers, tear congested membrane, or do other injury. Of 304 THERAPEUTICS OF THE RESPIRATORY PASSAGES. course, when used for their constitutional effect these objections may scarcely apply. A softer consistence has been attained by the employ- ment of fruit-paste — as in the favorite black-currant lozenges ; and this substance has been more extensively used of late years. Extract of liquorice, as in " Pontefract cakes " and gelatine, have also been utilized. A more recent innovation is the effervescent base introduced by Mr. Cooper, which, for some purposes, is of special value. The French, so famous for all kinds of confectionery, have given us tlie pdte de Gui- inauve / but the defect of this is that it does not keep well. We owe to them also our best jujubes, a sweetmeat first made with the juice of the Hhamnus zizyphus, but now never containing that agreeable fruit. Experimental experience, extending over more than a quarter of a century, leads me to conclude that a 7>a JAN 6 REC'D BIOMEO UB. Form L9-42m-8/49(B5573)444 /iP»28'88 THE LIBRARY \>JF /4-0 1884- 8589 /