THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES LOGIN BROS. MEDICAL BOOKS IftU W. HARRISON ST. CHICAGO DENTAL MATERIA MEDICA AND THERAPEUTICS PKINZ DENTAL MATERIA MEDIGA AND THERAPEUTICS With Special Reference to the Rational Application of Remedial Measures to Dental Diseases A TEXT BOOK FOR STUDENTS AND PRACTITIONERS BY HERMANN PRINZ, A.M., D.D.S., M.D. Professor of Materia Medica and Therapeutics, The Thomas W. Evans Museum and Dental Institute School of Dentistry University of Pennsylvania; formerly Professor of Materia Medica, Therapeutics, and Pathology, and Director of the Research Laboratory, Washington University Dental School, St. Louis FIFTH EDITION ENLARGED AND REVISED ACCORDING TO THE UNITED STATES PHARMACOPEIA, NINTH DECENNIAL REVISION ST. LOUIS C. V. MOSBY COMPANY 1922 COPYRIGHT, 1909, 1911, 1913, 1916, 1917, BY C. V. MOSBY COMPANY. Authority to use for comment the Pharmacopeia of the United States of America, Ninth Decennial Revision, in this volume has been granted by the Board of Trustees of the United States Pharmacopeial Convention, which Board of Trustees is in no way responsible for the accuracy of any translations of the official weights and meas- ures, or for any statement as to strength of official preparations. Press of C. V. Mosby Company St. Louis WU Ytt PREFACE TO FIFTH EDITION The complete exhaustion of the Fourth Edition of "Dental Materia Medica and Therapeutics" within less than one year after its publication again has necessitated a revision of its text. The recently published Ninth Decennial Revision of the United States Pharmacopeia contains numerous important changes rela- tive to average doses of drugs and also the addition of a number of valuable compounds of special interest to the dental practi- tioner. These changes have been duly considered in this present revision of the text. The writer is gratified to know that the suggestions which he made in his report as Chairman of the Committee of Revision of the United States Pharmacopeia, Sec- tion of Stomatology, American Medical Association, have been found worthy of consideration by the general committee and have been duly added to the text of the present Pharmacopeia. These newly added drugs of special interest to the dental prac- titioner are: Cotarin hydrochlorid, nitrogen monoxid, oxygen, paraformaldehyd, beta-eucain hydrochlorid and sodium per- borate. To facilitate the ready location of drugs according to their therapeutic uses a properly classified index of drugs has been added so as to assist the practitioner in the quick selection of a suitable remedy when needed. The article on Electro-Sterilization (Ionic Medication) has been completely rewritten ; about twenty new illustrations have been added and numerous minor changes have been found neces- sary so as to harmonize the text with the latest achievements in dental materia medica and therapeutics. H. P. UNIVERSITY OF PENNSYLVANIA, EVANS INSTITUTE. PREFACE TO FIRST EDITION A systematic classification of drugs which shall answer all pur- poses has never been, and probably never will be, successfully arranged. Such a classification will, according to the standpoint from which the subject is treated, evince individual trend of thought. The chemist, for example, prefers a classification ac- cording to the chemic relationship of the drugs, the pharma- cologist is principally interested in a classification according to the physiologic action of drugs, while the clinician groups the drugs according to their therapeutic effects. The author, guided by extensive class-room experience and clinical practice, has made an effort to point out how pharmacologic research and clinical observations may be advantageously combined in the rational use of remedial agents for the purpose of favorably in- fluencing disease. The entire subject matter is, therefore, treated from the standpoint of the pharmaco-therapeutist. The practice of dentistry requires, in addition to specific phar- maceutic preparations, quite a large number of remedies which are seldom employed by the medical practitioner, unless used by him for totalty different purposes. These remedies are gener- ically termed dental remedies, and consequently their impor- tance demands special discussion. To draw a definite line of de- marcation between dental and general remedies is not only im- possible, but is distinctly undesirable. Frequently conditions arise where a knowledge of general remedies is absolutely neces- sary for the dental practitioner as, for example, the treatment of certain phases of pericementitis requires the administration of uric acid solvents, specific infection calls for cathartics, anti- pyretics, etc., and the mitigation of pain may necessitate general anodynes. The progress of dental pharmaco-therapeutics has not kept pace with the remarkable advances made in the technical branches of dentistry. The unsatisfactory classification of dental remedial agents is largely due to a gross disregard of the prog- ress made in general pharmacology and pathology. The prin- cipal part of operative dentistry is surgery, but unfortunately 6 PREFACE 7 the average practitioner applies the same mechanism to drug action, and, expecting too much from a drug, is frequently disappointed. The difficulties which presented themselves to the author in systematizing the subject were the many conflicting statements found in literature relative to the action of dental remedies. An effort has been made to avoid vague information and to elucidate only clinical facts which have been established by pharmacologic research. Both factors are essential in determining the true value of the action of a drug. The pharmaceutic descriptions of chemicals and drugs, and their preparations and doses, are in conformity with those given in the latest editions of the Pharma- copeias of the United States and Great Britain. The author acknowledges his indebtedness to workers in both general and dental pharmaco-therapeutics, and especially to the text books of A. Cushny, R. Kobert, R. Heinz, T. Sollmann, and many others which he has freely consulted. He desires to thank his friends, Professor Carl Jung, of Berlin, for the use of the micro-photographs of tooth powder preparations, and Doctors James A. Brown and L. Neuhoff for assistance in the preparation of most of the original illustrations. He also acknowledges his obligations to the S. S. White Dental Manufacturing Company, Ransom & Randolph Company, Lennox Chemical Company, Gebauer Chemical Company, Modern Medical Company, Consoli- dated Dental Manufacturing Company, Wm. Meyer Company. R. S. Squibb & Sons, Burroughs Wellcome & Co., and Parke, Davis & Co. for the use of various illustrations of dental appli- ances. H. P. WASHINGTON UNIVERSITY DENTAL SCHOOL, St. Louis, September, 1909. CONTENTS PART I. GENERAL THERAPEUTICS. PAGE INTRODUCTION 17 THE Am OF THERAPEUTICS 30 NATURE OF DRUG ACTION , 37 CLASSIFICATION OF DENTAL REMEDIES 44 SELECTION OF THE REMEDY 52 METHODS OF ADMINISTERING MEDICINES 54 PRESCRIPTION WRITING 63 INCOMPATIBILITIES 74 WEIGHTS AND MEASURES 79 THE PHARMACOPEIA AND PHARMACEUTIC PREPARATIONS 86 SYNOPSIS OF THE NATIONAL NARCOTIC (HARRISON) LAW 97 AVERAGE DOSES OF THE MOST IMPORTANT DENTAL DRUGS 100 PART II. PHARMACO-THERAPEUTICS. DRUGS WHICH EXERCISE No DEFINITE ACTION ON SPECIFIC ORGANS. ANTISEPTICS 103 Salts of the Heavy Metals, their Oxids, and their Organic Com- pounds 108 The Acids, the Alkalies, the Halogens and their Derivatives . 120 Solutions Which Evolve Nascent Oxygen 134 Antiseptics of the Aromatic Series 150 Antiseptics of the Marsh Gas Series 165 Essential Oils, their Derivatives, and their Synthetic Substitutes 184 ASTRINGENTS 199 Metallic Astringents 201 Vegetable Astringents 209 CAUSTICS 212 Liquid Caustics 214 Dry Caustics 215 HEMOSTATICS AND STYPTICS 250 Absorbents 251 Caustics and Astringents 251 Agents Which Act After Being Absorbed Into the Circulation 253 Agents Which Act on the Vessels, but Not on the Blood . . 254 9 10 CONTENTS PAGE PKOTECTIVES, DEMULCENTS, AND EMOLLIENTS 255 IRRITANTS AND COUNTERIRRITANTS 260 ANTACIDS 268 DRUGS WHICH ACT ON SPECIFIC ORGANS. Drugs Which Act on the Mouth and Teeth. BLEACHING AGENTS 270 PREPARATIONS FOR THE MOUTH AND TEETH (ORAL HYGIENE) .... 277 Mouth Washes 293 Tooth Powders ..... . . 297 Toothpastes 306 Tooth Soaps 308 Drugs Which Act on the Peripheral Nerves. LOCAL ANESTHETICS AND OBTUNDENTS 309 Soluble Local Anesthetics 312 Insoluble Local Anesthetics 322 Refrigerant Local Anesthetics 326 Drugs WJiich Act on the Central Nervous System. GKNKRAL ANESTHETICS 328 Physiologic Action of Nitrous Oxid 334 Administration of Nitrous Oxid 335 Physiologic Action of the Anesthetics of the Me than Series . 350 Administration of Ethyl Chlorid 353 Preparation of the Patient 358 Choice of the Anesthetic 358 Treatment of Accidents of General Anesthesia 359 HYPNOTICS 366 ANODYNES 368 SEDATIVES 374 CEREBRAL STIMULANTS 376 Drugs Which Act on the Gastro-Intcslinal Canal. STOMACHICS AND DIGESTIVES 379 EMETICS 383 CATHARTICS 392 Drugs Which Act on the Circulation. CIRCULATORY STIMULANTS AND DEPRESSANTS 399 Drugs Which Act on the Kespiration. RESPIRATORY STIMULANTS AND DEPRESSANTS 404 Drugs Which Act on Metabolism. TONICS 406 ALTERATIVES 412 Drugs Which Act on the Secretions. SlALOGOGUES AND ANTISIALOGOGUES 419 DIAPHORETICS 421 CONTENTS 11 PAGE DIURETICS 42'j URIC ACID SOLVENTS 424 Drugs Which Act on the Temperature. ANTIPYRETICS 431 ORGANO AND SERUM THERAPY. ORGANO THERAPY 436 SERUM THERAPY 435 PART 111. PHYSICAL THERAPEUTICS. ARTIFICIAL HYPEREMIA 442 MASSAGE 458 LIGHT THERAPY 463 HEAT AND COLD 474 PLUGGING BONE CAVITIES WITH INERT OR MEDICATED SUBSTANCES . . 478 ELKCTKO-STKRILIZATION 484 PART IV. LOCAL ANESTHESIA. HISTORY 514 MEANS OF PRODUCING LOCAL ANESTHESIA 518 PHYSIOLOGIC ACTION OP ANESTHETICS 519 LOCAL ANESTHETICS 530 HYPODERMIC ARMAMENTARIUM 536 TECHNIQUE OF THE INJECTION 542 SIDE AND AFTER EFFECTS OF LOCAL ANESTHETICS AND THEIR KELATION TO THE PENAL CODE 579 APPENDIX. DIAGNOSIS OF DISEASES OF THE PULP BY THE ELECTRIC CURRENT . . . 585 IMMEDIATE TREATMENT OF ACUTE POISONING 595 GLOSSARY OF THERAPEUTIC TERMS 599 DIAGNOSTIC AIDS 603 TlIERMOMETRIC EQUIVALENTS 605 DOSE TABLE . . 606 ILLUSTRATIONS FIG. PACE - 1. Office Dropping Bottle 50 2. Salt-Mouth Bottle 50 3. Aseptic Medicament Tray 51 4. Dental Applicator 51 5. The Miller Pyorrhea Pen 51 6. Powder Blower 56 7. Glaseptic Hypodermic Syringe 5 1 8. Steam Atomizer 58 9. Hand Atomizer 59 10. Fac-Simile of a Correctly Written Prescription ....... 67 11. Graduated Medicine Glass 73 12. Medicine Dropper 74 13. Percolation 91 14. Infusion Jar 92 15. Casserol for Decoctions 92 16. Empty Gelatin Capsules 93 17. Konseals 93 18. Pill Machine 95 19. Suppository Mould 95 20. Finished Suppository 96 21. Tablet Mould 96 22. Hypodermic Tablet Mould 97 23. Sample Page of Record of Narcotic Drugs Dispensed 98 24. Culture Plate, with Pack's Cylinders and Abbey's Noncohesive Foil 110 25. Imaginary Diagram of a Solution of Mercuric Chlorid in Water . Ill 26. Liquid Soap Dispenser 129 27. Minim Syringe for Applying H 2 O 2 Solutions 138 28. Pyrozon Probe Cup 140 29. Oxygen Inhalation Apparatus 142 30. Portable Oxone Generator (Autogenor). Closed 143 31. Portable Oxone Generator (Autogenor). Opened 144 32. Formanganate Disinfector, Solution, and Briquettes 170 33. Aseptic Absorbent Paper Points 180 34. Silver Nitrate Applied to Carious Dentin (low power) .... 220 35. Silver Nitrate Applied to Carious Dentin (high power) .... 221 36. Action of Silver Nitrate on Dentinal Fibrils 223 37. Action of Silver Nitrate on Living Dentin 224 38. Adjustable Silver Nitrate Pencil 226 39. Action of Arsenic on the Human Tooth Pulp 234 40. Section of Fig. 39, highly magnified 236 41. Necrosis of Pulp after Application of Arsenic 238 13 14 ILLUSTRATIONS FIG. PAGE 42. Enlarged Section of Fig. 41 :239 43. Total Necrosis of Pulp after Six Days' Arsenic Application . . 241 44. Luxuriant Growth of Penicillium Brevicaule 246 45. Marsh Apparatus for Detection of Arsenic 247 46. Dental Mustard Plasters in Position 266 47. "Eveready" Mouth Lamp 275 48. Zeiss Tooth Bleaching Lamp 276 49. Electric Heater and Spray Outfit 293 50. Magnified Specimens of Tooth Powder Substances 299 51. Same as Fig. 50 1500 52. Same as Fig. 50 301 53. Same as Fig. 50 303 54. Apparatus for Making Nitrous Oxid 333 55. Soft Wood Mouth Props 336 56. Semi-Solid Rubber Bite Blocks .336 57. Lawrenz Adjustable Mouth Prop 337 58. Nitrous Oxid Gasometer 338 59. Nitrous Oxid Gasometer. Sectional view 339 60. Universal Gas Stand for Nitrous Oxid 340 61. Surgeon's Portable Nitrous Oxid and Oxygen Apparatus .... 341 62. S. S. White Nitrous Oxid and Oxygen Apparatus 342 63. Coleman's Nasal Inhaler, connected 343 64. Teter's Combination Gas Stand 344 65. Nitrous Oxid Inhaler, with celluloid hood 345 66. The S. S. White Nasal Inhaler 346 67. Simplex Inhaler. Sectional view 346 68. The Gwathmey Gas Oxygen Apparatus 347 69. Ethyl Chlorid Dropping Tube 354 70. Ferguson's Inhaler 354 71. Ethyl Chlorid Tube 355 72. Ermold-Stark's Inhaler 355 73. McFarlane's Ethyl Chlorid Inhaler 356 74. Gebauer's Combination Inhaler 357 75. Artificial Respiration, expiration 362 76. Artificial Respiration, inspiration 363 77. Camera Lucida Drawings of Endameba Gingivalis 389 78. Photomicrograph of Endameba Gingivalis 390 79. Composite Outlines of Moving Endameba Gingivalis 390 80. Tracing the Blood Pressure under Synthetic Suprarenin .... 403 81. Glass Tube for Taking Corrosive Medicines ........ 408 82. Dunn's Bifluorid Syringe 429 83. Schematic Drawing of an Abscess 445 84. Suction Cup for Alveolar Abscesses about the Gums 450 85. Suction Cups for Abscesses about the Cheeks, Lips, and Chin . . 450 ILLUSTRATIONS 15 FIG. PAGE 86. Application of the Elastic Bandage for the Production of Obstruc- tive Hyperemia of the Head 452 87. Application of Suction Cup over the Sinus of an Alveolar Abscess . 453 88. Hyperemic Suction Cup Applied to a Chin Fistula 454 89. Suction Cup Applied to a Fistula on the Cheek Near the Border of the Mandible 455 90. Hyperemic Suction Apparatus for the Treatment of Pyorrhea Alveolaris 457 91. Dental Vibrator 4G1 92. Dental Massage Apparatus 462 93. Dental Electric Therapeutic Lamp 464 94. Dobrzyniecki 's Heat and Light Reflector 465 95. Mode of Application of the Therapeutic Lamp 466 96. Electric Thermaphone Pad 476 97. Bohm's Syringe for Bone Plombe 479 98. Collapsible Tube for Bone Plombe 480 99. A Hypodermic Syringe Prepared for Bone Plombe 481 100. A Large Cavity in the Mandible Filled with Bone Plombe . . . 482 101. Manifestations of Bismuth Poisoning in the Mouth Following Bismuth Paste Injection 483 102. Scheme Showing the Movement of Ions 490 103. Experiment Showing Passage of Ions 492 104. The S. S. White Current Controller 498 105. Weston Milliamperemeter 498 106. Metal Negative Hand Electrode 499 107. Sponge Negative Hand Electrode 500 108. Sponge Wrist Electrode 500 109. Long Handle Electrode With Iridio-Platinum Point 501 110. Insulated Electrode Holder 501 111. Galvanic Battery for Electro-Sterilization 502 112. Switchboard for Electro-Sterilization 503 113. Switchboard for Electro-Sterilization 504 114. Lower Right Second Bicuspid 508 115. Same Tooth as in Fig. 114, after treatment 508 116. Upper Left First Bicuspid 508 117. Same Tooth as in Fig. 116, after treatment 508,. 118. Plasmolysis of Cells of Tradescantia Discolor 520 119. Diagrams Showing the Effect Upon Human Red Blood Corpuscles of (A) Isotonic, (B) Hypotonic, and (C) Hypertonic Solutions 522 120. Contraction of the Heart of a Frog 523 121. Ethyl Chlorid Spray Tube (Glass) 525 122. Ethyl Chlorid Spray Tube (Metal) 526 123. Application of the Ethyl Chlorid Spray 527 124. Large and Small Porcelain Dissolving Cups for Preparing Sterile Novocain Solution 533 125. Dropping Bottle 534 16 ILLUSTRATIONS IMG. PAGE. 126. Glass Measure For Local Anesthetics 534 127. Hermetically Sealed Glass Ampuls of Various Types 535 128. Novocain Armamentarium 5o(J 129. The S. S. White Aseptic All-Glass Syringe 537 130. Thoma Sterilizer for Hypodermic Syringes, Dissolving Cups, etc. 538 131. All-Metal Syringe and Curved Needle Attachment 539 132. Dental Hypodermic Needles 540 133. Hypodermic Needles of Various Designs for Dental Purposes . 540 134. Needle Attachments for Parke, Davis & Co.'s Syringe .... 541 135. Cross Section of a Eight Lower Jaw 544 136. Horizontal Section Through the Alveolar Process of the Lower Jaw 545 137. The Nerve Supply of the Upper and Lower Jaw 546 138. The Nerve and Blood Supply of the Hard Palate 547 139. Subperiosteal Injection 548 140. Direction of Needle in the Subperiosteal Injection About a Canine 549 141. Subperiosteal Injection About an Upper Molar 550 142. Peridental Injection about a Bicuspid 551 143. A, Subperiosteal Injection; B, Peridental Injection; C, Intra- osseous Injection about a Canine 552 144. Perineurial Injection about the Foramen of Scarpa and about the Posterior Palatine Canal 554 145. Mandibular Sulcus 555 146. Relation of Nerve and Vessels in the Pterygomandibular Space . 556 147. Horizontal Section of a Frozen Head made 1 cm. above the Oc- clusal Surfaces of the Teeth of the Lower Jaw 558 148. Injection into the Mandibular Foramen 559 149. Seidel's Technique 560 150. An Abnormal Course of the Mandibular Canal 561 151. Perineurial Injection About the Infra-orbital Foramen and the Alveolar Foramina 562 152. Loeffler's Pressure Syringe Attachment For Anesthetizing the Pulp 565 153. An Aqueous Solution of Eosin Forced Through Dentin With a Jewett-Wilcox Syringe 566 154. Section Through the Boot of a Molar 568 155. Points for Pressure Obtunding Syringe 569 156. Weaver High Pressure Obtunding Syringe 571 157. Anesthetizing a Small Tumor by Rhomboid Injection 577 158. Section Through an Anesthetized Tumor 578 159. Typical Small Faradic Battery, with Induction Coil and Core Shield 586 160. Dental Electrode 587 161. Dental Hard Rubber Electrode with Interrupter 587 PART I GENERAL THERAPEUTICS INTRODUCTION The practice of medicine is as old as the human race. How- ever crude the efforts may have been, we are justified in believ- ing that men have tried from the earliest times to render assist- ance to their fellowmen in case of illness. Most likely these first attempts were principally of a surgical nature, and only later in- ternal diseases received attention. In due time the natural in- stinct inherent in both man and beast led to the utilization of the products of their immediate surroundings primarily of herbs and plants, and later of animal drugs. It became a part of the sym- pathetic duties of woman to look after the ills of the family. Close observation and practice enlarged the circle of medical vision, and "the wise woman of the clan" originated, of whom we find even today isolated specimens. With the progress of civilization and the entering of religion into the routine duties of the daily life, diseases were mostly regarded as punishments from the gods, and it was left to the priests to care for both the spiritual and the bodily welfare of their community. Among the less cultured the curing of diseases consisted in administering mysterious concoc- tions, accompanied by the claptrap of the conjuror, a remnant of which we find in the present practice of the medicine man of the aborigines. With the evolution of the races the practice of se- lecting suitable remedies for certain diseases became a matter of systematic observation and study. Instinctive empiricism selected a number of remedies which were especially suited for its pur- poses those which were used to remove certain dangerous symp- toms, or to bring about and strengthen other symptoms which ap- parently had a beneficial influence upon the disease. Irritants and counterirritants applied externally and, to a limited extent, inter- nally were probably the first therapeutic attempts at influencing 17 18 GENERAL THERAPEUTICS diseased conditions. They were followed by those remedies which mitigate irritation and allay inflammation, and finally by those which alleviate pain. Popular medicine is the foundation of the scientific therapeutics of all nations. Naturally, the remedial agents differ with each nation. Systematic search for new rem- edies was introduced much later as a result of close observation of the action of certain drugs. For example, the bark of various species of cinchona, a native tree of Western South America, is an old and trusted remedy in certain specific febrile diseases, especially malaria. The Indians of Peru, Bolivia, etc., used it for such purposes prior to the invasion of their country by the Spaniards in 1604. The vicereine of Peru, Countess Ana of Chinchon, was cured of an attack of malaria by this drug in 1638, and in her honor Linnagus in 1740 named the plant chinchoua. Someone blundered in the original spelling of "chinchona" and ever since it has been written cinchona. Countess Ana collected large quantities of the powdered bark and distributed it among her people ill with ' ' tertiana, ' ' a form of malaria. The powder became known as "Pulvo de la Condesa. " At the beginning of the seventeeth cen- tury it was introduced into Spain through the activities of the Jesuit Fathers and it was then and is even today familiarly referred to as "Jesuit or Countess Powder or Bark" or simply as "Bark." An English nobleman by the name of Talbot or Talber established quite a trade in France by selling the powder as a secret preparation under the name of Febrifugum Anglicum. He was fortunate enough, in 1682, to cure the Dauphin of France of a case of ague and Louis XIV was so very much delighted with Talbot 's services that he paid him a truly "royal" fee for divulging his secret. The King ordered the publication of the secret and 'quinquina," as the remedy was known in France during the seventeenth and eighteenth centuries, soon be- came the world famous panacea for the cure of malarial fever. The alkaloid quinin was discovered by Pelletier and Caventou in 1820. Its pharmacologic action on the blood was observed by Binz in 1869. Finally, in 1880, Laveran discovered the causative factor of malaria, the plasmodvum malariae, in the human blood, and scientists were now able to demonstrate the microbicidal effects of quinin when it was brought in contact with blood which contained this parasite. Again, the use of oil of cloves employed as a toothache remedy is of an old and unknown origin. Its pharmacologic action depends on the pres- ence of eugenol, an unsaturated aromatic phenol. Pure oil of cloves as well as eugenol are slightly caustic. To overcome this defect benzoyl-eugenol and cinnamyl-eugenol were prepared. Both compounds, however, possess little therapeutic efficiency. The basic constituent of eugenol consists of para- amido-benzoic acid, a body which as such does not exhibit any therapeutic effects. Its methylester, anesthcsin, is an efficient local anesthetic; how- ever, it is only slightly soluble in water. Einhorn and Uhlfelder, taking anesthesin as a base for their synthetic research produced in due time some INTRODUCTION 1 9 four hundred odd combinations and finally succeeded in preparing para- amido-benzoyl-diethly-amino-ethanol, commercially known as novocain, which at present is the most efficient substitute for cocain. And ipecacuanha, which has been recently introduced by Smith and Bar- rett in the form of its alkaloidal salt, emetin hydrochlorid, as a curative agent in the treatment of pyorrhea alveolaris, has had within the last four centuries a most interesting career. Ipecacuanha, also written " hypecacuana " by the practitioners of bygone days or known as poaya by the Brazilians- and commonly referred to as ipecac, is the dried root of what is commercially known as Kio, Brazilian, and Para, or as Carthagena ipecac. The name ipecacuanha seems to be of Indian origin, and may be interpreted as "vom- iting-producing weed. " It is a native of South America and was intro- duced in Europe at about 1617. From an historic point of view, ipecac is first mentioned in literature by a Portuguese friar who it seems had re- sided in Brazil from about 1570 to 1600. He mentions three remedies for the "bloody flux," one of which is called igpecaya or pigaya. The drug here referred to is undoubtedly ipecac. Piso and Marcgraf, in their scien- tific exploration of Brazil, record the plant ipecacuanha, which they depicted, and they also described its medicinal properties. As stated above, it was introduced in Europe in 1617. Although well known from the accounts given by Piso and Marcgraf, and in common use in Brazil as a remedy in dysentery, ipecac was not employed in Europe prior to the year 1672. At that time a physician named LeGras brought from South America a quantity of the root to Paris, but administering it in too large doses he damaged rather than aided the reputation of this drug. A few years later a merchant of Paris named Grenier or Gamier became possessor of 150 pounds of ipecac, the valuable properties of which in dys- entery he vaunted to his medical attendant Afforty and to Jean Claude Adrien Helvetius, a pupil of the latter. Grenier presented a quantity of this new drug to Afforty, who, however, attached but little importance to it. Hel- vetius, on the other hand, was induced to prescribe it in cases of dysentery, which lie did with the utmost success. He even caused placards to be af- fixed to the corners of the streets (one of which may still be seen in Paris) announcing his successful treatment with this new drug. Through Grenier he obtained ample supplies from Spain and sold it as a secret medicine. The fame of the cures effected with this drug by Helvetius reached the French court and caused some trial to be made at the Hotel Dieu. These trials having been fully successful, Louis XIV accorded to Helvetius the sole right of vending his remedy. Subsequently, several well-known personages, in- cluding the Dauphin of France, experienced the beneficial action of this drug upon their own bodies. The King became again interested in this drug, and consulted with his physician, D'Aquin, and his father confessor, and through them negotiated the purchase from Helvetius of his secret for a thousand louis d'or, and made it public. The right of Helvetius to this payment was disputed in law by Grenier, but maintained by a decision of the Chatelet of Paris. In 1696 ipecac was introduced into Germany by the renowned philosopher 20 GENERAL THERAPEUTICS Leibnitz, who by its use had been cured of a severe case of dysentery. It be- came known in German literature as "Ruhrwurzel" (dysentery root), and only much later its name changed to " Brechwurzel " (vomiting-producing root). The first title seems to have been in general favor with medical writers of that period, as in the older works on materia medica ipecac is fre- quently referred to as radix antidysentaria, indicating its therapeutic appli- cation. Prior to the beginning of the nineteenth century ipecac was not em- ployed to any extent as an emetic; its greatest virtues were extolled in the treatment of the various forms of dysentery and ' ' bloody flux, " as it was known, and in similar disturbances of the intestinal canal. It is stated that during an endemic outbreak of dysentery in Nimeguen (Holland) in 1727 many thousands of soldiers became afflicted with this serious malady. The army surgeons administered ipecac empirically as a specific, and Geoffrey's report tells us that "in one day whole companies of soldiers afflicted with this most distressing ailment were cured by ipecacuanha like magic." Ipecac, in conjunction with opium, forms the principal component of the world-famous Dover's powder, and both drugs share equal rights in the ther- apeutic fame of this galenic preparation. The inventor of this widely used remedy, Thomas Dover, was born in Barton-on-the-Heath, England, in 1660. He studied under the renowned Thomas Sydenham and obtained his medical degree at Cambridge in 1687. In 1708 he fitted out an expedition to the South Seas, accompanying the ship's crew as their surgeon. It is stated that in 1709 he discovered a sailor by the name of Alexander Selkirk, marooned for four years on Juan Fernandez Island. Selkirk returned with Dover to England, and it is supposed that he is the original of Daniel Defoe's Rob- inson Crusoe. Dover finally settled in England and assumed the practice 01 medicine in Bristol in 1711. In 1762 was published his famous work "An- cient Physician's Legacy to His Country," which among many other in- teresting material contains the formula of his diaphoretic powder. In 1875 Loesch found amebas in the stools of dysenteric patients, but did not regard them as a cause of the disease. Finally, in 1896, Kartulis ap- parently settled the question by stating that dysentery and tropical liver abscess associated with dysentery were caused by the presence of the ameba coli. While ipecac has been lauded again and again in the treatment of this disease, especially in more modern times by Dock, Manson, and others, it was left to Vedder to show that emetin would kill the endameba in vitro. The chain of evidence was finally closed by Rogers, in 1912, when he demon- strated the specific nature of emetin in patients suffering from endamebic dysentery. When we realize that ever since Riggs of Hartford, in 1867, called espe cial attention to the treatment of pyorrhea alveolaris, which since has been christened Riggs' disease, the greater majority of those drugs which generic- ally are classified as antiseptics, caustics, and astringents and incidentally not a few other drugs which in reality have no bearing whatsoever on the subject have been recommended at one time or another by that vague and humorous phrase, "It is of value in the treatment of pyorrhea," the intro- INTRODUCTION 21 duction of emetin as a remedial agent for such purposes must be heralded as an epoch-making step in pathology and therapeutics. The discovery of en- damebas in pyorrheal pus, and the subsequent treatment of this disease with emetin, as recorded by Smith and Barret, and independently verified by Bass and Johns, and by many other observers, is an attainment of pa- tient scientific investigation which is deserving of the unrestricted praise of the dental and medical professions the world over. The early history of dental medicine is so closely interwoven with that of medical therapeutics that it is impossible to distin- guish it from its mother science. The Babylonians, Egyptians, Assyrians, Hebrews, Hindus, Greeks, and Romans were the early cultured inhabitants of whom historical records exist. The re- cent excavations in Babylon have brought to light some interest- ing facts concerning the practice of dentistry under King Ham- murabi, at about 2250 B. c. The law stated that "if one knocks out a tooth of one of his caste, his own tooth shall be knocked out, while, if it is the tooth of a freeman, he pays one-half mine silver." The Egyptian medical history is principally recorded in the various papyri, especially those of Ebers and of Brugsch, which probably cover the period of 3700 to 1500 B.C. The Egyp- tian physicians were largely specialists, and it is very probable that some were selected to look after the welfare of the teeth. Most of the dental remedies found in the papyri consist of pastes, powders, plasters, decoctions, etc., in which St. John's bread, sage seed, honey, and some unknown plants play important parts. The treating of abscesses, caries, and loose teeth seems to have been known. The Hindus were apparently very proud of their teeth. It is recorded that the use of tooth powders and washes, and especially the use of the tooth cleaner, "rinacarya," were necessities of their daily toilet. As a toothpick they employed a bitter tasting wood, which when chewed, produced a fibrous bun- dle, which was then used as a brush for the gums and the teeth. The aborigines of the western coast of Africa are still using the wood of the sissako and the molungo tree for such purposes and a toothbrush of this very same nature has been recently intro- duced in the United States, in Great Britain, and in Russia. In the writings of Hippocrates and Pliny frequent allusion is made to drugs which were especially advocated for diseases of the teeth and the mouth. With the simpler remedies as hyssop, licorice, dog's milk, goat's butter, etc. many disagreeable substances, espe- 22 GENERAL THERAPEUTICS cially of the animal kingdom, were recommended. In Pliny's writ- ings we find, among other dental suggestions, that "if one wishes to be free from toothache, one should eat a whole mouse twice a month." The ancient writings on dental therapeutics contain so many conflicting statements relative to the sources of specific medications that it is extremely difficult to reach an unbiased decision regard- ing their origin. Plagiarism was of common occurrence among the early scribes ; it was, however, not looked upon as a breach of literary etiquette in the same sense of the word as we interpret this term today. As an illustration we may be permitted to cite Pliny (79 A.D.), who in his famous "Naturalis Historia" prides himself on the fact that he is able to present excerpts of nearly one hundred writers and their two thousand works. He is honest enough, however, to name these authors, while many of his col- leagues of this and a later period prefer silence on this point. Even the renowned Galen (131-200 A.D.) owes most of his botani- cal knowledge as presented in "De simplicium medicamentorum " to the materia medica of Dioscorides, which he duly acknowledges. Again, the seven books of Paulus ^Egineta (about 600 A.D.) are primarily compilations culled from Galen and Oribasius (about 360 A.D.) . The dental therapeutics as presented by the more important Greco-Roman writers Galen, Oribasius, Celsus, Aurelianus, Paulus J^gineta, etc. ; the Arabo-Persians Rhazes, Ali Abbas. Abulcasis, Avicenna, and Mesue ; the early Germans Schenck von Grafenberg. Heinrich von Pfolsprundt, and Ryff; the early Italians Arcu- lanus and Vigo; and the early French Guy de Chauliac, Vales- cus, Pare and Houillier; all, in their final analysis, are culled from Dioscorides. Especially Avicenna (980-1037), "the prince of Arabian physicians," as he has been styled, and whose treatise on general medicine the "Canon" for many centuries enjoyed equally as high a reputation as did the works of Galen, and today is still to be found in many homes of Asiatic Turkey, has been a flagrant plagiarist of Dioscorides' dental medicine. And Walther n. Ryff (1500-1572), that "jack-of-all-trades" to whom Haeser refers as "the roving plagiator, " compiled his dental medicine from the same source via Arculanus. The dental remedies re- ferred to by that mixture of charlatanism and necromancy, John INTRODUCTION 23 Gaddcsden (about 1310 A.D.), sometime professor in Merton Col- lege, Oxford, are so thoroughly tainted by medical avarice, super- stition, and ignorance that it would be an insult to the enumerated writers if we place him in the same category. Merely to men- tion a typical example of the disgusting therapeutic measures re- corded in his bizarre tome, "Rosa medicines," which has been sig- nificantly dubbed by the illustrious Guy de Chauliac, ' ' Rosa f atua, ' ' the following "mixtum compositum" in the form of a decoction which he recommended to be taken against dental podagra (neu- ralgia), may be cited: The gall of a cow, wormwood, alum, pep- per, nutgalls, cloves, pitch, mustard seed, the heart of a magpie, the fat of mice, crow-dung, plantain, and lice. The famous German "Artzney Buchlein wider allerlei Kranck- heit und Gebrechen der Zeen gezogen aus dem Galeno, Avicenna, Mesue, Cornelio Celso," etc., Leipsic, 1530, is an ananymous com- pilation which, as far as its pharmaco-therapeutics is concerned, merely exhibits the same stigmata as do the works of the above mentioned writers, i.e., it is an epitome from Dioscorides' disserta- tions, with slight alterations, as a sequence of having passed through the works of the various authors enumerated on its title-page. In a most interesting collection of Anglo-Saxon manuscripts bear- ing the quaint title, "Leechdoms, Wortcunning and Starcraft," which in modern English would signify "Physicians' Prescrip- tions, the Knowledge of Plants, and Astrology," and which was published some decade ago in London numerous references re- lating to the diseases of the teeth are contained. Here, again, one meets with many drugs which are readily traced to a dis- semination of dental knowledge by the Greco-Roman military sur- geons accompanying the conquering cohorts during their occupa- tion of Britain. It is probably not amiss to depict at this moment a conception of the practice of medicine, and incidentally of dentistry, as one may gather it from the study of the medical works written dur- ing the early centuries of the Christian era. The freeborn Roman looked upon the practice of medicine as a handicraft, the pursuit of which was not compatible with the dignity of a "civis Ro- manus." The practice of medicine in Rome prior to its invasion by the better educated Greek physicians was carried on by slaves ; the larger estates depended on their "servus medicus, " a slave who had acquired some routine medical knowledge, or the ills of 24 GENERAL. THERAPEUTICS the subjects of the household were looked after by the patriarchal "pater familias." Some of these latter representatives of lay medicine gathered together quite an extensive knowledge of the healing art, and their recorded experiences furnish some of the most valuable data to the medical historians. Celsus, Pliny, and Cato are elucidative types of Roman lay practitioners, and inci- dentally are voluminous and fruitful litterateurs on this subject. To the cultured Romans, who were highly conscious of the bless- ings of personal hygiene, the demand for the services of some genius who would keep their masticating organs in perfect condi- tion was a matter of necessity. The works of medical writers of this period are filled with innumerable recipes for tooth prepara- tions. The mechanical side of dentistry, which by necessity must have been carried out by specialists, has received its ample share, as is testified by an excerpt from the famous Law of the XII Tables, enacted 450 B.C., which contains the following paragraph: "Neither add any gold (to a corpse), but if anyone shall have teeth bound with gold, it shall be no offense to bury or burn him with it." Numerous specimens of Roman and Etruscan dentistry have been found in burial-places. The great satirist, Martial, has preserved the name of at least one dentist, Cancellius, "who has grown rich like a senator among the grands and belles dames, and who cures the tooth diseases; and how he can extract!" It is also of interest to note that in the epigrams of Martial many al- lusions are made to the teeth and their care. So we read, for instance : Esse quid hoc dicam, quod olent tua basia myrrham? How do I explain it that your kiss smells of myrrh? Myrrh, which was brought from Asia Minor and Egypt, seems to have been quite a favorite mouth preparation with the Roman ladies. Aside from its use as a mouth wash, it was also applied in combination with other fragrant gums as mouth pastilles (cachous) : Ne gravis hesterno fragres, Frescennia, vino Pastillas Cosmi, luxuriosa, voras. That the breath of your mouth may not smell from yesterday's wine. Frescennia, you use Cosmus' mouth pastilles. Artificial teeth seem to have been quite fashionable with the Roman dames, as the following would indicate: INTRODUCTION 25 Dentibus atque comis, nee te pudet, uteris emtis; Quid fades oculo, Laelia? Non emitur. Without shame you make show with bought teeth and hair; But what about the eye, Laelia; can one buy this also? Specimens of Etruscan dentistry in the form of bridges, crowns, bands, etc., are still preserved in the National Museum of Naples. With the exception of a few monographs the early literature of dentistry is found scattered among the various treatises on gen- eral midicine. In the large majority of instances these records are published by medical practitioners, although sometimes by lay- men who themselves did not practice the art of dentistry. Prior lo the appearance of the work of Fauchard, "Le Chirurgien Dcn- tiste" (1728), who has been significantly styled the "Restaurateur de la chirurgie dentaire, " dentistry is not entitled to the cognomen of a "learned profession." In reality it constituted the handi- craft of vagabonds who traversed the country from one end to the other practicing medicine, dentistry, alchemy, chiromancy, and necromancy as occasion demanded, now and again interspersing these with a little pilfering. The professional mountebank who presented himself as a tooth-puller, barber, leech, and theriac ven- der was a familiar figure in the market-places of the big cities or at the annual fairs of the smaller towns. The extraction of the aching tooth was incidentally an incentive for the sale of some tooth preparation or an amulet for the prevention of the occur- rence of pain in the remaining teeth. The "dentatores" or "den- tispices" of the Romans, the "cavadenti" of the Italians, the "ar- racheur des dents" of the French, the "zahnbrecher" of the Ger- mans, and the "kindhart" of the English represented the bulk of our professional ancestors. Henry Chatlee of London published an interesting volume in 1539, in which he describes this latter itin- erant tooth-drawer. Usually he was rigged up in a fantastic cos- tume, wearing a cap on which he displayed conspicuously a large leaden brooch, being an effigy of St. George, which was commonly regarded as one of his peculiarities. To signify his profession he had his belt garnished with a string of extracted teeth. Chattlee defines this professional charlatan in the following way: "Gentle- men and good fellows, whose kindness having christened me with the name of Kindhart binds me in all kind course I can to de- serve the continuance of your love: Let it not seem strange, I beseech ye, that he that all the days of his life hath been famous 26 GENERAL THERAPEUTICS for drawing teeth should now in drooping age hazard contempt- ible infamy by drawing himself into print." The keen-pointed pencil of the satirist Hogarth has left us a barber's sign displayed in that famous thoroughfare Charing Cross (about 1740), with this legend: "Shaving, bleeding, and teeth drawn with a touch. Ecce signum!" In Paris, during the sixteenth to the eighteenth centuries, the "Pont-Neuf" was the common meeting-ground for establishing the "theatre ordinaire de ces imposteurs," as Fauch- ard ironically refers to it; and at least one of these "arracheurs des dents," LeGrand Thomas, as he styled himself, succeeded in being counted among the ' ' Immortels. ? ' Among the ancient writings on dental medicine a most interest- ing record is available which furnishes a complete and luminous description of the then existing state of dental therapeutics, and which is not duplicated in any other work known to the writer. The book is entitled "The Home Remedies of Pedanios Dioscoridcs. " It comprises the pharmaco-therapeutics of the then known dis- eases, such as headaches, diseases of the eyes and the ears, the teeth and the gums, the other diseases of the mouth and throat, the diseases of the hair, of the skin, etc. It is rather strange to observe that in the various works of dental history, i.e., Carabelli, Geist-Jacoby, Lemerle, Guerini, etc., there is no specific reference found in regard to this important work. Pedanios Dioscorides or Dioskurides of Anazarbus (Asia Minor) lived during the second half of the first century. Nothing definite is known concerning his life. It seems, however, that at one time he was engaged as an army surgeon, and during his sojourn with the Roman legions visited many countries. As he states of him- self, from early youth he was passionately fond of nature study, and his love for botany is largely responsible for his minute and accurate description of the many hundred specimens of vegetable drugs, of which he gives a detailed account in his "Materia Med- ica." Incidentally, with the creation of this work the term "ma- teria medica" was introduced into general medicine. The volume is divided into five books, and contains nearly one thousand drugs, primarily of the vegetable kingdom, although many animal drugs and quite a few mineral compounds are enumerated. Dioscorides has depicted the medicinal plants so accurately that with his aid, more than 1900 years later, botanists were able to INTRODUCTION 27 locate the greater majority of these plants in the respective coun- tries. For more than sixteen centuries this important work has formed the basis of all teachings in botany and pharmacology. It has been translated into most of the languages of the cultured nations, and innumerable editions have appeared. Various epi- tomes and commentaries of this work have been prepared, and. with the financial aid of crowned heads of Europe, beautifully il- lustrated editions have been printed. In the various libraries of Europe there are about twelve more or less complete codices (manu- scripts) of this work of Dioscorides preserved. During a careful perusal of this most interesting text, the writer has been able to locate more than one hundred passages referring to diseases of the teeth and their adnexa. Dental historians, wton referring to the practice of oral therapeutics of the early Ro- man period, invariably cite Scribonius Largus as their authority. His "de Compositiones, " a medical formulary, written between 40 and 50 A.D., contains several prescriptions for tooth-powders and quite a few drugs which are employed in dental diseases. Compared with the references found in the "Materia Medica" and the "Home Remedies" of Dioscorides relative to dental ther- apeutics, the formulary of Scribonius Largus is completely out- shadowed. The patron saint of dentistry, St. Apollonia, was canonized in Rome about 300 A.D. Being a Christian, St. Apollonia was tor- tured by her persecutors by having her teeth, one by one, ex- tracted, and finally suffered death by fire. Her memory is com- memorated on February 9th of each year. Remains of her skele- ton are preserved in the various churches of Rome, Naples, Co- logne, Antwerp, Brussels, and Quebec, and excellent pictures of the saint by Guido Reni, Carlo Dolci, and others are found in Milan, Florence, and other cities. The name of St. Apollonia is frequently mentioned in prayers in the various prayer books of the middle ages, and is especially intended for the relief of tooth- ache. Prior to 1840 comparatively few important communications on dental surgery had appeared. The foremost literature of this time was published in France and England, and a few books of importance appeared in Germany. The United States was at this period principally concerned with the practical development 28 GENERAL THERAPEUTICS of this new branch of the healing art, and, with the exception of the writings of Longbotham, E. Parmly, L. S. Parmly, Flagg, Trenor, Fitch, Bostwick, Spooner, S. Brown, the Burdells, and others, little was printed in relation to dentistry. Dental text- books, if used at all, were imported from England, or translations of French works were published. Leonard Koecker, a practitioner of international reputation, pictured the situation quite correctly when he stated, in 1826, that "in the United States, although lit- tle or nothing has been done in the way of publishing on the sub- ject of dental surgery, yet I feel myself authorized to say that in no part of the world has this art obtained a more elevated sta- tion." It must also be remembered, that the individual practi- tioner of this period was extremely jealous of any special knowl- edge which he happened to possess, and he usually guarded this acquired proficiency very carefully. No specific current dental literature was in existence at that time, and comparatively few medical journals tried to disseminate the progress of medical and, incidentally, dental knowledge. The few journals were seriously hindered in this laudable cause by the extreme difficulties of in- terchange on account of the very limited facilities of the postal service. The first dental periodical of this or any other country appeared in 1839 under the name of "American Journal of Den- tal Science," and was published by E. Parmly, E. Baker, and S. Brown. The first regularly organized dental society of any im- portance was the "American Society of Dental Surgeons," which was founded in New York on August 18, 1840, with Horace H. Hayden as president. The birth of dentistry as a distinct and definite profession may be recorded simultaneously with the date of incorporation of the first dental college of the world, the Bal- timore College of Dental Surgery, which received its charter in 1839. Its first session commenced in the following year, with a faculty composed of Horace A. Hayden, Chapin A. Harris, Thomas E. Bond, and H. Willis Baxley. Medicine and dentistry were from that year practically divorced, and, while dentistry in its early days depended very largely on medicine for its further de- velopment, it bases its fundamental studies at present on general biology exactly in the same manner as medicine, veterinary medi- cine, or any other branch of the healing art is forced to. do. Arkovy has said that "in operative dentistry, empiric thera- peutics has reached far ahead of pathologic knowledge." The INTRODUCTION 29 truth of this axiom finds its explanation, as we have stated above, in an absence of organization of the comparatively few dental practitioners prior to 1840. No specific books on dental remedies were then in existence, and the little knowledge concerning the action of drugs was scattered through the few dental works, or it was closely guarded by its possessor. Since then quite an ex- tensive literature on dental materia medica and therapeutics has appeared, which furnishes ample proof of the immense stride made, especially in the last decade, in this particular phase of dental science. The drugs which were principally applied as den- tal remedies were usually such agents as were also employed, ac- cording to their therapeutic indications, for disturbances of a similar pathologic nature in other parts of the body. Prominent among these remedies are the commoner astringents nutgalls, oak bark, myrrh, alum, etc. Of the caustics, silver nitrate and the mineral acids, especially nitric acid, were much in vogue. Ar- senic trioxid has always occupied an important place in dentistry as a powerful caustic. In 1836 it was recommended by Shearjas- hub Spooner 1 for the purpose of destroying the dental pulp, and, in spite of the many substitutes offered, it still maintains an en- viable reputation for this purpose. Creosote, and to a still greater extent phenol, which was discovered by Runge in 1834, have al- ways been favorite remedies, which were employed as caustics, obtundents, and, unwittingly, as antiseptics. The antiseptic era was, however, inaugurated by Joseph Lister many years later. Its birthday may be registered at 1867, when Lister published his epoch- making paper entitled: "On the Antiseptic Principle of the Prac- tice of Surgery." 2 Many of the essential oils the oils of cloves, cinnamon, peppermint, spearmint, turpentine, etc. have been em- ployed for many centuries as obtunding agents in the treatment of pulpitis, and they have always enjoyed quite a reputation as flavoring agents for mouth preparations. Aromatic and analgesic fomentations consisting of cataplasms prepared from mixtures of chamomile, henbane, poppy heads, hops, ground linseed, or roasted figs and bruised raisins, occupied a prominent place as antiphlogis- tics for the relief of inflammation about the teeth and their adnexa. Of the true analgesic drugs, opium and aconite are probably the 1 Shearjashub Spooner: Guide to Sound Teeth, or a Popular Treatise on the Teeth, New York, 1836. 1 British Medical Journal, Aug. 8, 1867. 30 GENERAL THERAPEUTICS most important representatives. Among the aromatic tinctures and lotions which were used as soothing and healing mouth washes, alcoholic extracts of balsams and resins as myrrh, frankincense, benzoin, mastic, etc. and decoctions and infusions of herbs, barks, and roots as arnica, anise seed, cloves, cinnamon, chamomile, sweet flag, ginger, merigold, scurvy grass, mallow, sage, etc. were in common use. Innumerable formulas for tooth powders are found in the older works pertaining to the treatment of the teeth, and consisted largely of a base made from prepared chalk, burnt oy- ster shells, charcoal, crabs' eyes, Armenian bole, pumice stone, etc., mixed with cuttlefish bone, magnesia, vegetable powders, espe- cially spices, and coloring materials. A record concerning the more important events of the develop- ment of dental pharmacology would be incomplete if the dis- covery of general anesthesia were not mentioned, even if it is only en passant. To the dental profession of the United States belongs the honor of having introduced into surgery the first practical method of obtaining complete anesthesia. The discovery of anesthesia is the greatest boon ever bestowed on mankind for the relief of suffering. With the introduction of nitrous oxid as a general anesthetic in 1844 by Horace Wells, the stimula- tion for further researches was initiated, and the future develop- ment of anesthesia was merely a sequence of this incentive. THE AIM OF THERAPEUTICS. The object of medical art is to cure disease, to relieve suffering, and to maintain health. Aside from the various technical means employed in relieving the sick, there are at the service of the physician hygienic and physical measures, and the use of a num- ber of substances which, when applied to or introduced into the body, bring about decided changes. These substances are known as drugs. The rational administration of drugs depends on a clear conception of their physiologic action. It is supposed, how- ever, that the physician possesses a comprehensive knowledge of the causes which produce disease general pathology and that he utilizes this knowledge together with that of the physiologic action of drugs in the struggle of combating disease. The materials and substances used in medicine comprise the animal, vegetable, and mineral kingdoms; and the study of their THE AIM OF THERAPEUTICS 31 names, sources, physical character, and chemic properties, their preparations, doses, etc., is referred to as materia medica. The term materia medica as stated above was introduced by Dioscori- des. He published the first compilation of descriptions of drugs, which were mostly vegetable in character, while the first collec- tion of prescriptions a formulary was edited by Scribonius Largus. Drugs pliarmaca are remedies; the study of drugs that is, the changes which are induced in the living organism by their administration is known as pharmacology. A remedy, in the broadest sense of the term, is anything which cures, palliates, or prevents disease, and, consequently, comprises the utilization of all means and methods which are employed for the purpose of relieving the sick and favorably influencing the evolution of dis- ease, while drugs proper are the material substances obtained from the animal, vegetable and mineral kingdoms employed as thera- peutic agents to produce a cure. Drugs are either pure chemicals, mixed mineral products, or certain animal or vegetable substances. "Crude drugs" is a commercial term designating natural animal or vegetable drugs as they are brought to the market. In a re- stricted sense of the word, only the changes which are produced by the action of drugs in the healthy or diseased organism is known as pharmacology, while the power of drug action itself is known as pJiarmaco-dynamics. At the present time pure pharmacology is classified as a department of biology; all biologic sciences, how- ever, serve in some form or another as handmaids to general medicine. In the teaching as well as in the clinical application of pharmacology a number of questions arise which indicate its close relationship to physiology and to pathology. Through the action of drugs on normal tissues we are led to understand their effects on the disturbed functions of these tissues. In the experi- mental study of antipyretics, for instance, their influence on the normal temperature as well as on the increased temperature in fevers, together with an understanding of the nature of the lat- ter, is essential for the full comprehension of their therapeutic ap- plication. In its broadest conception, then, we understand by phar- macology the science of the changes which occur in the vital re- actions of healthy and diseased tissues under the influence of chemic substances. The application of remedial substances in the treatment of diseased conditions of the body is based on our knowl- edge of pharmacology, and it is at present referred to as phar- 32 GENERAL THERAPEUTICS macotherapy, a term which was introduced by Kobert (1887). It constitutes the most important branch of therapeutics. Some substances, when ingested into the living body, possess little medic- inal value, but they act as poisons by bringing about dangerous or even fatal results. The study of their effects on the tissues and the methods of their detection is known as toxicology. It is difficult to draw a distinct line between a drug and a poison; frequently only the quantity given and the method of its adminis- tration will determine whether the substance acts as a food, a drug, or a poison. The description of the drugs, their habitats, their composition, and their recognition is spoken of as pharma- cognosy, while pharmacy is usually defined as the art of prepar- ing medicines for use and dispensing them on the order of the therapeutist. The term pharmacy is also applied to the place of business of the druggist; the latter is also known as pharmacist or apothecary. The application of remedial measures for the purpose of relieving the sick and favorably modifying the evolu- tion of disease is referred to as therapeutics. While in the past the administration of remedies was largely based on empirical con- ceptions, modern research endeavors to employ rational methods for the treatment of diseases. By medical empiricism we under- stand the treatment of the sick by symptoms only, knowing noth- ing of the disease, while rational therapeutics implies the basing of the treatment on a thorough knowledge of the causative factors of disease. A few diseases are directly amenable to drug action as malaria, syphilis, anemia, etc. and the remedies employed for such definite purposes are known as specifics. Unfortunately only a very few of these specifics are at our command, and most of them were discovered by empirical medication. Within recent years rational methods have been adopted for the treatment of certain infectious diseases, which resulted in the discovery of def- inite, specific products known as antitoxins, which act against the disease producing toxins very much in the the same manner as an antidote acts against a poison. The introduction of salvarsan by Ehrlich-Hata in 1910 as an etiotropic remedy for the treatment of syphilis has marked a new era in experimental therapy and it is to be hoped that this truly marvelous discovery will lead to further specific remedies which may aid in the battle against some of the greatest scourges of the human race. It is not always possible to reach the diseased organ directly THE AIM OF THERAPEUTICS GO by the administered remedy- that is, to remove the causative fac- tors of the disease. Sometimes it will be found that a disease has progressed so far as to exclude direct medication. The thera- peutist may, however, be able to relieve the painful symptoms, or he may at least mitigate the conditions. Symptomatic treatment is frequently of great benefit to the patient; the latter is prin- cipally interested in getting relief from things which annoy him, and he cares less about things which may be harmful. The phy- sician must be able to judge from the symptoms which he recog- nizes in the diagnosis of the disease what remedies are best indi- cated for his patient; he -must know the best method of their ad- ministration, their dose, the length of time they should be given, etc. If a disease has altered, or even destroyed, a part of certain tissues or their functions, it does not necessarily follow that a permanent injury must result, provided that the work of the dis- eased organ is carried on by some other organ. A kidney may be- come so affected that its removal is indicated. This does not necessarily mean that the patient has to succumb, as the other sound kidney is sufficiently active to carry on the work which nature had intended for the two organs, and the patient may still enjoy fairly good health. When, however, an organ is so altered by a disease that its work cannot be accomplished by an- other organ for example, the valves of the heart have become weakened drugs may be administered which will beneficially in- fluence the symptoms of this diseased condition, but they will never cure the ailment. Etiologic and symptomatic therapeutics will be, more or less, always applied simultaneously. It should not, however, be under- stood that the symptoms of diseases, even if they cause more or less annoyance to the patient, should be treated at once by drug administration. These subjective disturbances are frequently re- active measures of the organism created for the purpose of de- stroying the disturbing elements. It is immaterial whether these disturbances are the cause of the disease or its product. At pres- ent fever is generally considered a means of self-defense of tin disturbed organism, and is instituted by nature against the dis- turbing agencies, which have gained access to the tissues. Na- ture may, however, in her efforts to battle with the invading foe, go too far, and the fever may rise above 104 F. (40 C.), and, as a consequence, will endanger not only the disease producers, 34 GENERAL THERAPEUTICS but also the heart. It is now the duty of the physician to regu- late the activity of self-medication by the body and keep it within proper channels by the application of suitable remedies. Again, in inflammation, which is at present recognized as a reaction of the tissues against an injury, the preliminary hyperemia is one of the foremost means of self-defense that the body possesses. The application of antiphlogistics is usually counter-indicated in the early stages of the disturbances; if the pain that accompanies an inflammatory condition becomes unbearable, then it is the duty of the physician to counteract the eager efforts of nature by ap- plying carefully selected remedies that will keep it within proper limits. While modern medicine has profited extensively by its associa- tion with pharmaceutic chemistry, it should not be forgotten that the old and well-tried remedies as opium, mercury, potassium iodid, digitalis, etc. still hold an important place in the arma- mentarium of the conscientious physician, and that they are as yet not supplanted by the so-called modern substitutes. It is a false illusion that only the new is valuable and reliable, and the old is a relic of the past. On the other hand, it should be remem- bered that there still prevail a great many notions regarding the action of certain remedies which are not in harmony with the modern rational conception of the physiologic action of drugs. Some of these ' ' pharmacologic f etishims, ' ' as they have been very appropriately termed by a writer, are so deeply implanted in the minds of some practitioners that the latter have become slaves in the blind following of this belief. For instance, the idea of administering potassium chlorate with the intention of exerting a beneficial influence on all forms of diseases in the mouth by the liberation of nascent oxj^gen is wholly unfounded. Potassium chlorate is principally a blood poison, and as a therapeutic agent it possesses no advantage over any other simple salt, as sodium chlorid. Again, potassium iodid and sulphureted lime are lauded by many as panaceas in the treatment of disturbances arising from general infection. As a matter of fact, neither of these chemicals is indicated as a specific in these conditions. Sulphur- eted lime has no place in modern therapeutics, and potassium iodid possesses only one real indication, and that a most impor- tant one in certain stages of syphilis. THE AIM. OF THERAPEUTICS 35 Quite frequently the question is asked, "Do drugs ever cure?" Before an attempt is made to answer this question it is necessary to have an understanding of what constitutes a "cure" and, inci- dentally, what is meant by health and disease. It does not mat- ter for our present consideration from which point of view we look upon life. To us it means the reaction of cell activity of the organism as a whole produced by various external agents. When- over the normal equilibrium of this cell activity is disturbed by a morbific cause, the organism reacts against it, producing a series of phenomena which is known as disease. Nature possesses as an inherent quality the power of re-establishing normal conditions vis medicatrix naturae i.e., to heal the disease. To aid nature in the reconstruction of her disturbed functions, the physician applies remedial agents which are intended to "cure" the dis- ease. Expressed in the words of Celsus, these two processes are defined as natura sanat, medicus cur at. In the layman's mind there is not the remotest doubt that a drug or a combination of drugs possesses the power of producing a cure. He takes a headache powder with the definite expectation of curing his head- ache. This very idea is still entertained by a number of prac- titioners of the old school, and it is largely based upon the in- herent popular desire for drugs. Even Galen complained most bitterly about this generally established notion by saying: The people want prescriptions! Since the first publication of Vir- chow's Cellular Pathology in 1858, and the consequential ad- vances made in experimental pharmacology, this prevalent notion has greatly changed. It was shown that the drugs themselves had no direct influence on the disease itself. As soon as this fact became known it was quite fashionable to laugh at the curative effects of drugs, thus establishing the folly of drug nihilism with certain erratic physicians. This drug skepticism frequently re- sults from errors regarding the medicines themselves, or from im- proper utilization of drugs at the wrong time or in the wrong disease or their definite action is not distinctly understood. Un- familiarity with the fundamental principles of incompatibility is quite frequently another case of drug nihilism. While we are aware that the vis medicatrix naturae is the profound basis of a cure, we are also aware that the action of the drugs is materially instrumental in coaxing nature to bring about a change in the prevailing conditions. Numerous instances could be cited to eluci- 36 GENERAL THERAPEUTICS date this tenet. The physician administers quinin to his patient to kill the plasmodia malarice, the true cause of malaria, but the many disturbances which the malaria germs have produced in the various organs of the body are restored by nature. The den- tist removes a tooth which is the cause of a purulent infiltration of the soft and hard tissues, but the restoration of the distorted tissues and the healing of the wound is accomplished solely by nature. Or, a man breaks his jawbone, and the skillful dental surgeon puts the broken parts in proper position, applies a splint, and the parts unite without leaving the least trace of a deformity ; but without nature's reparative process without formation of the callus the best surgical skill would be of no avail. Such in- stances are met in very old people, in whom, in spite of the best treatment, fractured parts refuse to unite. On the other hand, without having the parts put in proper position, a great deform- ity may result, or the fracture may remain ununited in spite of a superabundance of nature's reparative power. "Faith in the Gods or in the Saints cures one, faith in little pills another, hyp- notic suggestion a third, faith in a plain, common doctor a fourth. In all ages the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. The cures in the temples of Esculapius, the miracle of the Saints, the remarkable cures of those noble men, the Jesuit missionaries, in this country, the modern miracles of Lourdes, and the wonder-workings of the so-called Christian Scientists are often genuine and must be con- sidered in discussing the foundation of therapeutics." (Osier.) The young graduate, fresh from college, usually starts out with a long. list of drugs, ready to combat all diseases. When he gets his first patient with some difficult ailment, where drug adminis- tration is indicated, he finds that the remedy which he has cho- sen is utterly incapable of influencing the existing conditions; his faith receives a severe shock, and usually tumbles down to a disbelief in drug action. A small number of drugs, meeting the every-day indications, should be employed in the bulk of a dentist's work. Constant acquaintance familiarizes him with their nature and their uses, and with these few remedies his best work is usually done. Therapeutic nihilism is just as erroneous as the polypharmaceutic shotgun prescription of our ancestors. Prac- titioners of large experience usually obtain the best result with NATURE OF DRUG ACTION 37 a few of the simple remedies, while many of the younger dis- ciples of Esculapius seize after new compounds because they do not know how to employ either of them. "When called to guide a patient through an illness, the physician should be constantly a watchman, and a therapeutist only when necessity arises." NATURE OF DRUG ACTION. Within the last fifty years the theories regarding the pharmaco- logic action of drugs have undergone remarkable changes. Em- piricism in medicine has held sway ever since remedies were used for the purpose of alleviating diseases, and it was only through the introduction of experimental pharmacology in the early six- ties of the last century that a slow but radical change in the ad- ministration of drugs took place. The science of modern phar- macology is based on Virchow's conception of cellular pathology, and with its introduction into general medicine, in 1858, the hu- moral pathology of Hippocrates received its death-blow. In the conception of this great physician of Cos, Hippocrates, the knowl- edge of medicine was based on seven natural phenomena res nat- urales and he considered the body as being made up of the four elements, i.e., fire, earth, air, and water. These elements were supposed to invest the body with the proper temperaments (com- plexiones) the heat, the cold, the dry, and the wet, which when combined in different proportions in the different individuals were productive of the four humors, i.e., the blood (sanguis), the phlegm (phlegmon), the yellow bile (clwler), and the black bile (mel- ancholer). It was further supposed that one or the other of these humors must always be present in a preponderance, so as to create the specific physical organization which is peculiar to the respective individual. According to the ruling fashion and the practice of medical art, including its stepdaughter, dentistry, has always been gov- erned by it the remedies employed in treating diseases were in accordance with the predominating school. The number of rem- edies which are at the disposal of the physician are countless; the drugs of real merit, however, may be gathered within a small com- pass. In the Ebers papyrus, for instance, which comprises the period 3700 to 1500 B.C., about eight hundred remedies are enu- merated, and Dioscorides describes about a thousand drugs. Again, 38 GENERAL THERAPEUTICS in the Pharmacopoeia Medico-physica, published by Schroder in 1664, the goodly number of six thousand remedies is recorded. We may probably gain a better understanding of the use of these many drugs when we remember that about that period polyphar- macy had reached its zenith. In those days the combination of ten, twenty, or even more simples in a single prescription was very much of a routine practice. For instance, such mystic com- pounds as theriaca and mithridate, which enjoyed a world-wide reputation in their days as ' ' cure-alls, ' ' were concocted of seventy- five or even more simples. The London pharmacopeia of 1667 published a formula for the preparation of a mithridate confectio damocratis which called for eighty-five different ingredients in its make-up. A recent example of poly pharmacy is the still fa- mous Warburg's tincture, which originally called for some twenty- odd simples for its preparation. The action of drugs on the organism is known only in a very few instances. After a drug is absorbed by the tissues, a chemic reaction between this substance and the protoplasm of the cell occurs, which is genetically expressed as irritation. What con- stitutes this irritation and its subsequent reaction with the dis- eased organism is as yet unknown. Apparently all pharmacol- ogic action is governed by the same biologic law which controls every manifestation of the living cell, i. e. : Minute irritation augments vital function, medium irritation increases the same, strong irritants lower these functions and the strongest irritation changes them completely. The degree of irritation is purely a matter of individuality and, incidentally, a supposed primary de- pression will always be, relatively speaking, an irritation. The basic law governing pharmacologic action may be expressed as follows: Drugs ingested into the body must be soluble in the tissue fluids in order to combine with the cell contents and there- by exercise their function. This axiom, well known to the ancient medical chemists, was dogmatically expressed as: Corpora non agunt nisi soluta seu solubilia. In other words, pharmaco-dyna- mic action is the result of a chemic reaction between the drug and the living organism. However, the term ' ' chemic ' ' in this particu- lar instance must not be restricted to narrow bounds; the reac- tion between the drug and the cell contents, i.e., albumin, lecithin, salts, water and other compounds usually is not of a pure chemic nature but, in most instances, a physico-chemic process in which NATURE OF DKU(i ACTION 39 diffusion, filtration and osmotic pressure play important parts. It may be explained as a process of dissociation of a complicated group of molecules into simpler ones or even into ions, brought about or facilitated by the presence of specific ferments or enzymes and accompanied by hydrolytic decomposition, oxidation, reduc- tion, precipitation, substitution, synthetization or other compli- cated procedures. The term, solubility in the tissue fluids, car- ries with it a far-reaching significance and its initial conception must not be based on similes observed outside of the body. Ex- pressed in simple language, the results of a test tube experiment must not be interpreted as producing similar reactions within the living organism. As a well-known example we may cite the phar- macologic action of calomel. The mild mercurous chlorid is in- soluble in the ordinary fluids in the test tube ; when administered internally, however, even in the so-called broken doses, i.e., one- tenth of a grain, marked therapeutic effects are observed. The result of the calomel action is not to be explained on the mechani- cal basis of its mere presence, but it is the sequence of its enter- ing into solution through the agencies of the tissue fluids. Whether minute quantities of the readily soluble sublimate are formed or whether intermediary products are resultant from the albumin- sodium chlorid-enzyme, etc., action is of less importance at this moment. The mere fact remains that the otherwise insoluble cal- omel does enter into solution when brought in contact with the living cells and hence by its physico-chemic reaction is capable of bringing about profound therapeutic effects. Certain drugs apparently react with all the cells, while others possess an elective action to specific cell groups. To produce phar- macologic action, an adequate amount of the drug, constituting its average dose, is essential. Only an immeasurably small portion of the administered drug reacts with the specifically susceptible cells. After absorption, the blood and the lymph stream distribute the drug throughout the whole body and, depending on its spe- cial affinity, it is retained by the various cells. Apparently, no direct relationship exists between the quantity of the absorbed drug and its elective pharmacologic action, i.e., as yet we have no more conception why a grain of strychnin will kill a sound, healthy man within a few minutes after absorption than why a spark fall- ing into a barrel of gunpowder will cause its explosion. Two def- inite factors apparently play an important role in the therapeutic 40 GENERAL, THERAPEUTICS action of drugs first, the power possessed by the drug itself, and, second, the reactive power possessed by the organism. Recent experimental observations seem to point to the fact that patho- logically altered tissues react quite differently to chemic substances than do normal tissues, and that the condition of the organism, within certain limits, determines whether the same pharmacologic action will produce good or bad results. The irritation produced by the absorbed drug manifests itself as stimulation or as depres- sion of the function of the organism. These reactions depend largely on ite dose and on the age, sex, and individuality of the patient. Some drugs, when ingested in small quantities, increase the bodily functions, while, when taken in large doses, decrease the same function. Again, certain drugs exercise specific influ- ence on certain organs. All changes which occur within the tis- sues as a result of the action of a drug are of a chemic nature. Usually three forms of reaction between the drug and the cell of the body are recognized: 1. A superficial combination between the cell Avail and the chemic substance occurs, which lasts as long as the cell is active and is not injured. The chemic substance does not enter into the protoplasm of the cell proper. 2. A combination of the chemic substance and the cell con- tents is produced as a result of the easy penetration of the sub- stance into the protoplasm proper. 3. A combination is formed between the chemic substance and the protoplasm which lies intermediate between the first and sec- ond group that is, it may require minutes, or even days, before this combination is obtained. Nature will always hold its own as far as the supremacy of drug influence is concerned it will ahvays react against drug action as long as it possesses vitality. If the tissue does not possess sufficient strength to resist the action of the drug, death is the result, while, if the diseased tissue wins the battle by in- creased reaction against the drug, it will return to its normal function. All drugs that are ingested into the body are again removed from it by the secretions and excretions. This process depends largely on the stability of the union which the drug has formed with the tissues. Some drugs show a predilection for certain NATURE OF DRUG ACTION 41 glands for their removal as, mercury is largely removed by the salivary glands, potassium iodid through the glands on the mucous membrane of the eyes, etc. Dose. The Ninth Decennial Revision (1916) of the Pharma- copeia of the United States has again admitted average approxi- mate doses of medicine for adults to be used internally or hypo- dermically. These doses are not, however, obligatory on the phy- sician, and they may be increased or reduced according to cir- cumstances. It is a matter of clinical experience with each prac- titioner to safely adjust the dose for the case in hand. In using a powerful remedy, it is best to start with a small dose and in- crease cautiously. Various circumstances modifying the dose de- mand attention. Age. Children and the aged require smaller doses than the adult. The following rule of Dr. Young is now almost universally adopted: For children under twelve years the dose of most med- icines must be reduced in the proportion of the age to the age increased by twelve, i.e., twelve is added to the child's age and the same is divided by the age. For example, at two years the dose is reduced to 1/7 ( 2 f 12 ) = 1 /7 or 2+12 = 14-^-2 = 7. The adult dose divided by 7 is the proper dose for the child. Frequency and Time. The effect derived from the medicines is largely the guiding post of frequency and time at which they should be taken. Purgatives are usually taken in a single dose in the morning; emetics are to be taken once, and repeated only in case vomiting is not induced ; drugs which induce sleep are nat- urally given at bedtime ; alkaline stomachics, before meals ; tonics, three times a day continuously. The interval between the doses should be calculated and the second dose administered before the effect produced by the first has passed off. The daily dose is three times as large as the single dose. The exceptions are: If the single dose is */ grain, the daily dose is = 2 grains. If the single dose is = 2 grains, the daily dose is = 8 grains. If the single dose is = 4 grains, the daily dose is = 15 grains. If the single dose is = 25 grains, the daily dose is = l 1 /^ drams. The daily dose is twice that of the single dose: 1. Of all strychnin preparations, 2. Of all hypnotics (sulfonal, veronal, trional, etc.), 3. Of pilocarpin hydrochlorid, and 42 GENERAL THERAPEUTICS 4. Of all single doses of 50 grains or more. In estimating the maximum daily dose, the day is to be counted as 24 hours. Sex, Temperament, Idiosyncrasy, and Tolerance. Females and persons of sanguine temperament require somewhat smaller doses than males and the phlegmatic. Certain persons exhibit peculiar pronounced reactions toward ordinary doses of drugs while others may take much larger doses without any ill effect. This char- acteristic state of individuality is referred to as idiosyncrasy. As yet no satisfactory explanation of this peculiarity has been brought forward. It is well known that apparently normal in- dividuals will quickly react to extremely small doses of calomel, opium, antipyretics, etc. Again, certain foods exhibit unusual re- actions in certain persons, as, for instance, crawfish, strawberries, raspberries, etc. Occasionally it is observed that an individual apparently does not react to the ordinary dose of a medicine, i.e.. tolerance to the drug is recognized. The prolonged use of a drug, i.e., morphin, arsenic, cocain, etc., may establish an acquired tolerance known as drug habit. The most familiar examples of acquired tolerance are those of tobacco, alcohol, coffee and tea. Some drugs as calomel, chloral hydrate, and arsenic are pecul- iarly well borne by children, being taken by them in relatively large doses. On the other hand, children are peculiarly suscep- tible to the influence of opium. Again, many drugs as ipecac- uanha, tartar emetic, alcohol, etc. have different action in dif- ferent doses. Cumulative Effect and Synergy. Drugs may be given at longer or shorter intervals, depending on man}' circumstances. Custom, habit, and tolerance play the most important part. Occasionally in the administration of drugs, it will be observed that after a number of doses have been taken with no apparent or, but slight, effect that sudden symptoms arise which are much more pro- nounced than those manifested after the first dose. This effect is referred to as cumulative action of drugs. Absorption may be more rapid than excretion and each new dose thus adds to the total quantity present in the blood and in the different organs of the body. A classic example is digitalis, although strychnin, atropin, arsenic, iodids, etc., are known to induce this state of cumulative action. The metal salts, especially those of mercury, lead, copper and silver are productive of chronic poisoning by NATURE OF DRUG ACTION 43 these cumulative effects. In most cases, except in those of the metal salts, the retardation will last only a few days, rarely weeks, while arsenic, mercury, lead, etc., may remain for months; silver, under suitable conditions, may be retained for years or even permanently in the system. Frequently mixtures of drugs of which each individual substance is known to produce the same effect in the body, are administered to induce increased action a cooperation of the powers known as synergy. The synergistic effect of mixtures of purgatives offers a striking example ; the mix- ture acts usually distinctly more efficiently than any one drug of the same mixtures given in quantity equal to all of them. Of great practical importance is the synergism of the narcotics, i.e., the combined effects of scopolamin and morphin, or morphin and ether, etc. Mixtures of the antiseptics of the benzol ring series with other groups exhibit marked synergistic action, as formo- cresol. Drugs when administered simultaneously may antagonize each other, i.e., they are physiologically incompatible. (See In- compatibilities.} Occasionally it will be observed that the in- gestion of drugs, and, to some extent, articles of food, are fol- lowed by a peculiar form of skin eruption, known as drug rash (dermatitis medicamentosa). This disturbance may be the result of ingesting an excessive amount of the drug or to an idiosyncrasy of the individual. The most common drug dermatoses are those following the ingestion of bromids and iodids, although quinin, salicylic acid and many other drugs and articles of food, as straw- berries, buckwheat and shell fish are known to produce this dis- ease. The prolonged use of mouth preparations (washes, powders and pastes) containing appreciable quantities of such skin irri- tants as salicylic acid, salol, menthol, and essential oils are oc- casionally productive of morbiliform eruptions about the corners of the mouth or the lower lip in susceptible patients. These erup- tions are generically known as mouth wash eczema. Formalin is prone to cause a most persistent and painful eczematous erup- tion about the hands of the dentist. The remarkable achievements made by the progress of or- ganic chemistry have materially aided the rapid development of pharmaco-therapeutics. The discovery of the active constituents of plants, the alkaloids, and their preparation in a pure state has furnished the physician with a great many very important medicinal agents, which are now used by him in preference to 44 GENERAL THERAPEUTICS the crude drugs. The discovery of the chief alkaloid of opium morphin by Sertiirner, in 1805, marked a new era in pharma- ceutic chemistry. It was rapidly followed by the discovery of atropin in belladonna leaves, cocain in coca leaves, strychnin in nux vomica, etc., and at present there are probably very few medicinal plants of which the active constituents have not been isolated. These alkaloids allow an accurate dosage, and, to in- crease the rapidity of their action, Alexander Wood, in 1855. introduced an important chaaige in their administration the hypodermic method. The analysis of the alkaloids has led the way to the discovery of a number of synthetic compounds which proved to be, in some instances at least, superior to the action of the natural alkaloids in the treatment of disease. For instance, after the chemic constituents of cocain had been positively worked out, various groupings of the original molecules, with certain ad- ditions and omissions, furnish the many synthetic cocain sub- stitutes which since have proved to be of even greater value than the original cocain. This is also true of many antipyretics, anti- septics, diuretics, diaphoretics, and a host of similar synthetic substances. The newer remedies which have been introduced into materia medica within the last forty years owe their discovery almost exclusively to the chemic laboratory. They were discovered, not by accident, but by definite, previously outlined experimental work. The introduction of chloral , hydrate as a hypnotic by Liebreich, in 1869, was probably the first step in modern experi- mental pharmacology. Lander Brunton, in 1867, introduced amyl nitrite for the purpose of lowering the blood pressure; in 1884 Filehne discovered antipyrin, which was soon followed by acetanilid, phenacetin, and numerous other antipyretics. Not alone had plant alkaloids to furnish their quota of remedial agents, but the various glands of the animal had to give up their active constituents for the treatment of disease. In 1894 Oliver. Schafer, and Moore discovered the blood pressure raising principle of the suprarenal capsules, and since then a number of similar organo preparations have found their way into modern therapy. CLASSIFICATION OF DENTAL REMEDIES. The first systematic classification of drugs according to their pharmacologic action was introduced by Buchheim in 1856. and CLASSIFICATION OF DENTAL REMEDIES 45 since the appearance of "Dei* Grundriss der Arzneimittellehre, " by Schmiedeberg, in the early eighties of the last century, a revo- lution in drug medication has taken place. This revolution was made possible only by the complete elimination of empiricism, and by utilizing the results obtained from experimental work on healthy and artificially diseased animals, and, to some extent, on man. Aside from the above-named experimenters, such men as Magen- die, Beaumont, Claude Bernhard, B. W. Richardson, Crum Brown, Frazer, Binz, Liebreich, Lauder Brunton, Filehne, Kobert, Ehr- lich, Cushny, Abel, Heinz, Pawlow, and others too numerous to mention, have paved the way in the past or are still actively en- gaged in solving the intricate problem of drug action, and thereby have created a new branch in biological science known today as experimental therapy. Unfortunately the dental profession has been slow in keeping pace with the progress made in general phar- macology, and as a consequence there is still much empiricism in- volved in the practice of dental medicine. Broadly speaking, there is no excuse for such laxity. The last decade offers ample proof of the immense effort which has been made to place dental therapeutics on a rational basis; yet many notions prevail in the minds of some practitioners regarding the action of certain rem- edies which are not in harmony with the modern conception of the physiologic action of drugs. The stereotyped prescriptions which are so often displayed in current dental literature, and the consequent practice of "making the disease fit the remedy," are much to blame for this pharmacologic idolatry. Even some of the text-books persist in the transmission of certain antiquated views in regard to the therapeutic action of drugs. Very recently the writer had occasion to look over many hundred questions re- lating to the subject of materia medica and therapeutics as asked by various state boards, and lie was rather surprised at the pe- culiar conception of pharmaco-therapy which these questions dis- played on the part of the examiners. A systematic classification of drugs, i.e., a classification into groups according to Buchheim-Schmiedeberg, which should serve the needs of the dental practitioner, as has been suggested by some theorists, is from a didactic as well as a practical point of view a total failure. The practice of dental medicine is a spe- cialized field of the healing art which utilizes not merely drugs but any rational method and means which may be of service in 46 GENERAL THERAPEUTICS the curing of disease or in the alleviation of its symptoms. In his endeavor to present a record of the action of drugs and their application and other remedial measures which are employed by the dental practitioner, the writer has grouped the various agents according to the viewpoint of the pharmaco-therapeutist, i.e., it is his desire in the rational consideration of their application to com- bine pharmacologic research with clinical observation. Conse- quently no definite line of demarcation can be drawn between the various groups. The chief divisions are so arranged as to best serve the clinical practitioner, and not the theoretical pharma- cologist. To facilitate the ready comprehension of the various classes, an introduction explaining the general action of the rem- edies under discussion precedes each group. The largest group of the medicinal substances that are used by the dentist in his clinical practice are drugs that exercise no definite action on specific organs. The disturbances of the oral cavity that lie within the province of the dental practitioner are principally of an infectious nature, and consequently the agents that are employed to combat septic influences the antiseptics form the most important group of dental remedies. Antiseptics, in their action, are so closely related to caustics and astringents that it is often merely a question of quantity (concentration of the solution), and not of quality, that governs the primarily de- sired effect. All precipitants of albumin are classed as astrin- gents, and in relatively concentrated solutions they act as caus- tics. Hand in hand with the destruction of the protoplasm of the cell of the individual goes the destruction of the unicellular organisms found in or about the cell the bacteria and as a con- sequence these same remedial agents act in most cases incidentally as antiseptics. Again, astringents, when applied to bleeding sur faces, exercise specific functions which are designated as hemo- static or styptic action. Aside from their chemic action, hemo- statics or styptics often afford mechanical protection to the de- nuded surfaces, and they are therefore closely related to protec- tives and emollients. In connection with the protectives we may class those agents which remove the exciting cause of disturb- ance antacids, irritants, and counterirritants. To restore the equilibrium of the oral cavity, and incidentally to act purely for cosmetic purposes, the many mouth specialties washes, powders, pastes, soaps, bleaching agents, etc. are employed. CLASSIFICATION OF DENTAL REMEDIES 47 Aside from their general action, certain drugs exercise specific functions on definite organs or sets of organs on the peripheral nerves, the central nervous system, the gastro-intestinal canal, the circulation, the respiration, metabolism, the secretions, etc. Most of the morbid disturbances and almost all of the operations which form an integral part of the work of the dental surgeon are ac- companied by more or less pain. To be able to relieve pain is one of the greatest triumphs of modern pharmacology, and the re- markable achievements of present-day conservative dentistry are largely to be credited to the possibilities of mitigating pain. Hence local anesthetics, general anesthetics, and, in the broadest sense of the word, hypnotics, anodynes, and sedatives, deserve a detailed discussion. The mouth is the main gateway to the body; dis- eases present in the mouth may, under certain conditions, be the cause or the result of disturbances of its continuity- the gastro- intestinal canal. The more important functions of this continuity must be understood by the broad-minded dental practitioner, and he should possess a fair knowledge of those drugs which influence the respective pathologic disturbances stomachics, emetics, ca- thartics, etc. Changes in the circulation which, according to con- ditions, require either depressants or stimulants, and those which influence respiratory activity necessitate for their treatment cer- tain drugs which form an integral part of the general pharmaco- logic knowledge possessed by the dentist. The influence of the lat- ter groups of drugs is especially of significance in the administra- tion of anesthetics and other powerful poisons. A fair acquaint- ance with drugs that exercise special functions on tissue changes tonics, alteratives, etc. and on the secretions of the body sialo- gogues, diaphoretics, diuretics, uric acid solvents is necessarily of importance. Within recent years so-called biologic therapeutics the use of animal products or those obtained from bacterial activity have become powerful adjuncts to modern materia medica. These ther- apeutic possibilities are classed under the general heading of or- gano and serum therapy. While our knowledge of biologic prod- ucts is still in its infancy, an acquaintance with their general prin- ciples and their possibilities in the treatment of specific dental ail- ments pyorrhea alveolaris is essential to the progressive practi- tioner. In addition to the administration of drugs, the treatment of den- 48 GENERAL THERAPEUTICS tal lesions frequently requires other remedial applications, which are classed, for want of a better term, as physical therapeutics. The most remarkable achievements attained with Bier's hyperemic treatment in general diseases has led to its adoption in dental sur- gery, and the truly astonishing results produced by it lead us to believe that it will play an important role in the future practice of oral therapeutics. The application of massage, light, heat, cold, and other physical measures as therapeutic considerations, as well as the plugging of bone cavities with inert or medicated materials, which has been recently introduced, should also be fully under- stood. Classification of Dental Remedies. I. DRUGS WHICH EXERCISE No DEFINITE ACTION ON SPECIFIC ORGANS. Antiseptics : Salts of the Heavy Metals, their Oxids, and their Organic Compounds. The Acids, the Alkalies, the Halogens and their Derivatives. Solutions which evolve Nascent Oxygen. Antiseptics of the Aromatic Series. Antiseptics of the Marsh Gas Series. Essential Oils, their Derivatives, and their Synthetic Substi- tutes Astringents : Metallic Astringents. Vegetable Astringents. Caustics : Liquid Caustics. Dry Caustics. Hemostatics and Styptics: Absorbents. Caustics and Astringents. Agents Which Act After Being Absorbed Into the Circulation. Agents Which Act on the Vessels, but Not on the Blood. Protectives, Demulcents, and Emollients. Irritants and Counterirritants. Antacids. CLASSIFICATION OF DENTAL REMEDIES 49 II. DRUGS WHICH ACT ON SPECIFIC ORGANS Drugs Which Act on the Mouth and Teeth. Bleaching Agents. Preparations for the Mouth and Teeth. Drugs Which Act on the Peripheral Nerves. Local Anesthetics and Obtundents. Drugs Which Act on the Central Nervous System. General Anesthetics. Hypnotics. Anodynes. Sedatives. Cerebral Stimulants. Drugs Which Act on the Gastrointestinal Canal. Stomachics and Digestives. Emetics. Cathartics. Drugs Which Act on the Circulation. Circulatory Stimulants and Depressants. Drugs Which Act on the Respiration. Respiratory Stimulants and Depressants. Drugs Which Act on Metabolism. Tonics. Alteratives. Drugs Wliich Act on the Secretions. Sialogogues and Antisialogogues. Diaphoretics. Diuretics. Uric Acid Solvents. Drugs Which Act on the Temperature. Antipyretics. Organo and Serum Therapy. Organo Therapy. Serum Therapy. III. PHYSICAL THERAPEUTICS. Artificial Hyperemia. Massage. Light Therapy. 50 GENERAL THERAPEUTICS Heat and Cold. Plugging Bone Cavities with Inert or Medicated Substances. Ionic Medication. The drugs used by the dentist in his clinical practice are usual- ly of a very potent nature. On an average, only minute quan- tities are employed in a single application. To obtain the best results from the pharmacologic action of drugs, it is essential to procure the purest materials obtainable. For many reasons it is good policy to order drugs in original containers from a re- liable manufacturer. Drugs and chemicals that are obtained from an open stock have frequently deteriorated. For example, the essential oils are usually found to be thick, viscid, and dis- Fig. 1. Office preparation bottles. Fig. 1, dropping bottle; Fig. 2, salt-mouth bottle. colored; oxygen compounds may have lost most of their oxygen from frequent exposures to moist air ; zinc oxid may have changed to zinc carbonate by absorbing carbon dioxid from the air; coal tar creosote is often substituted for beechwood creosote; cresol is more or less always of a poor quality; formaldehyd solution has often lost most of its gaseous constitutent, etc. Inefficient drugs as applied in the treatment of dental diseases are worse than dull instruments; both are sequences of neglect and should be eliminated from the carefully adjusted armentarium of the conscientious practitioner. It is gratifying to learn that the dental profession is showing a growing interest in the phar- macologic action of drugs and in their rational application. The CLASSIFICATION OF DENTAL REMEDIES 51 practitioner of today is discarding untrustworthy and feeble remedies and ready made compounds and is depending more and more on those drugs whose efficiency has been clin- ically established. Drugs, chemicals pharmaceutic preparations, etc., must be carefully stored if one wishes to preserve their potency. The original containers should be kept in a cool place, protected from light. The office preparation bottles are preferably selected from stock made of colored glass blue, green, or amber color- to keep out the rays of light. For liquid preparations the dropping bottles (Fig. 1), are best adapted, while for semi-solid and dry materials the glass stoppered salt-mouth bottles (Fig. 2) are very serviceable. Office preparation bottles may now be procured with indestructible labels, which materially assist in keeping the containers neat in appearance. In using drugs or chemicals, the necessary quantity is preferably placed on a glass slab or a watch crys- tal, and then applied, instead of dipping the instru- ment directly into the bottle. This latter method is Fig. 3. Aseptic medicament tray. (S. S. White.) Fig. 4. Dental applicator. Fig. 5. The Miller pyorrhea pen. especially to be condemned with regard to anesthetic solutions, ad- renalin solutions, and other liquids which are easily contaminated 52 GENERAL THERAPEUTICS or decomposed. For applying the various solutions of power- fully acting drugs phenol, sulphuric acid, iodin, silver nitrate, etc. the author advises a looped iridio-platinum wire inserted into a metallic handle, which is readily sterilized in an open flame. By bending the wire in the desired direction, any tooth surface in the month may be reached. A number of these applicators of various sizes should be kept on hand for convenient use. The "Miller Pyorrhea Pen" is equally useful for the same purposes and deserves to be recommended. SELECTION OF THE REMEDY. After the diagnosis of a disease is made, the proper remedy is selected. Depending on the nature of the disease, a psychic, a physical, a hygienic, a surgical (mechanical), or a pharmacologic method is chosen for the treatment of the ailment. Usually a combination of two or more methods is employed. No sharp line of demarcation can be drawn between the various groups of rem- edial agents, and a division of the whole subject matter therefore meets with difficulties. Medicine is not an abstract science it has its fashions and its schools. In the early days of medical prac- tice the Greek and Roman schools were predominating, and the pharmacologic treatment consisted principally of the use of in- numerable pharmaceutic compounds of vegetable drugs, which to this day are known as galenic preparations (named after Ga- len). The Arabian physicians continued the same practice, but added to the materia medica a number of new organic and inor- ganic compounds, which were prepared by their chemists or were accidentally discovered by the alchemists. With the introduction of iatrochemistry into medicine by Paracelsus, the galenic prepa- rations and the methods of treatment of the Greek and Arabian physicians received a severe setback. When on St. John's Day, in 1527, Paracelsus burned publicly on the market place of Basel the works of Celsus, Galen, Avicenna, and others, exclaiming, "I have burnt all these books so that all misery may be carried away with their smoke," a new era had dawned in scientific med- icine. During the seventeeth and eighteenth centuries a com- plete change of the practice of therapeutics was inaugurated, which started almost simultaneously in various parts of Europe. Sydenham, of London (1660) ; Boerhaave, of Leyden, (1720) ; Van SELECTION OF THE REMEDY 53 Swieten, of Vienna (1745) ; Hoffmann, of Halle (1725), and Stahl, of Berlin (1730), were the most influential reformers, and their names are indelibly inscribed on the historic pages of the prog- ress of modern therapeutics. The growing tendency of overdrug- ging received a severe check through the introduction of Hahne- mann's (1810) method of treating diseases with very small doses, which, combined with other extreme changes in therapeutics, re- sulted in the foundation of the homeopathic school. No definite knowledge regarding drug action had become available to the practicing physician, and, as a consequence of the empiric ad- ministration of drugs, it became customary to poke fun at those who regarded drugs necessary in the treatment of diseases. Espe- cially Skoda and Dietl (1830 to 1870), of the Vienna school, ex- pressed erratic views in regard to drug medication, and both ex- tremists carried the idea of drug nihilism to such an extent as to almost eliminate materia medica from the curriculum of the study of medicine. Dietl was wont to express his extreme skepticism re- garding the action of drugs in this dogmatic statement. "There are no real therapeutics there are only lucky physicians." Bear- ing in mind the fact that no tangible knowledge of pharmacology existed at that time, our judgment of these outbursts of overzealous minds is materially modified when we consider that even at this day the drugless "Christian scientist" and the supporter of the "Emmanuel movement" hold sway over the minds of the cred- ulous. To designate the various methods of therapeutic measures, the term iatro (from the Greek iatros, the physician) is used as a pre- fix in signifying its connection with the healing art. Therapeutic methods may be conveniently divided into: 1. Physical Therapeutics, or 1 atrophy sics. They include the physical and hygienic means and methods employed as remedies as light, heat, cold, electricity, climate, exercise, and health resorts. 2. Mechanical Therapeutics, or latromechanics. They are rep- resented by massage, gymnastics, orthopedics, and the instruments utilized in the performance of surgical operations. 3. Psychologic Therapeutics, or latropsychics. They are prin- cipally concerned with the psychologic influences exercised by the physician on the patient. Especially are nervous diseases amen- 54 GENERAL THERAPEUTICS able to this method of treatment, although certain bodily func- tions may also be materially influenced by the method. 4. Chemic (physiologic) Therapeutics, or latrochemistry They include the feeding, the many spas, and, finally, the great mass of drugs proper. METHODS OF ADMINISTERING MEDICINES. Medicines may be administered by any of the accessible tissues or cavities of the body, and the mode of administration very often determines the effect of the remedy. In general remedies may be applied locally, or topically, and internally. The former are usually intended to produce local effects, while the latter, through their absorption into the blood, produce general action. Relative to the general action of drugs, it should be remembered, as we have stated above, that a drug must be in solution or in vapor form to produce its action. The solution which brings the drug to interact with the protoplasm of the cells should be so con- stituted as to be readily soluble in the body juices. Consequently the quickest action of a drug is obtained when it is dissolved in a solution equal in its density to a physiologic salt solution. In certain cases retarded absorption is important, and therefore col- loidal substances, and sometimes fatty substances, are added to the solution. Retarded action usually goes hand in hand with prolonged effects. In the administration of medicines usually one of the follow- ing methods is selected: By inunction and fumigation; By the mouth or stomach; By the rectum; By hypodermic injection; By inhalation; By inoculation, and By cataphoresis (ionic medication). Local action of remedies is expected when they are applied to the skin, to the mucous membrane of the alimentary, respiratory, and genito-urinary tracts, to the eye. and to the teeth. The skin is protected with the horny layer of the epidermis and with seba- ceous secretions, which prevent the ready penetration of aqueous solutions. Oily or fatty substances mix readily with the sebaceous METHODS OF ADMINISTERING MEDICINES 55 matter of the skin. If friction is applied, the substances may penetrate through the outer layer and even into the deeper struc- tures. Diffusible and volatile substances as chloroform, ether, alcohol, essential oils, etc. penetrate comparatively quickly and may reach the blood. The application of remedies to the skin with the object of producing general action is largely discarded at present, although inunctions with mercury ointment is still in favor with some practitioners. Remedies applied to the skin to pro- duce local effects are principally used to act on some local disturb- ance. Blisters, poultices, liniments, plasters, powders, lotions, col- lodions, etc., are examples of local medicaments. Occasionally absorption of the drug will occur, and general action is produced. The mucous membranes quickly absorb aqueous solutions of drugs, while fatty substances have very little action on these tissues. If an ointment is applied, the moist surface must be pre- viously carefully dried. Mucous membranes are much more sus- ceptible to drugs than the unbroken skin, and very quick action is usually obtained in the mouth from their ready absorption, as the rich blood supply of the oral tissues favors ready dissemina- tion. In applying solutions to the sensitive mucous surfaces, it should be remembered that isotonic solutions produce the least irritation. If the drugs themselves do not produce an isotonic solution, the addition of one per cent of sodium chlorid readily accomplishes the purpose. The application of remedies to the mucous membranes, with the exception of those of the stomach and the intestines, is principally intended for their local action. Drugs are administered as solutions, paints, powders, mixtures, solids, or in vapor form. Diseases of the mouth and throat are treated with mouth washes, gargles, paints, lozenges, powders, and, sometimes, salves. Inhalations of vaporized medicines are also used in the treatment of oral disease. For the latter purposes a paraffin vehicle is not advisable. The mouth washes are employed with a gargling motion . (See Mouth Washes.) Paints should be applied with a toothpick wound with cotton, and caustic or cor- rosive liquids with a glass rod, or preferably with a small looped iridio-platinum wire. Powders are often used with a powder blower (insufflator), and powders having starch as a base are used with some advantage in the oral cavity. They absorb moisture and form a mucilaginous cover over the diseased surfaces. Small plasters over the roots of the teeth are frequently used. The mu- 56 GENERAL THERAPEUTICS cous surfaces should be carefully dried prior to an application. Poultices in the form of cut figs or raisins, steeped in hot water, are placed over an offending tooth root, and held in place by the cheeks or lips. The application of medicines to the teeth is of a specific nature and is referred to in the discussion of the various remedies. The larynx and pharynx are treated by inhalation, in- sufflation, and by applications made with probes, syringes, etc., and the nasal mucous membrane receives its medication through douches, insufflations, bougies, and specific applications. The treatment of the other mucous surfaces conjunctiva, bladder, urethra, etc. is of no special interest to the dental practitioner. The alimentary canal is the most common route for the ad- ministration of remedies. The remedies that are given by the mouth may act locally on the stomach and intestines, or they may Fig. 6. Powder blower. act by being absorbed into the blood. Most remedies are given in aqueous solution, or in mixtures, emulsions, etc., for the pur- pose of increasing their ready absorption. Nauseous, ill-tasting medicines, or those prepared for special purposes or for conveni- ence, are given in pills, powders, capsules, cachets, confections, troches, etc. Relatively speaking, medicines are slowly absorbed from the stomach. They are usually diluted with the gastric juice, unless they chemically interact with it, and are gradually passed into the small intestines, where absorption takes place, depending on certain conditions. Oils and fats pass in most cases unaltered through the stomach, and are emulsified and changed further by the pancreatic juice. If it is intended to protect the medicines against the action of the gastric juice, they are usually administered in pill form and coated with some substance that is insoluble in the gastric fluids as keratin, salol, etc. Occasionally indications arise that prohibit the administration of remedies by the mouth. Disturbances of this nature may interfere with the METHODS OF ADMINISTERING MEDICINES 57 act of swallowing as stricture of the esophagus, gastric or in- testinal diseases, surgical procedures, etc. The mucous membrane of the rectum is sometimes selected as a means of absorbing remedies and foods. Substances soluble in water, or those which may be transformed into soluble materials, are preferably employed for such purposes. An injection into the rectum (enema, clyster) varies in quantity, and depends on the specific purposes for which it is intended. A nutrient enema isually measures from four to six ounces, while simple injections intended for local action may measure from one-half to two pints. Glycerin injections, which are strongly irritating when used in large quantities, are usually given in one to two-dram doses. Fig. 7. Glaseptic hypodermic syringe (Parke, Davis & Co.) in case. The hypodermic method is usually applied to introduce medi- cines in aqueous solutions into the subcutaneous areolar tissues, from which a solution is quickly absorbed. A special syringe, car- rying a sharp, hollow needle, is used for this purpose. Hypo- dermic injections were introduced by Alexander Wood in 1853. The syringes used at present are modifications of the one de- signed by the French surgeon, Pravaz; hence the name Pravaz 58 GENERAL THERAPEUTICS syringe, a term which is still in common use in continental Europe. About the body the needle is inserted into the integument by hold- ing a fold of the skin between two fingers, but not pinching it. The least sensitive parts of the body should be selected the back, the rear part of the thigh, or the arm. Care should be exercised not to inject air into the tissues. The injection into the oral tis- sues necessitates detailed description. (See Technique of the In- jection.) The hypodermic method possesses great advantages, as precise doses of powerful alkaloids can be quickly administered, avoiding possible reactions between the drugs and the contents of Fig. 8. Steam atomizer. the stomach. The solutions should always be made fresh from sterile water, or, still better, from an isotonic salt solution, which materially lessens the pain of the hypodermic injection. The skin at the place of injection should be cleansed, and aseptic care must be taken to avoid infection, as otherwise abscesses are sure to follow. The quantity of solution injected is usually limited to 15 to 30 drops (1 to 2 C.c.), although antitoxic sera frequently require larger doses. The absorption takes place very rapidly along the lymph canals and into the capillaries, and usually a METHODS OF ADMINISTERING MEDICINES 59 typical drug effect is obtained within a few minutes. The same dose of medicine administerd in solution by the mouth would require half an hour or more before the action could be demon- strated. Intramuscular injection is sometimes resorted to, and is usually restricted to oily or aqueous solutions of irritant drugs. Intravenous injection (transfusion, hypodermoclysis) is occasion- ally practiced, and it consists in injecting directly into a vein. It is most frequently employed for the transfusion of blood or for the injection of a large quantity of physiologic saline solution for the purpose of restoring the quantity of blood after severe hemor- rhage, or securing excretions in certain intoxications as in uremia, diabetic coma, etc. The endermic method is employed to obtain a rapid action of a remedy, and consists in raising a blister by Fig. 9. Hand atomizer. stronger water of ammonia, or by a blistering plaster, and, after cutting away the raised epidermis, sprinkling the drug on the ex- posed surface. This method is, however, only of historical in- terest at present. The enepidermic metlwd endeavors to bring about the absorption of drugs through the skin by simple con- tact without friction, and chloroform and solutions of drugs in oleic acid (oleats) are used for such purposes. In the epidermic method, or inunction, the remedy is usually employed in the form of an ointment, oil, etc., with friction to promote the passage through the epidermis. Inhalations arc employed in the administration of remedial sub- stances into the upper air passages or into the lung by active 60 GENERAL THERAPEUTICS inspiration. Substances in vapor form, or in very fine division in the form of fumes or clouds, are inhaled, and thus brought into close contact with the diseased surfaces, or, by ready absorption, they act on the general system as in general anesthesia. In the latter case special apparatus (masks, etc.) are necessary, while a spray (atomizer) conveys the medicine into the posterior part of the mouth. Inoculation is employed for the purpose of introducing medici- nal agents through the scraped or punctured skin (vaccination). The application of medicines by cataplwresis, also known as ionic medication, is discussed under Physical Therapeutics. Apparently there is still some misunderstanding as to whether a dentist has the legal right to administer drugs intended for sys- temic treatment. While there is no specific legislation on this particular question, the courts in the United States and Great Britain have uniformly held that the registered dental practitioner has the right to employ such therapeutic measures, including drugs, as may be needed for the relief of suffering, or to produce curative results, in dental disorders. The qualified dentist is fully entitled to prescribe drugs for local or general disorders which bear a direct relationship to the practice of dental surgery, includ- ing the administration of anesthetics. Dentistry, in the broadest sense of the term, is "a special department of the science and art of healing, embracing a knowledge of the structures, physiology, and pathology, and the therapeutic, surgical, and mechanical treat- ment of the mouth and its contained organs ; also a knowledge of the materials used and their manipulation in the restoration of the dental and oral structures." (Kirk.) The evolution of the medical specialist within the province of the general practitioner received its present impetus with the dawn of the nineteenth century through the introduction of specific re- search. However, even in the remotest periods of medical history we meet with examples in which physicians confined their activity to the treatment of special diseases. Apparently there has always existed a desire on the part of the general practitioner to limit the field of his usefulness to the care of disturbances of single or- gans or to the treatment of specific ailments. Herodotus, for in- stance, makes a very positive assertion regarding the specialization among the Pastophores, i.e., the Egyptian physicians. He states that: "Medicine is practised among them (the Egyptians) upon METHODS OF ADMINISTERING MEDICINES 61 a plan of separation; each physician treats a single disease and no more. Thus the country swarms with medical practitioners, some undertake to cure diseases of the eye, others of the head, others again of the teeth, others of the intestines, and some others which are not local." In the early writings of the Zend-Avesta, definite instructions are given to the surgeon, i.e., "that he must first thrice essay his skill upon a slave or on a lower caste of man before operating upon their betters." Among the Greeks med- ical specialists apparently were of common occurrence. Plato in "The Charmides" records the following pertinent complaint as made by Socrates regarding the increased tendency of special- ization: "And this is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they are igno- rant of the whole, which ought to be studied also, for a part can never be well unless the whole is well." Similar conditions pre- vailed among the Romans; their leading physicians were either native Greeks or they had received their medical education on Greek soil. To receive proper recognition by the medical fraternity it was essential for the young practitioner of ancient times to in- clude in his curriculum a pilgrimage to the world-famous shrine of knowledge, the University of Alexandria. From the time of its foundation by Alexander the Great, about 320 B.C., to its de- struction by Omar, A.D. 641, this exalted seat of learning exer- cised a most wholesome influence on the higher types of educa- tion in all its branches of the then known civilized world. The paralyzing influence of the medieval age on scientific matters in general impressed its stamp of retardation also indelibly on the development of medicine. The only bright star in this period of orthodox despotism is the appearance of Paracelsus, the Luther of Medicine, as he has been appropriately christened. Fortunately, medicine has had its renaissance. With the re- organization of the Vienna Medical School by Van Swieten, in 1750, scientific research received a reverberating impulse, and its vibrations are felt to this very day. Laryngology saw its birth in 1855 with the introduction of the laryngoscope, more or less simultaneously, by Garcia, Czermak and Tuerck; although Liston had stated in 1837 that "the existence of the swelling of the laryn- geal mucosa can often be ascertained by means of a speculum; by such a glass as is used by the dentists on a long stalk previously dipped in hot water," etc. The dental mirror, by the way, the 62 GENERAL THERAPEUTICS most utilitarian instrument of our whole armentarium, was intro- duced about 1800 by Chevalier Bartholomeo Ruspini, a promi- nent Italian dentist then practicing in London. There seems to be sufficient evidence to assume, however, that the Roman sur- geons at the beginning of the Christian era used such an instru- ment for the inspection of the oral cavity. The divorcing of ophthalmology from surgery was largely brought about by the fundamental operative work of von Grasfe (1850) in which he was materially aided by the discovery of the ophthalmoscope by Helmholz in 1851. About this period the knowledge of diseases of the ear was placed upon a rational basis by Politzer and Gruber, and Hebra founded the science of dermatology. The diseases of the teeth and their adnexa can by reason of special fitness best be treated by the dentist. The oral cavity is his chosen field and Magitot's much coveted desideratum: "Tout dentist e doit etre medecin et tout medecin doit etre dentiste" will always remain a sincere wish. At present dentistry is regarded as a distinct profession. It is closely related to, but not identical with, medicine and surgery. A dentist is, therefore, not to be classified as a specialist of a branch of medicine. To be a specialist means to be "one who has a special knowledge of some particular subject; thus, ophthal- mologist, neurologist, or gynecologist is a specialist of medicine." (Century Encyclopedia.) In other words, to be a medical spe- cialist means to be primarily the possessor of that knowledge, ac- cording to the conception of the law, which entitles one to prac- tice medicine in all its branches by virtue of the state medical license. Some courts have held that dentistry is a specialty of medicine. In the opinion of the Supreme Court of Minnesota, in the case of State vs. Taylor, 1 a person holding a state medi- cal license can not practice dentistry under the statutes of that state. The following is a synopsis of the decision in that case: "For reasons of public policy, with which the Court has no particular con- cern, the Legislature adopted the policy of dividing the field of medicine and surgery, and making a separate profession of a part thereof. It was thought that men who engaged in the treatment of diseases of the dental organs should receive special preparation and be specially licensed to practice that particular branch or department of medicine and surgery. A State Board of Dental Examiners was created and authorized to determine who should be 'Journal of A. M. A., 1909, p. 122. PRESCRIPTION WRITING 63 licensed and entitled to practice dentistry in the state. A department of Dental Surgery was also established at the University (of Minnesota), with a course of study, the satisfactory completion of which would entitle the stu- dent to a special degree of Dental Surgery. An examination of this course shows that it includes a considerable part of the work required in the med- ical school, but it also includes studies which relate particularly to diseases of the dental organs and others designed to insure efficiency in the mechanical work connected with the treatment. From an examination of the statutes of other states relating to the practice of dentistry, the Court learns that many contain express exceptions in favor of physicians and surgeons. Probably the most of them permit physicians to extract teeth, or perform such other com- paratively simple work. In the absence of any such exceptions, it must con- clude that the Legislature intended to restrict the scope of the practice of the physician and surgeon, and require him, if he desires to practice dentistry, to obtain a license from the State Board of Dental Examiners in addition to his other certificate." PRESCRIPTION WRITING. A prescription, from the Latin prae (before) and scribo (I write), may be denned as a written order for medicines sent by a qualified medical, dental or veterinary practitioner to a pharmacist. Prescriptions are termed simple if containing but one ingre- dient, and compound if containing more than one. Aside from ingredients which are used to give the requisite form to medicines, such as solvents, diluents, and excipients, drugs may be combined in prescriptions for the following reasons: (1) To obtain the conjoint effect of two or more active substances; (2) to diminish or annul undesirable effects produced by one or more active in- gredients; (3) to increase the solubility or aid the dissemination of active substances; and (4) occasionally, to produce a new com- pound. The writing of a prescription involves a series of diffi- cult problems, and, when first attempted, imposes a great task on the student. To become an expert prescription writer is largely a matter of practice. There are, however, a few simple, funda- mental rules which, when once fixed in the mind, will materially assist in overcoming these difficulties. "In writing prescriptions, the Latin is preferred: (1) It is the language of science, and is understood to a greater or less extent throughout the civilized world ; in addition, it is a dead language, and therefore not subject to the changes that are common to all living forms of speech. (2) The Latin names for medicines are distinctive, and very nearly the same in all countries. (3) It is frequently necessary, and always advisable, to withhold from the 64 GENERAL THERAPEUTICS patient the names and properties of the medicinal agents adminis- tered." (Remington.) "What an insignificant piece of paper a prescription is; yet it may be the cause of much unhappiness of at least three persons the patient, the pharmacist, and the physician." (Kobert.) The pharmacist who dispenses the medicine should invariably retain the original prescription for future reference and as a rec- ord for a limited period say, five years. That is for his own protection as well as for that of the prescriber and the patient. The medicine prescribed should be supplied not more than once on the same prescription in the following instances: (a) If ordered by the prescriber "not to be repeated," or marked "ne repetatur." (b) If it contains medicinal substances commonly called nar- cotic or habit forming drugs. (c) If asked for by a person known to be the original holder. The often discussed question of the ownership of the prescrip- tion has given rise to much unnecessary complexity. As a matter of fact, it is not a question of ownership, but a question of pos- session. Ownership implies an intrinsic value in the thing owned, while possession denotes to have or to hold as a property. A physician's prescription does not exhibit the same character of pur- pose at all periods of its existence, and therefore the right to possess it does not always lie with the same individual. As long as it remains in the hands of the physician it represents the embodiment of that therapeutic skill which the prescriber has decided that his patient stands in need of, in the form of an order upon a licensed druggist to carry out the material details of the treatment. Up to this point it belongs to the physician. As soon as the physician gives it to the patient, the nature of its purpose changes. It now becomes the embodiment of advice which the patient has received from the doctor and to which he unquestionably has the right of possession and dis- position. He may avail himself of the skill which it represents by having it filled; or he may reject it. Whatever disposition he may make of it, it is certain that until the prescription is turned over to the druggist for fill- ing, the right to possess it lies with the patient or his assigns. The instant it is given to a druggist to be filled, the character of its purpose undergoes a further change. Having received the treatment, in the shape of medicine, for which the prescription calls, the transaction between the physician and the patient is completed, and so far as the relations between these two are concerned, the prescription might just as well be destroyed. The druggist, on the other hand, has every reason for possessing it, and therefore every right to its possession at this time. It has ceased to be an embodiment of medical advice, given or received, and has taken on the character of a PRESCRIPTION WRITING 65 voucher. The law, enacted for the protection of both physician and pa- tient, prohibits the druggist from dispensing those drugs unless specifically ordered to do so by the prescribe!-. The law may at any moment require the druggist to show cause for dispensing the drugs in question and unless he possesses the physician 's prescription, he is a convicted criminal. In fact, the laws of some states, and in case of dispensing opium or cocain, etc., the United States, requires the druggist to preserve all prescriptions on file for several years and to produce them for inspection to properly con- stituted authorities. A modern prescription may be divided into the following parts: 1. THE NAME OF THE PATIENT. Although frequently omitted, the name of the patient should always be written at the top of the prescription in order to avoid the possibility of serious mis- takes. It should be written also on the label by the compounder. 2. THE SUPERSCRIPTION, OR HEADING. The symbol I^, 1 repre- senting the Latin word recipe (take), is placed at the head of all Latin prescriptions. In French prescriptions, the letter "P" (prenez, take) is usually substituted. 3. THE INSCRIPTION, OR THE NAMES AND QUANTITIES OF THE INGREDIENTS. This part of the prescription is the most impor- tant, and requires the greatest care. The official names of the drugs should always be used. The inscription 2 often consists of a number of ingredients, and may be subdivided into: (a) The basis, or chief active ingredient; (b) the adjuvant, auxiliary, or aid to the basis that is, to assist its action; (c) the corrective, which is intended to qualify the action of the basis and adjuvant ; (d) the vehicle, diluent, or excipient, which serves to hold to- gether, to dilute, or to give the whole the proper consistency, form, and color. Each ingredient and its quantity should occupy only one line, and the ingredients should follow each other in the order of their importance. "These four parts of a formula," says Pereira, "are intended to accomplish the object of Asclepiades : curare cido, tute et jucunde, or, in other words, to enable the basis to cure quickly, safely and pleasantly." lit was customary with the Roman physicians to prepare a prescription with a pious in- ' " sym heading luuuciii H* *-^*- pi'""-' ' " .*,.. ----- ^ - r^- - - . . ~ = This classic form of the inscription was originally evolved by Dr. Pans from a careful analysis of the older and more complex types of prescriptions, and consisted of basis, ad- juvans, corrigens, et excipiens. 66 GENERAL THERAPEUTICS Many prescriptions contain but one or two ingredients there being no special use for a corrective, vehicle, or diluent the ten- dency of modern therapeutics being against polypharmacy and in the direction of simple and concentrated remedies, or those having positive effects. There are, however, many advantages to be de- rived from the combination of ingredients even when they have similar medicinal action. The method generally followed by phy- sicians to ascertain the quantity of each ingredient is, first, to write the names of the ingredients in the proper order, each on a separate line, without affixing the quantities; second, having de- cided upon the total number of doses that are to be given, to mul- tiply the correct quantity of a single dose of each ingredient by the total number of doses to be given, and thus obtain the re- quired quantity of each ingredient. Great care should be used in abbreviating, so that each abbreviation is distinctive, and not liable to be mistaken for an article not intended by the writer. For example, acid, liydroc. may mean acid, hydrochloric or acid, hydrocyanic; hydr. chlor. may mean calomel, corrosive sublimate, or chloral hydrate. The cabalistic characters in present use desig- nating the quantities in a Latin prescription must be plainly writ- ten if serious errors are to be avoided. 4. THE SUBSCRIPTION, OR THE DIRECTIONS TO THE COMPOUNDER. Usually no specific directions are given to the compounder. A single letter, or two or three letters, will serve as a subscription as M., misce (mix) ; D.S., detur signetur (give and mark) ; M.D.S., misce, da, signa, or misce, detur, signetur (mix, give, and mark) ; S., solve (dissolve) ; P., fiat (make). 5. THE DIRECTIONS FOR THE PATIENT. S. or Sig., indicating signatura, precedes the directions for the patient, which should always be written in full and in plain English. Not properly specifying the directions for example, writing "as directed," or "use as directed," accompanied by verbal instructions is a care- less habit, and has led to serious consequences. 6. THE NAME OR INITIALS OF THE PHYSICIAN AND DATE. The name of the prescribe!' should always appear on the prescription, either in print or plainly written. The following is an example of how a prescription should be written. PRESCRIPTION WRITING 67 Name of Patient Superscription (Heading) For Mr. Charles Jones. Inscription (Ingredients) Subscription (Direction) July 36, 1916. Basis Acid, benzoic. 3 j Adjuvant Tinct. kramer. fl3 iv Corrective Ol. menth. pip. gtt. xx Vehicle Alcohol q. s. ad flS iv M. Sig.: Half a teaspoonful in a glass of water as a mouth wash. JAMES KING, D.D.S. Telephone . Baring 150 Registry No. 3675 I. District .of Pa. JAMES KING, D.D.S. 5O3 Penna Building Philadelphia, Pa. Date: For: Address: / <- 6 Hours: 9 to 4 /6 ' 9 ' <<> & * D.D.S. Fig. 10. Fac-simile of a correctly written prescription. The present mode of having prescription blanks printed with the full name and address of the prescriber, etc., is greatly to be encouraged. In accordance with the specifications demanded by the National Narcotic Law (see page 97) prescriptions calling 68 GENERAL THERAPEUTICS for opium or cocain, or any of their preparations, salts or sub- stitutes, must have indicated on the blank: 1. The prescribe! 1 's name in full; 2. The location of his office; 3. The date the prescription was signed ; 4. The prescribe! 1 's registry number; and 5. The name and address of the patient. If simple solutions are used, prescriptions may be written so as to express the strength of the solution in per cents, as follows : R Solutio cocainae hydrochloridi 4% flg iv (120 C.c.) Ill preparing a percentage solution, it should be remembered that the specific amount of the soluble matter is dissolved in 100 parts of the solution as, a 4 per cent aqueous solution of cocain hydrochlorid is composed of 4 parts of cocain hydrochlorid and 96 parts of distilled water. Percentage solutions are best pre- pared by weighing both the soluble matter and the liquid. The quantity of soluble substance and solvent necessary to make a specified quantity of any particular percentage solution may be readily ascertained by the following rule: Multiply the quantity of solution desired, in grams or grains, by the number expressing the percentage, divide the product by 100, and the quotient will indicate the quantity of soluble substance necessary; subtract this from the total quantity of solution desired, and the remainder will indicate the necessary quantity of solvent. Metric Prescription Writing. Metric prescription writing is universally employed in all coun- tries except in those inhabited by English-speaking communities. In the United States and England it is at present practiced only to a limited extent, although strenuous efforts are made to popu- larize this method by teaching it in the various medical, dental and veterinary schools. In continental Europe all ingredients en- tering into a prescription are weighed, no measures of capacity, except drops, being emploj^ed. The unit of weight is the gram. In the United States two methods of expressing the quantities are in vogue one is the volumetric method, which, following the usual American practice, measures the liquids, and the other is the European or gravimetric method. The former is preferred by many. The unit of measure is the cubic centimeter (abbrevi- PRESCRIPTION WRITING 69 ated C.c.), which is the equivalent of one gram of distilled water at 4 C. The gravimetric method weighing of all ingredients is by far the better method, as under all conditions (temperature, specific gravity, etc.) it will furnish the exact quantity as specified in the prescription. An example will illustrate the two methods: VOLUMETRIC. GRAVIMETRIC. Gm. vel C.c. Acid, benzoic 4 Tinct. kramer 15 Ol. menth. pip 1 Alcohol q. s. ad 120 Acid, benzoic 4.0 Tinct. kramer 15.0 Ol. menth. pip 1.5 Alcohol q. s. ad 120.0 Grammatical Construction of a Latin Prescription. The advantage of writing a prescription in Latin has been referred to on page 63. To correctly construct the terminology of a prescription requires a fundamental knowledge of Latin gram- mar. In writing the heading of the prescription, I> recipe (take) [thou] the imperative singular is employed, as it refers to the quantity to be taken. The latter is, in consequence, placed in the accusative : Ii drachmam imam. Take [thou] one dram. The quantity expressed refers to the name of the drug, and the latter, according to rule, is placed in the genitive: R Magncsii sulphatis drachmam imam. Take [thou] one dram of sulphate of magnesia. When "ad" follows the vehicle, the latter is placed in the ac- cusative : IJ Magncsii sulphatis drachman unam. Aquam ad fluid unciam unam. Take [thou] one dram of sulphate of magnesia [and] enough water to make a fluidounce. Owing to common practice, the last syllable of the Latin words, which varies with the case, is usually omitted, but, to correctly 70 GENERAL THERAPEUTICS interpret the Latin words, the case endings must be remembered. The following simple rules will serve to call to mind the above mentioned principles : Rule I. The noun expressing the name of the medicine is put in the genitive case when the quantity of it to be used is expressed. Rule II. If no quantity is expressed, but only a numeral ad- jective follows, the noun is put in the accusative. Rule III. The quantity is put in the accusative case, governed by the imperative Recipe. Rule IV. Adjectives agree with these nouns in gender, num- ber, and case. Latin Genitive Case Endings. NOMINATIVE. GENITIVE. EXCEPTIONS. -a -ae . . . .Cataplasma, enema, physostigma, aspidospenna, and gargarisma end in -atis; folia (pi.), folio rum; coca is unchanged, though cocae is used by some. -us, -um, -os...-i Ehus, rhois; flos, floris; bos, bovis; limon, limonis; erigeron, erigerontis; quercus, eornus, fructus, spiritus, haustus, and potus are unchanged. -as -atis . .Asclepias, adis; mas, maris; sassafras is unchanged. -is -idis . .Pulvis, -eris; arsenis, phosphis, sulphis, and all salts ending in -is take the ending -itis; berberis, can- nabis, digitalis, hydrastis, and sinapis are un- changed. -o -onis . Mucilago, ustilago, and solidago end in -inis; con- durango, kino, sago, and matico are unchanged. -1 -lis . . . .Fel, fellis; mel, mellis; sumbul, sumbuli. -en -inis ..Azcdarach, buchu, catechu, curare, jaborandi, and amyl are unchanged, though amylis is sometimes used. -ps -pis . . . -rs . . .-rtis . -r -ns -x -cis Terms Used in Prescription Writing 1 . The more important abbreviations and Latin terms used in writing prescriptions : PRESCRIPTION WRITING 71 aa, ana of each. ad to, up to. adde add to it. ad lib., ad libitum. at pleasure. bis twice. b. i. d., bis in die. twice daily. caute cautiously. cochleare a spoonful. cochleare mag- num a tablespoonful. cochleare parvum.a teaspoonful. coctio boiling. cola .strain. contusus bruises. cujus of which, of any. cum with. da, detur give. decanta pour off. d. t. d., dentur tales doses let such doses be given. dilue dilute. d. in p. seq., divide in partes sequa- los let it be divided in equal parts. ejusdem of the same. ct and. f., fiat, fiant let it be made. filtra filter. idem the same. inter between. misce mix. non not. omni hora .every luur. pro for. p. r. n., pro re nata occasionally. q. s., quantum satis as much as is suf- ficient. reccns fresh. i opctatur let it be repeated. s. a., se cun dum artem according to art. scmel once. signa mark. sine without. solve dissolve. talis such, like this. t. i. d., ter in die.. three times daily, tore . rub. Reference Abbreviations. U. S. P. .United States Pharmacopeia. B. P British Pharmacopeia. P. G German Pharmacopeia. N. F National Formulary. tb 5 3 9 gr C Signs and Numerals Used in Prescription Writing. .............................. octarius flJ5 .............................. fluiduncia fl3 .............................. fluidrachma IT). .............................. minim gtt ............................. gutta recipe ...................... take. libra ....................... a pound. uncia ...................... an ounce. drachma .................... a dram. scrupulus ................... a scruple. granum .................... a grain. congius .................... a gallon. a pint. -a fluidounce. a fluidram. a drop. a drop. .semis half. 72 GENERAL THERAPEUTICS The Use of Latin Numerals. All Latin numbers are expressed by one, or a combination of two or more, of the following letters: I, V, X, L, C, D, and M. I means 1 ; V, 5; X, 10; L, 50; C, 100; D, 500; and M, 1000. These should be written together as capital letters, but in prescrip- tions we find them usually written as small letters, or in print as "lower case" letters, and it is customary to write a single "i, " or the final "i" when several numeral letters are used together, as a small "j." The letters arc combined thus: 1 XX 20 2 XL 40 3 L 50 4 LX 60 5 XC 90 (5 C 100 7 CO ... . 200 8 D 500 9 DC 600 10 M 1000 11 MCMXVII . ..1917 Estimation of Quantities. The estimation of the quantity of each ingredient entering into a compound prescription is usually ascertained after the various drugs have been written in their order, beginning with the solids. The amount of the whole mixture, powder, etc., is written after the last ingredient, which is usually the diluent, and the quantity of each drug is ascertained by multiplying tlie single dose by the number of doses represented in the ivlwle prescription. The fol- lowing may serve as an example: It is desired to write a prescription for a four-ounce mixture, with a dram (a teaspoonful) at' a dose, each dose to represent two grains of quinin sulphate, one-eighth of a grain of codein phos- phate, half a dram of syrup of licorice, and water enough to make a teaspoonful. As 4 ounces are 32 drams, the prescription will read as follows: JJ Quinin sulphate 2 gr. x 32 = 3 j Codein phosphate % gr. x 32 = gr. iv Syrup of licorice J /2 dram x 32 = fl3 ij Water enough to make fl3 iv M. Sig. : Teaspoonful every two hours. ESTIMATION OF QUANTITIES 73 To assist the coinpounder in filling the prescription, it is cus- tomary to express the multiples of grains, when they closely ap- proximate half a drain or more, in round numbers. In the above case, to be exact, 64 grains of quinin sulphate are called for, but, following the rule, one dram is written. The bottles used in the United States and England have a capacity of one, two, and four fluidrams, and one, two, three, four, six, eight, twelve, sixteen, and thirty-two fluidounces, or their relative metric equivalents expressed in cubic centimeters (C.c.). It is good practice, in prescription writing, to conform the quan- tity of the mixture to the above sizes of bottles. The quantity of medicine ordered should last from two to three days, except in the treatment of chronic diseases. Mouth washes may be ordered in four to sixteen-ounce quantities. In meas- uring out the medicine to the patient, a graduated medicine glass is far preferable to the domestic measures, as the latter vary considerably. The domestic teaspoonful varies greatly in size, and Wilbert there- fore suggests that a teaspoonful should be represented by 114 drams, or 5 cubic cen- timeters. Drops should always be meas- ured with a medicine dropper or dispensed in a special drop bottle. The size of the individual drops and their number present in a given amount of fluid varies greatly; it depends largely on the specific gravity, consistency, surface ten- sion and temperature of the liquid, on the lip of the bottle from which they are dropped, etc. As stated above, dropping bottles are to be recommended for measuring out liquids by the drop, but they have to be individually standardized before they are employed. Dr. Seaman recommended to the Committee on Revision of the United States Pharmacopeia the following method of accurate drop measure: "An official medicine dropper has its delivery end three millimeters in external diameter, and adapted to deliver 20 drops of distilled water to a gram at 15 C." Powders are usually prescribed to weigh from three to ten grains; if they contain nauseating tasting drugs, they should be dispensed Fig. 11. Graduated medicine glass. 74 GENERAL THERAPEUTICS in capsules or wafers. Pills usually weigh from one to three grains, and those that weigh less than a grain are known as gran- ules. Salves are prescribed in one-half to two-ounce quantities. Fig. 12. Medicine dropper. Oils, balsams, oleoresins, and similar liquids, if prepared in drop doses, are best dispensed in soft or hard gelatin capsules. Solid and semi-solid dentifrices such as powders, pastes, and soaps are usually dispensed in specially prepared containers, while bot- tles containing mouth washes are often provided with sprinkler tops. INCOMPATIBILITIES. Incompatibilities may be defined as conditions produced by bringing substances together which result in chemic decomposi- tion, pharmaceutic dissociation, or therapeutic opposition. (Rem- ington.) In writing a prescription which contains more than one drug, one or all of the above possibilities may be the result of the mix- ture, unless the prescriber exercises extreme care in considering the physical, chemic, and physiologic properties of the ingredi- ents entering into the compound. Never prescribe more than one drug at a time, if the one remedy will serve the purpose for which it is intended! 1. CHEMIC INCOMPATIBILITY. It may result in (a) explosion in mixing chlorates or permanganates with readily oxidizable sub- stances (all organic substances sulphur, etc.) ; (b) precipitation in general, inorganic bases or their salts precipitate inorganic acids, and salts of metals precipitate organic substances; (c) pro- duction of a substance with undesirable properties iodids, bro- mids, iodates, bromates, and chlorates with strong mineral acids or strong oxidizing agents. 2. PHARMACEUTIC INCOMPATIBILITY. (a) Alcolwl should not be added to solutions of acacia, gelatin, and proteins, or to emul- sions and strong salt solutions ; (b) water should not be added to INCOMPATIBILITIES 75 alcoholic liquids in general (tinctures, spirits, fluid extracts) ; (c) certain chemicals, like camphor or antipyrin, when mixed with phenol, thymol, cocain, salol, resorcinol, etc., produce oily liquids; (d) cocain and borax form an insoluble borate of cocain. 3. THERAPEUTIC INCOMPATIBILITY. As a rule, a drug is in- compatible with its antidotes as pilocarpin and atropin; cocain and morphin; strychnin and alcohol, etc. As it is impossible to consider in detail all the incompatibilities, only a few of the more important ones will be enumerated : An acid should not be combined with an alkali. Most of the acids precipitate albumin. Arsenic trioxid is precipitated by salts of iron and magnesia, which are its official antidote. Phenol forms a phenolsulphonate when added to a soluble sulphate. Salicylic acid is incompatible with salts of iron. Alkalies should not be combined with alkaloids. Alkaloids and metallic salts are incompatible with tannic acid or substances containing tannin, and with alkalies or their salts. Alcoholic fluid extracts are precipitated by water or aqueous liquids. lodin or iodids should not be given with alkalies. Oils, volatile and fixed, resins, oleoresins, resinoids, and balsams are precipitated by water. Sugar forms an explosive with sulphuric acid. Corrosive sublimate, silver nitrate, potassium iodid, and the salts of lead should preferably be prescribed alone. Corrosive sublimate is frequently prescribed in combination with potassium iodid, when a precipitate is formed which is readily dissolved. Silver nitrate and lead acetate are frequently prescribed with the extracts of opium and hyoscyamus. Substances containing loosely combined oxygen as chromic acid, concentrated nitric acid, per- manganates, chlorates, etc. should not be combined with easily oxidizable substances (as all organic substances tannic acid, sul- phur, sulphids, sulphites, iodin, iodids, phosphorus, phosphites, and reduced iron which form highly explosive compounds). Vegetable astringents containing tannic acid should not be mixed with iron, as they form a tannate of iron (ink). Alcohol and alcoholic liquids are incompatible with mucilages. 76 GENERAL THERAPEUTICS Examples of Incompatibility. ft Cocainse hydrochlor. gr. v Sod. borat. gr. x Aq. ad flB j M. Sig. : Use as a paint. An insoluble cocain borate is formed. ft Sod. borat. 3 vj Mucilag. acac. flB j Aq. menth. pip. ad flB viij M. Sig.: Tablespoonful three times daily. The borax will be precipitated by the mucilage in translucent flocculerit masses. ft Pot. permangan. 3 j Aq. hydrogen, dioxid. flB ij Aq. ad flB viij M. Sig. : Antiseptic solution. The potassium permanganate is decomposed by the solution of hydrogen dioxid. ft Pot. permangan. 5 j Liq. formaldehyd. flB iij Aq. ad flB viij M. Sig.: For disinfecting purposes. A violent reaction between the potassium permanganate and the solution of formaldehyd results, setting free vapors of formal- dehyd. ft Phenol. Camphora) aa 3 ij M. f. plv. No. j. Sig.: Dissolve in a quart of water. Phenol and camphor liquefy when triturated together, and very little of the camphor will dissolve in the water. ft Magnes. oxid. 3 ij Aq. menth. pip. flB iij M. Shake the bottle. Sig.: Tablespoonful three times daily. INCOMPATIBILITIES 77 The magnesia settles to a solid mass, which cannot be readily disintegrated by shaking. IJ Liq. plumbi subacet. fl5 iv Tinct. opii fl j Aq. ad fl3 xvj M. Sig.: Use externally. This is the much used lead water and laudanum. The alkaloids of opium are precipitated by the solution of lead subacetate, and, besides, opium does not exert any local action. I Sod. borat. gr. iij Zinc sulphat. gr. iv Aq. destill. fl3 j M. Sig.: Drop into the eye. An insoluble zinc borate is formed. I Argenti nitrat. 3 ij Aq. rosse fl3 j M. Sig. : Concentrated silver nitrate solution for dental pur- poses. Most of the silver nitrate is precipitated as a black powder by the oil of rose and the impurities of the rose water. Only distilled water should be used in making silver nitrate solutions. B Pot. chlorat. 3 j Acid, tannic. 3 ss Amyl. ad 5 ij M. f . plv. Sig.: Use as a dusting powder. An explosive compound results. n Phenol. Thymol. fifi 3 ij M. f. plv. No. ij. Sig.: Dissolve in one ounce of alcohol, and use for the treatment of putrescent root canals. Phenol and thymol liquefy when triturated together. 78 GENERAL THERAPEUTICS R Chloral hydrat. Sulphonal. aa gr. xv M. f. plv. No. vj. Sig. : One powder every other evening. When triturated together the two drugs form a soft, pasty mass. Coloring and Flavoring Agents. To facilitate the administration of medicines and their psycho- logic effect, in some cases at least, coloring and flavoring agents are needful aids. COLORING AGENTS. About 10 drops of any of the following liquids will color four ounces of a colorless mixture: Red: Com- pound tincture of lavender, compound tincture of cardamom; Brown: liquid caramel; yellow: tincture of safron, tincture of tumeric. The following syrups may also be employed for the same pur- pose, although larger quantities have to be used: Simple Syrup colorless; Syrup of Orange golden yellow; Syrup of Wild Cherry cherry red (for acid mixtures only) ; Syrup of Tolu light yellow; Syrup of Lemon light yellow; Syrup of Licorice root brown; Syrup of Rhubarb brown-red (for alkaline mix- tures only) ; Syrup of Ginger light brown ; Syrup of Raspberry rose red (for acid mixtures only) ; Syrup of Senega light brown ; Syrup of Ipecac faintly yellow (for alkaline mixtures only). FLAVORING AGENTS. Syrups are the usual flavoring agents em- ployed. They may be given undiluted to children, unless the existing diseases should contraindicate their administration. Mix- tures intended for adults should not contain more than 25 per cent of syrup, except when bitter medicines are prescribed. Flavoring Agents for Acid Mixtures. Simple syrups or the syrups of ginger, lemon, orange, raspberry, tolu or wild cherry. Flavoring Agents for Bitter Mixtures. The syrups of orange, ginger, tolu, etc. For Quinin Mixtures. The syrup of yerba santa or of licorice root. For Ammonium Chlorid Solution. Syrup of licorice root. For Potassium lodid Solution. Milk, peppermint water. WEIGHTS AND MEASURES 79 For Chloral Hydrate Solution. The syrups of licorice root, orange, tolu, etc. For Cod Liver Oil. Oil of peppermint. For Caster Oil. Oil of peppermint, syrup of orange, etc. WEIGHTS AND MEASURES. The system of weights and measures as used in the United States was standardized in 1836, when the then Secretary of the Treasury was authorized by Congress to furnish each state of the Union with a complete set of revised standards for weights, liquid measures, and measures of length. These various methods of weights and measures are quite confusing when an examination of their comparative units is made that is, it is perplexing to find that a pound is not a pint, an ounce does not equal a fluidounce, and a drop is neither a grain nor a minim. The United States National Prototype Standards, from which all weights and measures now used in this country are derived, are the meter and the kilogram, and they are preserved in the custody of the National Bureau of Standards at Washington. The United States meter and kilogram are identical with the interna- tional standards of the same capacity. The United States standards of weights and measures are: The apothecaries' or troy ounce .= 480 grains. The commercial or avoirdupois ounce = 437.5 grains. The apothecaries' fluidounce (identical with the fluidounce of the liquid gallon) = 480 minims. The weights and measures used in the British Pharmacopeia are the Imperial weights and measures, legal for commercial pur- poses in the British Empire. The English apothecaries' weights are the same as those used in the United States. Apothecaries' Weight. Pound. ft) 1 Troy ounces. Drams. 12 = 96 Scruples. = 288 Troy grains. = 5760 3 1 8 24 480 3 1 = 3 = 60 3 1 = gr. 20 Troy Weight. Pound. Troy ounces. Pennyweights. Troy grains. lb 1 = 12 = 240 = 5760 31 20 480 dwt. 1 - = gr. 24 80 GENERAL, THERAPEUTICS Avoirdupois Weight. Pound. Ounces. Drams. Troy grains. mi 16 = 256 = 7000. ox. 1 16 437.5 dr. 1 gr. 27.34375 Relative Value of Troy and Avoirdupois Pounds. 1 troy pound = 0.822857 avoirdupois pound. 1 avoirdupois pound = 1.215277 troy pounds. Apothecaries' or Wine Measure (United States). Gallon. Pints. Fluidounces. Fluidrams. Minims. Cubic inches. Cong. 1 = 8 = 128 =: 1024 = 61440 = 231 O 1 16 = 128 = 76SO = 28.875 flS 1 = 8 = 480 = 1.8047 fl3 1 = Til 60 .2256 Liquid Measure. I gallon 4 quarts. 1 pint = 4 gills. 1 quart 2 pints. 1 gill = 4 fluidoimccs. Imperial Measure (British Pharmacopeia). Gallon. Pints. Fluidounces. Fluidrams. Minims. 1 8 = 160 1280 = 76800 1 = 20 160 9600 1 8 480 1 60 The Metric System. 1 The metric or decimal system of weights and measures origi- nated with Prince de Talleyrand, bishop of Autun, in 1790. Its almost universal adoption by civilized nations, its legality (though not compulsion) in England and the United States, and its adop- tion by the United States Pharmacopeia of 1890 demand that it should be understood by the progressive practicing physician. Ex- cept in the English-speaking world, it is the only system of weights and measures used for governmental, statistical, and scientific pur- poses. It is based upon the decimal system that is, the denomi- nations increase by tens and decrease by tenths. The starting point is the unit of linear measure, the meter, which represents one-ten-millionth part of the polar quadrant of the earth that is, the distance from the equator to the poles and is equivalent to 39.37 English inches. The gram (Gm.) is the unit of weight; 1 The metric system was legalized in Great Britain in 1864, and in the United States by act of Congres's in 1866. It is now required in medical work of the Army and Navy Departments and in the Public Health Service. .WEIGHTS AND MEASURES 8l the liter, of capacity (although the cubic centimeter is oftenev preferably used) ; the are, of surface measure. The denomina- tions representing the subdivisions of any unit are expressed by prefixing the Latin numerals deci, centi, and milli to the unit meaning respectively one-tenth, one-hundredth, and one-thou- sandth; the multiples arc expressed by prefixing the Greek num- erals deka, liecto, kilo, and myria meaning ten, hundred, thou- sand, and ten thousand. The gram is derived as follows: The meter is divided into one nundred equal parts, called centimeters. On one centimeter as a base a cube is erected, having for its three dimensions one centi- meter (Cm.) each. The contents of this cube will be one cubic centimeter (C.c.), measuring one milliliter. This quantity of dis- tilled water at its maximum density (39.2 F., 4 C.) and 30 inches barometric pressure weighs one gram, or 15.432 grains. The liter is derived as follows: The meter is divided into ten equal parts, called decimeters. On one decimeter as a base a cube is erected, having for its three dimensions one decimeter (dm.) each. The contents of this cube will be one cubic decimeter (dm. 3 ), the capacity of which is one liter, equivalent to 1,000 cubic centimeters, or 33.81 fluidounces, or 2.113 pints. One liter of distilled water at 4 C. and 30 inches barometric pressure weighs 1,000 grams, or 1 kilogram, or 2.2 pounds avoirdupois, or 15,432 grains. The present U. S. Pharmacopeia (IX. revision) has replaced the term cubic centimeter by the word mil (the first three letters of the word milliliter), claiming that the term cubic centimeter is a mis- nomer. The U. S. Bureau of Standards has declared that there is a slight difference between the thousandth part of a liter and the cubic centimeter. Metric Weights and Measures. The meter, or unit of length, 39.37043 inches. The liter, or unit of capacity, 33.814 fluidounces (U. S.). The gram, or unit of weight, 15.432348 troy grains. Metric Measures of Length. English inches. English inches. Millimeter (mm.) .03937 Decimeter (dm.) 3.93704 Centimeter (cm.) .39370 Meter (m.) = 39.37043 Kilometer = 39370.43 English inches. 82 GENERAL THERAPEUTICS Metric Measures of Capacity. English cubic inches. Milliliter (Cc.) = .06102 Deciliter (dl.) Centiliter (cl.) .61028 Liter (L.) Hectoliter = 6102.8 English cubic inches. English cubic inches. = 6.10280 = 61.02800 Milligram (mg.) Centigram (eg.) Metric Measures of Weight. Troy grains. .0154 .1543 Decigram (dg.) Gram (Gm.) Kilogram = 15432.34 troy grains. Troy grains. 1.5432 15.4324 Apothecaries' Weight and Metric Equivalents. Vioo g'-ain 140 Vic Vl2 Vw 1 grain 2 grains 3 " 4 " 5 " 6 " S " 10 " 12 = 0.0006 grams. > ly grains = 0.97 = 0.001 " 15.4 " = 1. 0.0013 " 20 " 1.3 = 0.0016 " 24 " 1.55 =z: 0.002 " 30 " = 1.94 0.003 " 40 " = 2.6 = 0.004 ' ' 45 " 2.92 ZZI 0.005 " 50 " = 3.23 == 0.006 " 60 " (1 dram) 3.89 = 0.008 " l 1 /^ drams = 5.58 = 0.011 " 1% " 6.81 = 0.012 " 2 " = 7.78 = 0.015 " 2% " = 9.72 = 0.022 'f 3 = 11.65 0.032 " 4 (i 15.55 = 0.048 " 5 = 19.43 = 0.065 " 6 " = 23.3 = 0.13 " 1 ounce (480 grains)= 31.1 = 0.2 " 2 ounces = 62.2 = 0.26 " 3 " = 93.3 = 0.32 " 4 " 124.4 0.39 " 6 " 186.6 0.52 " 8 = 248.8 = 0.65 " 10 " 311. 0.78 " 12 " = 373.2 grams. WEIGHTS AND MEASURES 83 Apothecaries' Measure and Metric Equivalents. 1 minim 2 minims 3 " 4 " 5 " 9 10 15 20 25 30 40 45 50 0.06 C.c. 60 minims (Ifluidram) 3.70 C.c. 0.12 " 1V4 fluidrams = 4.65 " 0.18 " 1% " 5.60 " 0.24 " 1% " = 6.50 i C 0.30 " 2 < i = 7.50 I f 0.36 " 3 c e 11.25 I < 0.42 " 4 1 1 15.00 " 0.50 " 8 " (Ifluidoz )= 30.00 f I 0.55 ", (more exactly) 29.57 1 1 0.60 " 2 fluidounees 59.15 1 1 0.92 " 3 1 1 88.72 ( C 1.25 " 4 1 1 = 118.29 1 1 1.54 " 8 i c = 236.59 ( I 1.90 " 16 " (Ipint) =r 473.18 1 1 2.50 " 32 1 1 = 946.36 t ( 2.80 " 128 " (1 gallon) 3785.43 1 1 = 3.10 Weight Equivalents. To convert grains into grams multiply by 0.065 To convert grams into grains multiply by 15.5 To convert drams into grams multiply by 3.9 To convert ounces (avoirdupois) into grams multiply by 28.4 To convert pounds (avoirdupois) into grams multiply by 453.6 Measure Equivalents. To convert cubic centimeters into grains multiply by 15.5 To convert cubic centimeters into drams multiply by 0.26 To convert cubic centimeters into ounces (avoirdupois) multiply by. . 9.03 To convert pints into cubic centimeters multiply by 473. To convert liters into ounces (avoirdupois) multiply by 35.3 To convert gallons into liters multiply by 3.8 Approximate Measures. A A A A drop equals roughly teaspoonful = dessertspoonful = tablespoonful = 1 1 2 % minim, fluidram. fluidrams. fluidounce. A A A A wineglassful teacupful tumberful handful = 2 = 4 = 8 = 4 fluidounees. fluidounees. fluidounees. ounces. 84 GENERAL THERAPEUTICS Percentage Solution Table. Showing the quantity of drug and water to use for prepar- ing aqueous solutions of different strengths. In these calcula- tions 456 grains have been taken as the weight of one fluidounce of distilled water at ordinary temperature. Water Grains of Drug to Make a Solution Containing Fluid ounces 1 in 5000 1 in 2000 1 in 1000 1 in 500 y 2 % 1% 2% 3% 4% 5% 10% 20% 25% 50 % >/2 1 2 0.046 0.091 0.182 0.114 0.228 0.456 0.228 0.456 0.912 0.456 0.912 1.82 1.14 2.28 4 56 2.3 4.6 9.2 4.6 9.1 18 2 6.8 13.7 27 3 9.1 18.2 36 5 11.4 22.8 45 6 22.8 45.6 91.2 45.6 91.2 182.4 57. 1 114. 114. 228. 228. 456. 3 4 6 8 12 16 0.273 0.365 0.546 0.729 1.094 1.46 0.684 0.912 1.37 1.82 2.74 3.65 1.37 1.82 2.74 3.65 5.47 7.3 2.73 3.64 5.47 7.30 10.94 14.6 6.84 9.12 13.68 18.24 27.4 36.5 13.7 18.2 27.4 36.5 55. 73 27.4 36.5 54.7 73. 109.5 146.0 41. 54.7 82. 119.4 164.4 218.9 54.7 73. 109.5 146. 218.9 291.8 68.4 91.2 136.8 182.4 273.6 364.8 136.8 182.4 273.6 364.8 547.2 729.6 273.6 364.8 547. 729. 1094. 1459. 342. 684. 456. 912. 684. 1368. 912. 1824. 1368. 2736. 1824. 3648. The above directions yield slightly more than the usually prescribed quanti- ties 1 fluidounce, 2 fluidounces, etc. owing to the increase in volume caused by the drug entering into solution. In the case of the weaker solution up to 1 or 2 per cent. this increase is not appreciable. Short Rule for Determining Percentages in Mixtures. Multiply 456 by the percentage desired and point off two right-hand figures. The figures at the left of separatrix will give the number of grains or drops, 456 being the number of grains to the ounce. Example: 456x4=1824; 18.24=18 1 / 4 ; 18 1 /! grains to an ounce of liquid, a 4 per cent solution. Table of Solubility. Name Water Alcohol Ether Glycerin Acetanilid 230 3.5 readily Acid arsenic 80 5 Acid benzole 400 3 3.5 10 Acid boric 25 15 10 Acid carbolic 15 readily readily readily Acid citric 1 1 50 readily Acid salicylic. 500 readily readily Acid tannic . . . 1 2 2 Acid tartaric 1 2.5 readily Acid trichloracetic readily readily readily Alum 12 3 Ammonium bromid 1 3 Ammonium carbonate 4 TABLE OF SOLUBILITY 85 Table of Solubility Continued. Name Water Alcohol Ether Glycerin Ammonium chlorid 3 5 Antipyrin 1 1 50 Apomorphin hydrochlorid .... 35 35 Atropin sulphate 1 10 readily Borax 17 Camphor readily readily Caffein 80 50 300 Chloral hydrate readily readily readily readily Cocain hydrochlorid 0.5 4 Copper sulphate 4 4 lodin 5000 10 3 lodoform 50 6 lodol 5000 3 15 Iron sulphate 2 4 Lithium carbonate 80 Magnesium sulphate 1 Menthol difficult readily readily Mercuric chlorid 16 3 4 15 Morphin hydrochlorid. 25 50 5 Morphin sulphate 20 5 Phenacetin 1400 16 Pilocarpin hydrochlorid 10 readily Potassium acetate 0.5 2 Potassium bicarbonate 4 readily Potassium bromid 2 200 4 Potassium carbonate 1 15 Potassium chlorate 16 130 32 Potassium iodid 1 12 2 5 Potassium permanganate . . . 21 explosive Potassium sulphate 10 Potassium tartrate 1 Quinin hydrochlorid 34 3 Quinin sulphate 800 90 Resorcinol 1 0.5 0.5 5 Saccharin 250 25 Salol 10 0.3 Silver nitrate. ... ..... 0.6 10 readily Sodium acetate 3 30 15 Sodium benzoate 2 13 Sodium bicarbonate . . . 12 4 Sodium bromid 1.2 5 1 Sodium carbonate 2 5 Sodium chlorid 3 difficult Sodium phosphate . 6 difficult Sodium salicylate . 1 6 readilv Sodium sulphate 3 1 Strychnin sulphate. 31 65 Sugar 0-5 Tartar emetic . . 17 readily Thymol 1100 1 1 Zinc sulphate 0.6 3 86 GENERAL THERAPEUTICS Number of Drops in a Fluidram. Table showing number of drops in a fluidram of different liquids, with weight in grains and in grams: Name Drops in 1 fluidram (60m) Weight of 1 fluidram In grains In grams Acid, aceticum 108 Acid, aceticum dilut 68 Acid, hydrochlor 70 Acid, hydrochlor. dilut 60 Acid, lacticum Ill Acid, nitricum 102 Acid, nitricum dilut 60 Acid, sulphur 128 Acid, sulphur, aromat 146 Acid, sulphur, dilut 60 JEther fortior 176 Alcohol 146 Aqua 60 Aqua ammon. fortior 66 Chloroform, purificat 250 Creosotum 122 Glycerinum 67 Hydrargyrum 150 Liq. potassi arsenitis 57 Oleum caryophylli 130 Oleum cinnamomi 126 Oleum gaultheriae 125 Phenol liquid Ill Spiritus ammon. aromat 142 Syrupus 65 Tinctura aconiti 146 Tinctura iodi 148 Tinctura opii 130 58 55 65 56 66 77 58 101 53 39 44 55 50 80 56 Yi 68 760 55 57 62 59 48 72 46 47 53 3.75 3.56 3.62 3.49 4.27 4.98 3.62 6.54 3.43 3.79 2.52 2.85 3.56 3.24 5.18 3.66 4.40 49.24 3.56 3.69 3.46 01 82 3.11 4.66 2.98 3.04 3.43 THE PHARMACOPEIA AND PHARMACEUTIC PREPARATIONS. The Pharmacopeia. In all civilized countries the governments have found it neces- sary to issue at certain intervals a standard guide for the regula- tion of medicinal preparations kept in the drug stores for dispens- ing purposes. This book is termed a Pharmacopeia from pliarmakon (a drug) and poiein (to make). The United States government, however, does not issue the Pharmacopeia, but it rec- PHARMACOPEIA AND PHARMACEUTIC PREPARATIONS 87 ognizes its authority as published by the National Committee of Revision, a body composed of members by appointment or elected by a convention of the various medical and pharmaceutic socie- ties, schools, and United States Medical Corps. The book is re- vised every ten years, the present edition being the Ninth Decen- nial Eevision, published by authority of the United States Phar- maceutical Convention, held in Washington, D. C., in 1910. The Pharmacopeia furnishes the official standard for the identification, purity, strength, and quality, with suitable directions for prepara- tion, purification, and preservation, of drugs, chemicals, and me- dicinal preparations. The title of the drug is given in Latin, fol- lowed by the English name, and, in the case of chemicals, by the formula and molecular weight. The preparations contained in the Pharmacopeia are therefore termed "official," while all other medical substances usually kept in a drug store are termed "non- official" or "officinal" from officin, an ancient name for the apothecary's shop. Drugs which were at one time "official" are frequently termed "obsolete." Quite a number of much used preparations which are not contained in the United States Phar- macopeia are standardized by having their formulas published in the National Formulary, a book published and revised at intervals under the direction of the American Pharmaceutical Association. Another very large class of remedies are those substances which are usually termed the newer remedies. These agents are either too new to have gained recognition by the Committee on Revision of the Pharmacopeia, or they possess so little real merit that they have been purposely omitted, although they are very largely pre- scribed. To somewhat clarify this chaos of grain and chaff, the American Medical Association in 1906 created a Council of Pharmacy and Chemistry, whose duty it is to select from the enormous mass of these articles those which have their definite constituents or formulas published, or otherwise comply with the rulings of this body. At present (1917) there are about twelve hundred of these articles tentatively approved by the above named Council, and they are termed new and non-official remedies. The pharmacopeias of different countries vary greatly not only with regard to the drugs they contain but also as regards strength and composition of preparations and similar names. To over- come these difficulties a tentative attempt has been made to unify pharmacopeial formulas of potent drugs. The governments of 88 GENERAL THERAPEUTICS Great Britain, Germany, Austria-Hungary, Belgium, Bulgaria, Denmark, Spain, the United States of America, France, Greece. Italy, the Grand Duchy of Luxembourg, Norway, the Netherlands. Portugal, Russia, Servia, Sweden, and Switzerland, having recog- nized the utility of concluding an agreement with the view to the unification of the pharmacopeial formulas for potent drugs on the basis indicated in the Final Protocol signed on September 20. 1902, as a result of the conference held at Brussels, have agreed upon the following stipulations: (a) No potent drug shall be directed to be prepared in the form of a medicinal wine, (b) Tinctures of potent drugs shall be directed to be prepared of the strength of 10 per cent and by percolation, (c) Fluid extracts of potent drugs shall be prepared of the strength of 100 per cent, (d) The Contracting Governments shall adopt a normal drop- measure, the external diameter of whose outlet tube shall be ex- actly 3 millimeters, that is to say, which, at a temperature of 15 degrees centigrade and with distilled water, shall yield 20 drops to the gram. Besides the Pharmacopeia and National Formulary there arc books which contain descriptive matter of substances used in medicine, with various detailed information. These books are com- pilations and commentaries on the above Avorks, and are termed dispensatories. Various books of this character are published in the United States The United States Dispensatory and the Na- tional Standard Dispensatory being in general use. CONSTITUENTS OF ORGANIC DRUGS. Organic drugs are composed of medicinally active constituents and of medicinally inactive constituents. The inert constituents are principally cellulose, wood, starch, albumen, wax, fat, coloring matter, etc., which exhibit practically no pharmacologic action although they may modify the activity of the pharmacologic principle. The active constituents may comprise pharmacologically active principles, i.e., they act on the animal tissues, and pharmaceutically active principles, i. e ., they may cause precipitation or otherwise chemically influence a mixture or compound. The physiologic ac- tion of a drug depends, either wholly or in part, upon its active principles. CONSTITUENTS OF ORGANIC DRUGS 89 The active constituents of organic drugs may be divided into: PLANT OR ORGANIC ACIDS AND THEIR SALTS. Tartaric acid of grapes, citric acid of lemon, tannic acid of oak bark, salicylic acid of sweet birch, etc., are representatives of this class. ALKALOIDS. They are natural organic bases containing prin- cipally carbon, hydrogen and nitrogen ; they possess the power of neutralizing acids with the formation of salts without the elimi- nation of hydrogen. All alkaloids (caff em excepted) have cer- tain properties in common; they have a bitter taste, turn red lit- mus paper blue, have a profound physiologic action and leave no post-mortem changes. They are soluble in ether, chloroform, and oils, less so in alcohol, and are comparatively insoluble in water. Alkaloidal salts are soluble in water and alcohol, but are insoluble in ether or chloroform. Examples : Atropin sulphate, Cocain hydrochloric!, Codein phosphate, Morphin sulphate, Strychnin sulphate, Pilocarpin hydrochlorid. GLUCOSIDES. They are proximate principles existing in plants and in most instances are chemically neutral bodies. When treated with strong acids, they decompose and form sugar with one or more other bodies. They do not follow rules in regard to taste, solubility or importance. Examples : Digitalin, Glycyrrhizin, Salicin, Strophantin. A number of other substances gcnerically known as neutral prin- ciples and which very closely resemble glucosides, may also be present in organic drugs. They are practically insoluble in water and have a more or less pronounced bitter taste. TANNINS. They are an ill-defined class of substances, deriva- tives of benzol, and distinguished by giving a bluish-green color with ferric salts. They are soluble in water and alcohol but readily form insoluble compounds with many substances, i.e., metallic salts, alkaloids, proteins, etc. This precipitation leads to astringent ac- tion. Tannins may be physiologic or pathologic products of plants. SUGARS, STARCHES AND GUMS. These compounds are known as carbohydrates; they possess only slight importance as remedies. 90 GENERAL THERAPEUTICS being usually employed for their soothing action as demulcents, dietetics, and in the arts. They constitute one of the most im- portant classes of useful products of nature. FERMENTS. They are substances capable of producing chemic changes without entering into the reaction or forming a part of the end-product. Examples: Pepsin, pancrcatin, papain. RESINS. They are alcohol soluble constituents of vegetable drugs, as: Podophyllin, jalapin. OLEORESINS. They are ether soluble constituents of vegetable drugs, as: Copaiba, male fern, capsicum. BALSAMS. They are mixtures of resins and oleoresins contain- ing benzoic acid, cinnamic acid, etc. The chief balsams are those of peru, of tolu, and storax. CAMPHORS. They are insoluble in water but soluble in alcohol, ether, etc., as: camphor, eucalyptol, menthol, etc. GUMRESINS. They are mixtures of gum with resins or oleo- resins and soluble in diluted alcohol, as: asafetida, ammoniac, myrrh and gamboge. GUMS. They are water soluble substances which are readily precipitated by alcohol, as: gum arabic, tragacanth, etc. FIXED OILS. They are usually obtained by expression and are not readily volatilized, as : castor oil, linseed oil, olive oil, etc. VOLATILE OILS. They are usually obtained by distillation, as: oils of cassia, cloves, eucalyptus, etc. Pharmaceutic Methods. COMMINUTION. Reducing drugs to smaller pieces. DECANTATION. Drawing or pouring off a supernatant liquid into another vessel. DESICCATION, OR DRYING. To drive off some volatile constitu- ent from the solid, the fixed residue being the portion desired. Crude drugs are subjected to this method to reduce their bulk, to assist preservation, and to facilitate comminution. Drying may be accomplished in spreading the drugs in airy lofts, or by heat in drying closets. Care must be taken not to injure the volatile ingredients of the drugs. DISTILLATION. Evaporation of a liquid and condensing the vapor into a liquid in a separate vessel. Fractional distillation PHARMACEUTIC METHODS 91 is the process of separating a mixture of liquids of different boil- ing points by distillation. EVAPORATION. Vaporizing a solvent from a solution so as to concentrate the dissolved substance. EXPRESSION. Separation of liquids from solids by pressure. EXSICCATION, OR CALCINATION. Depriving a solid of its mois- ture or volatile constituents by heat without fusion. Fig. 13. Percolation. FILTRATION. Separation of liquids from suspended solids by pouring them through a filter medium as filter paper, charcoal, sand, etc. MACERATION. Dissolving soluble active constituents of drugs by suspending them in a menstruum for a sufficient length of time. 92 GENERAL THERAPEUTICS PRECIPITATION. Separating solids from their solvents, which is usually accomplished by chemic or physical means. PERCOLATION, OR DISPLACEMENT. A process of exhausting a drug by a suitable menstruum. It consists in "subjecting a sub- stance or mixture of substances in powder, contained in a vessel called a percolator, to the solvent action of successive portions of a certain menstruum in such a manner that the liquid, as it trav- Fig. 14. Infusion jar. Fig. 15. Casserol for decoction. erses the powder in its descent to a receiver, shall be charged with the soluble portion of it, and pass through the percolator free from insoluble matter." (U. S. Pharmacopeia.) SOLUTION. The diffusion of solid molecules in a liquid in such a manner as to become widely separated, with no solid particles discernible by any means. A simple solution is purely a physical process, as the substance undergoes no alteration. A chemic solu- tion is a chemic alteration of the dissolved body by the solvent. If a solution is fully charged with the ' dissolved substances so as not to retain any more of it, it is termed a saturated solution. A saturated solution of one substance is still capable of dissolving other bodies to a limited extent. Circulatory solutions dissolve or exhaust a substance which is suspended in the solvent. The process of making a simple solution depresses and that of a chemic solution raises the temperature of the solvent. SUBLIMATION. Separating a volatile from a nonvolatile solid. TRITURATION. Rubbing a substance to a very fine powder in a mortar. PHARMACEU'flC PREPARATIONS 03 Pharmaceutic Preparations. CAPSULES (CAPSULE). Gelatin coverings of various sizes for drugs. KONSEALS (rice flour capsules) or wafers (thin sheets of dried flour paste) are sometimes used to enclose drug powders. Fig. 16. Empty gelatin capsules. CERATES (CERATA). Unctuous preparations similar to oint- ments, having for their bases the simple cerate, composed of 30 parts white wax, 20 parts petrolatum, 50 parts benzoinated lard as camphor cerate. Fig. 17. Konseals. (Rice flour capsules.) COLLODIONS (COLLODIA). Liquid preparations having for their base a solution of gun cotton (pyroxylin) in a mixture of ether and alcohol as flexible collodion. 94 GENERAL THERAPEUTICS CONFECTIONS (CONFECTIONES). Medicinal substances formed in- to a mass with sugar, honey, and water as confection of rose. DECOCTIONS (DECOCTIONES). Vegetable substances boiled in water and strained as decoction of sarsaparilla. ELIXIRS (ELIXIRIA). Sweetened, spirituous preparations contain- ing medicinal substances in small quantities as elixir of gentian. EMULSIONS (EMULSIA). Aqueous preparations in which oils, oleoresins, balsams, resins, or other substances which are insoluble in water are suspended by means of gum or other viscid excipients as cod-liver oil emulsion. EXTRACTS (EXTRACTA). Solid or semi-solid substances of ac- tive principles of drugs as extract of opium. FLUID EXTRACTS (FLUIDEXTRACTA). Active principles of drugs prepared by percolation. They are liquid, and one gram of the drug corresponds to one cubic centimeter of the finished product as fluid extract of ergot. GARGLES (GARGARISMA). Mixtures or solutions for application to the pharynx or to the mouth. GLYCERITES (GLYCERITA). Mixtures or solutions of medicinal substances with or in glycerin as glycerite of tannic acid. HONEYS (MELLITA). Vehicles for drugs as honey of rose. INFUSIONS (!NFUSA). Comminuted drugs exhausted with hot or cold water as infusion of digitalis. INJECTIONS (!NJECTIONES). Liquid preparations for introduc- tion into the cavities of the body by means of a syringe. JUICES (Succi). Expressed juices of fresh drugs as lemon juice. LINIMENTS (LINIMENTA). Liquid ointments to be applied with friction to the skin as soap liniment. LOTIONS (LOTIONES). Mixtures or solutions of medicinal agents for external application. MASSES (MASS^E). Dough mixtures of pillular consistency for making pills as mass of mercury. MIXTURES (MISTUR^:). Solids suspended in aqueous liquids as chalk mixture. MUCILAGES (MUCILAGINES). Gums dissolved in water as mu- cilage of acacia. OINTMENTS (UNGUENTA). Soft, fatty mixtures melting by fric- tion at body temperature as zinc ointment. OLEATES (OLEATA). Solutions of metallic salts or alkaloids in oleic acid as oleate of mercury. PHARMAOEUTIC PREPARATIONS 95 OLEORESINS (OLEORESIN^E). Natural as copaiva and turpen- tine; or artificially prepared by extracting drugs with ether as oleoresin of ginger. PAPERS (CHARTS). Paper impregnated with medicinal sub- stances- as mustard paper. PILLS (PILULJE). Small spherical bodies, containing medicinal substances by aid of some vehicle and covered with various sub- stances as cathartic pills. (Dragee, granule, and bolus are modi- fications of pills.) PLASTERS (EMPLASTRA). Adhesive, fatty, or resinous com- pounds spread on textile fibers, leather, muslin, etc., and are either dry or soft as lead plaster. POULTICES (CATAPLASM ATA ). Means of applying heat and moisture to certain parts of the body as cataplasm of kaolin. Fig. 19. Suppository mould. POWDERS (PULVERES). Drug mixtures in very fine state of division as Dover's powder. RESINS (RESINS). Natural exudations as rosin; or artificially prepared principles of drugs as resin of jalap. SOLUTIONS (LIQUORES). Watery solutions of non-volatile sub- stances as solutions of magnesium citrate. SPIRITS (SPIRITUS). Solution of volatile substances in alcohol as spirit of peppermint. 96 GENERAL THERAPEUTICS SUPPOSITORIES (SUPPOSITORIA).- Medicines mixed with cocoa but- ter and formed into cones intended for introduction into the rectum or vagina; for urethral use they are called bougies as glycerin suppositories. SYRUPS (SYRUPI).- Solutions of various kinds containing largo quantities of sugar as syrup of tolu. TINCTURES (TINCTUR/E). Solutions of medicinal active con- stituents of drugs in an alcoholic menstruum as tincture of kra- meria. Fig. 20. Finished suppository. TRITURATIONS (TRITURATIONES). Intimate mixtures of one part of the substance with nine parts of sugar of milk. TROCHES (TROCHISCI). Small compressed tablets or cakes of some medicinal substances with some vehicle as troches of san- tonin. VINEGARS (ACETA).- Solutions of active principles of drugs in dilute acetic acid as vinegar of squills. WATERS (AQU/E). Solutions of volatile substances in water as rose water. SYNOPSIS OF NATIONAL NARCOTIC LAW 97 WINES (VINA). Solutions of medicinal substances in wine as wine of opium. Fig. 22. Hypodermic tablet mould. SYNOPSIS OF THE NATIONAL NARCOTIC (HARRISON) LAW AS IT AFFECTS THE DENTAL PRACTITIONER. On March 1, 1915, the National Narcotic (Harrison Antinar- cotic Bill, H. E. 6282) Law, went into effect. This law* has in many respects a direct bearing on the practice of dentistry, as the two basic drugs to which it refers namely, opium and cocain and their derivatives are quite frequently employed by the den- tal practitioner. The following summary is a synopsis of the law as it affects the dentist : (1) The law provides that on and after July, 1915, and annually there- after, every person, firm, or corporation that imports, manufactures, com- pounds, deals in, disposes of, sells, distributes, or gives away opium, or coca leaves, or any compound, manufacture, salt, derivative, or prepara- tion thereof, shall register with the Collector of Internal Eevenue of the district in which he resides, his name or style and his place of business. Persons registered under this law will be held responsible for the acts of their employees in dispensing or distributing any of the drugs coming within the scope of this law. Where two or more dentists are in partner- ship, doing business under a firm name, it is necessary for the firm to be registered, the firm registry number to be indicated in ordering any of the drugs for use in the office practice of the members of the firm, each individual dentist in such partnership should register and pay the an- nual tax under his own name, if also engaged in private practice. If *In a recent (April, 1917) decision rendered by the United States Circuit Court of Ap- peals for the Second Circuit confirming the decision of the United States District Court, it was held that novocain, anesthesin, orthoform and holocain do not come under the National Narcotic (Harrison) Law and, therefore, dentists prescribing or using these drugs may do so under the above ruling without registering or employing the Harrison narcotic blanks in ordering them. 98 GENERAL THERAPEUTICS maintaining an office in more than one internal revenue district must register in each district. (2) The specified drugs may be purchased only upon official order blanks issued by the Internal Revenue Department, at a cost of one cent each for each original order or duplicate thereof. Whenever the dentist orders any of the above-named drugs he must fill out the official order blank, retaining the duplicate copy thereof for two years and in a man ner open to inspection by the proper authorities. (3) The dispensing or distribution of any of the aforesaid drugs to a patient by a dentist duly registered under the act, in the course of his professional practice only, is not interfered with by this law, nor does the law apply to the sale or disposal in any w r ay of the said drugs by a dealer on the written prescription of a dentist. But such prescriptions must be dated as of the date on which they were signed and must bear the signature of the dentist who issued the same. A duplicate copy thereof should be retained for two years by the prescriber. RECORD OF NARCOTICS DISPENSED OR DISTRIBUTED DATE KINO Of DRUG QUANTITY PATIENT'S NAMfc PATIENT'S ADDRESS . s-s -^ -I ^-" " ? ^~ ^ ' ~~^^~^~ Fig. 23. Sample page of record of narcotic drugs dispensed. (4) The dentist may dispense without restriction to his patients the prescribed drugs when he personally attends upon his patient, in the course of his professional practice. If the dentist does not personally attend upon the patient and distributes or dispenses any of the prescribed drugs he must keep a record of such drugs so dispensed or distributed, the amount dispensed or distributed in each instance, the date, and the name and address of the patient. It will be noted that this record is only required when the dentist does not personally attend upon the patient. (5) The law exempts from its provisions all preparations and remedies which do not contain more than two grains of opium, or more than one- fourth grain of morphin, or more than one-eighth grain of heroin, or more than one grain of codein, or of any salt or derivative of any of them, in one fluidounce, or, if a solid or semisolid preparation, in one avoirdupois ounce; all liniments, ointments, and preparations which are prepared for external use only, except liniments, ointments, and other preparations which contain cocain or any of its salts, or any synthetic substitute for them. The exemptions as to the preparations above named npply only when they are sold, distributed, given away, dispensed, or otherwise disposed of as medicines and not for the purpose .of evading SYNOPSIS OF NATIONAL NARCOTIC LAW 99 the provisions of the act. Dentists using in office practice cocain and similar drugs are permitted to make up stock solutions, recording only, the date of preparation and the date of exhaustion of same. (C) It is a crime under the act for any person who is not registered and has not paid the tax to have in his possession or under his control any of the aforesaid drugs, and such possession will be construed as pre- sumptive evidence of a violation of the act. This provision, however, docs not apply to any employee of a registered person, or to a nurse under the supervision of a dentist registered under the act, having such possession by virtue of his employment or occupation and not on his own account. This act in no way interferes with the operation of the laws of any State respecting the manufacture, sale, or use of narcotic drugs unless such laws are in direct conflict therewith. The penalty for violating any of the requirements of the act is a fine of $2,000, or imprisonment for not more than five years, or both, in the discretion of the court. From all appearances, all local anesthetic solutions, tablets, pel- lets, pastes, etc., containing cocain or opium, or any of their de- rivatives, are amenable to this law. Liniments, ointments, or other preparations containing drugs not specifically exempt, used for oral, nasal, aural, ocular, rectal, urethra!, or vaginal administra- tion are not in such cases used externally and are therefore not exempt from the provisions of this law. Tropacocain is a synthetic product of cocain, consequently its sale will be governed by the law, while chloretone, i.e., aceton- chloroform, and quinin and urea hydrochlorid are not affected by it. The practitioner who purchases ready-made solutions, tablets or other pharmaceutic compounds should carefully read the at- tached labels so as to familiarize himself with the components of the respective preparations. Aside from the before-mentioned drugs there are a number of pharmaceutic preparations employed by the dental practitioner upon which the new law has a direct bearing. The most important compounds are herewith enumer- ated: Fluid extracts, tinctures, and elixirs, powders, pills, tab- lets (compressed and hypodermic), and pastes containing opium, coca, or their derivatives, such preparations including the follow- ing compounds: Warburg's tincture, Dover's powder, ipecac and opium pills, Brown's chlorodyne, brown troches, Tully's powder, opium and lead wash, some of the anti-neuralgic liniments, most of the pulp-devitalizing compounds, and such local styptics as stypticin (cotarnin hydrochlorid) or styptol (cotarnin phthalate), 100 GENERAL THERAPEUTICS and the occasionally internally employed hemostatic camphor, opium, and lead acetate pill. Many of the anodyne compounds which are administered by the dentist as pain-relievers contain opium or its derivatives, i.e., codein, heroin, morphin, etc. Inci- dentally, this is equally true of most cholera drops and cough mixtures. Preparations for the mouth and teeth in the form of washes, powders, pastes, and soaps are usually free from opium or cocain admixtures, while a number of other pharmaceutic com- pounds used by the dentist contain these drugs. Merely to enu- merate a few, the following preparations may serve as examples: A widely advertised abscess cure contains morphin; mummifying pastes are known to contain cocain. This is equally true of cer- tain antiseptic and anesthetic pastes employed for polishing teeth and massaging the gums. It may seem ridiculous, but neverthe- less it is true that even some root-filling compounds are known to contain morphin. AVERAGE DOSES OF THE MOST IMPORTANT DENTAL DRUGS. Drugs. Grains or minims. Grams or C.c. Acetanilid 3 Acetphenetitin (see Phenacetin) Acid, acetic, diluted (Vinegar; 6%) 30 benzoic Ty 2 boric Ty 2 carbolic (see Phenol, liquefied) hydrochloric, diluted (10%) 15 hydrocyanic, diluted (2%) \\fa nitric, diluted (10%) 30 phosphoric, diluted (10%) 30 salicylic 12 sulphuric, aromatic (20%) 15 sulphuric, diluted (10%) 15 tannic 71^ A conite 1 ' ' tincture of, (10%) 5 Aconitin 1/400 Aloes, purified 4 Alum 7:^ Ammonia, aromatic spirit of 30 Amyl Nitrite 3 Antipyrin 5 Apomorphin hydrochlorid (emetic) 1/10 Arsenic trioxid 3 Sol. pot. arsenite (Fowler's solution; 1%) j 1/30 Atropin sulphate (see Belladonna leaves) 0.2 2. 0.5 0.5 1. 0.1 2. 2. 0.75 1. 1. 0.3 0.065 0.3 0.00015 0.25 0.5 2. 0.2 0.3 0.005 0.002 0.2 AVERAGE DOSES 101 Average Doses of the Most Important Dental Drugs Continued. Drugs. Grains or minims. Belladonna loaves " tincture of, (10%) Atropin sulphate 1/120 Benzosulphinid (Saccharin) Bismuth subnitrate Blue mass (see Mercury, mass of) Caffein 2% ' ' citrated 5 Calomel (see Mercury, mild chlorid) Camphor I 1 V?. Cascara sagrada 15 Cerium oxalate Chloral, hydrated . . . 8 Cinchona .' Quinin or its salts Coca Cocain or its salts I /4 Codein (see Opium) j Cream of tartar (see Potassium bitartrate) Creosote Copper sulphate (emetic) ! Digitalis " tincture of, (10%) Dover's Powder (see Ipecac, powder of, and; opium) j Emetin (see Ipecac) Epsom Salt (see Magnesium sulphate) Ergot 30 Eucalyptol 5 Eugenol 3 Fowler's solution (see Sol. pot. arsenite) Glauber 's salt (see Sodium sulphate) Glycerin 60 Guaiacol 8 Hexamethylenamin (Urotropin) Ipecac (expectorant and antiamebic) 1 " Powder of, and opium (Dover's powder; of each 10%) | 7% Emetin or its salts j 1/3 lodid, ferrous, syrup of (5%) i 15 lodin, tincture of (7%) 1% Krameria, tincture of (20%) 00. Laudanum (see Opium, tincture of) ] Lead acetate (Sugar of lead) I 1 Lime, syrup of 30 Lithium and its salts 8 Magnesium sulphate (Epsom salt) 240 Mercury chlorid, corrosive (Corrosive sublimate) . i 1/20 chlorid, mild (Calomel) I 2V 2 iodid, yellow (Protiodid) | 1/6 mass of, (Blue mass; 33%) 4 Morphin (see Opium) Grams or C.c. 0.065 0.75 0.0005 0.2 0.5 0.15 0.3 0.1 1. 0.2 0.5 1. 0.25 2. 0.015 0.25 0.25 0.065 0.5 2. 0.3 0.2 4. 0.5 0.25 0.06. 1 ) 0.5 0.0:22 1. 0.1 4. 0.065 2. 0.5 16. 0.003 0.15 0.01 0.25 102 GENERAL THERAPEUTICS Average Doses of the Most Important Dental Drug's Continued. Drugs. Grains or minims. Grams or C.c. Nitroglycerin, spirit of (1%) 1 Novocain hydrochlorid 1/2 Nux vomica 1 " " tincture of, (0.1% strychnin) 8 Strychnin or its salts ] /40 Opium 1 ' ' granulated (10% morphin) 1 " tincture of, (Laudanum; 10%) 8 " tincture of, camphorated (0.4% opium; Paregoric) 00 ' ' tincture of, deodorized (10%) 8 Codein or its salts | 1/2 Morphin or its salts 1/8 Oil, Castor 240 Clove 3 Cassia (Cinnamon) 3 Eucalyptus 8 Peppermint 3 Wintergreen 15 Paregoric (see Opium, tincture of, camphorated) . Phenacetin (Acetphcnetitin) Phenol, liquefied (Carbolic acid, 86.4%) 1 ' ' salicylate (Salol) 5 Phosphorus 1/128 Pilocarpin hydrochlorid (hypodermic) 1/12 Potassium bicarbonate 15 bitartrate (Cream of tartar) 30 bromid 15 chlorate 4 citrate i 15 and sodium tartrate (Rochelle salt)... 150 iodid 5 sulphate 30 Quinin (see Cinchona) Rochelle salt (sec Potassium and sodium tartrate). Rhubarb 15 Saccharin (see Benzosulphinid) Salol (see Phenol salicylate) Scopolamin hydrochlorid (hypodermic) 1 /200 Silver nitrate 1/5 Sodium bicarbonate 15 bromid 15 chlorid 240 phosphate 60 salicylate 15 sulphate (Glauber 's salt) 240 Strychnin (see Nux Vomica) Sugar of lead (see Lead acetate) Sulphonmcthan (Sulphonal) 12 Sulphur, washed 60 Thymol 2 Urotropin (see Hexamethylenamin) Zinc sulphate (emetic) 15 0.065 0.03 0.065 0.5 0.0015 0.06 0.06 0.5 4. 0.5 0.03 0.008 0.*2 0.2 0.5 0.2 0.3 0.06 0.3 0.0005 0.005 1. 2. 0.'25 1. 10. 0.3 2. o.ooo:; o.oi i. i. 16. 4. 1. 16. 0.75 4. 0.125 1. PART II PHARMACO-THERAPEUTICS ANTISEPTICS. At present it is generally recognized that the breaking down of highly organized bodies, when subjected to certain causative conditions, is brought about by the activity of minute vegetable organisms the bacteria. This process is called putrefaction, or, under certain conditions, fermentation. These terms are applied to strictly analogous processes, with this differentiation putre- faction refers to the decomposition of animal proteins, while fer- mentation is restricted to the cleavage action of bacteria and of certain ill-defined bodies known as ferments on vegetable material. The presence of certain bacteria is instrumental in the produc- tion of severe physiologic changes, resulting in the various vital phenomena known as infectious diseases. As soon as this fact became recognized, investigators directed their attention to the discovery of agents capable of inhibiting or destroying the action of these germs, with the object of rendering infected or septic conditions perfectly clean, or antiseptic. By the term sepsis, then, we understand the existence of a con- dition in which bacterial infection and its sequelae- fermentation or putrefaction is brought about by the presence of germs or their products, while asepsis implies an entire freedom from such infection that is, an aseptic condition. If a primarily septic con- dition is changed by some method or means that inhibits the growth of putrefactive organisms, antisepsis is secured. Conse- quently antiseptics are chemic agents that merely inhibit the ac- tion and growth of bacteria, while germicides destroy the vitality of the infective organisms. Disinfectants also kill the bacteria, and chemically change their poisonous products to some inert compounds. Disinfectants must, therefore, be germicides. Thus it will be seen that an antiseptic is not necessarily a germicide 10P, 104 PHARMACO-THERAPEUTICS or a disinfectant that is, glycerin will inhibit the growth of cer- tain bacteria, and is therefore antiseptic, but it has very little or no power to destroy the micro-organisms themselves or their spores, and consequently possesses no germicidal or disinfectant properties. On the other hand, formaldehyd solution is an ef- fective germicide, possesses also powerful disinfectant properties, and is successfully employed for both purposes, while milk of hypochlorid of lime is extensively used as a disinfectant, which, of course, incidentally means germicidal action. Quite frequently putrefactive processes are accompanied by the production of malodorous gases arising from the formation of new compounds. Again, agents are employed to destroy these offensive odors, and such agents are termed deodorants. The true deodorants usually have very little or no antiseptic action as iron sulphate. If an agent is employed solely for its cleansing power, either mechanically or chemically as soapsuds it is termed a detergent, while all those chemicals that possess the power to inhibit the action of ferments are called antizymotics. The action of antiseptics depends on their chemic relationship to the albumin of the cell; they act as poisons, and are therefore closely related to caustics and astringents. The ideal antiseptic would be one that inhibits or destroys the bacteria and their products without seriously injuring the cell of the host. Accord- ing to our present conception of biologic laws, the search for such a material is apparently fruitless. Antiseptics are usually divided into those used for external or local application and those employed internally. External anti- septics include all those agents that are used on the skin, the external mucous surfaces, including the oral cavity, wounds, and ulcers, the intestinal tract, the bronchi and lungs, and, in a round- about way, the urinary tract, while the destruction of infectious material on instruments, clothing, rooms, food, etc., is accom- plished by disinfectants. The destruction of all forms of bacteria and their products, and their removal from external surfaces, is referred to as sterilization, and is usually performed by means of heat. The administration of internal antiseptics is based on the sup- position that the blood and the body juices become saturated with them to such an extent as to kill or neutralize the bacteria and their waste products without harming the tissues themselves. As ANTISEPTICS 105 yet very little is known about the action of antiseptics when ad- ministered in the above manner. Clinical observations show, how- ever, that certain infectious diseases as malaria, syphilis, acute articular rheumatism, probably sepsis, and a few others are posi- tively influenced by such treatment, and that their uses are there- fore justified. Kecently efforts have been made to introduce anti- septic medication by inunction or by intravenous injection as quinin in malaria, mercury salts in syphilis, silver compounds and formaldehyd solution in sepsis, etc. While such procedures, per se, may be justified, they should not be followed indiscriminately. When we speak about the potency of any given antiseptic, it should be remembered that this potency is only relatively ex- pressed. We have as yet no accepted standards of antiseptic strength. Various efforts have been made in this respect; for in- stance, Rideal and Walker have attempted to introduce the so- called "phenol-coefficient." With the methods formerly used in determining the value of a disinfectant in terms of its phenol co- efficient, the results that may be obtained even by the same worker are misleading and subject to wide variations. The Rideal-Walker method is now extensively used, but it is not without its faults. The Lancet method, while not as simple or as easily performed as the Rideal-Walker method, seems to be the best one so far proposed. Briefly stated, the phenol coefficient in the Kideal-Walker method is arrived at by dividing the figure indicating the degree of dilution of the disinfectant that kills an organism in a given time by that expressing the degree of dilution of the phenol that kills the same organism in the same time under exactly similar conditions. Leaving out details, the determina- tion of the Eideal-Walker coefficient is substantially as follows :i Certain standard conditions are considered essential to the proper per- formance of the test. Phenol solutions of known strength are used; cul- tures are grown in a standard medium, transplants being made every 24 hours; the loops used for all inoculations are of a standard size (about 4 mm. in diameter). Usually four dilutions of suitable strengths of the dis- infectant to be used are made. Phenol controls of a suitable strength are also prepared. Five C.c. of each of these dilutions are placed in sterile test tubes, to which are added at intervals of one-half minute a 24-hour broth culture of B. typhosus in the proportion of 1 drop of culture to each cubic centimeter of disinfectant used (according to Partridge, 1 drop of culture equals about 0.1 C.c.). At the end of two and a half minutes a loopful of each of the mixtures is inoculated into a test tube containing 'Andersen and McClintic: Hygienic Laboratory Bulletin No. 82, Washington, 1912. 106 PHARMACO-THKRAPKUTICS 5 C.c. of standard broth, an interval of half a minute being thus allowed between taking the samples from the different dilutions. This is repeated at 5, 7 l /2, 10, 12%, and 15 minutes. The broth tubes, after being in- cubated at 37 C. for 48 hours, are examined for growth. The results of the examination are then noted, and if suitable comparative strengths of the disinfectant and phenol have been selected the phenol coefficient is determined as above stated. The following table illustrates the manner of determining the phenol coefficient of a disinfectant according to the Rideal-Walker method: Name, "A." Temperature of medication, 20 C. Culture used, B. typhosus, 24-hour, extract broth, filtered. Proportion of culture and disinfectant, 0.1 C.c. 5 C.c. Time culture exposed to action of disinfectant Sample Dilution for minutes Phenol coefficient 2^ 5 tYi 10 12 Yi 15 Phenol 1.90 1.100 + + + + 100)550 5.5 Disinfectant "A".. . . 1.500 + + coefficient 1.550 + + + 1.600 + + + + Phenol Coefficient of Some Commercial Disinfectants. Names of Disinfectants Without Organic Matter With Organic Matter Phenol 2. 2. Bacterol 1.58 1.34 Carbolene 1.36 .65 Chloro-naphtholeum 6.06 3.21 Cremoline 1.26 .69 Creolin 3.25 2.90 Crude Phenol 2.75 2.63 Compound solution of cresol 3.00 1.87 Lysol 2.12 1.57 Tricresol 2.62 2.50 Electrozone 0.9 Phenol Sodique. A 20 per cent solution of phenol sodique did not kill B. typhosus within 15 minutes. The determination of the coefficient is impracticable. Plait's Chlorides. In diluted form, required 10 minutes in ANTISEPTICS 107 which to kill B. typhosus. Therefore the coefficient was indeter- minable. Dioxygen. The determination of the coefficient is impracticable. In the following table the more common antiseptics are ar- ranged approximately according to their relative strength. It- must be borne in mind, however, that the absolute strength of these antiseptics can be correctly determined only by laborious tests, using germs of the same family, and exposing them in equal numbers and under absolutely equal conditions to nutrient media, temperature, and time; in other words, they have to be standard- ized. The table is compiled from the various publications of Koch, Sternberg, Miquel, and Kitasato. Antiseptics. EXTREMELY STRONG ANTISEPTICS. Solution hydrogen dioxid. Mercuric chlorid. Silver nitrate. Solution of formaldchyd. Chinosol. Sublainin. VERY STRONG ANTISEPTICS. lodin. Thymol. Crcsol. Compound solution of cresol. Creosote. Phenol. STRONG ANTISEPTICS. Cupric sulphate. Zinc chlorid. Aluminum chlorid. .Salicylic acid. Chloroform. Boric acid. MEDIUM STRONG ANTISEPTICS. I'otassium permanganate. Quinin sulphate. Arsenic trioxid. Alcohol. Benzoic acid. Acctanilid. Ferrous sulphate. Sodium borate. WEAK ANTISEPTICS. Ammonium chlorid. Sodium chlorid. Glycerin. The following table gives the concentration of the various anti- 108 PHARMACO-THERAPEUTICS septics in which they can be utilized in the mouth according to Miller i 1 Mercuric chlorid 1:2,000 Benzole acid 1:300 Salicylic acid 1:300 Hydronaphtol 1 : 1,500 Lysol 1:200 Phenol 1:100 Boric acid 1 :50 Zinc phenolsulphonate 1:250 Solution aluminum acetate. 1:20 Solution hydrogen dioxid. . 2-4:100 Saccharin, easily soluble... 1:120 Potassium chlorate 1:40 Potassium permanganate. .. 1:2,500 Thymol 1:2,000 Eugenol 1:750 Oil of cinnamon 1:400 Oil of cloves 1:550 Oil of eucalyptus 1:625 Oil of peppermint 1:600 Oil of pinus pumillio 1:360 Saccharin 1:400 Oil of wintergreen 1:530 All those chemicals that are generically termed "antiseptics" may, for the sake of convenience, be grouped under the following headings : 1. Salts of the heavy metals, their oxids, and their organic compounds. 2. Acids, alkalies, halogens and their derivatives. 3. Solutions which evolve nascent oxygen. 4. Antiseptics of the aromatic series. 5. Antiseptics of the marsh gas series. 6. Essential oils, their derivatives, and their synthetic substi- tutes. Salts of the Heavy Metals, their Oxids, and their Organic Compounds. The salts of the heavy metals form an important group of those agents that collectively are termed antiseptics. Metals, in their pure state, do not usually induce any serious symptoms in the living organisms unless their salts or oxids are formed. Mercury, copper, silver, etc., may pass unaltered through the body without causing poisonous effects. The soluble and insoluble salts of gold, nickel, or tin are not absorbed by the intestines, even if they are administered continuously for months; hence vessels that are made from such metals, or that are covered with a continuous coating thereof, and that are used for culinary purposes are free from danger if kept clean. Silver salts, if administered for a 1 Miller: Die Mikroorganismen der Mundhohle, 1893. ANTISEPTICS 109 longer period, may be absorbed and deposited in a reduced form in the connective tissues, causing a grayish discoloration of the skin (argyria). Lead, bismuth and mercury salts are readily ab- sorbed, and consequently, when administered in continuous doses, produce typical chronic intoxications lead colic, lead palsy, and mercurialism. When administered in sufficiently large doses, the absorbable salts of the heavy metals cause collapse and death; in small doses they produce necrosis of the specific tissues, affecting primarily the liver and the kidneys. Certain metals as mercury, bismuth, iron, etc. are readily excreted by the lower bowel; some metals, as mercury, show a predilection for diseased mucous mem- branes. The constant irritation produced by their excretion through the saliva causes various forms of stomatitis (mercury and bismuth), and in cases of lead salts causes a deposit of lead sulphid along the gingival line, known as the "lead line." Some few metals, in their pure state, possess antiseptic action. Accord- ing to Miller, gold, silver, and mercury and, to a less extent, copper, nickel, and zinc inhibit the growth of certain forms of pathogenic micro-organisms, while iron, tin, and lead practically show no action. This antiseptic action is the result, according to Behring, of the reaction of certain waste products of the bacteria with those metals that are capable of forming small quantities of soluble salts and that diffuse through the medium. The salts of the heavy metals are principally protoplasm poi- sons, but differ widely in their toxic action. In concentrated solu- tions they may act as severe caustics, while, when well diluted, only astringent effects are obtained. The soluble metallic salts possess an astringent and nauseating, sweetish taste. If swallowed in more or less concentrated solutions, they induce vomiting, which is so very effective with certain metallic salts that they are frequently employed as reliable emetics as copper sulphate and zinc sulphate. The insoluble salts of the heavy metals do not, of course, possess any germicidal action, or even produce physio- logic effects as, for instance, the insoluble mercury sulphid (arti- ficial cinnabar). It should be remembered, however, that insol- ubility in water does not necessarily mean insolubility in the body juices. While the latter are largely aqueous in their nature, they contain sodium chlorid, fatty acids, albumin, etc., which are prone 110 PHAEMA CO-THERAPEUTICS to produce soluble double salts by acting on the metallic salts. On this supposition we are able to explain why the otherwise in- soluble calomel or bismuth subnitrate produce definite action when brought in contact with the surface of a wound or of the intestines. The local action of the metallic salts does not depend upon the combination of their molecules as a whole, but on the dissocia- tion of their ions and oxids in solution. To more readily comprehend the effect of a solution the dis- sociation of a solid, liquid, or gas in a solution on tissue, it is necessary to understand the physical laws governing this process Fig. 24. Culture plate with Pack's cylinders and Abbey's noncohesive foil, a, b, c, d, an- nealed; e, f, g, not annealed. The latter did not allow any growth to appear within close proximity. (Miller.) that is, the theory of electrolytic dissociation of Arrhenius. When acids, salts, or bases are dissolved in a liquid, usually water, the molecules of these compounds break up into ions. The resulting solution possesses the property of conducting an electric current, and is, according to Faraday, called an electrolite. When a cur,- rent passes through the electrolytic solution, the latter undergoes certain changes which are generically termed electrolysis. If, on the other hand, a liquid has not the power of dissociating mole- cules into ions, it can not conduct an electric current. Now, ac- cording to Arrhenius, the conductibility of an electrolyte is pro- portionately depending on (1) the number of ions, (2) the relative ANTISEPTICS 111 electric charge of these ions, and (3) the speed of the ions. Fur- thermore, the resulting ions depend, with limits, on the degree of dilution of the solution ; a certain definite dilution dissociates completely all molecules, and further dilution merely separates the ions farther from each other. For example, if mercuric chlorid (HgCl 2 ) is dissolved in water, one positive Hg ion and two negative Cl ions are the result. All ions are charged with positive or negative electricity. The negatively charged ions, which travel to the positive pole, are termed an ions, while those charged Fig. 25. Imaginary diagram of a solution of mercuric clilorid in water. The atoms of mercury are represented by the large circles marked Hg, the chlorin atoms by the smaller circles marked Cl. Some of the mercury atoms are depicted joined on the two chlorin atoms to form the salt. Some are depicted as dissociated "ions" swimming about in the free state. The signs -f- and attached to these indicate positive (cations) and negative (anions) electric charges. (Andrews.) with positive electricity and traveling toward the negative pole are termed cations. We may express the ions of a completely dissociated mercuric chlorid solution as Hg-}- and Cl . Water has, so far as known, the greatest dissociating power, with the possible exception of hydrogen dioxid. Formic acid, methyl al- cohol, ethyl alcohol, ammonia, and others are, however, known to possess this peculiarity to a greater or less degree. The organic compounds are much less dissociated than the inorganic salts, and their ions are more complex and are very little understood at present. Although all definite soluble bodies possess more or less 112 PHARMACO-THERAPEUTICS the same property, at present we can speak only of the salts of the metals and alkalies with some positive knowledge. The practical application of the above theories of physical chem- istry in relation to the action of the metallic salts on bacteria is very significant. Our present knowledge on this subject is largely the result of experiments of Paul and Kronig, which were pub- lished in the various scientific journals. It is impossible to relate the details of these experiments, but the reiteration of a few important points may serve for a better comprehension of the theory of electrolytic dissociation. As subjects for experiments, the authors used the spores of anthrax and the staphylococcus pyogenes aureus (a pus organism). Now, if we remember that an electrolyte in solution is dissociated into its ions only in part when the solution is not infinitely diluted, then the effect of this solution must be attributed to the combined actions of the ions and the undissociated molecules present in it. Paul and Kronig investigated, first of all, the role played by the ions of the undis- sociated molecules in the disinfectant solutions. For this purpose the germicidal power of several mercury compounds, which are dissociated to different degrees in aqueous solutions, was examined. The following are the names of a few of these compounds, ar- ranged in the order of their decreasing degree of dissociation: 1. Mercuric chlorid, HgCl 2 . 2. Mercuric bromid, HgBr 2 . 3. Mercuric cyanid, Hg(CN) 2 . If the germicidal action of the halogen ions and the undisso- ciated molecules is slight as compared with that of the Hg ions, then the disinfectant action of these solutions will be dependent in the main on the concentration of the Hg ions that is, on the degree of dissociation of these salts. We may conclude from these experiments that the greater the dissociation of the mercury com- pounds that is, the greater the number of mercury ions present in the unit volume of the given solution the greater is its disin- fectant action. Furthermore, it is not so much the concentration of the solution alone, but also the specific action of the metallic salt, that influences its power as a disinfectant; if the cation of the metallic salt solution is very complex, it is less concentrated and consequently less active. Similar results were obtained by Paul and Kronig with silver, gold, and copper salts. The investi- ANTISEPTICS 113 Cation of the germicidal action of acids and bases has also brought, to light many interesting facts. A few of the general conclusions drawn by the above named authors from their experiments follow : 1. The germicidal action of solutions of acids runs parallel to that of their degree of dissociation that is, parallel to the number of hydrogen ions contained in the unit volume of solution. The anions, and also the undissociated molecules of hydrofluoric, nitric, and trichloracctic acid, have a specific toxic effect on bacteria. This toxicity, when compared with the germicidal effects of the hydrogen ions, becomes insignificant with progressive dilution. 2. The disinfectant action of bases as calcium, sodium, lith- ium, and ammonium hydroxid runs parallel to the number of free hydroxyl ions contained in the unit volume of the solution. As is the case in every investigation, new problems arise here also. Thus, for example, it has been found that, while such salts as corrosive sublimate or silver nitrate, when dissolved in absolute methyl or ethyl alcohol, have only slight germicidal powers, cor- responding to the slight dissociation in these media, aqueous so- lutions of these salts show an increased disinfectant action when not too large an amount of these alcohols is added thereto. The same metals attached to different acids produce different effects, depending on the free acid that is, the milder acetic acid formed from lead acetate acts more as an astringent than the stronger nitric acid formed from lead nitrate. This latter acid is highly corrosive and acts as an irritant. The actions of the various acids that may be attached to one metal differ widely in their therapeutic effect so much so that all intermediate stages from a mild astringent to a widespread necrosis may be produced. The chlorids and the nitrates form the most corrosive acids, the sulphates are milder, while the iodids and bromids are still less irritating. The mildest acids are those formed from the organic salts. The albuminates of the metals do not irritate unless the poisonous effects of the metals themselves are manifested. The antiseptic properties of the more important metals may be arranged according to the following scale, beginning with the mildest one: Iron, aluminum, lead, copper, zinc, silver, mercury, etc. The organic metallic compounds and the double salts of metals form weak precipitates with albumin; they are less irri- tating, and only slowly dissociate and diffuse over the parts. Within recent years, through the investigations of Bredig, solu- tions of very pure metals in water have been introduced for anti- -1 14 PHARMACO-T HKRAPKUTI ( S septic purposes. These solutions are variously termed colloidal solutions, pseudo-solutions, or simply sols. It seems paradoxical to speak of a water-soluble gold, silver, mercury, etc. It must be borne in mind, however, that such solutions are merely mechanical suspensions of extremely fine particles of metal metals in their amorphous state in water. Accordingly these pseudo-solutions of colloids (from the Latin colla, glue) are physically different from true solutions the crystalloids. Most likely the application of metals in their colloidal state will gain some prominence in the near future. Silver, mercury, copper, iron, and gold are produced at present in this form, and no doubt other metals will soon follow. For some time past chemists have endeavored to remedy the irritating properties of the inorganic metallic salts by preparing synthetically organic metallic compounds. In the last few years quite a number of these compounds appeared on the market, especially organic salts of silver and mercury. Some of these compounds give extreme satisfaction, and it seems safe to prog- nosticate a good future for their general use. In general, the metallic salts have an acid reaction, and pre- cipitate albumin by virtue of their acid or basic components. These precipitates differ very markedly in regard to their density, and depend largely on the various metallic salts employed. Silver nitrate, for instance, produces a hard, compact, and dry precipi- tate, which is definitely localized and which prohibits the further penetration of the salt, while zinc chlorid produces a loose, floccu- lent mass resembling the precipitate of alkalies, and this sponge- like precipitate does not prohibit the further penetration of the salt in depth and width. Hence metallic salts or other antiseptics which precipitate albumin or are interfered with by the presence of organic matter are more or less useless as disinfectants as bichlorid of mercury. The antiseptic action of the metallic salts depends largely on the formation of metallic compounds when brought in contact with proteins or albumins. Usually these newly formed albuminates are insoluble in water; some, however, are soluble in an excess of proteins as mercury and some will dissolve in solutions of neu- tral salts (sodium chlorid) or organic acids (tartaric or citric acid). ANTISEPTICS Il5 When a solution of a metallic salt is applied to a mucous mem- brane or to the surfaces of a wound, the albumin is at once pre- cipitated, and the acid with which the metal is combined is set free. Thus a more or less dense and continuous film is formed over the surface, which acts as a mechanical protective to the parts involved, lessening, or even completely checking, the further pene- tration of the solution into the deeper structures. The free acid acts as an irritant, which stimulates the circulation of the in- volved part, thereby increasing cell activity and effusion of ex- udates. The germs that are present, being largely albuminous in their nature, are acted on in the same manner as the superficial cells; they become coagulated and the surrounding medium is changed simultaneously to an unfavorable pabulum for the new growth of micro-organisms. The liquid exudates, being freed from their protein, become more diffusible and are more easily absorbed, while the blood vessels slightly contract and become less permeable. CORROSIVE MERCURIC CHLORID; HYDRARGYRI CHLORIDUM CORRO SIVUM, U. S. P. ; HYDRARGYRI PERCHLORIDUM, B. P. ; IIgCl 2 . ETYMOLOGY. From the Greek liydrargyros (liquid silver). SYNONYMS. Mercurius sublimatus corrosivus, corrosive subli- mate, perchlorid or bichlorid of mercury ; sublime corrosif , F. ; Aetzender Quecksilbersublimat, G. SOURCE AND CHARACTER. Mercuric chlorid is obtained by sub- liming a mixture of mercuric sulphate, sodium chlorid, and some black oxid of manganese. The latter is added to prevent the formation of calomel. HgS0 4 +2NaCl+Mn0 2 =HgCl 2 +Na 2 S0 4 +Mn0 2 . It occurs in heavy, colorless rhomboid crystals or masses, odor- less, and has an acrid and persistent metallic taste; permanent in the air. When in fine powder it is soluble at 60 F. (16 C.) in 13 parts of water, in 3 parts of alcohol, in 4 parts of ether, in 2 parts of boiling water, and in about 14 parts of glycerin. It is incompatible with alkalies and their carbonates, potassium iodid, lime water, tartar emetic, silver nitrate, albumin, soaps, and tannic acid. It attacks steel and nickel-plated instruments. 1 1 Regarding the action of corrosive sublimate on metallic objects, it should be remem- bered that it not only causes -a precipitate of metallic mercury on them, but the disin fectant solution is also abolished in proportion as the mercury is precipitated. lib PHARMACO-THERAPEUTICS AVERAGE DOSE. % grain (0.003 Gm.). PREPARATIONS. Liquor Hydrargyri Percldoridi, B. P. 1 part dissolved in 875 parts of distilled water. Average dose, % fluidram (2 C.c.). Lotio Hydrargyri Flava; Yellow Wasli (Aqua Pliagedenica). Mercuric chlorid, 25 grains (1.5 Gm.) dissolved in lime water, 16 ounces (473.17 C.c.). For external use. Sal Alenibroth (Salt of Wisdom}. Equal parts of mercuric chlorid and ammonium chlorid. MEDICAL PROPERTIES. Antiseptic, disinfectant, caustic, anti- phlogistic, specific. LOCAL ACTION. Applied on the unbroken skin, mercuric bi- chlorid produces little irritation unless kept there for some time. On wounds and mucous surfaces, weak solutions are antiseptic and disinfectant; if concentrated, they are caustic. Solutions are readily absorbed, and they may produce poisonous effects. Mer- curic chlorid, like all metallic salts, coagulates albumin and com- bines with the protoplasm of the cells. This precipitated albumi- nate of mercury is, however, soluble in an excess of albumin or in sodium chlorid solutions. For the sake of convenience, corrosive sublimate tablets are now prepared, having tartaric acid, citric acid, ammonium chlorid, etc., as a component to render the mer- cury more soluble and to prevent its precipitation as an insoluble compound. (Laplace.) Bernay's antiseptic tablets are a con- venient form for making extemporaneous solutions with measures of water ordinarily used. Each tablet contains I 4 %o grains of mercuric chlorid and S ~/IQQ grains of citric acid. One tablet dis- solved in 4 ounces of water gives a 1 :1,000 solution. These tablets are frequently colored (red or blue) with small quantities of anilin dyes. THERAPEUTICS. Mercuric chlorid is still extensively used in antiseptic surgery. For disinfectant purposes a solution of 1 :1,000 is employed, while as a general antiseptic 1 :5,000 is quite sufficient. In dentistry its application as a mouth wash, although very effi- cient, is not to be recommended ; the superficial epithelial cells of the mucous lining of the mouth are readily destroyed by its pro- longed use. As a disinfectant for putrescent root canals and for abscesses and fistulas, a slight acid solution of 1 part in 1,000 parts of hydrogen dioxid solution is one of the most effective agents at our command. It is also recommended for the disinfection of ANTISEPTICS 117 pyorrhea pockets (a glass syringe with a platinum point should be used). Miller has recommended its application with thymol as a mummifying agent for pulp stumps; teeth treated in this manner usually become badly discolored (mercuric sulphid being formed), the color ranging from a greenish-blue to a dark blue-black. Ad- ministered internally, corrosive sublimate, like all other mercurials, is changed to a double sodium and mercury chlorid, which is soluble in an excess of sodium chlorid. It enters the blood very rapidly, but seems to have no direct action on the blood. It quick- ly leaves the blood and enters the tissues, where it may remain in- definitely; here it manifests its specific influence on syphilis. As it is very slowly excreted, the secretions of all the glands (saliva, milk, sweat, urine, and bile) are stimulated. It is a powerful sialogogue, causing an increased flow of saliva which contains mer- cury. The saliva has a metallic taste, and acts as an irritant on the mucous membrane of the mouth, which may result in a typical decubital ulceration, known as mercurial stomatitis. TOXICOLOGY. If swallowed in poisonous doses, intense pain in the throat, stomach, and bowels is produced, accompanied by nausea, retching, bloody vomiting, diarrhea, cold sweats, and diffi- cult respiration, followed by convulsions and death. The treat- ment should be primarily directed to relieve the gastro-enteritis ; white of eggs beaten up with water, or milk, to form insoluble albumin compounds, should be freely given, or wheat flour may be substituted. The stomach should be washed out before the acid contents render the albumin compounds soluble. The after effects should be treated with opiates, counterirritants, and demulcent drinks. Two grains have been known to kill a man in half an hour, and an infant died from the constitutional effects of corrosive sublimate sprinkled on an excoriated surface. ANTISEPTIC SOLUTION. R Tablet, antiseptic. Bernays No. j Aq. hydrogen, dioxid. flS iv (120 C.c.) M. Sig.: Antiseptic solution. Mercuric Cyanid; Hydrargyri Cyanidum; Hg(CN) 2 . It forms colorless crystals, without odor and with a bitter, metallic taste. It is soluble in about 12 parts of water, in 15 parts of alcohol, and 118 PHARMACO-THERAPEUTICS in 3 parts of boiling water. Mercuric cyanid resembles corrosive sublimate closely in its action, but it is less active and much less irritating. For this reason it is used hypodermically in syphilis. It does not attack steel instruments very readily. Mercurol; Mercury Nucleinate. It is an organic compound of mercury and nucleinic acid (yeast nuclein), containing about 10 per cent of metallic mercury. It appears in the form of a brownish- white powder, soluble in water, but insoluble in alcohol. It docs aot precipitate albumin, but has marked bactericidal power, and possesses the typical action of a soluble mercury compound. It is used in 1 to 2 per cent solutions as an antiseptic. Sublamin. It is an organic mercury compound, which is chem- ically defined as mercuric sulphate-ethylcndiamin. It is composed of 3 molecules of mercuric sulphate and 8 molecules of ethy- lendiamin, and contains about 44 per cent of mercury. It occurs in white needle-like crystals, which readily dissolve in water, with an alkaline reaction, but which are only slightly soluble in alcohol. Sublamin is recommended for the disinfection of the skin, hands, etc., in 1 :1,000 solution. As it does not precipitate albumin, it possesses greater penetrating power than mercuric chlorid, and is less poisonous, less irritating, and more readily soluble than the latter salt. It is stated that it does not attack metallic instruments. This statement is not correct; sublamin attacks metallic surfaces, although less so than corrosive sublimate. Sapodermin. It is an albuminate of mercury in the form of a soap in which the mercuric chlorid is incorporated with a refined stearin and glycerin. It is principally used for hand disinfection. Hermoplienyl; Sodio -Mercuric Plienol DisulpJionate. It is a very soluble mercuric compound, which has gained some reputa- tion as an antisyphilitic. Eecently it has been recommended as a substitute for mercuric chlorid in dentistry. Red Mercuric Oxid; Hydrargyri Oxidum Rubrum, U. S. P.. B. P. ; HgO ; Red Precipitate. It is an orange-red amorphous powder. It is insoluble in water and in alcohol. Yellow Mercuric Oxid; Hydrargyri Oxidum Flavum, U. S. P.: HgO. It is a light orange-yellow amorphous powder. Red Mercuric lodid; Hydrargyri lodidum Riibrum, U. S. P.. B. P. ; HgI 2 . It is a scarlet-red amorphous powder. Average dose !/, grain (6.003 Gm.). Yellow Mercurous Todid; Hydrargyri lodidum Flavum, U. S. ANTISEPTICS 119 P. ; Hgl. It is a bright-yellow amorphous powder, tasteless and odorless. It is insoluble in alcohol, water, and ether. Average dose, % grain (0.01 Gm.). Ammoniated Mercury; Hydrargyrum Ammoniatum, U. S. P. ; B.. P.; HgNH 2 Cl; White Precipitate. It is a white amorphous powder, without odor and with an earthy, metallic taste. It is al- most insoluble in water and alcohol. BISMUTH SUBNITRATE; BISMUTHI SUBNITRAS, U. S. P., B. P. White bismuth, magisterium bismuthi; sous-azotate de bismuth, F. ; Wismutsubnitrat, G. SOURCE AND CHARACTER. It is a white heavy powder, consisting of a mixture of bismuth oxid, nitrate, and hydrate, and containing about 80 per cent of pure bismuth oxid. It is odorless and almost tasteless, insoluble in water or alcohol, but soluble in nitric and hydrochloric acid. It is incompatible with potassium iodid, calomel, salicylic acid, tannic acid, and sulphur. AVERAGE DOSE. iy 2 grains (0.5 Gm.). MEDICAL PROPERTIES. Astringent, mildly antiseptic and protec- tive. THERAPEUTICS. Bismuth subnitrate is principally used as an internal astringent in diseases of the gastro-intestinal canal and as a dusting powder on wound surfaces. For the latter purpose it is useful, as it readily diminishes the secretions of the wound. A number of fatal poisonings have been recorded lately in which bismuth subnitrate was used in large quantities as dusting powder or in the form of Beck's bone paste. (See Plugging of Bone Cavities.) Bismuth poisoning manifests itself in the mouth by a distinct bluish-black line about the gum margin, salivation, and swelling of the gums and tongue. Gangrene of the soft palate has also been observed. Bismuth subnitrate is used in the form of an unctuous injection (bismuth subnitrate, 10 parts; oil of cotton seed or oil of sesame, 15 parts; spermaceti, 30 parts) in radioscopy. The liquefied ma- terial is injected into the cavity, and the x-ray picture shows a deep-black shadow which distinctly outlines the normal or patho- logic cavity, sinus, etc. Occasionally, general poisoning is observed with this bismuth paste, i. e., the insoluble bismuth subnitrate is changed by 1he tissue fluids into a soluble nitrite. Xcroform : Bismuth Tribrompli en oldie; C H 8 O 4 Br g Bi 8 . It is a 120 PHARMACO-THERAPEUTICS fine yellow powder, nearly odorless and tasteless, insoluble in water and alcohol, but partially soluble in weak hydrochloric acid. It is a nonirritating and nontoxic astringent, and has been recom- mended as a substitute for iodoform. For some time past it was much lauded as a component of a root filling material composed of 1 part of xeroform, 2 parts of zinc oxid, and sufficient eugenol to make a stiff paste. Quite a number of other bismuth compounds bismuth subcarbonate, bismuth subgallate (dermatol), bismuth sub- salicylate, etc. are official, but they are of minor importance to the dental practitioner; they are principally employed as weak antiseptics intended for the gastro-intestinal canal. As previously stated (see Salts of the Heavy Metals), all salts of the heavy metals are antiseptics, and many of these salts are also powerful astringents. Certain metallic salts the silver, cop- per, and zinc salts are superseded in their antiseptic action by their astringent qualities, and are principally emplo3 7 ed for this purpose in dental medicine. Consequently we have preferred to classify these metallic salts under the general heading of astrin- gents. The Acids, the Alkalies, the Halogens and their Derivatives. THE ACIDS. All inorganic and most organic acids possess more or less anti- septic action. Many of the acids act as astringents when applied in a weak solution, and as caustics when used in a pure state. All inorganic acids, with the exception of phosphoric acid, the chlorin substituting fatty acids, and many of the aromatic acids, provided they are readily soluble in water, act as precipitants of albumin. The inorganic acids, with the exception of boric acid, can not be used as antiseptics in the oral cavity, as they attack more or less readily the calcium salts of the tooth structure. The mineral acids are frequently administered in diluted form as antiseptics in dis- turbances of the gastro-intestinal canal ; they should always be taken through a glass tube, to protect the teeth. Many of the organic acids are classified as aromatic compounds and others as caustics, and consequently they are discussed under their respective headings. (See Antiseptics of the Aromatic Series, and Caustics.) ANTISEPTICS 121 BORIC ACID; ACIDUM BORICUM, U. S. P., B. P.; H 3 B0 3 ; BORACIC ACID; ACIDE BORIQUE, F.; BORSAURE, G. SOURCE AND CHARACTER. It is usually prepared from native borax (sodium borate). It is a light, white, very fine powder, unctuous to the touch, or translucent, colorless scales, odorless, and having a faintly bitter taste. It is soluble in 18 parts of water, 15 parts of alcohol, 5 parts of glycerin, and readily soluble in boil- ing water. AVERAGE DOSE. iy 2 grains (0.5 Gm.). MEDICAL PROPERTIES. Antiseptic and astringent. THERAPEUTICS. Boric acid is a mild, nonirritating antiseptic and slight astringent; it is the only mineral acid which does not affect tooth structure. In the form of a dusting powder, as a glycerite or an ointment, and in saturated aqueous solutions, it is widely used as an external and, occasionally, internal antiseptic. It is apparently more active on molds and fission fungi than on pathogenic bacteria. In the form of Thiersch's solution it is of service in washing out the antrum or other body cavities. On ac- count of its very mild acidity it is largely used as the principal component of many proprietary mouth washes. As a dusting powder on large wound surfaces, boric acid must be used with cau- tion, to prevent too rapid absorption. A few cases of poisoning, of which two have ended fatally, have resulted from the too liberal use of this antiseptic. Boric acid is sometimes added to foods as a preservative, which has given rise to heated discussions in regard to its deleterious effects on the health of the consumer. Its use for such purposes is prohibited in the United States. Glycerite of B or o glycerin; Glyceritum Boroglycerini, U. S. P. ; Glyceritum Acidi Borici, B. P. It is a compound formed by heat- ing boric acid in glycerin, which is then dissolved in glycerin. It contains 31 per cent of boric acid. Ointment of Boric Acid; Unguentum Acidi Borici, U. S. P., B. P. A paraffin ointment containing 10 per cent of boric acid. Antiseptic Solution; Liquor Antisepticus. It contains 2 per cent boric acid, 0.1 per cent benzoic acid, 0.1 per cent thymol, and is flavored with eucalyptol and the oils of peppermint, wintergreen, and thyme. This solution is apparently intended to replace the many proprietary compounds of a similar nature. If this is true, it is a poor substitute. Its taste is most disagreeable, and its combina- 122 PHARMACO-THERAPEUT1CS tion is not in accordance with modern conceptions of an antiseptic solution. Strictly speaking, liquor antisepticiis is a toilet prepara- tion and has been dismissed from the present pharmacopeia (1916). HYDROCHLORIC ACID; ACIDUM HYDROCHLORIUM, U. S. P.; HC1; MURIATIC ACID ; ACIDE CHLORHYDRIQUE, F. ; SALZSAURE, G. It contains 31 per cent by weight of absolute hydrochloric acid. It is a colorless, fuming liquid of a pungent odor and an intensely acid taste, and should be kept in glass-stoppered bottles. HYDROCHLORIC ACID, DILUTED; ACIDUM HYDROCHLORICUM DILUTUM, U. S. P., B. P. It contains 10 per cent (15.58 per cent, B. P.) of absolute hydro- chloric acid. AVERAGE DOSE. 15 minims (1 C.c.), well diluted. NITRIC ACID; ACIDUM NITRICUM, U. S. P., B. P.; HN0 3 ; ACIDE AZOTIQUE, F. ; SALPETERSAURE, G. It is a colorless, fuming liquid, of a very corrosive and caustic nature, having a suffocating odor. It stains the skin and the tis- sues a bright yellow, and is used as a very powerful caustic by placing a drop of the acid with a glass rod on the tissue to be de- stroyed. It contains 68 per cent (70 per cent, B. P.) by weight of absolute nitric acid. It should be kept in glass-stoppered bottles. NITRIC ACID, DILUTED ; ACIDUM NITRICUM DILUTUM, B. P. It contains 10 per cent (17.44 per cent, B. P.) by weight of ab- solute nitric acid. AVERAGE DOSE. 30 minims (2 C.c.), well diluted. NlTROHYDROCHLORIC ACID ; AdDUM NlTROHYDROCHLORICUM. U. S. P. ; AQUA KEGIA ; EAU KEGALE, F. ; KONIGSWASSER, G. It is formed by mixing 180 parts of nitric acid with 820 parts of hydrochloric acid. It has been suggested to use this mixture as a substitute for sulphuric acid in the opening of root canals, accord- ing to Callahan 's suggestion. NlTROHYDROCHLORIC AciD, DILUTED; AdDUM NlTROHYDROCHLORICUM DILUTUM, U. S. P., B. P. It is formed by mixing 40 parts of nitric acid with 180 parts of hydrochloric acid, and with enough water to make 1.000 parts (6 ANTISEPTICS 123 parts nitric acid, 8 parts hydrochloric acid, and 50 parts distilled water, B. P.). AVERAGE DOSE. 15 minims (1 C.c.). SULPHURIC ACID; ACIDUM SULPHURICUM, U. S. P., B. P.; H 2 SO,; OIL OF VITRIOL ; ACIDE SULPHURIQUE, F. ; SCHWEFELSAURE, G. It is a colorless, oily liquid, containing 92.5 per cent (98 per cent, B. P.) by weight of absolute sulphuric acid. It is very caustic and corrosive, often causing charring of the tissues and leaving a coal-black slough. It should be kept in well-stoppered bottles. Sulphuric acid in 50 per cent solution has been recommended by Callahan 1 as a means of opening and enlarging obstructed root canals; it is very useful for such purposes. The acid may be car- ried to the root canal with a platinum probe or on a few fibers of asbestos wrapped about the probe. It is well to remember that in diluting pure sulphuric acid the acid must be added in a thin stream to the water with constant stirring, to avoid spluttering and overheating of the mixture. SULPHURIC ACID, DILUTED; ACIDUM SULPHURICUM DILUTUM, U. S. P., B. P. It contains 10 per cent (13.65 per cent, B. P.) of absolute sul- phuric acid. AVERAGE DOSE. 30 minims (2 C.c.), well diluted. SULPHURIC ACID, AROMATIC; ACIDUM SULPHURICUM AROMATICUM, U. S. P., B. P. ; ELIXIR OF VITRIOL ; ELIXIR VITRIOLIQUE, F. ; AROMATISCHE SCHWEFELSAURE, G-. It is an alcoholic solution, flavored with ginger and cinnamon, containing 20 per cent (8 per cent, B. P.) of absolute sulphuric acid, partly in the form of ethyl-sulphuric acid. It is employed as a caustic, styptic, and antiseptic, and is much lauded in the treatment of bone diseases. Since the introduction of phenol- sulphonic acid it has been largely superseded by the latter com- pound. AVKRAOK DOSE. 15 minims (1 C.c.), well diluted. 'Callahan: Proceedings Ohio State Dental Society, 1894. 124 PHARMACO-THERAPEUTICS PHENOLSULFONIC ACID; ACIDUM PHENOLSULFONICUM ; C 6 H 6 S0 4 ; SULFOCARBOLIC AdD ; SULFOPHENOL ; AciDE PHENOLSULPHON- IQUE, F. ; PHENOLSCHWEFELSAURE, G. SOURCE AND CHARACTER. When phenol is treated with sulfuric acid, an acid radical is substituted for an H in the C 6 H 5 OH of the phenol, and a new compound is formed which is known as phenol- sulfonic or sulfo-carbolic acid. Depending upon the mode of pro- cedure, theoretically three types of phenol-sulfonic acid may be obtained the ortho, the meta, and the para acid. By treating phenol directly with sulfuric acid, only the ortho or the para acid is formed, while the production of the meta acid requires a more complicated procedure. The ortho acid is formed when phenol and sulfuric acid are brought together at a low temperature, while by subjecting this same mixture to prolonged heating the pure para acid is formed. The various acids thus obtained always contain a variable small amount of free sulfuric acid. Phenolsulfonic acid (the ortho or the para acid) is a syrupy, yellowish liquid, becoming darker with age and having a pronounced acid reaction. It is readily soluble in water, alcohol, and glycerin, but insoluble in ether, chloroform, and some oils. It is practically odorless, or only feebly so, resembling phenol. It should be kept in glass-stoppered bottles, protected from light. MEDICAL PROPERTIES. Antiseptic and caustic. THERAPEUTICS. Phenolsulfonic acid was introduced into chem- istry some forty years ago by Laplace and Kekule, and since that time Annesen, Fraenkel, Vigier, Serrant, Hueppe, Schneider, and others have worked out its therapeutic value. It was soon found, however, that it possessed no demonstrable advantage over sulfuric acid, hence it was quickly discarded by the medical profession. Dentistry owes its reintroduction principally to Buckley, Cook and MaWhinney. When phenolsulfonic acid is applied in weak aque- ous solutions it acts primarily as an antiseptic; in concentrated form it is a caustic. Solutions in alcohol or glycerin largely nullify these effects. The action of phenolsulfonic acid may be denned as being anti- septic in a weak solution and caustic when applied in a concen- trated solution. Incidentally it acts as an astringent on account of its sulfuric acid content. From the very nature of the composition of phenolsulfonic acid, its primary action on living soft tissue mani- fests itself as a protoplasm poison, i. e., it precipitates the proteins. ANTISEPTICS 125 forming an eschar which is ultimately cast off. When brought into contact with bone or tooth structures its action depends largely upon the nature of its composition. The ortho acid acts purely as a rapid decalcifier, leaving the swelled organic matrix of the bone or tooth substance intact, while the para acid acts somewhat like sul- furic acid, i. e., it destroys the structures in toto, only to a much milder degree. Sulfuric acid acts principally as a caustic. It pre- cipitates the proteins of the soft tissues, forming a white eschar which ultimately becomes black by carbonization. When brought in contact with bone or tooth structure it kills the organic content, removes the water present, breaks up the organic material by form- ing water from the liberated oxygen and hydrogen, leaving ul- timately nothing but carbon. The calcium salts are simultaneously dissolved and removed with the organic matrix. Its action is much more rapid on dead bone or tooth structure. In regard to the anti- septic action of phenolsulfonic acid, the experimental work of Hueppe, Vigier, Serrant, Schneider, and others has clearly demon- strated the important fact that of the three types of phenolsulfonic acid, the ortho acid is the most active, and the para acid is the weakest, while the meta acid stands intermediate between the two. According to Schneider, the ortho-phenol -sulfonic acid is three times as effective as the para acid. A one per cent solution of ortho- phenol-sulfonic acid is equal in its antiseptic power to a 1 per cent solution of phenol, while, consequently a 1 per cent solution of para acid is approximately three times less effective. 1 The phenol con- tent of the phenol-sulfonic acid plays no active part in the thera- peutic effect of the latter ; the phenol is changed into a more or less inert compound by the formation of the sulfon radical. Ortho- and para-phenol-sulfonic acid may be advantageously dis- pensed with in dental therapeutics. For many years past, sulfuric acid has been used as a true bone solvent (caustic) in general surgery, and it has been employed with marked success for the same purposes in dental surgery. Its great- est benefits, however, are derived from its application for the pur- pose of opening and enlarging root-canals, and incidentally for the destruction of pulp remnants present in these canals. Callahan, 2 in 1893, advocated it for such purposes, and to him the dental pro- fession is greatly indebted for having introduced this chemic pro- cedure into operative dentistry, marking a distinct step of progress. >Prinz: Dental Cosmos, 1912, p. 397. - Callahan: Ohio Denial Journal, January, 1894. 1 26 PHAR M ACO-THKRAPEUTICS PHOSPHORIC ACID; ACIDUM PHOSPHORICUM, U. S. P.; ACIDUM PHOS- PHORICUM CONCENTRATUM, B. P. ; H 3 P0 4 ; AdDE PHOSPHORIQUE, F. ; PHOSPHORSAURE, G. It is a colorless liquid, of syrupy consistency, containing 85 per cent (66.3 per cent, B. P.) by weight of absolute orthophosphoric acid. It is colorless and has a strongly acid taste. It should be kept in glass-stoppered bottles. In commerce three kinds of phosphoric acid are met: Orthophosphoric acid, H 3 P0 4 . Metaphosphoric acid, HP0 3 (glacial phosphoric acid). Pyrophosphoric acid, H 4 P 2 7 (white, hygroscopic, glassy masses). Metaphosphoric acid is used as a component of the so-called oxy- phosphate of zinc dental cements. A satisfactory acid for dental cement powders may be prepared as follows: 1 ounce (30 Gm.) pure zinc phosphate, 20 ounces (600 Gm.) glacial phosphoric acid in sticks, and 10 ounces (300 Gm.) distilled water, all quantities by weight, are placed in a glass-stoppered bottle, and set aside in a moderately warm place and occasionally shaken until the solution is completed. The acid is then filtered through a cone of glass wool placed tightly into the neck of a glass funnel. The first portions of the filtrate are returned to the funnel until the solution runs off perfectly clear. The acid is immediately transferred to small dry glass bottles and tightly corked. If the cement, when mixed with this acid, hardens too quickly, the latter may be slightly concentrated on a sand bath; if the cement sets too slowly, a very small quantity of distilled water should be added to the acid. Oc- casionally it will be found that the last part of the acid gives poor results in mixing the cement ; it is then best to discard the fluid in- stead of trying to remedy the evil. PHOSPHORIC ACID, DILUTED; ACIDUM PHOSPHORICUM DILUTUM, U. S. P., B. P. It contains 10 per cent (13.8 per cent, B. P.) by weight of ortho- phosphoric acid. AVERAGE DOSE. 30 minims (2 C.c.) well diluted. THE ALKALIES. The antiseptic action of the alkalies depends principally on their power of disorganizing albumin by dissolution. They are there- ANTISEPTICS 327 fore, closely related to the caustics. The alkali salts which liberate oxygen or halogens during their dissociation sodium dioxid, sodium fluorid, etc. act principally through their negative ions. The hydrates of the alkalies are the strongest and the carbonates are the weakest antiseptics of this group. The soaps (alkaline oleates) are weak antiseptics; they act principally as detergents by virtue of their solvent power on fats, etc. Soaps are often combined with specific antiseptics (formaldehyd, phenol, tar, etc.), and then they become important therapeutic agents in dermatology. Liquid soap, containing alcohol with the addition of an active antiseptic, is a valuable hand disinfectant ; it is to be preferred for the operating room over the ordinary cake soap. Lime, in the form of freshly slacked lime, or milk of lime, is a powerful disinfectant for excreta, provided it is used in at least 20 per cent solutions. Its action is decidedly more powerful when combined with chlorin (chlorinated lime) . Sodium and potassium bicarbonate can not be classed as anti- septics; sodium chlorid, in a 1 per cent solution (physiologic salt- solution), heated to body temperature, may be used as a temporary mouth wash when an absolute, neutral, mild antiseptic lotion is re- quired. Ammonia is a weak antiseptic; its powerful irritating properties (see Irritants and Counterirritants) prohibits its use for antiseptic purposes. The hydroxids of potassium and sodium are powerful caustics; they are occasionally employed as antiseptics in the treatment of gangrene of the pulp. (See Decomposition of the Tooth Pulp and its Treatment.) SODIUM BORATE ; SODII BORAS, U. S. P. ; BORAX, B. P. ; Na,B 4 7 +10H,0 ; BORAX, F., G. SOURCE AND CHARACTER. It forms colorless crystals or a white powder, odorless, and having a sweetish, alkaline taste. It is sol- uble in 20 parts of water, very soluble in glycerin, but insoluble in alcohol. To a nonluminous flame it imparts an intense yellow color. AVERAGE DOSE. iy 2 grains (0.5 Gm.). THERAPEUTICS. Sodium borate is a mild antiseptic, and is free- ly employed in diseases of the mucous membranes. It is an im- portant component of the widely used Dobell 's solution. Combined with solutions of formaldehyd, it is found to be very serviceable for the sterilization of metallic instruments. 128 PHARMACO-THERAPEUTICS DOBELL'S SOLUTION (N. F.). Ifc Sodium borate gr. cxx (8 Gm.) Sodium bicarbonate gr. cxx (8 Gm.) Phenol, liquid gr. xxiv (1* C.c.) Glycerin fi$ ss (15 C.c.) Water fi$ xvi (500 C.c.) STERILIZING FLUID FOR INSTRUMENTS. IJ Solution of formaldehyd 3 v (20 C.c.) Sodium borate 3 iii (12 Gm.) Water 3 x (40 C.c.) SOAP; SAPO, U. S. P.; SAPO DURAS, B. P.; HARD SOAP; CASTILE SOAP ; SAVON, F. ; SEIFE, G. It is prepared from sodium hydroxid and olive oil. Soft Soap; Sapo Mollis, U. S. P., B. P. ; Green Soap. It is a soft, unctuous, brownish-green soap made from potassium hydroxid, linseed oil, and alcohol. Curd Soap; Sapo Animalis, B. P. It is a hard soap made from sodium hydroxid and some purified animal fat containing chiefly stearin. A very serviceable liquid soap for the operating room, which may be readily made in large quantities on an economical basis, is, ac- cording to Wilbert's 1 formula, prepared as follows: R Sodium hydrate 3 viij (32 Gm.) Potassium hydrate 3 L (200 Gm.) Cottonseed oil 3 C (400 Gm.) Alcohol 3 L (200 C.c.) Distilled water 3 D (2000 C.c.) In a suitable container, preferably a glass-stoppered bot- tle, dissolve the sodium hydrate and the potassium hydrate in 250 parts of distilled water, add the alcohol, and then add the cottonseed oil in 3 or 4 portions, shaking vigorously after each addition. Continue to agitate the mixture occa- sionally until saponification has been completed; then add the remaining portion of distilled water and mix. The only precautions that are at all necessary is to use U. S. P. grade of ingredients, and to be sure that saponification is com- plete before adding the remaining portion of the distilled water. 1 Wilbert: American Druggist, 1908, p. 139. ANTISEPTICS 129 The addition of 2 per cent solution of formaldehyd increases the antiseptic effect of this liquid soap very markedly. Liquid soap Fig. 26. Liquid soap dispenser. dispensers are at present available in the market, which materially facilitate the ready use of this toilet necessity. THE HALOGENS AND THEIR DERIVATIVES. The antiseptic value of the halogens bromin, chlorin, fluorin, and iodin depends on the chemic reaction which ensues when they are brought in contact with albumin; they substitute their own atoms for the hydrogen atoms of the albumin molecule and thereby destroy the latter. Incidentally, halogen acids are formed which act as precipitants of albumin. The halogens are rarely used as antiseptics or disinfectants in solid form or as gases ; they act only in the presence of moisture. In aqueous solution they are power- ful disinfectants, and are used as such, especially chlorin, on a large scale. Bromin or its compounds and fluorin are not employed as antiseptics. Sodium fluorid possesses powerful antiseptic prop- erties; its use has been suggested as an addition to tooth powders (see Preparations for the Mouth and Teeth), and it is largely em- ployed in the industries for checking fermentation in manufactur- ing yeast, in distilleries, breweries, etc. Head has recently intro- 130 PHARMACO-THERAPEUTICS duced an ammonium bifluorid as a "tartar solvent." (See Uric Acid Solvents.) Chlorin in the form of chlorinated lime has found a wide field of application as a disinfectant for dejecta, bedding, etc., and incidentally as a bleaching agent. (See Bleaching Agents.) lodin in compound aqueous solutions and as iodin tri- chlorid possesses powerful antiseptic properties; at one time the latter compound was recommended as an antiseptic for root canal treatment, but it has never come into general use. Tincture of iodin applied as an antiseptic has become quite prominent within the last few years. Surgeons are utilizing the powerful antiseptic properties of iodin in alcoholic solution with marked success as a means of asepticizing the skin prior to an incision. The technique is very simple. The field of operation is cleansed in the ordinary way with hot water and soap, and the tincture of iodin is painted over the surface within the region of the incision in the form of a broad band. The iodin solution keeps the bacteria and their germs fixed to the surface during the operation. The application of this method for operations in the mouth deserves to be recommended. Aseptic wounds that heal by first intention often fail to give the clean linear cicatrix aimed at by both surgeon and patient. After the sutures are removed, the margin of the incision often leaves small cuneiform fissures, which finally result in an irregular scar. To stimulate rapid cell proliferation, the slightly irritating prop- erty of tincture of iodin is useful. The action of its alcoholic com- ponent is responsible for the light form of hyperemia which, to- gether with the iodin, influences the healing of the wound most markedly, and usually a clean, small scar results. The tincture should be applied once a day for 'our or five days following the removal of the stitches. Iodin achieved its greatest triumph through its many aromatic compounds, of which iodoform is the typical representative. The various solutions of iodin are prin- cipally employed as irritants (see Irritants and Counterirritants) , while its salts are largely used as specifics in the third stage of syphilis and to favorably influence metabolism. (See Alteratives.) IODOFORM ; IODOFORMUM, U. S. P., B. P. ; CHI 3 ; TRIIODOMETHAN ; lODOFORME, F. ; JODOFORM, G. SOURCE AND CHARACTER. It is usually obtained by the action of iodin on alcohol in the presence of an alkali or alkali carbonate. It is a fine lemon-yellow powder or small crystals, possessing- a very ANTISEPTICS 131 persistent and penetrating odor and a disagreeable taste. It is practically insoluble in water, but soluble in about 50 parts of alco- hol, 6 parts of ether and fixed and volatile oils. It is incompatible with calomel, mercuric oxid, silver nitrate, tannin, and balsam of Peru. AVERAGE DOSE. 4 grains (0.25 Gm.), MEDICAL PROPERTIES. Antiseptic, alterative, and anesthetic. THERAPEUTICS. lodoform is the wound antiseptic par excellence. It has many objections which materially limit its use in surgery, lodoform, per se, does not possess antiseptic properties, in spite of its high iodin component (96 per cent) ; ordinarily it is not even sterile. Its very penetrating and persistent odor, which invades everything with .which it comes in contact, makes its use disagree- able to patient and practitioner alike. lodoform is easily decom- posed ; when it is dissolved in alcohol, ether, or fatty oils, it readily liberates free iodin. The secretions of a purulent wound contain large quantities of fatty substances which dissolve iodoform, especially when air is excluded. Iodin in statu nascenti acts as a powerful antiseptic. Certain bacteria tetanus, tubercle bacillus, etc. produce iodin reducing substances; they are, therefore, readily destroyed by iodoform. The products of bacterial activity are oxidized by iodoform, and hence it acts as a deodorant. Its slightly irritating properties stimulate cell proliferation and reduce the migrating power of the leucocytes. On irritable skin it is liable to cause various exanthematous eruptions. When larger quantities of iodoform are quickly absorbed, they produce specific intoxica- tion ; as the iodoform action is better understood, intoxications are rare at present. lodoform is a sovereign remedy to keep clean, fresh wounds aseptic and to check wound secretions. In abscess cavities and on ulcerating surfaces, or in regions which are easily infected from their surroundings the mouth it acts as an extremely service- able prophylactic. It quickly clears up and deodorizes a foul wound ; it is slightly anesthetic and favors granulation. The opinions regarding the use of iodoform in dentistry are divided. Some practitioners have lauded it very highly, especially as an excellent antiseptic in the treatment of gangrenous pulps, while others condemn it absolutely. A wrong conception regarding its action is probably responsible for these diametrically opposed views. As a component of a devitalizing paste it has no place, and, 132 PHARMACO-THERAPEUTICS since we have more powerful antiseptics for the treatment of gan- grenous pulps, it may be readily dispensed with for such purposes. In the form of a 5 or 10 per cent moist gauze it is superior to any other known iodin preparation for the dressing of foul ulcers, deep-seated pockets, purulent antra, certain disturbances arising from the difficult eruption of a lower third molar, etc. For the treatment of the purulent stages of pyorrhea, iodoform as a paste or an emulsion is still employed by many practitioners. As a com- ponent of a permanent root filling it is favored by many, although it is difficult to understand what purpose it should serve in this con- nection. To overcome the disagreeable odor of iodoform, admixtures of cumarin (the odoriferous principle of the tonka bean), ground coffee beans, thymol, menthol, etc., have been suggested, but they possess very little practical value. Whenever the odor of iodoform is positively removed, its composition is chemically altered and its therapeutic action is largely destroyed. To overcome the many drawbacks of iodoform, chemists have endeavored to create iodin compounds which are free from these objections. So far no per- fect substitute has been produced, although a few of the more re- cent compounds answer the purpose fairly well. An early repre- sentative is iodol. It is apparently less readily decomposed than iodoform, and is little used at present. Aristol thymol iodid has been widely employed for some time ; it is very readily decomposed, but its iodin component is materially less than that of iodoform. Sozoiodolates of potassium, sodium, and zinc have been prepared ; the latter salt has been quite extensively used in the past. Nosophen, antinosin, and entoxin are trade names given to iodin compounds of phenol-phthalate, while europhen is a complex preparation of cresol and iodin. Again, iodin compounds of al- bumin have been created ; iodalbin and iodof ormogen are examples of the more important representatives of this group. Recently a compound of iodin with quinolin as a base has been introduced as a substitute for iodoform under the name of viof orm ; from all ap- pearances it seems to be at present quite a favorite with the sur- geons. It is successfully employed in the mouth in all those con- ditions where iodoform is indicated. IODOL ; IODOLUM ; C 4 I 4 NH ; TETRAIODOPYRROL. It is a light grayish-brown powder, without odor or taste, in- ANTISEPTICS 133 soluble in water, but soluble in alcohol, chloroform, and ether. It contains about 89 per cent of iodin. AVERAGE DOSE. 4 grains (0.25 Gm.). THYMOL IODID ; THYMOLIS IODIDUM, U. S. P. ; C 20 H 24 2 I 2 ; DlTHYMOL-DlIODID ; ARISTOL. It is a light reddish-yellow bulky powder, with a slight aromatic odor, containing 45 per cent of iodin. It is insoluble in water and glycerin, but readily soluble in alcohol, chloroform, ether, and volatile and fatty oils. In the form of an oily solution it is used as a substitute for the tincture of iodin or the solutions of iodin in fatty oils. (See Irritants and Counterirritants.) Europhen; Diisobutyl Cresol lodid. It forms a yellow, volumi- nous powder, containing 28 per cent of iodin and having a faint, saffron-like odor. It is insoluble in water and in glycerin, but readily soluble in alcohol, ether, chloroform, and volatile and fatty oils. It resembles thymol iodid very closely in its action. Vioform; lodochloroxyquinolin; Nioform. It is a very volu- minous light-yellow powder, practically odorless, and insoluble in water, but slightly soluble in alcohol. It may be sterilized without decomposition. Vioform contains 41.57 per cent of iodin. It is nontoxic and nonirritant, and it is claimed to be an ideal sub- stitute for iodoform. It deserves to be recommended for dental purposes. A compound known as loretin has recently been introduced as an iodoform substitute; it is closely related to vioform. IODOFORM BONE PLOMBE. IJ Iodoform 3 v (20 Gm.) Oil of sesame fl3 j (30 C.c.) Spermaceti 3 ii (60 Gm.) IODOFORM PASTE. Iodoform powder is mixed with 5 per cent phenol solution ; after 24 hours the supernatant fluid is poured off, and the iodoform is mixed with lactic acid to a thick paste. This paste is used for the treatment of purulent pockets, etc., about the mouth. The odorless vioform may be substituted for iodoform in the above preparations. 134 PHARMACO-THERAPEUTICS CHLORINATED LIME ; CALX CHLORINADA, U. S. P., B. P. BLEACHING POWDER ; Sous CHLORURE DE CHAUX, F. ; CHLORKALK, G. Chlorinated lime is often improperly called chlorid of lime. It is a mixture of calcium hypochlorite, calcium chlorid, lime, and water, and it should contain not less than 35 per cent of available chlorin. It is a white or grayish-white powder, with the odor of chlorin, and giving off chlorin gas in the air, especially in the presence of an acid. It is only partially soluble in water. Chlo- rinated lime is used in the preparation of the various chlorinated solutions, as a bleaching agent, and as a disinfectant on a large scale. For the latter purposes it is best employed in the form of milk of lime, with an excess of acid ; it must be used liberally if complete success should be insured. As a deodorizer of the oral cavity in the form of a tooth powder it should not be used. PREPARATIONS. Liquor Sodce Clilorinatce, U. S. P., B. P.; Solution of Chlori- nated Soda. Labarraque's solution or eau de Javelle. It is a clear, pale green liquid, having an odor of chlorin and containing at least 2.6 per cent (2.5 per cent, B. P.) by weight of available chlorin. It readily bleaches vegetable colors, and was formerly largely used as a bleaching agent of discolored tooth structure. Liquor Golds Clilorinatce, B. P.; Solution of Chlorinated Lime. A solution of chlorinated lime, yielding about 3 per cent of avail- able chlorin. Antiformin. It is a strongly alkaline solution of sodium hypo- chlorid. It may be readily prepared by mixing equal quantities of the official solutions of soda and of chlorinated soda. Under the name of radicin it has been advocated for the treatment of in- fected root canals. Solutions Which Evolve Nascent Oxygen. Molecular oxygen, in its pure state or mixed with nitrogen and other gases in the form of air, does not manifest an inhibitory or destructive action on bacteria. For a long time chemists have been familiar with the powerful affinity of oxygen in its nascent state for other substances, which process is known as oxidation. Robin has experimentally shown that the therapeutic effect of a substance is greatly intensified if it is set free from its compound ANTISEPTICS 135 in the organism if it is present in statu nascendi. This is espe- cially true of many of the oxygen compounds. Nascent oxygen may be furnished by two kinds of autoxidizers one direct source is its allotropic form known as ozone, and the other is represented by the many dioxids, chiefly hydrogen dioxid, and those of the alkali and alkaline earth metals. The nascent oxygen obtained from both sources is based on the same principle of formation : Ozone=0 0, or 3 , is split up in 2 -}-0 (nascent state). A dioxid, 1 X 00, or X0 2 , is split up in XO-fO (nascent state) . According to Nernst, the formation and the association of ozone is illustrated by the following equation : Only one atom of the three atoms of the ozone molecule enters into active or atomic oxygen, the other two forming molecular or inactive oxygen. This very fact is true of the oxygen molecule of a dioxid one atom is set free, while the other one remains combined with the metal in the form of an oxid. The ozone molecule and the dioxid molecule play the role of a single atom of oxygen in the reaction of oxidation. The amount of available oxygen in a dioxid depends on the degree of superoxidation of the original oxid. Ozone, as well as the dioxids, are endothermic compounds that is, they require energy in the form of heat or electricity for their formation. They are comparatively easily decomposed, liberating again the same amount of energy in the form of heat which was absorbed in their formation. Ozone has, so far, been produced only as a gas, while the dioxids, with the exception of hydrogen dioxid, are solids. Oxygen obtained from ozone is usually produced by electric energy at the place of its consumption ; it is an unstable gas, which, for practical purposes, can not well be stored. The dioxids are usually fairly stable com- pounds; they furnish any fixed amount of oxygen, if so desired. at any moment, and are, in reality, transportable accumulators of available oxygen. Atomic oxygen oxygen in its nascent state has a free valency ; it can not remain in that state, but energetically seeks to combine 1 X represents any metal combined with two atoms of oxygen into a dioxid. 136 PHARMACO-THERAPEUTICS with organic matter. This powerful affinity for every oxidizable substance, including albumin, is known as oxidation, or, when ac- companied by heat and light, as combustion. The antiseptic ac- tion of the oxygen carrying metals depends on this fact. The negative nascent oxygen which is set free during ionization of the metallic dioxids is very little irritating to the soft tissue, while certain of the positive metallic ions act as caustics ; this factor pro- hibits the use of the latter compounds as wound antiseptics sodium dioxid. In the industries the powerful oxidation of albuminous sub- stances by electric ozonization is made use of in the purification of drinking water. Ozonizing plants are now in practical use in several large European cities and in the United States. It is claimed that 15 to 135 grains (1 to 9 Gm.) of ozone are sufficient for the sterilization of 24,025 cubic inches (1 cubic meter) of pol- luted water. Of the many dioxids, hydrogen dioxid, the dioxids of calcium, magnesium, and zinc, and the perborate of sodium and, indirectly, oxone, are medicinally employed. Recently some organic dioxids succinic dioxid known as alphozon, and the benzoyl-acetyl dioxid known as acetozon have been introduced as antiseptics for internal and external purposes. Aside from its action as an anti- septic and sterilizing agent, nascent oxygen is employed as a bleacher of discolored teeth, and as an oxidizing or reducing agent in certain metallurgical processes in the dental laboratory. Gen- eral medicine has made use of pure oxygen in the treatment of pulmonary diseases and as a restorative agent in accidents from general anesthesia or in poisoning with other gases. SOLUTION OF HYDROGEN DIOXID; AQUA HYDROGENII DIOXIDI, U. S. P. ; LIQUOR HYDROGENII PEROXIDI, B. P. SYNONYMS. Solution of hydrogen peroxid, pyrozon; solution de peroxide d 'hydrogen, eau oxygenee, F. ; Wasserstoffsuper- oxydlb'sung, Perhydrol, Peraquin, G. SOURCE AND CHARACTER. Hydrogen dioxid was discovered by Thenardin 1818, and was then known as oxygenated water. It was not used to any extent until Richardson, in 1860, introduced it into medicine. It is often found in small quantities in the at- mosphere after heavy storms, or by any other process in which ozone is formed in the presence of water. Whenever solutions of ANTISEPTICS 137 certain dioxids sodium dioxid or barium dioxid are treated with diluted acids, it is readily formed according to the following equation : Ba0 2 +H 2 S0 4 ==H 2 2 -fBaS0 4 . For manufacturing purposes, usually barium dioxid is decom- posed in the presence of sulphuric or phosphoric acid; the acids form an insoluble compound with the barium. For dental purposes an alkaline solution of hydrogen dioxid of various strengths may be extemporaneously prepared by dissolving sodium diborate in water. Absolute hydrogen dioxid (about 99 per cent pure) is a thick, oily colorless liquid, specific gravity 1.45 which does not congeal at 22 F. ( 30 C.). When brought in con- tact with certain metals gold, silver, platinum, etc. or when ex- posed to sunlight or heat, it readily decomposes, often with ex- plosive violence. The official preparation is a slightly acidulous aqueous solution of hydrogen dioxid, containing, when freshly pre- pared, about 3 per cent by weight of the pure H 2 2 , which cor- responds to about 10 per cent by volume of available oxygen. It has a specific gravity of 1.006 to 1.007. Its solutions are prefer- ably stored in amber-colored bottles, away from light and sudden changes of temperature. It will gradually diminish in strength, and age, heat, and protracted agitation decompose it prematurely in water and oxygen. To preserve hydrogen dioxid solution, tan- nic acid and acetanilid in small quantities have been suggested. Of the former, about 1 :6,000 and of the latter about 1 :2,000 are necessary. Almost all of the present commercial hydrogen dioxid solutions contain small quantities of acetanilid as a preservative. The ordinary 3 per cent solution may be concentrated by carefully heating it to a temperature not over 140 F. (60 C.) on a water bath. It loses chiefly water, but, when rapidly heated, it is apt to explode. It is incompatible with alkalies, albumin, ammonia, arsenous salts, phenol, chlorids, ferric salts, iodids, lime water, mercurous salts, nitrates, permanganates, sulphates, tartrates, and with most tinctures. Aside from the ordinary 3 per cent solution of hydrogen dioxid, higher concentrated solutions are found on the market. A 25 per cent solution of hydrogen dioxid in ether is known as caustic pyrozon, and a 30 per cent solution in water is known as per- hydrol, or as peraquin. Caustic pyrozon is put up in glass tubes 138 PHARMACO-THERAPEUTICS O containing a few cubic centimeters, while perhydrol is marketed in paraffin-lined bottles of various sizes. In opening a pyrozon tube great care should be exercised to prevent ex- plosion by placing the tube in cold water and wrap- ping it in a wet towel before the end is broken off. Its contents must be transferred at once to a glass- stoppered bottle, provided with a ground cap, to prevent evaporation of the ether. Perhydrol solu- tion is to be greatly preferred whenever a highly concentrated solution of hydrogen dioxid is desired. It is a chemically pure solution of H, 2 0o in distilled water, furnishing about 30 per cent by weight or 100 per cent by volume of available oxygen. It is absolutely free from acid, and may be diluted with water or alcohol to any desired strength. Solutions should preferably be made fresh when needed. If carefully preserved in the original container and stored in a cool place, perhydrol will retain its oxy- gen for some time. Very recently, hydrogen dioxid in dry form, known as perhydrit, has been placed on the market. Perhydrit is a compound of hy- drogen dioxid and urea, containing about 30-35 per cent of available hydrogen dioxid. It is a very unstable compound. A simple test for hydrogen dioxid is made as follows: Mix 10 cubic centimeters of distilled water with 10 drops of diluted sulphuric acid, 1 drop of potassium chromate test solution (1 part potassium chromate dissolved in suffi- cient water to make 100 cubic centimeters), and 2 cubic centimeters of ether. On the addition of the solution con- taining hydrogen dioxid, a blue color will appear at the line of contact which will, after shaking, separate with tho ethereal layer. AVERAGE DOSE. 1 fluidram (4 C.c.). THERAPEUTICS. The ideal external antiseptic for [resolutions 8 tne bdy the skin, external mucous membranes, and wound surfaces is a substance which destroys the bacteria and their products, but which will not harm the tis- sues of the host. Hydrogen dioxid approaches this ideal more Fig. 27. Minim syringe ANTISEPTICS 139 closely than any other known antiseptic. When brought in con- tact with bacteria and their products, it acts as a powerful anti- septic and deodorant; it is not absorbed by the tissues, but by its reaction with the living cell it is split up into oxygen and water. 1 This decomposition of hydrogen dioxid into molecular oxygen and water depends primarily upon the presence of the ferment cata- lase. This ferment is present everywhere in living animal tissues, especially in the blood and in all secretions and excretions, includ- ing the saliva. More or less all fungi and bacteria contain ap- preciable quantities of catalase. According to Heinz 2 its action on staphylococcus pyogenes aureus and bacillus pyocyaneus is recorded as follows : SOLUTION OF HYDROGEN DIOXID Concentration Staphylococcus pyogenes aureus Bacillus pyocyaneus After 24 hours After 48 hours After 72 hours After 24 hours After 48 hours After 72 hours 1 percent + + + + + + + + + 0.75 percent 0.5 percent 0.25 percent 0.1 percent. . . Much confusion seems to exist in the minds of some practition- ers relative to the nature of acidity of hydrogen dioxid solutions. It should be remembered that normally the official solution of hy- drogen dioxid is "a slightly acid, aqueous solution," the acidity corresponding to 10 C.c. of a tenth-normal sulphuric acid, V.S. (U. S. P.) to 100 C.c. of the dioxid solution. Unfortunately, many of the commercial preparations contain much higher percentages of acid, as much as 26.6 C.c. of a tenth-normal sulphuric acid has been found. While some of this acid content may be of an or- ganic nature as a result of the decomposition of the preservative acetanilid added to the dioxid solution, nevertheless, too high per- centages of inorganic acids are frequently observed. Distinct marks of decalcification of tooth structure in the mouths of per- sons who use such acid compounds as a daily mouth wash have been observed, hence the importance of rendering the dioxid solution 'Fette: Dental Cosmos, 1915, p. 615. : Heinz: Handbuch dcrHxperiinentellen Pathologic und Phannakologie, 1904. 140 PHARMACO-THERAPEUTICS alkaline by the addition of small quantities of borax at the time of its use. An absolute neutral preparation may be obtained by the proper dilution of perhydrol with distilled water. When hydrogen dioxid is brought in contact with blood, pus, serum, wound exudates, etc., it produces a heavy froth as a result of the catalytic action of the ferment catalase, incidentally destroy- ing the bacteria chemically and cleansing the wound surfaces mechanically. It acts as a strong deodorant by oxidizing the odor- ous gases arising from putrefactive processes. It should not be in- jected into pus cavities unless free drainage is established, as otherwise the free liberation of oxygen will force the infection into deeper structures. The same principle holds good in treating dis- turbances of the antrum of Highmore. To remove any obstruc- tions, it should always be preceded in such cases by copious in- Fig. 28. Pyrozon Probe Cup. jections of physiologic salt solution heated to body temperature. On fresh granulating surfaces it should not be employed, as it tends to break down this new delicate tissue growth. In the various forms of stomatitis, and as a prophylactic in mercurial ad- ministration in syphilis, it deserves to be highly recommended, and especially when combined with a metallic astringent and rendered slightly alkaline as, for instance, by the addition of small quantities of borax. H 2 2 solutions possess distinct styptic properties ; they should not be used for such purposes in root canals, as their ac- tion on the hemoglobin of the blood may cause a discoloration of the tooth structure. Strong solutions of H 2 2 (pyrozon, perhy- drol) are powerful caustics, and they are used as such for the de- struction of gum tissue, in fistulous tracts, in pockets of pyorrheal ANTISEPTICS 141 teeth, and as styptics in severe hemorrhage. Andresen 1 advocates perhydrol as the sovereign remedy in the treatment of hypersensi- tive dentin, especially in cervica* cavities. It will not blacken the cavity like silver nitrate, which is usually employed for such pur- poses, but instead whitens the tooth structure. The caustic solu- tion requires careful handling, and the soft tissues have to be well protected by suitable napkins, a coating of vaselin, etc. Burns from caustic H 2 2 solutions are relieved by immediate washings with water and covering the burned surfaces with a mild ointment. In using these powerful solutions it is good practice to pour the necessary quantity into a watch crystal or into a "pyrozon probe rap," and then apply it .with a suitable applicator, a platinum minim syringe, wooden probe, etc. Great care should be exercised to prevent the caustic solution from coming in contact with wool- en fabrics, as it will char them, or even set them on fire. ANTISEPTIC SOLUTIONS. R Hydrargyr. chlorid. gr. j (0.06 Gm.) Aquae hydrogen, dioxid. fig ij (60 C.c.) M. Sig.: Inject with a platinum pointed syringe into pus pockets in pyorrhea. I Resorsinol 3 j (4 Gm.) Zinc, chlorid. gr. x (0.65 Gm.) Menthol. gr. xx (1.3 Gm.) Thymol. gr. xv (1.0 Gm.) Glycerin. fig j (30 C.c.) Alcohol. &$ ij (60 C.c.) Aquae hydrogen, dioxid. ad fl3 viij (240 C.c.) M. Sig.: Teaspoonful in a tumblerful of warm water as a gargle in syphilis of the mouth. OXYGEN ; OXYGENIUM, U. S. P. ; O ; OXYGENE, F. ; SAUERSTOFF, G. SOURCE AND CHARACTER. Oxygen may be prepared from heat- ing at a low temperature a mixture of 5 parts of potassium chlo- rate and 1 part of manganese dioxid. It must be purified before storing by passing it through wash bottles containing alkali, and is dried by passing it through sulphuric acid. It may be liquefied 1 Andresen: Deutsche Monatsschrift fur Zahnheilkunde, 1905, p. 25. 142 PHARMACO-THERAPEUTICS by pressure, forming a bluish liquid, which can be readily stored in steel cylinders. In commerce these cylinders contain 40, 75, and 100 gallons of the compressed gasrespectively, and are painted red to differentiate them from the nitrous oxid cylinders, which are painted black. Pure oxygen is readily obtained by decomposing oxone, a solid, fused sodium dioxid. Oxone is neither combustible nor explosive; it may be stored in air-tight tin cans for any length of time, or may be transported without danger, and is always ready for use. When oxone is brought in contact with water it instantaneously produces oxygen. Approximately one pound (453 Gm.) furnishes Fig. 29. Oxygen inhalation apparatus. A cylinder of liquid oxygen connected with a wash bottle half filled with water, and rubber tubing, ready for use. two cubic feet (60 liters) of pure oxygen, which corresponds to about 320 times its own weight. A very simple apparatus, the oxone generator, made by the Foregger Company, Inc., of New York, is readily available for such purposes. One charge of the apparatus furnishes about fourteen to fifteen gallons of pure oxygen within a few moments' time. So far as known, it is the simplest method of obtaining pure oxygen for medicinal purposes and for the laboratory. The value of an oxone generator is readily appreciated by those w r ho utilize pure oxygen in their practice. Oxygen is a colorless, inodorous gas; 1 liter weighs 1.43 grams ANTISEPTICS 143 at 32 F. (0 C.), and 100 volumes of water at 32 F. (0 C.) dis- solve 4.1 volume of oxygen. It combines readily with most ele- ments, forming oxids. This process is known as oxidation, and, when attended by great heat and light, as combustion. THERAPEUTICS. Oxygen is necessary to carry on life. In the form of air (% of the atmosphere is oxygen, the remainder being nitrogen, with small proportions of carbon dioxid, etc.), it fur- nishes the means for oxidation of some of the waste products of the body. In plant life two processes, oxydase and catalase, re- spectively bind or furnish free oxygen. The latter is essential for the maintenance of the vegetable cell. In medicine pure oxy- l-'ig. 30. Portable oxone generator (Autogenor). Closed. gen gas is used by inhalation in pulmonary diseases and as a re- storative agent in those conditions where the tissues have been im- perfectly supplied with this gas as in coal gas poisoning, anes- thesia, etc. It is also used, in combination with nitrous oxid, for anesthetic purposes to overcome cyanosis and to furnish enough oxygen with the anesthetic vapor to maintain life. CALCIUM DIOXID; CALCII DIOXIDI; Ca0 2 ; CALCIUM PEROXID; BORITE. It is a light-yellow powder, odorless and tasteless, and contain- ing about 13 per cent available oxygen. It is almost insoluble in 144 PHARMACO-THERAPEUTICS water, but decomposes in the presence of moist organic matter. Weak acids readily decompose it into active oxygen and, usually, into insoluble calcium salts. Calcium dioxid has been advocated as a component of tooth powders for the purpose of liberating free oxygen in the mouth. It is not as well suited for this purpose as some of the other oxygen compounds. (See Preparations for the Mouth and Teeth.) As an internal remedy it is much lauded in acid dyspepsia and in summer diarrhea of children in 3 to 10- grain (0.2 to 0.6 Gm.) doses. Calcium dioxid is also largely used Fig. 31. Portable oxone generator (Autogenor). Opened. in the industries as a harmless preservative of foods, for aging beverages, as a preventive of seed diseases, etc. MAGNESIUM DIOXID; MAGNESII DIOXIDI; Mg0 2 ; MAGNESIUM PER- OXID; MAGNESIUM PERHYDROL; BIOGEN. It is a compound of magnesium dihydroxid and magnesium hy- droxid, containing from 20 to 30 per cent of pure magnesium di- oxid and averaging about 7 to 8 per cent available oxygen. It is a tasteless, white, amorphous powder, almost insoluble in water, but readily soluble in the presence of acid media. On account of its very mild alkalinity it is much lauded as a component of tooth powders (see Preparations for the Mouth and Teeth), and is freely administered internally in 4 to 8-grain (0.25 to 0.5 Gm.) doses in rheumatism, diarrhea, intestinal diseases, etc. As a means of furnishing free oxygen to cell activity and thereby increasing ANTISEPTICS 145 metabolism, it is recommended, although the claims for such ac- tion have as yet not been substantiated. Under the name of biogen it has been widely advertised for such purposes. Mag- nesium dioxid can be safely employed as a harmless disinfectant for the sterilization of drinking water. STRONTIUM DIOXID; STRONTIUM DIOXIDI; Sr0 2 ; STRONTIUM PEROXID. It contains about 80 per cent of pure strontium dioxid and fur- nishes about 12 per cent available oxygen. It is a voluminous white powder, almost insoluble in water, but parts with its oxy- gen in the presence of acids. In its general behavior it resembles closely calcium dioxid, and is used more or less for the same pur- poses. SODIUM DIOXID; Soon DIOXIDI; Na 2 2 ; SODIUM PEROXID. Sodium dioxid is a yellowish powder, which is readily soluble in water, developing great heat with the formation of caustic soda and the evolution of hydrogen dioxid. It is a very hygroscopic salt, and must be kept in tightly closed tin cans or glass bottles. To ascertain its efficiency, the following simple test may be em- ployed: In a clean, dry test tube place about 15 grains (1 Gm.) of the powder and add to it 15 to 30 minims (1 to 2 C.c.) of water. If the specimen is of a good quality, enough oxygen should be gen- erated to kindle a glowing splinter held at the mouth of the tube. Sodium dioxid is an exceedingly active oxidizer. It was intro- duced into dentistry in 1893 by Kirk for the purpose of bleaching teeth (see Bleaching Agents) and for the treatment of putrescent root canals. (See Decomposition of the Tooth Pulp, etc.) For such purpose it is used as a dry powder or in the form of a concen- trated aqueous solution. The latter is best prepared extempo- raneously as follows: Place a thin beaker, holding a few drams of distilled water, in a basin filled with cold water or pounded ice, and sift slowly small quantities of sodium dioxid into the water until a saturated solution is obtained, which is manifested by a semi- opaque appearance of the latter. The dioxid solution will clear up in a few moments, presenting a straw-colored appearance, when it is ready for use. When sodium dioxid is fused, a solid mass is obtained, which is marketed as "oxone. " (See Oxygen.) 146 PHARMACO-THEKAPEUTICS ZINC DIOXID; ZINCI DIOXIDI; Zn0 2 ; ZINC PEKOXID; ZINC PER- HYDROL; DERMOGEN. It is a superoxidized zinc oxid, containing about 45 per cent of pure zinc dioxid, and averaging about 8 per cent available oxygen. It is a yellowish-white powder, insoluble in water, but readily soluble in an acid medium. In the presence of moisture from a wound, moist skin surfaces, etc., it will slowly and continuously liberate active oxygen; the remaining zinc oxid is a nonirritating astringent. Hence its greatest field of therapeutic application lies in the domain of the dermatologist. It is widely used in skin dis- eases as a dusting powder or in the form of ointments, and it is much lauded for the treatment of burns. When applied in the form of an ointment it should never be mixed with an animal fat, as it will decompose the latter, forming rancid (fatty acid) com- pounds with the ointment base, which would, of course, irritate the skin or wound surfaces. Liquid or solid petrolatum are the only permissible bases for such purposes. n Zinc, dioxid. 3 j (4.0 Gm.) Petrolat. alb. 5 j (30.0 Gm.) M. f. ungt. Sig.: Ointment for burns. $ Zinc, dioxid. 5 ij (8.0 Gm.) Acid, boric. 3 ss (15.0 Gm.) Talc, purific. ad 5 ij (GO.O Gin.) M. f . plv. Sig.: Dusting powder for wounds. SODIUM DIBORATE; Soon PERBORAS, U. S. P. ; NaB0 3 +4H 2 ; SODIUM PERBORATE. It should furnish not less than 9 per cent of available oxygen. It is a white crystalline powder, readily soluble in about 40 parts of water forming a colorless alkaline solution of hydrogen dioxid. With u rise of temperature and the addition of small quantities of acids, the solubility of sodium diborate is increased and solutions of various strengths may be readily obtained. Extemporaneously, solutions of this mixture may be prepared as follows: 2 PER CENT (BY VOLUME) SOLUTION. R Sodium diborate 3 j (30 Gm.) Boiling distilled water, enough to make flj xxxij (1000 C.c.) Filter if necessary. ANTISEPTICS 147 5 PER CENT (BY VOLUME) SOLUTION. R Sodium diborate 3 ii (C5 Gm.) Tartaric or citric acid, powdered 3 v (20 Gm.) Boiling distilled water, enough to make fl3 xxxij (1000 C.c.) Filter if necessary. 10 TO 12 PER CENT (BY VOLUME) SOLUTION. f Sodium diborate 3 vij (210 Gm.) Tartaric or citric acid, powdered 3 iijss (100 Gm.) Boiling distilled water, enough to make fl5 xxxij (1000 C.c.) Filter if necessary. On account of their mild alkalinity, these freshly made solu- tions of hydrogen dioxid are especially useful in those diseases of the mucous membrane where the acidity of the ordinary hydro- gen dioxid is an objection. As an addition to tooth powders, dust- ing powders, dry dressings, etc., sodium diborate is a valuable means of furnishing nascent oxygen in the presence of moisture. PERGENOL. A mixture of sugar, citric acid and sodium diborate and compressed into tablets and recommended for the extempora- neous preparation of dioxid solutions. Recently some organic dioxids have been introduced. These substances part with their oxygen less readily than the inorganic oxygen compound. Commercially, two of these compounds are available at present alphozon, a succinyl dioxid, and acetozon, a benzoyl-acetyl dioxid. Both chemicals are advocated as inter- nal antiseptics and as bleaching agents. Their chemistry and physiologic action is at present not fully worked out. OXYGENATED TALCUM POWDER. Purified talc 3 iij (94 Gm.) Sodium diborate 3 j ^4 (5 Gm.) Essence of violet gtt. xvi (1 C.c.) 148 PHAKMACO-THERAPEUTICS OXYGENATED HAND CLEANSER (FINGER BLEACH). Castile soap, powdered 3 j (30 Gm.) Pumice stone, powdered 3 ss (2 Gm.) China clay % jss (45 Gm.) Sodium diborate 3 v (20 Gm.) Oil of sweet orange gtt. viij (*& C.c.) Oil of bergamot gtt. viij (*/ C.c.) Oil of bitter almonds gtt. xxxij (2 C.c.) POTASSIUM PERMANGANATE; POTASSII PERMANGANAS, U. S. P., B. P.; KMn0 4 ; PERMANGANATE DE POTASSE, F. ; UEBERMANGAN- SAURES KALI, G. SOURCE AND CHARACTER. It appears in dark-purple or deep violet-red slender crystals, which have a bluish, metallic luster. It is odorless and has an astringent taste. It is readily soluble in 15 parts of water at ordinary temperature, very soluble in boiling water, while when brought in contact with alcohol it is decom- posed. Its aqueous solutions, which react neutral to litmus paper, have a deep-violet color when concentrated and a rich rose color when much diluted. Readily oxidizable substances as glycerin, citric acid, acetic acid, tartaric acid, sugar, gum, tannin, etc. are quickly oxidized when brought in contact with potassium per- manganate solutions. When mixed with glycerin, syrup, and other organic liquids, or when triturated in a mortar with sulphur or other inflammable bodies, the mixture readily explodes. Solution of Potassium Permanganate; Liquor Potassii Per- manganas, B. P. A 1 per cent solution of the salt in water. A paste made of potassium permanganate, charcoal, and petro- latum is known as styptogan, and is used as an external styptic. Condy's fluid, a commercial preparation, which is much used in Great Britain, is a concentrated solution of potassium perman- ganate, and is principally employed for disinfecting purposes. THERAPEUTICS. Potassium permanganate has been much lauded as an oral antiseptic and deodorant. Only concentrated solutions are of service for such purposes, but, on account of the persistent discoloration of the teeth resultant from the precipita- tion of manganese oxid and of the deleterious action on tooth sub- stances, it should not be used in the mouth. In weak solutions (1:2,000) it is of some service in washing out abscess cavities, the antrum of Highmore, etc. Recently concentrated solutions ANTISEPTICS 149 of potassium permanganate have been recommended for the local treatment of snake bites. When it comes in direct contact with the poison it has undoubtedly some value, and it may be used for such purposes as a wash. POTASSIUM CHLORATE ; POTASSII CHLORAS, U. S. P., B. P. ; KALIUM CHLORICUM, P. G. ; KC10 3 . SYNONYMS. Chlorate of potash, kali oxymuriaticum ; chlorate de potasse, F. ; Chlorsaures Kali, G. SOURCE AND CHARACTER. It appears in colorless, shining plates or crystals; it is odorless, and has a soothing saline taste and a neutral reaction. When heated to about 634 F. (334 C.) it melts, and at a slightly higher temperature gives up free oxygen. Potassium chlorate is soluble in about 16 parts of water at ordi- nary temperature, very soluble in hot water, and soluble in about 130 parts of alcohol. When brought in contact with organic mat- ter cork, tannic acid and its many modifications, sugar, etc. or with easily oxidizable substances sulphur, phosphorus, antimony sulphid or if the mixture is subjected to heat, trituration, or concussion, violent explosions are liable to occur. Special care should be exercised in prescribing the salt as a component of tooth powders. THERAPEUTICS. Potassium chlorate has a very limited range of usefulness. At one time it was believed that this salt possessed specific properties which made it invaluable for the treatment of infectious disturbances of the oral cavity. This belief is still en- tertained by many practitioners. Kobert, Cushny, Heinz, and others have called attention to the easy manner in which this salt is readily absorbed by the tissues when used as a gargle. After it has entered the blood it produces severe changes, resulting in the destruction of the red blood corpuscles, with the production of hemoglobinuria, a condition which is known as "potassium chlorate poisoning." Cases are on record where the simple gar- gling with potassium chlorate solution has resulted in death. About 90 per cent of the absorbed potassium chlorate is excreted by the urine, and the balance leaves the body through the salivary and other glands. Its antiseptic action is about equal to sodium chlorid. Recently potassium chlorate has been again introduced in the form of a tooth paste, containing 50 per cent of the salt, as a panacea for the treatment of mercurial stomatitis, gingivitis, 150 PHARMACO-THERAPEUTICS and other disturbances of the oral cavity. Potassium chlorate in the form of a paste, powder, or as a gargle in diseases of the mouth, or as a toilet requisite for daily use, should be emphatic- ally prohibited. Antiseptics of the Aromatic Series. According to the earliest historical records, the balsams, the spices, and wood tar and many of its derivatives have been util- ized to check the effects of decay and to heal wounds. The Assy- rians, Persians, and especially the Egyptians employed these sub- stances very largely for the preservation of their dead by embalm- ing. Herodotus has left us a fairly good description of the meth- ods employed by the Egyptians. After a person had died the brain and abdominal viscera were removed, the body was thor- oughly washed and cleansed, and saturated with aromatic sub- stances and bitumen. It was then subjected for seventy days to a strong brine solution, dried, and wrapped or swathed in cloth that was liberally saturated with aromatics. The prepared body was then "laid to rest in the tomb to await the summons to the Elysian fields of Aahlu. " With the introduction of phenol into surgery by Lister in 1868 the aromatics have become important factors in the treatment of wounds. A very large number of chemicals belonging to the aromatic series have been discovered within the last thirty years; some have become important constituents of materia medica, while others, after a very brief sojourn, have been discarded. Of the hydroxyl compounds, phenol, C H 5 OH, is the most im- portant member; it is the oldest important representative and is still largely used. By substituting chlorin for hydrogen in the benzol ring, monochlorophenol, C ( ,H 4 C10H, is formed. By oxida- tion three dioxybenzols are obtained, of which rcsorcinol. C ); H 4 (OH) 2 stands out very prominently. The latter is reported as being an oral antiseptic of some repute. Closely related to the phenols are the cresols; the latter are largely used at present in the form of cresol, C.EL.OH that is, a mixture of the three isomeric cresols, or in the form of any of the many modifications of which the compound solution of cresol is the best representative. Thymol, C 10 H 14 0, and its isomer carvacrol, are prepared from oil of thyme. The former is much lauded in dentistry. Of the naphtols the betanaphtol, C, H 7 OH (hydronaphtol) has found ANTISEPTICS 151 many admirers. Creosote, a mixture of phenol and phenol deriva- tives, prepared from beechwood tar, has been used widely in den- tistry, even long before the inauguration of the antiseptic era. Its chief constituents, guaiacol, C 7 H 8 2 , is much praised, either alone or in any of its many modifications, as an internal antiseptic in tuberculosis. Through the introduction of the carboxyl group, COOH, into the aromatic series many important compounds are formed which are much less poisonous than the original phenol. Some of the important representatives of this group are salicylic acid and benzoic acid, and their many derivatives. A very large group of aromatic antiseptics is represented by the essential oils and their derivatives, and their importance in dentistry necessi- tates detailed description in a special chapter. The antiseptics of the aromatic series play a very important role in the practice of conservative dentistry and oral hygiene, and are principally applied locally. When the aromatic poisons are brought in contact with living protoplasm, they kill the cell with- out visible changes, and consequently they are referred to as protoplasm poisons. It is claimed, and clinical experience seems to verify this fact, that a solution of several antiseptics of this and other groups are more strongly antiseptic than those containing only an equal percentage of the individual chemical. The strong- est antiseptic action is obtained from those substances which are readily soluble in a fluid which is also soluble in the protoplasm of the cell. Quite a few of the antiseptics of the aromatic series act as caustics by precipitating albumin when applied in concen- trated aqueous solution. It should be borne in mind, however, that the newly formed precipitate is of a loose, flocculent nature, Avhich does not check the further penetration of the antiseptic. PHENOL ; PHENOL, U. S. P. ; ACIDUM CARBOLICUM, B. P. ; C (i H,,OH; CARBOLIC ACID. SYNONYMS. Phonic or phenylic acid, phenyl hydroxid, hy- drozybenzol ; acide phenique, F. ; Carbolsaure, G. SOURCE AND CHARACTER. Phenol was discovered in 1834 in coal tar by Runge. It is obtained from coal tar by fractional dis- tillation or made synthetically. It appears in colorless, needle- shaped crystals or white masses, which melts at about 104 F. (40 C.), having a peculiar odor and a sweetish, burning taste. It is deliquescent in moist air. By ago the liquid phenol usually 152 PHARMACO-THERAPEUTICS acquires a slightly pinkish tint ; this is not, however, an indication of any impurity, as it develops most rapidly in the pure acid and does not in any way affect its medicinal action. Phenol is soluble in about 20 parts of pure water at ordinary temperature; it is very soluble in alcohol, ether, chloroform, and glycerin, and in fixed and volatile oils. It reacts faintly acid to blue litmus paper. Phenol is frequently confounded with creosote, with which it is identical in many points. CHIEF POINTS OF DIFFERENCE BETWEEN PHENOL AND CREOSOTE. PHENOL. Soluble in about 20 parts of water. Freely soluble in glycerin. Crystallizable. Ferric chlorid test solution produces a permanently violet-blue color. CREOSOTE. Soluble in about 140 parts of water. Insoluble in glycerin. Not Crystallizable. Ferric chlorid test solution produces a very transient violet-blue color. It is stated in some text books that phenol will coagulate al- bumin, while creosote will not. This certainly is a mistake, as both behave in exactly the same manner toward albumin. AVERAGE DOSE. 1 grain (0.065 Gm.). MEDICAL PROPERTIES. Antiseptic, antipyretic, caustic, anes- thetic. PREPARATIONS. Phenol Liquefactum; Liquid Phenol, U. S. P. ; Acidum Car- bolicum Liquefactum, B. P. ; Liquid Carbolic Acid. It is liquefied phenol, containing about 13.6 per cent by weight of water. Aver- age dose, 1 minim (0.05 C.c.). Glyceritum Phenolis; Glyceriie of Plienol, U. S. P. ; Glycerinum Acidi Carbolici, B. P. A mixture of 20 parts of liquid phenol and 80 parts of glycerin. Unguentum PJienolis; Ointment of Phenol, U. S. P. ; Unguen- tum Acidi Carbolici, B. P. ; Ointment of Carbolic Acid. It con- tains 5 per cent of phenol. Zinci Phenolsulphonas ; Zinc Phenolsulphonate, U. S. P. ; Zn(C 6 H 5 O 4 S) 2 4-8H 2 0; Zinc Sulphocarbolate. It forms colorless, transparent crystals, odorless, and has an astringent, metallic taste. It is soluble in 1.7 parts of water or alcohol. GENERAL AND LOCAL ACTION. Phenol, when administered in- ternally in very diluted form, is promptly absorbed and exercises a definite influence on the central nervofs system. It acts as a ANTISEPTICS 153 depressing and stupefying agent, but rarely produces convulsions in man. The i aspiration and the heart's action are accelerated and the temperature is slightly decreased, while the secretions are increased. The urine becomes brownish-black ; it should be under- stood that this discoloration is not due to the presence of blood, but is due to the phenol administration. Locally applied, phenol acts as a general protoplasm poison. Phenol solutions are only weakly ionized; their action does not depend so much on the ion, C 6 H 5 0, as on the whole molecule, C 6 H 5 OH, and this is partially the reason why the phenol salts, which are much more readily dis- sociated in solution, are much less active antiseptically. Phenol precipitates albumins and proteins, but the resultant precipitate is quite different from that formed by tannie acid or the metallic salts. The phenol precipitate of albumin is of a loose, flocculent nature; it does not prevent the further penetration of the phenol, and the latter may be readily washed out from the precipitate. The question of phenol coagulation at one time gave rise to heated discussions in dental circles until York, in 1899, proved the sound- ness of the above mentioned facts. On bacteria the action of phenol varies greatly with the species of the .micro-organisms. The ordinary pyogenic bacteria are usually readily destroyed by a 3 to 5 per cent solution, while spores are very resistant even to con- centrated solutions. "When applied to the skin in concentrated solution, phenol produces a white opaque scar, which falls off in a few days, leaving a light, reddish-brown stain, which may re- main for several days, or even weeks. Even in weak solution (5 per cent), when applied for some time and prevented from evaporation, it may produce necrosis of the parts. Numbness of the covered area, or even almost complete anesthesia, may accom- pany the phenol application. If phenol is applied to mucous membranes in concentrated solution, it produces sloughing, and acute inflammation may follow. Sometimes general effects are observed from the absorption of large quantities of the solution when applied locally. Phenol is rather a poor deodorant as com- pared with cresol and similar bodies. It should be remembered, however, that deodorization does not mean antiseptic action. THERAPEUTICS. The antiseptic value of phenol in solution de- pends largely on the solvents used. If a chemical is to penetrate into the structure of an organism (bacterium), it must be as solu- ble in the cell fluids as in the fluids in which it is applied. Koch 154 PHARMACO-THERAPEUTICS pointed out long ago that phenol and other antiseptics dissolved in alcohol and especially in oil are practically valueless when ap- plied as antiseptics. It is interesting to observe that, on the other hand, the addition of small quantities of sodium chlorid to an aqueous phenol solution increases its antiseptic action very mark- edly. Temperature also has a decided influence on the antiseptic action of phenol solution. Raising the temperature to 120 to 140 F. (50 to 60 C.) increases its disinfecting action very materially Phenol solutions are rarely used at present for surgical purposes ; its irritating action and the possibility of producing necrosis are probably the chief factors of its elimination from wound surfaces. As a gargle from 1 to 2 per cent solutions are employed. Carbo- lated oil or vaselin (5 to 10 per cent) are recommended as lubri- cants for surgical instruments. Liquid phenol is quite freely used as a caustic for small tumors, gum tissue, fistulous tracts, abscess cavities, etc. Its application should be always immediately fol- lowed by alcohol to limit its action. TOXICOLOGY. Phenol is frequently taken with suicidal intent. It is a most deadly poison ; the lethal dose is about 0.25 C.c. of the official liquid phenol per pound of body weight and usually it produces its effects very quickly. The presence of food in the stomach greatly increases the chances of recovery, even though a large quantity of the poison has been taken. The odor of phenol and the caustic action on the mucous membranes of the mouth and the lips are in most cases readily recognizable symptoms of phenol poisoning. The treatment consists of the removal of the poison with the stomach tube and the administration of demulcent drinks, as white of egg, or lime suspended in sugared water. Ac- cording to Macht, 1 lavage of the stomach is the prime requisite in treating phenol poisoning. From experimental study of the sub- ject, he reaches the following conclusions : 1. The efficiency of lavage in phenol poisoning depends on the quantity of poison taken, on the time after poisoning that the lavage is begun, and on the solution used for washing the stomach. 2. A strong solution of sodium sulphate appears to be the most useful for the purpose ; next in efficiency comes plain water. 3. The influence of alcohol in phenol poisoning depends on 1 Macht: The Johns Hopkins Hospital Bulletin, Vol. XXVI, April, 1915. ANTISEPTICS 155 the time of its administration. An animal that is previously in- toxicated with alcohol can withstand better the effects of phenol taken afterwards. On the other hand, alcohol administered to an animal after poisoning with phenol, will aggravate the symptoms and hasten death. 4. The use of alcohol in phenol poisoning should therefore be strongly discouraged. Heat applied to the body surfaces and the judicious use of gen- eral stimulants are useful adjuncts. As stated above the internal administration of alcohol in the belief of forming definite chemic inert compounds with phenol is a mistaken idea, as there is no evidence of chemic antagonism between the two substances. Vinegar given in large quantities has also proved to be affective. Recently tincture of iodin administered in very diluted form, one dram (4 C.c.) in a tumblerful of water, has been found to be ser- viceable. The local caustic effects of phenol may be quickly miti- gated by thoroughly washing the parts with alcohol, which dis- solves the phenol, and then covering the cauterized surfaces with a bland ointment. Quite a large number of phenol compounds have been favorites with dental practitioners. Some of the better known compounds, including their approximate composition, are the following: SOLUTION OF SODIUM PHENOLATE (PHENOL SODIQUE). B Phenol crystals I j (30 Gm.) Sodium hydrate 3 ss (2 Gm.) Water I j (30 C.c.) Dissolve the sodium hydrate in the water, add the phenol, and warm gently. CAMPHORATED PHENOL; CARBOLATED CAMPHOR; CAMPHO- PHENIQUE. A solution of camphor and phenol in liquid petrolatum. It is a simple solution of the two components and not, as it has been claimed, a new chemic compound. It is much less caustic than liquid phenol, the camphor and the liquid petrolatum act as sol- vents and diluents of the phenol and prevent its ready action on the tissues. 156 PHARMACO-THERAPEUTICS R Phenol crystals 3 ij (8 Gm.) Camphor 3 iv (16 Gm.) Liquid petrolatum fl3 iv (16 C.c.) Place the components in a dry bottle, and within a few hours they will form a homogeneous liquid. A more effective and widely used substitute has the following composition : IJ Phenol crystals 5 j (30 Gm.) Camphor I ij (60 Gm.) Alcohol fl3 iiss (10 C.c.) Prepare as directed above. PHENOLATED THYMOL; THYMOL-CAMPHENE. A solution of phenol, thymol, and camphor. It is much lauded in the treatment of putrescent root canals. R Phenol crystals 3 ij (8 Gm.) Thymol 3 ij (8 Gm.) Camphor 3 j (4 Gm.) Place the components in a dry bottle, and within a few hours they will form a homogeneous liquid. BLACK'S 1-2-3. R Oil of cassia fl3 j (4 C.c.) Phenol crystals 3 ij (8 Gm.) Oil of wintergreen fl3 iij (12 C.c.) Mix the oils and add the melted crystals of phenol. ARKOVY'S MIXTURE. IJ Phenol crystals 3 ij (8 Gm.) Camphor 3 j (4 Gm.) Oil of eucalyptus fl3 j (4 C.c.) MONOCHLOROPHENOL ; PARA-MONO-CHLORO-PHENOL ; C 6 H 4 C1(OH). A product of chlorin substitution, replacing one or more hydro- gen atoms of phenol. It appears in colorless crystals, very soluble in ether and alkalies, less soluble in water. In many respects it acts like phenol, but it is much more poisonous to micro-organ- isms. It possesses very strong disinfecting properties, and has a great power of penetration. It acts as a valuable obtundent. ANTISEPTICS 157 Walkhoff, Romer, Dorn, Michel, and others have lauded its value in the treatment of pyorrhea alveolaris. CREOSOTE ; CREOSOTUM, U. S. P., B. P. ; BEECHWOOD CREOSOTE ; OIL OF SMOKE. SOURCE AND CHARACTER. Creosote is a mixture of phenols and phenol derivatives, chiefly guaiacol and cresol, obtained from wood tar, preferably from beech tar. It is an almost colorless, yellow- ish oily liquid, with a smoky odor and a burning, acrid taste. It is soluble in about 140 parts of water at ordinary temperature, readily soluble in alcohol, ether, chloroform, and fixed or es- sential oils. AVERAGE DOSE. 3 minims (0.2 C.c.). THERAPEUTICS. Creosote was introduced into dentistry soon after its discovery by Reichenbach (1830), and it at one time oc- cupied a very prominent place in dentistry, being the most im- portant antiseptic used for the treatment of diseases of the pulp. At present it is obsolete, and phenol, cresol, and the many modern antiseptics have taken its place. Creosote that is, beechwood creosote should not be confounded with coal tar cresote, a sub- stance prepared from coal tar. The latter is of a different compo- sition and poisonous, and should not be substituted for beech- wood creosote. GUAIACOL; GUAIACOL, U. S. P.; C 7 H 8 2 . It is one of the principal products of beechwood creosote, or pre- pared synthetically. It is a colorless crystalline solid, melting at about 85 F. (30 C.), or a colorless refractive liquid, having an agreeable aromatic odor. It is soluble in about 55 parts of water, in alcohol, ether, and glycerin. Guaiacol Carbonate, U. S. P., also known as duotal, is a deriva- tive of the above compound. Average dose, 8 minims (0.5 Gm.). CRESOL; CRESOL, U. S. P.; C 7 H 7 .OH; TRICRESOL. SOURCE AND CHARACTER. Cresol presents a mixture of three isomeric cresols obtained from ^oal tar, freed from phenol, hydro- carbons, and water. Commercially the mixture is known as tricresol. It is a straw-colored reactive liquid, having a phenol- like odor and turning brown on prolonged exposure to light. Cresol is soluble in 60 parts of water at ordinary temperature, and 1 58 PHAttMACO-TilEUAPEUTiCg it is miseiblc with alcohol, ether, glycerin, and alkali hydroxid solution. By fractional distillation the following constituents are obtained : Orthocresol, at about 371 F. (188 C.), colorless crystals. (35 per cent.) Paracresol, at about 389 F. (198 C.), crystalline masses. (25 per cent.) Metacresol, at about 394 F. (201 C.), light-yellowish liquid. (40 per cent.) Kresamin is the name given to a clear watery solution of 25 per cent of tricresol and 25 per cent of ethylen-diamin. AVERAGE DOSE. 1 minim (0.05 C.c.). THERAPEUTICS. Cresol is a strong antiseptic, resembling close- ly phenol in its general action. It is said to be about three to four times as strong as phenol, but less poisonous. Metacresol is by far the most active of the cresols. The cresols are principally used as external antiseptics and as germicides. Like all phenols, they act as local obtundents. The cresols are soluble in solutions of certain organic substances in soap solution and other alkaline solutions. The most important representative of this group is : Compound Solution of Cresol; Liquor Cresolis Compositus, U. S. P. ; Lysol. It is a 50 per cent solution of cresol in a linseed oil soap ; it mixes freely with water, forming a clear solution, which is very soapy in its nature. Solveol and solutol are similar compounds, while creolin is an emulsion of cresols with resin soap. RESORCINOL-; RESORCINOL, U. S. P.; C 6 H C O 2 . SYNONYMS. Resorcin, metadioxybenzol. SOURCE AND CHARACTER. A neutral or slightly acid diatomic phenol obtained from benzol by various processes. It is found in galbanum, asafetida, ammoniac, and other gum resins. It ap- pears in colorless or slightly pinkish crystals, having a faint odor and a sweetish, disagreeable taste. It is soluble in 0.5 parts of water or alcohol, readily soluble in ether and glycerin and melts at about 248 F. (120 C.). It is incompatible with ferric salts and bromin water. AVERAGE DOSE. 2 grains (0.125 Gm.). MEDICAL PROPERTIES. Antiseptic and disinfectant; internally, antipyretic. THERAPEUTICS. Resorcinol is much lauded as an antiseptic for ANTISEPTICS 159 the oral cavity. A 2 per cent aqueous solution, flavored with an essential oil, may be used with impunity as a mouth wash. While resorcinol seems to be as antiseptic as, or even more strongly anti- septic than, phenol, it is at present seldom employed as a sub- stitute for the latter. In the form of an ointment (5 to 10 per cent) it is much used in skin diseases. COMPOUND RESORCINOL OINTMENT. H Resorcinol 3 jss (6 Gm.) Zinc oxid 3 jss (6 Gm.) Bismuth subnitrate 3 jss (6 Gm.) Oil of cade 3 iij (12 C.c.) Petrolatum 3-ijss (10 Gm.) Hydrous woolfat I j (35 Gm.) Make into an ointment. BENZOIC ACID; ACIDUM BENZOICUM, U. S. P., B. P.; HC 7 H 5 2 . SYNONYMS. Flowers of benzoin ; acide benzoique, B. ; Benzoe- saure, G. SOURCE AND CHARACTER. An organic acid obtained from ben- zoin by sublimation, or prepared artificially, usually from toluol. It may be prepared also from hippuric acid and other organic compounds. It appears in light, feathery needles, having a slight- ly aromatic odor and a warm, acid taste. It is soluble in about 281 parts of water and 15 parts of boiling water, readily soluble in alcohol, ether, and in fixed or volatile oils. Its solubility in water is much increased by the addition of borax or other alkalies. It is incompatible with mercuric chlorid and many of the other metal- lic salts. Benzoic acid should be preserved in amber-colored bot- tles. AVERAGE DOSE. iy 2 grains (0.5 Gm.). MEDICAL PROPERTIES. Antiseptic, disinfectant, and antipyretic. THERAPEUTICS. A 1 per cent solution of benzoic acid will tem- porarily sterilize the oral cavity in about half a minute. (Miller.) It is preferable in many respects over thymol, phenol, and similar preparations as an effective constituent of mouth washes. It is almost nonpoisonous, and has no irritating effect on the mucous membrane. Tooth structure is apparently not affected by benzoic acid. Internally, benzoic acid and its salts are administered to increase the amount of expectoration by stimulating the secretions and the respiratory organs. 160 PHARMACO-THERAPEUTICS MYRRH. MYRRIIA. U. S. P., B. P. It is a solid gum resin obtained from Commiphora Myrrh a and contains a small quantity of essential oil. In the form of its tinc- ture, a 20 per cent solution in alcohol, it has been lauded in the past as a veritable panacea in all diseases of the oral cavity. At present it is obsolete. SALICYLIC ACID; ACIDUM SALICYLICUM, U. S. P., B. P.: HC 7 H 5 3 . SYNONYMS. Ortho-oxybenzoic acid; acide salicylique, F. ; Salicylsaure, G. SOURCE AND CHARACTER. Salicylic acid has been known since 1834 to exist in the form of an aldehyd (salicin) in many plants, especially in the oils of wintergreen, sweet birch, willow bark, etc. At present it is usually prepared synthetically. Salicylic acid appears in light, fine white needles; it is odorless, having a sweet- ish, afterward acrid, taste. It is soluble in about 310 parts of cold and in 14 parts of boiling water, in 2 parts of alcohol, in 80 parts of glycerin, and in ether and chloroform. It is incompati- ble with ferric salts, quinin, and spirit of nitrous ether. AVERAGE DOSE. iy 2 grains (0.5 Gm.). MEDICAL PROPERTIES. Antipyretic, antiseptic, antirheumatic, and anhidrotic. PREPARATIONS. PJienyl Salicylate; Phenylis Salicylas, U. S. P. ; Salol, B. P. ; C 13 H 10 3 . Salol is prepared by the interaction of a sodium salt of salicylic acid and phenol with phosphoryl chlorid. It appears as a white crystalline powder, with a faintly aromatic odor and little taste. It is freely soluble in ether and alcohol, almost in- soluble in water. Average dose, T 1 /^ grains (0.5 Gm.). Sodium Salicylate; Sodii Salicylas, U. S. P., B. P. ; NaC 7 H 5 3 . Sodium salicylate is a white odorless powder, with a sweetish, saline taste; it is very soluble in water. Average dose, 15 grains (1 Gm.). Aspirin; Acetylsalicylic Acid. It is a white powder, slightly soluble in water, but readily soluble in alcohol. It has a very slightly acid taste. It has a well-earned reputation as an anal- gesic. Average dose, 7% grains (0.5 Gm.). THERAPEUTICS. As salicylic acid is only sparingly soluble in ANTISEPTICS 161 water, it is seldom employed as an antiseptic, although it is almost equal in strength to phenol. It is extensively used as a surgical dressing in the form of cotton wool impregnated with the acid. Formerly it was highly praised as a mouth wash in alcoholic solution. Salicylic acid acts very deleteriously on tooth structure, and even in % P er cent solution it will affect the enamel. Its sodium salt is used as a specific for acute rheumatism ; it reduces the temperature and the pain, and removes the local symptoms of this disease. Aspirin and similar preparations have largely supplanted the use of salicylic acid and sodium salicylate. Salol is the principal constituent of a much advertised proprie- tary mouth wash; it is broken up by the saliva into its compo- nents salicylic acid and phenol and is as detrimental to the enamel of the teeth as salicylic acid alone. The prolonged use of a salol solution as a mouth wash is very apt to produce mor- billiform eruptions about the lips, especially about the corners of the mouth, which are known as "mouthwash eczema." CHINOSOL ; CHINOSOL ; C 9 H 6 N.KS0 4 . SYNONYMS. Potassium oxychino-sulphate ; oxychinolin alum. SOURCE AND CHARACTER. Chinosol is obtained from the inter- action of oxychinolin (chinophenol) and potassium pyro-sulphate in alcoholic solutions. It occurs in the form of a crystalline lemon-yellow powder, having a pleasant aromatic odor and an astringent taste. It is very freely soluble in water; insoluble in alcohol and ether. It is incompatible with the alkaline salts and the salts of iron. Steel instruments will be blackened, but not corroded, when brought in contact with it; the stain is easily removed by polishing with an abrasive. MEDICAL PROPERTIES. Antiseptic, styptic, and antipyretic. THERAPEUTICS. Administered internally, chinosol acts as a prompt antipyretic and intestinal antiseptic. It is lauded as a specific in influenza and general "colds." Externally applied, it is a very efficient nontoxic antiseptic. It is claimed that its germi- cidal power is in many respects equal to that of mercuric chlorid. ft does not coagulate albumin, is very diffusible, and has no caustic effect on tissues. Grunert, in 1895, introduced it into den- tistry, and called special attention to its great deodorizing power and its destructive effects on pus micro-organisms. Bb'hm, dock. MaWhinney, and others have lauded it very highly as an oral 162 PHARMACO-THERAPEUTICS antiseptic. As a general antiseptic, aqueous % P^r cent solu- tions are usually employed. For injection into pus cavities, 1 or 2 per cent solutions are recommended. Good results are obtained with it in the form of weak solutions and as gauze packings in the treatment of empyema of the antrum. Prolonged use in the mouth slightly darkens the teeth. Chinosol has been recently reintroduced into dentistry in tablet form under the name of Keys-All; each tablet contains 1 grain (0.06 Gm.). BETANAPHTHOL ; BETANAPHTHOL, U. S. P. ; C 10 H 7 OH ; NAPHTHOL. SOURCE AND CHARACTER. A monatomic phenol occurring in coal tar, but usually prepared from naphthalene. It appears as a pale buff colored, shiny crystalline powder, having a faint phenol- like odor and .a sharp, pungent taste. It is soluble in about 950 parts of water, very soluble in alcohol and ether. Hydronaphthol. a proprietary preparation, is claimed to be an impure beta- naphthol. AVERAGE DOSE. 4 grains (0.25 Gm.). MEDICAL PROPERTIES. Antiseptic and disinfectant. THERAPEUTICS. Alcoholic solutions of betanaphthol in various concentrations are recommended as mouth washes, especially in pyorrhea alveolaris. BETANAPHTHOL MOUTH WASH. R Betanaphthol gr. xv (1 Gm.) Alcohol. Glycerin. Aquae aa fl? j (30 C.c.) M. Sig.: Half teaspoonful in a small glass of warm water, to be used twice a day. (James Truman.) ANTISEPTIC CAVITY VARNISH. R Select gum copal 3 x (40 Gm.) Ether fl3 jss (45 C.c.) Betanaphthol 3 j (4 Gm.) Sig. : Dissolve the copal and the betanaphthol in the ether, filter through a well-covered filter, and add enough ether to make the whole measure 2 ounces (60 C.c.). Keep in well- stoppered bottles. ANTISEPTICS 163 BALSAM OF PERU; BALSAMUM PERUVIANUM, U. S. P., B. P.; BAUME DES INDES, F. ; PERUVIANISCHER BALSAM, G. SOURCE AND CHARACTER.- Balsam of Peru is obtained from Toluifera Pereirce, Bailton. family Leguminosce, a tree growing in El Salvador. It is a thick, viscid liquid, having a brown color and an agreeable vanilla-like odor. Its taste is of a bitter, acrid nature and very persistent. It is completely soluble in absolute alcohol, chloroform, and glacial acetic acid, partially soluble in other, and soluble in 5 parts of alcohol. "Water, when agitated with the balsam, shows an acid reaction to blue litmus paper. Balsam of Peru consists of 65 per cent of perubalsam oil, known as cinnamen, of vanillin, cinnamic acid, and about 35 per cent of resinous substances. The balsam is quite frequently sophisti- cated with cheaper balsams and essential oils. AVERAGE DOSE. 5 to 30 minima (0.3 to 2 C.c.). THERAPEUTICS. Balsam of Peru enjoys quite a reputation in the treatment of skin diseases. Eecently Suter 1 tested its anti- septic qualities, and found that the viscid balsam is, in a certain sense, a reservoir of bactericidal substances, which gradually dif- fuse to the surrounding medium and which mechanically and chemically interfere with the growth of bacteria. It also pos- sesses chemotactic properties. Mayrhofer 2 recommends the bal- sam very highly as the ideal root filling material in asepticized canals. He injects the balsam with a small syringe and covers it with cement or amalgam. He claims that balsam of Peru is a very persistent antiseptic, which fills every nook of the root canal and does not change its volume, nor does it discolor the tooth. Some years ago a preparation known as "balsamo del deserto, " which resembled balsam of Peru to some extent, was much lauded as a root filling material. At present it is apparently little used. Other balsams and balsamic resins as balsam of Tolu, styrax, benzoin, etc. are seldom employed in their pure state as anti- septics. TRINITROPHENOL ; TRINITROPHENOL, U. S. P. ; C 6 H 3 7 N S ; PICRIC ACID; PICRONITRIC ACID. It occurs in yellow, lustrous crystals, odorless, and having an intense bitter taste. It is soluble in 10 parts of alcohol, 6.5 parts 1 Suter: In Prinzipien der Pulpagangran, by Mayrhofer, 1909. 2 Mayrhofer: See Suter. 104 PHARMACO-THERAPEUTICS of ether, and 170 parts of water. It is readily oxidized, and forms dangerous compounds when mixed with sulphur, phosphorus, etc. It should never be applied in substance. It is claimed that a hydro-alcoholic solution of picric acid is extremely useful in all forms of burns. SOLUTION FOR BURNS. IJ Acid, picric. 3 iss (6.0 Gm.) Alcohol fi$ ij (60 C.c.) Aq. destillat. ad ft$ xxxij (1,000 C.c.) M. Sig. : Strips of lint are soaked in this solution, placed over the burned surface and kept moist with it. Anilin Dyes. A group of compounds of the aromatic series commercially known as anilin dyes and which are primarily employed in the in- dustries and as staining media for the identification of tissues. have also proved to be of value as therapeutic agents. According to Stilling, these dyes are non-poisonous, they are readily soluble, they diffuse deeply into the tissues, they do not coagulate albumin and they possess germicidal action. The principal representatives are methylene blue, methylene violet, and scarlet red and its color- less modifications. METHYLENE HYDROCHLORID, METHYLENE BLUE, U. S. P., C 10 H 18 N 3 SC1. It is obtained by the action of hydrogen sulfid upon an oxidation product of para-amino-dimethyl-anilin. It is a dark green, crystal- line powder, readily soluble in water, somewhat less soluble in al- cohol, the solution having a deep blue color. Metlrylene violet, known as pyoktanin and methylene yellow, known as auramin, are modifications of methylene blue. They are soluble in about 75 parts of water, in alcohol, etc. These various dyes have been lauded in the treatment of the ulcerative forms of stomatitis, especially the tubercular types, Vincent's angina and similar disturbances of the oral cavity. The dyes may be dusted over the diseased surfaces in substance or applied with a swab in 10 per cent solutions. SCARLET RED. BIEBRICH. It is a diazotised amino-azo-ortho-toluol with betanaphthol. It ANTISEPTICS 165 is a dark reddish-brown powder, insoluble in water, soluble in al- cohol, ether, chloroform, fats and fatty oils. An almost colorless modification of scarlet red, possessing the same characteristics, is known as dimazon or, in continental Europe, as pellidol. Scarlet red exercises a most beneficial influence on the new formations of epithelium over denuded surfaces when applied in the form of a 5 to 8 per cent ointment. Schmieden introduced this "scarlet salve" for the purpose of inducing fresh granulation and the re- sults obtained are most gratifying. The ointment is spread thinly on the dressing material and covered by cotton or lint to prevent staining of the linen. If a less highly colored prepara- tion is desired, dimazon ointment may be substituted. Antiseptics of the Marsh Gas Series. Marsh gas (methan, CH 4 ) furnishes the basic radical of a very large group of organic compounds that have been used with re- markable success in therapeutics. The vast majority of these compounds are characterized by a depressing action on the nerv- ous system. The hydroxyl compounds of certain derivatives of methan are known as alcohols. The simplest form is methyl alco- hol, CH 3 OH, a product of oxidation of methan. Methyl alcohol is rarely used as an antiseptic, and wh * . Fig. 77. Camera lucida draw a and b showing the ings of Endameba gingivalis (Gros), stained with iron hematoxylin; usual central or subcentral position of the nucleus; c, a and e, separated from the larger one). (Smith and Barrett.) purulent contents of one of the pockets is taken up on a suitable instrument such as a flat stiff sealer not more than from one-tenth to one-eighth of an inch in width, and this is diffused in a drop of slightly warmed normal saline solution deposited on a warm slide. This preparation is covered with an ordi- nary thin cover-glass, and the fresh and unstained material examined at once, without further preparation, using a 4 mm. objective. If so desired, one may use, in order to bring out to some degree the nucleus in the living parasite, a small amount of very dilute neutral red solution diffused under the cover-glass. In the midst of the pus and red blood cells and myriads of bacteria and lepto- thrix threads, the protozoa may be readily made out with the microscope. 390 PHARMACO-THERAPEUTICS They are actively motile in such preparations for fifteen minutes or more at ordinary temperature. Permanent preparations are best made by spreading the contents of the pocket upon a cover-glass and fixing, while moist, in a sat- urated solution of mercury bichlorid in alcohol, and afterward washing out the mercury with iodin and alcohol and staining by the Giemsa method. For diagnostic purposes, however, examination of unprepared material for the mov- Fig. 78. Photomicrograph of Endameba gingivalis (Gros), stained with iron hematoxylin, from material from pyorrhea pocket. (Smith and Barrett.) Fig. 79. Composite outlines of moving Endameba gingivalis (Gros), including five camera lucida sketches; time included, twenty seconds; to show activity of movement and long type of pseudopod at times assumed; magnification as in Fig. 76. (Smith and Barrett.) ing organism is quite sufficient, and in some ways advantageous, particularly in the matter of economy in time. Caution as to the maintenance of the warmth of the preparation should be insisted upon a matter which is not of much difficulty in the warmer months but may require the use of a warm stage in the winter of such a climate as that of this city. When seen in its living state the organism is a gelatinous-looking cell, ranging up to about 30 EMETICS 391 micromillimeters in diameter, moving in characteristic amebiform manner, and thrusting out, here and there about its periphery, one or two thick lobose to digitate pseudopodia, with a distinct but scant ectosarc (best seen in the pseudopods and about their bases), and with a granular and more or less vacuolated endosarc. The nucleus is practically always invisible in the un- stained specimen; in stained preparations it is small in size and contains but little chromatin, in grains or scant threads. The nuclear membrane is thin and poorly defined, and the karyosome small. In the cytoplasm there are, at least in the larger examples, and as a rule seen best after staining, numerous coarse ingested bodies, remnants of leucocytic nuclei, of red blood cells, and often a large number of bacteria. Undigested red blood cells are occasionally seen in the living amebic body; but these, if watched only for a few minutes, rapidly disappear owing to the effectiveness of the amebic intracellular digestive agencies. It is perhaps well to suggest that, in withdrawing the contents of the pockets for examination, violent scraping of the wall of the pocket be avoided, so as to prevent the admixture of any great proportion of blood, which, of course, adds to the confusion already sufficiently great because of the pus and myriads of vegetable organisms. Bass and Johns suggest the following procedures in preparing stained experiments: Staining. (1) The smear is first fixed to the slide by passing the slide, film side up, through the flame of an alcohol lamp or Bunsen burner one or more times until the slide feels fairly hot when applied to the back of the hand. (2) Apply one or two drops of Czaplewski's carbol-fuchsin for a few seconds. Einse off excess of stain with water. (3) Apply Loeffler's methylene-blue for fifteen to thirty seconds. Usually the stain is applied for a short time, rinsed off with water and examined against a light background. If not stained sufficiently the stain is again ap- plied. Properly stained preparations have a deep purple color. (4) Blot off excess of water. Dry in the air. Examine with the y 12 mm. oil immersion lens. Examination and Identification. Material from the proper location in the lesions will show about as many red blood cells as pus cells, with a good many large cells from the granulating surface, many bacteria, spirochetes and a large number of endamebse. The red blood cells stain a deep red. Pus cells show a bright purple irregularly-shaped nucleus with a light pink protoplasm. The larger tissue cells show a red to pink staining protoplasm with a small purple nucleus. Bacteria and spiroclietes, depending upon the species and varieties, stain blue, purple, or bright red. The endamebse vary from about the size of a pus cell to about four times their size. The endoplasm stains a deep blue and is surrounded by the slightly irregular border of purple stain- ing ectoplasm. A small, round or oval nucleus staining a deep port wine color is found centrally along with from one to ten or twelve inclusion bodies of 392 PHARMACO-THERAPEUTICS nuclear material staining a deep purple or blue-black. These inclusion bodies are contained in vacuoles shown by a clear ring about each one. Usually the whole endameba appears to be surrounded by a clear zone showing the retrac- tion of the protoplasm while drying. Once properly-stained endamebse are found, it will be readily appreciated that their appearance is so characteristic that they will never be mistaken for any other body likely to be found in pus from the locality in question. CATHARTICS. Cathartics, commonly known as pliysic, are remedies used for the purpose of unloading the bowels per anum defecation. They were used much more freely in olden times; in fact, to take medicine internally was at one time almost synonymous with tak- ing a physic. The term physic has been used, and is, to some ex- tent, employed at present, to indicate the art of therapeutics. With the progress of medical knowledge quite a number of specific terms have been created to designate the many sub- divisions of this large group. The Greeks spoke of cathartics and the Romans of purgatives, both meaning to clean up, when they referred to drugs which were employed to free the body of diseased juices and accumulated feces. Again, the term evacuant, to re- move the feces, is used, while aperient indicates to open the bowels. A drastic, to force through, is a powerful cathartic, while a laxa- tive is a drug which means softening of the fecal matter. Car- minatives are employed to remove gases from the bowels. The flow of bile is increased by a cholagogue, and to produce watery evacuations liydragogues are administered. The term saline indi- cates a cathartic consisting of neutral salts of the metals of the alkalies or alkaline earths. The formation of the feces is the result of the accumulation of nonabsorbable remnants of the mixed foodstuffs cellulose, ani- mal fibrous tissue, cartilage, etc. With the aid of the glandular secretions, ferments, and intestinal bacteria, putrefaction is pro- duced, which results in the formation of carbon dioxid, marsh gas, sulphuretted hydrogen, ptomains, and the many other products of decomposition. The fecal matter remains in the lower intestines for about fifteen hours; through the absorption of fluid the formed feces are produced, which finally are expelled by peristalsis, in- volving a complicated process of nervous impulses. The inhibition of normal peristalsis produces acute and chronic constipation CATHARTICS 393 (obstipation); to relieve this condition, cathartics are indicated. In acute constipation cathartics may be taken with impunity, while in chronic constipation other means as regulation of the diet, etc. are to be preferred to the continued administration of cathartics. In acute catarrh of the bowels, and sometimes in acute poisoning, cathartics are of service. Obesity is occasionally favor- ably influenced by the judicious administration of cathartics. Cathartics are not indicated in peritonitis, sutures, or other surgi- cal interferences with the bowels, in extreme general weakness, and in hemorrhage of the bowels. The action of cathartics depends very much on the nature of the remedy employed. Direct irritation of the smooth muscular coat of the bowel is rarely accomplished; the great bulk of cathartics act by indirect irritation of the motor ganglia of the intestines, which results in an increased peristalsis. The quick removal of the feces by these cathartics prevents their formation into a solid mass. The resultant stool is usually of a fluid nature. Vegetable ma- terials which are rich in pectin manna, tamarinds, honey, jellies, preserves, etc. form colloidal solutions in the intestines, and re- tain large quantities of water, and by their softening influence act as mild laxatives. The various alkali salts the sulphates, phos- phates, and tartrates which are diffusible only with difficulty, and the salts of the alkaline earth metals magnesium carbonate, sulphate, etc. act in a somewhat similar manner ; incidentally they are mild irritants. The salines retain in the bowel the water of their own solution; by osmosis they abstract fluid from the surround- ing blood and lymph tissues until they become isotonic with the body fluids, and by the increased bulk, fluidity, and peristaltic movement produce copious stools. The readily diffusible salts sodium chlorid, etc. do not retain the water of their solution, and are easily absorbed by the bowel. Certain mild cathartics act by indirect stimulation of the motor ganglia, which is caused by their bulky mass coarse bread, corn bread, pumpernickel, regulin. Dangerous irritation, followed by severe inflammation and annoy- ing tenesmus, are often caused by drastics croton oil, jalap, colocynth and are rarely employed at present. Cathartics are conveniently divided into vegetable cathartics and saline cathartics; sulphur, calomel, and liquid petrolatum occupy an exempted position among the cathartics. 394 PHARMACO-THERAPEUTICS Vegetable Cathartics. RHUBARB ; RHEUM, U. S. P. ; RHEI RADIX, B. P. ; RHUBARBS, F. , RHABARBER, G. It is the dried rhizome of Rheum officinale and other species. It is principally administered as an extract, fluidextract, or tincture. AVERAGE DOSE. 15 grains (1 Gm.). ALOES ; ALOE, U. S. P. ; ALOE BARBADENSIS, B. P. ; ALOE, F., G. It is the inspissated juice of the leaves of Aloe vera and other species. It is principally administered in its purified form as an extract, tincture, or wine. AVERAGE DOSE. 4 grains (0.25 Gm.). CASCARA SAGRADA ; RHAMNUS PURSHIANA, U. S. P. ; CASCARA SAGRADA, B. P. It is the dried bark of Rliamnus purshiana. It is principally administered as a fluidextract, tincture, or aromatic syrup. AVERAGE DOSE. 15 grains (1 Gm.). FRANGULA; FRANGULA, U. S. P.; BUCKTHORN; ECORCE DE BOURO- DINE, F. ; FAULBAUMRINDE, G. It is the dried bark of Rhamnus frangula. It is principally ad- ministered as a fluidextract or- tincture. AVERAGE DOSE. 15 grains (1 Gm.). COLOCYNTH; COLOCYNTHIS, U. S. P.; COLOCYNTHIDIS PULPA, B. P.; COLOQUINTE, F. ; KOLOQUINTEN, G. It is the peeled dried fruit or pulp of Citrullus colocynthis. It is best administered as an extract in pill form. AVERAGE DOSE. 1 grain (0.06 Gm.). JALAP; JALAPA, U. S. P., B. P.; JALAP TUBEREUX, F. ; JALAP- PENKNOLLEN, G. It is the dried tuberous root of Exogonium purga. It is prin- cipally employed as a powder, extract, or tincture. AVERAGE DOSE. 15 grains (1 Gm.). CATHARTICS 395 PODOPHYLLUM; PODOPHYLLUM, U. S. P.; PODOPHYLI RHIZOMA, B. P. ; MANDRAKE ROOT ; VEGETABLE CALOMEL ; PODOPHYLLUM, F., G. It is the dried rhizome of Podopliyllum peltatum. It is prin- cipally administered as an extract or resin in pill form. AVERAGE DOSE. iy 2 grains (0.5 Gm.). SENNA; SENNA, U. S. P.; SENNA ALEXANDRINA, B. P.; FEUILLES DE SENE, F. ; SENNESBLATTER, G. The dried leaflets of Cassia acutifolia. Senna is principally ad- ministered in powder form or as an infusion. AVERAGE DOSE. 60 grains (4 Gm.). Tamarind; Tamarindus, U. S. P., B. P. ; Figs, Ficus, U. S. P., B. P. ; Prunes, Prunum, U. S. P., B. P. They contain sugar and pectin in variable quantities, and are mild laxatives. CASTOR OIL; OLEUM RICINI, U. S. P., B. P.; HUILE DE RICIN, F. ; RICINUSOL, G. It is the fixed oil expressed from the seeds of Ricinus communis. AVERAGE DOSE. 4 fluidrams (16 C.c.). CROTON OIL ; OLEUM TIGLII, U. S. P. ; OLEUM CROTONIS, B. P. ; HUILE DE CROTON TIGLIUM, F. ; KROTONOL, G. It is a fixed oil, expressed from the seeds of Croton tiglium. AVERAGE DOSE. 1 minim (0.05 Gm.). Saline Cathartics. SODIUM PHOSPHATE; SODII PHOSPHAS, U. S. P., B. P.; Na 2 HPO, +12H 2 0; PHOSPHADE DE SOUDE, F. ; NATRIUMPHOSPHAT, G. It appears in large, colorless crystals, odorless, and having a saline, cooling taste. It is soluble in about 5.5 parts of water and almost insoluble in alcohol. Sodium phosphate is best admin- istered in the compound solution of sodium phosphate, U. S. P.. or as the effervescent sodium phosphate, U. S. P. AVERAGE DOSE. 30 grains (2 Gm.). 396 PHARMACO-THERAPEUTICS SODIUM SULPHATE; SODII SULPHAS, U. S. P., B. P.; Na 2 S0 4 -flOH 2 0; GLAUBER'S SALT; SAL DE GLAUBER, F. ; GLAUBER- SALZ, G. It appears in large, colorless crystals, odorless, and having a saline taste. It is soluble in about 3 parts of water and almost insoluble in alcohol. AVERAGE DOSE. 240 grains (16 Gm.). MAGNESIUM SULPHATE ; MAGNESII SULPHAS, U. S. P.. B. P. ; MgS0 4 +7H 2 0; EPSOM SALT; SEL D'EPSOM, F. ; BITTERSALZ, G. It appears in small, colorless needles, without odor, and having a cooling, saline, and bitter taste. It is soluble in 1 part of water and almost insoluble in alcohol. It is best administered as the effervescent magnesium sulphate, U. S. P., B. P. AVERAGE DOSE. 240 grains (16 Gm.). Solution of Magnesium Citrate; Liquor Magnesii Citratis, U. S. P. It is a solution of magnesium citrate, with an excess of citric acid, to which potassium bicarbonate is added. The solution must be kept tightly corked, and effervesces when poured from the bottle. Average dose, 12 fluidounces (360 C.c.). POTASSIUM BITARTRATE ; POTASSII BITARTRAS, U. S. P. ; POTASSII TARTRAS ACIDUS, B. P.; KHC 4 H 4 6 ; CREAM OF TARTAR; CREME DE TARTARE, F. ; WEINSTEIN, G. It is a white, gritty powder, odorless, and has a pleasant, acidulous taste. It is soluble in about 200 parts of water and al- most insoluble in alcohol. AVERAGE DOSE. 30 grains (2 Gm.). POTASSIUM CITRATE; POTASSII CITRAS, U. S. P., B. P.; K 3 C 6 H 5 7 -fH 2 0; CITRATE DE POTASSE, F. ; KALIUMCITRAT, G. It is a white, granular powder, odorless, and having a cooling, saline taste. It is soluble in about 0.5 part of water and almost insoluble in alcohol. It is best administered as effervescent potas- sium citrate, U. S. P. AVERAGE DOSE. 15 grains (1 Gm.). Potassium and Sodium Tartrate; Potassii et Sodii Tartras, U. S. P.; Soda Tartarata, B. P.; KNaC 4 H 4 6 -f4H 2 ; RocJielle Salt; CATHARTICS 397 Sel de Seignette, F. ; Seignettesalz, G. It is a white powder, odor- less, and having a cooling, saline taste. It is soluble in about 1.2 parts of water and almost insoluble in alcohol. Average dose, 120 grains (8 Gm.). Compound Effervescing Powder; Pulvis Effervescens Com- positus, U. S. P.; Pulvis Soda Tartaratce Effervescens, B. P.; Seidlitz Powder; Poudre de Sedlitz, F. ; Sedlitz Pulver, G. This powder is put up in two papers, blue and white; the blue one contains a mixture of 31 parts of sodium bicarbonate and 93 parts of potassium and sodium tartrate, and the white paper contains tartaric acid 160 grains (10.4 Gm.) of Rochelle salt to 38 grains (2.25 Gm.) of tartaric acid. When the powders are dissolved separately in water and the solutions are mixed, the tartaric acid acts on the sodium bicarbonate and releases carbonic acid, with effervescence. SULPHUR, WASHED; SULPHUR LOTUM, U. S. P.; SULPHUR SUB- LIMATUM, B. P. ; WASHED FLOWERS OF SULPHUR ; SOUFRE LAVE, F. ; GEREINIGTE SCHWEFELBLUMEN, G. It is prepared by washing sublimed sulphur with water and ammonia. It is a fine, yellow powder, insoluble in water and slightly soluble in alcohol. AVERAGE DOSE. 60 grains (4 Gm.). MERCUROUS CHLORID, MILD; HYDRARGYRI CHLORIDUM MITE, U. S. P.; HYDRARGYRI SUBCHLORIDUM, B. P.; HgCl; CALOMELAS; CALOMEL, E., F., G. It is a white, heavy, impalpable powder, odorless and tasteless; insoluble in alcohol, water, and ether. It is incompatible with bromids, iodids, sulphates, sulphids, carbonates, limewater, alka- lies, ammonia, cocain, etc. It is best administered in powder form. AVERAGE DOSE. 2 grains (2.125 Gm.). As an alterative it is given in "broken" doses, % grain (0.01 Gm.) every two hours, followed by a saline cathartic. Mass of Mercury; Massa Hydrargyri, U. S. P. ; Blue Mass; Blue Pill. It is prepared by rubbing together metallic mercury with honey of rose, glycerin, althaea, and licorice until the globules of mercury are invisible under a lens magnifying ten diameters. 398 PHARMACO-THERAPEUTICS Blue mass contains about 33 per cent of mercury. It is admin- istered in pill form. Average dose, 4 grains (0.25 Gm.). PHENOLPHTHALEIN, U. S. P. It is a compound obtained by the interaction of phenol and phthalic anhydride. It is used as a pur- gative in doses of l 1 /^ 3 grains (0.1 0.2 Gm.). It is best adminis- tered in tablet form, and should be thoroughly chewed and followed by a tumblerful of water. It forms the principal constituent of many of the popular modern laxatives ; purgen, prunoids, probilin, laxaphen, phenolax, etc. Recently, liquid petrolatum, petrolatum liquidum, II . S. P., either obtained as such or sold under various copyrighted names, is used extensively as a laxative. When administered internally it is not absorbed from the intestinal canal, but acts purely mechanical as a lubricant of the tract. It may be given in doses of one or two tablespoonfuls at bedtime, the amount to be increased or reduced according to conditions, age, etc. Solutions of potassium, sodium, magnesium sulphate, and other alkaline salts in the form of bitter waters are much employed as mild laxatives. The more important natural mineral waters are Hunyadi-Janos, Carlsbad, Friedrichshall, Seidlitz, etc. These waters are principally drank in the early morning on an empty stomach. SALINE CATHARTIC SOLUTION. IJ Magnesii sulphatis 5 j (30 Gm.) Acid, sulphur. diL gtt. xv (1 C.c.) Syr. limonis fig j (30 C.c.) Aquae ad flJ5 iv (120 C.c.) M. Sig. : Tablespoonful in a glassful of water every three urs. hours. TONIC LAXATIVE. Tinct. nuc. vomic. gtt. xv (1 C.c.) Fluidextract. rhamni pursh. aromatic. fl3 j (30 C.c.) Syr. limonis ad fl ij (60 C.c.) M. Sig.: Half a teaspoonful every two hours. CIRCULATORY STIMULANTS AND DEPRESSANTS 399 CIRCULATORY STIMULANTS AND DEPRESSANTS. Drugs which are employed for the purpose of stimulating the circulation are known as circulatory stimulants, and they are sometimes referred to as vasoconstrictors, while drugs which de- press the circulation are spoken of as circulating depressants or vasodilators. Those drugs which exercise a tonic influence on the heart are known as analeptics. Every organ of the body requires for its undisturbed function an uninterrupted rich supply of continuously renewed blood. The blood is inclosed in a system of elastic tubes the arteries and veins and the heart. The latter exercises the double function of a muscular suction and pressure pump, and by rhythmic con- traction and relaxation produces circulation. The blood flows through the heart in the direction of the valves, which open only toward the arteries. The heart is divided into two halves, and each half into two chambers the auricle and the ventricle ; the various dividing walls are provided with a number of valves. The four chambers of the heart are essential for the proper sucking and pumping of the blood from the veins into the arteries. The rhythmic contraction and relaxation constitutes the heart cycle ; the contraction of the auricular musculature constitutes the auricular systole it forces the blood into the ventricles. The latter are now filled completely with blood (its back flow being prevented by the closure of the tricuspid and mitral valves), and, as soon as the inner pressure of the ventricles is above that of the pulmonary artery and the aorta, the semilunar valves open and the blood is ejected into the arteries by the ventricular systole. A period of rest and relaxation of ventricles and auricles now fol- lows, which constitutes the auricular and ventricular diastole. The heart beats about seventy-two times a minute, and each cycle of the heart occupies about 0.8 seconds. When the normal functions of the circulation are disturbed and the heart has to perform an increased amount of labor, nature has fortunately provided for this emergency by increasing the diam- eter of the fibers of the heart muscle, and thereby hypertrophy of the heart is established. The heart muscle may carry on this in- creased work for years, provided the patient avoids any undue exertion, without materially interfering with his welfare; it com- pensates the weak heart. To relieve or mitigate this compensa- 400 PHARMACO-THERAPEUTICS tion, digitalis is the supreme remedy. It performs two functions it slows the heart beat and increases the arterial pressure. Strophanthus, especially its g-alkaloid, has a somewhat similar action as digitalis. Occasionally it is necessary to quickly overcome an acute weak- ness of the heart "heart failure." A direct stimulation is best accomplished with caffein, camphor, and alcohol, or ether; to in- sure their prompt action, they should be injected hypodermically, except caffein. For the purpose of increasing the activity of the vasomotor centers, which results in an increase of the blood pressure, stim- ulants are administered. They act by direct or by reflex action. The most powerful direct stimulation is produced by the absence of oxygen from the inspired air; this procedure is not employed therapeutically. The principal drugs employed for such purpose are strychnin and to some extent, atropin. Strychnin acts prin- cipally on the vasomotor centers of the medulla oblongata; it increases the blood pressure and the heart beat becomes slower. To insure quick action strychnin is preferably administered by hypodermic injection. As an antidote in intoxication with paralyzing poisons general anesthetics, opium and its salts. choral hydrate it acts as a powerful excitant. Atropin in small doses increases the pulse rate as a result of its inhibitory influence on the vagi nerves; it apparently antagonizes the action of morphin, and is much lauded as an antidote in morphin poison- ing. Paralysis, or, rather, diminished activity of the vasomotor cen- ters, is principally accomplished by the administration of the nitrites. Certain halogen substitution compounds chloroform, chloral hydrate, etc. have a pronounced paralyzing influence on the nervous system. Their action on the vasomotor centers is too severe, however, and consequently they are not used for such pur- poses. The nitrites dilate the peripheral vessels, especially those of the face and in the brain, and they increase the heart beat. Amyl nitrite and nitroglycerin are the principal representatives of this group. The vessel wall may be directly influenced by cer- tain drugs, which are applied locally, or they may act by internal administration through the blood. The dilation or contraction of the vessel wall is the result of the action of the drug on the muscle fibers. Dilation of vessels is quickly obtained by ex- CIRCULATORY STIMULANTS AND DEPRESSANTS 401 ternally applied irritants (see Irritants and Counterirritants) , while contraction of the vessel is the direct sequence of the appli- cation of certain astringents. (See Astringents.) A few drugs exhibit specific action as vasoconstrictors without possessing all the functions of an astringent. The two typical representatives of locally applied vasoconstrictors are cocain and the extract of the suprarenal gland. Cocain is principally used as a local anes- thetic. Its vasoconstrictor side action is a valuable factor in the production of local anesthesia. (See Local Anesthesia.) The ex- tract of the suprarenal gland, on account of the ready decomposi- tion of its solution, is not used therapeutically. The hydrochloric salt of its alkaloid or its synthetic substitutes are the principal pharmaceutic preparations employed for such purposes. Ergot and golden seal (hydrastis), or their alkaloids, are principally ad- ministered internally for the purpose of powerfully contracting the muscular coat of the uterus ; both drugs seem to possess a specific af- finity for the smooth muscle fibers of this organ. Styptol and styp- ticin, which are both chemically related to hydrastin, are important local vasoconstrictors; their functions have been referred to under Hemostatics and Styptics. DIGITALIS; DIGITALIS, U. S. P.; DIGITALIS FOLIA, B. P.; FOXGLOVE; FEUILLES DE DIGITALE POURPREE, F. ; FINGERHUT, G. They are the dried leaves of Digitalis pur pur ea, collected from plants of the second year's growth. Digitalis is preferably admin- istered in the form of an infusion ; the extract and the tincture are claimed to be less effective. The alkaloids of digitalis are uncer- tain in their action. AVERAGE DOSE. 1 grain (0.06 Gm.). STROPHANTUS ; STROPHANTHUS, U. S. P.; STROPHANTHI SEMINA, B. P., STROPHANTUS, F., G. It is the ripe seed of StropTianthus Kombe, and is preferably ad- ministered as the tincture. The alkaloid of strophanthus (stro- phanthinum, U. S. P.) varies much in its composition. G-strophan- thinin is claimed to be a reliable preparation. AVERAGE DOSE. 1 grain (0.06 Gm.). 22 402 PHARMACO-THERAPEUTICS STRYCHNIN SULPHATE; STRYCHNINE SULPHAS, U. S. P.; (C 21 H N 2 2 ) 2 .H 2 S0 4 -f-5H 2 0; SULFATE DE STRYCHNINE, F. ; SCHWEFEL- SAURES STRYCHNIN, G. It is the sulphate of the alkaloid strychnin, prepared from Strychnos nux-vomica. It appears in colorless crystals, or as a white crystalline powder, odorless, and having an intensely bitter taste. It is soluble in about 31 parts of water and 65 parts of al- cohol. Strychnin and its salts are intensely poisonous. AVERAGE DOSE. % grain (0.0015 Gm.). Strychnin Nitrate; Strychnince Nitras, U. S. P. ; Strychnin Hy- drochlorid; Strychnince Hydrocliloridum, B. P. They are em- ployed practically for the same purpose and in the same dose as strychnin sulphate. AMYL NITRITE; AMYLIS NITRIS, U. S. P.; AMYL NITRIS, B. P.; AZOTITE D' AMYL, F. ; AMYLNITRIT, G. It is a liquid, containing about 80 per cent of amyl nitrite. It appears as a yellowish liquid, having a peculiar, ethereal, fruity odor and a pungent, aromatic taste. It should be kept in hermeti- cally sealed glass bulbs in a cool and dark place. Small glass "pearls" containing from 2 to 5 drops of amyl nitrite are now procurable. When needed, a capsule is broken in a napkin and held before the patient's face. "Spirets" are small glass capsules containing 5 drops of amyl nitrite; they are wrapped in lint, and when used they are crushed between the fingers. AVERAGE DOSE. 3 minims (0.02 C.c.). SPIRIT OF NlTROGLYCERIN ; SPIRITUS GLYCERYLIS NlTRITIS, U. S. P. ; LIQUOR TRINITRINI, B. P. ; SPIRIT OF GLYCERYL TRINITRATE ; SPIRIT OF NlTROGLYCERIN ; SPIRIT OF GLONOIN. It is an alcoholic solution, containing 1 per cent by weight of glyceryl trinitrate. It is a clear, colorless liquid, having the odor and taste of alcohol; even small doses produce violent headache. Glyceryl trinitrate is also marketed in tablet form; they readily deteriorate. The solution must be handled with extreme care to avoid explosion. AVERAGE DOSE. 1 minim (0.05 C.c.). CIRCULATORY STIMULANTS AND DEPRESSANTS 403 DESICCATED SUPRARENAL GLANDS; GLANDULE SUPRARENALIS U. S. P.; GLANDS SURRENALES DESSECHEES, F. ; GETROCKNETE NEBENNIERE, G. SOURCE AND CHARACTER. They are the suprarenal glands of the sheep or ox, freed from fat, and cleaned, dried, and powdered. They form a light yellow-brown amorphous powder, having a slight, characteristic odor, and are partially soluble in water. The powdered glands or their extract are rarely used at present; their isolated active principle has superseded the cruder preparations. The alkaloid is known as adrenalin, epinephrin, suprarenin, etc., and is employed as a 1 :1,000 solution. The solutions are preserved Fig. 80. Tracing the blood pressure under synthetic suprarenin. One milligram of the supra- renin hydrochlorid solution, 1:1,000, was injected at a into the carotid artery of a dog. (Abderhalden-Miiller.) with small quantities of chloretone, thymol, etc. Epinephrin solu- tions do not keep well, exposure to air or minute quantities of alkali quickly destroy them ; this latter process is hastened by diluting the solutions. Recently an artificial substitute has been introduced, and is known as synthetic suprarenin. Chemically it is the dioxy- phenylethanolmethylamiii hydrochlorid, or, briefly, the methylam- inoalcohol. In its chemic, physiologic, and physical properties, synthetic suprarenin is strictly identical with the products obtained from the adrenal glands, except that it is optically inactive. It is a chemically pure body, which does not vary in its composition, and consequently it is superior to the product of the natural gland (See Active Principle of the Suprarenal Capsule.) 404 PH ARM A CO-THERAPEUTICS AVERAGE DOSE OF EPINEPHRIN HYDROCHLORID. Viooo grain (0.00006 Gm.). AVERAGE DOSE OF EPINEPHRIN HYDROCHLORID SOLUTION, 1 :1,000. 1 minim (0.05 C.c.). THERAPEUTICS. When epinephrin, even in very minute doses, is injected into the circulation of an animal, it causes a quick and powerful rise of blood pressure, with a strengthening of the heart beat. In a few minutes the increased pressure passes off slowly. No other known drug will produce a similar effect. Local applica- tion on mucous surfaces or hypodermic injection of epinephrin solution produces a pronounced anemia within the affected area. Its continuous application causes a peculiar thickening of the ves- sel walls, which results in a degeneration of their muscular coat. Epinephrin solutions are locally applied to control small hemor- rhages, or by injection to produce anemia of the field of operation. Combined with cocain or novocain, it restricts the action of these local anesthetics to the involved area, thus lessening their absorp- tion and thereby increasing their action, and incidentally lessen- ing their poisonous effects. (See Local Anesthesia.) The internal administration of epinephrin, with the hope of act- ing through the blood after being absorbed, is useless; no effect will follow its absorption into the circulation. Epinephrin is of benefit in hay fever, in epistaxis, and in small hemorrhages from the mouth, nose, ear, etc. The quantity necessary for hypodermic injection is extremely small ; one minim of 1 :1,000 solution, di- luted with a cubic centimeter of an isotonic salt solution, is amply sufficient for the purpose, and 5 minims constitute the maximum dose of a single injection, w y hich should not be exceeded. Caffein, camphor, validol, alcohol, and ether have been referred to under Cerebral Stimulants. CAMPHOR SOLUTION FOR HYPODERMIC INJECTION. B Camphorse 3 ss (2 Gm.) Athens flg j (30 C.c.) M. Sig. : A cubic centimeter injected in cases of collapse. RESPIRATORY STIMULANTS AND DEPRESSANTS. Respiration is divided into external and internal respiration. External respiration is carried on by the lungs; it consists in the RESPIRATORY STIMULANTS AND DEPRESSANTS 405 absorption of oxygen and the giving off of carbon dioxid by the blood when it passes through the lungs. Internal respiration is concerned with the interchanges of oxygen and carbon dioxid by the capillaries and the tissue cells. The apparatus connected with respiration consist of the nose, naso-pharynx, trachea, bronchi, bronchioli, and the alveoli of the lungs. By the prolonged ab- sence of oxygen and the increase of carbon dioxid the centers of respiration become paralyzed. The normal rhythmic movements of the latter are regulated by certain ganglia located within these centers. Most of the inhaled oxygen is chemically bound to the hemoglobin, and only a small part is physically dissolved in the blood. Carbon dioxid is always present in the air in small quan- tities (0.03 per cent) ; when this amount is materially increased, the air becomes "foul." The exhaled air of man or animal is not poisonous, provided it does not contain too large quantities of car- bon dioxid. Pure carbon dioxid is a poisonous gas, and produces asphyxia. Some physiologists claim that the normal carbon dioxid of the air performs an important function in respiration, and that it is the permanent stimulant of the respiratory centers. Respiration, aside from the changes occurring in the composition of the air, may be materially influenced by injuries of the muscles of the thorax or diaphragm; by contraction of the larger and smaller bronchi and alveoli, which may interfere with the ready passage of the air; by interference with the ready flow of blood through the capillaries, and thereby preventing close contact with the oxygen; by an inability of the blood to absorb oxygen when the blood is already chemically saturated with some other gas, as in potassium chlorate poisoning, etc. ; or by an inability of the tissue cells to take up oxygen, as in poisoning with cyanids. The usual result of these many disturbances is dyspnea that is, a difficult or labored breathing. Dyspnea tends to remove the obstructions in various ways. Forcible respiration is the usual method employed by nature to give relief. The artificial provision of oxygen, including air, under slight pressure is usually of marked benefit, and incidentally quickly replaces the accumulated carbon dioxid. Drugs which are intended to relieve the various causes of disturbances of respira- tion depend on the nature of the latter. Antiseptics, astringents, and styptics are principally called for in tubercular diseases of the lungs. Oil of turpentine and other essential oils of the pine 406 PHARMACO-THERAPEUTICS family, oleo-resins, cresote, and guaiacol are largely employed in phthisis; they are preferably administered in a very fine state of division by using an atomizer. Hypersecretion of the mucous membranes is checked by mild doses of atropin sulphate, while an increased secretion is usually readily obtained by the adminis- tration of expectorants. Ipecac, potassium iodid, and ammonium chlorid, together with many drugs containing sugar and muci- laginous substances licorice, marshmallow, Irish moss, mullein, elder flowers, squills, honey, etc. are much lauded in liquefying the dried-up secretions. The irritation of a cough is best delayed by opium or, morphin. Irritability of the centers of respiration is usually readily reduced by morphin and quebracho. True asthma tonic spasms of the smooth muscle fibers of the bronchial alveoli is relieved by carefully adjusted doses of atropin sulphate, and by lobelia, amyl nitrite, and the fumes of saltpeter. The centers of respiration may be directly stimulated by hypodermic injec- tions of strychnin sulphate. Artificial respiration is of prime im- portance in cases of complete cessation of respiration ; it is referred to under General Anesthetics. COUGH MIXTURE. IJ Ammonii chlorid. 3 j (4.0 Gm.) Tinct. opii camphor. fl3 iv (15 C.c.) Fluidextract. liquoric. fl5 j (30 C.c.) Aquae ad flg iv (120 C.c.) M. Sig. : Tablespoonful three times a day. TONICS. Tonics, sometimes referred to as roborants, are medicines in- tended to give strength or "tone" to the system. Tonics, like alteratives, do not belong to a definite pharmacologic group ; they do not act on specific organs, but on the organism as a whole. Tonics are administered for the purpose of increasing the nutrition of the whole body by a slight stimulation of all its vital functions, and thereby give greater resistance to the organism against external deleterious influences. Iron, arsenic, phosphorus, and calcium are the principal types of true tonics. Iron is known as exercising a specific influence on the blood, and consequently it is sometimes referred to as a hematinic. Arsenic seems to cause a definite un- TONICS 407 known stimulation of cell activity in general, and phosphorus fur- nishes most necessary components of the soft tissues as well as of the bones. Calcium is the essential component of bone structure, and is present in the blood. Iron. Iron is a normal constituent of the blood^pt is present in the hemoglobin of the red corpuscles. Hemoglobin is the agent which is directly concerned with the interchanges of oxygen and carbon dioxid in indirect respiration. The average daily waste of iron derived from the red blood corpuscles and other cells amounts to about YQ to 1/4 grain (0.01 to 0.016 Gm.). This loss of iron is more than readily replaced by the organic iron which is contained in the ordinary mixed foodstuffs. In certain diseases, however, which are principally the result of an altered composition of the blood (chlorosis), or of an insufficiency of its quality and quantity (anemia), the natural supply of iron is not sufficient, and an ar- tificial increase of the iron component is essential. Usually within a comparatively short time marked improvement in the blood is shown after the iron administration. Just how iron acts in the body is not fully known at present, but it is probably certain that it causes a direct stimulation of the blood-forming centers the erythroblasts in the marrow of the long bones. The iron of the blood and of the foodstuffs is a peculiar organic compound, which is not altered by the ordinary iron precipitants. The inorganic iron preparations are represented by ferrous and ferric salts. "WTien they are taken internally in moderate doses, only very small quantities of these salts are absorbed ; for the most part they are excreted with the feces. Concentrated iron salt solu- tions act as caustics on the mucous membrane of the gastro-in- testinal canal. Chemists have endeavored to produce organic iron compounds analogous to those existing in the body. Quite a large number of organic compounds, which represent the iron in a so- called "masked" (nonionic) form, have been introduced within the last decade. The prototype of these compounds is ferratin, a ferric albumin acid containing 6 per cent of iron. Ferratin is readily absorbed, and is easily borne by the patient; neverthe- less clinicians of wide experience claim that with this or any other masked iron no better therapeutic results are obtained than with 408 PHARMACO-THERAPEUTICS the old-fashioned inorganic compounds or the ferruginous mineral waters. Manganese is sometimes added to iron to increase its action on the blood; its therapeutic value is denied by most clinicians. It is usually administered as an organic iron and manganese pepto- nate in a weak alcoholic solution flavored with aromatics. Iron is usually administered after meals, and the many official preparations leave a wide choice for the selection of the proper form of medicament. Quite a large number of iron preparations are described in the pharmacopeias, and it is quite unnecessary to enumerate all of these compounds. The preparations especially in favor with the clinicians are : Mass of ferrous carbonate, massa ferri carbonatis, U. S. P. ; Val- let's mass; average dose, 4 grains (0.25 Gm.). Pills of ferric car- bonate, pilules ferri carbonate, U. S. P., B. P. ; average dose, 2 pills. Saccharated ferrous carbonate, ferri carbonas saccharatus, U. S. P., B. P.; average dose, 4 grains (0.25 Gm.). Various Fig. 81. Glass tube for taking corrosive medicines. wines, syrups, and solutions containing iron salts, and the many organic preparations, among which the following are the more prominent: Ferratin, carniferin, hematogen, hemol, hemogallol, ovoferrin, triferrin, and the solution of ferro-mangan peptonate. The latter solution has been apparently very largely prescribed in the last few years. Certain inorganic iron compounds, especially solutions of iron chlorid, iodid, lactate, sulphate, and pyrosulphate, readily destroy the enamel and cause a pronounced black discolora- tion of the teeth. This is also true, as Morgenstern has shown, in regard to many of the ferruginous mineral waters. Most of these iron compounds act on the enamel, principally by virtue of their acid component; reduced iron, saccharated iron, and masked iron do not affect the teeth. When corrosive iron preparations are pre- scribed, they should be taken well diluted and through a glass tube which reaches sufficiently far back in the mouth. Immediately after taking an iron compound, the mouth should be thoroughly rinsed. TONICS 409 IRON TONIC. Strychnin, sulphat. gr. ss (0.03 Gm.) Liquor, ferro-mangan. pepton. fl3 iv (120 C.c.) M. Sig. : Dessertspoonful three times daily after meal?. Caution: Avoid acid fluids. Arsenic. The action of arsenic on the animal organism manifests itself as a typical protoplasm poisoning; it kills the cell by chemically disturbing its contents. Administered in therapeutic doses, arsenic exercises a definite function on the tissues of the skin, on the blood- forming organs, on the osseous tissues, and apparently on the lymphatic system. Furthermore, arsenic seems to favorably in- fluence certain pathologic disturbances, and it is frequently em- ployed in syphilis, in remittent fevers, especially in pernicious malaria, in neuralgias, and in other nervous diseases. The thera- peutic action of arsenic is not fully understood. It is believed that arsenic produces some form of irritation which stimulates the cells to greater activity. This supposition is based on observations made in regard to its action on the tissues when administered as a poison. For a detailed description of the action of arsenic trioxid on the pulp see page 230. Arsenic is principally administered in the form of Fowler's solution, in pill form, and as natural arsenical mineral water. The principal spas which are known to be rich in arsenic are those of Kudowa (Silesia) and of Levico and Roncegno (Tyrol). Recently organic preparations of arsenic in the form of an alkyl com- pound, and known as atoxyl arsenate, have been introduced. They are intended for internal or hypodermic administration. Arsenic preparations are preferably taken after meals. SOLUTION OF POTASSIUM ARSENITE; LIQUOR POTASSII ARSENITIS, U. S. P.; LIQUOR ARSENICALIS, B. P.; FOWLER'S SOLUTION. It is a 1 per cent solution of arsenic trioxid neutralized with potassium bicarbonate in water, to which compound tincture of lavender is added to give it color and flavor. AVERAGE DOSE. 3 minims (0.2 C.c.). 410 PHARMACO-THERAPEUTICS ARSENICAL TONIC. Ifc Liquor, potass, arsenit. fl.3 iij (12 C.c.) Aquae menth. pip. ad flS j (30 C.c.) M. Sig. : 5 drops in water three times daily after meals. The dose is increased daily by 1 drop until 15 drops three times daily are taken. Phosphorus. Phosphorus is present in extremely small quantities in the al- bumin of every cell, and as calcium phosphate it furnishes an important inorganic component of the bones and teeth. The thera- peutic administration of phosphorus is restricted principally to diseases of the bones rachitis and osteomalacia. If the true tonic action of phosphorus is desired, it should be given in an oily solu- tion; cod liver oil is much employed for this purpose. The many solutions of hypophosphites, lactophosphates, and, recently, of glycerophosphates in syrup, which constitute an important item in popular medicine and with many practitioners, are ill adapted for this purpose; they are not absorbed by the tissues, and prac- tically all of the administered phosphates leave the body with the urine. Through their rich sugar component they frequently de- range the digestion. Phosphorus poisoning has been frequently observed in those ex- posed to its vapors, especially in match factories. The phosphorus vapors pass through a carious tooth or some other channel into the body of the jaw, causing a severe periostitis, which is followed by necrosis. Microbal infection as a sequence of the lessened resist- ance of the involved tissues is necessary to complete the clinical picture of true phosphorus necrosis. The substitution of amor- phous phosphorus for the metalloid and improved dental hygienic conditions of the workmen have largely eradicated the causative factors of this disease. PHOSPHORUS TONIC. IJ Phosphorus gr. iij (0.2 Gin.) Olei morrhuae fl xvj (500 C.c.) M. Sig. : Teaspoonf ul three times daily an hour after meals. TONICS 411 Fluorin. Flnorin in the form of calcium fluorid has been recently sug- gested as a therapeutic means to increase the resistance of tooth structure against caries. Fluorin is principally found in the en- amel, although only in very small quantities. According to recent analyses made by Hempel and Jodlbauer the average amount of fluorin present in the enamel of human teeth varies from 0.26 to 0.35 per cent. Some observers claim that the resistance of the teeth against dental caries depends largely on the fluorin compo- nent of the enamel. Daninger 1 claims that the internal administra- tion of calcium fluorin does no harm, and that it increases the firm- ness of the teeth and the alveoli. The children of women who had taken calcium fluorid daily during their pregnancy had, without exception, good teeth. In older children calcium fluorid also had a good effect on the formation of the teeth. Following Daninger 's suggestion, Brissemoret 2 has administered calcium fluorid with ap- parent good results in the medicinal treatment of dental caries and in fractures. As yet no positive proof has been furnished for this supposition ; but, as calcium fluorid in therapeutic doses is a harm- less remedy, it seems reasonable to try it in suitable cases. Calcium. Calcium salts are important constituents of the animal tissues, and form the most important inorganic component of bones and teeth. They are also found in the soft tissues, and apparently ex- ercise important functions on certain ferments fibrinogen of the blood, etc. The lime salts are rather insoluble, and when they are administered internally they usually leave the body unaltered. In calcium starvation in children a deficiency of calcium in the food undoubtedly an insufficient amount of calcium is deposited in the bones and the teeth. The results are the well-known ill-formed bones in rickets and weak teeth ; the latter show a pronounced ten- dency to caries. Rose 3 has recently shown that a deficiency of cal- cium salts must be, to a large extent, held responsible for the so- called soft teeth which are so frequently met in persons living in regions- in which the natural calcium supply of the drinking water is below the normal. 1 Daninger: Deutsche Zahnarztliche Wochenschrift, 1907, p. 196. 2 Brissemoret: Revue Internationale de Me'decine. 1908, p. 351. Rose: Krdsalzarmut und Entartung. 1906. 412 PHARMACO-THERAPEUTIQS The normal individual ingests with his daily mixed diet in one year approximately a pound of calcium oxid and about seven pounds of phosphoric acid. The very largest part of these sub- stances is utilized by the body for the maintenance of the body frame. An average human skeleton weighs about 24 pounds, and is composed, according to Heintz, of 9.26 pounds of lime and 12.9 pounds of phosphoric acid. According to the above calculation, the mixed diet furnishes in two years more than the necessary quantity of phosphoric acid, while about ten years will be required to bring up the amount of calcium salts to the standard. It seems but rational, therefore, to select such foodstuffs, especially for in- fants and children, as contain a large percentage of organic cal- cium salts. As to furnishing the body with inorganic substances in the form of calcium, magnesium, fluorin, and phosphorus compounds, which are needed in building up the osseous tissues, it is questionable if these insoluble compounds are of benefit. As far as calcium salts and phosphorus compounds are concerned, it is known that for the most part they are again excreted. If there is a real need for these substances, a rational therapy points to the utilization of compounds which furnish these materials in organic combinations and which are products of nature. Coarse wheat and rye flour are rich in phosphoric acid, while calcium salts (inorganic lime) are usually found in hard drinking water and in most vegetables, espe- cially beans, cauliflower, rutabaga, and cabbage. The addition of small quantities of lime water to milk or drinking water apparently has a beneficial influence on bone formation. En passant it may be mentioned that the stories which still circulate among the laity, and to some extent among practitioners, regarding the removal of lime salts from the teeth of the mother during pregnancy to build up those of her offspring, are wholly unfounded. A well-regulated diet, rich in lime and phosphates, and sufficiently coarse to call forth vigorous use of the jaws, and regular exercise in the open air, is the foundation of a strong skeleton and sound teeth. ALTERATIVES. Alteratives (to change) are drugs which so favorably modify nutrition as to overcome morbid processes; they promote metabol- ism. Modern pharmacologists have discarded the term alteratives ALTERATIVES 413 because the drugs belonging to this group do not act on specific organs, but on the organism as a whole. The drugs which are usually referred to as alteratives do not produce distinct symptoms when taken in ordinary doses ; apparently no direct stimulation or depression can be observed, but nevertheless their therapeutic in- fluence on the system as a whole is an assured clinical fact. The simplest remedy which causes changes in the metabolism of the tissues is water. Water, when systematically ingested, cleanses the mucous linings of oral cavity and stomach, and there- by increases their activity. Its passage through the body hastens the breaking down and the removal of protoplasm, which appears in increased quantities as nitrogenous compounds in the urine. Mild saline solutions sodium chlorid, with minute additions of sodium bicarbonate and impregnated with carbon dioxid are of still greater benefit to the organism. Their influence on the mucous linings of the stomach manifests itself in an increased ap- petite, and, as in the drinking of plain water, the quantity of urine and its solid constituents are increased. Ingesting potassium salts increases the excretion of sodium salts from the body; the latter must be replenished to restore the normal equilibrium of the tis- sue fluids. Certain other salts, especially iodin and mercury com- pounds, exercise, aside from their general action, a specific influ- ence on the whole system. The iodids form the most important group of those drugs which generically are termed true alteratives. Potassium iodid is the most favored representative of this group. Of the other iodin preparations, sodium iodid and syrup of hydriotic acid are the most universally employed compounds. Almost equally as impor- tant as the iodin compounds are the mercury preparations. Again, only the readily soluble salts of mercury are employed as altera- tives, especially the bichlorid and the biniodid of mercury. When mercury passes through the body of the cell it forms a union with the albumin of its protoplasm and produces irritation, which, de- pending on the quantity of the absorbed mercury, is more or less pronounced. If the absorbed quantity is too large, the cell dies from the caustic action of the poisoning. (See page 116.) Of the vegetable drugs, sassafras, guaiac, sarsaparilla, etc., have an old reputation as being highly valued alteratives; the latter has been much lauded as being especially efficacious, and is still widely used in the treatment of syphilis. This belief is wholly un- 414 PHARMACO-THERAPEUTICS founded; the empiric use of sarsaparilla in the form of a syrup, decoct, etc., as a vehicle for potassium iodid or mercury bichlorid has no influence on the disease. The alkalies and, to some extent, the acids, when ingested into the system, are of importance in so far as they furnish chemicals which are needed for the maintenance of the proper composition of the body juices. The alkalies are especially called for to rehabilitate, under certain conditions, the alkalinity of the blood in coma of diabetes, where relatively large quantities of acid are stored in the organism. Only mild alkalies, especially the sodium bicarbonate, are useful for internal admin- istration; potassium bicarbonate, lithium carbonate, and a few others are also used. The acids were much more freely employed in former years, with the belief that they could influence nutrition. The fruit acids act only as relishes. lodids. lodin, in its pure state, is not used internally, but sometimes it is administered in the form of an alcoholic solution, well diluted with water, or as an oily solution. Its pharmacologic action is most pronounced when it is ingested in the form- of its soluble salts, especially as potassium or sodium iodid. Potassium iodid is decom- posed in the body in the presence of sodium chlorid into potassium chlorid and sodium iodid; both salts are removed from the tis- sues by the urine and through all the glands. The iodin ion stimu- lates the cells to a higher activity, and incidentally promotes ab- sorption. The latter fact is important in the treatment of chronic metallic poisoning lead and bismuth line in the mouth, argyria, etc. Pathologic tissues are markedly influenced by iodids ; they ap- parently cause a forcible breaking down of necrotic and necrobiotic structure; hence their value in the treatment of tertiary stages of syphilis. The resistance of the vessel walls is lessened by the iodin salts, and this fact may help to explain their beneficial action in arterio-sclerosis. lodids are often given with expectorants to render the bronchial secretions more soluble. Prolonged admin- istration of an iodid is prone to cause iodism, which manifests it- self in salivation, frontal headache, and cough. lodids have a dis- agreeable, bitter taste; they are best administered in milk. The various organic compounds of iodin and their solutions are referred to under Halogens, and Irritants and Counter-irritants. ALTERATIVES 415 POTASSIUM IODID; POTASSII IODIDUM, U. S. P., B. P.; KI; IODURE DE POTASSIUM, F. ; JODKALI, G. It forms transparent, colorless, or opaque white crystals, or a white granular powder, having a peculiar, faint, iodin-like odor and a pungent, saline, bitter taste. It is soluble in 0.7 parts of water, about 12 parts of alcohol, and about 2.5 parts of glycerin. It is incompatible with calomel, chloral hydrate, acids, and alka- loidal and metallic salts. AVERAGE DOSE. iy 2 grains (0.5 Gm.). Sodium lodid; Sodii lodidum, U. S. P., B. P. ; Nal ; lodure de Soude, F. ; Jodnatron, G. It forms colorless, cubical crystals, or a white, granular powder, having a saline, bitter taste. It is soluble in about 0.5 part of water and 3 parts of alcohol. Average dose, 7i/ 2 grains (0.5 Gm.). Ointment of Potassium lodid; Unguentum Potassii lodidi, U. S. P., B. P. It is an ointment containing 10 per cent of potas- sium iodid. CONCENTRATED POTASSIUM IODID SOLUTION. B Potassii iodid. 3 j (30.0 Gm.) Aquae destill. ad flg j (30 C.c.) M. Sig. : 5 drops three times daily in a glass of milk. Mercury Salts. Mercury possesses a great affinity for albumin, with which it very quickly enters into a chemic union. The readily soluble mer- cury compounds naturally act the quickest, while mercury, in its metallic state or in an insoluble form, passes unaltered through the body ; hence the assertion that red dental rubbers, which are often colored with natural cinnabar or with artificial red mercuric sul- phid (vermilion), cause mercurial stomatitis is wholly unfounded, and the same is true of the mercury component of amalgam fillings. Mercurials are comparatively easily absorbed by the mucous lin- ings of the intestinal tract, and they may then cause chronic in- toxications. Acute poisoning with mercurials is never observed, but it may be artificially induced. The absorbed mercury is ex- creted by the kidneys, the intestines, the mucous surfaces, and the various glands. Intense salivation is often noticed as a result of 416 PHARMACO-THERAPEUTIC3 mercury absorption; it is apparently due to a direct stimulation of the secretory centers. The saliva contains mercury and has a pronounced metallic taste. 1 The irritation caused by the mercury produces excoriation of the mucous linings of the mouth, starting usually about the posterior teeth. Teeth with ragged edges and those covered with calcareous deposits invite irritation. The denudation in the presence of path- ogenic bacteria soon leads to ulceration, which is accompanied by an intensely foul odor. The destruction of the soft tissues may in- volve large parts of the gums, the palate, etc., followed by per- iostitis, but rarely by necrosis of the bone. Thorough, hygienic care of the oral cavity before and during a course of mercurial treat- ment invariably precludes the formation of mercurial stomatitis. The compound solution of hydrogen dioxid (see page 141) deserves to be specially recommended as an oral antiseptic under these con- ditions. Mercury has been in the past the remedy par excellence in the treatment of syphilis; at present it is largely replaced by salvar- san. Whether mercurials act as a direct poison to the recently dis- covered causative factor of syphilis, the spirochete pallida, is as yet not fully known. A carefully inaugurated mercury treatment will rarely do harm. It will keep the exciting organisms in check, and prevents the secondary stage of syphilis if ingested early. The constitutional treatment of syphilis belongs to the domain of the medical practitioner. The administration of mercury depends on its various salts, on the metal in a fine state of division (mercurial ointment or colloidal mercury) and on recently introduced organic compounds. These remedies may be introduced by internal admin- istration, by injection, or by inunction. The various salts of mer- cury have been discussed under Salts of the Heavy Metals. Very recently, mercury succinimid has been introduced by Wright and White as a specific in the treatment of pyorrhea alveo- 1 Examination of saliva for mercury for the prevention of mercurial stomatitis during treatment with mercury. Severino says that the mouth secretions during administration of mercury give, on addition of tincture of iodin, a red color, due to the formation of mercury biniodid only in case the organism is oversaturated with the metal. In such an event it seems advisable to interrupt the use of mercury in order to prevent symptoms of poisoning with the drug, and especially the appearance of a stomatitis. Severino has de- vised a simple method of carrying out this test. He paints the anterior surfaces of the upper and lower incisor teeth with tincture of iodin and then asks the patient to wet the teeth thoroughly with saliva. In case the reaction is positive, a more or less intense rose- colored stain appears on the teeth within half a minute. (Sahli.) ALTERATIVES 417 laris. Mercury succinimid is a white crystalline powder, soluble in 75 parts of water and it is not affected by albumen. According to the originators of this treatment, 1 the dosage and method of its application is as follows: "In this disease, in the male patient, a deep muscular injection of mercuric succinimid gr. 1 (65 mgm.) should be administered every seventh day, until the discharge of pus has entirely disappeared, and the gums have regained their normal condition and appearance. If the pockets have not been entirely ob- literated and the loose teeth have not become firmly fixed by this time, they will quickly do so without further treatment, providing the hygiene of the mouth and teeth is properly carried out. Of course, when a tooth socket has become destroyed by alveolar absorption, it is impossible for the tooth to be- come fixed, and it should be removed. In female patients the dose should be from gr. l/ 5 (13 mgm.) to gr. % (26 mgm.) less than that administered to males. Mercurialism of any marked degree should be met with smaller doses at succeeding injections, or, if the symptoms are severe, the mercury is dis- continued until they have disappeared. In treating cases complicated by a secondary systemic infection, the dosage and interval between injections will materially differ from the above, according to the nature of the secondary infection, whether acute or chronic, severe or mild, etc. As this question more properly belongs to the realm of internal medicine, I refer those interested to my former publications. I have seen several cases of pyorrhea recover com- pletely under the above treatment without local surgical intervention, but these were those in which calcareous deposits and tartar had not formed, nor was the omission of local treatment desired by me, but due to the absence on leave of my dental colleague." Precisely what we said about the curative effect of emetin as a specific in the treatment of pyorrhea will also apply to the thera- peutic use of mercuric succinimid, i. e., this drug is an etiotropic remedy which destroys the spirochete. But it should be under- stood that with the elimination of this protozoal agent alone pyor- rhea is by no means cured. The late Ehrlich introduced a number of etiotropic remedies, i.e., specifics for the treatment of those disturbances caused by spiril- loses, especially syphilis, malaria, relapsing fever and frambesia. Among these remedies, salvarsan, also known as "606," occupies probably the foremost place. Salvarsan, dioxydiaminoarseno- benzol hydrochlorid and neosalvarsan, a sodium salt of the mother substance and combined with some inert inorganic salts, contain the trivalent arsenic. Salvarsan contains about 3iy 2 per cent of arsenic while 3 parts of neosalvarsan are approximately equal to i Wright and White: Dental Cosmos, 1915, pp. 405, 779 and 1003. 418 PHARMACO-THERAPEUTICS that of 2 parts of salvarsan. These substances are preferably ad- ministered intravenously in freshly made solutions. Zilz 1 highly recommended the local application of salvarsan in freshly prepared 10 per cent solution in water or glycerin or suspended in olive oil or liquid paraffin as a topical remedy in Plaut- Vincent angina, in severe forms of stomatitis and scorbutic ulcerations of the oral tissues. With a cotton swab the solution is applied 3 times daily upon the ulcerated surface which has been previously cleansed with warm physiologic salt solution. FOR MERCURIAL STOMATITIS. R Vioformi 3 ss (2 Gm.) Glycerin! fi$ j (30 C.c.) M. Sig. : Paint on the ulcerated surfaces and cover with strips of lint. Within the last few years a remedy has been introduced in thera- peutics which is said to possess a selective power on pathologic fibrous tissues, causing its absorption and facilitating the stretch- ing of the cicatrix. It is known as fibrolysin, and, as no other pharmacologic group will allow its admittance, we prefer to discuss it at this point. Fibrolysin is an aqueous solution of thiosinamin and sodium salicylate, marketed in sterilized sealed tubes, each containing 35 minims (2.3 C.c.), which is equivalent to 3 grains (0.2 Gm.) of thiosinamin. The solution is preferably introduced by intramus- cular injections as closely as possible to the seat of the cicatrix, but not into it. Special care is necessary not to inject too close to the surface, as it may cause sloughing. The injection is made under strict aseptic conditions, and should be repeated every second or third day. It is difficult to state how many injections are neces- sary, as that will depend largely on the size of the cicatrix. Usually from eight to ten injections are required, and, again, as many as twenty-five injections have been necessary in large scars. There are scarcely any unpleasant after effects to be recorded; slight rise of temperature and a few cases of nausea and vomiting have been noticed. The exact mechanism by which fibrolysin acts is unknown ; it has been stated that a hyperemic congestion is estab- : Miinchener Medicinische Wochenschrift, 1913. SIALOGOGUES AND ANTISIALOGOGUES 419 lished, which may explain the cause of the softening of the fibrous tissues. The injection of fibrolysin in dental surgery is indicated in scars caused by an alveolar abscess discharging upon the face. These scars are usually very disfiguring, and fibrolysin deserves to be tried in such cases, especially where there is an opportunity to use it soon after their formation. SIALOGOGUES AND ANTISIALOGOGUES. Drugs which increase the flow of saliva are known as sialogogues or as ptyalogogues (to cause the flow of saliva), and those which diminish it are known as antisialogogues. Human saliva represents the mixed secretions from the three pairs of salivary glands and the minute mucous glands distributed over the oral cavity. Saliva may be defined as being a weak solution of alkalis, as present in the body juices, more or less saturated with carbon dioxid. It contains, furthermore, several organic substances, among which mucin and the several ferments which accelerate the changes of starches into maltose, i. e., the hydrolysis of polysaccharids into soluble disaccharids. The ferments of human saliva are repre- sented by the carbohydrate splitting type, principally amylase (ptyal-in) and, less so, maltase, although the catalyzers, oxydase and catalase, are always present in more or less variable quan- tities. The physiologic function of mucin consists in mechan- ically assisting the food bolus in its easy passage into the stomach and to protect the oral mucous membrane and the teeth against irritating substances. Mucin has been held responsible by some investigators (Lohmann, etc.) as a factor in the production of dental caries. This statement has been emphatically denied by Miller, Michel, and others. Mucin is insoluble in water; in the presence of alkalis it forms a colloidal solution, while acids pre- cipitate it. The so-called ropy saliva contains larger quantities of mucin than normal and by precipitating this sticky compound it adheres to the surfaces of the teeth and thereby produces the much discussed gelatinous plaques which serve as a mechanical retainer of food debris and bacteria. (See Preparations for the Mouth and Teeth.) 420 PHARMACO-THERAPEUTICS Sialogogues. Sialogogues are indicated in an abnormal dryness of the mouth. Diminished secretion of saliva results from the injections of cer- tain drugs belladonna (atropin), henbane, opium scopola, stra- monium, etc. or from so-called ptomain poisoning, which may re- sult from eating decaying meat, cheese, fish, etc. Many febrile diseases also diminish the flow of saliva, or cause a drying up of the normal moisture of the oral mucous linings. Dry mouth (xerostomia) results from an impaired secretion of saliva, which may be caused by severe physical or psychic disturbances of the nervous system, diseases of the digestive tract, and other un- known factors. Atrophy of the salivary glands may destroy their functions completely. To prevent dryness of the air in the sick room, which is very likely to occur in the modern furnace- heated houses, pans filled with fresh water should be placed about the room. Small quantities of fresh drinking water, or acidulated with organic acids (lemon juice, tartaric acid), should be given at frequent intervals to the patient. Spices and the simple bitters gentian, quassia, columbo, dandelion, etc. as well as the chewing of semi-solid, insoluble material gum, rubber, etc. increase the flow of saliva. Tobacco, the iodin compounds, certain mercury preparations, and vomiting also cause a profuse flow of saliva. The supreme sialogogue is pilocarpus (jaborandi). It is best prescribed as the hydrochloric salt of the alkaloid, pilocarpin. Pilocarpin acts on the terminations of the secretory nerves, espe- cially the minute fibrils which ramify between the epithelial cells. It is principally indicated in the treatment of dry mouth (xeros- tomia). If this disease results from, nervous disturbances, elec- tricity is of some value. While recovery from true xerostomia is very problematic, the patient may be made comfortable by the use of pilocarpin. PILOCARPIN HYDROCHLORID ; PILOCARPIN^ HYDROCHLORIDUM, U. S. P.; C^H^NAHCl. It is the hydrochlorid of an alkaloid obtained from jaborandi leaves. It appears in small white crystals, odorless, with a slightly bitter taste. It is very soluble in water and alcohol. AVERAGE DOSE. % grain (0.01 Gm.). DIAPHORETICS 421 PILOCARPIN NITRATE; PILOCARPIN.JE NITRAS, U. S. P., B. P.; C 11 H 16 N 2 2 HN0 3 . It is the nitrate of an alkaloid obtained from jaborandi leaves. It forms a white crystalline powder, which is soluble in about 10 parts of cold water and freely soluble in hot alcohol. AVERAGE DOSE. % 2 grain (0.005 Gm.). FOR DRY MOUTH. B Pilocarpin. hydrochloric!. gr. v (0.3 Gm.) Aquae destillat. fl-5 ss (15 C.c.) M. Sig. : 5 drops three times daily. Slowly increase the dose by 1 drop until from 8 to 10 drops per dose are taken. Antisialogogues. Ptyalism often results from a general poisoning with mercury, bismuth, iodin, and bromin preparations, pilocarpin, aconitin, physostigmin, etc. These poisons may have been administered by the mouth, hypodermically, or they may have been absorbed from wound surfaces. The supreme remedy to stop the flow of saliva is atropin; it paralyzes the chlorda tympani and the sympathetic nerve endings in the salivary glands. Small doses of atropin are often given advantageously to a patient afflicted with an abnormal flow of saliva prior to dental operations in which the rubber dam can not be applied. ATROPIN SULPHATE; ATROPIN^E SULPHAS, U. S. P., B. P.; (C 17 H 23 N0 3 ) 2 .H 2 S0 4 . A white crystalline powder, prepared from the alkaloid atropin derived from belladonna leaves. It has a very bitter taste, and is freely soluble in water and alcohol. AVERAGE DOSE. % 50 grain (0.0004 Gm.). R Pil. atropin. sulphatis gr. i/ 150 (0.0004 Gm.) No. ij Sig.: One pill in the evening and one in the morning be- fore the dental operation. DIAPHORETICS. Diaphoretics (to carry through), sometimes called sudorifics (to sweat), are remedies employed for the purpose of increasing perspiration. Normal perspiration is constantly produced by the 422 PHARMACO-THERAPEUTICS sweat glands, while the so-called insensible perspiration results from the evaporation of water which is derived from superficial capillaries and lymph channels. Perspiration is spontaneously increased in heated surroundings and during muscular exertion. The control of perspiration is principally due to specific nerves, although direct irritation of the sweat glands may also produce perspiration. The true diaphoretics excite the sweat centers as well as the peripheral endings of the sweat nerves, while the in- direct diaphoretics create only an active hyperemia of the skin. Psychic influence fear, excitement, etc. may also produce perspiration by reflex action. The sweat is principally composed of water (9iy 2 to 991/2 per cent), the solid constituents being cholesterin, aromatic fatty acids, aromatic oxy-acids, ethyl sul- phuric acid, urea, and various salts., especially sodium chlorid and alkaline sulphates and phosphates. The normal fresh perspira- tion of man reacts acid, but the stagnated sweat is usually alkaline. Pure meat diet produces an acid sweat, while vegetable diet al- ways furnishes alkaline perspiration. In infectious diseases the sweat may eliminate waste products of microbal origin, in diabetes it may contain sugar, and in uric acid diathesis it may contain uric acid salts. Internally administered drugs salicylic and benzoic acid and their salts, iodin, bromin, mercury, lead, quinin, essential oils, etc. may also be excreted by the sweat. Apparent- ly the production of sweat diminishes with the age of the in- dividual. Sweating as a therapeutic procedure is rarely practiced at pres- ent, except in certain chronic diseases and in those conditions which are generically termed "colds." The simplest means of bringing about profuse perspiration is by the ingestion of hot fluids and a diminishing of heat radiation by wrapping the patient in heavy covers. Mild alcoholic liquids in the form of hot toddies, hot coffee or tea are especially productive of free perspiration. Pilocarpin is the most effective of all diaphoretics; it may be ad- ministered as its hydrochloric salt, or in the form of an infusion of the jaborandi leaves. Elder flowers and linden flowers are still largely used by the laity for this purpose. Dover's powder in small doses, alone or combined with the salicylates (aspirin), or the spirit mindererus (solution of ammonium acetate, U. S. P., B. P.), are frequently employed by the clinician for the produc- tion of mild perspiration. Turkish, electric light, hot air, and DIURETICS 423 sun baths as means of producing profuse perspiration have gained much favor in recent years. Pilocarpin and its salts have been referred to under Sialo- gogues and Antisialogogues. DIURETICS. Diuretics (to increase the secretion of urine) are remedies em- ployed for the purpose of promoting the secretion of urine. The organ which secretes the urine is the kidney. Under normal con- ditions the kidney performs three functions it maintains the osmotic equilibrium of the blood, it removes the end products of metabolism of the protoplasm, and it eliminates foreign substances from the system. Urine is secreted by the combined activity of the glomeruli and the convoluted tubes; the former secrete a fluid- poor in salts, but rich in water, while the latter reverse the process rich in salts, poor in water. The urine may be acid, alkaline, or neutral in reaction. Occasionally it is desirable to produce an increased flow of urine which should react either acid, alkaline, or neutral. From a physiologic point of view it is also of interest to know that with the urine certain drugs are excreted which were administered for specific purposes. Diuretics are administered for the purpose of removing path- ologic collections of exudates which may have been confined in body cavities or between the tissues, as in diseases of the heart, nephritis, cirrhosis, etc. They are also given to remove poisons which have entered the body or which are formed in the body, and to mechanically flush the uriniferous tubules, which may be clogged by foreign materials. Flushing of the entire urinary tract includes the kidney, ureter, and bladder, and it is often employed for the purpose of preventing the formation of concrements in these tissues. The many drugs which possess a more or less pronounced diuretic action are closely related to diaphoretics and uric acid solvents. Water is an important diuretic, and we have referred to it more particularly under Alteratives and Uric Acid Solvents. An indirect irritation of the epithelial coat of the kidneys, which produces increased activity, is caused by many essential oils oil of turpentine, juniper, parsley and many roots and herbs which 424 PHARMACO-THERAPEUTICS contain irritating substances. Many salines, especially potassium and sodium acetate, sodium nitrite, lithium carbonate, etc., are lauded as diuretics; the solutions of ammonium acetate, U. S. P., B. P., and the spirit of nitrous ether, U. S. P., B. P., enjoy a wide reputation. Of the heavy metals, calomel in large doses is productive of an increased quantity of urine. A direct stimu- lation of the epithelium of the kidneys is readily obtained by caffein and theobromin; they do not irritate the kidneys, and may be given in comparatively large doses. Theobromin is prin- cipally administered in combination with sodium salicylate. known as diuretin. Caffein has been referred to under Cerebral Stimu- lants. THEOBROMIN SODIUM SALICYLATE; THEOBROMIN^: SODIO-SALI- CYLAS, U. S. P.; NaC 7 H 7 N 4 2 +NaC 7 H 5 3 ; DIURETIN. It is a white powder, odorless, and having a saline taste. It is freely soluble in water, but is decomposed in the presence of car- bon dioxid. It should be given in well-diluted solutions. AVERAGE DOSE. 15 grains (1 Gm.). URIC ACID SOLVENTS. Uric acid solvents, also referred to as litliontriptics or antilitliics (stone destroyers), and as antiarthritics (gout remedies), are drugs employed for the purpose of dissolving uric acid and in- creasing its excretion. Uric acid as a causative factor of dental disease has been for more than a decade a prolific theme of discussion. Like all subjects pertaining to medicine, as well as many other matters which are clothed in mystery, it gives rise to much unsound speculation. Regarding the process of uric acid formation, excretion, destruc- tion, retention, deposition, and solution in health and disease, very few absolute facts are known, and consequently the therapeutic measures, as far as remedies are concerned, are very limited. There is probably no other field in therapeutics about which so little "truth" is known and about which so much "poetry" is written as the uric acid problem. 1 Apparently, however, this is not true in the mind of the nostrum maker. To him the bugbear 1 Barker: Truth and Poetry Concerning Uric Acid, Chicago, 1905. URIC ACID SOLVENTS 425 of uric acid diathesis has been and still is the very shibboleth of uncounted possibilities. It is not within our present consideration to enter into a detailed discussion of the formation of uric acid in the body. Let it suffice to say that uric acid is formed in the body in various ways as a product of oxidation from the nucleins of the tissue cells and from the xanthin bases of ingested foodstuffs, or it may be formed synthetically in the human body, just as it is in the body of birds. The acid is excreted in the form of purin bodies uric acid united with xanthin bases. Uric acid diathesis is, in all probability, due to increased presence or to decreased ex- cretion of formed uric acid. The first possibility may result from an increased formation, a decreased destruction, or the solution and removal of gouty deposits (tophi). The formation of tophi may result from a disturbed function of the excretory organs, which produces an increased deposition of sodium monourate in the tissues, especially in the hyaline and fibrous cartilages, in the tendons and in the subcutaneous and intramuscular connective tissue, or from a retention of uric acid in the blood and the other tissues. "It must be admitted that, in the present status of our knowledge, no adequate theory to explain gout has been advanced and that we hardly know more than that it is associated in some way with a perversion of uric acid metabolism." (Krehl.) The rational treatment of uric acid diathesis consists in a well- regulated diet, together with proper general hygienic measures. The diet should be simple and rather spare; overloading the sys- tem must be carefully avoided. According to the observations of Minkowski, 1 the average daily food should consist of about 4 ounces (120 grams) of proteins, 2 to 3 ounces (60 to 90 grams) of fat, and 8 to 10 ounces (240 to 300 grams) of carbohydrates. Ac- cording to Haig 2 an average day's food may consist of 16 to 20 ounces (480 to 600 grams) of breadstuff s, 8 ounces (240 grams) of dried fruit, and 8 ounces (240 grams) of fresh fruit; each meal consisting of 5 to 7 ounces (150 to 210 grams) of breadstuffs, with 2 to 3 ounces (60 to 90 grams) of dried fruit, and a similar quan- tity of fresh fruit, A little potato may often be substituted with advantage for fruit at breakfast ; some do well with a little potato at each meal and less fresh fruit. Nuts may be added or taken 'Minkowski: In Bunge's Physiologic Chemistry, 1902. 2 Haig. Uric Acid as a Factor in the Causation of Disease, London, 1 426 PHARMACO-THERAPEUTICS in place of some of the breadstuffs by those who like and can digest them. Animal food should be used very moderately. From the following dietary a suitable uric acid free diet may be readily selected: DIETARY. ALLOWED. Water, especially mild alkaline min- eral water. Very weak tea. White meat of chicken, turkey, quail. Meat soups in small quantities only. All cereals, rice, and breakfast foods. All green vegetables. Cabbage in moderation. Dried fruits and nuts. All breads. Eggs in moderation. Milk. PROHIBITED. All raw meats (beef, mutton, and pork) . All glandular tissues (kidneys, liver, and sweetbreads). Asparagus, celery, radishes. Beans and peas. Coffee. All liquors, wines, and spirits. Pastry and confections. Sharp sauces and mayonnaise. Mushrooms. Frequent bathing, gentle massage, and a few hours' daily ex- ercise will be of marked benefit. If a month's vacation can be taken, with much outdoor exercise and living the simple life, with a well-controlled appetite, it will prove highly beneficial. In the treatment of dental diseases resulting from uric acid diathesis, local and general factors are to be considered. An in- creased presence of uric acid can be positively determined only by an analysis of the urine, and it should always be made in every case where the general conditions point to its presence. Entire- ly too much guess work is done in this matter by the average dental practitioner. The local treatment consists in the thorough removal of the deposits about the teeth 1 and the restoration of hygienic conditions of the oral cavity. Internal medication is di- rected toward the lessening of the formation of uric acid, and to an increased excretion. The formation of exagenous uric acid is readily controlled by a suitable diet. All foods rich in nucleins and purin derivatives are to be avoided sweetbreads, liver, kid- neys, etc. ; in fact, all meats or meat soups should be partaken of sparingly. Vegetable proteins, which are found in abundance in peas and beans, and which are direct forestages of uric acid 1 Endelman: The Uric Acid Problem as Related to Pericemental Inflammation, Dental. Cosmos, 1908, p. 1076. URIC ACID SOLVENTS 427 formation, should also be restricted in their use as foodstuffs. Whether the formation of uric acid in the body can be inhibited at all is as yet not proved. Alcoholic liquors, especially beer, ex- ercise a known harmful influence on gouty predisposition. It is claimed that quinic (china) acid possesses inhibitory action on the formation of uric acid, and as a consequence quite a number of compounds containing this acid are found on the market urosin, sidonal, lycetol, lysidin, etc. Their therapeutic value is problematic. An increase of the destruction of uric acid in the body has also been attempted at various times. So far no positive knowledge exists to justify such procedures, although many drugs are recommended for this purpose. Again, an increased excretion of uric acid is favored by many as a valuable therapeutic aid, and here at least positive results can be obtained by materially increas- ing the amount of urine excretion. The simplest means for such purpose is the copious drinking of water. Ordinary table water or mild alkaline mineral waters will answer equally as well. The amount of water taken within twenty-four hours should be in- creased to about one gallon, which equals approximately sixteen tumblerfuls. The salicylates, especially lithium salicylate, have been highly recommended without proof, however as a solvent or as a means of increasing uric acid excretions. It is claimed that many of the alkaline metallic salts, especially the salts of lithium, possess a definite solvent power on uric acid. While such claims have never been substantiated, and are emphatically denied by many investigators, lithia is nevertheless widely used at present. The administration of lithium compounds is of value as sug- gestive therapeutics. A patient may forget, or even object, to carry out the instruction in regard to the drinking of large quan- tities of water which, in his estimation, may be of little conse- quence, while, on the other hand, a prescription calling for lithium citrate tablets, with the proper directions, may readily overcome this difficulty. Rendering uric acid, when present in the blood, more soluble may probably be accomplished by ingesting certain organic substances which readily combine with the acid to form nonsalt-like compounds. Of the various preparations which are suggested for such purposes, formaldehyd deserves mentioning. Formaldehyd in the form of hexamethylen, or compounds of a similar nature, furnishes free formaldehyd in the body. It ap- pears in the urine as an easily soluble compound of uric acid, the 428 PHARMACO-THERAPEUTICS diformaldehyd-uric acid. The combination of these preparations with colchicum is often of some advantage; the clinical results obtained justify their empiric administration. Atophan in doses of from 4-8 grains (0.25-0.5 Gm.) increases uric acid excretion within one hour. In doses of from 30-45 grains (2-3 Gm.) the nor- mal uric acid excretion is doubled and sometimes even trebled in twenty-four hours. It is especially useful in the acute attacks of gout. If taken for 4 or 5 days in succession, it occasionally de- ranges the digestion. The dental disturbances of uric acid diathesis manifest them- selves principally in pericemental inflammation, resulting in a specific type of systemic pyorrhea alveolaris. The latter term is unfortunately still frequently, but wrongly, interpreted as signi- fying a pathologic entity. Pyorrhea alveolaris is a collective term employed to designate a local manifestation of disease brought about by many causes. According to Miller, it may be defined as a chronic destructive inflammation of the pericementum, with more or less necrosis of the alveolar process of the affected tooth. The constitutional causes of pyorrhea may be manifold; diabetes, syphilis, B right's disease, gout, etc., are among the more promi- nent factors of its production. Gouty pericementitis, a name given by Pierce 1 to a form of pyorrhea produced by uric acid arthritis, has received much attention in dental literature. The formation of uratic deposits occurs on the roots of the teeth in the perice- mentum principally about the upper half of the root. The de- posited urates establish a point of minor resistance in the peri- dental membrane, and thus predispose it to the invasion of pyo- genic bacteria. The nature of the invading micro-organisms de- termines the character of the inflammatory process. To eliminate the endameba buccalis, emetin should be applied. (See Emetin.) In regard to the systemic treatment of the gouty form of pyor- rhea, it is essential to conform to the general rules of the treat- ment of uric acid diathesis. To relieve acute pain, the salicylates, especially aspirin, to- gether with hot fomentations, are beneficial. If pericemental abscesses are present, an early incision, proper drainage, and antiseptic care is of importance in the quick relief of the local 1 Pierce: Pyorrhea Alveolaris, in Kirk's "American Text Book of Operative Dentistry," 1905. URIC ACID SOLVENTS 429 symptoms. 1 The thorough removal of the deposits from the teeth and their proper splinting is essential to the local treatment of this ailment. To facilitate the ready disintegration of calcareous deposits on the roots of teeth, Head 2 has introduced a solution of ammonium bifluorid which is commercially known as tartar sol- vent. Head has given the following directions for using this solu- tion: For the treatment of pyorrhea scrape the roots with sealers as thoroughly as possible, and wash out the pockets with warm water. Protect the cheek and lips with a napkin ; then, after dry- ing the pockets, fill them with the solvent injected by means of a platinum pointed syringe, wiping off all excess from the gums. Change the napkins to avoid the possibility of any of the solvent creeping up on the cheek through capillary attraction. At the end of two minutes rinse the mouth with water. Apply the sol- vents twice a week not oftener. During the second or third treat- ment explore the pocket for softened tartar scales which may not Fig. 82. Dunn bifluorid syringe. have been entirely dissolved. When the pockets begin to heal by granulation, take care not to allow instrumentation to break down the adhesions. When teeth are loose, without tartar, the repeated application of the solvent twice a week causes them to become useful for mastication. Fistulas may be injected full of the sol- vent, and the mouth rinsed at once. The tartar solvent should al- ways be injected and never inserted on cotton. If allowed to dry on the mucous membrane, it will burn like phenol. Ordinary care in wiping off any excess will render this impossible. It should be remembered that this tartar solvent, on account of its hydrofluoric acid component, destroys glass, and consequently a glass syringe is ill suited for its application. A special small syringe, the Dunn bifluorid syringe, has been put on the market to overcome these defects. It is made entirely of rubber, or it may 1 Endelman : Uratic Deposits Upon the Roots of Teeth, Dental Cosmos, 1905. 'Head: Items of Interest, 1909, p. 174. 430 PHARM A CO-THERAPEUTICS be had with a transparent celluloid barrel ; the advantages of the latter are obvious. The needle of the syringe is made of iridio- platinum. LITHIUM CARBONATE; LITHII CARBONAS, U. S. P.; Li 2 C0 3 . A light white powder, odorless, and having an alkaline taste. It is soluble in 75 parts of water and readily soluble in carbonated water. AVERAGE DOSE. iy 2 grains (0.5 Gm.). Lithium Citrate; Litliii Citras, U. S. P., B. P.; Li 3 C 6 H 5 7 + 4H 2 0. A white, odorless powder, having a cooling, alkaline taste. It is soluble in about 3 parts of water. Average dose, 7i/ 2 grains (0.5 Gm.). Lithium Salicylate; Lithii Salicylas, U. S. P. ; LiC 7 H 5 3 . A white, odorless powder, having a sweetish taste. It is very soluble in water. Average dose, 15 grains (1 Gm.). Lithium Citrate, Effervescent; Lithii Citras Effervescens, U. S. P., B. P. A granular effervescent salt, containing 5 per cent of lithium citrate. Average dose, 120 grains (8 Gm.). HEXAMETHYLENAMIN ; HEXAMETHYLENAMINA, U. S. P. ; C 6 H 12 N 4 ; UROTROPIN; CYSTOGEN; AMINOFORM; FORMIN. It forms colorless, lustrous crystals, having a slight alkaline taste. It is soluble in 1.5 parts of water and 10 parts of alcohol. AVERAGE DOSE. 4 grains (0.25 Gm.). Citarin; Sodium Anhydromethylen Citrate. It is a white gran- ular powder, having a faintly saline taste and a slightly acid re- action. It is soluble in 1.5 parts of water. In the presence of alkalis it is split up in formaldehyd and sodium citrate. Average dose, 15 grains (1 Gm.). ATOPHAN; PHENYL-QUINOLIN-CARBOXYLIC ACID. It appears in small colorless crystals, insoluble in water, but readily soluble in alkalies, and hot alcohol. It has a slightly bit- ter taste. It is best borne when administered simultaneously with 60 grains (4 Gm.) of sodium bicarbonate. Average dose, 7y 2 grains (0.5 Gm.) three to four times a day, suspended in large quantities of water. ANTIPYRETICS 43 1 PlPERAZIN ; DlETHYLENEDIAMIN. It forms colorless, lustrous, very hygroscopic crystals, which are very readily soluble in water, forming strongly alkaline, but not caustic, solutions. AVERAGE DOSE. iy 2 grains (0.5 Gm.). Lycetol, a piperazin tartrate, and si'donoil, a piperazin quinate, have been lately introduced as substitutes for pure piperazin. FOR GOUTY PERICEMENTITIS. R Hexamethylenaminse 3 ss (16.0 Gm.) Colchicinae gr. ss (0.03 Gm.) M. f. tablet. No. Lx. Sig. : A tablet dissolved in a tumblerful of water five times daily. IJ Atophani gr. viij (0.5 Gm.) Tablet. No. xij. Sig. : A tablet dissolved in a tumblerful of water 3 or 4 times daily. ANTIPYRETICS. Antipyretics or antifebriles, both meaning against fever, are remedies employed for the purpose of reducing increased bodily temperature. They incidentally act as sedatives and anodynes, and are frequently employed in dentistry to relieve neuralgia; hence they are sometimes referred to as antineuralgics or anti- nervins. The normal temperature of man is comparatively constant that is, the changes vary within a very narrow limit. Normally, the body temperature ranges between 98.5 and 99.5 F. (36.9 and 37.4 C.). The external air has very little influence on the temperature of the human body. It is immaterial whether we are exposed to the broiling sun of the equator (120 F., 49 C.) or to the icy cold of Spitzbergen (40 F., 40 C.) ; our in- ner temperature of 99 F. (37.3 C.) remains unaltered. The regulation of the body temperature is controlled by specific nerves, although we are able by suitable protection heavy or light cloth- ing, warm rooms or shady, airy, open spaces to materially in- fluence the radiation of bodily heat. The regulation of heat- 432 PHARMACO-THERAPEUTICS producing foodstuffs is of prime importance; cold climates require easily combustible fats or other carbohydrates, while in the tropics we instinctively avoid a steaming dish of "pork and beans." A rise of temperature of the surroundings causes dilation of the peripheral vessels, which forces the warm blood to the surface to be cooled off, and the ready evaporation of perspiration from an increased action of the sweat glands cools the body surface. The combined process of heat production and regulation is based on physiologic, chemic, and physical laws. An abnormally increased heat produced by physical exertion and unfavorable external con- ditions high heat, humid atmosphere, etc. may lead to over- heating of the body; 104 F. and even as high as 113 F. (40 to 45 C.) have been observed in sunstrokes. A rise in the body temperature is, in the majority of cases, the symptom of fever, provided this higher temperature is of a fairly constant nature. Fever is not a disease, but a pathognomonic sign of disturbance of the equilibrium of the organism as a whole. In most cases fever is the result of infection, although traumatic dis- turbances subcutaneous fractures may cause a so-called aseptic fever, which in its production is somewhat analogous to an aseptic suppuration. The causes of the increased temperature in fever have given rise to various theories; the present consensus of opin- ions seems to point to the fact that fever is an indication that the centers of heat regulation are gauged to a higher standard than that which is normally present in the body. Accepting this hypothesis, we may explain the causative factors of fever as fol- lows: Certain pyretogenic (fever producing) chemic substances act on the centers of heat regulation by interfering with the normal equilibrium of heat production and heat radiation, and as a con- sequence these centers are shifted to a higher plane and a higher constant body temperature is the result. The true antipyretics act on the higher gauged centers, and their influence causes the centers to return to their normal position. External influence on heat production and heat regulation do not interfere with the action of the true antipyretics. Indirect antipyretics quinin, salicylic acid, etc. as they are sometimes called, influence the heat centers partially, but they act principally on heat production and heat radiation. The pathologic significance of fever has kept pace with the spirit dominating medical practice. At one time it was thought ANTIPYRETICS 433 that fever was a dangerous disease and had to be cured, and, again, it was looked upon as an expression of vis medicatrix naturae, a view which is at present favored by leading clinicians. Conse- quently fever should not be "treated" immediately. If, however, the organism, in its effort to combat an infection, produces an ab- normal high temperature, it is the duty of the sensible practitioner to administer suitable antipyretics to coax nature to return to her normal functions. Fever may damage the organism in various ways. Abnormal high temperature is imminently dangerous to the heart, and, furthermore, a high temperature causes increased metabolism, with loss of strength, as the destroyed albumin mole- cule can not be replaced with sufficient rapidity. The increased temperature is accompanied by a disturbed psyche ; the patient is fidgety, and sleeplessness and restlessness cause the loss of much valuable vital resistance. The action of antipyretics in general is confined to the central nervous system ; they reduce the temiperature and incidentally act as sedatives and anodynes. QUININ SULPHATE; QUININE SULPHAS, U. S. P., B. P.; (C 20 H 24 2 ) 2 .H 2 S0 4 +7H 2 0; SULPHATE DE QUININE, F. ; SCHWEFEL- SAURES CHININ, G. SOURCE AND CHARACTER. It is the sulphate of the alkaloid qui- nin, obtained from the various species of Cinchona. It appears in white, silky, light, flexible crystals, or hard prismatic needles, colorless, and having a persistent bitter taste. It absorbs moisture from the air. It is soluble in 720 parts of water, 86 parts of al- cohol, and 36 parts of glycerin ; diluted acids increase its solubility in water. It is incompatible with ammonia, alkalies, lime water, tannin, potassium iodid, etc. AVERAGE DOSE. 4 grains (0.25 Gm.). THERAPEUTICS. Quinin is the sovereign remedy in malaria ; here it acts as a specific. It is a protoplasm poison; administered in therapeutic doses, it destroys the causative factors of malaria, the plasmodia malaria, without materially altering the protoplasm of the cells of the host. Quinin should be administered three to four hours before the typical malarial attack is manifested, so as to allow sufficient time for its absorption. It is a prompt prophy- lactic against this disease. Its action as an antiseptic on bacteria 434 PHARMACO-THERAPEUTICS or their spores is very weak. It inhibits the migration of leucocytes, and for this reason Binz and Helmholz recommended it at one time as an antiphlogistic. Its local application based on this sup- position, was much lauded in the treatment of pyorrhea alveolaris. While it is true that quiniii inhibits the migration of the white blood corpuscles, and, as a consequence, retards the typical symp- toms of inflammation, it increases the spreading of the infection. When inflammation, which is nature's curative agent against in- fection, is checked, the infection progresses unhindered on its path of destruction. Quiniii acts on the central nervous system as an anodyne; it reduces the irritability of the sensory nerves, and is used as an antineuralgic. In influenza and in septicemia it de- serves to be recommended. Quinin is best administered in loose- filled capsules, in pills, or suspended in syrup of yerba santa. In- jected locally in the readily soluble form of quinin and urea hydro- chlorid it acts as a local anesthetic. (See Local Anesthetics.) Aside from quinin sulphate, quite a large number of other quinin salts, artificial alkaloids, and a tincture and infusion of cinchona bark are medicinally employed. Acetylsalicylic acid, known as aspirin, and in a recent modifica- tion as novaspirin, is a prompt and valuable antipyretic and ano- dyne. It is specially recommended in neuralgic and rheumatic pain about the face and head. It is only slightly soluble in water, but readily soluble in alcohol. It is best administered in tablet form. Average dose, iy 2 grains (0.5 Gm.). Salicylic acid and its many salts and synthetic substitutes glycosal, salophen, salacetol have been referred to under salicylic acid. ANTIPYRIN ; ANTIPYRINA, U. S. P. ; PHENAZONUM, B. P. ; CnHjjjNjjO; ANALGESINE, ANTIPYRINE, F. ; ANTIPYRIN, G. SOURCE AND CHARACTER. It is a derivative of pyrazolon, and forms a colorless, almost odorless, crystalline powder, having a slightly bitter taste. It is soluble in less than 1 part of water, and 1 part of alcohol. It is incompatible with acids, alkalies, tannin, salicylates, etc. AVERAGE DOSE. 4 grains (0.25 Gm.). THERAPEUTICS. Antipyrin is a general antipyretic and anodyne. It acts on the central nervous system, and reduces the higher ANTIPYRETICS 435 gauged centers of heat regulation to their normal position. It is an effective remedy in neuralgia, migraine, lumbago, and sciatica. It should be given in strong doses from 4 to 8 grains (0.25 to 0.5 Gm.), dissolved in water or in gelatin capsules. Some persons show a distinct idiosyncrasy to this drug, which is often accom- panied by skin eruptions. A number of other pyrazolon derivatives have appeared within the last decade, of which migrainin, trigemin, pyramidon salicy- late and salipyrin are the best known representatives. The lat- ter is especially lauded in facial neuralgia and the various forms of toothache, and is given in T^-grain (0.5 Gm.) doses. ACETANILID; ACETANILIDUM, U. S. P., B. P.; C 8 H 9 NO ; ANTI- FEBRINE, ACETANILIDE, F. ; ANTIFEBRIN, G. SOURCE AND CHARACTER. It is the monacetyl derivative of ani- lin. It is a colorless, crystalline powder, odorless, and having a slightly burning taste. It is soluble in 180 parts of water, 2.5 parts of alcohol, and in chloroform and ether. It is incompatible with nitrous ether, bromids, iodids, phenol, resorcinol, and thymol. AVERAGE DOSE. 3 grains (0.2 Gm.). THERAPEUTICS. Acetanilid acts on the central nervous system as a powerful anodyne. In large doses it acts as a blood poison by forming methemoglobin, which manifests itself in pronounced cyanosis. Acetanilid forms the base of many ' ' headache ' ' powders and of many copyrighted pharmaceutic preparations generically known as "coal tar derivatives." Many cases of poisoning result- ing from the indiscriminate use of these compounds are on record. Acetanilid is a prompt antipyretic ; it is best administered in pow- der (capsules, tablets, or cachetes), in alcoholic solutions, or as the compound powder of acetanilid, pulvis acetanilidum compositus. The average dose of the latter is l l /2 grains (0.5 Gm.). Acetphenetidin; AcetpJienetidinum, U. S. P. ; PJienacetinum, B. P. ; C 10 H 13 N0 2 ; Phenacetin. It is a derivative of anilin and closely related to acetanilid, but it is less poisonous than the latter. It is a white crystalline powder, having no odor or taste. It is sol- uble in 925 parts of water and 12 parts of alcohol. It is best administered in powder form. It is a prompt antipyretic and ano- dyne, and its toxic side action, as compared with acetanilid, is decidedly less. Average dose, 5 grains (0.3 Gm.). 436 PHARMACO-THERAPEUTICS A number of other anilin derivatives are known lactophenin, phenocoll, kryofin and are given in about the same doses as phenacetin, but apparently do not possess any therapeutic advan- tages over the latter. FOR FACIAL NEURALGIA. B Phenacetin. 3 j (4.0 Gin.) M. f. pulv. No. viij Sig.: A powder every three hours. ORGANO AND SERUM THERAPY. Organo Therapy. The immense strides which have been made within the last few decades in general therapeutics have occasioned the utilization of animal tissues or their products for medicinal purposes. Their application is known as organo therapy. The use of animal drugs for medicinal purposes is probably as old as the history of the human race ; organic secretions, parts of the animal, and, in some instances, the whole animal have always played with our remotest ancestors a more or less important role in curing diseases. The use of testicles against impotence, the gall of snakes, birds, fishes, etc., in diseases of the brain, or the bile of a snake or scorpion are accredited with high curative power in most of the medical records of the early civilized nations of the old world. The tendency of medicinally applying organic prepara- tions seems to center in the natural desire to cure a diseased organ by an extraction, decoction, tincture, or similar preparation of the same organ or its secretion obtained from some animal. So, then. we find that in diseases of the urinary organs the drinking of urine, in the bite of a rabid dog the stewed gall of a dog affected with hydrophobia, and in the presence of intestinal worms decoc- tions of worms in oils were highly lauded. The empiric evolution of therapeutic applications was apparently based on the supposi- tion to cure like things by like, a doctrine which many centuries later was adopted as similia similibus curantur by the homeo- pathic school. Modern organo therapy received its scientific in- centive from the work of Brown-Sequard by the presentation of his epoch-making essay relative to the use of the extract of testicles before the French Academy of Science in 1869. He based hip ORGANO AND SERUM THERAPY 437 conception on "internal secretions," which, as he claims, continu- ously supply the blood and lymph stream with certain materials intended to perform important functions in the cycle of living processes. Claude Bernhard had called attention to the secretion of the ' ' ductless glands, ' ' as well as to certain other glands, which produce specific bodies. These bodies are probably in the nature of ferments, and they are absolutely essential for the maintenance of bodily functions. According to Hansemann it seems that an altruistic relationship exists between the various types of tissue cells. One type of cells will undertake the work of other types, and, vice versa, these other types will do the work of the one type of cells. This conception is closely allied to the theory of Fraser regarding the formation of antitoxins in the bodies of those ani- mals which produce a definite poison that is fatal to other animals, but not to themselves. The thyroid gland is a typical representative of a ductless gland. The administration of the dried, powdered gland or its extract in diseases which are connected in one way or another with this gland myxedema, goiter, cretinism has produced most remark- able results. Its administration must be continued for a long period, often throughout life, to prevent relapses. The thyroid gland contains in its cell a peculiar globulin known as thyroglob- ulin. The active constituent of this body seems to be an organic form, of iodin iodothyrin. Its greatest influence is manifested by its action of metabolism ; it increases the waste of proteins and the oxidation of fats in the body, with an unusually large amount of urine excretion. The extract of the testicles, or an alkaloid obtained therefrom and known as spermin, is recommended in cases where the dimin- ished sexual powers call for a stimulation of their activity. The extract of bone marrow and of the spleen are recommended in per- nicious anemia to increase the formation of erythroblasts. The thymus gland or its extract has been advised in exophthalmic goiter. An extract of the pituitary body has been advocated in diseases associated with hypophysis. Fresh and purified ox gall is employed as a cholagogue, purgative, and intestinal antiseptic. The extract of the suprarenal gland or its alkaloid, epinephrin. has been suggested in Addison's disease, a peculiar affection of these glands. The very remarkable property of epinephrin to in- crease the blood pressure, and incidentally cause local anemia when 438 PHARMACO-THERAPEUTICS applied locally or injected hypodermically, is referred to under Suprarenal Glands. Serum Therapy. The introduction of bacteriology into general medicine has ex- ercised a most powerful influence on the biologic conception of infectious diseases. The discovery of specific organisms as the causative factors of specific infectious diseases has completely changed the therapeutic application of remedial measures by creat- ing a definite method of treatment known as serum tlierapy or as biologic therapeutics. The bacteria of certain infectious diseases invade the body only in definite places as diphtheria in the throat but nevertheless the reaction of the entire body to this disease indicates that specific products of these causative factors must have reached the blood. Infection is more or less always accompanied by intoxication ; the latter is the result of the absorbed specific poisons. The isolation of these poisons (toxins of bacterial origin, especially from putre- fying protein substances) led to the discovery of ptomains cadav- erine, putrescine, neuridine, etc. These peculiar alkaloid-like bodies are, however, not the specific cause of the disease, as it was soon found that the real poisons are ferment-like bodies known as bac- terial toxins. These compounds are very powerful poisons, and the smallest quantity will produce toxic symptoms which are not equaled in their intensity by any other known substance. The toxins differ from other poisons in so far as they require a certain period of incubation before they develop their powerful destruc- tion, and they are not necessarily equally poisonous to all animals. When an animal is inoculated with a certain pathogenic organ- ism without producing specific symptoms of the disease, it is said to be immune. This peculiar condition is referred to as natural immunity when the animal does not react to the inoculated organ- ism without a preliminary preparation, and as acquired immunity when it does not react after it has passed through a mild attack of the disease, or when it is artificially prepared against it by injec- tion of certain substances. Immunity is the result of the action of substances present in the blood of the individual the alexins. If a person has passed through a mild attack of measles, smallpox, scarlatina, etc., he is usually immune for a shorter or longer period against a future attack of these diseases. Weak, attenuated cul- ORGANO AND SERUM THERAPY 439 tures of bacteria, when inoculated into the body, will accomplish the same results. Attenuated cultures may be prepared by ex- posing the ordinary virulent pure cultures to light, heat, chemic agents, etc., or by passing them through the body of an animal which is especially rich in alexins. The principle is based on the original empiric vaccination with cowpox against smallpox as in- augurated by Jenner in 1796. After an active immunization the blood is found to contain specific antibodies, which act against the invading bacteria or their poisonous products in the nature of an antidote. These antibodies are substances of an albuminous character, and are relatively very weak compounds, especially to heat, cold, light, chemicals, etc. It has been found that when blood obtained from animals which are especially rich in these antibodies that is, blood from animals which are actively im- munizedis injected into other animals which have not been pre- viously treated, these latter animals will become immune against the specific organism. This form of immunization produces pas- sive immunity. Passive immunity lasts only a short time about three weeks in diphtheria while active immunity may last the entire life. Passive immunization is sometimes employed as a prophylactic against a specific disease, but principally as a cura- tive agent in the early stages of infectious diseases. The injected antibodies will attack the toxins present in the blood ; they act as true curative agents, and are known as antitoxic sera. The anti- toxins may act in two ways they may be specific antibodies against a specific bacterium (always against only one species), or they may act as antibodies against the toxins present in the blood of the infected individual. The antitoxins are true antidotes; they com- bine with the toxins somewhat in the same manner as an acid will neutralize an alkali. Aside from the explanation regarding the action of antitoxins and other bactericidal substances as presented by Behring, Kitasato, Nuttall, Pfeiffer, Ehrlich, and others, the phagocytes have been held responsible by Metchnikoff for the mech- anism of immunity. He claims that the phagocytes are certain white blood corpuscles, which act as digesters, scavengers, and chief defenders against the invading bacteria. "The diapedesis of the white blood corpuscles, their migration through the vessel wall into the cavities and tissues, is one of the principal means of defense possessed by an animal. As soon as the infective agents have penetrated into the body, a whole army of white cor- 440 PHARMACO-THERAPEUTICS puscles proceeds toward the menaced spot, there entering into a struggle with the micro-organism. ' n The action of the phagocytes may be intensified or diminished in various ways. To accomplish this purpose certain other substances present in the blood of the individual nmst be determined. These substances are known as opsonins, and Wright has devised an ingenious method for de- termining the amount of opsonins present in the individual, or, as he refers to it, to establish the opsonic index. 2 The opsonins (to prepare for food) are substances which, in some unknown manner, act on the bacteria and prepare them for digestion by the phagocytes. The opsonic index indicates whether the opsonic substances present in the blood are above or below the normal standard. The treatment of infectious diseases by opsonins has found many admirers among clinicians, and it has been recently introduced by Goadby 3 for the treatment of pyorrhea alveolaris. The technic of preparing the opsonic index and the treatment of pyorrhea with opsonins has been clearly set forth by Hecker. 4 A recent interesting hypothesis regarding the existence of bac- terial substances in the body fluids has been made by Ehrlich, and is known as side-chain or receptor theory. While the doctrine of reception is largely an assumption, it is nevertheless a most in- genious attempt to explain the action of antitoxic serum, and it may aid as an incentive for further research in this interesting field of therapeutics. The antitoxic sera are principally administered by hypodermic injection; they enter the blood and combine directly with toxins of the disease, thereby destroying poison. The toxins of infectious disease remain only a very short time in the circulation. They usually combine more or less quickly with the protoplasm of such cells for which apparently they possess an affinity, and then they are reached only with difficulty, or not at all, by the antitoxins; hence the importance of an early injection of the latter is ap- parent. The various sera, bacterial vaccines, and similar biologic prod- ucts are at present manufactured on a large scale. To insure uni- formity of these products, and to prevent their indiscriminate 1 Metchnikoff : Immunity, 1905. * Wright: Proceedings of the Royal Society of England, 1903 1 Goadby: British Dental Journal, 1907, p. 885. 4 Hecker: Pyorrhea Alveolaris, St. Louis, 1915. ORGANO AND SERUM THERAPY 441 compounding by the inexperienced, the United States government, after a careful investigation of the respective laboratories, has licensed certain manufacturers to prepare these various biologic products. An antitoxic serum against diphtheria, which has been used with very gratifying results, a serum against tetanus, and various sera against tuberculosis are universally employed at present in general medicine. Of the many vaccines, those of the staphylo- cocci, streptococci, gonococci, lactic acid bacilli, and a few others are the principal representatives. The pus vaccines and a lactic acid culture known as massolin are used at present in the treat- ment of dental lesions. The pus vaccines are employed hypo- dermically, according to Wright's method, after establishing the opsonic index, while massolin is used with a spray in chronic antral diseases. For the latter purpose it is recommended to in- ject the lactic acid culture in 1-cubic-centimeter doses with an atomizer every other day into the diseased sinus until pus forma- tion ceases. Based on the same principle, sour milk has been used for the above purposes by Lohmann some years ago. A culture of the bacillus pyocyaneus, known as pyocyanase, is recommended by the above author in the local treatment of pyorrhea alveolaris. The application is simple: After the preliminary cleansing of the mouth and the removal of calcareous deposits from the teeth, etc., pyocyanase is injected into the pus pockets, and the latter are covered with an unctuous paste to temporarily prevent its wash- ing away by the saliva. The remedy may be applied once or twice a day, according to the severity of the case, until pus formation ceases. The application of serum therapy in dentistry is as yet in its infancy; the results obtained with biologic therapeutics in gen- eral medicine are, however, very encouraging, and it is but reason- able to apply the same principle in diseases of the oral tissues. PART III PHYSICAL THERAPEUTICS ARTIFICIAL HYPEREMIA In the treatment of diseases a variety of methods and measures are employed as remedial agents which can not be properly classi- fied as drugs if we restrict the latter term to organized substances which, when introduced into the living body, counteract disease. A remedy, in the broadest sense of the term, is anything which cures, palliates, or prevents disease, and, consequently, thera- peutics comprise the utilization of all means and methods which are employed for the purpose of relieving the sick and favorably modifying the evolution of disease i.e., the art of healing. In addition to the use of drugs and surgical procedures, a number of mechanical and physical forces are employed, which, for the want of a better term, are classified as physical therapeutics, and they include Bier's artificial hyperemic treatment, massage, heat, cold, light, electricity, etc. The pathologic study of infectious diseases and their treatment has been completely revolutionized within the last few decades. The primary cause of this change may be attributed to the re- markable development of the science of bacteriology, and its in- troduction into biology marks a conspicuous epoch in the scientific progress of medicine. Louis Pasteur was the founder of bacteri- ology. Joseph Lister introduced it as "antisepsis" into surgery, and when Robert Koch, in 1876, brought forward convincing evi- dence that certain specific micro-organisms were the cause of cer- tain specific diseases, the old superstitious belief in miasms. con- tagion, and spontaneous generation received its death blow. Bac- teriologic research revealed the important fact that the body fluids possess the power of destroying or neutralizing poisons which enter the body from without. It is rather remarkable that the developmental study of diseases selected the most difficult ones 442 ARTIFICIAL HYPEREMIA 443 anthrax, hydrophobia, diphtheria, tuberculosis, etc. for its in- itial investigation, while ordinary, simple infection, until lately, has been grossly neglected. Recently certain sera have been pre- pared for the purpose of combating the invasion of the pus pro- ducing micro-organisms, and in many eases they have given en- couraging results. Within recent years a new remedial measure has been intro- duced into therapeutics for the purpose of combating infectious diseases which is so surprisingly simple, and yet so very definite in its final result, that one can only wonder why it was not dis- covered a long time ago. The object of the treatment consists in the increased utilization of the natural resources which the body possesses in the fight against local infection, and is known at pres- ent as the hyperemic treatment of Bier. Bier founded his con- ception of this treatment on observations which he had made in the clinic of Rokitansky in Vienna. He had repeatedly pointed out that a lung with a chronic obstructive hyperemia resulting from some valvular insufficiency of the heart would not, in the great majority of cases, be attacked by tuberculosis. On logical reasoning Bier applied the same principle with surprisingly good results in the treatment of chronic infections of the joints. In due time the technic of this treatment, depending largely upon the construction of suitable apparatus, had to undergo many modi- fications; but, even with the remarkable increase of the scope of its utilization it is still employed by comparatively few practi- tioners. According to Meyer-Schmieden, 1 the aim of Bier's hyperemic treatment is to bring about "the increase of the beneficial inflam- matory hyperemia resulting from the fight of the living body against invasion," and the most important principle underlying this treatment is that "the blood must continue to circulate there must never be a stasis of the blood." In German, Bier calls his treatment Stauungshyperamie, 2 a term which expresses the cause as well as the effect. Stauung, translated into English, means stowing. Many interpretations of the German term have been at- tempted as congestive, induced, artificial-active and artificial-pas- sive, or artificial-arterial and artificial-venous hyperemia, and sometimes, although an absolutely false translation, stasis hyper- 1 Willy Meyer-Schmieden: Bier's Hyperemic Treatment, 1908. *Bier: Hyperamie als Heilmittel. 1903. 444 PHYSICAL THERAPEUTICS emia. As yet no definite term has been adopted by the English- speaking profession, and, as we have so far followed the trend of thought as outlined by Meyer-Schmieden, we adopt their sugges- tion and use the term "obstructive hyperemia" in the following pages. Before entering into the philosophic conception of obstructive hyperemia according to Bier, it is probably well to rehearse in a preliminary way the significance of inflammation from a modern pathologic point of view. At present it is generally conceded that inflammation is not a disease, but that it is the local defense of the tissues against an injury, manifesting itself by more or less pronounced symptoms as redness, heat, swelling, pain, and impaired function. The most important changes occur in the blood vessels, which are distended by an increased influx of blood that is very quickly displaced by a retarded afflux. The white corpuscles conglomerate in bunches near the vessel wall, especially in the veins and capillaries, while the red blood corpuscles keep more to the center of the blood stream. The leucocytes and the lymphocytes now pass between the endothelial cells through the vessel walls of the veins and of the capillaries, but not of the arteries. This wandering of the white corpuscles diapedesis is accompanied by the transudation of blood serum, which fills the surrounding tissues, causing an edematous swelling. Later on the red blood corpuscles follow, but they migrate in very much smaller quantities. The nature of the transudation, the quantity of the blood corpuscles, and the admixture of foreign bodies determine the character of the in- filtration, as it may be a serous, fibrmous, purulent, hemorrhagic, or croupous exudate. Another important, but as yet less recog- nized, symptom of inflammation is the increased osmotic pressure within the infiltrated area. Hamburger 1 and others have shown that the normal osmotic pressure of the tissue fluids amounts to about 7.5 to 7.9 atmospheres, which, when exposed relative to the freezing point of a physiologic salt solution, equals 0.55 to 0.57 C. Under normal conditions the osmotic pressure is promptly regulated by the organism; probably, according to Mas- sart, through specific nerves that is, the normal equilibrium of the isotonic index of the blood and tissue fluids remains station- 1 Manninger: Heilung Lokaler Infectionen mittelst Hyperamie, Wurzburger Abhand- lungen, Vol. VI, No. 6. ARTIFICIAL HYPEREMIA 445 ary. In pathologically altered tissues the composition is contin- ually interfered with, and usually results in a marked increase of the osmotic pressure hyp v irisotonicity. Increased osmotic pres- sure produces pronounced morphologic changes in the cells, and is largely responsible for the resultant pain, followed by inflam- mation, within the affected area. According to Ritter 1 the va- rious changes in tissues, if a simple abscess is taken as an ex- ample, may be described as follows: In the center of the pus cavity the osmotic pressure may reach a density of 0.6 to 1.4 C. (0.56 being normal), but in the surrounding hyperemic zone the pressure is less, gradually diminishing in the manifest edema, and becoming less and less toward the periphery until normal pressure is reached. Aside from these quantitative changes with- in the inflamed area, qualitative changes of the constituents of Fig. 83. Schematic drawing of an abscess. The abscess and the surrounding infiltrated area show the various degrees of osmotic pressure, a, abscess; b, hyperemic zone; c, manifest edema; d, latent edema. the exudates undoubtedly have some important significance. The nature of these latter changes is at present too obscure to allow any definite statements to be made. Whenever living tissue is injured whether by mechanical, thermal, or chemic means the system at once tries to protect itself against the invading foe by an increased rush of blood into the injured area, resulting either in a victorious fight complete resolution, or in a surrender to the enemy necrosis. Local hyperemia, which is the forerunner of acute inflamma- tion, results from an increase in the quantity of blood in the in- jured part. If it is due to an increase in the flow of blood, it is referred to as arterial or active hyperemia, while, if resulting 1 Schade: Miinchner Medizinische Wochenschrift, 1907. 446 PHYSICAL THERAPEUTICS from an obstruction which retards its outflow, it is known as venous or passive hyperemia. In active hyperemia the involved area is bright red in color, and the temperature is slightly elevated and usually accompanied by a marked swelling. Passive hyperemia manifests itself by a bluish-red color (cyanosis) of the involved area, with a somewhat lessened temperature. The veins are distended, and an edematous swelling is soon observed, result- ing from the transudation of the various constituents of the blood. The cardinal factors of the early stages of inflamma- tion which bear a direct relationship to the proper conception of Bier's hyperemic treatment are the migration of leucocytes, the transudation of serum, and the increased activity of the fixed tissue cells. At present it seems to be proved that the therapeutic benefits derived from hyperemia find an explanation in the bac- tericidal action of the blood serum. To enter into a detailed* dis- cussion of the nature of these protective substances whether they be called alexins, antibodies, lysins, opsonins, or phagocytes is of no consequence in our present consideration of the subject. Let it suffice to say that nature utilizes, so far as we know, three important principles of self-protection against local infection preparation of the way for transudation of the serum, positive chemotaxis, and increased activity of cell proliferation. Quite a number of theories have been promulgated to explain the nature of the defensive properties of hyperemia. Buchner claims that the increase of the leucocytes and, in consequence, the alexins are the factors. Hamburger believes that the increased amount of car- bonic acid in the blood as a sequence of the congestive hyperemia is responsible. The same views are shared by Chantemesse 1 and Lubarsch. 2 Notzel favors this view, provided it is restricted to recent exudations, while Metchnikoff, supported by Leyden, Lazarus, and others, believes that the phagocytotic action of the leucocytes is the predominating factor. Be that as it may, the facts remain that hyperemia is the essential factor which nature provides in a more or less pronounced degree to combat local in- fection, and that we owe it to Bier to have therapeutically utilized this very same principle, artificially provided, to assist nature in warding off disease by producing inflammation. It seems para- 1 Chantemesse: Academic de Medicine, 1903. 2 Lubarsch: Allgemeine Pathologic, 1905. ARTIFICIAL HYPEREMIA 447 doxical to speak of warding off disease by providing inflamma- tion. From a therapeutic point of view, it has been our aim to treat inflammation by antiphlogistic measures, while the Bier treatment apparently advocates the opposite irritants. An ulti- mate analysis of the action of antiphlogistics will convince us, however, that in reality they act as irritants by increasing the factors which are productive of inflammation instead of diminish- ing them. Bier has rightly said that the laity is not so foolish as to always use for centuries and centuries the same remedies if they were of no value, or even dangerous. The layman ripens the abscess with a bread and milk poultice, or some similar irri- tant. From the earliest times heat, in the form of a poultice or fomentation, has been applied by means of heated rags, stones, china, etc., and has always ruled supreme in the treatment of local infections. Tincture of iodin paint, the hot-water bottle or the ide bag, the modern alcohol poultice or the Priessnitz bandage, the therapeutic lamp or the electric light bath, and massage ac- complish in reality one and the same purpose they produce cer- tain forms of artificial hyperemia. Many of these remedies act only by counterirritation, producing a secondary inflammation in order to relieve the primary irritation. Bier has selected two types of direct mechanical excitants to produce two definite forms of hyperemia the elastic bandage or the suction cup for the pro- duction of passive or venous hyperemia, and hot air for the pur- pose of rushing an accelerated blood stream into the tissues by active or arterial hyperemia. Occasionally these two forms of artificially produced hyperemia are so closely blended as to make it impossible to draw a definite line of demarcation. Both means are very powerful therapeutic agents, and consequently their cor- rect application as to degree and duration requires a delicate technique in order to produce beneficial results only and not do harm. The advantages of hyperemic treatment over other therapeutic procedures are manifold. Some of these advantages are suppres- sion of infection and avoidance of suppuration, diminution of pain, and culmination of pathologic processes ; large incisions into abscessed cavities may be entirely dispensed with; simple punc- tures, which naturally heal quicker, leaving very small or no scars, are usually sufficient for drainage by the suction cup. In the very early stages an artificially increased inflammation may 448 PHYSICAL THERAPEUTICS successfully abort an incipient infection, and in already existing suppuration the processes of demarcation and final resolution are materially hastened. The bactericidal function of congestive hyperemia has been fairly well established by carefully conducted experiments. Notzel has shown that an injection of virulent cultures of streptococci into the extremities of animals subjected to a powerful con- gestive hyperemia would do little harm, while the same injection into control animals invariably produced death. It is furthermore sufficiently proven by experimental work, as well as by clinical experience, that active hyperemia as produced by direct heat ma- terially increases the absorption of watery and water-soluble ma- terials by the capillaries, and not by the lymph vessels, as was formerly believed, all solid and non-water-soluble liquids being absorbed solely by the lymphatics. 1 These two factors deserve to be seriously considered by the dental surgeon who uses such poisons as cocain, epinephrin, etc., for injecting into the gum tis- sue. Absorption is lessened during hyperemia, and it is increased after the obstruction is removed. Local hyperemia exerts a definite solvent or softening power upon exudates which may have collected about joints or in the tissues as blood clots, joint stiffness, phlegmonous infiltration, etc. It favorably influences nutrition, and it seems to be a well- established fact that the formation of callus, especially the amount of calcium salts, in the repair of broken bone is materially in- creased. Methods of Inducing Hyperemia. THE ELASTIC BANDAGE. The oldest and most favored method of inducing obstructive hyperemia is tho elastic bandage. The bandage is usually made of soft rubber, but for dental purposes a bandage made of garter elastic is preferable. The material should be about three-fourths to one inch wide and about eighteen or more inches in length, with a hook at one end and a number of eyes on the other. In general surgery the bandage is usually applied upon the extremities, and in dental surgery it is used around the neck for the purpose of producing obstructive hy- peremia of the head, the superficial veins being very amenable 1 Mislowitzer: Berliner Zahnarztliche Halbmonatsschrift, 1908, p. 194. ARTIFICIAL HYPEREMIA 449 to this procedure. A few simple, but important, rules govern the successful technique of the application. One must at all times feel the pulse below tlie place surrounded by ike, bandage, and the technique is correct if there is absolutely no increase of pain, and if there is visible hyperemia of the part subjected to this treatment. Beginners are very apt to place the bandage too tightly. The bandage must partially obstruct only the superficial veins, and there must never be an increase of pain. The bandage is placed about the neck below the larynx. It should feel somewhat like a tight-fitting collar, but it must never produce any degree of dis- comfort, and the patient is the best judge of the proper fit Its action may be increased by placing upon the jugular vein a pledget of soft cloth. If the bandage should irritate, a strip of flannel may be placed under it. Patients suffering from arterio- sclerosis require special care. When treating acute inflammatory conditions about the head, a slight edema may be easily and safe- ly produced. Under no conditions must the obstruction be so great as to quickly produce a dark, bluish-red color or red blotches. The tissues located distally of the bandage must have a slight bluish-red, but never a white, appearance. Soon after the bandage is adjusted the focus of acute inflammation will show an increase in the cardinal symptoms marked redness, heat, and swelling, but with a slow, definite diminution of pain. The latter decreases with the increase of the edema. It should be remem- bered, however, that obstructive hyperemia does not and will not abort an abscess. If pus is present, the old Hippocratian postulate, ubi pus ibi evacuatio (where pus is it must be evacuated), should be rigidly complied with, even if Bier's treatment is to be used to advantage, or, as Meyer-Schmieden rightly state, "the knife takes care of the pus hyperemic treatment fights the inflamma- tion. ' ' The bandage placed about the neck for the purpose of com- bating acute inflammation should remain in position from twenty to twenty-two hours per day, when it should be removed to al- low the slight edemic condition to pass away. Chronic affections require shorter applications, about two to four hours per day hav- ing been found sufficient. The correctly adjusted bandage can be worn with perfect comfort and safety during sleep. THE SUCTION CUP. The suction cups used for the purpose of producing congestive hyporemia are made of glass, representing various modifications of the old-fashioned cupping glass. De- 450 ' PHYSICAL THERAPEUTICS pending upon the various surfaces of the body, bell-shaped cups of many sizes, or tubes, or boot-shaped vessels provided with a nozzle, are employed, and may be procured from surgical depots. Hyperemic treatment in the sense of Bier, as applied to dentistry, Fig. 84. Suction cup for alveolar abscesses about the gums. is as yet practiced to a very limited extent if we are permitted to judge from the scarcity of the literature on this subject, and con- sequently the special apparatus needed for dental work have to be, to a large extent, home-made. The larger cups intended for work on the external surfaces of the jaws may be procured from Fig. 85. Suction cups for abscesses about the cheeks, lips, and chin. the depots, while the small tubes intended for the oral cavity are readily made from glass tubing by bending and shaping it to the proper angles over a Bunsen flame. The end of a soft glass tube of suitable size is held in the hottest part of the flame with the left hand, and continuously rotated to insure uniform heat- ARTIFICIAL HYPEREMIA' 451 ing, until it becomes soft. A heated excavator shank is now held against this edge at the proper angle, and thus the lip of the tube may be enlarged and its edge turned over. By heating the tube beyond the cup-shaped enlargement, the correct bend of the tube may be easily obtained. Suction is accomplished with strong rubber bulbs, or with the suction pump fastened to the nozzle of the cup with stout rubber tubing. The action of the suction pump is best illustrated by the working of a bicycle pump, remembering, of course, that the reverse action of the pump is needed for suction. The author has found that the very best and simplest method of suction is readily obtained by utilizing the sucking action of the saliva ejec- tor of the fountain cuspidor. By means of a short piece of stout rubber tubing the suction cup is connected with a piece of glass tubing fastened to the joint of the saliva ejector, and, by regulat- ing the water pressure, suction of the desired degree is readily obtained, which is far superior to any other means of suction. All degrees of congestive hyperemia may thus be obtained with per- fect precision and greatest ease. Therapeutic Indications. The practice of dentistry offers a wide and prolific field for the application of Bier's hyperemic treatment. The indications for its use are manifold, its technique is extremely simple, and the results obtained with it are so very gratifying that it deserves the highest recommendation. CONGESTIVE HYPEREMIA WITH ELASTIC BANDAGES. Congestive hyperemia by means of the elastic bandage is primarily indicated in all painful disturbances of the periosteum of the teeth and jaws. It is a well-known fact that as soon as the cheek swells as soon as nature establishes congestive hyperemia in the involved area the pain arising from an acute pericementitis will cease. The painful periosteal disturbances arising from the difficult eruption of a third lower molar, including the dangerous phleg- monous infiltrations about the angle of the jaw and the glandular enlargement as a sequence of these traumatic or infectious in- juries, as well as the many other forms of pericementitis, are especially amenable to this treatment. Pain following inflamma- tion or suppuration after the offending tooth has been extracted 452 PHYSICAL THERAPEUTICS is much benefited by the application of the bandage. In the various forms of fractures of the jaws the bandage materially mitigates the resultant pain and apparently exercises a beneficial influence on callus formation. Facial neuralgia is not influenced by congestive hyperemia. The technique of applying the bandage has been alluded to on page 449. The bandage should be continuously applied for about Fig. 86. Application of the elastic bandage for the production of obstructive hyperemia of the head. The hyperemia is increased by placing a piece of soft cloth over the large veins of the neck beneath the bandage. twenty hours, or twice each day for about ten hours each time, with an interval of two hours. It should be borne in mind that the bandage should be applied with just a sufficient degree of tightness not to increase the pain. It must never strangulate, but should produce a visible hyperemia in the parts under treat- ment. ARTIFICIAL HYPEREMIA 453 Treatment of Dental Lesions with the Suction Cup. According to the location of the lesion within the mouth, the proper suction cup or tube which sufficiently covers the inflamed area is selected, and a thin coat of vaselin is spread over its rim to insure better adhesion. The various forms of suction cups have been referred to on page 450. Klapp, Bier's former assist- ant, and Witzel 1 and his assistant Hauptmeyer have devised cer- Fig. 87. Application of a suction cup over the sinus of an alveolar abscess. tain modifications of the cups so as to make them amenable to dental purposes. A useful small cup, especially serviceable for alveolar abscess treatment, is readily made by slipping a soft rubber polishing cup over the slightly enlarged end of an eye pipette. Hunter has advised a similar treatment, and speaks of it as follows : One of 'the rubber cups used for cleaning teeth 1 Witzel, J. : Die Bierische Stauung und deren Anwendung als Heilmittel in der Zahn- heilkunde, 1906. 454 PHYSICAL THERAPEUTICS and mounted on a mandrel is forced down flat against the gum, covering the fistula, and by removing the pressure from the cup, but keeping its edges in close contact with the gum, a suction is created, drawing the medicament through the abscess tract. If syphon suction is not available, a stout rubber bulb slipped over the end of the cup or tube answers the purpose. If the cup is used in connection with the syphon of the fountain cuspidor, a U-shaped piece of glass tubing is inserted between the syphon and the cup proper to act as a receptacle for pus and blood. The suction must be of a mild degree, and is applied but once a day Fig. 88. Hyperemic suction cup applied to a chin fistula. This fistulous opening was caused by a dead pulp in a lower incisor. for about three-quarters of an hour five minutes at a time, with three minutes' intermission, repeating the ^ suction five to six times at the same sitting. If this treatment is applied in the early stages of pericemental trouble, the formation of an abscess may be ARTIFICIAL HYPEREMIA 455 readily aborted, provided the root canal of the affected tooth has been properly cleansed and drained, and suitable antiseptics have been applied. If suppuration has already set in, the abscess is simply punctured, and no large incision is necessary. The cup is now applied for further treatment, which must be continued until all infiltration has subsided. After the second treatment, Fig. 89. Suction cup applied to a fistula on the cheek near the border of the mandible. The abscess is caused by a dead pulp in a lower molar. The cup is connected with the sypho of the fountain cuspidor. usually nothing but blood is drawn away by the cup, and, if some strong antiseptic as a solution of iodin in cresol is placed into the root canal, it is readily sucked through the fistula. If an alveolar abscess opens on the face, the treatment by the 456 PHYSICAL THERAPEUTICS suction cup is practically the same, only that suitabla larger cups have to be used. If a crust has formed over the fistula, it must be removed before suction is started. A simple ointment dress- ing held in place by collodion is applied after the treatment. Ab- scesses treated in this manner practically leave no disfiguration on the face after cicatrization has set in. In the treatment of an acute abscess without a fistula (blind abscess), suction also is employed with marked benefit. The root canal must be thoroughly cleansed, and the foramen is slightly enlarged before suction is started. Two methods of applying the suction cup are in vogue a large hypodermic needle is cemented into the root canal with temporary stopping, or a short thick- walled rubber tube is drawn over the tooth. Either appliance is now connected by means of glass and rubber tubes with the rub- ber bulb or the syphon. Dill 1 and Schroder 2 have advised the use of a powerful metal syringe (aspirator) for this treatment, while Miller 3 praises the syphon of the fountain cuspidor as a good suc- tion medium. Congestive hyperemia applied in the treatment of certain stages of pyorrhea alveolaris is of marked benefit. Specific ap- paratus are needed for each case, but, as they are difficult to adjust, their general application is limited. Schroder 4 has pub- lished some preliminary reports concerning this method of treat- ment, but the apparatus used by him was rather cumbersome. A special suction cup has to be constructed for each individual case. A cup for the anterior lower teeth may be made of hard vulcanite, with a rim of soft velum rubber, from a model of the involved parts, or a cup may be made from an impression taken in modeling compound. Suitable trays for such work are con- structed and used as follows: The handle and heels of a lower Angle impression tray are cut off ; a hole a quarter of an inch wide is drilled in the center of the tray, and a piece of brass tubing three-eighths of an inch long is soldered into the hole; the cup is now trimmed so as to fit the involved area as nearly as pos- sible; the tray is filled with modeling compound and an impres- 1 Dill: Schweizer Vierteljahrsschrift fur Zahnheilkunde, 1901, No. 3. 2 Schroder: Deutsche Monatsschrift fur Zahnheilkunde, 1907, p. 356. * Miller: Lehrbuch der Konservativen Zahnheilkunde, 1908. 4 Schroder: Loc. cit. ARTIFICIAL HYPEREMIA 457 sion is taken of the involved lower anterior teeth, pressing the tray as deeply as possible into position; six or even eight teeth may be covered by the tray. The tray is now removed, and the modeling compound is cut away from the inner surface of the cup, leaving only a thick continuous roll of compound covering the rim of the tray; the tray is now connected with the syphon, Fig. 90. Hyperemic suction apparatus for the treatment of pyprrhea alveolaris. A specially pre- pared impression cup for the lower incisors, lined with a rim of softened impression compound and connected by a piece of rubber tubing with a suction pump. or a strong syringe, or a pump, and the compound rim is slightly warmed and placed over the soft tissue, the latter being thoroughly dried and covered with a thick film of vaselin to facilitate the formation of an air-tight joint. A cup for the molars and bi- cuspids may be constructed on similar principles from the cut- 458 PHYSICAL THERAPEUTICS off heels, and other suitable modifications which may be needed are left to the ingenuity of the operator. The suction must be of a mild degree, and is applied but once a day in short repetitions, as outlined above. In acute forms of empyema of the maxillary sinus, congestive hyperemia produced by suction or by the elastic bandage deserves to be recommended. In chronic cases it is of no benefit what- soever. Active Hyperemia. Pronounced active hyperemia is readily produced by dry hot air or by moist heat. The sources of heat may be manifold. Dry heat is readily obtained from a gas flame, coal oil lamp, electric heater or light globe, Japanese pocket stove, hot- water bag, etc., and moist heat from a hot wet pack or a poultice. Bier advises the use of hot air conveyed through a tube provided with a nozzle, which sprays, as it were, the heated air over the affected parts. He also advocates the use of hot-air boxes boxes so shaped as to accommodate the diseased part of the body, to which the hot air is conveyed. The latter are rarely applicable to dental lesions. Therapeutic Applications. Acute and particularly chronic inflammation and their sequela adhesions, infiltrations, and exudations are readily amenable to active hyperemic treatment. Of the specific diseases, neuralgia in its various forms is especially favorably influenced by heated air. The affected part is brushed over with the hot douche or with the therapeutic lamp for about ten minutes, and imme- diately after, or even during, the heat application is kneaded and rubbed by massage movements. If the therapeutic lamp (see page 465) is used in this connection, no asbestos screen is neces- sary for the protection of the parts. MASSAGE. Massage (kneading or rubbing) is a therapeutic measure em- ployed for the purpose of treating diseases by mechanical move- ments. In medicine it is known by various terms kinesitherapy (motion treatment), mechanotherapy, massotherapy, and, recent- ly, osteopathy. Massage is one of the most ancient remedial agents. MASSAGE 459 and in the form of medical gymnastics it has played an important part in the destiny of many nations. Its systematic employment has been equally lauded in bygone days by the physicians of Baby- lon, Alexandria, Athens, and Rome, and, while Europe of today enjoys a revival of massage under the name of Swedish move- ment, the United States, the "land of unlimited possibilities," has its modern apostle of the art of kneading in the person of Dr. Still, the founder of the osteopathic cult. Hippocrates, in his medical aphorisms, advises that "the physician ought to be acquainted with many things, and, among others, with friction." The therapeutic results of massage seemed to be fully appreciated by him, for he declares that "rubbing can bind a joint that is too loose, and can loosen a joint that is too rigid; that much rubbing causes parts to waste, while moderate rubbing makes them grow." The Chinese and Japanese are thoroughly familiar with muscle kneading, and the marvelous dexterity of the am- ma, the blind Japanese masseur, excites the surprise and admira- tion of the western visitor. Even the aboriginal inhabitants of Africa and the South Sea islands practice massage in one form or another, and it is quite fashionable in Honolulu to be "lomi- lomied" after a hearty meal. The lomi-lomi is used not only by the natives, but among almost all the foreign residents; and not merely to procure relief from weariness consequent to overexer- tion, but to cure headaches, to relieve the aching, and neuralgic, and rheumatic pains, and by the luxurious as one of the pleasures of life. In 1780 Tissot reintroduced massage into France, and his and Meibom's (1795) writings helped much to popularize it among the masses. It was revived by Metzger, of Amsterdam, and his pupils in 1873. Henry Peter Ling, of Stockholm, worked out a system of mechanotherapeutics, which has become famous as the Swedish movement, or Lingism, and especially through Schrei- ber's manual on "Massage or Methodical Muscle Exercise" it has gained access to medical clinics of both continents. By massage we understand a series of mechanical movements best executed by the hands of the operator, affecting the skin as well as the deeper structures of the body. To employ it on a scientific basis, a fair knowledge of regional anatomy and physi- ology must necessarily be possessed by the operator. It is some- what difficult to describe minutely the various movements em- 460 PHYSICAL THERAPEUTICS ployed in the art of massaging, and they are best acquired by personal instructions by a skilled operator. The object of massage is to bring about increased cell activity in the parts. Massage in- creases the flow of body juices blood, lymph, chyle, etc. in- creases secretion and excretion, and excites muscular activity. In general, its physiologic effects and therapeutic advantages are nearly identical with those obtained from any other source which is capable of producing artificial hyperemia. The technique of massage may be divided into the following methods of application: Stroking, friction, kneading, percussion, and vibration, active and passive movements, or medical gym- nastics. The movement of the hands in applying massage de- pends on the method employed. In stroking, the whole palm or the radial border of the hand, or the tips of the fingers, are used, the pressure being light in the beginning and gradually increas- ing to as much force as the case demands. The direction of the strokes in most cases is venous centripetal, or toward the heart. Upon the head the movements are directed from the vertex down- ward. Friction is best applied by forcible, circular rubbing of the surface, starting at the border of the altered tissues and work- ing toward the center from all directions. In kneading, squeez- ing, rolling, etc., the movements of pressure and relaxation are alternately and rhythmically employed to simulate natural mus- cular action, the object being to act upon the circulation of the deeper seated structures. The veins, capillaries, lymph vessels, and lymph spaces are emptied by pressure, the valves in the ves- sels preventing a return of the expelled fluids, but making room for a fresh influx. Percussion and vibration consist of a series of tapping, pounding, or beating movements very rapidly and rhythmically performed with the fingers, with the radial border of the hands, or by means of mechanical contrivances worked by the hand, a spring, or electricity, which causes muscular contraction. In the active, or Swedish, movement the patient concentrates his will on the muscle under treatment, causing it to act, while the operator tries to resist the movement with slightly less force. Af- ter the muscle has fully contracted, the operator employs force, while the patient diminishes his resistance, until the muscle is brought back to its original position. In passive massage all the movements of the muscles and joints are executed by the operator without resistance or assistance on the part of the patient. MASSAGE 461 Medical gymnastics are principally employed for the purpose of exercising all those muscles which are seldom used, or which, for some special reason, require strengthening. From the viewpoint of the dental therapeutist, mas- sage is a serviceable adjunct to his armamentarium. It is indicated in all those conditions where a sluggish circulation in the soft tissues exists, and consequently all those diseases in which chronic inflammation is an otiologic factor gingivitis, pyorrhea alveolaris, etc. are directly amenable to this treatment. As a prophy- lactic measure, massage, in combination with the daily routine toilet of the mouth, deserves to be highly rec- ommended. In the mouth proper the finger (bare or covered with a coarse linen finger cot or stall), the tooth brush (made of soft or coarse bristles, rubber, or woody fibers), or even some specially devised me- chanical appliances, are used. Existing conditions and the individuality of the patient govern the meth- ods and their application. The operator has to decide which grade and what kind of a tooth brush is best for the case in hand. Rotary movement and moderate pressure applied by a fairly coarse brush apparently produce better results than a too soft or a too coarse brush used with heavy friction. The time required for oral massage is also dependent on conditions. On the average about five minutes three times daily are sufficient. For external facial massage, the finger tips or the electric vibrator are indicated. This also de- pends on conditions, the operator selecting the method best suited to his purpose. An electric dental vibrator has been devised and advocated by Mitchell. 1 It con- sists of a "cam-like piece of metal, perforated at its smaller end for mounting upon a screw mandrel, Fig 91 and is held in the dental hand piece strapped to the Dental vibrator hand. Its centrifugal force imparts a vibratory mo- tion to the hand, which can be utilized for massage with the finger tips, or by holding in the hand an instrument having on * Mitchell: Dental Brief, 1908. * An S. S. White engine mallet is provided with a soft or hard rubber cup, mounted on a suitable shank. Any desired degree of speed and force is readily obtained by the proper regulation of the mallet. 4G2 PHYSICAL THERAPEUTICS Fig. 92. Dental massage apparatus. (Vibrator.) LIGHT THERAPY 463 its end a soft rubber cup. The parts to be massaged should be lubricated with vaselin." Ointments are used merely for the purpose of rendering the skin soft and pliable, and to enable the fingers to glide easily over the surface. Mechanical vibrators suitable for the oral cavity are at present to be found in the market. An instrument for the purpose may be readily con- structed as follows : A suitable mandrel is provided with a threaded shank to fit the socket of an S. S. White engine mallet No. 4. The mandrel is bent to a slight obtuse angle, and mounted with a soft rubber tip, or Morrison polisher; or a number of mounted cups and tips are kept on hand, and, when needed, securely fastened in a suitable porte polisher. Any desired degree of speed and force is readily obtained by the proper regulation of the mallet. It has been stated that a moose hide disk, mounted off the center and rotated in the dental engine, produces sufficient vibration for dental purposes. While this is true, the rapid rota- tion will incidentally produce a rubbing motion, which readily lacerates the gum tissue by brushing away its epithelial coating. The electric vibrator employed by professional masseurs should be used with caution on the face, as the author has seen a case where the too powerful strokes of the instrument on the cheek of a lady almost completely knocked out a single standing lower molar. LIGHT THERAPY. Within recent years, light, in the form of sunlight or artificial light, has been freely discussed as a therapeutic agent of some im- portance. A comprehensive knowledge of light rays from the physicist's point of view is essential to a clear understanding of their therapeutic action. The solar spectrum furnishes a band of colors consisting of violet, indigo, blue, green, yellow, orange, and red shades, which overlap each other. Beyond either end of the spectrum there are found a number of rays, the more im- portant ones being known as the infra-red and the ultra-violet rays. Certain rays possess specific functions. The infra-red rays are heat producers, and are spoken of as thermic or caloric rays; the yellow and green rays are predominant in the production of light and are referred to as luminous rays, while the blue and violet rays, especially the ultra-violet rays, exercise a marked chemic influence on organic and inorganic matter, and are known 464 PHYSICAL THERAPEUTICS as chemic or actinic rays. Concerning the therapeutic value of the various rays, it is known that the thermic rays produce active hyperemia, the actinic rays exercise a definite chemic influence on cell structure, and the luminous rays possess an analgesic effect. By special constructed apparatus certain rays may be concentrated, others may be eliminated, and combinations of the rays in varying degrees may be produced at will. The various sources of light employed for therapeutic purposes are direct sun- light, the Finsen light, and the incandescent globe. For dental purposes, direct sunlight is probably rarely used. The Finsen light, on account of its expense, is largely confined to special sanatoria, while the incandescent globe, on account of its sim- plicity, deserves to be recommended. Fig. 93. Dental electric therapeutic lamp. The Finsen lamp produces an intense, cold light ; it is especially rich in ultra-violet rays, while the thermic rays have been largely excluded. The chemic influence of the Finsen light manifests it- self principally in the destruction of the pus-producing elements, without, however, unfavorably influencing cell proliferation. Its essentially preservative action results in the formation of white, smooth scars, without contraction of the tissues. The Finsen light is much lauded for the treatment of lupus and similar dis- eases of the skin and mucous membranes. As stated above, the therapeutic action of the mixed light rays is destructive to micro- organisms; the rays act as analgesics, and they produce intense active hyperemia, with all its sequences. We possess, however, at present so very little definite knowledge concerning their action LIGHT THERAPY 465 on living tissue that positive statements regarding their therapeutic indications should be regarded only as possibilities based largely on empiricism. The electric light best suited for dental purposes is a one-hun- dred-candle power incandescent globe, having a hard carbon fila- ment, and inclosed in a suitable projector. Much confusion ex- ists regarding the relative therapeutic value of lamps of different candle power. It should be borne in mind that a one-hundred- candle power lamp is just as efficient, therapeutically speaking, as a five-hundred-candle power light. The patient can bear only a certain amount of heat, and any more heat produced by the lamp is wasted. A one-hundred-candle power lamp furnishes Fig. 94. Dobrzyniecki's heat and light reflector, a, lens; b, lens; c, lens; d, flame; e, mirror. sufficient caloric rays to readily burn tissue. The projector should be of the parabolic type that is, so constructed as to furnish parallel rays only. It is claimed that the metal best suited for a reflector is an alloy of aluminum and manganese. To modify or intensify the various rays of this lamp, yellow, blue, or amber colored glass screens may be clamped to the projector. A free current of air should circulate through the reflector, as this will prevent ready blistering of the patient. In using a high power lamp, a quick-acting switch is necessary, as all other forms of cut- offs readily burn out. If electricity is not available, a common coal oil lamp, with a one-half-inch round burner, provided with a reflector, answers the purpose fairly well. A simple and efficient 466 PHYSICAL THERAPEUTICS reflector may be constructed, according to Dobrzyniecki, 1 as fol- lows: A three-inch convex mirror reflects the rays through a plano-concave lens two inches in diameter; the longer end of the cone-shaped connecting tube, being about ten inches long, is pro- vided at its largest diameter with a three-inch double convex lens; the small end of the tube measures about four inches, and has a two-inch double convex lens near the outlet. The rays are reflected by the mirror and pass through the series of lenses, the last one being brought in close contact with the patient. Therapeutic Applications. In the practice of dentistry the mixed rays of light obtained from what is technically known as a one-hundred-candle power Fig. 95. Mode of application of the therapeutic lamp. The therapeutic portable lamp is guided by the operator. The patient protects himself with an asbestos screen, which has a hole cut near the center to allow the rays to pass through. therapeutic lamp are usually employed. In the mouth proper only the anterior teeth and gum tissue are directly amenable to this treatment. To expose the parts as much as possible, a 1 Dobrzyniecki: Wiener Zahnarztliche Monatsschrift, 1903, p. 287. LIGHT THERAPY 467 mouth speculum is inserted, and the patient's face is protected by an asbestos screen, with an opening cut in the center about two inches long and one-half inch wide, which is held by the patient about two inches in front of the parts to be treated. The lamp is held in front of the screen, the distance depending on the degree of heat produced. The light is used with a brushing motion, and should not be focused too persistently on any one point. On the face it is used in practically the same manner. A thin coat of vaselin spread over the surface to be treated relieves undue ten- sion. To receive the full benefit of the light treatment, the part to be treated should be continuously exposed twice at one sitting for about fifteen minutes each time, with an interval of half an hour, and preferably immediately followed by massage. Radio-Active Substances. In 1896 Roentgen made the world-renowned discovery that cer- tain rays obtained from a Crookes tube would penetrate sub- stances which, under ordinary conditions, are known to be opaque. In the same year the late French physicist, Henry Becquerel, observed that uranium salts, when brought into contact with a photographic plate protected by a tight-fitting cover of black paper, become sensitized. Certain substances are known to pos- sess the power of emitting light rays, i.e., they cause fluorescence or phosphorescence. It should be borne in mind, however, that these latter substances have to be exposed to sunlight or artificial light for some time before they re-emit some of this stored-up energy in the form of light rays. On the other hand, minerals which contain uranium will bring about the same phenomenon without being previously exposed to light rays. Light is a form of energy; it cannot be completely destroyed nor can it be created out of nothing. Since uranium salts pro- duce light rays apparently indefinitely, it was supposed that they must contain certain specific substances which possess, as an in- herent property, the power of light emanation. The isolation of these substances was finally accomplished, and their discovery is primarily to be credited to the late Professor Pierre Curie and to his wife, Mme. Curie, of Paris. Both experimenters worked with crude uranium minerals and from it they isolated radium the radiant and polonium, so termed in honor of Mme. Curie's 468 PHYSICAL THERAPEUTICS native country, Poland. Shortly after the discovery of these two elements, Debierne of Paris isolated a third radio-active element from the crude uranium, which he named actinium. The chief minerals from which radium is derived are carnotite or chalkolite, and pitchblende. The quantity of radium present in the various minerals is extremely small, about five million parts of pitch-blende containing one part of radium. A ton of pitch- blende, containing about fifty per cent of uranium, furnishes about two grains (0.13 grams) of radium. To extract this small quan- tity, tedious mineralogic processes are necessary. The present available amount of radium throughout the whole globe, expressed as the bromid salt, may be estimated at about an ounce and a half (45 grams), which represents a value of about five million dollars. One milligram, i.e., about one-sixty-fourth of a grain, is listed at present (1915) at one hundred and twenty dollars. Radio-Active Substances. These substances may be classified in three distinct groups: Actinium, thorium, and uranium. Each primary element, by transmutation, transforms itself into a num- ber of other substances. According to Rutherford and Soddy, all radio-active substances are continuously undergoing transforma- tion. During the transformation of a radio-active element, an- other element is created whose atoms possess less power of emana- tion than is possessed by the one from which it is created. Re- stricting our discussion to uranium and thorium only, the follow- ing substances derived from the respective mother substances may be enumerated: Uranium, Uranium X, Ionium, Radium, Radium emanation, Radium A, Radium B, Radium C, Radium D, Radium E, and Radium F. Thorium, during the process of transforma- tion, produces the following so-far-known substances: Thorium, mesothorium, radiothorium, Thorium X, Thorium emanation, Thorium, A, B, C, and D. Incidentally, the products of transforma- tion possesses a variable period of "life," i.e., time of existence. A specific quantity of radium decomposes by about one-half in seven- teen hundred years, radium emanation in 3.8 days, radium A in three months, radium B in twenty-six minutes, radium C in nine- teen minutes, radium D in twelve years, radium E in six days, and radium F in one hundred and forty days. Radium is an element closely related to barium in its chemical behavior. It is a white metal, melting at about 1,316 F. (700 C.), and energetically decomposes water. Aside from the ordinary LIGHT THERAPY 469 properties possessed by the barium group, it is endowed with three remarkable additional functions: It emits heat continuously at a constant rate, it is the source of radiation, and it generates a gas which is radio-active. Radiation Energy. The transformation of one radio-active ele- ment into another is adcompanied by the liberation of various rays, which are known as the alpha, beta, and gamma rays. Alpha and beta rays are not true rays ; the alpha rays are positively charged ions of helium given off by the element, while the beta rays are negatively charged ions. The gamma rays are true rays; they do not contain free ions and are very similar to the Roentgen rays. The gamma rays are not distorted in a magnetized field, while the other two rays are turned to the right or left respectively. The power of penetration of these various rays differs markedly; the alpha rays are least active, the beta rays are slightly more so, while the gamma rays pass through a sheet of lead one centimeter thick, the human body, the walls of a house, etc. The relationship of the radiation of these various rays may be expressed by the equation, 1 :100 :10,000. Methods of Estimating and Measuring Radio-Active Emanation. Until recently, the strength of radio-active substances has usu- ally been expressed in Mache units a Mache unit representing 0.001 electrostatic unit as measured by the amperemeter and mul- tiplied by 1,000. At present, to standardize this somewhat arbitrary method, the term "curie" is employed. A curie represents the amount of emanation in equilibrium with one gram of radium:; a " microcurie, " i.e., one millionth of a curie, is the amount of emana- tion in equilibrium with 0.001 milligram radium. A microcurie equals about 2,700 Mache units. The various rays emanated by radio-active substances act upon photographic plates, they pro- duce fluorescence in certain bodies, they electrify gases, and they produce measurable quantities of heat. Upon these factors are based the various methods of measuring the radio-active emana- tion, i. e., the radiographic, the fluoroscopic, the electric, and the thermae. Various ingenious apparatus have been devised to ac- complish these purposes. Biologic and Physiologic Action of Radio-Active Substances. Every living cell, when subjected to radium emanation, is in- fluenced by it; however, the reaction of the cell depends upon its specific nature and upon the kind of rays employed. In conse- 470 PHYSICAL THERAPEUTICS quence, certain tissues are more easily amenable to the rays than others. Nervous tissue reacts most energetically, while intestinal and serous tissues are far less strongly influenced. Muscle tissue is the least reactive. Connective tissue, when subjected to the rays, is readily stimulated to proliferation. Histologic examination in- dicates that the typical phenomena of inflammation, with their long chain of changes, i.e., from an early hyperemia to the final necrosis, may be produced at will. The internal organs react in various ways; readily influenced are lymphoid tissues, especially the spleen, less so the kidneys, and still less the salivary glands and mucous membrane. No living tissue will stand the prolonged exposure to the rays without showing some definite change, and it is immaterial whether the tissue is of animal or vegetable origin. Ferments, on an average, are slightly activated. Saliva ferments are usually at first slightly paralyzed and later activated; the re- sults obtained, however, are so very variable that little significance can be placed on these observations. Low-type organisms, i.e., bacteria, protozoa, etc., are comparatively very slightly influenced by radiation. Upon pathological tissues the effect of the rays is much more pronounced than upon normal structure, hence the great significance of the rays in the treatment of diseases. As stated by Strieker, pathological tissues react to the gamma rays according to the following scale: Leukemic tissues, mycosis, eczema, sarcoma, carcinoma, lupus, tubercular ulcers, lipoma, myoma, and fibroma. The physiologic effect, as Von Norden ex- presses it, results in an internal electric ionization of the tissues. So far, no danger from the application of small doses of emanation have been observed; large doses are productive of destructive re- sults. From a therapeutic point of view, innumerable diseases have been subjected to the effects of radium emanation. In due time it was found that specific results were obtained in certain forms of skin diseases, including neoplasms, in disturbances of metabolism, especially gout, and in painful alterations of the nerv- ous system, i.e., neuralgia, locomotor ataxia, etc. Methods of Application of Radio-Active Substances.. Of the various radio-active substances, radium and mesothorium in nu- merous modifications are the principal elements employed thera- peutically at present. The salts of these elements may be preserved in small metal, ebonite, or other suitable containers, covered by a filter usually consisting of a thin sheet of mica or aluminum. LIGHT THERAPY 471 Various-shaped tubes, boxes, sounds, compresses, etc., are avail- able so as to conform to the various types of body surfaces and cavities. If a radio-active substance is to be administered in the form of gas emanation, it is preferably carried out in an inhala- torium. Many of the well-known sanatoriums of Europe and the United States are at present provided with such radium emanation inhalatoriums. For the internal administration of radium emana- tion, water artificially charged with radio-active gases or with the dissolved salts, or natural springs containing radio-active sub- stances are chiefly employed. For the charging of water with radium emanation, various methods are in vogue. The water may be charged by direct solution of a soluble radium salt, i.e., the bromid or the chlorid, or by submerging a very finely powdered insoluble salt, i.e., the sulfate. To present as large a surface as possible, the insoluble radium salts are employed in various modi- fications. They may be precipitated upon asbestos in a porous cell, they may be mixed with charcoal and formed into slabs, they may be mixed with cement and formed into balls, and lastly, they may be mixed with clay and fired. Most of these processes of sub- dividing radium salts are protected by patents. The "life" of these various modifications of radio-activity is usually very pro- longed; the fireclay rods, it is estimated, may be used seventeen hundred years, and still have one-half of their radium content available. For many centuries it has been known that the water of certain mineral spas is endowed with peculiar therapeutic qualities which cannot be attributed to the organic or inorganic constituents of these spas. It was found that certain artificially compounded mineral waters prepared according to formulas obtained from most carefully conducted analyses will not produce the same thera- peutic effects as the water employed at the respective spas. While climatic conditions, change of environment, and similar factors no doubt play an important role in balneologic therapeutics, the fact remains, however, that the water of certain spas, when drunk at the springs, exercises some peculiar beneficial effect on the sick. To explain these curious properties, folk-lore has endowed certain springs with mystic spirits, the "Brunnengeist," the "spirit of the spring," as it has been appropriately designated in bygone days by the Germans. Soon after the emanation of radium had become an established fact, investigation was carried on in the 472 PHYSICAL THERAPEUTICS hope of finding similar possibilities possessed by the various spas, and it was discovered that many of the famous watering resorts owe their renown in a large measure to the presence of radium emanation in their spas. The more important watering resorts of Europe containing emanation are : Bath, Baden-Baden, Gastein, Landeck, Joachimstal, etc. Therapeutic Application. Kadium was introduced into dental therapeutics in 1912, by M. Levy, of Berlin. Aside from his nu- merous publications, the writings of Walkhoff, Trauner, Mamlok, Leger-Dorez, Warnekros, and many others are available to the inquiring student. According to Levy, the following oral diseases have been subjected to radium emanation: Psoriasis of the oral mucous membrane, pyorrhea alveolaris, loosening of the teeth with- out the presence of pus, marginal gingivitis, leukoplakia, chronic aphthae, fistulas, and ulcerative stomatitis caused by gout. The therapeutic application of radio-active substances about the mouth may be accomplished by utilizing the following methods and means : The drink cure, mouth-washes, tooth-pastes, compresses, injec- tions, irrigation, inhalation, and finally, variable combinations of these procedures. The drink cure and the application of the mouth-washes are probably the two most prominent means of utilizing radium emanation for such purposes; the other enum- erated methods are of questionable value. The technique of the various methods is comparatively simple. As a drink cure, Levy recommends the following procedure : Water charged with emana- tion, or water containing a specific quantity of a soluble radium salt may be used. The radium content should correspond to about 1,000 to 3,000 Mache units per day, although higher con- centrations have been used with no deleterious side-effects. Every twenty to thirty minutes during the two or three hours follow- ing the three main meals, a small quantity of the charged water should be taken. The object is to furnish the organism with small quantities of the products of decomposition of radium, which are slowly absorbed. In due time they reach the blood current and finally are eliminated, primarily through the lungs and to a less extent by the urine, the skin, perspiration, and the saliva. "Within twenty minutes after partaking of 600 Mache units, radium emana- tion has been shown to be present in the saliva. As a gargle. Trauner recommends the following procedure: A quart of water containing about 375 Mache units forms the basis of the mouth- LIGHT THERAPY 473 wash. Of this solution, the patient uses two glassfuls (about 10 fluidounces each) per day as a mouth- wash, observing the follow- ing precautions: Every dose of the solution which should not be too large, so as to find ample room in the mouth has to be worked forcibly between the cheeks and the teeth for at least a minute and a half, so as to de-emanize the water. The water should then be removed from the mouth slowly and in a thin stream. The emanation will separate from the water and precipitate itself upon the mucous surfaces of the mouth. From twenty to thirty minutes are necessary to use up the content of a glassful of the solution. After the gargling, the patient should not eat or drink, and if possible should not speak, for at least one or better two hours, to retain the gaseous emanation in the mouth. With this simple pro- cedure Trauner claims to have obtained most remarkable results. The formation of pus and subjective symptoms are checked in two or three days, remaining only, and to a milder degree, upon those places where accumulations of calcareous deposits are pres- ent. The tartar has to be removed thoroughly, and at future sit- tings careful examination has to be made for remnants of tartar, which represent a constant and sure source of pus production. Large-sized pockets are successfully treated by syringing with two cubic centimeters of a concentrated emanation solution. Radium treatment is slowly settling down to the specific phase in medical and dental practice to which undoubtedly it is en- titled. The two dental institutes which have primarily investi- gated radium therapy are the institutes of the University of Ber- lin and of Graz. At the Berlin Institute, Zahnarzt Mamlok, and at Graz Professor Trauner, have carried out extensive investiga- tions on the subject. Trauner is still an ardent advocate of radium therapy, and he is convinced that its influence is very marked in the treatment of inflammatory conditions of the oral mucous membrane. On the other hand, Mamlok is rather skepti- cal at present, and he sums up his experience by stating that the prolonged utilization of water charged with radium emanation has a tendency to lower the virulence of the ordinary pus bacteria usually found in inflammatory conditions of the mouth. He has obtained good results in the treatment of pyorrhea alveolaris by combining the following procedures : Careful removal of all tartar deposits, establishing perfect occlusion, splinting of loose teeth, application of radio-active substances, and rigid oral hygiene. 474 PHYSICAL THERAPEUTICS Patients who suffered with pain in connection with their dental ailments are unanimous in their statements that washing with radium-charged water relieves this condition, like "magic," as they express it. Of the many other benefits claimed by dental practitioners and patients alike relative to the therapeutic effects of radium mouth-washes, pastes, etc., the writer is extremely skep- tical. He has not been able to observe any special value derived from such procedures. In a number of counter-tests, in which a warm physiologic salt solution was substituted for the radium preparations, the comparative results obtained were equally as good. In certain chronic and malignant diseases of the oral cav- ity and its adnexa, i.e., carcinoma, epithelioma, leucoplakia, etc., the treatment with radium seems to be followed by marked benefit. As stated above, radium seems to be entitled to a legitimate place in general therapeutics. So far as its application in the treatment of oral diseases, especially pyorrhea alveolaris, is concerned for which it has received the bulk of its indorsement at present no positive results can be recorded. HEAT AND COLD. Heat and cold are frequently referred to as distinct entities, but in reality they are merely relative terms, expressing the variations above and below normal temperature. By the latter term the temperature of the human body about 98.4 F. (36.9 C.) is meant, and is taken as the average caloric indicator. Heat is applied in two forms dry heat and wet, or moist, heat. The physiologic effect of both is the same, and they produce a pronounced active hyperemia, with all its phenomena. Dry heat can be borne by the body at a very much higher degree than moist heat. In the Turkish bath temperatures as high as 140 to 150 F. (60 to 66 C.) are frequently reached, while moist heat in the form of a poultice should be limited to 105 to 110 F. (40 to 43 C.). Above this temperature moist heat is injurious to the soft tissues. The body protects itself against great heat by the free evaporation of profuse perspiration and the powerfully accelerated blood stream within the heated area. Dry heat is conveyed to the tissues through the air, and, as air is a very poor conductor, much of the heat is lost ; while moist heat is kept in intimate contact with the tissues, and is held there for a definite period. The continu- HEAT AND COLD 475 ous application of heat on pathologically altered tissues produces definite changes in the structures. The resulting increased osmotic pressure exerts a powerful influence on the centrifugal flow of the lymph, and the products of the early stages of inflammation are carried away from the center toward the periphery, to be poured into the circulating blood stream or otherwise disposed of. If pus is about to gather, the heat will materially assist in the ready breaking down of the affected structures, and will help to "ripen" the abscess. The general effects of cold on the tissues manifest themselves in lowering the temperature, diminishing the sensibility, and contracting tissues and vessels, thereby reducing the volume of these parts. Cold continuously applied benumbs the part, and produces in due time a definite local anesthesia. Cold, when locally and continuously applied in the form of an ice pack, cold water coil, towels wrung out in iced water, etc., causes a temporary inhibition of inflammation in its very early stages. Its anti- phlogistic action is manifested by retarding circulation and in- hibiting the emigration of the leucocytes. As soon as the cold application is removed, the inflammatory process starts with re- newed activity. When applied to an infiltrated area, it produces anemia and increases the osmotic pressure within the edematous field surrounding the focus of inflammation, which results in severe pain and, under certain conditions, in distinctly dangerous symptoms as, for instance, in passive hyperemia or stasis of the pharynx. Therapeutic Applications. Heat and cold are applied for general purposes in the many varieties of the bath, while locally any neutral material which will convey and retain either one for a sufficient length of time may be used. Apparently there exists quite a diversity of opinion relative to the use of moist heat, dry heat, and cold. Both forms of heat, locally applied, are productive of the same results. They induce intense active hyperemia, and apparently it makes little difference what form, of heat is employed. The choice between heat and cold, in general conditions, is largely governed by the wish of the patient, except in fever, and the patient will usually assert that one of the two is more agreeable to him. If we are 476 PHYSICAL THERAPEUTICS dealing with a pericemental inflammation and the consequential formation of an alveolar abscess, the conditions for the require- ment of heat and cold can be more definitely outlined. Clinical experience has taught that in the early stages of pericemental in- flammation ice chips held in the mouth are useful in retarding the process of inflammation and mitigating the pain. If the infiltra- tion of the tissues has proceeded to such an extent as to indicate possible pus formation, a hot poultice placed directly over the offending tooth and covering the entire inflamed area, applied in the oral cavity, is extremely serviceable. Poultices (cataplasma, L. ; cataplasme, F. ; Breiumschlag, G.) are soft, moist applications, usually employed hot, but sometimes cold; and occasionally they may contain drugs indicated to exert some specific action. Poultices furnish more or less constant heat and moisture, and thereby relax the skin, thus favoring swelling. Fig. 96. Electric thermaphone pad. but lessening tension of the tissues. Whenever a hot poultice is employed, it should always cover the field of inflammation in its entirety, or it may be applied in the form of a broad ring. It should never be so small as to cover the center of inflammation only, as then the pain is certain to increase. A hot poultice has no place on an opened or a septic wound, as it would practically seal up the infected focus, and the pent up infection would rapidly involve the surrounding tissues. A hot poultice placed externally on the cheek in pericemental infiltration is always dangerous, as it will assist in drawing the pus to the surface, which means an external opening, with the possibility of a disfiguring scar. A serviceable poultice to be applied over a tooth, and one which will retain heat for a suf- ficient time, is preferably applied in the form of raisins or figs HEAT AND COLD 477 cut into slices and boiled in water. These slices should be ap- plied as hot as can be borne, and renewed as often as necessity demands. For the application of dry heat on external body surfaces many forms of heat carriers are employed. The heated brick, hot-water bottle, heated salt bags, the Japanese stove, and many other means are utilized to retain heat for a limited time. A permanent source of heat is obtained by wrapping an electric light globe in suitable material (cotton), and placing it against the diseased part. To avoid the danger of breaking the globe, an electric heating pad, known as a thermaphone, has recently been placed on the market, which, from all appearances, seems to serve its purpose well. Within recent years the introduction of the so-called clay poul- tices, under various fanciful names, have been much discussed in current literature. From the ludicrous advertisements of the makers of the various clay poultices the practitioner may be placed under the impression that this new panacea is far superior to any other form of poultice. One preparation carries the fol- lowing teleologically constructed explanation regarding its action : "The skin may be regarded as a permeable membrane separat- ing two fluids of different densities the blood and the clay poul- tice. If the * * * (clay poultice) is applied hot under such con- ditions, something definite happens, and that scientifically an interchange of fluids, most marked toward the clay poultice ; hence the deduction that the mixture acts through reflex action and dialysis, the latter scientifically including the physical processes of exosmosis and endosmosis, and that the blood pressure from the overworked part is reduced, the muscular and nerve resistances are relaxed, and refreshing sleep is invited." Roth 1 and, very recently, Pilchen 2 have experimentally dem- onstrated that an old-fashioned flaxseed poultice holds the heat markedly longer than its modern substitute, and that, "further- more, one is immediately convinced that no process of osmosis or endosmosis is involved, for the much simpler explanation suffices that the gain of weight is due to the absorption by the clay poul- tice of the increased local perspiration, which latter in turn is due to the local application of continuous heat. Indeed, the pre- vailing scientific opinion is that nothing passes from within out- ward through the intact skin except by way of the sweat glands." J Roth: Journal American Medical Association, April 15, 1905, p. 1185. 'Pilchen: Journal American Medical Association, March 6, 1909, p. 752. 478 PHYSICAL THERAPEUTICS PLUGGING BONE CAVITIES WITH INERT OR MEDICATED SUBSTANCES. The filling of cavities caused by the destruction of bone with inert or medicated substances is materially simplified by employ- ing the ingenious methods outlined by the late Mosetig-Moorhof. Mosetig 1 divides the substances that are used for this purpose into absorbable and nonabsorbable materials. The absorbable ma- terials are again divided into autoplastic and heteroplastic sub- stances. The filling of bone cavities by the Mosetig process is ac- complished by using only heteroplastic substances. In the practice of general surgery, bone filling by divers materials is utilized to quite an extent, and the Macewen operation, Senn's bone grafting, etc., are examples of such procedures. Mosetig ad- vised the use of a solid, but readily absorbable, material which can be easily introduced into the "dead spaces" in a liquid form, so as to fill all the nidi and crevices that are liable to remain after a bone operation or after bone absorption. The material advo- cated by Mosetig consists of a mixture of iodoform, spermaceti, and oil of sesame, and is known in general surgery as "bone plombe." 2 Mayrhofer 3 recognized the value of the Mosetig bone plombe in its relation to dental surgery, and he advocated its use in a modified form in 1905. The dental indications for this pro- cedure are manifold. It is especially serviceable after root ampu- tations, in abscess cavities with or without fistulas, in bone cavities resulting from the various causes of necrosis, in the treatment of pyorrhea alveolaris, to some extent in the treatment of chronic empyema of the antrum, etc. In applying this method of treat- ment a few salient factors are essential, and their strict recogni- tion is of the utmost importance for the success of the treatment. The cavity which is to be filled with the bone plombe must be absolutely dry. This can be readily accomplished by packing the cavity with strips of gauze, which are removed at the very moment the liquefied plombe is put in place. The hot air blast is often of 1 Mosetig-Moorhof: Wiener Klinische Wochenschrift, 1906, No. 44. 1 Plombe is the German term for the filling of a tooth, and Plombierung indicates the process of .filling teeth. Plombe is derived from plumbum, the Latin term for lead, a ma- terial which at one time was in general use for stopping cavities in teeth. The term bone plombe has been generally accepted by American and English writers as a special, descrip- tive term for the Mosetig process of filling the dead spaces after bone operations. 1 Mayrhofer: Osterreich-Ungarische Vierteljahrsschrift fur Zahnheilkunde, 1905, No. 2; 1906, No. 3: 1907, No. 1. 479 great assistance for such work. The plombe must completely fill the cavity that is, it must not contain air spaces. By press- ing the semisolid material into place with tampons of gauze, and by using a heated pointed instrument, a solid filling is readily obtained. The filling in the bone cavity after a root amputa- tion, etc., should be covered with the primarily lifted up muco- periosteum, while in the case of fistulas no further protection is necessary. Mayrhofer advocates holding the periosteal flap in position by a suture. We have never had occasion to use a suture for this purpose. After the flap is replaced, the lip or cheek exercise sufficient pressure to hold it in correct position. In 1901 Bb'hm 1 constructed a small syringe with which it is possible to Fig. 97. Bohm's syringe for bone plombe. deposit the medicated bone plombe in the form of a bougie in an even manner in any crevice or corner which can not be reached otherwise. This little syringe is supplied with a number of can- nulas of various shapes, and is especially of service in the treat- ment of chronic alveolar abscesses. This little device has been successfully employed for such work by Bb'hm, Misch, 2 Lies, 3 and others. The technique of placing the plombe is simple. In the early days of the operation, Mayrhofer used a hot water jacket syringe, 'Bohm: Zahnarztliche Rundschau, 1901, No. 451. * Misch: Osterreichische Zeitschrift fur Stomatologie, 1904, No. 4. Lies: Deutsche Zahnarztliche Wochenschrift, 1903, No. 4. 480 PHYSICAL THERAPEUTICS but at present he relies upon a wax spatula and a few pointed in- struments. Beck advises an all-metal syringe or a collapsible tube, fitted with a flexible cannula having a fine, tapering point made of pure silver. In all cavities that afford ready access an ordinary wax spoon, a pointed metallic instrument, and a few Fig. 98. Collapsible tube for bone plombe. A flexible cannula attached to a collapsible tube for placing the bone plombe. gauze tampons answer the purpose sufficiently well. For cavities having no direct access, a syringe with a curved cannula, or a col- lapsible tube with a flexible cannula, is necessary. For the fill- ing of very narrow cavities fistulous tracts, pockets of pyorrhea PLUGGING BONE CAVITIES 481 alveola ris, etc. the Bohm syringe is very serviceable. The syringe is applied with various bent cannulas, which readily reach any part of the mouth. For the treatment of an abscess, a small Fig. 99. A hypodermic syringe prepared for bone plombe. A flexible cannula is attached to the hypodermic syringe for the purpose of conveying the bone plombe to a root canal of a tooth. amount of slightly warmed, but not liquefied, paste is rolled into a cylinder (a bougie), which is inserted into the Bohm syringe supplied with the proper cannula, and a slight pressure is asserted 482 PHYSICAL THERAPEUTICS upon the piston until the paste appears at the point of the can- nula. A small piece of rubber tubing or temporary stopping is now placed about the tip of the cannula to form an air-tight joint, and the syringe is tightly inserted into the root canal. Slight, but continuous, pressure is now applied to the piston until the bone filling appears at the mouth of the fistula. The canal is sealed with temporary stopping. If necessary, the treatment is repeated in a few days. The bone filling consists of an unctuous base, to which some strong antiseptic has been added. The original Mosetig bone plombe was prepared by melting together equal parts of oil of sesame (oil of benne) and spermaceti, filtering and sterilizing the liquid in a water bath, and then pouring 60 grams of the Fig. 100. A large cavity in the mandible filled with bone plombe. hot mixture into a large dry bottle containing 40 grams of finely pulverized iodoform, and shaking constantly until the mass hardens. For dental purposes, Mayrhofer advises the follow- ing modified formula: Spermaceti 30 drams (120 Gm.) Oil of sesame 15 drams ( 60 C.c.) Iodoform 10 drams ( 40 Gm.) This combination produces a more durable filling, as it is of a harder consistency than the original formula. The iodoform odor is extremely disagreeable, and even nauseating, to some patients. By substituting an odorless iodin compound as ourophen, vio- PLUGGING BONE CAVITIES 483 form, aristol, etc. this objection is readily overcome without materially lessening the antiseptic qualities of the filling. The ready-made filling is kept in small well-stoppered bottles, test tubes, or collapsible tubes. By placing the bottle or tube in a container filled with hot water, it is heated to the point of lique- faction, stirred, and is then ready for use. Recently Rudolph Beck 1 has described a similar filling which was suggested to him by Emil and Joseph Beck. The latter em- Fig. 101. Manifestations of bismuth poisoning in the mouth following bismuth paste injection. (Case of Dr. E. B. Freilich. 2 ) ploy this paste in sinuses of joints and abscess cavities. The Beck bone paste is composed as follows: Bismuth subnitrate 6 drams (24 Gm.) White wax 1 dram ( 4 Gm.) Paraffin 1 dram ( 4 Gm.) Vaselin 12 drams (48 Gm.) The ingredients are mixed by boiling. The technique of applying the Beck paste is similar to Mayr- hofer's method- Rudolph Beck and, recently, Warner speak very highly of its value in dental surgery. Rudolph Beck recom- mends this paste especially as a means of treating pyorrhea alveo- laris. He injects the liquefied paste with gentle, but steady, pres- 1 Rudolph Beck: Dental Review, 1909, No. 1. 'Freilich: Journal American Medical Association, 1917, p. 111. 484 PHYSICAL THERAPEUTICS sure into the pus pockets about the teeth, so as to reach the very bottom of every crevice. There are certain objections to the Beck paste which render it of less value as compared with Myrhofer's modification of the Mosetig plombe. The principal objection is the danger arising from bismuth intoxication. Within the last few years a goodly number of serious results arising from the ab- sorption of this paste have been reported, even from relatively small quantities as required for dental purposes, so that at pres- ent its use is largely abolished. Horsley's bone wax, consisting of: Phenol crystals 1 dram ( 4 Gm.) Olive oil 2 drams ( 8 C.c.) Wax 7 drams ( 28 Gm.) is employed for the same purpose by many surgeons with satis- factory results. A paste made of zinc oxid and petrolatum has also been much lauded. The rationale of the bone plugging com- pound seems to consist in completely obliterating the cavity with a sterile, absorbable plug. In an extensive necrosis of the mandible the author has injected about 1^ ounces (40 Gm.) of Mayrhofer's iodoform paste, the largest quantity ever used by him for a single operation. There were no systemic effects produced by the slow absorption of the paste, and within four months the destroyed tissues were partially replaced by new bone formation. ELECTRO-STERILIZATION. The most serious question that confronts the dental profession today and for that matter confronted it in the past is that which is involved in the problem of establishing absolute sterility of an infected root canal. The disposal of this problem in a truly scientific manner necessitates the determination of established sterility by bacteriologic tests in each individual case. While the writer realizes that the carrying out of such procedures in the average dental office of today will meet with numerous difficulties, due to the fact that the older members of our profession have not had sufficient training in these directions, nevertheless there exists no valid reason why it should not be done for the practitioner through a laboratory. The time is not far distant when the public will demand a laboratory diagnosis of serious root canal infections for the same reason that a bacteriologic examination of a diph- theritic throat is demanded at present. Since the sequences of im- ELECTRO-STERILIZATION 485 perfect root canal sterilization in the form of focal infections re- sulting in metastatic disturbances of distant organs are of com- mon occurrence, it must follow that our present methods of estab- lishing perfect sterility of a root canal are inadequate. The treatment of an infected root canal resolves itself into three definite phases the mechanical, the chemic, and the therapeutic procedures. Mechanical manipulations are intended to dispose of the debris of the dead pulp, chemic procedures are primarily ap- plied for the purpose of removing obstructions, and therapeutic applications are utilized to overcome septic conditions. For the latter two procedures some of the most powerful chemicals and drugs at our command are employed. Callahan, in 1893, advo- cated the use of 50 per cent sulfuric acid other investigators sug- gested 10 per cent hydrochloric or even pure nitro-hydrochloric acid for the enlargement of obliterated root canals, and Kirk, in 1894, recommended the use of sodium dioxid in conjunction there- with. As an initial step, these combined procedures constitute the very foundation of successful root canal treatment from a chemic point of view, and they should, as a matter of routine, be employed in every case. Experimental proof of the soundness of this con- ception and long-extended clinical observations substantiate this claim. Soon after the inauguration of the antiseptic era in surgery, in 1868, by Lister, dentistry adopted his methods for the treatment of root canals in an empirical way by using phenol as advocated by Witzel, in 1873. Since then innumerable drugs and drug com- pounds have been recommended at various times for this purpose. From a clinical point of view the cresol-formalin mixture as in- troduced by Gysi, in 1899, and which was widely popularized by Buckley, in 1904, has received greater approval than any other medicinal compound recommended for such purposes. The true criterion of the efficiency of an antiseptic is its bacteriologic test. The high standard of germicidal activity of formalin has been fre- quently established by rigorous experiments. Clinical data col- lected in the early days of the use of the above mixture pointed to most favorable results. In due time, however, it was observed that while "clearing up" of an infected root canal, as far as the ordi- nary diagnostic evidence is concerned as applied in the average 486 PHYSICAL THERAPEUTICS dental office, i. e., absence of foul odors, occurred much more rap- idly by the use of this mixture than by employing any of the nu- merous other drugs usually advocated for this purpose, neverthe- less secondary manifestations about the periapical tissues were of frequent occurrence. These disturbances are an indication that the supposed sterility of the canal was not obtained at the time of its treatment with the cresol-formalin mixture, or that this com- pound produces a predisposition of the periapical tissues to future infections. To be sure, dental literature is pregnant with state- ments such as this (referring to the cresol-formalin mixture) : ' ' This dressing should remain for at least three days, by which time the remedy will have sterilized the entire tubular structure of the dentin, thus establishing asepsis." As no bacteriologic proof is furnished to substantiate the claim, this empiric statement does not carry any scientific weight, honest as its intention may have been. Much stress has been placed in the past on the nature of the root canal filling material. As a matter of fact, the discussion of root canal treatment in current literature centers almost exclusively about the filling of the canal, and less so about the means of obtain- ing its sterility. Artistic root canal fillers will display roent- genograms "before" and "after" the operation, claiming that now, as the picture shows, a perfect root canal filling obliterates the en- tire canal. These men seemingly forget that they have filled only the largest tract of the deltoid branches of the root canal within the apical region, and that the half dozen, more or less, additional rami- fications have escaped their notice. And it is in these smaller canals, unless the entire region is definitely sterilized, that bacteria are har- bored to await a suitable opportunity for propagation. A sterile root canal filling acts as a "mechanical" antiseptic; its intention is to hermetically seal up that space of the tooth which at one time has been occupied by the pulp. If root canal fillings were a perfect re- plica of the former pulp, no further trouble would be anticipated. The numerous recurrent infections, however, tell a different story. On the other hand, if one starts out with a sterile root canal and can furnish proof that the dentin to the depth of one or two millimeters is sterile, especially so within the apical region, which is the primary seat of infection and of reinfection, the root canal fillings placed with care and precision will furnish a greater per- ELECTRO-STERILIZATION 487 centage of "successes" than if primarily the filling is begun in a root canal of questionable sterility. Any new method, therefore, which promises to possess superior merits over existing less satis- factory procedures, is worthy of discussion. The writer is con- vinced that the process of electro-sterilization of infected root canals as a means of establishing asepsis is an advance step in dental therapeutics, and is deserving of earnest consideration by the clin- ical practitioner. HISTORY. The utilization of the electric current for the purpose of checking bacterial growth is by no means of recent origin. In 1883 Cohn and Mendelsohn employed a galvanic current experimentally to study its effect upon bacteria suspended in nutrient solution. Apostoli and Laquerriere, in 1890, used a current of 100 to 150 mil- liamperes for similar purposes, claiming, however, that it is not the current as such but the electrolytic decomposition of the nutrient fluid which produces the desired effects. Similar results were ob- tained by Prochowink and Spaeth in the same year. In 1891 Yer- soogen claimed that the bactericidal effect of the current depended on the end products of the electrolytic dissociation of a suitable fluid, i. e., acid at the positive pole and alkali at the negative pole. The application of this principle for the purpose of sterilizing root canals was probably first attempted by Breuer of Vienna, who, as early as 1890, referred to this method in a tentative manner. In 1895 Rhein, at the suggestion of Morton, employed this procedure in an empiric way with apparent good success; he, again demon- strated it in 1897, and has referred to it at various times ever since. A systematic investigation of this procedure was first attempted by Bethel in 1896-97, and a careful perusal of his publications is of the highest interest. However, it remained for Zierler to furnish a de- tailed account of the nature of the action of the galvanic current on bacterial infection of root canals, and his work, carried out in con- junction with Lehmann at the University of Wiirzburg,in 1900, must be regarded as a very complete expose of the procedure. Since then quite a host of writers have elaborated on this problem, among whom Hoffendahl, Miller, Peter, J. Forbes Webster, Frank D. Price, Stur- ridge, and many others should be mentioned. The English-reading dental profession is particularly to be congratulated on the excel- lent discussion of this procedure as recorded by Sturridge in hig commendable work "Dental Electro-therapeutics." 488 PHYSICAL THERAPEUTICS The term ionization as applied to the specific purpose of electro- sterilization of root canals is ill chosen. Ionization designates purely a chemico-physical process, i. e., by the phenomenon of elec- trolysis ions are induced to migrate. Again, the term ionic medica- tion is employed for such procedures. Lewis Jones defines it as follows : ' ' Ionic medication is a method of treatment in which elec- tric currents are used for their power of setting the constituents of a saline solution in orderly motion in a definite direction. It is used for the introduction of drugs into the superficial parts of the body through the surface." While the above explanation is com- patible with the nature of ionic medication for general medicinal purpose, it does not specifically designate the end for which this procedure is applied in the treatment of root canals. The sole object in applying this treatment consists in combating infection by the most powerful method known, i. e., sterilization. The latter is induced by a weak electric current through the migration of certain ions. Hence the term sterilization by electrolysis, or in short, elec- tro-sterilization, as first suggested by Zierler, is eminently suitable for this purpose, and its general adaptation is strongly urged by the writer. It has been suggested that the term electro-sterilization merely indicates a substitute for the once famous therapeutic pro- cedure known as cataphoresis. This conception is not correct. Cata- phoresis designates the mechanical movement of suspended mole- cules by means of the electric current. As such it is a process inde- pendent of electrolysis. The rationale of electro-sterilization de- pends on the interaction of two definite processes: (1) the disso- ciation of a suitable chemic compound in a solvent (electrolyte) into ions, and (2) the movement of these ions in the direction of specific poles within the tissues, brought about by the passage of a weak galvanic current. Theory of Electrolytic Dissociation. When a solid, liquid, or gas enters into solution and is capable of conducting an electric current, according to Arrhenius, the solu- tion undergoes certain changes which are grouped under the generic term electrolysis. This latter term and the following nomenclature was introduced by the English physicist Faraday (1791-1867) and is still universally employed. The solution itself is known as the ELECTRO-STERILIZATION 489 electrolyte, while the dissociated products are referred to as ions. The terminals at which the electric current enters or leaves the elec- trolyte are called electrodes. An ion (ion = going) may be referred to as being the dissociated product of a chemic decomposition which is capable of conducting an electric charge, and which travels in the direction of an oppositely charged pole. Those ions which are charged negatively migrate to the anode, i. e., the positive pole, and are known as anions, while the positively charged ions migrate to the negative pole, the cathode, and are known as cations. Relatively speaking, all metals, alkaloids and hydrogen, are positive ions, i. e., cations, while all acids, bases, halogens, hydroxyl compounds, and oxygen are negative ions, i. e., anions. TABLE OF IONS, THEIR ELECTRO-CHEMIC EQUIVALENTS AND RELATIVE VELOCITIES ACCORDING TO LEDUC. Ions Milligrams per Coulomb Milligrams per Milliampere- Minute Relative Velocities Anions: Bromin . . 82 0.049 0.9 Chlorin 0.367 0.022 1.0 Hydroxyl 0.18 0.01 1.27 lodin . . 1.31 0.078 1.16 Salicylic Acid 1.4 0.085 Cations: Ammonium 0.06 0.003 1.56 Calcium 0.206 0.012 0.5 Cocain 3.0 0.18 0.59 Gold 0.678 0.04 1.22 Hydrogen 0.01 0.0006 0.88 Lithium . 0.07 0.004 1.28 Magnesium 0.115 0.007 0.5 Mercury 1.03 0.062 0.8 Potassium 0.4 0.024 1.0 Quinin 3.9 0.234 0.62 Radium 1.13 0.066 Silver 1.1 0.06 6.5 Sodium 0.23 0.014 1.6 Strychnin 3.4 0.207 Sulphur 0.16 0.01 Zinc 0.33 0.02 6.6 As Ostwald has suggested, the cation may be designated by the positive sign -f- or by , and the anion by the negative sign or by '. "An ion may be either a charged atom, as in the case of the silver ion, or a charged group of atoms, or molecules. In the case of silver nitrate, Ag N0 3 , the cation is Ag, and the anion is the mole- 490 PHYSICAL THERAPEUTICS cule or radicle N0 3 . The charge of the N0 3 ion is one negative unit, and that of the Ag ion is one positive unit, as both the ions are monads, or monatomic. " (Lewis Jones.) A simple solution of salt in water dissociates the salt into electro- molecules, the ions, which exist independently of the action of a gal- vanic current. The number of positively and negatively charged ions is equi-molecular, i. e., the solution is electrically neutral. The ions themselves are suspended in the solution in a chaotic mixture. The passing of the galvanic current, according to Nernst, by its electro-motive force causes a definite movement of the ions in an or- E- 0- -------- Fig. 102. Scheme showing the movement of ions. derly direction to their specific centers of attraction; i. e., respec- tively to the positive and the negative pole. The nature of the movement of ions may be theoretically ex- plained, according to Nernst, by the following schematic drawing (Fig. 102). According to the above scheme, if two zinc electrodes are charged, A and B, suspended in a zinc chlorid solution, D, from a battery C, the positive zinc ions, F, are attracted to the negatively charged electrode, B, and slowly they move in the direction of this pole. ELECTRO-STERILIZATION 491 The zinc ions discharge their positive charge, thereby releasing the negatively charged electrode. The discharged zinc ions are now formed into ordinary metallic zinc. The positively charged elec- trode, A, attracts the negatively charged chlorin ions, E ; the latter discharge themselves and dissolve metallic zinc, forming zinc chlorid, which at once is again ionized. The resultant ions zinc and chlorin are dispersed in the solution. Undissociated molecules, G, of zinc chlorid present in the solution are not acted upon by the current. The movement of these ions occurs comparatively slowly and may be accurately measured by means of an ingenious apparatus devised by Kohlrausch. EXPERIMENT: IONIZATION. (1) Moisten a piece of starch-iodid paper with water. Apply the two poles about one inch apart. A blue spot will develop under the positive pole. The iodid salt is ionized, and the liberated iodin colors the starch blue. (2) Moisten a piece of cotton with a weak solution of potassium ferricyanid. The positive pole of the battery consists of a piece of clean iron wire. After the battery is turned on an intense blue color, Prussian blue, i. e., iron ferrocyanid, appears at the positive pole. The degree of concentration of the solution to be ionized has no effect upon the number of ions produced ; the latter depends upon the strength of the current multiplied by the time for which it is applied. In other words, ionization is a manifestation of trans- formed electric energy in accordance with Faraday's law. The amount of decomposition of an electrolyte is proportional to the amount of electricity which flows through it. The process of electro-sterilization of infected root canals con- cerns itself primarily with the disinfectant action of the liberated ions, and less so with their supposed medicinal qualities. The dis- infectant action is principally confined to the surface of the object treated although a certain depth of penetration is desirable. Ac- cording to Sir Oliver Lodge, chlorin the principal agent depended upon in root sterilization develops a velocity of penetration amount- ing to 2.16 mm. per hour for a drop of potential of 1 volt per cm. EXPERIMENT: MOVEMENT OF IONS. (1) A saturated solution of copper sulphate is placed in a small beaker to the depth of one inch. An insulated piece of copper wire having one-half inch exposed at each end is placed into the solution and united to the negative 492 PHYSICAL THERAPEUTICS pole. A similar piece is hung over this solution and united to the positive pole. A one-half per cent sodium chlorid solution is care- fully flowed over the copper solution by means of a pipet. The cur- rent is turned on, and slowly the blue cupric ions are seen moving into the colorless sodium chlorid solution. (2) A glass tube, three inches long and one-half inch in diameter, is filled with an alkaline 10 per cent gelatin solution containing 1 per cent of sodium chlorid and colored pink with phenolphthalein. Insert a cork carrying a platinum wire at each end, and unite the wires to the two poles. In due time the pink color will disappear near the posi- tive electrode, indicating the move- ment of the chlorin (hydrochloric acid) ions. (3) Repeat the above experi- ment, but substitute for the wire of the one cork a tooth having a gan- grenous pulp (Fig. 103). The debris of the pulp is removed, and the broach passed through the fora- men. The canal is filled with salt water and the iridio-platinum elec- trode positive pole is inserted into the root canal, passing slightly beyond the foramen. Apply a cur- rent of 5 milliamperes for six min- utes. Notice the discolored zone near the foramen of the tooth, which becomes more definitely out- lined within the next twenty-four hours. Remove the tooth and split it open. Notice the odor of chlorin and the bleaching effect on the surface of the root canal. (4) Place a positive pole of zinc and a negative pole of copper into a weak solution of zinc chlorid. Within a few minutes the Fig. 103. Experiment showing passage of ions. ELECTRO-STERILIZATION 493 negative copper pole will be coated over (plated) with metallic zinc. The electric current per sc, i. e., at least in the strength suitable for root sterilization, does not produce any measurable bactericidal action. A weak current passed for hours through diluted sulphuric acid prior to entering an inoculated Petri dish did not inhibit the growth (Lehmann). In the presence of an electrolyte, the current acts on the dissociated ions of the latter, and, depending upon their specific chemic nature, some of the most powerful disinfectants may be obtained. It is claimed that certain pure metals as such possess slight antiseptic action. This property was first observed by the late Professor Miller. According to Behring, this antiseptic action is the result of the reaction of certain waste products of bacteria, primarily lactic acid, with those metals which are capable of form- ing soluble salts, and which diffuse through the medium. This antiseptic action of metals must not be confounded with the oligo- dynamic action of certain pure metals in their colloidal state, as copper, for instance, on low-type plant cells. Of the pure metals, according to the classic experiments made by Thiele and Wolf, mercury, silver, and copper are the only ones which produce poi- sonous salts in the presence of bacteria, while the other tested metals, i. e., platinum, palladium, gold, aluminum, magnesium, zinc, lead, tin, and iron are wholly devoid of action. In the discussion of electro-sterilization of infected root canals, great stress is fre- quently laid by certain men upon the specific nature of the metallic electrode placed in the root canal as being the factor which pro- duces the desired germicidal effect. Rhein, for instance, insists on using a chemically pure zinc electrode in the presence of a sodium chlorid solution, claiming that "nascent zinc chlorid" is formed during the process of electrolysis. Other practitioners employ a copper electrode and a weak zinc chlorid solution as a substitute for the sodium chlorid solution. A zinc electrode employed for electro- sterilization of root canals is not only devoid of any germicidal action, but it is also an ill-chosen metal for this purpose, because a zinc wire is too brittle to be filed fine enough so as to readily enter a minute root canal without inviting danger of breaking. lonization of a metallic electrode occurs primarily in the presence of a suitable electrolyte, i. e., a solution of a salt of the metal of the respective electrode. While theoretically it is true that ions of the respective electrode must be produced as a secondary sequence 494 PHYSICAL THERAPEUTICS of the primary ionization of the electrolyte, practically, in em- ploying the low amperage tolerated by the human body these ions are not demonstrable with the ordinary chemie reactions, conse- quently they can not exercise any therapeutic effect. A zinc elec- trode in the presence of a sodium chlorid solution is not ionized in the short space of time and with the low amperage employed in the electro-sterilization of root canals, consequently "nascent zinc chlorid" ions, which Ehein believes to have been produced from his zinc electrodes, are imaginary therapeutic bodies ; such ions do not exist. When a high amperage is employed in experimental work outside of the human body sufficient hydrochloric acid is ob- tained as a secondary product which will act on the zinc pole, form- ing zinc chlorid.* EXPERIMENTS. (a) To show the nonexistence of zinc ions in the presence of a sodium chlorid electrolyte. (1) The positive zinc electrode and a negative copper electrode are placed about an inch apart in a dish filled with a 1 per cent sodium chlorid solution. A current of 5 milliamperes is passed through the solution for 6 minutes. The addition of ammonium sul- phid does not reveal the presence of zinc in solution. By adding one drop of a weak zinc chlorid solution, the presence of metallic zinc is at once manifested. (2) Repeat the same experiment as above, but substitute the zinc electrode by a silver electrode. No precipitation of silver chlorid occurs, consequently no silver ions are formed. (b) To show the existence of zinc ions in the presence of a zinc chlorid electrolyte. The positive zinc and the negative copper electrodes are placed in a dish filled with a 1 per cent zinc chlorid solution, and the current is applied as above. In a few minutes the copper electrode is com- pletely covered by a coating of zinc, i. e., it is "zinc-plated." If the zinc electrode is carefully weighed before and after the experiment, a ponderable difference of this zinc electrode is demonstrable. To cite the often repeated experiment of placing copper electrodes into a hard-boiled egg and then passing a current through it and thus producing green-colored copper compounds near the positive ELECTRO-STERILIZATION 495 pole as a proof of the ionization of copper, is by no means a coun- terproof of what has been stated above, but rather supports the author's contention. The coagulated albumen, of course, does not represent albumin as present in the tissues. If a comparison is to be drawn from this experiment, fresh egg albumen should be used instead. By passing a current through it, it will be seen that green- colored copper compounds are formed about the positive pole, and coagulation (by heat) occurs near the negative pole. Albumen is a highly complicated amphoteric electrolyte, i. e., it represents multi- basic acids and multi-acid bases, hence the reaction. This holds equally good for gelatin solutions, although they are more pro- nouncedly acid in reaction. Copper or silver wires may be used as positive poles in electro- sterilization. They are inferior, however, to iridio-platinum, because in the presence of suitable electrolytes they are ionized, i. e., de- stroyed, and incidentally they discolor tooth structure. Pure plati- num is not measurably altered by the process of electrolysis, but it is too soft for our purpose. An alloy of iridio-platinum possesses the ideal qualifications regarding adaptability and durability as a root canal electrode, and it is therefore strongly recommended by the writer as the most suitable metal for the purpose in view. The variability of resistance of the human body to the passing cur- rent naturally materially influences its therapeutic effects. Taking into consideration the distance between the two poles, the respective biologic nature of the tissues, and other factors, it may be stated that, in round figures, the human body offers a resistance which equals from 5000 to 100,000 ohms. In a pulpless tooth the root canal of which is filled with salt water for the purpose of electro- sterilization, the resistance is low, i. e., only a few volts are required ; while if a tooth is previously deprived of its natural moisture or if its foramina are closed, an enormously high voltage, i. e., up to the full capacity of the current, is required to force its passage laterally through the dentin. (c) To show the depth of the penetration of ions into the dentin in a tooth with a closed foramen. A tooth whose foramen is tightly closed by gutta-percha, and the apex of which is dipped into melted paraffin, is filled with silver nitrate solution ; the positive electrode consists of a piece of pure silver wire. The tooth is suspended in a sodium chlorid solution up 496 PHYSICAL THERAPEUTICS to within a quarter of an inch of its gingival margin. Usually, the full voltage of the current is required to register one milliampere of flow. Slowly the amperage increases to about 4 milliamperes. After about ten minutes the current is turned off, the tooth is removed, washed, and sections are cut. Under the microscope, the penetration of the silver nitrate can be observed only to the depth of a few millimeters. No precipitation of silver chlorid takes place in the salt water. The same experiment repeated with an iron electrode in the presence of a potassium ferricyanid solution showed only the very faintest trace of Prussian blue upon the inner wall of the canal. A most naive explanation ' ' to show the antiseptic or germicidal properties of zinc ions ' ' is furnished in a recent paper by J. Forbes Webster. He says : ' ' To show the antiseptic or germicidal properties of zinc ions, three U tubes, a, 6, c, were taken, and a small quantity of ordinary broth medium (which contains meat extract, peptone, and NaCl) was introduced into each. Each tube of broth was lettered and then inoculated with some saliva, a was kept as a control. & was connected with a battery, the anode or positive pole being a small piece of pure zinc. A current of 15 to 20 M.A. was passed for 25 min- utes, c was used as a control to &, being connected to the battery in the same way, but no current passed. The three tubes were then put 'in the incubator for twenty-four hours, a and c showed abundant growth, but no growth was visible in 6, nor could sub-cultures be obtained from b. This goes to prove that the zinc ions had sterilized the broth." Webster 's deductions are based upon insufficient chemical knowl- edge. Aside from the statement, "This goes to prove that the zinc ions had sterilized the broth, ' ' no real proof is furnished to substan- tiate his claim. The true nature of the sterilization as demonstrated by this experiment is found in the fact that the current has ionized the sodium chlorid present in the broth. If Webster had substituted a platinum wire, which is not ionized, for his zinc electrode, he would have been surprised to obtain identically the same results. Webster cites a second experiment: "To show that the zinc ions pass through the tissues, I devised an experiment by passing the ions through coagulated albumen." He describes in detail the ap- paratus employed, stating that "The negative electrode consisted of a platinum wire leading to a pledget of cotton wool moistened with a normal saline solution. The zinc electrode was then care- fully brought in contact with the coagulated albumen," etc. He ELECTRO-STERILIZATION 497 claims that "No growth was obtained, which goes to prove that the zinc ions had passed through the coagulated albumen and sterilized the broth." If Webster had left out of this experiment "a pledget of cotton wool moistened with normal saline solution," his "zinc ions" would have never sterilized his broth. The Electric Current and Its Accessories. The only current suitable for electro-sterilization is the direct cur- rent. The alternating current as such can not be used unless it is changed by a transformer. This may be accomplished by a chemic "rectifier" or a small motor dynamo. The chemic rectifier without potential equalizer has not been found satisfactory by the writer. The source of the current may be obtained from the main line, from an accumulator or a storage battery, or from a series of cells. If the street current is used, it must be reduced by a rheostat to about 30 to 40 volts. A number of lamps, mounted in series, one lamp of suf- ficiently high voltage, or a wire rheostat, is usually employed for this purpose. An ordinary switchboard is less suitable, as there is always danger of shocking the patient through imperfect control. If the street current is used a knife switch should be interposed be- tween the rheostat and the current controller. If cells are employed and many practitioners and most of the reliable electric supply houses regard a cell series as the safest means for the purpose in view about 18-24 Leclanche wet cells or an equal number of ordi- nary dry cells (Columbia No. 6) are most useful. The silver chlorid cell is less serviceable for our purpose. An ordinary wet or dry cell furnishes approximately a little over one and one-half volts. Ke- cently, compact types of dry-cell batteries furnishing a current of very low amperage and medium voltage, intended for wireless teleg- raphy, have been placed on the market. These cells are also useful for dental electro-sterilization. The cells are mounted in series, and connected to binding-posts. From these posts the current is con- veyed by means of flexible conducting cords of specific colors to a suitable controller. The most important feature of a serviceable controller consists in the gradual increase or decrease of the current in very small fractions of a milliampere without shocking the patient. A graphite or a series wire rheostat, either plain or as a shunt, is serviceable for such purposes. The markings on the current con- 498 PHYSICAL THERAPEUTICS troller (Fig. 104), be they volts or arbitrary numbers, have little bearing on the practical application of the current. The current controller, in turn, is connected with a milliampere- meter, an instrument for measuring the quantity or strength of the current. The milliamperemeter is the instrument of precision which Fig. 104. The S. S. White current controller. Fig. 105. VVeston milliamperemeter. guides the operator in his work, consequently too much emphasis can not be placed upon the importance of obtaining a perfect work- ing instrument. At this point the writer may be permitted to digress for a moment ELECTRO-STERILIZATION 499 Fig. 106. Metal negative hand electrode. 500 PHYSICAL THERAPEUTICS from the subject proper and call to the mind of the reader the fun- damental nomenclature governing electrical measurements as far as it is utilized in the following discussion. By the term ampere is meant the unit of strength of a current. A milliampere is a thou- sandth part of an ampere, expressed as M.A A volt is the measure of the unit of pressure of the current, i. e., the electric power neces- sary to drive a current of one ampere through a resistance of one Fig. 107. Sponge negative hand electrode. Fig. 108. bponge wrist electrode. ohm. It is referred to as the electro-motive force and expressed as E.M.F. An ohm measures the resistance of a circuit through which a current flows. From the above explanation as related to the process of electro- sterilization, it is obvious that the correct measurement of the ELECTRO-STERILIZATION 501 amount of current applied to a patient is of the utmost importance, as it is the safest means of guiding us during its application. Hence the importance of procuring a trustworthy milliamperemeter. The best instruments are those constructed after the Deprez-d 'Arsonval deadbeat (nontrembling) type. The Weston milliamperemeter (Fig. 105) is a most reliable current gauge. The face of the latter instrument, suitable for this work, should be calibrated into five mil- liamperes, with subdivisions of a tenth to a twentieth of a milli- ampere. To convey the current to the patient, different colored flex- ible cords are employed which terminate in suitable electrodes. In Fig. 109. Long-handle electrode with iridio-platinum point. connecting up the whole apparatus extreme care must be observed in joining equal poles to each other ; viz., positive pole must be con- nected to positive pole, and vice versa. To locate the respective poles, the following simple experiment may be employed. EXPERIMENT: LOCATION OF POLES. Moisten a piece of blue lit- mus paper with water. Place the two poles of the battery about one inch apart on the wet paper and turn on the current. In a few mo- ments a pink spot will develop where the positive pole touches the paper. Fig. 110. Insulated electrode holder. The two electrodes are terminals attached for the purpose of con- veying the current to the patient, and consist of a negative electrode which is to be placed on the patient's skin surface, and a positive electrode to be introduced into the tooth. The negative electrode may be a piece of metallic tubing held firmly in the patient's hand, or a sponge electrode fastened to his wrist, or one of various modifi- cations thereof. The size of the negative hand electrode is import- ant ; it should present at least five square inches surface area, which are to be brought into contact with the patient. A large surface of 502 PHYSICAL THERAPEUTICS the negative electrode reduces the resistance, and consequently the tingling sensation or even blistering caused by the heat of a small electrode is avoided. The writer prefers the plain tube hand elec- trode, as it avoids the cumbersome wetting with salt water, loss of time in adjusting it, etc. It is immaterial in which hand the elec- trode is held. Rings, bracelets, wrist-watches, etc., must be removed, otherwise blistering of the patient's skin by mere contact may oc- Fig. 111. Galvanic battery for electro-sterilization. cur. To place the negative electrode upon the patient's cheek, lip, or gum surface by means of a clamp or spring, as recommended by some operators, is to be avoided, for the reason that severe burns may result. It has been stated that this blistering results from the formation of caustic sodium hydroxid near the negative pole. The blistering is the result of imperfect contact between the skin and ELECTRO-STERILIZATION 503 the metal electrode, thereby increasing the resistance of a small area to such an extent as to produce high heat, i. e., an electric burn. The positive electrode to be introduced into the tooth consists of a piece of iridio-platinum wire No. 20 gauge, about one inch long and tapered to a delicate point. The iridio-platinum alloy possesses the necessary flexibility, which is lacking in pure platinum. The point itself is ground blunt so as to avoid being caught when introduced Fig. 112. Switchboard for electro-sterilization. (Mclntosh.) into tortuous canals. Various sizes of these points may be kept on hand. No other metal should be employed for such purposes. To substitute the iridio-platinum point by zinc, copper, or any other metal with the view of aiding its therapeutic effects is not only use- less but it markedly interferes with the action of electrolysis in the relatively small area of a root canal, or the resultant ions may dis- 504 PHYSICAL THERAPEUTICS color the tooth. A long-handle electrode holder, insulated with hard rubber, is essential to suitably unite the electrode with the conduct- ing cord. The holders may be of various types so as to give ready access to all parts of the oral cavity. From the foregoing description of the source of the current, its control, and its mode of application, it may be observed that essentially it is a duplicate of the armamen- tarium as applied in producing cataphoresis. Any apparatus, there- Fig. 113. Switchboard for electro-sterilization. fore, that is or has been used for inducing cataphoresis may be equally successfully employed for the electro-sterilization of root canals. Chlorin as a Disinfectant. Of all the known cheniic disinfectants, chlorin, freshly prepared, and in the presence of moisture and a suitable temperature, possesses the greatest known germicidal power. Chlorin forms the active constituent of Labarraque's solution, Javelle water, antiformin, ELECTRO-STERILIZATION 505 otherwise known as dental radicin, electrozone, or dental meditrina, and of the antiseptic solution so successfully employed at present in the English and French war hospitals according to Dakin's formula by the Carrel method, which latter preparation is now advertised abroad as eusol, and in our country in the form of a salt, as chlora- zene. The great success obtained with Dakin's solution rests pri- marily upon the fact that a fresh preparation according to a specific (Carrel) method is employed, which, while acting deleteriously on the germs, does little harm to the tissue cells, as it is a nonirritating isotonic wound antiseptic. All of these solutions have sporadically come to prominence in the past. While the laboratory reports, as far as the germicidal power of these solutions is concerned, appear to be highly satisfactory, practical application does not bear out the enthusiasm. It should be borne in mind that most of these preparations are irritating, and that chlorin solutions are labile compounds. All of these enumerated solutions lose their activity within a week or two,' hence the disappointing results when com- mercial stock preparations are employed. The rationale of sterilizing an infected wound surface by the Carrel method is based on the following conception: "To render an infected wound sterile it is necessary to employ a suitable anti- septic in such a manner that the chosen antiseptic comes into con- tact with every portion of the wound, that the antiseptic is main- tained in a suitable concentration throughout the entire wound, and that this constant strength is maintained for a prolonged period. If these conditions are fulfilled, every wound will show its response to the treatment by the diminution and disappearance of its micro-organisms." To the ionization of a 1 per cent sodium chlorid solution by means of the galvanic current within a root canal furnishes free chlorin in statu nascendi in the presence of moisture and body temperature which is most active, and admir- ably suited for our purposes. The free chlorin sterilizes the walls of the root canal (see below) and bleaches the discolored dentin. Incidentally, the ionization of the salt water furnishes an appre- ciable amount of hydrochloric acid which acts as a superficial sol- vent of tooth structure, and thereby enlarges the root canal. The two chemicals, according to Lehmann-Zierler, are present in the proportion of five parts chlorin to three parts of hydrochloric acid. The small quantities of sodium compound which are formed within 506 PHYSICAL THERAPEUTICS the vicinity of the negative pole are taken care of by the tissue fluids. EXPERIMENT: PRESENCE OF CHLORIN. Place the two poles upon a piece of filter paper moistened with a solution of indigo blue in sodium chlorid solution. Within a few minutes the blue color will disappear, due to the reducing (bleaching) effect of the liberated chlorin. Notice the odor of chlorin. Much importance has been attributed by some writers to the presence of ozone and nascent oxygen formed during the decomposition of sodium chlorid according to the equa- tion : H 2 -f- C1 2 = 2HC1 -{- 0. The presence of ozone could not be detected chemically. The small quantity of free oxygen may be considered a negligible factor as far as disinfectant action in this connection is concerned. Silver salt solutions, as has been definitely demonstrated by Bethel, or copper or mercury salt solutions, may be used for the purpose of sterilizing root canals in connection with the electric current. While these solutions, if one depends upon their metallic ions, are proportionately weaker than the chlorin ion obtained from a sodium chlorid solution, incidentally they al- ways discolor the tooth structure, and consequently offer no ad- vantage. Zinc chlorid solution, which seems to be largely em- ployed for such purposes, does not possess superior merits over the simple sodium chlorid solution; the active agent, free chlorin, ob- tained in both instances is the same. The ionized zinc of the zinc chlorid solution possesses no merits as an antiseptic agent. For dental purposes, a 1 per cent solution of sodium chlorid in water is best suited. Eoughly speaking, a scant teaspoonful of salt dissolved in a pint of boiled water answers the purpose. Electro-Sterilization Equation. In the various communications treating on root sterilization by electrolysis the very important questions concerning the time during which the current is applied, the number of milliamperes employed and bacteriologic tests of the resultant sterility are usually vaguely treated. To illustrate the author's contention the following extracts picked at random from recent publications on this subject are appended : ELECTRO-STERILIZATION 507 A perfect method of sterilizing root canals is to be found in ionic medi- cation. In a tortuous or constricted canal the application of two or three milliamperes of current for five or six minutes is sufficient to produce ions from a compound solution of antiseptic salts which will penetrate the length of the canal and sterilize it effectively. (Sturridge.) A current of three milliamperes for fifteen minutes, using zinc or iodin properly applied, will sterilize a root and surrounding tissue as no retained medication ordinarily accomplishes. (Frank Price.) A current of from two to three milliamperes is then passed for fifteen minutes. (Forbes Webster.) The Edison 110-volt current passing through a rheostat furnishes the power by means of which the zinc is decomposed and nascent chlorid of zinc forced through the end of the root, with the accompanying electric ions. This destroys the pathogenic tissue, and leaves an environment in which is is impossible for micro-organisms to exist. The electrolytic action is maintained for from three to fifteen minutes, depending on the extent of diseased tissue that is to be eradicated. The average strength of the current is about one milliampere. (M. L. Ehein, 1911.) From a careful perusal of the above quotations it will be seen that the strength of the current and the time for its application as stated are empiric suggestions. No proof is furnished concern- ing the resultant bacteriologic action of the electrolytic process, and as a consequence the term sterility as used by the authors cited is employed in a purely arbitrary manner. The process of electro- sterilization, therefore, would merely add another method of em- piric medication to the numberless procedures in existence unworthy of lengthy discussion, if it could not be definitely proved that it would furnish unquestionable evidence of obtaining the absolute sterility of an infected root canal. Fortunately such proofs are available, and the establishing of this fact at once places this pro- cedure far above any other known therapeutic measures employed for such purposes. When sterility of a primarily infected root canal is spoken of in the present light of bacteriologic knowledge, the truth of this as- sertion has to be proved by rigorous tests, otherwise the term ster- ility loses its significance. These tests are readily made by obtain- ing cultures at stated intervals from the canal under treatment until complete negative results of growth are obtained. Regard- ing the bacteriologic tests as applied to electro-sterilization, the au- thor proceeded as follows : Cultures of the infected root canal were made before treatment was instituted, and then every five minutes thereafter for a given period of time, usually twenty minutes. The infected agar plates were incubated in the routine manner (see PHYSICAL THERAPEUTICS below). Incidentally, the time of applying the current, and also its strength, were carefully noted. By comparing the results ob- tained, a definite relationship between the strength of the current, the time of application, and the resultant sterility could be estab- lished. Zierler deserves credit for having first noted the inter- relationship of these factors, and he has suggested the use of a Fig. 114. Fig. 115. (Mrs. A. B.) Lower right second bicus- (Mrs. A. B.) Same tooth as in Fig. 114. pid. Root canal is imperfectly filled. An Root canal received three treatments by area of disturbance is visible about the electro-sterilization; root-canal filled. For- apical tissues. Continuous gnawing pain, mer trouble has completely subsided. X- increased on pressure (mastication). X- ray taken Jan. 4, 1917. Again inspected ray taken May 16, 1916. Feb. 20, 1917; tooth in perfect condition. Fig. 116. Fig. 117. (Mrs. S. W.) Upper left first bicuspid. (Mrs. S. W.) Same tooth as in Fig. 116. Chronic pericementitis with abscessed area Root canal received three treatments by about the foramen; root canal filled with electro-sterilization. Root canal filled. X- pus. Continuous pain for over a week. ray taken January 12, 1917. On inspection X-ray taken July 10, 1916. no further trouble found. numerical constant which furnishes a working basis for its clinical application. This constant is 30. By multiplying the number of milliamperes employed by the time in minutes used in the process of obtaining a sterile root canal, invariably a number was obtained which closely hovered about the figure 30 ; or, reversely, by divid- ing the constant 30 by the number of milliamperes employed, a ELECTRO-STERILIZATION 509 quotient is obtained which gives the time in minutes during which the current must be applied. Apparently, a given infected surface area requires for its sterilization a specific amount of migrating ions; at least this assertion can be verified as far as the germi- cidal action of ionized chlorin is concerned in the sterilization of infected root canals. Hence the numerical constant 30 may be looked upon as expressing in units the surface area of an average root canal. In the author's experimental work and in clinical prac- tice he has based his observations upon the above principle, and has collected sufficient data as proofs that the appended electro- sterilization equation, as this formula has been termed, is a reliable guide for the application of these procedures in the treatment of 30 infected root canals : - = T, the 30 representing the numerical M.A. constant, M.A. the number of milliamperes, and T the time in minutes. The accompanying tables, selected from experimental records, will substantiate these claims. TABLE A. ELECTRO-STERILIZATION OF TEETH IN THE MOUTHS OF PATIENTS Patient Milliamperes Electrolyte 5 min. 10 min. 15 min. Constant No. 1 " 2 " 3 ' 4 " 5 0.5 2.5 3.0 3.5 1.5 1% sod. chl. solution + + + + + + + + + + 37^ 30 35 Growth +. No growth 0. The inoculated agar plates are incubated for 24 hours at 40 C. If the three constants are added which show sterility=102V2 and the total divided by the number of patients, the average con- stant will be 34, which in round figures may be reduced to 30. Various attempts were made to materially lower this constant, but so far (as regards sodium chlorid solution) have not been suc- cessful. The above experimental work furnishes sufficient proof, and this fact is borne out in clinical practice, that sterility of the walls of an infected root canal may be obtained by electro-sterilization. It should be borne in mind, however, that this particular type of steril- ization means sterility of the walls of the root canals only and not 510 PHYSICAL THERAPEUTICS TABLE B. ELECTRO-STERILIZATION OF EXTRACTED TEETH HAVING GANGRENOUS ROOT CANALS Teeth Milli- amperes Electrolyte 5 min. 10 min. 15 min. 25 min. Constant No. 1 0.5 l%sod.chl. solution + + + + " 2 1 " -j- -j- -)- 25 " 3 2 " -|- -(- 30 " 4 3 " -f 30 " 5 5 " 25 Growth +. No growth 0. The inoculated agar plates are incubated for 24 hours at 40 C. Total constants: 110:4 =27^ average constant. TABLE C. ELECTRO-STERILIZATION OF PLATED MIXED CULTURES OBTAINED FROM GANGRENOUS ROOT CANALS IN AGAR Plate Milliamperes Electrolyte 5 m\n. 10 min. 15 min. Constant No. 1 1 1% sod. chl. solution + + + " 2 2 " -|- -|- 30 " 3 3 " -|- 30 " 4 4 + 40 Growth +. No growth 0. The inoculated agar plates contain 1% sodium chlorid and are incubated for 24 hours at 40 C. Total constants: 100:3 =33j/ average constant. of the entire tooth root. To prove the correctness of this statement, which on its very face is self-evident, tooth roots Nos. 2, 3, and 4 of the experiments recorded in Table C were cut into coarse shavings, plated on agar, and placed in the incubator. In twenty-four hours all three plates showed luxuriant growth. Here will be emphasized again what has been stated in the past at frequent intervals : Com- plete sterilization of an infected tooth root in situ is impossible by any of the present known methods ; complete sterilization of the sur- face of an infected root canal is possible by electro-sterilization as outlined above. Clinical Application of Electro-Sterilization. To convey to the reader a practical working knowledge of the clinical application of the principles of electro-sterilization, it is probably best to describe the actual modus operandi in detail as em- ployed in a typical case. The patient being seated in the chair is covered by a rubber apron sufficiently large to reach over the chair arms, so as to protect him from accidental shock by "grounding" ELECTRO-STERILIZATION 511 the current. The root canal of the tooth to be treated must be me- chanically cleansed of its debris, and if necessary enlarged so as to give free access to the wire electrode. Before starting the ionizing process it is best to assure oneself of the correct working of the current by bringing the two poles together for a moment ; the mov- ing of the needle of the milliamperemeter in the right direction acts as an indicator that the apparatus is in working order. The rub- ber dam having been adjusted, the root canal is now flooded with a 1 per cent saline solution an S. S. W. minium syringe is useful for such purpose. The patient takes a firm hold of the negative elec- trode with his hand, which must not carry rings, bracelets, etc. Be- fore introducing the freshly flamed positive pole into the canal the operator should see for himself that the knife switch is open, and that the controller is set at zero. If the wire electrode fits the canal too loosely, a few fibers of cotton moistened with salt water are wrapped about it. The needle is introduced as near to the apex as possible, and the knife switch is closed. The controller is now very slowly turned on, and the patient is told to at once raise his hand when he feels the slightest sensation. The moving needle of the milliamperemeter will indicate to the operator that the current is flowing in the right direction. When the patient raises his hand the controller is turned very slightly back, left at this point for about half a minute, and again very slowly turned forward until the patient again responds, or until the point of tolerance is established. This point the writer has termed the "irritation point." A glance at the milliamperemeter conveys to the operator the number of mil- liamperes employed. The operator now recalls to his mind the nu- merical constant 30, and quickly calculates the time of his particular case of electro-sterilization by dividing thirty by the number of mil- liamperes employed. The resultant quotient gives the time in min- utes for which the current must be applied. Example : If patient's irritation point is 2.5 M.A., 12 minutes by the watch are required for the sterilization of this particular root canal. If the resultant quotient is a fraction, the writer recommends that the next higher unit be substituted as the indicator of the time. Each root canal of a multi-rooted tooth is preferably treated separately. If a clamp electrode holder is employed to clasp the two or three wires inserted into the multi-rooted tooth care should be exercised to prevent short- circuiting. To avoid polarization of the positive electrode, i. e., 512 PHYSICAL, THERAPEUTICS covering by a film of nascent gases which materially interferes with the flow of the current, the needle should be removed at five- minute intervals (turn off current previously!) and wiped off. During the process of electro-sterilization a drop of salt water should be added every few minutes to make up for loss by evaporation. Care must be exercised to prevent short-circuiting of the current by allowing salt water to seep under the rubber dam and thus transfer the current to the gum tissue. After finishing the operation the controller is slowly turned to zero, the knife switch is opened, and the electrode removed from the tooth. Never remove the electrode without having first cut off the current, otherwise the patient re- ceives a disagreeable shock or a flash of light passing in the eyes. On passing a few fibers of cotton or a paper cone in the root canal, a pronounced odor of chlorin should be perceptible. A wisp of cotton or a cone wet with salt water is placed into the root canal, and the latter is closed with gutta-percha stopping. The treatment is to be repeated within forty-eight hours, and if necessary again on the fifth day, and the canal is immediately filled after the last treatment. A root canal should never be filled immediately after the initial treat- ment; an interval of at least twenty-four hours should be allowed before doing so. Migrating ions do not develop their maximum de- gree of therapeutic efficiency within the short period of time during which the current is applied. It requires practically twenty-four hours to produce their full activity within the region of a root canal and its surroundings. The clinical indications of complete sterility are definite odor of chlorin and a clean paper or cotton cone after forty-eight hours' insertion. In doubtful cases sterility should be verified by a bacteriologic test. If a metal filling is pres- ent in the tooth under treatment, it should be removed, because if touched by the electrode after the current is turned on it may be short-circuited through the filling, and the patient will receive a shock. Moreover, the action of the chlorin ions upon the metals of the filling materials results in the formation of metallic chlorids, which infiltrate the dentin structure, producing discoloration. This is particularly true in the case of gold chlorid thus formed, which by secondary decomposition stains the tooth structure a deep purple tint. When the products of pulp decomposition pass beyond the fora- men of a tooth, localized pathologic disturbances of the pericemen- ELECTRO-STERILIZATION 513 turn arise, which usually lead to the formation of an abscess. With- out entering into the further discussion of the pathology of the dis- turbances at this moment, let us assume that the disturbances are eradicated by establishing drainage along the lines of least resist- ance. If the drainage takes place through the root canal, this con- dition is spoken of, although wrongly, as a blind abscess, while if the drainage occurs through an artificially established canal through the bone and gum tissue a fistula results. Acute types of the enumerated disturbances yield readily to electro-sterilization, pro- vided the salt solution and the positive electrode reach the seat of the infection. For the treatment of an abscess drainage through the root canal the positive electrode is thrust through the foramen into the abscess cavity ; the treatment of an abscess with a fistula requires a somewhat modified application. In the latter case complete com- munication between the root canal and the mouth of the fistula must be first established by forcing warm salt water through the canal. The root canal is now treated as outlined above; the fistula itself requires a separate application of the procedure. The positive elec- trode is passed into the fistula, entering at its outlet and carried along the fistulous tract until the root is felt, while the negative pole, consisting of a piece of copper wire surrounded by salt water, is placed in the root canal. The sterilization equation for this treat- ment is the same as already outlined. Usually the patient re- quires a lower milliamperage for such work. All types of chronic abscesses will yield to this method of treatment, provided the ne- crotic area involved is very small, and that the seat of disturbance is reached by the electrode and by the salt water. Well defined granu- lomata, complicated by large areas of necrosis are not benefited by electro-sterilization ; they require surgical interference as the last resort. Root amputation is indicated for such purposes, and if carried out according to special technical methods, usually pro- duces most satisfactory results. PART IV LOCAL ANESTHESIA HISTORY. The elimination of pain during surgical operations is insepa- rably interwoven with the history of the human race. It has always been the aim of those interested in the cure of bodily ills to relieve pain in some empirical manner. The efforts to solve the riddle of painless operations were, however, seemingly so very futile that even as late as 1832 Velpeau was led to express his pessimism as follows: "To escape pain in surgical operations is a chimera, which we are not permitted to look for in our time." Little did he expect that he stood at the very threshold of the discovery of anesthesia, and that less than a decade later the "nirvana" of painless operations would be an accomplished fact. And when Dieffenbach, in 1847, wrote those classical words re- garding the use of ether as an anesthetic, "the beautiful dream, to eliminate pain, has become a fact pain, the highest conscious- ness of our earthly existence, its clearest conception of the im- perfections of our body, it has to bow low before the powers of the hum^an mind," the world at large awakened to the fact that pain had been conquered. The discovery of anesthesia is essentially to be credited to the dental and medical profession of the United States, and the names of Crawford W. Long, Horace Wells, William P. G. Morton, and Charles F. Jackson are inseparably connected with it. "If America has contributed nothing more to the stock of human happiness than anesthetics, the world would owe her an everlasting debt of gratitude," said the late Samuel D. Gross, the eminent surgeon, who had ample opportunity to observe in his own operating room the most remarkable changes that followed the introduction of anesthetics. From an historical viewpoint, comparatively few important 514 HISTORY 515 methods for the purpose of locally obtunding pain are to be recorded prior to the introduction of cocain. The compression of nerve trunks for the abolition of pain seems to be of an old and unknown origin, which was revived by Guy du Chauliac and Ambroise Pare, and finally found a permanent place in surgery as the Esmarch elastic bandage. Physically reducing the tem- perature of a part of the body by the application of cold was instituted much later. Bartholin and Severino introduced this xnethod in the middle of the sixteenth century. It became a lost art, however, until John Hunter, of London, again called attention to its benefits by demonstrating it upon animals, yet the idea never seems to have occurred to him that the same agent might be useful in abolishing human suffering, and Larrey, the chief surgeon of Napoleon's army, employed it for amputating pur- poses (1807). James Arnott, in 1848, utilized a freezing mixture, consisting of ice and salt, as a means of producing local anesthesia. Through the efforts of Sir B. W. Richardson, in 1866, it was placed on a rational basis by the introduction of the ether spray. The various narcotics which were employed for internal purposes were also made use of as local applications. Mandragora, henbane, aconite, the juice of the poppy head, and many other analgesic drugs enjoyed a world- wide reputation. There is probably no other medicinal plant around which clusters more mysterious and quaint associations than mandragora. It should be remembered, however, that mandrake, or mandragora (atropa mandragora), must not be confounded with American mandrake, or may apple (podophyllum peltatum), to which it bears no relation. Probably the oldest known dental prescription that was used for the purpose of abolishing pain arising from an aching tooth is recorded upon a clay tablet that was found in Niffer, and its age may be approximately placed at 2250 B. C. Recent excavations that have been made near Niffer and Babylon have brought to light valuable information regarding the practice of medicine under Hammurabi, king of Babylon, a contemporary of Abraham. The clay tablet is written in the Babylonian tongue, which was the official language of diplomatic intercourse from the Euphrates to the Nile. The contents of this tablet refer to the "worm" theory of dental caries, and the treatment consists in filling the painful cavity of the tooth with a cement prepared by mixing 516 LOCAL ANESTHESIA powdered henbane seed with gum mastic. While filling the "up- per part of the tooth" suitable incantations were recited. It is interesting to observe that the physiologic conception of this text is humoral (hematic), and that the health of the teeth is depend- ent upon the circulation within the tooth substance. 1 In Egypt the suet of the crocodile, locally applied, was believed to relieve pain, and Pliny refers casually to the mystic Lapis Mempliitis, the stone of Memphis, which, when rubbed on the surface of the skin in conjunction with sour wine, was said to produce local anes- thetic effects. Nepenthe, a preparation of purified opium, was much praised by the Greeks. Alcohol, in its various forms, always enjoyed a wide reputation as a pain reliever, and seems to be as old as the world's history. In an early Cymric manuscript, said to have been compiled by Howell, the physician, who w T as the son of Rhyr and a lineal descendant of Einion, and which was probably written about the end of the fifteenth century, among a large number of conjectures we find the following: "How to extract a tooth without pain: Take some newts, by some called lizards, and those nasty beetles which are found in ferns in the summer time. Calcine them in an iron pot, and make a powder thereof. Wet the forefinger of the right hand, and insert it in the powder, and apply it to the tooth frequently, refraining from spitting it off, when the tooth will fall away without pain. It is proven." 2 During the middle ages the following mixture, as recorded by Cardow, was frequently used as a local anodyne in the form of an ointment: "Opium, celandine, saffron marrow and fat of man, together with oil of lizards." The "Herbals" (books on vegetable remedies), of the sixteenth and seventeenth centuries contain innumerable compounds which are recommended as spe- cific dental remedies. The empirical search for new methods and means pressed the mysticism of the electric current into service, opening a prolific field to the charlatan, which even to this day has not lost its charm. Richardson's voltaic narcotism for a time attracted the attention of the medical and dental profession. Its inventor claimed "that by the action of a galvanic current, passing through a narcotic solution, held in contact with the part to be operated 1 Von Oeffele: Mitteilungen zur Geschichte der Medizin, etc., 1904. 3 Hermann Peters: Der Ant und die Ilelllmnst, 1900, HISTORY 517 upon, some of the narcotic substance passed much more rapidly into the tissue, and that in many instances complete local anes- thesia was in this way produced by solutions which are entirely inert when applied, even to the most delicate tissue, without the galvanic current." This very same principle, discovered by Reuss in 1807, and introduced by him as "electric endosmosis," or as " cataphoresis " by E. du Bois-Raymond, was "newly dis- covered ' ' and reintroduced into dentistry about two decades ago. In cyclonic fashion it swept over the globe, but today it is almost forgotten. Electric or galvanic anesthesia was suggested as far back as 1851 by A. Hill, 1 of Connecticut. Francis, 2 in 1858, recommended the attachment of the electric current to the well- insulated handles of the forceps for the painless extraction of the teeth, and, as dental depots still offer appliances of this na- ture for sale, it seems that this method is still in vogue with some operators. According to Regner and Didsbury, as cited by Sauvez, 3 a current of electricity of high frequency, when directed toward the long axis of a tooth for a shorter or longer period previous to its extraction, produces insensibility to pain. In 1880 Bonwill 4 suggested his method of "rapid breathing as a pain ob- tunder," which he claimed "produces a similar effect to that of ether, chloroform, and nitrous oxid gas in their primary stages." In the early days of modern dentistry many feeble efforts were made to alleviate pain during trying operations. Chloroform, alcohol, ether, aconite, opium, the essential oils, and many other drugs were the usual means that were employed, either separately or as compounds, usually under fanciful names, for such pur- poses. Snape's calorific fluid, composed of chloroform, tincture of lemon balm, and oil of cloves; nalyolis, consisting of gly- cerite of tannic acid and a small quantity of chloral hydrate ; Mor- ton 's leiheon, which was sulphuric ether mixed with aromatic oils, are examples of proprietary preparations which enjoyed quite a reputation in their time. 5 In 1844, F. Rynd, an Irish surgeon, introduced a method of general medication by means of hypo- dermic injections, which, in 1853, was much improved by Alex- iHill: New York Dental Record, Vol. VI, p. 145. 2 Francis: American Journal of Dental Science, 2d Series, Vol. VIII, p. 433. 'Sauvez: A Study of the Best Means of Local Anesthesia, Paris, 1904. 4 Bonwill: American System of Dentistry, Vol. Ill, p. 213. * Flagg-Foulks: Dental Pathology, etc., 1885, p. 110. 518 LOCAL ANESTHESIA ander Wood, of Edinburgh, and a few years later the French sur- geon Pravaz modified the old style syringe for this special purpose, which since is known as the "Pravaz" or hypodermic syringe. At once it was suggested to apply such drugs as morphin or tinc- ture of opium for the purpose of producing local anesthesia. The results were not encouraging, however, until cocain was advocated. Cocain was discovered by Niemann in 1859, but it required twenty-five years to make known the remarkable anesthetic prop- erties which this alkaloid possessed when applied in the ready soluble form of its hydrochloric salt. It was on September 15. 1884, that Carl Roller, 1 of Vienna, had presented his epoch-making communication at the Ophthalmologic Congress at Heidelberg, in which he demonstrated the effects of cocain as a local anesthetic. With the introduction of this drug into therapeutics, local anes- thesia achieved results which were beyond expectations, and its final adoption created a new era in local anesthesia. MEANS OF PRODUCING LOCAL ANESTHESIA. The term anesthesia (without sensation), which was suggested in 1846 by that great physician-litterateur, Oliver Wendell Holmes, to Dr. Morton, is usually defined as an artificial depriva- tion of all sense of sensation, while the mere absence of pain is referred to as analgesia. Correctly speaking, the term local anes- thesia is partially a misnomer. In producing local anesthesia we do not fully comply with all the requirements that anesthesia demands, because a part of the sensorium the sense of touch and that of temperature, for instance is not fully abolished. Analgesia, i.e., loss of sensibility to pain or absence of pain, would be a better term. The term local anesthesia has, however, ac- quired such universal recognition that it would seem unwise to recommend a change. Anesthesia may be artificially produced by inhibiting the sensory nerve fibers at their central end-organs in the brain or at their peripheral end-organs in the tissues, thus producing gen- eral and local anesthesia. Local anesthesia may be obtained in two definite ways: We may inhibit the function of the peripheral nerves in a circumscribed area of tissue, and we refer to this 1 Roller: 16th Ophthalmologenkongress, Heidelberg, 1884. MEANS OF PRODUCING LOCAL ANESTHESIA 519 process as "terminal anesthesia," while, if we block the conduc- tivity of a sensory nerve trunk somewhere between the brain and the periphery, we speak of it as "conduction anesthesia." Dental terminal anesthesia is usually produced by a subperiosteal injec- tion (indirect anesthetization) or a peridental injection (direct anesthetization) while conduction anesthesia may be produced by injecting into the nerve trunk proper endoneural injection or by injecting into the tissues surrounding a nerve trunk peri- neural injection. The latter form is the usual method pursued when conduction anesthesia for dental purposes is indicated. Local Anesthesia Terminal anesthesia Conduction anesthesia Subperiosteal Peridental Endoneural Perineural injection injection injection injection The successful practice of local anesthesia involves the care- fully adjusted cooperation of a number of important details, each one constituting a definite feature in itself, which, when neglected, must necessarily result in failure. As a whole, the practice of local anesthesia by the hypodermic method represents the composite of the following factors: 1. A sterile solution of drugs possessing active anesthetic potencies and which, in their Composition, must correspond to the physical and physiologic laws which govern certain functions of the living cell. 2. A carefully selected sterile hypodermic armamentarium. 3. A complete mastery of the technique. 4. A proper selection of the correct methods of injection suit- able for the case on hand. 5. Suitable preparation of the site of injection. 6. The complete cooperation of the patient. 7. Good judgment of prevailing conditions. PHYSIOLOGIC ACTION OF ANESTHETICS. According to more recent therapeutic conceptions, it is gen- erally recognized that a drug or combination of drugs which si- 520 LOCAL ANESTHESIA multaneously produce local anemia and inhibition of the sensory nerves in a circumscribed area of tissue is the logical solution of the question of local anesthesia. Certain important factors, how- ever, relative to the physiologic and physical action of the solu- tion employed for hypodermic injection upon the cell govern the successful application of such methods. It is of prime impor- tance, therefore, to comply with the laws regulating the absorp- tion of injected solutions osmotic pressure. If we separate two solutions of salt of different concentration by a permeable animal membrane, a continuous current of salt and water results, which ceases only after equalization of the density of the two liquids that is, equal osmotic pressure (ac- cording to the Boyle- Van 't Hoff law) is established. The current passes in both directions, drawing salt from the stronger to the Plasmolysis of cells of Tradescantia Discolor. (Hugo de Vries.) a, normal cell; b, beginning plasmolysis; c, pronounced plasmolysis. weaker solution, and water vice versa, until osmotic equilibrium is obtained. The resultant solutions are termed, according to De Vries, 1 isotonic. The latter studied these conditions carefully with plants, especially with the leaves of tradescantia discolor. If the leaves of this plant are placed in a fairly concentrated salt solution, water is removed from the cells until the osmotic pressure of the cell contents and the surrounding fluid are equal- ized. The volume of the cell is reduced, the cell protoplasm draws away from the cell wall, usually starting in the corners, 1 De Vries: Wissenschattliche Botanik (Jahrbiicher), 1884. PHYSIOLOGIC ACTION OF ANESTHETICS 521 until it is attached only by a few strands to the framework. This process is called by De Vries plasmolysis. Osmotic pressure is a physical phenomenon possessed by water and all aqueous solutions, and is dependent on the number of molecules of salt present in the solution and on their power of dissociation. In organized nature these osmotic interchanges play an important factor in regulating the tissue fluids of both ani- mals and plants. The life of the cell depends on the continuous passage of these tissue fluids, which furnish the nutrient mate- rials, consisting of water, salt, and albumin. These chemicals are normally present in certain definite proportions. The membrane of the living cell is, however, only semi-permeable that is, the cell readily absorbs distilled water when surrounded by it. The cell becomes macerated, loses its normal structure, and finally dies. If, on the other hand, the surrounding fluid be a highly concentrated salt solution, the solution absorbs Avater from the cell only, and no salt molecules enter into the cell body proper. The cell contracts and finally dies. This process of cell death is in general pathology referred to as necrobiosis. Another im- portant factor teaches that all aqueous solutions that are isotonic possess the same freezing point that is, all solutions possessing an equal freezing point are equimolecular, and possess equal osmotic pressure. This law of physical chemistry has materially simplified the preparation of such solutions. The freezing point of human blood, lymph, serum, etc., has been found to equal ap- proximately 0.55 C., which in turn corresponds to a 0.85 per cent sodium chlorid solution. Such a solution is termed a physio- logic salt solution. In the older works on physiology a 0.6 per cent sodium chlorid solution is referred to as a physiologic salt solu- tion, and corresponds to the density of the blood of the frog. A slight deviation above and below the normal percentage of the solid constituents is permissible. When physiologic salt solution at body temperature is injected into the loose connective tissues under the skin in moderate quantities, neither swelling nor shrinking of the cell occurs. A simple wheal is formed, which soon disappears, and, as no irritation results, consequently no ap- preciable pain is felt. Other similar bodies that are equally solu- ble in water act in the same manner, with the exception of the salts of the alkali and alkaline earth metals as potassium or 522 LOCAL ANESTHESIA sodium bromid. The latter substances produce intense physical irritation, followed, however, by prolonged anesthesia, and in consequence are termed by Liebreich painful anesthetics. If, on the other hand, simple distilled water is injected, only a superficial anesthesia is produced; the injection itself is painful, and acts as a direct protoplasm poison by maceration of the cell contents, which results in the death of the cell. If distilled water ap- proximately at a ratio of 10 drams to the pound of body weight is injected into dogs, they will succumb in a short time. The in- jection of higher concentrated salt solutions produces opposite ef- fects; water is removed from the tissues with more or less pro- nounced pain, and followed by superficial anesthesia. Severe tis- sue disturbances result, which may terminate in necrosis. Hypo- tonic solutions solutions containing less than 0.9 per cent of sodium chlorid cause swelling of the tissue, while hypertonic WflS A B C Fig. 119. Diagrams showing the effect upon human red blood corpuscles of (A) isotonic, (B) hypotonic, and (C) hypertonic solutions. solutions solutions containing more than 0.9 per cent of sodium chlorid produce shrinkage. These manifestations are propor- tionately the more intense the further the solution is removed from the freezing point of the blood. Furthermore, hypotonic as well as hypertonic solutions require much more time for their absorption than isotonic solutions, as the osmotic pressure has to be standardized to the surrounding fluids that is, to the isotonic index of the tissue fluids. Kecent dental literature is replete with suggestions relative to the preparation of a physiologic salt solution intended as a base for anesthetic solutions. Numerous "new" and "improved" distilling apparatus are recommended and great emphasis is laid on a special distilled water for such purposes. The object of pre- paring a solution which in its physico-chemic relationship cor- responds to the tonicity of the fluids of the body is not to disturb PHYSIOLOGIC ACTION OF ANESTHETICS 523 the surface tension of the surface colloids of the exposed cells. The coagulative and liquefactive forces at the cell surface should be so compensated as to remain physiologically normal, i.e., to preserve the vital equilibrium. J. Loeb has shown that sea-water possesses these qualities to the highest degree. Einger and Locke have empirically suggested artificial substitutes. These solutions usually contain very small quantities of calcium and potassium chlorid in addition to the sodium chlorid. The claims as made for the great advantage of such solutions for local anesthetic pur- poses are wholly ephemeral. The minute quantities of the calcium and potassium ions present in the few cubic centimeters which constitute the average injection for dental purposes is too small Fig. 120. Contraction of the heart of a frog. 1, Effect of distilled water; 2, Contraction restored by normal saline solution; 3, Effect of distilled water again applied to the heart; 4, Con- traction restored a second time by normal saline solution. (After Pembrey and Phillips.) to be of any traceable influence on the involved cell structure. In general surgery frequently 200 and more cubic centimeters of physiologic salt solution are injected without ill results. Relative to the use of distilled water decidedly less emphasis should be placed on the stilling process as on the fact to use a boiled, i.e., sterile water. ' ' In practical medicine and surgery normal tap-water saline solution, which has been previously sterilized by boiling, is the most suitable fluid for transfusions, washing out the peritoneal cavity, and in some cases cleaning the cavities of wounds." 1 Pembrey and Phillips: The Physiologic Action of Drugs, London, 1901. 524 LOCAL ANESTHESIA Local anemia, or ischemia a temporary constriction of circu- lation prevents, as it has been experimentally shown, the rapid absorption of fluids that are injected into the affected area. Re- tarded absorption of the injected fluid, holding poisonous drugs in solution, means increased action of these poisonous drugs within the injected area. Increased action denotes increased consumption of the poisonous drugs, and, as a consequence, there is less danger from general absorption. The more important means applied for the purpose of producing local anemia are: 1. The Esmarch elastic bandage. 2. The application of cold. 3. The extract of the suprarenal capsule, or its synthetic sub- stitutes. Some observers have maintained that local anemia produces anesthesia. This is not the case ; it is merely an important means to confine the injected anesthetic to the anemic region, and thus bring about an increased and prolonged action of the drug. Con- sequently the concentration of the anesthetic solution may be of a lower percentage, which, of course, lessens the danger of in- toxication. For plausible reasons the Esmarch elastic bandage can not be made use of for dental operations. Physically reducing the temperature of the body by the appli- cation of cold (ice pack, ice and salt mixture, cold metals, etc.) was practiced by the older surgeons. Arnott, in 1848, and Blum- dell, in 1855, advocated ice packs for the painless extraction of teeth. Through the efforts of Sir B. W. Richardson, in 1866, this method was placed on a rational basis by the introduction of his ether spray. To obtain good results, a pure ether (boiling point 95 F., 35 C.), free from water, is necessary. Certain other hydrocarbons possess similar properties in varying degrees, depending on their individual boiling point. In 1867 Rotten- stein called attention to the use of ethyl chlorid as a refrigerating agent, and Rhein, in 1889, introduced methyl chlorid for the same purpose. In 1891 Redard reintroduced ethyl chlorid as a local anesthetic, which since has become known by many trade names as antidolorine, kelene, narcotile, etc. and mixtures of the first two in various proportions, known as anestol, anestile, coryl, metethyl, etc., are extensively used in minor oral and general sur- gery. A pure ethyl chlorid (boiling point 55 F., 13 C.) is best PHYSIOLOGIC ACTION OP ANESTHETICS 525 suited for this purpose, as it lowers the temperature of the tissues sufficiently to produce a short superficial anesthesia in a few min- utes. Too rapid cooling or prolonged freezing by methyl chlorid (boiling point 12 F., 24.5 C.), or the various mixtures there- of, produce deeper anesthesia, but such procedures are dangerous. They frequently cut off circulation in the affected part so com- pletely as to produce sloughing (necrosis). Liquid nitrous oxid, liquid or solid carbon dioxid (recently known as carbonic acid snow), and liquid air, all of which have a boiling point far below zero, are recommended for similar purposes, but they require cum- bersome apparatus and some of these agents are extremely dan- gerous to use. Ethyl Chlorid and Its Administration. ETHYL CHLORID. Monochlorethane ; hydrochloric ether, C H g Cl. "A haloid derivative, prepared by the action of hydrochloric acid gas on absolute alcohol." At normal temperature, ethyl chlorid Fig. 121. Ethyl chlorid spray tube (glass). is a gas, and under a pressure of two atmospheres it condenses to a colorless, mobile, very volatile liquid, having a characteristic, rather agreeable, odor and burning taste. It boils at about 55 F. (13 C.), and is very inflammable, burning with a smoky, green- edged flame. It is stored in sealed glass or metal tubes, and when liberated at ordinary room temperature (70 F., 21 C.) it evap- orates at once. In commerce it is supplied in plain or graduated glass tubes of from 3 to 60 grams capacity, or stored in metal cyl- inders holding from 60 to 100 grams or more- To remove the ethyl chlorid from the hermetically sealed smaller tubes, the neck 526 LOCAL ANESTHESIA has to be broken off, while the larger glass and metal tubes are provided with suitable stop cocks of various designs to allow def- inite amounts of the liquid to be released. MODE OF APPLICATION. For the extraction of teeth, immediate removal of the pulp, opening of abscesses, and other minor opera- tions about the oral cavity, the tube should be warmed to body temperature by placing it in heated water, and its capillary end should be held about six to ten inches from the field of operations. The distance depends on the size of the orifice of the nozzle, and complete vaporization should always be produced. The Gebauer tube is fitted with a spray nozzle, which shortens the distance to one to two inches, and is especially well adapted for dental pur- poses. The stream is directed upon the tissues until the latter Fig. 122. Ethyl chlorid spray tube (metal). are covered with ice crystals and have turned white. For the ex- traction of teeth the liquid should be projected directly upon the surface of the gum, as near to the apex of the root as possible, but care should be taken to protect the crown of the tooth on ac- count of the painful action of cold on this part. Tissues to be anesthetized should first be dried and well surrounded by a film of vaselin or glycerin, and protected by cotton rolls and napkins, to prevent the liquid from running into the throat. Let the pa- tient breathe through the nose. Occasionally light forms of gen- eral anesthesia are induced by inhaling the vapor. On account of the difficulty of directing the stream of ethyl chlorid upon the tissues in the posterior part of the mouth, it is not successfully ap- plied in those regions. The intense pain produced by the extreme cold prohibits its use in pulpitis and acute pericementitis. To anesthetize the second and third branch of the fifth nerve, it is recommended to direct the stream of ethyl chlorid upon the cheek PHYSIOLOGIC ACTION OF ANESTHETICS 527 in front of the tragus of the ear, but the author has not seen any good results from such a procedure. Caution should be exercised in using ethyl chlorid near an open flame or in conjunction with the thermo-cautery, as severe burns have resulted by setting the inflammable vapor on fire. . Fig. 123. Application of the ethyl chlorid spray. The Active Principle of the Suprarenal Capsule and its Synthetic Substitutes. Within the last decades the active principle of the suprarenal capsule has evoked extensive comments in therapeutic literature. It has been isolated by a number of investigators under different names, as epinephrin by Abel (1897), suprarenin by Fuerth (1898), and adrenalin by Takamine and Aldrich (1901). Many other 528 LOCAL, ANESTHESIA titles are given to this alkaloid as adnephrin, adrin, paraiiephrin, suprarenalin, hemostasin, epinin, etc. Epinephrin is a grayish- white powder, slightly alkaline in reaction, and perfectly stable in dry form. It is sparingly soluble in cold and more soluble in hot water, is insoluble in ether or alcohol, and with acids it readily forms soluble salts. The preparation that is employed mostly for therapeutic purposes is a 1:1,000 solution of epmephrin hydro- chlorid in a physiologic salt solution, to which preservatives as small quantities of chloretone, thymol, etc. are added. Alkali of any kind is especially destructive to this sensitive alkaloid; even the small quantities of free alkali present in ordinary glass are dangerous. Bottles intended for storing epinephrin solutions should be made of amber-colored alkali-free or Jena glass or bottles of ordinary glass should be immersed in a diluted solution of hy- drochloric acid for a few days and then thoroughly washed in run- ning water before they are used. Epinephrin solutions do not keep well. On exposure to air and to light they are easily decom- posed, becoming pink, then red, and finally brown, and with this change of color their physiologic property is proportionally de- stroyed. If the epinephrin solution be further diluted, it often becomes practically worthless within a few hours. When epinephrin is injected into the tissues, even in extremely small doses, it temporarily raises the arterial blood pressure, act- ing as a powerful vaso-constrictor by stimulating the smooth mus- cular coat of the blood vessels, and thus produces local anemia. Large doses finally reduce the blood pressure, and heart failure results. The respiration at first quickly increases, but slows down and finally stops with expiration. Its action is largely confined to the smooth muscle fibers of the peripheral vessels. Epinephrin is destroyed by the living tissue cells, the body ridding itself of the poison in some unknown manner. While epinephrin does not possess local anesthetic action, it increases very markedly the effect of certain anesthetics when combined with them. These observa- tions are of vast importance in connection with the production of local anesthesia. Carpenter. 1 Peters. 2 Moller, 3 and others referred to the use of adrenalin in this respect, and finally Braun, 4 in 1902, 1 Carpenter: Dental Review, 1901, No. 6. 1 Peters: British Journal of Dental Science, 1902. *- Moller: Deutsche Monatsschrift fur Zahnheilkunde, 1902, No. 9. 4 Braun: Archiv fur Klinische Chirurgie, 1902, p. 69. PHYSIOLOGIC ACTION OF ANESTHETICS 529 published his classic researches, and to him and his coworkers, specially Heinze and Lawen, 1 belongs the credit of establishing a rational basis for the production of local anesthesia. It is claimed that secondary hemorrhage frequently occurs after the anemia produced by the epinephrin has subsided, and that the tissues themselves suffer from the poisoning effects of the drug, resulting in necrosis. Such results are produced only by the injection of too large quantities of the drug, which by their deeper action close up the larger arteries. The prolonged anemia will give way to ;i dilatation of the blood vessels, and, if the tissues are too long deprived of the circulation, we are able to understand why slough- ing may result. Small doses of epinephrin have no effect upon the tissues or on the healing of a wound. Palpitation of the heart and muscular tremor, which were occasionally noticed in the early period of the use of the drug, are the direct result of too large doses. Recently a synthetic epinephrin has been successfully pre- pared by Stolz, 2 which, with hydrochloric acid, forms a stable and readily soluble salt. It is marketed by the Farbwerke-Hoechst Company, of New York, as synthetic suprarenin hydrochlorid. The new chemical has been carefully tested physiologically and in clini- cal work, and the general consensus of opinion points to the fact that it is not alone equal, but in certain respects superior, to the organo preparations. Synthetic suprarenin solutions may be readily sterilized by boiling. They are relatively stable, and their chemic purity insures uniform results. They are comparatively free from dangerous side actions. Our own observations regarding the value of synthetic suprarenin relative to its actions and its general be- havior is in full accordance with the above statements, and its advantages over the organo preparations has led us to adopt it ex- clusively as a component in the preparation of local anesthetic solu- tions. For dental purposes that is, for injecting into the gum tissue the dose may be limited to one drop of the epinephrin solu- tion (1 :1,000) or the synthetic suprarenin solution (1 :1,000) added to each cubic centimeter of the anesthetic solution, five drops being approximately the maximum dose to be injected at one time. The dosage of the relative amounts of epinephrin solution may be arranged as follows: 1 Lawen: Archiv fiir- Kxperimentale Pathologic, 1904, Vol. II. 'Stolz: Bericht tier Chemischen Gesellschaft, 1904, p. 4149. 530 LOCAL ANESTHESIA Add 1 drop of epinephrin to 1 C.c. of the novocain solution. " 2 drops " " " 3 " " " " " it 3 tf lt (i lt 5 " " " '' '' ii ^ it (( ii tc g d tt ti " 5 " " " " 10 or more C.c. of the novocain solution. LOCAL ANESTHETICS. Ever since the introduction of cocain into materia medica for the purpose of producing local anesthesia, quite a number of sub- stitutes have been placed before the profession, for which superi- ority in one respect or another is claimed over the original cocain. The more prominent members of this group are tropa-cocain, the eucains, acoin, nirvanin, alypin, stovain, novocain, and quinin and urea hydrochlorid. 1 None of these compounds, with the ex- ception of novocain, has proven satisfactory for the purpose in view. The classic researches of Braun have established certain facts which are essential as regards the therapeutic value of a local anesthetic. The principal properties of a modern local anes- thetic must correspond to the following claims: 1. In comparison with its local anesthetic value, it must be less toxic than cocain, and the difference of toxicity must be ab- solute that is, the quantity of the chemical necessary to produce the same anesthetic effect as a definite quantity of cocain must be less toxic to the amount of body weight. 2. The chemical must be absolutely indifferent to the tissues when injected in more or less concentrated solution, and the prog- ress of wound healing must not be interfered with by the solution. 3. The chemical must be readily soluble in water, the solution must be comparatively stable, and it should be possible to sterilize it by simple means. 4. The chemical must be tolerant to the additions of epinephrin without interfering with the vaso-constrictor power of the latter drug. 5. When applied to mucous surfaces, ready penetration of the chemical is necessarj^. There is at this moment no need to enter into the pharmaco- logic action of the drugs usually classified as local anesthetics. (See pages 309. et alt.} Let it suffice to state how the above-men- 1 The materia medica of local anesthetics is more fully discussed on pages 312, et alt. LOCAL ANESTHETICS 531 tioned chemicals fulfill the demands of Braun. Tropa-cocain is less poisonous, but also less active, than cocain, and completely destroys the action of epinephrin. The eucains partially destroy the action, and are, comparatively speaking, equally as poisonous as cocain. Acoin is irritating to the tissues, and much more poi- sonous than cocain. Nirvanin possesses little anesthetic value. Alypin and stovain are closely related, and when injected they produce severe pain and occasionally necrosis. This is equally true of quinin and urea hydrochlorid. Novocain fully corre- sponds to every one of the above claims ; its toxicity is about six to seven times less than cocain; it does not irritate in the slightest degree when injected, and consequently no pain is felt from its injections, per se; it is soluble in its own weight of water; it will combine with epinephrin in any proportion without interfering with the physiologic action of the latter, and is readily absorbed by the mucous membranes. The studies of Biberfeld 1 and Braun brought to light another extremely interesting factor concerning the novocain-epinephrin combination. Both experimenters, working independent of each other, observed that the epinephrin anemia on the one hand and the novocain anesthesia on the other hand were markedly in- creased in their total effect on the tissues. Consequently a smaller quantity of this most happy combination is required to produce the same therapeutic effect than a larger dose of each drug alone would produce when injected separately; besides, the injection of a solution of the combined drugs is confined precisely to the in- jected area. The relative toxicity of a given quantity of cocain solution de- pends on the concentration of the solution. Reclus 2 and others have clearly demonstrated that a fixed quantity of cocain in a 5 to 10 per cent solution is almost equally as poisonous as five times the same quantity in a 1/5 per cent solution. From the ex- tensive literature on the subject we are safe in fixing the strength of the solution for dental purposes at 1 per cent. This quantity of cocain raises the freezing point of distilled water just a little above 0.1 C. To obtain an isotonic solution corresponding to the freezing point of the blood, 0.8 per cent of sodium chlorid must 1 Biberfeld: Medizinische Klinik, 1905, No. 48. * Reclus: I/Anesthesie Locale par la Cocaine, 1905. 532 LOCAL ANESTHESIA be added. Having thus prepared a cocain solution which is equal to the blood in its osmotic pressure on the cell wall, it is now neces- sary to aid the slightly vaso-constrictor power of the drug by the addition of a moderate quantity of epinephrin, thus increasing the confinement of the solution to the injected area by producing a deeper anemia, for a two-fold purpose first, to act as a means of increasing the anesthetic effect of cocain, and, second, to lessen its toxicity upon the general system by slower absorption. As stated above, one drop of epinephrin added to one cubic centimeter of the isotonic cocain solution is sufficient to produce the desired effect. A suitable solution for dental purposes may be prepared as follows : Cocain hydrochloric! 5 grains (0.3 Gm.). Sodium chlorid 4 grains (0.25 Gm.). Sterile water 1 fluidounce (30 C.c.). To each cubic centimeter add one drop of epinephrin when used. As stated above, the relative toxicity of a given quantity of co- caiii in solution depends on its concentration, but this peculiarity is not shared by novocain. The dose of iiovocain may be safely fixed at one-third of a grain for a single injection. For dental pur- poses a 11/2 per cent solution is preferably employed, and as much as three grains of a iy 2 per cent solution in combination with epinephrin have been injected without any ill results. For the purpose of confining the injected novocain to a given area, the ad- dition of epinephrin in small doses on account of its powerful vaso- constrictor action is admirably adapted. It is the important factor which prevents the ready absorption of both drugs. An in- jection of 15 drops of a simple l ] /2 per cent solution of novocain labially into the gum tissue produces a diffuse anesthesia, lasting approximately twenty minutes; the same quantity with the addi- tion of one drop of epinephrin increases the anesthetic period to about one hour and localizes the effect upon the injected area. A suitable solution of novocain for dental purposes may be pre- pared ns follows: Novocain 7 grains (0.45 Gm.). Sodium chlorid 4 grains (0.25 Gm.). Distilled water 1 fluidounce (30 C.c.). Boil the solution. LOCAL ANESTHETICS 533 To each cubic centimeter add one drop of epinephrin when used. Ready-made solutions of cocain and, to some extent, of novo- cain will not keep when frequently exposed to the air. A perfect sterile solution may be made extemporaneously by dissolving the necessary amount of novocain-suprarenin in tablet form in a given quantity of boiling physiologic salt solution. A suitable tablet may be prepared as follows : Novocain 14 grain (0.015 Gm.) . Suprarenin hydrochloric!, synthetic Vizoo grain (0.000054 Gm.). One tablet dissolved in 20 minims (1 cubic centimeter) boiling physiologic salt solution makes a l^/o per cent solution of novocain ready for immediate use. Ready-made sterile tablets of the above or a similar composition may be obtained from dental supply houses. These tablets must be carefully protected against moisture and light. Preparation of the Anesthetic Solution. Solutions for hypodermic purposes should be made fresh when needed. A simple porcelain crucible or a graduated porcelain Fig. 124. Large and small porcelain dissolving cups for preparing sterile novocain solution. dissolving cup held by a suitably twisted aluminum tongue and a dropping bottle constitute the simple outfit for this work. The 534 LOCAL ANESTHESIA dropping bottle should hold from one to four ounces. A groove on one side of the neck of the bottle and a vent on the other con- nected with two grooves in the back of the stopper allow the con- tents to flow out drop by drop. A quarter turn of the stopper closes the bottle tightly. The number of drops present in each cubic centimeter differs with the various sizes of the dropping bottles, hence each bottle has to be standardized with a tested minim graduate or a tested burette. The standard number of Fig. 125. Fig. 126. Fig. 125. Dropping bottle. Fig. 126. Glass measure for local anesthetics. The measure is marked for 10, 20, 30, or 40 minims. It is useful for measuring anesthetic solutions, or for dissolving tablets in stipulated quantities of liquids. drops may be marked on the respective bottle with a carborundum stone. The hypodermic solution can be made extemporaneously in a few seconds as follows : Place a tablet in the porcelain dissolving cup, add the necessary number of drops (1 C.c.) of physiologic salt solution, and boil for a few seconds by holding the cup above the flame of the burner. The solution is now ready for immediate use. Ready-made sterile solutions of local anesthetics are also sold at LOCAL ANESTHETICS 535 present, and are marketed in hermetically sealed ampuls of vari- ous designs. To open the ampul, a small groove is made with a file at one end, which is then readily broken off. The contents are aspirated by inserting the syringe provided with the needle directly into the opened ampul. The practitioner is especially cautioned in regard to the use of local anesthetics in the form of ready-made solutions. Solutions of cocain, even when rendered sterile by fractional sterilization, will not remain so after the contents of the bottle are exposed to the air for a short time. Ready-made solutions that are sold in the Fig. 127. Hermetically sealed glass ampuls of vario-s types. They contain sterile anesthetic solutions. shops under more or less fanciful names require still greater pre- caution. The Food and Drugs Act (1906) and more recently (1915) the Harrison Narcotic Law (see page 97) require that all solutions containing cocain, or any substitute thereof, must be so labeled. Most of the many so-called safe and reliable anesthetics found in the market contain cocain or its substitutes in varying quantities. The addition of epinephrin to a ready-made solution not only destroys this alkaloid in a very short time, but the prod- ucts of its decomposition make the solution still more dangerous. The printed formulas that accompany many of the ready-made solutions of local anesthetics frequently show an utter disregard 536 LOCAL ANESTHESIA of the pharmacologic action of the individual ingredients, which forces us to conclude that they are a slur on the intelligence of the practitioner who uses such compounds. HYPODERMIC ARMAMENTARIUM. A hypodermic syringe that answers all dental purposes equally well is an important factor in carrying out the correct technique Fig. 128. Novocain armamentarium. of the injection. The injection into the dense gum tissue requires often 10 or more pounds of pressure as registered by an inter- posed dynamometer, while in pressure anesthesia even greater pressure is frequently applied. HYPODERMIC ARMAMENTARIUM 537 The selection of a suitable hypodermic syringe is largely a mat- ter of choice. All-glass syringes, glass-barrel syringes, and all- metal syringes are the usual types found in the depots. An all- glass syringe that answers every reasonable demand regarding asepsis, durability, and perfect construction, and that is giving universal satisfaction, has been recently brought out by the S. S. White Dental Mfg. Co. The syringe is constructed after the well known Luer pattern, holding iy 2 C.c. and it is marked with suitable divisions on the barrel. The piston and the barrel are ground so perfectly that no washers are required to make water-tight joints. Fig. 129. The S. S. White aseptic all-glass syringe. An adjustable finger-rest is easily slipped over the assembled parts which greatly assists in adjusting the needle-opening in any de- sired direction and in exerting pressure on the piston. The piston- rod, made of solid glass, is sufficiently long to allow about two inches of space between the finger-rest and the piston-top. This space is of importance, as it allows the last drop of fluid to be expelled under heavy pressure without tiring the fingers. A re- movable cane-handle, made of metal, greatly facilitates the exer- tion of pressure on the piston. The needle-adapter carries a uni- versal thread so as to accommodate the hub of the ordinary hypo- 538 LOCAL ANESTHESIA dermic needles. The various parts of the syringe may be de- tached in a few moments to allow sterilization by boiling. Broken parts may be replaced without obtaining a complete new syringe. Glass-barrel syringes are not to be recommended for dental pur- poses, as they are too troublesome to keep in order. After care- Fig. 130. Thoma sterilizer for hypodermic syringes, dissolving cups, etc. fully testing most of the all-metal hypodermic syringes offered in the dental depots within the last ten years by means of the pres- sure gauge and in clinical work, subjecting the syringes to a routine wear and tear, the author has found that the syringes of the so-called "Imperial" type are to be preferred over other makes. They are usually made of nickel-plated brass, which, however, is HYPODERMIC ARMAMENTARIUM 539 a disadvantage, as the nickel readily wears off from the piston, and exposes the easily corroded brass. The piston should prefer- Fig. 131. All-metal syringe and curved needle attachment. ably be made of pure German silver. An all-metal syringe as pictured in Fig. 131 gives good results in heavy pressure work and can be recommended. The syringe holds 40 minims (2 C.c.), is 540 LOCAL ANESTHESIA provided with a strong finger crossbar, and is extremely simple in construction. The piston consists of a plain metal rod, with- out a thickened or ground piston-end or packing. The packing consists of leather washers inserted at the screw-joint, and is quickly removed and replaced if necessary. The hypodermic syringe requires careful attention. It is not I Fig. 132. Dental hypodermic needles, a, incorrectly ground needle point; b, correctly ground needle Doint. Fig. 133. Hypodermic needles of various designs for dental purposes. necessary to sterilize it by boiling after each use, unless it should be contaminated with blood or pus. The simple repeated washings with a mixture of 8 parts of alcohol and 2 parts of glycerin and careful drying is sufficient. If the syringe is boiled all the leather washers must be removed. The syringe is best kept in a covered glass or metal case, and a large bacteriologic Petri dish is suitable HYPODERMIC ARMAMENTARIUM 541 for this purpose. Leather-lined or felt-lined boxes afford breed- ing places for bacteria. Some operators prefer to constantly keep their syringes in an antiseptic solution when not in use, and others prefer to place them in a special sterilizing bottle, which bottles may now be purchased at dental depots. As a suitable sterilizing liquid for this purpose the above referred to alcohol- glycerin mixture is well adapted. Dental hypodermic needles should be made of seamless steel, or, still better, of vanadium-steel, 24 to 26 B. & S. gauge, and pro- vided with a short razor-edge point. Thicker needles cause un- necessary pain, and thinner needles are liable to break. Iridio- v ' iT y o= Fig. 134. Needle attachments for Parke, Davis & Co.'s syringe. A, butt and adapter with Schim- mel needle; B, cross section of butt and adapter with Schimmel needle; c, Schimmel needle; D, tube of Schimmel needles; E, curved attachment for Schimmel needles; F, cross section of Schimmel needles enlarged; G, cap for syringe when not in use. platinum needles are preferred by many operators, as they may be readily sterilized in an open flame. The needle should measure from a quarter to a half inch. For infiltration or conduction anesthesia one-inch needles are neces- sary, and curved attachments of various shapes are essential in reaching the posterior parts of the mouth. The "Schimmer' needles are excellent, but do not, however, fit every syringe. For pressure anesthesia special needles are required, and may be bought at the depots, or quickly prepared by grinding off the steel needle at its point of reinforcement. The sterile needles should be kept in 542 LOCAL ANESTHESIA well-protected glass containers. The needles are sterilized by boil- ing after each use in plain water, dried with the hot air syringe, and immediately transferred to a sterile glass dish" The sterile needles should not be again touched with the fingers, and the cus- tomary wire insertion is unnecessary. As stated, novocain is pre- cipitated from its solution by sodium carbonate. If soda, lysol, or similar compounds are used for sterilizing purposes, the syringe and the needles must be washed with sterile water to remove all traces of alkali. TECHNIQUE OF THE INJECTION. Various methods of injecting the anesthetic solution about the teeth are in vogue. For the sake of convenience, we may be per- mitted to divide them as follows: 1. The subperiosteal injection. 2. The peridental injection. 3. The intra-osseous injection. 4. The mandibular injection. 5. The infra-orbital injection. 6. The extra-oral injection. 7. Insufflation anesthesia of the upper anterior teeth. 8. The injection into the pulp. Before starting any surgical interference in the mouth, the field of operation should be thoroughly cleansed and sterilized by painting with diluted tincture of iodin. Surgery owes the intro- duction of this excellent method to Grossich, of Trieste. As tinc- ture of iodin is too irritating, a suitable diluted alkaline solution is preferably employed. A serviceable mixture for such purposes is made as follows : Tincture of iodin (U. S. P.) % ounce (15 C.c.). Aceton 1 ounce (30 C.c.) . Keep in glass stoppered bottles and apply with a cotton swab. Tincture of aconite should never be added to such a mixture. It should be remembered that the sterilization of the field of oper- ation by the above solution is primarily a mechanical procedure; the quick drying iodin solution glues the bacteria to the mucous surface and its light color does not materially interfere with the epinephrin anemia. TECHNIQUE OF THE INJECTION 543 After the diagnosis is made the method of injection best suited for the case on hand is then decided upon. The necessary quantity and the concentration of the anesthetic solution is now prepared, and the syringe and hypodermic needle fitted, ready for the work. The correct position of the syringe in the hands of the operator and its proper manipulation is an important factor, and has to be acquired by practice. The hand holding the syringe is exclusively governed in its movement by the wrist, so as to al- low delicate and steady movements, and the fingers must be trained to a highly developed sense of touch. The syringe is filled by drawing the solution up into it ; it is held perpendicular- ly, point up, and the piston is pushed until the first drop appears at the needle point, which precaution prevents the injection of air into the tissues. Before entering into a discussion of the various methods of the technique of the injection, it is essential to recall to one's mind the anatomic structure of the alveolar process, as this factor plays an important part in the distribution of the injection within the bone. Anatomic Structure of the Alveolar Process. Regarding the anatomic structure of the alveolar process of both jaws, it should be remembered that this bone is transitory in structure, becoming thinner with age, and is very readily ab- sorbed when the teeth are removed. The process is composed of soft, spongy cancelloid bone, which is penetrated by Haver- sian and Volkmann's canals (the latter carrying the vessels of Von Ebner), and also contains lymph vessels. The anterior wall of the alveolar process of the maxilla is a thin plate throughout, except about the border of the molar teeth, while the posterior surface is reinforced by the intermaxillary bone and palatal proc- esses. In the mandible the anterior portion is the thinnest part, while in the molar regions the external and internal ob- lique lines materially increase the thickness of this bone. Fluids injected into the periosteum covering the alveolar process pene- trate the bone by diffusion, as Dzierzawsky 1 has experimentally shown by employing methylen blue injections, but this diffusion occurs only when the injected fluid is held under a certain pres- 1 Dzierzawsky: See Braun, Die Lokalanasthesie. 1904. 544 LOCAL ANESTHESIA sure by the overlying tissues. Penetration through this bone can not be expected from an injection into a loose mucosa, from which the fluid is, sponge like, absorbed. This factor explains the failure of the infiltration method of Schleich when applied about the al- veolar process. The nerve supply of the anterior surface of the maxilla, in- cluding the teeth and gum tissue, is received from branches of the second division of the fifth nerve, known as the superior maxil- Fig. 135. Cross section of a right lower jaw. They show the mesial surfaces of the teeth and their relation to the bone structure. (Loos.) lary. The nerve divides into the posterior, middle, and anterior superior dental branches. The posterior branch supplies the molar teeth, the gums, and adjacent buccal mucosa, while smaller branches terminate in the canine fossa; the middle branch passes along the outer wall of the maxillary sinus, supplying the bicus- pid teeth ; and the anterior branch, the largest, passes through TECHNIQUE OF THE INJECTION 545 a canal close to the infra-orbital foramen over the anterior wall of the maxillary sinus, and distributes its filaments to the incisor and canine teeth. All the branches communicate with each other about the alveolar process. The hard palate, the periosteum, and the palatine gum tissue receive their innervation from the anterior palatine nerve from Meckel's ganglion, which enters through the posterior palatine foramen and the accessory palatine canals, passing forward in a Fig. 136. Horizontal section through the alveolar process of the lower jaw. (I^oos.) groove and joining anteriorly with the naso-palatine nerve as it emerges from the anterior palatine foramina of Scarpa. The mandible receives its nerve supply from the largest of the three divisions of the fifth nerve, known as the mandibular branch or the inferior dental nerve. "From its point of origin it passes downward internally to the external pterygoid muscle, and, upon reaching a point between the ramus of the mandible and the sphenomandibular ligament, it enters the inferior dental canal through the posterior or inferior dental foramen. Before 546 LOCAL ANESTHESIA entering the foramen, two branches are given off a lingual and a mylohyoid branch. The nerve is accompanied through the inferior dental canal by the inferior dental artery, and, when the mental foramen is reached, it terminates by dividing into an incisive and a mental branch. Between the dental foramen and the mental foramen the nerve gives off a series of twigs to the bicuspid and molar teeth, and, by communicating with one another within the substance of the bone, forms a fine plexus. J Fig. 137. The nerve supply of the upper and lower jaw. The incisive branch follows the incisive arteries through the sub- stance of that part of the bone between, the mental foramen and the symphysis, and supplies the incisor and canine teeth, while the mental branch passes forward to supply the chin and lower lip." (Broomell.) TECHNIQUE OF THE INJECTION 547 Fig. 138. The nerve and blood supply of the hard palate. Subperiosteal Injection. The subperiosteal injection about the root of an anterior tooth is best started by inserting the needle midway between the gin- gival margin and the approximate location of the apex. Nothing is more dreaded by the patient than this first puncture. A fine, very sharp-pointed needle causes very little pain, and the sim- ple compression of the gum tissue with the finger tip is often quite effective. The pain may be entirely obviated by pressing a pledget of cotton saturated with a concentrated novocain solu- tion (20 per cent), on the gum tissue or by applying a very small drop of liquid phenol on the point of puncture. The ethyl chlorid spray may also be used with great advantage for such purposes. The needle opening faces the bone, the syringe is held in the right hand at an acute angle with the long axis of the tooth, while the left hand holds the lip and cheek out of the. way. After punctur- ing the mucosa, a drop of the liquid is at once deposited in the tissue, and the further, injection is painless. Slowly and steadily the needle is forced through the. gum tissue and periosteum along the alveolar bone toward the apex of the tooth, depositing the fluid under pressure close to the bone on its upward and return 548 LOCAL ANESTHESIA trip I'injection tracante et continue, as Keclus calls it. The continuous slow moving of the needle prevents injecting into a vein. Another injection may be made by partially withdrawing the needle from the puncture and swinging the syringe anteriorly or posteriorly, as the case, may be, from the first route of the in- jection. This latter method is especially indicated in injecting the upper molars. After removing the needle, place the finger tip over the puncture and slightly massage the injected area. A circular elevation outlines the injected field. The naturally pink Fig. 139. Subperiosteal injection. color of the gum will shortly change to a white anemic hue, in- dicating the physiologic action of the epinephrin on the circula- tion. No wheal should be raised by the fluid, as that would in- dicate superficial infiltration and consequently failure of the anesthetic. A second injection should always be made into the gum tissue surrounding the tooth near its free margin. The alveolar process in this region offers innumerable minute openings for the ready absorption of the injected solution. As the liquid requires a definite length of time to pass through TECHNIQUE OF THE INJECTION 549 the bone lamina and to reach the nerves of the peridental mem- brane and the apical foramen of the tooth, from five to ten minutes should be allowed before the extraction is started. The length of time depends on the density of the surrounding bone structure. The progress of the anesthesia may be tested with a fine-pointed probe, and its completeness indicates the time when the extraction should be started. The lower eight anterior teeth are comparatively easily reached by the injection. The straight needle is inserted near the apex of the tooth, the syringe is held in a more horizontal position, and the injection proceeds now as outlined above. The lower molars require a buccal and lingual injection. The needle is inserted midway between the roots, the gum margin, and the apices. The external and internal oblique lines materially Fig. 140. Direction of needle in the subperiosteal injection about a canine. hinder the ready penetration of the injected fluid, and therefore ample time should be allowed for its absorption. If two or more adjacent teeth are to be removed, the injection by means of infiltrating the area near the gum fold directly over the apices of the teeth is to be preferred. It is advisable to use a half-inch needle for this purpose, holding the syringe in a horizontal position, so as to reach a larger field with a single in- jection. If all the teeth of one jaw are to be removed at one sit- ting, from two to four injections, using two or three tablets dis- 550 LOCAL ANESTHESIA solved in from two to five cubic centimeters of water, may be necessary, according to circumstances; for the complete anes- thetization of a single-rooted tooth, one tablet of the novocain- suprarenin compound is sufficient; and for the molars, one and, according to conditions, two tablets may be required. The quan- tity of novocain to be injected at one sitting should be limited to three tablets (one grain). It should be borne in mind that the absorption of fluids in- jected into the gum tissue takes place very rapidly on account of the rich lymph circulation in these parts. The injection into inflamed tissue, into an abscess, and into Fig. 141. Subperiosteal injection about an upper molar. phlegmonous infiltration about the teeth is to be avoided. The injection into engorged tissue is very painful; the dilated vessels quickly absorb cocain without producing a complete anesthesia, and general poisoning may be the result. In purulent condi- tions the injection is decidedly dangerous, as it forces the infec- tion beyond the line of demarcation. If the abscess presents a definite outline, the injection has to be made into the sound tissue surrounding the focus of infection. If a tooth is affected with acute diffuse or purulent pericementitis, a distal and a mesial injection usually produce successful anesthesia by blocking the sensory nerve fibers in all directions. Ethyl chlorid in connec- tion with the injection is frequently helpful, but a painless ex- TECHNIQUE OF THE INJECTION 551 traction should not, however, be promised in such cases. Conduc- tion anesthesia is the correct procedure for such purposes. Some years ago Schleich introduced a special method for the purpose of thoroughly infiltrating the tissues with very weak isotonic cocain solutions. He injects the solution into the sub- cutaneous tissue, thereby raising a definite circular wheal ; he now inserts the needle in the anesthetized region, near the periphery of the wheal, injecting again and raising a second wheal, and thus he continues until a circle of wheals has been established which incloses a completely anesthetized surface. If deeper structures are to be operated upon, the anesthetizing of these structures by infiltration has to be performed in the same manner. The Schleich method can not be employed with any degree of success in the oral cavity, and in general surgery it is at present largely aban- doned. Schleich deserves much credit for having worked out the basic principles of local anesthesia, and its subsequent wide use in special and general surgery is largely due to his investigations. Peridental Injection. Teeth or roots standing singly, or teeth affected by pyorrhea or similar chronic peridental disturbances, are frequently quickly and satisfactorily anesthetized by injecting the fluid directly into Fig. 142. Peridental injection about a bicuspid. the peridental membrane. This method is known as peridental anesthesia, and its technique is very simple. In single-rooted teeth a fine and short hypodermic needle is inserted mesially or distally under the free margin of the gum, or through the inter- 552 LOCAL ANESTHESIA dental papilla, into the peridental membrane between the tooth and the alveolar wall. Sometimes the needle may be forced through the thin alveolar bone so as to reach the peridental mem- brane direct. To gain access to this membrane in teeth set close together, slight separation with an orange wood stick or other suit- able means is often found to be of advantage. In molars two in- jections are essential. One puncture is made buccally between the bifurcation of the roots near the gum margin, and the same pro- cedure is repeated on the opposite side of the tooth. A drop of Fig. 143. A, Subperiosteal injection; B, Peridental injection; C, Intraosseous injection about a canine. fluid is now deposited in the tissue, and the injection is slowly continued. To force the liquid into the membrane usually re- quires a higher pressure than that which is necessary for inject- ing into the periosteum covering the alveolar process, but the quantity of the anesthetic liquid is less than that which is required for the former injection. Acute inflammatory conditions of the peridental membrane and its sequelae prohibit the use of this method. In peridental anesthesia the seat of the nerve supply of TECHNIQUE OF THE INJECTION 553 the tooth is very quickly reached, and as a consequence the results obtained are in the majority of cases extremely satisfactory, pro- vided that general conditions justify its application. Intraosseous Injection. To facilitate the passage of the injected fluid into the bone structure proper, Otte, 1 in 1896, recommended a method by which he forces the anesthetic solution directly into the spongy cancelloid bone. Otte terms this procedure the intraosseous method of injec- tion. When Otte's paper was published, the technique of local anesthesia was in its infancy, and as a consequence his recom- mendations were soon forgotten. Nogue, 2 in 1897, again called attention to it under the name of anesthesie diploique. This method is especially indicated in the anesthetization of lower molars, because the dense bony ridges on both sides of the mandible materially interfere with the ready penetration of the fluid. The technique of the injection is described by Otte as follows: After the gum tissue is thoroughly cleansed with an antiseptic solution, it is anesthetized about the neck of the tooth in the usual man- ner. After waiting two or three minutes, an opening is made into the gum tissue and the bone on the buccal side with a fine spear drill or a Gates-Glidden drill. The opening should be made more or less at a right angle with the long axis of the tooth, a little below the apical foramen in single-rooted teeth or between the bi- furcation in the molars. The right-angle hand piece is preferably employed for this purpose. The drill should be of the same diam- eter as the hypodermic needle. The gum fold is tightly stretched to avoid laceration from the rapidly revolving drill. As soon as the alveolar process is penetrated, a peculiar sensation conveyed to the guiding hand indicates that the alveolus proper is reached, and the sensation felt by the hand is about the same as that experienced when a burr enters into the pulp chamber. In this artificial canal the close-fitting needle of the hypodermic syringe is now inserted, and the injection is made in the ordinary way. The quantity of fluid used is much less than is usually needed for a subperiosteal injection. As has been stated above, the roots of the teeth are imbedded in a sieve-like mass of bone J Otte: Nederlandsche Tandmeesters Vereeniging, 1896. 2 Nogue: Anesthesie Diploique, 1907. 554 LOCAL ANESTHESIA tissue, which allows a ready penetration of fluid when injected under pressure. Within ten minutes the peridental membrane and the pulp are sufficiently anesthetized to insure a painless ex- traction. If an inflammatory condition of the involved area ex- ists, the injection should be made into the sound tissue prefer- Fig. 144. Perineurial injection about the foramen of Scarpa and about the posterior palatine canal. A, Insertion of needle; B, Foramen of Scarpa; C, Insertion of needle; D, Posterior dental foramina. ably distally of the tooth and, if this should not be sufficient, an- other injection is made mesially of the tooth. As in all highly inflamed processes about teeth, an absolutely painless extraction should not be promised in such cases. Otte's intraosseous method of anesthetization involves a comparatively simple technique. Af- TECHNIQUE OF THE INJECTION 555 ter mastering its essential detail^, good results are universally ob- tained, and this method deserves to be recommended in suitable cases. Injection Into the Mandibular Nerve. The complete anesthetization of the third, and sometimes of the second, lower molar by the subperiosteal or by the intraos- seous method is frequently fraught with much difficulty on account o'f the bony ridges on both sides of the teeth, and posteriorly by the compact bone of the ascending ramus, which forms a strong barrier to the ready penetration of the liquid into the bone. These difficulties are usually more pronounced in a malpost or an im- Fig. 145. Mandibular sulcus. a, External oblique line; b, Internal oblique line; c, Position of the needle; d, Occlusal plane; the dotted outline forms the boundary of the mandibular sulcus. (Seidel.) pacted third molar, while the same tooth standing alone seldom presents difficulties to the ordinary method of injection. In the latter case the tooth has more or less always moved toward the median line. To overcome these difficulties Braun, in 1905, intro- duced a method of centrally anesthetizing the mandibular and incidentally the lingual nerve, which since is known as the con- duction anesthesia of the mandibular nerve. In describing the technique of the injection, the author has followed very closely Braun 's description of this method. 556 LOCAL ANESTHESIA By palpating the lingual surface of the ramus in the mouth with the finger, the anterior sharp border of the coronoid process is easily felt about five-eighths of an inch posterior of the third molar. The process passes downward and backward of the third molar, and enters into the external oblique line. Mesial! y from this ridge is to be found a small triangular concave plateau, which is facing downward and outward, being bound mesially by a dis- tinct bony ridge and covered with mucous membrane. As there is no anatomic name attached to this space, Braun has called it the retromolar triangle (trigonum retromolare} . In the closed Fig. 146. Relation of nerve and vessels in the pterygomandibular space. (Zuckerkandl.) mouth it is located at the side of the upper third molar, and in the open mouth it is found midway between the upper and lower teeth. Immediately back of the mesial border of this triangle, directly beneath the mucous membrane, lies the lingual nerve, and about three-eighths of an inch farther back .the mandibular nerve is to be found. This last nerve lies close to the bone, and enters into the mandibular foramen, which is partially covered by the mandibular spine. Before starting the injection the patient should be cautioned to rest his head quietly on the headrest of the chair, as any sud- den movement or interference with the hand of the operator may TECHNIQUE OF THE INJECTION 557 be the cause of breaking the needle in the tissues. The syringe, provided with a one-inch needle, is held in a horizontal position, resting on the occluding surfaces of the teeth from the canine backward and slightly toward the median line. The needle is to be inserted three-eighths of an inch above and the same distance back of the occluding surface of the third lower molar, the needle opening facing the bone. This position will insure the correct direction of the needle point so as to reach the tissues immediate- ly surrounding the nerves, and not lose the injection in the adjacent thick muscle tissue. The needle must always be in close touch with the bone, and is now slowly pushed forward, deposit- ing a few drops of fluid on its way until the ridge (Fig. 145, a) is reached. About five drops of fluid are injected in this imme- diate neighborhood for the purpose of anesthetizing the lingual nerve. The needle is now pushed very slowly forward, always keeping in close touch with the bone and depositing fluid on its way, until it is pushed in about five-eighths of an inch. It is important to carefully feel the way along the bony wall of the ramus, as the needle may have to pass over roughened and bony elevations, which afford attachment to the internal pterygoid muscle. During the injection the syringe should remain in the same horizontal position as heretofore outlined. Soon after the injection, paresthesia of one-half of the tongue on the side of the injection occurs, which is soon followed by anesthesia of the mandibular nerve. Paresthesia of the mucous membrane and half of the lower lip is also established. The pulps of the lower teeth, including the canine and lateral incisor, and the gum tissue on both sides of the jaw, are anesthetized, including a part of the anterior floor of the mouth. The complete anesthesia of the two nerves also anesthetizes the whole alveolar process in this region. About five minutes are required for the complete anesthetization of the lingual nerve, and at least fifteen minutes for the mandibular nerve. Braun claims that the injection is absolutely free from dan- ger, while Rb'mer states that danger may arise if the whole quan- tity of the solution should accidentally be injected into a vein. This contingency is avoided by carefully following the advice of Reclus, to never inject cocain solution unless the syringe is con- stantly moving. The quantity of anesthetic fluid necessary for 558 LOCAL ANESTHESIA this purpose is the same as is needed for any other tooth one cubic centimeter of the solution. Fig. 147. Horizontal section of a frozen head made 1 cm. above the occlusal surfaces of the teeth of the lower jaw. a, Mandibular sulcus; b, Mandibular vein; c, Mandibular artery; d, Mandibular nerve; e, Ramus; f, Internal pterygoid muscle; g, Lingual nerve; h, Internal oblique line; i, External oblique line; j, Masseter muscle; k, External pterygoid muscle; 1, Tongue. Conduction anesthesia" of the mandibular nerve is possible only when the patient can open the mouth sufficiently to allow the ready introduction of the syringe. If the tissues about the third molar are highly infiltrated with inflammatory exudations, local anesthesia TECHNIQUE OP THE INJECTION 559 is absolutely prohibited. If it is insisted upon, the resultant failure should not be attributed to the anesthetic, but to the faulty judgment of the operator. General narcosis by means of nitrous oxid, etc., is to be preferred in such conditions, as well as in pro- nounced trismus, if a painless operation is promised. To successfully perform conduction anesthesia on the mandibu- lar nerve according to Braun's method, a thorough anatomic knowledge of the parts involved and an expert dexterity of tech- nical detail, which can be mastered only by experience, are re- quired. As already stated, before starting the injection the pa- tient should be cautioned to keep perfectly quiet. In spite of Fig. 148. Injection into the mandibular foramen. this warning, it may happen that through an unexpected move- ment the needle will break off and become buried in the tissues. Unless the broken piece can be quickly grasped by the pliers, further attempts to find it are usually unsuccessful, and a search for its removal must be given up. Peckert 1 reports a few of such accidents occurring at the dental clinic of the Heidelberg Uni- versity. He claims that the broken needles were simply left undisturbed, and they were borne by the tissues without further annoyance. He emphasizes, however, that the needles used were always sterile, and he attributes the absence of future disturb- ances to this fact. Seidel employs on either side of the jaw the thumb of the left hand for palpation. He justly recommends "not to allow the patient to open the mouth 1 Peckert: Deutsche Zahnarztliche Wochenschriit, 1908, No. 4. 560 LOCAL ANESTHESIA too far, as the retromolar triangle, and especially the internal oblique line, are much more easily felt when the muscles are somewhat at rest." His technique consists of four steps: (1) The insertion of the needle. The beginner usually selects the point of insertion too far mesially. The point never lies directly posterior to the lower teeth, but always laterally, and close to the nail of the thumb, which rests in the retromolar triangle and at the moment of the insertion is retracted so far as to uncover its mesial half. The needle strikes the bone directly under the mucous membrane; this is the best safeguard for the beginner. The most favorable height for insertion is 0.75 to 1 cm. above the occlusal plane of the lower teeth. The syringe lies laterally to the teeth of the same side. (See Fig. 149,4.) A B C D Fig. 149. Seidel's technique. (2) Now the needle is retracted to the submucosa and gradually directed mesially until the bone is lost. The stretching of the tissues has the advantage of pressing the advancing needle against the bone like a rubber band. The syringe rests approximately on the teeth of the same side (Fig. 149-B.) (3) Swinging of the syringe. The syringe is now turned to the opposite side until the advancing needle again finds the bone, but on the inner aspect of the ascending ramus. Whether the syringe rests on the canine, lateral in- cisor, or bicuspi-d of the opposite side depends on the angle which the ascend- ing ramus forms with the sagittal plane, the most important point being to Iceep in touch with the bone. (See Fig. 149C.) (4) Advancing to the sulcus. In most cases it is very easy from this point to proceed, without resistance, between bone and muscle to the mandibular space. (See Fig. 1497).) TECHNIQUE OF THE INJECTION 561 To anesthetize the lingual nerve and to operate painlessly, Seidel injects 0.5 C.c. on the way to the sulcus. There 1.5 C.c. of the solution is deposited under steady backward-and-forward motion of the needle. Certain anatomic malformations of the roots of the lower third molars may, on rare occasions, be the cause of very profuse ar- terial hemorrhage and other serious damage as a result of their extraction. There are, as far as the author knows, five cases on record in which the developing tooth inclosed in the body of its roots the contents of the mandibular canal the artery, vein, and Fig. 150. An abnormal course of the mandibular canal. The roots of the thi united into a cone, and the nerve, artery, and vein pass through a foram united roots. (Loos.) .rd molar (a) are .men formed in the nerve. The extraction of a tooth possessing such malformation means tearing of the vessels and the nerve, causing extreme hemor- rhage, excruciating pain, and finally permanent insensibility of one-half of the lip. These are the symptoms as recorded from cases which occurred in the practice of Rose 1 in Munich, in 1898, and Vorslund-Kjar 2 in Copenhagen, in 1908. 1 R6se: See Witzel, Entwickelung der Kiefer, etc., 1907. *Kjar: Dental Cosmos, 1908. 562 LOCAL ANESTHESIA The Infra-orbital Injection. To reach the nerve plexus which passes through the infra-orbital foramen and furnishes innervation to the upper canine and incisor teeth, an injection is readily made in this region and it is always followed by the desired results. The infra-orbital foramen is easily located about 1/4 inch below the middle of the inferior ridge of the orbit by palpating with the index finger of the left hand ; the lip is drawn up with the thumb and the one and a half inch needle is inserted directly into the gum fold between the canine and the first bicuspid tooth. Slowly the needle is forced upward, injecting a few drops of fluid on its way until the needle point is felt under the ball of the compressing finger resting over the foramen. The syringe is now slowly emptied and withdrawn. Fig. 151. Perineurial injection about the infra-orbital foramen and the alveolar foramina. After the injection, slight massage is here, as in every case, of advantage. To reach those branches of the anterior superior dental nerve which enter into the maxillary bone, a good sized cotton tampon saturated with a 20 per cent novocain solution is placed in the lower meatus of the nose and left there during the operation. A few drops of the anesthetic solution injected about the marginal gum tissues of the tooth or teeth under considera- tion will materially assist in insuring an absolute painless opera- tion. TECHNIQUE OF THE INJECTION 563 The Extra-oral Injection. Very recently, extra-oral injections for the purpose of reaching certain nerve trunks more easily have been recommended by some dental surgeons of Europe. Such procedures are recommended for the infra-orbital foramen and the mandibular foramen by piercing respectively the cheek and the tissues about the angle of the jaws. For ordinary dental purposes extra-oral injections are not called for, hence the descriptions of these methods are omitted. Insufflation Anesthesia of the Upper Anterior Teeth. Shortly after the introduction of cocain for anesthetic purposes (1884), Petsch, of Berlin, discovered that anesthetization of the lower nostrils with a cocain solution produces a more or less pro- nounced anesthesia of the upper anterior teeth. After some ex- perimental work he published his observations, and called this new procedure "The Insufflation Method of Local Anesthesia." At this time no one seemed to take any notice of this new method, and it was soon forgotten. In 1907 Lederer, of Prague, and Escat, 1 of Toulouse, independently of each other, described anew this method of endonasally producing anesthesia of the upper front teeth. Very recently (1908) M. de Terra, 2 of Zurich, pub- lished a detailed account of this procedure. De Terra's technique is very simple. In accordance with the anatomic relations, the right nostril is selected for the right upper teeth, and, vice versa, the left nostril for the left side. The head of the patient is slight- ly bent forward, and with a nose speculum the nostril is enlarged, thus exposing the nasal septum on the one side and the lateral cartilage on the other side. With an absorbent tampon, fastened on a metallic probe and dipped into a "cocain epinephrin solution, the tissues are slightly massaged by moving the tampon to and fro. A slight tingling and disagreeable sensation is produced for a few minutes, accompanied by free lachrimation. In from two to three minutes the anesthesia of the mucous membrane of the nose is completed. A cotton ball tied to a short string is now saturated with the anesthetic solution and placed in the lower nostril. During the time the tampon remains in the nose the patient should assume a sitting posture to avoid the possible escape of some of 1 Escat: Dental Register, 1907, p. 306. 2 De Terra: Correspondenzblatt fur Zahnarrte, 1908, p. 244. 564 LOCAL ANESTHESIA the liquid into the posterior nares. " Escat has studied with the utmost care the effects of nasal anesthesia on the teeth, and sum- marizes the results of his observations as follows : 1. In thirty-six cases a complete anesthesia was obtained of the central incisor and of the canine on the side corresponding to that of the nasal fossa subjected to the action of the anesthetic; also an incomplete anesthesia of the first bicuspid adjoining the anesthetized cuspid, and of the lateral incisor on the opposite side. 2. In eight cases the anesthetized area included, in addition to the incisors and canine on the corresponding side of the anes- thetized nasal fossa, the incisors and canine on the opposite side. 3. In one case the anesthesia of the incisors and canine on the opposite side of the anesthetized nasal fossa was complete, while that of the incisors and canine on the corresponding side was in- complete. In order to explain this form of anesthesia, Escat offers the following plausible explanation: 1. The infiltration of the floor of the nose, the penetration through the mucous lining and the thin lamina of bone, and the absorption by the lymphatics carry the anesthetic solution to the nerves supplying the teeth. 2. The cocain is taken up directly by these nerves, which fur- nish branches to the incisors and to the canine teeth. In order to explain the anatomic mechanism of this form of anesthesia, Clermont, of Toulouse, undertook the study of a large number of specimens. He has found that the anterior superior dental branch of the superior maxillary nerve, which supplies the in- cisors and canines, and gives off a nasal branch which supplies the mucous membrane of the anterior portion of the nasal cavity, is not inclosed deeply in the substance of the maxilla, but that, on the contrary, it runs in close proximity to the floor of the nasal cavity. In twenty-nine specimens of a series of fifty-five he found the canal normally formed, but with an extremely thin upper lamina so thin indeed that it was transparent and easily pierced and in thirteen cases the canal was really a groove, as it lacked the upper wall, or lamina. This intimate relationship of the anterior superior dental nerve with the nasal mucous mem- brane explains satisfactorily, the author says, the anesthesia of the upper teeth following anterior intranasal anesthesia, for in 47 per TECHNIQUE OF THE INJECTION 565 cent of the cases the cocain tampon is separated from the anterior superior dental branch by only the mucous membrane, and in 53 per cent of the cases the tampon is separated from the nerve by a very thin lamina of the osseous tissue, through which, it is easy to conceive, the cocain readily reaches the nerve. Insufflation anesthesia is not always reliable. Many patients, especially anemic, and extremely nervous individuals, are highly reactive to cocainization of the nose, and frequently complain about a feeling of general malaise, lasting for hours after the anestheti- zation. Injection Into the Pulp (Pressure Anesthesia). By pressure anesthesia, pressure cataphoresis, pulp anesthesia, or contact anesthesia, as the process is variously termed, we un- derstand the introduction of an anesthetizing agent in solution by Fig. 152. . . L,oeffler's pressure syringe attachment for anesthetizing the pulp. mechanical means through the dentin into the pulp or directly into the exposed pulp for the purpose of rendering this latter organ insensible to pain. Simple hand pressure with the finger or with a suitable instrument, with the hypodermic syringe or with the so-called high pressure syringe, is recommended for such purposes. The term "pressure anesthesia," as Ottolengui 1 relates, was first suggested by Wm. James Morton at a dental meeting in 1897, and later appeared in his work on "Cataphoresis." Its intro- duction into dentistry, with a description of a practical method, however, is to be credited to Edward C. Briggs, of Boston, 2 who, in 1890, read a paper before the Harvard Odontological Society, 1 Ottolengui: Items of Interest, 1890. 2 Briggs: International Dental Journal, 1891, p. 296. 566 LOCAL ANESTHESIA entitled: "Removal of the Pulps by the Use of Cocain." Since quite a few claimants of this most valuable therapeutic procedure have appeared, it is, from an historic point of view, of interest to credit priority to the right source. As is frequently the case with inventions of merit, priority is usually claimed by some one else, and so we are informed in an editorial in the Items of In- terest, 1899, that ' ' A certain person, or, rather, an uncertain per- son is traveling through the West selling 'a method of painlessly Fig. 153. An aqueous solution of eosin forced through dentin with a Jewell- Willcox syringe. Time, one and one-half minules. The pulp is stained. (Miller.) removing pulps,' and charging twenty-five dollars for the 'secret.' The secret being too good to keep, fraternal fellowship has led to its exposure. Pulps may be painlessly extirpated (so we are in- formed by a correspondent who desires that his name be not pub- lished) by carefully observing the following instruction" and then the editor describes a method which, in its essential prin- ciples, is practically the same as is utilized today. TECHNIQUE OF THE INJECTION 567 The literature on so-called pressure anesthesia has grown to very large proportions ; the following names, arranged in chrono- logical order according to the year of the publication of the es- says, represent the more important writers on this subject: Wil- liam James Morton, R. Ottolengui, Otto Walkhoff, R. C. Young, J. A. Johnson, R. B. Tuller, Clyde Davis, T. S. Phillips, J. J. E. DeVries, H. A. Sanders, H. J. Goslee, W. D. Miller, E. T. Loeffler, George Zederbaum, J. B. Buckley, W. A. Johnson, L. H. Ziegler, S. M. Weaver, W. Price, C. G. Meyers, George Koerbitz, Guido Fischer, and a host of others. Before describing the modus operandi of the various methods, the histologic structure of the dentin should be briefly recalled. Dentin is made up of about 72 per cent inorganic salts, about 10 per cent water, and an organic matrix constituting the remain- ing per cents. The dentin is perforated by a large number of tubules, radiating from the pulp cavity more or less wave-like to- ward the periphery, where they branch off, forming a deltoid network. Ro'mer has counted 31,500 dentinal tubules within the area of a square millimeter. The dentinal tubules are filled with the processes of the odontoblasts, and are known at present as Tomes' fibers. As a matter of historical fact, Joseph Linderer described these fibers some years prior to Tomes' publication in his "Handbuch der Zahnheilkunde" (1848), and speaks of them as "Saftfasern" (juice fibers), which carry on the metabolic changes in the dentin. The odontoblasts form a continuous cover over the pulp. The dentinal fibrils are protoplasmic in their nature, and normally do not carry sensation in the sense of the word as we understand this term. We can cut, file, or otherwise injure the sound dentin without much inconvenience to the pa- tient. When the fibers have become highly irritated, a mere touch on the dentin may at once call forth a paroxysm of pain. Patho- logically, this condition is referred to as hypersensitive dentin. Gysi 1 explains the theory of hypersensation of dentin on the fol- lowing basis: The dentinal tubules contain no nerves, but an or- ganic substance which carries on metabolic changes in the dentin. The sensitiveness of dentin is, therefore, not a physiologic process, and the physiologic sensitiveness of a tooth is conceived only by means of the nerves of the pulp and of the pericementum. Sen- J Gysi: Deutsche Monatsschrift fur Zahnheilkunde, 1905. 568 LOCAL ANESTHESIA sitiveness of dentin results from pressure, tension, or torsion on the organic substance of the tubules, which in turn convey the dis- turbance to the odontoblasts and then to the nerve-endings of the pulp proper. The contents of the tubules are aqueous in their nature, and, as water can not be compressed to any appreciable extent, the organic substance confined in the tubules represents a C D' Fig. 154. Section through the root of a molar. Shows irregular (secondary) dentin. (Reich.) C, Cementum; D, U, Normal dentin; P, Pulp; ] D, Irregular dentin in two layers (a, b). fixed, although comparatively easily mobile, column (water filled in a tube one meter in length can be compressed only about Kooo millimeter). As there are no nerves in the dentin, the sensitive- ness can not be overcome by an anesthetic, unless this anesthetic is conveyed through this organic substance into the pulp proper. Substances which coagulate albumin as phenol, silver nitrate, TECHNIQUE OP THE INJECTION 569 zinc chlorid, etc. destroy the albumin molecule with which they come in contact, but their deeper action is more or less cut short by their own coagulum. If, however, drugs are applied which are noncoagulants and which are absorbed by the organic con- tents of the tubules, and are thus conveyed to the pulp, they may act as direct protoplasm poisons, depending on their individual pharmacologic action destroying the vitality of the pulp com- pletely like arsenic trioxid, or paralyzing the nerve tissue like cocain. Methods of Anesthetizing the Pulp. 1. THE PULP is WHOLLY OR PARTIALLY EXPOSED. Isolate the tooth with the rubber dam, and clean it with water and alcohol. Excavate the cavity as much as possible, and, if the pulp is not fully exposed, wipe out the cavity with chloroform to remove Points for pressure obtunding syringe, a, An ordinary dental hypodermic needle is ground off at its point of reinforcement; b, Specially shaped point made to fit the drill hole; c, Specially shaped point with attachment for rubber washer. fatty deposits from the cartilaginous layer of dentin, and de- hydrate with alcohol and hot air. Saturate a pledget of cotton or a piece of spunk with a concentrated cocain or novocain solution (one novocain-suprarenin tablet dissolved in 5 drops of water), place it into the prepared cavity and cover it with a larger pledget of cotton, and then, with a piece of unvulcanized rubber or gutta- percha, and with a suitable burnisher or other specially devised instrument, apply slowly, increasing continuous pressure from one to three minutes. The pulp may now be exposed and tested. If it is still sensitive, repeat the process. Loeffler 1 states: "This pressure may be applied by taking a short piece of orange wood, 1 Loeffler: Dental Digest, 1908, p. 665. 570 LOCAL ANESTHESIA fit it into the cavity as prepared, and direct the patient to bite down upon this with increasing force. In this way we can obtain a well-directed regulated force or pressure, and with less discom- fort to the patient and operator." Loeffler 1 has recently devised attachments, of different sizes and shapes, which are to be used with the pressure syringe. The attachment is placed into the cavity, over the exposure of the pulp, and cemented into place. After the cement has hardened sufficiently, the eoeain solution is forced to its destination in the usual way. Loeffler claims that "the results obtained in a number of almost hopeless cases have been very gratifying, to say the least. ' ' This method requires ex- treme care, as in applying too much force the tooth is liable to be split. Miller 2 describes his method as follows: "After excavat- ing the cavity as far as convenient and smoothing the borders of it, take an impression in modeling compound, endeavoring to get the margins of the cavity fairly well brought out; put a few threads of cotton into the cavity and saturate them thoroughly with a 5 to 10 per cent solution of cocain, cover this with a small bit of rubber dam, and then press the compound impression down upon it. We obtain thereby a perfect closure of the margin, so that the liquid can not escape, and one can then exert pressure with the thumb sufficient to press the solution into the dentin." 2. THE PULP is COVERED WITH A THICK LAYER OF HEALTHY DENTIN. With a very small spade drill bore through the enamel or direct into the exposed dentin at a most convenient place, guid- ing the drill in the direction of the pulp chamber. Blow out the chips, dehydrate with alcohol and hot air, and apply the hypo- dermic or high pressure syringe, provided with a special needle, making as nearly as possible a water-tight joint. Apply slow, continuous pressure for two or three minutes. With a burr the pulp should now be exposed, and, if still found sensitive, the process is to be repeated. Regarding the principle of pressure anesthesia, it should be re- membered that we can not force a liquid through healthy dentin by a mechanical device without injury to the tooth itself. An attempt to force fluids by high pressure through sound living dentin into a pulp will result in failure. Walkhoff has tried to 1 Loeffler! Dental Summary, 1906, Vol. VII. * Miller: Dental Register, 1904, Vol. IV. TECHNIQUE OF THE INJECTION 571 force colored solutions into freshly extracted teeth by applying six atmospheres pressure for half an hour without success. If a cocain solution is held in close contact with the protoplasmic fibers of the dentin, the absorption of cocain takes place in accord- ance with the laws of osmosis. The imbibition of the anesthetic is enhanced by employing a physiologic salt solution as a vehicle. Living protoplasm, however, reacts unfavorably against the ready absorption of substances by osmosis for two reasons: First, as Graham has shown, the albumin molecule is relatively large and not easily diffusible, and, second, as an integral part of its life it possesses "vital" resistance toward foreign bodies. These bio- logic facts, as stated by Walkhoff, 1 describe in a pregnant man- ner some of the most important physiologic functions of the odon- Fig. 156. Weaver high pressure obtunding syringe. toblasts. The accuracy of this dictum is easily demonstrated by the fact that it is almost impossible to stain living tissue, while dead tissue is at once penetrated by a suitable staining solution. Contact anesthesia is possible only when the medicament is placed on dentin in the form of a solution, and consequently dehydration of the protoplasm increases the endosmosis of the anesthetic solu- tion markedly. When we apply the same pressure anesthesia on carious dentin, the above statements do not hold good. We are able to press fluids quite readily through carious dentin. We must bear in mind that such dentin has been largely deprived of its inorganic 1 Walkhoff: Das Sensibile Dentin, 1899. 572 LOCAL ANESTHESIA salts, leaving an elastic, spongy matrix in position. The carti- laginous dentin should be suitably prepared prior to the intro- duction of the anesthetic solution that is, the fatty deposits should be removed with chloroform, or still better, with aceton, and the moisture dehydrated with the hot air blast. If the anesthetic fluid is now confined under a suitable water-tight cover, the pressure applied by the finger or with an instrument is quite sufficient to obtain the desired result. Aqueous eosin solutions may be forced through such dentin in less than two minutes, and even thick layers of dentin may be readily penetrated by such colored solu- tions by slightly increasing and prolonging the pressure. It should be borne in mind that these experiments, if conducted with teeth out of the mouth, do not at all represent the conditions as found in teeth in their normal anatomic surroundings. In teeth not fully calcified and in so-called "soft" teeth, pressure anesthesia is more readily obtained, while, according to Zeder- baum, 1 the process fails in teeth of old persons, teeth of inveterate tobacco chewers, worn, abraded, and eroded teeth with extensive secondary calcific deposits, teeth whose pulp canals are obstructed by pulp nodules, teeth with metallic oxids in tubules, teeth with leaky old fillings, badly calcified teeth, mainly all from one and the same cause namely, clogged tubules. In most cases no amount of persistent pressure will prove successful. The recent classic researches of Reich 2 on the formation of irregular dentin have amply demonstrated that secondary deposits of dentin are much more frequently present in the pulp chamber than have hitherto been supposed. The histologic structure of secondary dentin, as observed under the microscope, frequently shows an irregular mass of twisted tubules, which have no connection with the odontoblasts. Such dentin, as well as the presence of pulp nodules, mechanically bars the forcible introduction of fluids into the pulp. According to Hertwig 3 the protoplasm of the cell primarily transfers irritation, and, secondly, transmits absorbed materials, and therefore the anesthetic solution has to pass through the en- tire length of the dentinal fiber before the nerve tissue of the pulp J Zederbaum: Dental Register, 1904, p. 80. 'Reich: Das Irregulars Dentin, 1907. 'Hertwig: The Cell, 1903. TECHNIQUE OF THE INJECTION 573 proper is reached. Consequently a certain period of time is re- quired before the physiologic effect of the anesthetic is manifested, and this period of latency is dependent on the thickness of the in- termediate layer of dentin or bone. The successful anesthetization of the pulp depends largely on this most important factor of allow- ing sufficient time for the proper migration of the drug. Immediate root filling following the extirpation of the pulp by cocain anesthesia is not to be recommended. Among the many good reasons why a root canal should not be filled at this sitting, the following may be mentioned: The tissues above the foramen may have become anesthetized, and they do not act as a guide when the root is to be thoroughly filled; the tearing of the pulp from its connections at the apex produces more or less severe ir- ritation, which can be readjusted only by time; the root filling coming in contact therewith will only further irritate these tis- sues; and consequently hemorrhage and the formation of a clot in the apical area may also cause future severe irritation if the root is filled at the same sitting. A bland antiseptic should be in- serted in the root canal for a day or two, or until the much dam- aged tissues about the apex of the tooth have regained their normal equilibrium. Within recent years a number of complicated syringes, variously known as high pressure syringes and obtunders, have been advo- cated for the purpose of forcing anesthetic solutions through tooth substance by intense pressure. As we have stated, this conception of pressure anesthesia is erroneous. Close contact of the anes- thetizing fluid with the dentinal fibers, plus the necessary time for conveying the absorbed anesthetic to the nerve endings, explains the phenomenon very plausibly. A strong metal syringe, provided with a specially prepared needle to make a watertight joint as near as possible, is all that is required. Those who prefer a special high pressure syringe for such purposes may purchase any one of the many devices that will best suit their fancy. The "Weaver ob- tunder or the Jewett-Willcox syringe are much lauded for such purposes. Any of the various methods for anesthetizing a tooth for the purpose of its extraction, as outlined under "The Technique of the Injection," may be used for anesthetizing the pulp. Under 574 LOCALi ANESTHESIA certain conditions such procedures may be preferred to the various methods of pressure anesthesia. Treatment of Hypersensitive Dentin. Normal dentin has no sensation. The prolongations of the odontoblasts the dentinal fibrils when irritated directly or in- directly, may become extremely hypersensitive. This condition lasts as long as the pulp remains in a state of irritation. The remedies that are employed for the purpose of relieving the irrita- tion may be conveniently divided as follows : 1. General sedatives and anesthetics. 2. Local sedatives and anesthetics. 3. Caustics. The general sedatives and anesthetics are administered internally with the object of reducing the sensibility of the entire nervous system. Such drugs are opium, chloral hydrate, the bromids, and the general anesthetics. The local sedatives and anesthetics are applied on the dentin or on or in the tissues surrounding the tooth. The object of the latter method is to reach the nerves at the apical end of the tooth, and the drugs used for this purpose are cocain and its substitutes, certain essential oils, and the re- frigerant agents. The caustics are applied locally, and destroy the dentinal fibrils progressively. Most caustics are more or less self-limiting, and must be brought into intimate contact with the fibrils in order to destroy them. Arsenic trioxid, which, correctly speaking, is not a caustic, and formaldehyd (paraform), are not self-limiting in their action, and when applied on dentin always destroy the pulp via the dentinal fibrils. At present these agents are not used for the purpose of reducing hypersensitiveness of the teeth. (See Buckley's desensitizing paste, p. 167.) Without entering into a discussion of the value of the various methods employed, we wish to merely call attention to the local anesthetization of the pulp, either through the dentinal fibrils or by way of reaching the nerves at the apex of the individual tooth. To desensitize the dentin, any of the various methods that have been discussed under "The Technique of the Injection," in- cluding pressure anesthesia, may be successfully employed. It should be remembered that the tooth pulp is practically a transi- tory organ, which is subject to many changes during its life. In TECHNIQUE OF THE INJECTION 575 the young the pulp mass is large and very vascular, while in the old it is usually atrophied and studded with pulp stones or lime concretions of various shapes. It should be kept in mind that only a few drops of a 2 per cent novocain-epinephrin solution are required to completely anesthetize the pulp, provided sufficient time be allowed for the action of the anesthetic, and the anesthesia lasts from forty to sixty minutes. The objections made to this method that the pulp may die, or otherwise become injured by the anesthetic, are unfounded, provided the minimum quantity of the anesthetic solution is used. We have been able to satisfac- torily demonstrate by tests made with the electric current, that the pulp always regained its normal activity after it had been anesthetized for the above purpose. Recently exhaustive tests have been made on animals by Euler, with a view to establishing the possibility of producing death of the tooth pulp by injecting novocain-epinephrin according to the above method. In no case did he succeed in permanently injuring the pulp even by em- ploying relatively large quantities of the above solution. Acci- dentally cutting into the pulp in preparing the cavity may be considered a source of danger, as the normal sensation of the pulp, w r hich acts as a warning guide when too closely encroached upon, is temporarily abolished, and this fact may mislead the operator when excavating a cavity. Careful observation of the field of operation will cause a halt when the danger line is ap- proached. Some years ago potassocoin, a solution of cocain in alcohol and ether, with the addition of a small quantity of caustic potash, and vapocain, "a local obtundent containing 15 per cent cocain hydro- chlorid in ethereal solution," were freely discussed in dental litera- ture as useful remedies for the treatment of hypersensitive dentin. Both solutions are active only through their cocain component. The latter is materially interfered with in its ready absorption by the alcohol or ether solvent. Potassocoin apparently disappeared from the market, while vapocain is seemingly still in use. When applied to dentin, the ether has to be evaporated before the cocain can act on the dentinal fibers, and has to be redissolved by the aqueous contents of the tubules in order to act. "Vapocain is found in practice to possess great penetrating power, and this ac- tion seems to be due to the fact that the heat of the mouth vapor- 576 LOCAL ANESTHESIA izes a portion of the ether, driving the natural fluid of the tooth out of the tubules, thus securing a rapid distribution of the re- maining portion throughout the tooth structure. From this por- tion the ether is dissipated, leaving the cocain salt distributed in minute subdivisions throughout the tubules. The cocain is then redissolved by the natural fluid of the tooth, securing a rapid and effective anesthesia." Under pressure anesthesia we have discussed the fallacy of "driving cocain into the tubules of a liv- ing tooth." Some years ago cataphoresis was much lauded for the purpose of densitizing dentin. The principle of cataphoresis electric en- dosmosis consists in carrying a drug, which must be an electro- lyte, by means of the electric current into the tissues. The medic- ament is decomposed by the current electrolysis into ions. The ion, which is deposited on the positive pole, is known as the anion, and the deposit on the negative pole is referred to as the kation. For the above purposes cocain is usually employed. The complicated apparatus and the many difficulties that are encoun- tered in the application of cataphoresis do not justify the results obtained, as they are often unsatisfactory, and the method has been generally abandoned. From an historical point of view it is in- teresting to observe that Reuss, 1 of Moscow, wrote as early as 1809 on the subject of electric endosmosis. He was followed in later years by a number of other investigators, especially by Wiedemann (1856), Du Bois-Reymond (1860), Clemens (1860), and Beer (1869). When cataphoresis was introduced into dentistry in 1895 it seems that the past literature on the subject had escaped the notice of the majority of the writers on this subject, and many of the known facts had to be "rediscovered." Local Anesthesia for Operations About the Mouth, Exclusive of the Extraction of Teeth. In operating about the mouth for an abscess, a cystic or a solid tumor of the approximate size of a large walnut, a malposed tooth, or for any other purpose, the rhomboid infiltration according to Hackenbruch 2 affords the simplest methods of producing a most 1 Reuss: Notice sur un Nouvel Effect de 1" filectricite Galvanique. Memoirs de la Societe Imperiale des Naturalistes a Moscou, Vol. II. 2 Hackenbruch: Schmerzverhutung in der Chirurgie, 1906. TECHNIQUE OF THE INJECTION 577 satisfactory anesthesia. After previously cleansing the field of operation with an antiseptic solution, a very small drop of phenol is placed at a and & (Fig. 157) to superficially obtund the point of puncture. The needle is quickly thrust through the mucosa at a, and at once slow pressure is exerted on the piston, moving the needle steadily along the external line of the tumor. The needle is now partially withdrawn, without, however, leaving the origi- nal puncture, and a second injection or as many as may be needed are made in opposite directions. This maneuver is now repeated at &, and thus a circumscribed infiltration of the whole tumor is obtained. If the tumor, etc., is very large, additional punctures and injections may be made as outlined in the schematic draw- ing. After ten to fifteen minutes' waiting the extirpation of the Fig. 157. Anesthetizing a small tumor by rhomboid injection. (Ilackenbruch.) tumor may be begun. For injecting the soft tissues other than the gum, a 1 per cent novocain-epinephrin solution is quite suffi- cient. The anesthetization of the soft and hard palate is comparatively easily accomplished. The injection on the hard palate is started at the gingival edge of the alveolar periosteum on both sides of the jaw toward the median line. As this gum tissue is extremely dense, great force is required for a complete infiltration in this region, and only small quantities of the solution are required. The soft palate is easily infiltrated by inserting the curved needle posteriorly of the third molar. Small tumors and cysts on the tongue or the floor of the mouth are best anesthetized by the rhomboid infiltration of Hackenbruch. 578 LOCAL ANESTHESIA For the complete extirpation of a ranula, the injection is made into the cyst wall near the periphery, after which the cyst is slit open and a small quantity of the anesthetic solution is injected into the inner surface of the cyst. Large cysts, tumors, and major operations on the tongue require the anesthetization of both lin- gual nerves, as described on page 533. In injecting and operat- ing on the floor of the mouth, the index finger of the left hand should be placed on its external surface as a guide to the needle or the knife. The opening of the maxillary sinus (antrum of Highmore) from the oral cavity, whether by the Cowper-Drake operation through the alveolus of an extracted tooth or by the Lamorier- Desault modification through the canine fossa is successfully accomplished under local anesthesia. If the sinus is opened Fig. 158. Section through an anesthetized tumor, a, b, the zone of infiltration. (Hackenbruch.) through an alveolus, the technique of the injection is practically the same as used for the extraction of a tooth. If the perfora- tion is to be made through the anterior wall of the sinus, the in- filtration of the tissues is made as follows: The corner of the mouth is lifted upward and backward by means of a cheek re- tractor, the injection is started by inserting the needle horizon- tally over the canine tooth near the gum fold and in close con- tact with the bone, and the needle is m,oved posteriorly in various directions so as to infiltrate as large a field as possible. A sec- ond injection is made near the infra-orbital foramen. Two to three cubic centimeters of the anesthetic solution are necessary. After ten minutes ' waiting a large semi-circular cut is made, reach- ing from the canine eminence to the first molar; the flap, includ- ing the periosteum, is lifted up, and the extremely thin bone is now penetrated with a suitable drill. The sensitive mucous lining of the sinus is usually sufficiently anesthetized by the penetration of the fluid through the thin bone. We can recommend this method of opening the antrum of Highmore as the most satisfactory pro- cedure from the dental surgeon's standpoint. AFTER EFFECTS OF LOCAL ANESTHETICS 579 SIDE AND AFTER EFFECTS OF LOCAL ANESTHETICS AND THEIR RELATION TO THE PENAL CODE. Since cocain and its many substitutes, employed for the pur- pose of producing local anesthesia, have become an important ad- junct to the armamentarium of a routine practice, quite a num- ber of cases are on record in which the administration of these chemicals has caused serious untoward effects, which resulted in bringing the respective practitioners in conflict with the law. From a legal point of view these side and after effects may be considered as resulting in death of the patient, or producing in- tense psychic disturbances. Deaths from cocain, administered hy- podermically, were comparatively frequent in the earlier days of its history, and may be attributed to two specific causes first, to an impure product, and, second, to a too large dose. Cocain intoxication usually manifests itself in three definite ways. The first stage is characterized by intense psychic excite- ment; violent incoherent gesticulations are predominant, which are accompanied by muscular tremors and garrulity; the pulse is rapid and the respiration is very much increased ; frequently pro- nounced depressing sensations are noticed ; very slowly the patient will become quiet again. The second form of intoxication is rela- tively seldom met with; clonic and tonic spasms of groups of muscles, especially of the arms and limbs, are predominant; oc- casionally complete spasms may occur; after diminishing of the disturbance, the patient falls into a deep sleep. The third and most common form of cocain intoxication is the so-called cocain collapse; the patient faints; the skin is cold and clammy; the pulse is low, very rapid, and sometimes irregular; the respiration is much increased, being laborious in the beginning and later on weaker and irregular, resembling what is known as the Cheyne- Stokes respiration ; there is a pronounced feeling of fear from suf- focation and heart weakness; the patient collapses into a deep coma, and death results from cessation of respiration. Lewin 1 cites some very interesting factors concerning the side action of cocain. He states that neither the dose, the point of ap- plication, nor the individuality plays an important part in the 1 Lewin: Nebenwirkungen der Arzneimittel, 1899. 580 LOCAL ANESTHESIA untoward effects of cocain. These disturbances may occur either within a few minutes or even months after the administration of the poison. Cases are on record which show that patients have suffered for several weeks, or even for months, from its side effects. Women who have received cocain may display erotic conditions, with or without disturbance of consciousness. This fact makes it apparent that it is advisable to have a third person present when cocain is to be administered by the practitioner. In one instance the injection of cocain produced voluptuous emotions in a man, which resulted in ejaculation, and thus became the primary cause of his becoming a cocain habitue. The disturbances of the central nervous system manifest themselves in more or less intense excite- ment, either temporarily or lasting for hours, or even weeks. The patient is usually very garrulous or hilarious; he will boast of his great corporal strength and his immense mental faculties; he may remember facts which occurred twenty or thirty years ago, or he may talk in a quivering voice, or show signs of slight in- toxication ; often he runs to and fro, moving his arms or his body violently, or gives signs of hallucinations; occasionally the excite- ment may become so intense as to resemble mania. The paroxysm of intense excitement is usually followed by a more or less last- ing depression, which often reaches a melancholic or apathetic state. Intense psychic disturbances from average doses of cocain and its substitutes are comparatively rare at present, but nevertheless the recorded cases that have found their final settlement in courts of law are of sufficient importance to the general practitioner to warrant special mention. While it is an established fact that af- ter general narcosis whether the anesthetic be chloroform, ether, ethyl chlorid, ethyl bromid, nitrous oxid, etc. erotic dreams and sexual excitement have been frequently observed in men, and more especially in women, it is also important to remember that such disturbances do occur after the injection of local anesthetics. Cocain and its substitutes do not produce general narcosis, but they are known to have brought about a form of semi-conscious sleep, which apparently resembles hypnotic sleep. Fischer 1 re- ports a case of this nature as follows: A lady about 36 years of age, well built and of sound health, 1 Fischer: Deutsche Zahnarztliche Wochenschrift, 1908, p. 545. AFTER EFFECTS OF LOCAL ANESTHETICS 581 wished to have the abscessed roots of a lower molar extracted. Fischer injected 3 cubic centimeters of a 2 per cent novocain- thymol solution, to which he had added at the time of the injec- tion 3 drops of the new synthetic suprarenin solution (Hochst), 1 :1000. The injection, as in all patients of good constitution, was completed without pain. The time necessary for the diffusion of the liquid through the lower jaw bone was approximately calcu- lated at fifteen minutes. To make use of the intervening time, Fischer excavated two cavities on the same side of the mouth in the upper jaw. About one minute after the injection the patient noticed a complete anesthesia of the entire half of the left lower jaw; after about five minutes she was unable to feel the touch of the drinking glass on the lips on the affected side, and at about this time a slight increase in the pulse rate, lasting from one to three minutes, was perceptible. The patient fell into a half slum- ber, and she was barely able to open the mouth sufficiently to allow the preparation of the cavities in the upper teeth. The pulse and the respiration were soon normal again, and the patient had the appearance of a peaceful sleeper. She opened and closed her mouth at the doctor's command, and followed instructions, without, however, opening her eyes. The cavities were excavated without apparently feeling any pain, although the pulps were nearly exposed. About twenty minutes may have elapsed, and the two badly decayed root remnants were extracted. The patient awoke with a start, opened her eyes, and at the doctor's command washed out her mouth. She was now perfectly normal, and stated that a sudden pain from pressure awakened her. The anesthesia on the left side of the mouth was still persistent. The patient claimed that she always had been perfectly sound and healthy, and that she reacted very quickly and strongly to medicines. She had no knowledge of what happened during the sleep, and she was glad to know that the teeth were filled and the roots extracted. Another interesting case that illustrates very forcibly the pro- nounced psychic effects of local anesthetics, resulting in this in- stance in grave charges against the attending dental surgeon, oc- curred in Korner's 1 dental clinic at the University of Halle (Ger- many). The wife of a school teacher presented herself at the in- firmary to have a root of a bicuspid extracted. The tissues were 'Korner: Deutsche Monatsschrift fur Zahnheilkunde, 1904, p. 283. 582 LOCAL ANESTHESIA locally anesthetized with the ethyl chlorid spray, and the root was extracted by a student in the presence of the instructor. Not the slightest indication of a general narcosis, as sometimes oc- curs by inhaling the vapors of ethyl chlorid when sprayed on tis- sues in the mouth, was noticed. Immediately after the tooth was removed the woman left the operating room, being instructed to return in a week's time to have her mouth inspected. A week later the woman appeared before the chief of police, and in the presence of a physician made the statement that she had been raped by both the instructor and the student at a dental institu- tion. The recalling of this supposed episode occurred to her a week after the operation at the very moment when she re-entered the dental infirmary. Korner at once demanded a medical examina- tion of the woman, and the neurologists diagnosed an acute psy- chotic disturbance, which resulted in committing her to an insane asylum, from which, after months of treatment, she was discharged. Hallucinations produced under cocain influence may result in definite lasting impressions regarding certain persons or circum- stances. The following case furnishes a definite illustration : l A young lady claimed that she had been grossly insulted in a dental institute in Vienna, and that she recognized in the person of Doctor X, the supervisor of the clinic, her assailant. Her testi- mony consisted in one stereotyped answer to all questions, "It is he." On this testimony, and in spite of the Doctor's plea that he had never seen the person before, the Doctor was sentenced to serve eight days in jail. The defense appealed the case for re- vision, and Doctor X introduced a few snapshot pictures that were made with a camera by some friends while they and he were on a visit some miles away from Vienna on the same day and at the same hour which the plaintiff had specified in her claim. On being confronted with the pictures, the woman again pointed to the Doctor's figure in the picture and exclaimed. "It is he." The Court thereupon dismissed the case. Cocain intoxication, when combined with hysteria, may in some instance place the operator in an extremely embarrassing posi- tion, as illustrated in the following case: 2 A miss had a tooth extracted at a dental clinic, a local anesthetic 1 Ritter: Berliner Zahnarztliche Halbmonatsschrift, 1908, Vol. XVIII. 2 Ritter: Rechte, Pflichten und Kunstfehler in der Zahnheilkunde, 1903. AFTER EFFECTS OF LOCAL ANESTHETICS 583 being used. She showed signs of slight cocain intoxication and hysteric disturbances, but soon rallied and went home. Shortly afterward the assistant of the clinic, who was present at the opera- tion, but whom, the lady did not know even by name, received love letters from her. They remained unanswered, and three days later the lady killed herself by shooting after she had written to the assistant that she would do so unless she received an answer from him. To illustrate the temporary paralyzing effect of cocain intoxica- tion, the following case will serve as an example :* On the 29th day of August, 1888, a woman went into the office of Doctor E. P. Maloney, of New Orleans, to have a tooth ex- tracted. In order to extract it without pain, the doctor injected cocain hypodermically, in accordance with the demand. She stated that she had had the drug administered previously, and that she was keenly sensible to its effects, the last operation having rendered her ill for nearly three weeks. With these facts as a guide, Doctor Maloney proceeded to inject a small quantity of a weak solution 2 per cent into the gums. The lady demanded that more of the drug be used, as the gums still ached, and when the doctor demurred she left the chair without the tooth having been extracted. At the time she left she felt ill, and a moment later, after she had passed out of the office into the hall, the Doctor was startled at hearing a piercing scream coming from that direc- tion, and, hastily going to the spot, found that the lady had fallen unconscious. She remained in that condition for several hours, and ten thousand dollars damages were demanded for the injuries sustained from the injection of cocain. The case was thrown out of court on a technical error. The defense of a charge of assault claimed to have been com- mitted while the patient was under the influence of local anes- thesia requires the careful consideration of certain important fac- tors. Judge and jury are seldom confronted with cases of this nature, and they are only too apt to place the guilt on the dentist, especially if he is a young practitioner and is unable to bring wit- nesses for his defense. If the plaintiff is a young miss, the chances are still worse for the practitioner. J Rehfuss: Dental Jurisprudence, 1892, p. 65. 584 LOCAL ANESTHESIA From a medical point of view the strong plea of the defense should center about the following facts c 1 1. Cocain and most likely its alkaloid and synthetic substi- tutes employed as local anesthetics are known to produce more or less intense side and after effects, which may result in severe psychic disturbances. 2. The local uses of cocain and its substitutes do not produce general narcosis. They are known to have induced sexual excite- ment and erotic disturbances, which are prone to appear more often in woman than in man. 3. Local anesthesia, as produced in the mouth by ethyl chlorid or similar hydrocarbons, may also produce light forms of general anesthesia if some of the vapor is inhaled. Frequently a well-prepared brief, setting forth the side and after effects of local anesthetics, including an index of the litera- ture on the subject, and placed in the hands of the presiding judge, may materially assist in bringing about a broader conception of the case under consideration. 1 Dorn: Odontologische Blatter, 1906, p. 223. APPENDIX DIAGNOSIS OF DISEASES OF THE PULP BY THE ELECTRIC CURRENT. When a weak electric current is passed through the body of a vital tooth, a more or less pronounced reaction is produced, which is an expression of the vitality of its pulp. By carefully gauging the current, the resulting irritation expressed as pain becomes a most valuable diagnostic agent in determining the stage of vi- tality of the pulp. The correct diagnosis of a normal, a diseased, or a dead pulp is always a matter of great difficulty, and this difficulty is proportionally increased if the tooth under considera- tion does not present any visible signs of derangement. Various physical tests color, translucency, conductivity of temperature, percussion sound, etc. are at present in vogue, either alone or in their combined forms. The diagnostic value of these various tests is, to some extent at least, helpful in arriving at some pos- sible diagnosis, but these tests furnish no positive proof of the con- dition of the pulp. The transparency of the tooth may not be altered perceptibly by the death of the pulp. The discoloration of a tooth, on the other hand, may be brought about by the va- rious filling materials themselves, by recurrent caries under the filling, or by leakage of the filling. The transillumination of a tooth by means of the electric mouth lamp furnishes a fairly re- liable shadow picture of a healthy pulp ; the picture is diffused or dull when a dead pulp is present. Owing to the natural size of the teeth, the anterior teeth are more easily transilluminated. In the bicuspids, and especially in the molars, the thick body of the tooth crowns prevents ready transillumination, and as a con- sequence the diagnostic value of the light rays is much diminished. Transillumination of the oral structures should always be con- ducted in a darkened room, as it will materially assist in bring- ing out the shadow pictures much clearer than in the presence 585 586 APPENDIX of light. The heat test is also useful, but by no means absolute. Usually this test is made by placing a pellet of heated gutta- percha or some similar material on the surface of the suspected tooth. A tooth with a dead pulp does not respond in the same manner as a tooth with a normal, living pulp. The thickness of the tooth structure and the presence of the various filling materials may, according to their nature, increase or decrease the Fig. 159. Typical small faradic battery, with induction coil and core shield. The battery shows the hand electrode and the dental electrode connected with the combined current. conductivity of heat. An existing pulpitis may sometimes be fairly well diagnosed by the use of water of various temperatures. Walkhoff makes the statement that a normal pulp will not re- act between 68 and 120 F. (20 and 50 C.). Pain produced by water below 98 F. (37 C.) indicates inflammation, while pain produced above this temperature indicates the formation of pus. Tapping the tooth with a steel instrument is helpful. DIAGNOSIS OF DISEASES OP PULP BY ELECTRIC CURRENT 587 Percussion is best performed by striking the tooth with the butt end of an excavator, employing a short, sharp blow. The peculiar dullness of the resulting sound from a tooth with a dead pulp, as compared with that from a normal tooth, can be distinctly dis- cerned by the trained ear. The dullness of the sound is probably caused by inflammatory changes of the peridental membrane re- sulting from the disturbances of the products from the dead pulp or from external causes. The infiltration and the thickening of Fig. 160. Dental electrode. Charged with a wisp of cotton, ready for use. the fibers change the relationship of the tooth to the alveolar bone, and consequently the sound waves produced by the tap- ping have not that full, clear tone which we perceive from a similar percussion of a tooth with a normal pulp and healthy per- icementum. Within recent years the electric current has been ad- vocated as a means of diagnosing diseases of the pulp. The results Fig. 161. Dental hard rubber electrode with interrupter. obtained by this process are very gratifying, and its use for such purposes deserves to be highly recommended. HISTORY. In a remarkable book, "Treatise on Dental Caries," by Magitot 1 (Paris, 1867) and translated by Chandler (Boston, 1878) the following statement is recorded: "This examination (of the dental system) under circumstances so obscure, demands a careful attention. . . . Another method has also been pro- posed ; it consists of causing an electric current to pass along the 'Magitot: Treatise on Dental Caries, translated by T. H. Chandler, Boston, 1878. 588 APPENDIX whole extent of the dental arches by means of one of the little in- duction apparatuses so frequently employed nowadays in medicine. By the passage of a current so feeble as not to cause of itself any pain, the carious tooth will become the seat of an acute and clearly localized pain. John S. Marshall, 1 in a paper entitled, "Electricity as a Thera- peutic Agent in the Treatment of Hyperemia and Congestion of the Pulp and the Peridental Membrane," makes the following statement : ' As a means of diagnosis in obscure cases of the vitality or nonvitality of the dental pulp, I know of nothing so sure to demonstrate to a positive certainty these conditions as the elec- trical currents, both the galvanic and the faradic. In the more obscure cases, however, the faradic is superior to the galvanic, for if there is the slightest vitality remaining in the pulp, it will demonstrate it instantly by causing a response in the tooth." In 1896 Woodward 2 demonstrated the following: ''If a few cells of a cataphoric apparatus are in action, and the positive electrode be applied to the dentin or a metallic filling in a vital tooth, while the negative pole is at the cheek or wrist of the patient, a distinct sensation should be felt, while in case of a dead pulp there will be no response ; usually even a small filling will transmit a distinct shock in a vital tooth, which is absent in a devitalized tooth. A mild interrupted current has also been used for the test." 3 Marshall's as well as "Woodward's recommendation of testing the pulp by the electric current has never received the recognition by the profession which it justly deserves. In 1902 Puyt 4 pub- lished his researches "about the use of weak interrupted currents for the purpose of locating certain diseases in the pulp." About the same time, but independent of Fuyt, Hafner 5 utilized the re- duced direct current for the same purpose. A year before the publication of Fuyt's and Hafner's observations, Schroder 6 had used the secondary electric current for diagnosing diseases of the tooth pulp, and he published his observations in the annual report of his institution (1902). Since then quite an extensive amount of 'Marshall: Dental Cosmos, 1891, p. 973. 'Woodward: Proceedings Philadelphia Academy of Stomatology, 1896. * Inglis, Philadelphia: Private communication, 1908. 4 Fuyt: Zahnarztliche Rundschau, 1902, p. 533. 5 Hafner-Schurter: Schweizer Vierteljahrsschrift fiir Zahnheilkunde, 1902, No. 4. Schroder: Correspondenz Blatt fur Zphnarzte, 1905, No. 1. DIAGNOSIS OF DISEASES OP PULP BY ELECTRIC CURRENT 589 literature on this interesting subject has appeared, the more impor- tant publications being those of Witthaus, 1 Grevers, 2 Hamburger, 3 Frohmann, 4 Hesse, 5 An der Lahn, 6 Schroder, 7 Tousey, 8 etc. It is interesting to note that the various observers differ as far as the nature of the electric current is concerned. Fuyt advises the pri- mary current and Schroder uses the secondary current of the faradic battery, while Hafncr advocates the reduced direct cur- rent. The alternating current can not be used for such purposes. All investigators, however, obtained precisely the same results. To judge from the various publications on the subject, coupled with our observations in the use of this method, the primary and sec- ondary combined faradic current is best suited for this work on account of the simplicity of the apparatus and the easy manner in which this current can be regulated. THE FARADIC CURRENT AND ITS ACCESSORIES. The faradic bat- tery delivers an easily controlled current of minute quantity. Two forms of induction coils, in connection with the battery, are in general use for this purpose the induction coil with a core shield (the tube of Duchenne) and the sledge induction coil of Du Boys-Reymond. The source of electricity for the smaller in- duction coil is usually received from a single dip battery (acid potassium bichromate solution) or an ordinary dry cell, 9 while the sledge induction coil may be fed from a series of batteries, or from the street current, which is reduced by a reostat. The small, transportable induction coil with one dry cell battery gives universal satisfaction for the purpose in view, and on account of its cheapness, simplicity, and easy transportation deserves to be recommended. The induction coil produces a secondary current in a circuit placed near to, but not in contact with, the galvanic field. This 1 Witthaus: Deutsche Monatsschrift fur Zahnheilkunde, 1902, No. 11. 2 Grevers: Dental Cosmos, 1903, p. 58. Hamburger: Deutsche Monatsschrift fur Zahnheilkunde, 1907, No. 6. 'Frohmann: Deutsche Monatsschrift fur Zahnheilkunde, 1907, No. 3. 5 Hesse: Deutsche Monatsschrift fur Zahnheilkunde, 1907, No. 3. An der Lahn: Osterreich-Ungarische Vierteljahrsschrift .fur Zahnheilkunde, 1907, No. 2. 7 Schroder: Der Inductionsstrom als Diagnosticum in der Zahnarztlichen Praxis, 1907. 'Tousey: Dental Cosmos, 1909, p. 513. Battery fluid for the dip battery: To 5 pints of water add, under constant stirring, 8 fluidounces of sulphuric acid in a thin stream. Dissolve at once TYi ounces of powdered potassium bichromate in the hot mixture; after cooling, the fluid is ready for use. 590 APPENDIX galvanic field, the primary current, is represented by three or four layers of coarse copper wire, which are wound about the hollow, nonconducting cylinder, and the two ends of which are united with the binding posts. Within the cylinder is found a core of soft iron rods, which are covered in the simple induction coil by a movable brass tube (the tube of Duchenne). Outside of the core and the primary current is a second coil, usually consisting of a great many turns of fine copper wire. The ends of this coil are also connected with the binding posts. When the current from the cell passes through the coil of coarse wire the primary current a current is also produced in the secondary coil of fine wire because the passage of the primary current makes the iron core strongly magnetic. A vibrator is placed in close proximity to the iron core. When the current passes through the primary coil and becomes magnetized, the steel spring of the vibrator is attracted and breaks the current. The magnet is now immediately released and the spring reasserts itself. The control of the cur- rent is guided by moving the brass tube ; the gradual removal of the tube strengthens the current and vice versa. To furnish an approximate guide of the strength of the current, the tube of Duchenne is divided into ten equal parts by making file marks in the tube, or by pasting a narrow strip of paper, on which the divisions have been registered, on the tube. The divisions are re- ferred to as degrees. In the sledge induction coil of Du Boys- Reymond the secondary coil is moved bodily over the primary current. The registration of intensity is marked on a scale fas- tened to the apparatus, which is divided, according to the size of the apparatus, in 10, 50, or 100 degrees. This instrument is much more sensitive than the tube induction coil, and an exact dif- ferentiation between the various degrees is more readily obtained. The small faradic battery carries three binding posts and fur- nishes three definite currents. Posts 1 and 2 furnish the mild primary current, posts 2 and 3 furnish the more intense secondary current, while posts 1 and 3 furnish the strong combined current. The latter current is the one which is usually made use of for our purposes. The positive metallic hand electrode is held in the hand by the patient, while the negative pole carries the conducting cord, to which a specific dental electrode is attached. This dental electrode may consist of a piece of hard rubber in the form of DIAGNOSIS OP DISEASES OF PULP BY ELECTRIC CURRENT 591 a penholder, with a piece of German silver wire passing through its body. A socket is left at each end for the attachment of the conducting cord and the copper point. The latter is slightly roughened to carry a small piece of wet cotton; it may be bent to any desired angle. A serviceable dental electrode may be made as follows: The end of an opaque saliva tube is heated over a Bunsen flame, drawn to a point, and broken off so as to leave at its curved end a small opening about one-sixteenth of an inch in width. A piece of No. 26 German silver wire, about eight inches long, is soldered to a small disc of the same metal so as to fit the neck of the tube snugly at about one-quarter of an inch from its smaller opening. The wire is now loosely coiled, and its other end twisted to a spiral, which should fit the contact pin of the conducting cord. The coil is now pushed into the prepared glass tube, and, if necessary, cemented in place at its lower end. In using the electrode a piece of cotton wet with salt water is in- serted into the small opening and the other end is attached by means of the conducting cord to the negative pole of the battery. THE ACTION OF THE FARADIC CURRENT ON THE PULP. The diag- nosis of the condition of the pulp for clinical purposes resolves itself into hyperemia, inflammation, and death of this organ. As far as simple hyperemia of the pulp is concerned, the routine therapeutic treatment is so well known that no further discussion is needed at this moment. If inflammation of the pulp is pres- ent that is, when micro-organisms have gained access to the pulp the experienced practitioner will lose no time in destroying this pulp. The treatment of pulp gangrene is a matter of specific dis- cussion, which has no interest at present. The action of the electric current on a sound tooth calls forth a definite sensation which is in accordance with the normal re- ' action of the patient to electric stimulation. The strength of the current needed for this purpose varies with the individual. The sensation manifests itself in a peculiar tingling sensation, but not in pain. This point is known as the irritation point. After hav- ing established the irritation point in a sound tooth of the patient, and after having expressed it in figures from the markings on the tube of Duchenne, it is a simple matter to distinguish a diseased pulp reaction from a normal pulp reaction. By applying these figures, a reliable clue for the diagnosis of existing diseases of 592 APPENDIX the pulp is furnished. The following scheme may serve as a guide for making a diagnosis by means of the faradie current: 1. The normal pulp responds to the faradie current at the ir- ritation point. 2. The irritated pulp responds to the faradie current at the irritation point, or just slightly below it. 3. The inflamed pulp responds to the faradie current below the normal irritation point. The more severe the inflammation, the more ready the response to the current. 4. The inflamed pulp with pus infiltration (abscess formation) responds to the faradie current above the normal irritation point. The more severe the purulent condition, the less ready the response to the current. 5. The dead pulp does not respond at all, not even to the full strength of the faradie current. To illustrate this diagnostic scheme by figures as obtained from measurements with the tube of Duchenne, the following data may serve as examples: Degrees. Diagnosis. 1. Upper central incisors 3.5 Normal irritation point. 2. First upper right bicuspid 3 Pulp irritation. (The tooth shows a slight carious defect.) 3. First lower right molar 1.5 Acute pulpitis. (The tooth shows a deep carious defect.) 4. Second lower left molar 7.5 Purulent pulpitis. (The tooth is apparently in- tact; it has a large compound amalgam nil- ing-) 5. Second upper left bicuspid No response Dead pulp. (The tooth from current. has a large cement fill- ing-) THE TECHNIQUE OF APPLYING THE FARADIC CURRENT TO THE TOOTH. The positive metallic hand electrode of the faradie battery is held by the patient, or a wet cork or felt electrode is fastened to his wrist. The negative pole carries the dental electrode, which is manipulated by the operator. The current is started at its low- est amperage that is, the tube of Duchenne is completely pushed over the core, or the sledge is started at zero. The irritation point DIAGNOSIS OP DISEASES OF PULP BY ELECTRIC CURRENT 593 of the , patient is now obtained by holding the dental electrode against any of the apparently sound teeth. The upper central incisors are preferably selected for this purpose. The wet cot- ton of the electrode is placed near the center of the labial surface of the incisor, but always away from any present filling. The tube is now gradually withdrawn until slight, but distinct, sensa- tion is noticed by the patient. The sensation must never be ex- pressed as pain. The number on the scale of the tube is read, and the same maneuver is repeated on the other incisor. The average of the two readings furnishes the irritation point of the patient under treatment. It has been suggested by An der Lahn 1 to place both electrodes on the tooth, one lingually and one la- bially, and then pass the current directly through the crown of the tooth. This method does not give the same positive results as when the current travels through the long axis of the tooth and thereby passes through the entire pulp. The average irrita- tion point is not the same for every tooth and for every patient. A layer of thick enamel on a heavy body of dentin requires a stronger current and vice versa. Consequently the irritation point in the young is much lower than in old individuals. The con- dition of the nervous system of the patient may also influence the response to the current; a disturbed psyche is usually much more sensitive to electric stimulation than a normal condition. If the electrode is placed on or very close to a metallic filling in a vital tooth, the response is very pronounced, and even painful, as compared to the same amount of current passing through a tooth without a metallic filling. This is also true if the electrode is placed on a thin shell of enamel which covers a metallic fill- ing. The severity of the shock depends on the size of the filling. All filling materials gold, amalgam, or the cements, with the ex- ception of gutta-percha are better electric conductors than en- amel. The tooth under observation must be dry, and not in too close contact with its neighbors, as the current may switch to those teeth. The close proximity of large contour fillings or metallic crowns deserves special care. In such cases the rubber dam or strips of the dam placed between the adjacent teeth is necessary for isolation. The electrode must not be placed too near the gum line, or the gum tissue will react before the pulp is reached. The 1 An der Lahn : Loc. cit. 594 APPENDIX sensation felt on the gum is quite different from that in the pulp. It is not acute, but manifests itself as a tickling or crawling feel- ing. Devitalized teeth which carry fillings will also react if the electrode is placed on or near the filling; they will not react if the electrode is placed on sound enamel, provided that the root filling consists of gutta-percha. If the root carries a metallic post, a prompt shock is felt from the current. If a present filling reaches the gum line, a very quick and painful response is ex- perienced, even from a mild current, when placed in contact with the filling. The absence of enamel acts somewhat similar to the presence of a filling. A shock is usually produced when the cur- rent is placed on exposed dentin, which must therefore be avoided. A tooth with a dead pulp, but with a sound crown, will also re- act to the current if an acute pericementitis is present. Usually, however, a somewhat stronger current is required than that which is necessary to establish the irritation point. In multirooted teeth the pulp may be dead in one canal and highly inflamed in another canal. In such cases a reaction similar to that obtained from pur- ulent pulpitis is usually observed. The examination of the pulp by means of the faradic current requires a thorough mastering of the many details connected there- with. The practitioner can best familiarize himself with the cur- rent by using his own battery and induction coil, and by testing the instruments on himself and on an experimental patient. The teeth, gums, lips, and tongue are the organs which should be pre- liminarily tested. Before testing a tooth for pulp disturbances, it is always advisable to establish, if possible, the irritation point in the corresponding sound tooth of the opposite side of the jaw. The difference of the recorded figures furnishes the base for its diagnostic utilization. It is understood, of course, that no thera- peutic measures have been previously applied to the teeth under consideration or to the general system; their presence would ma- terially influence the reaction of the current. Some interesting experiments in this respect have been made by Schroder. 1 Mor- phin administered in average doses will reduce the reaction of the current three to four degrees below the normal irritation point. Its action manifests itself about fifteen to twenty minutes after its administration, and lasts from one and a half to two hours. 1 Schroder: Loc. cit. IMMEDIATE TREATMENT OP ACUTE POISONING 595 while chloral hydrate in 15-grain (1 Gm.) doses acts within three to four minutes, and reduces the scale two to three degrees, but its action lasts only from ten to fifteen minutes. The action of bromids and of bromural is also very pronounced. Their administration for the purpose of reducing the hypersensi- tiveness of teeth which have to undergo operative procedures Is referred to under Sedatives. The faradic current as a diagnostic aid in pulp diseases is far superior to any other method so far known, but it should be re- membered that it is not absolute in every case. IMMEDIATE TREATMENT OF ACUTE POISONING. GENERAL DIRECTIONS. When a poison has been swallowed, the stomach should at once be evacuated with the stomach tube, or, in its absence, with a fountain syringe. If corrosives have been swallowed and the mucous membranes are greatly swollen, the stomach tube is not indicated, as laceration of the soft tissues may follow. Emetics are of prime importance. Certain metallic salts, especially copper sulphate in 3-grain (0.2 Gm.) doses, and zinc sulphate in 10-grain (0.65 Gm.) doses, dissolved in a glassful of water, act very promptly. If the patient is unable to swallow, apomorphin hydro- chlorid, 1-10 grain (0.006 Gm.), hypodermically, acts promptly and vigorously. As an emergency remedy a tablespoonful of ground mustard stirred in a cupful of tepid water usually produces quick vomiting. If the poison is of an unknown origin, emetics, bland liquids, and stimulants, together with suitable systematic treatment, is indicated. ACETIC, HYDROCHLORIC, NITRIC, NITRO-HYDROCHLORIC, AND SULPHURIC ACIDS. No emetic should be given. To dilute and neutralize the acid, milk mixed with chalk, whiting, magnesia, or baking soda, strong soap suds, or white of egg beaten up with water, is given; later oil and mucilaginous drinks of flaxseed or slippery elm are indi- cated. Usually intense ulceration follows the acid burns. To re- lieve pain, morphin sulphate, 14 grain (0.015 Gm.), or tincture of opium, 15 drops (1 C.c.), is administered. 590 APPENDIX HYDROCYANIC ACIDS AND ALL CYANIDS, ALCOHOL, CHLOROFORM, ETHER, CHLORAL HYDRATE, GASOLIN, CARBON DISULPHID, AND SULPHURETS OP THE ALKALIES. Hydrocyanic acid and cyanids require very prompt measures ; they are quick and powerful poisons. Emetics may be given if necessary. The patient is put in a recumbent position, the head lowered, and plenty of fresh air allowed for free respiration. Per- sistent artificial respiration should be instituted if needed. Keep the body warm, and try to arouse the patient with ammonia vapors; put cold douches to his head and apply friction to the extremities. Strong stimulants whisky, nitroglycerin solution in i/2-drop doses, etc. are indicated. OXALIC ACID AND ITS SALTS. Give chalk or whiting mixed with two tablespoonfuls of vinegar and an equal quantity of water; do not give soda or potash with the object of neutralizing the acid. Vomiting should be induced at once and followed by olive oil or mucilaginous drinks. Gen eral stimulants- whisky, etc. and warmth applied to the extremi ties are essential. PHENOL (CARBOLIC ACID) AND ITS COMPOUNDS, CRESOL, CREOSOTE, LYSOL, AND RESORCINOL. Induce vomiting and give large quantities of sodium sulphate solution in the early stages. Remember that alcohol is not a chemic antidote for phenol or its compounds. Later give bland liquids, olive oil, and general stimulants as required. CAUSTIC ALKALIES AND AMMONIA. Promote vomiting by large draughts of warm water. Mild acids in the form of diluted vinegar or lemon juice are indicated, which should be followed by olive oil, white of egg beaten up with water, and mucilaginous drinks. Severe pain calls for mor- phin sulphate, 14 grain (0.015 Gm.), or tincture of opium, 15 drops (1 C.c.). ARSENIC AND ITS COMPOUNDS. Promote vomiting with large draughts of warm water and ad- minister at once hydra ted oxid of iron (the official antidote for IMMEDIATE TREATMENT OF ACUTE POISONING 597 arsenic) or dialysed iron. The official antidote may be prepared extemporaneously by mixing a teaspoonful of calcined magnesia with a cupful of water, add three teaspoonfuls of tincture of iron chlorid, mix well, and give the whole of it at once. This is to be followed with olive oil, white of egg beaten up with water, and mucilaginous drinks. ANTIMONY SALTS, COPPER SALTS, IODIN AND ITS PREPARATIONS, MERCURY SALTS, POTASSIUM BICHROMATE, TARTAR EMETIC, TIN AND ITS SALTS, ZINC AND ITS SALTS, COLCHICUM, CAN- THARIDES, AND THE OlLS OF CROTON, SAVIN, AND PANSY. Induce vomiting, which is usually produced by the metallic salts themselves. Give large draughts of raw white egg (about half dozen or more) beaten up with water, or flour stirred in water, strong tea or coffee, and general stimulants. To relieve pain and tenesmus, morphin sulphate, 1/4 grain (0.015 Gm.), is indicated. BARIUM AND LEAD SALTS. Give magnesium sulphate, 4 drams (15 Gm.), or sodium sul- phate, 1 ounce (30 Gm.), dissolved in a large tumblerful of water. Promote vomiting with warm water or with mustard, and follow with milk or demulcent drinks. Pain is relieved by morphin sulphate, 1/4 grain (0.015 Gm.), or tincture of opium, 15. drops (1 C.c.). SILVER NITRATE. Give common salt one-half tablespoonful dissolved in a tumbler- ful of warm water, and induce vomiting; later, large draughts of demulcent drinks starch, flaxseed, or slippery elm stirred in water are indicated. PHOSPHORUS (RAT PASTE, ETC.) Give a prompt emetic copper sulphate, 3 grains (0.02 Gm.), dissolved in a tumblerful of water every five minutes. Old, thick oil of turpentine in 1-dram (4 C.c.) doses, suspended in flour water and repeated every hour, is much lauded. Do not give oils or fats. Milk of magnesia is often beneficial. When indicated, give general stimulants. 598 APPENDIX ATROPIN, COCAIN, GELSEMIN, PILOCARPIN, AND ALL PREPARATIONS CONTAINING THESE ALKALOIDS. Induce vomiting, give large draughts of warm water, strong coffee and tea, and general stimulants. If the patient is drowsy, rouse him with ammonia vapors; apply heat to the extremities and institute artificial respiration if necessary. ACONITE, COTTON BOOT, DIGITALIS, ERGOT, LOBELIA, TOBACCO, VERA- TRUM, AND PREPARATIONS CONTAINING THESE SUBSTANCES. Give an emetic, which should be followed with large draughts of warm water, strong tea or coffee. Keep the patient in a hori- zontal position, apply warmth and friction to the extremities, and use artificial respiration if needed. OPIUM AND ITS PREPARATIONS, MORPHIN AND ITS SALTS, AND INDIAN HEMP. If necessary, vomiting should be induced. Give strong tea or coffee and large draughts of warm water. Keep the patient awake, and, if possible, in motion. A cold douche is beneficial. Strych- nin sulphat, 1-30 grain (0.002 Gin.), and atropin sulphate, 1-100 grain (0.0006 Gm.), administered hypodermically, are often of benefit. Persistent artificial respiration should be kept up, even after life seems to be extinct. NUX VOMICA AND ITS PREPARATIONS, STRYCHNIN AND ITS SALTS, AND FlSHBERRIES (COCCULUS INDICUS). Induce vomiting, followed by large draughts of warm water, and give tannic acid in 1 per cent solution of iodid of starch. Spasms are relieved by inhalation of chloroform, or by chloral hydrate. 15 grains (1 Gm.) dissolved in a tumblerful of water. Evacuate the bowels and give the patient absolute rest. FORMALDEHYD AND ITS SOLUTIONS. Give ammonia in very diluted solutions and demulcent drinks. General stimulants should be given when indicated. WOOD ALCOHOL. Give immediately a tablespoonful of common salt dissolved in a large tumblerful of warm water, and repeat at short intervals. GLOSSARY OF THERAPEUTIC TERMS 599 If necessary, stimulate the respiration with strychnin sulphate, 1-30 grain (0.002 Gm.), hypodermically, and give strong coffee or tea. DECAYED MEAT OR VEGETABLES. These materials are often productive of ptomain poisoning. In- duce vomiting and cleanse the bowels with full doses of castor oil. Strong stimulants, and heat and friction applied to the extremities, are beneficial. POISONOUS FUNGI. Evacuate the stomach as quickly as possible by promptly acting emetics. Give atropin sulphate, 1-100 grain (0.0006 Gm.), hypo- dermically, and tannic acid in the form of strong tea or coffee. GLOSSARY OF THERAPEUTIC TERMS. The following are brief definitions of the more important tech- nical terms employed to designate the medicinal properties of remedies : ABORTIVES Drugs which produce abortion Oil of savin. ABSORBENTS Drugs which promote absorption Charcoal. ABSTERGENTS Detergents. ADJUVANTS Substances which assist in the action of the principal drugs. ALTERATIVES Drugs which so favorably modify nutrition as to overcome morbid processes Potassium iodid. ANESTHETICS Drugs which produce general insensibility to pain Chloroform. ANESTHETICS, local Drugs which produce insensibility to pain in a localized area of tissue Cocain. ANALEPTICS Restorative drugs Validol. ANALGESICS Drugs which allay pain Acetanilid. ANAPHRODISIACS Drugs which depress sexual desire Camphor- ated opium. ANODYNES Drugs which relieve pain Morphin. ANTACIDS Drugs which neutralize acids Sodium bicarbonate. ANTHELMINTICS Drugs which destroy intestinal worms Santonin. ANTIARTHRITICS Drugs which relieve gout Hexamethylenamin. ANTIEMETICS Drugs which relieve vomiting Cerium oxalate. 600 APPENDIX ANTICONVULSANTS Drugs which relieve spasms Potassium bromid. ANTIHYDROPICS Drugs which relieve dropsical conditions Potas- sium acetate. ANTILITHICS Drugs which prevent the formation of stone or cal- culus Lithium carbonate. ANTILUETICS Antisyphilitics. ANTIPERIODICS Drugs which relieve malarial or recurrent fevers Quinin. ANTIPHLOGISTICS Drugs which counteract inflammation and fever Aconite. ANTIPYRETICS Drugs which reduce temperature or relieve fever Antipyrin. ANTIRHEUMATICS Drugs which relieve or prevent rheumatism Sodium salicylate. ANTISEPTICS Drugs which inhibit the growth of micro-organisms Diluted phenol. ANTISIALOGOGUES Drugs which decrease the flow of saliva Atropin. ANTISPASMODICS Drugs which relieve nervous irritability and spasms Sodium bromid. ANTISYPHILITICS Drugs used in the treatment of syphilis Mer- cury. ANTITOXINS Defensive proteins developed in the body as a result of the inoculation of a poison and acting as a neutralize!' of the poison Diphtheria antitoxin. ANTIZYMOTICS Drugs which inhibit fermentation Salicylic acid. APERIENTS Mild cathartics. APHRODISIACS Drugs which stimulate sexual impulse Nux vomica. AROMATICS Drugs characterized by a spicy odor and taste; used to stimulate the mucous membrane of the intestinal tract Colombo. ASTRINGENTS Drugs which induce contractibility of tissues and arrest discharges Tannic Acid. BLISTERS Drugs which, applied locally, cause inflammatory exuda- tion of serum; produce vesication Cantharides. CALEFACIENTS Drugs which, applied externally, produce a sense of warmth Capsicum. CARDIAC DEPRESSANTS Drugs which decrease the heart's action Amyl nitrite. GLOSSARY OF THERAPEUTIC TERMS 601 CARDIAC STIMULANTS Drugs which increase the heart's action Digitalis. CARMINATIVES Drugs which expel air from the bowels; relieve flatulence Oil of caraway seed. CATHARTICS Mild purgatives which quicken and increase expul- sion from the bowels Sodium sulphate. CAUSTICS Drugs which destroy living tissue Trichloracetic acid. CHOLAGOGUES Drugs which promote the flow of bile Calomel. CONVULSANTS Drugs which cause convulsions Cannabis indica. CORRECTIVES Drugs which correct or render more palatable the ac- tion of other drugs. . CORRIGENTS Correctives. COUNTERIRRITANTS Substances which, by counterirritation, relieve some other irritation Tincture of iodin. DEMULCENTS Mucilaginous substances which, in solution, soothe or protect inflamed or abraded surfaces Mucilage of acacia. DENTIFRICES Preparations which cleanse the teeth. DEODORANTS Drugs which destroy foul odors Potassium perman- ganate. DEPILATORIES Substances which remove hair Barium sulphid. DEPLETIVES Drugs which remove fluids from the system Magne- sium sulphate. DEPRESSANTS Sedatives. DETERGENTS Substances which cleanse or purify Soap. DIAPHORETICS Drugs which produce slight sweating Dover 's powder. DIETETICS Substances which regulate the diet. DIGESTANTS Ferments which aid digestion Pepsin. DILUENTS Substances which dilute secretions and excretions ; also render drugs less irritant Water. DISINFECTANTS Drugs which chemically destroy and render infec- tious material sterile or inert Chlorinated lime. DIURETICS Drugs which increase or promote secretion of urine Diuretin. DRASTICS Drugs which produce violent purgation Croton oil. ECBOLICS Drugs which accelerate labor Ergot. EMETICS Drugs which cause vomiting Apomorphin. EMMENAGOGUES Drugs which stimulate menstruation Tansy. EMOLLIENTS Substances which mechanically soften and protect tissues Petrolatum. 602 APPENDIX EPISPASTICS Blisters. ERRHINES Drugs which increase nasal secretions Boric acid. ESCHAROTICS Substances which produce caustic effects Silver nitrate. ETIOTROPICS Drugs which act on the causes of disease. EVACUANTS Drugs which evacuate; chiefly applied to purgatives, and also to emetics or diuretics. EXPECTORANTS Drugs which act on the pulmonic mucous mem- brane and increase or alter its secretion Ipecac. FEBRIFUGES Drugs which dispel or reduce fevers Acetanilid. GALACTAGOGUES Drugs which increase the secretion of milk Fen- nel. HEMOSTATICS Drugs which arrest hemorrhage Stypticin. HEPATICS Drugs which act on the liver Sodium phosphate. HYDRAGOGUES Purgatives which cause large, watery discharges Jalapin. HYPNOTICS Drugs which produce sleep Sulfonal. IRRITANTS Drugs which cause irritation Ammonia water. LAXATIVES Mild purgatives. MOTOR EXCITANTS Drugs which excite motor activity Strychnin. MOTOR DEPRESSANTS Drugs which lessen motor activity Curare. MYDRIATICS Drugs which cause dilation of the pupil ; mydriasis Atropin. MYOTICS Drugs which cause contraction of the pupil; myosis Physostigmin. NARCOTICS Drugs which produce sleep or stupor and simultane- ously relieve pain Opium. NEUROTICS Drugs which act on the nervous system Strychnin. NUTRIENTS Substances which nourish Foodstuffs. OBTUNDENTS Drugs which locally alleviate pain by partial anes- thesia Oil of cloves. ORGANOTROPICS Drugs which influence the function of organs. OXYTOCICS Drugs which stimulate uterine contraction Ergot. PERISTALTICS Drugs which increase peristalsis Magnesium ci- trate. PROPHYLACTICS Substances which prevent contracting or develop- ing disease. PROTECTIVES Drugs which protect a part Collodion. PTYALOGOGUES Sialogogues. DIAGNOSTIC ACIDS 603 PURGATIVES Drugs which cause copious discharge from the bowels Aloin. REFRIGERANTS. Drugs which decrease the bodily temperature Ethyl chlorid. REVULSANTS Drugs which, by causing irritation, draw nervous force and blood from a distant diseased part ; counterirritation. RUBEFACIENTS Drugs which cause irritation and redness Cap- sicum. SEDATIVES Drugs which decrease functional activity Henbane. SIALOGOGUES Drugs which stimulate the salivary glands to secre- tion Pilocarpin. SOMNIFACIENTS Soporifics. SOPORIFICS Drugs which cause profound sleep Chloral hydrate. SORBEFACIENTS Drugs which cause absorption. SPECIFICS Drugs which have a direct curative influence on certain specific diseases Mercury on syphilis. STIMULANTS Drugs which increase functional activity Alcohol. STOMACHICS Stimulants to the stomach Nux vomica. STYPTICS Local hemostatics. SUDORIFICS Diaphoretics. TENIAFUGES Drugs which expel tape worms Pelleterin. TONICS Drugs which restore the normal tone by stimulating nutri- tion. TOPICS Local applications. VERMICIDES Drugs which kill intestinal worms Thymol. VERMIFUGES Drugs which cause expulsion of intestinal worms American worm seed.. VESICANTS Blisters. VULNERARIES Drugs which promote healing of wounds lodo- form. DIAGNOSTIC AIDS. Frequency of Pulse. A.t birth 130 to 150 times a minute. At the first year 100 to 130 At the seventh year 72 to 90 At the time of puberty 80 to 85 At middle life 69 to 75 At old age 50 to 60 604 APPENDIX Frequency of Respiration. At the first year 35 times a minute. At the second year 25 " " At the time of puberty 20 " " Above twenty years of age 18 " " Temperature of the Body. Normal temperature 97% to 98V& F. (36.3 to 36.9* C.) Feverishness 99 to 100 F. (37.3 to 37.8 C.) Slight fever 100 to 101 F. (37.8 to 38.4 C.) Moderate fever 102 to 103 F. (38.9 to 39.5 C.) High fever 104 to 105 F. (40. to 40.6' C.) Intense fever 105 F. (40.6 C.) Comparison Between Temperature and Pulse. A temperature of 98 F. (36.7 C.) corresponds to a pulse of 60 " 99 F. (37.2 C.) " " 70 " 100 F. (37.8 C.) " " 80 ' ' 101 F. (38.4 C.) " " 90 " 102 F. (38.9 C.) " " 100 " 103 F. (39.5 C.) " " 110 " 104 F. (40. C.) " " 120 " 105 F. (40.6 C.) " " 130 " 106 F. (41.2 C.) " " 140 THERMOMETRIC EQUIVALENTS 605 THERMOMETRIC EQUIVALENTS. To reduce Centigrade degrees to those of Fahrenheit, multiply by 9, divide by 5, and add 32; or, degrees Centigrade X 1.8+32= degrees Fahrenheit. To reduce Fahrenheit degrees to those of Centigrade, subtract 32, multiply by 5, and divide by 9 ; or, degrees 32-^-1. 8=degrees Centigrade. Degrees Degrees Degrees Degrees Cent Fahr. Cent. Fahr. Cent. Fahr . Cent Fahr. -20 -4. 17 62.6 54 129.2 91 195.8 -19 -2.2 18 64.4 55 131. 92 197.6 -18 -0.4 19 66.2 56 132.8 93 199.4 -17 1.4 20 68. 57 134.6 94 201.2 -16 3.2 21 69.8 58 136.4 95 203. -15 5. 22 71.6 59 138.2 96 204.8 -14 6.8 23 73.4 60 140. 97 206.6 -13 8.6 24 75.2 61 141.8 98 208.4 -12 10.4 25 77. 62 143.6 99 210.2 -11 12.2 26 78.8 63 145.4 100 212. -10 14. 27 80.6 64 147.2 101 213.8 - 9 15.8 28 82.4 65 149. 102 215.6 - 8 17.6 29 84.2 66 150.8 103 217.4 1 19.4 30 86. 67 152.6 104 219.2 - 6 21.2 31 87.8 68 154.4 105 221. - 5 23. 32 89.6 69 156.2 106 222.8 - 4 24.8 33 91.4 70 158. 107 224.6 - 3 26.6 34 93.2 71 159.8 108 226.4 - 2 28.4 35 95. 72 161.6 109 228.2 - 1 30.2 36 96.8 73 163.4 110 230. 32. 37 98.6 74 165.2 111 231.8 1 33.8 38 100.4 75 167. 112 233.6 2 35.6 39 102.2 76 168.8 113 235.4 3 37.4 40 104. 77 170.6 114 237.2 4 39.2 41 105.8 78 172.4 115 239. 5 41. 42 107.6 79 174.2 116 240.8 6 42.8 43 109.4 80 176. 117 242.6 7 44.6 44 111.2 81 177.8 118 244.4 8 46.4 45 113. 82 179.6 119 246.2 9 48.2 46 114.8 83 181.4 120 248. 10 50. 47 116.6 84 183.2 121 249.8 11 51.8 48 118.4 85 185. 122 251.6 12 53.6 49 120.2 86 186.8 123 253.4 13 55.4 50 122. 87 188.6 124 255.2 14 57.2 51 123.8 88 190.4 125 257. 15 59. 52 125.6 89 192.2 126 258.8 16 60.8 53 127.4 90 194. 127 260.6 606 The doses given in this table are those commonly employed for adults and per mouth unless otherwise stated. The figures in the first column of doses represent grains when the remedy is a solid and minims when it is a liquid. The figures in the second col- umn signify grams when the remedy is a solid and cubic centi- meters when it is a liquid. Remedy Grains or minims Grams or C.c. Abstract, aconite J /4 V2 520 '/r-lVi 13 12 13 13 25 13 320 510 '/< Vi 515 520 25 510 515 11 310 120180 515 1540 Ve V 515 Veo Vso 1030 515 13 1030 Vs 2 26 * 1030 510 820 815 520 '/2 3 510 3090 310 1030 1020 25 0.015 0.3 0.03 0.06 0.06 0.06 0.06 0.13 0.06 0.03 0.03 0.015 0.3 0.3 0.13 0.3 0.3 0.06 0.2 8. 0.3 1. 0.01 0.3 0.001 0.6 0.3 0.06 0.06 0.03 0.13 0.6 0.3 0.5 0.5 0.3 0.03 0.3 2. 0.2 0.6 0.6 0.13 0.03 1.3 0.1 0.2 0.13 0.2 0.2 0.3 0.2 1.3 0.6 - 0.03 1. 1.3 0.3 0.6 1. 0.13 0.6 12. ^ 2^5 0.03 1. 0.0003 2. j 0^2 2. 0.13 0.4 2. 0.6 1.3 1. 1.3 0.2 0.6 6. 0.6 2. 1.3 0.3 aspidosperma belladonna . . . cannabis indica conium digitalis gelsemium hyoscyamus . . . ignatia ipecac jalap nux vomica phytolacca pilocarpus podophyllum senega valerian veratrum viride Acetanilid . Acetal Acetone Acid, acetic agaricic anisic arsenous benzoic boric cacodylic camphoric carbolic cathartic citric cubebic di-iodo-salicylic filicic, amorphous gallic gynocardic hydriodic hydrobrom, diluted hydrochlor. diluted hydrocinnamic hydrocyanic, diluted . . DOSE TABLE 607 Remedy Grains or minims Grams or C.c. Acid, hypophosphorous 310 0.2 0.6 lactic 1530 1. 2. luricic ^agaricic). . . i/ i/ 01 03 mono-iodosalicylic 15 45 1 3. naphtionic 10 20 0.6 1.3 nitric, diluted 5 30 0.3 2. nitro-hydrochlorid, diluted 5 20 0.3 1.3 osmic 1/64 0.001 oxalic Vr1 0.03 0.06 oxynaphtoic 13 0.06 0.2 paracreosotic 220 0.13 1.3 phenylacetic 24 0.13 0.25 phosphoric 26 0.13 0.4 diluted 20 60 1.3 4. picric 1/22 0.03 0.13 propylacetic 3 5 0.2 0.3 quinic 820 0.5 1.3 salicylic 1040 0.6 2.5 santoninic 15 0.06 0.3 sclerotic Vr-1 0.03 0.06 succinic 515 0.3 1. sulphanilic 1020 0.6 1.3 sulphuric, aromatic 1020 0.6 1.3 diluted 1530 1 2. sulphurous 1560 1 4. tannic 220 0.13 1.3 tartaric . 1030 0.6 2. valerianic 210 0.13 0.6 Aconapellin VM Vi2 0.0025 - 0.005 Aconitin, cryst 0.0001 - 0.0003 Adonidin Vl6 V4 0.004 0.016 Agaricin Vr- - 1 0.015 0.06 Agathin 28 0.13 0.5 Agoniadin 24 0.13 0.25 Airol 25 0.13 0.3 Alantol V V 0.01 0.03 Alcohol methylic 1040 0.6 2.5 Aletrin 13 0.06 0.2 Allyl sulphid daily 12 daily 0.06 0.13 tribromid 510 0.3 0.6 Alnuin 25 0.13 0.3 Aloes 220 0.13 1.3 purified ^ 110 0.06 0.6 Aloin Vr 2 0.03 0.13 Alphol 815 0.5 1. Alphozon Vr 2 0.03 0.12 Alum 515 0.3 1. emetic 60120 4. 8. ammonioferric 515 0.3 1. Aluminium acetate 510 0.3 0.6 chlorid 15 0.06 0.3 Ammonia water 1030 0.6 2. cone 410 0.25 0.6 Ammoniac 515 0.3 1. Ammonium, acetate. . 1530 1 2. 608 APPENDIX Remedy Grains or minims Grams or C.c. Ammonium arsenate i/ 20 i/ 1Q 003 006 benzoate 1030 0.6 2. bicarbonate 515 0.3 1. bisulphate 10 30 0.6 2. bisulphite 10 30 0.6 2. borate 1020 0.6 1.3 bromid 1530 1 2. camphorate 13 0.06 0.2 carbolate 26 0.13 0.4 carbonate 520 0.3 1.3 chlorid 520 0.3 1.3 embelate 3 6 0.2 4 chlorid ferrated 4 12 25 8 fluorid 11 31 0.005 0.05 formate 510 0.3 0.6 glycerine-phosphate 36 0.2 0.4 hypophosphite 1030 0.6 2. hyposulphite 530 0.3 2. iodid 35 0.2 0.3 phosphate 520 0.3 1.3 picrate ii ii/ 0.015 0.1 salicylate 210 0.13 0.6 succinate 13 0.06 0.2 sulphite 520 0.3 1.3 sulphocarbol 15 0.06 0.3 tartrate 530 0.3 2. valerianate 28 0.13 0.5 and iron tart 1030 0.6 2. Ammonamid 515 0.3 1. Ammonol . . 520 0.8 1.3 salicylate 820 0.5 1.3 Ampelopsin 24 0.13 0.25 Amygdophenin 515 0.3 1. Amyl nitrite 25 0.13 0.3 salicylate, daily 30 2. valerianate 36 0.2 0.4 Amylamine, hydrochlorate 315 0.3 1. Amylen-chloral 830 0.5 2. hydrate 1530 1. 2. Anesthesin 5 0.3 Analgen 515 0.3 1. Anemonin V 1 0.015 0.06 Anilin sulphate 3/ 4 _ll/ 2 0.05 0.1 Anilipyrin 1530 1. 2. Anthemin 13 0.06 0.2 Antiarthrin 610 0.4 0.6 Antifebrin, acetanilid 310 0.2 0.6 Antikol 310 0.2 0.6 Antimony arsenate Veo Vso 0.001 0.0002 iodid /4 1 0.015 0.06 oxid 13 0.06 0.2 and potassium tart 1/32 Vs 0.002 0.008 Antinervin 1020 0.6 1.3 Antipyrin 1020 0.6 1.3 salicylate ... 515 0.3 1. tannate. . 2045 1.3 .3 DOSE TABLE 609 Remedy Grains or minims Grams or C.c. Antirheumaticum 1 2 06 13 Antisepsin 28 0.13 05 Antispasmin 1/62 0.01 13 Antithermin 1 3 0.06 02 Apiol, cryst 5 15 0.3 1 fluid 5 10 0.3 06 Apiolin 3 2 Apocodein hydrochlorate Vs 1 02 06 Apolysin 824 05 15 Apomorphin, hydrochlorid. ... i/ 11 003 008 Arbutin 515 03 1. Arsenhemol : 13 0.06 0.2 Arsenic bromid i/ 60 1/ 16 001 004 chlorid i/ 60 1/ 15 001 004 iodid i/ 60 i/ u 0.001 004 Asafetida 515 03 1. Asaprol 5 15 03 1. Asclepin 24 0.13 0.25 Asepsin 2 8 13 05 Aspidium 30 90 2 6 Aspidospermin 12 06 0.13 Aspirin 530 0.3 2. Atropin i/ 20 1/ 60 0005 0.001 Avenin i/ 20 1/ 60 0005 0.001 Balsam, fir 530 0.3 2. euriun. . 1060 0.6 4. peru. . 1030 0.6 2. tolu 5 15 0.3 1. traumatic 3060 2. 4. Baptisin l /f 6 03 0.3 Barium chlorid 006 0.03 iodid ij i/ 0.006 0.03 sulphid i/ i 03 0.06 Barosmin 24 0.13 0.25 Basham's mixture 240480 15. 30. Bebeerin 03 1. Benzacetin 815 0.5 1. Benzanlid 0.1 1. Benzene (Benzol) 210 0.13 0.6 Benzonaphthol 515 0.3 1. Benzoparacresol 48 0.25 0.5 Benzosol 315 0.2 1. Benzoyleugenol 815 0.5 1. Berberin 0.3 0.1 hydrochlorid 510 0.3 0.6 sulphate 815 0.5 1. Betin 24 0.13 0.25 Betol 48 0.25 0.5 Bismal 25 0.13 0.3 Bismuth, albuminate 515 0.3 1. benzoate 515 0.3 1. betanaphtol 515 0.3 1. carbolate 515 0.3 1. citrate 1 3 0.06 0.2 lactate. . 515 0.3 1. 610 APPENDIX Remedy Grains or minims Grams or C.c. Bismuth nitrate (tri-) 510 515 56 310 3060 310 515 38 510 515 530 48 310 540 1030 13 25 815 520 2040 3090 510 1530 15 1530 315 2060 515 13 60240 1012 1575 220 drops 1530 'A 2* 520 V '/ IVi 4 15 210 26 310 310 1030 15 1030 510 25 1040 520 515 310 0.3 0.3 0.3 0.2 2. 0.2 0.3 0.2 0.3 0.3 0.3 0.25 0.2 0.3 0.6 0.06 0.13 0.01 0.5 0.3 1.3 2. 0.3 1. 0.06 1. 0.2 1.3 0.3 0.06 4. 0.6 1. 1. 0.005 0.015 0.3 0.005 0.1 0.06 0.13 0.13 0.2 0.2 0.6 0.6 0.6 0.3 0.13 0.6 0.3 0.3 0.2 - 0.6 (U 0.6 4. - 0.6 1 / oxid oxybromid oxyiodid (subiod.) peptonized phosphate soluble pyrogallate resorcinate 0.5 - 0.6 1. 2. 0.5 0.6 2.5 2. 0.2 0.3 0.05 1. 1.3 2.5 6. 0.6 2. 0.3 2 i! 4. 1. 0.2 15. 0.75 5- 2. 0.03 0.13 1.3 0.01 0.25 0.3 0.6 - 0.4 0.6 0.6 2. 0.3 2. 0.6 0.3 2.5 1.3 1. 0.6 salicylate acid salicylate (basic) subcarbonate subgallate subiodid = bismuth oxy-iodid subnitrate tannate valerianate and ammonium citrate and cinchonid. iodid Bismuthan Blennostasin Borax Boroglycerin Borol Brayerin Brenzcain Bromalbacid Bromal hydrate Bromalin Bromamid Bromin Bromipin (10 per cent) Bromochinal Bromocoll Bromoform Bromo-hemol Brucin Bryonin Butyl-chloral hydrate Cadmium sulphate Caffein triiodid < Caffein citrated hydrobromate and sodium benzoate and sodium salicylate Calcium benzoate borate bromid bromo-iodid carbolate . . . carbonate . chlorid eosolate dioxid . DOSE TABLE 611 Remedy Grains or minims Grams or C.c. Calcium, ferrophospholactate 38 0.2 05 glycerinophos 310 0.2 0.6 hippurate 515 0.3 1. hypophos 1030 0.6 2. hyposulphite 310 0.2 - 0.6 iodid 25 0.13 0.3 iodate 34 0.2 0.25 lactate 310 0.2 0.6 lactophosphate 310 0.2 0.6 phosphate 1020 0.6 1.3 permanganate 12 0.06 0.13 quinovate Ve Vz 0.01 0.03 saccharate 10 30 0.6 2. salicylate 820 0.5 1.3 santoninate Vr l l / 0.03 0.1 sulphid, yellow IVa 3 0.1 0.2 sulphite 15 0.06 0.3 sulphocarbol 515 0.3 1. Calendulin 13 0.06 0.2 Calomel V 1 0.02 0.06 cathartic 515 0.3 1. Camphor 25 0.13 0.3 carbolated 510 0.3 0.6 citrated 310 0.2 0.6 monobrom 25 0.13 0.3 salicylated 15 0.06 0.3 valerianated 15 0.06 0.3 Cannabin tannate 815 0.5 1. Cannabindon V l 0.02 0.06 Cannabinon X /2 1'/2 0.03 0.1 Cantharidin 0.00004 Capsicin VlO V4 0.006 0.015 Capsicum 15 0.06 0.3 Carniferrin 38 0.2 0.5 Cellotropin 58 0.3 0.5 Cerberin V240 1 /60 0.000250.001 Cerium nitrate 13 0.6 0.2 oxalate 15 0.06 0.3 Cerolin 510 0.3 0.6 Cetrarin lVr-8 0.1 - 0.2 Charcoal 1030 0.6 2. Chelidonin phosphate IVr 8 0.1 0.2 sulphate 1V 3 0.1 0.2 tannate 3 0.2 Chelidonium 1030 0.6 2. Chelonin 12 0.06 0.1 Chenopodium 1040 0.6 2.5 Chimaphilin 24 0.13 0.25 Chimaphenin 510 0.3 0.6 Chionanthin 13 0.06 - 0.2 Chirata 1030 0.6 2. Chloralamid 1545 1. 3. Chloral-ammonia 1530 1. 2. Chloralbacid 815 0.5 - 1. Chloral-caffein 36 0.2 0.4 subcut. subcut. 612 APPENDIX Remedy Grains or minims Grams or C.c. aformamid 1545 1. 3. 1030 0.6 2. 1530 1. - 2. 312 0.2 - 0.8 1045 0.6 - 3. 620 0.4 - 1.3 60240 4. 15. 60120 4. - 8. 520 0.3 - 1.3 f^hlnrnfnrm 25 0.13 - 0.3 60120 4. - 8. Vs V 0.008 - 0.015 530 0.3 2. l /r-2 0.03 - 0.13 515 0.3 - 1. 12 0.06 0.13 12 0.06 - 0.13 15 0.6 0.3 1030 0.6 - 2. 28 0.13 - 0.5 subcut. 1530 subcut. 1. - 2. 815 0.5 1. Pitmllin Ve Vs 0.01 0.02 0.015 - 0.03 i/ Jt i/ g 0.005 - 0.01 Vr-lVi 0.03 0.1 Codein i/ 2 2 0.03 0.13 */2 1 0.03 - 0.06 Colchicein subcut. Vi20 Veo subcut. 0.0005 0.001 Colchicin Vl20 VSO 0.0005 0.002 Vso 0.00075 13 0.06 - 0.2 24 0.13 - 0.25 Colocynth 310 0.2 - 0.6 V. 2 /3 0.01 - 0.04 Columbin Vi 1 0.03 - 0.06 Condurancrin VlO V4 0.006 - 0.015 0.001 - 0.004 Contradolin 48 0.25 0.5 Convallamarin i/ 2 i 0.03 0.06 24 0.13 0.25 Conv olvulin 13 0.06 0.2 2060 1.3 4. Vs 1 U 0.008 0.015 Vno every 0.005 every V* nitrate */2 hour hour 0.005 0.01 3 /4 1V 0.05 0.01 phosphate Vs V 0.008 0.03 sulphate 0.01 0.02 emetic 25 0.13 0.3 and ammonium sulphid ! /2 2 0.03 0.13 Cordol 1530 1. - 2. Coriamvrthin . . Veo 0.001 DOSE TABLE 613 Remedy Grains or minims Grams or C.c. Cornin 2 4 0.13 0.25 Cornutin citrate i/ 20 1/ 8 0.003 - 0.008 Coronillin 10 0.6 daily Cosaprin 515 0.3 1. Cotarnin hydrochloric! (stypticin) 3 /44 0.05 - 0.25 Cotoin 23 0.13 - 0.2 Creatin 12 0.06 - 0.13 Creatinin 12 0.06 - 0.13 Creolin 2 15 13 - 1. Creosotal 20 80 1.25 5. Creosote 115 0.06 1. carbonate 1530 1. 2. phosphate 1530 1. - 2. phosphite 115 0.06 - 1. valerianate 310 0.2 - 0.6 Cresol, meta 13 0.6 0.2 Cubebs 1560 1. - 4. Cupro-hemol 36 0.2 - 0.4 Curare 11 11 0.005 - 0.01 Curarin Veo Vi2 0.001 - 0.005 Cypripedin 13 0.06 - 0.2 Cystogen 5 0.3 Cytisin hydrochlorid 1/24 Vl 2 ' 0.0025 0.005 Damaianin 25 0.13 0.3 Daturin i/ 250 1/ 64 0.00025 0.001 Delphinin Veo J /20 0.001 - 0.003 Dermatol 48 0.25 - 0.5 Diaphtherin 815 0.5 - 1. Diastase 13 0.06 - 0.2 taka 35 0.2 - 0.3 Diathesin 815 0.5 1. Diethylketone 815 0.5 - 1. Digalen V*x> 0.0003 Digitalein ' 1/64 Vie 0.001 - 0.004 Digitalin, French 1/ 250 1/60 0.00025 0.001 German Vie Vi 0.006 0.03 Digitalis 13 0.06 0.2 Digitoxin 0.00025 0.0005 Dionin 1/41 0.015 0.06 Dioscorein 14 0.06 0.25 Diosmal 210 0.12 0.6 Dithion '. 315 0.2 - 1. Diuretin 15 1. Dorrniol 830 0.5 - 2. Dover's powder 520 0.3 - 1.3 Duboisine sulphate . . Vso Vzo 0.0008 0.003 . Duotal (carbonate) 415 0.25 - 1. Eigon, beta 1545 1. 3. alpha-sodium 1545 1. - 3. Elaterin Vzo Vu 0.003 0.005 Elaterium V Vl 0.008 - 0.03 Emetin alkaloid VIM Veo 0.0005 0.001 emetic Vie '/ 0.004 0.008 Emulsion, ammoniac. . 240480 15. 30. 614 ATPENDIX Remedy Grains or minims Gram s or C.c. Emulsion asafetida . 120360 8. 24. chloroform 60120 4. 8. Enesol '/ 0.01 Fititerin 515 0.3 1. Ergot 2090 1.3 6. Ergotin bombelon 3090 2. - 6. bonjean 310 0.2 - 0.6 Erythrol tetranitrid Vr 1 0.03 0.06 Erythrophlein hydrochlorid V32 Vl6 0.002 0.004 Erythroxylin V 1 0.015 0.06 Eserin salicylate 1/ 120 1/ 30 0.0005 0.002 Ether . . 1040 0.6 2.5 ozonized 3060 2. 4. petroleum 210 0.12 0.6 valerianic 12 0.06 0.12 Ethyl bromid *5 10 0.3 0.6 formate 60120 4. 8. iodid 515 0.3 1. valerianate 12 0.06 0.13 Ethylen bromid 12 0.06 0.13 Eucalyptol 412 0.25 0.8 Eudoxin 515 0.3 1. Eugenoform 515 0.3 ^ Eugenol 830 0.5 2. Eunatron 48 0.25 0.5 Eumenol 60 4. Eumydrin Veo */24 0.001 0.0025 Eunatrol 1015 0.6 1. Euonymin IVz 6 0.1 0.4 Eupatorin 13 0.06 0.02 Euphorbin Vi 3 0.015 - 0.2 Euphorin 815 0.5 1. Eupurpurin 14 06 0.25 Eupyrin 1530 1. 2. Euquinin. l lt 2 0.03 0.13 Europhen . Vz l'/2 0.03 0.1 Exalgin . . 25 0.13 0.3 Exodin 1545 1. 2 Extract, absinth., alcoholic 520 0.3 1.3 absinth, fluid 2060 1.3 4. achillea, alcoholic 520 0.3 1.3 fluid 3060 2. 4. aconite 1/4 V2 0.015 0.03 fluid l / 1 0.015 0.06 adhatoda, fluid 1560 1. 4. adonis root, fluid Vr 5 0.03 0.3 vern., aqueous Ve 1 0.01 0.06 a?sculus, glab., fluid. 1020 0.6 1.3 hippocast. bark, fluid 2060 1.3 4. seeds, fluid 1030 0.6 2. agrimonia, fluid 2060 1.3 4. aletris, alcoholic J /2 3 0.03 0.2 fluid 3060 2. 4. allium, fluid 3060 2. 4. aloes 16 0.06 - 0.4 *2J^ 5 fluidrams (10 20C.C.) as inhalation anesthetic. DOSE TABLE 615 Remedy Grains or minims Grams or C.c. Extract aloes, fluid 1030 3060 3060 3060 520 3060 3060 3060 3060 315 3060 1020 60120 815 520 530 14 315 3060 3060 2060 45120 1030 310 530 12 510 3060 60120 210 3060 520 1560 3060 60120 3060 3060 60240 3060 210 1060 '/ V. '/ 1 26 26 1030 3060 510 3060 3060 48 3060 520 26 2060 510 0.6 2. 2. 2. 0.3 2. 2. 2. 2. 0.2 2. 0.6 4. 0.5 0.3 0.3 0.06 0.2 2. 2. 1.3 3. 0.6 0.2 0.3 0.06 0.3 2. 4. 0.13 2. 0.3 1. 2. 4. 2. 2. 4. 2. 0.13 0.6 0.008 0.015 0.13 0.13 0.6 2. 0.3 2. 2. 0.25 2. 0.3 0.13 1.3 0.3 2. 4. 4. - 4. - 1.3 - 4. - 4. - 4. 4^ 1^ 4.' 1.3 8. 1. 1.3 2. 0.25 I 4! 4^ 4! 8. 2. 0.6 2. o!i3 0.6 4. 8. 0.6 4^ l!3 4 4! 8. 4. - 4. 15. - 4. 0.6 - 4. 0.03 0.06 0.4 0.4 2. - 4. 0.6 - 4. - 4. 0.5 4. 1.3 0.4 - 4. 0.6 alstonia, fluid althea, fluid alnus serrul., fluid ampelopsis, fluid anemone hepat., fluid angelica root, fluid seed, fluid anise fluid anthemis, aqueous fluid apium, alcoholic fluid aplopappus, fluid apocynum, fluid androsaemifol fluid cannab, alcoholic apple ferrated aralia hisp. fluid racem. fluid arctostaph, glauca, fluid areca, fluid ailanthus, fluid arnica flowers fluid arnica root fluid artemis abrotan, fluid frig., fluid vulff. . fluid asafetida, fluid asarum, fluid ascep. syriaca, fluid curassav., fluid incarn., fluid asparagus, fluid aspidium fluid aspidosperma fluid aurant amar., alcoholic baptisia, fluid belladonna leaves, alcoholic aqueous dry fluid berberis aquif., alcoholic fluid vulg., fluid blackberry, aqueous fluid black haw, fluid boldo, fluid borage, fluid brunfelsia, fluid bryonia, alcoholic fluid buchu. alcoholic. . 616 APPENDIX Remedy Grains or minims Grams or C.c. Extract buchu alcoholic, fluid 1530 2060 3060 3060 26 1560 26 1560 420 210 520 3060 1560 25 15150 15 2 3060 510 3060 1660 1030 510 3060 520 1560 26 1545 60120 520 30120 25 1030 3060 3060 1560 310 3060 520 1560 3060 3060 310 3060 1030 3060 25 2040 15 26 1545 110 515 25 1030 1. 1.3 2. 2. 0.13 1. 0.13 1. 0.25 0.13 0.3 2. 1. 0.015 0.13 1. 0.006 0.06 2. 0.3 2. 1. 0.6 0.3 2. 0.3 1. 0.13 1. 4. 0.3 2. 0.13 0.6 2. 2. 1. 0.2 2. 0.3 1. 2. 2. 0.2 2. 0.6 2. 0.13 1.3 0.06 0.13 1. 0.06 0.3 0.13 0.6 4. 4. 4. 4. - 0.4 4. 0.4 4. 1.3 - 0.6 - 1.3 - 4. - 4. 0.06 0.3 10. - 0.03 0.3 - 4. 0.6 4. 4. 2 o!e 4. 1.3 4. 0.4 3 8.' - 1.3 8. 0.3 2 4! - 4. 4 o!e 4. 1.3 4. - 4. - 4. 0.6 4. 2 4. - 0.3 2.5 0.3 0.4 3. 0.6 o!3 2 comp buckthorn berries, fluid burdock, fluid . calamus, dry fluid calendula, alcoholic fluid calumba, alcoholic dry fluid calycanthus, fluid canella, fluid cannab. indicus fluid capsella, fluid capsicum . fluid caraway, fluid cardenia, aqueous, dry fluid carthamus, fluid carum copt., fluid caryoph, fluid cascara, amarga sagr fluid cascarilla, alcoholic fluid castanea, fluid catechu, aqueous, dry fluid caulophyllum, alcoholic fluid celastrus, fluid cephalanthus, fluid cercis, fluid cereus grandiflora, fluid chamaelirium, fluid chelidonium, alcoholic fluid chenopodium, fluid chimaphila, fluid chionanthus fluid chirata, fluid chrysanthemum, fluid chrysophyllum, aqueous, dry cicorium cicuta, fluid cimicif uga fluid cinchona fluid cinch, calis., alcoholic, dry . . cinnamon, fluid. . DOSE TABLE 617 Remedy Grains or minims Grams or C.c. Extract, citrullus valg., fluid 60120 415 2060 3060 830 310 2060 2060 25 1560 13 310 410 2060 13 310 510 '/ 2 25 25 14 1530 515 3060 2060 510 3060 515 26 210 1560 15 1030 1030 15 1030 1030 25 1530 15 '/4 V V. 1 13 1560 3060 13 520 '/4-1 510 520 30120 3060 530 60240 60120 3060 4. 0.25 1.3 2. 0.5 0.2 1.3 1.3 0.13 1. 0.06 0.2 0.25 1.3 0.06 0.2 0.3 0.03 0.13 0.13 0.06 1. 0.3 2. 1.3 0.3 2. 0.3 0.13 0.13 1. 0.06 0.6 0.6 0.06 0.6 0.6 0.13 1. 0.06 0.015 0.01 0.06 1. 2. 0.06 0.3 0.015 0.3 0.3 2. 2. 0.3 4. 4. 2. 8. - 1. - 4. 4. 2. - 0.6 - 4. - 4. - 0.3 4. 0.2 - 0.6 - 0.6 4. - 0.2 0.6 O.H 0.1 0.3 0.3 0.25 2. 1. - 4. - 4. - 0.6 - 4. ^ 0^4 0.6 4. 0.3 2. 2. 0.3 2. - 2. 0.3 2. 0.3 0.03 0.06 0.2 - 4. 4. 0.2 1.3 0.06 0.6 1.3 8. - 4. 2. 15. 8. 4. coca alcoholic, dry fluid cochlearia, fluid officio coffee (green), alcoholic (green), fluid (roasted), fluid cola alcoholic, dry fluid colchicum seed acetic fluid collinsonia fluid colocynth compound fluid conium fluid leaves fluid convallaria, alcoholic fluid flowers, fluid corallorhiza, fluid coriander, fluid cornus flor . fluid coto crocus alcoholic cubeb fluid curcuma alcoholic fluid cusparia fluid cynoglossum aqueous fluid cyperus fluid cypripedium fluid delphin consolida, fluid digitalis alcoholic dry fluid dioscorea, fluid diospyros, fluid drosera fluid duboisia fluid dulcamara, alcoholic fluid echinacea, fluid elephantopus, fluid . embelia fluid ephedra, fluid ecifacus. fluid. . 618 APPENDIX Remedy Grains or minims Grams or C.c. Extract, epigasa, fluid 3060 3060 3060 515 30120 3060 2060 412 530 515 13 520 1040 60240 25 1560 2060 410 510 3060 530 3060 3060 310 1530 1020 2040 3060 15 1030 1060 815 3060 3060 12 1560 3060 M K 25 26 1030 1030 3060 510 3060 310 3060 60120 510 3090 1560 240720 310 2060 3060 310 2. 2. 2. 0.3 2. 2. 1.3 0.25 0.3 0.3 0.06 0.3 0.6 4. 0.13 1. 1.3 0.25 0.3 2. 0.3 2. 2. 0.2 1. 0.6 1.3 2. 0.06 0.6 0.6 0.5 2. 2. 0.06 1. 2. 0.015 0.13 0.13 0.6 0.6 2. 0.3 2. 0.2 2. 4. 0.3 2. 1. 15. 0.2 1.3 2. 0.2 4 4! 4. - 1. 8. 4. 4. 0.8 - 2. - 1. 0.2 1.3 2.5 15. - 0.3 - 4. - 4. 0.6 0.6 4. 2 4'. 4. 0.6 2. 1.3 2.5 - 4. 0.3 2. - 4. 1. 4. 4_ o!i3 4. - 4. - 0.03 0.3 0.4 2. 2. 4. 0.6 4 o!e 4. - 8. - 0.6 6. 4. 45. 0.6 - 4. 4. 0.6 epilobium, fluid equisetum, fluid ergot fluid erigeron, fluid eriodictyon, fluid alcoholic erythraea, aqueous erythrophleum, fluid eucalyptus, alcoholic, dry fluid seed, alcoholic fluid euonymus fluid eupatorium, fluid eupator, perfol . . . eupator. purpur fluid euphorb. coroll, fluid euphorb. pilulif., fluid fennel, fluid frangula, aqueous, dry fluid frankenia, fluid fraximus americ., fluid frax. sambucif., fluid fucus, dry fluid fumaria, aqueous galega, aqueous galium aparine, fluid galium ver., fluid garcinia fluid gaultheria, fluid gelsemium, alcoholic, dry fluid gentian . . . fluid gentian, fluid, co quinquefl., fluid geranium fluid gossypium, alcoholic, dry fluid gouania, fluid granatum, alcoholic, dry (tenif uge) fluid (tenifuge) grindelia, aqueous fluid guaco, fluid guaiac. . DOSE TABLE 619 Remedy Grains or minims Grams or C.c. Extract, guaiac, fluid 30120 25 1560 310 1560 1560 3060 /f IVi 3060 25 1020 3060 25 410 3060 310 1030 13 12 Vr-1 515 V V. 14 26 1030 1030 25 60120 310 1560 1030 3060 60240 210 515 1560 210 Vi-2 1030 1060 48 3060 310 2060 1560 '/2-2 210 210 1020 3060 3060 1 0240 240 60240 310 30120 2. 0.13 1. 0.2 1. 1. 2. 0.03 2. 0.13 0.6 2. 0.13 0.25 2. 0.2 0.6 0.06 0.06 0.03 0.3 0.008 0.06 0.13 0.6 0.6 0.13 4. 0.2 1. 0.6 2. 4. 0.13 0.3 1. 0.13 0.03 0.6 0.6 0.25 2. 0.2 1.3 1. 0.03 0.13 0.13 0.6 2. 2. 8. 15. 4. 0.2 2. 8. 0.3 4. 0.6 4. 4. 4. 0.1 4. 0.3 1.3 4. 0.3 0.6 4. 0.6 2. 0.2 0.13 0.06 1. 0.3 - 0.25 - 0.4 2. 2. 0.3 8. 0.6 4. 2. 4. 15. 0.6 1. 4. 0.6 0.13 2. 4. 0.5 4. 0.6 4. 4. 0.13 0.6 0.6 - 1.3 - 4. 4 15! 15. 0.6 8. guarana, dry fluid hamamelis, alcoholic, dry fluid hedeoma, fluid helianth, fluid hellebor, niger niger, fluid vir hematoxylon humulus, fluid alcoholic aqueous hydrangea, fluid hydrastis fluid hyoscyamus leaves seed, dry fluid ignatia, alcoholic, dry fluid iris fluid jaborandi, fluid ialap . karnala fluid kava-kava fluid kino, fluid kousso alcoholic fluid krameria alcoholic fluid lactucarium lactuca alcoholic lactuc, can lactucar fluid lappa alcoholic fluid leptandra fluid levisticum, fluid lobelia fluid seed, fluid lupulin, fluid lycop, europ., fluid magnolia, fluid male fern oleores . malt dry marrubium fluid.. 620 APPENDIX Remedy Grains or minims Grams or C.c. Extract matico alcoholic 510 3063 28 1560 1030 60120 3060 13 3060 1560 25 520 1030 12 30120 Via 1 Vs 5 V Vz 15 1560 3060 14 1030 3060 30120 3060 1030 25 13 * 515 15 312 1560 25 1030 1040 515 2060 3060 36 1030 310 28 1040 25 1030 215 2060 60120 3060 310 2060 0.3 2. 0.13 1. 0.6 4. 2. 0.06 2. 1. 0.13 0.3 0.6 0.06 2. 0.006 0.03 0.008 0.06 1. 2. 0.015 0.015 0.06 0.6 2. 2. 2. 0.6 0.13 0.005 0.06 0.3 0.015 0.06 0.2 1. 0.13 0.6 0.6 0.3 1.3 2. 0.2 0.6 0.2 0.13 0.6 0.13 0.6 0.13 1.3 4. 2. 0.2 1.3 0.6 4. 0.5 4. 2. Q O. 4. 0.2 4. 4. 0.3 1.3 2. 0.13 8. 0.06 0.3 0.03 0.3 4. 4. 0.06 0.06 0.25 2. 4. Q o. - 4. 2. 0.3 0.015 - 0.2 - 1. 0.06 - 0.3 0.8 4. 0.3 2. 2.5 1. - 4. 4. 0.4 2. 0.6 0.5 2.5 0.3 2 1. 4. 8. 4. 0.6 4. fluid matricaria, alcoholic fluid melia fluid . melissa, fluid menispermum, fluid mezereum, dry michella, fluid monarda, fluid monesia myristica, fluid myrrh, fluid naregamia, fluid nepeta, fluid nicotiana, alcoholic fluid nux vomica fluid nymphs? fluid. cenothera, fluid opium aqueous papaver, alcoholic fluid pareira, fluid parsley, root seed fluid passiflora, fluid phellandrium, alcoholic physostigma fluid phytolacca berries root fluid pichi (f abiana) fluid pilcarpus, dry fluid pimentia, fluid pimpinella fluid pinus strob, fluid pinus sylvest piper jabor, fluid methyst . . . nigra fluid podophyllum fluid polyporus, fluid polytrichum, fluid pomegran, fluid populus balsam . nigra prunus virsr.. fluid. . DOSE TABLE 621 Remedy Grains or minims Grams or C.c. Extract, ptelea, fluid 1530 1. 2 pulmonaria, fluid 3060 2. 4. pulsatilla '/4 1 0.015 fluid 25 0.13 0.3 pyrethrum 3060 2 4. pyrus, fluid 60120 4. 8. quassia, alcoholic, dry . . 1 5 06 3 aqueous, dry 2 5 13 0.3 fluid 1030 0.6 0.2 quebracho, dry 25 0.13 0.3 quercus 3 10 0.2 0.6 quillaja 25 0.13 0.3 rhamnus, cath., fluid 3060 2 . . 4. f rang 310 0.2 0.6 pursh 520 0.3 1.3 rhododendron, fluid 3060 2 4. rhubarb 13 0.06 0.2 (laxative) 36 0.2 0.4 (purgative) . . 610 0.4 0.6 fluid 530 0.3 2. drv . 110 0.06 0.6 fluid, arom 1060 0.6 4. and senna, fluid 3060 2. 4. rhus arom., fluid 1560 1. 4. glabra, fluid 3060 2. 4. radicans, fluid 15 0.06 0.3 ricinus, leaves 3060 2. 4. seed fluid . 1030 0.6 2. rose fluid 3060 2. 4. rubia, aqueous 310 0.2 0.6 rubus, fluid 3060 2. 4. strig., fluid 1060 0.6 4. villos, aqueous 510 0.3 0.6 villos, fluid 3060 2. 4. rumex acetos 510 0.3 0.6 crisp 310 0.2 0.6 crisp fluid 1560 1. 4. uta alcoholic 25 0.13 0.3 fluid 1530 i 2. sabadilla, fluid 515 0.3 1. sabbatia angul., fluid 3060 o 4. sage, fluid 1560 1. 4. salix alb. fluid 3060 2. 4. salix nigr. bark, fluid 560 0.3 4. buds, fluid 3060 2. 4. sambucus, fluid 30120 o 8. sanguinaria, aqueous Ve Vi 0.01 0.02 emetic IVr 8 0.1 0.2 fluid 320 0.2 1.8 santonica, alcoholic 25 0.13 0.3 saponaria, alcoholic 820 0.5 1.3 fluid 40120 2.5 8. sarsapar., alcoholic, dry 520 0.3 1.3 co., fluid 30120 2. 8. fluid 30120 2. 8. sassafras, aaueous. . 28 0.13 0.5 622 APPENDIX Remedy Grains or minims Gram s or C.c. Extract, sassafras, fluid 3060 2. 4. satureja, fluid 3060 2. 4. savine, alcoholic l lt 2 0.03 0.13 fluid 520 0.3 1.3 scoparius, fluid 3060 2. 4. scopolia, fluid 13 0.06 0.2 scutellaria 510 0.3 0.6 fluid 3060 2. 4. senecio 210 0.13 0.6 fluid 1060 0.6 4. senega, alcoholic, dry 13 0.06 0.2 fluid 520 0.3 1.3 senna, alcoholic 1040 0.6 2.5 fluid 60240 4. 15. serpentaria 15 0.06 0.3 fluid 1030 0.6 2. sesamum, fluid 110 0.06 0.6 solidago odor, fluid 3060 2. 4. solidago virg., fluid 3060 2. 4. sorghum, fluid 3060 2. 4. spigelia co., fluid 90180 6. 12. spigelia, fluid 60120 4. 8. spigelia and senna, fluid 90180 6. 12. spiraea, fluid . . . . 3060 2. 4. squill co., fluid 215 0.13 1. squill, fluid 13 0.06 0.2 stachys, fluid 3060 2. 4. statice, fluid 1030 0.6 2. stillingia 310 0.2 0.6 fluid 1560 1. 4. fluid co. . . 3090 2. g stramonium leaves, alcoholic, dry 1 U~ 1 0.015 0.06 fluid 13 0.06 0.2 stramonium seed l / V 0.015 0.03 fluid 13 0.06 0.2 strophanthus VM Vie 0.001 - 0.004 fluid Vf V 0.008 0.03 strychn. malac., fluid 1030 0.06 2 stylosanthes, fluid 1020 0.6 1.3 sumbul 25 0.2 0.3 fluid 2060 1.3 4. sycocarpus, fluid 1030 0.6 2. symphytum, fluid 3060 2. 4. symplocarpus, fluid 1020 0.6 1.3 tansy, fluid 3060 2. 4. taraxacum 1030 0.6 2. fluid 60120 4. 8. teucrium, fluid 3060 2. 4. thapsia, fluid 210 0.13 0.6 thuja, fluid 3060 2. 4. thymus, fluid 530 0.3 2. tonga, fluid . . . 1030 0.6 2. tormentilla, dry. . 515 0.3 1. fluid 3060 2. 4. trillium, fluid. 60120 4. 8. triticum, aqueous. . 830 0.5 2 DOSE TABLE 623 Remedy Grains or minims Grams or C.c. Extract, triticum, aqueous, fluid 60240 520 60120 3060 210 1530 515 60120 3060 515 1030 Vr-1 14 3060 1030 3060 515 1560 3060 2060 3060 60120 60120 510 1560 2010 3090 '/ 1 48 58 35 515 510 240 24 815 15 13 Vs 3 530 215 515 1020 25 1030 15 830 Vi20 Vao 1030 310 13 46 520 3060 4. 0.3 4. 2. 0.13 1. 0.3 4. 2. 0.3 0.6 0.015 0.06 2. 0.6 2. 0.3 1. 2. 1.3 2. 4. 4. 0.3 1. 1.3 2. 0.02 0.25 0.3 0.2 0.3 0.3 15. 0.13 0.5 0.06 0.06 0.03 0.3 0.13 0.3 0.6 0.13 0.6 0.06 0.5 0.0005 0.6 0.2 0.06 0.25 0.3 2. 15. - 1.3 - 8. - 4. 0.6 2. - 1. 8. 4. 1. 2. 0.06 0.25 4. 2. - 4. 1. 4. 4. 4. - 4. 8. 8. 0.6 4. - 2.5 - 6. 0.06 0.5 0.5 0.3 1. 0.6 0.25 1. 0.3 0.2 - 0.2 2 1 i! 1.3 0.3 2. 0.3 2 0.'002 2. 0.6 0.2 - 0.4 1.3 4. turnera fluid tustilago, fluid urechites, fluid urtica, fluid uva ursi fluid vaccinium, fluid . . valerian, alcoholic fluid veratr. vir fluid verbascum, fluid verbena, fluid viburn. opul., fluid viburn. prun., alcoholic, dry fluid viola, fluid wild cherry, fluid white oak, fluid xanthium spin., fluid xanthium strum., fluid xanthoxylum fluid berries, fluid zea, fluid Feralboid .... Ferratin . Ferratogen Ferrinol . Ferropyrin . . Ferrostyptin . . Fluoroformol (fluorol) Formanilid . Formin Fowler's solution Fraserin Fuchsin . . Gaduol Gaiacophosphal . Gallogen Galbanum Gall, ox, inspiss Gallobromol . Gamboge . Geissospermin Gelseminin Gentian Geosote Geraniin Gillenin Ginger Globon.. 624 APPENDIX Remedy Grains or minims Grams or C.c. Gluside 15 06 0.3 Glycerin 60 240 4. 15 Glycerite, acid carbolic 520 0.3 - 1.3 acid gallic 2060 1.3 4. acid tannic 2060 1.3 - 4. tar 60 120 4. - 8. Glycogenol 510 0.3 - 0.6 Glycyrrhizin 515 0.3 - 1. Gold and potassium bromid :/ 2/ 001 - 0.04 and sodium chlorid il il 0025 01 arsenite i /64 i/ 12 0.001 0.005 bromid il 11 0.003 - 0.012 cyanid i/ 2a 1/ 10 0.003 - 0.006 chlorid . . i/ 50 1/, 5 0.0012 0.004 iodid . . il 11 0.001 0.008 oxid i/ M i/ 4 0.003 0.015 and sod. brom . . 11 il 008 - 03 Gomenol 48 0.25 0.5 Gonosan ' 515 0.3 - 1. Gossypiin 15 0.06 - 0.3 Griserin 58 0.3 0.5 Guaiac 515 0.3 1. Guaiacetin 830 0.5 2. Guaiacol 215 0.13 1. phosphate 510 0.3 - 0.6 Guaiacyl 1/2 11/2 0.03 - 0.1 Guaiamar 315 0.2 - 1. Guaiaquin .... 5 10 0.3 0.6 Guaiperol 1030 0.6 2. Guaranin . . . 15 0.06 0.3 Guarana 15 60 1. - 4. Guethol 510 0.3 0.6 Gujasanol 1530 1. - 2. Hamamelin 13 0.06 2. Hashishin 3 / 4 daily 0.05 daily Hedonol ... 1530 1. - 2. Helenin i/ 6 1/ 2 0.01 0.03 Helicina 210 0.12 0.6 Heliotropin . . . 15 1. Helleborein '/ Vs 0.01 - 0.02 Helonin 25 0.13 0.3 Helmitol . . . 15 1. Hemalbumin 1530 1. - 2. Hemogallol 4 8 0.25 - 0.5 Hemoglobin .... 2040 1.25 - 2.5 Hemol 28 0.13 - 0.5 Heparaden 30 2. Heroin Vi2 Ve 0.005 0.01 hydrochlorid Vi2 V 0.005 0.01 Hetralin 824 0.5 15. Histosan 60240 4. 15. Hopagan 27 0.12 0.4 Hydracetin v i 0.015 0.06 Hydragogin 815 0.5 1. Hydrastin . . V* 1 0.015 0.06 DOSE TABLE 625 Remedy Grains or minims Grams or C.c. Hydrohydrastinin 5 4 15 *'/200 VlOO '/128 1 /M 35 1530 25 1030 820 315 60240 510 13 1530 1030 60 Vil V.' 46 60240 30120 510 13 520 310 515 110 28 520 210 28 510 515 820 Vi 1 1020 210 13 24 310 310 515 520 1015 13 * Vs-1 315 15 If 9 / 2 ^ 15 13 515 0.015 0.3 0.0003 0.008 0.0005 0.2 1. 0.13 1. 0.5 0.2 4. 0.3 0.06 1. 0.6 4. 0.015 0.004 0.25 4. 2. 0.3 0.06 0.3 0.2 0.3 0.06 0.12 0.3 0.13 0.13 0.3 0.3 0.5 0.03 0.6 0.13 0.06 0.13 0.2 0.2 0.3 0.3 0.6 0.004 0.06 0.02 0.2 0.06 0.03 0.06 0.06 0.3 0.03 1. 0.0006 0.015 0.002 - 0.3 2. 0.3 2. 1.3 ^ 15! - 0.6 - 0.2 2. 2. 0.06 0.012 - 0.4 15. 8. - 0.6 - 0.2 - 1.3 0.6 1. 0.6 0.5 1.3 0.6 0.5 0.6 1. 1.3 0.06 1.3 0.6 0.2 0.25 0.6 0.6 j^ 1.3 1. 0.008 0.2 0.06 1. 0.3 0.13 0.3 0.2 1. Hydroquinon Hyoscin Hyoscyamin, amorph cryst Hypnacetin Hypnal . Hypnon Ichthalbin Ichthoform Ichthyol Infus digitalis Ingluvin Inulin lodalbacid lodantipyrin lodgelatin lodin trichlorid vasogen lodipin 10 per cent lodipin 25 per cent lodocaffein lodoform lodoformogen . lodohemol lodol lodomuth lodophenin lodopyrin lodosin lodothein lodotheobromin lodothyrin lodovasogen Ipecac emetic I quinin Iridin Irisin Iron acetate albuminate dry pepton sacch arsenate benzoate bromid ferric ferric sacch ferrous bromo-iodid cacodylate camphorate . . carbonate *ln the insane 1 /tt grain (0.002 Gm.) cautiously increased until effect is produced. 626 APPENDIX Remedy Grains or minims Grams or C.c. Iron carbonate, sacch 1030 0.6 2. caseinate 310 0.2 0.6 chlorid, ferrous 24 0.13 0.25 dialysed, liq 1030 0.6 2. scales , V 2 0.03 0.13 f errocyanid 25 0.13 0.3 glycerinophosphate 25 0.13 0.3 hydrocyanate X /2 1 0.03 0.06 hypophosphite 510 0.3 0.6 iodid V 3 0.03 0.2 sacch 25 0.13 0.3 lactate , 15 0.06 0.3 oxalate 26 0.13 0.4 oxid, black 24 0.13 0.25 brown 60240 4. 15. saccharated 1030 0.6 2. peptonized 520 0.3 1.25 phosphate, precip 510 0.3 0.6 solution 510 0.3 0.6 picrate l lt 1 0.015 0.06 pyrophosphate 510 0.3 0.6 reduced 25 0.13 0.3 salicylate 310 0.2 0.6 subsulphate 25 0.13 0.3 succinate 1060 0.6 4. sulphate 13 0.06 0.2 dried Vr 2 0.03 0.13 t artrate 510 0.3 0.6 valerianate 315 0.2 1. and ammon. citr 310 0.2 0.6 sulphate, ferric 515 0.3 1. and magnesium sulphate 510 0.3 0.6 and manganate lactate 25 0.13 0.3 and manganate peptonized, dry 520 0.3 1.25 and maganate sulphate 12 0.06 0.13 and potassium tartrate 510 0.3 0.6 and quin. arsenate 1 lu Vs 0.004 0.008 citr 310 0.2 0.6 citrate, with strychnine 410 0.25 0.6 hypophosphate 310 0.2 0.6 valer 210 0.13 0.6 and sod. oxal 315 0.2 1. and strychnin cit ate 25 0.13 0.3 Isopral 722 0.5 1.5 Isson 3060 2. 4. Jaborandi 1030 0.6 2. Jalap 1030 0.6 2. Juglandin 25 0.13 0.3 Juice, belladonna . 310 0.2 0.6 celandine. ... . . 1020 0.6 1.3 cineraria, in eye 23 0.13 0.2 conium. . . . . 2060 1.3 4. digitalis. . . 310 0.2 0.6 hyoscyamus. . 3060 2. 4. DOSE TABLE 627 Remedy .., . Grains or minims Gram s or C.c. Juice, pawpaw, dry 510 0.3 0.6 sambucus 60240 4. 15. scoparius 60120 4. - 8. taraxacum 60 240 4. 15. Kairin ... 28 0.12 0.5 Kalagua 38 02 0.5 Kamala . . . . 60 120 4. 8. Kermes mineral, emetic 520 0.3 1.3 Kino 1020 0.6 1.3 Kolanin 35 0.2 0.3 Kosin 2030 -1.3 2. Koussein, amorph 1530 1. 2. Krameria 1560 1. 4. Kreosolid 510 0.3 0.6 Kryofin 815 0.5 1. Labarraque's solution 2060 1.3 4. Lactucin 15 0.06 0.3 Lactopeptin 1020 0.6 1.3 Lactophenin 815 0.5 1_ Lactucarium 2220 0.13 1.3 French . 330 0.2 2. Lantanin 1530 1. 2. Largin 58 0.3 0.5 Lead, acetate 14 0.06 0.25 iodid 14 0.06 0.25 nitrate 14 0.06 0.25 Lecithin 38 0.2 0.5 Leontodin 24 0.13 0.25 Leptandra 2060 1.3 4. Leptandrin 18 0.06 0.5 Levulose (daily) ... 375 25. Levurinose 60240 4. 15. Lienaden 120240 8. 15. Lime sulphurated . . V 2 0.015 0.13 Lipanin 60240 4. 15. Lithium acetate 824 0.5 1.5 arsenate Veo Vu 0.001 0.004 benzoate 520 0.3 1.8 bitartrate 5 0.3 borocitrate 15 0.06 0.3 bromid 520 0.3 1.3 carbonate 515 0.3 1. citrate 515 0.3 1. dithiosalicyl 310 0.2 0.6 formate . 13 0.06 0.2 glycerinophosphate 25 0.13 0.3 hippurate 520 0.3 1.3 iodid 15 0.06 0.3 phosphate 1030 0.6 2. salicylate . '. 1030 0.6 2. sulphate (daily) . 1030 0.6 2. urate (daily) 530 0.3 2. valerian . 515 0.3 - 1. vanadate (daily 1 ). . 3060 2. - 4. 628 APPENDIX Remedy Grains or minims Grams or C.c. Lithium and potassium tartrate /! 1030 1030 v i 510 210 1020 410 14 30120 Vr-2 520 1030 520 520 1530 1020 '/ 1 30120 240480 30120 1020 V 1 310 1560 60120 1020 1030 210 1545 315 30120 1060 12 520 1560 60240 240480 1060 1530 310 1020 815 Vrr-1 Vw V* 28 1040 312 13 210 1020 13 15 15 210 0.004 0.6 0.6 0.01 0.3 0.13 0.6 0.25 0.06 2. 0.03 0.3 0.6 0.3 0.3 1. 0.6 0.03 2. 15. 2. 0.6 0.04 0.2 1. 4. 0.6 0.6 0.13 1. 0.2 2. 0.6 0.06 0.3 1. 4. 15. 0.6 1. 0.2 0.6 0.5 0.04 0.002 0.13 0.6 0.2 0.06 0.13 0.6 0.06 0.06 0.06 0.12 2. 2. o!oe 0.6 0.6 1.3 0.6 0.25 8. 0.13 1.3 2. 1.3 1.3 2. 1.3 0.06 8. 30. 8. 1.3 0.06 0.6 4. 8. 1.3 2 o!e 3. i. 8. 4. 0.12 1.3 4. 15. 30. 4. 2. 0.6 13. 1. 0.06 0.12 0.5 2.5 0.75 0.2 0.6 1.3 0.2 0.3 0.3 0.6 and sod. benz and sod. salicyl Lobelin sulphate Loretin-bismuth Lugol's solution Lupulin Lycetol Lycopin Lysol Macrotin Magnesium, benzoate biphosphate bisulphate . . . borate borocitr bromid cacodylate carbonate chlorid citrate copaivate . ergotinate glycerine-phosphate gynocardate hydrate, moist hypophosphate . hyposulphate . .... iodid lactate lactophosphate malate oxid peptonized phosphite salicylate silicate sulphate sulphite sulphophenolate valerianate Malakin Malarin Mallein, horse Manganese, arsenate bromid carbonate chlorid citrate dioxid hypophosphite iodid lactate lactophosphate. . oxid . . DOSE TABLE 629 Remedy Grains or minims Grams or C.e. Manganese, peptonized . . 1030 15 310 515 520 315 15 1030 240180 60480 38 315 1030 36 3060 V Vi 3045 1 I 1 /* 15 1030 35 15 815 Vw V. 'At '/ v-v. Vn Vit Vi V l /l /M / Vl >// W 1 515 Vi V 13 / Vr-2 Vr-1 VW Vt Vo V Vi-3 V.-1 v-i 13 25 i u Vt '// 315 1530 12 12 5 24 VM Vl 0.6 0.06 0.2 0.3 0.3 0.2 0.06 0.6 15. 4. 0.2 0.2 0.6 0.2 2. 0.01 2. 0.06 0.06 0.6 0.2 0.06 0.5 0.005 0.005 0.002 0.002 0.004 0.02 0.004 0.03 0.015 0.02 0.3 0.004 0.06 0.01 0.03 0.03 0.001 0.002 0.015 0.01 0.02 0.06 0.13 0.015 0.012 0.2 1. 0.06 0.06 0.13 O.COI 2. 0.3 0.6 1. 1.3 1. 0.3 2. 30. 30. 0.5 1. 2. 0.4 4. 0.03 3. 0.1 0.3 2. 0.3 0.3 1. 0.01 0.01 0.008 0.015 0.005 0.015 0.006 0.03 0.06 1. 0.008 0.2 0.13 0.06 0.008 0.015 0.2 0.06 0.06 0.2 0.3 0.03 0.025 1. 2. - 0.13 0.13 0.3 0.25 0.002 phosphate salicylate sulphate sulphite sulphophenol te and i on lactate Mangasol Manna Mannit Maretin Mass, blue copaiba ferrous carbon Matico Meconarcein Medulladen Melonemetin Menispermin Menispermum Menthol Mercurol Mercury, albumin., liq amido-prepionate asparaginate benzoate, mercuric bichlorid biniodid . bisulphate bromid, mercuric bromid, mercurous. cacodylate carbolate chlorid, mild (cathartic) . . cyanid gallate . glycocolate ... . iodid proto naphtolate . . . . . nitrate, mercuric mercurous oxid, black phosphate (mercuric and mercurous) . . salicylate sozoiodolate subsulphate (alterative) succinimid sulphid, black red tannate .... . . .... thymol-acetate. . .... tribrom phenol-acetate. and antimony sulphid and arsen. iod. . 630 APPENDIX Remedy Grains or minims Gram 3 or C.c. Mercury and potassium hyposulphate. . . J /& Vs 012 01 with chalk 310 0.2 - 0.06 Mesotan 60 4. Metacresol . 13 06 0.2 Metaldehyd . 28 13 - 0.5 Methacetin 48 0.25 0.5 Methyl, salicylate 510 0.3 0.6 Methylal 860 0.5 4. Methylen blue 24 0.13 - 0.25 Mezereum 510 0.3 - 0.06 Migrainin 15 1. Migrol 510 0.3 0.6 Mirmol 480600 30. 40. Mixture acid sulphuric 5 20 0.3 1.3 ammon chlor 60240 4. 15. almond B. P. . 60120 4. 8. camphor, acid 60240 4. 15. chalk . 120480 8. 30. carminative 60240 4. 15. chloral and potassium bromide 3060 2. 4 chloroform 60240 4. 15. and cannab. ind. co 520 0.3 1.3 copaiba co 60240 4. 15. creosote B. P . . .... 240960 15. 60. diarrhoea, N. F 1560 1. 4. guaiac . 240960 15. 60. glycyrrhiza co . 120240 8. 15. iron arom., B.P 480960 30. 60. comp. . i 480960 30. 60. and ammon. acet 120480 8. 30. licorice comp 120360 8. 24. magnes and asafet 1030 0.6 2. oil tar 30120 2. 8. oleobalsamic 1030 0.6 2. potass, citr 120480 8. 30. rhubarb co 60120 4. 8. rhubarb and soda 240960 15. 60. sassafras and opium 60120 4. 8. scammony, B. P 480960 30. 60. soda and peppermint 120480 8. 30. Monesin VlO 1 /2 0.006 0.03 Monobromacetanilid 28 0.13 0.5 Morphin v v 0.008 0.03 Mucin 10 0.6 Muscarin, nitrate V32 Vl6 0.002 0.004 Musk 310 0.2 - 0.6 Myricin 13 0.06 - 0.2 Myrrh 520 0.3 1.3 Myrtol 515 0.3 1. Naphthalin. 215 0.13 1. Naphthol (beta) 38 0.2 - 0.5 Narcein Vs 1 0.02 0.06 Narcotin 310 0.2 0.6 Narcyl (daily) 1 0.06 Neurodin 525 0.3 1.6 DOSE TABLE 631 Remedy Grains or minims Grams or C.c. Neuronal 815 510 V 1 */ v*> Vso V 1060 520 1530 15 45 515 120480 520 510 12 12 530 >/6 >/l 520 24 12 12 110 12 240480 12 15 420 10 Ve V 13 15 60240 25 120240 515 25 12 515 13 310 1030 515 515 510 26 26 520 13 310 15 2--10 15 15 28 0.5 0.3 0.03 0.001 0.0008 0.6 0.3 1. 0.06 0.3 8. 0.3 0.3 0.06 0.06 0.3 0.01 0.3 0.13 0.06 0.06 0.06 0.06 15. 0.06 0.06 0.25 0.6 0.01 0.06 0.06 4. 0.13 8. 0.3 0.13 0.06 0.3 0.06 0.2 0.6 0.3 0.3 0.3 0.13 0.13 0.3 0.06 0.2 0.06 0.13 0.06 0.06 0.13 1. 0.6 - 0.06 - 0.003 - 0.003 4. 1.3 2. 0.3 3. 1. 30. 1.3 - 0.6 - 0.13 - 0.13 2. 0.03 1.3 0.25 0.13 0.13 0.6 0.13 30. 0.13 0.3 1.3 0.03 0.2 0.3 15. 0.3 15. j^ 0.3 0.13 1. 0.2 0.6 2. 1. 1. 0.6 0.4 0.4 1 3 0.2 0.6 0.3 0.6 0.3 0.3 0.5 Nickel bromid Nickel sulphate Nicotin Nitroglucose Nuclein (5 per cent) Nutmeg Nutrose Nux vomica Oculin Oil amber, rectif almond expressed animal anise balm basil birch bark bitter almond cajuDut. . camphor Canada snakeroot canella caraway . cardamon castor celery chamomile German chaulmoogra . chenopodium cherry-laurel cinnamon cloves cod-liver cochlearia cocoanut copaiba coriander croton cubebs cumin dill erigeron eucalyptus fennel . fir, Scotch fireweed garlic gaultheria jrineer . hedeoma hops horsemint hyoscyamus . . hyssop iatrooha curcas. . 632 APPENDIX Remedy Grains or minims Grams or C.c. Oil juniper K 1C O 1 ' '/2 3 15 1030 210 Vs 1 U l lt 4 415 15 25 120480 310 13 15 15 25 510 25 1020 520 13 15 240480 25 15 25 310 530 35 520 12 12 15 1040 520 120240 10 4 30 J /2 2 25 120240 315 J/2-1 10 4 30 410 48 515 37 515 815 3060 1530 36 0.3 0.03 0.06 0.6 0.13 0.03 0.008 0.03 0.25 0.06 0.13 8. 0.2 0.06 0.06 0.06 0.13 0.3 0.13 0.6 0.3 0.06 0.06 15. 0.13 0.06 0.13 0.2 0.3 0.2 0.3 0.06 0.06 0.06 0.6 0.3 8. 0.015 0.6 0.03 0.13 8. 0.2 0.03 0.015 0.6 0.03 0.25 0.25 0.3 0.2 0.3 0.5 2. 1. 0.2 1. 0.2 0.3 2. 0.6 0.06 0.015 0.25 1. 0.3 0.3 30. 0.6 0.2 0.3 0.3 - 0.3 - 0.6 0.3 1.3 1.3 0.2 0.3 30. 0.3 - 0.3 0.3 0.6 2. 0.3 1.3 - 0.13 0.13 0.3 2.5 1.3 15. 0.06 2 O.'l3 0.3 15. 1. 0.06 0.06 2. 0.13 0.6 0.5 1. 0.45 1. 4! 2. 0.4 i aurel lavender male fern marjoram, wild matico mustard myrtle niaouli . nutmeg expressed olive pennyroyal pepper peppermint phosphorated pimento pinus pumilio rosemary rue santal sassafras savin sesam spearmint tansy tar thyme turpentine valerian wintergreen wormseed, levant wormwood yarrow Oleocreosote Oleoguaiacol ... Oleoresin, aspidium capsicum cubebs ginger . . lupulin male fern matico mezereon pepper Olibanum Opium, powdered Orexin tannate Orphol Orthin hydroch Orthoform New Ossagen Ovaraden Ovariin. . DOSE TABLE 633 Remedy Grains or minim Grams or C.c. Oxaphor (daily) 4560 815 r /lVi l / Vi 1560 11 V 515 28 25 Vir- V. 48 515 515 815 3090 3060 13 510 824 3 /4 1V 180300 315 515 40120 1030 v i 60180 515 815 520 824 520 510 515 1020 13 1020 48 830 1015 VlOO '/JO 1530 115 48 Vl20 V0 8 15 13 VlOO V30 Vr-Vi /*-/ 1030 1040 510 515 3. 0.5 0.03 0.01 1. 0.06 0.3 0.12 0.13 0.005 0.25 0.3 0.3 0.5 2. 2. 0.06 0.3 0.5 0.05 12. 0.2 0.3 2.5 0.6 0.02 4. 0.3 0.5 0.3 0.5 0.3 0.3 0.3 0.6 0.06 0.6 0.25 0.5 0.6 0.0006 1. 0.06 0.25 0.0005 0.5 0.06 0.06 0.0006 0.01 0.008 0.6 0.6 0.3 0.3 4. 1 - o!i 0.02 4. 0.1 1. 0.5 0.3 0.02 .5 1. - 1. 1. 6. 4. 0.2 0.6 - 1.5 0.1 20. 1 i! 8. 2. 0.06 12. 1. 1. 1.3 1.5 1.3 0.5 1^ 13 0.2 1.3 0.5 2. 1. 0.003 2. 1 0.'5 0.002 0.3 0.2 0.002 0.02 0.015 2 2.5 0.6 1. (oxycamphor) Oxyspartein Palladium, chlorid Pancreaden Pancreatin-albumin Pancreatin Pankreon Papain Papaverin, child Paracotoin . . . Parachlorsalol . Paracresalol ... Paraformaldehyd Paraldehyd Pareira Parthenicin Pelletierin sulphate Pelletierin tannate Pellotin hydrochlor Pental Pepper. . Pepsin sacchar Pereirin Peronin Petrolatum, liq Phaselin. . Pheduretin Phenobromate Phenacetin Phenalgin Phenobromate Phenocoll hydrochlor salicylate Phenolphthalein ' Phenosal Phenoxycaffein Phesin Phloridzin . . Phosphorus . Phosote Phosphotal Phthisin . . . Physostigmine eserine . . Phytin Phytolacca root Phytolaccin. . Picrotoxin Piliganine Pilocarpin hydrochlor Pilocarpus Pimenta Piperazin . . . Pioeridin. tartrate 634 APPENDIX Remedy Grains or minims Grams or C.c. Piperin Vs 1 03 06 Pipitzahoac 45 75 3 5 Podophyllin if 11 008 03 (acute constip.) 31. 11/ 05 01 Podophyllotoxin I/.. l/ fi 005 01 Poliganin VB V* oi 02 Pomegranate 60 120 4. 8 Populin 2 4 13 25 Potassa 11. 1 015 06 sulphurated 2 10 0.13 0.6 Potassium, acetate 10 60 0.6 4. antimonate .... 8 24 05 - 1 5 arsenate 11 11 003 006 arsenite 11 11 002 004 benzoate 5 20 0.3 1.3 bicarbonate 20 60 1.3 4. bichromate 11 11. 004 0.015 binoxalate 11. ii/. 008 01 bisulphate . 60 120 4 8 bitartrate go 480 4. 30. bromid 15 go 1 4 camphorate 1030 0.6 2. cantharidate 0.0001 0.0002 carbolate 1 5 06 03 carbonate. 10 30 05 2 chlorate 10 20 0.6 1.3 chlorid 520 0.3 1.3 citrate 10 40 0.6 2.5 chromate it 11 oi 0.03 cy anid i/ 16 1/ 8 0.004 0.008 ferrocyanid 10 15 06 1. glycerinophosphate, 75 per cent 410 0.25 0.6 hydrate l/ 4 1 0.015 - 0.06 hypophosphite 10 30 0.6 - 2. iodid 3 30 0.2 2. nitrate 1060 0.6 4. nitrite l /4 2 0.015 0.13 osmate i/ 16 _i/ 4 0.004 - 0.015 permanganate 12 0.06 0.13 perchlorate 515 0.3 1. phosphate 1030 0.6 - 2. salicylate 5 20 0.3 - 1.3 salicylite 515 0.3 - 1. succinate 510 0.3 0.6 sulphate 20120 1.3 - 8. sulphite 15_160 1. - 4. sulphocyan 13 0.06 - 0.2 tartrate 1530 1. 2. (laxative) 60150 4. 10. tellurate V 3 /4 0.015 0.05 valerianate 25 0.13 .03 and sod. tartrate 120480 8. 15. Powder, antimonial 210 0.13 0.6 glycyrrhiz. co 60120 4. - 8. jalap co 2060 1.3 - 4. "James". . 210 0.13 0.6 DOSE TABLE 635 Remedy Grains or minims Grams or C.c. Powder morph. co 5 20 03 1 3 rhubarb co 30 120 o g Prasoid 15 30 1 2 Prostaden 5 15 03 1 Protan 20 30 13 2. Protonuclein 3 10 2 0.6 Protylin 15 60 1 4. Ptelein. 13 0.06 0.2 Ptyalin 10 30 0.6 2. pepsin 10 30 0.6 2. Pumpkin seed 60 120 4 8 Pyoktanin 15 0.06 0.3 Pyramidon 38 0.2 0.5 Pyramidon camphorate, neutral 12 15 75 1. salicylate 8 12 05 0.75 Pyrantin 515 0.3 1. Pyranum 1530 1. 2. Pyridin 210 0.13 0.6 Pyrodin l /r 1 0.015 0.06 Pyrosal 815 0.5 1. Quassia 1030 0.6 2. Quassin, pure 1/30 Vs 0.002 0.02 French l /r-2 0.03 0.13 Quebrachin 12 0.06 0.13 Quillaja 1030 0.6 2. Quinacetin sulph . 515 0.3 1. Quinalgen 515 0.3 1. Quinaphtol . 815 0.5 1. Quinetum 18 0.06 0.5 Quinidin '/2 3 0.03 0.2 Quinin and salts 2 15 0.13 1. albuminate 215 0.13 1. antimonate I 1 /* 6 0.1 0.4 arsenate Vie ll 0.004 0.008 arsenite l /ir */ 0.004 0.008 biniodid (subcut.) li/i 0.1 dihydrobromate 320 0.2 0.3 ferroarsenate Vis Vs 0.004 0.008 ferroarsenite Vu V 0.004 0.008 ferrocyanid 510 0.3 0.6 ferroiodid 815 0.5 1. ferrolactate 815 0.5 1. glycerinophos 25 0.13 0.3 peptonate 560 0.3 4. salicylate 230 0.13 2. sulphocarbol 28 0.13 0.5 tannate child 515 0.3 1. valerian 26 0.13 0.4 and antipyrin salicylate 2Q 0.12 0.5 and urea hydrochlor., subcut 28 0.13 0.5 Quinoidin 215 0.13 1. Quinolin salicylate 815 0.5 1. and antipyrin valerianate 28 0.12 0.5 sulph 520 0.3 1.3 tartrate. . 1 520 0.3 1.3 636 APPENDIX Remedy Grains or minims Grams or C.c. Quinoral 820 825 30 515 13 Vr-Vi 12 38 18 V 'A 510 23 26 310 12 515 15 2060 13 15 1020 3060 1545 510 3075 1030 35 515 510 515 1030 1020 515 1020 830 1015 320 Yii-Ya 30 24 15 815 515 '/ 1 l /f V '/ Vio 515 '/zoo Veo 14 13 Vi 2 60240 1030 150300 0.5 1.3 0.5 1.5 2. 0.3 - 1. 0.06 - 0.2 0.008 0.03 0.06 0.12 0.2 0.5 0.06 - 0.5 0.01 0.015 0.3 0.6 0.13 0.2 0.13 0.4 0.2 - 0.6 0.06 - 0.13 0.3 1. 0.06 0.3 1.3 4. 0.06 0.2 0.06 0.3 0.6 - 1.3 2. - 4. 1. 3. 0.3 - 0.6 2. 5. 0.6 2. 0.2 0.3 0.3 - 1. 0.3 - 0.6 0.3 1. 0.6 2. 0.6 1.3 0.3 1. 0.6 1.3 0.5 2. 0.6 1. 0.2 1.3 0.005 0.2 2. 0.13 - 0.25 0.06 0.3 0.5 1. 0.3 1. 0.02 0.06 0.01 0.03 0.001 0.002 0.3 1. 0.000250.001 0.06 - 0.25 0.06 - 0.2 0.03 0.13 4. 15. 0.6 - 0.2 10. 20. Quinopyrin Renaden . . Resin, copaiba jalap . podophyllum quebracho scammony sumbul veratrum Resopyrin Resorcin Rhamnin Rhubarb Rhusin '. . . Rubidium bromid iodid .... and ammon bromid Rumin Saccharin Saffron Safrol Salacetol Salf ene Salibromin ~. Salicin Salicylamid Salicyl-resorcin Saliformin . . Saligenin Salipyrin Salocoll Salol Salophen Saloquinin Salicylate Sanguinaria Sanguinarin Sanguinoform Santonin Santoninoxim Sarcosin Scammony > Scillipicrin Scillitin Scillitoxin . . ... Scoparin Scopolamin hydrobrom Scutellarin . . Senecin Senegin Senna Serpentaria Serum, antistreotococcic. . DOSE TABLE 637 Remedy Grains or minims Grams or C.c. Sidonal 1520 3045 45 Vi20 Veo Vr-lVi Veo VM Vi2 Vs V4-1 Vs V* V.2 V. 13 310 Vi 1 15120 515 Vu Vs 1040 1040 1030 2040 30120 1530 515 12 1060 15 210 520 315 515 1060 1015 510 Va-1 1560 515 1030 324 V20 V/4 210 60300 510 Vi2 Ve V2-3 410 6075 515 1020 Vi-1 1030 520 560 120480 Veo Vs Vi IV. 310 1. 2. 3. 0.0005 0.03 0.001 0.005 0.015 0.008 0.005 0.06 0.2 0.03 1. 0.3 0.0025 0.6 0.6 0.6 1.3 2. 1. 0.3 15. 0.6 0.06 0.13 0.3 0.2 0.3 0.6 0.6 0.3 0.02 1. 0.3 0.6 0.2 0.00:5 0.13 4. 0.3 0.005 0.03 0.25 4. 0.3 0.6 0.03 0.6 0.3 0.3 8. 0.001 0.03 0.2 1.3 3. 0.001 0.01 0.003 - 0.0 0.06 - 0.03 0.03 0.2 - 0.6 - 0.06 8. - 1. 0.008 2.5 2.5 2. 2.5 8. 2. 1. 30. 4. 0.3 0.6 1.3 - 1. - 1. 4. 1. 0.6 0.06 4. 1. 2. 1.5 0.015 0.6 20. 0.6 0.01 0.2 0.6 5. 1. 3.1 0.06 2. 1.3 4. 15. 0.008 0.1 0.6 new .... Silin (daily) Silver, arsenite chlorid cyanid iodate iodid nitrate oxid Smilacin amorph Soap Soda (caustic) Sodium, acetate anisate arsenate benzoate bicarbonate bisulphite borate borobenzoate borocitr borosalicyl . borotartrate bromid cacodylate carbolate carbonate . cetrarate chlorate chlorid chloroborate choleate cinnimate, subcut citrate . . citrobenzoate copaivate . . cresotinate cyanid dithiosalicylate ethyl-sulph fluorbenzonate fluorid formate glycerino-phosph (75 per cent) glycocholate (daily) gynocardate hippurate . hydrate . . hypophosphite hyposulph . . . . iodid . . lactate meta-vanadate methylarsenate (daily) naohtolate. . 638 APPENDIX Remedy Grains or minims Grams or C.c. Sodium, nitrate . . . 10 gO 06 4. nitrite 13 06 0.2 oleate 25 12 - 0.3 paracresotate 2 20 13 - 1.3 persulphate 1 3 06 - 0.2 phenolsulphonate 8 30 05 - 2. phosphate 540 0.3 - 2.5 pyrophosph . 5 40 03 2.5 saccharinate 15 06 0.3 salicylate 5 40 0.3 2.5 santonate 1 6 0.06 0.4 santoninate 1 6 06 0.4 sozoidole 530 0.3 2. succinate 15 0.06 -- 0.3 sulphanilate 1015 06 1. sulphate 120 480 8. 30. sulphite 1060 0.6 - 4. sulphosalicyl 10 30 0.6 2. sulphovinate go 300 4. 20. tartrate 240 480 15. 30. taurochol .... 26 0.13 - 0.4 tellurate '/ 1 0.015 - 0.06 thiosulph 520 0.3 - 1.3 valerianate 15 0.06 - 0.3 vanadate i/ it 0.001 - 0.008 Solanin !/4 1 0.015 - 0.06 Solution, acid arsenous 28 0.13 0.5 acid phosphoric comp 60120 4. - 8. alumin, acet 515 0.3 1. ammon, acet 120480 8. 30. concent 30120 2. 8. citrate, cone 30 60 2. 4. ammon. succin 2030 13 2. arsen. and mere, iod 510 0.3 0.6 atropin sulphate 14 0.06 - 0.25 bismuth 60240 0.4 15. bismuth and ammon. ctr 30120 2. 8. cal. chlorydrophos 510 0.3 0.6 chlorid 1560 1. 4. ergotin 1030 0.6 2. ext. licorice 60120 4. - 8. Fowler's 15 0.06 0.3 ginger 30120 2. 8. gold and arsen. bromides 515 0.3 1. hydrogen perox 60240 4. 15. hypophosphites 1560 1. - 4. iodin comp 210 0.13 - 0.6 iron acetate 210 0.13 - 0.6 cone 15 0.06 0.3 iron album 60240 4. 15. iron chlor. ferrous 515 0.3 - 1. iron citr 515 0.3 1. iron iodid 15 0.06 0.3 iron malate 30120 2. 8. iron nitr 515 0.3 1. iron oxvchlor. . 1030 0.6 2. DOSE TABLE 639 Remedy Grains or minims Grams or C.c. Solution, iron protochlor 15 210 240480 520 3060 2060 1560 480960 60120 815 25 1560 415 1560 13 60240 30120 60240 2060 520 15 15 530 2060 310 520 1530 15 57 /< 1 Vi iVi l /i l'/. 60120 18 60120 30120 30120 3060 1030 3060 3060 30120 13 60180 240480 3060 13 3090 30120 1040 1540 315 13 310 K-i 24 0.06 0.13 15. 0.3 2. 1.3 1. 30. 4. 0.5 0.13 1. 0.25 1. 0.06 4. 2. 4. 1.3 0.3 0.06 0.06 0.3 1.3 0.2 0.3 1. 0.06 0.3 0.015 0.03 0.03 4. 0.06 4. 2. 2. 2. 0.6 2. 2. 2. 0.06 4. 15. 2. 0.06 2. 2. 0.6 1. 0.2 0.06 0.2 0.015 0.13 0.3 0.06 30. 1.3 4. 4. - 4. 60. 8. - 1. 0.3 - 4. 1. - 4. 0.2 15. 8. 15. 4. 1.3 0.3 0.3 2. 4. 0.6 1.3 2. 0.3 0.4 0.06 0.1 0.1 8. 0.5 8. 8. 8. 4. 2. 4_ 4! 8. 0.2 12. 30. 4. 2 6.' 8. 2.5 2.5 1. 0.2 0.6 0.06 0.25 iron subsulph iron and ammon. acet iron and ammon. citr iron and mangan. pept lime, chlorin sacchar magnes. carbon magnesium bromid glycochol mercury and potass, iodid morphin acet citrate sulph nitroglycer pancreatic pepsin arom phosphorus potassa . . , . . potass, arsenate and brom arsenite saccharin soda, chlorin sodium arsenate hydrate Somnal Somnalgesin Somnoform . Spartein sulph Spasmotin. Sphacelotoxin Spigelia Spinol . . . Spirit, ammonia, arom anise aromatic . . chloroform cinnamon . . ether ... comp . . gaultheria glonoin juniper comp melissa. cone nitroglycer. (spt. glonoin). . ... nitrous ether nutmeg phosphorus spearmint witch-hazel . . . Squill Starch iodized Steresol Stillinein.. 640 APPENDIX Remedy trains or minims Gram s or C.c. Storax 5 20 3 13 Stramonium seed 1 3 06 02 leaves 2 5 13 03 Strontium, acetate 1 U 1 015 06 arsenite i/ i/ 002 004 bromid . . . 10 40 6 o 5 iodid 10 20 6 1.3 lactate 10 30 6 2 salicylate 10 40 6 2 5 Strophanthin 0003 001 Strychnin i/ i/ 001 004 arsenate i/ i/ 001 004 arsenite ... i/ R . i/... 001 004 cacodylate i/, n i/. 002 02 hypophosp i/ it 002 005 nitrate '. . ii i/ 001 002 sulphate i/ i/ 001 00 Stypticin , 31 3/ 025 0.05 Styptol 1 2V* 06 0.15 Sugar, milk, daily 1 g OZ- 30 180. Sulfonal 1545 1. 3. Sulphaminol, salicylate 3 6 2 4 Sulphur, iodid 1 4 06 0.25 precipit 30 120 2 8. washed 60 180 4 12. Syrup, acacia 120 480 8 30. acid citric 120 480 8 30 acid hydriod 30 60 2 4. blackberry, arom .... 120 240 8 15 calcium, iodid 60 120 4 8. lactophosphate 60 120 4 8. with iron 60 240 4 15. and sod. hypophosph 60240 4. 15. chondrus, comp 60 120 4 8. chloral 30 120 2 8. cinnamon 60 240 4 15. codein 60240 4. 15. eriodictyon, arom 60 240 4 15. garlic 60120 4 8. ginger . 120240 8 15. glycyrrhiza 60240 4. 15. hypophosphites 60 240 4 15. with iron 60 120 4. 8. ipecac 20240 1.3 15. and opium 60180 4. 12. iron arsen 60120 4. 8. bromid 1030 0.6 2. citro-iodid 1560 1. 4. hypophosph 60180 4 12. iodid 1530 1. 2 lactophosphate 60120 4. 8. oxid 60120 4. 8. phosphate 3060 2. 4. protochlor 30120 2. 8. quin. and strych. phosph 60120 4. 8. saccharated. . 60180 4. 12. DOSE TABLE 641 Remedy Grains or minims Grams or C.c. Syrup, iron, arsen., mangan. iodid 1030 60240 30120 3060 3060 60240 120480 60180 60120 60180 60120 60120 60240 60240 60250 3060 60480 60240 3060 120240 1560 120480 30120 120240 60240 60240 60240 3060 1560 60240 60240 60240 60240 60240 60240 15 530 530 220 415 830 1560 1530 3060 V 32 Vw Vl4 V. Vi 420 1530 315 25 1530 30 23 38 0.6 4. 2. 2. 2. 4. 8. 4. 4. 4. 4. 4. 4. 4. 4. 2. 4. 4. 2. 8. 1. 8. 2. 8. 4. 4. 4. 2. 1. 4. 4. 4. 4. 4. 4. 0.06 0.3 0.3 0.13 0.25 0.5 1. 1. 2. 0.002 0.0025 0.03 0.25 1. 0.2 0.13 1. 2. 0.12 0.2 2. 15. 8. - 4. 4. 15. 30. 12. 8. 12. 8. 8. 15. 15. 15. 4. 30. 15. 4. 15. 4. 15. 8. 15. 15. 15. 15. 4. 4. 15. 15. 15. 15. 15. 15. 0.3 2. 2. 13. 1. 2. 4. 2. 4. 0.004 0.008 1.3 2. 1. 0.3 2. 0.2 0.5 krameria lactucarium. lemon lime manna orange flowers pectoral peppermint phosphates, comp poppy. . prun. virg raspberry rhamnus cath rhoeados rhubarb and potassa, comp roses rubus sanguinaria sarsaparilla, co senega senna aromat comp sodium hypophosph squill comp stillingia, comp tar trifolium, comp violets wild cherry white pine, comp Taka diastase Tannalbin Tannigen Tannin Tannoform Tannopin Tannosal Taphosote Tar Tartar emetic (expectorant) (emetic) Terebene Terpene hydrochlorid Terpin hydrate Terpinol Tetronal Testaden Thallin, periodid tartrate.. 642 APPENDIX Remedy Grains or minims Grams or C.c. Thallin sulphate 38 38 I 1 It 3 '/ '/I 510 13 515 515 515 151 48 15 38 58 38 7 8 4 520 515 520 Vi IVi 515 110 24 '/ 2 2 VitVi 13 '/2 2 1030 320 3060 1560 30120 2060 1060 1030 2040 2060 1060 1015 520 2040 3060 60240 30 1015 520 310 1560 60120 30120 60120 60120 60120 0.2 0.2 0.1 0.012 0.012 0.3 0.06 0.3 0.3 0.3 1. 0.25 1. 0.2 5.0 0.2 0.4 0.5 0.25 0.3 0.3 0.3 0.03 0.3 0.06 0.13 0.03 0.005 0.06 0.03 0.6 0.2 2. 1. 2. 1.3 0.6 0.6 1.3 1.3 0.6 0.6 0.3 1.3 2. 4. 2. 0.6 0.3 0.2 1. 4. 2. 4. 4. 4. 0.5 0.5 0.2 0.6 0.2 ^ ll 1. - 0.5 0.5 0.3 0.5 1.3 1. - 1.3 - 0.1 - 1. - 0.6 0.25 - 0.13 - 0.03 - 0.2 - 0.13 2. - 1.3 4. 4. 8. - 4. 4. o Li. 5. 4. - 4. - 1. 1.3 2.5 4. 15. 1. 1.3 0.6 4. 8. 8. 8. 8. 8. tartrate Thallium acetate Thallium, chlorid sulphate Thanatol guethol Thebain, hydrochloric! Theobromin and lith. benz and lith. salicylate and sod. benz and sod. iodosalicyl and sod. salicyl Theocin Theocin-sodium acetate Theophyllin sodium . sodium salicylate Thermifugin Thermodin Thermol Thiocol Thiosinamin Thymacetin . Thymol Thyraden Thyroidin (Merck) Tin chlorid stannous Tincture, aconite Fleming adonis a?stiv. vernalis adulsa vasaca aloes and myrrh antiperiodic . apocynum . arnica flow root asaf etida avena sativa sat., co. . belladonna Ivs benzoin ... comp ... bryonia. . bursa pastor cactus grandiflor. . . cannab. ind cantharides capsicum cardamom castoreum catechu co cinchona jiimicifuea. . DOSE TABLE 643 Remedy Grains or minima Gri ims or C.c. Tincture, cinnamon 60 240 4 15 seed 20 60 1 3 4 convallaria 5 20 3 1 1 coronilla 5 15 3 1 coto 10 20 6 1 1 gelsemium 10 30 6 2 gentian co 60 120 4 8 cinger. . 15 60 1 4 guaiac 2060 1 3 4 ammon 60 120 4 g hops 60 180 4 12 hydrastis 30 120 2 8 hyoscyamus 2060 1 3 4 iodin 310 0.2 06 comp 515 3 1 ipecac and opium 5 15 3 1 iron, acet., ether 10 30 6 2 chlor 5 20 3 1 3 chlor., ether. . ... ... 10 30 6 2 citro-chlor .... 10 30 6 2 pomated . . 3090 2 6 jalap. . 520 0.3 3 kino 60180 4. 12 lactucarium . . 640 4 25 lobelia 1040 0.6 25 musk 30120 2. 8. myrrh 30120 2. 8 naregamia l /2 2 0.03 o ia nerium oleander Ivs 20 1.3 nutgall 3060 2. 4 nux vom 520 0.3 1.3 opium 520 0.3 1.3 opium camph 60240 4. 15. paracoto 1020 0.6 1.3 physostigma 515 0.3 1. pulsatilla 520 0.3 1.3 quassia 60180 4. 12. quillaja 2060 1.3 - 4. rhubarb 60240 4. 15. aqueous 60240 4. 15. arom 30120 2. 8.- sweet 60240 4. 15. and gentian 60240 4. 15. toxicodend 530 0.3 2. saffron 60180 4. 12. serpentaria 60180 4. 12. simulo 3060 2. - 4. squill 620 0.4 1.3 stramonium 620 0.4 1.3 strophanthus . 310 0.2 1.6 sumbul . . 1560 1. 4. tolu 30120 2. 8. valerian, ammon 60120 4. Q veratrum, br 520 0.3 1.3 vir 310 0.2 0.6 Warburg's. . 2060 1.3 4. 644 APPENDIX Remedy Grains or minims Gram s or C.c. Tolypyrin 5 15 03 1. Tolysal . 8 30 5 2 Tribrommethan bromoform 2 20 13 13 Tribromphenol 3 10 2 0.6 Tribromsalol 15 30 1 2. Trif errin 5 0.3 Trigemin 5 20 3 1.3 Trilliin 2 4 13 0.25 Trional 15 30 1 2 Trioxymethylen 8 15 5 1. Triphenin 4 20 0.25 1.3 Try psin 8 24 0.5 1.5 Tuberculin 0003 O.OOOJ Turpentine, chian 25 0.13 0.3 Tussol 2 15 13 1. Ulexin 003 006 Uraliam 30 45 9 3 Uranium nitrate 1 15 06 1. Urea 10 20 0.6 1.3 Urethan 10 4o 0.6 3 Uricedin ... . 15 30 1. 2. Uriseptin 60120 4. 8. Urosin 1015 0.6 1. Urotropin ... 8 15 5 1. Uva ursi 60 120 4. 8. Valerian 10 30 0.6 2. Valerydin .... 8 15 5 1. Validol 10 20 0.6 1.3 camphorated 10 15 0.6 1. Valofin 10 25 6 1.5 Valyl 26 0.12 - 0.4 Vanadin, daily 6 30 0.4 2. Vanillin 0.01 - 0.02 Veratrin alkaloid 11 i/ 0.001 0.003 Veratrol . ... 12 0.06 0.12 Veronal 515 0.3 1 Viburnin 13 0.06 0.2 Vieirin 1 4 0.06 0.25 Vinegar opium 5 20 0.3 1.3 Vinegar squill. . .... 10 30 0.6 2 Water, ammonia 10 30 0.6 2 cone 410 0.25 0.6 bitter almond 10 20 0.6 1.3 cherry laurel 1020 0.6 1.3 chlorin 15240 1. 15. Wine, aloes 60120 4. 8. camphorated 60 240 4. 15. colchicum seed 2060 1.3 4. ipecac 5 10 0.3 0.6 emetic ; 60180 4. 12. iron 60240 4. 15. bitter ... 120180 8. 12. opium. . 520 0.3 1.3 DOSE TABLE 645 Remedy Grains or minims Gran or C.e. Wine, pepsin 60 240 4 15 quinin. . 240 480 15 30 tar 30 120 2 g tobacco 5 30 3 2 white ash 60 120 4 8. wild cherry 60 120 4 - 8. f errated 60 120 4 8 Xeroform 515 03 1 Xanthoxylin .... 1 2 006 13 Xvlen (xylol) 5 15 03 1 Xylenol (ortho-) salicyl 2 6 13 - 4 Yohimbin / 006 Zinc , acetate 1 . 2 13 04 bromid 1 2 0.06 13 chlorid l lt l i^ ,-,,-,-3 002 citrate 3 8 02 05 cyanid . i M i 4 g ,-,,-, .5 015 ferrocyanid 0.03 0.24 hemol 28 0.13 0.5 hypophosphite . . i . 1 . 0.03 0.1 iodid 1 2 0.06 13 lactate 1 1 0.03 0.06 oxid 15 0.06 0.3 phosphid l l 4 0.003 0.015 phosphate 25 0.12 0.3 salicylate i ', 1 '. 0.03 0.2 subgallate. . 1 4 0.06 0.25 sulphate 0.015 0.03 emetic 1530 1. 2. sulphocarbolate 2 4 0.13 0.25 tannate 1 3 0.06 0.1 and potassium cyanid . . I 'M 1 0.006 0.06 valerianate 13 0.06 0.2 INDEX OF DRUGS Classification of Drugs According to Their Therapeutic Uses Drugs Which Exercise No Definite Action on Specific Organs. Antiseptics. General principles, 103 Acetylsalicylic acid, 160 Aspirin, 161 Balsam of Peru, 163 Betanaphthol, 162 Bismuth subnitrate, 119 Boric acid, 121 Calcium dioxid, 143 Camphor, 194 Chinosol, 161 Chlorinated lime, 134 Cinnamic aldehyd, 195 Corrosive mercuric chlorid, 115 Cresol, 157 Creosote, 157 Essential oils, 184 Eucalyptol, 195 Eugenol, 196 Formaldehyd, solution of, 165 Guaiacol, 157 Hydrogen dioxid, 136 lodoform, 130 Magnesium dioxid, 144 Menthol, 197 Mercuric cyanid, 117 Methylene hydrochlorid, 164 Methyl salicylate, 197 Oxygen, 141 Paraform, 166 Phenol, 151 Phenyl salicylate (Salol), 160 Potassium chlorate, 149 Potassium permanganate, 148 Resorcinol, 158 Salicylic acid, 160 Scarlet red, 164 Sodium borate, 127 Sodium diborate, 146 Sodium dioxid, 145 Sodium salicylate, 160 Strontium dioxid, 145 Thymol, 198 Thymol iodid, 133 Zinc dioxid, 146 Astringents. General principles, 199 Bismuth subgallate, 206 Bismuth subnitrate, 206 Copper sulphate, 201 Lead acetate, 203 Rhatany, 211 Tannic acid, 209 White oak bark, 211 Witch-hazel water, 211 Xeroform, 207 Zinc acetate, 209 Zinc chlorid, 203 Zinc iodid, 206 Zinc oxid, 207 Zinc phenolsulphonate, 205 Zinc sulphate, 205 Caustics. General principles, 212 Alloy of potassium and sodium, 216 Arsenic trioxid, 230 Chromium trioxid, 216 Lactic acid, 215 Nitric acid, 215 Osmium tetroxid, 216 Potassium hydroxid, 215 Silver nitrate, 217 Sodium hydroxid, 216 Trichloracetic acid, 214 Tlemostatics and Styptics. General principles, 250 Alum, 252 647 648 INDEX OF DRUGS Hemostatics and Styptics Cont'd. Coagulen, 253 Coagulose, 253 Epinephrin eWorld, solution of, 254 Ferric subsulphate, solution of, 252 Gelatin, 253 Hydrastinin hydrochlorid, 254 Iron chlorid, solution of, 251 Penghawar djambi, 251 Purified cotton, 251 Styptic collodion, 251 Styptic cotton, 251 Stypticin, 254 Styptol, 254 Thromboplastin, 253 Protectives, Demulcents, and Emollients. General principles, 255 Acacia, 258 Collodion, 257 Exsiccated calcium sulphate, 258 Glycerin, 257 Gutta-percha, 256 Paraffin, 257 Petrolatum, 257 Eubber, 256 Solution of sodium silicate, 258 Tragacanth, 258 Irritants and Counterirritants. General principles, 260 Ammonia water, 267 Cantharides, 266 Capsicum, 266 lodin, 262 Mustard, 265 Antacids. General principles, 268 Magnesia, 269 Magnesium carbonate, 269 Milk of magnesia, 270 Precipitated calcium carbonate, 269 Prepared chalk, 269 Sodium bicarbonate, 270 Solution of calcium hydroxid (lime water), 269 Drugs Which Act on Specific Organs. Bleaching Agents. General principles, 270 Barium dioxid, 274 Hydrogen dioxid, aqueous solution of (Perhydrol), 274 ethereal solution of (Pyrozon), 274 Sodium dioxid, 273 Preparations for the Mouth and Teeth. General principles, 277 Abrasives, 291 Antacids, 291 Antiseptics, 291 Astringents, 291 Correctives, 292 Mouth washes, 293 Stimulants, 292 Tooth pastes, 306 Tooth powders, 297 Tooth soaps, 308 Local Anesthetics and Obtundents. General principles, 309 Acoin hydrochlorid, 319 Alypin, 319 Anesthesin and Subeutin, 323 Chlorbutanol (Chloretone), 320 Cocain hydrochlorid, 312 Cycloform, 323 Ether, 326 Ethyl chlorid, 326 Eueain A and B, 319 Holocain hydrochlorid, 319 Methyl chlorid, 327 Nervoeidin, 320 Nirvanin, 319 Novocain, 317 Orthoform, 322 Propsesin, 323 Quinin and urea hydrochlorid, 320 Stovain, 319 Tropa-cocain hydrochlorid, 318 INDEX OP DRUGS 649 General Anesthetics. General principles, 328 Carbon tetrachlorid, 349 Chloroform, 347 Ether, 348 Ethyl bromid, 348 Ethyl chlorid, 348 Methyl chlorid, 349 Somnoform, 349 Hypnotics. General principles, 366 Hydrated chloral, 367 Paraldehyd, 367 Sulphonethylmethan (Trional), 367 Sulphonmethan (Sulphonal) 367 Veronal, 368 Anodynes. General principles, 368 Aconite, 372 Atropin, 373 Codein, 370 Morphin, 369 Opium, 369 Sedatives. General principles, 374 Ammonium bromid, 375 Bromural, 375 Potassium bromid, 375 Sodium bromid, 375 Valerian, 376 Cerebral Stimulants. General principles, 376 Brandy, 379 Caffein, 378 Whisky, 378 Wine, red, 379 Wine, white, 379 Stomachics and Digestives. General principles, 379 Columbo, 381 Dandelion, 381 Gentian, 381 Hops, 382 Pancreatin, 383 Stomachics and Digestives Cont'd. Pepsin, 382 Quassia, 382 Serpentaria, 382 Emetics. General principles, 383 Apomorphin hydrochlorid, 386 Antimony and potassium tartrate (Tartar emetic), 385 Copper sulphate, 385 Emetin hydrochlorid, 386 Ipecac, 386 Cathartics. General principles, 392 Aloes, 394 Cascara sagrada, 394 Castor oil, 395 Colocynth, 394 Croton oil, 395 Jalap, 394 Magnesium sulphate, 396 Mercurous chlorid (Calomel), 397 Podophyllum, 395 Potassium citrate, 396 Rhubarb, 394 Senna, 395 Sodium phosphate, 395 Sodium sulphate, 396 Sulphur, 397 Circulatory Stimulants and Depressants. General principles, 399 Amyl nitrite, 402 Digitalis, 401 Nitroglycerin, spirit of, 402 Strophantus, 401 Strychnin sulphate, 402 Suprarenal glands, desiccated, 403 Respiratory Stimulants and Depressants. General principles, 404 Tonics. General principles, 406 Arsenic, 409 Calcium, 411 Fluorin, 411 Iron, 407 Phosphorus, 410 650 INDEX OP DRUGS Alteratives. General principles, 412 lodids, 414 Mercury salts, 415 Sialogogiies and Antisialogogues. General principles, 419 Atropin sulphate, 421 Pilocarpin hydrochloric!, 420 Diaphoretics. General principles, 421 Diuretics. General principles, 423 Thcobromin sodium salicylate, 424 Uric Acid Solvents. General principles, 424 Atophan, 430 Hexamethylene (Urotropin), 430 Lithium carbonate, 430 Lithium citrate, 430 Lithium salicylate, 430 Antipyretics. General principles, 431 Acetanilid, 435 Acetphenetidin (Phenacetin), 435 Acetylsalicylic acid (Aspirin), 434 Antipyrin, 434 Quinin sulphate, 433 Organo and Serum Therapy. General principles, 436 GENERAL INDEX Abrasives, 291 Absorbents, 251 Acacia, 258 mucilage of, 258 A. C. E. mixture, 349 Acetanilid, 435 Acetocaustin, 215 Acetozon, 147 Acetphenetedin, 435 Acid, acetylsalicylic, 160 arsenous, 230 benzoic, 159 boric, 121 ointment of, 121 carbolic, 151 china, 428 chromic, 216 gallic, 210 hydrochloric, 122 diluted, 122 lactic, 215 muriatic, 122 nitric, 122, 215 diluted, 122 nitrohydrochloric, 122 diluted, 122 osmic, 216 phenic, 151 phenolsulfonic, 124 picric, 163 phosphoric, 126 diluted, 126 salicylic, 160 sulphocarbolic, 124 sulphuric, 123 aromatic, 123 diluted, 123 tannic, 209, 255 trichloracetic, 214 uric, 424 Acids, 120 Acoin, 319 Aconite, 372 tincture of, 372 Actol, 228 Adrenalin, 527 Agents, bleaching, 270 coloring and flavoring, 78 Aids, diagnostic, 603 Albargin, 228 Albargol, 228 Alcohol, ethyl, 182 methyl, 182 Alkalies, 126 Aloes, 394 Alphozon, 147 Alteratives, 412 Alum, 252 burnt, 202 exsiccated, 252 Alumnol, 207 Alveolar process, anatomic structure of, 543 Alypin, 319 Aminoform, 166 Ammonium bifluorid, 429 bromid, 375 Amyl nitrate, 402 Anesthesia: insufflation, of the upper anterior teeth, 563 local, 514 about the mouth, 576 history, 514 means of producing, 518 pressure, 565 symptoms of, 353 Anesthesin, 323 Anesthetics, choice of, 358 general, 328 statistics of, 352 local, 309, 530 651 652 GENERAL INDEX Anesthetics, local Cont'd chemic relationship, 323 insoluble, 322 physiologic action of, 519 side and after effect in relation to penal code, 579 refrigerants, local, 326 Anesthetizing the pulp, 569 Anesthile, 327 Anestol, 327 Anilin dyes, 164 Anion, 111 Anodynes, 368 Antacids, 268, 291 Antifebrin, 435 Antiformin, 134 Antimony and potassium tartratc, 385 Antipyretics, 431 Antipyrin, 434 Antiseptic solution, 121 Antiseptics, 103 of aromatic series, 150 of marsh gas series, 165 Antisialogogues, 419 Antitoxins, 438 Aperients, 392 Apomorphin hydrochlorid, 386 Aqua regia, 122 Argentamin, 228 Argentol, 229 Argonin, 228 Argyria, 223 Argyrol, 229 Aristol, 133 Arkovy's mixture, 156 Armamentarium, hypodermic, 536 Arsenic, 409 and mercury iodid, solution of, 23 1 trioxid, 230 trisulphid, 230 Artificial dentin, 208 Aspirin, 160, 434 Astringents, 199, 291 metallic, 201 vegetable, 209 Atophan, 430 Atoxyl arsenate, 416 Atropin sulphate, 373, 421 Auramin, 164 Auripigment, 230 Balsam del deserto, 163 Balsam, Friars', 257 of Peru, 163 Turlington's, 257 Barium sulphid, 217 Benzoin, compound tincture of, 257 Betanaphthol, 162 Biogen, 144 Bismuth paste, 483 subgallate, 206 subnitrate, 119, 206 tribromphenolate, 119, 207 Blackberry, 211 Black's 1-2-3, 156 Bleaching agents, 270 processes, 273 Blue stone, 201 Bone plombe, 478 Borax, 127 Borite, 143 Borneol, 194 Brandy, 379 Bromural, 375 Buckthorn, 394 Burnett's disinfecting fluid, 204 Burns, solution for, 164 Butylchoral hydrate, 367 Caffein, 378 citrated, 378 effervescent citrated, 378 Calcination, 91 Calcium, 411 carbonate, precipitated, 269 chlorid, 253 dioxid, 143 hydroxid, solution of, 269 lactate, 253 sulphate, exsiccated, 258 Calomel, 397 vegetable, 395 GENERAL INDEX 653 Campho-phenique, 155 Camphor, 194 Cantharides, 266 Caoutchouc, 256 Capsicum, 265 Capsules, 93 Carbon tetrachlorid, 349 Carvon, 195 Cascara sagrada, 394 Cataplasms, 476 Catechu, 212 Cathartics, 392 saline, 395 vegetable, 394 Cation, 111 dry, 215 liquid, 214 Caustic, iodin, 265 iodin, Churchill's, 265 mitigated, 218 Caustics, 212 Cavity varnish, antiseptic, 162 Cellulo-aceton, 259 Cement, Sorel's, 207 Cerates, 93 Chalk, precipitated, 299 prepared, 269 Charcoal, 302 Chinosol, 161 Choral hydrate, 367 Chlorbutanol, 320 Chloroform, 347 Chloro-percha, 183, 259 Chloretone, 320 Chromic trioxid, 216, 255 Cinnamic aldehyd, 195 Citarin, 430 Cleanser, hand, oxygenated, 148 Coagulen, 253 Coagulose, 253 Cocoa, fluidextract of, 314 wine of, 314 Cocain hydrochlorid, 312, 530 Cocain, oleate of, 314 phenate, 314 Cocainism, 316 Codein phosphate, 370 Collargol, 228 Collodion, 93, 257 flexible, 257 styptic, 251 Colocynth, 394 Columbo, 381 Comminution, 90 Condy's fluid, 148 Confections, 94 Copper sulphate, 201, 385 Correctives, 292 Coryl, 524 Cotarnin hydrochlorid, 254 phthalate, 254 Cotton, purified, 251 styptic, 251 Counterirritants, 260 Cream, dentist's hand, 260 Cream of tartar, 396 Creosote, 157 Cresol, 157 compound solution of, 158 formothymol, 167 Croton, chloral hydrate, 367 Cuprol, 202 Cuttlefish bone, 302 Cycloform, 323 Cystogen, 166 Dandelion, 381 Decantation, 90 Decoctions, 94 Demulcents, 255 Dentinagen, 208 Dentin, artificial, 208 hypersensitive, treatment of, 574 Depressants, circulatory, 399 respiratory, 404 Dermatol, 206 Desiccation, 90 Diaphoretics, 421 Digestives, 379 Digitalis, 401 Dimazon, 165 Discs, devitalizing, 249 654 GENERAL INDEX Disinfectants, 103 Disinfection of rooms, 169 Displacement, 92 Dissociation, electrolytic, 110 Distillation, 90 Diuretics, 423 Diuretin, 424 Dose, 41 Dose table, 606 Doses, average, of dental drugs, 100 Drastics, 392 Drops, Jesuits', 257 Drugs, 31 action of, 37 organic constituents of, 88 Dry mouth, 421 Eau de Botot, 295 Ecgonin, 324 Electro-sterilization, 484 Elixirs, 94 Elixir of vitriol, 123 Emetics, 383 Emetin, 19, 386 Emollients, 255 Emulsions, 94 Epinephrin, 403, 505 Epinephrin chlorid, solution of, 254 Equivalent, thermametric, 605 Ergot, 254 Escharotics, 212 Ether, 326, 348 Ethyl bromid, 348 carbamate, 367 chlorid, 326, 348 administration of, 353 Eucain, 319 Eucalyptol, 195 Eugenol, 196 Europhen, 133 Evacuants, 395 Evaporation, 91 Expression, 91 Exsiccation, 91 Extracts, 94 fluid, 94 Extract, Goulard's, 203 Ferratin, 407 Ferripyrin, 252 Ferropyrin, 252 Fibers, devitalizing, 249 Fibrolysin, 418 Figs, 476 Filtration, 91 Finsen light, 464 Fluid, Burnett's disinfecting, 204 sterilizing, for instruments, 128 Fluorin, 411 Formagen, 167 Formaldehyd, solution of, 165 Formalin, 165 Formalin, dermatitis, 168 Formamint, 166 Formin, 166 Formocresol, 172, 183 Formol, 165 Frangula, 394 Gangrene of pulp, 174 Gargles, 94 Gelatin, 253 General anesthesia, treatment of ac- cidents, 359 Gentian, 381 Germicides, 103 Glands, suprarenal, 403 Glass, liquid, 258 Glycerin, 257 Glycerite of boroglycerin, 121 Glycerite of phenol, 152 Glycerites, 94 Glycerol, 257 Golden moss, 251 Golden seal, 254 Guaiacol, 157 Guaiacol carbonate, 157 Gutta-percha, 256 Halogens, 129 Heat and cold, 474 Heavy metals, salts of, 108 Hemorrhage, 250 GENERAL INDEX 655 Heinostatics, 250 Hermophenyl, 118 Hexamethylenamin, 166, 430 Holocain, 319 Honeys, 94 Hops, 382 Hydragogues, 392 Hydrastinin hydrocblorid, 254 Hydrated chloral, 367 Hydrogen dioxid, 255 solution of, 136 Hydronaphthol, 162 Hyperemia, artificial, 442 methods of inducing, 448 therapeutic indications, 451 Hypersensitive dentine, treatment of, 574 Hypnotics, 366 latrochemistry, 53 lotromeclianics, 53 lotrophysics, 53 lotropsyehics, 53 Immunity, 437 Incompatibilities, 74 Infusions, 94 Injections, 94 Injection, extra oral, 563 infra-orbital, 562 into the mandibular nerve, 555 intraosseous, 553 peridental, 551 subperiosteal, 547 technique of, 542 lodids, 414 lodin, 262 compound solution of, 263 Talbot's, 265 tincture of, 263 lodoform, 130 bone plombe, 133 paste, 133 lodo-glycerol, Talbot's, 265 lodol, 132 Tonic medication, 488 Ions, 111 Ipecac, 19, 386 Ipecac and opium, powder of, 370 Iron, 407 carbonate, 408 chlorid, solution of, 251 masked, 409 oxid, saccharated, 408 perchlorid, solution of, 252 subsulphate, 252 subsulphate, solution of, 252 Irritants, 260 Itrol, 228 Jaborandi, 420 Jalap, 394 Juices, 94 Kalium-natrium, 216 Kava-kava, 327 Kelene, 524 Keys-all, 162 Kino, 211 Krameria, 211 Kresamin, 158 Kryofin, 432 Largin, 228 Laudanum, 369 Laughing gas, 332 Law, national narcotic, 97 Laxatives, 392 Lead acetate, 203 Lead, subacetate, solution of, 203 sugar of, 203 Light therapy, 463 Lime, chlorinated, 134 Liniments, 94 Liniment, ammonia, 267 dental, Hoff's, 267 iodin, 263 Liquores, 95 Lithium carbonate, 430 citrate, 430 salicylate, 430 Logwood, 211 Lotions, 94 656 GENERAL INDEX Lunar caustic, 218 Lycetol, 431 Lysoform, 166 Lysol, 158 Maceration, 91 Magnesia, 269 milk of, 270 Magnesium carbonate, 269, 301 citrate, solution of, 396 dioxid, 144 oxid, 269 sulphate, 396 Mandrake, 395 Marsh gas, 165 Mass, blue, 397 Valet's, 398 Massage, 458 Masses, 94 Masticol, 260 Menthol, 197 Mercurol, 118 Mercurous chlorid, 397 Mercury, ammoniated, 119 biehlorid, 115 cyanid, 117 iodid, red, 118 iodid, yellow, 118 mass of, 397 oxid, red, 118 oxid, yellow, 118 salts, 415 subsulphate, 386 succinimid, 417 Metacresol, 158 Metallic salts, action of, 111 Methethyl, 327 Methods, pharmaceutic, 90 Methylene blue, 164 violet, 164 yellow, 164 Methyl chlorid, 327, 349 salicylate, 197 Mixtures. 94 Monk's hood, 372 Monochlorphenol, 156 Morphin acetate, 369 Morphin, compound powder of, 370 hydrochlorid, 370 sulphate, 370 Mouth wash, alkaline, 295 antiseptic, 294 betanaphthol, 162 chinosol, 297 colors, for, 297 hydrogen dioxid, 297 Miller's, 296 PickerilPs, 296 Pruyn's, 295 resorcinol, 296 Komer's, 296 saccharin, 296 Mouth washes, 293 Mucilages, 94 Mustard, 265 Myrrh, 24, 160 Myrtol, 198 Narcotic law, national, 97 Narcotics, 328 Narcotile, 524 Nargol, 229 Necrosis of pulp, 172 Neosalvarsan, 417 Nervocidin, 320 Neurocain, 314 Nioform, 133 Nirvanin, 319 Nitrogen protoxid, 332 Nitroglycerin, spirit of, 402 Nitrous oxid, 332 administration of, 335 physiologic action of, 334 Novocain, 317, 530 Oak bark, white, 211 Obtundents, 309, 317 Oil, bay, 193 betula, 190 cajuput, 191 cananga, 194 caraway, 191 GENERAL INDEX 65? Oil Cont'd cassia, 191 castor, 395 cinnamon, 29, 191 clove, 18, 29, 192 croton, 395 essential, 29, 184 eucalyptus, 192 gaultheria, 193 mustard, volatile, 193 myrcia, 193 of smoke, 157 of vitriol, 123 peppermint, 29, 193 sweet birch, 190 teaberry, 193 thyme, 194 wintergreen, 193 ylang ylang, 194 Ointment, compound resorcinol, 159 phenol, 152 Ointments, 94 Oleates, 94 Oleoresins, 95 Opium, 369 powdered, 369 tincture of, 369 tincture of, camphorated, 369 tincture of, deodorized, 369 Opsonins, 437 Oral hygiene, 277 Organic drugs, constituents of, 88 Organo-therapy, 436 Orexin hydrochlorid, 382 Orpiment, 230 Orthocresol, 158 Orthoform, 322 new, 322 Osmium tetroxid, 216 Oxone, 136 Oxymethylen, 166 Oxygen, 141 Oyster shells, prepared, 300 Ozone, 135 Paint, iodin, Carson's, 265 Pancreatin, 383 Papain, 383 Papers, 95 Papoid, 383 Paracresol, 158 Paraffin, 257 Paraform, 166 Paraformaldehyd, 166 Paraldehyd, 367 Paranephrin, 528 Paregoric, 369 Paste, depillatory, 217 desensitizing, Buckley's, 167 devitalizing, 249 pulp capping, 197 pulp mummifying, 184 Scheuer's root filling, 184 Pellidol, 165 Penghawar Djambi, 251 Pental, 333 Pepsin, 382 Peraquin, 136 Percolation, 92 Pergenol, 147 Perhydrol, 136, 255 Petrolatum, 257 Petrolatum liquid, 398 Pharmacology, 31 Pharmaco-dynamics, 31 Pharmacopeia, 86 Phenacetin, 435 Phenol, 151 camphorated, 155 coefficient, 105 glycerite of, 152 ointment of, 152 sodique, 106, 155 Phenolphthalein, 398 Phenyform, 166 Phenyl salicylate, 160 Phosphorus, 410 Pills, 95 Pilocarpin hydrochlorid, 420 nitrate, 421 Piperazin, 431 658 GENERAL, IXDEX Plaster, mustard, 266 Plasters, 95, 259 Platt's chlorides, 106 Plugging bone cavitie 4 s, 478 Podophyllum, 395 Poisoning, acute, treatment of, 595 Potash, caustic, 215 Potassium arsenite, solution of, 231 bitartrate, 396 bromid, 375 chlorate, 149 citrate 396 hydroxid, 215 iodid, 415 ointment of, 415 permanganate, 148, 254 Potassium and sodium alloy, Shreier's, 216 Potassium and sodium tartrate, 396 Poultices, 95, 476 Powders, 95 Powder, compound effervescing, 397 ^Dover's, 370 "Monsel's, 252 Seidlitz', 397 styptic dusting, 210 Tully's, 370 Precipitation, 92 Preparations, pharmaeeutic, 93 Prescription writing, 63 coloring and flavoring agents, 78 construction, 69 dose, 41 estimation of quantities, 72 metric, 68 metric system, 80 pharmaeeutic methods, 90 pharmaeeutic preparations, 93 pharmacopeia, 86 signs and numerals, 71 terms used in, 70 Propsesin, 323 Protargol, 228 Protectives, 255 Pulp, diagnosis of diseases of, by the electric current, 585 Pumice stone, 300 Pyoktanin, 164 Pyorrhea, treatment of, by emetin. 387 Pyrozon, 137, 255 Quassia, 382 Quinin, 18 Quinin and urea hydrochlorid, 320 Quinin sulphate, 433 Kadio-aetive substances, 467 Resins, 95 Remedy, Robinson's, 216 Resorcinol, 158 Resorcinol ointment, compound, 159 Rhatany, 211 Rhubarb, 394 Robinson's remedy, 216 Root canal filling materials, 183 Root canals, infected, treatment of, 171 Rosin, carbolized, 259 Rubber, 256 Saccharin, 108 Sal Alembroth, 116 Saliva, 278 examination of, for mercury, 416 Salol, 160 Salt, English smelling, 268 Rochelle, 396 Salvarsan, 417 Sandarac, 259 Sandarach, 233 Sapodermin, 118 Scarlet red, Biebrich, 164 Sedatives, 374 Senna, 395 Serpentaria, 382 Serum therapy, 438 Sialogogues, 419 Sidonal, 431 Silex, liquid, 258 Silver acetate, 228 citrate. 228 GENERAL INDEX 659 Silver lactate, 228 nitrate, 217 Silverol, 229 Snake root, Virginia, 382 Soap, liquid, 128 Soaps, 128, 302 Soda, caustic, 216 chlorinated, solution of, 134 Sodium bicarbonate, 270 borate, 127 bromid, 375 chlorid, 107 diborate, 146 clioxid, 145 ethylate, solution of, 215 hydroxid, 216 iodid, 415 perborate, 146 phenolate, solution of, 155 phosphate, 395 salicylate, 160 silicate, solution of, 258 sulphate, 396 Solution, anesthetic, preparation of, 533 Dobell's, 128 Donovan's, 231 Fowler's, 231 iodin, Talbot's, 265 iodin, Younger 's, 265 Labarraque 's, 134 local anesthetic, 317 Lugol's, 263 Monsel's, 252 Solutions, 92, 95 Somnoform, 349 Spirits, 95 Steresol, 260 Stimulants, 292 cerebral, 376 circulatory, 399 respiratory, 404 Stomachics, 379 Stovain, 319 Strontium dioxid, 145 Strophauthus, 401 Strychnin nitrate, 402 sulphate, 402 Styptics, 250 Stypticin, 254 Styptogan, 254 Styptol, 254 Subcutin, 323 Sublamin, 118 Sublimate, corrosive, 115 Sublimation, 92 Suction cup, treatment with the, 453 Sulfur, 397 washed, 397 Sulphonal, 367 Sulphonethylmethan, 367 Sulphonmethan, 367 Sumach, 211 Suppositories, 96 Suprarenalin, 528 Suprarenin, 527 Syrups, 96 Talcum powder, oxygenated, 147 Tamarinds, 395 Tanacol, 211 Tannalbin, 211 Tannigen, 211 Tannin, 209 Tannoform, 211 Tannopin, 211 Tartar emetic, 385 Tartar solvent, 429 Terms, therapeutic, glossary of, 599 Theobromin sodium salicylate, 424 Thymol, 198 caniphene, 156 iodid, 133 iodid, solution of, 265 phenolated, 156 Thymotal, 199 Tinctures, 96 Tonics, 406 Tooth paste, 306 Miller's, 307 660 GENERAL LS'DEX Tooth paste Cont'd Kolynos, 308 Saline, 308 Tooth powder, 297 colors for, 304 Cook's, 306 Fitzgerald's, 304 Harlan's, 305 Lasar's, 305 Miller's, 305 oxydizing, 305 Pedley's, 306 Philadelphia Dental Dispensary, 305 red, 306 Vegetol, 306 violet, 306 Tooth pulp, decomposition of, 172 Tooth soap, 308 Austrian, 308 Bergmann's, 308 Kobert's, 309 thymol, 309 Tragacanth, 258 Tricresol, 157 Trinitrophenol, 163 Trional, 367 Trioximethylen, 166 Triturations, 92, 96 Troches, 96 Turpeth mineral, 386 Urethan, 367 Uric acid solvents, 424 Urosin, 357 Urotropin, 166 Valerian, 376 Validol, 376 Varnish, antiseptic cavity, 162 sandarac, 259 shellac, 259 wound, 260 Vaselin, 257 Vennillion, 417 Veroform, 166 Veronal, 368 Vibration, 460 Vinegars, 97 Vioform, 133 Vitriol, blue, 201 white, 205 Wash, yellow, 116 Waters, 97 Water, ammonia, 267 ammonia, stronger, 267 lime, 269 witch-hazel, 211 Weights and measures, 79 Wines, 97 Wine, red, 379 white, 379 Witch-hazel extract, 211 Whisky, 378 Xanthin, 422 Xanthoprotein, 225 Xeroform, 119, 207 Yellow wash, 116 Yohimbin, 327 Zinc acetate, 209 cement, 207 chlorid, 203, 255 dioxid, 146 iodid, 206 oxid, 207 phenolsulphonate, 152, 205 sozo-iodolate, 209 subgallate, 206 sulphate, 205 sulphocarbolate, 152, 205 Zineol, 209 UNIVERSITY Form L9-Series 493 A 000 373 749 1